Every finding on record at Milwaukee Health and Rehab

Based on observation, interview and record review, the facility did not ensure that residents who are unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 (R11) of 14 residents reviewed for Activities for Daily Living (ADL).*R11 was observed to be double briefed during incontinence cares.Findings:The Facility provided policy, titled Incontinence with no last review/revised date, indicates . 4. Residents that are incontinent of bladder will receive appropriate treatment to prevent infections and to restore continence to the extent possible. R11 was admitted to the facility on [DATE], with diagnoses including Dementia (an umbrella term for severe cognitive decline (memory, thinking, reasoning) that impairs daily life), Alzheimer's Disease (a progressive brain disorder, the most common cause of dementia, characterized by memory loss, impaired thinking, and difficulty with daily activities) and retention of urine (the inability to fully empty bladder). R11's Quarterly Minimum Data Set (MDS), dated [DATE], indicated R11 has a Brief Interview for Mental Status (BIMS) score of 5, indicating R11 has severe cognitive impairment. R11's MDS documents R11 is dependent on staff for toileting needs and is always incontinent of bowel and bladder.Surveyor reviewed R11's care plan and noted the following focus areas: R11 has bladder and bowel incontinence, with an initiation date 3/1/2018. Interventions include brief use- use disposable briefs and change every 2-3 hours, incontinence-check every 2-3 hours, as needed, and provide peri care. R11 has an ADL (Activities of Daily Living) self-care deficit, intervention includes toilet use- total assist of 1, check and change every 2-3 hours and as needed.Surveyor reviewed the Facility provided Kardex for R11. Surveyor noted under bowel and bladder indicates, R11 uses disposable briefs and to check and change every 2-3 hours.On 12/04/2025, at 9:32 AM, Surveyor observed Hospice Certified Nursing Assistant (CNA)-H assisting R11 with incontinence cares. Surveyor noted a strong urine smell, R11 to be double briefed and completely soaked through to the chuck pad with urine. Surveyor asked Licensed Practical Nurse (LPN)-E if R11 should be double briefed, LPN-E informed Surveyor that no one should be double briefed.On 12/04/2025, at 10:44 AM, Surveyor spoke with Nursing Home Administrator (NHA)-A regarding concerns of R11 observed being double briefing and both briefs were soaked with urine threw to the chucks pad. NHA-A informed Surveyor that double briefing is not allowed, is unacceptable and is not something the Facility endorses to promote good personal hygiene for residents or to assist with ADLs.

Based on observation, interview, and record review the facility did not ensure 1 (R45) of 1 resident receive appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.*R45 was observed to not have a splint in place for R45's right hand.Findings include:The facility's policy titled, Use of Assistive Devices with no reviewed/revised date, indicates the following, . 2. The use of assistive devices will be based on the resident's comprehensive assessment, in accordance with the resident's plan of care. 3. The facility will provide assistive devices for residents who need them. Nursing, dietary, social services, and therapy departments will work together to ensure availability of devices, such as for ordering and/or replacement.R45's diagnoses includes Hemiplegia (affecting one side of the body, severe weakness or complete loss of movement, sensation, and coordination on the affected side.) affecting right, dominate side and contracture (a permanent tightening and shortening of muscles, tendons, skin, or other tissues, causing joints to become stiff and restricting normal movement) of right hand. Surveyor reviewed R45's current care plan and noted R45 has a focus area for Activities of Daily Living (ADL) self-care performance deficit with an intervention of R (right) hand splint (can be a splint, stuffed animal, or palmar splint, washcloth) for contraction prevention.R45's admission minimum data set (MDS), with an assessment reference date of 6/19/2025, indicates R45 has a brief interview for mental status (BIMS) score of 4, indicating R45 has severe cognitive impairment, has impairment in upper and lower extremities range of motion on 1 side of body and is dependent on staff for upper body dressing.R45's Visual/Bedside Kardex Report as of 12/4/2025, does not include application of a splint to R45's right hand.On 12/03/2025, at 1:10 PM, Surveyor observed R45 to not have a right-hand splint in place.On 12/04/2025, at 9:06 AM, Surveyor observed R45 to not have a splint in place in R45's right hand.On 12/04/2025, at 9:08 AM, Surveyor asked Certified Nursing Assistant (CNA)-G if R45 needs a splint for R45's right hand. CNA-G was unsure if R45 is supposed to have splint on her hand, CNA-G then went to ask Licensed Practical Nurse (LPN)-E. LPN-E informed CNA-G that R45 should have a splint in R45's right hand. CNA-G expressed being unable to find a splint. LPN-E looked at assignment sheet and informed CNA-G to use a towel for R45's right hand as indicated on the assignment sheet.On 12/04/2025, at 10:44 AM, Surveyor spoke with Nursing Home Administrator (NHA)-A regarding concern R45 did not have R45's right hand splint in place per care plan. NHA-A informed Surveyor she will look into it but would expect R45 to have a splint in place if indicated.No additional information was provided.

Based on interview and record review, the facility did not ensure it completed accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to the Centers for Medicare & Medicaid Services (CMS). This had the potential to affect all 56 residents residing in the facility.Staffing information for Quarter 2 (January 1 - March 31) of the Payroll Based Journal (PBJ) was not accurately submitted to CMS. Findings include: The CMS Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, indicates: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS .1.2 Submission Timelines and Accuracy. Direct care staffing and census data will be collected quarterly and is required to be timely and accurate .Report Quarter: staffing and census data will be collected for each fiscal quarter. Staffing data includes the number of hours paid to work by each staff member each day within a quarter. Census data includes the facility's census on the last day of each of the three months in a quarter. The fiscal quarters are as follows: Fiscal Quarter, Date range: (quarter) 1 October 1-December 31, (quarter) 2 January 1-March 31, (quarter) 3 April 1-June 30, (quarter) 4 July 1-September 30 . Surveyor reviewed the Payroll-Based Journal (PBJ) Staffing Data Report, CASPER Report 1705D, for Fiscal year 2025 (run on 8/11/25) which indicated the Facility had excessively low weekend staffing for the 2nd Quarter (January 1-March 31). Surveyor reviewed the Facility's weekend schedules from January 1, 2025, to March 31, 2025. Surveyor noted licensed nurses and certified nursing assistants present on each shift, for each unit. Surveyor noted these schedules included call ins, agency staff and staff who picked up shifts. Surveyor noted there did not appear to be excessive call-ins.Surveyor reviewed the Facility Assessment and compared to schedules provided. Surveyor noted the Facility consistently meets staff ratios based on the Facility assessment.On 12/04/2025, at 11:51 AM, Surveyor asked Nursing Home Administrator (NHA)-A about the triggered PBJ report for low staffing weekends. NHA-A informed Surveyor the PBJ report is completed by corporate with the assist of Human Resources (HR) and NHA-A. NHA-A must look further into why the PBJ report triggered for low weekend staffing during the 2nd Quarter.On 12/08/2025, at 10:16 AM, Surveyor interviewed Human Resource (HR) scheduler-I. HR scheduler-I indicated HR scheduler-I started at the Facility in August 2025. HR scheduler-I prepares the schedule ahead of time by 2-3 weeks and will go by census and needs of residents when making the schedule. Usually, for a census of 65 and up- HR scheduler-I will staff 3 Certified Nursing Assistants (CNA)s on each floor for 1st and 2nd shift. For night shift, HR scheduler-I schedules at least 2 CNAs on each floor. The Facility does not use agency staff. For open shifts, HR scheduler-I will post open shifts in On Shift an electronic system a month in advance for open hours and has not identified issues with staff picking up. For call in's, HR scheduler-I will make calls right away to try to get shift covered. HR scheduler-I also has CNA certification and can help if needed but has not had to work the floor yet, indicating staff are very good about coming in. HR scheduler-I indicated being responsible for the PBJ report. Corporate will send a quarterly report of nursing coverage, will let the Facility know if they were short and HR scheduler-I will see if there was something entered in wrong, and will then go in and correct it. NHA-A joined the conversation with HR scheduler-I. NHA-A indicated after looking into the report further, she believes the census was wrong on certain days, has call ins. NHA-A indicated managers are not afraid to jump in and help and sometimes that does not reflect in the PBJ report. The Facility was made aware of the concerns regarding PBJ report triggering for low weekend staffing due to inaccurate information being submitted. No further information was provided as of time of write up.

Based on interviews and record review, the facility did not ensure allegations of verbal abuse were immediately reported to the Administrator. This was observed with 1 (R1) of 1 resident reviewed for allegations of verbal abuse.On 6/29/2025 staff and R1 heard Registered Nurse (RN)-D call R1 a dizzy bitch around 9:30pm. The verbal abuse was observed by other staff but not reported to Nursing Home Administrator (NHA)-A until the following morning on 6/30/2025. RN-D continued to finish RN-D's shift which ended at 11:00pm. Findings include:The facility policy titled ABUSE POLICY no initiation or revision date documents: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. IV. Internal Reporting Requirements and Identification of Allegations. Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. Upon learning of the report, the administrator or a designee shall initiate an incident investigation. Any allegation of abuse or any incident that results in serious bodily injury will be reported to the required regulatory agencies immediately, but not more than two hours of the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours. V. Protection of Residents . Employees of this facility who have been accused of abuse, neglect, exploitation, mistreatment or misappropriation of resident property will be removed from resident contact immediately. The employee shall not be permitted to return to work until the results of the investigation have been reviewed by the administrator and it is determined that any allegation of abuse, neglect, exploitation mistreatment or misappropriation of resident property is unsubstantiated.R1 was admitted to the facility on [DATE] and has diagnoses that include anxiety disorder, and paraplegia. R1's admission minimum data set (MDS) dated [DATE] indicates R1 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 11 and the facility assessed R1 to require total assist with 2 staff members for dressing, transferring, and repositioning. R1's MDS documents at the time of assessment R1 did not have mood or behavior symptoms. R1 has a urostomy and is always incontinent of bowel. R1 was their own person and did not have an activated power of attorney (POA).Surveyor reviewed the facility self-report that was initially submitted to the State Agency on 6/30/2025, at 9:57 AM. A brief summary of incident documents R1 reported yesterday evening (6/29/25) RN-D called R1 a bitch at the nurse's station. RN-D is not on duty at the time of report. Facility initiated an investigation. R1 states feels safe in building. The final submission of the facility self-report was submitted to the State Agency on 7/3/2025, at 7:10 PM, which documents on 6/29/2025, at 9:30 PM, RN-D was overheard saying loudly enough for R1 to hear (R1's name) is such a dizzy bitch. The staff members present heard RN-D make this statement and R1 acknowledged hearing RN-D.Surveyor notes the shift ends at 11:00 PM. Staff members were aware of the verbal abuse by RN-D towards R1 but did not report the allegation immediately to NHA-A. RN-D remained in the facility until 11:00 PM, allowing RN-D to have contact with R1 and other residents in the facility. RN-D was not immediately removed from the resident care areas pending further investigation of the situation.On 7/10/2025, at 10:00 AM, Surveyor interviewed licensed practical nurse (LPN)-C who stated LPN-C was sitting next to RN-D at the nurse's station on 6/29/2025 and heard RN-D call R1 a name when R1 came off the elevator. Surveyor asked why they thought RN-D called R1 a name. LPN-C stated they just think RN-D had had it with R1 being rude to the staff that day. Surveyor asked if R1 was RN-D's patient on 6/29/2025. LPN-C stated R1 was LPN-C's patient that day. Surveyor asked if LPN-C reported RN-D calling R1 a name. LPN-C stated LPN-C did not tell anyone and stated LPN-C is aware that it should have been reported right away. LPN-C stated someone reported it because LPN-C was questioned the next day, and a statement was taken. Surveyor asked if RN-D continued to work the rest of the shift the night of 6/29/25. LPN-C stated LPN-C and RN-D both finished their shifts around 11:00 PM on 6/29/2025. On 7/10/2025, at 11:15 AM, Surveyor interviewed NHA-A who stated NHA-A found out about the verbal abuse towards R1 from RN-D in the morning meeting the next day. NHA-A stated that NHA-A went to talk with R1 about the incident and then an investigation began. Education with staff that such accusations need to be reported to administration right away. On 7/11/2025, at 11:45 AM, Surveyor observed R1 sitting up in bed getting ready for the day. Surveyor asked if there were any concerns with staff. R1 stated not much, and that R1 could handle themself. R1 mentioned a staff member called her a bitch but could not remember who and has not seen them for a while. Surveyor asked if R1 told anybody. R1 stated that someone did because NHA-A came to talk to her about it and took care of it. Surveyor asked how R1 felt about the situation. R1 stated R1 could handle their own and feels fine. Surveyor asked if R1 had concerns with other staff members. R1 stated as long as they do what R1 wants and gets care by the staff R1 likes, everything will be fine. R1 stated NHA-A and R1 came up with a personalized schedule that staff follow and has been fine so far. Surveyor asked R1 if R1 was cared for by the staff member the day R1 was verbally abused. R1 stated that staff took R1 to R1's bedroom and got ready for bed and has not seen them since. On 7/10/2025, at 12:14 PM Surveyor interviewed RN-D who acknowledged calling R1 a bitch and meant to say under breath, but it just came out. Surveyor asked RN-D about the situation. RN-D stated R1 was being rude to staff all day calling staff names. RN-D stated RN-D was charting at the desk and R1 came off the elevator and started yelling at LPN-C and RN-D had just had it and called R1 a ‘bitch but did not realize it came out loudly until staff said that RN-D cannot say that. Surveyor asked if RN-D finished working the shift. RN-D stated that R2 was not on RN-D's assignment and RN-D completed the shift and went home about 11:00 PM. RN-D stated RN-D was called the next morning pending an investigation into the verbal abuse against R1 and RN-D had to do some education before returning to work and the facility also took a statement from RN-D. On 7/10/2025, at 1:17 PM Surveyor interviewed LPN unit manager (LPNUM)-G who stated that she reported the incident in the morning meeting the next day. LPNUM-G stated she heard from certified nursing assistant (CNA) about the incident, but RN-D's shift already ended and R1 was fine.On 7/10/2025, at 1:28 PM, Surveyor interviewed CNA-H who also works in the facility as a med-tech and scheduler. CNA-H stated R1 is also CNA-H's great aunt. CNA-H stated staff called CNA-H at home that night and stated R1 was being mean to staff and calling them names and R1 wanted CNA-H to come help her. CNA-H talked with R1 and agreed to go into the facility later that night and assist with getting R1 ready for bed. CNA-H stated that when CNA-H got off the elevator with R1 to get R1 ready for bed. R1 started yelling and calling the nursing staff names and that is when RN-D called R1 ‘bitch. CNA-H stated that CNA-H took R1 to R1's bedroom and got R1 ready for bed. CNA-H stated that R1 was upset at first then calmed down and settled in for bed. CNA-H stated that CNA-H left the facility around 11:00 PM and called LPNUN-G and reported the verbal abuse towards R1 by RN-D. On 7/10/2025, at 2:20 PM. Surveyor shared concerns with NHA-A that the verbal abuse made against R1 by RN-D was not reported to the Nursing Home Administrator or the State Agency in a timely manner and RN-D was able to continue working with residents after the incident since it was not reported timely.

Based on interview and record review, the facility did not ensure the safety and supervision of 1 (R1) of 1 resident reviewed for supervision and accidents. On 6/28/2025 while sitting outside R1 asked another resident to push them to the store. The other resident began to push R1's wheelchair to the store. The facility did not re access R1 for elopement risk, ability to leave the facility unsupervised, or initiate a care plan to prevent future incidents from happening. Findings include:The facility policy titled Elopements and Wandering Residents reviewed/revised 5/8/2025 documents: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Policy Explanation and Compliance Guidelines: . 3. The facility shall establish and utilize a systemic 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. 4. 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 and throughout their stay by the interdisciplinary care plan team (IDT). b. IDT will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. R1 was admitted to the facility on [DATE] and has diagnoses that include type 2 diabetes with foot ulcer, peripheral vascular disease, anxiety disorder, and paraplegia. R1's admission minimum data set (MDS) dated [DATE] indicated R1 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 11 and the facility assessed R1 needing total assist with 2 staff members for dressing, transferring, and repositioning. R1's MDS documents at time of assessment that R1 did not have mood or behavior symptoms. R1's admission elopement risk assessment dated [DATE] indicated R1 was not at risk for elopement. R1 was their own person and did not have an activated power of attorney (POA). On 6/28/2025, at 2302 (11:01 PM) in the progress notes nursing documented (R1) was outside today and asked another resident to push (R1) to the store. Facility staff were able to catch up to R1 and the other resident and bring back to the facility.Surveyor reviewed R1's medical record and noted that there was not an elopement assessment done on R1 to indicate if R1 was an elopement risk after R1 was brought back to the facility.Surveyor reviewed R1's comprehensive care plan and noted there was not a care plan initiated to indicate a risk/concern R1 would ask another resident to assist R1 away from the facility or interventions in place to prevent further incidences from re-occurring.On 7/10/2025, at 2:20 PM, Surveyor shared concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that R1 was not reassessed for elopement risk after R1 left the facility without staff knowledge on 6/28/2025 and that there was not a care plan initiated to indicate R1's risk/potential to ask peers for assistance with leaving the facility without staff knowledge. DON-B stated that R1 is R1's own person and that R1 is not an elopement risk and that R1 can leave the facility. NHA-A stated staff interfered because they thought R1 was going to get alcohol. Surveyor shared concern there are no interventions or concerns in R1's care plan related to alcohol seeking behaviors. Surveyor asked if R1 signed out from the facility on 6/28/2025 when R1 left the facility. DON-B stated R1 had not signed out and would agree maybe a community safety/awareness assessment should have been completed but did not think an elopement assessment should have been completed. Surveyor shared that a concern remained as R1's ability to leave the facility unknown and unassisted by staff was not assessed by the facility and a care plan was not initiated with interventions so staff are made aware and can act if R1 leaves the facility again without signing out.

Based on record review, interviews, and review of the facility's policy, the facility failed to ensure one of nine sampled residents (Resident (R)1) had a bowel program implemented. This deficient practice may result in bloating, pain, and general discomfort. Findings include: Review of a facility policy titled, Bowel Elimination Protocol, dated 09/2024, indicated, .CNAs [Certified Nurse Aides] are responsible for documenting bowel movements and for asking alert residents who toilet themselves about their elimination each shift . Residents who have had no BM (bowel movement) for 72 hours will be considered for pharmacological intervention or increased non-pharmacological intervention. Additional information related to elimination may need to be gathered . e.g. bowel sounds. Review of R1's electronic medical records (EMR) titled Admission Record, located under the Profile tab, indicated the resident was admitted to the facility on [DATE]. Review of R1's EMR titled Clinical Physician Orders, located under the Orders tab, indicated physician ordered Senna Oral Tablet 8.6 milligrams (mg), give two tablets by mouth every 12 hours as needed for constipation. In addition, the physician ordered MiraLax oral powder 17 grams (gm) per scoop every 24 hours as needed for constipation. Review of R1's EMR titled admissions Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/24/24, indicated the resident had a Brief Interview for Mental Status (BIMS) score of six out of 15, which revealed the resident was severely cognitively impaired. The assessment indicated the resident had an impairment on one side of his upper and lower extremities. The assessment indicated the resident required substantial/maximal assistance from staff for toileting. The assessment indicated the resident was always incontinent of bowel. Review of R1's EMR titled Care Plan, located under the Care Plan tab and dated 05/17/24, indicated the resident had a deficit with activities of daily living, specifically with toileting and required staff to provide the resident with extensive assistance. Review of a document provided by the facility titled, Bowel Function, for the month of 07/2024, failed to contain evidence that R1 had a bowel movement from 07/20/24 through 07/24/14. There was no evidence that the resident had a bowel movement from 07/28/24 through 07/31/24. Review of R1's EMR titled, Medication Administration Record (MAR), for the month of 07/2024, indicated the resident was not administered the bowel protocol from 07/20/24 though 07/31/24 and from 07/28/24 through 07/31/24. During an interview on 10/30/24 at 8:33 AM, Licensed Practical Nurse (LPN) 1, who was also the Unit Manager for the Third Floor, stated the facility was to provide the bowel protocol after three days. LPN1 stated R1 was incontinent of bowel and bladder. LPN1 reviewed the EMR for R1 and verified the bowel protocols orders were not implemented. An interview was conducted on 10/30/24 at 9:21 AM with the Director of Nursing (DON) and Regional Nurse Consultant. The DON stated the CNAs' s documentation was not accurate. The DON stated the CNAs were not documenting accurate information on R1's BMs. During an interview on 10/30/24 at 2:51 PM, LPN3 stated it was important for staff to document a resident's BMs to address the potential of a bowel obstruction.

Based on record review, observation, staff interviews, and facility policy review, the facility failed to assess nutritional status after a significant weight gain and loss and failed to take corrective action after the facility determined the weight gain and loss was an error for one of one resident (Resident (R) 1) reviewed for nutrition in a total sample of nine residents. Findings include: Review of a facility policy titled, Weight Monitoring Program, dated 09/29/23 indicated . Each resident's weight will be monitored consistently and closely by the interdisciplinary team. All residents with patterned or significant weight changes will be assessed by the facility's interdisciplinary team as indicated. Interventions to address nutritional issues will be initiated and incorporated into the resident's care plan and re-evaluated on a timely and periodic basis . The IDT is responsible for reviewing weights, notifying appropriate disciplines of significant changes, initiating corrective actions and completing documentation . If the resident's significant weight loss/gain is explainable (i.e. weight reduction program, dialysis, diuretic therapy), documentation must be entered into the resident's medical record to support this determination, with appropriate revisions to the care plan and addressed with the IDT team . Review of R1's electronic medical records (EMR) titled Admission Record, located under the Profile tab, indicated the resident was admitted to the facility on [DATE]. Review of R1's EMR titled hospital Discharge Summary, located under the Misc (Miscellaneous) tab and dated 05/17/24, revealed the resident's weight was 159.2. Review of R1's EMR titled Weights Summary, located under Weights & Vitals tab and dated 05/17/24, indicated the resident weighed 159.2. Review of R1's EMR titled Care Plan, located under the Care Plan tab and dated 05/23/24, indicated the resident was at risk for alterations in nutrition, and the intervention directed the facility to weigh the resident every month or per physician/Registered Dietician (RD) order and to document and notify the physician or RD of any significant weight changes Review of R1's EMR titled Mini Nutritional Assessment, located under the Note tab and dated 05/23/24, indicated the resident scored eight out of 14 and determined the resident was at risk of malnutrition. Review of R1's EMR titled Nutritional Assessment, located under the Note tab and dated 05/23/24, indicated the RD indicated the facility was to monitor weights as ordered. Review of R1's EMR titled Clinical Physician Orders, located under the Orders tab and dated 05/24/24, indicated the physician ordered to weigh the resident once a week for four weeks and then monthly. Review of R1's EMR titled, Weights & Vitals, located under the Weights & Vitals tab, indicated the following resident's weights: on 05/17/24 he weighed 159.2; on 05/24/24 he weighed 161.2; there were no weights taken for the month of 06/2024; 07/11/24 he weighed 152.0; on 07/21/24 he weighed 156.2; on 08/14/24 he weighed 173.0 and next to this weight it stated that it was the resident's hospitalization weight. On 09/19/24, RD1 crossed this weight out, due to the weight being inaccurate. The resident was then reweighed at 164.5 and was weighed in his wheelchair. Finally, on 10/18/24, the resident weight was 148.7 pounds. This was a 9.6 percent weight loss (15.8 pounds) in one month, from 09/19/24 through 10/18/24. Review of R1's EMR titled quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) date of 08/23/24, indicated the resident had a Brief Interview for Mental Status (BIMS) score of six out of 15, which revealed the resident was severely cognitively impaired. The assessment indicated the resident had an impairment on one side of his upper extremity. The assessment revealed the resident weighed 173 pounds. The assessment indicated the resident had a significant weight gain. There was not a corrected assessment completed after this date. Review of R1's EMR titled Mini Nutritional Assessment, located under the Note tab and dated 08/24/24, indicated the resident scored eight out of 14 and determined the resident was at risk of malnutrition. During an observation on 10/29/24 at 12:14 PM, R1 was in the dining room. There were multiple staff present. R1 stated the food was very good. At 12:21 PM, the resident was served his regular meal of baked chicken thigh with a leg, steak fries, bread, canned fruit, and a glass of lemonade. At 12:55 PM, the resident completed his entire meal. During an interview on 10/30/24 at 8:33 AM, Licensed Practical Nurse (LPN) 1, who was also the Unit Manager for the Third Floor, stated R1 was a good eater, and weights were to be done on a monthly basis. LPN1 confirmed the resident was not on a diuretic. LPN1 reviewed the resident's EMR during this interview and stated the resident was not re-weighed when there was a change in his weight. LPN1 stated more than likely, the staff did not subtract the weight of the resident's wheelchair during the weight taken on 09/19/24. LPN1 confirmed she took the resident's weight and recorded it on 10/18/24. LPN1 stated she subtracted the weight of the wheelchair, so he had an accurate body weight. During an interview on 10/30/24 at 10:19 AM, RD1 stated she came to the facility on e time per week. RD1 stated she typically did not reference the hospital weight on a resident since hospitals tend to use bed scales and there can be a 30-pound variance. RD1 stated she was not the person who placed R1's weight of 173 pounds in the EMR. RD1 stated the quarterly assessment for nutrition was completed by RD2, and she was a subcontractor. RD1 stated she was the person who crossed out R1's weight on 08/14/24. RD1 stated RD2 was responding to a significant weight gain for the resident per the quarterly assessment. As for the resident's weight loss, the RD1 stated if the resident had an actual weight loss, she would have recommended a supplement, and these recommendations would be placed in the resident's progress notes. A telephone message was left on 10/30/24 at 12:01 PM for RD2, and there was no return call received prior to the exit of the survey. During an interview on 10/30/24 at 1:45 PM, the Administrator stated the RD sends over a report of any outrageous weight changes. The Administrator stated the facility was still old school and was trying to get staff to enter the weights in the EMR and not document weights on paper. During an interview on 10/31/24 at 9:08 AM, the Director of Nursing (DON) stated her expectation was for the staff to re-weigh a resident if there was a weight different. The DON confirmed the weights varied for R1 and stated re-weights should have been done. She stated if there was an accurate weight loss, then staff would contact the RD, and the RD would make recommendations such as supplements or double portions of food. The DON stated the physician or the Nurse Practitioner (NP) would then be contacted.

Based on record review, staff interview, and facility policy review, the facility failed to ensure hospital physicians orders were implemented for one of one resident (Resident (R) 1) reviewed for implementation of physician orders out of a survey sample of nine. Specifically, the facility failed to obtain a laboratory blood test for vitamin D (to determine low bone density, fatigue, bone pain). In addition, the facility failed to coordinate services with R1's responsible party to ensure that one medical appointment was to be scheduled after the resident was discharged by the hospital and readmitted back to the facility. This failure had the potential for the resident to not receive appropriate continuum of care. (Cross Reference F690 and F692) Findings include: Review of a facility policy titled Physician Orders, dated 01/31/18, indicated .To provide general guidelines when receiving, entering, and confirming physician or prescriber's order. The policy failed to address following physician orders from another medical system when a resident was admitted or readmitted to the facility. Review of R1's electronic medical records (EMR) titled Admission Record, located under the Profile tab, indicated the resident was admitted to the facility on [DATE] with diagnoses that included post stroke, anxiety disorder, and vascular dementia. Review of R1's EMR titled admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/24/24, indicated the resident had a Brief Interview of Mental Status (BIMS) score of six out of 15, which revealed the resident was severely cognitively impaired. Review of R1's EMR titled Care Plan, located under the Care Plan tab and dated 05/29/24, indicated the resident had impaired memory with decision-making and had a legal guardian who was the decision-maker for the resident. Review of R1's EMR titled nursing Progress Notes, located under the Prog (Progress) Note tab and dated 08/02/24, indicated the facility received a call from R1's physician's office. The office called the facility to notify them that the resident was being transported to the emergency room due to low blood pressure and dizziness. Review of R1's EMR titled hospital Discharge Summary, located under the Misc (Miscellaneous) tab and dated 08/14/24, indicated R1 arrived at the hospital, directly from a medical appointment due to being hypotensive (low blood pressure). The physician who wrote the discharge summary also indicated the resident had an elevated PSA (prostate-specific antigen blood test to identify possible cancer), and a referral was made to a urologist. Finally, the physician indicated the resident had a low vitamin D level and was treated with supplements and recommended a blood level to be drawn on 10/01/24, to determine if the resident required additional supplements to treat his low vitamin D level. Review of R1's EMR titled SNF (Skilled Nursing Facility) progress notes, located under the Prog Note tab and dated 09/17/24, indicated the Nurse Practitioner (NP) mentioned the resident had an outpatient appointment for urology for an elevated PSA. Review of R1's EMR titled SNF progress notes, located under the Prog Note tab and dated 09/19/24, 09/26/24, 10/01/24, and 10/08/24, indicated the NP mentioned on each date that the resident had an outpatient appointment for urology for an elevated PSA. A review was conducted of R1's EMR, and there was no evidence the resident received a physician's order for a blood draw to check his vitamin D level. There was no evidence in the clinical record that the facility had followed up on the hospital referrals for a follow-up urology appointment. During an interview on 10/29/24 at 3:39 PM, Licensed Practical Nurse (LPN)1, who was also the Unit Manager for the third floor, stated she reviewed the records for R1 and could not locate a physician order for the vitamin D level or the follow-up appointments for urology. LPN1 stated typically when a resident was readmitted to the facility, the admissions nurse will transcribe the hospital physician orders and enter them into the EMR. LPN1 stated that any follow-up medical appointments would then be scheduled. During a subsequent interview on 10/30/24 at 8:33 AM, LPN1 confirmed again there was not an order for a vitamin D level for R1. LPN1 stated the physician hospital orders carry over to the facility to implement. LPN1 stated all the medical appointments were then placed in an appointment book, and since R1's family member was involved in his care, the facility coordinated with the family since the family member typically met the resident at his medical appointments and the facility provided the transportation. During an interview on 10/30/24 at 3:07 PM, Registered Nurse (RN) 2 stated he did not remember the readmission of R1 on 08/14/24. The Director of Nursing (DON) was present during this interview and stated she was confused about the orders from R1's hospitalization upon readmission. She stated she just made the urology appointment for R1 for 11/05/24. The DON stated it was her error in the interpretation of the hospital discharge summary. During an interview on 10/31/24 at 9:08 AM, the DON stated her expectation was for the admitting nurse to review the hospital discharge summary, to schedule the appointments for a resident, and place this information in the schedule book. The DON stated the management team would then ensure the appointments were scheduled and discussed in the morning meetings.

Based on interviews and record review, the facility did not implement their water management plan based upon current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of waterborne pathogens. This deficient practice has the potential to affect all 64 residents. The facility's water heating system stopped working on 8/10/2024. The facility was without hot water from 8/10/2024 - 8/15/2024. ~The facility did not call a contracted company to come to the facility to assess the concern until 8/12/2024 and the contracted company did not get to the facility until 8/14/2024 to assess and fix the concern. ~Water temperatures and testing were not completed during the time the water heater system was not working (8/10/2024 - 8/14/2024) and the facility did not take corrective actions when control limits were not met. Findings include: The 7/6/18 revised CMS (Centers for Medicaid and Medicare Services) Quality, Safety and Oversight Letter 17-30 titled, Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD) states: Facilities must have water management plans and documentation that, at a minimum, ensure each facility: - Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system. - Develops and implements a water management program that considers the ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) industry standard and the CDC (Centers for Disease Control) toolkit - Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. - Maintains compliance with other applicable Federal, State and local requirements The 6/24/21 CDC Toolkit titled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings identifies the key elements of a water management program for healthcare facilities to include: 1. Establish a water management program team 2. Describe the building water systems using text and flow diagrams 3. Identify areas where Legionella could grow and spread 4. Describe where control measures should be applied and how to monitor them 5. Establish ways to intervene when control limits are not met 6. Make sure the program is running as designed and is effective 7. Document and communicate all the activities The facility policy entitled Water Management Plan (WMP)- Legionella Bacteria Risk Management dated 8/22/2023 documents: . To ensure the safety of [Facility name] patients, visitors, and employees by defining the processes by which [Facility name] manages the safety of its building water systems, the plan is inclusive of all requirements associated with industry best practice for safely managing portable and utility water systems. Verification of plan execution and environmental sampling validation will be reported though the water management team recurring meetings. EXECUTION of HACCP (Hazard Analysis and Critical Control Points) WATER MANAGEMNT PROGRAM PRINCIPALS . 2- Identify critical control points (CCP). 3- Establish control limits for each CCP. 4- Establish a monitoring plan for each CCP. 5- Establish corrective actions for each CCP. Processing step: . 2. Hot water tank and /or hot water storage, mixing valve: Potential growth of microorganisms in heating systems. HIGH RISK: There is potential for microbial growth at the heating step. This is reduced at temperatures > (greater than) 124 degrees Fahrenheit. Adjust temperature to provide further microbiological control 4. Hot water distribution-manual and electronic faucets/showers and hoses / water hammer arrestors / pipes, valves, and fittings / aerators / faucet flow restrictors: Microbial growth in the potable water distribution system which could be transmitted by sink faucets and showers. HIGH RISK: The hot water system is extensive and complex. There is potential for 15-20 degree Fahrenheit temperature drops after the hot water supply leaves the hot water heaters which can bring the water into prime temperature ranges for microbial growth (105 - 112 degree Fahrenheit). Along with these favorable temperatures for microbial growth, there is potential for free chlorine residuals to dissipate and leave the hot water system with low level of control. The factors for growth in conjunction with the potential for water to be aerosolized present a high risk at this processing step. On 8/19/2024, at 9:21 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated when NHA-A came back from vacation on 8/12/2024 the facility did not have hot water. NHA-A contacted an outside company via email on 8/13/2024 because the outside company was not coming to the facility per phone request. NHA-A stated the outside company was not aware the facility was without hot water and the outside company came to the facility on [DATE] and 8/15/2024. NHA-A stated the facility had hot water again the morning of 8/15/2024. Surveyor asked NHA-A what was control measures were implemented once the facility was without hot water for staff and residents. NHA-A stated residents got sponge baths with body wipes or water from the faucets, residents were able to choose which they preferred. NHA-A stated that heating up the water in the microwave was encouraged, but not always feasible. Surveyor asked NHA-A when the loss of hot water was reported. NHA-A stated NHA-A was on vacation, but it was reported to maintenance on 8/10/2024. Surveyor requested to review the facility's water management plan, and maintenance logs for water monitoring/testing. On 8/19/2024, at 12:00 PM, NHA-A stated the facility's boiler system gets inspected every three years and the last it was inspected was 6/28/2023 and due next around 7/31/2025. NHA-A stated on 8/5/2024 maintenance was alerted by staff regarding a smell of gas in the facility. [gas company] was called out and the gas was turned off by [gas company] for inspection. NHA-A stated it was noted there was not a concern of a gas leak but a venting issue in the pipes due to corrosion. NHA-A state the [gas company] turned the facility's gas back on and no further concerns were noted. Surveyor asked how often water temperatures are checked. NHA-A stated NHA-A believed water temps are checked weekly and random rooms are tested . Surveyor reviewed the logbook for water temperatures and noted water temperatures were last tested on [DATE] and not again until 8/16/2024, before the loss of hot water and not until after the hot water was restored. Surveyor reviewed the logs for temperature monitoring of the water heaters (5 water heater tanks, 3 tanks for the facility and 2 for the kitchen and laundry) and noted temperatures were not documented for 8/11/2024 - 8/14/2024. The last recorded temperature for the facility's water heaters (all 5 water heaters) was 80 degrees Fahrenheit on 8/10/2024. Surveyor noted that there was no additional testing done during the timeframe the hot water was noted to be off. On 8/19/2024, at 1:12 PM, Surveyor interviewed Maintenance Director (MD)-C who stated MD-C was not made aware that the facility did not have hot water until 8/10/2024. MD-C stated MD-C monitors and documents temperatures for the water heaters everyday Monday through Friday, and tests water temperatures in random rooms biweekly so water temperatures would not have been due during the time the hot water was not working. Surveyor asked MD-C if any monitoring was being done for the hot water during the time the hot water was off. MD-C stated MD-C was not sure why temperatures would have to be monitored because the hot water was not working, it was going to be cold. MD-C stated there was not really anything the facility could do, just call [outside company] company, the facility does not have back up water heaters. MD-C stated no additional temperatures were taken, the water would have been around 70 degrees Fahrenheit. Surveyor notes the Facility did not increase control measures such as increased flushing of the water system when they were made aware the hot water heaters were not maintaining temperatures. Surveyor requested a timeline of when the [outside company] first came to the facility for the hot water concern. On 8/19/2024, at 3:00 PM, NHA-A stated the following timeline: - On 8/5/2024, there was smell of potential gas in the facility, [gas company] came out to assess. Noted no gas leak concern, but concern noted in venting. - On 8/9/2024, [outside company] came to assess and gave a quote to fix the venting/pipe issues that were found by [gas company]. NHA-A stated at that time, there were no concerns regarding issues with the hot water and temperature logs documented all temperatures were within range. - On 8/10/2024, MD-C was notified the facility did not have hot water. - On 8/12/2024, [outside company] was contact via phone and message left about facility concern with having no hot water. - On 8/13/2024, [outside company] contacted via e-mail by NHA-A regarding the immediate need of [outside company] needing to go to facility and assess due to no hot water in the facility. [Outside company] notified NHA-A they were not aware of the immediacy and would be out to facility on 8/14/2024. - On 8/14/2024, [outside company] at facility to assess and noted will need to work on water system 8/15/2024 as well due to issue being more extensive. - On 8/15/2024 on the AM, the facility had hot water again. On 8/19/2024, at 3:30 PM, Surveyor shared concerns with NHA- A that the [outside company] was not contact until 8/12/2024 (2 days after the facility was without hot water) and [outside company] did not get into the building to assess the concern until 8/14/2024 (4 days later) and hot water was not restored until 8/15/24. Surveyor also shared the concern the facility did not identify the increased risk for waterborne pathogens due to the drop in water temperatures which can be favorable for microbial growth, or the potential for chlorine residuals to dissipate and leave the hot water system with low level of risk control.

Based on observation, interview, and record review, the facility did not ensure sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This deficient practice has the potential to affect all 66 residents residing in the facility at the time of this survey. *On 7/23/24 at 11:07 AM, Surveyors conducted the resident council interview task. R58 shared with surveyors that night shift at the facility is like a ghost town due to lack of staff. R58 shared that they have had their call light unanswered for almost an hour at times. R58 told Surveyor that they have been afraid at times that they would be incontinent of bladder due to waiting for toileting assistance but were able to hold their bladder. The facility triggered for low weekend staffing for Fiscal Year Quarter 2 (January 1st 2024-March 31st 2024.) Findings include: On 7/23/24 at 8:30 AM, Surveyor reviewed facility's CASPER PBJ (Payroll Based Journal) report. Surveyor noted the facility triggered for low weekend staffing for Fiscal Year Quarter 2 (January 1st 2024-March 31st 2024.) Surveyor requested staffing schedules for Fiscal Year Quarter 2 and the previous 30 days. On 7/23/24 at 12:40 PM, Surveyor reviewed the Facility Assessment Tool with a initiation date of 8/2022 and review date of 2/21/24. The facility's staffing plan indicates the following: Licensed Nurses providing direct care .Total Number Needed or Average or Range: Licensed Staff: Days & PMs - 1:20-24, NOCs (Night Shift) - 1:35-45 .Certified Nurse Aides .Total Number Needed or Average or Range: Days and PMs - 1:12-18 residents, NOCs 1:15-22 residents. Surveyor reviewed Fiscal Year Quarter 2 staffing schedules. On 1/19/24, there was 1 Certified Nurse Aide scheduled on NOC shift with a facility census of 64. On 1/22/24, there was no Certified Nurse Aide scheduled on NOC shift with a facility census of 64. On 1/27/24, there was 1 Certified Nurse Aide scheduled and 1 licensed nurse on NOC shift with a facility census of 64. On 2/7/24, there was 1 licensed nurse scheduled on NOC shift with a facility census of 64. On 2/10/24, there was 1 licensed nurse scheduled on NOC shift with a facility census of 60. On 2/14/24, there was 1 licensed nurse scheduled on NOC shift with a facility census of 57. On 3/20/24, there was 1 Certified Nurse Aide scheduled on NOC shift with a facility census of 63. On 3/9/24, there was 1 Certified Nurse Aide scheduled on NOC shift with a facility census of 63. On 3/20/24, there was 1 Certified Nurse Aide and 1 licensed nurse scheduled on NOC shift with a facility census of 63. On 3/24/24, there was 1 Certified Nurse Aide and 1 licensed nurse scheduled on NOC shift with a facility census of 63. On 3/25/24, there was 1 licensed nurse scheduled on NOC shift with a facility census of 63. On 3/28/24, there was 1 licensed nurse scheduled on NOC shift with a facility census of 63. Surveyor reviewed staffing schedules for the previous 30 days. On 6/25/24, there was 1 Certified Nurse Aide scheduled on NOC shift with a facility census of 63. On 6/28/24, there was 1 Certified Nurse Aide scheduled on NOC shift with a facility census of 63. On 6/30/24, there was 1 Certified Nurse Aide and 1 licensed nurse scheduled on NOC shift with a facility census of 63. On 7/3/24, there was 1 Certified Nurse Aide and 1 licensed nurse scheduled on NOC shift with a facility census of 63. On 7/5/24, there was 1 Certified Nurse Aide and 1 licensed nurse scheduled on NOC shift with a facility census of 63. On 7/8/24, there was 1 Certified Nurse Aide scheduled on NOC shift with a facility census of 63. On 7/9/24, there was 1 Certified Nurse Aide scheduled on NOC shift with a facility census of 63. On 7/11/24, there was 1 Certified Nurse Aide scheduled on NOC shift with a facility census of 63. On 7/24/24 at 9:05 AM, Surveyor conducted interview with Scheduler-I. Surveyor asked Scheduler-I how staffing levels are determined. Scheduler-I told Surveyor they staff the facility by census. Surveyor asked Scheduler-I if facility utilizes agency staff to address short staffing. Scheduler-I told Surveyor the facility does not utilize agency staff. Surveyor asked Scheduler-I if they are aware of the staffing shortages occurring on NOC shift based off of the facility assessment tool. Scheduler-I responded they try to over staff on NOCs to anticipate call ins but sometimes it is challenging to address shortages. On 7/24/24 at 12:50 PM, Surveyor met with NHA (Nursing Home Administrator)-A, Corp Consultant-J, and Corp Consultant-K. Surveyor shared concern that facility had triggered for low weekend staffing during Fiscal Year Quarter 2. Surveyor shared that after reviewing staffing schedules it was noted that multiple NOC shifts did not have adequate staffing for Certified Nurse Aides and licensed nurse staff in accordance with the facility assessment tool's proposed staffing ratios. The facility did not provide any further information regarding Surveyor's staffing concern at this time.

Based on observation and interview the facility did not ensure residents had a safe, clean, comfortable and homelike environment for 1 of 2 shower rooms observed in the facility. On 7/23/24, at 10:55 AM, Surveyor observed the 2nd floor shower room had yellow tape across the door and a sign that read out of order. All facility residents that required showers had to use the 3rd floor shower room which was not maintained in a hygienic manner. Findings include: The facility did not have a policy and procedure specific to cleaning of shower rooms. Surveyor was provided a sheet of paper titled Daily Room Cleaning checklist which addressed cleaning of resident rooms only. On 7/23/24, at 10:55 AM, Surveyor observed the 2nd floor shower room had yellow tape across the door and a sign that read out of order. On 7/23/24, at 11:00 AM, Certified Nursing Assistant (CNA)-H showed Surveyor the shower room on the 3rd floor. CNA-H confirmed the 3rd floor shower room is working and staff is using it for residents' showers because the 2nd floor shower room is broken. Surveyor observed the following in the 3rd floor shower room: The sink contained 3 dirty, gray-colored wet washcloths, 4 empty skin/hair cleanser bottles, a bottle of Dove micro moisture and the shower head was resting in the sink with the hose extending to the floor. There was a pink basin which contained approximately an inch of water under the sink with an empty bottle of moisture lotion on the floor. Surveyor observed the shower pipe extending out of the wall was dripping constant water with standing water on the floor that extended approximately 5 feet in length from the sink to shower drain. The drain was covered with dirt, debris and hair. The entire floor of the shower area was dirty with a black substance and there was dirt and hair in the shower drain under the shower chair. Surveyor observed a brown, slimy film covering 4 tiles along the base of the wall under the shower. Surveyor observed the shower room appeared to be used for storage as well. The room contained a hoyer lift, 2 shower chairs, 4 bedside commodes, a broda chair, a wheelchair, 2 mechanical lift chargers (1 on the floor, 1 on a shower chair) and a bed bolster labeled Integra equipment. Inside the tub was a bedside commode bucket which was dirty on the inside with brown and yellow stains resembling stool and urine. On 7/23/24, at 11:13 AM, Registered Nurse (RN)-E accompanied Surveyor to the 3rd floor shower room. Surveyor asked RN-E if the room is used for residents' showers. RN-E stated Yes, the other one is broken, so we're using this one. Upon entering the shower room, RN-E stated Oh wow, I didn't realize it was like this. Surveyor asked if the area is used for storage. RN-E stated It looks like it. Surveyor asked if staff cleans equipment before storing it in the shower room. RN-E stated Yes. I think they're just keeping stuff in here because there's nowhere else to go with it. Surveyor showed RN-E the dirty bedside commode inside the tub. RN-E reported she didn't know how long it had been there, as the tub has not been used for years. Surveyor showed RN-E the other concerns in the shower room as observed above. RN-E stated Wow. I don't think I'm the person to talk to, maybe you should talk to maintenance. On 7/24/24, at 9:33 AM, Maintenance-D accompanied Surveyor to the 3rd floor shower room. Surveyor noted the sink faucet was now dripping water. The same empty bottles and dirty washcloths were in the sink. Surveyor observed several wet towels and a wet incontinence bed bad on the floor and the pipe for the shower was no longer dripping water. Maintenance-D reported he saw the shower room yesterday with the Life Safety Surveyor and discussed the leak which is believed to be from pipes involving the sink. Maintenance-D reported he noticed water dripping from the shower pipe and that someone forgot to turn the water off all the way. Maintenance-D reported he saw the shower head in the sink and that it must have broken off in the morning. Maintenance-D confirmed he was not notified of the broken shower head, but has ordered a new one. Maintenance-D reported housekeeping is responsible for cleaning the shower room. Surveyor showed Maintenance-D all the above observations and concerns, including (but not limited to) the standing water, dirty wet linen, floor drain containing dirt and hair, and the brown slimy film covering the tile. Maintenance-D stated It doesn't look like mold. Maintenance-D wiped the area with his finger and stated I think it's scum, I'll have housekeeping come clean this room. On 7/24/24, at 10:05 AM, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the above concerns regarding the dirty shower room. No additional information was provided.

Based on observation, interview, and record review the facility did not ensure that residents who enter the facility with an indwelling catheter are assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary and residents received appropriate treatment and services to restore continence to the extent possible for 1 of 2 (R55) residents reviewed for catheters. R55 had Urologist orders that were not followed. Findings include: R55 admitted to the facility on [DATE] and has diagnoses that include Transverse Myelitis in Demyelinating Disease of Central Nervous System, Neuromuscular Dysfunction of Bladder and Paraplegia. R55's Admission Minimum Data Set (MDS) dated [DATE] documents: Indwelling catheter (including suprapubic catheter and nephrostomy tube) - Yes. The Care Area Assessment (CAA) worksheet documents (in part) . Triggered Indwelling Catheter: Current Dx (diagnosis) of acute transverse myelitis in demyelinating disease, pressure ulcer of sacral region, neuromuscular dysfunction of bladder, paraplegia, need for assistance with personal care. Does have an indwelling catheter in place. His catheter is managed by staff. Will continue to monitor. Continue with POC (Plan of Care). R55's Care Plan Focus Area revised 5/1/2024 documents: The resident has Urinary Catheter. Neurogenic bladder. Goal: The resident will be/remain free of complications from catheter-related use through review date. Interventions include: The resident has 16 Fr (French) 10 cc (cubic centimeter). Position catheter bag and tubing below the level of the bladder and away from entrance room door. Monitor for s/sx (signs/symptoms) of discomfort on urination and frequency. Monitor s/sx of catheter complications i.e. (example) leaking, obstruction, etc (etcetera). Monitor/document for pain/discomfort due to catheter. On 7/22/24, at 10:20 AM, Surveyor spoke with R55 who reported he has had a catheter since he was hospitalized and thinks they're going to take it out soon. Surveyor observed a catheter bag hanging on the right side of the bed. The hospital Physician note dated 4/17/24 documents: Neurogenic bladder. AKI (Acute Kidney Injury) likely multifactorial w (with)/ATN component and obstruction in setting of neurogenic bladder - improving. Pt (patient) on Bethanechol PTA (prior to admission). Discussed w/urology, OK with discontinuing. Patient will discharge with Foley. Foley placed by urology, will continue Foley throughout admission and will schedule urology follow up. R55's Urology consult dated 5/21/24 documents: Pt unable to empty his bladder. Foley catheter replaced. FU (follow up) w/(named doctor) 5/30/24. Foley catheter change 4 weeks. R55's Urology consult dated 5/30/24 documents: Neurogenic bladder. Will continue Foley for now. Will start Vesicare 10 mg (milligrams) q (every) HS (hour of sleep). Return 3 weeks for cath change and renal US (ultrasound). If all is well res (resident) can start by cycling his bladder by capping/uncapping Foley. Once his bladder can hold 250-300 of urine he may begin CIC (clean intermittent catheterization). R55's Physician order dated 6/3/24 documents: Every day and every shift every 4 hours empty Foley bag and clamp Foley until pt feels pressure and can no longer handle Foley being clamped. Unclamp and measure output. Goal is to have pt able to hold 250-300 cc in bladder every 4 hours for Foley. R55's Urology consult dated 6/28/24 documents: (R55) is hoping to get the catheter out and start CIC. He understands his bladder capacity and compliance will need to improve significantly. If not, he would consider a SPT (Suprapubic catheter). Plan - Continue Vesicare 10 mg. Cycle bladder BID (two times a day). If spasms are better and hydro has resolved can consider cycling his bladder by capping/uncapping the SPT. If he can safely store urine in his bladder for about 3 hours we can consider Foley removal and start CIC. Surveyor noted this order was not transcribed. R55's July, 2024 Medication Administration Record (MAR) documented the 6/3/24 Physician's order every day and every shift every 4 hours empty Foley bag and clamp Foley until pt feels pressure and can no longer handle Foley being clamped. Unclamp and measure output. Goal is to have pt able to hold 250-300 cc in bladder every 4 hours for Foley with times starting at midnight and every 4 hours thereafter - which were signed out as having been completed. Surveyor noted there was no documentation of urine output in on the MAR or in R55's progress notes. Surveyor noted there was no documentation in the progress notes indicating the outcome of the ordered procedure every 4 hours. There was no documentation staff performed the ordered procedure or if it is effective (ie: feeling pressure/can no longer handle Foley being clamped) or if the resident is meeting goal of holding urine in his bladder. Surveyor reviewed of Point of Care (POC) documentation of fluid output for the past 30 days documented: Only 1 entry of output daily 6/25-6/28, 7/1, 7/5, 7/7, 7/8, 7/11, 7/13, 7/16, 7/18, 7/19 and 7/20/24. There was no entry of urine output on 6/29, 6/30, 7/2-7/4, 7/6, 7/9, 7/10, 7/12, 7/14 and 7/17/24. There were 2 entries of urine output on 7/15/24. Surveyor noted the Physician's order was to clamp the Foley every 4 hours until the resident can no longer handle Foley being clamped, unclamp and measure output. The POC documentation of urine output reveals the order was not followed as evidenced by only daily or no urine output documented. The Nurse Practitioner progress noted dated 7/2/24 documents: Abdominal ultrasound unremarkable besides moderate gas noted. On 7/23/24, at 9:48 AM, Surveyor spoke with the Unit Manager, Licensed Practical Nurse (LPN)-F. Surveyor advised LPN-F of the Urology consult and Physician's order dated 6/3/24 regarding clamping of catheter every 4 hours. Surveyor asked how staff is assessing or monitoring if this procedure is effective or working, as there is no documentation. LPN-F reported she was not aware of the order for clamping of the catheter, so she is not sure about the results. Surveyor advised the order was obtained on 6/3/24 and is signed out on the MAR as having been completed every 4 hours. Surveyor advised there is no documentation of R55's tolerance, reaction or if he is meeting the goal to hold 250-300 cc in bladder. LPN-F stated I did not even know this was being done. Let me look into it. LPN-F reported R55's next urology appointment is 8/5/24. On 7/23/24, at 10:03 AM, Surveyor spoke with LPN-G and asked what catheter care she provides for R55. LPN-G stated We clean it and flush it with acetic acid liquid. We usually empty his bag twice a shift because it fills up so fast, we don't want urine backing up into the tubing or his bladder. Surveyor asked if she does anything else specific with his catheter like clamping it throughout the day. LPN-G stated No, we just empty it. Surveyor read the Physicians' order on the MAR aloud regarding every 4 hours clamping the Foley until pt feels pressure and can no longer handle, unclamping and measuring output, with the goal to have pt able to hold 250-300 cc in his bladder. LPN-G stated I don't remember ever seeing that. Surveyor asked, so you've never done this? LPN-G stated No, I don't remember seeing that. On 7/23/24, at 2:40 PM, MDS-C and Director of Nursing (DON)-B asked to provide additional information to Surveyor. MDC-C read the 5/30/24 urologist documentation if all is well res can start by cycling his bladder by capping/uncapping Foley. MDS-C reported staff is not doing it because the resident is still having spasms. Surveyor advised the Physician's order on 6/3/24 does not include instructions to not perform the procedure if the resident is having spasms and there is no documentation staff is not performing the ordered procedure because resident is having spasms. MDS-C reported the 6/3/24 order was the clarification order. Surveyor advised again that the order does not indicate the procedure is not to be done if the resident is having spasms. In addition, staff is signing it out as having been completed every 4 hours. There is no documentation the procedure was attempted and/or not completed due to spasms and no documentation of R55's reaction, tolerance or effectiveness of the procedure. Surveyor advised nurses are signing the order as completed, although LPN-G interview reported she was not even aware of the order. MDS-C stated That's because they're not doing it because he is still having spasms. Surveyor advised staff is signing the procedure as completed and there is no documentation anywhere that it is not being completed due to spasms. In addition, there is no documentation the urologist was notified the procedure is not being done due to spasms. On 7/24/24, at 11:57 AM, Surveyor advised DON-B of the above concern. DON-B reported she understood and no additional information was provided.

Based on interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act by reporting 3 of 5 allegations of abuse (slap in face, kicked, and slapped) to law enforcement and immediately reporting 5 of 5 allegations of abuse to the State Survey Agency for 1 of 5 (R1) residents reviewed for abuse. * On 10/8/2023, R1 and R1's family member made an allegation of R1 being slapped on the face. Registered Nurse (RN-C) did not immediately notify the Administrator of this allegation of abuse. This allegation of abuse was not reported to the State Survey Agency until 10/9/2023. This allegation of abuse should have been reported to the State Survey Agency no later than 2 hours after the allegation was made. Law Enforcement was not contacted immediately after allegation of R1 being slapped. * On 10/10/2023, an allegation was made that R1 was kicked because of a bruise on R1's leg and slapped on 9/21/2023. The allegations of abuse were not reported to the State Survey Agency no later than 2 hours after the allegation was made. Law Enforcement was not contacted immediately after allegations of R1 being slapped on 9/21/2023 or kicked on 10/10/2023. * On 10/11/2023, an allegation was made that R1 was beat up 11 out of 15 days at the facility and made an allegation of R1 potentially being raped. The allegations of abuse were not reported no later than 2 hours after the allegation was made to the State Survey Agency. Law enforcement was notified of these allegations but chose not to come to the facility as there was no accused perpetrator identified in regards to these allegations of abuse. * On 10/12/2023, Law Enforcement arrived at the facility due to an allegation made by the hospital of R1 arriving to the emergency room from the facility with bruising on R1's face, chest, and leg. The facility did not report the allegation of abuse involving injuries of unknown origin immediately to the State Survey Agency. Findings include: The facility policy entitled Abuse Policy, with no implementation date, states: The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, or mistreatment of residents. This facility prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. This will be done by: . - Orienting new employees . on how to recognize and report occurrences of abuse, neglect, exploitation, and misappropriation of property. - Identifying occurrences and patterns of potential mistreatment, - Immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property. - Filing accurate and timely investigative reports. II. Orientations and Training of Employees During orientation of new employees, the facility will cover at least the following topics: . - What constitutes abuse, neglect, exploitation, and misappropriation of resident property. - Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property. IV. Internal Reporting Requirements and Identification of Allegations Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. If there is a reasonable suspicion that a crime has been committed that results in serious bodily harm, a report shall be made to local law enforcement and Division of Quality Assurance (DQA) immediately. R1 was admitted to the facility on [DATE] and has diagnoses that include Dementia with other behavioral disturbance, muscle weakness, anxiety disorder, Alzheimer's disease, and cognitive communication deficit. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 3 and the facility assessed R1 as needing extensive assist with 1 person for bed mobility, transferring, dressing, toileting, hygiene, and bathing. R1 has an indwelling catheter and was always incontinent of bowel. R1 has behaviors of wandering and had a one to one during the day, evening, and when awake and staff did fifteen minute checks on R1 during the night when in room sleeping. Surveyor reviewed the facility self-report. On 10/8/2023, R1's family notified Certified Nursing Assistant (CNA)-E that R1 alleged R1 was slapped on the cheek. On 10/18/2023 at 10:04 AM, Surveyor interviewed CNA-E who stated CNA-E was walking into the facility to start CNA-E's shift and R1's family member was also walking into the facility and asked CNA-E who to report abuse of R1 to. CNA-E replied to R1's family member to report to the nurse, fill out a form, or let the administrator know. CNA-E stated R1's family member stated R1 mentioned someone with a pony tail slapped R1 and that it could be the other CNA on duty which was CNA-D. CNA-E stated she told CNA-D to stay away from the family and told the nurse on duty which was Registered Nurse (RN)-C. On 10/18/2023 at 10:30 AM, Surveyor interviewed CNA-D who stated CNA-D did not know about any accusations of R1 being slapped until CNA-E told CNA-D to stay away from R1's family. CNA-D stated CNA-D did not have R1 on CNA-D's task load for that day because R1 is a one to one and is assigned a CNA specifically to R1. CNA-D stated CNA-D had no contact with R1 or R1's family members during CNA-D's shift on 10/8/2023. CNA-D mentioned CNA-D reported the allegation and situation to the nurse on duty. CNA-D could not recall who the nurse on duty was. On 10/18/2023 at 11:32 AM, Surveyor interviewed RN-C who stated R1's family was at the facility to celebrate a birthday. RN-C stated CNA-E reported that family stated someone was beating up their grandmother. RN-C stated RN-C told CNA-E to stay away from family. Surveyor asked RN-C if RN-C reported the allegation of abuse to anyone, RN-C replied no. Surveyor asked RN-C what the policy was for reporting abuse? RN-C replied that the family appeared drunk, so what the policy for drunken people was, I don't know. According to the facility self-report on 10/9/2023, Nursing Home Administrator (NHA)-A was made aware of R1's allegation of being slapped on the cheek from RN-K and the facility initiated an investigation and submitted a report to Division of Quality Assurance (DQA.) On 10/16/2023 at 12:46 PM, Surveyor interviewed RN-K who stated RN-K was notified by the night nurse that R1's family caused issues the day prior. RN-K stated when RN-K saw R1 in the private room R1 stated R1 was slapped on the cheek the day prior. RN-K stated RN-K performed a skin assessment and reported the accusation to NHA-A and Director of Nursing (DON)-B. RN-K stated RN-K was not told about any other accusations or talk with R1's family. Surveyor noted that law enforcement was not contacted by the facility on 10/8/2023 or 10/9/2023 with R1's allegations that R1 was slapped on the cheek. According to the facility self-report on 10/10/2023 the Social Service Director (SSD)-H spoke with R1's family and another allegation of R1 being slapped on R1's day of admission (9/21/2023) and being kicked on 10/10/2023 was made because R1 had a bruise on R1's leg/injury of unknown origin. Surveyor noted that the facility did not file a self-report or add an addendum to the report already submitted with the new abuse allegations on R1 from R1's family member. Surveyor also noted law enforcement was not contacted about the new allegations of R1 being slapped on 9/21/2023 and a bruise/injury of unknown origin on 10/10/2023. According to the facility self-report on 10/11/2023 SSD-H spoke with R1's family member and R1's family member made an allegation that R1 has been beat up 11 out of 15 days of R1 being in the facility and that R1 had said something about rape but the family member stated they did not believe this (allegation of rape) as it could have been someone doing peri-care. Surveyor noted that the facility did not file a self-report or add an addendum to the report already submitted with the new abuse allegation from R1's family member. Surveyor noted that law enforcement was not called until 10/11/2023 which was 3 days after the initial allegation of abuse on 10/8/2023 from R1. On 10/11/2023, the facility contacted the police regarding the allegation of R1 possibly being raped however the police did not come to the facility as there was no accused perpetrator. On 10/12/2023, R1 was to be discharged back to R1's home. R1 developed abdominal pain and low blood pressure while in the facility. The nurse practitioner wrote an order to be sent to the emergency room via ambulance. R1's family was present and agreeable to R1 being transferred. On 10/12/2023 around 10:00 PM, Law Enforcement showed up at the facility due to the hospital reporting a potential abuse to R1 with bruising to the right eye, sternum, and R1's right leg upon arrival to the hospital. Surveyor noted that the facility did not file a self-report with the State Agency on 10/12/2023 with the new allegation of abuse involving injuries of unknown origin for R1's bruised right eye, sternum, and right leg. On 10/18/2023 at 12:46 PM, Surveyor interviewed NHA-A and DON-B. Surveyor asked NHA-A when NHA-A found out about the initial allegation of R1 being slapped on the cheek? NHA-A replied NHA-A found out on 10/9/2023, reported right away, and started the investigation. NHA-A said expectations of staff would have been to notify NHA-A right away on 10/8/2023 and submit a self-report on 10/8/2023. Surveyor asked NHA-A when law enforcement was contacted for the abuse allegations? NHA-A replied law enforcement was not notified until 10/11/2023 because the facility was not able to get information from R1's family right away. Surveyor noted regulatory requirements indicate law enforcement should be called when there is any reasonable suspicion of a crime involving a resident. Surveyor asked NHA-A why the allegations made by R1's family regarding the slap to R1's face on 9/21/2023, bruise to R1's right leg on 10/10/2023, allegation made on 10/11/2023 that R1 has been beat up 11 out of 15 days while in the facility, R1's allegation of potential rape, and allegation of abuse made from the hospital on 10/12/2023 were not reported to the state agency as separate allegations of abuse and/or addendums to the first abuse allegation, and why allegations were not always reported to the police as reasonable suspicion of a crime? NHA-A replied she (NHA-A) thought she could put all the allegations into one report (within their initial investigation) since the allegations were all made within a five day investigation window with the initial allegation made on 10/8/23. Surveyor informed NHA-A and DON-B that new facility self-reports should be filed with each abuse allegation or at the minimum an addendum added to the open investigation so each allegation can be investigated separately. Surveyor expressed concerns the abuse allegation made by R1 on 10/8/2023 was not immediately reported to the State Survey Agency, that each abuse allegation made by R1's family during investigation was not reported to the State Survey Agency, and that law enforcement was not contacted until 10/11/2023, three days after the initial allegation of abuse made from 10/8/2023. No further information was provided at this time.

Based on staff interviews and record review the facility did not ensure allegations involving abuse were thoroughly investigated for 1 (R1) or 5 residents reviewed for abuse. On 10/12/2023 Law Enforcement arrived at the facility due to the hospital reporting potential abuse to R1 upon arrival to the emergency room with bruising to R1's eye, sternum, and leg. The abuse allegation was not in itself investigated by the facility but instead was mentioned within an investigation pertaining to a different allegation made on 10/8/23 regarding R1 being slapped. There was no staff interviews pertaining to the R1 having been identified on 10/12/23 with bruising of unknown orgin to the right eye, sternum, and R leg upon arrival to the hospital. Findings include: The facility policy, entitled Abuse Policy, with no implementation date, states: The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, or mistreatment of residents. This facility prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. This will be done by: . -Implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences promptly and aggressively. VI. Internal Investigation 1. All incidents will be documented whether or not abuse . was alleged or suspected. 2. Any incident or allegation involving abuse . will result in a thorough and concise investigation. 4. Investigation Procedures: the appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. If there is a reasonable suspicion that a crime has been committed that results in serious bodily harm, a report shall be made to . the Division of Quality Assurance (DQA) immediately. R1 was admitted to the facility on [DATE] and has diagnoses that include Dementia with other behavioral disturbance, muscle weakness, anxiety disorder, Alzheimer's disease, and cognitive communication deficit. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 3 and the facility assessed R1 needing extensive assist with 1 person for bed mobility, transferring, dressing, toileting, hygiene, and bathing. R1 has an indwelling catheter and was always incontinent of bowel. R1 has behaviors of wandering and had a one to one during the day, evening, and when awake and staff did fifteen minute checks on R1 during the night when in room sleeping. On 10/12/2023 R1 was to be discharged back to R1's home. R1 developed abdominal pain and low blood pressure while in the facility. The nurse practitioner wrote an order for R1 to be sent to the emergency room via ambulance. R1's family was present and agreeable to R1 being transferred. On 10/12/2023 around 10:00 PM Law Enforcement showed up at the facility due to the hospital reporting potential abuse to R1 with bruising to the right eye, sternum, and R leg upon arrival to the hospital. Surveyor noted that the facility did not file a self-report on 10/12/2023 with the new allegation of abuse involving injuries of unknown origin for R1's bruised right eye, sternum, and right leg. On 10/18/2023 at 12:46 PM Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. Surveyor asked NHA-A why a report was not filed with the State Survey Agency when an allegation of potential abuse to [R1] was made by the hospital on 10/12/2023. NHA-A replied NHA-A thought NHA-A could include the new allegation into the investigation that was already open for [R1]. Surveyor informed NHA-A and DON-B that a new report should have been filed and a new investigation conducted due to the new allegation made by the hospital on behalf of [R1] regarding potential abuse from the facility upon [R1's] arrival to the hospital. Surveyor expressed concern that the allegation of abuse from the hospital involving [R1] was not fully investigated when brought to the facility's attention from law enforcement on 10/12/2023. NHA-A and DON-B stated they have reached out to the law enforcement, ambulance service, and adult protective services to get more information regarding the accusations made regarding R1's bruising to R1's face, sternum, and leg, but have not received call backs from either entity yet. No further information was provided at this time.

Based on interview, record review, and facility policy review, the facility failed to ensure timely reporting of an allegation of verbal abuse to facility administration related to one (Resident (R) 15) of 17 residents reviewed in the sample. Findings include: Review of the facility's undated policy titled, Abuse Policy indicated, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents; and Internal Reporting Requirements: Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator, immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. In the absence of the administrator, reporting can be made to an individual who has been designated to act in the administrator's absence. Review of R15's Admission Record, dated 09/21/23 and found in the EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including history of right knee replacement. Review of R15's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/07/23 indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident had intact cognition. Review of R15's Progress Notes, indicated no progress notes were entered for the resident between 08/03/23 and 08/07/23. The facility's reportable occurrences/investigation documentation related to R15 was requested by the survey team. The facility's Verification of Investigation Report, dated 08/07/23 and provided directly to the survey team, indicated, On Monday Aug [August] 7, [R15] reported to social services about an interaction that took place on the evening of Saturday [DATE]th with [Registered Nurse (RN)1]. Social Services notified DON [Director of Nursing] and NHA [Nursing Home Administrator]. [R15] stated she had put her call light on for a pain pill, a staff member stated they would inform the nurse. [R15] stated she noticed [RN1] walking back and forth down the hall so she called his name. [RN1] responded with you can walk. I'm not bringing you your meds [medications]. [R15] states an hour passed and still no medication, [R15] admits becoming angry and yelling down the hall calling [RN1] a prick. [R15] states that [RN1] was very rude to her calling her lazy white trash, an allegation that [RN1] denies. Pain medication was provided by another staff member and not (sic) further issues with medication. Further review of the investigation documentation revealed interviews with two staff members, Certified Nursing Assistant [CNA2] and Medication Aide/Certified Nursing Assistant [CNA1] were aware of the reported allegation of potential abuse and did not report the potential abuse to the Administrator. [CNA2] Witness Statement dated 08/07/23 indicated, I went in to her [R15's] room to get laundry, I saw that she was upset and her roommate was comforting her. I asked her what was wrong. She stated that her and nurse [RN1] got into it. I told her I was sorry and to let me know if she needed anything and then I left the room. When asked if she reported the incident to anyone, [CNA2] indicated, Yes I told [RN1] she was upset, and saying they had got into it. CNA1's Witness Statement dated 08/07/23 indicated, [R15] was upset with [RN1] because he did not bring her PRN [as needed] pain pill right away when her alarm went off. She always turns on her alarm for the next time her PRN is due. I heard [RN1] tell her she needed to wait he was in the middle of something but she could come to the desk and meet him there for it. After a while I heard her coming down the hall yelling and asking me where that prick was. She came up to the desk calling [RN1] a prick and demanding her pain pill. She attempted to get behind the desk kind of blocking [RN1] from getting out and I have (sic) to step in between them. I took [R15] back to her room and got the pill for her soon after. I made sure I brought her pain pills for the rest of the night and the time she want to keep the peace (sic). There was no indication on the statement that [CNA1] reported the incident to the Administrator. The survey team was not able to reach CNA2 or CNA1 for interview. During an interview conducted with the Administrator on 09/21/23 at 9:30 AM, she confirmed allegations of abuse were to be reported to her. She confirmed the allegation of potential abuse had not been reported to her by CNA2 or CNA1 and stated her expectation was all allegation of potential abuse be reported to her immediately so a timely investigation could be initiated.

Based on observation and interviews the facility did not ensure each resident received food that is palatable and at an appetizing temperature for 4 of 4 (R28, R36, R48 and R53) R48 reported they receive cold eggs with breakfast. Resident Council participants (R28, R36 and R53) reported room meal trays are served cold. Findings Include: R48 admitted to the facility on [DATE] and has a Brief Interview for Mental Status (dated 3/27/23) of 13, indicating no cognitive impairment. On 4/10/23, at 9:43 AM, R48 reported she eats breakfast in her room and sometimes eats in the dining room for other meals. R48 reported she eats eggs every day and they are always cold. Surveyor asked if staff will reheat food. R48 stated: I suppose so, but they have a lot of people, it would take too long. On 4/12/23 at 11:00 AM during the resident council meeting with facility residents, R28, R36 and R53 reported food is cold, concern is realted to meals being delivered to floor/units and then it cools down before delivered. The Facility Policy and Procedure titled Food Temperatures which was not dated, documents (in part) . Policy: The temperatures of all food items will be taken and properly recorded prior to service of each meal. 4. Foods should be transported as quickly as possible to maintain temperatures for delivery and service. If food transportation time is excessive, food should be transported using a method that maintains temperatures (i.e. (for example) hot/cold carts, pellet systems, insulated plate bases and domes, etc. (etcetera). 6. Foods sent to the units for distribution (such as meals, snacks, nourishments, oral supplements) will be transported and delivered to unit storage areas to maintain temperatures at or below 41 degrees F (Fahrenheit) for cold foods and at or above 135 degrees F for hot foods. On 4/13/23, at 8:30 AM, Surveyor observed 2 metal meal carts delivered to the 3rd floor dining room. On 4/13/23, at 8:50 AM, Surveyor observed staff passing out fluids to residents in the dining room and no meal trays had been served. On 4/13/23, at 8:52 AM, Surveyor obtained a test tray from the meal cart. The breakfast meal consisted of scrambled eggs, hot cereal (cream of wheat) and toast. Surveyor noted the food is served on a white porcelain plate on a plastic maroon plate holder, covered with a plastic maroon cover. Surveyor noted there was no hot plate (pellet system) underneath the porcelain plate. The toast was lukewarm and palatable. The scrambled eggs were cold to the touch and taste. The cream of wheat was cold to the touch and taste. On 4/13/23, at 9:08 AM, Surveyor spoke with Dietary Manager-L regarding tray meal service to units. Dietary Manager-L reported the facility does not use metal hot plates for food service to units. Dietary Manager-L reported the facility uses a plate warmer which is plugged in at 6:00 AM for breakfast service and 10:30 AM for lunch service. Surveyor observed a metal cart containing white porcelain plates in the dishwashing room. Dietary Manager-L reported the cart is stored and then brought into the kitchen area and plugged in before meal service. Dietary Manager-L reported she was not aware of any residents complaining of cold food. On 4/13/23, at 10:34 AM, Surveyor advised the facility of residents concerns regarding cold food and observation of test tray containing cold food. No additional information was provided.

Based on interview and record review the facility did not ensure 5 (R33, R17, R26, R47, and R48) of 5 residents reviewed received a written notice of the bed hold policy when they were transferred to the hospital. The facility did not provide written information to the resident (R33,R17, R26, R47, or R48) or resident representative that specifies (i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; (ii) The reserve bed payment policy in the state plan; (iii) The nursing facility's policies regarding bed-hold periods permitting a resident to return before a nursing facility transfers a resident to a hospital. Findings include: Surveyor reviewed the facility's Bed Hold Notification policy with no review date. Documented was: Guideline: The facility resident is transferred to a hospital or requests a therapeutic leave, the center will provide written notice to the resident and/or resident representative regarding the resident's bed hold rights and the center's bed hold policy. Bed Hold - Temporary Leave: When hospitalization or a therapeutic leave is necessary, the Resident's bed will be held automatically for 15 days at a rate of 100% of the Resident's current daily rate, unless the Resident or Resident Representative notifies the Facility's Business Office or Social Work Department or unless a condition of involuntary removal has been met. A statement will be given to the Resident outlining the Facility's bed hold policy at the time of transfer to the hospital or at the beginning of a leave. The Medical Assistance program may cover, up to the extent provided by law, the bed hold for those Residents eligible for Medical Assistance/T19/Medicaid. In the case of a Medical Assistance Resident whose hospitalization or therapeutic leave extend beyond the bed hold period (15 days), the Resident will be readmitted to the Facility to their previous room if available or immediately upon the first availability of a bed in a semi private room if the resident (A) requires the services provided by the facility; and (B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services and (C) the facility is able to provide the services required and (D) the resident desires to return to the facility. Residents whose stay is covered by Medicare are not eligible for bed hold benefits payable by the Medicare program. For a Resident whose stay is being paid for privately, the Facility will hold the Resident's bed in the absence of instructions not to do so, provided the Resident continues to be responsible for payment for the 15 day bed hold period. The Facility will release the bed hold when the Facility's Business Office or Social Worker Department is notified that the Resident no longer wishes the Facility to hold the bed or the bed hold period is exceeded. Should a Resident/Resident's Representative choose to continue to pay privately to hold the bed beyond the 15-day bed hold, the Resident will be readmitted to the Facility to their previous room if the resident (A) requires the services provided by the facility; and (B) Is eligible for nursing facility services and (C) the facility is able to provide the services required and (D) the resident desires to return to the facility. Charges for the room will be the same as 100% of the Resident's daily room rate existing at the time of hospitalization . Charges for the room will be made up to and including the date of notification that the Resident no longer wishes to hold the bed. In the event of a temporary absence, charges shall be made in the same manner. When a Resident leaves the Facility, and indicates that he or she does not intend to return, the Facility may make arrangements to release the Resident's bed immediately after the scheduled day of departure. The Facility cannot guarantee a bed will be available for the Resident in the event the decision to leave the Facility is rescinded. 1. R33 was admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia with Behaviors, Heart Failure, Chronic Kidney Disease, Unspecified Psychosis and Muscle Weakness. The medical record indicated R33 was transferred to the hospital 2/12/23 due to a change in condition. Surveyor reviewed R33's medical record and was not able to locate the bed hold notice for the 2/12/23 hospitalization . 2. R17 was admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia with Behaviors, Hypertensive Heart Failure without Heart Disease, Peripheral Vascular Disease and Muscle Weakness. The medical record indicated R17 was transferred to the hospital 12/20/22 due to a change in condition. Surveyor reviewed R17's medical record and was not able to locate the bed hold notice for the 12/20/22 hospitalization . On 4/11/23 Surveyors requested copies of R26, R47, R33, R17, and R58's bed hold notices and documentation that bed hold was provided. No documentation was provided. On 4/12/23 at 9:07 AM Surveyor interviewed Consultant-D. Surveyor asked if any bed hold notices had been found for the 5 residents. Consultant-D stated no. Consultant-D stated the facility was cited for not having bed hold notices on a past survey and had put a Performance Improvement Plan in place. Consultant-D stated she was not sure what happened. Consultant-D stated they should have been completed. Consultant-D stated the nurses who send the resident out to the hospital should send them with the resident. Consultant-D stated they have an audit tool to fill out the next day and follow up with the hospital if needed. Consultant-D stated it got missed and no one was following up to make sure they were completed. 16584 3. Surveyor conducted a review of R26's medical record on 04/11/23. The medical record indicated R26 was transferred to the hospital on 4/5/23. R26's medical record did not include documentation that a written notice of the bed hold policy had been given to the resident and/or representative for the hospitalization . On 4/12/23, at 10:30 AM, the Corporate Consultant-D was interviewed and indicated a bed hold notice was not completed for R26 on 3/29/23 and should have been. The above findings were shared with the Administrator and Director of Nursing on 4/12/23 at 3:00 PM at the daily exit meeting. Additional information was requested if available. None was provided. 22692 4. On 04/11/23, Surveyor reviewed R47's medical record and it indicated R47 was transferred to the hospital on 04/05/23. R47's medical record did not include documentation that a written notice of the bed hold policy had been given to the resident and/or representative for the hospitalization . On 4/12/23. at 10:30 AM, the Corporate Consultant-D was interviewed and indicated a bed hold notice was not completed for R47 on 04/05/23 and should have been. The above findings were shared with the Administrator and Director of Nursing on 4/12/23 at 3:00 PM at the daily exit meeting. Additional information was requested if available. None was provided. 38146 5. R48 admitted to the facility on [DATE] and has diagnosis that include Acute Respiratory Failure with hypoxia, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease stage 3, Spondylosis lumbar region, Adult Failure to Thrive and Atherosclerotic Heart Disease. R48's Brief Interview for Mental Status score dated 3/27/23 documented a score of 13 indicating R48 as Cognitively Intact. R48 has a Health Care Power of Attorney (POA) which is not activated and her daughter is listed as responsible party. R48's medical record indicated she was transferred to the hospital on 12/14/23 due to a change in condition. Surveyor was unable to locate the bed hold notice in R48's medical record. Facility progress notes documented: 12/14/22, at 6:26 AM, Resident not responding in normal manner. Unable to get up through night, c/o (complained of) severe headache. Unable to transfer self. Daughter called and writer left message. 6:40 AM paramedics transfer resident to (hospital). 12/14/22 at 1:30 PM Writer received a call from RN (Registered Nurse) at (hospital) with an update on resident's status. Per RN, resident is positive for Influenza and Covid-19, and troponin levels elevated at 59. Resident placed on oxygen due to SpO2 (blood oxygen level) not maintaining. Resident will be kept overnight. Resident's daughter is aware. R48 readmitted to the facility on [DATE] with diagnosis Acute Hypoxic Respiratory Failure secondary to Covid and Influenza. Surveyor was unable to locate evidence the resident or resident's representative was provided written notice of bed hold. On 4/11/23 at 12:23 PM Surveyor spoke with Social Worker (SW)-K. SW-K reported the facility notifies the Ombudsman regarding discharges monthly, per their request. SW-K reported bed hold information would be in paper chart or medical records and she would look for information. Surveyor verified the Ombudsman was notified. On 4/12/23 at 10:05 AM SW-K advised Surveyor the facility did not have evidence the resident and/or the resident representative was provided written notice bed hold information.

Based on interview and record review, the facility did not ensure 5 (R26, R47, R33, R17, and R48) of 5 residents reviewed that required hospitalization s were given a written reason for transfer to the hospital. Before being transferred to the hospital, the facility did not notify the resident and/or the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility did not record the reasons for the transfer or discharge in the resident's medical record. R33, R17, R26, R47 and R48 and/or their resident representative did not receive written notice of the reason for transfer prior to their transfer to the hospital. Findings include: R33 was admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia with Behaviors, Heart Failure, Chronic Kidney Disease, Unspecified Psychosis and Muscle Weakness. The medical record indicated R33 was transferred to the hospital 2/12/23 due to a change in condition. Surveyor reviewed R33's medical record and was not able to locate documentation of the transfer notice for the 2/12/23 hospitalization . R17 was admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia with Behaviors, Hypertensive Heart Failure without Heart Disease, Peripheral Vascular Disease and Muscle Weakness. The medical record indicated R17 was transferred to the hospital 12/20/22 due to a change in condition. Surveyor reviewed R17's medical record and was not able to locate documentation the transfer notice for the 12/20/22 hospitalization . On 4/11/23 Surveyors requested copies of R33's, and R17's transfer notice documentation for transfer to the hospital from the facility. No documentation was provided. On 4/12/23 at 9:07 AM Surveyor interviewed Consultant-D. Surveyor asked if any transfer notices had been found for R33 and R17. Consultant-D stated no. Consultant-D stated the facility was cited for not having transfer notices on a past survey and had put a Performance Improvement Plan in place. Consultant-D stated she was not sure what happened. Consultant-D stated they should have been completed. Consultant-D stated the nurses who send the resident out to the hospital should send them with the resident. Consultant-D stated they have an audit tool to fill out the next day and follow up with the hospital if needed. Consultant-D stated it got missed and no one was following up to make sure they were completed. 16584 3) Surveyor conducted a review of R26's medical record on 4/11/23. The medical record indicated R26 was transferred to the hospital on 3/29/23. R26's medical record did not include documentation that a transfer notice had been given to the resident and/or representative for the hospitalization . On 4/12/23, at 10:30 AM, the Corporate Consultant-D was interviewed and indicated a transfer notice was not completed for R26 on 3/29/233 and should have been. The above findings were shared with the Administrator and Director of Nursing on 4/12/23, at 3:00 PM, at the daily exit meeting. Additional information was requested if available. None was provided. 22692 4) On 4/11/23 R47's medical record and it indicated R47 was transferred to the hospital on 04/05/23. R47's medical record did not include documentation that a transfer notice had been given to the resident and/or representative for the hospitalization . On 4/12/23 at 10:30 AM, the Corporate Consultant-D was interviewed and indicated a transfer notice was not completed for R47 on 04/05/23 and should have been. The above findings were shared with the Administrator and Director of Nursing on 4/12/23 at 3:00 PM at the daily exit meeting. Additional information was requested if available. None was provided. 38146 5) R48 admitted to the facility on [DATE] and has diagnosis that include Acute Respiratory Failure with hypoxia, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease stage 3, Spondylosis lumbar region, Adult Failure to Thrive and Atherosclerotic Heart Disease. R48's Brief Interview for Mental Status score dated 3/27/23 documented a score of 13 indicating R48 as cognitively intact. R48 has a Health Care Power of Attorney (POA) which is not activated and her daughter is listed as responsible party. R48's medical record indicated she was transferred to the hospital on 12/14/23 due to a change in condition. Surveyor was unable to locate the transfer notice in R48's medical record. Facility progress notes documented: 12/14/22, at 6:26 AM, Resident not responding in normal manner. Unable to get up through night, c/o (complained of) severe headache. Unable to transfer self. Daughter called and writer left message. 6:40 AM paramedics transfer resident to (hospital). 12/14/22, at 1:30 PM, Writer received a call from RN (Registered Nurse) at (hospital) with an update on resident's status. Per RN, resident is positive for Influenza and Covid-19, and troponin levels elevated at 59. Resident placed on oxygen due to SpO2 (blood oxygen level) not maintaining. Resident will be kept overnight. Resident's daughter is aware. R48 readmitted to the facility on [DATE] with diagnosis Acute Hypoxic Respiratory Failure secondary to Covid and Influenza. Surveyor unable to locate documentation the resident and the resident's representative was notified of the transfer/discharge and the reasons for the transfer in writing. On 4/11/23, at 12:23 PM, Surveyor spoke with Social Worker (SW)-K. SW-K reported the facility left a message with R48's daughter regarding transfer to the hospital. Surveyor asked for evidence of transfer notice provided to the resident or resident representative in writing. SW-K reported transfer paperwork is sent to the hospital with the resident. SW-K was unable to locate documentation in R48's medical record indicating the resident or representative was provided a transfer notice in writing.

Based on record record review and staff interviews, the facility did not ensure that 1 (R8) out of 1 resident 's reviewed with significant weight loss were provided with nutritional care and services to maintain acceptable parameters of nutritional status based on a comprehensive assessment. On 12/9/22, R8 weighed 212 pounds. On 1/6/23, R8 weighed 198 pounds, which was a significant weight loss of 14 pounds in 1 month. On 2/23/23, R8 was documented to weigh 179. This further weight loss of 19 pounds is a significant weight loss. As of 4/13/23, R8 weighed 178 pounds and did not have any further comprehensive assessment of their significant weight loss. The facility did not revise the plan of care to identify if this weight loss was desirable or physician prescribed or identify additional interventions to help R8 maintain weight if the weight loss was not desired. R8 experienced a severe weight loss of 16.04% over 4 months. This is evidenced by: Review of facility policy titled, Weight Monitoring Program, revised 9/29/2008, and 9/1/2022 documents in part, . Each resident's weight will be monitored consistently and closely by the interdisciplinary team. All residents with patterned or significant weight changes will be assessed by the facility's interdisciplinary team as indicated. Interventions to address nutritional issues will be initiated and incorporated into the resident's care plan and re-evaluated on a timely and periodic basis. Procedure: (includes) 2.) Weights are to be taken (by nursing staff) at least monthly or as ordered by the physician. If a patterned or significant weight loss/gain of at least 5% in 30 days, 7.5 % in 90 days or 10% in 180 days, the following interventions will be carried out: - Notification of attending physician by the nursing staff - Notification of Dietician. The Dietician will assess the resident, document the assessment, and make recommendations. Orders may be obtained for nutritional supplements or other interventions. -Notification of family member/responsible party and physician -Revision to the care plan as needed. 4.) If the resident's significant weight loss/gain is explainable (i.e , weight reduction program, dialysis, diuretic therapy), documentation must be entered into the resident's medical record to support this determination with appropriate revisions to the care plan as needed. R8 was readmitted to the facility on [DATE] with diagnosis that included Hypertension, Type 2 Diabetes, Hyperlipidemia, Bipolar Disorder, Anxiety Disorder, Dementia and Schizoaffective Disorder, Bipolar type. MD ( Medical Doctor) Order, dated 10/29/22 documents, Diet orders, including supplements, hydration, and enteral nutrition, may be delegated to the Registered Certified Dietitian. MD order dated 11/4/2022 documents, Weekly weights x (for) 4 weeks then monthly, every day shift, every Fri (Friday) for 4 Weeks AND every day shift starting on the 2nd and ending on the 2nd every month. Nutritional Assessment (re-admission), dated 11/3/2022 documents R8's weight at 217 pounds and a BMI (body mass index) at 39.6 - Obese category. No weight changes have been noted, mechanical soft diet texture, thin liquids eating refused 100% at meals, averaging 60% at meals. R8 feeds herself once tray is set-up, without reported tolerance issues at meals per CNA (Certified Nursing Assistant) documentation. [R8] does have bilateral lower edema. Current diet order appropriate to meet estimated nutritional needs as provided. Plan: continue with current diet order and plan of care and monitor weights as resident allows offer snacks between meals. Surveyor conducted a review of R8's plan of care and noted R8's plan of care documents a potential nutritional problem r/t (related to) need for mech (mechanically) altered texture (edentulous (lacking teeth)), Obesity with BMI>30, history DM (diabetes), history tardive dyskinesia, dementia, bipolar. Date Initiated: 03/08/2019, revision on: 11/03/2022 Interventions include: *[R8] will maintain adequate nutritional status as evidenced by maintaining stable weight, no s/sx (signs/symptoms) of aspiration, and consuming at least 75% of at least 2 meals daily through review date. Date Initiated: 03/08/2019, Revision on: 05/02/2022; *Administer medications as ordered. Monitor/Document for side effects and effectiveness. Currently on diuretic and was readmitted with edema from hospital 10/2022, has potential for weight loss d/t (due to) diuresis. Date Initiated: 03/08/2019 Revision on: 11/03/2022; *Monitor/record/report to MD (Medical Doctor) PRN (as needed) s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3 lbs in 1 week, > (greater than) 5% in 1 month, >7.5% in 3 months, >10% in 6 months. Date Initiated: 03/08/2019; *RD (Registered Dietitian) to evaluate and make diet change recommendations PRN. Date Initiated: 03/08/2019. R8's weights documented in the EMR (Electronic Medical Record) 4/5/2023 183.0 Lbs Wheelchair 3/27/2023 181.0 Lbs Wheelchair 3/24/2023 257.5 Lbs Wheelchair 3/1/2023 198.0 Lbs Manual Incorrect Documentation 2/20/2023 179.5 Lbs Manual 1/6/2023 198.0 Lbs Manual 12/9/2022 212.0 Lbs Manual 11/3/2022 216.5 Lbs Wheelchair 10/29/2022 212.0 Lbs Wheelchair Quarterly Mini Nutritional Assessment 2/2/23 weight 217# (pounds) at risk for malnutrition. Summary: Qtr (Quarterly) RD (Registered Dietician) note: [R8] scored 10/14 MNA (Mini Nutritional Assessment) screening, indicating res (resident) could be at risk for malnutrition. [R8] continues LCS, mech soft, thin liquid diet, eating 50-100% at meals. [R8] is able to tell staff her needs. No reported tolerance issues at meals per CNA (Certified Nursing Assistant) documentation. No reported skin issues. Chronic BLE (bilateral lower extremity) pitting edema per MD progress note. Last available wt: 216.5#-11/3, using this wt (weight), no sig (significant) wt changes in 6 mo (months); BMI: 39.6, considered obese. Last labs 12/28: H BUN-poss. r/t renal status, H alk phos and H LFTs-indicating liver dysfunction and could be reason for low alb 3.5. No noted recent med changes. Plan: continue w/ current diet order and POC (plan of care) request updated weight when res will allow. The most current, quarterly MDS ( Minimum Data Set), dated 2/3/23 documents R8 weighs 217 pounds and there is no noted weight loss or gain. Nutrition Dietary note dated 3/5/2023, at 2:19 p.m., 2/20 wt: 179.5#, if all the weights are correct, this would be a sig. wt loss of 9.3% in 1 mo (month), sig. wt loss of 17.1%/3 mo, sig wt loss of 14.9% in 6 mo.BMI: 32.6, considered obese. Question if decreased po (oral) intake and wt loss r/t behaviors of occ (occasionally) refusing cares, not coming out of her room often, see SW (Social Work) notes re: med (medication) changes. Plan: request to update MD re: wt change follow for med changes and meal acceptances monitor wts as ordered. Surveyor conducted further review of the medical record and did not find evidence that the Physician or R8's guardian was made aware of the significant weight loss. A review of the weights taken after the nutritional note indicated that RD (Registered Dietician)-E entered a weight of 257.8 pounds on 3/24/23 and did not document this weight as being an error. R8's weight was taken again on 3/27/23 noted to be 181 pounds and again on 4/5/23 R8 weighed 183 pounds. Both of these weights were obtained by facility staff, and they did identify that this was a significant weight loss for R8 since 2/2/23 when R8's weight was 217 pounds. Surveyor interviewed RD- E on 4/12/23, at 1:00 p.m. Surveyor asked RD-E how she is made aware of resident weights and if there has been any weight loss/gain. RD-E stated that she is at the facility 1 day a week and has access to the electronic medical records. RD- E will request staff to weigh residents or re-weigh if needed. If it is noted that a resident has lost/gained weight, RD- E will send out a fax form to the facility and the facility is then responsible for forwarding the information onto the resident's primary physician. RD- E stated she will cut and paste what she wrote in note and have them send it. Surveyor asked RD- E if she was aware of R8's significant weight loss. RD- E stated she has been waiting on these weights. RD- E stated that in one week, the facility scale had to be recalibrated 3 times. Surveyor asked RD- E about the nutrition note dated 3/5/23 where she documents that R8 may have significant weight loss if the weights are correct. RD- E stated she didn't know what weight was right and indicated this in her report to the facility. RD- E stated that Administrator- A is aware that the scale was not working and have been conducting audits. RD- E stated that she did not always have access to all the weights because sometimes the weights were documented on paper and this paper was lost. RD- E stated that R8 does have some behaviors that includes refusals. Surveyor asked if RD- E had re-assessed R8 since 3/5/23 when the significant weight was noted. RD- E stated that she did observe R8 last time she was here and R8 looks the same in face. RD- E stated she didn't notice muscle wasting. RD- E stated that she did not document any of this about R8 that it was an informal assessment. RD- E was asked if she was aware if the facility had notified the Physician. RD- E stated that she is not sure if they did or not, her job is to offer suggestions and she suggested the facility notify the physician. RD- E stated that she assumed if the physician wanted anything done differently, the facility would have followed up- on that order. RD- E stated that every week she comes in she provides a list of residents that need re-weights on and looks in the electronic medical record for any updates. RD- E stated that she does not only go by weights, but she will also review meal intakes and talk with staff. Surveyor asked if she had identified any new interventions for R8 due to the weight loss. RD- E stated that she had not, and she can only recommend interventions due to her contract with the facility. Surveyor asked RD- E if she had a current weight for R8, RD- E stated she did not. Surveyor requested to see of R8's weight being taken to verify if there had been any additional loss. Surveyor conducted a review of the meal intakes for R8 for the months of February, March and April 2023. It was noted that the facility staff did not always document, 3 times daily with each meal served, the percentage that R8 consumed. For those meals that were documented on, R8 varied between 51-75% of the meal consumed to 76%-100% meal consumed. On 04/12/23, at 3:00 p.m , Surveyor conducted an interview with Administrator- A and RN (Registered Nurse)Consultant- D regarding R8's significant weight loss. Surveyor shared concerns that weights have been obtained inaccurately by not using the same method to weigh R8. Surveyor spoke about the large discrepancies and questioned how the staff can conduct comprehensive assessment without the correct weights. Surveyor stated that R8's significant weight loss should have been addressed on 1/6/2023 when the weight was 198 which was down 14 pounds from 12/9/22 weight of 212 pounds. Surveyor expressed concerns that the potential significant weight loss was not addressed until March 5, 2023, and recommendation was to alert the physician. The facility has not provided evidence that the MD was made aware of the weight loss. Surveyor asked Administrator- A was asked if she was aware of the facility scales were not working correctly. Administrator -A stated that she did know about an issue with the scale on the 2nd floor being off by 20 pounds and has since put an audit in place by placing a 5-pound weight on the scale after it was calibrated. Administrator- A stated that there were no concerns brought forth about the scale on the 3rd floor and it has been working correctly. It is noted that R8 would have been weighed by the scale on the 3rd floor. On 04/13/23, at 09:37 am, Surveyor followed up to see if R8 had been weighed. Surveyor was told that R8 is refusing at this time but Social Services obtained a weight on R8 last evening (4/12/23) Social Services verified that R8 weighs 178 pounds and that the weight showed 216.5 pounds and they subtracted the weight of the wheelchair which is 38.5 pounds On 04/13/23, at 9:50 a.m., Surveyor interviewed Administrator- A and RN Consultant- D and Social Worker (SW) - K about R8's continued significant weight loss. RN Consultant- D stated that R8's percentage of eating is on average 76-100 % and a few entries where it is 51-75% of the meal consumed. RN- D stated that they would like for the staff to document on all meals. Administrator- A stated she was aware there was a weight discrepancy and she spoke with RD- E about the documented weight of 257.5 pounds. RD- E stated she got the number off a piece of paper, and it didn't have the wheelchair weight subtracted. RN- D stated that R8 is still considered obese according to her BMI. Surveyor stated that R8 has lost 15.67% of her weight in the past 2 months and nobody has re-assessed her as to why she is losing this significant amount of weight. Surveyor stated that R8 was also noted to have edema in her lower extremities and wondered if anyone considered this when evaluating the weight loss. RN- D stated that she is not aware of an assessment being conducted but RD- E did visually see R8 and determined that she was not malnourished or experiencing muscle wasting. RN- D stated that R8 has had labs that have been abnormal, and this is due to liver functioning concerns. R8 has also had adjustments to her psych medications. SW - K stated that R8 believes her weight loss is related to her psych issues and medication adjustments. R8 has had refusals of meals, or she may choose not to eat the entire meal. R8 eats better when out in the dining room. When R8 is feeling well she eats 100% of her meal. Surveyor asked if R8's Guardian was aware of the significant weight loss. SW- K stated she speaks with the Guardian regularly and would have discussed it although it has not been documented in the record. SW- K stated that R8 has told her that she feels too large and desired to lose eight. Surveyor asked if this had been addressed any where with the Physician or Dietician and then care planned for. SW- K stated she was not sure. Surveyor spoke about the physician progress notes from the visits on 12/16/22 where the physician references a weight of 216.5 pounds on 1/23/23. It was noted this is a future weight from the date in which the MD had a virtual encounter with R8. It was also discussed that the MD had another virtual, monthly encounter with R8 on 2/20/23 where the MD references R8's weight to be 179.5 with a date of 3/13/23. Again, it was noted that this was a future weight. The facility was not able to provide any information as to why the MD did not have the weights at the time of the monthly visit as he has access to the electronic record. Further review of the MD progress notes does not indicate he was made aware of the significant weight loss and ordered any further interventions. The MD does indicate on the 2/20/23 progress note that R8 is morbidly obese that is likely hereditary with the effect of psychotropic medications and also the effect of insulin and sedentary lifestyle. Monitor labs pertinent to obesity. Whenever possible, R8 should receive weight neutral medications, provided psychiatry concurs. Encourage physical activity. R8 diet will be adjusted according to dietary recommendations. It was noted that R8 weighed 179.5 pounds on 2/20/23 which was 18 pounds less than the weight on 1/6/23 of 198 pounds. The MD did not address this weight loss as being desired by both R8 and/or Guardian or the physician. As of the time of exit, the facility did not provide any additional information as to why R8 had experienced a significant amount of weight loss without being further assessed by the Dietician and additionally did not update the plan of care to indicate that the weight loss was desirable or further interventions to assist R8 in not losing additional weight.

Based on observation, interview, and record review the facility did not ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for 1 (R9) of 2 residents reviewed for range of motion. R9 was observed not wearing left hand palm splint for three days of survey. Findings include: R9 admitted to the facility on [DATE] and has diagnoses that include major depressive disorder, hemiplegia and hemiparesis following cerebrovascular disease affecting left dominant side, vascular dementia and end stage renal disease. R9's Quarterly Minimum Data Set (MDS) dated [DATE] section G0400-Functional Limitation in Range of Motion documents: Upper extremity (shoulder, elbow, wrist, hand) Impairment on one side. R9's care plan focus area revised 5/1/21 documents; The resident has an ADL (Activity of Daily Living) self-care performance deficit r/t (related to) Dementia, Hemiplegia, Limited Mobility. Interventions include: Left hand palm splint for 8-12 hours or per tolerance initiated 4/30/21. R9's CNA (Certified Nursing Assistant) Kardex as of 4/12/23 documents: Dressing/splint care - left hand palm splint for 8-12 hours or per tolerance. Skin checks q (every) shift. On 4/10/23 at 10:38 am during initial tour, Surveyor observed R9 to have a left hand contracture and not wearing splint. Surveyor asked R9 if he can open his hand, R9 stated Sure, but don't feel like it right now. On 4/11/23 at 9:45 am Surveyor spoke with CNA-G and asked if R9 wears a splint or brace on his left hand. CNA-G reported R9 does have a hand split, He is supposed to wear it every morning when he gets dressed. I believe it went down to the wash and it never came back up. On 4/11/23 at 9:50 am Surveyor asked Licensed Practical Nurse (LPN)-F about R9's left hand splint. LPN-F stated He doesn't have his splint right now. It has been lost. Another will have to be ordered from OT (Occupational Therapy). On 4/12/23 at 7:45 AM Surveyor observed R9 laying in bed, the left hand splint was not on. Surveyor reviewed R9's medical record. OT Notes dated 3/9/21 document: Short Term Goal-The therapist will assess appropriate splint for pt (patient) with therapist able to donning/doffing splint within Left hand following PROM (passive range of motion). Goal - The caregiver/therapist will donning/doffing soft comfort palmer splint within Left hand following PROM. With pt able to tolerate for 2 hours with no skin irritation/redness in order to reduce risk for joint/muscular contracture. On 4/12/23 at 9:06 AM Surveyor spoke with Therapy Director-H. Therapy Director-H reported R9 has a left palm splint that he is supposed to wear everyday. Therapy Director-H reported that R9 does not want to wear it at times, often pulls it apart and it takes a lot of encouragement to get him to wear it. Surveyor asked if therapy was notified the splint was missing. Therapy Director-H stated, No. We usually have two so there is one to replace when the other goes down to laundry. Therapy Director-H walked into the therapy room and brought another splint to show Surveyor there were extra splints available. On 4/12/23 at 10:47 AM Surveyor observed R9 sitting up in his Broda chair in the hallway near the nurses' station. Surveyor noted he was not wearing the left hand splint. Facility Progress Notes dated 4/12/23 at 11:08 AM document: Resident allowed writer and therapy to don left hand splint. Skin was cleansed and is intact. Offered to trim resident fingernails x 3 with different staff and resident adamantly refused stating I don't want anyone to touch my nails. On 4/12/23 During the daily exit meeting the facility was notified of Surveyor's concern related to observations R9 not wearing a palm splint during survey. Surveyor asked for facility policy and procedures regarding splints. On 4/13/23 at 8:01 AM Nursing Home Administrator (NHA)-A advised Surveyor the facility does not have policy and procedure for splints. No additional information was provided. On 4/13/23 at 8:09 AM Surveyor observed resident sitting up in the Broda chair wearing new clean palm protector in left hand.

Based on interview and record review, the Facility did not ensure staff provided basic life support to 1 (R15) of 3 Residents who required Cardiopulmonary Resuscitation (CPR.) The facility currently has 49 out of 62 residents who desire CPR (Full Code.) The failure of staff to immediately call a code for R15 on the over head page system, the failure to not start CPR immediately, the failure to have the required supplies on the crash cart, and the failure of the facility to ensure there was an AED (Automated External Defibrillator) when an AED had been used in a code a month earlier created a finding of immediate jeopardy that began on [DATE]. Administrator-A, DON (Director of Nursing)-B, & Nurse Consultant-C were notified of the immediate jeopardy on [DATE] at 4:30 p.m. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope/severity of E (potential for more than minimal harm/pattern) as the facility continues to implement and monitor their action plan. Findings include: The Cardiopulmonary Resuscitation - CPR policy & procedure with an effective date of [DATE] documents under guidelines, This facility will provide basic life support including CPR - Cardiopulmonary Resuscitation, when a resident requires such emergency care, prior to the arrival of emergency medical services, subject to physician order and resident choice indicated in the resident's advanced directives. Under CPR Procedure documents: 1. Employee to verify safety of the scene/environment. 2. Check for resident response. Tap or shake shoulder of resident asking, Are you okay. 3. Simultaneously assess the resident for breathing and pulse for 10 seconds. If necessary, open the airway: Head-tilt/chin-lift technique. If a head, neck, or spinal injury is suspected, utilize the modified jaw-thrust maneuver. 4. Shout for nearby help or pull the call light for assistance. Activate emergency response System by announcing overhead, 3 times CODE BLUE and LOCATION. 5. Staff immediately instructed to retrieve emergency cart/equipment. If collapse was witnessed and staff member alone, leave resident to activate the emergency response system and retrieve emergency cart (unless another staff member is able to retrieve device) before beginning CPR. 5. Identify code status/advance directive preferences. If the resident has a valid advance directive, indicating Do Not Resuscitate, DO NOT PERFORM CPR: ILLINOIS - a POLST (Physician Orders for Life-Sustaining Treatment Form that indicates that resuscitation is not desired.) WISCONSIN - a POST (Physician Orders for Scope of Treatment form that indicates that resuscitation is not desired). 6. If a DNR order/Advanced Directive does NOT exist or if Advance Directive does not indicate DO Not Resuscitate, begin resuscitation efforts. 7. If Resident does not exhibit normal breathing and has a pulse, begin rescue breathing. 1 breath every ,d+[DATE] seconds (,d+[DATE] per minute) using face mask or Resuscitator Bag. If resident is presenting with agnal breaths, continue as if resident is not breathing. 8. Check pulse approximately every 2 minutes. 9. If no pulse, begin CPR. Place backboard under resident in bed or assist resident to a firm, flat surface if possible. Compress chest compressions at a rate of ,d+[DATE] per minute (place 2 hands on the lower half of the sternum). Compress to a depth of at least 2 (inches). Ensure full recoil following each compression. Minimize any pauses in compressions. Ventilate 2 breaths after 30 compressions, each breath to be delivered over 1 second, causing chest to rise (30:2 Ration for both 1 or 2 rescuers). Use face mask or resuscitator bag. 10. Continue resuscitation efforts until one of the following occurs: Resident presents with effective, spontaneous circulation. Care is transferred to emergency responders to provide advanced life support. The rescuer is not able to continue due to exhaustion, dangerous environmental hazards or efforts to resuscitate places others in danger. Reliable and valid criteria that indicates irreversible death are met, criteria of obvious death are identified or criteria for termination of resuscitation is met. 11. Turn CPR over to emergency personnel upon arrival and prepared to take over. R15 was readmitted to the facility on [DATE] with diagnoses which included acute kidney failure, chronic kidney disease, diabetes mellitus, cocaine abuse, asthma, peripheral vascular disease, hypertension, and major depressive disorder. The physician orders dated [DATE] document Full code provide CPR. The nurses note dated [DATE] at 1:58 p.m. documents Resident alert responsive. Remains on abt/uti (antibiotic/urinary tract infection). No adverse reactions noted. Foley patent. The nurses note dated [DATE] at 5:05 p.m. documents NP (Nurse Practitioner) [first name] in to see resident, NOR (new order received) probiotic bid (twice daily) po (by mouth) x (times) 1 wk (week), zofran 4 mg (milligrams) prn (as needed) q (every) 8 hrs (hours) po x 1 wk. The nurses note dated [DATE] at 5:56 p.m. documents Resident on ABT/UTI, no adverse effects, Foley patent draining yellow urine. The next nurses note is dated [DATE] at 5:00 a.m. which documents, Writer went in room [number] to give resident a prn (as needed) pain medication and found resident unresponsive, CPR initiated, 911 called, Emergency contacts #1 and #2 called, unable to talk with either one, [first name] or [first & last name], message left for contacts to call the facility ASAP (as soon as possible), emergency contact #3 called, writer spoke with [first & last name] and updated him on resident's change of condition, and that resident is being worked on by fire dept (department)/paramedics, will update as soon as the fire department/paramedics are through. [Name] RN (Registered Nurse) DON (Director of Nursing) and [name] administrator called, message left on answering service to call facility. 0520 (5:20 a.m.) [name] returned call and writer updated him on resident's changed of condition and will update as soon as fire dept/paramedics are through. 05:35 (5:35 a.m.) Lt (lieutenant) [name] from fire dept, Med 3 Engine 32 Doc 0134, pronounced resident expired, [name] stated that it's a standard protocol. 05:45 (5:45 a.m.) writer called [name] and updated him that resident did not make it, death was pronounced at 05:35 (5:35 a.m.). Writer asked [name] if any family members want to come out and view the body? [Name] stated that he will call back and let the facility (know). 06:02 (6:02 a.m.) [name] on call for [Physician's name], updated resident expired, Lt. [name] pronounced death at 05:35 (5:35 a.m.). This nurses note was written by LPN (Licensed Practical Nurse)-M. The nurses note dated [DATE] at 7:07 a.m. documents Writer spoke with Medical examiner, [name] wants the funeral home to stop by the medical office for blood work. The nurses note dated [DATE] at 8:24 a.m. documents May release body to funeral home. The nurses note dated [DATE] at 1:57 p.m. documents [Name of] funeral home came approx (approximately) 1200 (12:00 p.m.) to pick up body. On [DATE] at 10:28 a.m., Surveyor asked LPN (Licensed Practical Nurse)-K if there is an AED (automated external defibrillator) on the 3rd floor. LPN-K informed Surveyor there isn't one on the third floor and doesn't know if there are any in the building. Surveyor asked LPN-K if there is a crash cart on the 3rd floor. LPN-K replied yes, it's in the medication room. LPN-K then unlocked the medication room and showed Surveyor the crash cart. Surveyor asked LPN-K if she could remove the crash cart from the medication room in order for Surveyor to check the cart. LPN-K removed the crash cart from the locked medication room. At 10:33 a.m., Surveyor noted there is list of items for the crash cart which consists of: 1 resuscitation bag, 1 suction pump, 1 suction plastic bottle, 1 short suction tubing, 1 long suction tubing, 1 yankaur, 1 nasal cannula, 1 oxygen mask, 1 5:1 connector, 1 oxygen tubing 7 (inch), 1 nebulizer kit, 1 Christmas tree, 1 airway channel, 1 disposable stethoscope, 1 CPR board, 1 sharps disposal, 4 by 4 gauze, 1 spill clean up kit, 1 roll tape, 1 flash pen light, 1 box gloves, isolation gowns, eye protection, and face mask. Surveyor observed there is not a disposable stethoscope or face mask in the crash cart. On [DATE] at 10:51 a.m., Surveyor spoke with LPN-D & LPN-N who were at the nurses station. Surveyor asked if there is a crash cart and AED on the 2nd floor. LPN-N informed Surveyor the AED is with the crash cart. Surveyor went with LPN-D & LPN-N to a small room inside the dining room where staff showed Surveyor the crash cart. Surveyor inquired if the crash cart is usually in this room. LPN-N replied yes. Surveyor asked about the AED. LPN-N informed Surveyor it is usually with the cart and doesn't know where it is. Surveyor asked what would happen if someone went into cardiac arrest. LPN-N informed Surveyor they would probably have to go up to the 3rd floor to see if they have it. At 10:52 a.m. Surveyor checked the 2nd floor crash cart. Surveyor noted the list for the items to be in the crash cart are the same as the 3rd floor with the exception of the 2nd floor list also has glucometer, test strips, basin, emesis basin, & towel. Surveyor noted the oxygen mask, 5:1 connector, Christmas tree, airway channel, spill kit, and flash light are not in the 2nd floor crash cart. At 11:20 a.m. Surveyor informed LPN Manager-H Surveyor was unable to locate the oxygen mask, 5:1 connector, Christmas tree, airway channel, spill kit, and flash light in the 2nd floor crash cart. LPN Manager-H looked in the 2nd floor crash cart and informed Surveyor she doesn't see these items either. On [DATE] at 11:23 a.m., Surveyor asked LPN Manager-H if there is an AED on the 2nd floor. LPN Manager-H informed Surveyor it is usually sitting on top of the crash cart. Surveyor asked LPN Manager-H if she knows where the AED is. LPN Manager-H replied, I do not. Surveyor asked if there is an AED on the 3rd floor or just on the 2nd floor. LPN Manager-H informed Surveyor there is supposed to be one on each floor, 1st, 2nd, & 3rd. LPN Manager-H informed Surveyor she thinks on Friday one the nurses noted the AED was missing and it is going to be replaced. Surveyor asked if there is a crash cart on the first floor. LPN Manager-H replied yes, in the copier room. On [DATE] at 11:29 a.m., Surveyor checked the first floor crash cart located in the copier room. Surveyor observed the nasal cannula and disposable stethoscope are not in the first floor crash cart. On [DATE] at 11:35 a.m., Surveyor informed MDS/CPC (minimum data set/care plan coordinator)-I Surveyor is unable to locate the nasal cannula and disposable stethoscope which should be in the 1st floor crash cart according to the list. MDS/CPC-I checked the 1st floor crash cart and informed Surveyor she doesn't see the nasal cannula or stethoscope either. At 11:37 a.m., Surveyor asked MDS/CPC-I if there are AEDs in the building. MDS/CPC-I informed Surveyor she thinks they are on the emergency cart but hasn't seen one for the first floor. On [DATE] at 11:47 a.m., Surveyor met with DON (Director of Nursing)-B and NC (Nurse Consultant)-C. Surveyor asked if the Facility has AED machines. DON-B replied we do not, found out recently they are unavailable. Surveyor inquired about the AEDs being unavailable. DON-B informed Surveyor they don't have any here currently. Surveyor asked if there were AEDs in the building. DON-B informed Surveyor at one point they did. NC-C explained they searched the building and were unable to locate any AEDs so she reached out to their supplier. NC-C informed Surveyor no one in the building is able to tell them where the AEDs went. NC-C informed Surveyor she called CNA (Certified Nursing Assistant)/Central Supply-P to see if he knew where the AEDs were and he told her he throws them away after they are used. NC-C informed Surveyor they do CPR, call 911, and are actively working on getting AEDs but there is a problem with sourcing. NC-C informed Surveyor she was working with DON-B to look at crash carts, the process of who is checking them, etc. Surveyor asked DON-B if anyone informed her the AEDs were missing. DON-B replied no. Surveyor inquired when she became aware there were no AEDs. DON-B informed Surveyor last week. NC-C informed Surveyor they also reached out to the previous DON and he said CNA/Central Supply-P reorders supplies. NC-C informed Surveyor they developed a four point plan which NC-C provided to Surveyor. Surveyor noted this ad hoc QAPI (Quality Assurance Performance Improvement) meeting/four point plan of correction and summary dated [DATE] includes under root cause AEDs were not on the crash carts. The QAPI summary reflects, after investigation, no staff member was able to identify where the AEDs were located. One staff member stated he thought the AEDs were disposed of after each code. No one is assigned to manage the crash cart process and AED maintenance. Nurse consultant emailed facility supply company to have them order (2) AEDs for the facility. The nurses are trained to perform CPR with or without an AED. An updated list of employees certified to perform CPR will be maintained by HR (Human Resources.) On [DATE] at 2:00 p.m., Surveyor asked LPN-K if she checks the crash carts to ensure all the required items are in the cart. LPN-K replied no and informed Surveyor she really doesn't know who is responsible. On [DATE] at 2:29 p.m., Surveyor asked NC-C if there is an AED policy. NC-C informed Surveyor regulations don't require them to have AED. Surveyor informed NC-C that is true, but if the Facility is using AEDs there should be a policy. NC-C informed Surveyor they don't have an AED policy. On [DATE] at 4:25 p.m., Surveyor spoke with CNA (Certified Nursing Assistant)-O on the telephone regarding R15. Surveyor asked CNA-O if she was working the night R15 passed. CNA-O informed Surveyor she was. Surveyor asked CNA-O to explain what happened. CNA-O informed Surveyor she saw R15 eating a hostess cake around 11:30 p.m. or so. CNA-O explained she was the only CNA working this night along with the nurse. Surveyor asked CNA-O if she went into R15's room between the time she saw R15 eating a hostess cake and when LPN-M found R15 unresponsive. CNA-O replied no, and stated she was the only CNA working on the floor. CNA-O informed Surveyor she was charting and LPN-M came up to her stating the name of R15 is unresponsive and asked her to go to the room with her. CNA-O informed Surveyor LPN-M didn't do anything right away and thinks the nurse was looking for the crash cart. CNA-O informed Surveyor she stayed in the room and checked her (R15's) pulse and under her neck. Surveyor asked CNA-O what she found. CNA-O replied nothing, the nurse was saying she was going to look for the crash cart. Surveyor asked CNA-O if anyone called a code over the loud speaker. CNA-O informed Surveyor she didn't know but the ambulance was called. Surveyor asked CNA-O if the nurse brought the crash cart into the room. CNA-O informed Surveyor shortly before the EMTs (emergency medical technicians) came. Surveyor asked if the nurse performed CPR before the EMTs came. CNA-O replied no, didn't perform CPR. Surveyor asked if anyone else other than herself and LPN-M came into R15's room. CNA-O replied no. CNA-O informed Surveyor LPN-M went to look for the crash cart and something happened to the crash cart. Surveyor inquired what CNA-O meant by something happened to the crash cart. CNA-O informed Surveyor she was looking for it. Surveyor asked CNA-O if LPN-M left her alone with R15. CNA-O replied yes, she had to, I was the only one there. CNA-O informed Surveyor when the EMTs came they started doing CPR in the bed but apparently it was too soft so they put her on the floor and did it there. Surveyor asked CNA-O if she stayed in the room when EMS was there. CNA-O replied no, it was a bit much. Surveyor asked if anyone called code blue. CNA-O informed Surveyor she didn't know. Surveyor asked CNA-O if she did CPR for R15. CNA-O replied no, and explained she is not CPR certified but can assist. Surveyor asked again if LPN-M started CPR on R15 before EMS arrived. CNA-O replied I don't remember, don't want to get 2 stories mixed up. CNA-O informed Surveyor she knows LPN-M started CPR on R13 (a different resident who had a code the previous month) and then stated, I don't think so. Surveyor asked CNA-O if any staff from the 3rd floor came down to help. CNA-O replied no. CNA-O informed Surveyor R15 was pretty independent, got herself dressed. Surveyor asked CNA-O if anyone from administration talked to her about what happened during R15's code. CNA-O replied no. Surveyor asked CNA-O if the Facility has AEDs. CNA-O informed Surveyor they have one and that it comes in a case. Surveyor asked CNA-O if she knows where the AED is located. CNA-O replied no, I don't. On [DATE] at 5:55 p.m., Surveyor spoke with LPN-M on the telephone regarding R15. LPN-M informed Surveyor she found R15 when she went in to give her prn (as needed) pain medication early in the morning. LPN-M indicated she went into the room and found her (R15) unresponsive. LPN-M indicated R15 wasn't breathing, there was no pulse and she tried to wake her. Surveyor then asked LPN-M what she did. LPN-M replied, we started CPR on her. Surveyor asked LPN-M if she was the only staff on the floor. LPN-M informed Surveyor it was herself and 2 CNAs. Surveyor informed LPN-M there was only one CNA on the floor that night. LPN-M then informed Surveyor she thinks there was just the 2 of them and it's hard to remember. LPN-M informed Surveyor she started CPR, called 911, & called the family. Surveyor asked LPN-M how she was doing CPR. LPN-M informed Surveyor she had the ambu bag and chest compressions. Surveyor asked if LPN-M had the crash cart. LPN-M replied yes, in the room. Surveyor inquired where the crash cart was. LPN-M informed Surveyor it was in the small room off the dining room. Surveyor inquired if she had problems locating the crash cart. LPN-M replied no. Surveyor asked LPN-M if she called a code on the over head page system. LPN-M replied no, it's a small building and she could go upstairs. Surveyor informed LPN-M Surveyor was informed she did not do CPR on R15. LPN-M then informed Surveyor the crash cart did not have an ambu bag so she went upstairs to get the bag & the aide went to get oxygen. LPN-M indicated she got the stuff together and then did CPR. Surveyor asked LPN-M if she went to get the ambu bag first and then started CPR. LPN-M informed Surveyor she found R15 unresponsive, got the crash cart but there was no ambu bag, put oxygen on R15, went to get the ambu bag, got the bag & started CPR. Surveyor asked LPN-M if she took the stairs or elevator. LPN-M informed Surveyor she took the stairs. LPN-M informed Surveyor the other nurse was on the floor with her. Surveyor asked who the other nurse was. LPN-M informed Surveyor the first name of LPN-L. Surveyor asked if LPN-L did CPR for R15. LPN-M replied she thinks she was the only one doing it and LPN-L made calls. LPN-M informed Surveyor when the paramedics came they took over CPR. Surveyor asked LPN-M if there are AEDs in the facility. LPN-M replied there are but I couldn't find one, one wasn't on my cart. Surveyor asked if there is usually an AED on the crash cart. LPN-M replied yes, there was one in there doesn't know if someone used it. LPN-M informed Surveyor there was an AED when she did the code for R13 (a different resident) & it said no shock required. On [DATE] at 7:31 a.m., Surveyor asked LPN-J who checks the crash carts to ensure all the required items are in the cart. LPN-J informed Surveyor the night shift. On [DATE] at 7:39 a.m., Surveyor asked LPN-D who checks the crash carts to ensure all the required items are in the cart. LPN-D informed Surveyor it used to be central supply but now 3rd shift does. On [DATE] at 9:56 a.m., Surveyor spoke with LPN-L on the telephone regarding the night R15 on the 2nd floor was found unresponsive. Surveyor asked LPN-L if there was a code announced on the over head page system. LPN-L replied no and explained the nurse came up to the floor and wanted to see her crash cart. LPN-L indicated she went to the medication room, LPN-M took the ambu bag and asked about an AED. LPN-L informed Surveyor she asked LPN-M what she could do. LPN-L informed Surveyor she went to the first floor, stayed on the first floor to let the fire department in. Surveyor asked LPN-L if she went to 2nd floor. LPN-L indicated she didn't and that she went to the first floor. LPN-L informed Surveyor LPN-M came up to get the ambu bag and asked about the AED. LPN-L informed Surveyor she has never seen an AED machine on the 3rd floor and the AED on the 2nd floor wasn't working. LPN-L informed Surveyor the last time the AED machine on the 2nd floor was used was for name of R13 (different resident.) Surveyor asked LPN-L how she knew there was an emergency on the 2nd floor. LPN-L replied because the nurse came up to the floor. On [DATE] at 12:03 p.m., Surveyor spoke with CNA-Q on the telephone regarding R15. CNA-Q was a CNA assigned to the 3rd floor. Surveyor asked CNA-Q if she went downstairs to the 2nd floor to help with R15. CNA-Q replied no. CNA-Q informed Surveyor she saw LPN-M come on their floor (3rd floor) to get the nurse and the crash cart as there was an emergency downstairs. Surveyor inquired if LPN-M said what the emergency was. CNA-Q replied no, she was in a room and when she came out of the patient's room, she saw the two nurses going into the elevator with the crash cart. Surveyor asked CNA-Q if there are AEDs in the Facility. CNA-Q replied I think, I'm not so sure, I think they do. On [DATE] at 12:23 p.m., Surveyor informed NC-C Surveyor needed clarification regarding the AEDs and inquired if only the pads were thrown away after a code or was the machine. NC-C informed Surveyor he, referring to CNA/Central Supply-P, said the whole thing. NC-C informed Surveyor she didn't believe it and had people search for the AEDs. On [DATE] at 8:15 a.m., Surveyor asked Administrator-A after there has been a code for a Resident, do they discuss the code. Administrator-A informed Surveyor they kind of discuss it in clinical meeting. They briefly discuss the code, review the notes, was CPR initiated, and was EMS here. Administrator-A informed Surveyor her thing is were they alive when they left. Administrator-A informed Surveyor it was unexpected for R15, she was alert & orientated. On [DATE] at 9:18 a.m., Surveyor asked DON-B after a code, does she speak with the staff involved in the code. DON-B informed Surveyor they have conversations as part of the interdisciplinary team meeting but doesn't think there has been a code since she has been at the facility. Surveyor inquired about R15's code on [DATE]. DON-B explained she started at the Facility on [DATE], the previous DON was at the Facility until [DATE] and the week after the previous DON left she was out sick. Surveyor noted DON-B was out sick during R15's code. On [DATE] at 10:56 a.m., Surveyor met with Administrator-A, Nurse Consultant-C, and DON-B. Surveyor shared Surveyor's concerns regarding R15's code. Surveyor informed Administrator A, Nurse Consultant-C, and DON-B there were only two staff, a nurse and CNA on the floor. Surveyor spoke with both staff members regarding the code. Surveyor informed Administrator A, Nurse Consultant-C, and DON-B no code was announced overhead so the third floor staff would become aware there was an emergency on the 2nd floor. The CNA (O) informed Surveyor the nurse didn't do CPR but then stated maybe she did. LPN-M first informed Surveyor she started CPR with two aides present then corrected herself, stating there was herself and a CNA. LPN-M informed Surveyor there was no ambu bag on the 2nd floor crash cart, went upstairs to find the nurse for an ambu bag on the 3rd floor crash cart which is locked in the medication room. There was no AED which LPN-M had previously used on a code for R13. Surveyor informed staff of the crash carts on the 1st, 2nd, & 3rd floor which were missing supplies. Administrator-A informed Surveyor they discussed R15's code but were not aware supplies were missing, they just read the note, and didn't know details about the nurse having to go upstairs for an ambu bag. Nurse Consultant-C informed Surveyor they checked all carts & revamped the check list and indicated previous administration may not have done this. Nurse Consultant-C informed Surveyor they are trying to fix things as they find them and are trying as fast as they can to fix things. The facility removed the immediate jeopardy on [DATE] when it had completed the following: * All departments received and are receiving re-education on basic life support including CPR policy in the form of verbal education with verification of competency. Training will be provided by NHA (Nursing Home Administrator), DON (Director of Nursing), and Nurse Managers. Training was initiated on [DATE] and is ongoing. The training occurs both individually and in small groups. Staff are receiving training prior to the beginning their next shift. * Education includes: How to respond in the event someone is found unresponsive. Location of Crash Carts. Activation of Emergency Response. Identification of Code Status. * The facility is not using AEDs (automated external defibrillator), therefore a policy has not been developed. * Review of CPR policy by IDT (interdisciplinary team) team completed on [DATE]. * Crash Cart inventory audit was in place on [DATE] to be completed daily. * Facility has developed a process for internal review of code status events to be completed by IDT team following a Code event. The IDT team will Audit Post Code Forms following each code event. This is ongoing. * Crash Cart Inventory Forms are being audited and will be audited by Unit Managers Weekly and following a code event. This is ongoing. * All Audits will be reviewed during QAPI as an ongoing component of QAPI.

Based on interview and record review, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 2 of 3 residents (R2 & R1) reviewed with a history and/or diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . * The facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident when the facility did not follow their facility assessment by screening R1 for behavioral issues prior to admission, did not develop a person centered care plan for behavioral and suicide attempts, and did not train staff on how to handle R1's behavior after de-escalation did not work for R1. * The facility was not administered in a manner to use its resources effectively and efficiently when the facility did not ensure staff competency on how to provide direct services to R2 to assure R2's safety and highest practible physical, mental and psychosocial well-being based on history of [CONDITION(S)] and delusions. Facility staff members did not implement person-centered care approaches designed to meet the individual needs of R2 including developing and implementing non-pharmacological interventions for R2's behavioral needs. This deficient practice has the potential to affect a pattern of residents residing at the facility with mental and psychosocial disorders, history of trauma, and/or post-traumatic stress disorder with behavioral issues. The Facility's failure to administer the Facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident led to a finding of immediate jeopardy which started on 9/16/22. On 11/14/22 at 4:50 p.m., Administrator A was informed of the immediate jeopardy. The immediate jeopardy was not removed at the time of exit from the facility on 11/14/22. Findings include: Since the last recertification survey, the facility received the following high-level citations; F600 (J) immediate jeopardy cited on 9/1/22 F745 (J) immediate jeopardy cited on 9/1/22 The Facility Assessment Tool reviewed & accepted 8/26/22 under the section Diseases/conditions, physical and cognitive disabilities for category documents Psychiatric/Mood Disorders. Under common diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .), Impaired Cognition, Mental Disorder, Depression, [CONDITION(S)] Disorder (i.e., [CONDITION(S)]/Depression), [CONDITION(S)], Post-Traumatic Stress Disorder, Anxiety Disorder, Behavior that Needs Interventions. Under 1.4 Describe the process to make admission or continuing care decisions for persons that have diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . For example, how do you determine, if you have the opportunity to admit a person with a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] ? documents, The Interdisciplinary Team meets to review referrals to determine feasibility of the admission. Disease processes and the need for staff education is reviewed. Policies and procedures are reviewed for staff education when new clinical techniques are needed for deliverance of resident's care. Staffing patterns are considered. When additional or specialized education and/or resources are needed, the facility may consult with ancillary providers for support. Under 1.7 Describe other pertinent facts or descriptions of the resident population that must be taken into account when determining staffing and resource needs (e.g. residents' preferences with regard to daily schedules, waking, bathing, activities, naps, food, going to bed, etc) documents, There is a higher manifestation of mental health, substance abuse, and other psycho-social issues in our present (and past) resident population due to the inner city setting of the facility. The average age of the facility's resident population is younger than most other nursing homes. Combining these factors with significant co-morbidities resulting from life style choices results in unique staffing challenges. Under 2.1 for General Care documents Mental health and behavior. Under Specific Care or Practices documents Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/[CONDITION(S)], other psychiatric diagnoses, intellectual or developmental disabilities. R1 is a [AGE] year old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 has a Legal Guardian. The hospital referral information dated 9/28/22 includes a physician note dated 9/26/22 which documents Patient seen examined; was very agitated and trying to bite, scratching and spitting on staff. 5 mg (milligram) [MEDICATION(S)] was given. The nurses note dated 10/23/22 documents, Upon entering unit, resident in hallway screaming, hitting and biting staff, resident bit security guard (name) right hand drawing blood, Writer attempted to calm resident attempted to bite writer, resident taken outside to calm down, resident attempted to leave property numerous times, Milwaukee police crisis team called, social worker (name) called, (name) unit manager updated MD [name] updated on incident, NOR (new order received) [MEDICATION(S)] 50 mg (milligrams) po (by mouth) now. Resident placed in bed by social worker [name], after intervention with crisis team and medication administration. Resident sleeping at present. The social service note dated 10/23/22 documents Writer received a call from the facility stating that they were having trouble with R1 being combative and wheeling herself down the parking lot. Upon arrival to the building R1 was wheeling her wheelchair down the parking lot saying that she wanted to leave. Writer was able to get her to come inside to try to talk with her to see what was upsetting her. Once inside, she refused to answer any questions, she kept saying, I want to leave, I don't want to be here. Writer continued to try to get [R1] to explain what caused her to become upset and she eventually stated, They don't like me. Writer assured her that the staff does care for her and that she was safe. She became more agitated and yelling louder that she wanted to leave to go stay with her sister. Writer along with security assisted her to the day room to keep the hallways clear for residents and visitors to pass through without fear of [R1] striking out. Once in the day room she continued to get loud and attempted to hit, bite, and scratch the security guard as he sat in the doorway. Writer continued to attempt to redirect. Writer then contacted the Crisis team for assistance. Writer continued to try to calm [R1] and let her know that in the morning we would contact her case manager to start working on discharge options if she did not want to stay at [name of facility] any longer. [R1] continued to yell and scream and started to bang on the glass windows of the dayroom door. Writer would pull her wheelchair away from door and she continued to try to fight scratch and bite. Writer and security transferred her to a standard chair to attempt to prevent the repeated attempts to bang the doors. Once in the standard chair she slid herself to the floor and started to scoot across the floor. Once Officers arrived she calmed down rather quickly and began to be remorseful. She asked to call her mother and was very apologetic to both writer and security guard. During this time, MD (medical doctor) was being updated and had given the order for a one time dose of [MEDICATION(S)] to help calm her down. She initially refused but once officers were present she did agree to take the medication. RN (Registered Nurse) [name] came down to assist with getting her back in her chair and giving her the medication. [R1] allowed writer to put her to bed without incident. Officers exited the building once she was in bed. The nurses note dated 10/24/22 documents [R1] continues to make attempts to leave the facility, stating that she doesn't want to be here because, they called the cops on me yesterday. One to one being provided at this time. Case Manager [name] contacted, no answer and message left. Psychologist [name] called. He attempted to redirect the behavior as well but was unsuccessful. [Name] states that he will come to the building as soon as possible. Call placed to Guardian [name], no answer, message left. MD contacted and updated. The social service note dated 10/24/22 documents Writer observed [R1] yelling and attempting to leave the unit. Extremely difficult to redirect. Combative with staff during redirection. Refusing oral medications. One to one attempted throughout the day. She had pockets of calm and then back to anger and combativeness. Her Psychotherapist [name] did visit this morning and he too had difficulty with redirection. The Crisis team was called and is going to bring in a Psychologist that is familiar with her from the Milwaukee County Mental Health that is familiar with her to come over assist the facility with redirection. The nurses note dated 10/24/22 documents Milwaukee County Crisis Team onsite with resident earlier in the shift. Resident once again began to escalate shortly after Crisis Team left the facility. Resident once again screaming, kicking, hitting and biting staff and herself. Resident making numerous attempts to leave the facility and go out into the street. Very difficult to redirect. Activity distractions, offers of snacks/treats, verbal cues ineffective. Resident continues to physically attack staff who are attempting to take her back to the 2nd floor. Resident putting her hands in between the closing elevator doors and grabbing onto the doors, putting herself at risk for smashing her hands. Staff had to pry her hands off of the doors. Resident moved to the 2nd floor dining room in attempts to keep her and other residents safe. Resident had grabbed a large handful of the ST's (speech therapist) hair and was pulling hard, along with pummeling her in the face. This writer intervened to loosen her grip on the ST's hair. Resident bit this writer 2 times on the right forearm and both times breaking the skin and causing severe bruising. Resident's mouth had to be pried off this writer's arm. Resident slamming her head, kicking at, and pounding with her fists at the dining room doors, in attempts to break the glass. Resident continues screaming and cursing. Resident noted to be biting herself and tearing at her skin. Pea sized open area noted to her left forearm. Resident trying to slide her fingernail under the open skin in order to tear her skin off her arm. Security guard on site and in to assist this writer with resident. Resident continues aggressively striking out and attempting to bite staff. Resident did intentionally put herself onto the floor from her wheelchair. Wheelchair removed from the room for her safety. Resident now crawling on the floor and again pounding her fists against the glass doors in attempts to break the glass. Resident also grabbing at guard's ankles and trying to trip him and bite him. MPD (Milwaukee Police Department) & paramedics on site and in with resident to assess her. Was informed by MPD that she will be removed and taken to [name of hospital] for evaluation and treatment. Resident removed from the facility shortly before 5 pm. The whole incident occurred over the course of about 3 hours. [Name of physician] updated. The nurses note dated 10/24/22 documents Late entry: (1600) (4:00 p.m.) Resident con't (continued) yelling and being disruptive. Staff was unable to redirect resident. Constantly making an attempt to get on elevator. Eventually resident took meds after refusing several times. Noted physical aggression towards staff scratching and hitting staff. Resident was transferred to [name of hospital] ER (emergency room ). Report given. The nurses note dated 10/25/22 documents Resident returned to facility by [name of] Transportation via w/c (wheel chair). Resident unable to redirect upon admission, insisting on going outside. Resident was taken to room and transferred to bed for body check. Skin intact with bruising or swelling noted. Resident c/o (complained of) pain to left arm. No further bx (behavior) noted at this time. 132/100 100 24 T (temperature) 98. The nurses note dated 10/29/22 documents Writer was called to the dining area at 0920 (9:20 a.m.) and noted resident rolling in w/c trying to grab and bite CNA (Certified Nursing Assistant) who was working with the resident 1:1. Resident attempted to grab other residents as they passed by. All resident were removed from the dining room and resident was taken out of the W/C to sit on the floor. Resident then scooted on buttocks to writer, a resident and another CNA swiped at all with both arms. Resident then was noted scooting to dining room doors pounding on the glass panels. Writer then proceeded to call 911 to report residents uncontrollable behavior. Writer went back to dining room noting the resident trying to kick CNA. Writer stated the police was called and resident replied I don't give a [expletive]. Resident then scooted to the window dragging a dining chair and began pounding the glass windows. Resident screaming I don't want to be here. Writer notified the Director of Nursing as well. Police arrive and noted resident hitting the writer, the glass window, and tried to scoot to the elevator sating she was leaving. Officer [name] stated there was nothing that they can do because resident has not committed a crime. The officers left at 0941 (9:41 a.m.). Writer contacted Dr. [name] and updated on the events. Dr. [name] stated staff should not give the resident the attention that she is seeking with the negative behavior displayed. MD ordered to administer PRN (as needed) [MEDICATION(S)] that is ordered and NOR (new order received) for one time dose of [MEDICATION(S)] 2 mg (milligram)/ml (milliliter) via IM (intramuscular). Writer contacted the guardian and updated on events and NOR (new order received). Guardian, [name] stated she doesn't know what to do but to let resident know that she isn't mad and to try to calm down and look forward to the birthday celebration next week. Writer stated to resident what [name of Guardian] stated on phone. Resident agreed to take PRN [MEDICATION(S)] by mouth. The nurses note dated 10/29/22 documents Resident continue to try to scoot to the elevator to leave. Writer administered the one time dose of [MEDICATION(S)] via IM. Will continue to monitor PPOC (per plan of care). The nurses note dated 10/29/22 documents Resident was noted to calm down and take a nap between 1245 and 1315 (1:15 p.m.). Resident awakened and began to scream I want to leave and attempted to go to the elevator. Resident continues to swing at staff who are redirecting. Writer received a follow up call from Dr. [name]. Dr. [name] was updated. Writer was directed to have staff not give attention to the negative behavior. Writer explained to the resident that because staff cannot redirect her while she is outside that she cannot be taken outside for the next day. Dr. [name] also suggested offering PRN (as needed) [MEDICATION(S)] 30 mins (minutes) before the resident has to come back in. Staff will try the intervention given. Will monitor PPOC. The nurses note dated 11/8/22 documents Resident alert responsive. Remains on 1:1. Resident began yelling at the beginning of the shift, requesting to get up. After resident was up in w/c she attempted to get on the elevator, screaming at staff, and unable to redirect. Resident then preceded to get on elevator and went down ramp. Resident was assisted back to floor. The social service note dated 11/8/22 documents, As writer entered the facility this morning around 8 a.m., [R1] was observed at the front desk attempting to leave the building. The activity staff member was trying to calm her down and told her that she would take her outside but she needed to work on one thing first and she would take her in about 5 minutes. [R1] began to yell and scream and started bucking in her chair, almost causing the chair to tip backwards. Writer intervened and allowed [R1] to go outdoors, Writer assisted her down the ramp and into the smoking area. At this time there were no residents present, however the unit manager was also outside to assist writer if any additional support was needed. [R1] attempted to roll her chair into the parking lot screaming, I'm leaving. Writer walked along side of her and continued to stress to [R1] that her team continues to work on finding her placement. When asked where she is going, she states to my friends house. I am going to go on the freeway. After several minutes of reasoning with [R1] she began to get cold and allowed writer to bring her back in the building. She was brought up to the social service office and offered breakfast. She refused. After being in the office about 5 minutes she began to yell and scream again, I don't want to be here. I want to leave. Writer made a call to her case manager [name] to find out how her team was doing with placement. Per [name], she was working from home and was ill. She needed to reach out to her team and get an update. After speaking with [name], writer contacted her guardian [name] to try to speak with [R1] and calm her down. After [R1] was unhappy with the conversation with [name of guardian], she attempted to push the phone off the desk. Writer ended the call with [name] and let her know that writer will update her late. [R1] continued to be behavioral for at least 2 more hours before she finally settled down. During the process she continued to make attempts to destroy things around the office. Once she was settled down she agreed to eat lunch and was given a hamburger and a soda. After lunch she went to activities staff members and was taken to be changed before they went to activities. She stayed with the activity staff until approximately 5 p.m Writer was not informed of any further incidents over the rest of the evening. The nurses note dated 11/9/22 documents Writer received a call from Team leader, writer informed that resident had struck a peer multiple times about the head and also struck a staff, once writer arrived on the unit resident was in her room yelling and cursing, SS (social service) notified, Crisis team call, no agent available, operator stated that someone will give writer a return call, call placed to 911 for officer assistance, 911 stated someone should be here shortly. NHA (nursing home administrator) aware. The social service note dated 11/9/22 documents, Writer received a call from the facility at approximately 8 a.m. stating that [R1] had attacked another resident and scratched his face up. Once writer entered the facility [R1] could be heard yelling and screaming from the second floor. The social service assistant responded to the unit and was going to do one to one with her but the Activity aide was in the process of attempting to take her for a walk and try to calm her down. Within minutes the Activity aide called for the Social service assistant to come get [R1] because [R1] had hit her. The social service assistant brought her up to the social service office to sit with writer. Once in the office [R1] continued to scream, throw things, attempt to damage property. Once she could not wheel around the room the way she wanted to, she put herself on the floor to continue to slide around attempting to grab anything within reach. She started screaming, I want to die, I want to die. She grabbed a trash can and pulled out a plastic grocery bag that was in the trash can and put it over her face. Writer and Social service assistant was able to tear the bag and remove it immediately. She then proceeded to bang her head against the concrete floor. The 911 call was made by the unit manager. The unit manager had already contacted the crisis team for assistance when the behaviors initiated with the attack on the peer. Once police arrived [R1] calmed down for a few minutes but was still very agitated and attempting to destroy things. Police indicated that they were unable to assist us and that the MD would need to try to have her sent to [name of hospital] or [name of hospital] to their Psychiatric unit. MD was notified and face time was done. He observed some of the behaviors [R1] was displaying and requested that writer contact 911 and have her sent to [name of hospital]. Writer contacted [name of hospital] and they stated that they did not have any available beds. MD then suggested to sent to [name of hospital]. 911 called for ambulance transport. During the waiting period for ambulance to arrive, [R1] continued to display aggressive and destructive behaviors, unable to be redirected. Her Psychotherapist arrived and attempted to calm her down. She was calm briefly with him and once he left the room she continued with the behaviors. Once ambulance arrived, she would not allow the drivers to properly secure her to the gurney. Police had to be called into the building before she would allow them to properly secure her. Guardian was notified during this process and informed of the suicide attempt and that the facility was sending her out to [name of hospital]. Her case manager [name] was updated as well. Report called into [name of hospital] ER (emergency room ) and spoke with nurse [name]. She was informed that the guardian gives consent to admit. Guardian information provided. The nurses note dated 11/9/22 documents Late entry (0730) (7:30 a.m.). CNA (Certified Nursing Assistant) stated to writer that resident wanted to get up in w/c while CNA was doing cares on roommate. Writer told resident that she would have to wait for a few minutes. Resident preceded to move self to edge of bed attempting to reach for w/c, after writer moved w/c, resident began to hit at writer and swearing at writer and CNA. Writer tried to assist resident to edge of bed and resident to hit at writer. CNA transferred resident to w/c, resident propelled self down hallway, trying to hit staff members. Resident eventually came to nrsg (nursing) station continued to swear at staff. Grabbed resident [room number] arm and tried to hit resident. Resident was difficult to redirect. Refused to go into dining room and tried to get on elevator. Later resident was seen hitting [room number] in the face with closed fist. Resident then attempted to hit [room number]. UM (unit manager) was notified at this time. The nurses note dated 11/9/22 at 5:03 p.m. documents Resident returned from [name of hospital], resident immediately began screaming, I do not want to be here, Social service in room with resident. The nurses note dated 11/9/22 documents Resident pulled TV down and flipped dresser over, furniture removed from room. The nurses note dated 11/10/22 documents Dr. [name] called to update orders for resident. [MEDICATION(S)] increased to 200 mg for evening dose and 50 mg twice daily. The nurses note dated 11/10/22 documents Resident alert responsive. Remains 1:1. Resident was redirected at the beginning of the shift. Up in w/c attempting to hit at staff. Resident up at nrsg (nursing) station yelling and put self on the floor and crawl to nrsg station, refusing to get in w/c. Resident received scheduled meds and PRN (as needed) [MEDICATION(S)]. Refused breakfast but had lunch. No further aggression noted at this time. The social service note dated 11/10/22 documents Writer received a call at 6:15 a.m. stating that [R1] had destroyed her room and was scooting down the hallway with no clothing on. She was yelling and screaming she wanted to go with the scheduler. Nursing assistant got her dressed and in her chair. The scheduler came to get her and brought her down to her office. Once calmed down she was taking back upstairs to her 1:1 and once the Scheduler left the unit, she began to yell and scream again. Social services took over the 1:1 9:45. She eventually calmed down within the hour and was able to continue with her day. On 11/11/22 at 12:02 p.m. Surveyor spoke with CNA-P regarding R1. CNA-P informed Surveyor she used to take care of R1 when R1 was in elementary school. CNA-P informed Surveyor on Saturday R1 was assigned to CNA-T. Surveyor inquired if this was on Saturday, October 29th. CNA-P indicated it was. CNA-P explained CNA-T took R1 outside and MRD (Medical Records Director)-U was at the front desk. CNA-P indicated she heard MRD-U say she's fighting her. CNA-P informed Surveyors she went outside as she's had special needs training. CNA-P informed Surveyor after she went outside and wheeled R1 backwards into the building. There was another Resident outside the elevator who she told not to come into the elevator but the resident did. CNA-P informed Surveyor after she got to the floor she took R1 into the small room inside the dining room as there were residents eating. Surveyor asked CNA-P to show Surveyor this small room. Surveyor then accompanied CNA-P into the small room inside the dining room. CNA-P informed Surveyor she took R1 out of her wheelchair and put R1 onto the floor because when R1 is in her wheelchair she is dangerous, very dangerous. CNA-P then indicated she got two chairs and placed them in front of the door so R1 couldn't get out and get to the other residents. CNA-P informed Surveyor R1 started beating her head on the windows in the small room and was hitting her head on the heater. Surveyor observed this heater which has a large metal cover. CNA-P informed Surveyor she removed R1's glasses so they wouldn't break. CNA-P informed Surveyor LPN-S came in and said she called DON (Director of Nursing )-B and explained to him what was happening. CNA-P informed Surveyor she along with another resident were sitting in the two chairs she placed in front of the door way but R1 managed to wiggle through the chairs. Once in the dining room R1 started turning over tables, dragging chairs and was biting on the leg of a chair. CNA-P informed Surveyor the police came and said they were not taking her. CNA-P informed Surveyor R1 was banging her head on the dining room door windows so she took her (R1's) feet and pulled her (R1) back into the small room where she started to bang her head on the heater & windows. CNA-P informed Surveyor she ask staff to move the residents in the dining room so R1 wouldn't hurt any residents. CNA-P showed Surveyor the windows on the dining room doors R1 was banging her head on. Surveyor observed there are two french style doors with wood panels which go across and the length with glass panes inside the wood panels. CNA-P informed Surveyor she didn't grab R1 by her shoulders but grabbed her (R1's) ankles and pulled her (R1) into the small room leaving R1 on the floor in the small room. CNA-P informed Surveyor she didn't know what to do but didn't want R1's face going through the glass on the door. CNA-P informed Surveyor this went on from 9:00 a.m. until about 3:30 p.m. CNA-P informed Surveyor they haven't had any training and she did go down to speak with DON-B about R1's behavior telling him someone is going to get hurt. CNA-P informed Surveyor the only thing she knew was that she didn't want R1's face or hands going through the glass and she didn't know how to stop it. Surveyor asked if the nurses were there when she dragged R1. CNA-P replied no. Surveyor asked CNA-P after she dragged R1 into the small room, did she place R1 in her wheelchair. CNA-P replied no that's when she is dangerous. CNA-P informed Surveyor there is no training here that's why we got scratched and they have residents admitted to the facility without any training to the staff. CNA-P informed Surveyor CNA-T was suppose to have R1 but she was scared. CNA-P informed Surveyor the nurse called the Social Worker, the Social Worker said what do you want me to do, I could just sit with her but nobody came. CNA-P then informed Surveyor she and the nurse had to hold R1 down because the nurse gave her a shot in the hip. CNA-P informed Surveyor she didn't know what kind of a shot but they had to restrain her. Surveyor inquired who the nurse was that administered the shot to R1. CNA-P stated the first name of LPN-S. Surveyor asked how they restrain R1. CNA-P informed Surveyor she held her hands and LPN-S held onto her ankles because she had to give it in her hip. Surveyor asked CNA-P how LPN-S administered the shot if she was holding onto both ankles. CNA-P explained when LPN-S was giving the shot she held onto one of R1's ankles. CNA-P informed Surveyor R1 said she (CNA-P) hit her and she was suspended for 2 days. Surveyor asked CNA-P if she hit R1. CNA-P replied no I didn't hit her, I dragged her (R1)by the ankles so her face wouldn't go through the glass. CNA-P informed Surveyor R1 told her she was going to tell SSD (Social Service Director)-J she hit her. CNA-P informed Surveyor she did the best she could do to prevent R1 from hurting her, other residents and herself that's why she placed R1 on the floor. Surveyor asked CNA-P if she has received any training on how to handle R1 when she is having behaviors. CNA-P replied absolutely not. On 11/11/22 at 2:12 p.m. Surveyor Administrator-A, Corporate Consultant-C & Regional Clinical of Operations-D who reviews potential admissions. Surveyor was informed they have an admission liaison who sends referrals to Corporate Consultant-C, Administrator-A, Social Service Designee-I, Social Service Director-J, MDS (minimum data set), Business office, DON (Director of Nursing)-B and LPN (Licensed Practical Nurse) Manager-W. Surveyor was informed DON-B has the final decision as to whether the Facility can handle a Resident. On 11/11/22 at 2:17 p.m. Surveyor spoke to SSD (Social Service Designee)-I regarding R1. Surveyor inquired if he was involved with R1's admission. SSD-I informed Surveyor he didn't think he was involved in R1's admission. SSD-I then looked at his computer and informed Surveyor this one was MD (Medical Director)-V's referral and as a team they didn't review R1's referral. Surveyor inquired after R1's suicide attempt was there an assessment completed. SSD-I explained there isn't an assessment but a care plan. SSD-I indicated if the resident does not have a (suicide) plan the resident is referred to psych and if there is a plan they try to get the resident out. Surveyor asked SSD-I if he has any involvement with R1. SSD-I explained when R1 was first admitted there were no issues, R1 was a typical resident. SSD-I informed Surveyor about three or four weeks ago R1 had a visitor over the weekend that R1 called her sister although SSD-I indicated he didn't think it was her real sister. SSD-I informed he thinks the issue is R1 wants to go with her sister and this is when the behavior started. SSD-I informed Surveyor R1 started cursing, putting herself on the floor, kicking, screaming and once she calms down R1 will say she is sorry. SSD-I informed Surveyor he doesn't think R1 has mental illness but is looking for someone to trust. Surveyor asked SSD-I what is being done so R1 doesn't hit, bite or scratch staff or other residents. SSD-I informed Surveyor put R1 in a room by herself or keep R1 at arm length away from others. SSD-I informed Surveyor they removed the garbage can so there aren't any garbage bags in R1's room, took the dresser away as there is a closet to hang R1's clothing. Surveyor inquired when this was done. SSD-I informed Surveyor Wednesday night R1 tried to use the dresser as a weapon and Tuesday put a plastic bag over her face and stated she [TRUNCATED]

Based on observation, record review, and interview, the facility did not have sufficient staff with appropriate competencies and skill sets to provide direct nursing and related services to assure resident safety and for each resident to attain or maintain their highest practicable physical, mental, and psychosocial well-being for 2 of 3 residents (R) reviewed (R1 and R2) who have a history and/or diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . *R2 leaped from a second story window after experiencing delusions and hallucinations. Prior to this, R2 had been on 15 minute checks for wandering in/out of other Resident rooms, and was not on behavioral monitoring for being on [MEDICATION(S)], an anti-psychotic, or for the wandering behavior. R2 sustained a [CONDITION(S)] and was hospitalized for status seizures. *On [DATE], R1 was screaming, hitting, biting staff, and attempting to leave the Facility. The Milwaukee police crisis team was notified and R1's physician ordered [MEDICATION(S)] 50 mg (milligrams). On [DATE], R1 was screaming, kicking, hitting, pulling hair, and biting staff & herself. R1 was slamming her head, kicking at and pounding her fists on the dining room doors in an attempt to break the glass. This behavior occurred over a period of 3 hours. Police were notified and R1 was transferred to the hospital, returning the next day. On [DATE], R1 was outside attempting to hit the Certified Nursing Assistant (CNA) who was with her. R1 was brought back inside the Facility and taken to a small room located inside the dining room. CNA P placed R1 on the floor. CNA P informed Surveyor she (R1) was dangerous to staff & residents when she was in the wheelchair. CNA P stated R1 was hitting her head on the windows & heater inside the dining room so CNA P placed two chairs in the doorway to prevent R1 from scooting into the dining room. R1 wriggled her way through the chairs and entered the dining room, turning over tables & chairs. R1 then started banging her head on the glass panels of the doors leading into the dining room. CNA P stated she didn't know what to do so she grabbed R1's feet and dragged her on the floor back into the small dining room in order to prevent R1's face from going through the glass. Licensed Practical Nurse (LPN) S indicated the police were called as staff did not know what to do. R1's physician was notified and ordered [MEDICATION(S)] PRN (as needed) by mouth and [MEDICATION(S)] IM (intramuscular). In order to administer R1's [MEDICATION(S)], R1 was held down by CNA P & LPN S. On [DATE], R1 was taken outside to the smoking area. R1 then attempted to go into the parking lot and was yelling that she wanted to leave. R1 was taken to the social service office where she attempted to throw the phone and attempted to destroy other things in the social service office. According to the social service notes, this behavior continued for more than 2 hours. On [DATE], R1 hit & scratched R4 in his head along with hitting staff. R1 was brought to the social service office where she continued to yell, throw things, and attempted to place herself on the floor. R1 started screaming she wants to die, grabbed a trash can, pulled out a plastic garbage bag, and placed the garbage bag over her head. The garbage bag was removed by social service staff and R1 then proceeded to bang her head against the concrete floor. R1's physician was contacted and R1 was transferred to the hospital returning later that same day ([DATE].) After R1 returned from the hospital, R1 flipped over the TV & dresser in her room. R1 was transferred to another room with the furniture being removed except for a closet. Surveyor observed that after R1's suicide attempt, the window blind cord in her room was hanging down, along with the call light cord and light string. R1's behavior care plan did not include specific interventions for R1's behavior and was not updated to include R1's suicide attempt. Multiple staff interviewed revealed staff had been educated on how to deescalate Residents behavior in August but did not know how to handle R1's behavior and had not been trained on her behavior. The facility's failure to follow through on their facility assessment to have the Interdisciplinary Team (IDT) review R1 to determine the feasibility of R1's admission and competency needed by staff to provide care and staff not implementing person-centered care approaches designed to meet the individual needs of R1 and R2, including developing and implementing non-pharmacological interventions created a finding of immediate jeopardy that began on [DATE]. Administrator A was notified of the immediate jeopardy on [DATE] at 4:50 pm. At the time of exit on [DATE], the immediate jeopardy was not removed. Findings include: Surveyors reviewed the facility's assessment last reviewed [DATE] to determine the need for staff with skills and competencies in order to provide nursing and related behavioral health services to maintain safety for R1 and R2. .Purpose The purpose of the assessment is to determine what resources are necessary to care for Residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the Residents in your facility. Using a competency-based approach focuses on ensuring that each Resident is provided care that allows the Resident to maintain or attain the highest practicable physical, mental, and psychosocial well being. The intent of the facility is for the facility to evaluate its Resident population and identify the resources needed to provide the necessary person-centered care and services the Residents require. The assessment is organized in three parts: 1. Resident profile including numbers, diseases/conditions, physical and cognitive disabilities, acuity, and ethnic/cultural/religious factors that impact care 2. Services and care offered based on Resident needs(includes types of care your Resident population requires) 3. Facility resources needed to provide competent care for Residents, including staff, staffing plan, staff training/education and competencies, education and training, physical environment and building needs, and other resources, including agreements with third parties, health information technology resources and systems, a facility-based and community-based risk assessment, and other information that you may choose The facility assessment indicated that the facility accepts Residents with Psychiatric/Mood Disorders such as [CONDITION(S)] (Hallucinations/Delusions), Impaired Cognition, Mental Disorder, Depression, [CONDITION(S)] Disorder ([CONDITION(S)]/Depression), [CONDITION(S)], Post-Traumatic Stress Disorder, Anxiety Disorder, Behavior that Needs Interventions. The facility is also able to accept Residents with [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], Multiple [CONDITION(S)], Alzheimer's Disease, Non-Alzheimer's Dementia, [CONDITION(S)] Disorder, [CONDITION(S)], TIA, Stroke, Traumatic Brain Injuries, [CONDITION(S)], Down's Syndrome, Autism, [CONDITION(S)] Disease, [CONDITION(S)] Syndrome, [CONDITION(S)], [CONDITION(S)]. The Interdisciplinary Team (IDT) meets to review referrals to determine feasibility of the admission. Disease processes and the need for staff education is reviewed. Policies and procedures are reviewed for staff education when new clinical techniques are needed for deliverance of Resident's care. Staffing patterns are considered. When additional or specialized education and/or resources are needed, the facility may consult with ancillary providers for support. There is a higher manifestation of mental health, substance abuse, and other psycho-social issues in our present (and past) Resident population due to the inner city setting of the facility. The average age of the facility's Resident population is younger than most other nursing homes. Combining these factors with significant co-morbidities resulting from life style choices results in unique staffing challenges. Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/[CONDITION(S)], other psychiatric diagnoses, intellectual or developmental disabilities. The Resident population and census is routinely reviewed for sufficient staffing. Resident behaviors can require constant monitoring and reporting. Alcohol use by the Residents (despite being heavily discouraged) continues to be an ongoing issue. 483.70(e) Facility Assessment Behavioral Health Services 483.40(a) The facility must have sufficient staff who provide direct services to Residents with the appropriate competencies and skills sets to provide nursing and related services to assure Resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each Resident, as determined by Resident assessments and individual plans of care and considering the number, acuity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -These competencies and skills include, but are not limited to knowledge of and appropriate training and supervision for:483.40(a)(1) Caring for Residents with mental and psychosocial disorders, as well as Residents with a history of trauma and/or post-traumatic stress disorder, that have been identified in the facility assessment conducted pursuant to 483.70(e). 483.95(i) Behavioral Health. A facility must provided behavioral health training consistent with the requirements at 483.40 and as determined by the facility assessment at 483.70(e) . Surveyor reviewed the facility's Elopement Prevention policy and procedure dated [DATE] and noted the following: .Purpose: To create an environment that is as safe as possible for Residents that are at risk for elopement, while allowing them to move about the facility freely. Policy Statement: It is a policy of this facility that all Residents are afforded adequate supervision to meet each Resident's nursing and personal care needs. All Residents will be assessed for behaviors or conditions that could potentially place them at risk for elopement. All Residents so identified will have these issues addressed in their plan of care. Routine Procedures for the Prevention of Missing Residents and Elopements: Upon admission, re-admission or the development of elopement behaviors, all Residents will be assessed for elopement risk utilizing the Elopement Risk Assessment form. Residents identified as at risk for elopement will be reassessed quarterly and with a significant change of condition in conjunction with the MDS schedule . 1. Surveyor reviewed R2's hospital discharge summary dated [DATE] and noted that R2 was originally admitted to the hospital with behavioral concerns. On this hospital admission, R2 had a very prolonged and complicated hospital course. R2 had severe [CONDITION(S)] and agitation for which multiple adjustments were made with R2's psychiatric medication. At time of discharge ([DATE]) R2 was showing evidence of being very improved. Additionally, Surveyor reviewed an undated hospital Social History and Psychosocial Assessment which documents that R2 was having hallucinations and delusions and was on [MEDICATION(S)] to assist in the management of behavior symptoms. R2 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], R2's Health Care Power of Attorney (HCPOA) was activated. Surveyor reviewed R2's nursing progress notes and noted the following: [DATE], 4:36 PM-Attempting to get out of bed [DATE], 7:46 PM-Remains impulsive and needs redirection as he is unsteady on his feet. Needed reorientation to his room frequently when up in wheelchair [DATE], 8:03 AM-R2 had to be redirected and reintroduced on how to utilize call light [DATE], 5:41 PM-R2 remains impulsive, attempting to get out of bed but is too weak to follow through. [DATE], 6:34 PM-Alert at times and will follow directions but remains somewhat impulsive with periods of lethargy. [DATE], 9:13 PM-R2 observed roaming in other Residents rooms. Placed on 15-minute checks. [DATE], 2:47 PM -15-minute checks were started today. Surveyor reviewed R2's Admission Data Collection and Baseline Care Plan dated [DATE], noting the baseline care plan was not completed within 48 hours of admission. Surveyor noted the following on the Admission Data Collection and Baseline Care Plan: 11. Did a complete drug regimen review identify potential clinically significant medication issues? -Not assessed/no information 9. What Mood best describes the Resident? -Wanders mentally 10-f Anti-Convulsant/Mood Stabilizer Planning: Interventions: Monitor side effects and effectiveness every shift. Monitor: May cause dizziness, drowsiness, sedation, fatigue, confusion, impaired cognition, agitation, dry mouth, nausea, vomiting, constipation, anorexia, tremor, incoordination, blurred vision, worsening of mood, emotional lability, depression, suicidal thoughts, hallucinations, [CONDITION(S)], bruising, fever, liver and blood abnormalities, rash, pancreatitis, ataxia, possible falls, subdued behavior, withdrawal compared to baseline. An Admission Summary Progress Note dated [DATE] and located in the Admission Data Collection and Baseline Care Plan Tool documented: Alert at times with transient ability to follow direction and periods of lethargy. Surveyor reviewed the facility Social History and assessment dated [DATE] which documents that R2 in the past has had depression and has taken medications. Surveyor reviewed the facility Screening for Aggressive/Harmful Behavior dated [DATE] and noted the following was documented as being a moderate problem: 1. General awareness, insight, judgment, reasoning, memory and orientation. 2. Diagnosis(es) of severe mental illness, e.g., [CONDITION(S)], major depressive disorder, [CONDITION(S)], antisocial personality disorder, etc. 3. History of substance abuse. Substance abuse with recent relapse. 4. History of criminal behavior with coding of moderate problem for felony arrest, serious infractions, h/o of incarceration, etc. Surveyor reviewed the facility Brief Trauma Questionnaire dated [DATE] and noted that R2 answered yes to the question: Have you ever been in any other situation in which you were seriously injured, or have you ever been in any other situation in which you feared you might seriously injured or killed. Review of R2's comprehensive care plan notes the following applicable to R2 and behavior management: R2 is on a mood stabilizer/anti-convulsant therapy due to [CONDITION(S)] Initiated: [DATE] -Administer mood stabilizer/anti-convulsant medication(s) as ordered by physician. Monitor side effects and effectiveness every shift. Initiated: [DATE] -Monitor: May cause dizziness, drowsiness, sedation, fatigue, confusion, impaired cognition, agitation, dry mouth, nausea, vomiting, constipation, anorexia, tremor, incoordination, blurred vision, worsening of mood, emotional lability, depression, suicidal thoughts, hallucinations, [CONDITION(S)], bruising, fever, liver and blood abnormalities, rash, pancreatitis, ataxia, possible falls, subdued behavior, withdrawal compared to baseline. Initiated: [DATE] Potential for anxiety due to traumatic life event (Specify: delusions of being shot by a famous rapper T.I.) Initiated: [DATE] -Administer medications appropriately and monitor the side effects or dependence Initiated: [DATE] -Assess anxiety level to determine severity of condition and course of treatment or therapy Initiated: [DATE] -Determine other psychological effects, change in mood/affect Initiated: [DATE] Surveyor reviewed the facility Elopement Risk Evaluation dated [DATE] which documents R2 was not risk for elopement. However, Surveyor notes that R2 was put on 15-minute checks on [DATE] for wandering in/out of other Resident rooms. An Elopement Risk Evaluation was not completed given the new behavior of wandering. The facility did not assess R2's wandering behaviors to determine a root cause analysis as to the reasoning for R2's wandering. Surveyor reviewed R2's active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] Tablet 200 mg every 12 hours by mouth related to seizures. Side effects: May cause blurred vision, double vision, clumsiness, unsteadiness, dizziness, drowsiness, sleepiness, or trouble sleeping -[MEDICATION(S)] Tablet 750 mg every morning and bedtime related to other seizures. This medication is prescribed for mood and behavior changes and irritability. -[MEDICATION(S)] Tablet 3 mg Give 1 tablet at bedtime for sleep aid (The facility was unable to provide documentation that a sleep study was implemented.) -[MEDICATION(S)]-25 mg-Give 1 tablet in the morning related to [CONDITION(S)] (No behavior monitoring was completed as the medication was being tapered down.) **Of note, [MEDICATION(S)] is used to treat certain mental/mood conditions (such as [CONDITION(S)], [CONDITION(S)] disorder, sudden episodes of [CONDITION(S)] or depression). This medication can decrease hallucinations and improve concentration. -Controlled substances: -[MEDICATION(S)] 1 mg 3 times a day -[MEDICATION(S)] 10 mg every 12 hours -[MEDICATION(S)] 0.5 mg 1 time a day All 3 medications can cause paranoid or suicidal ideation and impair memory, judgment, and coordination. -[MEDICATION(S)] 0.1 mg 1 tablet by mouth 3 times a day-side effect is anxiety. Surveyor noted there is no facility documentation that behavior monitoring for any side effects of the above medications was being completed for R2. On [DATE], R2 was discharged from the facility to the hospital and admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor reviewed the facility's self-report for R2. According to the facility's self report, on [DATE] at 11:40 PM, the following is documented: R2 climbed out of the window of R2's bedroom on the second floor of the facility. Despite staff attempting to grab R2 to prevent R2 from climbing out, he fell to the ground. R2 was attempting to crawl away from staff and made the statement that R2 had to 'get out of the place' because R2 did not know what they were going to do to R2. The facility initiated a self-report based on the statement R2 made about needing to leave the building for unknown reasons. R2's demeanor demonstrated a paranoid appearance at the time of the event. The initial report documents that at 11:30 PM, R2 jumped out of his 2nd floor bedroom window. Surveyor reviewed the hospital discharge summary dated [DATE] which documents that R2 was admitted with new onset [CONDITION(S)] and paranoia and [CONDITION(S)]. R2 stated to the hospital that he went out the 2nd story window after feeling he was going to get shot and someone was after him. While at the hospital, R2 had stated that R2 felt the staff was trying to kill him. On [DATE], R2 returned to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 expired in the facility on [DATE]. Surveyor reviewed R2's Admission Minimum Data Set (MDS) dated [DATE] and noted the MDS documents that R2 had both short and long term memory impairment and demonstrated moderately impaired skills for daily decision making. R2's Patient Health Questionnaire (PHQ-9) score was 5, indicating R2 had some mild depression. R2's MDS does not document any behaviors, however, it is noted the MDS assessment was completed after R2 returned from the hospital on [DATE]. R2 did not transfer out of bed. R2 required extensive assistance for bed mobility and total assistance for dressing. R2's care plan was updated on [DATE] to include: R2 demonstrates movement behavior that may be interpreted as wandering, pacing, or roaming into and out of Resident rooms related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Problems understanding the immediate environment and delusions. Symptoms are manifested by wandering/going in and out of other patient rooms. Initiated: [DATE] Interventions: -15-minute checks to be done on-going until R2 is adjusted, and behaviors have improved. Initiated: [DATE] -Assess for potential elopement/unauthorized departure risk Initiated: [DATE] -Make rounds/room checks per facility protocol to minimize chances of authorized leave Initiated: [DATE] -Post a picture of the Resident at/near the front desk and/or nursing station in a discrete place identifying possible elopement risk. Notify staff of risk potential Initiated: [DATE] -Use apply electronic monitoring device with appropriate consent (wanderguard) Initiated: [DATE] Surveyor reviewed R2's Bedside Kardex Report as of [DATE] and noted R2 was not being monitored for any behavioral signs and symptoms other than to determine other psychological effects, change in mood/effect which the facility was not documenting. Surveyor conducted the following interviews in regard to R2 and R2's behavior: On [DATE] at 11:40 AM, Surveyor spoke to social service designee (SS I) who stated that R2 had reported R2 had been shot by a famous rapper. SS I confirmed R2 had been shot at 1 point in R2's life. SS I stated that when R2 returned from the hospital to the facility after jumping from the window, R2 was a completely different person and was always sedated. On [DATE] at 12:13 PM, Surveyor interviewed Certified Nursing Assistant (CNA) G who tried to stop R2 from jumping from the 2nd floor window. CNA G stated that on [DATE], CNA G took R2 to his room and put R2 to bed at approximately 10:45 PM. R2 requested that he get laid down on the mattress on the ground next to the bed. CNA G stated that while CNA G was getting R2 ready for bed, R2 had a look of distance. CNA G described it as a wild look about him. CNA G stated that R2 did not speak and CNA G asked R2 if he was okay. CNA G stated CNA G got no answer. CNA G stated, Had a wild stare about him. CNA G stated CNA G went to take care of another Resident and heard a commotion and found R2 on top of the windowsill. CNA G went to grab for R2 and was trying to hold on to R2's ankles but R2 slipped out of CNA G's hands as R2 leaped out the window. CNA G stated CNA G looked outside the window but could not find R2. R2 was found crawling towards the busy street behind the facility. CNA G stated that CNA G had heard several times that CNA G had wanted to leave the facility. CNA G heard R2 tell the ambulance drivers that night, I have to go. CNA G stated that CNA G will never forget the look in R2's eyes when R2 leaped from the window. A look that will never go away. On [DATE] at 2:34 PM, Surveyor interviewed Registered Nurse (RN) F. RN F was aware that R2 was on 15-minute checks due to wandering in and out of other Resident rooms and stated it was a constant thing on RN F's shift which is second shift (2:30PM-10:30PM). RN F also stated that R2 had stated to staff when R2 returned (from the hospital) that R2 would jump out of the window again if R2 could. On [DATE] at 2:51 PM, CNA H informed Surveyor that R2 had talked about wanting to leave on a regular basis before the incident. On [DATE] at 11:10 AM, Surveyor interviewed Social Service Director (SSD) J. SSD J stated that during the initial interview, R2 stated R2 had been shot by a famous rapper. SSD J spoke to the hospital after R2 had jumped from the facility window and was informed that R2 stated R2 jumped from the window because people were after him. On [DATE] at 12:24 PM, Surveyor spoke to Licensed Practical Nurse (LPN) E who stated LPN E knew R2 well and worked with R2 on a regular basis. LPN E also worked the night that R2 leaped from the window ([DATE].) LPN E stated R2 had delusions and hallucinations from the day R2 arrived at the facility. LPN E stated LPN E was familiar with R2 going in/out of other Resident rooms and stated it was because R2 was having delusions and hallucinations that someone was after R2. LPN E stated R2 was anxious. LPN E stated R2 was hiding in other Resident rooms to get away from the person after R2. LPN E stated on [DATE], prior to R2 leaping from the window, R2 had been saying people were after him. On [DATE] at 12:28 PM, Surveyor spoke with Corporate Consultant (CC) C and shared the concern that there was no behavior monitoring for R2. Surveyor had requested documentation multiple times and the facility was unable to provide any behavior monitoring documentation. CC C stated that the facility was not doing any behavior monitoring for the [MEDICATION(S)] because the facility was tapering down the [MEDICATION(S)] which was the plan from the beginning. Based on facility assessment, the facility did not conduct behavior monitoring of R2's delusions/hallucinations or reasons for wandering despite staff knowing that R2 had delusions of the paranoid type. Staff did not have the training to identify signs and symptoms of delusions/hallucinations and thus put interventions in place to keep R2 safe and for R2 to attain or maintain their highest practicable physical, mental and psychosocial well being. 2. R1 is a [AGE] year old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 has a Legal Guardian. The hospital referral information dated [DATE] includes a physician note dated [DATE] which documents Patient seen examined. Was very agitated and trying to bite scratching and spitting on staff. 5 mg (milligram) [MEDICATION(S)] was given. The resident demonstrates behavioral distress Physical and Verbal aggression care plan initiated & revised [DATE] has the following interventions: * Allow a cool down period and return later. Initiated [DATE]. * Ask the resident to calmly explain what is causing this upsetting behavior. Praise the resident for speaking calmly and appropriately. Initiated [DATE] & revised [DATE]. * Assist her with calling family. Initiated [DATE] & revised [DATE]. * Explain to resident the obligation to treat others with dignity and respect at all times. Ask the resident to treat others as he/she would like to be treated. Initiated [DATE]. * If talking to the resident is not successful in stopping the behavior, try to walk with the resident to a quiet area, away from other individuals. Initiated [DATE] & revised [DATE]. * Include her Psychotherapist [name] for additional support. Initiated [DATE]. * Offer music when [R1] is feeling agitated. Initiated [DATE]. * Offer one to one time playing cards such as Uno, and listen to music. Initiated [DATE] & revised [DATE]. * Offer to take her outdoors when the weather permits. Initiated [DATE] & revised [DATE]. * Private room with minimal objects to destroy or throw. Initiated [DATE]. * When she is having aggressive behaviors, keep a safe distance of at least arms length between her and other residents. Initiated & revised [DATE]. The resident has a behavior problem Confabulations care plan initiated & revised [DATE] has the following interventions: * Administer medications as ordered. Monitor/document for side effects and effectiveness. Initiated [DATE]. * Anticipate and meet the resident's needs. Initiated [DATE]. * Assist the resident to develop more appropriate methods of coping and interacting such as talk therapy, one to one visits, music. Encourage the resident to express feelings appropriately. Initiated & revised [DATE]. * Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by. Initiated [DATE]. * Coordinate consistent team staff responses with the interdisciplinary team. Initiated [DATE]. * If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Initiated [DATE]. * Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Initiated [DATE]. * Provide a program of activities that is of interest and accommodates residents status. Initiated [DATE]. The resident has a history of self-harmful ideation and/or behavior care plan initiated & revised [DATE] has the following interventions: * As warranted conduct a room check/search and remove: Any sharp objects or similar contraband (razor blades, razor, knives, scissors, hammer, nails, screw driver, screws, needles, etc.). Alcohol/drugs including over the counter medications. Cleaning supplies (potentially poisonous solutions). Any other object that (in the opinion of health care professionals) may pose a threat to safety. Initiated [DATE]. * As warranted conduct/carry out (as situations occur): Daily monitoring and supervision of the resident. Room safety checks, personal wellness check. Mouth check during medication pass. Behavior monitoring of the resident, look especially for any change. Evaluation of mental status, mood state, thought content. Initiated [DATE]. * Conduct a psychiatric evaluation. Review the persons risk for harm. Initiated [DATE]. * Notify psychiatrist of any remarks made by resident regarding suicide. Initiated [DATE]. * S/S (social service) to meet with resident as needed. Initiated [DATE]. The admission MDS (Minimum Data Set) with an assessment reference date of [DATE] documents a BIMS (brief interview mental status) score of 8 which indicates moderately impaired. The total severity mood score is 10 which indicates moderate depression. R1 is coded as not having any behavior. R1 answered very important to the questions how important is it to you to listen to the music you like, how important is it to you to do your favorite activity, & how important is it to you to go outside to get fresh air when the weather is good. R1 requires extensive assistance with two plus person physical assist for bed mobility & toilet use, dependent with two plus person physical assist for transfers, does not ambulate and requires limited assistance with one person for eating. R1 is frequently incontinent of urine and always incontinent of bowel. The Behavior CAA (care area assessment) did not trigger. The Mood CAA dated [DATE] under analysis of findings is blank. Under care plan considerations documents Please see SS (social service) notes. The care conference summary dated [DATE] under Social Service review Mood/Affect/Behavior/Cognition/Communication, D/C (discharge) Plans, Concerns & goals documents Alert and oriented times 2. She has a BIMS (brief interview mental status) score of 8 and PHQ-9 score of 10. She has good long term memory recall. She understands that she is in a rehab facility. She has had some behaviors over the past 90 days both of verbal and physical aggression. Since her admission she has not shown any negative behaviors. She will be monitored in the behavior binder. Under [CONDITION(S)] Regimen (if applicable). Med (medication)/Dose/Purpose/Efficacy/Side Effects: Currently taking [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. She will be followed by the Psych NP (nurse practitioner). She has her own Psychotherapist that will visit 2 times a week. The nurses note dated [DATE] documents Upon entering unit, resident in hallway screaming, hitting and biting staff, resident bit security guard [name] right hand [TRU

Based on interview and record review, the facility did not ensure 1 (R12) of 5 Residents reviewed received medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. R12 demonstrated hypersexuality behavior upon admission. The facility failed to assess R12's sexualized behaviors to thoroughly understand R12's ability to consent. The facility did not develop and implement psychosocial interventions to address R12's pattern of sexual activity based on assessments and behavior demonstrated in the facility, thus limiting R12's ability to exercise her Resident Rights. This left R12 vulnerable and subject to potential sexual abuse. The facility's failure to assess R12's ability to consent to sexual activity - thereby hindering the facility in keeping R12 free from sexual abuse or from respecting her choices to engage in sexual activity - created a finding of Immediate Jeopardy, which began on 5/27/22. The facility failed to assess R12's sexualized behaviors on admission, did not create and implement an appropriate care plan with person centered interventions to protect R12 and promote R12's Resident Rights. On 8/18/22, at 5:45 PM, Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B and Corporate Consultant (CC)-E were informed of the Immediate Jeopardy. The facility removed the jeopardy on 9/1/22 ; however, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its removal plan. Findings Include: Surveyor reviewed the facility policy and procedure, entitled Resident-Rights Relationships, last reviewed 2/10/21, which documents: I. Policy: All Resident relationships, including those of a consensual intimate and sexual nature, should be respected, protected, and embraced by all while balancing that with the need to protect vulnerable Residents. II. Procedure: Assessment driven Interdisciplinary Team (IDT) decisions regarding a Resident's ability to consent to physical sexual expressions and appropriate response strategies will result in honoring Resident Rights while protecting all residents from sexual abuse and exploitation. A, The following four guidelines will be used as the basis for an assessment to determine a Resident's ability to consent to sexual contact. Depending on the uniqueness of situation, additional considerations might be appropriate. Assessment efforts should focus on the Resident revealing his/her understanding of the following four guidelines: 1. The Resident must understand the distinctively sexual nature of the of the conduct. 2. The Resident recognizes her/his body is private and that she/he has the right to refuse to engage in sexual activity. 3. The Resident recognizes the sexual contact may create possible health risks and physical consequences. 4. The Resident needs to understand that there may be negative social or societal response to the sexual behavior. B. Assessment protocols will include: History, Observations, Interviewing, Analysis, Care Planning, and Re-Assessment C. The IDT Decision Guide-Resident Ability to Consent to Physical Expressions will guide the IDT in further analysis of assessment protocol results in determining consent guideline responses, ability to consent, and appropriate response strategies. D. Care planning to address a Resident's sexual expression should be based on the information gathered in the assessment process and on the individual's ability, or lack of ability, to consent to sexual contact. The IDT Decision Guide-Resident ability to Consent to Physical Sexual Expressions will guide decisions and response strategies. E. Education regarding Resident Rights and Resident Relationships will be provided to Residents and their responsible party upon admission, reviewed through the Resident council meeting annually, or individually as needed. F. Education regarding Resident Rights and Resident Relationships will be provided to all employees upon orientation and annually thereafter. G. The Resident has the right to engage in any consensual relationship even if the relationship creates challenges to religious, doctrinal, family, or social beliefs, including pertinent privacy and confidentiality issues. H. The facility will honor all Resident Rights, all relationships and strive to make all Residents comfortable regardless of sexual identity. I. Agents under an activated Health Care Power of Attorney (HCPOA) are responsible to make health care decisions based on the preferences of the principal. A decision regarding intimacy or a sexual relationship by a consenting adult will often not involve a health care decision. A finding of incapacity does not automatically preclude a Resident from making all decisions and depending on ongoing assessment a Resident may maintain the ability to provide consent to an intimate or sexual relationship. On 8/18/22, at 11:17 AM, Surveyor was informed by Corporate Consultant (CC)-E the facility follows the Board on Aging and Long-Term Care recommendations and was provided a document outlining the recommendations and notes the following: Resident Rights Resident rights are the foundation for all decisions in long-term care organizations. Clearly, all Resident relationships, including those of a consensual intimate and sexual nature, should be respected, protected and embraced by all. Educating Residents, family members, HCPOA agents and guardians regarding the inherent rights of every Resident is imperative to assure all rights are respected, promoted, protected, while also balancing that with the need to protect vulnerable Residents. Definitions and Discussion of Terms Sexual Contact- the meaning of sexual contact for this policy is derived from the Wisconsin Sexual Assault Statue. A facility's regulatory obligation to protect vulnerable Residents from any form of abuse and the legal implications related to ability to consent are paramount when discussing sexual relationships. Consent- there are no definitions in Wisconsin statues that address the issue of consent as it relates to sexual contact in anything other than the context of criminal activity. Consent, as used in the Sexual Assault section of the Wisconsin, Status, means words or overt actions by a person who is competent to give informed consent indicating a freely given agreement to have sexual intercourse or sexual contact. The statue goes on to say the following persons are presumed incapable of consent, but the presumption may be rebutted by competent evidence: a person suffering from mental illness or defect which impair capacity to appraise personal conduct. Education Education should be provided to Residents at time of admission, at Resident council meetings and individually as needed, to ensure that they are aware of their right to maintain and develop all mutually consensual relationships, including those which are intimate or sexual in nature. Education should be provided to all employees upon orientation and annually regarding intimate and sexual relationships in the long-term care setting. Education provides staff with the knowledge and tools needed to address situations appropriately and with sensitivity. Given the complexity associated with Residents having sufficient capacity to consent it is imperative that there will be open dialog with health care agents, guardians, and family members. R12 was admitted to the facility on [DATE] with diagnoses that include: Unspecified Toxic [CONDITION(S)], Alcohol Use with Persisting Amnestic Disorder, Alcoholic [CONDITION(S)] of Liver with Ascites, Alcohol Use, Unspecified with Withdrawal [CONDITION(S)], Unspecified Symptoms and Signs Involving Cognitive Functions and Awareness, Attention-Deficit [CONDITION(S)] Disorder, Predominantly [CONDITION(S)] Type, Generalized Anxiety Disorder, and Major Depressive Disorder. At the time of admission, R12 was her own person. On 7/29/22, R12's Health Care Power of Attorney (HCPOA) was activated. Surveyor reviewed R12's Admission Minimum Data Set (MDS) assessment, dated 5/15/22, documents R12's Brief Interview for Mental Status (BIMS) score of 12, indicating R12 demonstrates moderately impaired skills for daily decision making; Personnel Health Questionnaire (PHQ-9) score of 10, indicates R12 has moderate depressive symptoms; no behavior concerns are documented; independent with bed mobility, toileting and transfers; requires supervision for dressing and hygiene. On 8/10/22, a BIMS assessment was completed again. R12's score was 13, indicating R12 was cognitively intact for daily decision making and a PHQ-9 score indicated moderately severe depressive symptoms. Surveyor reviewed R12's comprehensive care plan, which documents R12's memory is impaired. Consequently, R12 has problems with decision-making, insight, logic, calculations, reasoning, planning, and judgement. The problem is due to R12's diagnosis of [CONDITION(S)]. Initiated: 5/16/22 R12's care plan documents she is at risk for elopement, with impaired safety awareness, R12 wanders aimlessly. Initiated: 5/17/22 On 6/14/22, R12's care plan was updated to include a concern R12 exhibits sexually inappropriate behavioral symptoms related to: kissing, accusations of fondling, and accusations of fell ation. These behavioral symptoms are manifested by cognitive deficits and the lack of logical thinking. This focused problem was resolved on 7/12/22. On 7/7/22, R12's care plan was updated to include: R12 is alert, aware, and coherent and chooses to exercise R12's rights to engage in intimate/sexual relationship. Surveyor reviewed R12's progress notes, which document: On 5/12/22, R12 working with physical therapy and speech therapy. R12 has a lot of confusion and cognitive deficits. On 5/26/22, Working with physical and speech therapy. Severe cognitive impairment and forgetfulness. On 5/27/22, Writer called to R12's room. R12 was in male Resident's room. Both Residents were fully clothed. R12 redirected with no complications. Staff will continue to monitor. On 5/28/22, R12 is placed on 15-minute checks for exit seeking and sexual behavior with another peer. A psychiatric note on 5/31/22 indicates R12 was seen for an initial psychiatric evaluation with the chief complaint being wandering, confusion, memory loss and sexual inappropriate behavior (found in bed with male Resident). The evaluation also documents R12 has recent and remote memory impairment, thought and judgement is not intact. It is documented, based on impression, R12 has behavioral disturbance and is physically impulsive. On 6/5/22, R12 noted to be delusional. Bizarre statement noted. Redirection needed at times. On 6/6/22, Behavior Meeting: Sexualized behaviors. Severe history with alcohol. On 6/10/22, at 6:58 AM, Physician Progress Note-R12's confusion persists and R12 has cognitive impairment and suspected 12 [NAME]-Korsakoff Syndrome. (A condition caused by a deficiency of [MEDICATION(S)] or vitamin B1. Patients classically present with a clinical triad of ophthalmoplegia (paralysis of the extraocular muscles that control movement of the eye), altered mental status and ataxia (lack of muscle coordination). R12 has some underlying cognitive deficit otherwise walks around. On 6/10/22, at 6:11 PM, R12 found in bed with another Resident with R12's underwear off giving other Resident oral pleasure. R12 did not have on underwear. When asked what R12 was doing in another Resident's bed, R12's response was what we do all the time. R12 redirected without difficulty. R12 is currently on every 15-minute checks for inappropriate behavior. On 6/10/22, at 7:05 PM, R12 transferred to a different room. Psychiatric note on 6/20/22 indicates: R12 reports an increase in sleep, decrease in appetite. R12 reports feeling anhedonia and more withdrawn. R12 has been feeling anxious, sadness, crying at times, and difficulty concentrating. On 7/6/22, R12 was crying uncontrollably and could hardly get words out. Nurse reported that she came into room to a do a blood sugar on R12's roommate. Roommate of R12 reported that a man came into the room and attempted to kiss R12 and put his tongue down R12's throat. The nurse looked at R12 and noticed R12 crying. R12 who was still struggling to get her words out, reported R12 was laying in her bed, when a guy came into the room and tried to kiss R12 and put his tongue down her throat. R12 reported not knowing the guy. Cameras were reviewed and the identity of the man was identified as R13. The police were called, however, R12 chose to not press charges. On 7/12/22, R12 remains on 15-minute checks for inappropriate behaviors/elopement attempts. On 7/19/22, R12 remains on 15-minute checks exit seeking behavior. Psychiatric note on 7/27/22 indicates: R12 reports biggest stressors are R12's adjustment to the facility/area, R12 is used to being in a more rural setting. Psychiatric note on 8/10/22 indicates: R12 presenting with anxious/depressed mood and appropriate affect. R12 tearful and confused about R12's day. R12 having trouble sleeping at night. On 8/16/22, Care Conference Summary-R12 is alert and oriented times 2. R12 has impaired cognition due to toxic [CONDITION(S)]. R12 has poor short term memory recall. R12 has periods of confusion and occasional delusions. Surveyor notes an Assessment for Consent for Physical/Sexual Intimate Expressions was completed by Social Service Director (SSD)-C, dated 7/7/22. However, the assessment is not signed and there is no documentation of a determination of whether R12 can give consent for sexual interaction. Surveyor notes on 7/29/22, R12's Health Care Power of Attorney (HCPOA) was activated. Surveyor requested the psychiatric or Medical Doctor evaluation that determined the HCPOA needed to be activated. The facility was unable to provide documentation of that evaluation. Surveyor notes R12's 15-minute checks for exit seeking and sexual behavior with another peer started on 5/28/22. Documentation of the 15-minute checks ends on 7/19/22. Surveyor was provided documentation of 15-minute checks for R12 until 6/27/22. Surveyor notes there are no documented 15-minute checks for R12 on 6/10/22, the day R12 was found in bed with male Resident. Surveyor notes there are missing 15-minute check documentation for 6/9/22-6/15/22. Surveyor also notes many days where there are long periods of time when 15-minute checks are not documented indicating the facility staff was not aware of R12's whereabouts or activity. Interaction between R12 and R3 On 6/10/22, it is documented R3 was found in R3's bed with another Resident (R12). R12 was pleasuring R3 orally. R12 has a history of engaging in inappropriate behavior with Residents. R12 was moved to room[number]. R3 has diagnoses of [CONDITION(S)] and [CONDITION(S)] Following Cerebral Infarction Affecting Left Non-Dominant Side, Chronic Kidney Disorder, Other Recurrent Depressive Disorders, and Unspecified Mood Affective Disorder. R3 is currently his own person. Surveyor reviewed R3's Quarterly MDS assessment, dated 5/20/22, which documents R3's BIMS score of 11, indicating R3 demonstrates moderately impaired cognitive skills for daily decision making skills, no behavior concerns or issues with mood. R3 requires extensive assistance with bed mobility, dressing, toileting, and personal hygiene. R3 is totally dependent on staff for transfers and has range of motion (ROM) impairment on upper and lower extremities on one side. Surveyor reviewed R3's comprehensive care plan, which documents R3's memory is impaired. Consequently, R3 has problems with decision making, logic, calculation, reasoning, planning, and judgement. Initiated 2/19/22. Surveyor notes a thorough investigation of this incident between R3 and R12 was not completed, and the incident was not reported to the State Survey Agency. The immediate intervention was to separate R3 and R12. R12 was moved to another floor to deter interaction. Surveyor also notes at this time, R3's and R12's care plans did not document person centered approaches related to their desire for sexual activity and/or ability to consent to a sexual relationship. Surveyor also notes there was no assessment completed at this time to determine R3's and R12's ability to consent to sexual activity. Both R3 and R12 were receiving psychotherapy at the time. However, there is no documentation in R3 or R12's psychotherapy notes addressing the incident or the residents' ability to consent to sexual activity. On 7/7/22, the facility updated R3's care plan, which documents R3 is alert, aware, and coherent and chooses to exercise R3's rights to engage in intimate/sexual relationship. Interaction between R13 and R12 Surveyor reviewed the Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report submitted to the State Survey Agency, dated 7/6/22, alleging R13 attempted to kiss R12 without R12's permission. The facility summary of the incident notes R13 was immediately placed on 1:1 supervision and it continued for 24 hours. However, R13 did become irritable and agitated with the 1:1 supervision. So, the decision was made to reduce the monitoring to 15-minute checks. R13 has diagnoses of Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Chronic Kidney Disease, Alcoholic Polyneuropathy, Alcohol Abuse, and Major Depressive Disorder. R13 is currently his own person Surveyor reviewed R13's Quarterly MDS assessment, which documents R13's BIMS score of 13, indicating R13 is cognitively intact related to daily decision-making skills. R13's MDS documents no behavior concerns or mood issues, independent with bed mobility, transfers, dressing, toileting, and hygiene. Surveyor reviewed R13's comprehensive care plan which documents R13's memory is impaired. Consequently, R13 has problems with decision making, insight logic, calculation, reasoning, planning, and judgment. Initiated 3/9/22 R13's physician discontinued R13's testosterone depo injection due to side effects of increased libido and aggression. Surveyor notes staff and other Resident statements were not obtained as part of the investigation. Surveyor notes an Assessment for Consent for Physical/Sexual Intimate Expressions was not completed for R13 prior to the interaction between R12 and R13. On 7/7/22, The facility updated R13's care plan, which documents R13 is exhibiting sexually inappropriate behavioral symptoms related to crossing personal boundaries. The behavioral symptoms are manifested by: Making an attempt to kiss a female Resident without her consent. Strengths and Abilities: He is alert and oriented x3 (person, place, and time). Able to comprehend consequences of his actions. On 8/18/22, at 9:25 AM, Surveyor spoke with R12. R12 does not recall an incident of a man coming into her room and kissing her. R12 does not recall the police being called. R12 informed Surveyor R12 does not remember the incident at all. On 8/18/22, at 9:27 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-F regarding R12. CNA-F stated R12 is ambulatory and independent. CNA-F stated R12 is very forgetful. CNA-F is not aware of any behaviors concerns between R12 and R13 and has never seen R12 and R13 together. On 8/18/22, at 9:40 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-G who stated R12 is alert and oriented to R12's self only. LPN-G states R12 is very forgetful. LPN-G stated R13 usually stays in his room so finding R13 in R12's room was very unusual. On 8/18/22, at 9:50 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding R12. NHA-A stated R12 had hyper sexualized behaviors when admitted to the facility. NHA-A stated R12 would go into many male resident rooms. NHA- stated, in reference to the 6/10/22 incident between R12 and R3, R12 sought out R3. On 8/18/22, at 10:05 AM, Surveyor interviewed Social Service Director (SSD)-C. SSD-C stated R12's care plan was changed due to R12 being found in R3's bed and it was decided R3 and R12 were consenting adults. SSD-C agreed both R12 and R3 demonstrate moderately impaired skills for daily decision making. SSD-C stated consenting adult means someone understands what it means to be in an intimate relationship. However, SSD-C agreed this can be a fine line when it comes to cognitive status. SSD-C stated the Assessments for Consent for Physical/Sexual Intimate Expressions for R3 and R12 were completed because corporate office told me to do them. SSD-C stated the assessments are not done on admission for every Resident, only if there is a problem. SSD-C stated R12 had [CONDITION(S)] when first admitted but the [CONDITION(S)] has cleared. SSD-C stated R12's cognitive status of being confused and oriented to self is baseline since admission. On 8/18/22, at 11:17 AM, Corporate Consultant (CC)-E informed Surveyor the initial reaction after the 6/10/22 incident was to separate R3 and R12 by moving R12 to another floor. CC-E confirmed the assessments for Consent for Physical/Sexual Intimate Expressions are only completed as needed. CC-E stated as of 7/7/22, the facility is now following the State Long Term Care Ombudsman guidelines after the incident between R3 and R12 and SSD-C and SW-D have been trained on the guidelines. On 8/18/22, at 12:38 PM, NHA-A informed Surveyor the facility has not provided training to the staff related to Residents having the right to participate in sexual activity and the facility policy and procedure on this topic including the assessment used to determine a Resident's ability to consent to sexual contact. On 8/18/22, at 2:15 PM, Surveyor shared with NHA-A the concern the facility was aware R12 was demonstrating hyper sexualized behaviors upon admission. The facility did not address this concern by assessment or care plan interventions thus putting R12 at significant risk for sexual abuse. Surveyor shared on 5/27/22, R12 was found in a male Resident's room with no further documentation, explanation, or investigation. There was no assessment or care plan interventions put into place to protect R12 or her peers when R12 was found in a potentially vulnerable situation. On 6/6/22, R12 was reviewed in the facility behavior meeting for sexualized behaviors. No new person-centered interventions were implemented to protect R12 or her peers. On 6/6/22, R12 was found in R3's bed engaged in sexual activity. A care plan was put into place on 6/16/22, indicating R12 was demonstrating inappropriate sexual behavior. On 7/6/22, a Misconduct Incident Report was submitted to the State Survey Agency alleging R13 attempted an unwanted sexual exchange with R12, indicating R12 was vulnerable to sexual abuse. On 7/7/22, R3's and R12's care plans were updated indicating R3 and R12 were consenting adults and able to engage in sexual activity. However, documentation and interviews indicate R12 demonstrates moderately impaired skills for daily decision making, is oriented to self only, and lacks judgment and logical thinking which has been baseline since admission. R3 is also documented to demonstrate moderately impaired skills for daily decision making. Surveyor shared the concern related to the lack of assessment of R12's s ability to consent to sexual activity and implementation of care plan interventions when R12 was identified, upon admission, or thereafter demonstrating sexualized behaviors thus putting R12 at risk for sexual abuse as well as other Residents. Surveyor shared the concern for serious harm by not assessing R3's, R12's, or R13's ability to consent to engage in sexual activity. NHA-A provided no further information at this time. On 8/18/22 at 4:45 PM, Surveyor notes that NHA-A did provide a training dated 7/26/22-7/28/22 for all facility staff which indicated that Resident right to intimate relationships was discussed. This documentation was provided after NHA-A was informed of the concern for serious harm concerning R3, R12, and R13 and the sexual activity. Failure to provide medically related social services by failing to determine if R12 was able to consent to sexual activity (which prevented facility staff from knowing if R12 should or should not be allowed to engage in sexual activity) created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The facility removed the jeopardy on 9/1/22 when it implemented the following: Brief Trauma questionnaire completed on all residents, social history and psychosocial assessments completed for all residnts to determine current or anticiapted intimate relationships or sexual activity and ability to consent to intimate relationships and care plan accordingly, all staff training on unobtrusive observations of residents to determine care planning oppurtunities, audits of all new admissions to ensure social history and psychosocial assessments are completed and care plans implemented and a QAPI plan was implemented.

Based on interview and record review, the facility did not ensure 1 (R5) of 1 Resident reviewed was free from physical abuse. On [DATE], R6, who was assessed as being at moderate risk for aggressive behavior, physically assaulted his roommate, R5. The injuries R5 sustained were serious and required sutures before surgery (to repair a left side periorbital fracture) could be scheduled. The facility did not do a Preadmission Screen Annual Resident Review (PASARR) level 2 screen on admission despite R6's psychiatric diagnoses, did not address a previous incident when he was physically aggressive towards a certified nursing assistant (CNA), did not implement a care plan to address R6's behavior triggers with person centered approaches, and did not implement a behavior monitoring system that would accurately identify behavior concerns and effective interventions. The facility's failure to keep R5 free from physical abuse created a finding of Immediate Jeopardy, which began on [DATE]. On [DATE], at 5:45 PM, Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B and Corporate Consultants (CC): CC-E and CC-H were informed of the Immediate Jeopardy. The immediate jeopardy was removed on [DATE] . The deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings Include: Surveyor reviewed the facility's Abuse Prevention policy and procedure, revised [DATE], and notes the following applicable: .This facility is committed to protecting our Residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to facility staff, other Residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Physical Abuse: is the infliction of injury on a Resident that occurs other than by accidental means. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Resident to Resident physical altercations that must be reported include, any willful action that results in physical injury, mental anguish, or pain. III. Establishing a Resident Sensitive Environment This facility desires to prevent abuse, neglect, exploitation, mistreatment, and misappropriation of Resident property by establishing a Resident sensitive and Resident secure environment. This will be accomplished by a comprehensive quality management approach involving the following: Concern Identification and Follow-up Environmental Assessment Resident Assessment: As part of the Resident's life history on the admission assessment, comprehensive care plan, and Minimum Data Set (MDS) assessments, staff will identify Residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, or misappropriation of Resident property, or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment or misappropriation of Resident property for these Residents. Staff will continue to monitor the goals and approaches on a regular basis and update as necessary. The facility will revise the Resident's care plan if the Resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. Pattern Assessment Staff Supervision: Supervisors will monitor the ability of staff to meet the needs of Residents, including that assigned staff have knowledge of individual Resident care needs. R6 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6 had a legal guardian appointed while at the facility. R6 discharged from the facility on [DATE] accompanied by law enforcement and is currently admitted to a psychiatric environment. Surveyor reviewed R6's Admission MDS assessment, dated [DATE], and notes R6's BIMS score to be a 15, indicating R6 was cognitively intact for daily decision making. No behavior concerns are documented; R6 requires supervision only for bed mobility, transfers, dressing, toileting, and hygiene; is ambulatory. R6 was assessed to be 6'0 and weighing 133 pounds. R6's Social History, dated [DATE], documents R6 had delusions and hallucinations. R6 served [AGE] years in prison for attempted murder. R6 had had a problem with alcohol, and/or street drugs. R6 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor notes R6's Preadmission Screen Annual Resident Review (PASARR) Level 1 Screen documents R6 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This would be identified as a positive Level I screen, and the facility would need to refer R6 for an in-depth evaluation by a state-designated authority, known as a Level II screen. The Level II screen would consist of a comprehensive evaluation conducted by the state-designated authority that would determine whether an individual has a mental disorder and would determine the appropriate setting for the individual and recommend what, if any, specialized services and/or rehabilitation services the individual needs. The Level II PASARR cannot be conducted by the nursing facility. The facility did not refer R6 for a Level II PASARR screen after R6 was assessed and identified as having a positive Level I PASARR screen. Since R6 was not referred for a Level II screen it allowed for the potential for R6 to be placed in an inappropriate environment and/or not receive the necessary specialized mental health services. R6's Aggressive/Harmful Behavior Assessment, dated [DATE], indicates R6 was at moderate risk for exhibiting harmful/aggressive behavior. R6 scored an 8 on this assessment based on answers provided related to concerns with cognitive impairment, history of aggressive behaviors, history of substance abuse, history of non-compliance with medication and treatment regimen and history of criminal behavior. R6's care plan, dated [DATE], documents: The resident has an active order for [CONDITION(S)] medication(s) use antipsychotic. Interventions include: Discuss with MD (Medical Doctor), family re: ongoing need for use of medication. Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy, date initiated: [DATE]; Encourage group activities related to his interest, date initiated: [DATE]; Monitor/document/report PRN (as needed) any adverse reactions of [CONDITION(S)] medications: [MEDICAL RECORD OR PHYSICIAN ORDER] Monitor/record occurrences of targeted behavior symptoms: pacing, wandering, inappropriate response to verbal communication, violence/aggression towards staff/others, etc. and document per facility protocol, date initiated: [DATE]; Offer him one to one visits for expression of feelings, coping strategies and companionship, date initiated: [DATE]. Surveyor notes the facility identified R6's potential to demonstrate violence/aggression towards staff/others as it is documented in R6's care plan as a targeted behavior to be monitored and recorded by staff upon R6's admission to the facility. R6 also had a care plan addressing R6's history of substance abuse/chemical dependency manifested by a long history of smoking crack cocaine, initiated on [DATE]. Surveyor requested all psychiatric services documentation for R6. Surveyor reviewed R6's psychiatric services progress notes and notes the following: On [DATE], the Behavior Management/Medication Review form documents: [MEDICATION(S)] [MEDICATION(S)] ([MEDICATION(S)]-Antipsychotic medication) 25 mg (milligrams)/ml (milliters) (3 ml Q (each)) 14 days for [CONDITION(S)]. R6 was seen by the Psychiatric Nurse Practitioner on [DATE], who documents: a psychiatric history of [CONDITION(S)], receives [MEDICATION(S)] as treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor notes the areas of the assessment that address anger/irritability' verbal outbursts; calling out; physical aggression; delusion; hallucinations; manic symptoms and obsessive/compulsive symptoms were crossed off and not addressed. It is documented R6 should have a follow up appointment in 1 month with no date for the appointment documented. R6 was seen by the Psychologist on [DATE], which documents: the presenting problem/symptoms of resident seeing things-resident denied; nervousness-resident denies; psychiatric history: seeing things; [AGE] years in prison for murder, out [AGE] years ago; adequate grooming; poor eye contact; can stand, walk with a walker; demeanor: guarded; completely oriented; non memory deficits; adequate concentration; mildly impaired judgement; fair-poor insight; average intellect; affect is blunted/fair; denies depressed mood; thought is coherent; content is appropriate; denies seeing things; appetite is good; sleep is good; chronic pain in left foot and ankle. The documented treatment plan is to address R6's adjustment, with the goal of a smooth adjustment and to be seen bimonthly. No follow up appointment was arranged. Surveyor notes there is no further follow up with R6 and the Psychiatric Nurse Practitioner or the Psychologist after their initial consults. Surveyor reviewed R6's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Upon review of R6's MARs, Surveyor noted R6 was being monitored for the following behaviors: delusions, hallucinations, combativeness, physical or verbal aggression, sexually inappropriate, disruptive, antisocial, wandering, exit seeking, refusal of care/hygiene, homicidal/suicidal ideation. According to documentation in the MAR: February 2022 MAR-7 indications of behavior observations with no documentation in the progress notes of the specific behavior exhibited. [DATE] MAR-51 indications of behaviors observations, 10 more than before, with no documentation in progress notes of the specific behavior exhibited. [DATE] MAR-2 indications of behaviors observation with no documentation in progress notes of the specific behavior exhibited. Surveyor notes the specific behavior observed by staff is not coded. It is unclear what behavior R6 was demonstrating at the time. Surveyor also notes there is no documentation in the progress notes to describe the inappropriate behavior observed by staff, what interventions were implemented and if the interventions were effective. Without more specific information, the facility could not identify what behaviors were displayed and could not address these in the care plan. Surveyor reviewed R6's progress notes and notes the facility did document some concerns with R6's behavior as evidenced below. The facility identified concerns with R6 becoming easily agitated, difficulty adjusting to the facility, following facility safety rules, and challenges with roommates: On [DATE], R6 was found smoking in R6's room. On [DATE], R6 requested to speak to someone about hearing voices. On [DATE], Staff entered R6's room to find it smelling of cigarette smoke. On [DATE], R6 reported having a nightmare regarding a cat and needed to smoke. On [DATE], at 5:40 AM, R6 and a CNA were yelling, and R6 raised his arms to try and hit the CNA then grabbed the yellow wet floor marker to hit the CNA. On [DATE], Social Service Director (SSD)-C documented R6 was angry that he was getting awakened because R6's roommates needed cares during the night. R6 was transferred to another room. On [DATE], SSD-C was informed by R6's new roommate that R6 kept begging him for cigarettes and coffee. The new roommate didn't feel comfortable with R6. On [DATE] R6 was moved into a room with R5. R5 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5 was his own person while at the facility. Surveyor reviewed R5's Quarterly Minimum Data Set (MDS) assessment, dated [DATE], and notes R5's Brief Interview for Mental Status (BIMS) score to be a 15, indicating R5 was cognitively intact for daily decision making. R5's MDS documents no behavior concerns; required extensive assistance of 2 caregivers for bed mobility, transfers, dressing, toileting, and hygiene; lower extremity range of motion (ROM) impairment on both sides; and wheelchair dependent. R5 was assessed to be 5' (foot) 7 (inches) and weighing 298 pounds. R5 had advanced [CONDITION(S)]. R5 is a functional paraplegic due to [CONDITION(S)] on the spine. Verbal and Physical Altercation between R5 and R6 The facility submitted a Misconduct Incident Report, dated [DATE], which documented, on [DATE], at 11:56 PM, R5 and R6 engaged in a verbal argument that escalated into a physical altercation. R5 required medical care and was transported to the hospital by the paramedics. R6 was removed from the facility by law enforcement. Surveyor reviewed the facility's summary of R5 and R6's (roommates) Resident to Resident altercation. Surveyor notes the following: R5 and R6 got into a verbal argument over a bag of chips. Earlier in the day R5 had given R6 a bag of Doritos, but when R6 asked for another bag, R5 informed R6 no and an argument ensued. Nursing staff responded to the loud voices. Upon entering R5 and R6's room, the nurse found R5 lying in bed with R6 standing next to R5's bed. Staff attempted to re-direct R6 out of the room. However, R6 was perseverating about R5's phone. The summary indicates staff was getting R6 to calm down, when R5 pulled out his cell phone and appeared to be making a call'. R6 lunged for R5's phone and tried to wrestle it from R5. R6 then grabbed R5's wooden slide board and began to hit R5 with it. The nurse stepped between R5 and R6 and grabbed the slide board. The 2 Certified Nursing Assistants (CNAs) shoved R6 out of the room, into the hallway. R6 continued to go after and hit the nurse with the wooden slide board. R6 also destroyed R5's phone. It is documented that at some point during the incident, the security guard was called to the floor as well as law enforcement. One of the CNAs got the nurse to safety, and the security guard and another CNA tackled R6 and got the slide board away from R6. Staff kept R6 contained until law enforcement arrived. R5 was transported to the emergency room for medical care. R5 suffered contusions and lacerations to his head and face, as well as a left side periorbital fracture. R5 was treated and released to the facility on [DATE] with surgery pending for the left side periorbital fracture. It is documented R6 has a pending felony charge due to the incident related to the injuries to the nurse. Surveyor reviewed the police report, dated [DATE], which indicates the wood slide board is approximately 3 feet long by approximately 8 inches wide by one inch thick and featured a wide handle on either end. One end of the board was spattered with blood. The entire board had a smooth finish and was without blemish, except for a small dent on one of its edges approximately 1/2 inch long. It is documented in the police report that R5 was in bed, which faced the door, at the time the incident occurred. At the foot of bed on a shelf, an open bag of Salt and Vinegar chips was observed. Behind the curtain was R6's bed and a small bag of Doritos chips were observed on the ledge next to R6's bed. It is also documented in the police report that R5 was observed in bed with bloodied towels on his face. Due to the extent of R5's injuries R5 was transported to the hospital. R5 had a severe laceration, approximately 5 inches long on the right side of R5's face, in the area of R5's temple and right eye. R5 had a second laceration approximately two inches long on R5's left eye and temple area. Due to the urgent treatment being provided to R5's lacerations exact measurements were unable to be obtained. Both lacerations were sutured at the hospital. R5's left eye was also very swollen. The severity of R5's swelling under the left eye is the primary cause of transportation to the hospital. Surveyor reviewed R5's hospital record, dated [DATE], and notes the following: R5 presented with facial trauma-left orbital floor fracture. R5 did not recall the events leading to the hospital visit. R5 had a loss of consciousness at the scene. R5 reported blurry vision in left eye. R5 reports periorbital pain. R5 was admitted to the surgical floor in anticipation for left orbital floor fixation the same day. However, after evaluation by ophthalmology, it was recommended to defer surgical treatment until left eye [CONDITION(S)] improved. R5 was discharged on [MEDICATION(S)] 1% four times daily left eye and [MEDICATION(S)] 1% twice daily to the left eye. R5 was scheduled for eye surgery on [DATE]. Surveyor reviewed R5's progress notes upon his return to the facility and notes: On [DATE], R5 returned from hospital via post peer contact. Has multiple facial lacerations to both eyes and sutures are in place. Left eye is swollen shut. Also has left facial fracture. On [DATE], Both eyes remain swollen shut. On [DATE], Nutrition Note-Unsure if new facial fracture is going to affect chewing abilities. On [DATE], Sutured area without signs/symptoms of infection. Complaints of pain two times ,d+[DATE] related to facial trauma, as needed pain medication given with effective results. Surveyor reviewed R5's statement of the incident documented in the Facility Reported Incident, provided by Social Services Director (SSD)-C. R5 stated he had given R6 a bag of Doritos, pickle juice, and cranberry juice, even though the cranberry juice was used during R5's [CONDITION(S)] treatments earlier in the evening. R5 went to bed about 8:30 PM. R5 was eating Salt and Vinegar chips and R6 kept asking for R5's chips. R5 responded stating R5 had already given R6 chips. R5 stated R6 came over to R5's bed and became confrontational about the chips and using foul language. Staff heard the argument and came to R5 and R6's room. R5 stated R5 did pick up R5's phone to call R5's family. R6 then demanded R5 give R5's phone to R6. R5 refused. R6 continued to yell that R5 give R6 R5's cell phone. R5 stated the next thing R5 knew was R5 was being struck in the head with wooden slide board. R5 stated R5 doesn't remember much else because R5 was beaten and bloody. R5's final words were that it all started about some chips. The facility's summary of the incident documents the nurse believes' R5 most likely threatened R6 with calling the police or family prior to staff getting to the room. The nurse feels R5 intentionally took R5's phone out so R6 could see it, clearly not expecting that type of reaction from R6. However, there is no physical witness to this action, and R5 denies intentionally trying to agitate R6. The facility investigation included staff interviews along with other Resident interviews which documented no one expected this kind of physical aggression from R6. Nursing Home Administrator (NHA)-A documents the following conclusion related to the Facility Reported Incident, NHA-A suspects R6 has been forcibly removed by the police from settings in the past. Had the argument remained only about chips and juice, the facility did not feel that R6's behavior would have escalated. The facility felt R5 did threaten R6 with calling the police or family, causing R6 to feel threatened and fear for R6's safety. R5 bringing R5's cell phone out was the trigger that escalated R6's behavior to physical aggression. On [DATE], at 10:50 AM, NHA-A informed Surveyor there is no way the facility had prior knowledge or had an idea R6 would have demonstrated the level of physical aggression R6 did the evening of [DATE]. NHA-A stated the facility had no prior knowledge of any events indicating R6 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Surveyor notes R6's social history, obtained by the facility social worker upon R6's admission to the facility, which documented R6 had a criminal history related to a murder charge. On [DATE], at 11:17 AM, Social Worker (SW)-D informed this Surveyor the day after R6's admission to the facility he had issues with the nurse because the physician ordered blood sugar checks and R6 was agitated about that. SW-D stated he was aware of R6's prison time and that it was for murder. SW-D stated the facility only does a background check for potential residents related to a history of sexual issues. SW-D stated the guardian, who has known R6 for six years, was the one to inform SW-D of R6's criminal history related to prison time for murder. On [DATE], at 10:15 AM, Surveyor spoke with SSD-C. SSD-C stated she was aware of the altercation between R6 and the CNA on [DATE]. SSD-C confirmed she did not initiate a care plan for R6's behavior concerns nor did SSD-C update psychiatric services of R6's aggressive behavior. SSD-C stated she spoke to R6's caseworkers. SSD-C stated the caseworkers informed her R6 had started a fire at the rooming house when high on crack cocaine. SSD-C informed this Surveyor R6's second roommate, at the facility, did a background check on R6 and informed SSD-C of R6's criminal past and felt uncomfortable having R6 as a roommate. Surveyor shared the concern with SSD-C, that upon R6's admission to the facility a behavior care plan was not initiated based on history of R6's criminal history and starting a fire. Surveyor also shared the concern of R6's physical aggression towards the CNA was documented. However, a behavior concern care plan was not initiated. Surveyor expressed concern that a behavior concern care plan was not initiated until the day after the verbal and physical altercation between R6 and R5. SSD-C agreed, a behavior concern care plan should have been initiated for R6 upon admission to the facility. SSD-C stated it is the responsibility of Social Services to take the information gathered on the social history and other assessments and incorporate them into the Resident's comprehensive care plan and bring forward to the Interdisciplinary Team (IDT). On [DATE], at 9:17 AM, NHA-A confirmed no trainings have been held with staff on de-escalation of resident behaviors or implementing positive interventions for behaviors. NHA-A stated the facility is on a waiting list for a training and confirmed no training for staff took place after the incident between R5 and R6. On [DATE], at 9:17 AM, NHA-A informed Surveyor the facility had no background information on R6 and had the facility known about R6 and his history, the facility would not have admitted R6 to the facility. Following the incident with R5, the facility updated R6's care plan, which documents R6 has history of behavior problems: delusions, hallucinations, combativeness, verbal and physical aggression, and pilfering, irritability, and impatience due to [CONDITION(S)] diagnosis. Interventions include: Administer medications as ordered. Monitor/document for side effects and effectiveness, date initiated: [DATE]; Caregivers to provide opportunity for positive interactions, attention, date initiated: [DATE]; Coordinate consistent team staff responses with interdisciplinary team, date initiated: [DATE]; Explain all procedure to the resident before starting and allow the resident (5 minutes) to adjust to changes, date initiated: [DATE]; If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident, date initiated: [DATE]; Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed, date initiated: [DATE]; Minimize potential for the resident's disruptive behaviors pilfering through others' belongings, or verbal and physical aggression by offering tasks which divert attention such as helping with activity groups, extra smoke breaks, date initiated: [DATE]; Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involvement, and situation. Document behavior and potential causes, date initiated: [DATE]; Provide a program of activities that is of interest and accommodates residents status, date initiated: [DATE]. Surveyor notes, R6's behavior problem care plan was implemented 1 day after R6 physically assaulted R5 on [DATE]. Prior to this time R6's care plan did not address any behavior concerns. However, the facility identified R6's potential to demonstrate violence/aggression towards staff/others as it is documented in R6's need for [CONDITION(S)] medication care plan as a targeted behavior to be monitored and recorded by staff. On [DATE], at 2:15 PM, Surveyor shared with NHA-A the concerns of the seriousness of the incident between R5 and R6. Surveyor shared concern the facility was aware of R6's aggressive and violent history as it was documented on R6's social history he was in prison for murder; the facility documented screening for aggressive/harmful behaviors indicated the resident was at moderate risk for aggressive behaviors and was potentially able to integrate to the facility with structure, direction, and supportive counseling. Only initial assessments by the Psychiatric Nurse Practitioner and Psychologist were completed. No follow up was provided by either provider. Supportive counseling was not provided to help R6 integrate into the facility. Surveyor also shared the concern the facility had witnessed an example of R6's behavior concerns when R6 demonstrated physical aggression towards a CNA, and concerns with roommates. Surveyor shared the concern the facility had not implemented a behavior concern care plan until the day after R6 was discharged . Surveyor shared the facility failed to implement interventions to address R6's assessed risk for aggressive/harmful behaviors and behavior monitoring did not identify the specific behaviors R6 exhibited, what, if any, intervention was helpful to deescalate or prevent R6 from demonstrating aggressive behaviors. R6's behavior monitoring was not assessed/reviewed to determine a pattern to R6's behaviors. Surveyor shared the concern that according to R6's MARS, the resident was observed to display many instances of inappropriate behavior, most at night, which would have indicated a pattern of behavior and a need for increased supervision or intervention at night. Surveyor noted the verbal and physical altercation between R6 and R5 occurred at 11:56 PM. Surveyor shared the concern that serious harm/injury occurred to R5 because of R6's aggressive behavior. The failure to identify R6 to be at moderate risk for exhibiting harmful/aggressive behaviors as evidenced by a positive facility assessment for harmful/aggressive behaviors, the facility's failure to identify R6's positive PASARR Level I screen and make a referral for a Level II screen to determine the appropriate environment and/or necessary specialized mental health services; the failure to accurately document inappopriate behaviors, identify root cause and implement person centered approaches, created a reasonable likelihood for serious harm, resulting in a situation where R6 physically assaulted R5 causing serious injury to R5 requiring hospitalization and surgical repair related to his injuries. This led to a finding of immediate jeopardy. The facility removed the jeopardy on [DATE], when the facility implemented the following: screening for aggressive/harmful behavior for all residents and the screeing for aggressive/harmful behaviors will be completed upon admission, quarterly and as needed, using the score from the aggressive/harmful behavior assessment an individualized care plan will be implmented, residents that score a 6 or higher on the aggressive/harmful behavior assessment tool will be identified and interventions identified in an easy to access binder, all clinical staff will be educated on the behavior documentation tools and expectations, behavior binders will be audited and audit results will be reviewed at QAPI.

Based on interview and record review, the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fell outside of clinical reference ranges for 1 (R2) of 1 residents reviewed with laboratories orders originating from outside specialty physicians (not the facility's attending physicians). R2 had labs drawn and results were received by the facility. The facility faxed the results to the Medical Director and did not follow up with the Medical Director to make sure he received the results. Consulting physicians who ordered the labs were not ever faxed the results of these labs. CT scan follow up appointments were not made by the facility and Consulting Urology and Consulting Surgeon were not aware of results. R2 had increasing blood urea [MEDICATION(S)] (BUN), Creatinine, and decreasing Glomerular filtration rate (GFR) lab values that would suggest decreased kidney function. R2 had increasing blood C-reactive protein (CRP) and white blood cells (WBCs) lab values that suggest increased inflammation and a possible infection. These lab values were not given to the appropriate physician. Abnormal levels were received and not followed up on with any physician on 10/25/21. R2 was sent to the hospital on 10/27/21 and admitted with [CONDITION(S)] secondary to urinary tract infection ([CONDITION(S)]), pneumonia, acute [CONDITION(S)] and hydronephrosis. R2 passed away on 10/29/21. The facility's failure to promptly and timely report lab results to the ordering physician created a finding of Immediate Jeopardy beginning on 10/6/21. Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were informed of the Immediate Jeopardy on 11/11/21 at 4:06 PM. The Immediate Jeopardy was removed on 11/12/21 when the facility implemented an action plan related to lab results and follow up from the facility. This deficient practice continues at a scope/severity of D (potential for harm/isolated) as the facility continues to implement its action plan. Findings include: Surveyor reviewed the facility's Laboratory Results - Reporting policy with a date of 4/1/08. Documented was: All examination results, whether abnormal, normal or stat, are telephoned, faxed or otherwise promptly and reliably transmitted to the facility by the laboratory. Upon receiving the information, the charge nurse or designee verbally notifies the physician by phone; then transmits, via fax to the physician, all laboratory results as indicated by the clinic policy. This notification is documented in the nurses notes and/or on the laboratory data sheets. R2 was admitted to the facility on [DATE] after a hospitalization from [DATE] to 9/1/21 for acute pyelonephritis, bacteremia, [CONDITION(S)], toxic metabolic [CONDITION(S)], diverticulitis of intestine with perforation, [CONDITION(S)], acute renal failure. The hospital Discharge Summary documented: Reason for Admission [CONDITION(S)], acute renal failure and toxic metabolic [CONDITION(S)] Hospital Course [R2] has a [history (hx)] of [chronic kidney disease (CKD)], [hypertension ([CONDITION(S)])], [peripheral vascular disease (PVD)], unspecified neurocognitive disorder, recurrent falls, and partial [CONDITION(S)] who was taken to the ER (emergency room ) after a fall. Patient was found to be in acute renal failure with VRE [CONDITION(S)] and bacteremia, and with toxic metabolic [CONDITION(S)] due to uremia. Nephrology, urology, and general surgery were consulted with this stay. Patient admitted to floor for continued resuscitation and for work up of [CONDITION(S)], acute renal failure and toxic metabolic [CONDITION(S)]. Problem based summary as follows: Complicated VRE [CONDITION(S)] with [left (L)] hydronephrosis as well as kiebsiella bacteremia: most likely [secondary (2/2)] colovesicular fistula. [Infectious Disease (ID)] was consulted and recommended long term IV [antibiotic (Abx/ABT)] use until surgical intervention, on [MEDICATION(S)] and [MEDICATION(S)]. Plan for [infectious disease (ID) (MD)-N] [outpatient follow up (outpt f/u)] in 3-4 weeks. Urology was also consulted and had a Foley catheter and nephrostomy tube placed for decompression. Plan for urology outpt f/u in 3-4 weeks with [Urology (MD)-J]. Patients left nephrostomy tube will need to be exchanged by [[MEDICATION(S)] Radiology (IR)] on 9/23/21 . Will need [every (Q)] Monday [complete blood count with differential (CBC with diff)], [basic metabolic panel (BMP)], CRP, total [[MEDICATION(S)] kinase (CK)] . Complicated Diverticulitis w/ possible colovesicular fistula; adjacent phlegmon: most likely 2/2 to mass causing an obstruction vs. complicated sigmoid diverticulitis w/ perforation and fistula formation. Surgery was consulted and determined no surgical intervention needed at this time and no sign of surgical problem developing, but they will consider future surgery depending on goals of care and nutrition improvement. Colonoscopy performed this stay, showing diverticular stricture and mucosal [CONDITION(S)], biopsy pathologies with benign [CONDITION(S)]. Plan for patient to go to [sub-acute rehab ([NAME])]. If nutrition improving plan to move forward with follow up with surgery. If nutrition not improving and patient not candidate for surgery, will need ongoing goals of care discussion, with possible hospice, as complicated VRE and complicated diverticulitis likely not to improve without surgical intervention. Patient will need follow up in about a month with general surgery [MD-L] . Acute kidney injury on chronic kidney disease, resolved: Urine studies show [MEDICATION(S)] renal injury, likely [acute tubular necrosis (ATN)] improved with nephrostomy and Foley catheter placement. [Glomerular filtration rate (eGFR)] ~60 on discharge. Will need monitoring of kidney function . Surveyor reviewed R2's Comprehensive Care Plan with a start date of 9/2/21. Documented was: Focus: The resident has [CONDITION(S)] [related to (r/t)] Kidney disease . o Monitor for s/sx of hypovolemia (increased pulse, increased respirations, decreased systolic, sweating, anxiousness) or hypervolemia ([jugular vein distension (JVD)], increased [blood pressure (BP)], lung crackles, headache, [shortness of breath (SOB)], dependent [CONDITION(S)]). o Monitor lab reports of electrolytes and report to physician. Notify if [potassium (K)] over 5.5. o Monitor/document/report PRN any s/sx of acute renal failure: Oliguria (urine output <400ml per 24 hr.); Increased BUN and Creatinine; In the Diuretic phase, (output >500 ml/24 hr) the BUN and Creatinine level out. (Emphasis added.) o Monitor/document/report PRN the following s/sx: [CONDITION(S)]; weight gain of over 2 lbs a day; neck vein distension; difficulty breathing (Dyspnea); increased heart rate ([CONDITION(S)]); elevated blood pressure (Hypertension); skin temperature; peripheral pulses; level of consciousness; Monitor breath sounds for crackles . Surveyor reviewed Progress Notes for R2. Documented on 9/2/21 at 7:41 PM was Resident arrived via Bell Ambulance, Resident is alert with Single lumen peripherally inserted central catheter (PICC) right chest, Nephrostomy tube left back, Foley [catheter], multiple dressing to knees, legs, back. MD-M face time with resident, [new order (NOR)] CBC, [comprehensive metabolic panel (CMP)], [magnesium], [Phosphorus], [Vitamin D 25], [[CONDITION(S)] stimulating hormone (TSH)], [hemoglobin A1C], [Iron], [Ferritin], [Vitamin B12], [MEDICATION(S)], Lipids 9/6/21. Surveyor reviewed labs drawn on 9/6/21 and 9/13/21 with no abnormal results. Results were sent to MD-M (medical director) and no new orders were given. Results were not sent to MD-J (urologist), MD-L (surgeon) or MD-N (infectious disease). Surveyor reviewed labs drawn on 9/20/21, two of which (including BUN) were outside normal reference range. Results were sent to MD-M and no new orders were given. Results were not sent to MD-J, MD-L or MD-N. Lab results were: WBC 8.5 (normal reference range 3.9 - 11.2) BUN 24 (high) (normal reference range 6 - 23) Creatinine 1.01 (normal reference range 0.70 - 1.30) CRP 3.03 (high) (normal reference range 0.00 - 0.50) eGFR >60 (normal reference range >=60) Surveyor reviewed Progress Notes for R2. Documented on 9/23/21 at 2:16 PM was ABT were infused. Went out to an appointment to [MD-N]. Surveyor reviewed Report of Consultation from MD-N visit on 9/23/21. Documented under recommendations was: .3. Continue weekly labs 4. F/u [MD-N] 10/14/21 10:00 AM. Surveyor reviewed Progress Notes for R2. Documented on 9/30/21 at 11:54 AM was resident returned from Urology appointment with [MD-J] yesterday, MD recommended BMP lab work and a CT of the Pelvis/[abdomen (ABD)] [diagnosis] Left Renal mass and Left Pelvic abscess. Exam scheduled for Tuesday 10/12/21 @ 0745. Surveyor reviewed Report of Consultation from MD-J visit on 9/30/21. Documented under recommendations was: - BMP - CT of the Abd/Pelvis with and without contrast - Continue [with (c)] [left (L)] [nephrostomy] tube - continue c Foley - f/u c [MD-L] for results - f/u c [MD-J] for results Surveyor reviewed labs drawn on 10/6/21, three of which (including BUN) were outside normal reference range. In addition, creatinine was rising. Results were sent to MD-M and no new orders were given. Results were not sent to MD-J, MD-L or MD-N. Lab results were: WBC 6.1 (normal reference range 3.9 - 11.2) BUN 34 (high) (normal reference range 6 - 23) Creatinine 1.28 (normal reference range 0.70 - 1.30) CRP 7.22 (high) (normal reference range 0.00 - 0.50) eGFR 54 (low) (normal reference range >=60) On 11/11/21 at 9:30 AM Surveyor interviewed Physician Assistant (PA)-K for Urology MD-J. Surveyor noted the weekly labs taken for R2. PA-K stated those should have been sent to their office. PA-K noted MD-J ordered a BMP on 9/30/21 and they never received the results. Surveyor reported the weekly BUN and Creatinine numbers to PA-K. PA-K stated [BUN and Creatinine] are rising. We should have been made aware. I can't find anything in the chart. We haven't heard anything. PA-K stated he would have wanted to see the labs because if the BUN and Creatinine are rising there is a problem with the kidney function, possible blockage, infection or nephrostomy tube not functioning. PA-K stated we would have ordered further imaging. On 10/7/21 R2 went out to an appointment with MD-L. There was no Report of Consultation from MD-L visit. There was no documentation of any recommendations in Progress Notes. Per MD-J visit note, R2 should follow up with MD-L after the 10/12/21 scheduled CT scan. This is the last documented visit with MD-L. On 10/12/21 R2 went out for CT scan. The Report of Consultation from visit was blank. Handwritten on the bottom of the page was No report sent c (with) resident. There was no documentation of any follow up appointments with MD-L or MD-J for results. On 10/14/21 there is no documentation of R2 attending follow up appointment with MD-N (infectious disease) as noted on Report of Consultation from MD-N visit on 9/23/21. On 11/11/21 at 9:30 AM Surveyor interviewed Physician Assistant (PA)-K for Urology MD-J. Surveyor asked about R2's CT scan. PA-K stated by looking in the chart he had the scan 10/12/21 but no follow up appointment was ever made by the facility so the results were not reviewed with R2. PA-K stated there should have been a follow up appointment 2 to 3 days after the scan with their office and also a follow up appointment with MD-L after the scan to review results to plan for possible surgery. Surveyor reviewed labs drawn on 10/18/21, two of which, including BUN, were outside normal reference range. There was no documentation that results were sent to MD-M. Results were not sent to MD-J, MD-L or MD-N. Lab results were: WBC 9.6 (normal reference range 3.9 - 11.2) BUN 26 (high) (normal reference range 6 - 23) Creatinine 1.06 (normal reference range 0.70 - 1.30) CRP 3.23 (high) (normal reference range 0.00 - 0.50) eGFR >60 (normal reference range >=60) Surveyor reviewed labs drawn on 10/25/21. All five results were outside normal reference range. Results were not sent to MD-M, MD-J, MD-L, MD-N or PA-O. Lab results were: WBC 12.2 (high) (normal reference range 3.9 - 11.2) BUN 42 (high) (normal reference range 6 - 23) Creatinine 1.55 (high) (normal reference range 0.70 - 1.30) CRP 11.01 (high) (normal reference range 0.00 - 0.50) eGFR 44 (low) (normal reference range >=60) Handwritten on the top of the labs by Registered Nurse (RN)-E was Faxed 10/25. There was no documentation of any MD receiving a phone call with the abnormal lab values. On 11/11/21 at 11:50 AM Surveyor interviewed Unit Manager RN-E who wrote faxed 10/25 on the 10/25/21 labs. Surveyor asked who she faxed the labs to. RN-E stated all labs get faxed to MD-M. Surveyor asked if she called MD-M or any other MD for R2's labs. RN-E stated she would only call if they were abnormal. RN-E stated in the Lab Book on the unit it states whether the MD was called or faxed. Surveyor reviewed Lab Book and documented for the 10/25/21 labs by RN-E was faxed and no phone call. Surveyor reviewed Progress Notes for R2. Documented on 10/27/21 at 7:45 AM Writer was doing rounds and noted resident difficult to arouse, not normal for resident, skin warm dry pale writer asked resident if he was feeling okay resident said no, resident unable to express how he was not feeling well Foley catheter noted what appeared to be stool in upper part of Foley catheter tubing [vital signs (VS) temperature 97.1, pulse 69, respiration rate 18], MD-D notified of COC (Change of Conditon), NOR (New Order Received) to transfer resident to ED for [evaluation] and treatment as indicated. Surveyor reviewed ED documentation from admission on 10/27/21. Documented by the ED MD was .This morning at his nursing facility patient was reportedly unresponsive and [Emergency Medical Services] was called. On arrival to the ED, he was hypotensive, hypothermic and obtunded. His nephrostomy tube was out of place. Lab work shows a [MEDICATION(S)] of 2.3, BUN 79, [Creatinine] 3.97 (baseline 1.23), [WBCs] 35,000, [urinalysis] was grossly positive . On 10/27/21 R2 was admitted to ICU (Intensive Care Unit) with Septic shock due to [CONDITION(S)], pneumonia and acute [CONDITION(S)] due to left blockage. R2 passed away 10/29/21. On 11/11/21 at 10:23 AM Surveyor interviewed Licensed Practical Nurse (LPN)-D. Surveyor asked who follows up on lab results. LPN-D stated the labs that are faxed to the facility by the lab are looked at by the nurses and unit managers. Surveyor asked what the process was for following up on lab results. LPN-D stated floor managers will follow up with the MD within a day or 2 if the results are normal. LPN-D stated if the results are abnormal or critical the nurse or unit manager will call the MD right away. On 11/11/21 at 1:18 PM Surveyor interviewed medical director MD-M. Surveyor asked who should have been reviewing R2's labs. MD-M stated the MD who orders them. MD-M stated he always gets a copy as the primary physician but the ordering physician should also get the labs. Surveyor asked about the rising CRP lab. MD-D stated I don't look at that. CRP results should go to [MD-N]. Surveyor asked about the increased BUN and Creatinine labs. MD-M stated Urology and Nephrology should have been consulted on those labs. Surveyor asked if he reviewed the labs from 10/25/21. MD-M stated he looked in his chart and he never received any labs from 10/25/21. On 11/11/21 at 1:37 PM Surveyor interviewed NHA-A. Surveyor asked who was in charge of following up on R2's labs. NHA-A stated nursing should send them to the MD who ordered the labs. NHA-A stated if a Consulting doctor ordered the labs, they should consult on those labs. NHA-A stated each doctor has their own way they want to receive labs. NHA-A stated MD-M usually gets a copy of all the labs and he prefers to be faxed unless its abnormal, then the nurses will call. Surveyor asked who would be in charge of making sure the MD received abnormal lab results and they were followed up on. NHA-A stated the unit managers or Director of Nursing. Surveyor noted the concerns with labs not being reported to the consulting physicians. Surveyor noted no MD received the abnormal labs from 10/25/21 and no phone call was made. NHA-A stated I didn't know that. Surveyor asked if there was any other documentation stating consulting physicians were contacted on lab results. No additional documentation was received. The facility failure to inform physicians of the results of ordered lab work created reasonable likelihood of serious harm, which created a finding of Immediate Jeopardy. The jeopardy was removed on 11/12/21 when the facility implemented the following: ~ Resident no longer resides at the facility. ~ Facility reviewed its change of condition policy as it relates to labs. ~ Nurses were educated on prompt notification of lab results to physicians and the system to how the results are communicated back to facility and how to recognize changes in lab results including critical values and other indications of a change of condition. ~ All nurses received face to face education prior to the beginning of their next scheduled. ~ Facility reviewes lab orders daily to ensure the lab order clearly identifies which physician(s) should be notified of results, as well as proper follow through. ~ Labs will be reviewed to identify trends and patterns that may correlate to a change of condition. Results will be reviewed at Quality Assurance Performance Improvment for further recommendations.

Based on interview and record review, the facility failed to ensure that 1 (R2) of 3 residents reviewed for quality of care received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. 1. R2 had a nephrostomy tube which was not monitored regularly and not flushed daily per standards of care. There was no care plan for nephrostomy tube. When the resident arrived at the facility, no one followed up with Urology to verify care and orders of nephrostomy tube. The dressing order for the site in place was not an order urology would have put in place and did not follow standards of care for nephrostomy dressing care. There were no input and output (I&Os) recorded or tracked for resident. Daily nephrostomy charting was discontinued and there was no documentation from 10/8/21 through 10/27/21. R2 had a CT scan and a follow up appointment was not made with Urology and the results were not reviewed with the patient. Resident then had decreased output from nephrostomy that was not reported to Urology and R2 was sent to the hospital. R2 was admitted with a [CONDITION(S)] secondary to hydronephrosis and passed away 2 days later. 2. R2 had an indwelling Foley catheter which was not monitored regularly per standards of care. There were no input and output (I&Os) recorded or tracked for resident. Daily Foley catheter charting was discontinued and there was no documentation from 10/8/21 through 10/27/21. Resident then had decreased output from Foley catheter that was not reported to Urology and R2 was sent to the hospital. R2 was admitted with a [CONDITION(S)] secondary to hydronephrosis and passed away 2 days later. 3. R2 was admitted to the facility with a Peripheral Inserted Central Venous Catheter/PICC in his Right [MEDICATION(S)]. MD orders to change dressing weekly and measure catheter to make sure the catheter did not migrate. Measurements and dressing changes were not completed although they were signed out as completed in R2's Electronic Medical Record. The resident was admitted to the hospital on 10/27/21 and was found to have a PICC line dressing dated 9/15/21. The facility's failure to properly care for nephrostomy tube, Foley catheter and PICC line per standards of care, including the monitoring of I&Os, created a reasonable likelihood for serious harm (Immediate Jeopardy) beginning 9/2/21. Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were informed of the Immediate Jeopardy on 11/11/21 at 4:06 PM. The Immediate Jeopardy was removed on 11/18/21 when the facility implemented an action plan related to standards and quality of care for residents with nephrostomy tubes, Foley catheters and PICC lines. This deficient practice continues at a scope/severity of D (potential for harm/isolated) as the facility continues to implement its action plan and based on the following example: 4. The wound to R2's back was not assessed until 9/8/21 and that assessment was not documented on in his Electronic Medical Record (EMR) until Surveyor brought it to the attention of the facility. The first assessment documented was 9/15/21 and a treatment was not put in place until 9/17/21. Skin Observation Forms indicated intact skin throughout R2's stay at the facility. R2 was admitted to the hospital on 10/27/21 and bandage to back wound was dated 10/20/21. R2 was admitted to the facility on [DATE] after a hospitalization from [DATE] to 9/1/21 for acute pyelonephritis, bacteremia, [CONDITION(S)], toxic metabolic [CONDITION(S)], diverticulitis of intestine with perforation, [CONDITION(S)], acute renal failure. Discharge Summary from hospital documented: Reason for Admission [CONDITION(S)], acute renal failure and toxic metabolic [CONDITION(S)] Hospital Course [R2] .with [history (hx)] of [[CONDITION(S)] (CKD)], [hypertension ([CONDITION(S)])], [peripheral vascular disease (PVD)], unspecified neurocognitive disorder, recurrent falls, and partial [CONDITION(S)] who was taken to the ER after a fall. Patient was found to be in acute renal failure with VRE [CONDITION(S)] and bacteremia, and with toxic metabolic [CONDITION(S)] due to uremia. Nephrology, urology, and general surgery were consulted during this stay. Patient admitted to floor for continued resuscitation and for work up of [CONDITION(S)], acute renal failure and toxic metabolic [CONDITION(S)]. Problem based summary as follows: Complicated VRE [CONDITION(S)] with [left (L)] hydronephrosis as well as kiebsiella bacteremia: most likely [secondary (2/2)] colovesicular fistula. [Infectious Disease (ID)] was consulted and recommended long term IV [antibiotic (Abx)] use until surgical intervention, on [MEDICATION(S)] and [MEDICATION(S)]. Plan for ID [outpatient follow up (outpt f/u)] in 3-4 weeks. Urology was also consulted and had a Foley catheter and nephrostomy tube placed for decompression. Plan for urology outpt f/u in 3-4 weeks with [Urology (MD)-J]. Patients left nephrostomy tube will need to be exchanged by [[MEDICATION(S)] Radiology (IR)] on 9/23/21 . Will need follow up CT [anteroposterior (A/P)] toward the end of Abx therapy. Complicated Diverticulitis w/ possible colovesicular fistula; adjacent phlegmon: most likely 2/2 to mass causing an obstruction vs. complicated sigmoid diverticulitis w/ perforation and fistula formation. Surgery was consulted and determined no surgical intervention needed at this time and no sign of surgical problem developing, but they will consider future surgery depending on goals of care and nutrition improvement. Colonoscopy performed this stay, showing diverticular stricture and mucosal [CONDITION(S)], biopsy pathologies with benign [CONDITION(S)]. Plan for patient to go to [sub-acute rehab ([NAME])]. If nutrition improving plan to move forward with follow up with surgery. If nutrition not improving and patient not candidate for surgery, will need ongoing goals of care discussion, with possible hospice, as complicated VRE and complicated diverticulitis likely not to improve without surgical intervention. Patient will need follow up in about a month with general surgery . Acute kidney injury on [CONDITION(S)], resolved: Urine studies show [MEDICATION(S)] renal injury, likely [acute tubular necrosis (ATN)] improved with nephrostomy and Foley catheter placement. [Glomerular filtration rate (GFR)] ~60 on discharge. Will need monitoring of kidney function . Surveyor reviewed R2's MDS (Minimum Data Set) Admission Assessment with an assessment reference date of 9/9/21. Documented under Cognition was a BIMS (brief interview mental status) score of 11 which indicated moderately impaired. Surveyor reviewed Progress Notes for R2. Documented on 9/2/21 at 7:41 PM was Resident arrived via Bell Ambulance, Resident is alert with Single lumen PICC right chest, Nephrostomy tube left back, Foley [catheter], multiple dressing to knees, legs, back. 1. Surveyor reviewed facility's Nephrostomy and Cystostomy Tube Care and Maintenance policy with a date of 2020. Documented was: Policy: Residents with nephrostomy or cystostomy tubes will receive care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences . Policy Explanation and Compliance Guidelines: 2. The care and maintenance of nephrostomy/cystostomy tubes shall be in accordance with physician orders. The orders shall specify the type and frequency of dressing changes and emptying of collection bags along with any special instructions . 4. The resident's goals and preferences for care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions will include, but are not limited to: a. Frequency of dressing changes and emptying of collection bags . d. Interventions to prevent complications or promote dignity associated with the tube(s). i. Fluid preferences, and need for increased fluid intake. ii. Monitoring for symptoms of blockage (reduced or absent urinary output), urinary tract infection (fever, chills, back pain, new onset [CONDITION(S)], foul smelling or cloudy urine), or dislodgement (tube falls out, leaking urine around tube, increase in tube length). iii. Monitoring for skin breakdown or signs of infection (redness, warmth, swelling, abnormal exudate) around the insertion site(s). iv. Physical management of tubing and collection bags to prevent infection or dislodgement . 7. Considerations for care: a. Check tube(s) frequently for kinks or obstructions. These are likely to occur if the resident lies on the insertion site . c. Monitor output for changes in amount, color, clarity or odor. d. Monitor for signs of urinary tract infection or infection of insertion site . f. Record output from each tube. Specify location of output. g. Document abnormalities and report to physician immediately. Surveyor reviewed The Lippincott Manual of Nursing Practices - 10th edition with a Copyright date of 2014 used by the facility for Standard of Practice for care. Documented was: Urinary diversion refers to diverting the urinary stream from bladder so that it exits by way of a new avenue. A number of operative procedures may be performed to achieve this. Methods of urinary diversion include: .2. Nephrostomy- insertion of a catheter into the renal pelvis by way of an incision into the flank or by percutaneous catheter placement into the kidney. They are rarely placed for long periods of time; they area short-term method of diverting urine away from an obstruction or lesion below the level of the renal pelvis Postoperative Management 1. Patient is assed for immediate postoperative complications; wound or [CONDITION(S)] [urinary tract infection] urinary or fecal anastomotic leakage, small bowel obstruction, paralytic ileus, [CONDITION(S)], pulmonary embolism, and necrosis of stome. 2. Intake and output are monitored including amount of urinary output, patency of drainage catheters and degree of hematuria .Nursing Interventions . For continent urinary diversion patients: 1. Maintain patency of drainage catheters placed into internal urinary poud during surgery; irrigate with 30 mL saline every 2 to 4 hours to prevent obstruction from mucous accumulation. 2. Assess stoma-should be very small and flush. 3. urine output and character of urine. 4. Monitor output of pelvic drain (on gentle suction or gravity drainage) every 8 hours . Surveyor reviewed Nephrostomy and Biliary Tube Management - Appendix 2 Summary of Clinical Care Pathways with a date of 2014. Documented under Management of Nephrostomy Tubes was: General recommendations for patients and health care providers caring for nephrostomy tubes include routinely checking nephrostomy tube patency and monitoring for pain, leakage or bleeding, as well as fever . Unless contraindicated, patients are encouraged to drink 1.5 to 2.5 liters of fluid daily to ensure tube patency and prevent infection. Patient instruction to inspect their nephrostomy tube daily, looking for skin breakdown, soiled dressings, kinks in the tubing, and evidence of blockage such as decreased urine output, leakage around the insertion site or fever and chills was recommended. [NAME] and colleagues recommended periodic reassessment of the nephrostomy tube indication and removal of unnecessary tubes as a method of preventing associated infection. Prompt initiation of antibiotics in patients with signs of infection was also recommended if infection is suspected . An absence of urine, presence of blood in the collection bag, or flank pain may indicate that the tube is blocked. If blockage is suspected it was recommended that nephrostomy tubes be irrigated or flushed using gentle force with normal saline or sterile water using sterile or aseptic technique. Two documents stated that hand washing before and after flushing the nephrostomy tube is essential and sterile gloves should be worn. Four guidelines recommend that the tip of the tube be cleaned with [MEDICATION(S)] or alcohol wipe prior to flushing. The recommended volume of fluid which should be flushed into the tube varied widely in the literature. A maximum of 10 to 20mL (range 2 to 20mL) was recommended for flushing into the nephrostomy tube, with patient monitoring for urine flow and signs of infection. If a blockage is suspected, gently pulling back on the syringe may dislodge an obstruction, however, if too much force is used this may cause trauma and bleeding. Some guidelines recommend against this practice without supervision of a medical professional. Some literature recommended against routinely flushing a nephrostomy tube, as it may be associated with damage to the renal collecting system, however, if the nephrostomy tube is prone to blockage, then prophylactic flushing twice weekly may be attempted. Guidelines recommend that urine should be drained from the bag routinely (4 to 5 times per day or when the bag is approximately half to two-thirds full), as the bag can become heavy and result in dislodging of the tube. Recommendation for the frequency of changing drainage bags ranged from three times weekly to every 7 days. The recommended frequency of dressing changes also varied from every other day to twice weekly; however, there was generally agreement across references that the dressing should be changed if it becomes visibly soiled. Recommended nephrostomy tube dressings include drainfix, which is a specialized catheter anchor, [MEDICATION(S)] wafer, Op site, dry dressing, Uresil adhesive dressing, 3MTM No Sting Barrier Film and waterproof dressing prior to showering . https://www.ncbi.nlm.nih.gov/books/NBK 5/ Surveyor reviewed R2's Care Area Assessments (CAA) with an assessment date of 9/9/21. Documented under Urinary Incontinence and Indwelling Catheter was Nature of the problem/condition . [R2] has a [MEDICATION(S)]/foley cath that is monitored by staff. Surveyor reviewed R2's Comprehensive Care Plan with a start date of 9/2/21. There was no care plan for R2's nephrostomy tube which would address monitoring urine and signs and symptoms of infection. The only care plan in place was for renal insufficiency. Documented was: Focus: The resident has renal insufficiency r/t Kidney disease Goal: The resident will be free from infection through the review date. Interventions: o The resident will have no s/sx of complications r/t fluid deficit through the review date. o The resident will have no s/sx of complications relate to fluid overload through the review date. o Assist resident with [Activities of Daily Living (ADLS)] and ambulation as needed. Watch for [shortness of breath (SOB)] and match level of assistance to residents current energy level. o Elevate feet when sitting up in chair to help prevent dependent [CONDITION(S)] as will allow. o Monitor and report changes in mental status: lethargy; tiredness; fatigue; tremors; seizures. o Monitor for s/sx of hypovolemia (increased pulse, increased respirations, decreased systolic, sweating, anxiousness) or hypervolemia (JVD, increased BP, lung crackles, headache, SOB, dependent [CONDITION(S)]). o Monitor lab reports of electrolytes and report to physician. Notify if K over 5.5. o Monitor/document/report PRN any s/sx of acute renal failure: Oliguria (urine output <400ml per 24 hr.); Increased BUN and Creatinine; In the Diuretic phase, (output >500 ml/24 hr) the BUN and Creatinine level out. o Monitor/document/report PRN the following s/sx: [CONDITION(S)]; weight gain of over 2 lbs a day; neck vein distension; difficulty breathing (Dyspnea); increased heart rate ([CONDITION(S)]); elevated blood pressure (Hypertension); skin temperature; peripheral pulses; level of consciousness; Monitor breath sounds for crackles . Surveyor reviewed Visual/Bedside Kardex Report to be used by Certified Nursing Assistants (CNAs) for direction on cares and plan of care. There was no care plan for R2's nephrostomy tube. Surveyor reviewed CNA Task charting for R2. There was no documented I&Os for R2 for daily fluid intake and output in nephrostomy bag. Surveyor reviewed Progress Notes for R2. Documented on 9/2/21 at 10:26 PM was Resident had 500 cc drainage from nephrostomy bag. Documented on 9/4/21 at 6:41 AM was Alert and responsive . resting this am, no distress noted, 950 cc urine output. There was no other documented intake or output in cc's or mL that would quantify the amount in the nephrostomy bag each shift. There was no documentation of cc's or mL of fluids taken in. Surveyor reviewed MD orders with a start date of 9/10/21. Documented was Skilled Documentation Daily AM shift Nephrostomy Care .one time a day. This order was discontinued on 10/8/21. The chart does not indicate who discontinued this order, and staff had differing thoughts. This order is contrary to professional standards of practice. Subsequently, there is no documentation that nephrostomy care was completed 10/8/21 through 10/27/21. There was no order for cleaning the tube or bag, I&Os or emptying the bag. Surveyor reviewed MD orders with a start date of 9/15/21. Documented was Nephrostomy tube site: cleanse with [normal saline (NS)], apply t drain dressing around tube, [followed by (fb)] [MEDICATION(S)] weekly and PRN for saturation; every day shift every Wed. As evidenced below in interview with physician assistant (PA) - K, the dressing order in place was not acceptable for standards of care of a nephrostomy tube site. There was no order for dressing changes from 9/2/21 through 9/15/21. The treatment was not documented as completed until 9/22/21 in the Treatment Administration Record (TAR). On 11/11/21 at 10:42 AM Surveyor interviewed CNA-F. Surveyor asked how she would know how to take care of a resident. CNA-F stated the Kardex and she gets report before her shift. Surveyor asked if she emptied R2's nephrostomy bag. CNA-F stated yes. Surveyor asked if she noted any changes in R2 towards the end of his stay at the facility. CNA-F stated before he went to the hospital he stopped urinating as much in his Foley bag, sleeping more, had to be fed and stopped eating about a week leading up to going to the hospital. Surveyor asked if she reported this to anyone. CNA-F stated she reported it to a nurse but not sure which nurse. On 11/11/21 at 11:00 AM Surveyor interviewed CNA-G. Surveyor asked how she would know how to take care of a resident. CNA-F stated the Care Plan, the nurse or a CNA that is familiar with the resident. Surveyor asked if she emptied his nephrostomy bag. CNA-F stated yes. Surveyor asked if she noted any changes in R2 towards the end of his stay at the facility. CNA-F stated urine became less and less in his bags. CNA-G stated he was getting weaker and weaker and stopped eating. Surveyor asked if she reported this to anyone. CNA-F stated she reported it to Licensed Practical Nurse (LPN)-D. On 11/11/21 at 11:48 AM Surveyor interviewed CNA-G. Surveyor asked how she would know how to take care of a resident. CNA-F stated the Care Plan. Surveyor asked if she emptied his nephrostomy bag. CNA-F stated no, the nurse did that. On 11/11/21 at 10:23 AM Surveyor interviewed LPN-D. Surveyor asked if she did any treatments to R2's nephrostomy tube. LPN-D stated she would change the dressing if it needed it. LPN-D stated it was a [MEDICATION(S)] and gauze that was changed weekly and PRN. Surveyor asked if she changed it more than once a week. LPN-D stated maybe one more time a week. Surveyor asked if she every flushed the tube. LPN-D stated no. Surveyor asked if they charted I&O's for R2. LPN-D stated not really. Surveyor asked if she noticed any decreased output for R2 in his nephrostomy bag. LPN-D stated in the last week he was at the facility he had decreased output of about 5 cc's in a shift. Surveyor asked if she reported the decreased output to anyone. LPN-D stated no because it was not bloody or discolored. On 11/11/21 at 9:30 AM Surveyor interviewed Physician Assistant (PA)-K for Urology MD-J. Surveyor asked about standard of care for nephrostomy tube. PA-K stated at a minimum the facility should be doing daily dressing changes, emptying the bag and cleaning it at regular intervals, monitoring I&Os, flushing the tube daily and updating their office for any changes. Surveyor asked what the dressing should be around the nephrostomy tube. PA-K stated a dry t gauze or something similar. Surveyor asked if a [MEDICATION(S)] changed weekly was an appropriate dressing and treatment. PA-K stated never. PA-K stated the dressing needs to be breathable and changed daily or at least every other day. Surveyor asked how to care for the bag. PA-K stated emptying on regular intervals and before it gets full. PA-K stated cleaning the bag with [MEDICATION(S)] and switching to a new bag when needed if soiled. Surveyor asked how often I&Os should be monitored. PA-K stated every shift at least. PA-K stated the amount in the nephrostomy bag should be documented as well as the amount in the Foley bag documented separately. PA-K stated if output is significantly decreased the facility would need to call Urology to update. Surveyor asked about flushing the nephrostomy tube. PA-K stated the tube should be flushed with 10cc's normal saline daily to prevent blockage and check for patency daily or at least every other day. Surveyor asked what would happen if these standards are not followed. PA-K stated an infection or the tube not functioning properly which will cause backup into the kidneys and cause hydronephrosis. On 10/27/21 R2 was sent to the hospital and admitted to ICU with Septic shock due to [CONDITION(S)], pneumonia and acute renal insufficiency due to left blockage. 2. Surveyor reviewed the facility's Foley Catheter Care policy with no date. Documented was Purpose: To provide appropriate Foley catheter care and to prevent infection of the resident's urinary tract. General Considerations: 1. Observe the resident's urine level for significant increases or decreases. If there is low output or a rapid increase in output - contact the physician . 5. Maintain an accurate record of the resident's daily output if indicated. Urinary drainage bags should be emptied at least once every shift. 6. Monitor for signs and symptoms of urinary tract infection . Surveyor reviewed R2's Care Area Assessments (CAA) with an assessment date of 9/9/21. Documented under Urinary Incontinence and Indwelling Catheter was Nature of the problem/condition . [R2] has a [MEDICATION(S)]/Foley cath that is monitored by staff. Surveyor reviewed R2's Comprehensive Care Plan with a start date of 9/2/21. Documented was: Focus: The resident has Urinary Catheter. Goal: The resident will show no s/sx of Urinary infection through review date. Interventions: o CATHETER: The resident has (SPECIFY Size) (SPECIFY Type of Catheter). Position catheter bag and tubing below the level of the bladder and away from entrance room door. o Check tubing for kinks each shift. o Monitor for s/sx of discomfort on urination and frequency. o Monitor s/s of catheter complications i.e. leaking, obstruction, etc. o Monitor/document for pain/discomfort due to catheter. o Monitor/record/report to MD for s/sx [CONDITION(S)]: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Surveyor reviewed Visual/Bedside Kardex Report to be used by CNAs for direction on cares and plan of care. Documented under Bladder/Bowel was - CATHETER: The resident has (SPECIFY Size) (SPECIFY Type of Catheter). Position catheter bag below the level of the bladder and away from entrance room door. - Monitor [signs and symptoms (s/s, s/sx)] of catheter complications i.e. leaking, obstruction, ect. There was no specific size or catheter listed. There was no instruction on recording input and output (I&Os). There was no instruction on how often to empty or clean the catheter bag. Surveyor reviewed CNA Task charting for R2. There was no documented I&Os for R2 for daily fluid intake and output in Foley Catheter bag. Surveyor reviewed MD orders with a start date of 9/10/21. Documented was Skilled Documentation Daily AM shift .Catheter Care .one time a day. This order was discontinued on 10/8/21. There is no documentation that catheter care was completed 10/8/21 through 10/27/21. On 11/11/21 at 10:42 AM Surveyor interviewed CNA-F. Surveyor asked how she would know how to take care of a resident. CNA-F stated the Kardex and she gets report before her shift. Surveyor asked if she emptied his catheter bag. CNA-F stated yes. Surveyor asked if she noted any changes in R2 towards the end of his stay at the facility. CNA-F stated before he went to the hospital he stopped urinating as much in his Foley bag. Surveyor asked if she documented I&Os for R2. CNA-F stated she reported it to a nurse. On 11/11/21 at 11:00 AM Surveyor interviewed CNA-G. Surveyor asked how she would know how to take care of a resident. CNA-F stated the Care Plan, the nurse or a CNA that is familiar with the resident. Surveyor asked if she emptied R2's Foley catheter bag. CNA-F stated yes. Surveyor asked if she noted any changes in R2 towards the end of his stay at the facility. CNA-F stated urine became less and less in his Foley bag. Surveyor asked if she documented I&Os for R2. CNA-F stated she would document in the chart. The facility had no input and output (I&Os) recorded or tracked for resident. Daily Foley catheter charting was discontinued and there was no documentation from 10/8/21 through 10/27/21. Resident then had decreased output from Foley catheter that was not reported to Urology and R2 was sent to the hospital. R2 was admitted with a [CONDITION(S)] secondary to hydronephrosis and passed away 2 days later. 3. Surveyor reviewed facility's Catheter Insertion and Care: Central Venous Catheter Dressing Changes with a date of July 2016. Documented was: Policy Central venous catheter dressings will be changed at specific intervals, or when needed, to prevent catheter related infections that are associated with contaminated, loosened, soiled, or wet dressings. Preparation 1. Verify with state nurse practice act the scope of practice for [Register Nurses (RNs)] and [Licensed Practical Nurses (LPNs)] regarding this procedure . General Guidelines 1. Dressings must stay clean, dry, and intact. Explain to the resident that the dressing should not get wet. 2. Change transparent semi-permeable membrane (TSM) dressings at least every 5-7 days and [as needed (PRN)] (when wet, soiled, or not intact) . 7. Catheter site care and dressing changes will include: a. Removal of the old dressing; b. Observation and evaluation of the catheter-skin junction and surrounding tissue; c. Cleansing with an approved antiseptic solution (e.g., [MEDICATION(S)] solution); d. Replacement of any stabilization device; and e. Application of a sterile dressing . Surveyor reviewed R2's Comprehensive Care Plan with a start date of 9/2/21. Documented was: Focus: The resident is at risk for complications of IV/PICC line. Goal: The resident will not have any complications related to IV Therapy through the review date. Interventions: o IV DRESSING: Change dressing as per order. o Monitor/document/report PRN s/sx of leaking at the IV site: [CONDITION(S)] at the insertion site, Taut, shiny or stretched skin, whitening/blanching or coolness of the skin, slowing or stopping of the infusion, leaking of I.V. fluid out of the insertion site. o Monitor/document/report the site for Drainage, Inflammation, Swelling, Redness, Warmth. Surveyor reviewed R2's MD orders with a start date of 9/2/21. Documented was IV Access - Type: Central Venous Catheter. Side: Right [MEDICATION(S)] every day shift every Wednesday. Measure Catheter length from insertion site to tip of cap. Notify Dr/[Nurse Practitioner (NP)]/PA if length changed >2cm [due to] potential catheter migration. Surveyor reviewed Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Documented on the following dates as completed by LPN-D was 9/8/21 cm: NA; 9/15/21 cm: [Yes (Y)]; 9/22/21 Other: see Progress Notes; 9/29/21 cm: Y; 10/6/21 cm: Y; 10/13/21 cm: Y and 10/20/21 cm: Y. R2 was hospitalized on Wednesday 10/27/21, the next scheduled measurement day. Progress Notes had no rationale or documentation for 9/22/21 Other entry. Surveyor reviewed R2's MD orders with a start date of 9/2/21. Documented was IV Access - Type: Central Venous Catheter. Side: Right [MEDICATION(S)] every day shift every Wednesday Site care and Dressing change. Valve changed. Surveyor reviewed Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Documented on the following dates as completed by LPN-D was 9/8/21; 9/15/21; 9/22/21; 9/29/21; 10/6/21; 10/13/21 and 10/20/21. R2 was hospitalized on Wednesday 10/27/21, the next scheduled dressing change. Surveyor reviewed Emergency Department (ED) notes from admission on 10/27/21. Documented by the ED MD was .The patient had a PICC line or tunneled line in his right chest. I was concerned that this looked dirty, dressing indicated it was from 9/15/21. I thought it was best not to use this. I made an attempt to pull the line but it seemed affixed so further attempts were aborted . On 11/10/21 at 1:30 PM Surveyor interviewed LPN-D. Surveyor asked if she changed the PICC line dressing. LPN-D stated no, she only checked the dressing to make sure it was in place. Surveyor asked if she measured the PICC line catheter. LPN-D stated no, she never did anything with the PICC line except flush the line and run the IV medications. LPN-D stated that the Unit Manager Registered Nurse (RN)-E would do both of those treatments. On 11/11/21 at 11:50 AM Surveyor interviewed RN-E. Surveyor asked if she changed the PICC line dressing. RN-E stated no, that treatment was done by the nurse on day shift. Surveyor asked if she measured the PICC line catheter. LPN-D stated no, that was also done by the day shift nurse. The facility did not ensure measurements and dressing changes were completed although they were signed out as completed in R2's Electronic Medical Record. R2 was admitted to the hospital on 10/27/21 and was found to have a PICC line dressing dated 9/15/21. On 11/11/21 at 1:37 PM Surveyor interviewed NHA-A. Surveyor asked about R2's nephrostomy tube care. NHA-A stated he should have come from the hospital with specific orders. Surveyor asked if a resident comes to the facility without specific orders what is the process. NHA-A stated someone should have followed up with the MD and clarified. NHA-A stated Urology should have been called and asked for specific orders regarding site care, flushing. Surveyor asked what standard of practice the facility follows for nephrostomy tube care. NHA-A stated Lippencott's Nursing Procedures. Surveyor asked if a resident comes to the facility with a Foley catheter what the process is. NHA-A stated there are standing orders that are put in for catheter care and Urology would give orders for that as well. Surveyor noted that nephrostomy and Foley care and charting was discontinued on 10/8/21. Surveyor asked about recording I&Os for R2. NHA-A stated we would not have done it because there was no order for it. Surveyor asked if this should have been clarified with the Urology orders. NHA-A stated probably. Surveyor asked if he was made aware of R2's decreased output. NHA-A stated no, but if it was decreased it should have been reported to the MD. Surveyor asked how the facility would take care of a residents Central Catheter/PICC line. NHA-A stated dressing changes weekly, flushing per policy and orders and monitor every shift. Surveyor discussed that the ED paperwork documented the dressing was dated 9/15/21, and LPN-D signing out the TAR and stating she did not ever change the dressing. NHA-A stated this should not have happened. The facility's failure to properly care for a nephrostomy tube, Foley catheter and PICC line per standards of care, including the monitoring of I&O

Based on interview, observation and record review, the facility did not ensure 2 (R2 and R3) of 3 residents reviewed for pressure injuries (PI) received care, consistent with professional standards of practice, to prevent pressure injuries and did not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable; and residents with pressure injuries received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure injuries from developing. R2 was admitted to the facility on [DATE] with comorbidities that put the resident at risk for Pressure Injuries and was admitted with wounds and scabs to body. No interventions were initiated addressing R2's heels from developing pressure injuries until after a Deep Tissue Injury (DTI) was found on 10/15/21 to the left heel and left great toe. The DTIs were not staged or assessed correctly and it was noted during interview to be a 100% eschar unstageable Pressure Injury. Weekly skin observation forms noted skin intact. On 11/8/21, R3 developed an unstageable medical device related pressure injury from a leg immobilizer. The facility did not put interventions in place to prevent the pressure injury from occurring and did not identify the pressure injury until it was 100% eschar. Findings include: The facility Pressure Ulcer Prevention policy, revised 7/25/16, defines a deep tissue pressure injury as Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister .This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface .If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle of other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3, or Stage 4). The policy states under Skin Care and Early Treatment An integral part of any skin care program is a systematic skin assessment. It is through these inspections that early skin problems can be detected and intervention started. These inspections start on admission .Assessment must continue according to an appropriate schedule. Staff should evaluate skin condition and should pay attention to bony prominence's. 1. R2 was admitted to the facility on [DATE] after a hospitalization from [DATE] to 9/1/21 for acute pyelonephritis, bacteremia, [CONDITION(S)], toxic metabolic [CONDITION(S)], diverticulitis of intestine with perforation, [CONDITION(S)], acute [CONDITION(S)]. Surveyor reviewed R2's MDS (Minimum Data Set) Admission Assessment with an assessment reference date of 9/9/21. Documented under Cognition was a BIMS (brief interview mental status) score of 11 which indicated moderately impaired. Documented under Functional Status for Transfer was 3/3 which indicated Extensive assistance - resident involved in activity, staff provide weight-bearing support; Two+ persons physical assist. Documented under Functional Status for Bed Mobility was 2/2 which indicated Limited assistance - resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight bearing assistance; One person physical assist. Documented under Skin Conditions was Does this resident have one or more unhealed pressure ulcers/injuries? 0. No. Surveyor reviewed R2's Care Area Assessments (CAA) with an assessment date of 9/9/21. Documented under Pressure Ulcer/Injury was CAA's triggered Pressure Ulcer. [R2] requires extensive assist x2 with transfers and toileting, extensive assist x1 with dressing and personal hygiene, limited assistance x1 bed mobility, independent after set up with eating [alert and orientated x1]. Offer toileting 2-3 hr prn (as needed) for bowel incontinence, has [MEDICATION(S)] managed per staff. [R2] skin integrity monitored daily with cares and weekly showers . Surveyor reviewed R2's Comprehensive Care Plan with an initiation date of 9/7/21 and revision dates of 9/27/21 and 10/7/21. Documented was: Focus: The resident has actual impairment to skin integrity (trauma mid back, multiple scabs to bilateral lower legs) Goal: The resident will maintain or develop clean and intact skin by the review date. The resident's will have no complications through the review date. Interventions: o Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. o Educate resident/family/caregivers of causative factors and measures to prevent skin injury. o Encourage good nutrition and hydration in order to promote healthier skin. o Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] o Identify/document potential causative factors and eliminate/resolve where possible. o Keep skin clean and dry. Use lotion on dry skin. o Monitor for side effects of the antibiotics and over-the-counter pain medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . o Monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to MD. o Obtain blood work such as CBC with Diff, Blood Cultures and C&S of any open wounds as ordered by Physician. o Provide pressure relieving device(s): to w/c and bed. o The resident needs pressure reducing cushion to protect the skin while up IN CHAIR. o The resident needs pressure reducing mattress to protect the skin while IN BED. o Turn and position as necessary o Use a draw sheet or lifting device to move resident. o Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. o Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Surveyor reviewed R2's Admission Data Collection and Baseline Care Plan Tool with a date of 9/2/21. Documented under Skin Condition was Site: 13) Vertebrae (upper-mid); 37) Right knee (front); 38) Left knee (front). There were no Pressure Injuries documented. Surveyor reviewed R2's Braden Scale for Predicting Pressure Sore Risk with dates of 9/2/21 and 9/9/21. Documented was Braden Risk Scale Score: 15 which indicated at risk for Pressure Injuries. Surveyor reviewed R2's MD orders with a start date of 9/4/21. Documented was Complete Skin Observation in [Point Click Care (PCC)] every evening shift every Wed, Sat. Surveyor reviewed R2's Skin Observation Tool forms with a dates of 9/4/21, 9/18/21, 10/2/21 and 10/13/21. Documented was Skin Intact: Yes. Surveyor reviewed R2's Skin Impairment/Wound Form with dates of 9/15/21, 9/24/21, 9/30/21 and 10/8/21. Documented under Pressure Ulcer was Does the resident have a Pressure Injury? No. Surveyor reviewed R2's Progress Notes. Documented on 10/15/21 at 3:57 PM by Licensed Practical Nurse (LPN)-C was Writer observed darken area to left heel area 6.0 x 5.5 [cm] no drainage skin intact hard to touch no pain with palpation and left great toe 1.5 x 2.9 [cm] no drainage skin intact no [complaint of (c/o)] of pain. MD notified via Fax, [Director of Nursing (DON)-B]/Wound nurse also notified. Writer cleansed areas with [normal saline (NS)] and left open to air, applied bilateral pressure relieving boots to be worn at all-time except with care. Surveyor reviewed Comprehensive Care Plan with an initiation date of 10/15/21. Documented was: Focus: The resident has pressure ulcer [related to (r/t)] Immobility ([left (L)] heel, L great toe) Goals: The resident's Pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions: o Administer medications as ordered. Monitor/document for side effects and effectiveness. o Administer treatments as ordered and monitor for effectiveness. o Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. o Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] o Heels boots or heels up on at all times except with cares o If the resident refuses treatment, confer with the resident, [interdisciplinary team (IDT)] and family to determine why and try alternative methods to gain compliance. Document alternative methods. o Monitor dressing to ensure it is intact and adhering. Report loose dressing to nurse. o Monitor nutritional status. Serve diet as ordered, monitor intake and record. o Monitor/document/report [as needed (PRN)] any changes in skin status: appearance, color, wound healing, [signs and symptoms (s/sx)] of infection, wound size (length X width X depth), stage. o Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. o Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. o The resident needs assistance to turn/reposition at least every 2 hours, more often as needed or requested. o The resident requires supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. o Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. o Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Surveyor noted on 10/15/21 the facility initiated the use of heel boots or heel up at all times after R2 developed the DTI. Additionally the care plan indicates if R2 refuses treatment to confer with the Resident, IDT and family to determine why and try alternative methods to gain compliance and to document alternative methods. Surveyor reviewed R2's MD orders with a start date of 10/15/21. Documented was Left great toe [MEDICATION(S)] daily every shift and Left heel [MEDICATION(S)] daily every shift. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor reviewed R2's Skin Impairment/Wound Form with a date of 10/15/21. Documented under Pressure Ulcer was Does the resident have a Pressure Injury? Yes. Location: L heel. Stage of pressure injury: Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Measurement of Wound: 6.0 X 5.5 X [undetermined (UTD)] [cm] . Location: [right (R)] great toe. Stage of pressure injury: Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Measurement of Wound: 1.5.0 X 2.0 X UTD [cm] . The assessment refers to the R great toe which contradicts the Care Plan and Progress Note that refer to the L great toe. Surveyor reviewed R2's Skin Observation Tool form with a date of 10/16/21. Documented was Skin Intact: Yes. This contradicts the Skin Impairment/Wound Form with a date of 10/15/21 which documents Pressure injuries on left heel and right great toe assessed as DTI. Surveyor reviewed R2's Skin Impairment/Wound Form with a date of 10/22/21. Documented under Pressure Ulcer was Does the resident have a Pressure Injury? Yes. Location: L heel. Stage of pressure injury: Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Measurement of Wound: 6.0 X 6.2 X UTD [cm] . Location: [right (R)] great toe. Stage of pressure injury: Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Measurement of Wound: 1.5.0 X 2.0 X UTD [cm] . The assessment refers to the R great toe which contradicts the Care Plan and Progress Note that refer to the L great toe. Surveyor reviewed R2's Skin Observation Tool form with a date of 10/23/21. Documented was Skin Intact: Yes. This contradicts the Skin Impairment/Wound Form with a date of 10/15/21 which documents Pressure injuries on left heel and right great toe assessed as DTI. Surveyor reviewed Hospital Paperwork from 10/27/21 hospital admission. Documented by Emergency Department MD was .extensive skin abrasions, pressure ulcers [present on admission (POA)]. Wound consult . Documented by Hospital ICU RN-I on 10/27/21 at 1:37 PM was .Left heel large eschar area, with reddened edges. Left great toe tip black and red surrounding skin . This contradicts the assessments completed in the facility that the L heel was a DTI. Surveyor reviewed Hospital Paperwork from 10/28/21 Wound Consult. Documented was .Feet wounds appear to be due to pressure and vascular tissue. Present on admission . Left heel has unstageable pressure injury measuring 4 x 5 cm. Stable eschar . On 11/10/21 at 2:39 PM Surveyor interviewed Hospital ICU RN-I. Surveyor asked about the left heel of R2. RN-I stated it was a very large 3 inches by 3 inches eschar cap. RN-I stated the surrounding skin was red and inflamed. On 11/10/21 at 1:30 PM Surveyor interviewed LPN-D. Surveyor asked if R2 had any wounds. LPN-D stated he had a heel wound they were treating with [MEDICATION(S)]. LPN-D stated one time he rubbed it too hard and it opened up. LPN-D stated they put a bandage on the left heel after that. Surveyor asked what interventions were in place for R2 to prevent heels from breaking down. LPN-D stated when the heel wound was found they put blue boots in place. LPN-D stated the boots did not work because he kicked them off and refused to wear them. Surveyor noted there is no documentation the facility conferred with resident, IDT and family to determine why R2 was kicking off and refusing to wear the blue boots and to try alternative methods to gain compliance as indicated R2's care plan dated 10/15/21. Surveyor noted there was no documentation of heel wound opening or the treatment being changed from [MEDICATION(S)]. On 11/11/21 at 12:03 PM Surveyor interviewed LPN-C who identified the left heel and left toe wounds on 10/15/21. Surveyor asked what the wound looked like to his left heel. LPN-C stated it was a large, dark, round, eschar cap. LPN-C's note describing the area on 10/15/21 does not include the pressure injury as having an eschar cap. On 11/11/21 at 10:42 AM Surveyor interviewed CNA-F. Surveyor asked if she ever cared for R2. CNA-F stated yes. Surveyor asked if R2 wore blue boots on his feet. CNA-F stated she thinks he did the last week he was at the facility but not before then. On 11/11/21 at 11:00 AM Surveyor interviewed CNA-G. Surveyor asked if she ever cared for R2. CNA-G stated yes. Surveyor asked if R2 wore blue boots on his feet. CNA-G stated she was not sure. On 11/11/21 at 11:48 AM Surveyor interviewed CNA-H. Surveyor asked if she ever cared for R2. CNA-H stated yes. Surveyor asked if R2 wore blue boots on his feet. CNA-H stated yes, he wore them to bed. Surveyor noted R2's care plan dated 10/15/21 indicates for R2 to wear heel boots or heels up on at all times except with cares. On 11/11/21 at 1:37 PM Surveyor interviewed NHA-A. Surveyor asked about the Skin Observation Tool sheets that stated skin intact when R2 had wounds. NHA-A stated we have a couple nurses that do that (referring to documenting skin intact). Surveyor asked what should be done. NHA-A stated the DON measures the wounds so they were looked at. Surveyor asked about the left heel wound. NHA-A stated R2 got that when he was out at an appointment on 10/12/21. Surveyor asked where that was documented. NHA-A stated it was noted in the Skin/Wound assessment. Surveyor noted that the assessment was completed 10/15/21 and there is a Skin Observation Tool that states skin intact on 10/13/21. Surveyor noted that would make the wounds facility acquired. On 11/11/21 at 2:55 PM Surveyor interviewed DON-B. DON-B develops resident's skin impairment interventions and assesses wounds at the facility. DON-B informed Surveyor that the wound to the heel never progressed past a DTI. Surveyor noted to DON-B that all nurses doing treatments, hospital ICU RN and Wound Consult in hospital all noted left heel to be 100% eschar. Surveyor stated any additional information the facility had would be reviewed. No additional information was provided. 2. The facility Pressure Ulcer Prevention policy and procedure, revised July 25th, 2016, states A pressure injury is localized damage to the skin and/or underlying soft tissue over a bony prominence or related to a medical or other device .The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The policy defines an Unstageable Pressure Injury as Obscured full-thickness skin and tissue loss- Full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [CONDITION(S)] or fluctuance) on an ischemic limb or the heel (s) should not be removed. Under Additional pressure injury definitions the policy states Medical Device Related Pressure Injury: This describes an etiology. Medical device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system. R3 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3 receives renal [CONDITION(S)]. On 9/1/21 R3's Braden Score was 15 indicating R3 was at risk for the development of pressure injuries. On 9/30/21 R3 fractured their leg. An order was placed on 9/30/21 for an immobilizer to the left leg. R3's plan of care was not revised to prevent skin impairment from the immobilizer. On 10/14/21 R3's Braden score was 13, indicating R3 was at moderate risk for pressure injuries, an increased risk from their 9/1/21 assessment. There was no changes noted to R3's plan of care when R3 was noted to be at increased risk for pressure injuries. R3's Care Area Analysis for Pressure Ulcer/Injury, signed as completed by DON (Director of Nursing)-B on 11/2/21, documents the nature of the problem/condition as [R3] skin integrity is currently intact with no OA [open area] noted. Her skin integrity is checked daily with cares and weekly with showers. The Care Area Analysis documents, CAA [care area analysis] triggered Pressure Ulcer: [R3] is A&O x 3. [R3] has current dx [diagnosis] of Fc [fracture] of lower end L [left] tibia, DM [diabetes mellitus], [CONDITION(S)] [chronic obstructive pulmonary disorder], lack of coordination, [CONDITION(S)] [end stage renal disease], [CONDITION(S)], OSA [obstructive sleep apnea], [CONDITION(S)], [CONDITION(S)] [hypertension], depression, muscle weakness, abnormal posture, age related [CONDITION(S)], need for assistance with personal care, presence of artificial hip joint, [CONDITION(S)], chronic pulmonary embolism, GERD [gastroesophageal reflux disease], chronic pain. [R3] is a total assist of 2 with transfers, toilet use, bathing. [R3] skin integrity is currently intact with no OA [open area] noted. Her skin integrity is monitored daily with cares and weekly with showers. [R3] is currently in OT [occupational therapy], PT [physical therapy] 5x/wk. Call light is kept within reach. Encouraged to ask for assistance. Will continue to monitor. Continue with POC [plan of care]. On 11/5/21 a skin observation tool documents yes to skin intact. On 11/8/21 a Skin Impairment/Wound Form documents a 4.9 x 2.4 x UTD [unable to determine), unstageable pressure injury with 100% eschar to the left lateral lower leg. Additional comments documents, Wound from immobilizer. No s/s [signs/symptoms] of infection noted. No complaints of pain or discomfort noted. Will continue with current treatment. The current treatment is documented as cleanse with NS [normal saline], fb [followed by] skin prep to peri wound, fb Santyl to wound bed, fb foam border gauze QD [every day] and PRN [as needed] for soiling/saturation. Wound Education provided is documented as place tubi grip or pants or long socks on before putting immobilizer on L [left] leg, good nutrition to promote wound healing. On 11/9/21 the intervention to Apply tubi grip or sock to left leg before applying left leg brace. Inspect skin under brace daily and prn was added to R3's plan of care. On 11/10/21 the intervention to place tubi grip or pants or long socks on before putting immobilizer on L leg was added to R3's plan of care. On 11/10/12 at 1:11 pm the surveyor interviewed R3. R3 informed the surveyor she had a wound on her ankle from her brace. On 11/11/21 at 9:40 am the surveyor interviewed DON-B, who develops residents skin impairment interventions and assesses wounds at the facility. DON-B informed the surveyor if an aid finds a change in the skin they will let the lead nurse know and they will let her know to go and look. The surveyor asked how skin interventions are determined. DON-B stated they put in a standard care plan, will reposition however they need it depending on how frail they are or if have an open area. DON-B stated they will look at if needs an air mattress or heel boots depending on what is going on. The surveyor asked if a resident has an increase risk in their Braden score what is done. DON-B stated they may increase how often they do skin observations. The surveyor asked about R3's developing a pressure injury that was not noted until it was unstageable and 100% eschar. DON-B stated she was not really sure what happened, she kind of slipped away. DON-B stated she was in a different building for 2 weeks at that time and that nurses should have been doing skin assessments and letting her know. DON-B stated they should have been putting the brace over her pants, indicating R3 wears spandex style leggings or shorts. DON-B stated why they didn't see that I don't know and when she talked to R3 she told me she couldn't feel any pain. The surveyor informed DON-B of the concern of R3 developing an unstageable pressure injury from her immobilizer and having no interventions to prevent development of the pressure injury prior to it developing.

Based on interview, and record review, the facility did not provide necessary treatment and services to promote healing for 2 of 4 residents (R3 & R1) with pressure injuries. * R3 developed a pressure injury (right outer ankle) which was identified on 9/4/20. This area was not assessed by a RN (Registered Nurse) until 9/10/20 six days later at which time the area was described an Unstagable Pressure injury. On 9/10/20, the physician was called and the current treatment of [REDACTED]. A pressure ulcer development care plan was not developed until 9/16/20. The care plan did not address R3's favoring of lying on his right ankle while in bed. The pressure injury was not assessed during the week of 9/20/20 to 9/26/20. The pressure injury was incorrectly staged on 1/13/20 & 11/20/20. * R1 is dependent upon staff for all his activities of daily living. A Braden assessment identified R1 to be at high risk for the developement of pressure injuries. R1's potential impairment to skin integrity care plan interventions consisted of encouraging good nutrition and hydration in order to promote healthier skin and turn and resposition as necessary. The Facility did not develop a comprehensive resident centered care plan to prevent R1 from developing pressure injuries, On 12/16/20 R1 was identified as having a Stage 2 pressure injury to the sacrum, described as 3 x 3 x 0.2 cm, wound tissue bed 100% granulation. The Facility did not revise the potential for skin integrity care plan after developing the Stage 2 pressure injury. On 12/18/20 R1 received a speciality mattress. On 12/31/20, the sacral area was described as no active healing properties, 4.5 X 3 x 0.5, unable to visualize wound base, area 100% necrotic slough. Findings include: 1. R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R3 was discharged on [DATE] and reviewed as a closed record. The potential/actual impairment to skin integrity care plan initiated 3/20/20 documents interventions of; Encourage good nutrition and hydration in order to promote healthier skin. Initiated 3/20/20. Follow facility protocols for treatment of [REDACTED]. Provide pressure relieving device: Heel offloading boots. Initiated 3/20/20. Turn and position as necessary. Initiated 3/20/20. Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Initiated 6/2/20. Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Initiated 6/2/20. Identify/document potential causative factors and eliminate/resolve where possible. Initiated 6/2/20. Keep skin clean and dry. Use lotion on dry skin. Initiated 6/2/20. Monitor for side effects of the antibiotics and over-the-counter pain medications: [REDACTED]. Initiated 6/2/20. Monitor/document location, size and treatment of [REDACTED]. Initiated 6/2/20. Obtain blood work such as CBC (complete blood count) with Diff (differential), Blood Cultures and C & S (culture and sensitivity) of any open wounds as ordered by Physician. Initiated 6/2/20. The resident has pressure reducing mattress to protect the skin while in bed. Initiated 6/2/20. The resident needs pressure reducing cushion to protect the skin while up in chair. Initiated 6/2/20. Use a draw sheet or lifting device to move resident. Initiated 6/2/20. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Initiated 6/2/20. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Initiated 6/2/20. The pressure injury CAA (care area assessment) dated 4/23/20 under care plan considerations documents, R3 is A&OX1 (alert and orientated times one). R3 has current Dx (diagnoses) of [MEDICATION NAME] hemorrhage, muscle weakness, lack of coordination, abnormal posture, problems related to care provider dependency, [MEDICAL CONDITIONS], dysphagia, [MEDICAL CONDITION] disorder,[MEDICAL CONDITION](hypertension), [MEDICAL CONDITION], cocaine abuse, Hep ([MEDICAL CONDITION]) C. R3 is total assist of 2 with transfer. R3 is total assist of 1 with eating, toilet use, personal hygiene, bathing. R3 is extensive assist of 2 with bed mobility, dressing. R3 skin integrity is currently intact with no OA (open areas) noted. His skin integrity is monitored daily with cares and weekly with showers. R3 is currently in OT (occupational therapy), PT (physical therapy) 5x/wk (five times per week). Call light is kept within reach. Encouraged to ask for assistance. Will continue to monitor. Continue with POC (plan of care). The nurses note dated 9/4/20 documents, Writer called into residents room at this time. Noted 5 cent size discoloration with half exposing o/a (open area). Area cleansed dry drsg (dressing) applied and pressure relief boot put on. This note was written by a LPN (Licensed Practical Nurse). Surveyor noted there is no RN (Registered Nurse) assessment. The nurses note dated 9/5/20 documents, Alert and responsive, dressing intact to wound, no c/o (complaint of) pain or discomfort. This note was written by a LPN. The nurses note dated 9/6/20 documents, Alert and responsive, dressing intact to wound, no c/o pain or discomfort. This note was written by a LPN. The nurses note dated 9/8/20 documents, Drsg (dressing) clean dry and intact, resident conts (continues) to favor positioning right leg feet directly on affected area pressure reduction boots applied when in bed. This note was written by a LPN. The nurses note dated 9/9/20 documents, Resident alert and responsive. Treatment maintained to left lateral ankle. This note is written by RN-D. Surveyor noted there is still no RN assessment of the open area. The nurses note dated 9/10/20 documents, Writer made aware of alteration in skin to right outer ankle. Open area identified to site. Measures 1.5 x 3.1 x 0.2, soft cap covering wound base, edges well defined, surrounding skin intact. No drainage observed. Current treatment orders changed to Dakins 1/2 strength cleanse, skin prep periwound, apply Santyl to wound, cover with border gauze, daily and PRN (as needed) for dressing failure. resident has contracture to RLE (right lower extremity). Pressure reduction mattress in place, with off loading to site. MD (medical doctor) made aware, in agreement with POC (plan of care). Call placed to Daughter-S. Updated on findings and plan of care. Message left for Family Care to return call for notification. This note was written by Former Director of Nursing (DON)-T. The skin impairment wound form with an effective date of 9/10/20 for the question does the resident have a pressure injury yes is answered. For location documents, right out ankle. For stage of pressure injury documents Unstageable Pressure injury: Obscured full-thickness skin and tissue loss. Measurements of wound are 1.5 x 3.1 x 0.2 Under wound tissue bed slough 100. Surveyor noted this assessment is 6 days after R3 developed the pressure injury (observed on on 9/4/20.) The nurses note dated 9/10/20 documents, Drsg clean dry and intact, pressure relief boots on repositioned but resident favors positioning with right ankle under him when in bed. The nurses note dated 9/15/20 documents, Resident remains alert and responsive per usual and able to answer yes and no questions appropriately. His drsg (dressing) remains clean, dry, and intact and pressure relief boots on he still conts to favor lying on right ankle while in bed. Also noted tolerating TF (tube feeding) well. The resident's pressure ulcer care development r/t (related to) immobility care plan indicates, Right outer aspect of ankle open area initiated 9/16/20. Interventions documented are: Administer treatments as ordered and monitor for effectiveness. Initiated 9/16/20. Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Inform the resident/family/caregivers of any new area of skin breakdown. Initiated 9/16/20. Instruct/assist to shift weight in W/C (wheelchair) q (every) 15 minutes r.t (related to) positioning. Initiated 9/16/20. Monitor nutritional status. Serve diet as ordered, monitor intake and record. Initiated 9/16/20. Surveyor noted R3's care plan was not revised until 6 days after development of the pressure injury (on 9/4/20) and the care plan does not address R3's favoring of lying on his right ankle while in bed. Surveyor also noted there are no further revisions to the care plan. The nurses note dated 9/17/20 documents, Writer received order by IDT (interdisciplinary team) Dietitian to discontinue Vitamin C and Increase Prostat 30ml (milliliters) from BID (twice daily) to TID (three times day). Orders updated/completed. The Braden assessment dated [DATE] has a score of 13 which indicates moderate risk. The nurses note dated 9/21/20 documents, Late entry for 9/18/20 Resident seen per facility wound care MD (medical doctor). See Tissue Analytics noted. Right lateral site noted per wound care MD. Right lateral heel 2.1*2.7.0.1. Tx continues Cleanse with NS (normal saline) skin prep peri-wound then apply Santyl then apply bordered gauze daily and prn (as needed). Res (Resident) is own resp (responsible) part; agreeable to orders. Wished for no one to be contacted on this matter. Surveyor noted there is no assessment of R3's right lateral heel during the week of 9/20/20 to 9/26/20. The nurses note dated 9/28/20 documents Resident seen per wound care nurse for weekly wound assessment. Right lateral heel 2.1*2.7*0.1. Area remains with slough. Daily Santyl remains appropriate. Slough softening. Intervention in place remain. No chief concerns per wound care RN. Surveyor noted weekly assessment and did not have any concerns until 11/13/20. The skin impairment wound form dated 11/13/20 answers yes to the question does the resident have a pressure injury. Location is right outer ankle. Stage of pressure injury is Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Measurement of wound is 2.6 x 2.8 x 0.2. Wound tissue bed in percentage is Granulation 95 and Slough 5. Surveyor noted this pressure injury should have been staged as a Stage 3 pressure injury. The skin impairment wound form dated 11/20/20 answers yes to the question does the resident have a pressure injury. Location is right outer ankle. Stage of pressure injury is Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Measurement of wound is 2.6 x 2.8 x 0.2. Wound tissue bed in percentage is Granulation 95 and Slough 5. Surveyor noted this pressure injury should have been staged as a Stage 3 pressure injury. The skin impairment wound form dated 11/27/20 answers yes to the question does the resident have a pressure injury. Location is right outer ankle. Stage of pressure injury is Stage 3 Pressure Injury: Full-thickness skin loss. Measurement of wound is 1.9 x 2.3 x 0.2. Wound tissue bed in percentage is Granulation 100. R3 was discharged home on[DATE]. On 2/9/21 at 2:27 p.m. Surveyor asked RN-D if a LPN is informed of an open area/pressure injury by the CNA (Certified Nursing Assistant) what should the nurse do. RN-D informed Surveyor the nurse has to report this to the DON, fill out a skin sheet and a change of condition form. Surveyor asked where these would be located. RN-D informed Surveyor under forms in the computer. Surveyor asked who would be responsible for revising the care plan. RN-D informed Surveyor she believes it's the MDS nurse. Surveyor asked RN-D if she updates the care plan. RN-D replied no. Surveyor asked if the floor nurses update the care plan. RN-D replied no they don't. RN-D informed Surveyor when RN-R the former wound nurse was at the facility she would. Surveyor asked RN-D if she looks at pressure injuries. RN-D informed Surveyor the wound nurse usually looks at them and then would get a treatment. RN-D explained if the wound nurse was not here then they would contact the doctor and the following day the wound nurse will address and look at the open area. Surveyor asked RN-D how would the wound nurse know of any skin impairment. RN-D informed Surveyor they would notify her, a skin alteration discovery form is completed and she would get that sheet. On 2/9/21 at 3:05 p.m. Administrator-A, DON-B and Corporate Consultant-C were informed of the above and inquired if there was anyone Surveyor could speak to regarding R1's pressure injuries. On 2/10/21 Surveyor was informed RN-R still works at the facility on a PRN (as needed) basis and they would have RN-R call Surveyor. Surveyor did not receive a call from RN-R. 2. R1 was admitted to the facility on [DATE] and discharged on [DATE]. R1 was reviewed as a closed record. R1's [DIAGNOSES REDACTED]. R1 received a low concentrated sweet pureed texture diet. The Braden assessment has a score of 11 which indicates high risk dated 12/4/20. The potential impairment to skin integrity care plan initiated 12/4/20 & revised 12/8/20 has interventions dated 12/4/20 of Encourage good nutrition and hydration in order to promote healthier skin. and Turn and position as necessary. Surveyor noted the Facility did not develop a comprehensive person center care plan to prevent pressure injuries as R1 is total care and depends on staff for all of his activities of daily living. The nurses note dated 12/5/20 documents Am (morning) shift noted resident alert and responsive. Does not verbalize words but yells out. Good appetite noted. Needs assist with meals. Total assist with ADLs (activities daily living) positioning and toileting. Skin warm and dry intact. No s/so (signs/symptoms) pain or discomfort noted. Droplet isolation precautions maintained. no s/s of respiratory distress noted. The admission MDS (Minimum Data Set) with an assessment reference date of 12/11/20 documents R1 has short and long term memory problems and is severely impaired for cognitive skills for daily decision making. R1 requires extensive assistance with two plus person physical assist for bed mobility, transfers, and toilet use does not ambulate, requires extensive assistance with one person physical assist for eating, and is always incontinent of urine and bladder. R1 is at risk for pressure injury development and is coded as not having any pressure injuries. The pressure injury CAA (care area assessment) dated 12/20/20 under care plan considerations documents no presence of pressure areas and on going interventions to reduce risk for potential skin integrity impairment. The nurses note dated 12/16/20 documents, CNA (Certified Nursing Assistant) reported to the nurse resident has a new area on his coccyx will monitor. The nurses note dated 12/16/20 documents, Writer in resident room r/t (related to) report of a OA (open area); OA to sacrum noted 3 x # x 0.1 (three times three times 0.1) 100% granular with sheered edges. Area cleansed, measured and assessed. Foam dressing ordered q (every) Mon-Wed-Fri (Monday-Wednesday-Friday) and prn (as needed) if soiled or off. Will have facility wound care MD (medical doctor) to eval (evaluate) on next visit. MD aware of wound nurse recommendations. The skin impairment wound form dated 12/16/20 for the question does the resident have a pressure injury yes is answered. Location is sacrum, stage of pressure injury is Stage 2 Pressure injury: Partial-thickness skin loss with exposed dermis measurement of wound is 3 x 3 x 0.2 and wound tissue bed is granulation 100. R1's care plan was not revised after he developed a Stage 2 pressure injury. The December 2020 TAR (Treatment Administration Record) indicates R1 received a speciality mattress and staff were to check function every shift starting on 12/18/20. The nurses note dated 12/20/20 documents, Dressing to coccyx wound C/D/I (clean dry intact) pericare and repositioned every 2 hours/prn (as needed) 14 day droplet ISO (isolation) continues no respiratory distress or cold symptoms noted. The physician progress notes [REDACTED]. Patient receives wound care with iodosorb for sacral ulcer. On nutritional supplementation for wound healing and protein malnutrition. BG (blood glucose) readings usually less than 250 mg/dl (milligrams per deciliter). Patient is sitting up in a broda chair. No apparent distress. receives total care. The nurses noted dated 12/23/20 documents Spoke with Family Care Nurse-O at lengths on residents current condition, total care status, wound care status, etc. Spoke at lengths on res (resident) daughter desire to take him home eventually. Res. is total care, hoyer transfer, fed per staff. All needs anticipated per staff. Updated Case manager RN (registered nurse) that resident wound appears to have Kennedy ulcer characteristics. Rapid onset, poor circulated on color and tissue type. Area is on the inner sacral. Area measure 3 x 3. No drainage. Remain in a specialty mattress and broda chair. Turned per staff. Resident case manager agreeable to updated. Both parties agreeable to a care conference. Social services updated. Will schedule care conference. The skin/wound note documents Late entry for 12/31/20 4 pm. Resident seen per wound care nurse. Sacral open area presents with no active healing properties. 4.5 x 3 x 0.5. Unable to visualize wound base. area 100% soft necrotic slough. Edges macerated. APNP (advanced practice nurse prescriber)-P in facility aware. NOR (new order received) to change tx (treatment) to Dakin's 1/2 strength moistened packing daily and prn (as needed) if soiled or off. Speciality mattress in place. Repositioned per staff. All needs met per staff. Broda chair for mobility/Wound nurse recommends to be up in w/c (wheelchair) for 1 hr (hour) only. Daughter requests. Daughter-Q aware. Spoke with daughter regarding setting up a care conference. Daughter has multiple requests to be able to come in facility to feed resident; appetite varies. Case manage Family Care-O called for update; no answer message left. On 12/31/20 R1 experienced respiratory distress and was transferred to the hospital for evaluation and treatment. R1 was admitted to the hospital. On 2/9/21 at 2:31 p.m. Surveyor asked DON (Director of Nursing)-B if RN (Registered Nurse)-R is still the wound nurse. DON-B informed Surveyor she left the facility with the previous Director of Nursing. On 2/9/21 at 3:05 p.m. Administrator-A, DON-B and Corporate Consultant-C were informed of the above and inquired if there was anyone Surveyor could speak to regarding R1's pressure injuries. On 2/10/21 Surveyor was informed RN-R still works at the facility on a PRN basis and they would have RN-R call Surveyor. Surveyor did not receive a call from RN-R. \

Based on record review and interview the Facility did not ensure 1 (R4) of 5 Residents who required their blood levels to be monitored received the necessary care and treatment. * On 9/14/20 R4's physician ordered CBC (complete blood count), CMP (comprehensive metabolic panel), TSH ([MEDICAL CONDITION] stimulating hormone), Ammonia level, Pre [MEDICATION NAME], U/A (urinalysis) with C&S (culture and sensitivity) if indicated These labs were not drawn as R4's insurance would not pay. Physician-H was not informed of this nor was Administrator-A. On 10/3/20, R4 was hospitalized with an ammonia level of 110 (reference range 0-47 micromoles per liter (umol/L). Findings include: The hospital physician discharge summary dated 9/5/20 documents discharge [DIAGNOSES REDACTED]. R4 was admitted into the facility on [DATE] and was discharged on [DATE]. R4's closed medical record was reviewed. Physician orders [REDACTED]. The physician progress notes [REDACTED]. The nurses note dated 9/14/20 documents, Orders given by PCP (primary care physician) for CBC, CMP, pre-[MEDICATION NAME], TSH, and to obtain a UA (urinalysis) with C (culture) and S (sensitivity) if indicated (may need to straight cath to obtain specimen). Resident was transfused in prior facility and has displayed weakness and altered mental status with fluctuations and inability to participate with therapies effectively. pending lab results for comparison and to establish baseline for care and safe goal settings for dc (discharge). The nurses note dated 9/14/20 documents, Call placed to Utilization Management RN (Registered Nurse)-K for (name of health insurance) at this time. No answer but voice message left with request for consideration for new authorization in regards to pending lab and overall baseline status needing to be established. Pending return call to facility at this time. The nurses note dated 9/14/20 documents, order also for ammonia level. The nurses note dated 9/14/20 documents, Md (medical doctor) ordered CBC, CMP, TSH, Ammonia level, Pre [MEDICATION NAME], U/A with C&S if indicated for increased confusion and weakness. The nurses note dated 9/16/20 documents, Writer contacted lab regarding labs from 9/14/20. Lab work not completed. Writer faxed over lab request form and informed by lab technician that lab will be completed today. The nurses note dated 10/3/20 documents, CNA (Certified Nursing Assistant) came to this writer and stated resident would not eat and she was not acting normal. This writer went into resident room. she was lethargic, barely responding. She would open her eyes once encouraged to but not for long periods. She would not eat lunch. VS (vital signs) taken BP (blood pressure) 117/61, P (pulse) 100, R (respirations) 20 Temp (temperature) 98.6, O2 (oxygen) level 96% on room air, BS (blood sugar) 111. This writer notified house supervisor who came down to evaluate resident. We attempted to view and find current lab work. House supervisor will notify DON (Director of Nursing) and MD (medical doctor). The nurses note dated 10/3/20 documents, Assessment of resident at the request of RN-N d/t (due to) the resident being obtunded (state similar to lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation and tends to sleep more than normal.) as CNA reported to RN-N a change in mentation. Writer reviewed the medical record and spoke with Physician-H r/t (related to) labs, requested via stat request for CBC, CMP, TSH, [MEDICATION NAME], and Ammonia level. Orders received from Physician-H to have the resident transferred to . emergency room for an evaluation. The hospital H & P (history and physical) dated 10/3/20 documents, Patient is a 63 y.o. (year old) female present with Altered mental status and unable to take medications orally, known case of hepatic [MEDICAL CONDITION]. Patient could not be treated in the nursing home and was sent out to the emergency room where indeed elevated ammonia to 110 was detected. Patient will be admitted for further management and treated for [REDACTED]. The reference range for ammonia is 0-47 umol/L (micromoles per liter). On 2/9/21 at 10:01 a.m. Surveyor informed Corporate Consultant-F during R4's record review Surveyor was unable to locate labs which were ordered on [DATE]. On 2/9/21 at 10:37 a.m. Corporate Consultant-F informed Surveyor MDS (Minimum Data Set) had contacted the insurance company and the insurance company refused to pay for labs. Corporate Consultant-F informed Surveyor RN-D informed the doctor. Surveyor informed Corporate Consultant-F Surveyor was not able to locate the physician was notified. Corporate Consultant-F replied it's not in there. On 2/9/21 at 10:49 a.m. Surveyor asked RN-D about R4's labs which were ordered on [DATE]. RN-D informed Surveyor R4 never got them drawn because there was an issue with insurance. Surveyor asked if R4's physician was consulted with. RN-D informed Surveyor she updated the doctor to let him know they couldn't do the labs. Surveyor asked when the doctor was consulted with. RN-D informed Surveyor she was not sure of the date because of the insurance and wasn't able to give Surveyor an exact date. Surveyor asked who the physician was. RN-D replied Physician-H. Surveyor asked what Physician-H said. RN-D replied no orders at this time. Surveyor asked RN-D if she documented this. RN-D replied no. Surveyor asked RN-D why she didn't document this. RN-D informed Surveyor she probably intended to and was busy at the time. RN-D also informed Surveyor it didn't cross her mind at the time. Surveyor asked RN-D if she informed Administrator-A the insurance company wouldn't pay for R4's labs. RN-D informed Surveyor everyone in the morning meeting was informed. Surveyor asked who attends this meeting. RN-D informed Surveyor the Director of Nursing, Social Worker, MDS, and wound nurse. Surveyor asked if the Administrator was informed. RN-D informed Surveyor she didn't know. On 2/9/21 at 12:14 p.m. Surveyor called Physician-H's answering service and asked Physician-H call Surveyor. On 2/9/21 at 12:21 p.m. Physician-H called Surveyor. Surveyor asked Physician-H if anyone at the Facility called him to inform him the labs he ordered on [DATE] for R4 could not be drawn because insurance wouldn't pay for them. Physician-H informed Surveyor he doesn't remember anyone calling him and he never heard insurance wouldn't pay. Surveyor then asked Physician-H if he remembers RN-D calling him to inform him the labs couldn't be drawn because insurance wouldn't pay. Physician-H informed Surveyor he doesn't have a clue. Surveyor then informed Physician-H Surveyor had spoken to RN-D who informed Surveyor she had contacted him and he said no orders. Physician-H informed Surveyor he doesn't recall that at all and he has no clue. Surveyor asked if labs weren't drawn and in particular for ammonia is there anything the staff should be monitoring. Physician-H informed Surveyor behaviors. On 2/9/21 at 12:51 p.m. Surveyor asked SSD (Social Service Director)-G if she remembered R4. SSD-G informed Surveyor she does. Surveyor asked SSD-G if she remembers R4 was unable to have labs drawn because her insurance wouldn't pay for it. SSD-G replies yes and explained she remembers it being discussed in clinical and she thought the facility was going to pay for it. Surveyor asked SSD-G if she would be involved in contacting the insurance company to attempt to reverse their decision. SSD-G replied no and explained that BOM (Business Office Manger)-I or MDS/LPN (Minimum Data Set/Licensed Practical Nurse)-M. On 2/9/21 at 1:00 p.m. Surveyor asked Administrator-A if she recalls anyone informing her R4's insurance company wouldn't pay for the lab work and the labs were not drawn. Administrator-A replied no. Administrator-A informed Surveyor if the doctor wanted labs and labs were ordered the Facility would have paid. Administrator-A informed Surveyor the Facility has paid for other things. On 2/9/21 at 1:03 p.m. Surveyor asked BOM-I if she would be involved with contacting R4's insurance company if they refused to pay for labs which were ordered by the physician. BOM-I informed Surveyor she is involved in making sure the Facility gets paid for the stay and she would not have been involved. BOM-I informed Surveyor Former MDS Coordinator-J was here at the time and would have contacted the insurance company. Surveyor asked BOM-I if Former MDS Coordinator-J contacted the insurance company. BOM-I informed Surveyor she wouldn't know. On 2/10/21 at 9:53 a.m. Surveyor spoke with the Lab Representative-L and asked if labs which were ordered on [DATE] for R4 were completed. Lab Representative-L informed Surveyor they didn't draw any labs in September for R4 and they never received anything until October 2020 which was for a stool. On 2/10/21 at 11:10 a.m. Administrator-A, DON-B and Corporate Consutlant-C were informed of the above.

Based on observation, interview, and record review the Facility did not ensure 1 (R49) of 6 Residents reviewed for pressure injuries received the necessary treatment and services to promote healing and prevent new pressure injuries from developing. R49 developed a deep tissue injury pressure injury on her right heel on 9/13/19. There were no interventions implemented prior to prevent pressure injuries from developing on R49's heels. R49 developed a Stage 3 pressure injury on her coccyx which healed on 9/24/19. On 10/23/19 R49 was identified as having excoriation on R49's buttocks. There was no revision in R49's skin impairment care plan. On 10/29/19 R49 was identified as having a Stage 3 pressure injury on her buttocks/sacrum. There was no revision in R49's skin impairment care plan. R49 was observed being on a mattress which was for a Stage 1-2 pressure injury. Surveyor observed R49 in bed the first three days of survey. R49 has a history of having a pressure injury due to the oxygen tubing around her ears. R49 was observed without padding on the oxygen tubing. During observations on 11/4/19 barrier cream wasn't applied after incontinence care according to R49's CNA (Certified Nursing Assistant) care card. Findings include: R49's [DIAGNOSES REDACTED]. R49 started receiving hospice services on 6/5/19. The potential for skin impairment care plan initiated 3/17/15 & revised 9/13/19 documents the following interventions: air mattress initiated 9/13/19. Avoid scratching and keep hands and body parts from excessive moisture keep fingernails short. initiated 3/17/15. Educate resident/family/caregivers of causative factors and measures to prevent skin injury. initiated 3/17/15. Encourage good nutrition and hydration in order to promote healthier skin. initiated 3/17/15. Follow facility protocols for treatment of [REDACTED]. Identify/document potential causative factors and eliminate/resolve where possible. initiated 3/17/15. Keep skin clean and dry. Use lotion on dry skin. initiated 3/17/15. Monitor/document location, size, treatment of [REDACTED]. initiated 3/17/15. Obtain blood work such as CBC (complete blood count) with Diff, blood cultures, and C & S (culture and sensitivity) of any open wounds as ordered by physician. initiated 3/17/15. Placed on 24 hr (hour) board to monitor for injury from peer incident for negative effect. initiated 4/3/17. The significant change MDS (minimum data set) with an assessment reference date of 6/12/19 documents R49 has short & long term memory problems and is severely impaired for cognitive skills for daily decision making. R49 requires extensive assistance with two plus person physical assist for bed mobility, transfer & toilet use and does not ambulate. R49 is frequently incontinent of urine and bowel, is at risk for pressure injuries and is coded as not having any pressure injuries. The pressure ulcer/injury CAA (care area assessment) dated 6/21/19 under care plan considerations documents R49 is A&OX1-2 (alert and orientated times one to two). R49 has current Dx (diagnosis) of acute [MEDICAL CONDITION] with [MEDICAL CONDITION], DM (diabetes mellitus) [MEDICAL CONDITION] [MEDICAL CONDITION] disorder, depression, [NAME]D ([MEDICAL CONDITION]), disorganized [MEDICAL CONDITIONS] with behaviors, paranoid [MEDICAL CONDITION], repeated falls, constipation, alcohol dependence, frequency of micturition, nicotine dependence, polydipsia. R49 is total assist of 1 with bathing. R49 is extensive assist of 2 with bed mobility, transfer, dressing, toilet use, personal hygiene. R49 is limited assist of 1 with eating. R49 is hospice services. R49 skin integrity is currently intact with no OA (open area) noted. Her skin integrity is monitored daily with cares and weekly with showers. Call light is kept within reach. Encouraged to ask for assistance. Will continue to monitor. Continue with P[NAME] (plan of care). RIGHT EAR The nurses note dated 8/19/19 documents Resident noted to have small OA (open area) above R (right) ear from O2 (oxygen) tubing. Ear area cleaned with padding placed on O2 tubing for protection. DON (Director of Nursing) notified of O[NAME] _____ notified of O[NAME] MD (medical doctor) notified. No further complaints of pain or discomfort. Surveyor noted there were no revisions to R49's skin impairment care plan and there no weekly assessments until 10/10/19. The wound documentation dated 10/10/19 which documents for type of wound pressure ulcer, site right ear, and stage/tissue depth Stage II (2). Length n/a (non applicable), width n/a and depth n/a. Under additional comments documents resolved. padding for O2 (oxygen) tubing to continue. On 11/4/19 at 10:04 a.m. Surveyor observed R49 in bed. The prongs of the oxygen tubing are not in R49's nostrils. The oxygen tubing is around R49's ears and the prongs are on top of R49's forehead. Surveyor did not observe any padding on the oxygen tubing around R49's ears. On 11/5/19 at 10:10 a.m. Surveyor checked the oxygen tubing around R49's ears. Surveyor did not observe any padding on the tubing. On 11/5/19 at 3:39 p.m. Surveyor checked the oxygen tubing around R49's ears. Surveyor did not observe any padding on the tubing. On 11/6/19 at 8:05 a.m. Surveyor asked LPN (Licensed Practical Nurse)-M why there isn't any padding on the oxygen tubing around R49's ears. LPN-M checked the oxygen tubing around R49's right and left ear and informed Surveyor there's no padding. Surveyor informed LPN-M Surveyor hasn't observed any padding on the oxygen tubing since Surveyor has been at the Facility. LPN-M informed Surveyor they can get some. On 11/6/19 at 8:09 a.m. Surveyor observed LPN-P place padding on the oxygen tubing. The nurses note dated 9/6/19 documents R49 had a Braden completed. R49 scored 13.0 which puts R49 at MODERATE RISK for skin breakdown. The skin observation sheets dated 8/30/19, 9/3/19, 9/6/19, & 9/10/19 documents skin is intact. C[NAME]CYX The nurses note dated 9/11/19 documents CNA (Certified Nursing Assistant) reported to the nurse resident has a new red area on the butt 1/2 inch round will monitor. The nurses note dated 9/11/19 documents continue monitor reddened area proximal to coccyx applied mepiplex (sic) (dry dressing). The nurses note dated 9/13/19 documents Wound nurse informed of reddened area R (right) heel o/a's (open areas) coccyx area will cont. (continue) to be monitor. The wound documentation assessment dated [DATE] documents for type of wound pressure ulcer, site coccyx and stage/tissue depth is Stage 3. Length1.0, width 1.0 and depth 0 .2. Tissue bed is 100% granulation. Under comments documents Educated staff to reposition at least q2hr (every two hours) and limit time up in w/c. The nurses note dated 9/14/19 documents mepiplex (sic) to wound to coccyx support boots put on foot/heels at bedtime for rt (right) heel tissue injury. The nurses note dated 9/16/19 documents Wound care to R heal dark moistness skin remains intact treated as prescribed. o/a coccyx area slightly red to pink tiny dot side visible yellow tissue yellow drng (drainage) treated as prescribed this shift. The wound documentation dated 9/24/19 for type of wound documents pressure ulcer, site Coccyx, and Stage/tissue depth Stage 3. Length n/a (non applicable), width n/a, & depth n/a. Under additional comments documents Resolved. will continue Meplix (sic) for protection. The quarterly MDS with an assessment reference date of 9/12/19 documents a BIMS (brief interview mental status) score of 6 which indicates severe impairment. R49 requires extensive assistance with two plus person physical assist for bed mobility, transfer & toilet use and does not ambulate. R49 is always incontinent of urine and bowel, is at risk for pressure injuries and is coded as not having any pressure injuries. RIGHT HEEL The nurses note dated 9/13/19 documents Wound nurse informed of reddened area R (right) heel o/a's (open areas) coccyx area will cont. (continue) to be monitor. The wound documentation dated 9/13/19 documents for type of wound pressure ulcer, site right heel, and stage/tissue type deep tissue injury. Length 4.5 and width 4.5. Under additional comments documents Pressure relief boots applied to both feet. The nurses note dated 9/14/19 documents mepiplex (sic) to wound to coccyx support boots put on foot/heels at bedtime for rt (right) heel tissue injury. The nurses note dated 9/16/19 documents Wound care to R heal dark moistness skin remains intact treated as prescribed. o/a coccyx area slightly red to pink tiny dot side visible yellow tissue yellow drng (drainage) treated as prescribed this shift. The next wound documentation is 11 days later and is dated 9/24/19 documents for wound type pressure ulcer, site right heel, stage/tissue depth Deep tissue injury. Length 4.5 and Width 6.5. Under additional comments documents Pressure relief boots applied to both feet. Surveyor noted there was no revision in R49's care plan after the right heel declined. The next wound documentation is 17 days later and is dated 10/10/19 documents for wound type pressure ulcer, site right heel, stage/tissue depth Deep tissue injury. Length 4.0 and Width 6.0 Under additional comments documents Pressure relief boots applied to both feet. The wound documentation dated 10/16/19 documents for wound type pressure ulcer, site right heel, stage/tissue depth Deep tissue injury. Length 4.0 and Width 6.0. Under additional comments documents Pressure relief boots applied to both feet. The wound documentation dated 10/23/19 documents for wound type pressure ulcer, site right heel, stage/tissue depth Unstageable. Length 4.0 and Width 6.0. Wound tissue bed is 100% eschar. Under additional comments documents Pressure relief boots applied to both feet. Surveyor noted there was no revision in R49's skin impairment care plan. The wound documentation dated 10/29/19 documents for wound type pressure ulcer, site right heel, stage/tissue depth Unstageable. Length 3.0 and Width 4.0. Wound tissue bed is 100% eschar. Under additional comments documents Pressure relief boots applied to both feet. During the survey the Surveyor observed R49 wearing bilateral pressure relieving boots during all observations. BUTT[NAME]KS/SACRUM The wound documentation dated 10/23/19 under wound type documents other, specify other excoriation and site buttock. Stage/tissue depth PTW (partial thickness wound), Length see below, Width see below, and depth see below. Drainage scant and type of drainage Serous. Under additional comments documents Excoriation to 2 areas on buttock. 2.5 x (by) 1.5 1.5 x 1.5. The wound documentation dated 10/29/19 documents for wound type pressure ulcer, site sacrum/left buttock, stage/tissue depth Unstageable. Length see below, Width see below, & depth see below. Wound tissue bed is 50% granulation and 50% slough. Drainage is scant and type of drainage serous. Under additional comments documents Excoriated area is 6 x 5 cm (centimeters) with slough area in middle of wound 2 x 2 cm. Surveyor noted there was no revision in R49's skin impairment care plan. The CNA (Certified Nursing Assistant) Care Card dated 11/4/19 under the toileting section documents Check and change q2-3 (every two to three) hours. Apply barrier cream to buttocks after each incontinent episode. On 11/4/19 at 10:03 a.m. Surveyor observed R49 in bed with the head of the bed elevated, on her left side wearing pressure relieving boots. On 11/4/19 at 12:32 p.m. Surveyor observed R49 continues to be in bed with the head of the bed elevated on her left side wearing pressure relieving boots. On 11/4/19 at 2:01 p.m. CNA-N lowered the head of R49's bed down, turned the water on, and placed gloves on. CNA-N removed the bedding off R49, placed the call light on, unfastened the incontinence product telling R49 you are wet and I have to change you. Surveyor asked CNA-N why she placed the call light on. CNA-N informed Surveyor R49 has a wound and they check it. CNA-N washed R49's frontal perineal area, placed the wash cloth on top of a towel, informed R49 she had a BM (bowel movement) and needs to change her. CNA-N asked R49 if she was ready, pulled R49 towards her using the soaker pad, and positioned R49 on her right side. Surveyor observed the incontinence was saturated with urine and contained BM. CNA-N wiped the BM off with the incontinence product and washed R49's buttocks. After CNA-N completed washing R49's buttocks, CNA-N placed the wash cloth in a garbage bag. CNA-N removed a blanket from under R49's side, removed the foam dressing from R49's sacrum/buttocks, and placed an incontinence product under R49. CNA-N removed the soaker pad, threw the pad on the floor, pulled the incontinence product between R49's legs and fastened the incontinence product. CNA-N informed R49 she would be right back, removed her gloves, and left R49's room with the soiled items. Surveyor observed CNA-N did not apply any barrier cream on R49's buttocks according to the CNA Care Card. On 11/5/19 at 7:13 a.m. Surveyor observed R49 in bed on her left side wearing pressure relieving boots. On 11/5/19 at 2:48 p.m. Surveyor spoke with Anonymous Nurse-V regarding R49's pressure injuries. Anonymous Nurse-V informed Surveyor R49 has a significant wound on her heel, R49's coccyx was intact and now it's not. Surveyor asked if R49 wore pressure relieving boots before she developed the deep tissue injury on her right heel. Anonymous Nurse-V informed Surveyor R49 had them but they were on the bottom of her closet and did not wear them. Anonymous Nurse-V indicated he/she suggested boots or to float R49's heels but this never was done. On 11/6/19 at 7:47 a.m. Surveyor entered R49's room with LPN-M and LPN-P; who is in training. LPN-P washed her hands and placed gloves on. R49 was in bed on her left side wearing pressure relieving boots. LPN-M informed R49 they need to turn her. LPN-M & LPN-P positioned R49 toward the left side and then rolled R49 on her side. LPN-M washed her hands. LPN-M poured dakins into a cup, opened skin prep, placed santyl in a medication cup and using a syringe withdrew dakins. LPN-M opened a border foam dressing and placed gloves on. LPN-M unfastened R49's incontinence product, removed the dressing, removed her gloves and washed her hands. LPN-M placed gloves on, squirted Dakins onto the wound bed and reddened area around the pressure injury. LPN-M did not dry the wound bed. Using a cotton applicator, LPN-M applied santyl on the slough area of the pressure injury, applied skin prep around the periwound, removed her right glove, placed the glove on the over bed table and applied the border foam dressing over the pressure injury. LPN-M removed her left glove and washed her hands. LPN-P positioned R49 on her back and covered R49 with bedding. On 11/6/19 at 7:57 a.m. Surveyor asked LPN-M how R49 received the pressure injury on her sacrum/buttocks. LPN-M informed Surveyor it's from pressure and incontinence. LPN-M also informed Surveyor R49 being on hospice decreased her appetite. Surveyor noted R49 started receiving hospice services on 6/5/19. On 11/6/19 at 7:59 a.m. LPN-P washed her hands, while LPN-M removed the boot from R49's right foot, cut and removed the kerlix. Surveyor observed the entire back of R49's heel is black. LPN-P applied provodine iodine swab on R49's right heel pressure injury. LPN-M removed her gloves, washed her hands and placed gloves on. LPN-M placed a pad over the eschar, wrapped the right heel/foot with kerlix and taped the kerlix. On 11/6/19 at 8:03 a.m. Surveyor asked LPN-M how R49 received the pressure injury on her right heel. LPN-M replied have to take a guess from pressure. On 11/6/19 at 8:04 a.m. Surveyor checked the mattress and noted the name of the mattress is comfortex and is checked for new life. On 11/6/19 at 9:45 a.m. Surveyor observed R49 on her back with the head of the bed elevated. There is a pillow under R49's legs and R49 is wearing pressure relieving boots. On 11/6/19 at 11:27 a.m. Surveyor asked DON (Director of Nursing) for the manufacturers information for R49's mattress which is comfortex, new life. On 11/6/19 at 2:38 p.m. Surveyor informed DON-B Surveyor has not been provided with R49's mattress information. On 11/7/19 at 7:17 a.m. DON-B provided Surveyor with a one sheet of paper entitled Comfortex NewLife Mattress User Manual which documents (Pressure redistribution & support for increased comfort, pain reduction and pressure sore prevention. Stages 1-2. Surveyor informed DON-B the mattress R49 is on is only good for Stages 1-2 and R49 has two unstageable pressure injuries. DON-B informed Surveyor this mattress was provided by hospice and last night they switched out R49's mattress to an air mattress. On 11/7/19 at 9:25 a.m. Surveyor asked CNA-S when R49 started wearing the pressure relieving boots. CNA-S informed Surveyor she started wearing them after she developed the area on her heel. CNA-S informed Surveyor R49 was always a get up and if they got her up she would never have gotten the pressure sore. CNA-S informed Surveyor it happened so fast. CNA-S informed it happened so fast. Surveyor asked about the pressure injury on R49's buttocks. CNA-S informed Surveyor probably from being wet and that she used to be independent. On 11/7/19 at 11:32 a.m. Surveyor spoke to RN (Registered Nurse)-U, who is the wound nurse at the Facility regarding R49's pressure injuries. RN-U informed Surveyor the wound doctor has seen R49 in the past but doesn't see her now as R49 is hospice. Surveyor asked how often wound rounds are conducted and if there is a wound team. RN-U informed Surveyor he sees R49 every week and he's the one that does the assessments. RN-U informed Surveyor he does the wound assessments himself. Surveyor inquired how R49 developed the pressure injury on her buttocks. RN-U informed Surveyor he doesn't have an answer to that. The first time it was identified the area started as an excoriation, healed up and then turned into a pressure sore. RN-U informed Surveyor the area was probably still tender and fragile. Surveyor inquired who updates the care plans. RN-U informed Surveyor he thinks the care plans are updated during the wound and nutrition meetings. Surveyor asked RN-U if he was involved with this meeting. RN-U replied no and explained he usually gives the measurements to the staff. Surveyor informed RN-U Surveyor did not note R49's care plans were updated. RN-U informed Surveyor should speak to RN/MDS-R. On 11/7/19 at 11:42 a.m. Surveyor asked RN/MDS-R what is the wound/nutrition meeting. RN/MDS-R informed Surveyor herself, Dietitian-D, DON-B and if RN-U is able to attend meet to go over the wounds and any significant weights. RN/MDS-R informed Surveyor they also review anything Dietitian-D may have added or taken off, supplements and tube feeding. Surveyor asked who updates Resident's pressure injury care plans. RN/MDS-R informed Surveyor herself, RN-U and DON-B. Surveyor informed RN/MDS-R the concerns with R49 regarding her pressure injuries including the skin impairment care plan not being revised. On 11/07/19 at 2:45 p.m. Administrator-A and DON-B were informed of the above.

Based on observation, interview and record review the facility did not provide adequate supervision and assistive devices to prevent accidents for 2 (R9 and R27) of 9 residents reviewed at risk for falls. * R9 had 3 falls occurring on [DATE], [DATE] and [DATE]. The third fall, on [DATE], resulted in a laceration to the top of the head requiring staples. R9's fall investigations did not include an analysis of the falls, fall interventions initiated to prevent future falls and the care plan was not updated to include fall interventions. * The Interdisciplinary Teams (IDT) analysis of R27's falls did not indicate if R27's call light was accessible to R27 when he experienced falls. There was no indication if R27 was capable of remembering to and using the call light. On [DATE], Surveyor interviewed R27 and observed R27 having to share his call light with the Resident bed next to him. In addition, Surveyor observed R27's call light lying on the bed next to R27 and out of reach for R27. The IDT investigation for the fall on [DATE] had conflicting answers as to whether the call light was in R27's reach and whether the call light had been activated. Findings include: The facility policy entitled, Fall Prevention Program, not dated, states: .Procedure: 1. A Fall Prevention program will be implemented and maintained to assure the safety of all residents admitted to the facility. The program will be inclusive of measure which determine the individual needs of each resident by assessing the risk for falls, and implementation of appropriate staff interventions to assure adequate supervision is provided, and that assistive devices are utilized when necessary. Fall Incident Reports will be reviewed and quality issues identified to assure the on-going effectiveness of the prevention program. 2. A Fall Risk Committee will be responsible for reviewing resident falls, monitoring the effectiveness of fall prevention strategies, and for recommending individualized safety interventions. 3. The Fall Risk Committee will meet at a minimum of weekly at a designated time to review all resident falls that have occurred since the last meeting. Fall Incident Reports will be studied to determine any significant factors that may have caused the fall and to identify additional fall prevention strategies that may be indicated.Residents found to be at risk of falling will have a care plan implemented to address the need for additional safety precautions. The interdisciplinary care plan will include the risk of falls, reasonable goals, and appropriate interventions to prevent fall and/or injury from falls. 7. Resident will be evaluated after a fall has occurred in an attempt to identify and causative factors that need immediate correction. 8. Upon completion of a Root Cause Analysis by the IDT (Interdisciplinary Team) for any resident who has sustained a fall, fall prevention strategies will be implemented in accordance with the assessed need of the resident. 9. Fall prevention strategies will be utilized for all residents at risk for falls including individualized interventions in accordance with the assessed needs of each resident. 10. Nursing staff will complete an Incident Report for each fall to determine factors contributing to the fall and interventions to reduce the risk of further falls. R9 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. R9's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], documents a Staff Assessment of Mental Status score of 3, indicating that R3 is severely cognitively impaired. A Staff Assessment of Resident Mood (PHQ-9-OV) score of 6, indicating R9 is demonstrating mild depressive symptoms. The MDS also documents, R9 requires one person physical assistance to transfers, walking and toilet use. R9 is documented to be not steady when moving from a seated to standing position, moving on and off the toilet and from surface to surface. R9 was assessed to have had 2 falls since the last assessment resulting in injury. R9's Care Plan, dated [DATE], with a target date of [DATE], states: The resident is at risk for falls r/t (related to) unaware of safety needs. [MEDICAL CONDITION] drug use. Hx (History) wandering, impaired cognition secondary to dementia. Interventions include be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; educate the resident/family/caregivers about safety reminders and what to do if a fall occurs; encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility; ensure that the resident is wearing appropriate footwear; fit with shoes; follow facility fall protocol; labs ordered; medication review and 3 day sleep study; PT (Physical Therapy) evaluate and treat as a PRN (as needed) order; remove mats from floor; review information on past falls and attempt to determine cause of falls. Record possible root causes. After remove any potential causes if possible. Educate resident/family/caregiver/IDT as to causes; The resident needs a safe environment with: even floors free from spills and/or clutter, adequate, glare-free light; a working and reachable call light, the bed in low position at night, side rails as ordered, handrails on walls, personal items within reach; resident need encouragement and cues to participate in activities of choice that minimize the potential for falls while providing diversion and distraction. R9's Fall Occurrence Report, dated [DATE], documents R9 had a witnessed fall in the hallway at 3:35 PM. R9 was found sitting upright on the floor. Witness states that another resident was close to R9 and may have bumped resident by mistake. Another witness statement documents R9 was walking towards the dining room when another resident bump a wheelchair into R9 causing the fall. No injuries noted. The vital signs section of the form was not completed, the pain section of the form was not completed. The immediate action taken was to assist R9 off the floor with 1 or 2 staff. The contributing physical factors section was not completed. Contributing cognitive factors: dementia. Other contributing factors section was not completed. Interventions already in place section was not completed. Probable cause of the fall: Accident with other resident. What could have prevented the fall section is not completed; new interventions put into place section was not completed. The recommendation was to clear the hallway of congestion. This intervention was already added to the care plan on [DATE]. Interdisciplinary team review on [DATE] documents a recommendation of: Clear hallway congestion. No new interventions were put into place and Fall Occurrence Report does not state why the fall intervention of keeping the hallways clear of congestion was not followed. (Cross Reference F657) R9's Fall Occurrence Report, dated [DATE], documents a witnessed fall in the dining room at 9:00 AM. The description of the fall documents: R9 observed falling out of chair in dining room. Resident hit head hematoma and laceration noted. The position that resident was found in was not completed. Vital signs were taken and a pain assessment of ,[DATE] was documented. Last pain medication was given at 9:00 AM. Location of injury section documents a laceration without measurement and a hematoma without measurement or documentation of where the the injuries are located. Probable cause of the injury: hit head when fell out of dining room chair. Immediate action taken: Assisted off floor with 2 staff. Contributing physical factors section was not completed. Contributing cognitive factors: dementia. Other contributing factors section was not completed. Interventions already in place: toileting schedule. Probable case of fall: dizziness/[MEDICAL CONDITION]. What could have prevented the fall section was not completed. New interventions put into place section was not completed. Interdisciplinary team review on [DATE] documents a recommendation of ordering lab (laboratory) and UA (Urine Analysis). The investigation does not document the reason for the lab work and UA and how that would prevent future falls or why such testing was necessary. This intervention was added to the care plan. R9's Fall Occurrence Report, Dated [DATE], documents an unwitnessed fall at 12:15 PM. Detailed description of events: Resident sitting at dining room table eating lunch. CNA (Certified Nursing Assistant) in dining room serving meals when resident was heard hitting the floor. Resident was observed by other residents sitting at table falling forward out of chair hitting head on table. Resident on Lt (left) side of body. Laceration to top of head. The position resident was found in: Lying on left side of body on dining room floor. Vitals taken and pain assessment of ,[DATE] was documented. Last pain medication was given at: 9:00 AM. Type of injury: laceration to head but without measurements. Probable cause of injury section was not completed. Immediate action taken: Assisted off floor with 2 staff, sent to ER (emergency room ) and First Aid at facility. Contributing physical factors section was not completed. Contributing cognitive factors: dementia. Other contributing factors section was not completed. Interventions already in place: toileting schedule and footwear. Probable cause of the fall section was not completed. What could have prevented the fall section was not completed. New interventions put into place section not completed. Interdisciplinary team review dated [DATE] documents recommendations: Transferred to ED (Emergency Department) for eval (evaluation) of injury, medication review, 3 day sleep study. The interventions of medication review and 3 day sleep study were added to the care plan on [DATE], a month after the fall. (Cross Reference F657) The Fall Occurrence Report does not document why these interventions are appropriate and how they would prevent future falls. R9 required a CT (Computed Tomography) scan of the head and spine and staples to the [MEDICAL CONDITION]. On [DATE] at 1:06 PM, Surveyor interviewed Director of Nursing (DON)- B, who stated, the floor nurse is responsible for writing up the Fall Occurrence Report, informing the DON, doctor and resident responsible party of the fall. The facility then completes a review of all falls and the Fall Occurrence Reports on a daily bases at the facility clinical meeting. The clinical meeting is attended by the interdisciplinary team. At the clinical meeting each Fall Occurrence Report is reviewed, a review of all the resident's past falls and interventions are reviewed to asses if they are working or not working. The Interdisciplinary team review is then documented on the Fall Occurrence Report form and any new interventions needed are discussed and added as team recommendations. The care plan is updated during the meeting with the new interventions the interdisciplinary team has recommended. The DON then signs off on the completed Fall Occurrence Reports. The DON stated the above process occurs for all falls at the facility. The Surveyor informed the DON-B of the concern that R9's 3 fall investigations were not complete and were missing an analysis of why the fall occurred, appropriate interventions put into place that address the reason for the fall and to prevent future falls and that interventions were not always carried over to the care plan. DON-B stated he wasn't aware the investigations were not complete and did not include an analysis of the falls, fall interventions did not address the reason for the fall and the care plan was not updated. DON would expect that the fall interventions be complete and is not sure why that wasn't the case for R9's falls. On [DATE] at 1:30 PM, Surveyor informed Administrator-A and DON-B of the above concern. No further information was provided. The facility policy and procedure entitled Call Light dated [DATE] states: POLICY: 1. Make sure that all residents have been instructed in the use of the call light system. 2. Make sure that the call light is plugged in at all times and in good working order. Call light system defects will be reported to the Maintenance Department for servicing. 3. The call light should be within reach of the resident whether in bed or sitting in a chair in their room. R27 was admitted to the facility [DATE] with a history of malnutrition, [MEDICAL CONDITION], repeated falls, depression, muscle weakness, abnormalities of gait and mobility, lack of coordination, anxiety, [MEDICAL CONDITION], and unsteadiness on feet with abnormal posture. R27's admission MDS (Minimum Data Set) assessment dated [DATE] placed R27 at high risk for falls and needs extensive assistance with transfers and supervision with ambulation. R27 was attending physical therapy to improve balance and coordination. A fall care plan was in implemented on [DATE] with the intervention of having the call light in reach and encouraging R27 to ask for assistance as needed. On [DATE] at 3:15 PM, R27 had a fall out of bed with no injury. R27 had been sitting on the edge of the bed prior to the fall. The call light had not been activated. The interdisciplinary team (IDT) met and reviewed the fall. Therapy was consulted and treatment initiated to improve R27's bed mobility and sitting posture. On [DATE] at 5:15 AM, R27 had a fall out of bed with no injury. The IDT investigation did not indicate if the call light was in reach or activated. The fall was attributed to restlessness and a medication review was advised. On [DATE] at 8:50 AM, R27 had a fall while attempting to ambulate to the bathroom with no injury. The IDT investigation indicated the call light was in reach but not activated. The fall care plan was updated to encourage R27 to ask for assistance. On [DATE] at 3:30 PM, R27 had a fall while attempting to plug in a fan with no injury. The IDT investigation indicated the call light was in reach but not activated. The fall care plan was updated to ensure all electrical devices were plugged in at all times and to remind R27 to call or ask for assistance. On [DATE] at 6:15 AM, R27 had a fall out of bed with no injury. The IDT investigation indicated the call light was in reach but did not indicate if it was activated. R27 was lying with head at the foot of the bed. Recommendation was to encourage R27 to put head at the head of the bed and continue with plan of care. On [DATE] at 11:38 AM, R27 was observed ambulating to the dining room. R27 walked with a very fast paced, shuffling gait. R27 was pushing a wheelchair into the dining room, bumped the wheelchair into the table, and then maneuvered around to sit in the wheelchair without locking the brakes before sitting. Staff verbally encouraged R27 to slow down for safety. On [DATE] at 12:28 PM, R27 ambulated from the dining room with a fast shuffling step. R27's room had three beds. R27's bed was the first bed inside the door. A call light was lying on the second bed. When asked if R27 had a call light, R27 stated bed one and bed two share a call light. No one was in the second bed at the time of the interview. When asked how R27 reached the call light, R27 shrugged his shoulders in reply. On [DATE] at 11:45 PM, R27 had a fall with no injury while ambulating in room. The IDT investigation indicated the call light was in reach and not applicable and the call light was activated and not applicable. Both questions on the form had two answers that contradicted each other. Recommendations were made for R27 to slow down when ambulating and to ask for assistance when feeling weak. On [DATE] at 11:23 AM, Director of Nursing (DON)-B was interviewed in regards to R27's call light. DON-B stated he was not aware that R27 had to share a call light with the resident in the second bed and all residents should have their own. R27 had been in the current room for approximately a month. The previous room had adequate call lights. On [DATE] at 1:10 PM, Surveyor met with Administrator-A and DON-B. The falls on [DATE] and [DATE] occurred while R27 was in the current room with no available call light. No further information was provided at that time.

Based on interviews, and record review the facility did not ensure that care was provided to 1 (Resident #34) of 10 sampled residents in a manner that maintained or enhanced the Resident's dignity and recognized their individuality. Resident #34 was admitted to the facility from the hospital for rehabilitation. During her short stay in the facility the Resident reported that she was forced to wear incontinence briefs and told by staff to pee in her "diaper." Resident #34 expressed that this made her feel humiliated and like a baby. Resident 34's community case manager indicated that the experience of having to wear a diaper and wet it like a baby has affected the resident beyond her residing in the facility. The Resident expresses ongoing need to discuss what happened and how she feels like a failure for having to wet the product. Resident #34's case manager indicated that Resident #34 has required therapy to discuss her resulting feelings from her stay at the facility. Findings include: Surveyor # began record review for Resident #34 related to a complaint received on 3/9/15. The complainant alleged that Resident #34, age [AGE] years old, was admitted to the facility on [DATE] for rehabilitation of a right ankle fracture and unstable blood sugars. While a residing at the facility the complainant alleged that the resident was forced to wear "diapers" and the staff would take between 30 minutes to over an hour to toilet her. The complaint also alleges that when staff came in to toilet the Resident she was told that staff are very busy and she was encouraged to wear the "diaper" and this would allow her to "go in it 2-3 times" until staff is able to answer her call light. On 2/23/15 at 10:47am Surveyor # interviewed Social Services Director-FF who indicated that Resident #34 resided at the facility for a very short time before requesting a transfer. Social Services Director-FF indicated that she had spoken with the case manager of Resident #34 who stated that the resident was not used to a brief. Social Services Director-FF states that she spoke with Resident #34 who stated that she was not comfortable wearing briefs because she was continent and able to let staff know when she needed to be toileted. Social Services Director-FF stated that the Resident asked for a Bedside commode as well. When asked if the Resident had received the commode she stated that "she believed so." Surveyor # then asked if she had been made aware of any allegations being made related to staff not toileting Resident #34 on a timely basis, she reported she did not. Surveyor # requested to review her concern log at this time. The concern log dated 2/25/15 indicated that the Resident "had an issue with not being changed timely, and was wearing briefs but preferred not to ." The log also indicated that both the Social Services Director-FF and the Director of Nursing-B spoke with Resident #34 on this date. The entry from DON- B indicated that Resident informed her that she did not want to wear briefs and she directed staff discontinue use of briefs for Resident #34, and she is to be toileted upon request. Social Services Director-FF entry indicated that she followed up with Resident #34 later that day and she reported that she "had no distress and was in good spirits." There is no additional follow up indicated in the record review in the preceding dates that this incident was initially reported. At 11:18am Surveyor # interviewed Nurse Manager-P who stated the she was aware of the Resident not wanting to wear briefs and requesting a bedside commode instead. Nurse Manager-P stated that she was unaware that Resident felt staff was taking too long to toilet her and the next thing she knows, the Resident transferred. Surveyor # reviewed nurses' note from Nurse Manager-P dated 2/25/15 that stated that case manager for Resident #34 was visiting and shared concerns of the Resident wearing briefs with the staff and a bedside commode for the resident was discussed at this time. When asked if the Resident ever received the commode she stated that "she thought so but wasn't sure." At 11:33am Surveyor # spoke with Family care case manager for Resident #34 who indicated that Resident #34 called her the next day after being admitted on [DATE] and reported that it took the staff over 1 hour to toilet her and it caused her to "wet the bed really bad." She then stated the Resident reported that when staff finally came they told her that they are very busy and she should wear a "diaper" to keep from wetting the bed until they can get to her. The Resident also reported that a CNA told her "you can go in the brief about 2-3 times before you would need to be changed again." The case manager stated that Resident #34 indicated she wanted to go somewhere else immediately. The case Manager stated that she immediately informed her nurse manager of the concerns and the nurse manager spoke with the DON-B that day. The case manager also indicated that she immediately called Social Services Director-FF to inform her of the concerns and to request a transfer. She stated that Social Services Director-FF initiated the transfer immediately. Case manager also indicated that the DON- stated that she would fix this by taking the briefs away and providing the Resident with a commode. DON-also reported that she would address the staff involved and said that the allegations are unacceptable and will be handled appropriately. The case Manager stated that she came in to visit with the Resident on 2/25/15 and was informed that she was still wearing a "pull up" and no bedside commode had yet been provided and things remained this way until her discharge on 2/28/15. The Resident also reported that up until her discharge the facility continued to take at least 30 minutes to toilet her and continued putting briefs on her. The Resident was transferred to another facility on 2/28/15 and case manager reported that the Administrator-A called her after the transfer stating that they now had the commode and it had to be ordered because there were none available at the facility. Case Manager reports that the Resident was very upset and felt humiliated during her stay at the facility due to being fairly young and being forced to wet herself and being told to "pee in a diaper like a baby." At 11:52am Surveyor # interviewed DON-B who stated that she had spoken with Resident #34 regarding this issue. DON-stated that the Resident told her that she did not want to wear briefs so she told her staff to discontinue the use of the briefs. DON-B then stated that the Resident reported that it took the staff an hour to come and toilet her one night and she wet the bed. When staff finally answered her call light she was then told to wear a brief so that she can go in it and not wet the bed until staff is able to come. DON-B reported that she told Resident #34 that this was unacceptable and she would handle it. DON-B stated that she spoke with the CNA staff involved and told her that "you are never to tell a resident to go in their brief" and asked why it took so long for Resident #34 to be toileted. DON- B stated that CNA reported that she didn't believe it had taken an hour but that it may have taken a while because they were in the middle of rounds at that time. DON-B did not provide any documentation of retraining provided to this CNA related to appropriate patient care and was unable to remember the CNA involved. When asked why she did not report this incident as an allegation of abuse/neglect due to her telling the Resident to "go in her brief" she stated that she did not see this as abuse and didn't think it needed to be reported because she had done her own investigation. DON-B was asked if Resident #34 was assessed upon arrival and how it was determined that she was to wear briefs, she stated that she usually completes the assessments but is not sure why that wasn't done with this Resident. DON-B stated that after she was informed of the concerns she updated the CNA care card to indicate that the Resident is not to wear briefs because she was continent. Surveyor # was unable to find any information to support this and the facility also had not addressed toileting concerns on the Temporary Care Plan for Resident #34. When asked if the Resident received the bedside commode that was requested DON-B stated that they didn't have any in the building and had to order it but it did not arrive in time. Corporate Nurse-RR came in at 12:15pm and reported that she was unaware of all of the details surrounding this incident but would be conducting and submitting a formal investigation to the state agency immediately. On 3/24/15 at 11:52am Corporate Nurse-RR came in with CNA-NN staff who indicated that the Resident was using "pull ups because she didn't have any underwear." When asked if the facility has an inventory list of incoming items for all residents, Corporate Nurse-RR indicated they usually do. Surveyor # was unable to find an inventory list for this resident and was unable to substantiate that she came in with no underwear. The CNA also reported that Resident was never wet when she went to toilet her. Surveyor # reviewed the CNA bowel and bladder monitoring tool during the dates of 2/24/15-2/27/15 which indicated that the Resident was incontinent all 3 days until her discharge on 2/28/15. On 4/2/15 Surveyor # spoke with Resident #34's case manager to further discuss the effect that the Resident's stay at the facility had upon Resident #34. Case Manager - 1 indicated that the Resident was greatly affected by her stay there. When discussing the concept of harm Case Manger-I indicated that she had Resident #34 moved to a different facility very quickly after she expressed her feelings about being treated like a baby and that she was not receiving the assistance she needed. Case Manger-I indicated physically, Resident #34 was not harmed, although she was starting to develop itching from the lack of incontinence care. Case Manager-I indicated psychologically however, Resident #34 has been harmed. Case Manager-I indicated that Resident #34 continues to speak about her stay at the facility and becomes upset when talking about being treated like a baby and how humiliating it makes her feel. Case Manager-I indicated that Resident #34 also feels somehow like a failure for having to wet herself and for not being able to handle her stay at the facility. Case-Manager-I indicated that Resident #34 is actively in therapy where her stay at the facility is discussed and Resident #34 expresses her upset at how the care made her feel.

Based on observations, interviews and record review, facility staff did not provide necessary treatment and services to prevent pressure ulcers from developing, nor did they provide treatments to promote healing for 8 (Residents #9, #10, #3, #2, #4, #5, #1, and #7) of 8 sampled residents. Resident #9 was admitted to the facility on [DATE] without any pressure ulcers. On 1/14/15 Resident #9 developed a Stage 2 left heel pressure ulcer. No treatments were initiated and the care plan was not revised. On 1/23/15 the left heel pressure ulcer was identified as a Stage 3. Still no treatments were initiated and the care plan was not revised. On 1/27/15 a temporary care plan for Pressure Ulcer Stage 2 R (right) planter was developed. The physician was not contacted and no treatments were obtained. On 1/29/15 the wound visit report documents left posterior heel is a Stage 3 pressure ulcer and the right posterior heel is a suspected deep tissue injury pressure ulcer. The care plan was not revised to reflect the bilateral heel pressure ulcers. This wound note also did not address the right plantar pressure ulcer. The wound visit report for 2/6/15 documents left posterior heel Stage 3 pressure ulcer, right plantar posterior foot Stage 3 pressure ulcer, and right dorsal second toe Stage 2 pressure ulcer. Treatments for the heel were not started until 2/4/15 and for the right plantar until 2/7/15. Resident #10 had an open area on his right heel on 11/7/14. There was no measurements of the right heel, the stage was not documented and the care plan has not been updated to reflect the open area on the right heel. On 11/13/14 the wound visit report documented a Stage 2 right heel pressure ulcer. On 11/14/14 Resident #10 is identified as having necrotic tissue to the left ankle. There are no measurements and the care plan has not been updated to reflect the necrotic tissue on the left ankle. By 12/2/14, the pressure ulcer on the right heel had progressed to a stage 3 ulcer. Resident #3 was admitted to the facility on [DATE] with a Stage 1 coccyx pressure ulcer. No documentation was located until Wound MD-O assessed Resident #3's coccyx on 7/15/14 when it measured 3.2 x 2.7 cm. and had eschar/necrotic tissue and was unstageable. Resident #2 was admitted to the facility on [DATE] with a Stage 1 pressure ulcer on the coccyx and reddened heels. On 1/23/15 Resident #2's coccyx deteriorated to a Stage 3 and the treatment was changed to wound cleanser, protect periwound with skin prep, apply Santyl to wound bed, apply alginate to wound bed, cover wound bed with bordered gauze, change daily and PRN (as needed.) This treatment was not started until 1/30/15. Staff was applying barrier cream which in not an appropriate treatment for [REDACTED]. Resident #4 was admitted to the Facility without any pressure ulcers. Staff interview reveals that Resident #4 was wearing shoes that were tight fitting, was not wearing her prescribed compression stockings and developed a Stage 3 pressure ulcer to her right heel. Resident #5 was admitted to the Facility without any pressure ulcers. Staff were unable to explain how Resident #5 developed a Stage 3 pressure ulcer to his sacrum. The facility's failure to ensure proper prevention and care to individuals with pressure ulcers and at risk for pressure ulcers created a finding of Immediate Jeopardy. The Immediate Jeopardy started on 12/2/14. On 2/10/15 at 2:24 p.m. the Administrator, Director of Nursing, Corporate Regional Director-QQ, and Corporate Nurse-RR were notified of the Immediate Jeopardy. The Immediate Jeopardy was removed on 2/11/15. The deficient practice continues at a scope and severity (s/s) of an E (potential for harm that is not immediate jeopardy/pattern) as the facility continues to implement its action plan and as evidenced by current observations of Residents #3, #2, #1, & #7. Resident #3 was observed on his back for extended periods of time when his care plan calls for side to side positioning. The care plan also calls for positioning with a wedge cushion to help Resident #3 stay on his side, and for protective boots on his feet at all times. Neither intervention was observed during the survey. These interventions were not included on the CNA Care Card. Resident #2 was observed in bed without boots on his feet, his heels resting on the mattress and the soles of his feet pressed against the footboard of the bed. Resident #1 was observed without her pressure relieving boots on. Staff did not implement interventions to prevent skin breakdown for Resident #7. Resident #7 was not repositioned in her wheelchair and was observed to have her heels resting directly on the mattress. Findings include: On 2/5/15 at 4:10 p.m. Surveyor # asked the Director of Nursing (DON) about wound rounds with Wound Doctor-O. The DON informed Surveyor # that wound rounds are on Fridays and that Wound Doctor-O sees Residents with pressure ulcers. The DON stated that if Wound Doctor-O wants a treatment to start right away Wound Doctor-O will write a telephone order or she will have the DON or unit managers write the telephone order otherwise the treatment will be on the wound visit report. Surveyor # inquired when DON receives the wound visit report from Wound Doctor-O. The DON explained that she is suppose to receive them within twenty four hours but it is anywhere from two to five days. The DON stated that she checks the computer every day. Surveyor # inquired how long has this delay has been occurring. The DON informed Surveyor # that May, June, and July were good, in August she had to wait for one person. September was good but October, November, December, and January not great. The DON indicated that they have to wait for the wound visit reports because the treatment that was discussed during the wound rounds may not be the treatment that is on Wound Doctor-O's report. 1.) Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #9 was admitted with a soft cast to his right foot and was non weight bearing upon admission. Resident #9's height is 6 feet 7 inches. The nurse's note dated 12/19/14 documents: Body check reveals no open areas. Resident #9 had a Braden completed. Resident #9 scored 17.0 which puts Resident #9 at AT RISK for skin breakdown. On 12/19/14 the Facility developed a temporary care plan for potential for skin integrity. Interventions checked are: assess/document on skin condition, turn & reposition at least every 2 hrs. (hours) in bed, every hour in chair, preventative mattress and w/c (wheelchair) cushion, encourage/offer increased fluids, incontinent care as indicated, protective barrier as indicated, assess for underlying cause of skin issues, protective/[MEDICATION NAME] creams/lotions per MD order, monitor for s/sx (signs/symptoms) of adverse reaction to medications/treatments, use caution with transfers and repositioning, and update MD/family as indicated. Surveyor # noted there are no interventions relating to Resident #9's feet or cast. The nurse's note dated 1/2/15 documents: writer called into room by CNA (Certified Nursing Assistant.) OA (open area) noted to resident right coccyx. No drainage or odor noted. Resident denies pain or discomfort. Resident encouraged to reposition. MD-TT updated at 1025. New order for NSW (normal saline wash) to right coccyx f/b (followed by) skin prep to surrounding tissue f/b wound gel to OA f/b dsd (dry sterile dressing) BID (twice daily) until healed. Also reposition resident @ (at) 2 hrs. (hours) and PRN (as needed.) On 1/2/15 the Facility developed a temporary care plan for open area to right coccyx. The new interventions checked are: monitor for drainage and document any findings and treatment and/or medication per MD order. Continued interventions as checked on the 12/19/14 plan of care are: assess/document on skin condition, turn & reposition at least every 2 hrs. (hours) in bed, every hour in chair, preventative mattress and w/c (wheelchair) cushion, encourage/offer increased fluids, incontinent care as indicated, protective barrier as indicated, protective/[MEDICATION NAME] creams/lotions per MD order, monitor for s/sx (signs/symptoms) of adverse reaction to medications/treatments, use caution with transfers and repositioning, and update MD/family as indicated. There are still no interventions relating to Resident #9's feet or cast on the right foot. The wound visit report for 1/2/15 notes the resident's Right buttock has a partial thickness incontinence associated [MEDICAL CONDITION] that is not healed. Initial wound encounter measurements are 1.3 cm (centimeter) length x 2.4 cm width. The treatment is: cleanse wound with cleanser protect periwound with skin prep apply to wound bed barrier cream twice daily. Additional orders are: Pressure Relief/offloading. Follow Facility pressure ulcer prevention policy/protocol. Pressure redistribution mattress per facility policy/protocol. Wheelchair pressure redistribution cushion per facility policy/protocol. Offload heels per facility policy/protocol. Surveyor # noted that this note is not signed until 1/7/15, 5 days after the visit. The admission MDS (minimum data set) signed as completed on 1/5/15 documents a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. Resident #9 does not ambulate, is dependent upon staff with two persons for transfers, is continent of bowel and occasionally incontinent of bladder. Resident #9 is checked as being at risk for pressure ulcer development but currently does not have any pressure ulcers. Resident #9 is not checked as having any foot problems. Under skin and ulcer treatments pressure reducing device for chair, pressure reducing device for bed, and applications of ointments/medications other than to feet are checked. The pressure ulcer CAA (care area assessment) dated 1/5/15 under nature of the problem/condition documents: Resident #9 was admitted to facility from hospital with [DIAGNOSES REDACTED]. He currently has a soft cast to his right foot. He is non weight bearing to his right foot. He uses wheelchair for his mobility on and off the unit. He is independent with propelling own wheelchair.He is alert and oriented x (times) 3 and is able to alert staff to his wants and needs with use of clear speech.His skin is clean, dry and intact with a few scabs noted to lower extremities and old scars. No pressure ulcers noted at this time. He does have a pressure reducing mattress to his bed and a pressure reducing cushion to his wheelchair. Will proceed with care planning to continue to monitor. The nurse's note dated 1/9/15 documents: Resident #9 had a Braden completed. Resident #9 scored 21 which puts Resident #9 at risk for skin breakdown. The Facility developed a care plan stating: The resident has a stage 2 pressure ulcer to right coccyx or potential for pressure ulcer development r/t (related to) immobility and refusing to get out of bed. Date initiated is 1/12/15 and revision on 1/12/15. The interventions are: administer medication as ordered. Monitor/documents for side effects and effectiveness; Administer treatments as ordered and monitor for effectiveness; Assess/record/monitor wound healing weekly and prn (as needed.) Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD; assist to shift weight in w/c q (every) 15 minutes; Educate the resident/family/caregivers as to causes of skin breakdown including: transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition, and frequent repositioning; Encourage Resident #9 to get out of bed for meals; Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Document alternative methods; Inform the resident/family/caregivers of any new area of skin breakdown; Monitor dressing every shift and prn to ensure it is intact and adhering. Report loose dressing to treatment nurse; Monitor nutritional status. Service diet as ordered, monitor intake and record; Monitor/document/report prn any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length x width x depth), stage; Obtain and monitor la/diagnostic work as ordered. Report results to MD and follow up as indicated; teach resident/family the importance of changing positions for prevention of pressure ulcers; Encourage small frequent position changes; The resident requires pressure reducing device on (SPECIFY: bed and chair); Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort; and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. All of these interventions are dated 1/12/15. Surveyor # noted there are no interventions relating to Resident #9's feet or cast to the right foot such as float heels, pressure relieving boot etc. The PT (physical therapy) note for date of treatment of [REDACTED]. The nurse's note dated 1/15/15 documents: Writer informed by res. (resident) and caregiver of o/a (open area) on heel. Writer noted o/a 3.0 w (width) x (times) 2.8 l (length) with sm. (small) amt. (amount) of slough noted. Writer updated DON (Director of Nursing) and MD. Applied wound gel/f/b gauze and tape. Writer will inform wound MD on 1/16/15 of new o/a. Surveyor # noted there was no revision of Resident #9's skin care plan after Resident #9 developed a pressure ulcer on the left heel. The wound visit report dated 1/16/15 documents: Right medial buttock is a partial thickness incontinence associated [MEDICAL CONDITION] and has received a status of not healed. Subsequent wound encounter measurements are 0.5 cm length x 2.2 cm width. Right inferior buttocks is a partial thickness incontinence associated [MEDICAL CONDITION] and has received a status of not healed. Initial wound encounter measurements are 1.7 cm length x 1 cm width. Left posterior heel is a Stage 2 pressure ulcer and has received a status of not healed. Initial wound encounter measurements are 1.5 cm length x 2 cm width. The treatment for [REDACTED]. The treatment for [REDACTED]. Protect periwound with skin prep. Apply to wound bed: skin prep daily. Additional orders are the same as on the 1/2/15 wound visit report. Surveyor # noted that this wound visit report was signed by the wound doctor on 1/21/15, five days after the visit. Surveyor # reviewed Resident #9's telephone orders and January 2015 TAR (treatment administration record) and noted there was not a telephone order written nor is there any treatment documented on the January 2015 TAR for the left posterior pressure ulcer. The wound visit report dated 1/23/15 documents: Right medical buttock is a partial thickness incontinence associated [MEDICAL CONDITION] and has received an outcome of resolved. Right inferior buttocks is a partial thickness incontinence associated [MEDICAL CONDITION] has received an outcome of resolved. Left posterior heel is a Stage 3 pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 2.3 cm length x 2.8 cm width, with an area of 6.44 sq. (square) cm. There is small amount of drainage noted which has no odor. The patient reports a wound pain of level 0. Wound bed is 26-50% adherent, yellow slough, 26-50% granulation. The left posterior heel wound orders are: Cleanse wound with cleanser. Protect periwound with skin prep. Apply silver gel to wound bed twice daily. Cover wound with bordered gauze. change prn for soiling and/or saturation. The additional orders are the same as on the 1/2/15 wound visit report. Surveyor # noted that the wound MD signed the wound visit report on 1/28/15, five days after the visit. Surveyor # reviewed Resident #9's telephone orders and January 2015 TAR (treatment administration record) and noted there was not a telephone order written nor is there any treatment documented on the January 2015 TAR after Resident #9's left heel deteriorated from a Stage 2 to Stage 3 pressure ulcer. The nurse's note dated 1/27/15 documents: Resident went out to appt. (appointment) for f/u (follow up) with ortho surgeon @ (at) 0900 via van service, returned from appt. @ 1330 (1:30 p.m.) with orders for nwb (non weight bearing) status, f/u apt. needed in 2 weeks. Cast removed per orth, noted ulcer to rt. (right) plantar after removal of cast per ortho surgeon. The temporary care plan for Pressure Ulcer Stage 2 R (right) planter dated 1/27/15 has interventions checked of Measure and document on area(s) weekly., Monitor for drainage and document any findings., Treatment and/or medication per MD order., Preventative mattress and w/c cushion., and Update MD/family as indicated. Surveyor # noted that these are all interventions which were implemented prior. This care plan is not checked for float heels or boots. Surveyor # noted that Resident #9's physician was not notified and there was no treatment ordered for the right plantar pressure ulcer. Surveyor # reviewed the January TAR and there are no treatments for the right planter stage 2 pressure ulcer. The wound visit report dated 1/29/15 documents: Left posterior heel is a Stage 3 pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 1.5 cm length x 1.3 cm width x 0.1 cm depth, with an area of 1.95 sq. cm and a volume of 0.195 cubic cm. No undermining has been noted. There is a small amount of drainage noted which has no odor. The patient reports a wound pain of level 0. Wound bed is 26-50% adherent, yellow slough, 26-50% granulation. Right posterior heel is a suspected deep tissue injury pressure ulcer and has received a status of not healed. Initial wound encounter measurements are 4 cm length x 3 cm width with an area of 12 sq. cm. There was no drainage noted. The patient reports a wound pain of level 2. The left posterior heel wound orders are: Cleanse wound with cleanser. Protect periwound with skin prep. Apply Santyl to wound bed. Apply alginate to wound bed Cover wound with gauze. Secure dressing with Cloth tape. Change daily. Change PRN for soiling and/or saturation. The right posterior heel wound order is: Cleanse wound with cleanser. Protect periwound with skin prep. Apply to wound bed- skin prep daily. The additional orders are the same as on the 1/2/15 wound visit report. Surveyor # noted that the wound MD signed the wound visit report on 2/3/15, five days after the visit. The wound physician did not document the right plantar pressure ulcer. Surveyor # reviewed Resident #9's telephone orders and noted there is a telephone order dated 2/4/15, six days after the wound visit, which documents: 1. D/C (discontinue) tx. (treatment) to (R) (right) coccyx, (L) (left) post heel & (R) post heel. 2. Cleanse wound (L) post heels with NS (normal saline) f/b (followed by) skin prep to periwound fb Santyl to wound base fb alginate. Cover with gauze secure with clothe tape change daily & prn. 3. Cleanse wound (R) post heel with NS f/b skin prep to periwound and wound base daily. Copied from skin EP clinic sheet. Surveyor # reviewed the February TAR and noted these treatments started on 2/5/15. Prior to 2/5/15 there are no treatments for Resident #9 on the February treatment administration record. On 2/4/15 at 1:15 p.m. Surveyor # spoke with Resident #9 about his pressure ulcers. Surveyor # asked Resident #9 if he knew how he developed the pressure ulcers on his feet. Resident #9 replied, Bed was too short. Surveyor # asked Resident #9 if his feet were pressing against the foot board. Resident #9 replied, Yes. Surveyor # observed that Resident #9's bed was long and asked Resident #9 if he received a new bed. Resident #9 replied, Yes. Surveyor # ask Resident #9 if he knew when he received the new bed. Resident #9 replied, Last week. Surveyor # asked if he received the bed after he had developed the pressure ulcers. Resident #9 replied, Yes. Surveyor # then checked Resident #9's mattress and observed that it was a foam mattress. The wound visit report for 2/6/15 documents: Left posterior heel is a Stage 3 pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 1.5 cm length x 1.5 cm width x 0.1 cm depth, with an area of 2.25 sq cm and a volume of 0.225 cubic cm. No undermining has been noted. There is a small amount of drainage noted which has no odor. The patient reports a wound pain of level 0. Wound bed is 26-50% adherent, yellow slough, 51-75% granulation. The right posterior heel is a suspected deep tissue injury pressure ulcer has received an outcome of resolved. The right plantar posterior foot (other distal) is a Stage 3 pressure ulcer and has received a status of not healed. Initial wound encounter measurements are 1.5 cm x 1.5 cm width x 0.1 cm depth, with an area of 2.25 sq cm and a volume of 0.225 cubic cm. There is a small amount of sero-sanguineous drainage noted which has no odor. The patient reports a wound pain of level 0. Wound bed is 1-25% adherent, yellow slough 51-75% granulation. Right dorsal second toe is an acute Stage 2 pressure ulcer and has received a status of not healed. Initial wound encounter measurements are 1.8 cm length x 2.2 cm width, with an area of 3.96 sq cm. No undermining has been noted. There is no drainage noted. The left posterior heel wound orders are the same as on the 1/2/15 wound visit report. Surveyor # noted Resident #9's Stage 2 right plantar pressure ulcer did not receive any treatment until it was a Stage 3 pressure ulcer. The right plantar Stage 2 pressure ulcer is not listed on the January treatment administration record and the February treatment administration record reveals that the treatment for [REDACTED]. Surveyor # noted this is 11 days after the pressure ulcer was identified. On 2/9/15 at 1:20 p.m. Surveyor # spoke to the DON (Director of Nursing) regarding Resident #9's pressure ulcers. Surveyor # informed the DON that Surveyor # was unable to locate any telephone orders or treatment on the January 2015 TAR & February 2015 TAR for the pressure ulcers to Resident #9's right and left posterior heel. Physical therapy documented on 1/14/15 and nursing on 1/15/15 about the left posterior heel pressure ulcer. Surveyor # informed the DON that the left posterior heel pressure ulcer was identified at a Stage 2 and deteriorated to a Stage 3 without any treatments. The right posterior heel was identified on 1/29/15 as a suspected deep tissue injury. Surveyor # informed the DON that treatments did not start on the heels until 2/5/15 and there is no care plan for the pressure ulcers on Resident #9's heels. Surveyor # also informed the DON that Resident #9 had a stage 2 pressure ulcer on his right plantar 1/27/15 which she initiated a temporary care plan but there was no treatment ordered for this pressure ulcer until 2/7/15 when this area had deteriorated from a Stage 2 to a Stage 3 pressure ulcer. Surveyor # also asked the DON what type of mattress Resident #9 had on his bed and when Resident #9's bed was changed to a longer bed. The DON informed informed Surveyor # that she would have to look into this and get back to Surveyor # . On 2/9/15 at 3:28 p.m. the DON informed Surveyor # that she could not find a care plan for the pressure ulcers on Resident #9's heels. The DON stated that she could not find any treatments for the heels. The DON informed Surveyor # that she doesn't know how many times she went to the nurse manager who is no longer employed at the Facility and asked if she had contacted the doctor for treatments but apparently she did not. The DON informed Surveyor # that the bed was changed on 1/30/15 to an extra long bed and that the mattresses was a 36 inch foam. The DON also provided Surveyor # with the manufacturer's information for the mattress which Resident #9 was previously on. Surveyor # noted that the Panacea mattress is a foam pressure reducing and pressure redistributing mattress but does not indicate they should be used for a Resident with Stage 3 pressure ulcers. The nurse's note dated 2/9/15 documents: Air mattress was delivered at 2020 (8:20 p.m.) this evening. Resident #9 was in bed waiting for his treatment to his feet and refused to get out of bed. Stated to delivery person and myself that he was going to the doctor tomorrow and that mattress could be exchanged at that time. Air mattress and pump left in corner of Resident #9's room and half rails left in Nurse Managers office on unit. Resident #9 aware of this and is in agreement for tomorrow. On 2/10/15 at 8:16 a.m. Surveyor # asked LPN-C if she recalled Resident #9 having any treatments being done in January for Resident #9's heels. LPN-C informed Surveyor # that they didn't have anything for the heel because of the cast. Surveyor # asked if there were any treatments done after Resident #9 developed the pressure ulcers on his heels. LPN-C replied, Only thing I can recall is what we did the other day. 2.) Surveyor # reviewed Resident #10's medical record on 2/4/15 to 2/11/15. Resident #10 has [DIAGNOSES REDACTED].) Resident #10 is dependent upon staff for bed mobility, is transferred with a Hoyer lift and two staff, and does not ambulate. Resident #10 is always incontinent of bladder and frequently incontinent of bowel. Resident #10 started receiving hospice services on 9/15/14. Resident #10 does not have an activated power of attorney. The Braden Scale dated 9/11/14 has a total score of 16. A score of 15-16 is low risk. The care plan indicates: The resident has actual impairment to skin integrity of the right foot r/t (related to) impaired mobility and [MEDICAL CONDITION]. right foot transmetatarsal amputation. Has partial thickness open area to left side of nose r/t [DIAGNOSES REDACTED]. Date initiated is 9/14/14 and revision on 9/17/14. The interventions are: Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short; Encourage good nutrition and hydration in order to promote healthier skin; Follow facility protocols for treatment of [REDACTED]. Use lotion on dry skin. Do not apply on right foot near surgical site; Monitor for side effects of the antibiotics and over-the-counter pain medications: [REDACTED]. Report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration etc. to MD; Obtain blood work such as CBC (complete blood count) with Diff. (differential) Blood Cultures and C & S (culture and sensitivity) of any open wounds as ordered by physician; The resident needs pressure reducing mattress, pillows, to protect the skin while IN BED; The resident needs pressure reducing cushion to protect the skin while up IN CHAIR; Use a draw sheet or lifting device to move resident; Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface; and Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. All these interventions are dated 9/17/14. The significant change MDS (minimum data set) signed as completed on 10/17/14 documents a BIMS (brief interview mental status) total score of 15 which is cognitively intact and indicates that Resident #10 is at risk for developing pressure ulcers but currently does not have any pressure ulcers. The pressure ulcer CAA (care area assessment) dated 10/17/14 under analysis of findings documents: Resident #10 is at risk for pressure ulcers due to [DIAGNOSES REDACTED]. He has had hx. of pressure ulcers in the past that recently resolved in September of this year. He continues to have surgical wound to foot that is still receiving treatment daily. He does have a pressure reducing mattress to this bed and a pressure reducing cushion to his wheelchair. He is turned every 2 hours and prn (as needed) in bed. He is checked and changed every 2 hours and prn. His skin is routinely checked during am (morning) and hs (hour sleep) cares and during incontinent cares. Will proceed with care planning to continue to monitor. The nurse's note dated 11/7/14 documents: Hospice Nurse made Team leader aware that Resident had o/a (open area) to rt. (right) heel, order to cleanse with nsw (normal saline wash), cover with 4/4 then wrap with Kerlix daily until evaluated wound MD. Surveyor # noted there are no measurements of the right heel, the stage is not documented and the care plan was not updated to reflect the open area on the right heel. The wound visit report dated 11/13/14 documents: Right heel is a Stage 2 pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 3.2 length x 3.3 cm (centimeters) width, with an area of 10.56 sq. (square) cm. No sinus tract has been noted. No undermining has been noted. There is no drainage noted. The patient reports a wound pain of level 0. The wound orders are: cleanse wound with cleanser. Apply to wound bed: [MEDICATION NAME]. Change daily. Change PRN (as needed) for soiling and/or saturation. Additional orders: Follow Facility pressure ulcer prevention policy/protocol, pressure redistribution mattress per facility policy/protocol. Wheelchair pressure redistribution cushion per facility policy/protocol. Offload heels per Facility policy/protocol. This note is signed by the wound doctor on 11/15/14. Surveyor # noted these measurements are six days after the pressure ulcer was identified. Resident #10's skin integrity care plan was not updated to reflect the right heel pressure ulcer. There has been no change in interventions since 9/17/14 when the initial skin integrity care plan was developed. The nurse's note dated 11/14/14 documents: hospice nurse in for visit, updated on Wound MD assessment and new treatment for [REDACTED]. Necrotic tissue to lt. (left) ankle noted per hospice nurse, start silverdene cream daily per hospice. Surveyor # noted there are no measurements and the care plan was not updated to reflect the necrotic tissue on the left ankle. The skin observation assessment dated [DATE] documents under description: Resident has open area to rt. heel necrotic tissue to lt. outer ankle. Surveyor # noted there are no measurements. The nurse's note dated 11/17/14 documents: [MEDICATION NAME] giving (sic) prior to treating wounds. Open area on lateral ankle with med. (moderate) amount of serous sang. drainage scant amount of exudation non odorous. F/u (follow up) right heel noted med. amount serous sang. drainage nonodorous continued to tr

Based upon observation, interview and record review, the facility did not ensure that services were provided to 1 (Resident #3) of 7 sampled residents based upon current, acceptable standards of practice. Resident #3 was admitted to the facility on [DATE] with identified skin concerns including [DIAGNOSES REDACTED]. On admission Resident #3's skin was assessed as having open wounds on the right and left foot. Resident #3 was at risk for the development of pressure ulcers and stasis wounds given his history and diagnoses. On 4/14/14 Resident #3 developed an open area on the edge of a callous with bleeding on the resident's left foot. The open wound was not assessed by a Registered Nurse (RN); the physician was not notified nor was modifications made to Resident #3's care plan to address this change. On 4/16/14 the left heel wound measured 9.2 cm (centimeter) in length (l) and 6.7 cm width (w) with drainage; this observation was completed by two facility Licensed Practical Nurses (LPN's) with no RN assessment. Starting on 4/16/14 facility LPN staff start to document that there is a concern with Resident #3's skin that indicates that there is an infection. There is no indication that this was thoroughly assessed by an RN. On 4/19/14 LPN staff indicate that Resident #3's left heel wound has a foul odor; this was not assessed by an RN nor is there indication that Resident #3's physician was notified of this change. On 4/21/14 an LPN notes that Resident #3 has a "2.7 Stage 2 o/a's (open areas) to coccyx/btx (buttocks) site..." This area was not assessed by an RN until 4/22/14. On 4/22/13 Resident #3 was seen in a vascular clinic for evaluation of his heel wounds. The consultation indicates for Resident #3: Findings: Severe necrosis of the left heel. Likely down to calcaneus (heel bone). Smaller spot of necrosis on R (right) foot was not debrided. Diagnosis: [REDACTED]. *Surgical debridement vs. amputation of left foot. Keep heels floated or free from pressure. Scrub with gauze and saline daily and replace dressing. Following this evaluation, there is no indication that the facility followed through on implementing recommended preventative recommendations for Resident #3's wounds. On 4/25/14 Resident #3 was admitted back to the facility from the hospital; the Admission Nursing assessment dated [DATE] does not indicate that a comprehensive admission assessment was completed on Resident #3's wounds that would include details of the wounds including measurements. On 5/14/14 at approximately 4:00 pm the facility indicated that a RN was present as the LPN completed this admission assessment however, the assessment is incomplete as the RN believes she was pulled away from Resident #3's room to attend to another Resident. On 4/28/14 Resident #3 was readmitted to the hospital for altered mental status and deteriorating wounds. The facility's failure to properly assess Resident #3's wounds by licensed RN staff, implement preventative measures and monitor Resident #3's skin based upon current standards of practice, created a situation of Immediate Jeopardy at the scope and severity (s/s) of a K (Immediate Jeopardy/Pattern) that started on 4/14/14. The facility administration was notified of the Immediate Jeopardy on 5/14/14 at approximately 4:25 pm. The facility removed the Immediate Jeopardy on 5/15/14 however the deficient practice continues at a scope and severity (s/s) of an E (potential for harm/pattern) as the facility continues to implement its action plan related to wound care. A Licensed Practical Nurse was identified as being responsible for wound care and assessments for the second floor of the facility by facility administration. At the time of the survey, the resident census on the second floor was 38 Residents. This is evidenced by: ~According to the State of Wisconsin Administrative Codes N6.03: Standards of practice for registered nurses: 1. General nursing procedures. An RN shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process. (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. N6.04 Standards of practice for licensed practical nurses. (1) Performance of acts in basic patient situations. In the performance of acts in basic patient situations, the LPN shall, under the general supervision of an RN or the direction of a physician, podiatrist, dentist or optometrist: (a) accept only patient care assignments which the LPN is competent to perform; (b) provide basic nursing care; (c) Record nursing care given and report to the appropriate person changes in the condition of the patient; (d) Consult with an R.N., physician, podiatrist, dentist or optometrist in cases where an LPN knows or should know a delegated nursing or medical act may harm a patient and (e) Perform the following other acts when applicable; 1. Assist with the collection of data.... According to the standards for RNs and LPNs, an LPN can collect data, but an RN is the one who assesses/analyzes the data that has been collected. ~According to the 2009 National Pressure Ulcer Advisory Panel (NPUAP) Treatment Quick Reference Guide: Pressure Ulcer Assessment: 3. Assess and accurately document physical characteristics such as location, Category/Stage, size, tissue type(s), wound bed and peri-wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, necrotic tissue, odor, presence/absence of granulation tissue, and [MEDICATION NAME]. ~The undated facility policy and procedure for Skin Alteration Reference indicates: ...Purpose: To establish a comprehensive facility program to maintain optimal skin condition for the residents ... Nursing assessment will be utilized to identify residents at risk ...Through use of a skin protocol, all pressure areas will be identified and treatment begun immediately ... under Skin Rounds ...1. The team will consist of the DON (director of Nursing), Unit Manager and day RN/LPN of the individual unit. 2. Skin rounds are done on a weekly basis. 3. The licensed nurse responsible for the resident's care will initiate Wound Care Standing Orders using the Wound Care Protocol. 4. The licensed nurse is responsible to communicate any new skin breakdown to the DON to incorporate into the Skin Rounds Schedule. 5. The skin rounds team will determine if healing is present and when/if the treatment should be changed and will evaluate the current treatment plan. 6. Wound measurements will be documented weekly in the individual resident's record. 7. Pressure Ulcer Tracking - Skin Alteration Report is to be completed after Skin Rounds and submitted to the Director of Nursing. The Prevention of Pressure Ulcers Level II (2001 MED-PASS, Inc. Revise October 2010) lists Purpose: ...identification of pressure ulcer risk factors and interventions for specific risks factors. Preparation: ...1. Review the resident's care plan to assess for any special needs of the resident .... Under General Guidelines: ...6. The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, and reported to the practitioner, physician, and family, and addressed .... General Preventative Measures: ...10. Immediately report any signs of a developing pressure ulcer to the supervisor .... Documentation: The following information should be reported in the resident's medical records: ...5. Any change in the resident's condition. 11. The signature and title of the person recording the data. The facility policy regarding Skin Condition: Ulcers dated 11/11 indicates the ...Purpose: It is policy to properly identify and assess residents whose clinical conditions increase risk for impaired skin integrity, and pressure ulcers: to implement preventative measures: and to provide appropriate treatment modalities for wounds according to industry standards of care. Guidelines indicate ... 1. Prevention of Pressure Ulcers a. Braden Scale (and a skin audit) will be done: i. upon admission and readmission ii. Weekly for the first 4 weeks after admission and readmission iii. Quarterly and iv. With a significant change in status (including pressure ulcer development) b. Monitoring skin integrity i. The nursing assistant will observe skin daily with cares. If any skin concerns are noted, they are to be reported immediately to the designated nurse. ii. Weekly skin audits on the bath/shower day will be performed by the Licensed Nurse. iii. If a skin concern is noted refer to Wound Protocol iv. The care plan for skin integrity is to be evaluated and revised based on the response, outcomes and needs of the resident. The 10/23/13 Admission Nursing Assessment completed by RN Q indicates that Resident #3 has open areas on both feet indicating [DIAGNOSES REDACTED]. On the assessment sheet the written description indicates ... wound on rt (right) and lt (left) toes ...; ...rt toe great - back area 1 cm x 1 ? cm .... and the ....o/a (open area) lt. under gr. (great) toe 1cm x 1 ? cm .... A Hoyer lift is used for transfers and the resident is continent of bowel and bladder using a bedpan and a urinal. The admitting MDS (Minimum Data Set) of 10/30/13 reflects the facility has scored a BIMS (Brief Interview for Mental Status) of 15 indicating Resident #3 is cognitively intact, though the CAAS (Care Area Assessment Summary) triggers for confusion, forgetfulness, disorientation and assessment for [MEDICAL CONDITION]. Under the Behavior Section (E) Resident #3 is coded for rejection of care. Under Functional Status (G) of the MDS, the resident is coded for total dependence with assist of 2+ regarding transfers, toilet use and bathing and assist of 1 for bed mobility, dressing and personal hygiene. Resident #3 is able to eat independently with supervision. Resident #3 is continent of bowel and bladder using a urinal and a bedpan. Resident #3 is also coded for functional impairment of the lower extremity affecting one side and uses a wheelchair for mobility. The resident is also coded for the presence of frequent, moderate pain, history of falls and risk for pressure ulcers, with documentation indicating no current unhealed pressure ulcers presently. The number of venous and arterial ulcers is listed as 2. Interventions for skin include a pressure reducing device for the chair and bed, nutrition/hydration intervention and application of dressings to the feet. Though Resident #3 is coded for the need for assistance with bed mobility, turning and repositioning is not indicated on the MDS. The CAAS triggered for cognitive loss/dementia, ADL's, urinary incontinence, psychosocial well-being, behavioral symptoms, falls, nutritional status, dehydration, pressure ulcers, [MEDICAL CONDITION] drug use, pain and referral to return to the community. Surveyor Review of the CAAs for Resident #3 does not indicate specific interventions or considerations for Resident #3's specific care planning. The quarterly MDS of 2/11/14 codes the BIMS at 14, no change noted to functional status and remains continent of bowel and bladder. Pain has decreased in frequency to occasional mild pain. Risk of pressure ulcers continues and number of venous/arterial ulcers remains at 2. Resident #3's Care Plans were received from the facility on 5/12/14 upon request of Surveyor # . The Plan of Care: Skin Integrity of 11/5/13 indicates Resident #3 was admitted to the facility ... with a right foot ulcer with osteo[DIAGNOSES REDACTED]. The most recent Braden Scale performed on 10/23/13 is scored at risk for pressure ulcer development. Pressure ulcer prevention interventions are in place to reduce the risk of development of open areas. Goals - Resident #3's skin will remain intact through 2/14 ... with indication under the Review section ...Next Review 2/14 ... Approaches used on the plan of care include ...Ensure resident is clean and dry. Wash resident with soap and water after any incontinent episode. Apply moisture barrier after each incontinent episode with daily cares. Apply lotion to lower extremities and dry skin daily with cares. Reposition resident every 2 hours and as needed. Nurse to do body check weekly with bath or shower and document. Shower/bath weekly as per policy. Refer to PT/OT as needed to assist with positioning. Encourage resident to have good fluid intake with and between meals. Toilet/change Resident #3 as per toileting program. Report any red or open areas to unit nurse. Update MD on any open areas found. Refer to wound nurse/committee as per appropriate for evaluation .... There is a hand written update on the care plan indicating on ... 2/14/14 To Blister on R plantar skin prep BID (twice a day) ... A Temporary Care Plan for Skin Integrity, Impaired, dated 10/25/13 indicates a ...Pressure ulcer (unstaged) site L (left) & R (right) foot. Goal 1. Ulcer will reduce in size. Interventions Treatment and/or medication per MD order, Turn and reposition at least every 2 hrs (hours) in bed, every hour in chair, Assess for underlying cause of skin issue, Update MD/family as indicated, Float heels. There is no evidence that this information had been added to the Skin Integrity Care Plan of 11/25/13. A Temporary Care Plan for Skin Integrity dated 4/22/14 received by Surveyor # on 5/13/14 and signed by RN B indicates the ...Goal 1. Ulcer to reduce in size, 2. Ulcer will show no sign of infection, 3. Will have no further ulcers. Interventions: Measure and document on area (s) weekly, Monitor for drainage and document any finding, Treatment and or medication per MD order, Assess/document on skin condition, Turn and reposition at least every 2 hrs in bed, every hour in chair, Preventative mattress and w/c (wheelchair) cushion, Incontinent care as indicated, protective barrier as indicated, Update MD/family as indicated. The CNA (Certified Nursing Assistant)Care Card indicates Resident #3 needs assist of 1 for ADL's, assist of 2 for transfer, uses a w/c for mobility, uses a urinal and a bedpan, needs assist of 1 for turning, to lay down when requests, feeds himself and is at risk for falls and skin. When Unit Manager, LPN-H was asked on 5/13/14 where the CNAs chart the cares they have given related to the resident's change in position, she indicated they do not have a specific area or form where they chart that information such as toileting and turning/repositioning. Incomplete skin checks during bathing: Surveyor # requested and reviewed the bath sheets for Resident #3 that was to be completed twice weekly for each bath/shower showing that Resident #3's skin was inspected by both the CNA and the nurse. Surveyor # was provided with only 2 bath sheets for the period of time that Resident #3 resided in the facility. The first sheet was dated 2/21/14 which documents the left foot of the body diagram is circled and hand-writing on the sheet indicates ...bed bath, no new issues ...signed by CNA-X and LPN-U. The other sheet dated 4/16/14 has the right and left foot circled on the body diagram and also indicates ...bed bath ... signed by CNA-Y. Surveyor # observed that there is no nurse's signature noted on the form. On 5/13/14 at approximately 2:45 pm, Unit Manager LPN-H and DON-B indicated they could not find any other bath sheets for this resident year other than the two sheets presented. On 5/13/14 at 4:50 pm, LPN-U was asked how skin checks are completed on the residents in the facility. LPN-U indicated skin checks are completed on shower days, usually 2x per week, but at least weekly. If a resident refuses a shower, an attempt to complete a skin check is still made. The skin check is done from head to toe by the nurse on the unit at the time of the shower. A shower sheet is filled out by the CNA performing the shower who then marks the body diagram if any concerns are found and is signed by the CNA. The CNA will let the nurse know when the shower is complete and the nurse then does a skin check on the resident and co-signs (initials) the sheet. LPN-U indicated the nurse signs all shower sheets in conjunction with the CNA. LPN-U was asked if he recalled Resident #3. He indicated he did, and recalls treatments to the heels and barrier cream to the buttocks. LPN-U also indicated Resident #3 was self-dependent, showing anger if help was provided. LPN-U does not remember performing a skin check on the resident On 5/13/14 at 5:00 pm, LPN-II was asked how often shower sheets are completed. She indicated they are to be done weekly with showers. The CNA initiates and once the shower is completed, the nurse will do a body check to note any areas of concern, such as open areas, bruising, discoloration; measurements of open areas are completed. The M.D. and family are notified if warranted and orders received if necessary. The sheets are signed by the CNA and initialed by the LPN and placed under the door of the unit manager for review. Review of Resident #3's nurse's notes and Daily Skilled Nurse's Notes indicate no skin concerns for Resident #3 until 4/14/14. Licensed Practical Nurses Completing Wound Assessments: Review of Resident #3's Skin Condition Record dated 2/14/14 shows a diagram of the right foot marked with an X that Resident #3 has a right plantar blister measuring 2.5cm (l) x 2.5cm (w) with depth noted as UTD (unable to determine). The area is documented as red, intact and no drainage or pain. Dr.-P was notified on the same date the area was discovered and a new order for treatment for [REDACTED]. This wound observation was completed by LPN-H. There is no RN co-signature or documentation on the wound sheet to indicate that an RN was involved in the assessment. An Admission Nursing assessment dated [DATE] indicates a bruise on Resident #3's right wrist and a blood filled blister on the resident's right foot. Measurements were not documented. This observation was completed by Wound Nurse/Unit Manager LPN-H. Review of the 3/13/14 documentation on the Skin Condition Record (comparative to the weekly wound report) for the right plantar blister includes observation is ongoing, size is unchanged with 0 depth, area intact with a black wound bed, without drainage and progress is noted as improved and area surrounding the wound as healthy and continue treatment. Wound observation completed by LPN-H. On 3/21/14 the Weekly Wound Observation Report indicates a deep tissue injury of the R plantar area measuring 2.4cm x 2.5cm x 0cm (depth), edges of the wound are attached and red, the wound bed is 100% [MEDICATION NAME], without drainage, the periwound tissue is indurated. Progress and comments indicate no change, continue treatment. The observation was completed by LPN-H. On 3/26/14, The Weekly Wound Observation Report indicates the R plantar area is measured at 1.9cm x 2.2cm x 0cm, is without drainage, the wound bed is 100% [MEDICATION NAME], the edges of the wound are attached and the periwound tissue is indurated. The progress indicates improved and to continue treatment. The observation is completed by LPN-H. On 4/4/14, The Weekly Wound Observation Report indicates the R plantar area measures 0.5cm x 0.7cm, without drainage, wound bed is 100% [MEDICATION NAME] tissue, the wound edges and periwound tissue is healthy and area is documented as closed for 1 week. The observation is completed by LPN H. On 4/11/14, The Weekly Wound Observation Report indicates the R plantar area measures 0.2cm x 0.3cm, no drainage, wound bed at 100% [MEDICATION NAME], wound edges and periwound tissue is healthy and the area has been closed for 2 weeks. The observation is completed by LPN-H. Review of Resident #3's record indicates that on 4/14/14 Licensed Practical Nurse (LPN)-N completed a Daily Skilled Nurse's Note indicating that Resident #3 required extensive assistance for bed mobility and transfer and limited assistance of one person for toileting. LPN-N indicated on the form that Resident #3 has skin issues involving "other open lesion of foot." Additional review of the nurse's notes and wound sheets for Resident #3 do not indicate what this change was that LPN-N noted on Resident #3 on 4/14/14 and what steps were taken regarding this change. On 5/14/14 at 12:40 pm Surveyor # interviewed LPN-N regarding her Skilled Daily Nurse's note entry dated 4/14/14. LPN-N reviewed the record and indicated that on that date she did see an open area start on Resident #3's left heel. LPN-N indicated that Resident #3 had a callous on that heel that they were wrapping with Kerlix. LPN-N indicated that on the 14th a Certified Nursing Assistant (CNA) came to get her to look at Resident #3's heel because after the CNA cleaned the area it started to bleed. LPN-N indicated that she looked at the callous and could see that the callous had started to break off, away from the heel and that there was bloody drainage. When asked what LPN-N did following this change LPN-N indicated that she did not do anything other than clean the wound and wrap it back up with Kerlix. LPN-N was asked if she reported this to an RN for assessment or called the physician regarding the change and LPN-N indicated no. She looked at the wound and assessed it (which she is not qualifed to do by her license) and determined that Resident #3 always had a callous before so she didn't think that this was something new. LPN-N indicated that she decided to not put skin prep on it because she didn't think it would be useful for the area. LPN-N was asked if any care plan changes were made and LPN-N indicated no. LPN-N was asked what happened to Resident #3's left heel after she discovered the wound that was bleeding and LPN-N indicated that she knew the Resident had to have that heel debrided. Review of Resident #3's Nurse's Notes indicates on 4/16/14 at 10:00 am: ...Lt. & Rt. foot measure by LPN-H, wound nurse for the unit and LPN-N. ...Lt heel with previously noted callous with scant amount of bloody drainage and deep tissue injury to Lt. side of callous. Rt foot noted with pressure sites to rt lateral lower and rt. lateral upper. All areas tender to the touch. Lt heel wrapped with Kerlix. Placed call to Dr.-P. Awaiting return call ... Dr.-P ordered ...apply [MEDICATION NAME] to Lt heel, f/b (followed by) non-adherent dressing, f/b Kerlix q (every) day. Dr. P instructed to send Resident back to Dr. -AA. Appt (appointment) scheduled with Dr. AA on 4/22/14 at l:30. Guardian S made aware .... Review of the Weekly Wound Observation Report indicates that a venous stasis ulcer is identified on the right medial heel dated 4/16/14. The wound measures 1.6cm x 2.7cm x 0cm with no drainage, 100% granulation, the edges of the wound are pink and attached, and the periwound tissue is healthy. This observation was completed by LPN-H with no indication that an RN also assessed Resident #3's right heel wound. The Weekly Wound Observation Report dated 4/16/14 identifies that Resident #3's left heel is now: 9.2cm x 6.7cm x 0cm. A scant amount of serous drainage is present, the wound bed is 100% granulated, the edges of the wound are red and detached and the periwound tissue is macerated with induration (a process where the skin becomes firm, often surrounds a wound as a healing ridge or can be a sign of building bioburden) and pain. This observation was completed by LPN-H with no indication that an RN also assessed Resident #3's left heel wound. Review of the 4/16/14 Weekly Wound Observation Report documents that Resident #3 now has a wound located on the upper area of the right lateral foot. The type of wound is not identified. The wound measurements are: 2.5cm x 2.0cm, no documented depth, no drainage, 100% [MEDICATION NAME], edges of the wound are red and attached and the periwound tissue is indurated. This observation was completed by LPN-H with no RN assessment indicated. On 4/16/14 the Weekly Wound Observation Report indicates the presence of a venous stasis ulcer on the lower area of the right lateral foot. The wound measurements are: 3.5cm x 3.0cm and is without drainage, 100% [MEDICATION NAME], wound edges are red and attached and the periwound tissue is indurated. This observation was completed by an LPN with no RN assessment indicated. Review of the Nurse's Notes dated 4/19/14 (time not indicated), LPN-N documented: ...Lt heel with foul odor present, c/o (complaint of) pain to Lt leg. Drsg (dressing) intact. Review of Resident #3's record does not indicate that any additional assessment was completed of Resident #3's left heel despite LPN-N noting that the wound has a foul odor and Resident #3 has increased pain. On 5/14/15 at approximately 12:45 pm LPN-N was interviewed and asked what did she do when she observed that Resident #3's left heel wound had a foul odor to it. LPN-N could not recall what her shift was that day to help trigger her memory on what she may have done. LPN-N indicated that sometimes she puts the info on the 24 hour sheet and sometimes when leaves a written shift report note attached to the medication cart for the next shift to follow up on. LPN-N could not recall what she had done in this case. Review of Resident #3's medical record does not indicate that any additional follow up was completed regarding the foul odor to Resident #3's left heel wound. There is no indication that an RN completed an assessment or that the physician was notified with the change in the wound. On 4/21/14 at 1910 (7:10 pm) LPN-WW documented in the Nurse's Notes: Resident confused. Inc (incontinent) B/B (bowel and bladder) Has 2.7 Stage 2 o/a's (open areas) to coccyx/btx (buttocks) site. Site reddened. 0 (no) bleeding, 0 drainage. Assisted with cares. Transfers x2 to bed. Ate 75% with assist. MD faxed requests for treatment order. Signed LPN-WW. There is no indication that LPN-WW had Resident #3's coccyx assessed by an RN until 4/22/14. On 4/25/14 Resident #3 was discharged back to the facility. Review of the Admission Nursing Assessment form documents that Resident #3 has, according to the diagram, a wound on the: left heel, left posterior thigh, the coccyx, the right lower medial leg and right medial heel. Comments include ....resident's coccyx and left heel are both blk (black) & necrotic. (The left heel) necrotic black appr (approximately) 3"x 2 1/2" ... Under Current Status, Other, EZ Boots at HS .... is documented. Bowel and bladder evaluation indicate incontinence of bowel and bladder which is a decline from previous assessment. Surveyor # noted that this form is not signed to indicate who completed the assessment. Surveyor # also noted that the document only contains measurement of the left heel and no other wound measurements and the assessed intervention of EZ boots at HS is inconsistent with the hospital wound recommendation to have Resident #3 wear Prevalon boots at all times. On 5/14/14 at approximately 4:00 pm the RN-UU was interviewed regarding the 4/25/14 admission nursing assessment. RN-UU indicated that initially when the LPN was completing the admission assessment of Resident #3, she was present for the assessment. RN-UU indicated that there are entries on the form that are in her handwriting, including documentation of a necrotic black approx. 3" x2 ? " by the body diagram on the form. RN-UU was asked if she knew whether complete assessment details were taken of Resident #3's wounds including measurements, characteristics, location etc. RN-UU indicated that she did not know, that she was not present for the entire assessment as she must have been called away from Resident #3 to attend to another Resident. RN-UU was asked if she had assessed Resident #3 and she indicated not completely, that would have been the LPN. On 4/28/14, the unit wound nurse, LPN-H completed wound measurements on Resident #3's wounds. ~The right medial lower extremity described as a blister was measured at 5.0 cm x 5.7 cm, no drainage, 100% granulation, edges of wound are pink, periwound tissue healthy with comment that it's a ...."new open area ..." ~The left heel described as a venous stasis ulcer measuring at 9cm x 7cm with scant amount of serous drainage, 100% necrotic, wound edges are detached, the periwound tissue is indurated with comment ...area necrotic, will follow vascular recommend ... ~The right medial heel described as a venous stasis ulcer was measured at 1.0cm x 2.5cm, without drainage, 100% granulation tissue in wound bed, the edges of the wound are pink and attached with periwound tissue indurated. Progress is noted as improved from last measurement of 4/16/14. ~The right lateral lower foot identified as a venous stasis ulcer is measured at 3.5cm x 3.0cm is without drainage, the wound bed is 100% [MEDICATION NAME], the edges of the wound are red and attached and the periwound tissue is indurated. ~The right lateral upper foot, no description as to type of wound on wound observation report, measures 2.0cm x 2.0cm, is without drainage, the wound bed is 100% [MEDICATION NAME], the edges of the wound are red and attached and the periwound tissue is indurated. Progress is noted as improved from last measurement of 4/16/14, continue treatment. There is no indication that an RN participated in or completed these assessments of Resident #3's wounds. On 5/14/14 at approximately 1:30 pm Surveyor # shared with the facility administration the concerns related to Resident #3's wound care, specifically concerns related to RNs not assessing Resident #3's wounds according to license and facility policy, the facility not ensuring that the facility's policy related to wound/skin monitoring was carried out by nursing and CNA staff, concern that the care plans for Resident #3 are not individualized to address Resident #3's needed wound prevention, and that when Resident #3's wounds were discovered to exist or have a change in status that the wounds were properly assessed and that the physician was consulted with as indicated. DON-B was asked if it was typical practice in the facility to have the LPNs completing wound assessments on Residents. Don-B indicated yes and that the LPNs knew that if they needed an RN they could either come and find her or one the other RN's in the building to look at something. The facility administration indicated that Resident #3 had a number of medical conditions that made him at high risk for such wounds and the facility also indicated that Resident #3 would be resistive to cares and argue with staff. Surveyor # noted that there is no indication that the facility recognized the seriousness of Resident #3's comorbidities contributing to his elevated risk for such wounds by assessing and developing an individualized care plan for Resident #3/ Surveyor # also noted that there was no indication that the facility had thoroughly assessed Resident #3's described behaviors and developed a care plan to address such behaviors. (Cross Reference F309 and F314). The facility's failure to ensure that the facility's Resident's wounds were assessed according to acceptable standards of practice created a situation of Immediate Jeopardy at a scope and severity (s/s) of a K (immediate jeopardy/pattern) that started on 4/14/14. The Immediate Jeopardy was removed on 5/15/14 when the facility implemented the following action plan: 1. All current residents with wounds including vascular and pressure have been assessed on 5/15/14 by a Registered Nurse. 2. Treatment orders, care plans and care cards have been reviewed and revised as indicated and practitioners and families have been updates as indicated. 3. The facility contracted with a wound care specialist consultant who has been onsite. This consultant will actively participate in the education of the staff and the evaluation of the facility p

UNCORRECTED AT VERIFICATION VISIT Based on observation, interview, and record review the Facility did not provide appropriate care based on individual needs for 1 of 6 sampled Residents. On 6/17/14 Resident #13 was observed with a fluid filled blister on her right wrist. Resident #13 was assessed by Wound Physician-D on this date with LPN/Unit Manager-F. A telephone order from Physician-C dated 6/17/14 documents a treatment of [REDACTED]. Surveyor # noted June's TAR does not reflect this telephone order. On 6/18/14 the Facility received Wound Physician-D's progress note dated 6/17/14 which documents a plan of cleanse, apply 2% [MEDICATION NAME] cream and wrap with Kerlix daily. Unit Manager/LPN (Licensed Practical Nurse) -D did not read the plan for Resident #13 from Wound Physician-D, did not clarify with Wound Physician-D which treatment Resident #13 should be receiving and Wound Physician-D's plan was not implemented by Facility staff. Findings include: 1.) Surveyor # reviewed Resident #13's medical record on 6/23/14 & 6/24/14. The nurse's note dated 6/17/14 documents "Writer summoned to resident by CNA (Certified Nursing Assistant), noted fluid filled blister to (R) (right) intact, without redness, without itching noted. Seen by wound team, recommend skin prep and Kerlix wrap." The nurse's note dated 6/17/14 documents "MD (Medical Doctor)-C is aware of blister to (R) wrist, aware of wound team recommendation and possible [DIAGNOSES REDACTED].O. (telephone order)." The telephone order dated 6/17/14 documents "(1) To (R) wrist fluid filled blister, NSW (normal saline wash), F/B (followed by) skin prep BID (twice daily) til resolved F/B Kerlix. (2) If open culture area update MD." On 6/23/14 at 12:00 p.m. Surveyor # reviewed Resident #13's June 2014 TAR (treatment administration record) located with the MAR (medication administration record) in a binder on the medication cart. Surveyor # noted the only treatment was "To blister to (R) (right) hand & wrist apply skin prep BID til healed." Surveyor # noted the treatment on the TAR does not include normal saline wash and Kerlix which was ordered on [DATE]. On 6/23/14 at 2:04 p.m. Surveyor # observed Resident #13 in bed on her back. Surveyor # did not observe Kerlix on Resident #13's right forearm. On 6/24/14 at 7:55 a.m. Surveyor # observed CNA (Certified Nursing Assistant)-E reposition Resident #13 in bed. During this observation, Surveyor # did not observe Kerlix on Resident #13's right forearm. On 6/24/14 at 12:40 p.m. Surveyor # reviewed Wound Physician-D's visit report for 6/17/14 which was printed on 6/18/14 . The chief complaint documents "skin eruption." Under objective documents "Wound #1 Dorsal forearm/wrist is an acute bullous lesion w/(with) possible [MEDICAL CONDITION] and has received a status of Not healed. Initial wound encounter measurements are 5 cm (centimeters) length x (times) 3 cm width x 0.1 cm depth, with an area of 15 sq (square) cm and a volume of 1.5 cubic cm No sinus tract has been noted. No undermining has been noted. Wound bed is 76-100% non granulation. The peri wound skin texture is normal. The periwound skin moisture is normal. The periwound skin color is normal. Under plan documents "Rt. (right) forearm skin eruption: Cleanse area of rash and then apply 2% [MEDICATION NAME] cream once daily for one week, wrap forearm w/ Kerlix. Avoid bracelets, wrist bands or other foreign items to the skin. If not improving over next 3-5 days or if worsening, recommend culture of fluid from lesion and/or base of lesion for bacterial and [MEDICAL CONDITION] (HSV ([MEDICAL CONDITION] simplex virus) vs HZV ([MEDICAL CONDITION] virus))." On 6/24/14 at 12:42 p.m. Surveyor # spoke with LPN (Licensed Practical Nurse)/Unit Manager-F with Wound Physician-D regarding the treatment for [REDACTED]. Surveyor # informed staff that there was a telephone order dated 6/17/14 which documents to use normal saline wash, apply skin prep, & Kerlix twice daily and a Wound Physician-D visit report dated 6/17/14 which the Facility received on 6/18/14 documents to cleanse area and then apply 2% [MEDICATION NAME] cream daily for one week and to wrap with Kerlix. Wound Physician-D informed Surveyor # that the PCP (personal care physician) wrote the order and staff didn't note the recommendation. Wound Physician-D informed Surveyor # that she discusses with the staff what the plan is while they are looking at the wounds. Wound Physician-D indicated that she recently started at the Facility and it will take time. Surveyor # asked Wound Physician-D what treatment she would have expected staff to be applying to Resident #13's right wrist. Wound Physician-D replied "[MEDICATION NAME]." On 6/24/14 at 1:12 p.m. LPN/Unit Manager-F informed Surveyor # that she reviewed Resident #13's orders, saw the order for skin prep, and didn't see the order for [MEDICATION NAME] cream. On 6/24/14 at 1:25 p.m. Surveyor # asked LPN/Unit Manager-F who was with Wound Physician-D if she prints out Wound Physician-D progress notes. Wound Physician-D informed Surveyor # that the Director of Nursing has elected to print out the note herself and that her notes are available to the Facility within twenty four hours. Surveyor # asked LPN/Unit Manager-F after the DON (Director of Nursing) gave her Wound Physician-D progress note to her what did she do with this note. LPN/Unit Manager-F informed Surveyor # that she keeps them in a book in her office. LPN/Unit Manager-F told Surveyor # that "I should of looked at the plan and called Physician-C." LPN/Unit Manager-F indicated that she didn't know Wound Physician-D had recommended [MEDICATION NAME] cream. Surveyor # asked LPN/Unit Manager-F if she read Wound Physician-D's plan for Resident #13 which documents [MEDICATION NAME] cream. LPN/Unit Manager-F informed Surveyor # that she did not read the plan. On 6/24/14 at 1:36 p.m. Surveyor # interviewed the DON (Director of Nursing) to inquire which Residents are assessed by Wound Physician-D and the Facility's system regarding wounds. DON informed Surveyor # that Wound Physician-D sees all wounds unless the Resident goes to a wound clinic or surgeon. All the physicians have agreed that Wound Physician-D can see their patients and did give an order to follow Wound Physician-D's recommendations. The DON informed Surveyor # that since Wound Physician-D was new to the Facility the physicians did request for the next couple of months that the nursing staff inform them of Wound Physician-D's recommendations but they would follow her orders. The DON informed Surveyor # that if Wound Physician-D recommended a lab this would have to be ordered by the Resident's physician. The DON informed Surveyor # that the unit managers accompany Wound Physician-D who assesses and measures the wounds. The Unit Managers take notes of the measurements and recommended treatment during the observations. The DON informed Surveyor # that they are guaranteed access to Wound Physician-D notes in twenty four hours. The DON indicated that she goes into the computer and prints out two copies of Wound Physician-D progress notes of which she keeps one copy and gives one copy to the unit. Surveyor # inquired should the Unit Managers do with Wound Physician-D's progress notes once they receive them. The DON informed Surveyor # that the Unit Managers are suppose to read over the note to make sure what is written matches the notes they took. Surveyor # asked the DON if the plan is different than the orders that were written should the nurse call the doctor to clarify the order. The DON replied "yes." On 6/24/14 at 1:52 p.m. Surveyor # informed the DON that a telephone order for Resident #13 dated 6/17/14 documents a treatment of [REDACTED]. Surveyor # noted June's TAR does not reflect this telephone order. Also Wound Physician-D's progress note dated 6/17/14 which was received 6/18/14 documents a plan of cleanse, apply 2% [MEDICATION NAME] cream and wrap with Kerlix daily. Surveyor # informed the DON that an interview with Unit Manager/LPN-F revealed that she did not read the plan for Resident #13 from Wound Physician-D. Unit Manager/LPN-F did not clarify with Wound Physician-D which treatment Resident #13 should be receiving and Wound Physician-D's plan was not implemented by Facility staff. The DON informed Surveyor # that this is not what should have been done and assumed that LPN/Unit Manager-F was reviewing Wound Physician-D progress notes. The DON informed Surveyor # that she doesn't know why she didn't.

Based upon observation, interview and record review, the facility did not ensure that services were provided to 1 (Resident #3) of 7 sampled residents to maintain their highest practicable well-being. Resident #3 was admitted to the facility on [DATE] with identified skin concerns including [DIAGNOSES REDACTED]. On admission Resident #3's skin was assessed as having open wounds on the right and left foot. Resident #3 was at risk for the development of pressure ulcers and stasis wounds given his history and diagnoses. On 4/14/14 Resident #3 developed an open area on the edge of a callous with bleeding on the resident's left foot. The open wound was not assessed; the physician was not notified nor were modifications made to Resident #3's care plan to address this change. On 4/16/14 the left heel wound measured 9.2 cm (centimeter) in length (l) and 6.7 cm width (w) with drainage. On 4/22/13 Resident #3 was seen in a vascular clinic for evaluation of his heel wounds. The consultation indicates for Resident #3: Findings: Severe necrosis of the left heel. Likely down to calcaneus (heel bone). Smaller spot of necrosis on R (right) foot was not debrided. Diagnosis: [REDACTED]. *Surgical debridement vs. amputation of left foot. Keep heels floated or free from pressure. Scrub with gauze and saline daily and replace dressing. Following this evaluation, there is no indication that the facility followed through on implementing recommended preventative recommendations for Resident #3's wounds. The facility's failure to properly assess Resident #3's wounds, implement preventative measures and monitor Resident #3's skin created a situation of Immediate Jeopardy that started on 4/14/14. The facility administration was notified of the Immediate Jeopardy on 5/14/14 at approximately 4:25 pm. The facility removed the Immediate Jeopardy on 5/15/14 however the deficient practice continues at a scope and severity (s/s) of an E (potential for harm/pattern) as the facility continues to implement its action plan related to wound care. Findings include: The undated facility policy and procedure titled: Skin Alteration Reference indicates ...Purpose: To establish a comprehensive facility program to maintain optimal skin condition for the residents ... Nursing assessment will be utilized to identify residents at risk ...Through use of a skin protocol, all pressure areas will be identified and treatment begun immediately ... under Skin Rounds ...1. The team will consist of the DON, Unit Manager and day RN/LPN (Registered Nurse/Licensed Practical Nurse)of the individual unit. 2. Skin rounds are done on a weekly basis. 3. The licensed nurse responsible for the resident's care will initiate Wound Care Standing Orders using the Wound Care Protocol. 4. The licensed nurse is responsible to communicate any new skin breakdown to the DON (Director of Nursing)to incorporate into the Skin Rounds Schedule. 5. The skin rounds team will determine if healing is present and when/if the treatment should be changed and will evaluate the current treatment plan. 6. Wound measurements will be documented weekly in the individual resident's record. 7. Pressure Ulcer Tracking - Skin Alteration Report is to be completed after Skin Rounds and submitted to the Director of Nursing. Resident #3 is a [AGE] year-old resident with [DIAGNOSES REDACTED]. Resident #3 was admitted to the facility on [DATE]. The 10/23/13 the Admission Nursing Assessment completed by RN Q indicates that Resident #3 has open areas on both feet indicating [DIAGNOSES REDACTED]. On the assessment sheet the written description indicates ... wound on rt (right) and lt (left) toes ...; ...rt toe great - back area 1 cm x 1 ? cm .... and the ....o/a (open area) lt. under gr. (great) toe 1cm x 1 ? cm .... A Hoyer lift is used for transfers and the resident is continent of bowel and bladder using a bedpan and a urinal. The admitting MDS (Minimum Data Set) of 10/30/13 reflects the facility has scored a BIMS (Brief Interview for Mental Status) of 15 indicating Resident #3 is cognitively intact, though the CAAS (Care Area Assessment Summary) triggers for confusion, forgetfulness, disorientation and assessment for [MEDICAL CONDITION]. Under the Behavior Section (E) Resident #3 is coded for rejection of care. Under Functional Status (G) of the MDS, the resident is coded for total dependence with assist of 2+ regarding transfers, toilet use and bathing and assist of 1 for bed mobility, dressing and personal hygiene. Resident #3 is able to eat independently with supervision. Resident #3 is continent of bowel and bladder using a urinal and a bedpan. Resident #3 is also coded for functional impairment of the lower extremity affecting one side and uses a wheelchair for mobility. The resident is also coded for the presence of frequent, moderate pain, history of falls and risk for pressure ulcers, with documentation indicating no current unhealed pressure ulcers. The number of venous and arterial ulcers is listed as 2. Interventions for skin include a pressure reducing device for the chair and bed, nutrition/hydration intervention and application of dressings to the feet. Though Resident #3 is coded for the need for assistance with bed mobility, turning and repositioning is not indicated on the MDS. Resident #3's Plan of Care: Skin Integrity of 11/5/13 indicates Resident #3 was admitted to the facility ... with a right foot ulcer with osteo[DIAGNOSES REDACTED]. The most recent Braden Scale performed on 10/23/13 is scored at risk for pressure ulcer development. Pressure ulcer prevention interventions are in place to reduce the risk of development of open areas. Goals - Resident #3's skin will remain intact through 2/14 ... with indication under the Review section ...Next Review 2/14 ... Approaches used on the plan of care include ...Ensure resident is clean and dry. Wash resident with soap and water after any incontinent episode. Apply moisture barrier after each incontinent episode with daily cares. Apply lotion to lower extremities and dry skin daily with cares. Reposition resident every 2 hours and as needed. Nurse to do body check weekly with bath or shower and document. Shower/bath weekly as per policy. Refer to PT/OT as needed to assist with positioning. Encourage resident to have good fluid intake with and between meals. Toilet/change Resident #3 as per toileting program. Report any red or open areas to unit nurse. Update MD on any open areas found. Refer to wound nurse/committee as per appropriate for evaluation .... There is a hand written update on the care plan indicating on ... 2/14/14 To Blister on R plantar skin prep BID (twice a day) ... A Temporary Care Plan for Skin Integrity, Impaired, dated 10/25/13 indicates a ...Pressure ulcer (unstaged) site L (left) & R (right) foot. Goal 1. Ulcer will reduce in size. Interventions Treatment and/or medication per MD order, Turn and reposition at least every 2 hrs (hours) in bed, every hour in chair, Assess for underlying cause of skin issue, Update MD/family as indicated, Float heels. There is no evidence that this information had been added to the Skin Integrity Care Plan of Review of Resident #3's nurse's notes and Daily Skilled Nurse's Notes indicate no skin concerns for Resident #3 until 4/14/14. Left and right heel Wound: Review of Resident #3's record indicates that Resident #3 has skin issues involving "other open lesion of foot." Additional review of the nurse's notes and wound sheets for Resident #3 do not indicate what this change was that LPN-N noted on Resident #3 on 4/14/14 and what steps were taken regarding this change. On 5/14/14 at 12:40 pm Surveyor # interviewed LPN-N regarding her Skilled Daily Nurse's note entry dated 4/14/14. LPN-N reviewed the record and indicated that on that date she did see an open area start on Resident #3's left heel. LPN-N indicated that Resident #3 had a callous on that heel that they were wrapping with Kerlix. LPN-N indicated that on the 14th a Certified Nursing Assistant (CNA) came to get her to look at Resident #'s heel because after the CNA cleaned the area it started to bleed. LPN-N indicated that she looked at the callous and could see that the callous had started to break off, away from the heel and that there was bloody drainage. When asked what LPN-N did following this change LPN-N indicated that she did not do anything other than clean the wound and wrap it back up with Kerlix. LPN-N was asked if she reported this to an RN for assessment or called the physician regarding the change and LPN-N indicated no. She looked at the wound and assessed it and determined that Resident #3 always had a callous before so she didn't think that this was something new. LPN-N indicated that she decided to not put skin prep on it because she didn't think it would be useful for the area. LPN-N was asked if any care plan changes were made and LPN-N indicated no. LPN-N was asked what happened to Resident #3's left heel after she discovered the wound that was bleeding and LPN-N indicated that she knew the Resident had to have that heel debrided. Review of the Skilled Daily Nurse's Note dated 4/15/14 indicates that Resident #3 has a skin concern with no detail documented. This form indicates that Resident #3 requires limited assistance of one staff person for bed mobility and that Resident #3 requires extensive assistance of one person for transfer and total dependence of one person for toileting. The unsigned Skilled Daily Nurse's Note dated 4/16/14 indicates a skin concern for Resident #3 that includes a venous or arterial ulcer and an infection of the foot. This form indicates that Resident #3 requires limited assistance of one staff person for bed mobility and that Resident #3 requires extensive assistance of one person for transfer and total dependence of one person for toileting Review of Resident #3's Nurse's Notes indicates on 4/16/14 at 10:00 am: ...Lt. & Rt. foot measure by LPN-H, wound nurse for the unit and LPN-N. ...Lt heel with previously noted callous with scant amount of bloody drainage and deep tissue injury to Lt. side of callous. Rt foot noted with pressure sites to rt lateral lower and rt. lateral upper. All areas tender to the touch. Lt heel wrapped with Kerlix. Placed call to Dr.-P. Awaiting return call ... Dr.-P ordered ...apply [MEDICATION NAME] to Lt heel, f/b (followed by) non-adherent dressing, f/b Kerlix q (every) day. Dr. P instructed to send Resident back to Dr. -AA. Appt (appointment) scheduled with Dr. AA on 4/22/14 at l:30. Guardian S made aware .... Review of the Weekly Wound Observation Report indicates that a venous stasis ulcer is identified on the right medial heel dated 4/16/14. The wound measures 1.6cm x 2.7cm x 0cm with no drainage, 100% granulation, the edges of the wound are pink and attached, and the periwound tissue is healthy. This assessment was completed by LPN-H with no indication that an RN also assessed Resident #3's right heel wound. The Weekly Wound Observation Report dated 4/16/14 identifies that Resident #3's left heel is now: 9.2cm x 6.7cm x 0cm. A scant amount of serous drainage is present, the wound bed is 100% granulated, the edges of the wound are red and detached and the periwound tissue is macerated with induration (a process where the skin becomes firm, often surrounds a wound as a healing ridge or can be a sign of building bioburden) and pain. This assessment was completed by LPN-H with no indication that an RN also assessed Resident #3's left heel wound. Review of Resident #3's medical record indicates that no Daily Skilled Nurse's note was completed for 4/17/14. Review of a Nurse's Note dated 4/17/14 at 21:15 (9:15 pm) indicates: that (Resident #3) ...refused treatment to Rt. & Lt. feet... Surveyor # noted that there is no indication that education or encouragement was given to Resident #3 to allow the treatment nor is there indication that Resident #3 was re-approached at a later time to complete the treatment. Review of the Daily Skilled Nurse's Note dated 4/18/14 and 4/19/14 indicates that Resident #3 has skin concerns including and infected wound. The sheets for 4/18 and 4/19 indicate a skin concern and infection of the foot. Review of the Nurse's Notes dated 4/19/14 (time not indicated), LPN-N documented: ...Lt heel with foul odor present, c/o (complaint of) pain to Lt leg. Drsg (dressing) intact. Review of Resident #3's record does not indicate that any additional assessment was completed of Resident #3's left heel despite LPN-N noting that the wound has a foul odor and Resident #3 has increased pain. On 5/14/15 at approximately 12:45 pm LPN-N was interviewed and asked what did she do when she observed that Resident #3's left heel wound had a foul odor to it. LPN-N could not recall what her shift was that day to help trigger her memory on what she may have done. LPN-N indicated that sometimes she puts the info on the 24 hour sheet and sometimes when leaves a written shift report note attached to the medication cart for the next shift to follow up on. LPN-N could not recall what she had done in this case. Review of Resident #3's medical record does not indicate that any additional follow up was completed regarding the foul odor to Resident #3's left heel wound. There is no indication that an RN completed an assessment or that the physician was notified with the change in the wound. The Daily Skilled Nurse's Note dated 4/20/14 indicates that Resident #3 has skin concerns that are pressure ulcers. The 4/21/14 document indicates that there are skin concerns for Resident #3 including pressure ulcers and other open [MEDICAL CONDITION] on foot. The 4/22/14 document indicates that Resident #3 has skin concerns with no other details indicated On 4/22/14 a Temporary Care Plan for Skin Integrity was signed by RN B and indicates Goal 1. Ulcer to reduce in size, 2. Ulcer will show no sign of infection, 3. Will have no further ulcers. Interventions: Measure and document on area(s) weekly, Monitor for drainage and document any finding, Treatment and or medication per MD order, Assess/document on skin condition, Turn and reposition at least every 2 hrs in bed, every hour in chair, Preventative mattress and w/c (wheelchair) cushion, Incontinent care as indicated, protective barrier as indicated, Update MD/family as indicated. This care plan was developed following the identification of a facility acquired coccyx pressure ulcer on 4/21/14. (Cross Reference F314). Surveyor # noted despite ongoing heel wound issues, this care plan did not specifically address Resident #3's heel and foot ulcers. On 4/22/14 Resident #3 was seen in the vascular clinic for review of his wounds. The Report of consultation dated 4/22/14 indicates: Findings: Severe necrosis of the left heel. Likely down to calcaneus (heel bone). Smaller spot of necrosis on R (right) foot was not debrided. Diagnosis: [REDACTED]. *Surgical debridement vs. amputation of left foot. Keep heels floated or free from pressure. Scrub with gauze and saline daily and replace dressing. Surveyor # noted that despite Resident #3 returning from the wound clinic with a pressure ulcer that was debrided and a necrotic ulcer on her right heel no changes were noted to the care plan including documenting and implementing the intervention of floating Resident #3's heels. Right Upper & Lower lateral foot wounds: Review of the 4/16/14 Weekly Wound Observation Report documents that Resident #3 now has a wound located on the upper area of the right lateral foot. The type of wound is not identified. The wound measurements are: 2.5cm x 2.0cm, no documented depth, no drainage, 100% [MEDICATION NAME], edges of the wound are red and attached and the periwound tissue is indurated. This assessment was completed by LPN-H with no RN assessment indicated. On 4/16/14 the Weekly Wound Observation Report indicates the presence of a venous stasis ulcer on the lower area of the right lateral foot. The wound measurements are: 3.5cm x 3.0cm and is without drainage, 100% [MEDICATION NAME], wound edges are red and attached and the periwound tissue is indurated. This assessment was completed by an LPN with no RN assessment indicated. hospitalization : Review of Resident #3's record indicates that on 4/23/14, LPN-H, noted that Resident #3 ...was slow to respond, lethargic, not as cantankerous as usual. Dr.- P aware, nor (new order) to transfer to the Hospital for evaluation .... On 4/23/14 at 0951, Resident #3 was admitted to the hospital for altered mental status and a UTI. Review of the hospital record dated 4/23/14 indicates that upon arrival at the emergency room Resident #3's wounds were as follows: L (left) lateral heel - 5cm x 5cm, unstageable; right plantar foot, right lateral medial heel: 2cm x 2cm; right lateral foot, and a coccyx pressure ulcer - 8cm x 8cm, suspected deep tissue injury with surrounding [DIAGNOSES REDACTED] and R medial lower leg. A wound consult was requested. On 4/24/14 a wound consult was completed during the hospitalization by RN-DD which indicated: ~R (right) lower medial leg ulcer measuring 5.5cm x 3.0cm x 0.0cm, flat, pink, unroofed blister, granular with moderate drainage. Hydrogel applied. ~R foot plantar ulcer measuring 0.8 x 1.0 x 0.0, described as a black, brown adherent scab, eschar, resolving. ~L heel 6 x 9 x 0, R medial heel 1.5 x 2.0 x 0, coccyx 14 x 13 x 0 with description as poorly defined - unstageable necrotic tissue, wound bed slough 25%, wound be necrotic 75%, ~R lateral foot 5th MTP 3.0 x 2.5 x 0.0, R lateral 2.0 x 1.8 x 0.0. Recommendations by RN-DD include: Apply [MEDICATION NAME] swab to left heel, right plantar foot, right medial heel and right lateral foot to maintain and to continue to dry intact tissue daily. Prevalon boots to bilateral feet at all times. Staff to continue aggressive pressure redistribution measures a minimum of every two hours. Verbal report was given to RN-B at the facility. On 4/25/14 Resident #3 was discharged back to the facility. Review of the Admission Nursing Assessment form documents that Resident #3 has according to the diagram a wound on the: left heel, left posterior thigh, the coccyx, the right lower medial leg and right medial heel. Comments include ....resident's coccyx and left heel are both blk (black) & necrotic. (The left heel) necrotic black appr (approximately) 3"x 2 1/2" ... Under Current Status, Other, EZ Boots at HS .... is documented. Bowel and bladder evaluation indicate incontinence of bowel and bladder which is a decline from previous assessment. Surveyor # noted that this form is not signed to indicate who completed the assessment. Surveyor # also noted that the document only contains measurement of the left heel and no other wound measurements and the assessed intervention of EZ boots at HS is inconsistent with the hospital wound recommendation to have Resident #3 wear Prevalon boots at all times. On 4/28/14, the unit wound nurse, LPN-H completed wound measurements on Resident #3's wounds. ~The right medial lower extremity described as a blister was measured at 5.0 cm x 5.7 cm, no drainage, 100% granulation, edges of wound are pink, periwound tissue healthy with comment that it's a ...."new open area ..." ~The left heel described as a venous stasis ulcer measuring at 9cm x 7cm with scant amount of serous drainage, 100% necrotic, wound edges are detached, the periwound tissue is indurated with comment ...area necrotic, will follow vascular recommend ... ~The right medial heel described as a venous stasis ulcer was measured at 1.0cm x 2.5cm, without drainage, 100% granulation tissue in wound bed, the edges of the wound are pink and attached with periwound tissue indurated. Progress is noted as improved from last measurement of 4/16/14. ~The right lateral lower foot identified as a venous stasis ulcer is measured at 3.5cm x 3.0cm is without drainage, the wound bed is 100% [MEDICATION NAME], the edges of the wound are red and attached and the periwound tissue is indurated. ~The right lateral upper foot, no description as to type of wound on wound observation report, measures 2.0cm x 2.0cm, is without drainage, the wound bed is 100% [MEDICATION NAME], the edges of the wound are red and attached and the periwound tissue is indurated. Progress is noted as improved from last measurement of 4/16/14, continue treatment. On 4/28/14, a call was placed to Dr.-P with request for an order for [REDACTED].-P also updated regarding abnormal labs of 4/26/14 indicating low RBC (red blood cell count) at 3.4 (reference range 4.6-6.1), low Hemoglobin 10.2 (13.7-17.5), low Hematocrit 31 (40-51), high RDW (red cell distribution width) 15.3 (11.6-14.4), high [DIAGNOSES REDACTED] 75 (34-71) and low lymphocyte 1.08 (1.20-3.70), high [MEDICATION NAME] 12.7 (9.6-12.6), high Chloride 110 (98-107), low [MEDICATION NAME] 16 (22-32), high Glucose 321 (65-99), high BUN 38 (6-23), low Magnesium 1.5 (1.6-2.6), and low [MEDICATION NAME] 3.4 (3.5-5.2). Dr.-P ordered a transfer of Resident #3 to hospital. Review of the hospital record dated 4/28/14 indicates: (Resident #3) returned to hospital on [DATE] at 1442 (2:42 pm) with ED (emergency department) note entered by RN-EE ...care facility sends pt (patient) in with "much worse" decubitus ulcer on coccyx. Pt complaining of severe pain around penis. Pt states that "I know I'm going to die today, please help me, something is wrong."... The Emergency Department provider note of 4/28/14 at 1900 (7:00 pm) by Dr.-FF indicates ...presents to the emergency department for worsening of a decubitus ulcer over coccyx and blood sugars in the 300's. Information is per the nursing home notes as the patient is a poor historian. He also point to his groin area stating that he has pain there ... Resident #3 was readmitted to the hospital from ED on 4/28/14 at 1753 (7:53 pm) for elevated troponin level, [MEDICAL CONDITION] and decubitus ulcer of coccygeal region. The hospital wound consult note of 4/29/14 indicates wound recommendations for Resident #3 remain unchanged from the last assessment of 4/24/14. Photographs were again taken with assessment. It was noted there was an additional area identified on the left upper posterior leg which was not present on the initial assessment of 4/24/14. On 5/13/14 at 3:30 pm, Surveyor # spoke with Dr.-P via the telephone. Dr.-P indicated Resident #3 had very bad vascular disease and that the Resident had been hospitalized on several occasions. Dr.-P indicated that amputation had been initially recommended for the Resident's right foot in this past year, which the Resident refused and subsequently had healed. Dr.-P indicated that he thought that Resident (#3) may have been non-compliant with cares and indicated that he thought that perhaps Resident #3's wounds developed very quickly based on non-compliance. Surveyor # noted that despite Dr.-P's indication that Resident #3 may have been non-compliant with cares, there is no indication that the facility has assessed this possible behavior, care planned to help address this potential behavior, or that staff had actively worked with Resident #3 to educate him regarding cares and wound care. On 5/14/13 at approximately 11:55 am when LPN-H was asked how Resident #3 obtained these wounds and what preventions were being taken to prevent the wounds. LPN-H indicated the resident refused bathing, wound care, therapies and assist with transfers. Surveyor # shared with LPN-H that the record does not demonstrate that this was assessed or care planned. LPN-H stated she thought that she had a hand written temporary care plan (dated from last year) regarding non-compliancy. Review of the temporary care plan dated 11/1/13 referred to by LPN-H includes as a problem amputation of foot, decline wound assessment. There is no indication that these problem areas were carried over to a permanent care plan after 11/1/13. On 5/14/14 at approximately 1:30 pm Surveyor # shared with the facility administration the concerns related to Resident #3's wound care, specifically concerns related to RN's not assessing Resident #3's wounds according to license and facility policy, the facility not ensuring that the facility's policy related to wound/skin monitoring was carried out by nursing and CNA staff, concern that the care plans for Resident #3 are not individualized to address Resident #3's needed wound prevention, and that when Resident #3's wounds were discovered to exist or have a change in status that the wounds were properly assessed and that the physician was consulted with as indicated. The facility administration indicated that Resident #3 had a number of medical conditions that made him at high risk for such wounds and the facility also indicated that Resident #3 would be resistive to cares and argue with staff. Surveyor # noted that there is no indication that the facility recognized the seriousness of Resident #3's comorbidities contributing to his elevated risk for such wounds by assessing and developing an individualized care plan for Resident #3. Surveyor # also noted that there was no indication that the facility had thoroughly assessed Resident #3's described behaviors and developed a care plan to address such behaviors. Surveyor # also noted that the CNA's working with Resident #3 allowed Resident #3 to attempt to do cares beyond what the assessed need and care planned level of assistance indicated for Resident #3. On 5/15/14 at 11:15 am Surveyor # spoke to Dr.-AA via telephone to discuss Resident #3's wounds. Dr.-AA indicates that Resident #3 had an infected heel for a significant amount of time prior to admission to the nursing home and that Dr.-AA had seen the resident multiple times during that time period with recommendation for amputation to which neither the resident nor his guardian would agree to. Dr.-AA indicated that the resident's severe vascular problems, no pedal pulse, very bad circulation led to multiple vascular wounds. Dr.-AA indicated the resident was in to see him on 4/22/14 and was referred exclusively for his heels. The facility personnel failed to inform the wound nurse, the DON, or the M.D. of an open area on Resident #3's left foot identified on 4/14/14 which delayed assessment and treatment of [REDACTED]. The facility's failure to provide appropriate wound care to Resident #3 created a situation of Immediate Jeopardy at the s/s of J (immediate jeopardy/isolated) the facility removed the Immediate Jeopardy on 5/15/14 when the facility implemented the following action plan. 1. All current residents with wounds including vascular and pressure have been assessed on 5/15/14 by a Registered Nurse. 2. Treatment orders, care plans and care cards have been reviewed and revised as indicated and practitioners and families have been updates as indicated. 3. The facility contracted with a wound care specialist consultant who has been onsite. This consultant will actively participate in the education of the staff and the evaluation of the facility practices. 4. The facility's policies and procedures related to wound care were reviewed and approved by the facility's medical director. 5. All Licensed Practical Nurses (LPN's) are being educated by an RN prior to providing care. Education includes a review of Chapter N6: Standards of Practice for Registered Nurses and Licensed Practical Nurses of the State of Wisconsin Administration Code. The RN has instructed the LPN about the necessity of notifying the RN to obtain the assessment or evaluation of the Resident. 6. Additional in servicing has been established for nursing staff that includes: remedial/repeated education on the scope of practice for LPN per state regulation, the need to notify an RN on any change of condition, the need to observe and document on the condition of a diabetic Resident's feet daily, all updated policies and new forms will be reviewed at the training's. 7. All Residents with Braden scales that indicate that they are at risk for skin breakdown will have their care plans reviewed for appropriate interventions and revised as indicated. 8. The facility will create an auditing tool to be used to ensure ongoing compliance.

Based upon interview and record review, the facility did not consult with the physician or notify interested parties for 2 Residents (Resident #3 and #1) of 7 sampled residents reviewed when there was a need to review treatment or a change in status for a resident. ~ Resident #3 experienced a change in the callous located on his left heel on 4/14/14. The Licensed Practical Nurse (LPN) who observed the change did not consult with Resident #3's physician. On 4/16/14 the wound had progressed in size and was documented as being infected. On 4/19/14 an LPN noted that the wound had a foul odor. The LPN did not consult with the physician. On 4/22/14 Resident #3 was seen in a vascular physician's office who indicated that the left heel was necrotic likely down to the ankle bone and required debridement of the wound. On 4/21/14 an LPN observed a pressure ulcer on Resident #3's coccyx. Rather than consulting with Resident #3's physician with the observation of a new, facility acquired pressure ulcer, the LPN faxed the physician for a treatment. ~ Resident #1 received a chest x-ray and was started on an antibiotic and Resident #1's power of attorney for health care was not informed of this. Findings include: 1.) Resident #3 is a [AGE] year-old resident with [DIAGNOSES REDACTED]. Drug Abuse and [MEDICAL CONDITION] Disorder. Resident #3 was admitted to the facility on [DATE]. Left and right heel Wound: Review of Resident #14's record indicates that on 4/14/14 Licensed Practical Nurse (LPN)-N completed a Daily Skilled Nurse's Note indicating that Resident #3 required extensive assistance for bed mobility and transfer and limited assistance of one person for toileting. LPN-N indicated on the form that Resident #3 has skin issues involving "other open lesion of foot." Additional review of the nurse's notes and wound sheets for Resident #3 do not indicate what this change was that LPN-N noted on Resident #3 on 4/14/14 and what steps were taken regarding this change including whether LPN-N consulted with Resident #3's physician regarding this change. On 5/14/14 at 12:40 pm Surveyor # interviewed LPN-N regarding her Skilled Daily Nurse's note entry dated 4/14/14. LPN-N reviewed the record and indicated that on that date she did see an open area start on Resident #3's left heel. LPN-N indicated that Resident #3 had a callous on that heel that they were wrapping with Kerlix. LPN-N indicated that on the 14th a Certified Nursing Assistant (CNA) came to get her to look at Resident #'s heel because after the CNA cleaned the area it started to bleed. LPN-N indicated that she looked at the callous and could see that the callous had started to break off, away from the heel and that there was bloody drainage. When asked what LPN-N did following this change LPN-N indicated that she did not do anything other than clean the wound and wrap it back up with Kerlix. LPN-N was asked if she reported this to an RN for assessment or called the physician regarding the change and LPN-N indicated no. She looked at the wound and assessed it and determined that Resident #3 always had a callous before so she didn't think that this was something new. LPN-N indicated that she decided to not put skin prep on it because she didn't think it would be useful for the area. LPN-N was asked if any care plan changes were made and LPN-N indicated no. LPN-N was asked what happened to Resident #3's left heel after she discovered the wound that was bleeding and LPN-N indicated that she knew the Resident had to have that heel debrided. Review of the Skilled Daily Nurse's Note dated 4/15/14 indicates that Resident #3 has a skin concern with no detail documented. This form indicates that Resident #3 requires limited assistance of one staff person for bed mobility and that Resident #3 requires extensive assistance of one person for transfer and total dependence of one person for toileting. The unsigned Skilled Daily Nurse's Note dated 4/16/14 indicates a skin concern for Resident #3 that includes a venous or arterial ulcer and an infection of the foot. This form indicates that Resident #3 requires limited assistance of one staff person for bed mobility and that Resident #3 requires extensive assistance of one person for transfer and total dependence of one person for toileting. There is no indication that Resident #3's physician was contacted to consult on the determination that Resident #3 may have an infection of the foot. Review of Resident #3's Nurse's Notes indicates on 4/16/14 at 10:00 am: ...Lt. & Rt. foot measure by LPN-H, wound nurse for the unit and LPN-N. ...Lt heel with previously noted callous with scant amount of bloody drainage and deep tissue injury to Lt. side of callous. Rt foot noted with pressure sites to rt lateral lower and rt. lateral upper. All areas tender to the touch. Lt heel wrapped with Kerlix. Placed call to Dr.-P. Awaiting return call ... Dr.-P ordered ...apply [MEDICATION NAME] to Lt heel, f/b (followed by) non-adherent dressing, f/b Kerlix q (every) day. Dr. P instructed to send Resident back to Dr. -AA. Appt (appointment) scheduled with Dr. AA on 4/22/14 at l:30. Guardian S made aware .... Review of the Weekly Wound Observation Report indicates that a venous stasis ulcer is identified on the right medial heel dated 4/16/14. The wound measures 1.6cm x 2.7cm x 0cm with no drainage, 100% granulation, the edges of the wound are pink and attached, and the periwound tissue is healthy. This assessment was completed by LPN-H with no indication that an RN also assessed Resident #3's right heel wound. The Weekly Wound Observation Report dated 4/16/14 identifies that Resident #3's left heel is now: 9.2cm x 6.7cm x 0cm. A scant amount of serous drainage is present, the wound bed is 100% granulated, the edges of the wound are red and detached and the periwound tissue is macerated with induration (a process where the skin becomes firm, often surrounds a wound as a healing ridge or can be a sign of building bioburden) and pain. This assessment was completed by-H with no indication that an RN also assessed Resident #3's left heel wound. Review of Resident #3's medical record indicates that no Daily Skilled Nurse's note was completed for 4/17/14. Review of a Nurse's Note dated 4/17/14 at 21:15 (9:15 pm) indicates: that (Resident #3) ...refused treatment to Rt. & Lt. feet... Surveyor # noted that there is no indication that education or encouragement was given to Resident #3 to allow the treatment nor is there indication that Resident #3 was re-approached at a later time to complete the treatment. Review of the Daily Skilled Nurse's Note dated 4/18/14 and 4/19/14 indicates that Resident #3 has skin concerns including and infected wound. There is no indication that Resident #3's physician was notified of the possible infection documented these two days. Review of the Nurse's Notes dated 4/19/14 (time not indicated), LPN-N documented: ...Lt heel with foul odor present, c/o (complaint of) pain to Lt leg. Drsg (dressing) intact. Review of Resident #3's record does not indicate that any additional assessment was completed of Resident #3's left heel despite LPN-N noting that the wound has a foul odor and Resident #3 has increased pain. On 5/14/15 at approximately 12:45 pm LPN-N was interviewed and asked what did she do when she observed that Resident #3's left heel wound had a foul odor to it. LPN-N could not recall what her shift was that day to help trigger her memory on what she may have done. LPN-N indicated that sometimes she puts the info on the 24 hour sheet and sometimes when leaves a written shift report note attached to the medication cart for the next shift to follow up on. LPN-N could not recall what she had done in this case. Review of Resident #3's medical record does not indicate that any additional follow up was completed regarding the foul odor to Resident #3's left heel wound. There is no indication that an RN completed an assessment or that the physician was notified with the change in the wound. The Daily Skilled Nurse's Note dated 4/20/14 indicates that Resident #3 has skin concerns that are pressure ulcers. The 4/21/14 document indicates that there are skin concerns for Resident #3 including pressure ulcers and other open [MEDICAL CONDITION] on foot. The 4/22/14 document indicates that Resident #3 has skin concerns with no other details indicated On 4/22/14 a Temporary Care Plan for Skin Integrity was signed by RN-B and indicates Goal 1. Ulcer to reduce in size, 2. Ulcer will show no sign of infection, 3. Will have no further ulcers. Interventions: Measure and document on area(s) weekly, Monitor for drainage and document any finding, Treatment and or medication per MD order, Assess/document on skin condition, Turn and reposition at least every 2 hrs in bed, every hour in chair, Preventative mattress and w/c (wheelchair) cushion, Incontinent care as indicated, protective barrier as indicated, Update MD/family as indicated. This care plan was developed following the identification of a facility acquired coccyx pressure ulcer on 4/21/14. (Cross Reference F314). Surveyor # noted despite ongoing heel wound issues, this care plan did not specifically address Resident #3's heel and foot ulcers. On 4/22/14 Resident #3 was seen in the vascular clinic for review of his wounds. The Report of consultation dated 4/22/14 indicates: Findings: Severe necrosis of the left heel. Likely down to calcaneus (heel bone). Smaller spot of necrosis on R (right) foot was not debrided. Diagnosis: [REDACTED]. *Surgical debridement vs. amputation of left foot. Keep heels floated or free from pressure. Scrub with gauze and saline daily and replace dressing. Surveyor # noted that despite Resident #3 returning from the wound clinic with a pressure ulcer that was debrided and a necrotic ulcer on her right heel no changes were noted to the care plan including documenting and implementing the intervention of floating Resident #3's heels. Coccyx Pressure Ulcer: On 4/21/14 at 1910 (7:10 pm) LPN-WW documented in the Nurse's Notes: Resident confused. Inc (incontinent) B/B (bowel and bladder) Has 2.7 Stage 2 o/a's (open areas) to coccyx/btx (buttocks) site. Site reddened. 0 (no) bleeding, 0 drainage. Assisted with cares. Transfers x2 to bed. Ate 75% with assist. MD faxed requests for treatment order. Signed LPN-WW. Review of this indicates that LPN-WW faxed a request for a treatment to Resident #3's physician rather than actually consulting with the physician given the observation of a new, facility acquired pressure ulcer and indication that Resident #3 is confused and requiring a greater amount of care. On 5/14/14 at approximately 1:30 pm Surveyor # shared with the facility administration the concerns related to Resident #3's wound care, specifically concerns related to RN's not assessing Resident #3's wounds according to license and facility policy, the facility not ensuring that the facility's policy related to wound/skin monitoring was carried out by nursing and CNA staff, concern that the care plans for Resident #3 are not individualized to address Resident #3's needed wound prevention, and that when Resident #3's wounds were discovered to exist or have a change in status that the wounds were properly assessed and that the physician was consulted with as indicated. The facility administration indicated that Resident #3 had a number of medical conditions that made him at high risk for such wounds and the facility also indicated that Resident #3 would be resistive to cares and argue with staff. Surveyor # noted that there is no indication that the facility recognized the seriousness of Resident #3's comorbidities contributing to his elevated risk for such wounds by assessing and developing an individualized care plan for Resident #3. Surveyor # also noted that there was no indication that the facility had thoroughly assessed Resident #3's described behaviors and developed a care plan to address such behaviors. Surveyor # also noted that the CNA's working with Resident #3 allowed Resident #3 to attempt to do cares beyond what the assessed need and care planned level of assistance indicated for Resident #3. No additional information was provided by the facility following exit from the facility. 2.) Surveyor # reviewed Resident #1's medical record on 5/12/14 & 5/13/14/14. Resident #1 has a legal guardian. The nurses note dated 3/29/14 at 1700 (5:00 p.m.) documents "chest x-ray results in." The physician telephone order dated 3/29/14 documents "[MEDICATION NAME] 500 mg (milligrams) 1 x (times) day for 1 week for lt. (left) infiltrate." The nurse's note dated 3/29/14 at 1800 (6:00 p.m.) documents "MD called NOR (new order received) [MEDICATION NAME] 500 mg (milligram) 1 po (by mouth) daily x (times) 1 wk. (week) for Lt. (left) infiltrate." The next nurses note is dated 3/30/14 at 1100. The nurse's note dated 3/30/14 at 1100 (11:00 a.m.) documents "Alert and responsive without noted SOB (short of breath) SPO2 96% without noted cough nasal drng. (drainage) thick white breathing treatment this AM (morning) denies pain when asked." The nurse's note dated 3/30/14 at 1815 (6:15 p.m.) documents "On ABT (antibiotic)/URI (upper respiratory infection) without ill effects ate 100% without drainage, without SOB, without cough, without pain, total assist with cares." These are the only two nurses notes dated 3/30/14. The nurse's note dated 3/31/14 at 0600 (6:00 a.m.) documents "Abt/uri without adverse reactions noted without resp. (respiratory) distress or SOB noted. Resting in bed this AM. T. (temperature) 97." The nurse's note dated 3/31/14 at 1335 (1:35 p.m.) documents "Resident continues ABT. without s/sx (signs/symptoms) of adverse reaction noted. Loose nonproductive cough noted. Without SOB or resp. distress. 97.5." The nurse's note dated 3/31/14 at 1830 (6:30 p.m.) documents "Resident remains on PO ABT [MEDICATION NAME] 500 mg QD (once daily) x 1 week r/t (related to) Lt. infiltration no coughing noted no s/s (signs/symptoms) pain or discomfort T 96.5 no adverse effects." These are the only three nurses notes dated 3/31/14. Surveyor # was unable to locate documentation that Resident #1's guardian was notified of the results of the chest x-ray and antibiotic, [MEDICATION NAME]. On 5/13/14 at 8:33 a.m. Surveyor # informed LPN (Licensed Practical Nurse)/UM (Unit Manager)-H that Surveyor didn't see when Resident #1's guardian was notified of the results of the chest x ray and the order for [MEDICATION NAME]. LPN/UM-H reviewed Resident #1's nurses notes and informed Surveyor # that "I don't see it either." On 5/13/14 at 2:51 p.m. during the daily exit conference the Administrator and Director of Nursing were informed of the above.

Based upon observation, interview and record review, the facility did not ensure that 5 Residents (Resident's #3, #6, #7, #5 and #4) of 5 Resident's reviewed with or at risk for pressure ulcers did not develop a pressure ulcer unless it was unavoidable and that once a pressure ulcer developed the facility delivered the appropriate care and treatment to prevent it from worsening. ~ Resident #3 was admitted to the facility in October of 2013 with identified skin concerns and was assessed as being at risk for pressure ulcers. The facility did not implement a consistent system for monitoring Resident #3's skin such as skin checks on bath days. On 4/14/14 Resident #3's condition changed and Resident #3 started to have new areas on his lower extremities with no specific changes being made to his plan of care related to skin concerns (Cross reference F309). On 4/21/14 a Licensed Practical Nurse (LPN) noted that Resident #3 had a 2.7 Stage 2 open area on his coccyx/buttocks. This facility acquired area was not assessed by a RN. On 4/22/14 a temporary care plan for a Stage 2 pressure ulcer was created. On 4/23/14 the weekly wound observation report indicates that the coccyx wound was first observed on 4/23/14 and is a Stage 1 measuring 8.9 cm x 11.4 cm with 100% [MEDICATION NAME] tissue completed by a LPN. On 4/23/14 Resident #3 was admitted to the hospital with [REDACTED]. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment). On 4/25/14 Resident #3 was readmitted to the facility. The facility did not complete a comprehensive assessment of Resident #3's coccyx wound until 4/28/14 when a LPN indicates that the ulcer measure 9.5cm x 11.4cm, no drainage, the wound bed is 100% necrotic with wound edges red and attached. The assessment does not include documentation of the periwound tissue and comment ... will start Calaz ([MEDICATION NAME]) cream per hospital order (from 4/25/14). On 4/28/14 Resident #3 was readmitted to the hospital with [REDACTED]. Pt states that "I know I'm going to die today, please help me, something is wrong." ... ~ Resident #6 was admitted to the facility on [DATE] for a short convalescent stay following a right total knee replacement. On 4/16/14 a fluid filled blister of the left heel was noted. Resident #6, who is 6 feet 2 inches tall was observed, while sleeping, to have his heels pressed against the footboard of his bed with no indication that preventative measures were in place to off-load heel pressure or to prevent Resident #6 heels from pressing against the foot board of his bed. ~ Resident #7 was admitted to the facility with pressure ulcers. Resident #7 has a Stage 4 pressure ulcer located on his trochanter that is not progressing towards healing. Resident #7 was observed to not receive the proper treatment to this wound and was not provided with a mattress that was appropriate for the Resident's Stage 4 pressure ulcer. ~ Resident #5 was observed during the survey to be seated in a wheelchair without a proper pressure reduction cushion despite being at risk for pressure ulcers. ~ Findings include: The undated Skin Alteration Reference indicates: ...Purpose: To establish a comprehensive facility program to maintain optimal skin condition for the residents ... Nursing assessment will be utilized to identify residents at risk ...Through use of a skin protocol, all pressure areas will be identified and treatment begun immediately ... under Skin Rounds ...1. The team will consist of the DON, Unit Manager and day RN/LPN of the individual unit. 2. Skin rounds are done on a weekly basis. 3. The licensed nurse responsible for the resident's care will initiate Wound Care Standing Orders using the Wound Care Protocol. 4. The licensed nurse is responsible to communicate any new skin breakdown to the DON to incorporate into the Skin Rounds Schedule. 5. The skin rounds team will determine if healing is present and when/if the treatment should be changed and will evaluate the current treatment plan. 6. Wound measurements will be documented weekly in the individual resident's record. 7. Pressure Ulcer Tracking - Skin Alteration Report is to be completed after Skin Rounds and submitted to the Director of Nursing. The Prevention of Pressure Ulcers Level II (2001 MED-PASS, Inc. Revise October 2010) lists Purpose: ...identification of pressure ulcer risk factors and interventions for specific risks factors. Preparation: ...1. Review the resident's care plan to assess for any special needs of the resident .... Under General Guidelines: ...6. The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, and reported to the practitioner, physician, and family, and addressed .... General Preventative Measures: ...10. Immediately report any signs of a developing pressure ulcer to the supervisor .... Documentation: The following information should be reported in the resident's medical records: ...5. Any change in the resident's condition. 11. The signature and title of the person recording the data. The facility policy regarding Skin Condition: Ulcers dated 11/11 indicates the ...Purpose: It is policy to properly identify and assess residents whose clinical conditions increase risk for impaired skin integrity, and pressure ulcers: to implement preventative measures: and to provide appropriate treatment modalities for wounds according to industry standards of care. Guidelines indicate ... 1. Prevention of Pressure Ulcers a. Braden Scale (and a skin audit) will be done: i. upon admission and readmission ii. Weekly for the first 4 weeks after admission and readmission iii. Quarterly and iv. With a significant change in status (including pressure ulcer development) b. Monitoring skin integrity i. The nursing assistant will observe skin daily with cares. If any skin concerns are noted, they are to be reported immediately to the designated nurse. ii. Weekly skin audits on the bath/shower day will be performed by the Licensed Nurse. iii. If a skin concern is noted refer to Wound Protocol iv. The care plan for skin integrity is to be evaluated and revised based on the response, outcomes and needs of the resident. 1.) Resident #3 is a [AGE] year-old resident with [DIAGNOSES REDACTED]. Resident #3 was admitted to the facility on [DATE]. The 10/23/13 the Admission Nursing Assessment completed by RN Q indicates that Resident #3 has open areas on both feet indicating [DIAGNOSES REDACTED]. On the assessment sheet the written description indicates ... wound on rt (right) and lt (left) toes ...; ...rt toe great - back area 1 cm x 1 ? cm .... and the ....o/a (open area) lt. under gr. (great) toe 1cm x 1 ? cm .... A Hoyer lift is used for transfers and the resident is continent of bowel and bladder using a bedpan and a urinal. The admitting MDS (Minimum Data Set) of 10/30/13 reflects the facility has scored a BIMS (Brief Interview for Mental Status) of 15 indicating Resident #3 is cognitively intact, though the CAAS (Care Area Assessment Summary) triggers for confusion, forgetfulness, disorientation and assessment for [MEDICAL CONDITION]. Under the Behavior Section (E) Resident #3 is coded for rejection of care. Under Functional Status (G) of the MDS, the resident is coded for total dependence with assist of 2+ regarding transfers, toilet use and bathing and assist of 1 for bed mobility, dressing and personal hygiene. Resident #3 is able to eat independently with supervision. Resident #3 is continent of bowel and bladder using a urinal and a bedpan. Resident #3 is also coded for functional impairment of the lower extremity affecting one side and uses a wheelchair for mobility. The resident is also coded for the presence of frequent, moderate pain, history of falls and risk for pressure ulcers, with documentation indicating no current unhealed pressure ulcers presently. The number of venous and arterial ulcers is listed as 2. Interventions for skin include a pressure reducing device for the chair and bed, nutrition/hydration intervention and application of dressings to the feet. Though Resident #3 is coded for the need for assistance with bed mobility, turning and repositioning is not indicated on the MDS. The CAAS triggered for cognitive loss/dementia, ADL's, urinary incontinence, psychosocial well-being, behavioral symptoms, falls, nutritional status, dehydration, pressure ulcers, [MEDICAL CONDITION] drug use, pain and referral to return to the community. Surveyor Review of the CAAs for Resident #3 does not indicate specific interventions or considerations for Resident #3's specific care planning. The quarterly MDS of 2/11/14 codes the BIMS at 14, no change noted to functional status and remains continent of bowel and bladder. Pain has decreased in frequency to occasional mild pain. Risk of pressure ulcers continues and number of venous/arterial ulcers remains at 2. Resident #3's Care Plans were received from the facility on 5/12/14 upon request of Surveyor # . The Plan of Care: Skin Integrity of 11/5/13 indicates Resident #3 was admitted to the facility ... with a right foot ulcer with osteo[DIAGNOSES REDACTED]. The most recent Braden Scale performed on 10/23/13 is scored at risk for pressure ulcer development. Pressure ulcer prevention interventions are in place to reduce the risk of development of open areas. Goals - Resident #3's skin will remain intact through 2/14 ... with indication under the Review section ...Next Review 2/14 ... Approaches used on the plan of care include ...Ensure resident is clean and dry. Wash resident with soap and water after any incontinent episode. Apply moisture barrier after each incontinent episode with daily cares. Apply lotion to lower extremities and dry skin daily with cares. Reposition resident every 2 hours and as needed. Nurse to do body check weekly with bath or shower and document. Shower/bath weekly as per policy. Refer to PT/OT as needed to assist with positioning. Encourage resident to have good fluid intake with and between meals. Toilet/change Resident #3 as per toileting program. Report any red or open areas to unit nurse. Update MD on any open areas found. Refer to wound nurse/committee as per appropriate for evaluation .... There is a hand written update on the care plan indicating on ... 2/14/14 To Blister on R plantar skin prep BID (twice a day) ... Care Plans for Mobility, Toileting, ADL's (Activities of Daily Living), Risk of Injury, Falls, Pain, [MEDICAL CONDITION] Drug Use, [MEDICAL CONDITION], Cardiac Output, Anticoagulant Therapy, Diabetes, Infection, Inappropriate Behavior, Cognitive Loss, and Substance Abuse. All plans of care include the initiation date of 11/25/13 with a Goal (resolution date) of 2/14/14 with next review date of 2/14, except for care plans: Inappropriate behavior, Cognitive Loss, and Substance Abuse with goal date of 3/14/14 and next review date of 3/14. The Approaches listed on the care plans include computerized approaches with no noted individualization for Resident #3 and there is no evidence that the care plans have been updated. A Temporary Care Plan for Skin Integrity, Impaired, dated 10/25/13 indicating a ...Pressure ulcer (unstaged) site L (left) & R (right) foot. Goal 1. Ulcer will reduce in size. Interventions Treatment and/or medication per MD order, Turn and reposition at least every 2 hrs (hours) in bed, every hour in chair, Assess for underlying cause of skin issue, Update MD/family as indicated, Float heels. There is no evidence that this information had been added to the Skin Integrity Care Plan of 11/25/13. A Temporary Care Plan for Skin Integrity dated 4/22/14 received by Surveyor # on 5/13/14 and signed by RN B indicates the ...Goal 1. Ulcer to reduce in size, 2. Ulcer will show no sign of infection, 3. Will have no further ulcers. Interventions: Measure and document on area (s) weekly, Monitor for drainage and document any finding, Treatment and or medication per MD order, Assess/document on skin condition, Turn and reposition at least every 2 hrs in bed, every hour in chair, Preventative mattress and w/c (wheelchair) cushion, Incontinent care as indicated, protective barrier as indicated, Update MD/family as indicated. The CNA (Certified Nursing Assistant)Care Card indicates Resident #3 needs assist of 1 for ADL's, assist of 2 for transfer, uses a w/c for mobility, uses a urinal and a bedpan, needs assist of 1 for turning, to lay down when requests, feeds himself and is at risk for falls and skin. When Unit Manager, LPN-H was asked on 5/13/14 where the CNA's chart the cares they have given related to the resident's change in position, she indicated they do not have a specific area or form where they chart that information such as toileting and turning/repositioning. On 5/14/14 at approximately 9:00 am Surveyor # interviewed Occupational Therapist (OT)-HH regarding what Resident #3's needed level of assistance was while he resided in the facility. OT-HH indicated that Resident #3 required staff assistance to be able to properly care for him. OT-HH indicated that Resident #3 could wash his upper body or put on a shirt with set up assistance from staff but that anything involving the lower part of his body required extensive staff assistance. OT-HH was asked if at any point did Resident #3 experience a change in his level of need or activity. OT-HH indicated that a few weeks ago Resident #3 seemed to not be feeling well and he started to spend less time up in his chair and spent more time in his bed. OT-HH was asked if Resident #3 ever refused therapy or was resistive to it. OT-HH indicated that there were times when Resident #3 might initially refuse therapy but that if he was talked to he would allow you to do therapy with him. On 5/13/14 at 5:10 pm, CNA-JJ was interviewed regarding the level of assistance that Resident #3 required for cares. CNA-JJ indicated Resident #3 took care of his own needs. CNA-JJ indicated that she would set up towels and a basin and Resident #3 preferred to give himself a bed bath. CNA-JJ indicated the resident would also toilet himself when in bed. He had a urinal and bedpan next to the bed and could lift himself on and off the bedpan, would clean himself and leave the bedpan and dirty linen on the floor next to the bed for the CNA to empty. CNA-JJ was asked if she recalled any skin concerns with the resident. She indicated he was getting barrier cream applied to his bottom. She could not recall specifically if any skin checks were completed. On 5/13/14 at 5:15 pm, CNA-KK was asked about the level of assistance Resident #3 required for cares. CNA-KK indicated that Resident #3 took care of his own needs and staff would only assist if needed. CNA-KK indicated that Resident #3 was able to move himself in bed and used a slide at times to transfer. She indicated there were no problems with his cognition and she did not recall any yelling or aggressive behavior directed at her. Surveyor # noted that the interviews with CNA's-JJ and KK indicate that despite Resident #3's assessed need for assistance and care planned need for assistance; staff indicated that they often left Resident #3 to care for himself. Surveyor # requested and reviewed the bath sheets for Resident #3 that was to be completed twice weekly for each bath/shower showing that Resident #3's skin was inspected by both the CNA and the nurse. Surveyor # was provided with only 2 bath sheets for the period of time that Resident #3 resided in the facility. The first sheet was dated 2/21/14 which documents the left foot of the body diagram is circled and hand-writing on the sheet indicates ...bed bath, no new issues ...signed by CNA-X and LPN-U. The other sheet dated 4/16/14 has the right and left foot circled on the body diagram and also indicates ...bed bath ... signed by CNA-Y. Surveyor # observed that there is no nurse's signature noted on the form. On 5/13/14 at approximately 2:45 pm, Unit Manager LPN-H and DON-B indicated they could not find any other bath sheets for this resident year other than the two sheets presented. On 5/13/14 at 4:50 pm, LPN-U was asked how skin checks are completed on the residents in the facility. LPN-U indicated skin checks are completed on shower days, usually 2x per week, but at least weekly. If a resident refuses a shower, an attempt to complete a skin check is still made. The skin check is done from head to toe by the nurse on the unit at the time of the shower. A shower sheet is filled out by the CNA performing the shower who then marks the body diagram if any concerns are found and is signed by the CNA. The CNA will let the nurse know when the shower is complete and the nurse then does a skin check on the resident and co-signs (initials) the sheet. LPN-U indicated the nurse signs all shower sheets in conjunction with the CNA. LPN-U was asked if he recalled Resident #3. He indicated he did, and recalls treatments to the heels and barrier cream to the buttocks. LPN-U also indicated Resident #3 was self-dependent, showing anger if help was provided. LPN-U does not remember performing a skin check on the resident On 5/13/14 at 5:00 pm, LPN-II was asked how often shower sheets are completed. She indicated they are to be done weekly with showers. The CNA initiates and once the shower is completed, the nurse will do a body check to note any areas of concern, such as open areas, bruising, discoloration; measurements of open areas are completed. The M.D. and family are notified if warranted and orders received if necessary. The sheets are signed by the CNA and initialed by the LPN and placed under the door of the unit manager for review. Review of Resident #3's nurse's notes and Daily Skilled Nurse's Notes indicate no skin concerns for Resident #3 until 4/14/14 when a callous on Resident #3's left heel separated from the heel and had bloody drainage. On 4/22/14 Resident #3 required debridement of his left heel as the consult indicates: Findings: Severe necrosis of the left heel. Likely down to calcaneus (heel bone). Smaller spot of necrosis on R (right) foot was not debrided. Diagnosis: [REDACTED]. *Surgical debridement vs. amputation of left foot. Keep heels floated or free from pressure. Scrub with gauze and saline daily and replace dressing. (Cross reference F309). Coccyx Pressure Ulcer: On 4/21/14 at 1910 (7:10 pm) LPN-WW documented in the Nurse's Notes: Resident confused. Inc (incontinent) B/B (bowel and bladder) Has 2.7 Stage 2 o/a's (open areas) to coccyx/btx (buttocks) site. Site reddened. 0 (no) bleeding, 0 drainage. Assisted with cares. Transfers x2 to bed. Ate 75% with assist. MD faxed requests for treatment order. Signed LPN-WW. There is no indication that LPN-WW had Resident #3's coccyx assessed by an RN. On 4/22/14 at 5:30 am LPN-O indicates in the Nurse's Notes: ... O/A (open area) of R buttock, no noted bleeding, no noted drainage, barrier cream applied, turned to L side. 99.1, 80, 20, 104/54 ... On 4/22/14 a Temporary Care Plan for Skin Integrity was developed by DON-B related to the pressure ulcer on the R (right) buttock indicating Resident #3 has: a Stage II and signed by RN B and indicates the ...Goal 1. Ulcer to reduce in size, 2. Ulcer will show no sign of infection, 3. Will have no further ulcers. Interventions: Measure and document on area (s) weekly, Monitor for drainage and document any finding, Treatment and or medication per MD order, Assess/document on skin condition, Turn and reposition at least every 2 hrs in bed, every hour in chair, Preventative mattress and w/c (wheelchair) cushion, Incontinent care as indicated, protective barrier as indicated, Update MD/family as indicated. On 4/23/14 a Weekly Wound Observation Report is completed for the coccyx pressure ulcer. The date first observed is dated as 4/23/14 and the pressure ulcer is staged as a Stage I. The wound is measured as 8.9cm x 11.4cm, no drainage, wound is 100% [MEDICATION NAME] and edges of the wound bed are described as red and attached. This assessment was completed by LPN-H (Cross reference F281). On 4/23/14, LPN-H, noted Resident #3 ...was slow to respond, lethargic, not as cantankerous as usual. Dr.-P aware, nor (new order) to transfer to hospital for evaluation ....On 4/23/14 at 0951, Resident #3 was admitted to the hospital for altered mental status and a UTI. Review of the hospital Emergency Department Documentation indicates that Resident #3 has a: coccyx pressure ulcer measuring 8cm x 8cm, suspected deep tissue injury with surrounding [DIAGNOSES REDACTED]. A wound consult was requested. On 4/24/14 at 1139 (11:39 am) a wound consult by Wound Nurse RN-DD was completed with findings of a coccyx pressure ulcer measuring 14cm x 13cm x 0cm with description as poorly defined - unstageable necrotic tissue, wound bed slough 25%, wound bed necrotic 75%. Recommendations by RN-DD include surgical consult for coccyx decubitus pressure ulceration/deep tissue injury. Apply [MEDICATION NAME] sacral dressing to coccyx daily or may apply [MEDICATION NAME] cream 3 times per day and leave open to air, change bed pad when soiled. Staff to continue aggressive pressure redistribution measures a minimum of every two hours. Verbal report was given to RN-B at the facility. Photographs were taken of the affected areas. On 4/25/14 Resident #3 was discharged back to the facility. Review of the Admission Nursing Assessment form documents that Resident #3 has, according to the diagram, a wound on the: left heel, left posterior thigh, the coccyx, the right lower medial leg and right medial heel. Comments include ....resident's coccyx and left heel are both blk (black) & necrotic. (The left heel) necrotic black appr (approximately) 3"x 2 1/2" ... Under Current Status, Other, EZ Boots at HS .... is documented. Bowel and bladder evaluation indicate incontinence of bowel and bladder which is a decline from previous assessment. Surveyor # noted that this form is not signed to indicate who completed the assessment. Surveyor # also noted that the document only contains measurement of the left heel and no other wound measurements and the assessed intervention of EZ boots at HS is inconsistent with the hospital wound recommendation to have Resident #3 wear Prevalon boots at all times. On 5/14/14 at approximately 4:00 pm the RN-UU was interviewed regarding the 4/25/14 admission nursing assessment. RN-UU indicated that initially when the LPN was completing the admission assessment of Resident #3, she was present for the assessment. RN-UU indicated that there are entries on the form that are in her handwriting, including documentation of a necrotic black approx. 3" x2 ? " by the body diagram on the form. RN-UU was asked if she knew whether complete assessment details were taken of Resident #3's wounds including measurements, characteristics, location etc. RN-UU indicated that she did not know, that she was not present for the entire assessment as she must have been called away from Resident #3 to attend to another Resident. RN-UU was asked if she had assessed Resident #3 and she indicated not completely, that would have been the LPN. On 4/28/14, the unit wound nurse, LPN-H completed wound measurements on Resident #3's coccyx described as a pressure ulcer and indicating the ulcer measured 9.5cm x 11.4cm, no drainage, the wound bed is 100% necrotic with wound edges red and attached. No documentation of the periwound tissue and comment ... will start Calaz ([MEDICATION NAME]) cream per hospital order. Surveyor # noted that this assessment was completed by LPN H and that this is the facility's first measurement or detailed description of Resident #3's coccyx pressure ulcer since admission to the facility where the only documentation is that the area is necrotic black. On 4/28/14, a call was placed to Dr.-P with request for a Foley catheter placement related to the pressure ulcer on the coccyx. Dr.-P was also updated regarding abnormal labs of 4/26/14 indicating low RBC (red blood cell count) at 3.4 (reference range 4.6-6.1), low Hemoglobin 10.2 (13.7-17.5), low Hematocrit 31 (40-51), high RDW (red cell distribution width) 15.3 (11.6-14.4), high [DIAGNOSES REDACTED] 75 (34-71) and low lymphocyte 1.08 (1.20-3.70), high [MEDICATION NAME] 12.7 (9.6-12.6), high Chloride 110 (98-107), low [MEDICATION NAME] 16 (22-32), high Glucose 321 (65-99), high BUN 38 (6-23), low Magnesium 1.5 (1.6-2.6), and low [MEDICATION NAME] 3.4 (3.5-5.2). Dr. P ordered a transfer of Resident #3 back to the hospital ED. Resident #3 returned to Sinai hospital on [DATE] at 1442 (2:42 pm) with ED (emergency department) note entered by RN-EE ...care facility sends pt (patient) in with "much worse" decubitus ulcer on coccyx. Pt complaining of severe pain around penis. Pt states that "I know I'm going to die today, please help me, something is wrong." ... The ED provider note of 4/28/14 at 1900 (7:00 pm) by Dr.-FF indicates ...presents to the emergency department for worsening of a decubitus ulcer over coccyx and blood sugars in the 300's. Resident #3 was readmitted to the hospital from ED on 4/28/14 at 1753 (7:53 pm) for elevated troponin level, [MEDICAL CONDITION] and decubitus ulcer of coccygeal region. On 5/14/13 at approximately 11:55 am when LPN-H was asked how Resident #3 obtained these wounds and what preventions were being taken to prevent the wounds. LPN-H indicated the resident refused bathing, wound care, therapies and assist with transfers. Surveyor # shared with LPN-H that the record does not demonstrate that this was assessed or care planned. LPN-H stated she thought that she had a hand written temporary care plan (dated from last year) regarding non-compliancy. Review of the temporary care plan dated 11/1/13 referred to by LPN-H includes as a problem amputation of foot, decline wound assessment. There is no indication that these problem areas were carried over to a permanent care plan after 11/1/13. On 5/14/14 at approximately 1:30 pm Surveyor # shared with the facility administration the concerns related to Resident #3's wound care, specifically concerns related to RN's not assessing Resident #3's wounds according to license and facility policy, the facility not ensuring that the facility's policy related to wound/skin monitoring was carried out by nursing and CNA staff, concern that the care plans for Resident #3 are not individualized to address Resident #3's needed wound prevention, and that when Resident #3's wounds were discovered to exist or have a change in status that the wounds were properly assessed and that the physician was consulted with as indicated. The facility administration indicated that Resident #3 had a number of medical conditions that made him at high risk for such wounds and the facility also indicated that Resident #3 would be resistive to cares and argue with staff. Surveyor # noted that there is no indication that the facility recognized the seriousness of Resident #3's comorbidities contributing to his elevated risk for such wounds by assessing and developing an individualized care plan for Resident #3/ Surveyor # also noted that there was no indication that the facility had thoroughly assessed Resident #3's described behaviors and developed a care plan to address such behaviors. Surveyor # also noted that the CNA's working with Resident #3 allowed Resident #3 to attempt to do cares beyond what the assessed need and care planned level of assistance indicated for Resident #3. On 5/15/14 at 11:15 am Surveyor # spoke to Dr.-AA via telephone to discuss Resident #3's wounds. Dr.-AA indicates that Resident #3 had an infected heel for a significant amount of time prior to admission to the nursing home and that Dr.-AA had seen the resident multiple times during that time period with recommendation for amputation to which neither the resident nor his guardian would agree to. Dr.-AA indicated that the resident's severe vascular problems, no pedal pulse, very bad circulation led to multiple vascular wounds. Dr.-AA indicated the resident was in to see him on 4/22/14 and was referred exclusively for his heels; that he was not made aware of his coccyx wound. 2.) Resident #6 is a [AGE] year-old resident with [DIAGNOSES REDACTED]. Resident #6 was admitted to the facility on [DATE]. The admitting MDS (Minimum Data Set) of 3/29/14 reflects the facility has scored a BIMS (Brief Interview for Mental Status) of 15 indicating Resident #6 is cognitively intact. Resident #6 needs assistance of 2 staff for bed mobility, transfers, locomotion on and off the unit, dressing, hygiene and toilet use. A mechanical lift (sit to stand) is used for transfers. Staff members provide assistance with all ADL's (activities of daily living). The CAAS (Care Area Assessment Summary) indicates Resident #6 is at risk for pain, complications of immobility, incontinence and depression all related to the recent surgery. Resident #6 is also at risk for skin breakdown, falls, altered nutrition, psychosocial concerns and activities. Upon admission, the Admission Nursing Assessment sheet under skin condition, indicates Resident #6 has 26 staples, right knee, related to surgery, a gastric bypass scar on the chest, a fluid filled blister on the right leg below the knee, an occipital scar related to brain surgery and a left ankle surgical scar. A two person assist with transfers and ambulation (when full weight bearing), using a walker and wheelchair. Supportive elastic hose and a leg immobilizer are indicated under supportive devices. The form is signed by RN-B. A Braden Score of 20 on 3/22/14 was provided by the facility, no additional scoring was provided. Scoring of 15-16 represents low risk. A score of 12 or lower represents high risk. The weekly bath sheets reflecting completion of weekly skin checks are dated 3/26/14, signed by a CNA (Certified Nursing Assistant) but not signed or initialed by a nurse as indicated per facility policy, and indicates no skin concerns. A sheet dated 4/3/14, which indicates a bed bath given has been signed and dated by both the CNA and the nurse and indicates no concerns. A sheet dated 4/21/14 is also signed and dated by both the CNA and the nurse reflecting no concerns. There were no bath sheets provided for the weeks of 4/7, 4/14, 4/28, and 5/5/14. The CNA Care Card received by Surveyor # on 5/12/14 indicates Resident #6, now needs assist of 1 staff for ADL's, uses assist of 2 staff for transfers with the sit to stand, uses a wheelchair for transport, uses a urinal and a bedpan. Also assistance to

Based on interview and record review, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with a comprehensive assessment and plan of care. The facility did not provide the necessary care to 2 (Resident #14 and Resident #16) of 16 residents included in the sample. * Resident #14 has insulin-dependent diabetes, receiving scheduled meal time insulin as well as long-acting bedtime insulin. Resident #14 has physician orders [REDACTED]. On 8-11-12, Resident #14 experienced a BG of 66 on the evening shift, after having eaten very little to no food on the day shift; Resident #14's physician or the physician extender (nurse practitioner) were not consulted on the evening shift. On 8-12-12, Resident was found at 5:00 AM, unresponsive and with a BG of 20 (normal limits 65 to 99). Resident #14 was treated with [MEDICATION NAME] (concentrated glucose) and transported to the hospital. * Resident #16, who is at risk of hypothermia due to her clinical condition, was admitted to the facility on [DATE]. Resident #16 had a history of [REDACTED]. The facility did not recognize and assess factors placing Resident #16 at risk for hypothermia, did not define and implement care plan interventions in accordance with Resident #16's need for close temperature monitoring, and did not identify preventative efforts and treatment approaches for the resident's risk for hypothermia. On 10/19/12, at 12:00 p.m., Resident #16 was alert and responsive and had a rectal temperature that was less than 96 degrees Fahrenheit (F) . The facility continued to monitor the resident from 12:00 p.m. through 5:00 p.m. The resident's rectal temp continued to register below 96 degrees F. The facility spoke with the Nurse Practitioner between 2:30 p.m. and 3:00 p.m. The Nurse Practitioner did not recall hearing the temperature being reported as less than 96 degrees, and only heard that the resident had a " low grade temperature " and ordered lab work. On 10/19/12 at 4:10 PM, staff was unable to obtain a temperature because it measured too low on the thermometer. Staff called the physician but did not reach him. On 10/19/12, between 4:45 p.m. and 5:00 p.m., Resident #16 became lethargic, less responsive, had a drop in heart rate and the 911 Emergency Medical System was activated. Resident #16 was admitted to the hospital with [REDACTED]. Resident #16 experienced a compromise in her well-being as a result of the facility's failure to develop and implement a plan to try to meet the resident's need for maintenance of proper body temperature. On 10/23/12, the facility received a referral from the hospital for resident to be readmitted back to the facility. Findings include: 1. Resident #14 was admitted to the facility on [DATE] after a hospitalization and has [DIAGNOSES REDACTED]. The admission MDS dated [DATE] indicates Resident #14 is cognitively intact, requires extensive to total assistance for all activities of daily living (ADLs) and is able to make his needs known. The resident's clinical record indicates one manifestation of his [MEDICAL CONDITION], with frequent bouts (seven) of [MEDICAL CONDITION] (increased blood potassium level) and frequent contacts with the resident's physician and/or physician extender for intervention to lower the blood potassium level. The clinical record also documents Resident #14 experienced one episode on 6-4-12 with [DIAGNOSES REDACTED] (low blood glucose), that required the intervention of [MEDICATION NAME] and consultation with the resident's physician. The clinical record indicates the physician changed the bedtime insulin from 12 units to 10 units on 6-4-12, in addition to 3 units of [MEDICATION NAME] (meal time insulin) three times a day before meals with pre-meal BG checks on 6-5-12. The clinical record indicates Resident #14 had blood work drawn by the facility's contracted laboratory on 8-10-12 5:05 AM, the laboratory called the facility with a critical glucose of 36 (65 - 99). It is unknown when the facility received this critical value, however, a notation documented on the laboratory report by LPN-P dated 8-10-12 at 4:30 PM, indicates NP-O gave orders for Resident #14's BG to be checked at 5:00 AM for three consecutive mornings - 8-11-12, 8-12-12 and 8-13-12 and then consult with NP-O on 8-13-12. The general insulin record (medication administration record) for August 2012 documents the 8-11-12 early morning BG was not conducted, Surveyor # confirmed it was not done with the director of nurses, RN-B on 10-22-12 at 8:00 AM. The resident's clinical record documents on 8-12-12 at 5:30 AM, RN-Q found Resident #14 breathing but minimally responsive and after checking his BG, found it to be 20, administered one gram of [MEDICATION NAME] times two and after 15 minutes activated the emergency response system by calling 911. The notation indicates Resident #14's BG had come up to 40 by the time the resident was being prepared for transport to the hospital. Surveyor # contacted NP-O via telephone on 10-22-12 at 8:28 AM and asked if she had been called with the report of Resident #14's BG of 66 on 8-11-12 on the evening shift. NP-O indicated she had not been called with the 66 BG. Surveyor # then asked what the likely treatment course would have been, had she known the BG and the resident's poor meal consumption on the day shift; NP-O indicated she would have directed the nursing staff hold the evening meal time insulin. NP-O also stated Resident #14 required tight control on his blood sugars. 2. On 10/22/12, Surveyor # reviewed Resident #16's hospital records and closed medical record. The hospital discharge summary, dated 10/12/12, indicates Resident #16 was admitted to the hospital from home on 10/09/12. The summary indicates Resident #16 was admitted for the Primary [DIAGNOSES REDACTED]. The summary indicates Resident #16 had a CT scan of the head with the impression being small chronic infarcts. The summary also indicates a chest x-ray was done on 10/12/12 with the impression of left basilar atelectasis or pneumonitis. The hospital Vital Signs record, dated 10/10/12 through 10/12/12, was reviewed and indicates Resident #16 oral temperature was monitored. The temperatures were documented to be in the range of 95.8 degrees Fahrenheit (F) to 98.9 degrees F (Reference Range 95.9-98.6 F). Two temperatures were documented below the reference range at 95.8 degrees F on 10/11/12 at 7:44 p.m., and 95.8 degrees F on 10/11/12 at 2:47 p.m. (the day before discharge to the facility). Resident #16 was discharged from the hospital to the skilled nursing facility on 10/12/22. The closed medical record for Resident #16 indicates the Resident is [AGE] years old, was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The admission Nursing Assessment, dated 10/12/12, indicates Resident #16's vital signs on admission were temperature 97.2, pulse 58, respiratory rate 18 and blood pressure 142/100. The Nursing note dated 10/12/12, at 2:45 p.m., indicates Resident #16 was admitted to the facility from the hospital. The note indicates the Resident is alert, skin was warm and dry, no complaints of pain and that the nurse was unable to obtain the Resident's temperature due to body being cold. The note indicates the Resident's vital signs as pulse 58, respiratory rate 18 and blood pressure 142/100. There is no documented evidence in the record that the physician was notified of the nurse being unable to obtain a temperature due to the resident's body being cold. The nursing note dated 10/12/12, at 6:00 p.m., indicates Resident #16's vital signs were taken and temperature was 97.7, pulse 54, respiratory rate 20 and blood pressure 148/86. The nursing note dated 10/13/12, at 2:30 p.m., indicates Resident #16 is alert and responsive, temperature 98.1, pulse 60, respiratory rate 18 and blood pressure 162/80. The nursing note dated 10/13/12, at 9:30 p.m., indicates Resident #16's temperature was 97, pulse 100, respiratory rate 22 and blood pressure 160/100. The note does indicate the physician was notified of the elevated Blood Pressure and new orders were received for the Blood Pressure. The nursing note dated 10/14/12, at 3:10 a.m., indicates Resident #16 is alert and responsive, skin is warm and dry, temperature 97.1, pulse 61, respiratory rate 20 and blood pressure 136/85. The nursing note dated 10/14/12, untimed, indicates Resident #16 had a good appetite, temperature 98.1, pulse 78, respiratory rate 20 and blood pressure 154/92. The nursing note dated 10/15/12, at 11:00 a.m., indicates Resident #16 is alert and verbally responsive, temperature 94.9, pulse 73, respiratory rate 18 and blood pressure 124/89. There is no documented evidence in the record that the physician was notified of the low temperature of 94.9 degrees. The record does not indicate the route the temperature was taken. The nursing note dated 10/15/12, (untimed), indicates Resident #16's temperature was 98.3, pulse 81, respiratory rate 20 and blood pressure 164/93. The nursing note dated 10/16/12, at 8:20 a.m., indicates Resident #16's temperature was 97.4, pulse 60, respiratory rate 16 and blood pressure 138/86. The nursing note dated 10/16/12, at 6:30 p.m., indicates the resident is alert and verbally responsive, temperature 97.6, pulse 68, respiratory rate 20 and blood pressure 128/84. The nursing note dated 10/17/12, at 7:00 p.m., indicates Resident #16 is alert and responsive, was up in her wheelchair for supper, had no discomfort, temperature 95.5, pulse 88, respiratory rate 18 and blood pressure 122/76. There is no documented evidence in the record that the physician was notified of the low temperature of 95.5 degrees. The record does not indicate the route the temperature was taken. The nursing note dated 10/18/12, at 6:55 a.m., indicates Resident #16 is alert and responsive, temperature 97.4, pulse 69, respiratory rate 20 and blood pressure 133/75. The nursing note, dated 10/19/12 at 10:30 a.m., indicates Resident #16 is alert and responsive and has coarse lung sounds. The note indicates the Resident's vital signs were: temperature 98.1 degrees, pulse 74, respiratory rate 20 and blood pressure 130/98. The nursing note, dated 10/19/12 at 12:00 p.m., indicates Resident #16 was assisted to the floor after attempting to self-transfer. The note indicates a physical assessment was completed, the Resident did not sustain any injuries during the assisted lowering to the floor and that the Resident's temperature was less than 96 degrees rectally. The note indicates the blood pressure to be 128/86, pulse 66, respiratory rate 16 and shallow, the oxygen saturation was 98 % with room air and the blood glucose was 99. The note indicates the Resident was given extra blankets to warm the body and a call was placed to the physician. The nursing note dated 10/19/12, at 1:30 p.m., indicates a follow up call was placed to the physician by the facility. The next entry is dated 10/19/12, at 4:00 p.m., and indicates the Nurse Practitioner called the facility back. The note indicates the nurse notified the Nurse Practitioner of Resident #16's " low grade temp below 96.0 " degrees. Orders were received to obtain a urinalysis and a complete blood count. The note indicates the Nurse Practitioner did not want the resident sent out at this time. The Nursing note dated 10/19/12, at 4:10 p.m., indicates the nurse was unable to obtain a temperature on Resident #16 and a call was again placed to the physician. The blood pressure was 100/62, pulse 78 and respirations were 16. The next nursing note dated 10/19/12, untimed, indicates Resident #16's rectal temperature was below 96.0, the Resident was lethargic, barely responding. The nursing note dated 10/19/12, at 5:00 p.m., indicates Resident #16 was assessed to be cool to the touch, unresponsive to verbal stimuli, minimal responsive to painful stimuli, decreased breath sounds, [MEDICAL CONDITION] noted, Apical pulse 42, shallow respirations of 12 and pulse oxygenation of 94% with room air. The note indicates the 911 emergency medical system was activated and Resident #16 was transported to the hospital. The Hospital Emergency Department Note dated 10/19/12, at 6:15 p.m. and 6:20 p.m., indicates Resident #16's temperature was taken rectally and documented at 88.8 degrees. The record indicates the Resident was placed in bear hugger warmer, temperature sensing Foley was placed and warm IV fluids were ordered. The Emergency Department Notes indicate the Resident was found to have pneumonia and [MEDICAL CONDITION]. The note indicates the Resident's condition to be critical and that the Resident was admitted to the Intensive Care Unit (ICU). The hospital record indicates that on 10/21/12, Resident #16 was stable and was transferred out of the ICU. The note indicates the Resident continues to have low temperatures but is asymptomatic. On 10/22/12, at 11:05 a.m., Surveyor # spoke with the Director of Nursing (DON) who indicated he observed Resident #16 falling to the floor on 10/19/12 and that he assisted the Resident to the floor. The DON indicated a Post fall assessment was completed and Resident #16 did not sustain any injuries from the fall. The DON indicated that the assessment included taking Resident #16's vital signs and that the temperature did not register with the digital thermometer. The DON indicated he obtained a mercury thermometer; the Resident's temperature was taken rectally with the mercury thermometer and was, per charting, recorded at just below 96 degrees F. On 10/22/12, at 10:10 a.m., Surveyor # spoke with Registered Nurse (RN) Unit Manager- C who indicated that at approximately 12:00 p.m., on 10/19/12, after Resident #16 fell , vital signs were taken and the rectal temperature was low and did not register (noted on the mercury thermometer to be just below the 96 degree mark). RN Unit Manager-C indicated Resident #16 was cold, blankets were put on and the physician's office was called. RN Unit Manager-C indicated the physician's office did not return the call and at 1:30 the physician's office was recalled. RN Unit Manager-C indicated that from 12:00 p.m. through the time the Resident was transported to the hospital (5:00 p.m.) she had looked in on Resident and the Resident was responding to questions. RN Unit Manager-C indicated she did not complete an assessment of the Resident's condition again until 5: 00 p.m., when the Resident was lethargic, her heart rate had dropped, and 911 was called. On 10/22/12, at 9:30 a.m., Surveyor # spoke with Licensed Practical Nurse (LPN) Minimum Data Set (MDS) Nurse-D who was working on the unit on 10/19/12 while the floor nurse was on break. LPN MDS Nurse-D indicated she went to Resident #16's room on 10/19/12, at 1:00 p.m., and the Resident was alert, verbal and taking fluids. LPN MDS nurse-D indicated she was unable to obtain an oral or axillary temperature on Resident #16 and that a rectal temperature, using a mercury thermometer, was taken. LPN MDS Nurse-D indicated the temperature was less than 96 rectally, registering just below the 96 degree mark on the thermometer. LPN MDS nurse-D indicated extra blankets were put on the Resident and the physician's office was called by RN Unit Manager-C. LPN MDS Nurse-D indicated she reported Resident #16's low temperature and the call that was placed out to the physician's office, to the floor nurse (LPN-E) when the nurse returned from her break. LPN MDS nurse-D indicated she did not complete an assessment of the resident's condition again until between 4:50 p.m. and 5:00 p.m. when the Resident was slow to respond, her heart rate had dropped, and 911 was called. On 10/22/12, at 2:30 p.m., Surveyor #1372 spoke with LPN-E who indicated LPN MDS nurse-D informed her of Resident #16's low temperature and the call out to the physician's office, when she returned to the floor from her break on 10/19/12. LPN-E indicated the facility did not receive a return call back from the physician's office, and the office was recalled at 1:30 p.m. LPN-E indicated she observed the Resident between 12:00 p.m. and 2:30 p.m. and the Resident had multiple blankets on and was responsive to verbal stimuli. LPN-E indicated the Nurse Practitioner, from the physician's office, had called the facility back on 10/22/12, between 2:30 p.m. and 3:00 p.m., and that LPN-F, on second shift, took the phone call. On 10/23/12, at 10:00 a.m., Surveyor # spoke with Speech Therapist (S.T.)-H who indicated she observed Resident #16 on 10/19/12, at 10:00 a.m. and again between 2:00 and 2:30 p.m. S.T.-H indicated that at 10:00 a.m. the Resident was up in her wheelchair on the unit and was responsive. S.T.-H indicated that when she observed the Resident between 2:00 p.m. and 3:00 p.m., the Resident was in bed with extra blankets on and the resident was more tired and less alert, but responsive. S.T.-H indicated it was a "typical down day" for the resident. On 10/22/12, at 2:00 p.m., Surveyor # spoke with LPN-F who worked the second shift on 10/19/12. LPN-F indicated she started work at 2:30 p.m. and received report that Resident #16's temperature was less than 96 degrees and the facility was awaiting a call back from the physician's office. LPN-F indicated that on 10/19/12, at approximately 3:00 p.m., the Nurse Practitioner from the physician's office returned the call to facility. LPN-F indicated she informed the Nurse Practitioner that Resident #16's temperature was less than 96 degrees ans that the Resident felt cold. LPN-F indicated she asked the Nurse Practitioner for orders to send the Resident out to the emergency room for an evaluation but the NP ordered a urinalysis and Complete Blood Count. LPN-F indicated she initially completed an assessment of Resident #16 between 3:45 p.m. and-4:00 p.m. LPN-F indicated the Resident was responsive, her skin felt cold, and that she could not get a temperature. LPN-F indicated a recall to the Nurse Practitioner was made at approximately 4:00 p.m. LPN-F indicated she did not get a return call back from the Nurse Practitioner. On 10/22/12, at 12:10 p.m., Surveyor # spoke with Nurse Practitioner-G who indicated she called the facility on 10/19/12, between 3:00 p.m. and 4:00 p.m., and spoke with nurse on duty, caring for Resident #16. Nurse Practitioner-G indicated that when LPN-F was providing Resident #16's clinical condition to her, she did not hear the "temperature number" only " low grade temp." Nurse Practitioner-G indicated labs ordered. Nurse Practitioner-G indicated that if she was aware of the resident's temperature being less than 96 rectally, an order would have been provided to send the Resident out right away. On 10/23/12, at 9:15 a.m., Surveyor # spoke with Resident #16's Physician-I. Physician-I indicated Resident #16's clinical condition has affected the temperature regulation center in the Resident's brain and that the Resident would probably run low temperatures the rest of her life. The physician indicated the Resident had low temperature readings in the hospital prior to the admission to the facility. The physician indicated he was aware of Resident's low temperature reading on 10/15/12 and 10/17/12. The physician indicated the facility should have been completing routine vital signs, keeping the Resident warm, and that the low temperatures were not a serious threat to Resident #16. The physician indicated he did not provide the facility with temperature parameters or a treatment regime for the facility to utilize specific for Resident #16's low body temperature condition. On 10/22/12, at 3:00 p.m., and on 10/23/12, at 9:40 a.m., Surveyor # spoke with the Administrator and the Director of Nursing (DON) who indicated the facility did not have a policy and procedure specifically for hypothermia. The DON indicated the facility did not use the results from nursing assessments of Resident #16's current condition and history of low temperatures, to recognize and address the Resident's need for the development of a plan of care specific to Resident #16 needs. The DON indicated the facility did not develop a plan of care with goals and approaches, which would have included guidelines/protocols for Resident #16's low temperature readings, and how nursing would be monitoring the implementation of the care plan and changes in the Resident's condition. On 10/23/12 the facility received a referral from the hospital for the Resident to return to the facility.

Based on observation, resident and staff interviews and record review, facility staff did not effectively manage pain for 1 of 1 residents experiencing pain. For over 3 months, Resident #1 reported moderate to very severe pain daily. Resident #1 was given multiple doses of narcotic prn (as needed) pain medication daily, had [MEDICATION NAME]es on her knees, and staff applied Ben Gay at night which provided some relief, but no one assessed Resident #1's pain management program, including a review of prn pain medication usage, to further develop a pain management program that would reduce the number of episodes of moderate and severe pain- such as scheduling pain medication in an attempt to prevent the pain from getting severe. The [MEDICATION NAME]es and Ben Gay ointment were at the request of the family. Resident #1 used 178 tablets of prn [MEDICATION NAME] in December 2010, 150 tablets in January 2011, 170 in February and 64 for the first eight days in March. Resident #1 received two-tablet doses (indicting severe pain) every day in December 2010, every day in January 2011 except 1/2/11, every day in February 2011 and every day March 1-9. This created a direct threat to Resident #1's health, safety and welfare. Findings include: Resident #1 was admitted to the facility on [DATE] following a hospitalization . Resident #1 was taken to the hospital from home, when family had increased difficulty caring for her, stating, " she can hardly walk." Resident #1 had a stroke several years prior. On 3/9/11 at 10:05 a.m., Surveyor # observed CNAs (Certified Nursing Assistants)-D and E assist Resident #1 to the toilet using a Sara lift (Sit-to-Stand). When Resident #1 ' s slacks were lowered, Surveyor # observed a [MEDICATION NAME] on both of Resident #1's knees. CNA-D and CNA-E provided peri-care for Resident #1 while she was standing with the aid of a Sit-to-Stand lift. Resident #1 had the sling around her waist and was holding on to the handles of the lift; and she kept bending her knees. The CNAs asked/ reminded Resident #1 several times to straighten her knees and stand up straight. When seated in her wheel chair again, Surveyor # asked if the pain patches on her knees helped manage her pain. Resident #1 stated they help a little, they help some, but she still has pain in her knees. Resident #1 stated she would like to stand more but she has pain in her knees that keeps her from standing long or walking. On 3/9/11, Surveyor # interviewed Resident #1 as she propelled herself in her wheel chair back to the dining room for an activity. Surveyor # asked if Resident #1 did anything else for the pain in addition to the patches. Resident #1 stated she gets an ointment (Ben Gay) at night and motioned to her hips. Resident #1 also stated when the pain gets real bad she asks for a pain pill, and that helps for a while. Surveyor # reviewed Resident #1's medical record, including the Discharge Summary from the hospital dated 11/30/10 which indicates she is a [AGE] year old morbidly obese individual with [MEDICAL CONDITION], status [REDACTED]. Assessments Resident #1's Admission Nursing assessment dated [DATE] at 4:00 p.m. states: Pain on admission- No; Frequency- no pain; Intensity- no pain. A separate Pain Assessment form also completed on 11/30/10 states: Pain Triggers/ Contributing Factors: Right hip. Information obtained from Resident. Quality: aching, throbbing. Pain site: joint. Observations by nurse: agitated at times, restless/squirming at times. Severity/Intensity of pain identified with Verbal/Visual Pain Scale- staff circled #6 (moderate to severe pain) and #7 (Very severe pain) on the scale. Staff indicated Resident #1 has moderate pain (rating 4-6) and Severe to excruciating pain (7-10). Effects of pain: transfers and ambulation, ADLS (Activities of Daily Living). Onset and Duration: when did pain begin- has history of right hip pain; What makes it worse- movement; what makes it better- has PRN pain meds; how long does the pain last? (left blank). Treatment history: positioning/repositioning and resting have been effective. Current treatments: Tylenol 650 mg. Q (every) 4 hours PRN. Is current intervention effective? (left blank). Comments: able to make needs known. Resident's pain goal: will be free from pain. Action taken: assess for pain q shift and prn. An attached "Continuing Pain Assessment " starting with a 1st quarter review of the pain assessment is blank. (the first quarter review would have been at the end of February.) Surveyor # reviewed Resident #1's Initial MDS (Minimum Data Set) dated 12/13/10, which indicates Resident #1 had pain rated 8 on a scale of 0-10, 10 being the worst pain, was not on any scheduled pain medication, did receive prn pain medication, did receive non-medical intervention for pain, experienced pain frequently, and it was hard to sleep due to pain. The CAA (Care Area Assessment) for Pain dated 12/13/10 states Resident #1 "offers daily complaint of right hip pain as well as periods of general discomfort. Prn Medication is provided. Reports relief with current meds. Will care plan." The Quarterly MDS dated [DATE] indicates during the assessment reference period of 5 days prior to 2/18/11, Resident #1 was on a scheduled pain medication regimen, did not receive any prn pain medication, and did not receive non-medication interventions for pain. Resident #1 reported occasional pain, rated 2 on a scale of 0-10. Physician Orders Resident #1's Physician order [REDACTED]. (milligrams) / 325 mg. [MEDICATION NAME] p.o. (by mouth) - one tablet for moderate pain, two tablets for severe pain, every four hours prn (as needed) for pain. This order was for 60 days and was re-ordered for another 60 days on 2/1/11, and is a current order. Brand names of this medication include [MEDICATION NAME] and [MEDICATION NAME]. No scheduled oral pain medication was ordered for Resident #1 since admission on 11/30/10 through 3/9/11. Resident #1's current (March 2011) physician's orders [REDACTED]. Nurses' Notes dated 12/30/10 indicates: Per family /POA (Power of Attorney) request NOR (new order received). (This was the order for the Ben Gay.) Nurses ' Notes dated 12/31/10 state: Family also requesting [MEDICATION NAME]es to both knees- on AM off HS (hour of sleep/ bedtime). Ok ' d per M.D. Family pleased. No additional pain assessment was observed in Resident #1's medical record after the 11/30/10 assessment conducted on admission were noted the Nurses' Notes nor on a pain assessment form. No further information or pain assessment is documented when the family asked for two different pain management interventions on two separate days a month after Resident #1 was admitted to the facility on ,[DATE] and 12/31/10. Care Plan Surveyor # reviewed Resident #1's Care Plan written 11/30/10 with a goal date of 2/11, which includes a generic, pre-printed care plan for pain. Staff are to circle what applies to the individual resident. The care plan states: Problem- Pain related to impaired mobility (circled)- (staff did not circle arthritis or back pain); as evidenced by: left blank-nothing circled- choices were: Resident complains of pain: daily/less than daily/mild/ moderate/ times when pain is severe; Resident reports that pain medications are not effective; Nonverbal signs of pain are observed. Pre-printed goals are: Resident will report relief of pain; Resident will require fewer pain medications; Resident will demonstrate less non-verbal signs of pain. (None of the goals are circled or crossed out.) Interventions: Assess characteristics of pain: location, severity on a scale of 0-10, type, frequency, precipitating factors, relief factors; monitor nonverbal signs of pain- grimacing, moaning, increased vital signs, guarding areas of body, diaphoresis (sweating), dilated pupils; offer comfort measures such as: distraction, back rubs, readjusting position, heat or cold, slow breathing; discuss with resident factors that precipitate pain and what may reduce it; discuss with resident the need to request pain medications before pain becomes severe; administer pain medication as ordered. Nurses' Notes Surveyor # reviewed Resident #1's Nurses ' Notes which includes an Admission Note dated 11/30/10 at 4:00 p.m. stating Resident admitted from the hospital for dementia with weakness and decline in functional status. Other notes include: 12/2/10 10:10 a.m. Follow-up new admit: Resident alert, able to make all needs known, pain management: verbalizes 'my back hurting'; Resident repositioned, [MEDICATION NAME] 5/325 mg. two tabs given will continue to monitor ... " 12/5/10 3:00 p.m. " ...Has prn pain meds for c/o's (complaints of) pain/ is effective on pain control ... " A similar note is also documented 12/8/10 at 7:00 p.m., 12/12/10 at 4:00 p.m., 12/13/10 8:00 p.m., and almost daily after that until present. 12/10/10 8:00 p.m. " ...Has prn [MEDICATION NAME] 5/325 mg. ordered for pain complaints, is effective. " 12/11/10 12;10 p.m. " ...C/o bilateral knee pain (#5-6) Prn [MEDICATION NAME] given and effective- one hour after [MEDICATION NAME] given #0-1 pain level. As noted above, notes on 12/30 and 12/31/10 indicate Resident #1's family requested Ben Gay and [MEDICATION NAME]es; no nursing assessment was observed even when family members are requesting a change in the pain management regimen. Nurses ' Notes continue: 1/3/11 2:30 p.m. Medicated x2 (twice) this shift for c/o #7-8 (on scale of 0-10) knee/ back/ hip pain. One hour after [MEDICATION NAME] given pain rated #0-1. [MEDICATION NAME] effective along with Ben Gay and [MEDICATION NAME]es daily. (Note: on the facility's pain scale, a rating of 4-6 out of 10 indicates moderate pain, 7-10 is severe or excruciating pain.) 1/20/11 2:00 p.m. ...Does c/o #5-8 knee pain- prn [MEDICATION NAME] pain meds given and one hour after [MEDICATION NAME] given #0 pain level. 1/21/11 Weekly Summary: ...Frequent c/o knee/back pain (#4-5)- prn [MEDICATION NAME] effective; one hour after [MEDICATION NAME] given #0 pain reported. 1/22/11 " Frequent c/o bilateral knee / hip pain (#4-5) with ADLs/PT/OT (Activities of Daily Living/ Physical Therapy/ Occupational Therapy), medicated 1 hour prior to PT/OT or ADLs with [MEDICATION NAME], one hour after [MEDICATION NAME] given- decreased pain level. 1/24/11 2:00 p.m. ...Frequent c/o knee/ leg pain states #4-6 pain level. Alternate means to decrease pain issues include gentle ROM (range of motion), Ben Gay to knees, prn [MEDICATION NAME] given one hour prior to PT, one hour after [MEDICATION NAME] given #0 pain level reported- effective medication. 1/25/11 2:30 p.m. ...Medicated one hour prior to PT c/o pain #5-6 knee/ back pain ...effective 1/27/11 2:30 p.m. ...c/o #4-7 pain bilateral knees/ back pain ...one hour after [MEDICATION NAME] given #0 pain level reported. 2/2/11 2:00 p.m. ...c/o #5-6 knee/ leg/ back pain-prn [MEDICATION NAME] given and one hour after [MEDICATION NAME] given #0-2 pain level. Also Ben Gay and [MEDICATION NAME]es helpful. 2/3/11 ...PRN [MEDICATION NAME] given one hour before therapy for #5-6 knee, back pains; one hour after [MEDICATION NAME] given #0-2 pain level reported. 2/5/11 ...c/o #4-6 knee pain [MEDICATION NAME] given, after one hour #0 pain reported. 2/6/11 Medicare Status: ...Frequent/ at least 2 times a day c/o knee pain #4-8 (moderate to very severe) pain- prn [MEDICATION NAME] given, one hour after [MEDICATION NAME] given decreased pain to #0-2- helpful ... 2/11/11 ...Frequent c/o increased pain with cares / ADLs/ therapy. Two prn [MEDICATION NAME] given for pain level 4-6 (moderate); one hour after [MEDICATION NAME] given usually #0 pain level, [MEDICATION NAME]es in AM and Ben Gay at HS also helpful. 2/18/11 Mobile X-ray ordered of knees. (Resident had been out to Internal Medicine appointment -not primary care physician. The Report of Consultation dated 2/18/11 states: Findings-bilateral knee pain, bilateral lower extremity [MEDICAL CONDITION] +2/+3, lungs clear to auscultation. Family reported pain in knees; MD ordered X-rays, which were negative. Internal Med. Physician did not add or change pain medications, but noted Resident #1 has [MEDICATION NAME] available.) 2/22/11 2:00 p.m. ...Medicated twice for #4-6 pain- knees; one hour after [MEDICATION NAME] given #0 pain reported " it sure helps!" 2/23/11 11:45 a.m. Writer called to resident's room regarding RLE (right lower extremity) foot/ankle pain ...Resident had 3+ [MEDICAL CONDITION] this AM ...Resident c/o pain of 8 on scale of 0-10. [MEDICATION NAME] 5/325 mg. two tablets given ...Currently on 80 mg. [MEDICATION NAME] (diuretic) twice a day. 2/23/11 8:30 p.m. [MEDICAL CONDITION] to RLE ...Medicated twice for pain. 2/24/11 MD updated on [MEDICAL CONDITION], increased [MEDICATION NAME] dose. Encouraging resident to elevate legs, resident very non-compliant ... 3/7/11 Weekly Summary ...Bilateral knees- history of increased pain- usually #5-6 knee pain- one hour after [MEDICATION NAME] given- #1-2 pain level reported ...Pain management addressed q shift with [MEDICATION NAME]es and Ben Gay. Therapy Notes Surveyor # reviewed a Therapy Services Discharge Summary dated 2/17/11 stating Resident #1 was being discharged from Occupational Therapy, Long Term Goal not met due to medical condition, Resident's ability is extremely limited secondary arthritis in knees. A Therapy Services Discharge Summary dated 2/18/11 stating Resident #1 was being discharged from Physical Therapy, Long Term goals not met due to medical condition and pain. A Physical Therapy note dated 2/7/11 states: Goal #2- ambulate 15 feet with moderate assist of one- in progress- unable to ambulate more that a few steps secondary to knee pain ...Patient continues to present with impairments in: decreased strength, decreased mobility, increased pain. Medication Administration Records (MAR)/ Controlled Drug Records While reviewing Resident #1's current March 2011 MAR indicated [REDACTED]. Surveyor # and DON-B reviewed Resident #1's March PRN MAR. The front of the MAR indicated [REDACTED] 3/1/11 at 6:30 a.m. and 1:00 p.m.; 3/2/11 at 6:30 a.m. and 11:30 a.m.; 3/3/11 at 6:30 a.m. and 11:30 a.m.; 3/4/11 at 7:30 a.m.; 3/5/11 at 6:30 a.m. and 12:00 p.m.; 3/6/11 at 6:30 a.m. and 1:00 p.m.; 3/7/11 at 7:00 a.m. and 2:00 p.m.; a total of 13 two-tablet doses, or 26 pills. No doses were signed out on 3/8/11, or thus far on 3/9/11. The back of the March 2011, PRN MAR indicated effective." The Controlled Drug Record from March 1 through March 9, 2011 at 11:30 a.m., indicates nurses signed out 32 two-tablet doses, or 64 pills of [MEDICATION NAME] (same ingredients as [MEDICATION NAME], but from different manufacturer) during the same time period only 13 doses/ 26 pills were signed out on the MAR. The March 2011 doses of [MEDICATION NAME] did not have pre and post medication administration pain scale ratings. This information is needed to assess the effectiveness and duration of the pain medication. Surveyor # reviewed Resident #1's February 2011, PRN MAR indicated [REDACTED]. on the front of the PRN MAR. Nurses documented only a 2/18/11 8:00 a.m. dose of two tablets on the back for lower extremity pain. It is noted at 8:30 a.m. the medication was " helpful." Nurses also used the old form " PRN [MEDICATION NAME] Record/ Pain Flow Sheet " for February 2011, which contains the 0-5 pain scale rating, though they documented ratings greater than 5. Staff documented: 2/2/11 6:30 a.m. pain rated 8 (severe) in knees and legs, two [MEDICATION NAME] given, pain rating 0-2 at 10:00 a.m. 2/3/11 7:30 a.m. pain rated 8 in knees and legs, two [MEDICATION NAME] given, pain rating 0-2 pain rating at 10:00 a.m. 2/5/11 7:00 a.m. pain rating 7 (severe) in knees, two [MEDICATION NAME] given, pain rating 0 at 10:00 a.m. 2/5/11 12:00 p.m. pain rating 6 (moderate) in knees, two [MEDICATION NAME] given, pain rating 0 at 2:00 p.m. 2/15/11 7:00 a.m. pain rating of 6 in knees, two [MEDICATION NAME] given, pain rating 0 at 10:00 a.m. 2/15/11 2:00 p.m. pain rating 7 in knees, two [MEDICATION NAME] given, pain rating 0 at 3:00 p.m. The next four entries simply state the date and time and have "ditto" marks under Pain location, meaning pain in knees. The rest of the form is blank. The dates/ times are: 2/17/11 7:30 a.m. and 11:30 a.m., and 2/19/11 at 6:30 a.m. and 12:30 p.m. The nurses documented pain ratings/effectiveness for 7 of the 22 two-tablet doses, and the time and date of four more doses. For nurses to be giving two doses of [MEDICATION NAME], Resident #1's pain is to be severe; one tablet is to be given for moderate pain, so when to tablets are given, Resident #1's pain must have been considered severe. Resident #1 was given two tablets at least once every day in February. A review of the February 2011 Controlled Drug Record reveals Nurses signed out two-tablet doses (170 tablets) of [MEDICATION NAME] for Resident #1, and the PRN MAR indicated [REDACTED] Surveyor # reviewed Resident #1's January 2011 PRN MAR indicated [REDACTED]. While none of the prn administrations were documented on the back of the prn MAR indicated [REDACTED]. Each of the 24 entries indicates Resident #1 complained of pain in her knees, was given two [MEDICATION NAME]/[MEDICATION NAME] for pain ratings of mostly " 7 " (severe) with one 8, a few 5's and 6's and one rating of 4 (4-6 is moderate pain based on the facility Pain Assessment form; 7-10 severe pain.) Even when Resident #1 reported moderate pain, which should prompt nurses to give her one [MEDICATION NAME], they gave two tablets every time. The physician's orders [REDACTED]. The two [MEDICATION NAME] was effective each time, with pain ratings 0-2 an hour later. The January 2011 PRN [MEDICATION NAME] Record indicates Resident #1 reported moderate to severe pain on January 3, 5, 6, 8, 9, 10, 11, 13, 14, and twice each day on January 20, 21, 22, 23, 24, 25, 27 and 28. The January 2011 Controlled Drug Record indicates nurses signed out 150 tablets of [MEDICATION NAME] while the MAR indicated [REDACTED]. Eighty-six additional tablets were signed out on the Controlled Drug Record which is counted after every shift as compared to the MAR. Since each prn administration during January was two-tablets, and two tablets are for severe pain, Resident #1 experienced severe pain almost every day during January 2011 since the Controlled Drug Record has [MEDICATION NAME] signed out at least once (usually multiple times) every day in January except 1/2, 1/3, 1/9, 1/10, and 1/11. The front of Resident #1's January 2011 PRN MAR indicated [REDACTED]#1 did not have any [MEDICATION NAME] signed out on the Controlled Drug Record. January 2, 2011 is the only date in January 2011 that none of the medication documentation indicates [MEDICATION NAME] was given on that day. Surveyor # reviewed Resident #1's December 2010 MAR indicated [REDACTED]. (38 tablets). Just one dose, on 12/2/10, was documented on the back side where staff should write the location and rating of the pain, and the result/ effectiveness of the intervention. No PRN [MEDICATION NAME] Record/ Pain Flow Sheet was observed for December 2010. The December 2010 Controlled Drug Record indicates 178 [MEDICATION NAME] tablets were signed out for Resident #1 during the same time the PRN MAR indicated [REDACTED]. Multiple, two-tablet doses were signed out every day in December 2010, meaning Resident #1's pain was severe every day in December 2010 since if she reported moderate pain, one tablet would have been the appropriate dose. On 3/9/11 at 2:30 p.m., Surveyor # interviewed Director of Nursing (DON)-B and Corporate Registered Nurse (RN)-F regarding Resident #1's prn [MEDICATION NAME] usage, asking who monitors the amount of prn's a resident takes, since current standards of practice indicate if someone needs frequent prn medication, it is preferable to initiate around-the-clock dosing to keep a appropriate level of medication in the body to prevent pain from becoming severe. DON-B stated after the Controlled Drug Records are full, she reviews them to monitor some control numbers and dates, but has not been monitoring individual resident usage. DON-B stated the nurses on the floor that sign out the prns every day should be identifying the large amount of prn usage and discussing possible scheduled pain medication with the resident, family and physician. Surveyor # noted the only pain assessment in Resident #1's record was dated 11/30/10, upon admission. Resident #1's family requested Ben Gay and [MEDICATION NAME]es on 12/30 and 12/31, Resident #1 has used 150-178 prn [MEDICATION NAME] every month, therapy notes the pain interferes with Resident #1's progress, yet no other pain assessment was found. DON-B stated the RN manager should have completed a Quarterly pain assessment at the end of February, but she did not. The regularly scheduled nurses that are on the floor daily are LPNs (Licensed Professional Nurses), and an RN is to assess based on the scope of their practice. Surveyor # asked if Resident #1's pain should have been re-evaluated sooner than quarterly considering the large number of prn [MEDICATION NAME] consumed, her repeated reports of severe pain, and her stated goal in the admission pain assessment to be pain free. Corporate RN-F stated their policy is to assess pain on admission, quarterly and with a change of condition. Surveyor # noted Resident #1 did not have a change of condition, she used multiple [MEDICATION NAME] daily since admission. RN-F stated they are considering adding weekly pain assessments for the first four weeks following a new admission. Surveyor # noted the 2/18/11 Quarterly MDS states Resident #1 did not use any prns the previous 5 days, when she in fact used many. RN-F stated ...she would look into the discrepancy. Surveyor # reviewed the facility Pain Management policy and procedure dated 3/09. The Procedure states: It is the responsibility of all clinical staff to assess and periodically reassess the resident for pain and relief from pain ...At the time of admission to our facilities, the resident will be interviewed regarding pain during the initial nursing assessment ...The resident will undergo assessment of pain after every pain control mechanism employed by resident care providers. Pain control mechanisms include but are not limited to medications administered for the control or relief of pain or anxiety, repositioning, ambulation, mild exercise, therapeutic massage ...Pain management issues will be included in topics of discussion during interdisciplinary care planning conferences. Surveyor # reviewed the article " Pharmacological Management of Persistent Pain in Older Persons, American Geriatrics Society Panel on the Pharmacological Management of Persistent Pain in Older Persons " published in the Journal of American geriatrics Society, August 2009, Volume 57, No.8, which states: For continuous pain, medications should be provided around the clock. In these situations, a steady state [MEDICATION NAME] blood concentration maintains comfort more effectively. Most patients with continuous pain who are receiving long-acting or sustained-release preparations should also have fast-onset short-acting drugs for breakthrough pain. Breakthrough pain includes end-of-dose failure, resulting from decreased blood concentrations of [MEDICATION NAME] with concomitant increase in pain before the next scheduled dose; incident pain, usually caused by activity that can be anticipated and pretreated; and spontaneous pain, common with neuropathic pain that is often fleeting and difficult to predict.