Every finding on record at Mulder Health Care Facility

Based on interview and record review, the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (R61) reviewed for fall concerns. CNA G (Certified Nursing Assistant) did not utilize a gait belt while transferring R61 in the shower room. R61 fell sustaining a right hip fracture and other injuries. R61 is a 1 person assist with transfers and requires a gait belt. The facility failed to identify that CNA G did not utilize a gait belt for the transfer. As evidenced by:Per OSHA (Occupational Safety and Health Administration) Gait belts, also called transfer belts, are designed to provide caregivers with a secure grip to stabilize patients during transfers, ambulation, or repositioning. OSHA emphasizes safe patient handling to prevent musculoskeletal injuries among healthcare workers, and gait belts are a key component of these safety programs. Facilities are responsible for implementing policies that ensure proper use, training, and compliance with patient care plans and safety standards (OSHA facility guide) .Training and Compliance. Facilities should provide initial and annual refresher training on gait belt use, including hands-on practice and supervision by experienced staff. The facility's policy, Fall Prevention and Management, reviewed 1/2026, indicates in part as follows: Purpose: To assess resident risk for falls and implement interventions to reduce the incidence of falls and/or mitigate the risk of injury related to falls. 3. The Director of Nursing or clinical leader will review post-fall documentation to ensure: A. Data has been collected and documentation is complete B. Contributing factors have been identified C. If intervention/preventive measure is appropriate based on the root-cause of the fall D. Identify if further evaluation or assessment is needed E. Care plan has been updated F. Communication to direct care staff The facility's Orientation Checklist for staff, undated, documents in part as follows: Gait belt usage: Observe, participate in the following: Remember Gait belts are part of your unform, wear them each day. One person gait belt assist/transfer and ambulation; Two person gait belt assist transfer and ambulation. R61 was admitted to the facility 9/12/24 with diagnoses including but not limited to as follows: fracture humerus surgical neck displaced subsequent with delayed healing right, osteoporosis, and reduced mobility. R61's Quarterly Minimum Data Set (MDS) dated [DATE] indicates R61 scored 14 out of 15 on her Brief Interview for Mental Status (BIMS) indicating she is cognitively intact. R61 is her own person. R61's care plan does not document her transfer status (confirmed as 1 person assist) prior to the fall with fracture. ADON J (Assistant Director of Nursing) edited R61's transfer status to a Hoyer transfer versus resolving and adding a new intervention. Therefore, the previous intervention is not included in the care plan. On 11/27/24 Physical Therapy documented the following order for nursing order for R61: Ambulation: Manual A (assist) of 1Assistive Device: WalkerSpecial Instructions: Amb (ambulate) with FWW (front wheeled walker) to/from bathroom with A (assist) of 1.* All transfers with FWW (front wheeled walker) min (minimum) assist of 1. RN H (Registered Nurse) documented the following Fall InvestigationEvent Date: 6/27/26 9:31 PMDate Recorded: 6/28/26 12:47 AMDescription: Witnessed fall in shower roomExact Time Event Discovered: 6/27/26 9:30 PMWhat was the resident doing prior to fall event: alert per normal and laughing with staff. After shower fell while transferring to wheelchairDid the resident have any symptoms prior to fall: Other: unsure of what happened as resident just fell per staff that witnessed eventImmediately post fall ask the resident what happened and/or what they were attempting to do: Witnessed fall in shower. As assisting to stand to pivot resident either slipped or became weak and fell to the floor.Describe exactly what happened, provide factual data only: During shower as getting into wheelchair, resident fell backwardWere there any witnesses to the fall: YesSelect all witnesses to the fall: CNA G (Certified Nursing Assistant)Were the pathways clear: YesWas the support furniture stable: YesDid the resident have access to equipment or care items: YesWas the lighting in the room adequate: YesWas the floor integrity without tripping hazards: YesWas the equipment safe: YesWere side Rails or restraints in use: NoPain Observation: Does resident exhibit or complain of pain related to the fall: Yes, right hipOn a scale of 1-10, how does resident rate intensity of pain if able: 10What intervention(s) did you provide to provide comfort to resident post fall: Diversional activity, list - Soothing words and careAssessment for Injury: Bruise right forearm, Pain with ROM (Range of Motion) Right hip, Skin Tear Right ElbowWas there an injury to the head, neck or face: ROM (Range of Motion) painful/limited in lower extremity - right sideDoes resident exhibit or complain of any of the following since the fall: HeadacheMental Status: Agitation, anxiety, confusionPossible Contributing Factors: None apparentNotification to MD/NP/PA (Medical Doctor/Nurse Practitioner/Physician Assistant): 6/27/26 10:00 PMNotification of Resident Representative: 6/27/26 10:05 PMNotification of Nursing Clinical Leader: 6/27/26 10:00 PMPost Fall Risk Assessment - History of falls with injury: No (Note, this is incorrect, R61 sustained a fall with rip hip fracture prior to admission to the facility as well.)Fall Risk: 7.0; Level: High Risk Date & Time occurred: 6/27/26 9:31 PM On 6/27/26 CNA G (Certified Nursing Assistant) documented the following statement regarding R61's fall: Resident (R61) was playing cards until late, 9:00 PM. We asked the resident to shower and offered to shower tomorrow because its [sic] so late but she agreed to take it now. The shower went well and I had her standing at the bar to dry off her butt and pull up her pants. She (R61) let go of the rail to look back at the wheelchair behind her and lost her balance. She began tipping backwards and I couldn't stop her fall. She hit her head on the metal bar in the corner of the shower and I saw her arm scrape the wall causing a skin tear. Resident fell on her butt and I screamed for help immediately after establishing she was alert and sitting up. I stayed with her until she left. On 7/8/2026 at 3:43 PM, Surveyor spoke with CNA G. CNA G stated, we normally give R61 a shower between 7:00-7:30 PM and on this night we gave her a shower between 9:00-9:30 PM. CNA G stated that R61 needs constant oxygen. CNA G stated, she takes R61's oxygen off for showers. CNA G stated that R61's oxygen was off for up to 15 minutes maximum (including washing, drying, applying creams and powders). CNA G stated, she has not taken R61's oxygen off since the night before. CNA G stated that R61 hates to shower so she tries to make it quick. CNA G stated, she had R61 standing at the grab bar; CNA G stated R61 assisted herself to the bar and CNA G dried her folds and bottom. CNA G stated R61 was fully dressed including a top, pants, socks and shoes. CNA G stated that R61 was stable and everything seemed fine. CNA G stated, on this night she used a different shower chair than she normally uses. CNA G stated she brought the wheelchair closer and the shower chair was in the way. CNA G stated it is her process to set R61's dry clothes and powders in the wheelchair. CNA G stated, she pulled the shower chair back, grabbed the wheelchair and that was exactly when R61 was falling in the corner. CNA G stated she was not holding onto R61 at the time of the fall. CNA G stated, she cannot remember if she grabbed R61's hand. CNA G added, she could not grab R61 fast enough to stop her fall. CNA G stated, she called for RN H (Registered Nurse), put supplemental oxygen on R61. CNA G stated RN H worked on R61 immediately. Surveyor asked CNA G, did you put a gait belt on R61 prior to attempting to transfer her to the wheelchair and prior to the fall. CNA G stated, No, I wasn't planning on walking her. CNA G indicated She didn't plan on R61 pivoting just got the chair behind her. CNA G stated she has showered R61 hundreds of times. CNA G stated that R61 was having right hip pain and was sent to the ED (emergency department). CNA G stated, she usually leaves R61's oxygen on all the time except for showers. Surveyor asked CNA G has the facility provided any training to her and other staff following this incident. CNA G stated that the facility provided education to her regarding taking residents to shower earlier. Surveyor asked CNA G, did you and other staff receive education regarding gait belt usage following R61's fall with fractures. CNA G stated no. On 6/27/26 RN H (Registered Nurse) documented the following statement regarding R61's fall: This resident returned from playing cards in the dining room. Did VS (vital sign) check include sat (oxygen saturation) 96% on 2L O2 (2 liters oxygen). Lung clear. L (left) arm checked - some warmth and redness no worsening noted (previous Covid vaccine 2 days ago). Describe the event and any possible causes why event occurred: Resident in shower-CNA called this nurse and said resident fell. Resident up against wall - had hit head per CNA. No mark noted. Right elbow skin tear quarter size area - Internally rotated Right leg. Severe pain in Right hip. Kept comfortable and called EMS (emergency medical services)-Emergent due to concern of Right hip fx (fracture). Some confusion per resident (not her normal). Unsure what actually happened as may have slipped or had a weakness event. On 7/7/2026 at 4:45 PM, Surveyor spoke with RN H. Surveyor asked RN H to describe when R61 fell in the shower room. RN H stated R61 likes to shower late, always. RN H stated she was by the medication cart when R61 fell in the shower; RN H stated, her understanding is that R61 just went down. RN H stated, CNA G works with R61 all the time and knows her well. RN H stated, prior to the shower R61 was laughing and joking with us. RN H stated, when R61 fell she bumped her head and had a skin tear to her right arm. RN H added, she could see R61's leg hyper extended. RN H stated, she knew R61 needed to be transferred to the hospital via EMS (emergency medical services). RN H stated, EMS got R61 up off the floor with a hoyer (full body lift). RN H stated, there were 2 EMT's (Emergency Medical Technicians) and a police officer. RN H stated, it took EMS about 45 minutes - 1 hour to get R61 up off the floor as EMS needed to get R61's pain under control prior to transferring her. RN H stated, she notified the physician. RN H added, R61 was fully dressed and had shoes on at the time of her fall. Surveyor asked RN H, did R61 slip. RN H stated, we don't really know. RN H stated, when CNA G pulled R61's pants up she fell over. Surveyor asked RN H, was R61 wearing a gait belt at the time of the fall. RN H stated, she does not know. RN H stated, she started working with R61 right away after the fall and did not notice if she was wearing a gait belt. Surveyor asked RN H, should CNA G have applied the gait belt prior to transferring R61 to the wheelchair. RN H stated, yes On 6/28/26 at 12:47 AM, R61 Post Fall Follow Up Note documents as follows: R61 did sustain a fall on 6/27/26. She was having her shower completed with staff present in the room. She had completed the shower and was being dried and dressed. She did have legs and feet dried with pants and shoes/socks on feet during transfer. She was standing at the grab bar to have backside dried and pants pulled up. She then looked back at the w/c (wheelchair) and let go of the grab bar. She lost balance tipping backwards. She did land on buttock area. She did have immediate pain to area of the right hip with internal rotation. EMS (emergency medical services) was called on emergent basis, MD (Medical Doctor) on call and POA (Power of Attorney) were notified of fall and EMS transport. She does have BIMs (Brief Interview of Mental Status) that does have moderate cognitive impairment. She did fall risk assessment on 6/18/26 that was score 9 high risk, and risk assessment on 6/27/26 score 7 High risk. Care plans Interventions prior to fall: educated to look at the w/c prior to transfer, transfer assist of 1 staff with FFW (front wheeled walker), and non-skid footwear. She has been a resident at the facility since 9/12/2024 with no falls or hospitalizations until incident. At this time will wait to change care plan as she is in the hospital and did have surgery on hip fracture. Will update care plan at time of return. On 6/27/26, R61's hospital report documents as follows: Chief Complaint: Fall (Head strike, right hip pain) R61 has a history of COPD (Chronic Obstructive Pulmonary Disease), coronary artery disease, congestive heart failure, sleep apnea, obesity. She presents with severe right hip pain after suffering a fall. She resides in a nursing home and was in the shower. She fell and reportedly struck her head. She was complaining of severe right hip pain. EMS (Emergency Medical Services) had difficulty moving her because of the pain. She prefers to hold the right hip in a flexed and externally rotated position. She did not tolerate C-collar. EMS administered fentanyl, Versed and 30 mg (milligrams) of ketamine for pain control. There was no reported loss of consciousness.ED (emergency department) Course: Right femur x-ray showed periprosthetic diaphyseal fracture. CT (Computed Tomography) of the head and C-spine were negative for acute injury. She was given morphine for pain control. Transfer to different hospital (name) as we are unable to care for this injury at this facility. She was accepted as an ED (emergency department) to ED transfer for orthopedic surgery evaluation. R61 was hospitalized from 6/28 - 7/2/26. On 6/28/26 at 7:13 AM, R61 was admitted from the second ED (emergency department). On 6/29/26 R61 underwent a R (right) femur periprosthetic ORIF (Open Reduction and Internal Fixation) On 7/8/26 at 4:34 PM, Surveyors spoke with DON B (Director of Nursing). Surveyor asked DON B to describe R61's fall in the shower room. DON B stated, I was not here I was on PTO (paid time off). DON B added, she was notified that the fall occurred. DON B stated, RCD C (Regional Clinical Director) and NHA A (Nursing Home Administrator) helped with the fall review. DON B directed Surveyors to speak with RCD C regarding R61's fall with fracture. On 7/8/26 at 4:34 PM, Surveyors spoke with RCD C (Regional Clinical Director) with DON B (Director of Nursing) present for the interview. Surveyor asked RCD C to describe R61's fall in the shower room. RCD C stated, R61 sustained a fall in the shower room. RCD C stated that she was notified of R61's fall by NHA A (Nursing Home Administrator). RCD C stated, we looked at R61's care plan, we discussed we followed the care plan with her, she was wearing shoes, we looked and the floor was dry, she was dressed and CNA G (Certified Nursing Assistant) was pulling her pants up to transfer her. RCD C stated, R61's legs gave out and R61 went down. RCD C stated, R61 was standing while CNA G was pulling out the shower chair and putting in the wheelchair. RCD C stated, R61 has been educated to look and reach back for the wheelchair like all residents. RCD C stated she lost her balance or her leg gave out and that is when the fall occurred. Surveyor asked RCD C, would you expect CNA G to have a GB (gait belt) on R61 prior to transferring her. RCD C stated, I do not know what R61's care plan is without looking at the file. RCD C stated, she does not think the intent was for a moved transfer. Surveyor asked RCD C, for safety should CNA G have had a gait belt on R61, while R61 was standing up. RCD C stated, I would. Surveyor asked RCD C, were you aware that CNA G did not put a gait belt on R61 prior to the transfer and fall with fracture. RCD C reviewed R61's medical record. RCD C stated, CNA G had some education talking through things (note, nothing is documented), making sure the floors are dried and said she did those things. RCD C stated, the facility educated CNA G regarding showering residents earlier. RCD C stated R61's care plan just has the front wheeled walker (with 1 assist). RCD C stated, for safety reasons, she expects CNA G should have applied a gait belt on R61. RCD C stated R61 has not had any other falls since residing at the facility. Surveyor asked RCD C, has the facility provided education on gait belt usage since this incident. RCD C stated, I did not do education. Surveyor asked RCD C, did anybody in the facility provide education to staff regarding gait belt usage following this incident. RCD C stated, Without it being in this file I do not have knowledge of education. DON B added, R61 came to the facility with a fractured humerus surgical neck displaced subsequently with delayed healing of the right (hip fracture with delayed healing). DON B stated this was a fall that occurred on 8/20/24; DON B added, R61 was admitted to this facility on 9/12/24. Surveyor shared concerns regarding R61's fall with fracture. On 7/9/26 at 10:19 AM, Surveyors spoke with DON B. Surveyor stated that R61's transfer status prior to the fall with major injury is no longer on her care plan. DON B stated, ADON J (Assistant Director of Nursing) updated R61's care plan prior to R61 returning from the hospital. DON B stated that ADON J is not familiar with editing care plans and inadvertently edited R61's transfer status versus resolving and adding a new intervention. DON B stated, R61 was a 1 assist with FWW (front wheeled walker) at time of incident. Surveyor asked DON B, would you have expected CNA G to have a gait belt on R61 prior to transferring her from the shower chair to the wheelchair. DON B stated, it is not on R61's care plan so no. She was using the grab bar as an assistive device. DON B stated, Rehab Dir I (Rehab Director) provided her with the transfer status dated 11/27/24 indicating, All transfers with FWW (front wheeled walker) min (minimum) assist of 1. On 7/9/26 at 10:42 AM, Surveyor spoke with Rehab Dir I (Rehab Director). Rehab Dir I stated, the following single page document outlines R61 current intervention for transfer status prior to the fall with fracture. On 11/27/24 Physical Therapy documented the following transfer status for nursing to implement when caring for R61.Ambulation: Manual A (assist) of 1 (staff) Assistive Device: Walker. Special Instructions: Amb (ambulate) with FWW (front wheeled walker) to/from bathroom with A (assist) of 1.* All transfers with FWW (front wheeled walker) min (minimum) assist of 1. Rehab Dir I stated we give this document to the to the facility to update the resident's care plan. Surveyor asked Rehab Dir I, is R61 a 1 assist with transfers. Rehab Dir I stated, Yes. Surveyor asked Rehab Dir I, is R61 a Fall risk? Rehab Dir I stated, yes, she has fallen in the past and fractured which brought her to this facility. Rehab Dir I stated, aren't we all fall risks. Surveyor asked Rehab Dir I, prior to R61's fall with fracture how should staff transfer her. Rehab Dir I stated, she expects staff to transfer R61 with a gait belt, staff holding onto the gait belt because R61 requires a minimum of 1 assist. Rehab Dir I stated, normally we provide R61 with cues so she knows what she is doing. Rehab Dir I stated, if pivoting the wheelchair should be set up and locked. Rehab Dir I stated, if R61 is walking to the bathroom we cue her and open the bathroom door. Rehab Dir I stated, there are two (2) options for transferring. They have her hold the grab bar and pivot or hold the walker and pivot. The second option is to have R61 stand at the grab bar, take shower chair out and put wheelchair in so she can sit. Rehab Dir I stated, sometimes in shower rooms that is the safer option with moisture on the floor. Rehab Dir I stated, she expects staff to follow the standard of care, which is if we (staff) are standing or transferring a resident we have a gait belt on unless they have a care plan that says independent. Rehab Dir I stated, R61 is an assist of 1 (prior to the fall with fracture). Surveyor asked Rehab Dir I, would you have expected CNA G to have a gait belt on R61 while standing in the shower room preparing to transfer her. Rehab Dir I stated, Because she is an assist of 1, yes. On 7/9/26 at 11:05 AM, Surveyor spoke with ADON J. ADON J has been in this role for 3 1/2 years. Surveyor asked ADON J, do you update care plans. ADON J stated, not typically. ADON J stated, usually the MDS (Minimum Data Set) nurse does care plan updates. ADON J stated, she needed to update R61's care plan to a hoyer transfer following the fall and the MDS nurse was not in the facility. ADON J stated, R61 was a 1 assist with a walker at the time of the fall with fracture. ADON J stated, she did not know she needed to resolve the intervention and add a new one. ADON J added, when she changes physician orders, for example, they show the updated and previous entry. ADON J stated that she thought the care plan interventions were the same. ADON J stated, we don't print any care plans because residents' care plans change all the time. Surveyor asked ADON J, did you receive education. ADON J stated, yes. Surveyor asked ADON J when she received education. ADON J stated, this morning we realized that I messed it up. ADON J stated this was an error and she was not asked to make changes. ADON J stated, after Surveyor requested copies this morning DON B and RCD C were looking at what the previous intervention was prior to the fall with fracture. ADON J stated, DON B and RCD C asked if she resolved it. ADON J replied, what is that. On 7/9/26 at 12:20 PM, Surveyor spoke with IP O (Infection Preventionist) (Note, IP O is also in charge of Staff Development). Surveyor asked IP O, what training has been provided for all staff since you started. IP O stated four (4) mock codes. IP O stated he has not provided any further training for staff since his start date. On 7/09/2026 at 12:45 PM, Surveyor spoke with CNA K (Certified Nursing Assistant). Surveyor asked CNA K, when do you use a gait belt. CNA K stated a gait belt is needed for residents that requires 1 assist or 2 assist pivot or walking with walker. Surveyor asked CNA K, do you use a gait belt in the shower room. CNA K stated, yes, we use a gait belt for all residents for transfers, pivoting and standing. CNA K stated, she was taught this in orientation and training. On 7/9/26 at 2:55 PM, Surveyor spoke with NHA A (Nursing Home Administrator). Surveyor asked NHA A if he is aware that CNA G was not utilizing a gait belt at the time of R61's fall in the shower. NHA A stated, he was not aware of that. NHA A stated, the facility discussed at length as an IDT (Interdisciplinary Team) on 6/29/26. NHA A stated the IDT reviewed R61's care plan and everything was in place. NHA A stated, R61 was using the grab bar in the shower at the time she tipped. NHA A stated, IDT discussed whether to report and investigate more heavily. NHA A stated, R61 was holding the grab bar in the shower. NHA A stated, he asks staff to use a gait belt if ambulating anywhere. NHA A stated, he would not expect staff to use a gait belt if the resident is holding onto the grab bar in the shower. NHA A added, R61 is on a walking plan and staff use a gait belt when walking R61. NHA A stated, he would not expect staff to utilize a gait belt while the resident is standing holding on the grab bar. NHA A added, he does not see the need for the gait belt in that situation. NHA A stated, he was not aware that ADON J did not maintain the historical care plan intervention for R61 prior to the fall with fracture. NHA A stated, both staff that update care plans were not in the building. NHA A stated we need to get that updated. NHA A added, ADON J may not have been aware so that is some education we can do with our clinical leaders. Surveyor asked NHA A if he is aware staff are being trained in orientation to use a gait belt for all residents that are care planned for a 1 person and 2 person transfer. NHA A stated, no he is not aware of this. NHA A stated, he was asking the question and everybody agreed we do not need both (grab bar and gait belt). NHA A stated, if it is in there then obviously that is something CNA G should have done.

Based on interview and record review, the facility did not ensure that residents are free of any significant medication errors for 1 of 4 residents (R68) reviewed for medication errors out of a sample of 24.R68 had an order to stop oral chemotherapy medication. R68 was given chemotherapy medications and experienced nausea, weakness, worsening dysphagia, and dizziness. R68 was sent to the emergency room and was found to be significantly more anemic than the week prior. R68 required intervention in the ER when he was given a unit of blood and hospitalized for several days.Evidenced by:This The facility policy entitled, Med Pass, dated 4/2020, states, in part: . III. Medication Error Types: . B. Unauthorized Drug Error: Administration to the patient a dose of medication not authorized for the patient at the time. V. Medication Administration Procedures: . E. General Information: 1. Observe orders to hold drugs.The National Institutes of Health, National Library of Medicine, includes: Etoposide is a medication used in the management and treatment of various cancers. Adverse Effects: Etoposide is a relatively well-tolerated chemotherapeutic agent. Common adverse effects include alopecia and gastrointestinal toxicity. Gastrointestinal toxicity includes: nausea, vomiting, and stomatitis. Immediate concerns include: Myelosuppression: Etoposide's dose limiting side effect is the severe suppression of bone marrow. Administering extra doses when the patient is already weak can plummet white blood cell, red blood cell, and platelet counts. Low white blood cells increase the risk of neutropenic fever, while low platelets increase the risk for bruising and bleeding. Gastrointestinal Distress; potential for increased nausea, vomiting, or mouth sores.R68 admitted to the facility on [DATE]. His diagnoses include Peripheral T-cell lymphoma of lymph nodes of multiple regions, Neoplastic malignant related fatigue, Hemophagocytic lymphohistiocytosis (a severe, life-threatening hyperinflammatory syndrome caused by an overactive immune system that attacks healthy tissues), Bilateral Pulmonary Embolism without heart strain, Deep Vein Thrombosis (serious condition where a blood clot forms in a deep vein), Chemotherapy induced neutropenia, Moderate protein calorie malnutrition, Anemia, and Autoimmune hemolytic anemia with cold gluten syndrome (occurs when your immune system's antibodies attack and destroy your own red blood cells at cold temperatures).R68's Hospital Discharge summary, dated [DATE], includes: Date of Admission- 5/28/26. Date of discharge- 6/19/26. Principal diagnosis- T cell lymphoma, Neoplastic malignant related fatigue, hemophagocytic lymphohistiocytosis, bilateral pulmonary embolism, chemotherapy induced neutropenia, autoimmune hemolytic anemia, anemia, esophageal stricture, physical deconditioning, deep vein thrombosis. Medication list: . Etoposide 50 mg capsule. Commonly known as Vepesid. Take 4 capsules 200mg by mouth 2 times daily. Take only on day 2 and day 3 of each cycle. Follow up with Hematology on 6/23/26. Cycle 2 of chemotherapy scheduled for 6/24/26. Please notify your physician if you experience any of the following: chills, increased confusion, inability to eat/drink/take medication, temperature above 100.4, difficulty breathing, headache, or visual disturbances, pain not relieved by medication, constipation over 48 hours.R68's New Patient Assessment Note, dated 6/23/26, includes: Cancer Center Social Services Intervention. R68 has a new diagnosis of peripheral T-cell lymphoma. He presents today for consultation in Hematology and Medical Oncology. He is accompanied by his friend. R68 was previously hospitalized [DATE]- 6/19/26.R68's Hematology and Oncology Note, dated 6/23/26, includes: After visit summary: . Mobility and function status: Since moving to Skilled Nursing Facility on Friday afternoon, he has had trouble getting around. He can walk to and from the bathroom with help and a walker, but often uses a bedside urinal due to delays in getting assistance. He spends most of the day sitting in a chair and requires help to get up and move. Physical therapy started this morning. Respiratory Symptoms: He feels short of breath when standing up, which he attributes to prolonged bed rest during hospitalization. He has not had any fevers or sweats. Gastrointestinal Symptoms: He has not noticed any bleeding, black or red stools or vomiting. He sometimes experiences belly pain and mild nausea. He had a bowel movement yesterday and is able to pass gas. Nutritional Status: His appetite is very poor and he has not felt hungry in a long time. He has lost 7 pounds in 4 days, with his weight decreasing from 185 pounds six months ago to 155 pounds today. He continues to have trouble swallowing, even after esophageal dilation. He has not had supplemental drinks. but is open to trying them. He is not drinking enough fluids and sometimes goes hours without urinating. He continues to use a spit cup for phlegm. Instructions from MD: Focus on nutrition and supplements, Nutrition Consult, Continue Physical Therapy, PICC line to be placed. will determine based on improvement in functional status, Palliative Care Consult. Today's medication changes: STOP taking: etopside 50mg capsule, accurate as of June 23, 2026 2:24 PM. Patient seen today in clinic. Delaying treatment until better performance status. Contacted ADON J (Assistant Director of Nursing) to review plan. Facility can draw weekly labs and fax results. They request we fax orders to both faxes. This is complete. Team Registered Nurse will call Skilled Nursing Facility again next week Wednesday to check how he is doing and determine next steps.R68's Nurse Note, dated 6/23/26 at 1:48 PM, includes: Writer received phone call from Oncology nurse. Per nurse they are going to hold off on cancer treatment at this time, due to resident's recent hospitalization. Nurse is going to fax over new weekly lab orders to obtain at facility prior to resident's treatments. She will call each week to check on resident status prior to completing cancer treatments.R68's Nurse Note, dated 6/23/26 at 9:45 PM, includes: Resident returned from his chemotherapy appointment. Apparently, per his representative, resident was too sick to get chemo. Resident returned, sat in chair for supper then was assisted to bed. He had a bed bath as he was too tired to get into the shower.R68's MAR (Medication Administration Record), dated 6/1/26-6/30/26, indicates R68 received Etoposide on 6/25/26 and 6/26/26. Order- 50 mg capsule. Take 4 capsules (200mg) by mouth 2 times daily. Take on Day 2 and Day 3 of each cycle.(note: this medication was to be stopped on 6/23/26 per oncology note)R68's Nurse Note, dated 6/28/26 at 10:17 PM, includes: Resident has been getting Tylenol and Mucinex liquid as needed for complaints of pain and sore throat issues. Both as needed medications worked very well per resident and his representative. His representative stated that she thought the Tylenol was supposed to be scheduled. For now the resident was given medications as needed which has worked well at this time.R68's Nurse Note, dated 6/29/26 at 1:51 PM, includes: Resident's representative requested to have resident's lung sounds assessed as resident was said to be more short of breath. This writer assessed lung sounds and upon auscultation, lung sounds are clear in all lobes for this writer.R68's Nurse Note, dated 6/30/26 at 12:33 PM, includes: Resident felt dizzy while sitting in the chair before lunch. After lunch he went to the bathroom and felt dizzy and got back into bed. This writer asked if he was pushing hard to try and have a bowel movement and he said, No, I was really gassy. I got vital signs. They were 115/63 blood pressure, 111 heart rate, 94% oxygen, 17 respirations, and 99 degrees temperature. Resident was feeling nauseous, but refused any nausea medications. This writer encouraged more fluids. Nurse Practitioner notified and new order: vital signs every shift. Call on call if changes in condition worsen. Nurse Practitioner will see him tomorrow in house. This writer did go back in and discussed with the resident and representative that with him starting chemo medications last Thursday, it is expected to be nauseous and dizzy. And that I really recommend taking one of his as needed nausea medications. Resident agreed to take as needed Compazine. Received at 1:09 PM. Resident and representative agreed to see how he feels after a while in case they want R68 to be sent into emergency room or not.R68's Nurse Note, dated 6/30/26 at 2:21 PM, includes: This writer was helping R68 and his representative figure out what is going on with him. This writer did talk to Charge Nurse and ADON J. The representative called Hematology and had nurse on the phone. I spoke with her and she was concerned that he was not supposed to be on a Chemo medication orally. I looked at his orders and didn't see the Chemo medication due to it being scheduled on cycle of Chemo. We looked at R68's discharge paperwork from when he got here, and the orders were written off of what we received from the hospital. Hematology Nurse said she wanted to talk to a higher up nurse, and I gave her the number for the facility and told her to ask for the Charge Nurse or ADON J. This writer went back in to check on R68 and his representative told me that the Hematology Nurse called her back and was told to bring him to the emergency room and that they alerted the emergency room he was coming. The Hematology Nurse did not call the facility back to talk with Charge Nurse or ADON J, didn't inform of what was going on with this decision. Resident's representative took R68 to the emergency room transferring him by herself due to Hematology Nurse telling her to bring him in. They left at 2:22 PM. Bedhold was signed and emergency room packet was sent with them.R68's Nurse Note, dated 6/30/26 at 3:44 PM, includes: Writer spoke with Hematology Nurse regarding R68's Etoposide administration. No orders for Etoposide were included on the referral paperwork received by the facility on 6/23/26. Hematology Nurse stated the order had been entered into Epic but was not transmitted to our pharmacy. Hematology Nurse also clarified that the recommendation for R68 to be evaluated in the emergency department was based primarily on concerns related to his swallowing ability rather than the delay in chemotherapy administration.R68's MD (Medical Doctor) History and Physical, dated 6/30/26, includes: He was admitted from 5/28/26-6/19/26, initially presenting with weakness, fever, and night sweats. He underwent bone marrow biopsy and was diagnosed with peripheral t-cell lymphoma for which he was started on chemotherapy while admitted . Unfortunately his stay was also complicated by Hemophagocytic lymphohistiocytosis (a severe, life-threatening hyperinflammatory syndrome caused by an overactive immune system that attacks healthy tissues), autoimmune hemolytic anemia with cold gluten syndrome (occurs when your immune system's antibodies attack and destroy your own red blood cells at cold temperatures), bilateral pleural effusions, right lower extremity Deep Vein Thrombosis (serious condition where a blood clot forms in a deep vein) and continued dysphagia secondary to stricture, which is a chronic issue for him. He was discharged to the Skilled Nursing Facility and states that his dysphagia has only gotten worse. He can tolerate minimal by mouth intake at this point. Patient's friend contacts clinic. Reports she feels R68 is going downhill and has questions why he got oral chemo. Reviewed with her that he is not currently on any chemo. She has med technician from Skilled Nursing Facility with her who confirms he received oral Etoposide 6/25/26 and 6/26/26. She states, on his discharge paperwork was to give Etoposide on days 2 and 3 of each cycle. Reviewed with her that patient was seen in clinic since then and chemo was discontinued. Skilled Nursing Facility was updated on this last week on 6/23/26. She asks that I call and speak with ADON J . He was seen on 6/23/26 by hematology and given his worsening performance status, the plan was to hold chemotherapy. Unfortunately, he received oral etoposide on 6/25/26 and 6/26/26 at the Skilled Nursing Facility. He now presents due to his increased weakness and dysphagia and was found to be profoundly more anemic at 5.8 from over 9 a week ago. There are no signs of active bleeding currently other than one dark bowel movement yesterday. It is unclear where the miscommunication occurred in the chain of communication. Since then he has only continued to become more fatigued. In the Emergency Room, he was initially tachycardic to 104 but this did improve to 80s and 90s. He has a friend with him who attends all of his medical appointments as well. They both agree that he has done poorly since leaving the hospital. Discussed with . blood bank. They have 2 compatible units currently. Will give one now, but he asks that we hold off on the second unless he decompensates. We discussed his performance status and inability to tolerate by mouth intake. We discussed possible enteral feeding options including G tube. He seems treatment focused at this time. Discussed concern for possible active bleeding in the setting of anticoagulant. Inpatient level of care is appropriate because I am reasonably certain that hospital confinement will be medically necessary for at least two midnights. The medical treatment that will necessitate a stay of this duration is prolonged monitoring of hemoglobin, need for multiple transfusions. The patient was informed that the transfusion involves intravenous administration of the blood product packed red blood cells and does offer a good likelihood of improving anemia. Also discussed were possible problems or difficulties the patient may encounter if treatment was not pursued at this time. These include serious complication of anemia to include death, heart damage and other organ failure, prolonged symptoms of anemia to include shortness of breath and decreased energy level, continued bleeding or increased risk of bleeding.R68's Medication Error Report, dated 6/30/26, includes: date error began- 6/25/26. Date error discovered- 6/30/26. Error discovered by whom- Hematology Registered Nurse. What is the correct order- Etoposide to be discontinued. Describe the error- Resident received medication, though discontinued. Type of error- incorrect medication. Medication error classification- error occurred resulted in need for treatment or intervention. Adverse drug reactions present- complained of dizziness and nausea. Immediate measures taken as directed by the physician- emergency room evaluation. Education provided by ADON J. Notifications- Physician, Pharmacist, Resident.R68's Lab, dated 6/30/26 at 4:14 PM, indicates R68's Hemoglobin is 5.8 (normal limits are 13.6 -16.7g/dl)R68's Lab, dated 6/30/26 at 8:36 PM, indicate R68's Hemoglobin is 5.3 (normal limits are 13.6 -16.7 g/dl)R68's Lab, dated 7/1/26 at 1:34 AM, indicates R68's Hemoglobin is 6.6 (normal limits are 13.6 - 16.7 g/dl)R68's Lab, dated 7/1/26 at 4:39 AM, indicate R68's Hemoglobin is 5.8 (normal limits are 13.6 - 16.7 g/dl)R68's Lab, dated 7/1/26 at 5:35 AM, indicate R68's Hemoglobin is 6.1 (normal limits are 13.6 - 16.7 g/dl)R68's Lab dated 7/1/26 at 11:57 AM, indicates R68's Hemoglobin is 7.1 (normal limits are 13.6 - 16,7 g/dl)On 7/9/26 at 10:29 AM DON B (Director of Nursing) stated, I was the one they notified to say they canceled chemo that day and to increase protein take. From Nurse to Nurse report I was not told to make any other changes just to hold that day. Surveyor asked DON B if she read the paperwork that came back with R68. DON B indicated she had not seen the paperwork. Surveyor and DON B reviewed the paperwork, noting the medication changes section, stating STOP taking: Etopside 50mg capsule, accurate as of June 23, 2026 2:24 PM. DON B indicated she should have verified the orders.On 7/9/26 at 11:55 AM ADON J indicated R68 should not have received the Etoposide. ADON J indicated Medical Records Clerk S was new and she was just uploading the paperwork and not having a nurse sign off on it. Nurses should look at the incoming paperwork to be sure the orders match what they are told in nurse to nurse report over the phone. If the orders on the paperwork do not match what the nurse was told over the phone, the nurse should call the Provider to clarify the orders. ADON J indicated the facility is not monitoring for adverse reactions or side effects of Etoposide use in Medication Administration Record and there should be. ADON J stated, We never had a conversation with the Provider or Pharmacy to discuss the medication and what to monitor for. On 7/15/26 additional information was received and reviewed; citation remains unchanged.

Based on interview and record review, the facility failed to ensure the implementation of an effective antibiotic stewardship program, including adherence to evidence-based criteria and accurate tracking of antibiotic use, for 3 of 10 residents (R3, R13, R97) reviewed for antibiotic therapy. R97 was prescribed an antibiotic the identified organism was resistant to in April 2026. R97 then developed 3 more UTIs over the following weeks and developed resistance to two additional antibiotics. R97 eventually required treatment with IV (intravenous) antibiotics to treat their urinary tract infection. Antibiotic stewardship education was not given to the provider over this time period.R13 was prescribed Cefdinir, an antibiotic, however no sensitivity test was conducted to determine if the antibiotic was effective against the identified organism.R3 was prescribed Ciprofloxacin, an antibiotic to which the culture and sensitivity test indicated the organism was resistant. Findings include: Facility policy entitled, Antibiotic Stewardship Program, last reviewed 2/13/26, states, in part: . b. Monitoring antibiotic use: i. Monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made. 5. As indicated, Nursing will monitor the initiation of antibiotics on residents and reassess continued need and choice of antibiotic to monitor response to the antibiotic and review laboratory results and will consult with the practitioner to determine if the antibiotic is to continue or if adjustments need to be made based on the findings. Example 1:R97 was admitted to the facility on [DATE] with diagnoses including left ankle trimalleolar fracture (fractures in three different bones in the ankle creating an unstable joint), type 1 diabetes, and recurrent UTI. The recurrent UTI was diagnosed 2/20/15. On the April 2026 line list, R97 is listed twice for a possible UTI. The infection onset dates are listed as 3/31/26 and 4/20/26.(Of note: There appears to be a missing line list entry for the residents symptoms occurring around 4/12/26 as progress notes indicate that the course of treatment for the infection with the onset of 3/31/26 ended on 4/8/26). The culture and sensitivity, resulted 4/12/26, indicates R97's culture grew a colony count of 50,000 - 90,000 of a multi-drug-resistant organism (MDRO) Klebsiella pneumoniae. The sensitivity indicates that this organism is resistant to ciprofloxacin. On 4/13/26 at 1:44 PM, a Progress Note is written that states, in part: . NP (Nurse Pracitioner) aware of lab results. New orders received - start cipro (Ciprofloxacin) PO (by mouth) BID (twice a day) x3 days for UTI.(Of note: This note does not indicate if the Nurse Practitioner was notified that the organism was resistant to the prescribed antibiotic) On 4/14/26 at 11:12 AM, a Progress Note is written that states, in part: IDT Note. Based on culture results antibiotic does not meet McGeers. [Name], NP updated. Continue current POC (Plan of Care). NP referred to urology for further follow up due to frequent UTIs. Culture did grow back with MDRO - ESBL (Enterobacterales - enzyme produced by bacteria that inactivates many common antibiotics) producing bacteria. (Of note: At this time, R97 had received at least two doses of Ciprofloxacin, and the facility was aware the organism was a multi-drug-resistant organism. The note does not indicate if the sensitivity results were discussed at this time). The infection listed with an onset date of 4/20/26 is listed on the April 2026 Facility Event Summary Report indicates these symptoms meet McGeer's criteria. This report also indicates R97 was treated with the antibiotic Augmentin twice a day for 10 days for a UTI. The culture and sensitivity, resulted 4/19/26, indicates R97's culture grew a colony count of greater than a 100,000 of a MDRO, Klebsiella pneumoniae. The sensitivity indicates that this organism has an intermediate sensitivity to Augmentin.(Of note: An intermediate result indicates there is a high likelihood of therapeutic success if the antibiotic exposure is optimized by using higher doses or increased dosing frequency. Additionally, this culture result does indicate more bacterial colonies of the same organism grew compared to the previous culture.) On 4/21/26 at 2:17 PM, a Progress Note is written that states, in part: IDT Note: Resident restarted on antibiotics for continued UTI. Resident recently completed three day course of antibiotics for UTI. Resident continued to complain of urinary symptoms. Repeat clean catch UA (Urinalysis) obtained and resulted. Resident started on augmentin BID x10 days on 4/20/26. On 5/2/26 at 10:06 AM, a Progress Note is written that states, in part: Resident c/o (complains) of dysuria (pain with urination), and states she's concerned about have a UTI and going septic. She specifically c/o urinary frequency, burning with urination, lower mid-abdominal discomfort and foul smelling urine. Of note. Resident just finished a course of antibiotics for a UTI. When asked if she felt her symptoms ever resolved from her pervious UTI, she stated the symptoms returned as soon as she stopped taking the antibiotic. On call provider. notified of resident's request for a UA. The infection listed with an onset date of 5/2/26 is listed on the May 2026 Facility Event Summary Report indicates these symptoms meet McGeer's criteria. This report also indicates R97 was treated with the antibiotic Macrobid for a UTI. The culture and sensitivity, resulted 5/7/26, indicates R97's culture grew a colony count of greater than a 100,000 of a MDRO, Klebsiella pneumoniae. The sensitivity indicates that this organism has an intermediate sensitivity to Macrobid.(Of note: R97 prescribed Augmentin following the last culture and sensitivity result indicating R97 had an intermediate sensitivity to the antibiotic. This culture and sensitivity indicates R97 is now resistant to Augmentin.) On 5/6/26 at 3:15 PM, a Progress Note is written that states, in part: Provider notified of resident's culture results. Received new order. Start Macrobid 100 mg (milligram) capsule BID x 7 days for UTI. On 5/16/26 at 7:02 AM, a Progress Note is written that states, in part: Resident continues this overnight shift w/ (with) c/o [sic] frequent urination w/ little to no output and burning upon urination. Resident states it is not uncommon to have continuing UTI s/s (signs and symptoms) even after being treated for a UTI. Resident states she has previously required IV (intravenous) ABX (antibiotics) for UTI, as tablet forms of medication are usually ineffective. On 5/16/26 at 10:51 AM, a Progress Note is written that states, in part: Resident continued to c/o to this writer of burning/painful urination, frequency and urgency. Resident expressed concerns about having UTI and [sic] possibly a MDRO as resident has had one in the past that needed IV ABX. This writer reached out to on call physician. and received orders to obtain a UA and C&S. The culture and sensitivity, resulted 5/18/26, indicates R97's culture grew a colony count of greater than a 100,000 of a MDRO, Klebsiella pneumoniae.(Of note: R97 prescribed Macrobid following the last culture and sensitivity result indicating R97 had an intermediate sensitivity to the antibiotic. This culture and sensitivity indicates R97 is now resistant to Macrobid.) On 5/18/26, a Progress Note is written that states, in part: UA results received and routed to Dr. If worsening clinical symptoms or unstable vitals, to present to ED (Emergency Department) for IV ertapenem (antibiotic). Resident received first IV antibiotic today in infusion center. On 7/9/26 at 12:40 PM, Surveyor interviewed NP (Nurse Practitioner) P. Surveyor asked NP P what her process is for selecting which antibiotic to use to treat a UTI. NP P indicates she always uses the culture and sensitivity results to drive the treatment plan. NP P also notes antibiotics also get brought up in the interdisciplinary team meetings. Surveyor asked NP P how she receives culture and sensitivity results. NP P indicates the lab results are sent to both the NP P's and the facility's electronic health record. NP P also indicates that facility staff are good at updating her with lab results; however, she is aware that on-call physicians may have been responsible for ordering antibiotics and may not always order culture and sensitivity tests. On 7/9/26 at 8:25 AM, Surveyor interviewed RCD (Regional Clinical Director) C and IP (Infection Preventionist) O. RCD C notes IP O took over the infection preventionist role around a month prior to the survey entrance date (7/6/26) and that RCD C was assisting with infection control prior to IP O's appointment. Surveyor asked RCD C and IP O what standard of practice the facility uses for determining if an infection should be treated. RCD C indicates McGeer's criteria. Surveyor asked IP O how the facility assesses residents for antibiotic appropriateness. IP O indicates the facility utilizes McGeer's criteria to determine if an infection should be treated, he remains in contact with the provider regarding antibiotic coverage, he runs a report on antibiotic use and trends, and if they are new admissions, he requests the culture and sensitivity results from the hospital. Surveyor asked if R97's culture and sensitivity results were discussed with a provider following indication that the organism was resistant to the ordered antibiotic. RCD C indicates the progress notes say the Nurse Practitioner was updated on the lab results. Surveyor asked RCD C if the notes indicate education was provided. RCD indicates, no, however there is an IDT note that indicates R97's recurrent UTIs were discussed, and a urology appointment was scheduled.Example 2:R13 was admitted to the facility on [DATE] with diagnoses including age-related osteoporosis (bone demineralization causing fragile and weak bones) with current right femur pathological fracture, schizophrenia, and dementia. On the April 2026 line list, R13 is listed as having a UTI with signs and symptoms listed as agitation and pain or burning with urination. The line list also indicates test results of more than 50,000 bacteria and white blood cells present.The Facility Event Summary Report indicates R13's McGeer's Criteria, dated 4/16/26, does not meet criteria for a UTI. R13's urinalysis was completed on 4/14/26, however no culture and sensitivity was completed.R13 was prescribed the antibiotic cefdinir, 300 MG (milligrams) twice a day for 7 days for a UTI (urinary tract infection) On 7/9/26 at 12:40 PM, Surveyor interviewed NP (Nurse Practitioner) P. Surveyor asked NP P if anyone had ordered a culture and sensitivity following R13's urinalysis result which was dated 4/14/16. NP P indicates a culture and sensitivity was not completed, and she is not sure why, however she does note there was an electronic system change at that time which may have caused some issues. Surveyor asked NP P if she would expect facility staff to contact her if culture and sensitivity results indicated the organism was resistant to the ordered antibiotic. NP P states yes and acknowledges that it is also her responsibility to verify results as well.On 7/9/26 at 12:40 PM, Surveyor interviewed NP (Nurse Practitioner) P. Surveyor asked NP P if R3 should have been prescribed an alternative antibiotic as their culture and sensitivity results indicate the organisms were resistant to the ordered Ciprofloxacin. NP P indicates it is hard to say since multiple organisms were included in the culture.On 7/9/26 at 8:25 AM, Surveyor interviewed RCD (Regional Clinical Director) C and IP (Infection Preventionist) O. Surveyor asked RCD C since R13's sensitivity never resulted, if that should have been discussed with the Nurse Practitioner when they ordered the antibiotic. RCD C indicates this was reviewed with the medical director on 4/16/26 according to the progress notes. Surveyor asked RCD C if she attends the QAPI meetings and knows if antibiotic stewardship education was given to the providers. RCD C indicates she does not attend QAPI meetings so is unsure what specifically was discussed.Example 3:R3 was admitted to the facility on [DATE] with diagnoses including a left femur (bone forming the thigh and connecting the hip to knee) fracture, type 2 diabetes, retention of urine, and other obstructive and reflux uropathy (urine cannot flow normally or flows backwards). On 5/19/26, R3 had a culture and sensitivity (lab conducted to identify specific microorganisms and check the effectiveness of various antibiotics against that organism) result with three organisms: Morganella morganii, Pseudomonas aeruginosa, and Enterococcus faecalis. Morganella morganii and Enterococcus faecalis were resistant to the antibiotic Ciprofloxacin.R3's physician orders indicate they were treated with Ciprofloxacin. R3 had a second urinalysis and culture and sensitivity, which resulted on 5/24/26, finding the organism Morganella morganii which was also resistant to Ciprofloxacin.(Of note: The facility was unable to provide documentation indicating provider education or consultation occurred following the culture and sensitivity results.)On 7/9/26 at 8:25 AM, Surveyor interviewed RCD (Regional Clinical Director) C and IP (Infection Preventionist) O. Surveyor asked RCD C if any provider education on antibiotic stewardship was given when R3 was started on an antibiotic the organism was resistant to in May 2026. RCD C states, no. Surveyor asked RCD C if antibiotic stewardship education should have been provided at that time. RCD C states, yes.

Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 70 residents who reside in the facility.Surveyor observed staff turning wet dishware upside down on a tray creating a seal and not allowing the dishware to air dry completely.Surveyor observed food to be in circulation past the use by date.Surveyor observed an unclean mixer stored under a plastic covering.Evidenced by:Example 1Facility policy, titled Handling of Leftover Food, revised 1/2025, includes: .Leftovers should be covered, labeled, dated, and refrigerated as soon as the tray line is finished. Refrigerated leftovers should be used within 3 - 7 days after opening.On 7/6/26 at 10:45 AM Surveyor observed the following food to be in the facility's walk in refrigerator pass the use by date: barbeque chicken with use by date of 7/5/26, sweet and sour sauce with use by date of 6/30/26, creamed corn with use by date of 7/3/26, and baked beans with use by date of 7/3/26. During interview, RCD C (Regional Clinical Director) indicated the food should have been discarded on the use by date if it was not used.Example 2On 7/6/26 at 10:45 AM Surveyor and RCD C (Regional Clinical Director) observed a mixer to be stored under a plastic covering. RCD C lifted the plastic and food debris was observed on the under carriage. RCD C indicated the mixer should have been cleaned before being covered in plastic.Example 3Facility policy, titled Dish Machine High Temperature, revised 1/2025, does not include procedures for dishwashing.Th eFDA Food Code, section 4-901.11, states: After cleaning and sanitizing equipment and utensils: must be air dried.On 7/8/26 at 9:34 AM Surveyor and RCD C observed dishware, including mugs, cups, and bowls on the clean side of the dishwasher to be placed upside down on plastic trays. RCD C turned over several pieces of dishware. Surveyor and RCD C observed liquid to be trapped inside and unable to air dry completely. Dietary Manager E joined the observation and during interview he indicated dishware should be allowed to air dry completely before stacking or turning upside down.

Based on interview and record review the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, this has the potential to affect the census of 70. The facility did not monitor residents with potentially infectious symptoms. The facility policies do not indicate what data should be collected for the residents with potentially infectious symptoms. CNA R (Certified Nursing Assistant) did not complete hand hygiene per standards of practice while providing perineal care for resident (R21). This is evidenced by: Facility policy entitled, Monitoring Infection Control Practices, last reviewed 2/13/26, states, in part: . Policy: The facility's Infection Control Preventionist will conduct routine monitoring and surveillance to determine compliance with infection control policies and practices. Procedures:. If suspicion or evidence of an infection is detected within the resident population the following should be done. 7. The facility's Infection Control Preventionist will collect data and enter information into facility's electronic data program. Example 1 The facility's line lists, used for infection surveillance, dated April 2026 to May 2026 do not contain residents who showed signs and symptoms of a potential infection. In April 2026, R95 was experiencing signs and symptoms of a urinary tract infection including incontinence and dysuria (painful urination). R95 had a urinalysis (test used to assess for urinary tract infections and kidney function) and the nurse practitioner decided not to treat based on the urinalysis results. R95 was not included on the April 2026 line list. In April 2026, R27 was experiencing a runny nose. The facility completed a COVID test and a chest x-ray. R27 was not included on the line list. (Of note: R27 was also not included in the Facility Event Summary Report which lists each resident's McGeer's Criteria Assessment which provides guidelines for surveillance and treatment of infections.) In May 2026, R49 was tested for a urinary tract infection with urinalysis. R49 was not included on the line list. On 7/9/26 at 8:25 AM, Surveyor interviewed RCD (Regional Clinical Director) C and IP (Infection Preventionist) O. RCD C notes IP O took over the infection preventionist role around a month prior to the survey entrance date (7/6/26) and that RCD C was assisting with infection control prior to IP O's appointment. Surveyor asked RCD C and IP O what the process is for determining which residents are added to the line list. RCD C indicates that residents are only added to the line list if they meet McGeer's criteria. IP O indicates that's also his current practice. Surveyor asked RCD C and IP O how the facility tracks residents who are symptomatic but may not yet meet criteria at the time of assessment. RCD and IP O indicate the facility does not track the residents if they don't meet McGeer's criteria. (Of note: Facility infection control policies do not indicate what type of data should be collected, such as infection type, pathogen, signs and symptoms, etc.) Example 2: The Morbidity and Mortality Weekly Report dated 10/25/02 and published by the CDC (Centers for Disease Control and Prevention) entitled, Guideline for Hand Hygiene in Health Care Settings, Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene before donning gloves and touching the patient or the patient's surroundings. Further guidelines indicated recommendations to wash hands after touching a patient or patient's surroundings. The above information can also be found at: https://www.cdc.gov/handhygiene/providers/index.html with the page last reviewed on February 27, 2024. On 7/8/26 at 9:30 AM, Surveyor observed CNA R (Certified Nursing Assistant) and CNA Q (Certified Nursing Assistant) provide perineal care to R21. Surveyor observed CNA R move R21's bed with her gloved hands. Surveyor observed CNA Q open R21's brief. CNA R stated to R21, I'm going to pull back your scrotum. Surveyor observed CNA R lift R21's scrotum. CNA R did not doff (remove) her gloves after touching items in R21's environment (bed), perform hand hygiene and don (put on) clean gloves prior to assisting with R21's perineal care. On 7/8/26 at 9:40 AM, Surveyor spoke with CNA R (Certified Nursing Assistant). Surveyor asked CNA R when you should sanitize/wash your hands. CNA R stated, before and after removing gloves. Surveyor asked CNA Q should you have removed your gloves, sanitized your hands, and donned clean gloves after touching R21's bed and prior to pulling back R21's scrotum. CNA R stated, she is sorry and did not even think about it. CNA R stated, yes, she should have. On 7/9/26 at 8:48 AM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B when she expects staff to sanitize/wash their hands. DON B stated, when entering a resident room, exiting the room, between cares, removing gloves, before and after glove use and basically all the time. Surveyor asked DON B if a staff member touches items in the resident's environment with gloved hands prior to doing perineal care would you expect staff to remove their gloves, sanitize their hands, and apply clean gloves. DON B stated, yes. Surveyor shared the observation of CNA R not changing her gloves, sanitizing/washing hands and applying clean gloves prior to performing perineal care with R21. DON B stated that CNA R should have removed her gloves, sanitizer hands and donned clean gloves after touching R21's bed and prior to performing perineal care.

Based on interview and record review the facility did not ensure the required contents of the Notice of bed-hold policy and return was provided with the bed hold notice for 4 of 4 residents (R39, R53, R68, R9) reviewed for hospitalizations out of a sample of 24 Residents. R39 had an incomplete bed hold notice for 3/8/26 and 5/26/26. R53 had an incomplete bed hold notice for 6/15/26. R68 had an incomplete bed hold notice for 6/30/26. R9 was sent to the hospital on 2/5/26. The bed hold provided to R9 did not include the reason for transfer or include resources available for the resident. R9 was sent to the hospital on 4/8/26. The bed hold provided did not include resources available to resident. This is evidenced by: Per the State Operations Manual, The written notice must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged ; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and [NAME] of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. The Facilities Policy and Procedure entitled Bed Hold dated 01/25 does not speak to what the bed hold notice requirements are. Example 1 R39's bed hold dated 3/8/26 does not include the reason for discharge, the location to which R39 was transferred, the appeal rights, Ombudsman contact information or other Advocacy Agency contact information. R39's bed hold dated 5/26/26 does not include the reason for discharge, the location to which R39 was transferred, the appeal rights, Ombudsman contact information or other Advocacy Agency contact information. Example 2 R53's bed hold dated 6/15/26 does not include the reason for discharge, the location to which R53 was transferred, the appeal rights, Ombudsman contact information or other Advocacy Agency contact information. Example 3 R68's bed hold dated 6/30/26 does not include the reason for discharge, the location to which R68 was transferred, the appeal rights, Ombudsman contact information or other Advocacy Agency contact information. Example 4 R9 was admitted to the facility on [DATE], and has diagnoses that include Diabetes Mellitus Type 2, Acquired absence of right leg below knee and cellulitis of right lower limb. R9's Quarterly Minimum Data Set (MDS) Assessment, dated 6/11/26, shows R9 has a Brief Interview of Mental Status (BIMS) score of 15 indicating R9 is cognitively intact. R9's Bed Hold, dated 2/05/26 does not indicate the reason for the transfer nor does it provide the resident with resources available to assist with the financial aspect of holding the bed. R9's Bed Hold, dated 4/08/26 does not provide the resident with resources available to assist with the financial aspect of holding the bed. On 7/8/26 at 11:13 AM, Surveyor interviewed RN M (Registered Nurse). Surveyor asked RN M what is sent with a resident when they go to the hospital, RN M said there's a document on the computer that includes payor source information, contact information, medication list, diagnosis list, allergy list, most recent vital signs, immunizations, and parts of the care plan. Surveyor asked RN M who completes the bed hold form when a resident must go to the hospital, RN M replied the nurse does, usually verbally. Surveyor asked RN M if there is anything else that goes with a resident when they go to the hospital, RN M indicated a large 9x11 envelope that includes a transfer form and a bed hold form. RN M also stated the residents' original POST form also goes with them. On 7/8/26 at 5:03 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if the bed hold notices should include all the required information (where to, why, resources, etc.) and be completely filled out, DON B stated yes.

Based on observation, interview, and record review, the facility did not always serve food that was palatable and served at the right temperature. This has the potential to affect 1 of 1 sampled Residents (R33) and 2 of 2 supplemental residents (R17 and R79), and 1 of 1 test trays. This has the ability to affect more than a minimal number of Residents. Surveyor performed a test tray, and the results were not palatable. R79, R33, and R17 voiced concerns of their hot meals being served to them at cold and undesirable temperatures. During the Resident Council Group, residents voiced the coffee is always cold and residents do not get menus. Evidenced by: Facility policy, titled Food Temperature Records/Control, revised 1/25, includes: The temperature of all foods on serving line will be measured prior to resident service. Cold foods should be 41 degrees F (Fahrenheit) or less. Hot foods should be between 135-165 degrees F. Example 1 On 7/08/2026 from 11:45 AM to 12:01 PM Surveyor observed resident lunch trays in an insulated cart with the door open. On 7/8/26 at 12:02 PM Surveyor observed the first room tray to be passed from the insulated cart. On 7/8/26 at 12:12 PM Surveyor was served a test tray and recorded the following temperatures: spaghetti bake- 109 degrees F (Fahrenheit), zucchini-108 degrees F. coffee-119 degrees F, and cottage cheese 54 degrees F. On 7/8/26 at 12:30 PM Regional Clinical Director C indicated the door should not be left open on the insulated cart with the hot meals in it and the temperatures of the hot foods is too cool and the cottage cheese was too warm. Example 2: R79 admitted to the facility on [DATE]. Her most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 6/7/26 indicates R79's cognition is severely impaired with a BIMS (Brief Interview for Mental Status) score of 9 out of 15. On 7/9/26 at 7:59 AM during an interview, R79 indicated she gets served scrambled eggs at a cool and undesirable temperature at times. Example 3 R33 was admitted to the facility on [DATE] and has diagnoses that include Traumatic Brain Injury and Adjustment Disorder. R33's admission Minimum Data Set (MDS) Assessment, dated 3/30/26, shows R33 has a Brief Interview of Mental Status (BIMS) score of 15 indicating R33 is cognitively intact. On 7/06/26 at 2:50 PM, Surveyor interviewed R33. R33 indicated the food is atrocious. The menus do not match what is served. R33 indicated he wants frosted flakes every morning for breakfast and it is listed on his meal card. R33 indicates he does not get frosted flakes every morning and he will have to ask for them. R33 indicated it is upsetting and frustrating. R33 indicated that the coffee is never hot, it is always cold. The portion sizes are small. The meals are consistently cold. Example 4: On 7/06/26 at 1:34 PM, during the Resident Council Group with Surveyors, residents voiced the coffee is always cold and the residents do not get menus. Residents voiced concern that the toast is served dry and they must ask for butter if they want it. The time they get the butter the toast is cold. Example 5 R17 is a short-term resident of the facility. R17's most recent MDS (Minimum Data Set) dated 7/2/26 documents that R17 scored a 15 on her BIMS (Brief Interview of Mental Status), which indicates intact cognition. On 7/7/26 at 10:58 AM, Surveyor asked R17 how the food is here, R17 said the food is alright. Surveyor asked R17 if meals are received in the room or dining room, and R17 replied room. Surveyor asked R17 if her hot foods come hot and her cold food comes cold, R17 stated I never get coffee or tea hot. On 7/8/26 at 3:37 PM Dietary Manager E indicated hot meals should be served at a safe and desirable temperature and cold foods should be served at a cold and desirable temperature.

Based on interview and record review, the facility did not follow through with the appropriate steps of the PASARR (Preadmission Screening and Resident Review) process for 3 of 5 residents (R8, R9 and R72) reviewed for PASARR screening out of 24 sampled Residents. R8 had a Level 1 PASARR screening completed with a 30-day exemption request. The facility did not have a level II PASARR screening completed at the end of the 30-day exemption. R9 had a Level 1 PASARR screening completed with a 30-day exemption request. The facility did not have a level II PASARR screening completed at the end of the 30-day exemption. R72 did not have a level two PASRR (Preadmission Screening and Resident Review) completed. Evidenced by: The facility policy, entitled Pre-admission admission Process, dated 1/25, states, in part: Standard: Social Services will evaluate each resident's psychosocial and behavioral needs during the pre-admission process. Policy: Social Services will review each potential resident's psychosocial and behavioral needs and Pre-admission Assessment and Annual Resident Review (PASARR). 2. Social Services will ensure that the referring party obtains a Level 2 PASARR screening, when indicated. 3. Social Services will determine the needed facility services and programs to meet the potential resident's psychosocial and behavioral needs based upon pre-admission assessment and PASARR information. Example 1: R8 was admitted to the facility on [DATE], and has diagnoses that include Vascular Dementia, Post Traumatic Stress Disorder, Bipolar Disorder and Borderline Personality Disorder. R8's Minimum Data Det (MDS) admission Assessment, dated 4/28/26, shows R8 has a Brief Interview of Mental Status Score (BIMS) of 12, indicating R8 has moderate cognitive impairment. Surveyor reviewed R8's Level 1 PASRR screening which indicated the facility answered Yes to the question Does the person have a major mental disorder? The facility entered Yes for Hospital Discharge Exemption- 30 Day Maximum. The facility answered No to Is the person staying longer than the permitted exemption period? Example 2: R9 was admitted to the facility on [DATE] and has diagnoses that include Major Depressive Disorder. R9's MDS Quarterly Assessment, dated 6/11/26 shows R9 has a BIMS score of 15 indicating R9 is cognitively intact. Surveyor reviewed R9's Level 1 PASSR screening which indicated the facility answered Yes to the question Does the person have a major mental disorder? The facility entered Yes for Hospital Discharge Exemption- 30 Day Maximum. The facility answered No to Is the person staying longer than the permitted exemption period? Example 3 R72 is a short-term resident of the facility. R72 admitted with the following diagnoses: generalized anxiety disorder, major depressive disorder, and bipolar disorder. R72 had a level one PASRR completed on 1/19/26 and documents a 30-day exemption (indicating that R72 will only reside in the facility for 30 days). R72 is prescribed an antipsychotic medication, quetiapine. On 7/08/26 at 12:59 PM, Surveyor interviewed SS F (Social Services) and asked if R8, R9 and R72 have a Level 2 PASRR. SS F reviewed the medical records and indicated no. Surveyor asked SS F what the process is for obtaining PASRRs. SS F indicated for every resident admitted a Level 1 is completed and forwarded to Forward Health. When a Level 2 screening is required the facility receives a notice from the state. Forward Health completes the Level 2 screening. Once the Level 2 screening is completed the facility receives a report on the findings of the Level 2 and a copy of the Level 2. The Level 2 screening then goes into the resident's medical record. Surveyor asked what the process is for a 30-day exemption. SS F indicated another Level 1 screening would be completed at the end of the 30 days and submitted again to Forward Health. Forward Health would complete the Level 2 and the facility would receive a copy 1 to 3 weeks later. Surveyor asked if R8 should have had a Level 2 screening completed at the end of the 30-day exemption and placed in the medical record. SS F indicated yes. Surveyor asked if R9 should have had a Level 2 screening completed at the end of the 30-day exemption and placed in his medical record. SS F indicated yes. Surveyor asked SS F if R72 should have had a Level 2 screening completed at the end of the 30-day exemption and placed in his medical record. SS F indicated yes. Surveyor asked SS F who is responsible for ensuring the process for obtaining PASRRS is followed through. Surveyor referred Surveyor to the Quality Assurance Nurse. On 7/08/26 at 1:23 PM, Surveyor interviewed QAN L (Quality Assurance Nurse) who indicated he is responsible for auditing all residents, before admission or on the day of admission, have a Level 1 completed. QAN L indicated that the social worker would be responsible for obtaining Level 2 screenings. QAN L asked RCD C (Regional Clinical Director) if she was able to find out if the Level 2 screenings were completed but not uploaded into the system. On 7/08/26 at 2:02 PM, RCD C indicated the Level 2 screenings were not completed for R8, R9 and R72. Surveyor asked RCD C if she would expect all residents with a 30-day exemption to have a Level 2 screening completed at the end of the 30-day exemption. RCD C indicated yes, and the facility does not have the Level 2 screenings.

Based on interview and record review, the facility failed to ensure that services provided by the facility meet professional standards of quality for 2 of 5 residents (R8 & R44) reviewed for unnecessary medications. R8 is receiving Melatonin for insomnia and did not have a sleep assessment completed. R44 did not have any kind of assessment completed prior to or on a regular basis after beginning a sleep aid. Evidenced by: The facility policy entitled, Psychotropic Medication Use, dated 1/2026, states, in part: . Policy: Residents are not given psychotropic medication unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record. Policy Explanation and Compliance Guidelines: 1. Psychotropic medications include, but are not limited to: antipsychotics, antidepressants, anti-anxiety, and hypnotics. 2. The indications for use of any psychotropic drug will be documented in the medical record. a. Pre-admission screening may be used to determine indications for use of psychotropic medications ordered upon admission to the facility. c. Psychotropic medications will be initiated after other causes have been ruled out or addressed, and nonpharmacological interventions have been attempted. 8. Medications that have a documented use that appears to be a substitution for a psychotropic medication are subject to the same requirements as psychotropic medications. Note: Surveyor asked RCD C (Regional Clinical Director) for policy on sleep aides or sleep assessments. RCD C indicated there are no policies on sleep aides or assessments, just the psychotropic policy. Note: Surveyor asked RCD C (Regional Clinical Director) for policy on sleep aides or sleep assessments. RCD C indicated there are no policies on sleep aides or assessments, just the psychotropic policy. Example 1: R8 was admitted to the facility on [DATE] and has diagnoses that include Insomnia. R8's admission Minimum Data Set (MDS) Assessment, dated 4/28/26 shows that R8 has a Brief Interview of Mental Status (BIMS) Score of 12 indicating R8 has moderate cognitive impairment. R8's Physician Orders, dated for 6/08/26-7/08/26, states, in part: .Melatonin tablet; 3 milligrams (mg) amount: 9 mg oral. Special instructions: Administer 3 tablets (9mg) by mouth at bedtime for nocturnal calming. Start Date: 4/28/26 End Date: Open Ended. R8 did not have a sleep assessment completed related to melatonin use. On 7/07/26 at 3:00 PM, Surveyor interviewed RCD C (Regional Clinical Director) and asked for a sleep assessment for R8's melatonin use. RCD C indicated the facility does sleep aide monitoring on side effects of the medication and log the hours of sleep each shift on the medication administration record (MAR). RCD C indicated those are started on the MAR when the sleep aide starts or if a resident is admitted on a sleep aide. RCD C indicated the facility does not do sleep assessments prior to starting a sleep aide. On 7/09/26 at 8:33 AM, Surveyor interviewed DON B (Director of Nursing) and asked what the process is for starting a resident on a sleep aide. DON B indicated the facility does side effect monitoring and hours of sleep every shift. Surveyor asked DON B what the process for a new admission is admitting with a sleep aide ordered. DON B indicated it is the same. Surveyor asked DON B if the facility does sleep assessments for residents before starting them on a sleep aide. DON B indicated no. Surveyor asked if R8 has a sleep assessment and DON B indicated no. Example 2 R44 is a long-term resident of the facility. R44 has orders for melatonin 3 mg (milligrams) QHS (every bedtime) for nocturnal calming. This medication was started on 11/4/24. R44 does not have any kind of sleep assessment documented. On 7/9/26 at 8:26 AM, Surveyor interviewed RN M (Registered Nurse). If a resident complains of insomnia, what do you do with that information, RN M said he'd check the MAR (medication administration record) to see if they had an order for some type of medication and review their care plan to see if there are any non-pharmacological interventions to try. Surveyor asked RN M if a sleep assessment is completed before starting a sleep aid, RN M replied not a formal document, no. On 7/9/26 at 8:31 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if she would expect a sleep assessment to be done prior to a resident starting on a sleep aid, DON B indicated that many residents come into the facility already on them. Surveyor asked DON B if there should be a sleep assessment, DON B said they monitor the number of hours a resident sleeps each shift.

Based on interview and record review, the facility did not ensure it had procedures in place to assure the accurate acquiring, receiving, dispensing, and administration of all drugs and biologicals to meet the needs of each resident for 2 of 4 residents (R33 & R3) out of 24 sampled Residents. R33 had a scheduled colonoscopy with instructions to hold Eliquis prior to procedure. The facility administered R33's Eliquis and the colonoscopy had to be cancelled due to the Eliquis given. The facility did not follow physician orders resulting in a medication error. R3 received new orders to increase his losartan, and this medication was not provided per physician orders. Evidenced by: The facility policy entitled, Med Pass, dated 4/2020, states, in part: . III. Medication Error Types: . B. Unauthorized Drug Error: Administration to the patient a dose of medication not authorized for the patient at the time. V. Medication Administration Procedures: . E. General Information: 1. Observe orders to hold drugs. Example 1: R33 was admitted to the facility on [DATE], and has diagnoses that include Adjustment Disorder, Long Term use of Anticoagulants, and Central Cord Syndrome at C5 level of the spinal cord. R33's admission Minimum Data Set (MDS) Assessment, dated 3/30/26, shows that R33 has a Brief Interview of Mental Status (BIMS) score of 15 indicating R33 is cognitively intact. Gastroenterology and Hepatology Orders, dated 5/11/26, states: . Type of Procedure: Colonoscopy Date of Procedure: 6/11/26. Blood Thinners: Eliquis message sent 5/6/26 to hold 48 hours. Education completed: Educated [NAME] charge nurse [[NAME]] on 5/26/26. R33's Physician Orders, dated 5/09/26 – 6/09/26, states, in part: . Eliquis (apixaban) tablet; 2.5 milligrams (mg); amount: 2.5 mg; oral. Special Instructions: Administer 2.5 mg by mouth BID (twice a day) for recurrent DVT (Deep Vein Thrombosis) . R33's Medication Administration Record (MAR), dated 6/1/26-6/30/26, shows R33 received Eliquis 2.5 mg on: 6/9/26- AM & PM (2 times) 6/10/26- AM & PM (2 times) 6/11/26- AM & PM (2 times) Of note: Order was to hold Eliquis 48 hours prior colonoscopy on 6/11/26. R33's Progress Note, dated 6/11/26 at 10:11 AM, states, in part: Received a phone call from [Mayo Health System] stating that they are unable to do the colonoscopy due to him receiving his Eliquis last night. They will call back to reschedule another time. On 7/06/26 at 2:50 PM, Surveyor interviewed R33. R33 indicated he was to have a colonoscopy twice. The first time the bowel prep was not effective. The second time the facility administered the blood thinner that was to be held for the colonoscopy. R33 indicated he was told by the facility that [Mayo] did not call in the orders to the facility to hold the blood thinner. R33 indicated he reached out to his provider to question the instructions. The provider forwarded the documentation between the provider and the charge nurse at the facility regarding the instructions to hold the Eliquis prior colonoscopy. R33 showed Surveyor the email which confirmed the facility had indeed received the instructions for the colonoscopy. Surveyor asked R33 if he had the colonoscopy. R33 indicated no. R33 indicated he is not going through the prep again; two times was enough. On 7/09/26 at 10:35 AM, Surveyor interviewed DON B (Director of Nursing) and asked what the process is for ensuring instructions/orders received for scheduled diagnostic tests are carried through. DON B indicated the DON, ADON (Assistant Director of Nursing) or the charge nurse receives the fax with the instructions for whatever test is ordered. The information is then entered into the MAR to ensure the orders are carried out by the nurses. DON B indicated the instructions are also put on the 24-hour board. Surveyor asked DON B if she would expect physician orders to be followed. DON B indicated yes. Surveyor reviewed R33's notes regarding the colonoscopy scheduled for 6/11/26 and orders to hold the Eliquis. Surveyor asked DON B if the order was put on R33's June MAR to hold the Eliquis per colonoscopy instructions. DON B indicated no. Surveyor asked if the orders should have been transcribed onto R33's MAR for the scheduled 6/11/26 colonoscopy, and DON B indicated yes. Surveyor asked DON B if the Eliquis was administered 6/9/26-6/11/26, and DON B indicated yes and it should not have been. Surveyor asked DON B if this is a medication error. DON B indicated yes. Example 2: Facility policy, titled Med Pass, initiated 4/2020, includes: .Medication error- a dose of medication, which deviates from the physician's drug order on the patient chart. Medication Error Types: . Wrong dose error-Any dose constituting the wrong number of preformed dosage units and/or above or below the correct dose by 50% or more. R3 admitted to the facility on [DATE] with diagnoses, including Type 2 Diabetes Mellitus and Hypertensive Heart Disease. R3's Physician Orders, dated 6/1/26-6/30/26, include: start date- 11/18/25: Losartan tablet 50mg (milligrams), oral. once a day by mouth for Hypertension. R3's Physician Handwritten Order, dated 6/10/26, includes: Increase Losartan to 75 mg by mouth daily, manual blood pressure 2 times a week, review blood pressure on 7/1/26. R3's Clinic Outpatient Detail Report, dated 6/10/26, includes: Losartan 50 mg tablet. Take 1.5 tablets/75 mg by mouth daily for high blood pressure. Receipt confirmed by pharmacy on 6/10/26 at 9:47 AM. R3's Nurse Progress Note, dated 6/10/26 Received new order from Nurse Practitioner to increase Losartan to 75 mg by mouth daily, manual blood pressure 2 times a week, review blood pressure on 7/1/26. R3's Physician Orders, dated 6/1/26-6/30/26, updated to: Start date 6/11/26 Losartan tablet 50mg, amount to administer 75mg, oral. Give 1.5 tablets/75 mg total by mouth daily for Hypertension. R3's Medication Administration Record, dated 6/1/26-6/30/26, indicates R3's Losartan was administered as ordered from 6/1/26-6/23/26. R3's Medication Regimen Review, dated 6/23/26 at 11:36 AM, includes: (Monthly) Medication orders reviewed by Pharmacist. Medication dose, frequency, route of administration and duration are appropriate for resident's condition, manufacturer's recommendations and standards of practice. Losartan was increased, but pharmacy did not receive order. Will ask facility to send order again and will update provider. June labs reviewed, sodium improved with discontinuation of HCTZ. Med Therapy Recommendation: Losartan was increased on 6/10/26, but pharmacy did not receive order. Pharmacy has been supplying 50mg tabs every morning. Please send dose increase to pharmacy. Thank you. (It is important to note the medication was not being distributed by the pharmacy in the dose of 75mg. The pharmacy was only supplying 50mg tablets every morning and had not received the order. Nurses were signing out that they were giving 75mg from 6/11/26-6/23/26 while only giving 50mg tablets.) On 7/9/26 at 8:15 AM Surveyor asked Med Technician/CNA T (Certified Nursing Assistant) about R3's Medication Regimen Review and his Physician orders. Med Technician/CNA T and [NAME] President of Clinical Services U indicated the facility maybe did not send the medication order to the correct pharmacy and staff just kept signing it out while giving R3 the 50 mg doses. On 7/9/26 at 3:16 PM VP of Clinical Services U stated, This is a medication error. He only got 50 mg until the day the pharmacy brought the medications, after 6/23/26. A report should have been filled out. IDT (Interdisciplinary Team) should have looked into this. She needs to notify R3's MD (Medical Doctor) about this and I educated her today.

Based on interview and record review, the facility did not ensure that a resident's drug regimen was free from unnecessary medications for 1 of 5 residents reviewed for unnecessary medications (R8).R8 is receiving Trazodone for Insomnia. The facility failed to complete a sleep assessment prior to starting the medication. Evidenced by:The facility policy entitled, Psychotropic Medication Use, dated 1/2026, states, in part: . Policy: Residents are not given psychotropic medication unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record.Policy Explanation and Compliance Guidelines:1. Psychotropic medications include, but are not limited to: antipsychotics, antidepressants, anti-anxiety, and hypnotics.2. The indications for use of any psychotropic drug will be documented in the medical record.a. Pre-admission screening may be used to determine indications for use of psychotropic medications ordered upon admission to the facility.c. Psychotropic medications will be initiated after other causes have been ruled out or addressed, and nonpharmacological interventions have been attempted.8. Medications that have a documented use that appears to be a substitution for a psychotropic medication are subject to the same requirements as psychotropic medications. R8 was admitted to the facility on [DATE] and has diagnoses that include Insomnia.R8's admission Minimum Data Set (MDS) Assessment, dated 4/28/26 shows that R8 has a Brief Interview of Mental Status (BIMS) Score of 12 indicating R8 has moderate cognitive impairment.R8's Physician Orders, dated for 6/08/26-7/08/26, states, in part: . Trazodone tablet; 100 milligrams (mg); amount: 200 mg; oral. Special Instructions: Give (2) 100 mg tabs = 200 mg total by mouth daily at bedtime for insomnia. Start Date: 4/28/26 End Date: Open Ended. R8's Care Plan, dated 7/07/2026, states, in part: . Problem Start Date: 7/07/26. InsomniaGoal: Long Term Goal Target Date: 10/07/26 Resident will have at least 6 hours sleep per night.Approach: .-Administer medication per MD Order. Approach Start Date: 7/07/26.-Sleep study as needed. Approach Start Date: 7/07/26. R8's Medication Administration Record (MAR) for 4/2026 shows R8 received Trazodone for Insomnia 4/28/26- 4/30/26.R8's MAR for 5/2026 shows R8 received Trazodone for Insomnia 5/1/26- 5/31/26.R8's MAR for 6/2026 shows R8 received Trazodone for Insomnia 6/1/26- 6/31/26.R8's MAR for 7/2026 shows R8 received Trazodone for Insomnia 7/1/26- 7/08/26. On 7/07/26 at 3:00 PM, Surveyor interviewed RCD C (Regional Clinical Director) and asked for a sleep assessment for R8's Trazodone use. RCD C indicated the facility does sleep aide monitoring on side effects of the medication and log the hours of sleep each shift on the medication administration record (MAR). RCD C indicated those are started on the MAR when the sleep aide starts or if a resident is admitted on a sleep aide. RCD C indicated the facility does not do sleep assessments prior to starting a sleep aide.On 7/09/26, at 8:33 AM, Surveyor interviewed DON B (Director of Nursing) and asked what the process is for starting a resident on a sleep aide. DON B indicated the facility does side effect monitoring and hours of sleep every shift. Surveyor asked DON B what the process for a new admission is admitting with a sleep aide ordered. DON B indicated it is the same. Surveyor asked DON B if the facility does sleep assessments for residents before starting them on a sleep aide. DON B indicated no. Surveyor asked if R8 has a sleep assessment and DON B indicated no.

Based on observation, interview, and record review, the facility did not provide food that accommodates resident preferences; appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice for 1 of 1 sampled resident's (R33). R33 voiced concerns he does not receive his preferences as specified on meal tickets unless he asks for them.Evidenced by:The facility policy entitled, Nutritional Assessment, dated 1/25, states, in part: . Policy: A nutritional assessment will be completed on all residents within 5-14 days of admission.Procedure:1. Collect Data: A. Complete Nutritional Assessment Form in EMR (electronic medical record). 1. Assessment form includes: . f. Collecting likes/dislikes.Communicate Data: 1. Document nutrition related problems and approaches. 2. Communicate recommendations in writing to nursing. 6. Transfer appropriate information to computerized tray card and/or food service staff. R33 was admitted to the facility on [DATE] and has diagnoses that include Traumatic Brain Injury and Adjustment Disorder.R33's admission Minimum Data Set (MDS) Assessment, dated 3/30/26, shows R33 has a Brief Interview of Mental Status (BIMS) score of 15 indicating R33 is cognitively intact.R33's Physicians Orders, dated 6/10/26, states, in part: . Diet- Regular with thin liquids. Start Date: 3/24/26 End Date: Open Ended.-I authorize the facility's appointed qualified dietician/qualified nutrition profession who is acting within their scope of practice as defined by State Law the task of writing dietary orders while under the supervision of this physician. Start Date: 3/24/26 End Date: Open Ended. R33's Meal Card, dated 7/07/26 shows R33 would like Frosted Flakes daily for breakfast.On 7/06/26 at 2:50 PM, Surveyor interviewed R33. R33 indicated the food is atrocious. The menus do not match what is served. R33 indicated he wants frosted flakes every morning for breakfast and it is listed on his meal card. R33 indicates he does not get frosted flakes every morning and he will have to ask for them. R33 indicated it is upsetting and frustrating. On 7/08/26 at 11:04 AM, R33 requested to see this Surveyor. Surveyor went to speak with R33 and he indicated he did not get his frosted flakes again this morning. R33 indicated he had told the cna (certified nursing assistant) and she went to the kitchen to get them and brought the frosted flakes to R33.On 7/08/26 at 11:38 AM, Surveyor interviewed CNA N . CNA N indicated R33 did not get his frosted flakes this am and she had to go to the kitchen to get them for R33. Surveyor asked if R33 is to receive frosted flakes every morning with breakfast. CNA N indicated yes, it is on his meal card to receive frosted flakes every morning with breakfast. On 7/08/26 at 3:40 PM, Surveyor interviewed DM E (Dietary Manager) and asked what the process is for collecting and honoring residents' preferences. DM E indicated during intake DM E or the supervisor completes a preference sheet. The preferences are transferred onto the residents' meal slips. Surveyor asked how the dietary staff and nursing staff are made aware of their preferences. DM E indicated he verbally communicates it to the staff and it is changed on the meal slips. The meal slips are sent out on the residents' meal trays with meals. Surveyor asked DM E if he would expect residents' preferences to be honored. DM E indicated yes. Surveyor informed DM E of R33's concern with not receiving frosted flakes every morning for breakfast and the interview with CNA N about R33 not receiving frosted flakes this morning. On 7/09/26, at 8:33 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor informed DON B of R33's concern about not receiving frosted flakes every morning for breakfast, which is listed on R33's meal slips. Surveyor asked DON B if she would expect R33's preference for frosted flakes to be honored. DON B indicated yes.

Based on interview and record review the facility did not maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for 1 of 26 sampled residents (R53) for change of condition.The facility did not maintain a complete medical record for R53. Evidenced by:Facility policy, titled Clinical Record policies, reviewed 1/2026, includes: . The clinical record shall contain information to identify the resident clearly, a record of the resident's assessments, the plan of care and services, the results of pre-admission screening, and progress notes which indicate changes towards achieving care plan objectives. In addition, the resident's clinical record shall be readily accessible and systematically organized to facilitate retrieving and compiling information. The purpose of the clinical record is to document events through the course of the resident's stay. To provide a medium of communication among health care professionals involved in the resident's plan of care, to provide supportive documentation for reimbursement purposes, to service as a basis for evaluation of the facility's quality of care, to assist in protecting the facility's residents and health care providers' legal interests. Physician's progress notes are entered into the record at the time of each visit and signed and authorized by the physician. Progress notes, assessments, observations, medication and treatment records- In the resident's medical record as events occur in each facility department, documents will be authenticated and dated and may include. notation of physician visit, notation of resident's visits to clinics, hospitals, . notations of unusual incidents or accidents or actions taken.R53 admitted to the facility on [DATE] with the following diagnoses, including Type 2 Diabetes Mellitus, Malignant neoplasm of liver and intrahepatic bile, Acute Myocardial Infarction, and Chronic Obstructive Pulmonary Disease.R53's Progress Notes, dated 6/10/26 at 1:11 PM, includes: Received a phone call from hospital stating they are keeping him overnight due to low oxygen saturation and pain management. (Transportation company) was notified and ride was canceled. Resident is currently hospitalized at this time. Wound measurements not obtained due to hospitalization.(It is important to note RX's medical record did not contain notes from this hospital stay or the clinic visit where RX had the following procedure: IR Microwave Ablation with CT Guidance Liver.)R53's Progress Notes, dated 6/15/26 at 12:06 PM, includes: Resident is being admitted back to the facility today. Transportation and accompanied by a public transportation company. Resident is being discharged today from hospital with primary diagnosis of acute respiratory failure after having an IR microwave ablation procedure done. Resident transfers and ambulates with assist of 1 with a wheeled walker and gait belt. Last bowel movement was 6/15/26. Diet was changed to a carb controlled with thin liquids.On 7/6/26 at 4:00 PM Surveyor asked RCD C (Regional Clinical Director) to assist Surveyor with finding information regarding R53's clinic visit and/or hospitalization, dated 6/10/26. RCD C indicated she was unable to locate it in R53's record, but maybe it was not scanned in yet and she would talk with Medical Records.On 7/7/26 at 4:00 PM Surveyor asked RCD C for copies of R53's clinic visit or hospital visit, dated 6/10/26. RCD C indicated she was working on it. Surveyor asked if the facility had access to the Epic system. RCD C indicated they should.On 7/8/26 at 9:20 AM DON B brought Surveyor copies of R53's clinic visit and hospitalization for the time frame of 6/10/26-6/15/26. DON B indicated these should have been in R53's Medical Record, but there was staff turnover in the Medical Records Department. On 7/8/26 at 1:03 PM Medical Records Clerk S indicated R53's documentation from the clinic and the hospital should have been scanned into his record and wasn't. Medical Records Clerk S indicated if it was scanned in it would have a stamp on it that says scanned with a date. On 7/8/26 at 1:11 PM RCD C indicated either R53 didn't bring the paperwork to facility staff or facility staff didn't print them and scan them in. RCD C stated, Either way they should have been there.

Based on review of facility policy, record review and interviews, the facility failed to ensure four Residents (R)2, R3, R4 and R5) of a total of 16 residents reviewed for abuse/neglect/misappropriation were free from misappropriation of funds when money was stolen from each of the residents by a staff member (Certified Nursing Assistant (CNA1)). The facility's failure to ensure residents were free from misappropriation of property/funds created the potential for these and other residents to experience psychosocial harm related to the misappropriation and/or continued misappropriation of property/funds. A total of 16 residents were reviewed in the sample. Findings include:1. Review of R2's Resident Face Sheet, dated 01/22/26 and found in the EMR under the CCD Tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Adult Failure to Thrive and heart disease. The resident was discharged from the facility on 12/17/25. Review of R2's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/05/25 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact.Review of R2's record, including the Progress Notes, dated 08/01/25 through 12/17/25 and found in the EMR under the Progress Notes Tab, revealed nothing related to R2's allegation of misappropriation of property by CNA1. Review of the facility's investigation into R2's allegation of misappropriation, dated 10/03/25, revealed R2 reported she woke up from sleeping in her bed and CNA1 was in her room taking money from her wallet. A thorough investigation into the resident's allegation was completed by the facility. Additional reports of potential misappropriation of funds by CNA1 were received during the investigation. The facility report indicated, While the facility cannot definitively prove [CNA1 stole any money, the investigation led to questions regarding her involvement with multiple instances of missing money raises too many concerns, and the decision to terminate [CNA1's] employment has been made. [CNA1's] employment with the facility was terminated as a result of the investigation. R2 was not able to be interviewed related to the allegation of misappropriation of property since she was no longer residing in the facility.2. Review of R3's Resident Face Sheet, dated 01/22/26 and found in the EMR under the CCD Tab, revealed the resident was admitted to the facility on [DATE]. R3's diagnoses included morbid obesity and heart disease. Review of R3's Quarterly MDS assessment, with an ARD of 11/03/25 and found in the EMR under the MDS tab, indicated a BIMS score of 15 out of 15, which indicated the resident was cognitively intact.Review of R3's record, including the Progress Notes, dated 07/31/25 through 01/22/26 and found in the EMR under the Progress Notes Tab, revealed nothing related to R3's allegation of misappropriation of property by CNA1. Review of the facility's investigation into R3's allegation of misappropriation, dated 10/03/25, revealed during the facility's investigation related to R2's allegation of stolen money, R3 was interviewed and stated two to three weeks after her admission to the facility $55 to $75 dollars was taken out of her wallet. A thorough investigation was completed by the facility related to R3's report of missing money. Additional reports of potential misappropriation of funds by CNA1 were received during the investigation of missing funds for R2 and R3. The facility report indicated CNA1's employment with the facility was terminated as a result of the investigation. R3 was interviewed on 01/20/26 at 1:38 PM and confirmed money had been stolen from her during her first two to three weeks at the facility. 3. Review of R4's Resident Face Sheet, dated 01/22/26 and found in the EMR under the CCD Tab, revealed the resident was admitted to the facility on [DATE]. R4's diagnoses included congestive heart failure chronic kidney disease. Review of R4's Quarterly MDS assessment, with an ARD of 11/11/25 and found in the EMR under the MDS tab, indicated a BIMS score of 15 out of 15, which indicated R4 was cognitively intact.Review of R4's record, including the Progress Notes, dated 05/01/25 through 01/22/26 and found in the EMR under the Progress Notes Tab, revealed nothing related to R4's allegation of misappropriation of property by CNA1. Review of the facility's investigation into R4's allegation of misappropriation, dated 10/03/25, revealed during the facility's investigation related to R2's initial allegation of stolen money, R4 was interviewed and stated $50 to $65 dollars was stolen from her in May of 2025. A thorough investigation was completed by the facility related to R4's report of missing money. Additional reports of potential misappropriation of funds by CNA1 were received during the investigation of missing funds. The facility report indicated CNA1's employment with the facility was terminated as a result of the investigation. During an interview on 01/20/26 at 1:50 PM R4 stated, That lady [CNA1] stole my money. I don't remember exactly when. They [the facility] fired her. She has not been back.4. Review of R5's Resident Face Sheet, dated 01/22/26 and found in the EMR under the CCD Tab, revealed the resident was admitted to the facility on [DATE]. R5's diagnoses included history of stroke. Review of R5's Quarterly MDS assessment, with an ARD of 12/11/25 and found in the EMR under the MDS tab, indicated a BIMS score of 15 out of 15, which indicated the resident was cognitively intact.Review of R5's record, including the Progress Notes, dated 12/04/24 through 01/22/26 and found in the EMR under the Progress Notes Tab, revealed nothing related to R5's allegation of misappropriation of property by CNA1. Review of the facility's investigation into R5's allegation of misappropriation, dated 10/03/25, revealed during the facility's investigation related to R2's initial allegation of stolen money, R5 she had money go missing a while ago but she did not remember exactly when. The investigation indicated R5 named CNA1 as the person who she thought took her money. A thorough investigation was completed by the facility related to R5's report of missing money. Additional reports of potential misappropriation of funds by CNA1 were received during the investigation of missing funds. The facility report indicated CNA1's employment with the facility was terminated as a result of the investigation. During an interview with R5 01/20/26 at 1:30 PM, she stated, That money was taken almost a year ago. They [the facility] handled it. She [CNA1] was let go. I haven't seen her since.During an interview with the Director of Nursing (DON) and the Administrator on 01/22/25 at 12:33 PM, the Administrator confirmed the allegations of misappropriation of funds by CNA1. The Administrator stated the facility's investigation into the allegations of misappropriation of R2, R3, R4 and R5's money revealed CNA1 likely stole the residents' money and CNA1 was terminated and reported to the local Police Department as a result of the investigation. The Administrator stated his expectation was residents residing in the facility would be free from all forms of abuse including misappropriation of property. Review of the facility's Abuse Prevention Program Policy and Procedure dated last revised/reviewed in 01/2025 indicated, Each resident has the right to be free from abuse, neglect and corporal punishment of any type by staff or anyone. The facility will provide a safe environment and protect residents from abuse; and Misappropriation of Resident Property: The deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of residents' belongings or money without the resident's consent; and The provision of training on abuse prohibition alone does not relieve the facility of its responsibility to assure that the resident is free from abuse. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written.

Based on observations, interviews, and policy review, the facility failed to ensure menus were followed. This failure placed 78 of the 79 residents in the facility at risk for nutritional problems and dissatisfaction with their meals. Findings include:1. A review of the week three menu provided to the survey team indicated that on 01/20/26 the dinner meal would be Minestrone Soup, Saltines, Grilled Cheese sandwich, Lettuce, Tomato, Onion, French Fries, Apple Slices, Ketchup, Margarine, 2% (percent) milk and/or coffee. However, during the meal observation at 5:15 PM, residents were served a dinner consisting of Minestrone soup, a grilled cheese sandwich, canned pears, and a choice of 2% milk, coffee, or juice. There was no observation of French fries, apple slices, lettuce, tomato and onions as documented on the menu, A review of the week three menu for lunch on 01/21/26 would include Chili with Beans, Baked Potato, Sweet Potato Cornbread, Red Grapes, Sour Cream and Chives, Margarine, and 2% milk, coffee, or tea. An observation made at 12:30 PM, the residents received Chili with Beans, Baby Baked Potatoes, Sweet Potato Cornbread or Dinner Roll, Red Grapes, and the choice of 2% milk, coffee, or juice. There was no observation of sour cream and chives as documented on the menu. A review of the week three menu for supper on 01/21/26 would include Corn Dogs, Creamy [NAME] Slaw, Banana, Margarine, 2% milk, coffee, or tea. An observation made at 5:15 PM, the residents received Corn Dogs, Tater Tots, Coleslaw, Sugar Cookies, and a choice of 2% milk, coffee and/or juice. There was no observation of tater tots or a banana as documented on the menu. During an interview on 01/21/26 at 2:01 PM, Cook1 stated, The menus are pre-made, and we are on a four-week rotation. We usually don't order potatoes to bake because they come in so big that we are wasting more than what the residents are eating. That is why we went to the baby baker potatoes. We usually don't include the sour cream and chives because we can't split them like we did with the baked potatoes.During an interview on 01/22/25 at 12:33 PM, the Administrator stated, We put what we are having for the meal on the whiteboard and then [Dietary Manager (DM)] can also give the residents a printed copy of the menu if the resident would like it. The company says that the whiteboard serves as our menu and that is what we will be serving. We also put on the whiteboard that the menu is subject to change.During an interview on 01/22/26 at 1:27 PM, the Dietary Manager (DM) stated, The menus will vary depending on the supply and demand that we are having to deal with when ordering food. There are some foods that we just cannot get, so we have to adjust the menu. When asked if the DM was aware the registered dietician had to approve the adjustments that are being made with the resident's meals to make sure the residents were receiving the correct amounts of food and within the same food group and he stated, I was not aware of that.Review of the facility's policy Menu Planning dated January 2025 indicated, Menus are planned in advance & [and] [sic] are followed as written, in order to meet the nutritional needs of the residents, in accordance with established national guidelines.2. During a group interview conducted with five Residents (R9, R10, R11, R12 and R13) on 01/21/26 at 10:00 AM, the residents unanimously stated they would like a substantial alternate with each of their meals for each food group. The group stated they were unaware French fries and lettuce, tomatoes, onions and ketchup were on the menu to be served with their 01/20/25 dinner time meal and all indicated, We love French fries! All stated they would have liked to have received the fries and vegetables with their meal. The group stated they were not usually aware of what was on the facility's actual menu, but menu items were posted on a dry erase board in the dining room. The group confirmed substantial alternates were never posted on the dry erase board or anywhere else in the facility, but they all thought they could request a sandwich or a soup if they did not like what was being served. The group stated they were never told the fruit served with the 01/20/26 dinner meal was supposed to be apples (rather than pears) and two of the five residents stated pears were served too often and that they did not like pears but were not offered any alternate to the pears when served. The group unanimously agreed they were not notified when the menu changed, but stated they would not know the menu changed to begin with since they were never provided with the facility's actual menu (they were only notified of what was being served by what was printed on the dry erase board in the dining room). Review of R14's Resident Face Sheet, dated 01/22/25 and found in the EMR under the Continuity of Care Document (CCD) Tab, revealed the resident was admitted to the facility on [DATE] with diagnoses included dementia, chronic and acute kidney disease and cellulitis of her left lower limb. Review of R14's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 01/12/26 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of one out of 15, which indicated severely cognitively impaired. Review of R14's dietary physician's orders, dated 01/15/26 and found in the EMR under the Orders Tab, revealed an order for R14 to receive a regular chopped diet with think liquids. Review of R14's care plan, dated most recently revised 01/16/26 and found in the EMR under the Care Planning Tab, revealed the resident was at risk for significant weight loss. The care plan indicated all foods were to be served a regular diet cut into bite sized pieces. The care plan also indicated R14 required setup and cleanup assistance with meal service and was to be indirectly supervised by staff while eating meals.Review of R14's current diet card/tray card, issued with the resident's meal on 01/21/26 and used by dietary and nursing staff to ensure the resident was receiving her appropriate diet, revealed R14 had no recorded disliked food or fluid and revealed R14 was to receive a soft and bite sized regular diet. On 01/21/26 from 11:35 AM until 12:30 PM, R14 was observed in the dining room eating lunch. A dry erase board next to the kitchen service window indicated chili with beans, baby baked potato, corn bread/dinner roll and grapes were to be served for the meal. At 12:00 PM, R14 was observed being served the chili, a whole bread roll and whole grapes by staff. R14 refused the chili and chicken noodle soup was brought to R14 to replace the chili at 12:15 PM. R14 did not receive potatoes of any kind and R14's bread roll and grapes (large) were served whole. R14 was observed eating bread roll, soup and grapes quickly and independently without staff interaction. During an interview with the Dietary Manager (DM) the DON and the Administrator on 01/22/25 at 12:33 PM, the DM stated R14's roll should have been cut into bite sized pieces and R14 should have been served bananas instead of grapes with the meal. DM stated DM was unable to say why R14 was not served potatoes with the meal and confirmed any dislikes or allergies were to be noted on each resident's tray card. The DM stated the facility should be providing R14 with a diet to meet R14's needs. The DON and Administrator stated they were in agreement R14 should have been served a soft chopped diet and should have received potatoes with the meal and all residents were expected to receive meals to meet their preferences and needs.

Based on observations and staff interviews, the facility failed to ensure the kitchen staff prevented contamination of food containers while taking food temperatures and also when the kitchen staff was placing lids on the bowls that contained food the residents would eat. This failure had the potential to increase the risk of foodborne illness for 78 of the facility's 78 residents. During an observation on 01/21/26 at 11:20 AM, Cook1 was observed taking food temperatures of the Chili with Beans, Mashed Potatoes, and pureed Mixed Vegetables. Cook1 was observed to touch the inside of each of these food containers with her bare hand while taking the food temperatures.During an observation on 01/21/26 at 11:28 AM, Dietary Aide (DA)1 was observed touching the inside of the lids with her bare hands while placing the lids on the bowls of Chil with Beans and then placing these bowls on the resident's trays.During an interview on 01/21/26 at 2:01 PM, Cook1 stated, I was not aware that I did that. You are not to touch the inside of the food containers with your hand when you are taking the food temperatures.During an interview on 01/21/26 at 2:14 PM, asked DA1 if she was supposed to touch the inside of the lids when placing them on the bowls of chili with beans. DA1 stated, I don't know.During an interview on 01/22/26 at 1:27 PM, the Dietary Manager (DM) confirmed the kitchen staff were not supposed to touch the inside of the containers of food with their bare hands when taking the food temperatures or when they are placing the lids on the bowls of chili.

Based on review of facility policy, record review and interviews, the facility failed to ensure consistent and comprehensive management of nutritional services for one Resident (R ) R14) out of three residents reviewed for nutrition. The facility's failure to ensure consistent nutritional interventions were provided for R67 created the potential for this and other residents to experience significant/unanticipated weight loss or nutritional deficits. A total of 50 residents were reviewed in the sample. Findings include:Review of R14's Resident Face Sheet, dated 01/22/25 and found in the EMR under the Continuity of Care Document (CCD) Tab, revealed the resident was admitted to the facility on [DATE], with diagnoses included dementia, chronic and acute kidney disease and cellulitis of her left lower limb. Review of R14's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 01/12/26 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of one out of 15, which indicated the resident was severely cognitively impaired. The assessment indicated no significant weight loss prior to admission to the facility.Review of R14's dietary physician's orders, dated 01/15/26, and found in the EMR under the Orders Tab, revealed an order for the resident to receive a regular chopped diet with thin liquids. The orders indicated R14 was to be weighed weekly on shower days (Sundays) and R14 was to be offered a bedtime snack each evening and was to receive ProStat (a protein liquid) 30 milliliters (MLs) twice daily to support wound healing. Review of R14's care plan, revised 01/16/26, and found in the EMR under the Care Planning Tab, revealed the resident was at risk for significant weight loss. The care plan indicated all foods were to be served a regular diet cut into bite sized pieces, R14's intake was to be monitored and was to receive diet as ordered.Review of R14's current diet card/tray card, issued with R14's meal on 01/21/26 and used by dietary and nursing staff to ensure R14 was receiving her appropriate diet, revealed R14 had no recorded disliked food or fluid and revealed R14 was to receive a soft and bite sized regular diet. Review of R14's Weight Record, dated 01/21/26 and found in the EMR under the Vital Signs Tab, revealed the following weights:01/06/26: 118 pounds01/07/26: 113.8 pounds01/08/26: 114.0 pounds01/11/26: 110.0 poundsThere was no recorded weight entered into the record after 01/11/26. Review of R14's Vitals Report, dated 01/06/26 through 01/21/26 and provided directly to the survey team, revealed R14's meal intake was not recorded consistently per her plan of care. The record indicated meal intake was not recorded for 10 of a total of 46 meals consumed by R14 since admission to the facility on [DATE]. Review of R14's Initial Nutritional Assessment, dated 01/06/26 and found in the EMR under the Observations Tab, revealed R14 was at risk for significant weight loss. The document indicated R14 was underweight and indicated Will monitor need for additional high calorie supplements pending intake adequacy, skin, weight trends. RD (Registered Dietician) to update plan of care as needed.Review of R14's record revealed nothing to indicate the facility follow-up related to R14's weight loss since admission or effort made to document meal intake accurately or obtain weights according to her physician's orders. On 01/21/26 at 4:00 PM, R14 was observed as facility staff obtained R14's weight, which was 114.4 pounds. During an interview with the Director of Nursing (DON) and the Administrator on 01/22/25 at 12:33 PM, the DON confirmed the facility was not able to locate any documentation to show R14 had been weighed after 01/11/26 and had not been able to find anything to indicate the resident's meal intake had been documented consistently in her record. The DON stated her expectation was residents were to be weighed as ordered by the physician and meal intake was expected to be documented for each meal so the team would be able to determine and address any concerns with nutritional intake patterns. The DON confirmed facility staff should have been monitoring R14 more closely related to her nutritional status due to her medical status and recorded loss of weight while in the facility. Review of the facility's Weight and Height Records Policy dated last revised/reviewed in 01/2025 indicated, Residents will have their weight obtained by certified and licensed staff at monthly intervals unless more frequent monitoring is needed as determined by resident weight record, medical condition, or clinical staff; and Weight orders will be placed in the EMR if more frequent monitoring is needed than stated in facility policy; and Weights will be recorded in the EMR when obtained.Review of the facility's Monitoring Nutrient Intake Policy dated last revised/reviewed 01/2025 indicated, Nursing services will record intake according to percentage of entire meal eaten; and Nursing will document percentage of consumption of each meal and substitution in resident's record.

Based on interview and record review, the facility failed to put measures in place to prevent further abuse, following an allegation of abuse, for 1 of 1 allegation reviewed. This has the potential to affect a pattern of the facility's 75 residents. On 09/09/25, allegations of potential abuse were reported against Certified Nursing Assistant (CNA) G. CNA G was allowed to continue working with residents for the rest of that shift and worked again on 09/11/25 and 09/12/25 during the facility's investigation. This is evidenced by:The facility policy, titled Abuse Prevention Program, dated last reviewed 01/2025, states in part: Upon recognizing signs/symptoms of stressed staff, the observer will take action which may include but is not limited to. relieve the staff member of direct care duties.The investigation must include but not limited to: Identify alleged perpetrator, remove from resident care area immediately, suspend pending investigation conclusion, obtain statement.R4 was admitted to the facility in 2023, with diagnoses including, gastroenteritis, rheumatoid arthritis, osteoarthritis, weakness, and anxiety disorder. R4 is alert oriented and able to make her needs known. R4's Minimum Data Set (MDS) assessment, dated 06/29/25, indicated that her brief interview for mental status (BIMS) score is 15/15, indicating intact cognitive function. Surveyor interviewed R4 on 09/16/25 at 10:30 AM. When asked if she had had any recent care concerns, R4 responded that the other night a CNA, CNA G, had been haughty, condescending, and dictatorial, insisting that she move her pencil box off her bed herself. R4 stated CNA G pushed the over the bed table closer to her and insisted R4 pick it up, or she would leave. R4 stated CNA G grabbed her wrist twice. R4 stated the other gal, CNA D, called for the nurse, and the nurse came in and made CNA G leave. R4 stated CNA G had grabbed her right wrist, trying to force her to roll over. R4 stated that she told the CNA to let go, but she didn't. R4 stated CNA G was yelling in her face, to roll over. Surveyor asked how close CNA G was when she was in her face. R4 held her hand up to show the distance. Surveyor clarified, About a foot and a half away? R4 responded, Yes. R4 stated CNA G was condescending, ordering her around like a 3-year-old. Other CNAs are polite. R4 stated she asked CNA G to leave 3-4 times, but she didn't. When asked if she was afraid, R4 responded, a little bit her attitude, was more and more escalating. When asked if she had pain from being grabbed, R4 responded it left no marks, but CNA G held it tightly. When asked if it made her cry, R4 said no. When asked if she feels CNA G was abusive to her, she stated, Yes. When asked if she was still afraid, R4 stated, No, she hasn't been back. When asked if she feels safe, R4 stated, Yes, and added that overall, her care has been good. During the interview, R4 remained calm when speaking about the incident, the pace of her language did not change and she showed no changes in facial expression.Surveyor interviewed CNA D on 09/16/25 at 8:20 AM. CNA D worked with R4 on 09/09/25 at approximately 10:45 PM when the incident occurred. CNA D stated she asked CNA G to come assist her with R4's cares, as R4 requires the assistance of two staff, due to making false allegations towards staff. CNA D stated that when she first approached CNA G to ask for assistance with R4's cares, CNA G immediately said, No. CNA D stated she then explained no other staff were able to come assist, so CNA G came. CNA D stated that CNA G spoke to R4 in a condescending manner. CNA D stated that CNA G grabbed R4's wrist and did not let go when the resident asked. CNA D stated CNA G was scolding R4 and described the situation as a power trip.Review of CNA D's witness statement dated 09/09/25 at 10:45 PM reveals the following information. CNA D's statement states that CNA G told R4 she needed to move her belongings. R4 stated to move it for her. CNA G then responded, I'm not moving your belongings, you can, otherwise we can't help you. R4 then told staff, That's fine you can leave. CNA D then stated that if she leaves, I can't help you; there's no other staff that feels comfortable to help you on tonight. R4 asked who else could from other halls. CNA D stated she told her who, then CNA G stated, Do you want me to help? and the resident said, That's fine. Staff pulled the covers down, and CNA G grabbed the resident's arm/wrist to turn her to her left side. Resident tried to pull her arm away and said, You don't have to grab my arm. CNA G said, I'm trying to put you on the bed pan. Do you want my help or not? CNA G continued to hold onto R4's arm to turn her to assist with putting resident on bed pan. R4 continued to resist. CNA D stated I went to grab the nurse because the situation was not deescalating.On 09/16/25 at 10:30 AM, Surveyor interviewed Licensed Practical Nurse (LPN) F who stated she was in the hall when she was called to R4's room. LPN F stated that when she entered the room R4's eyes were watering, and she was visibly trembling. LPN F stated CNA G was speaking aggressively and was not appropriate. LPN F stated she asked CNA G to leave a couple of times before she did. LPN F stated that CNA G got really close to R4's face and asked her if she wanted her to leave, and R4 responded that, Yes she wanted her to leave. CNA G responded, Fine, and then left. When asked if she noticed anything with R4's wrist, LPN F stated the arm was slightly red, near the wrist. When asked if R4 was upset, while she continued with the cares, LPN F stated that R4 calmed as soon as CNA G left the room. When asked if she felt CNA G was abusive to R4, LPN G responded, Yes. LPN F stated she called the Director of Nursing (DON) right away to report the incident and began to gather statements for an investigation. LPN F stated she was surprised that CNA G was not removed from the building during the investigation. LPN F stated that CNA G continued to work the rest of the night shift on the 100 hall.Review of LPN F's witness statement dated 09/09/25 states in part, Nurse called to resident room by CNA D stating CNA G and R4 were arguing. The nurse walked into CNA G demanding resident roll. R4 had a look of fear and distress, so the nurse immediately asked CNA G to leave. CNA G told resident she's got it and she will continue cares. The nurse said no I'll take over. To which the CNA G responded no I got it. This nurse then said in a stern voice, You need to leave now. CNA G then turned to resident, leaning in inches from her face, and kept repeating, Do you want me to leave [R4]? This nurse repeated herself for the third time asking CNA G to leave as well as resident stating again that she would like CNA G to leave. This nurse then repeated to CNA to leave. CNA finally left and continued to talk aggressively to R4 on her way out. Nurse reported incident to DON within 30 minutes of interaction.On 09/15/25 at 4:19 PM, Surveyor interviewed Nursing Home Administrator (NHA) A who stated that following the incident, CNA G continued to work the rest of her shift, until 6:30 AM on the 100 hall. NHA A later provided information which stated that CNA G worked on 09/11/25 from 6 AM - 2:30 PM and on 09/12/25 from 6 AM - 2:30 PM. While working CNA G primarily worked on one of the facility's 4 halls, but she had the potential to assist with any of the residents on any of the halls.Review of the facility's roster matrix provided on 09/15/25 revealed that 16 residents resided on the 100 hall on 09/09/25.

Based on interview and record review, the facility did not ensure each resident remained free from abuse for 1 of 8 sampled residents (R4).R4 was spoken to in a manner that is described by the resident as abusive; the resident also states that staff did not release her wrist as requested.The facility policy, titled Abuse Prevention Program, dated last reviewed 01/2025, states, Each resident has the right to be free from abuse, neglect and corporal punishment of any type by staff or anyone. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.R4 was admitted to the facility in 2024, with diagnoses including, gastroenteritis, rheumatoid arthritis, osteoarthritis, weakness, and anxiety disorder. R4 is alert and oriented and able to make her needs known.Surveyor interviewed R4 on 09/16/25 at 10:30 AM. When asked if she had had any recent care concerns, R4 responded that the other night a Certified Nursing Assistant (CNA), CNA G, had been haughty, condescending, and dictatorial, insisting that she move her pencil box off her bed herself. R4 stated CNA G pushed the over the bed table closer to her and insisted R4 pick it up, or she would leave. R4 stated CNA G grabbed her wrist twice. R4 stated the other gal, CNA D, called for the nurse, and the nurse came in and made CNA G leave. R4 stated CNA G had grabbed her right wrist, trying to force her to roll over. R4 stated that she told CNA G to let go but she didn't. R4 stated CNA G was yelling in her face. Surveyor asked how close CNA G was when she was in R4's face. R4 held her hand up to show the distance. Surveyor clarified, About a foot and a half away? R4 responded Yes. R4 stated CNA G was condescending, ordering her around like a 3-year-old. Other CNAs are polite. R4 stated she asked her to leave 3-4 times, but she didn't. When Surveyor asked if R4 was afraid, R4 responded, a little bit, her attitude, was more and more escalating. When asked if she had pain from being grabbed, R4 responded, it left no marks, but CNA G held it tightly. When asked if it made her cry, R4 said no. When asked if she feels CNA G was abusive to her, she stated, Yes. When asked if she was still afraid R4 stated, No, she hasn't been back. When asked if she feels safe, R4 stated, Yes, and added that overall, her care has been good. During the interview, R4 remained calm when speaking about the incident, the pace of her language did not change and she showed no changes in facial expression. Surveyor interviewed CNA D on 09/16/25 at 8:21 AM. CNA D worked with R4 on 09/09/25 at approximately 10:45 PM when the incident occurred. CNA D stated she asked CNA G to come assist her with R4's cares, as R4 requires the assistance of 2 staff, due to making false allegations towards staff. CNA D stated that when she first approached CNA G to ask for assistance with R4's cares, CNA G immediately said, No. CNA D stated she then explained no other staff were able to come assist, so CNA G came. CNA D stated that CNA G spoke to R4 in a condescending manner. CNA D stated that CNA G grabbed R4's wrist and did not let go when the resident asked. CNA D stated CNA G was scolding R4 and described the situation as a power trip.Review of CNA D's statement dated 09/09/25 at 10:45 PM reveals the following information. CNA D's statement states that CNA G told R4 she needed to move her belongings. R4 stated to move it for her. CNA G then responded, I'm not moving your belongings, you can, otherwise we can't help you. R4 then told staff, That's fine you can leave. CNA D then stated that if she leaves, I can't help you; there's no other staff that feels comfortable to help you on tonight. R4 asked who else could from other halls. CNA D stated she told her who, then CNA G stated, Do you want me to help?? and the resident said, That's fine. Staff pulled the covers down, and CNA G grabbed the resident's arm/wrist to turn her to her left side. R4 tried to pull her arm away and said, You don't have to grab my arm. CNA G said, I'm trying to put you on the bed pan. Do you want my help or not? CNA G continued to hold onto R4's arm to turn her to assist with putting resident on bed pan. R4 continued to resist. CNA D stated I went to grab the nurse because the situation was not deescalating.On 09/16/25 at 10:30 AM, Surveyor interviewed Licensed Practical Nurse (LPN) F, who stated she was in the hall when she was called to R4's room. LPN F stated that when she entered the room R4's eyes were watering, and she was visibly trembling. LPN F stated CNA G was speaking aggressively and was not appropriate. LPN F stated she asked CNA G to leave a couple of times before she did. LPN F stated that CNA G got really close to R4's face and asked her if she wanted her to leave, and R4 responded that, Yes she wanted her to leave. CNA G responded fine, and then left. When asked if she noticed anything with R4's wrist, LPN F stated the arm was slightly red, near the wrist. When asked if R4 was upset, while she continued with the cares, LPN F stated that R4 calmed as soon as CNA G left the room. When asked if she felt CNA G was abusive to R4, LPN G responded, Yes. LPN F stated she called the Director of Nursing (DON) right away to report the incident and began to gather statements for an investigation. LPN F stated she was surprised that CNA G was not removed from the building during the investigation. LPN F stated that CNA G continued to work the rest of the night shift on the 100 hall.

Based on interview and record review the facility did not ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 1 resident incidents reviewed. (R4)R4 was spoken to in a manner that is described by the resident as abusive; the resident also stated that staff did not release her wrist as requested. This was not reported to the state survey agency within 24 hours.This is evidenced by:The facility policy, titled Abuse Prevention Program, dated last reviewed 01/2025, states in part:Reporting/Response All alleged or suspected violations are to be reported immediately to the Administrator or Director of Nursing, which are responsible to notify required officials, including to the State Survey Agency, .All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.R4 was admitted to the facility in 2023, with diagnoses including, gastroenteritis, rheumatoid arthritis, osteoarthritis, weakness, and anxiety disorder. R4 is alert and oriented and able to make her needs known. R4's Minimum Data Set (MDS) assessment, dated 06/29/25, indicated that her brief interview for mental status (BIMS) score is 15/15, indicating intact cognitive function. Surveyor interviewed R4 on 09/16/25 at 10:30 AM. When asked if she had had any recent care concerns, R4 responded that the other night a Certified Nursing Assistant (CNA), CNA G, had been haughty, condescending, and dictatorial, insisting that she move her pencil box off her bed herself. R4 stated CNA G pushed the over the bed table closer to her and insisted R4 pick it up, or she would leave. R4 stated CNA G grabbed her wrist twice. R4 stated the other gal, CNA D, called for the nurse, and the nurse came in and made CNA G leave. R4 stated CNA G had grabbed her right wrist, trying to force her to roll over. R4 stated that she told the CNA to let go, but she didn't. R4 stated CNA G was yelling in her face, to roll over. Surveyor asked how close CNA G was when she was in her face. R4 held her hand up to show the distance. Surveyor clarified, About a foot and a half away? R4 responded, Yes. R4 stated CNA G was condescending, ordering her around like a 3-year-old. Other CNAs are polite. R4 stated she asked CNA G to leave 3-4 times, but she didn't. When asked if she was afraid, R4 responded, a little bit, her attitude was more and more escalating. When asked if she had pain from being grabbed, R4 responded it left no marks, but CNA G held it tightly. When asked if it made her cry, R4 said no. When asked if she feels CNA G was abusive to her, R4 stated, Yes. When asked if she was still afraid, R4 stated, No, she hasn't been back. When asked if she feels safe, R4 stated, Yes, and added that overall, her care has been good. During the interview, R4 remained calm when speaking about the incident, the pace of her language did not change and she showed no changes in facial expression. Surveyor interviewed CNA D on 09/16/25 at 8:20 AM. CNA D worked with R4 on 09/09/25 at approximately 10:45 PM when the incident occurred. CNA D stated she asked CNA G to come assist her with R4's cares, as R4 requires the assistance of 2 staff, due to making false allegations towards staff. CNA D stated that when she first approached CNA G to ask for assistance with R4's cares, CNA G immediately said, No. CNA D stated she then explained no other staff were able to come assist, so CNA G came. CNA D stated that CNA G spoke to R4 in a condescending manner. CNA D stated that CNA G grabbed R4's wrist and did not let go when the resident asked. CNA D stated CNA G was scolding R4 and described the situation as a power trip.Review of CNA D's witness statement dated 09/09/25 at 10:45 PM reveals the following information. CNA D's statement states that CNA G told R4 she needed to move her belongings. R4 stated to move it for her. CNA G then responded, I'm not moving your belongings, you can, otherwise we can't help you. R4 then told staff, That's fine you can leave. CNA D then stated that if she leaves, I can't help you; there's no other staff that feels comfortable to help you on tonight. R4 asked who else could from other halls. CNA D stated she told her who, then CNA G stated, Do you want me to help? and the resident said, That's fine. Staff pulled the covers down, and CNA G grabbed the resident's arm/wrist to turn her to her left side. Resident tried to pull her arm away and said, You don't have to grab my arm. CNA G said, I'm trying to put you on the bed pan. Do you want my help or not? CNA G continued to hold onto R4's arm to turn her to assist with putting resident on bed pan. Resident continued to resist. CNA D stated I went to grab the nurse because the situation was not deescalating.On 09/16/25 at 10:30 AM, Surveyor interviewed Licensed Practical Nurse (LPN) F, who stated she was in the hall when she was called to R4's room. LPN F stated that when she entered the room R4's eyes were watering, and she was visibly trembling. LPN F stated CNA G was speaking aggressively and was not appropriate. LPN F stated she asked CNA G to leave a couple of times before she did. LPN F stated that CNA G got really close to R4's face and asked her if she wanted her to leave, and R4 responded that, Yes she wanted her to leave. CNA G responded fine, and then left. When asked if she noticed anything with R4's wrist, LPN F stated the arm was slightly red, near the wrist. When asked if R4 was upset, while she continued with the cares, LPN F stated that R4 calmed as soon as CNA G left the room. When asked if she felt CNA G was abusive to R4, LPN G responded, Yes. LPN F stated she called the Director of Nursing (DON) right away to report the incident and began to gather statements for an investigation. LPN F stated she was surprised that CNA G was not removed from the building during the investigation. LPN F stated that CNA G continued to work the rest of the night shift on the 100 hall.Review of LPN F's witness statement dated 09/09/25 states in part, Nurse called to resident room by CNA D stating, CNA G and R4 were arguing. The nurse walked into CNA G demanding resident roll. Resident had a look of fear and distress, so the nurse immediately asked CNA G to leave. CNA G told resident she's got it, and she will continue cares. The nurse said no I'll take over. To which CNA G responded no I got it. This nurse then said in a stern voice, You need to leave now. CNA G then turned to resident leaning in inches from her face and kept repeating, Do you want me to leave [R4]? This nurse repeated herself for the third time asking CNA G to leave as well as resident stating again that she would like CNA to leave. This nurse then repeated to CNA to leave. CNA finally left and continued to talk aggressively to resident on her way out. Nurse reported incident to DON within 30 minutes of interaction. Review of the facility self-report indicates it was reported to the state on 09/12/2025. The self-report indicates the incident occurred on 09/09/25.

Based on interview and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infections. This had the potential to affect all residents residing within the facility at the time of an outbreak on 1/2/25. This outbreak involved 49 out of 83 residents and 37 staff. As of 1/2/25, the facility was in a GI (gastrointestinal) outbreak with 2 staff and 1 resident with noted signs and symptoms of GI outbreak. - Facility staff line listings were not completed contemporaneously. - Temporary Care plans were not started for residents with GI signs and symptoms. - Residents with orders for Laxatives and Diuretics continued to take their prescribed medication without any monitoring for dehydration or bowel movement consistency and frequency. - Staff returned to work too soon following GI signs and symptoms. - Facility does not indicate when residents were taken off precautions following GI signs and symptoms. - Housekeeping did not ensure they cleaned non symptomatic resident rooms prior to those residents with GI signs and symptoms. - Housekeeping did not use any type of clothing barrier (e.g., apron) when sorting dirty laundry. - Facility did not notify DPH (Department of Public Health) of the outbreak until 1/6/25. The outbreak started on 1/2/25. - Facility did not complete a timeline of the outbreak. - Facility did not complete lessons learned following the GI outbreak. - Facility did not have an Ad Hoc QAPI meeting to discuss the GI outbreak. The facility's failure to mitigate the spread of the GI outbreak created a finding of immediate jeopardy that began on 1/3/25. NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were notified of the immediate jeopardy on 4/10/25 at 2:46 PM. The immediate jeopardy was removed on 1/14/25; however, the deficient practice continues at a severity/scope level of F (potential for more than minimal harm/widespread) as the facility continues to implement its action plan. This is evidenced by: The facility policy titled, Norovirus Prevention and Control, last reviewed 1/2025, states in part . Policy: This facility will implement infection control measures to prevent the transmission of norovirus infection. Procedure: 1. Place residents with symptoms of norovirus gastroenteritis on Contact Precautions in a private room. If a private room cannot be accommodated efforts must be attempted to separate symptomatic resident from asymptomatic residents. 2. Residents with norovirus gastroenteritis will be placed on Contact Precautions for a minimum of 48-72 hours after the resolution of symptoms. Longer periods of isolation or cohorting for medically complex residents may be considered. 3. Minimize symptomatic resident's movements within the unit; restrict recovering residents during 48-72 hour recover time frame also from leaving the resident-care area unless it is for essential care or treatment; and suspend group activities (e.g., dining events) for the duration of an outbreak. 4. During outbreak, frequent hand hygiene after providing care or having contact with residents suspected or confirmed with norovirus gastroenteritis. 5. Transfers may be limited to Contact Precautions are not able to be maintained; or transfers may be postponed until residents no longer require Contact Precautions. 6. Perform additional cleaning and disinfection of frequently touched environmental surfaces and equipment in resident care areas, resident with isolation and cohorted areas, as well as high-traffic clinical areas. Frequently touched surfaces include, but not limited to, commodes, toilets, faucets, hand/bed railing, telephones, door handles, computer equipment, and kitchen preparation surfaces. Clean and disinfect shared equipment between residents using EPA-registered products with label claims for use in healthcare which lists activity against norovirus. Follow the manufacturer's recommendations for application and contact times. 7. Clean and disinfect surfaces starting from the areas with a lower likelihood of norovirus (e.g., toilets, bathroom fixtures). Change mop heads when a new bucket of cleaning solution is prepared or after cleaning large spills of emesis or fecal material. 8. During outbreaks, change privacy curtains when they are visibly soiled and upon resident discharge or transfer. 9. Handle soiled linens carefully, without agitating them, to avoid dispersal of virus. Use Standard Precautions, including the use of appropriate PPE (e.g., gloves and gowns), to minimize the likelihood of cross-contamination. 10. Staff who work with, prepare or distribute food will be excluded from duty immediately if they develop symptoms of acute gastroenteritis. Any staff presenting with norovirus symptoms will be off work and not to return until a minimum of 48 hours after the resolution of symptoms or longer upon recommendation from Infection Control Preventionist or Infection Control Committee. The facility policy titled, Infection Control Program Introduction, last reviewed 1/2025, states in part . Introduction: Infections are among the most frequent and significant problems facing nursing facility residents today. They account for a large proportion of morbidity and mortality, and for many hospital transfers. This Infection Control Manual will provide information for the essential functions and practices of the facility and also be flexible enough to fit a facility's specific environment and able to accommodate new issues or requirements. Purpose of Infection Control Program: The major purposes of Infection Control Programs in the nursing facility are to minimize the effects of infections on residents and employees, and to educate the staff. A successful Infection Control Program requires an underlying commitment and facility-wide participation. It should not just be seen as a way to meet paperwork requirements but as a way to analyze and use information effectively to improve and prevent problems. Coordination and Oversight: The Director of Nursing has the responsibility of coordination and oversight of the Infection Control Program. The Director of Nursing may appoint a clinical staff person with interest and additional training in infection prevention and control to assist in the coordination and oversight of the Infection Control Program. All infections are tracked and logged regularly. The Infection Control Committee or its equivalent should review Elements of an Infection Control Program: The success of this Infection Control Program is base as facility-wide effort involving all disciplines and individuals. It should also be considered an integral part of a facility's overall quality assurance and performance improvement program, and have the active support of administration, residents, families, clinical, support staff, and attending physicians. The Centers for Medicare & Medicaid Services (CMS) require the long-term care facilities to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. All infections are tracked and to be logged regularly. The Infection Control Committee or its equivalent should review summaries of this information at least quarterly. Policies and Procedures: This review should also assess how well and how consistently the staff has complied with existing policies and regulations, and any trends or significant problems since the previous review. Surveillance: Surveillance refers to a system for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring employee infections, and detecting unusual pathogens with infection control implications. Prevention and treatment begin with recognizing the kinds of infections that occur and the signs and symptoms of their onset. Infections among the residents are not always obvious. Therefore, medical criteria and standardized definitions of infections are needed to help recognize and manage infections, (Corporation Name) will utilize McGeer's criteria to assist in the recognition of infections and ensure antibiotic usage is appropriate as part of their Stewardship program. The facility policy titled, Cleaning and Disinfecting Residents' Rooms, undated, states in part . Resident Room Cleaning: 9. When possible, precaution/isolation rooms should be cleaned last, and water discarded after cleaning room. 11. Clean curtains, window blinds and walls when they are visibly soiled and dirty. The facility policy titled, Standard Precautions, undated, states in part . Gowning: Wear a gown that is appropriate to the task, to protect skin and prevent soiling or contamination of clothing during procedures and resident-care activities when contact with blood, body fluids, secretions, or excretions is anticipated. Appropriated handling of laundry: Handle, transport, process used linen to avoid contamination of air, surfaces and persons. All soiled linens should be bagged prior to exiting room. Washing of linens will be in accordance with CMS (Centers for Medicare and Medicaid) requirements and per Chapter 5, Water Temperatures; Maintenance Manual. On 12/31/24, two staff members developed signs and symptoms related to GI outbreak. CNA (Certified Nursing Assistant) Q (NOC shift) was placed on the line list with vomiting and diarrhea and BOM (Business Office Manager) P was placed on the line list for diarrhea. On 1/2/25, R17, a resident on the 200 wing was placed on the line list for GI (gastrointestinal) s/sx (signs and symptoms). R17's symptoms included nausea, vomiting, and diarrhea. Surveyor reviewed R17's eMAR (electronic medication administration record) and eTAR (electronic treatment administration record) and noted that the facility was monitoring R17's bowel movements but not the consistency or frequency. On 1/3/25, R8, R18, R34, R64, and R70, were all noted to have GI s/sx. These five residents encompassed all 4 units of the facility. Surveyor reviewed R8's eMAR and eTAR. R8 had orders for Senokot tablet 8.6 mg (milligrams). Give 1 tablet PO (by mouth) daily for constipation, once daily. During the period in which R8 was experiencing s/sx of GI outbreak she continued to receive her Senokot without bowel monitoring in place for frequency and consistency. The facility did not update the physician or consider holding the medication while R8 was experiencing GI related s/sx. R8 had orders in the eMAR and eTAR to enter a progress note every shift to include symptoms present/not present related to acute gastroenteritis: nausea, vomiting, diarrhea, abdominal cramping, fever, chills, start 1/5/25 to 1/6/25. R8 was noted to be added to the line list for the GI outbreak on 1/3/25 with a well date of 1/4/25, indicating R8 was not being monitored for GI s/sx until after her well date. Surveyor reviewed R18's eMAR and eTAR. R18 had orders for furosemide tablet 20 mg (a diuretic.) Take 1 tablet by mouth daily for fluid in the lungs due to chronic heart failure. During the period in which R18 was experiencing s/sx of GI outbreak he continued to receive his furosemide without fluid monitoring. The facility did not update the physician or consider holding the medication while R18 was experiencing GI related s/sx. R18's eMAR and eTAR note that the facility was monitoring R18's bowel movements but not the consistency or frequency. Surveyor reviewed R34's eMAR and eTAR. R34 had orders for furosemide tablet 40 mg. Give 1 tablet daily for high blood pressure. During the period in which R34 was experiencing s/sx of GI outbreak she continued to receive her furosemide without fluid monitoring. The facility did not update the physician or consider holding the medication while R34 was experiencing GI related s/sx. R34's eMAR and eTAR note that the facility was monitoring R34's bowel movements but not the consistency or frequency. R34 had orders in the eMAR and eTAR to enter progress note every shift to include symptoms present/not present related to acute gastroenteritis: nausea, vomiting, diarrhea, abdominal cramping, fever, chills, start 1/5/25 to 1/7/25. R34 was noted to be added to the line list for the GI outbreak on 1/3/25 with a well date of 1/5/25, indicating R34 was not being monitored for GI s/sx until after her well date. Surveyor reviewed R64's eMAR and eTAR. R64 had orders for Senna-S tablet 8.6-50 mg. Take 1 tablet by mouth daily for constipation. During the period in which R64 was experiencing s/sx of GI outbreak she continued to receive her Senna-S without bowel monitoring in place for frequency and consistency. The facility did not update the physician or consider holding the medication while R64 was experiencing GI related s/sx. eMAR and eTAR note that the facility was monitoring R64's bowel movements but not the consistency or frequency. R64's eMAR and eTAR also include orders to monitor GI symptoms: Monitor lung sounds, vitals, and for additional symptoms Q (every) shift x (times) 72 hours TID (three times a day), start date 1/5/25 and end date 1/7/25. R64's GI s/sx started on 1/3/25 with a well date of 1/6/25, indicating R64 was not being monitored for GI s/sx until 2 days after he began experiencing s/sx. Surveyor reviewed R70's eMAR and eTAR. R70 had orders for Senokot-S tablet 8.6-50 mg. Give 2 tablets by mouth 2 times a day for constipation prevention. Hold for loose stools. During the period in which R70 was experiencing s/sx of GI outbreak he continued to receive his Senokot-S without bowel monitoring in place for frequency and consistency. The facility did not update the physician or consider holding the medication while R70 was experiencing GI related s/sx. R70 has orders in the eMAR and eTAR to enter progress note every shift to include symptoms present/not present related to acute gastroenteritis: nausea, vomiting, diarrhea, abdominal cramping, fever, chills, start 1/5/25 to 1/6/25. R70 was noted to be added to the line list for the GI outbreak on 1/3/25 with a well date of 1/4/25, indicating R70 was not being monitored for GI s/sx until after her well date. On 4/9/25 at 9:30 AM, Surveyor interviewed RNC/IP C (Regional Nurse Consultant/infection preventionist). Surveyor asked RNC/IP C when outbreak should have been called. RNC/IP C stated, after the second resident but can't give you the date. Surveyor gave RNC/IP C the infection control logs to review. RNC/IP C stated, 1/2/25 would have been the outbreak but I was not the IP at that time and cannot say when she called the outbreak. I was not notified of any outbreak until 1/4/25. Note: The facility should have considered this an outbreak starting on 1/2/25. However, the facility has no evidence they identified the outbreak until they contacted DPH (Department of Public Health) on 1/6/25. Note: Facility has no timeline or documentation to show when the outbreak was identified. Note: The facility has no documentation that shows that they updated any of the residents' PCPs (Primary Care Physicians) or the Medical Director of the outbreak. On 1/4/25, R1, R12, R38, R40, R46, R50, R60, R71, and R240 were all noted to be experiencing GI s/sx. These nine residents encompassed the 200, 300, and 400 units of the facility. Surveyor reviewed R1's eMAR and eTAR. R1's eMAR and eTAR note that the facility was monitoring R64 's bowel movements but not the consistency or frequency. R1's eMAR and eTAR include orders to monitor for 72 hours lung sounds and VS (vital signs) due to GI illness starting on 1/4/25 and ending on 1/5/25 and to enter progress note every shift to include symptoms present/not present related to acute gastroenteritis: nausea, vomiting, diarrhea, abdominal cramping, fever, chills, start 1/5/25 to 1/7/25. R1 was noted to be added to the GI outbreak line list on 1/4/25 with a well date of 1/8/25, indicating monitoring of R1 did not start until the day after sx began and ended a day prior to symptoms ending. R1's eMAR and eTAR also indicate R1 was placed on contact precautions on 1/4/25 and precautions were discontinued on 1/7/25. R1 had a well date of 1/8/25, indicated precautions were stopped the day prior to R1's well date. Surveyor reviewed R12's eMAR and eTAR. R12 had orders for furosemide tablet 20 mg, give 1 tablet PO daily for visible water retentions and furosemide 0.5 mg tablet (10 mg) PO in the afternoon for visible water retention. During the period in which R12 was experiencing s/sx of GI outbreak she continued to receive all but one dose of her furosemide without fluid monitoring. The facility did not update the physician or consider holding the medication while R12 was experiencing GI related s/sx. R12's eMAR and eTAR note that the facility was monitoring R12's bowel movements but not the consistency or frequency. R12 had orders in the eMAR and eTAR to enter progress note every shift to include symptoms present/not present related to acute gastroenteritis: nausea, vomiting, diarrhea, abdominal cramping, fever, chills, start 1/5/25 to 1/8/25. R12 was noted to be added to the line list for the GI outbreak on 1/4/25 with a well date of 1/9/25, indicating R12's monitoring did not start until the day after sx began and ended a day prior to symptoms ending. Surveyor reviewed R38's eMAR and eTAR. R38 had orders for Miralax 17 gram/dose, dissolve 17 grams into at least 8 ounces of beverage of choice and drink daily for bowel management, hold for loose stools/high volume ostomy output, increase to 2x (two times) daily if constipation and Sennosides-docusate sodium tablet 8.6-50 mg, take 1 tablet by mouth 2 times a day for bowel management, hold for loose stools/high volume ostomy output. During the period in which R38 was experiencing s/sx of GI outbreak he continued to receive his Miralax and Sennosides-docusate sodium without bowel monitoring in place for frequency and consistency. R38's eMAR and eTAR note that the facility was monitoring R38's bowel movements but not the consistency or frequency. R38 had orders in the eMAR and eTAR for GI symptoms: Monitor for and chart symptoms and temp Q shift x72 hours, start 1/7/25 to 1/7/25. R38 was noted to be added to the line list for the GI outbreak on 1/4/25 with a well date of 1/5/25, indicating R38's monitoring did not start until 3 days after s/sx began and 2 days after R38's well date. R38's eMAR and eTAR also indicate that R38's isolation precautions were discontinued on 1/7/25. Facility does not have time of well date for discontinuation of isolation precautions, unable to determine from documentation and interviews if precautions discontinued appropriately. Surveyor reviewed R40's eMAR and eTAR. R40 had orders in the eMAR and eTAR to enter progress note every shift to include symptoms present/not present related to acute gastroenteritis: nausea, vomiting, diarrhea, abdominal cramping, fever, chills, start 1/5/25 to 1/6/25. R40 was noted to be added to the line list for the GI outbreak on 1/4/25 with a well date of 1/5/25, indicating R40's monitoring did not begin until her well date and ended the following day. R40's eMAR and eTAR also indicates that R40's isolation precautions were discontinued on 1/7/25. Facility does not have time of well date for discontinuation of isolation precautions, unable to determine from documentation and interviews if precautions discontinued appropriately. Surveyor reviewed R46's eMAR and eTAR. R46's eMAR and eTAR note that the facility was monitoring R46's bowel movements but not the consistency or frequency. R46 also has orders to encourage fluids each shift, this is signed out every shift but does not include amounts of intake. R46's eMAR and eTAR orders include GI Symptoms: Monitor lung sounds, vitals, and for additional symptoms Q shift x 72 hours, start 1/5/25 to 1/7/25. R46 was added to the line list for the GI outbreak on 1/4/25 with a well date of 1/5/25, indicating R46's monitoring did not start until her well date. Surveyor reviewed R50's eMAR and eTAR. R50 had orders for Miralax 17 gram/dose. Give 17g (grams) PO BID (twice a day) for emptying of the bowel, titrate to have 1 BM (bowel movement) per day and Senokot-S tablet, 8.6-50 mg, take 1 tab PO BID for constipation. R50 was added to the GI line list for s/sx on 1/4/25 with a well date of 1/5/25. During the time that R50 was experiencing GI s/sx she continued to receive Miralax and Senokot-S BID. R50's eMAR and eTAR note that the facility was monitoring R50's bowel movements but not the consistency or frequency. R50 had orders in the eMAR and eTAR to enter progress note every shift to include symptoms present/not present related to acute gastroenteritis: nausea, vomiting, diarrhea, abdominal cramping, fever, chills, start 1/5/25 on PM shift and ending 1/7/25 on PM shift. R50's eMAR and eTAR also includes vitals x 72 hours each shift, plus lung sounds, start date 1/4/25 at 11:00 PM and ending on 1/5/25 at 11:00 PM. According to eMAR and eTAR R50's isolation precautions were discontinued on 1/7/25. Facility did not document the time of R50's last symptoms making it difficult to determine if isolation precautions were discontinued appropriately. Surveyor reviewed R60's eMAR and eTAR. R60 had orders for furosemide 20 mg, administer 1 tablet (20 mg) by mouth daily for hypertension. R60 was added to the GI line list for s/sx on 1/4/25 with a well date of 1/5/25. During the period in which R60 was experiencing s/sx of GI outbreak she continued to receive all doses of her furosemide without fluid monitoring. The facility did not update the physician or consider holding the medication while R60 was experiencing GI related s/sx. R60's eMAR and eTAR note that the facility was monitoring R60's bowel movements but not the consistency or frequency. R60's eMAR and eTAR includes an order for GI Symptoms: Monitor and chart for symptoms and temp Q shift x 72 hours, start date of 1/5/25 and end date of 1/7/25. R60's eMAR and eTAR note that the facility was monitoring bowel movements but not the consistency or frequency. Note: R60's monitoring for GI symptoms did not begin until her well date. Surveyor reviewed R71's eMAR and eTAR. R71 was added to the facility line listing for GI s/sx on 1/4/25 and a well date of 1/5/25. R71's eMAR and eTAR note that the facility was monitoring R71's bowel movements but not the consistency or frequency. R71 had orders in the eMAR and eTAR to enter progress note every shift to include symptoms present/not present related to acute gastroenteritis: nausea, vomiting, diarrhea, abdominal cramping, fever, chills, start 1/5/25 on PM shift and ending 1/7/25 on NOC (night) shift. R71's well date on the GI line list is documented as 1/5/25. R71's monitoring did not begin until the date of his listed well date. R71's eMAR and eTAR indicates Vitals x 72 hours each shift, plus lung sounds each shift, start date 1/4/25 and end date 1/5/25. Note: The vitals monitoring for R71 were started on 1/4/25 but only completed on 1/5/25. Surveyor reviewed R240's eMAR and eTAR. R240 was added to the facility line listing for GI s/sx on 1/4/25 and a documented well date 1/5/25. R240's eMAR and eTAR note that the facility was monitoring R240's bowel movements but not the consistency or frequency. R240 had orders in the eMAR and eTAR to enter progress note every shift to include symptoms present/not present related to acute gastroenteritis: nausea, vomiting, diarrhea, abdominal cramping, fever, chills, start 1/5/25 on PM shift and ending 1/7/25 on PM shift. Facility does not have time of well date for discontinuation of isolation precautions, unable to determine from documentation and interviews if precautions discontinued appropriately. On 1/5/25, R10, R56, and R239 were noted to be experiencing GI s/sx. These three residents encompassed the 200, 300, and 400 units. Surveyor reviewed R10's eMAR and eTAR. R10 was added to the facility line listing for GI s/sx on 1/5/25 and a documented well date of 1/6/25. R10 had orders for sennosides-docusate sodium tablet 8.6-50 mg. Give 2 tabs po BID for constipation. Torsemide tablet 10 mg (a diuretic.) Give 1 tablet (10 mg) with 20 mg tablet for total of 30 mg daily for edema. Torsemide tablet 20 mg. Give 1 tablet (20 mg) with 10 mg tablet for total of 30 mg daily for edema. During the period in which R10 was experiencing s/sx of GI outbreak she continued to receive all doses of torsemide and sennosides-docusate sodium without fluid monitoring. R10's eMAR and eTAR note that the facility was monitoring R10's bowel movements but not the consistency or frequency. R10 had orders in the eMAR and eTAR to enter progress note every shift to include symptoms present/not present related to acute gastroenteritis: nausea, vomiting, diarrhea, abdominal cramping, fever, chills, start 1/5/25 on PM shift and ending 1/8/25 on NOC shift. Facility does not have time of well date for discontinuation of isolation precautions on 1/8/25; unable to determine from documentation and interviews if precautions discontinued appropriately. Surveyor reviewed R56's eMAR and eTAR. R56 was added to the facility line listing for GI s/sx on 1/5/25 and a documented well date of 1/6/25. R56 had orders for Miralax 17 grams. Give 17 g PO daily for constipation. HOLD for loose stools. During the period in which R56 was experiencing s/sx of GI outbreak she received Miralax as scheduled aside from 1/6/25 when medication was held. R56's eMAR and eTAR notes that the facility was monitoring R56's bowel movements but not the consistency or frequency. R56's eMAR and eTAR include an order for GI Symptoms: Monitor and chart for symptoms and temp Q shift x 72 hours, start date of 1/5/25 AM shift and end date of 1/7/25 PM shift. Surveyor reviewed R239's eMAR and eTAR. R239 was added to the facility line listing for GI s/sx on 1/5/25 and a documented well date of 1/6/25. R239 had orders for Citrucel tablet 500 mg. Take 1 tab PO BID for constipation. Take with plenty of water. During the period in which R239 was experiencing GI s/sx her Citrucel was held on only 2 occasions, 1/5/25 AM shift and 1/7/25 PM shift. R239 received all other doses during this time frame. R239's eMAR and eTAR notes that the facility was monitoring R239's bowel movements but not the consistency or frequency. R239 had orders in the eMAR and eTAR to enter progress note every shift to include symptoms present/not present related to acute gastroenteritis: nausea, vomiting, diarrhea, abdominal cramping, fever, chills, start 1/5/25 on PM shift and ending 1/8/25 on PM shift. On 1/6/25, R5, R9, R16, R21, R22, R51, R54, R67, R80, and R242 were noted to be experiencing GI s/sx. These residents resided among all four units of the facility. There were also six staff (COTA (Certified Occupational Therapy Assistant) GG, AA (Activities Assistant) HH, PT (Physical Therapist) II, CNA JJ, CNA KK, CNA LL) that were experiencing GI s/sx. COTA GG was placed on the staff GI line list on 1/6/25 with symptoms of vomiting and diarrhea. COTA GG has no well date or return to work date listed. AA HH was placed on the staff GI line list on 1/6/25 with symptoms of nausea, vomiting, and abdominal cramping. AA HH has no well date listed but returned to work on 1/13/25. PT II was placed on the staff GI outbreak line list on 1/6/25 with symptoms of nausea, vomiting, and diarrhea. PT II has no well date or return to work date listed. CNA JJ was placed on the staff GI outbreak line list on 1/6/25 with symptoms of nausea, vomiting, and diarrhea. CNA JJ has no well date listed but returned to work on 1/9/25. CNA KK was placed on the staff GI outbreak line list on 1/6/25 with symptoms of nausea, vomiting, and diarrhea. CNA KK has no well date listed but returned to work on 1/12/25. CNA LL was placed on the GI outbreak line list on 1/6/25 with symptoms of nausea and vomiting. CNA LL has no well date listed but returned to work on 1/10/25. On 1/6/25, DPH was notified of the facility GI outbreak by the DON (Director of Nursing). At this point the facility had 28 residents and eight staff with GI signs and symptoms. Surveyor reviewed R5's eMAR and eTAR. R5 was added to the facility line listing for GI s/sx on 1/6/25 and a documented well date of 1/7/25. R5 had orders for furosemide tablet 20 mg for accumulation of fluid resulting from CHF (congestive heart failure), edema. Miralax 17 gram/dose. Mix 17 grams in drink of choice PO every other day for constipation and Senokot-S tablet 8.6-50 mg. Give 1 tablet PO daily for constipation. During the period in which R5 was experiencing s/sx of GI outbreak she continued to receive all doses of furosemide without fluid monitoring. R5 also continued to receive all doses of Miralax and Senokot-S. R5's eMAR and eTAR notes that the facility was monitoring R5's bowel movements but not the consistency or frequency. Surveyor reviewed R9's eMAR and eTAR. R9 was added to the facility line listing for GI s/sx on 1/6/25 and a documented well date of 1/7/25. R9's eMAR and eTAR notes that the facility was monitoring R9's bowel movements but not the consistency or frequency. R9's eMAR and eTAR include an order for GI Symptoms: Monitor and chart for symptoms and temp Q shift x 72 hours, start date of 1/6/25 AM shift and end date of 1/8/25 NOC shift. Surveyor reviewed R16's eMAR and eTAR. R16 was added to the facility line listing for GI s/sx on 1/6/25 and a documented well date of 1/9/25. R16 had orders for senna tablet 8.6 mg. Give 2 tablets by mouth daily for constipation. During the period in which R16 was experiencing s/sx of GI outbreak she continued to receive all doses of senna without monitoring frequency or consistency of bowel movements. R16 had orders in the eMAR and eTAR to enter progress note every shift to include symptoms present/not present related to acute gastroenteritis: nausea, vomiting, diarrhea, abdominal cramping, fever, chills, start 1/6/25 on PM shift and ending 1/9/25 on NOC shift. Surveyor reviewed R21's eMAR and eTAR. R21 was added to the facility line listing for GI s/sx on 1/6/25 and a documented well date of 1/7/25. R21 had orders for furosemide 20 mg. Give 0.5 tablet (10 mg) PO daily for chronic BLE (bilateral lower extremity) edema and Senna with Docusate Sodium tablet 8.6-50 mg. Give 2 tablets po BID for constipation. Hold for loose stools. During the period in which R21 was experiencing s/sx of GI outbreak she continued to receive all doses of furosemide and Senna with Docusate Sodium without monitoring frequency or consistency of bowel movements or fluid hydration. R21 had orders in the eMAR and eTAR to enter progress note every shift to include symptoms present/not present related to acute gastroenteritis: nausea, vomiting, diarrhea, abdominal cramping, fever, chills, start 1/6/25 on PM shift and ending 1/9/25 on NOC shift. Surveyor reviewed R22's eMAR and eTAR. R22 was added to the facility line listing for GI s/sx on 1/6/25 and a documented well date of 1/7/25. R22 had orders for Miralax 17 grams/dose. Give 17 grams PO in beverage of choice daily for constipation and psyllium husk powder. Give 3.4 grams in beverage of choice BID for constipation. During the period in which R22 was experiencing s/sx of GI outbreak he continued to receive all doses of Miralax and psyllium husk powder without monitoring frequency or consistency of bowel movements. Surveyor reviewed R51's eMAR and eTAR. R51 was added to the facility line listing for GI s/sx on 1/6/25 and a documented well date of 1/7/25. R51's eMAR and eTAR notes that the facility was monitoring R51's bowel movements but not the consistency or frequency. R51 had orders in the eMAR and eTAR to enter progress note every shift to include symptoms present/not present related to acute gastroenteritis: nausea, vomiting, diarrhea, abdominal cramping, fever, chills, start 1/6/25 on AM shift and ending 1/8/25 on NOC shift. R51's eMAR and eTAR include an order for GI Symptoms: Monitor and chart for symptoms and temp Q shift x 72 hours, start date of 1/6 [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 behavioral health related services to assure resident safety for each resident to attain or maintain their highest practicable physical, mental, and psychosocial well-being for 1 of 1 sampled resident (R11) and 1 of 1 supplemental residents reviewed (R55). R11 had expressed suicidal ideations related to his chronic pain (phantom limb pain) multiple times in the two months preceding R11 stabbing himself in the chest with scissors due to unrelieved pain. R11 was hospitalized for a self-inflicted stab wound to his chest and placed on an emergency psychiatric detention as a result of his suicide attempt. Following this incident, the resident returned to the facility and continued to express suicidal ideation and uncontrolled pain. Although R11 has had sharp objects removed from his room since the incident on 5/24/24, adequate supervision has not been provided when R11 expresses suicidal ideations. R55 expressed suicidal ideations multiple times between 8/5/24 and 4/10/25. Over this time, R55 obtained sharp objects on occasions. On 4/10/25, scissors were removed from R55's room, after which the resident stated that if he had them he would use them like this and proceeded to hold his hand up to his throat. The facility's failure to provide residents with sufficient staffing that had the appropriate competencies and skill sets to provide direct nursing and behavioral health related services to assure safety needs were met to attain or maintain their highest practicable physical, mental, and psychosocial well-being to address behavioral health needs such as monitoring, on going assessments, and interventions to improve or stabilize R11 or R55's condition created a finding of immediate jeopardy that began on 5/30/24. NHA A (Nursing Home Administrator) was notified of the immediate jeopardy on 4/10/25 at 2:46 PM. The immediate jeopardy was removed on 4/15/25. 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 action plan. This is evidenced by: The facility policy titled, Notification of Change, reviewed 1/2025, states in part: . The Residents physician and responsible party must be notified when an event involving the resident occurs or when the resident experiences a change in condition, potential discharge, room transfer or death .Notification Parameters: [Corporation Name] has adopted the current INTERACT Tools Change in Condition: When to report to the MD (Medical Doctor)/NP (Nurse Practitioner)/PA (Physician Assistant) . ASSESSMENT: 1. When made aware of a change in condition of a resident the Licensed nurse will perform an assessment based on their professional judgement . NOTIFY THE PHYSICIAN IMMEDIATELY IF THE RESIDENT REQUIRES IMMEDIATE ACTION . NOTIFICATION: . 4. Document each attempt in the residents medical record. 5. Notify the Director of Nursing of the Residents condition change. 6. The Licensed nurse is to provide frequent checks on the residents condition while waiting for a call back from the Physician and or NP. Alert the direct care givers of residents condition change and signs and symptoms to be watching for . 8. Inform the physician of the services available in the facility vs. automatic transfer of the resident to the emergency room or admission to the hospital . The facility policy titled, Pain Management Policy, reviewed 1/2025, states in part: . Purpose: to provide an approach to pain management that provides the resident with optimal comfort, dignity and quality of life. Resident experiencing pain will be treated using non-pharmacological and pharmacological methods to optimally control pain, maximize function and promote quality of life . 5. Each resident's plan of care will include interventions to effectively manage pain, including pharmacological and non-pharmacological interventions . 6. Pain will be reassessed after interventions to evaluate the effectiveness of the intervention and to recognize undesirable side effects and documented in the medical record. 7. The provider will be notified if comfort is not achieved following pain management interventions, for changes in pain characteristics and/or with new onset pain or breakthrough pain . The facility policy titled, Trauma Informed Care, reviewed 1/2025, states in part: . It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization . Trauma results from an event, series of events, or set of circumstances that is experienced by an individuals as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individuals' functioning and mental, physical, social, emotional, or spiritual well-being. Common sources of trauma may include, but are not limited to: . d. Physical, sexual, mental, and/or emotional abuse (past or present) e. Rape . i. Traumatic life events . Trauma-Informed Care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization .Policy Explanation and Compliance Guidelines: 1. The facility will work to facilitate the principles of trauma informed care which include: a. Safety - Ensuring residents have a sense of emotional and physical safety . 2. The facility will use a multi-pronged approach to identifying a resident's history of trauma . This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools . 6. The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident, and will be added to the resident's care plan .7. Trauma-specific care plan interventions will recognize the interrelation between trauma and symptoms of trauma such as . depression and anxiety . 10. In situations where a trauma survivor is reluctant to share their history, the facility will still try to identify triggers which may re-traumatize the resident, and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident. The facility policy titled, Behavioral Health Services, reviewed 1/2025, states, in part: . It is the policy of this facility to ensure residents receive necessary behavioral health services to assist them in reach and maintain their highest level of mental and psychosocial functioning. Policy Explanation and Compliance Guidelines: 1. The facility will ensure that necessary behavioral health care services are person-centered and provided to each resident. 2. Behavioral health care and services shall be provided in an environment that is conducive to mental and psychosocial well-being. 3. Conditions that may require specialized services and supports include, but are not limited to: a. Depression b. Anxiety . 4. The facility utilizes assessments for identifying and assessing a resident's mental and psychosocial status providing person-centered care. This process includes, but is not limited to: . b. Obtaining history regarding mental, psychosocial, and emotional health. c. Ongoing monitoring of mood and behavior. d. Care plan development and implementation. e. Evaluation . 6. All facility staff, including contracted staff and volunteers, shall receive education to ensure appropriate competencies and skill sets for meeting the behavioral health needs of residents. Education shall be based on the role of the staff member and resident needs identified through the facility assessment. Behavioral health training as determined by the facility assessment will include, but is not limited to, the competencies and skills necessary to provide the following: a. Person-centered care and services that reflect the resident's goals of care. b. Interpersonal communication that promotes mental and psychosocial well-being. c. Meaningful activities which promote engagement and positive meaningful relationships. d. An environment and atmosphere that is conducive to mental and psychosocial well-being. e. Individualized, non-pharmacological approaches to care . 7. Facility staff will implement person-centered care approaches designed to meet the individual goals and needs of each resident, which includes non-pharmacological interventions . 8. The Social Services Director shall serve as the contact person for questions regarding behavioral services provided by the facility and outside sources such as physician, psychiatrists, or neurologists . Surveyor reviewed the facility's assessment, last reviewed on 8/2/24, to determine the need for staff with skills and competencies in order to provide nursing and related behavioral health services to maintain safety for R11 and R55. Facility assessment indicates: .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. The use [sic] this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents at our facility. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their 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 Part 1 of the facility assessment, titled, Our Resident Profile with sub-heading, Diseases/Conditions, physical and cognitive disabilities indicates that the facility accepts residents with Psychiatric/Mood Disorders such as: Depression, Impaired Cognition, Mental Disorder, Bipolar Disorder (Mania/Depression), Post-Traumatic Stress Disorder (PTSD), Anxiety Disorder, Schizophrenia, Insomnia, Mood Adjustment Disorder, and Behavior that needs interventions. The facility is also able to accept residents with neurological disorders such as Alzheimer's Disease, Non-Alzheimer's Dementia, Down Syndrome, Traumatic Brain Injuries, Autism, Huntington's Disease, Tourette's Syndrome, and Cerebral Palsy. Part 2 of the facility assessment, titled, Services and Care We Offer Based on our Residents' Needs, indicates that the facility can provide care for residents with mental health and behavior needs, to include: managing 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/PTSD, other psychiatric diagnoses, and intellectual or developmental disabilities. This section also indicates that the facility can provide care for residents with a need for psycho/social/spiritual support, to include: finding out what resident's preferences and routines are, what makes a good day for the resident, what upsets him or her and incorporate this information into the care planning process, making sure staff care for the resident have this information, recording and discussing treatment and care preferences, supporting resident's emotional and mental well-being, supporting helpful coping mechanisms, providing opportunities for social activities and life enrichment, and identifying hazards and risks for residents. In the section titled, Contingency Planning for Staff, the facility assessment indicates in case of an emergency event requiring additional staffing: the administrator will direct available department heads to contact available staff to elicit ability to work, non-nursing staff will complete tasks to alleviate burden from nursing staff as allowed without certification or license, contact company affiliated facilities to determine availability to assist, contact the Regional Director of Operations to approve use of current company agency staffing contracts and offer additional incentives for staff to pick up open shifts such as bonuses. In the section titled, Staff training/education and competencies the facility assessment indicates various education, training, and competencies that are necessary for staff to provide the level and types of support and care needed for the facility's resident population. Trauma informed care is listed under the training section. Under annual competencies, the facility assessment indicates person-centered care, including care planning, resident and family education about treatments and medications, along with caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder, and implementing non-pharmacological interventions. Surveyor requested training provided by the facility to staff regarding suicidal ideation and precautions since R11's attempted suicide on 5/24/24. The education provided is print-outs of slide-show presentations titled, Behavioral Health Services and Non-Pharmacological Interventions. Surveyor reviewed the document provided by the facility regarding staff education. This document is untitled and undated. The earliest Completion Date reviewed noted by Surveyor was 2/1/24 and the latest date noted by Surveyor was 3/19/25. The Course Name of trainings include Behavioral Health Services, Non-Pharmacological Interventions (Pain and Behavior), and New Hire Behavioral Health. The titles of staff members include Registered Nurses (RN), Licensed Practical Nurses (LPN), Certified Nursing Assistants (CNA), Dietary staff, housekeeping staff, Activities Staff, and Maintenance Staff. Out of the 15 RNs reviewed, only 8 completed all three trainings, indicating a 53% training completion rate. Out of the 12 LPNs reviewed, 9 completed all three trainings, indicating a 75% training completion rate. Out of the 51 CNAs reviewed, 32 completed all three trainings, indicating a 63% training completion rate. SS N (Social Services) only completed the New Hire Behavioral Health training, according to the documentation provided. (Of note: This list does not include any therapy or agency staff.) According to the National Library of Medicine, risk factors for suicide include, in part: older populations, male, past suicide attempts, adverse childhood experiences, socioeconomic challenges, access to lethal means, recent diagnosis of terminal or chronic illnesses. Example 1: R11 was admitted to the facility on [DATE], with diagnoses that include: amputation of right toes, type 2 diabetes with diabetic polyneuropathy (damage to multiple peripheral nerves causing pain, tingling, burning, numbness, or sensitivity to touch), acquired absence of limb (amputation), phantom limb syndrome w/pain (sensation that limb is still attached to body and can include feelings of pain, numbness, tingling, or temperature changes), and other chronic pain. According to the National Library of Medicine, phantom limb pain is the perception of pain or discomfort in a limb that is no longer there. This pain most commonly presents as a result of amputation. While the cause of the pain is not completely understood, it is thought to originate with the trauma to the nerves surrounding the amputation site and involve neurons in both the spinal cord and brain as well. This pain is often described as tingling, throbbing, sharp, pins/needles in the limb that is no longer there. Pain severity varies and tends to be intermittent in frequency. Treatment has not been proven to be very effective for phantom limb pain and focuses on symptomatic control. Medication options include acetaminophen (Tylenol), ibuprofen, opioids, antidepressants, anticonvulsants (anti-seizure medications), beta blockers, topical anesthetics like Capsaicin, botulinum toxin injections, and local anesthetics. Phantom limb pain is very complex and difficult to treat and is best managed by an interprofessional team involving mental health professionals, pharmacists, and pain management physicians. R11's most recent Quarterly Minimum Data Set (MDS), with Assessment Reference Date of 1/9/25, states that R11 has a BIMS (Brief Interview for Mental Status) of 15 out of 15, indicating that R11 is cognitively intact. Section D indicates that R11 never has self-isolating behavior. Section J indicates R11 experiences pain frequently, the pain frequently interferes with his sleep and day-to-day activities. Physician orders include: May be treated by house Psychiatrist as needed . Start date: 4/1/24. End date: 5/30/24. Start date: 5/30/24. TENS (electrical current stimulates nerve cells and blocks the transmission of pain signals) unit may be applied for 20 minutes. Staff must assist resident with application and removal. TENS unit to be stored in med (medication) cart . Start date: 1/7/25 Due to suicidal ideation and attempt check room for sharp objects and remove every shift. May complete with 2 staff if needed. Three Times A Day . Start date: 10/25/24. Progress note each shift on resident status - include pain scale and mood/behaviors. Include nursing therapeutic interventions communication and interventions used. Every Shift . Start date: 5/31/24. End date: 9/9/24. Start date: 9/9/24. Pain Assessment every 4 hours - MUST BE COMPLETED. Must offer PRN (as needed) interventions and document progress note with interventions if pain is over 6/10. Special Instructions: 0 - 10 Scale. 0 = No Pain, 1-3 Mild, 4-6 Moderate, 7-10 Severe. Every Shift . Start date: 5/30/24. Behavior Monitoring: Yelling=1, Refusal of Care/Services=2, Combative=3, Hallucinations=4, Agitation=5, Delusions=6, Other=7 (if other please note specific behavior), None=8. Special Instructions: Interventions=calm/slow approach=1, avoid over-stimulation=2, reassurance=3, re-approach=4, re-direct=5, diversional activity=6, offer toileting/snack/drink=7, exercise=8, pain relief=9, other=10, n/a (not applicable)=11. Every Shift . Start date: 5/30/24. R11's current Comprehensive Care Plan indicates, in part: Problem: Resident displays physical and verbal behavioral symptoms that impact resident by putting them at risk for physical injury, interferes with participation in activities or social interactions and impacts others (staff and residents) by placing them at risk of physical injury and disrupts care or living environment. Start date: 9/23/24 . Interventions: Approach: Obtain a psych consult/psychosocial therapy as needed. Start: 9/23/24. Approach: Administer medications as ordered. Monitor and record effectiveness. Report adverse side effects. Start: 9/23/24. Approach: Maintain a calm environment and approach to the resident. Start: 9/23/24. Approach: Assess whether the behavior endangers the resident and/or others. Intervene if necessary. Start: 9/23/24. Approach: Observe for changes in behavior, document, and report to doctor. Start: 9/23/24. Approach: Observe for change in mental status, document and notify physician. Start: 9/23/24. Approach: Offer reassurance to resident as necessary. Start: 9/23/24. Approach: Allow distance in seating other residents around resident. Start: 9/23/24. Approach: Remove resident from group activities when behavior is unacceptable. Start: 9/23/24. Approach: Provide opportunity for resident to vent feelings. Listen in non-judgmental manner. Start: 9/23/24. Approach: Prepare and organize supplies before caring for resident. Avoid delays and interruptions in care. Start: 9/23/24. Approach: When resident becomes physically abusive, move resident to a quiet, calm environment. Start: 9/23/24. Approach: Maintain a calm, slow, understandable approach with the resident. Start: 9/23/24 Approach: When resident becomes physically abusive, keep distance between resident and others: staff, other residents, visitors. Start: 9/23/24. Approach: Seat resident where frequent observation is possible. Start: 9/23/24 Approach: Avoid over-stimulation: added noise, crowding, other physically active residents. Start: 9/23/24. Approach: Encourage (R11) to NOT use his motorized wheelchair when intoxicated. Assist to provide him alternate mobilization. Start: 9/23/24 Problem: Resident has expressed thoughts of being better off dead. Start date: 4/5/24. Last revised: 1/17/25 Interventions: Approach: Resident to be placed on 15 minute checks. To be completed if/when resident is making suicidal comments. Start date: 4/5/24. Approach: Provide 1:1 sessions with staff as needed. Start date: 4/5/24. Approach: Monitor for decline in resident's mood and report to physician for evaluation as needed. Start date: 4/5/24 Approach: Obtain a psych consult/psychosocial therapy PRN. Start date: 4/5/24 Approach: During acute phase, do not make demands on resident. Remove excess stimulation. Start date: 4/5/24. Approach: Convey an attitude of acceptance toward the resident. Start date: 4/5/24. Approach: Maintain a calm environment and approach to the resident. Start date: 4/5/24. Approach: Assess if mood endangers the resident and/or others. Intervene if necessary. Start date: 4/5/24. Approach: Encourage to verbalize feelings, concerns and fears. Clarify misconceptions. Start date: 4/5/24. Approach: Establish a trusting relationship with the resident and family. Start date: 4/5/24. Approach: Use distraction, relaxation, breathing techniques, etc. during acute phases. Monitor and record effectiveness. Start date: 4/5/24. Approach: Provide reassurance and comfort during acute periods. Start date: 4/5/24. Approach: Resident has a history of making thoughts of being better off dead, these statements are often made when experiencing pain. Offer pain interventions when states are made. Start date: 5/8/24. Approach: When resident makes suicidal ideation statements, contact provider (on-call during off hours). Start date: 10/24/24. Approach: Resident's room to be assessed every shift for sharp objects or other objects or forms of hurting oneself. May be completed with 2 staff as needed. Start date: 11/11/24 Problem: Resident has pain R/T: phantom limb syndrome with pain. Start date: 4/2/24. Last Revised/Reviewed: 1/17/25 Interventions: Approach: Monitor and record any non-verbal signs of pain: guarding, moaning, restlessness, grimacing, diaphoresis, withdrawal. Start date: 4/2/24 Approach: Evaluate effectiveness of pain management interventions. Adjust if ineffective or adverse side effects emerge. Start date: 4/2/24 Approach: Allow sufficient uninterrupted rest periods. Start date: 4/2/24 Approach: Handle gently and try to eliminate any environmental stimuli. Start date: 4/2/24 Approach: Position for comfort with physical support as necessary. Start date: 4/2/24 Approach: Administer medications as ordered. Monitor and record effectiveness. Start date: 4/2/24 Approach: Use pain relief measures such as distraction, imagery, relaxation, heat/cold, massage, etc. Monitor and record effectiveness. Start date: 4/2/24 Approach: Assess past effective and ineffective pain relief measures. Start date: 4/2/24 Approach: Monitor and record any complaints of pain: location, duration, quantity, quality, alleviating factors, aggravating factors. Start date: 4/2/24 Approach: Resident to have a pain assessment done every 4 hours. Start date: 5/31/24 Approach: Resident will hit his lower extremities and reports that this behavior is to treat the phantom pain he experiences. Offer pharmacological and non-pharmacological interventions when he is doing this. Resident often refuses additional interventions when displaying this behavior. Start date: 10/24/24 Approach: TENS Unit for Pain Relief: Resident is independent with use of TENS Unit for pain management of right foot phantom limb pain. Assist with charging unit as needed. Start date: 12/4/24 On 4/1/24, R11 was admitted to the facility with orders that indicate in part: capsaicin cream, 0.025%, scheduled to apply to right foot four times a day for pain, along with an order to apply to R11's skin as needed once a day for pain. Nortriptyline 25 mg scheduled every evening for nerve pain. Venlafaxine capsule, 24 hour extended release, for a total amount of 187.5 mg, scheduled daily. Acetaminophen (Tylenol) 1,000 mg, every 6 hours as needed for pain, Max dosing 3,000 mg in 24 hours. Diclofenac sodium get 1%, apply 4 grams to skin four times daily as needed for joint damage causing pain and loss of function. Complete a pain assessment every shift with a scale of 0-10, with 0 indicating no pain, 1-3 indicating mild pain, 4-6 indicating moderate pain, and 7-10 indicating severe pain. On 4/2/24 at 5:00 PM, a Progress Note was written by ADON K (Assistant Director of Nursing) that states, in part: Provider, [NP L's Name], NP (Nurse Practitioner) notified of resident's request to keep pain creams at bedside and to have a PRN muscle relaxant. Provider notified staff that the resident has an appointment with pain medicine on April 9th, the resident is willing to wait until this appointment to address muscle relaxer and medication management of pain . On 4/3/24, R11's Medication Administration Record (MAR) indicates R11 reported 7 out of 10 pain to Day shift. On 4/3/24 at 10:46 PM, R11's MAR indicates R11 received 1000 mg of PRN acetaminophen which was indicated to be Not Effective. On 4/3/24, MAR indicates R11 reported 7 out of 10 pain to Evening shift. On 4/4/24 at 12:30 AM, R11's MAR indicates R11 received 1000 mg of PRN acetaminophen for 9 out of 10 pain, which was indicated to be Somewhat Effective. 4 grams of diclofenac gel was also administered and marked to be Not Effective. On 4/4/24, R11's MAR indicates R11 reported 7 out of 10 pain to Day shift. On 4/4/24 at 7:55 AM, R11's MAR indicates R11 received 1000 mg of PRN acetaminophen for 7 out of 10 pain, which was indicated to be Not Effective. On 4/4/24 at 11:56 AM, a Progress Note was written by RN M (Registered Nurse), that states, in part: Resident c/o (complaining) of [sic] 9/10 R (right) foot/ankle pain in his R foot. Resident was heard hollering and yelling out in pain, and when this writer went into room to assess, resident was moaning and crying. Stated that he couldn't take the pain anymore, and stated he just wants the lord to take him, he can't live like this, it's been like this for years. Resident said that he hasn't slept in 3 days, since he's been here, and the Tylenol and cream you guys hive [sic] me doesn't do f**king s**t. Asked resident if there is anything that has worked in the past, and resident replied oxycodone (opioid medication) has helped me sleep and taken the pain away before. Resident was provided diclofenac (non-steroidal anti-inflammatory drug) cream as well, this did help resident. Reduced pain from 9/10, down to a 3/10 in about 10-15 minutes. Resident then requested more of it because pain was coming back. The writer asked resident what he meant by he wants the lord to take him, and he stated this pain makes me suicidal. This writer asked him if he had a plan, he replied no he did not, but this has been going on for years and none of these f**king doctors understand that this pain makes me not want to be alive anymore. DON (Director of Nursing), ADON, and social worker all updated about these comments, as well as APNP (Advanced Practice Nurse Prescriber) [NP L's Name] . On 4/4/24 at 12:15 PM, a Progress Note was written by DON B, that states, in part: Writer notified of resident's suicidal comments made this shift. Writer had 1:1 conversation with resident. Resident stated this pain is so bad, I just want to die. Resident denied having a plan. Resident sitting up in bed, with flat affect during conversation. Resident stated this isn't new to me, it happens all the time. Resident placed on 15 minute checks. [NP L's Name] NP aware and met with resident in house. NP reviewed residents history, and stated these comments and c/o pain are not new for resident. Resident is followed by pain clinic and has appointment next week. New orders received from [NP L's Name] . On 4/4/24, R11's Physician Orders indicate new orders were placed for: acetaminophen (Tylenol) 650 mg, scheduled three times a day for pain, not to exceed 4,000 mg in 24 hours. Voltaren (diclofenac sodium) gel, 1% apply 2 grams to the right lower extremity four times a day as needed for pain. On 4/4/24 at 3:49 PM, a Progress Note was written by SS N (Social services), that states: The writer followed up with resident regarding the suicidal ideation comments. Resident stated that he is in pain and the medication he is receiving is not helping. This writer made sure resident does not have a plan. (Of note: No PHQ-9 (Patient Health Questionnaire-9, a screening tool for depression) was completed at this time.) On 4/4/24, MAR indicates R11 reported 7 out of 10 pain to Evening shift. On 4/5/24, R11's Comprehensive care plan problem is created for, Resident has expressed thoughts of being better off dead. Interventions as noted above, including initiating 15 minute checks when R11 makes suicidal comments. On 4/5/24, MAR indicates R11 reported 9 out of 10 pain to Day shift. On 4/5/24 at 7:31 AM, R11's MAR indicates R11 received 4 grams of diclofenac gel and is marked to be Effective. On 4/7/24 at 3:13 PM, a Progress Note was written by LPN O (License Practical Nurse), that states: Resident reported 8/10 pain to right stump most of the shift. Rubbing stump occasionally in an attempt to minimize pain. Scheduled and PRN creams applied, resident reports not effective. Resident insisted he had a cream that is now used up that did work but not sure the name of that medication. Resident became upset when writer unable to provide him with the name or tube of medicated cream that he reported was effective. Resident reported he thought it may be lidocaine; however, he does not currently have order for Lidocaine ointment. Left note with resident's request for provider to follow up on (Of note: R11's MAR indicates the resident reported pain of 1/10, 3/10, and 0/10 for each shift of 4/7/24) On 4/8/24, MAR indicates R11 reported 8 out of 10 pain to Day shift. On 4/8/24 at 3:41 AM, R11's MAR indicates R11 received 1000 mg of PRN acetaminophen for 8 out of 10 pain, which was indicated to be Somewhat Effective. On 4/8/24 at 6:49 PM, a Progress Note was written by ADON K that states: Resident tearful and voiced depressive statements to staff prior to supper tonight. Resident stated I would be better off dead than deal with this pain, and Just kill me, it would hurt less. Writer did sit with resident who immediately stated, I don't want to hurt myself, I just don't want to hurt anymore. Resident denied having a plan to self harm when asked by writer. Writer did discus[TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure residents received adequate fluid intake to maintain acceptable parameters of hydration for 1 of 4 Residents (R19) reviewed for nutrition. On 3/7 - 3/13/25 R19 was hospitalized with aspiration pneumonia and received intravenous fluids during his hospitalization . On 3/17-3/19/25 R19 was hospitalized with dehydration requiring intravenous fluids. R19 was consistently not meeting his daily recommended fluid intake of greater than 1,400 ml (milliliters). R19 had a significant weight loss of 10.9% from 3/7/25 - 3/26/25. The facility failed to ensure R19 received adequate fluid intakes to maintain acceptable parameters of hydration by failing to total and assess daily fluid intake; accurately assess and complete on going assessments for signs and symptoms of dehydration (e.g., sunken eyes, cool/clammy skin, dry tongue, dark colored urine, and sticky saliva); failure to weigh resident weekly; failure to weigh resident upon readmission to the facility; failure to add/revise care plan interventions to prevent further dehydration and weight loss; failure to timely communicate weight changes to provider. This is evidenced by: Facility Policy entitled 'Dehydration/Fluid Maintenance, reviewed 1/2025, states in part: Purpose: To determine the risk status of residents to develop dehydration and to implement measures to assure adequate fluid/maintenance hydration. Goal: To prevent dehydration from happening by identifying risk factors which lead to dehydration and provide the resident with sufficient fluid intake to maintain proper hydration and health. Procedure: At the time of each resident's admission, readmission, quarterly review, or significant change in condition, a Nutritional Assessment will be completed by the DTR/RD with input from the interdisciplinary team. The attending physician will be notified of the results of the assessment if the resident is found to be at risk for dehydration and the appropriate recommendations will be written and protocols will be implemented to promote hydration. Risk factors include: a. Fluid loss exceeds the amount of fluids consumed, b. Elevated temperatures or infection, c. Dependence on staff for the provision of fluid intake, e. Renal disease, f. Dysphagia, g. Limited fluid intake lacking thirst sensation, h. Refusal of fluids. Once risk factors are identified, a plan of care will be initiated to provide sufficient fluid and maintain proper hydration. Plan for the amount of fluid provided at each meal, snack and additional fluids provided by nursing staff. Based on medical condition, ability to consume adequate fluids, and/or any resident that presents with a diagnosis of dehydration will have a care plan that addresses the potential for dehydration/fluid maintenance. Assessing and Care Planning: Follow the standard care process of identification, assessment, treatment and monitoring when addressing dehydration. Interventions should be individualized, aggressive, and revised as needed based on the residents responses, outcome and needs. Creative Suggestions include: (consider using to keep residents well hydrated) Offer additional fluids during medication time (4-8 ounces), Assist residents to drink fluids, Ensure that clients received thickened liquids are encouraged to consume adequate fluids due to their high risk of dehydration. According to Strategies for Ensuring Good Hydration in the Elderly, Dehydration is a frequent etiology of morbidity and mortality in elderly people. It causes the hospitalization of many patients and its outcome may be fatal. Indeed, dehydration is often linked to infection, and if it is overlooked, mortality may be over 50%. Older individuals have been shown to have a higher risk of developing dehydration than younger adults. Modifications in water metabolism with aging and fluid imbalance in the frail elderly are the main factors to consider in the prevention of dehydration. Particularly, a decrease in the fat free mass, which is hydrated and contains 73% water, is observed in the elderly due to losses in muscular mass, total body water, and bone mass. Since water intake is mainly stimulated by thirst, and since the thirst sensation decreases with aging, risk factors for dehydration are those that lead to a loss of autonomy or a loss of cognitive function that limit the access to beverages. The prevention of dehydration must be multidisciplinary. Caregivers and health care professionals should be constantly aware of the risk factors and signs of dehydration in elderly patients. Strategies to maintain normal hydration should comprise practical approaches to induce the elderly to drink enough. This can be accomplished by frequent encouragement to drink, by offering a wide variety of beverages, by advising to drink often rather than large amounts, and by adaptation of the environment and medications as necessary. https://onlinelibrary.[NAME].com/doi/pdf/10.1111/j.1753-4887.2005.tb00151.x The facility policy, Weight and Height Records Policy, revised 8/2023, documents, in part, as follows: In order to provide appropriate and resident centered care the facility staff will obtain and monitor resident weights as follows: Weight loss or gain of 3# (pounds) less for those residents 100# will resident in a resident being reweighed. Weights greater than 100# will follow weight bariance [sic] reporting for CMS/MDS (Centers for Medicare and Medicaid Services/Minimum Data Set) guidelines as follows: 5% +/-30 days, 7.5% +/-90 days, 10% +/-180 days. Weights will be recorded in EMR (electronic medical record) when obtained. Dietician/CDM (Certified Dietary Manager) weight range will not exceed +/-10% (percent). R19 was admitted to the facility on [DATE] with diagnoses including, but not limited to, as follows: multiple sclerosis (a central nervous system condition that disrupts communication between the brain and body), chronic kidney disease stage 3 (a moderate decline in kidney function), weakness, and dysphagia oropharyngeal phase (difficulty with the oral prepatory phase - trouble forming the food bolus before swallowing). On 3/27/24 RD G (Registered Dietician) completed the following Initial Assessment: Diet Fluids >1,400 ml/day (greater than 1,400 milliliters per day) On 9/27/24 DON B (Director of Nursing) ordered the following for R19: Weekly weight. Once a day on Monday R19 is a DNR (Do Not Resuscitate). It is noted in R19's record, R19's APOAHC (Activated Power of Attorney for Health Care) made the decision to enroll R19 in comfort care on 3/28/25. Of note, R19's APOAHC declined hospice care. R19's Quarterly Minimum Data Set (MDS) dated [DATE] indicates R19 has a Brief interview of Mental Status (BIMS) of 10 out of 15 indicating he is moderately cognitively impaired. R19's family member is his APOAHC (Activated Power of Attorney for Health Care). R19's comprehensive care plan documents, in part, as follows: (Problem Start Date: 3/19/25) R19 is at end of life, is receiving comfort care. (Approach start date: 3/28/25) R19's APOAHC (Activated Power of Attorney for Health Care) declined hospice services stating she would only like the facility staff to care for him and no other staff. R19's comprehensive care plan documents, in part as follows: (Problem Start Date: 4/7/23) Nutritional Status-Resident triggers at risk for malnutrition based on MNA (mini nutritional assessment), PMH (past medical history), mechanically altered diet textures, and disease progression. Goal: Resident will receive adequate nutrition/hydration. Approach: .(Approach Start Date: 4/7/23) Diet provides >1,920 cc's of fluids per day. Encourage nectar thick fluids at bedside and with activities. Monitor for signs & symptoms of fluid imbalance (i.e. swelling, shortness of breath, dry mucous membranes, dry skin, poor skin turgor). Monitor meal intake/record. Offer substitutes if consumes <50% of meals. On 1/20/25 R19 weighed 204.1 On 1/27/25 R19 weighed 202.9 On 2/10/25 R19 weighed 203.1 It is important to note, the facility is collecting intakes, however, the facility is not totaling R19's daily fluid intakes, therefore not assessing the data they are collecting. R19's intakes (calculated by Surveyor) leading up to hospitalization are as follows: 3/3: 200 ml 3/4: 900 ml 3/5: 400 ml 3/6: 800 ml Of note, R19 did not reach his fluids needs. On 3/6/25 the Nurse Practitioner wrote the following order: Encourage fluids/hydration throughout the shift. 7:00 AM - 3:00 PM, 3:00 PM - 11:00 PM and 11:00 PM - 7:00 AM R19 was hospitalized [DATE] -3/13/25 for aspiration pneumonia. R19 received IV (intravenous) fluids during this hospitalization . *See RD G's (Registered Dietician) note below. On 3/13/25 at 4:04 PM, RD G (Registered Dietician) documented the following Progress Note: Nutrition Update: Noted resident's return from the hospital following sepsis. Received IVF (intravenous fluids) d/t (due to) hydration needs. *Received an estimated total of 5,124 ml between 3/7-3/8, with an average of 731 ml per day over 7 days. Current diet order in place: Pureed with nectar thick liquids. Continue to monitor chewing/swallowing ability at this facility, SLP (Speech-Language Pathology) to eval (evaluate) in-house, RD G will continue to monitor and f/u (follow up) quarterly/prn (as needed) to assess intake, wt (weight) status, and diet tolerance. R19's intakes (calculated by Surveyor) leading up to hospitalization are as follows: 3/13: 320 ml 3/14: 580 ml 3/15: 370 ml 3/16: 680 ml Of note, R19 did not reach his fluids needs, the facility did not provide documentation of a dehydration assessment. The facility did not weigh R19 from 3/13 - 3/17/25. R19 was hospitalized ,d+[DATE]-[DATE] with dehydration requiring IV (intravenous) fluids. R19's hospital report documents, in part, as follows: Creatinine: 2.28 (High). Estimate GFR: 29 (High) Sodium: 144 (Reference Range 135-145) The hospital physician documents, in part, as follows: Patient was admitted to inpatient on 3/17/25 for Somnolence (excess sleepiness). admitted for infection vs dehydration causing AMS (Altered Mental Status) - appeared hemoconcentrated (increase in red blood cells, white blood cells and platelets in the blood due to a reduction in the volume of plasma (liquid portion of the blood).), high specific gravity. Urine and blood cultures negative at 24 hours, abx (antibiotics) discontinued. Patient continued to do well. Returned to baseline mentation after fluid administration - *feel this was dehydration with lack of infectious etiologies. The hospital has the following weights documented for R19: 3/7/25: 218.4 3/17/25: 208.3 - It is important to note, R19 lost over ten (10) pounds in 10 days. (Significant weight loss) = -4.62% 3/18/25: 206.1 = - 5.63% 3/19/25: 207.8 = -4.85% On 3/19/25 R19 was readmitted to the facility following a hospital stay. The facility did not obtain R19's weight upon readmission. On 3/20/25 at 3:05 PM, RD G (Registered Dietician) documented the following Progress Note: Nutrition Update: Noted resident's return from the hospital following an event of somnolence. Received IVF (intravenous fluids) d/t hydration needs. *Received an estimated total of 5,800 ml (milliliters) between 3/17-3/18/25, with an average of 834 ml per day over 7 days. Current diet order in place: Pureed with nectar thick liquids. Continue to monitoring chewing/swallowing ability at this facility, SLP (Speech-Language Pathology) to eval (evaluate) in-house. RD G will continue to monitor and f/u (follow up) quarterly/prn (as needed) to assess intake, wt (weight) status, and diet tolerance. (Of note: R19 has received over 10,000ml of IV fluids during hospitalization in less than 2 weeks.) On 3/26/25 R19 weighed 194.6 at the facility there is no documentation indicating R19's Physician/provider was updated. (It is important to note, R19 returned to the facility following a hospitalization on [DATE]. The facility did not weigh R19 until 3/26/25. During this time, R19 continued to lose weight.) From 3/19/25 - 3/26/25 R19 experienced a 6.35% weight loss. On 3/27/25 at 4:28 PM, RD G (Registered Dietician) documented the following Progress Note: Nutrition update: Noted resident's updated weight status, and 195 lbs (pounds) on 3/26/25. 9 lb loss over the past 1.5 months. The loss was anticipated r/t (related to) multiple hospitalization s within this timeframe. Continue to monitor wt (weight) status for goal of stabilization. Continue current diet textures and feeding precautions in place. RD G will continue to monitor and f/u (follow up) prn (as needed). Of note, there is no documentation of any weights/monitoring until eight (8) days after R19's readmission to the facility. There are no new care plan interventions indicated as being implemented upon R19's return after being hospitalized related to dehydration. No documentation was provided indicating nurses are monitoring or documenting signs and symptoms for R19 related to dehydration. On 4/7/25 R19 weighed 200 .9 On 4/14/25 at approximately 12:00 PM, Surveyor observed CNA CCC (Certified Nursing Assistant) assisting R19 with his lunch in the dining room. Surveyor observed R19 had ample fluids and food on his tray for the meal. R19 had 480 ml (milliliters) of fluid on his tray. Surveyor observed R19 drank 240 ml. On 4/14/25 at 1:00 PM, Surveyor spoke with RN DDD (Registered Nurse). Surveyor asked RN DDD, who documents fluid intakes. RN DDD stated, the nurses document fluid intakes at the end of the shift. RN DDD stated, nurses and CNA's (Certified Nursing Assistants) document in the same place. Surveyor asked RN DDD, who is responsible for totaling daily fluid intakes. RN DDD stated, she is unsure and the computer system may automatically. Surveyor asked RN DDD, what are symptoms of dehydration that require monitoring. RN DDD stated, staff should monitor output, skin turgor, dry lips, low blood pressure, etc. RN DDD stated, staff really have to be on top of offering R19 fluids while he is in his room. RN DDD stated, R19 needs assistance with eating and drinking and he has end stage MS (Multiple Sclerosis), a degenerative disease. On 4/14/25 at 1:40 PM, Surveyor spoke with CNA CCC (Certified Nursing Assistant). Surveyor asked CNA CCC (Certified Nursing Assistant) if R19 has difficulty eating or drinking. CNA CCC stated, sometimes R19 gets too sleepy so she will take a break or ask if R19 is finished. CNA CCC stated, R19 has better days than others. CNA CCC stated, sometimes R19 will hold food in his mouth and she will follow up and offer him juice to help get the food down. CNA CCC stated, R19 does not normally have any difficulty swallowing liquids. Surveyor asked CNA CCC, do you record fluid intakes for R19. CNA CCC stated, she records intakes or tells the CNA's what R19 ate or drank. CNA CCC stated, R19 had 480 milliliters of fluids on his tray and R19 drank 240 ml (milliliters) between nectar thick milk and orange juice at lunch today. CNA CCC stated, R19 was unable to finish the meal as he got too sleepy to finish the rest. CNA CCC stated, R19 would drop his head down. CNA CCC stated, R19 has fluids in his room such as apple juice (out of reach for safety reasons) that staff will offer R19 and give him a couple sips. On 4/14/25 at 2:00 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, is she aware that R19 was dehydrated during the 3/17-3/19/25 hospitalization . DON B stated, she does not remember if the facility has that documented or not. Surveyor shared RD G's (Registered Dietician) Progress Notes (above). DON B stated, yes, the facility is aware. Surveyor asked DON B, are you aware that R19's received IVF (intravenous fluids) during his prior hospitalization from ,d+[DATE]-[DATE]. DON B stated, yes, she is aware of that. Surveyor asked DON B, what is the facility doing to address this. DON B stated, R19 has an order in place to encourage fluids. DON B stated, R19 is following up with ST (Speech Therapy) & OT (Occupational Therapy). DON B stated, R19 is currently actively participating in ST and OT. Surveyor asked DON B, who is responsible for totaling R19's daily fluid intakes. DON B stated, she is unsure. DON B added, RD G may calculate the fluid totals. (Note, per interview with RD G (below), she does not calculate fluid totals on a daily basis. Currently, nobody at the facility totals daily fluid intakes. Subsequently, daily fluid intakes are not being monitored on a daily basis.) Surveyor asked DON B, how do you know that R19 is meeting his daily fluid needs when his fluid intakes are not totaled on a daily basis. DON B stated, there's no way to know if R19 is meeting his daily fluid needs. DON B stated, staff would need to add the fluid totals. Surveyor asked DON B, would you expect staff to total fluid intakes. DON B stated, yes. Surveyor asked DON B, why is this important. DON B stated to make sure R19 is adequately hydrated. DON B stated, we did recently have a goal of cares switched from Full Code to DNR (Do Not Resuscitate) due to weight loss and overall decline. Surveyor asked DON B, when were intakes put in place for R19. DON B stated, this started on 10/14/24 to encourage fluids. Surveyor asked DON B, what was this in response to. DON B stated, this was to a high Creatinine lab. Surveyor asked DON B, are staff to be encouraging fluids. DON B stated, yes. Surveyor asked DON B, should R19 have fluid in his room. DON B stated, staff can bring fluids when they check in on him and offer. DON B stated staff should be assisting him with fluids and should leave them out of R19's reach as R19 requires supervision with drinking and eating. Surveyor asked DON B, should the provider have been notified with R19's significant weight loss. DON B stated, yes. On 4/14/25 at 2:19 PM, Surveyor spoke with RD G (Registered Dietician). Surveyor asked RD G, where do staff record fluid intakes. RD G stated, she believes staff document intakes under vital signs and that's where she looks for intakes. Surveyor asked RD G, do staff document fluid intakes in any other locations. RD G stated, no, not that she is aware. Surveyor asked RD G, who is responsible for totaling daily fluid intakes. RD G stated, that would be the nursing realm. RD G stated she looks at fluid intakes as a whole picture and does not total them on a daily basis. Surveyor asked RD G, why is important to ensure that residents are getting enough fluids and adequately hydrated. RD G stated, to ensure residents do not become dehydrated. RD G stated, for R19 the facility provides nectar thick fluids, Magic Cups (supplement), encourage milk, juice, and water with all meals. The facility failed to ensure R19 received adequate fluid intakes to maintain acceptable parameters of hydration

Based on observation, interview, and record review, the facility did not ensure that each resident received adequate supervision to prevent accidents for 1 of 3 residents reviewed for needing assistance or supervision with meals. On 10/13/24, R1 was in the dining room for her supper meal. R1 was attempting to eat soup and spilled the soup onto herself causing 2nd degree burns to her right arm and abdomen. R1 required supervision during meals; supervision and assistance were not provided. Soup temperature following R1 suffering burns and after meal service was 177 degrees. The facility's failure to provide adequate supervision and assistance during meals and the failure to ensure foods and fluids were served at a temperature that would not cause burns created a finding of immediate jeopardy which began on 10/13/24. Nursing Home Administrator (NHA) A was notified of the immediate jeopardy on 10/30/24 at 9:30 AM. The immediate jeopardy was removed on 10/30/24; however, the deficient practice continues at a scope/severity of E (Pattern/Potential for Harm) as the deficient practice has the potential to affect 20 residents that need assistance with meals while the facility implements its removal plan. Evidenced by: The facility policy titled Hot/Liquid Food Management dated 1/2024, states, in part: Policy: It is the policy of this facility to manage resident consumption of hot liquids in order to prevent burns or serious injury. Procedure: 1. A Hot Food / Liquid Assessment will be performed upon admission, quarterly and with a resident significant change in condition by a facility clinical leader, and if needed in collaboration with Occupational Therapy. 4. Residents identified through the assessment process as at risk for injury related to exposure to hot liquids shall not be left unsupervised during meal service while pending completion of evaluation. 5. Intervention selections will be communicated with nursing, dietary staff, activity staff and updated on resident plan of care. 6. Residents identified as at risk will have selections listed on diet card in addition to an indicator Hot Spill Risk to alert staff during delivery of meal is at high risk for burn injury. 7. The individual resident care plan will reflect resident specific risk factors and appropriate interventions to assist in preventing burn injuries. 8. The dietary department will monitor hot food/beverage temperatures on the tray line on a daily basis to ensure appropriate temperatures are maintained. Subject: Identify Resident at risk for burns caused by hot liquids. Purpose: To reduce the risk of Residents burns related to hot beverages, liquids and foods, and to provide guidance on re-heating resident foods and/or liquids as well as provide guidance on steps to take if a burn occurs. Standard of Practice: - Hot liquids are not to be served at a temperature greater than 135 degrees F (Fahrenheit), unless care plan has specific identified alternatives. - Clothing protectors or cloth napkins will be available and offered to all residents during mealtime or when Hot Liquids or foods are served. - Dining room service will be supervised. - Resident at high risk will require 1 to 1 supervision. Procedure: 3. Maximum temperature at point of service should not exceed 135 degrees. 5. Residents who have liquid spills will receive lids with sippy openings and a clothing protector or cloth napkin as a temporary intervention until evaluated by Occupational Therapy. All hot liquids will be placed in insulated mugs with lids including soups. Care plan and diet cards will be updated as needed. The table below, from the State Operations Manual, shows the estimated time for a person to receive third degree burns at various temperatures. 155 F/68 C - 1 second 148 F/64 C - 2 seconds 140 F/60 C - 5 seconds 133 F/56 C - 15 seconds 127 F/52 C - 1 minute 124 F/51 C - 3 minutes 120 F/48 C - 5 minutes R1 was admitted to the facility on [DATE] and has diagnoses that include in part: cerebral infarction, aphasia, weakness, dysphagia, diabetes mellitus type 2, traumatic hemorrhage of left cerebrum, and hemiplegia and hemiparesis affecting right dominant side. R1's Quarterly Minimum Data Set (MDS) Assessment, dated 8/10/24, staff assessment of R1's cognitive status indicates R1 is moderately impaired with short- and long-term memory. Section GG shows that R1 has impairment to one side of upper and lower extremity. R1 has a mechanically altered diet needing supervision/touch assistance. R1's care plan states, in part: Problem: Problem Start Date: 11/27/22. Category: Nutritional Status Hot food/liquid assessment. Approach Start Date: 11/27/22. At risk-Encourage clothing protector or cloth napkin over the lap and chest when consuming hot food/liquids, cup with lid, inner lip plate, consume all hot liquids/food at table. Problem: Problem Start Date: 8/30/22. Category: ADLs (activities of daily living) Functional Status/Rehabilitation Potential Alteration in ADLs-self care deficit r/t (related to) Resident's participation and functioning level does vary/fluctuate. Approach Start Date: 10/25/24. Place all soups in coffee mugs. Approach Start Date: 11/17/22. Status of eating ability: Assist of 1 when she allows, refuses assistance often. Eats with her hands/fingers, refuses silverware often. Problem: Problem Start Date: 2/9/22. Category: Nutritional Status R1 is at Nutritional / Hydration risk d/t PMH (past medical history) of cerebral infarct w/ (with) l (left) side hemiplegia, dysphagia, aphasia, malnutrition, DM (diabetes mellitus), hyperkalemia, AKF (acute kidney failure). Approach Start Date: 2/9/22. Assist with meals as needed. Refuses assistance often, eats with her fingers and hands. Refuses silverware often. Approach Start Date: 2/9/22. Diet: Regular with chopped textures and thin liquids. Plate guard for all meals. Cut solid foods into bite sized pieces to discourage impulsively large bites. Receives lidded cups with all meals to prevent spilling. Staff provide PRN (as needed) assistance with meals. The facility document titled, Hot Food/Liquid Assessment, dated 8/18/24, states in part: Type of Assessment: Quarterly. Clinical Risk Review: Yes is answered for the following questions . does the resident have poor hand control; does resident have dementia, impaired cognition, or confusion; does resident have dx (diagnosis) of Parkinson's, CVA (cerebral vascular accident), multiple sclerosis, seizure disorder, left sided or right sided weakness; does resident have frequent impulsive acts/short tempered or behavior concerns; does resident have contractures to hands/fingers/elbows present; does the resident have any history of accident/injury with the use of hot liquids or foods. If any of the questions are answered with a Yes, STOP! The resident is considered to be high risk for possible management of hot foods or fluids that could place them at risk for injury. Select all appropriate intervention(s) that will reduce the resident risk. Resident's preferences are to be taken into consideration with selections. Those marked as interventions include . cup with lid, cup 1/2 (half) full, consume hot liquids/food while sitting at table only, clothing protector or cloth napkin over lap & (and) chest, scoop plate, staff to provide assistance with meal with hot foods or liquids. On 10/29/24, at approximately 8:45 a.m., Surveyor reviewed R1's meal ticket that is placed on the resident's tray when meal is sent out to be served. Meal ticket indicates R1 needs PRN assist with meals. Lids with beverages. Regular, Chop. Preferences: Cut up food into bite-sized pieces; Coffee, Juice; Cup with lid (1 each); Inner lip plate (1 each). Of note: Surveyor observed R1 during breakfast and lunch on 10/29/24. R1 was noted to not have cups with a lid or an inner lip plate during either meal service. Nurses Note from 10/13/24 at 6:08 PM, states, Resident was eating in the dining room and this writer heard uncomfortable screaming. Immediately went to dining room where resident was screaming. Observed soup all over resident's lap on right side, observed inflammation and redness to right arm. Asked resident if she spilt her soup and she said yes. Took resident to her room for further skin assessment and removal of clothing. Observable blisters and fluid form. Resident screaming in pain, grabbing at right arm. Cold compress immediately applied to areas. On call MD (medical doctor), and POA (power of attorney) was called and wanted her to go to the ER (emergency room ). DON (director of nursing) notified of event. Hospital ER note from 10/13/24, states in part, Significant 2nd degree burns, recommended consult with burn center. ER was unable to clear answer if the facility could manage the wounds so the burn center accepted her for transfer. Wounds covered with saran wrap, oxy (pain medication) given, IV (intravenous) bolus of 500 mL (milliliters), tetanus update, and basic blood work. Transferred to [hospital name] burn unit. IDT note from 10/14/24 at 12:06 PM, states, Resident obtained burns to right hand/forearm and abdomen on 10/13/24 at approximately 1705 (5:05 PM). Resident was sitting in the dining room for dinner, and spilled soup onto self. Redness and fluid filled blisters noted to area immediately following. Wound edges irregular. No bleeding or drainage noted. Cool compress immediately applied to area. Resident sent to ER for evaluation. New orders received from OT to assess self-feeding upon return to facility. R1 returned to the facility on [DATE] with wound orders for . Bacitracin, cuticerin, and gauze, change daily, apply derma fit to right arm and hand. Hospital Discharge Summary from 10/15/24 at 0651 (6:51 AM), states in part, Primary Discharge Diagnosis: Burn to abdomen and arms. Presenting Problem/History of Present Illness: Per admission H&P (history and physical), she was eating hot soup and spilled it on herself at dinner today, which was reported per staff. Patient was crying due to pain and developed some blisters on her right abdomen and right forearm. Per the facility she spilled 170 degree soup on herself and sustained 2nd degree burns to the right hand and righ [sic] side of abdomen with blistering. On exam patient is non-verbal and can acknowledge simple questions but not oriented to place or time. She appears non toxic and comfortable. [NAME]-[NAME] Burn Calculation: Total 2nd degree burns 3. TBSA (total body surface area) % burned (2nd) 3. The patient was admitted to the burn unit on 10/13/24 following her burn. She was started on multimodal pain control, a high protein, high calorie diet, bowel regimen, and DVT (deep vein thrombosis) prophylaxis. Initial wound cares and cleansing were completed which the patient tolerated well with appropriate IV (intravenous) and oral analgesia. Wound cares at her facility were arranged and she was discharged on ,d+[DATE] with scheduled follow up in Burn Clinic. Nurse's note from 10/15/24 at 5:35 PM, states in part, Returned to facility via ambulance at 1540 (3:40 PM). BP (blood pressure) 122/79, P (pulse) 82, R (respirations) 18, O2 sat (saturation) 97% (percent) on room air. Dressing and abdominal binder to right arm/hand and abdomen remain in place per orders. No drainage noted. Resident displayed no signs/symptoms of pain/discomfort. Resident currently resting in bed, no behaviors noted. Nurse's note from 10/15/24 at 6:54 PM, (recorded as a late entry on 10/16/24 at 7:00 PM), states in part, Resident re-admits [Hospital Name] with primary diagnoses of scald burn to right arm and right abdomen. She has comorbidities which include the following: stage 3 CKD (chronic kidney disease), atrial fibrillation with RVR (rapid ventricular rate), anxiety with agitation, type 2 diabetes mellitus, cerebrovascular accident, hypothyroidism, and hypertension. She is alert and oriented x (times) 1. Dressing put in place by wound care and are to remain in place until follow up appointment on 10/21/24. Current dressing is Mepilex AG (antimicrobial foam dressing that absorbs exudate and maintains a moist wound) - wound care instructions listed if dressing becomes soiled. She was given a prescription for oxycodone for pain if needed. She continues to be assist of 2 with hoyer lift for all transfers. She continues with a regular diet, chopped up foods. Wound Physician Notes from 10/23/24 state in part, Chief Complaint: Patient present with wound on her right arm; right lower abdomen, left lower abdomen. Additional System: Spilled soup on abdomen and R (right) arm 10/13/24 resulting in burn wounds 10/23/24 cellulitis to Rt (right) arm. Rec (recommend) Keflex 500 mg BID x1 week. Focused Wound Exam (Site1). Burn Wound of the Right Arm Full Thickness. Wound Size: 10 x 5.5 x 0.1 cm (centimeters). Exudate: Moderate serous (clear, thin, watery fluid). Slough: 70%. Slough (a yellow, white, or tan, stringy, or thick material) 10%. Dressing Treatment plan: Primary Dressing(s): Santyl apply once daily for 30 days; Xeroform gauze apply once daily for 30 days. Secondary Dressing(s): ABD (abdominal) pad apply once daily for 30 days; Gauze roll (stretch) 4 (inch) apply once daily for 30 days; Tape (retention) apply once daily for 30 days. Recommendations: Cleanse with saline at time of dressing change; Off-Load Wound; Antibiotic Choice: Keflex 500 mg bid x 1 week for cellulitis. Focused Wound Exam (Site 3). Burn Wound of the Right, Lower Abdomen Partial Thickness. Wound Size: 8 x 6.1 x Not Measurable cm. Exudate: None. Other viable tissue: 70% (Dermis). Primary Dressing: [NAME] sulfadiazine apply once daily for 30 days: Okay not to cover with secondary dressing. Patient allergic to adhesive tape. Nurse's note from 10/23/24 states, Cephalexin 500 mg (milligrams) BID (twice a day) for 1 week for cellulitis to the right arm. Wound orders from 10/24/24, state in part, Treatment to right arm burn. Area measures: 18 cm (centimeters) x 5.5 cm x 0.1 cm. Dressing: Santyl to wound bed. Cover with Xeroform (non-adherent primary dressing) and ABD (abdominal gauze pad). Secure with Kerlix (sterile gauze) and change daily. On 10/29/24 at 12:30 PM, Surveyor observed Assistant Director of Nursing (ADON) G complete wound care of R1's right arm as the abdomen is healed at this time. Wound care was completed, glove changes, and hand washing and sanitizing were appropriate. Surveyor then observed ADON G put on ordered Santyl directly into her gloved hand and applied it directly from her gloved hand to R1's wound bed. On 10/29/24 at 9:30 AM, Surveyor interviewed Licensed Practical Nurse (LPN) D. Surveyor asked LPN D to describe the details of the incident with R1 on 10/13/24. LPN D stated the incident happened on Sunday during the supper meal. I was at the nurses' station charting when I heard R1 yelling. When I went to the dining room R1 was holding her arm and I noted that her arm was wet. I scanned the table area and only saw an empty cup of grape juice so initially thought that is what R1 had spilled. I took R1 to her room to assess her and found remnants of soup. R1's arm was red, and blisters formed shortly after. Another LPN came into to assist me, and I sent her down to take the temp of the soup R1 was served. LPN D then went down and observed kitchen staff take the temperature of soup which was noted to be 177 degrees Fahrenheit at that time. I updated the MD. The Certified Nursing Assistants (CNAs) assisted with getting R1's clothes off and into bed. We immediately placed cold washcloths to areas on the arm and abdomen. R1's POA was updated and was ok with sending her in. Surveyor asked LPN D if LPN D remembers seeing anyone in the dining room. LPN D stated, I did not see anyone in the dining room. R1 did need feeding assistance. The process changed following incident to have someone with her during meals. R1 also developed cellulitis after returning to the facility and currently is on an antibiotic. Hospital called after R1 was sent out to ask if we could complete the dressing changes. LPN D indicated she called the DON and she said we could do the dressing changes, so I called the hospital back and let them know. R1 did not come back though and ended up in the burn unit in [city name]. R1 is currently receiving daily dressing changes. Surveyor asked LPN D if she remembers seeing R1 wearing any clothing protector or napkins when she entered the dining room. LPN D stated, R1 did not have clothing protector on when I went into the dining room and R1 is not able to remove them on her own. On 10/29/24 at 11:35 AM, Surveyor interviewed LPN E. Surveyor asked LPN E what she remembers from the incident that happened with R1 on 10/13/24. LPN E stated, LPN D asked if I could come help. R1's arm was quite burned, and cold compresses were applied. The burn was around her thumb and wrist then up the arm/mid arm, a couple of inches above the wrist and a couple of inches below the elbow, as well as the right groin. The areas blistered quickly. I walked away to get washcloths and when I came back the blisters had already formed. Surveyor asked LPN E if she was asked by LPN D to go to the kitchen. LPN E stated, LPN D had asked me to go to the kitchen and have the kitchen staff temp the soup while I watched, which I did, and the soup temperature was 177 degrees. I reported the temperature of the soup to LPN D and she documented it. Surveyor asked LPN E who serves the meals in the dining room. LPN E stated, the kitchen staff gets the trays ready and whoever is assigned to the dining room takes the trays to the residents. Kitchen staff do not serve meals that I am aware of. On 10/29/24 at 1:05 PM, Surveyor interviewed CNA F. Surveyor asked CNA F what type of assistance R1 required in the dining room. CNA F stated, R1 needs help with setup and clothing protector because she spills a lot. Surveyor asked CNA F if she was in the dining room when incident occurred. CNA F stated, I may have been in the dining room, but I think we were done passing trays. I was on the 100 wing that day and we didn't have any residents that were dependent for meal assistance. On 10/29/24 at 1:15 PM, Surveyor interviewed CNA J. Surveyor asked CNA J what the fork and knife the fork and knife next to a person's name on the staff schedules indicate. CNA J stated, means you are to go the dining room and pass trays but can switch with person you are working with. Those that need supervision or assist are fed last or someone will stop passing trays and sit and assist. R1 can feed herself but needs supervision after setup. As far as I know R1 was able to use left hand for anything she needed. On 10/29/24 at 11:45 AM, Surveyor interviewed CNA H. Surveyor asked CNA H if she was in the dining room at the time of R1's incident on 10/13/24. CNA H stated, I was not in the dining room when R1 got burned. I was helping another resident, and I went down the hall to ask where R1 was. When I got down the hall EMS (emergency medical services) were already here and I helped get R1 on the cot, but that was all. Surveyor asked CNA H if she saw R1's burns. CNA H stated, I saw the burn on the lower part of her arm by the wrist. The skin was peeling and blistered. Surveyor asked CNA H what type of assistance R1 required during meals. CNA H stated, R1 was encouragement assistance at the time from what I was aware. The CNA care plan in Matrix and in the binder is where that information is located. Since this incident though the binder has gone away and we are to only use the care plan in Matrix. Surveyor asked CNA H what the fork and knife next to your name on the schedule means. CNA H stated the fork and knife on the schedule means you are responsible for the dining room and to be serving trays. I was not in the dining room though; I had asked CNA I and LPN D to assist in the dining room while I assisted another resident. On 10/29/24 at 12:00 PM, Surveyor interviewed CNA I. Surveyor asked CNA I what she remembers from the incident on 10/13/24. CNA I stated, I was passing trays in the dining room. I can't remember who gave R1 her tray. Usually, R1 required supervision. R1 would eat on her own once given a tray. Surveyor asked CNA I if she knew what supervision R1 required. CNA I stated, I am unsure what supervision is required. R1 sits at an assist table for that and her ailments I would assume. Surveyor asked CNA I if she knows how or who serves the trays to residents that require assistance or supervision. CNA I stated, I am not sure how trays are served to the residents at the assist table. Surveyor asked CNA I if she assisted LPN D. CNA I stated, LPN D told me she heard R1 scream which I don't recall hearing. LPN D came into the dining room asking for my help. Surveyor asked CNA I if she saw LPN D come into the dining room to get R1. CNA I stated, I did not see LPN D come get R1 from dining room. When I went to assist LPN D, R1 was covered in soup. We transferred R1 to the bed to get her clothes off so that LPN D could assess her skin. R1's skin was peeling, red, and you could see the burn. The areas did not blister right away but within 10-15 minutes noted blistering. Cold washcloths were applied to the burned areas. Surveyor asked CNA I if she remembered seeing any other staff in the dining room. CNA I stated, I don't remember any other staff in the dining room. Of note: Nursing and CNA staff schedules have knife/fork next to names. Surveyor asked what that meant and was told by staff that those people are responsible for the dining room (serving, assist and supervision). During interviews staff indicate they are not always the ones that go to the dining room if they are busy. On 10/29/24 at 3:35 PM, Surveyor interviewed Director of Nursing (DON) B, Regional Nurse Consultant (RNC) C and Nursing Home Administrator (NHA) A. Surveyor asked what supervision means in relation to residents needing supervision during meals. DON B stated, in the dining room where staff can see her, but they do not have to be sitting with her. Surveyor asked how you ensure residents are safe with their hot liquids and foods, when they have been identified at risk. DON B stated clothing protector on times two and cups with lids. Surveyor asked what happens if a resident will not keep lid on cups. DON B stated, we would encourage them to keep the lid on and ask if we could cool the liquid down. If still refusing to keep lid on would expect staff still sit with them. Surveyor asked what the fork and knife meant on the staffing schedule. DON B stated the staff are to be in the dining room. Surveyor asked DON B if schedule is accurate for this. DON B stated, it is not changed on the schedule if someone else goes in the dining room for someone else that is busy, so the schedule is not accurate, and this happens frequently. On 10/29/24 at 8:50 AM, Surveyor observed R1 being served her meal. Staff set up R1's meal and sat with R1. R1 was served French toast sticks, sausage, and juice in a disposable small cup. R1 was eating her food using her left hand to pick up food. Of note: R1 was not served coffee even though it was a preference on her meal ticket. No cups with lids were observed during breakfast and lunch meal observation. On 10/29/24 at 11:45 AM, Surveyor observed [NAME] K taking food temperatures after the foods were put into the steamtable. The temperatures were as follows: Roast beef - 181 degrees Mixed vegetables - 207 degrees Pureed meat - 204 degrees Gravy - 202 degrees Ground meat - 180 degrees Mashed potatoes with gravy - 186 degrees On 10/29/24 at 11:58 AM, Surveyor interviewed [NAME] L. Surveyor asked [NAME] L what a safe serving temperature was. [NAME] L stated food was to be served at 180 degrees or below; that is a safe serving temperature. Surveyor asked [NAME] L if he was aware of R1's incident of being burned after spilling soup on herself. [NAME] L stated he was the [NAME] for that evening meal. [NAME] L stated he plated the meal service and nursing staff served the residents. Surveyor asked [NAME] L if any changes were made after the incident or if [NAME] L was educated after the incident. [NAME] L stated he was not educated to make any changes; he talked through the incident with the manager and was told everything was fine. On 10/29/24 at 12:50 PM, Surveyor observed R1 being served her meal. Staff set up R1's meal and left R1 to eat independently with a staff member sitting across the table from R1 assisting R3. R1 was served roast beef, mashed potatoes, mixed vegetables, cream pie, and juice in a disposable small cup. R1 was eating her food using her left hand to scoop the food up and into her mouth. Of note: R1 was not served coffee even though it was a preference on her meal ticket. No cups with lids were observed during meal service. On 10/29/24 at 1:00 PM, Surveyor received a test tray. Test tray temperatures were as follows: Roast beef - 140 degrees, palatable Mashed potatoes with gravy - 160 degrees, very hot to taste, burning Surveyor's tongue Mixed vegetables - 133 degrees, palatable Milk - 55 degrees, palatable On 10/29/24 at 1:10 PM, Surveyor interviewed Dietary Manager (DM) M. Surveyor asked DM M what his credentials were to be a Dietary Manager. DM M stated he was going through the CDM (Certified Dietary Manager) course. DM M stated he has a Corporate Dietician who he can consult with. Surveyor asked DM M when he would expect food temperatures to be taken. DM M stated the cook staff are to take temperatures at the steam table just before meal service begins. DM M stated this is a new policy since R1's incident of spilling soup. Surveyor asked for proof of education for other staff and was not provided the education. On 10/29/24 at 1:20 PM, Surveyor asked [NAME] K when she is to take hot food temperatures. [NAME] K stated she takes hot food temperatures when she removes the food items from the oven. Surveyor asked [NAME] K if she was ever educated to take hot food temperatures from the steam table just prior to meal service. [NAME] K stated no. DM M stated [NAME] K had been on vacation and had not yet been educated. Surveyor asked DM M to review the Daily Food Temperature Log for tray line. The log showed the following, in part: 10/13/24 - Dinner: Soup - 178 (degrees) Starch/gravy - 186 (degrees) Vegetable - 189 (degrees) Ground Meat - 182 (degrees) Puree Meat - 177 (degrees) Puree Vegetable - 181 (degrees) Coffee/Tea - 182 (degrees) 10/19/24 -Breakfast: Hot Cereal - 203 (degrees) Entree - 153 (degrees) Sausage/Puree - 203 (degrees) Puree Entree - 173 (degrees) Coffee - 171 (degrees) Surveyor asked DM M if these hot food item temperatures were taken when the foods were removed from the oven or at the steam table prior to service. DM M stated he was not sure. Surveyor asked DM M what safe serving temperatures of food was. DM M stated safe serving temperatures were 180 degrees and below for hot foods. Surveyor asked DM M what, if any, changes were made for residents who receive hot food and liquids and were at risk for spilling. DM M stated residents who are at risk are provided lids on cups and bowls. Surveyor asked DM M if R1 was provided lids on her cups and bowls. DM M stated yes, R1 is provided lids on her cups and bowls. DM M stated he does beverage pass before breakfast on days he is working. DM M stated he provides R1 with hot coffee in a covered cup. DM M stated R1 will remove the lid and drink the coffee. DM M stated he tells R1 she should leave the lid on the cup, but R1 still removes the lid. DM M stated he does not stay with R1 when she is drinking her coffee; there are staff in the dining room, and they keep an eye on her. The facility's failure to provide adequate supervision and assistance during meals and the failure to ensure foods and fluids were served at a temperature that would not cause burns created a reasonable liklelihood fore serious injury thus leading to a finding of immediate jeopardy. The facility removed the immediacy on 10/30/24 when they implemented the following: - All residents have been assessed and care plans have been updated to the level of supervision during meals (1:1, direct, or indirect). - Temperatures have been taken in the kitchen every 15 minutes on the serving steam table tray line due to a need for a part replacement. Part replacement occurred 11/1/24 prior to service. - Test trays are done at the point of service for all residents in the dining room and one on each hall tray carts to be checked prior to beginning of service to verify food temp is 135-150 degrees. - Residents that have a risk of hot liquid injury have cups with lids that snap on and are more difficult to remove and also have staff supervision per their care plan approach as agreed upon by IDT and therapy. - Starting 10/30/24, dietary staff have had direct supervision at meals and assist taking temperatures of foods prior to service. - Dietary staff is being educated on the correct temperatures of service of food to be between 135-150 degrees at the point of service to the residents. - Policies have been changed to reflect this change. - Nursing staff is being educated on the definition of supervision that is expected in the dining room with the residents that require supervision. This is being audited at every meal to monitor compliance with every meal that residents at risk are having the correct level of supervision that is required to maintain safety with hot liquids/foods. - Maintenance checked the steam table and parts were ordered and expedited. Replaced on 11/1/24 prior to the start of service. - Facility will continue with weekly checks of the steam table for proper function. Due to faulty parts the temps on the food in the steam table were checked every 15 minutes to maintain safe temps. - QAPI meeting held related to PIP started in relation to the changes that need to be completed. This was held on 10/30/24 at 1700. - Staff education started with temperature changes in the dietary dept started at 1700 on 10/30/24. - Education to nursing staff related to the definition of supervision: 1:1, direct, and direct, started on 10/30/24 at 1700. - Care plans related to the level of supervision that is required for residents at risk with hot liquids updated and educated to nursing staff starting at 1700 on 10/30/24. - All education is ongoing with this being completed prior to the start of the next working shift. - Both tray audits and the supervision audits are being completed at all 3 meals 7 days per week to maintain the safe environment for the residents at meal time. - 10/31/24, resident council meeting held for the update of the residents to the recent changes and the updates to dining service. - At this time all staff that have worked in the facility have been educated to the changes in policy and the level of supervision that is to be provided in the dining room at all meals.

Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure 2 of 7 residents (R33 and R16) reviewed for falls received assistance devices to prevent accidents. The facility failed to implement a fall prevention measure for R33; as a result, R33 sustained a fall on 12/10/22 which resulted in a fractured hip. R33 was then placed on hospice services and passed away. In addition, the facility removed a U-bar (a device attached to a medical bed to assist with positioning), without assessing R16 for safety. R16 used the U-bar to assist him in and out of bed. When the U-bar was removed by the facility, R16 took a folding chair and attached the chair with a gait-belt to the bed frame and used it as a transferring device. Findings include: Review of a document provided by the facility titled Fall Prevention and Management Program, dated 01/22 indicated .Atrium Centers has established a standardized policy with guidelines that assigns responsibility and provides procedures for identifying residents at risk for falls; to systematically assess fall risk factors, providing guidelines for fall and repeat fall preventative interventions; outlines procedures for documentation and procedures for communication . Example 1: R33 was admitted to the facility on [DATE] with a diagnosis of vascular dementia. The quarterly MDS (Minimum Data Set) assessment, dated 10/03/22, indicated R33 had a BIMS (Brief Interview for Mental Status score of 10 out of 15 suggesting moderate cognitive impairment. The assessment indicated R33 required extensive assistance of one staff for bed mobility and extensive assistance of two staff for transfers. The assessment indicated R33 had two or more falls since admission and had no major injuries as a result. An Observation Detail List Report dated 11/16/22 indicated the resident was considered to be at high risk for falls with a score of 9. The score grid, located on this document, revealed any score of five or greater was considered high risk. R33's Resident Progress Notes dated 12/04/22 indicated R33 was found by Certified Nursing Assistant (CNA) lying parallel on the floor next to his bed. R33 was wrapped in his blanket. The progress notes revealed the resident had to be transferred back to the bed by a mechanical lift. The resident sustained no injuries. The Interdisciplinary Team (IDT) reviewed the resident's fall from 12/04/22 and recommended to place a fall mat on the floor next to his bed. This intervention was placed on R33's care plan on 12/5/22, R33's Resident Progress Notes dated 12/10/22 indicated R33 sustained a fall to the floor. LPN E (Licensed Practical Nurse) indicated the resident was found by a CNA and he was screaming in pain. R33 was moved by a mechanical lift, and this was when LPN E noticed his right leg was shorter than the left. LPN E notified the guardian and the physician. R33 was sent to the emergency room after this incident. Another entry on this same date indicated the resident was admitted to the hospital for a right fractured hip. R33 was placed on comfort measures and surgical repair was not pursued. R33 was discharged back to the facility on [DATE]. During an interview on 12/29/22 at 10:36 AM, DON B (Director of Nursing) stated the floor mat was not placed on the floor next to R33's bed as directed by the resident's care plan dated 12/05/22. DON B stated this was discovered during the investigation into the fall. During an interview on 12/29/22 at 2:59 PM, LPN E stated she was the staff member present during R33's fall on 12/10/22. LPN E confirmed there was no fall mat present when she assessed the resident after his fall. LPN E stated the resident would typically sit on the edge of his bed but never saw the resident attempt to get out of bed on his own. During an interview on 12/30/22 at 7:41 AM, LPN F confirmed she was the nurse on duty when R33 fell on [DATE]. LPN F stated she went to look for a fall mat after this incident and could not locate a mat. LPN F stated she worked the night shift again on 12/09/22 and did not remember a fall mat. LPN F stated she passed the need for a fall mat during report to the next nursing shift and was not aware the fall mat was never implemented by the facility. During an interview on 12/30/22 at 9:46 AM, DON B and QAN G (Quality Assurance Nurse) were present. DON B stated the goal was to prevent accidents for all residents and to provide safety. DON B stated when R33 returned back to the facility the staff had rearranged his room and provided a fall mat and made sure fall/accident interventions were put into place. Example 2: R16 was admitted to the facility on [DATE] with alcohol induced ataxia (involuntary bodily movements). R16's Care Plan 08/16/21 indicated the resident was at risk for falls. There was no mention of a U-bar or other device to assist the resident into and out of the bed. R16's quarterly MDS dated [DATE] indicated R16 had a BIMS of 11 out of 15 which revealed the resident was moderately cognitively impaired. The assessment indicated the resident was independent with bed mobility and transfers. An Observation Detail List Report dated 11/16/22 indicated the resident was considered to be at high risk for falls with a score of six. The score grid, located on this document, revealed any score of five or greater was considered high risk. During an interview on 12/28/22 at 8:21 AM, R16 stated a U-bar was removed from the head of his bed and he used it to position himself and get himself in and out of his bed. Surveyor observed the resident's bed and he had a folding chair attached to the frame close to the head of the bed. A gait belt was used to attach the folding chair to the bed frame. During an observation on 12/28/22 at 2:36 PM, the folding chair was still attached with a gait belt to R16's bed frame. During an interview on 12/28/22 at 2:45 PM, CNA I and CNA H (Certified Nursing Assistant)confirmed they were familiar with R16. Both stated the resident used to have a U-bar to assist him into and out of the bed. Both stated the U-bar was taken off by the facility. Both CNAs stated they were aware of the folding chair being placed next to the bed. Also present during the conversation was was LPN J. All 3 of the staff entered R16's room and confirmed the resident had attached the folding chair to the bed frame. LPN J stated this was a potential accident hazard and would alert maintenance. During an interview on 12/28/22 at 2:50 PM, DON B stated the U-bar was removed from R16's bed and was not aware the resident used a folding chair as a positioning device. During an interview on 12/28/22 at 3:31 PM, DON B confirmed there was no assessment completed for R16 prior to the removal of the U-bar from his bed and was not aware the resident used the device to position himself. During an interview on 12/29/22 at 8:11 AM, DoR K (Director of Rehab) confirmed R16 was a fall risk based on his diagnosis of ataxia. The DoR K stated the use of a U-bar was appropriate for the resident.

Based on observation, interview, and record review, the facility did not implement professional standards of practice to ensure that a resident does not develop pressure injuries (PIs), receives necessary treatment and services to promote healing and prevent infection of PIs, or prevent new PIs from developing for 1 of 3 residents sampled for PIs out of a total sample of 20 residents (R57). R57 was admitted , on 4/09/21, without a pressure injury. R57 was at risk for PI development. The facility did not put interventions in place to prevent PI development until after a pressure injury developed. R57 subsequently developed 5 facility-acquired PIs, one which worsened to a Stage 4. The facility did not implement an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures led to R57's facility-acquired Stage 4 pressure injury. This created an Immediate Jeopardy (IJ) which began on 9/3/21 and was removed on 9/22/21. INHA A (Interim Nursing Home Administrator) was notified of the IJ on 9/21/21 at 12:00 PM. The deficient practice continues at a scope/severity of D (potential for more than minimal harm that is not immediate jeopardy/isolated) as the facility continues to implement its action plan. This is evidenced by: The AMDA (American Medical Directors Association) clinical practice guideline entitled, 'Pressure Ulcers and Other Wounds,' dated 2017, states in part: .A pressure ulcer (Injury) is localized damage to the skin or underlying soft tissue, usually over a bony prominence or related to a medical or other device. The ulcer may present as intact skin or as an open ulcer and may be painful. The ulcer occurs as a result of intense or prolonged pressure or pressure in combination with shear. .Recognition: Early recognition of pressure ulcers and of any risk associated with the development of pressure ulcers and other wounds is critical to their successful prevention and management .Assessment: The purpose of the assessment is to collect enough information to evaluate the patient's general condition, characterize a pressure ulcer; and identify related causes and complications. The National Pressure Injury Advisory Panel (NPIAP) at www.NPIAP.com defines PI's in the following categories: Category/Stage II: Partial thickness loss - Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguinous filled blister. Category/Stage III: Full thickness skin loss - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. Category/Stage IV: Full thickness tissue loss - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown. Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Suspected Deep Tissue Injury (DTI) - depth unknown. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. The facility policy titled Pressure Injury Prevention and Care, last revised on 3/2021, states in part . Purpose: To promote and facilitate pressure injury prevention, as well as implemented appropriate interventions and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Procedure indicates, in part . 2. Nurses will complete Braden Scale for residents on admission/readmission, weekly for 4 weeks, monthly, at time of new pressure injury identification, and as needed. 4. Interventions will be implemented and care planned to prevent pressure injury development or to promote pressure injury resolution. Examples of interventions based on individualized resident needs may include the following. This list in not all-inclusive nor does it apply to every resident or situation: A. Pressure reduction mattress on bed D. Promote nutrition and hydration - refer to Registered Dietician as needed G. Repositioning of residents; provision of required assistance as allowed and tolerated I. Maintain the head of bed at the lowest position based on resident medical condition J. Encourage and promote elevation of resident heels when in bed and prevent residents' feet from coming into contact with foot board. 10. Residents at-risk for developing pressure injury will have a care plan implemented to minimize the risk of skin breakdown. Resident risk factors will be reviewed and considered when developing the plan of care. Risk factors include, but are not limited to: history of pressure injury, Braden score less than or equal to 12, use of medical device that can cause pressure (example: catheter tubing, anti-embolism stockings, braces, casts, splints, etc.), risk diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R57 was admitted to the facility on [DATE]. R57's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R57's admission MDS (Minimum Data Set) assessment, with an assessment review date of 4/16/21, indicates R57 has no PI's. R57 has a BIMS (Brief Interview of Mental Status) of 5, indicating severe cognitive impairment. R57 requires extensive assistance of two staff for bed mobility and transfers; extensive assistance of one staff for transfers and hygiene; and independent with staff setup with eating. Section H indicates R57 is frequently incontinent of urine. (It is important to note R57 is not on a toileting program.) Facility documentation of Braden Scale for Prediction of Pressure Sore Risk was completed 4/0921. R57 scored a 16, meaning R57 was at risk for pressure injury development. Initial Care Plan started on 4/9/21 states in part . R57 is at risk for pressure sore/skin at risk due to ADL (activities of daily living) status. R57's care plan, dated 4/12/21, states in part . Problem: Problem Start Date: 4/12/21: Resident is at risk for skin breakdown r/t (related to) generalized weakness and comorbidities of dementia with confusions and agitation, CKD, [CONDITION(S)] (hypertension), [CONDITION(S)], and paranoia. Approach: Approaches started on 4/12/21: Report any signs of skin breakdown, turn and reposition every 2-4 hours and prn, and use pressure relieving mattress for pressure reduction when resident is in bed. The facility did not implement proactive measures to offload R57's heels. R57 was admitted on [DATE] and was placed on an Immerse Mattress. According to, Direct Supply at content.directsupplycdn.com states in part . WARNING - This mattress is not intended for stage III or IV pressure ulcers. Mattress wound stage ratings are general usage guidelines. On 7/02/21, a Braden assessment was completed. Score was 14, meaning R57 was not at Moderate Risk for pressure injury development. The facility did not revise R57's care plan to address this risk. On 7/19/21 at 12:44 PM, Skin Incident Event V2, states in part . Description: Blood blister to R (right) heel. [NAME] (In House Acquired). Size: 3.2 x 4. Wound Edges: Smooth. Description: Peri wound is blanchable. Wound bed is dark red in color. Pain: 3/10. Immediate Measures Taken: Cleansed area and Other-float heels, encourage repositioning, will inquire boots to float heels with IDT (Interdisciplinary Team). Additional Measures: Obtained orders for batadine [sic]. Notification: NP (Nurse Practitioner), Resident/Resident Representative, and DON (Director of Nursing) notified. Interventions were not added to the Care Plan until 7/27/21. Note: Initial discovery of a blood blister on the right heel was 7/19/21. R57's care plan was not updated to include the Rooke Boots until 7/27/21. Nurses Note from 7/20/21 at 8:24 AM states, Orders received from NP (nurse practitioner) for (1) [MEDICATION(S)] paint BID (twice daily) to blister on right heel until resolved (2) follow weekly wound rounds. IDT (Interdisciplinary Team) Note from 7/20/21 at 8:54 AM states, IDT reviewed skin event on 7/19/21; intact blood blister to right heel. [MEDICATION(S)] has been ordered. Wound nurse will assess during rounds. NP note from 7/23/21, states in part . Resident lying the supine position. R57 has developed a blood blister on the right heel. It has remained intact. Staff have been using pressure relief strategies and treating with [MEDICATION(S)]. R57 denies pain at the site. She spends most of her time in bed or in the wheelchair. On 7/26/21, Weekly Pressure Ulcer Progress Report, states in part . Description: Blood blister on R heel. [NAME]. Pain: 0/10. Stage 1. Size: 2.9 x 3.4. Description of Peri-Wound: Blood blister remained intact and is now dry and hard. Skin is tinged red and healthy tissue visible underneath. Remainder of heel is pink and blanchable. Nutrition/Hydration Status: At ideal body weight. Response to treatment/preventative measures: [MEDICATION(S)] BID. Progress: Improved. Notification: NP, Dietary, and Resident/Resident Representative Notified. On 7/26/21, Skin Incident Event V2, Large red area with 2 purple areas inside the red area. Location and Size of Skin alteration: Red area the size of a baseball with 2 purple areas inside the red area. 1 purple area measures 3cm x 3cm and looks like a bruise. The other purple area measure 1cm x 1cm and looks like a blood blister. Wound Edges: Smooth. Pain: 0/10. Immediate Measures Taken: Area cleansed. Notification: NP and Resident/Resident Representative. Orders: Treatments: Monitor and document red area to right buttock. Measure Monday. Nurses Progress Note 7/26/21 at 11:10 AM, states . This writer was asked by hallway CNAs (Certified Nursing Assistants) to assess resident's buttock. Upon assessment a red area that was is [sic] about the size of a baseball was noted to the R (resident) buttock with 2 purple areas inside the red area. One purple area is 3cm x 3cm and looks like a bruise. The other purple area looks like a blood blister and measures 1cm x 1cm. Area is blanchable, not open and no [sic] over a boney prominence. Change nurse, wound nurse, DON, POA (Power of Attorney) all updated. Nurses Note from 7/26/21 at 5:25 PM, states, NP notified of pressure area to resident's left heel. Order received to paint area with [MEDICATION(S)] bid until resolved. Nurse Note from 7/26/21 at 5:27 PM, states, NP notified of red area to resident's right buttock with bruise and blood blister. No changes to orders. NP Note from 7/26/21, states in part . Update from NH (nursing home) Staff: Resident has a bruise to her right buttock that aides said has gotten bigger (quarter sized) and a small blood blister - not open but surrounding skin is peeling. Area surrounding both is red and blanchable, not over bony prominence. Also - new 3 cm pressure area to left heel. Response/Plan: start [MEDICATION(S)] paint on the left heel. She needs aggressive offloading. She should have something like a Rooke boot when in bed. Note: NP note from 7/26/21 indicates R57 needs aggressive offloading. The facility did not put interventions in place to achieve this nor did they update R57's care plan to reflect any changes. Note: The facility documented the Blister on the L heel was initially discovered on 7/26/21 but the first wound documentation on this area is on 8/2/21. IDT Note from 7/27/21 states, IDT reviewed skin events on 7/26/21; - Pressure area to left heel. [MEDICATION(S)] being applied. Rooke boots and heels up cushion. - Bruise and blood blister to red buttock. Barrier was applied. Will reaccess [sic] and get treatment orders. Approach start date 7/27/21: Heels up pillow and Rooke boots (Rooke Boot is a vascular boot that built to provide total heel offloading and redistribution of pressure along the calf to help treat and prevent lower-extremity skin breakdown) to prevent skin breakdown to feet. Nurses Note from 8/1/21 at 2:16 PM states, Right buttock continues with dark red/purple coloration, blister is no longer intact but does have skin flap present over opening. Appears to have peeling skin around it. She denied pain when area touched. Barrier cream applied. Repositioned carefully to avoid pressure to right buttock. Has the heels up boots on with pillow between her legs and appears comfortable @ (at) this time. [MEDICATION(S)] tx (treatment) done to both heels, both remain intact @ this time. On 8/2/21, Weekly Pressure Ulcer Progress Report, states in part . Blister to L (left) heel. [NAME]. Pain: 0/10. Stage 2. Size: 2.6 x 3. Description of Peri-Wound: Heel is pink and blanchable. Blister has dried and skin is slightly harder where clear fluid was present. Nutrition/Hydration Status: At ideal body weight. Response to treatment/preventative measures: [MEDICATION(S)] BID. Progress: 1st measurement. Notification: Physician, Dietary, and Resident/Resident Representative. On 8/2/21, Weekly Pressure Ulcer Progress Report, states in part . Description: Blood blister right heel. [NAME]. Pain: 0/10. Stage 2. Size: 2.9 x 3.4. Description of Peri-Wound: Blood blister remained intact and is now dry and hard. Skin around blister is pink and blanchable. Nutrition/Hydration Status: At ideal body weight. Response to treatment/preventative measures: [MEDICATION(S)] BID. Progress: No Change. Notification: NP, Dietary, and Resident/Resident Representative Notified. Nurses Note from 8/2/21 at 2:57 PM states, This writer was asked by hallway CNAs to come look at resident's buttock this morning. Upon assessment a large dark purple area that looks bruised was found on the R buttock with a smaller superficially open area in the middle. Area is firm, but not raised. Area was thoroughly cleansed and barrier cream was applied. Charge nurse and wound nurse updated. Nurses Note from 8/2/21 at 3:33 PM states, Received new order from NP for a treatment to wound on right buttock cheek- Apply [MEDICATION(S)] with [MEDICATION(S)], cover with ABD (dresing) and change daily and prn (as needed) until healed. 8/3/21, New or Worsened Pressure Ulcer, L heel blister. [NAME]. Stage 2. Sixe 2.6 x 3. Resident's Condition prior to discovery of pressure ulcer: Normal. Describe exactly how Pressure Ulcer was discovered. Heel is pink and blanchable. Blister has dried and skin is slightly harder where clear fluid was present. Pain: 0/10. Did the resident have pressure relieving device(s) in place. Yes. If yes, list devices is use. Pressure redistributing chair cushion, other-pillow to float heels. Interventions to prevent weight loss. Dietary Supplements and weight monitoring. New interventions: New interventions: pressure redistributing mattress, heel offloading device, wound treatment as ordered by physician, and pillow to position resident. Treatment: [MEDICATION(S)] to heel BID. Notification: NP and Resident/Resident Representative. On 8/3/21, New or Worsened Pressure Injury, states in part . R heel blister. [NAME]. Stage 2. Size: 2.9 x 3.4. Describe how Pressure Ulcer was discovered. Blood blister remained intact and is now dry and hard. Skin around blister is pink and blanchable. No drainage. Pain: 0/10 . On 8/3/21, Weekly Pressure Ulcer Progress Report, states in part . R buttocks. [NAME]. Stage: Unstageable. Size: 11.3 x 5.5. Description of peri wound: Dark area is firm and unblanchable. Peri-skin is pink and blanchable. Superficial openings of skin over dark area. Pain: 0/10. Nutrition/Hydration: At ideal body weight. Treatment: [MEDICATION(S)] with [MEDICATION(S)], cover with ABD and change daily and prn until healed. Progress: 1st measurement. Pressure Relieving Pads: Yes, type: - Air mattress. Supplements: High Protein Supplement. Notifications: Physician, Dietary, Resident/Resident Representative Notified. Note: The facility indicates the air mattress was placed on R57's bed on 8/3/21. It should be noted that R57 has developed multiple facility acquired pressure injuries; left heel, right heel and right buttock, prior to the placement of the air mattress. Nurses Note from 8/3/21 at 1:53 PM states, Received new order from NP to DC (discontinue) treatment to wound on right buttock cheek- change dressing to apply a large [MEDICATION(S)] (dressing) over entire bruised area- change Mon and Fri and prn is soiled. NP Note from 8/3/21, states in part . Pressure ulcer of right heel, unstageable: Wound is stable. Pressure ulcer right buttock with suspected DTI, unstageable: Noted 7/26/21. Falls on 7/7/21 and 7/11/21 possibly contributing. Recommend treating entire bruised area and open area with [MEDICATION(S)]. Change 2 times a week and PRN. I would like her to be seen in the wound clinic as well due to the concern for worsening. Unintended weight loss: Weight has been in the 180's at the beginning of the year 2021. It is not [sic] in the 160s, with 10 lbs of this lost within the past month. I am concerned the weight loss and increased falls are linked to worsening dementia. Pressure injury of left heel, unstageable: Noted 7/26/21. Is currently stable. Continue with [MEDICATION(S)] paint, aggressive pressure offloading and encourage good nutrition. 5. Large bruise with central open wound on right buttock noted. Transfers with EZ stand. Primarily uses w/c (wheel chair) for mobility. Is able to propel short distances at times. Of note, the NP orders aggressive offloading although this intervention is never placed on R57's care plan. NP Note from 8/6/21, states in part . The open area over the right buttock has enlarged and encompasses much of the area that had previously bruised. The periwound is a little inflamed in the immediately adjacent tissue. There is induration in the area of the open wound, though not palpable in the periwound. Less bruising noted over the past 3 days. No odor. Some serosanguineous drainage on the dressing. On 8/9/21, Weekly Pressure Ulcer Progress Report, states in part . Right heel blister. [NAME]. Pain: 0/10. Stage 2. Size: 2.9 x 3.4. Description of Peri-Wound: Blood blister remained intact and is now dry and hard. Skin around blister is pink and blanchable. Nutrition/Hydration Status: At ideal body weight. Response to treatment/preventative measures: [MEDICATION(S)] bid. Progress: No Changed . On 8/9/21, Weekly Pressure Ulcer Progress Report, states in part . L heel. [NAME]. Pain: 0/10. Stage 2. Size: 2.6 x 3. Description of Peri-Wound: Heel is pink and blanchable. Blister has dried and skin is slightly harder where clear fluid was present. Nutrition/Hydration Status: At ideal body weight. Response to treatment/preventative measures: [MEDICATION(S)] BID. Progress: No Change . On 8/9/21, Weekly Pressure Ulcer Progress Report, states in part . Right buttock. [NAME]. Stage: Unstageable. Size: 5 x 10cm with Moderate amount of sanguinous [sic] drainage. Description of peri wound: Dark purple tissue present in middle of wound with white slough on perimeter. Periwound is red and blanchable. Inferior portion of the wound has pink wound bed. No warmth noted. Wound has foul odor. Pain: 4/10. Nutrition/Hydration: At ideal body weight. Treatment: Large [MEDICATION(S)] over wound change MON (Monday), FRI (Friday), and PRN. Progress: Improved. Supplements: High Protein Supplement . On 8/11/21, Skin Incident Event V2, states in part . Scab to left ear, superior. Location and Size of Skin alteration: 3mm x 2mm, superior part of left ear under helix. Pain: 0/10. Immediate Measures Taken: Other - ensure nails are trimmed. Activity during skin alteration occurrence: scratching. Notification: NP and Resident/Resident Representative. Note: On 8/11/21, the scabbed area on the left ear is the fourth pressure injury for R57. Nurses Note from 8/11/21 at 12:17 PM, states, Resident seen by NP for special visit r/t (related to) wound. Orders received for right buttock wound tx: cover with duoderm, change every other day or daily if significant drainage under dressing. Provider has call out to wound clinic to try to get resident in to be seen sooner than current scheduled appointment. Waiting to hear back. See full dictation when available. NP Note from 8/11/21, states in part . Was assisted to a side lying position. Right buttock dressing removed. The wound is irregularly shaped with thick firm adhered slough/eschar over the wound bed. There is a foul odor today when the dressing was removed. The entire wound area is indurated. On 8/12/21, Skin Incident Event V2, states in part . Right great toe bunion: intact, red, blanchable area back of left heel: fluid filled blister. [NAME]. Location and size of skin alteration: right great toe/bunion, red, intact, blanchable area: 1.0cm x 0.5cm. Back of left heel fluid filled blister: 1.0cm x 0.5cm. Wound Edges: Smooth. Pain: 0/10. Immediate Measures Taken: Cleansed area. Describe additional measures, if necessary. Kept foam boots of (sic) remainder of day. Added foot cradle. Obtain order from NP. Notification: NP and Resident/Resident Representative. Note: On 8/12/21, the bunion pressure injury is now the fifth pressure injury for R57. Note: DON states Skin Incident Event from 8/12/21 is in actuality the Left Lateral Bunion. Progress Note from 8/13/21 at 8:54 AM states, IDT reviewed skin even on 8/12/21; right bunion red with slow blanchability. New fluid filled blister to left heel. Placing foot cradle. Removed foam boots. Tried two different kinds of foam boots however these appear to cause more skin issues. Continues to use the heels up cushion. Padding between feel while in bed so they do not remove. Resident received mighty shakes. Nurses note from 8/14/21 at 11:20 AM, states, Dressing changed to the right buttock wound this am (morning) and was tolerated well. Wound is covered totally with eschar @ this time, periwound is red and is a thin line surround the wound. The rest of the right buttock is not a light pink. Noted to have a lg (large) amount of brown, odorous drainage. Blisters to both heels remain intact. Bunion remains red. Scab present to left ear. Nurses Note from 8/15/21 at 1:47 PM, states, Area to the right buttock not seen this shift as dressing to area has remained dry and intact. Blisters remain flat but intact to both heels. Right bunion area remains red. Scab present on left ear. Resident has shown no indication of discomfort this shift. Nurses Note from 8/16/21 at 2:10 PM, states, Fluid filled blister on back of left heel has reabsorbed and healed. Right bunion is pink and blanchable. POA notified of findings from weekly wound rounds and all questions answered. On 8/16/21, Weekly Pressure Ulcer Progress Report, states in part . Right heel. [NAME]. Pain: 0/10. Stage 2. Size: 2.9 x 3.4. Description of Peri-Wound: Blood blister remained intact and is now dry and hard. Skin around blister is pink and blanchable . On 8/16/21, Weekly Pressure Ulcer Progress Report, states in part . R buttock. [NAME]. Stage: Unstageable. Size: 6.3 x 5.5 with moderate amount of purulent foul smelling exudate. Description of peri wound: Dark purple tissue present in middle of wound with white slough on perimeter. Periwound is red and blanchable. Inferior portion of the wound has pink wound bed. No warmth noted. Pain: 4/10 . Nurses Notes from 8/16/21 at 6:29 PM, state, Resident seen by NP for special visit r/t wound. Orders received for Right buttock wound unstageable: 1. Remove dressing/packing 2. Rinse wound with normal saline 3. Pack with coarse gauze moistened with Dakin's 0.25% 4. Vaseline to periwound. 5. Cover with ABD 6. Change packing BID, change ABD BID & (and) PRN. See full dictation when available. NP Note from 8/16/21 states in part . The DTI on the right buttock has an eschar over the entire base with the exception of an open spot at the most interior aspect of the eschar that is 0.4cm. The eschar is irregularly shaped and is 6.3cm x 5.5cm. There was copious amounts of creamy tan drainage from the open area with a palpable cavity beneath it. The area was extended to 1.1cm in length. There is tunneling towards 2 o'clock 1.5cm - 7 o'clock 1cm - 4 o'clock 2cm. The depth is now measurable - 1cm. Periwound there is redness extending out about 0.5cm circumferentially. The redness is blanchable. R57's quarterly MDS (Minimum Data Set) assessment, with an assessment review date of 8/16/21, indicates R57 has two Stage 2 and 1 unstageable PI's. R57 has a BIMS (Brief Interview of Mental Status) of 5, indicating severe cognitive impairment. R57 requires extensive assistance of two staff for bed mobility, toileting, transfers and hygiene; Section H indicates R57 is frequently incontinent of urine. (It is important to note that R57 is not on a toileting program.) NP Note from 8/17/21, states in part . Call placed to resident guardian/daughter. Daughter would like care at NH and NP to complete [MEDICATION(S)]. Daughter understand that given residents chronic health issues, full healing of her wounds may not be attainable despite all of the best efforts of NH staff. Plan to do debridement later this week. Nurses Note from 8/18/21 at 5:24 PM, states, NP notified of resident's increase in drainage - brown soaked through dressing and into brief. Provider say ABD can be changed more frequently if saturated. Nurses Note from 8/19/21 at 1:42 PM, states, Treatment completed to buttocks as ordered this shift. Old ABD was covered with a large amount of brown drainage. Wound is open with tunneling present. Peri-wound area is black. Foul odor noted to wound and drainage. Resident had no c/o (complaints of) pain during treatment. Nurses Note from 8/19/21 at 11:13 PM, states, Tx done to right buttock at 2130 (9:30 PM) and was well tolerated. Old dressing was saturated with copious amt (amount) of brown serous drainage, along with soaking the brief. Drainage was very foul smelling. Wound was packed with 2, 4x4 gauze. Periwound is necrotic with pink outlining. NP Note from 8/20/21, states in part . NP Note: Seen for debridement today, right buttock. Pressure injury of the right buttock. There was a partial soft eschar over the superior portion of the wound. This was removed. Skin opening W1.5cm, L 6.2cm, D 1.5cm, there is tunneling at 11 o'clock position that extends in 8cm. There is also tunneling at 5 o'clock extended in 3cm. There is a necrotic odor and a large amount of necrotic tissue in the superior portion of the wound. The wound base continued to have a film of slough. Small amount of pink granulation tissue in the inferior portion of the wound where it was debrided previously. Some discomfort when the packing was removed and with cleansing of the wound. On 8/23/21, Weekly Pressure Ulcer Progress Report, states in part . Right heel. [NAME]. Pain: 0/10. Stage 2. Size: 2.9 x 3.4. Description of Peri-Wound: Blood blister remained dry and hard. Peri-wound is red and blanchable. Dried blister is beginning to peel off. Nutrition/Hydration Status: Below ideal body weight, losing weight and intake below 50%. Response to treatment/preventative measures: [MEDICATION(S)] BID. Progress: Deteriorated. Pressure Relieving Pads: Yes, type: air mattress, foot cradle, and foam boots. Supplements: High Protein Supplement. Notification: Physician, Dietary, and Resident/Resident Representative Notified on 8/30/21. Note: The Physician, Dietary and Resident/Resident Representative were not notified of the deterioration of the right heel for 7 days. On 8/23/21, Weekly Pressure Ulcer Progress Report, states in part . Right buttock. [NAME]. Stage 3. Size: 12 o'clock: 9 cm, 2 o'clock 9.6 cm, 3 o'clock 1.5 cm, 6 o'clock 2 cm, 6-11 o'clock non tunneling. Depth 2.5cm. Copious amounts of serosanguineous exudate with foul odor. Description of peri wound: Wound base is red and beefy. Edges are irregular and tunneling is mostly in superior portion of wound. Periwound is pink and blanchable. Strong found (sic) odor from wound. Nutrition/hydration: Below ideal body weight, weight stable, intake 50-75%. Treatment: Right buttock unstageable. 1. Remove dressing/packing. 2. Rinse wound with normal saline. 3. Pack with coarse gauze (should be (4) 4x4's) moistened with Dakin's 0.25%. 4. Apply zinc ointment to periwound with each dressing change and prn for skin irritation. 5. Cover with ABD (Abdominal Pads). 6. Change packing BID, change ABD BID and PRN. Special Instructions: Document the amount of 4x4's being applied into the wound bed. Progress: UTA (Unable to Assess) d/t (due to) wound being debrided since last assessment. Pressure relieving pad: Air Mattress. Supplement: High protein supplement. Notifications: Physician, Dietary, and Resident/Resident Representative Notified. Dietary Note from 8/25/2021 at 9:20 AM states, Nutrition Update: [Resident] has had significant wt (weight) loss of 21 lbs (12%) in 90 days. Current wt: 158 lbs (8/24) vs 179 (5/24). R57 continues on a regular diet with mech (mechanical) soft textures and thin liquids. Intakes have been poor, with 0-50% of meals consumed. Receives nutritional shakes TID with all meals. Noted that [MEDICATION(S)] was started (8/24) for appetite stimulant. Will monitor to ensure that intakes improve with this medication. Will also contact provider to start daily [MEDICATION(S)] for wound healing of stage 2 pressure ulcer on buttock. Will monitor wt status and supplement intake/tolerance. Nurses Note from 8/25/21 at 10:49 AM, states, Staff noticed resident has purple triangle shape to left hip area. Measures 4.1 x 3.9cm. Purple discoloration is non-blanchable. Noted dark pink discoloration surrounding the purple area. Dark pink skin is blanchable. Pink skin is 7.9 x 9.1cm. DON aware. Daughter notified. Note: The area on the left hip is the sixth [NAME] PI for R57. Progress Note from 8/26/21 at 9:04 AM, states, IDT reviewed skin event; found purple non-blanchable area to left hip. Resident was repositioned to take pressure off of area. Will obtain order for bordered foam dressing. Will continue to monitor for healing. Nurses Note from 8/26/21 at 9:48 AM, states, Nursing assistants brought this writer in because they found this skin problem while dressing resident. Upon inspection this writer found a small pressure related wound to her left lateral foot. Area is reddened, and raised slightly, tender to the touch, and semi-blanchable. At the center of the reddened area is a small, black area that is not blanchable. Resident does not c/o pain to the area, upon palpation. Area is not open, no s/s (signs or symptoms) of infection. Progress Note from 8/26/21 at 1:05 PM, states, IDT reviewed new discoloration found on left lateral foot found 8/26/21. Possibly from foam boots which were removed. Provider feels resident may be going into skin failure. Resident has air mattre [TRUNCATED]

Based on observation, interview, and record review, the facility did not implement professional standards of practice to ensure that a resident does not develop pressure injuries (PIs), receives necessary treatment and services to promote healing and prevent infection of PIs, or prevent new PIs from developing for 1 of 3 residents sampled for PIs out of a total sample of 20 residents (R57). R57 was admitted , on 4/09/21, without a pressure injury. R57 was at risk for PI development. The facility did not put interventions in place to prevent PI development until after a pressure injury developed. R57 subsequently developed 5 facility-acquired PIs, one which worsened to a Stage 4. The facility did not implement an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures led to R57's facility-acquired Stage 4 pressure injury. This created an Immediate Jeopardy (IJ) which began on 9/3/21 and was removed on 9/22/21. INHA A (Interim Nursing Home Administrator) was notified of the IJ on 9/21/21 at 12:00 PM. The deficient practice continues at a scope/severity of D (potential for more than minimal harm that is not immediate jeopardy/isolated) as the facility continues to implement its action plan. This is evidenced by: The AMDA (American Medical Directors Association) clinical practice guideline entitled, 'Pressure Ulcers and Other Wounds,' dated 2017, states in part: .A pressure ulcer (Injury) is localized damage to the skin or underlying soft tissue, usually over a bony prominence or related to a medical or other device. The ulcer may present as intact skin or as an open ulcer and may be painful. The ulcer occurs as a result of intense or prolonged pressure or pressure in combination with shear. .Recognition: Early recognition of pressure ulcers and of any risk associated with the development of pressure ulcers and other wounds is critical to their successful prevention and management .Assessment: The purpose of the assessment is to collect enough information to evaluate the patient's general condition, characterize a pressure ulcer; and identify related causes and complications. The National Pressure Injury Advisory Panel (NPIAP) at www.NPIAP.com defines PI's in the following categories: Category/Stage II: Partial thickness loss - Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguinous filled blister. Category/Stage III: Full thickness skin loss - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. Category/Stage IV: Full thickness tissue loss - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown. Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Suspected Deep Tissue Injury (DTI) - depth unknown. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. The facility policy titled Pressure Injury Prevention and Care, last revised on 3/2021, states in part . Purpose: To promote and facilitate pressure injury prevention, as well as implemented appropriate interventions and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Procedure indicates, in part . 2. Nurses will complete Braden Scale for residents on admission/readmission, weekly for 4 weeks, monthly, at time of new pressure injury identification, and as needed. 4. Interventions will be implemented and care planned to prevent pressure injury development or to promote pressure injury resolution. Examples of interventions based on individualized resident needs may include the following. This list in not all-inclusive nor does it apply to every resident or situation: A. Pressure reduction mattress on bed D. Promote nutrition and hydration - refer to Registered Dietician as needed G. Repositioning of residents; provision of required assistance as allowed and tolerated I. Maintain the head of bed at the lowest position based on resident medical condition J. Encourage and promote elevation of resident heels when in bed and prevent residents' feet from coming into contact with foot board. 10. Residents at-risk for developing pressure injury will have a care plan implemented to minimize the risk of skin breakdown. Resident risk factors will be reviewed and considered when developing the plan of care. Risk factors include, but are not limited to: history of pressure injury, Braden score less than or equal to 12, use of medical device that can cause pressure (example: catheter tubing, anti-embolism stockings, braces, casts, splints, etc.), risk diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R57 was admitted to the facility on [DATE]. R57's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R57's admission MDS (Minimum Data Set) assessment, with an assessment review date of 4/16/21, indicates R57 has no PI's. R57 has a BIMS (Brief Interview of Mental Status) of 5, indicating severe cognitive impairment. R57 requires extensive assistance of two staff for bed mobility and transfers; extensive assistance of one staff for transfers and hygiene; and independent with staff setup with eating. Section H indicates R57 is frequently incontinent of urine. (It is important to note R57 is not on a toileting program.) Facility documentation of Braden Scale for Prediction of Pressure Sore Risk was completed 4/0921. R57 scored a 16, meaning R57 was at risk for pressure injury development. Initial Care Plan started on 4/9/21 states in part . R57 is at risk for pressure sore/skin at risk due to ADL (activities of daily living) status. R57's care plan, dated 4/12/21, states in part . Problem: Problem Start Date: 4/12/21: Resident is at risk for skin breakdown r/t (related to) generalized weakness and comorbidities of dementia with confusions and agitation, CKD, [CONDITION(S)] (hypertension), [CONDITION(S)], and paranoia. Approach: Approaches started on 4/12/21: Report any signs of skin breakdown, turn and reposition every 2-4 hours and prn, and use pressure relieving mattress for pressure reduction when resident is in bed. The facility did not implement proactive measures to offload R57's heels. R57 was admitted on [DATE] and was placed on an Immerse Mattress. According to, Direct Supply at content.directsupplycdn.com states in part . WARNING - This mattress is not intended for stage III or IV pressure ulcers. Mattress wound stage ratings are general usage guidelines. On 7/02/21, a Braden assessment was completed. Score was 14, meaning R57 was not at Moderate Risk for pressure injury development. The facility did not revise R57's care plan to address this risk. On 7/19/21 at 12:44 PM, Skin Incident Event V2, states in part . Description: Blood blister to R (right) heel. [NAME] (In House Acquired). Size: 3.2 x 4. Wound Edges: Smooth. Description: Peri wound is blanchable. Wound bed is dark red in color. Pain: 3/10. Immediate Measures Taken: Cleansed area and Other-float heels, encourage repositioning, will inquire boots to float heels with IDT (Interdisciplinary Team). Additional Measures: Obtained orders for batadine [sic]. Notification: NP (Nurse Practitioner), Resident/Resident Representative, and DON (Director of Nursing) notified. Interventions were not added to the Care Plan until 7/27/21. Note: Initial discovery of a blood blister on the right heel was 7/19/21. R57's care plan was not updated to include the Rooke Boots until 7/27/21. Nurses Note from 7/20/21 at 8:24 AM states, Orders received from NP (nurse practitioner) for (1) [MEDICATION(S)] paint BID (twice daily) to blister on right heel until resolved (2) follow weekly wound rounds. IDT (Interdisciplinary Team) Note from 7/20/21 at 8:54 AM states, IDT reviewed skin event on 7/19/21; intact blood blister to right heel. [MEDICATION(S)] has been ordered. Wound nurse will assess during rounds. NP note from 7/23/21, states in part . Resident lying the supine position. R57 has developed a blood blister on the right heel. It has remained intact. Staff have been using pressure relief strategies and treating with [MEDICATION(S)]. R57 denies pain at the site. She spends most of her time in bed or in the wheelchair. On 7/26/21, Weekly Pressure Ulcer Progress Report, states in part . Description: Blood blister on R heel. [NAME]. Pain: 0/10. Stage 1. Size: 2.9 x 3.4. Description of Peri-Wound: Blood blister remained intact and is now dry and hard. Skin is tinged red and healthy tissue visible underneath. Remainder of heel is pink and blanchable. Nutrition/Hydration Status: At ideal body weight. Response to treatment/preventative measures: [MEDICATION(S)] BID. Progress: Improved. Notification: NP, Dietary, and Resident/Resident Representative Notified. On 7/26/21, Skin Incident Event V2, Large red area with 2 purple areas inside the red area. Location and Size of Skin alteration: Red area the size of a baseball with 2 purple areas inside the red area. 1 purple area measures 3cm x 3cm and looks like a bruise. The other purple area measure 1cm x 1cm and looks like a blood blister. Wound Edges: Smooth. Pain: 0/10. Immediate Measures Taken: Area cleansed. Notification: NP and Resident/Resident Representative. Orders: Treatments: Monitor and document red area to right buttock. Measure Monday. Nurses Progress Note 7/26/21 at 11:10 AM, states . This writer was asked by hallway CNAs (Certified Nursing Assistants) to assess resident's buttock. Upon assessment a red area that was is [sic] about the size of a baseball was noted to the R (resident) buttock with 2 purple areas inside the red area. One purple area is 3cm x 3cm and looks like a bruise. The other purple area looks like a blood blister and measures 1cm x 1cm. Area is blanchable, not open and no [sic] over a boney prominence. Change nurse, wound nurse, DON, POA (Power of Attorney) all updated. Nurses Note from 7/26/21 at 5:25 PM, states, NP notified of pressure area to resident's left heel. Order received to paint area with [MEDICATION(S)] bid until resolved. Nurse Note from 7/26/21 at 5:27 PM, states, NP notified of red area to resident's right buttock with bruise and blood blister. No changes to orders. NP Note from 7/26/21, states in part . Update from NH (nursing home) Staff: Resident has a bruise to her right buttock that aides said has gotten bigger (quarter sized) and a small blood blister - not open but surrounding skin is peeling. Area surrounding both is red and blanchable, not over bony prominence. Also - new 3 cm pressure area to left heel. Response/Plan: start [MEDICATION(S)] paint on the left heel. She needs aggressive offloading. She should have something like a Rooke boot when in bed. Note: NP note from 7/26/21 indicates R57 needs aggressive offloading. The facility did not put interventions in place to achieve this nor did they update R57's care plan to reflect any changes. Note: The facility documented the Blister on the L heel was initially discovered on 7/26/21 but the first wound documentation on this area is on 8/2/21. IDT Note from 7/27/21 states, IDT reviewed skin events on 7/26/21; - Pressure area to left heel. [MEDICATION(S)] being applied. Rooke boots and heels up cushion. - Bruise and blood blister to red buttock. Barrier was applied. Will reaccess [sic] and get treatment orders. Approach start date 7/27/21: Heels up pillow and Rooke boots (Rooke Boot is a vascular boot that built to provide total heel offloading and redistribution of pressure along the calf to help treat and prevent lower-extremity skin breakdown) to prevent skin breakdown to feet. Nurses Note from 8/1/21 at 2:16 PM states, Right buttock continues with dark red/purple coloration, blister is no longer intact but does have skin flap present over opening. Appears to have peeling skin around it. She denied pain when area touched. Barrier cream applied. Repositioned carefully to avoid pressure to right buttock. Has the heels up boots on with pillow between her legs and appears comfortable @ (at) this time. [MEDICATION(S)] tx (treatment) done to both heels, both remain intact @ this time. On 8/2/21, Weekly Pressure Ulcer Progress Report, states in part . Blister to L (left) heel. [NAME]. Pain: 0/10. Stage 2. Size: 2.6 x 3. Description of Peri-Wound: Heel is pink and blanchable. Blister has dried and skin is slightly harder where clear fluid was present. Nutrition/Hydration Status: At ideal body weight. Response to treatment/preventative measures: [MEDICATION(S)] BID. Progress: 1st measurement. Notification: Physician, Dietary, and Resident/Resident Representative. On 8/2/21, Weekly Pressure Ulcer Progress Report, states in part . Description: Blood blister right heel. [NAME]. Pain: 0/10. Stage 2. Size: 2.9 x 3.4. Description of Peri-Wound: Blood blister remained intact and is now dry and hard. Skin around blister is pink and blanchable. Nutrition/Hydration Status: At ideal body weight. Response to treatment/preventative measures: [MEDICATION(S)] BID. Progress: No Change. Notification: NP, Dietary, and Resident/Resident Representative Notified. Nurses Note from 8/2/21 at 2:57 PM states, This writer was asked by hallway CNAs to come look at resident's buttock this morning. Upon assessment a large dark purple area that looks bruised was found on the R buttock with a smaller superficially open area in the middle. Area is firm, but not raised. Area was thoroughly cleansed and barrier cream was applied. Charge nurse and wound nurse updated. Nurses Note from 8/2/21 at 3:33 PM states, Received new order from NP for a treatment to wound on right buttock cheek- Apply [MEDICATION(S)] with [MEDICATION(S)], cover with ABD (dresing) and change daily and prn (as needed) until healed. 8/3/21, New or Worsened Pressure Ulcer, L heel blister. [NAME]. Stage 2. Sixe 2.6 x 3. Resident's Condition prior to discovery of pressure ulcer: Normal. Describe exactly how Pressure Ulcer was discovered. Heel is pink and blanchable. Blister has dried and skin is slightly harder where clear fluid was present. Pain: 0/10. Did the resident have pressure relieving device(s) in place. Yes. If yes, list devices is use. Pressure redistributing chair cushion, other-pillow to float heels. Interventions to prevent weight loss. Dietary Supplements and weight monitoring. New interventions: New interventions: pressure redistributing mattress, heel offloading device, wound treatment as ordered by physician, and pillow to position resident. Treatment: [MEDICATION(S)] to heel BID. Notification: NP and Resident/Resident Representative. On 8/3/21, New or Worsened Pressure Injury, states in part . R heel blister. [NAME]. Stage 2. Size: 2.9 x 3.4. Describe how Pressure Ulcer was discovered. Blood blister remained intact and is now dry and hard. Skin around blister is pink and blanchable. No drainage. Pain: 0/10 . On 8/3/21, Weekly Pressure Ulcer Progress Report, states in part . R buttocks. [NAME]. Stage: Unstageable. Size: 11.3 x 5.5. Description of peri wound: Dark area is firm and unblanchable. Peri-skin is pink and blanchable. Superficial openings of skin over dark area. Pain: 0/10. Nutrition/Hydration: At ideal body weight. Treatment: [MEDICATION(S)] with [MEDICATION(S)], cover with ABD and change daily and prn until healed. Progress: 1st measurement. Pressure Relieving Pads: Yes, type: - Air mattress. Supplements: High Protein Supplement. Notifications: Physician, Dietary, Resident/Resident Representative Notified. Note: The facility indicates the air mattress was placed on R57's bed on 8/3/21. It should be noted that R57 has developed multiple facility acquired pressure injuries; left heel, right heel and right buttock, prior to the placement of the air mattress. Nurses Note from 8/3/21 at 1:53 PM states, Received new order from NP to DC (discontinue) treatment to wound on right buttock cheek- change dressing to apply a large [MEDICATION(S)] (dressing) over entire bruised area- change Mon and Fri and prn is soiled. NP Note from 8/3/21, states in part . Pressure ulcer of right heel, unstageable: Wound is stable. Pressure ulcer right buttock with suspected DTI, unstageable: Noted 7/26/21. Falls on 7/7/21 and 7/11/21 possibly contributing. Recommend treating entire bruised area and open area with [MEDICATION(S)]. Change 2 times a week and PRN. I would like her to be seen in the wound clinic as well due to the concern for worsening. Unintended weight loss: Weight has been in the 180's at the beginning of the year 2021. It is not [sic] in the 160s, with 10 lbs of this lost within the past month. I am concerned the weight loss and increased falls are linked to worsening dementia. Pressure injury of left heel, unstageable: Noted 7/26/21. Is currently stable. Continue with [MEDICATION(S)] paint, aggressive pressure offloading and encourage good nutrition. 5. Large bruise with central open wound on right buttock noted. Transfers with EZ stand. Primarily uses w/c (wheel chair) for mobility. Is able to propel short distances at times. Of note, the NP orders aggressive offloading although this intervention is never placed on R57's care plan. NP Note from 8/6/21, states in part . The open area over the right buttock has enlarged and encompasses much of the area that had previously bruised. The periwound is a little inflamed in the immediately adjacent tissue. There is induration in the area of the open wound, though not palpable in the periwound. Less bruising noted over the past 3 days. No odor. Some serosanguineous drainage on the dressing. On 8/9/21, Weekly Pressure Ulcer Progress Report, states in part . Right heel blister. [NAME]. Pain: 0/10. Stage 2. Size: 2.9 x 3.4. Description of Peri-Wound: Blood blister remained intact and is now dry and hard. Skin around blister is pink and blanchable. Nutrition/Hydration Status: At ideal body weight. Response to treatment/preventative measures: [MEDICATION(S)] bid. Progress: No Changed . On 8/9/21, Weekly Pressure Ulcer Progress Report, states in part . L heel. [NAME]. Pain: 0/10. Stage 2. Size: 2.6 x 3. Description of Peri-Wound: Heel is pink and blanchable. Blister has dried and skin is slightly harder where clear fluid was present. Nutrition/Hydration Status: At ideal body weight. Response to treatment/preventative measures: [MEDICATION(S)] BID. Progress: No Change . On 8/9/21, Weekly Pressure Ulcer Progress Report, states in part . Right buttock. [NAME]. Stage: Unstageable. Size: 5 x 10cm with Moderate amount of sanguinous [sic] drainage. Description of peri wound: Dark purple tissue present in middle of wound with white slough on perimeter. Periwound is red and blanchable. Inferior portion of the wound has pink wound bed. No warmth noted. Wound has foul odor. Pain: 4/10. Nutrition/Hydration: At ideal body weight. Treatment: Large [MEDICATION(S)] over wound change MON (Monday), FRI (Friday), and PRN. Progress: Improved. Supplements: High Protein Supplement . On 8/11/21, Skin Incident Event V2, states in part . Scab to left ear, superior. Location and Size of Skin alteration: 3mm x 2mm, superior part of left ear under helix. Pain: 0/10. Immediate Measures Taken: Other - ensure nails are trimmed. Activity during skin alteration occurrence: scratching. Notification: NP and Resident/Resident Representative. Note: On 8/11/21, the scabbed area on the left ear is the fourth pressure injury for R57. Nurses Note from 8/11/21 at 12:17 PM, states, Resident seen by NP for special visit r/t (related to) wound. Orders received for right buttock wound tx: cover with duoderm, change every other day or daily if significant drainage under dressing. Provider has call out to wound clinic to try to get resident in to be seen sooner than current scheduled appointment. Waiting to hear back. See full dictation when available. NP Note from 8/11/21, states in part . Was assisted to a side lying position. Right buttock dressing removed. The wound is irregularly shaped with thick firm adhered slough/eschar over the wound bed. There is a foul odor today when the dressing was removed. The entire wound area is indurated. On 8/12/21, Skin Incident Event V2, states in part . Right great toe bunion: intact, red, blanchable area back of left heel: fluid filled blister. [NAME]. Location and size of skin alteration: right great toe/bunion, red, intact, blanchable area: 1.0cm x 0.5cm. Back of left heel fluid filled blister: 1.0cm x 0.5cm. Wound Edges: Smooth. Pain: 0/10. Immediate Measures Taken: Cleansed area. Describe additional measures, if necessary. Kept foam boots of (sic) remainder of day. Added foot cradle. Obtain order from NP. Notification: NP and Resident/Resident Representative. Note: On 8/12/21, the bunion pressure injury is now the fifth pressure injury for R57. Note: DON states Skin Incident Event from 8/12/21 is in actuality the Left Lateral Bunion. Progress Note from 8/13/21 at 8:54 AM states, IDT reviewed skin even on 8/12/21; right bunion red with slow blanchability. New fluid filled blister to left heel. Placing foot cradle. Removed foam boots. Tried two different kinds of foam boots however these appear to cause more skin issues. Continues to use the heels up cushion. Padding between feel while in bed so they do not remove. Resident received mighty shakes. Nurses note from 8/14/21 at 11:20 AM, states, Dressing changed to the right buttock wound this am (morning) and was tolerated well. Wound is covered totally with eschar @ this time, periwound is red and is a thin line surround the wound. The rest of the right buttock is not a light pink. Noted to have a lg (large) amount of brown, odorous drainage. Blisters to both heels remain intact. Bunion remains red. Scab present to left ear. Nurses Note from 8/15/21 at 1:47 PM, states, Area to the right buttock not seen this shift as dressing to area has remained dry and intact. Blisters remain flat but intact to both heels. Right bunion area remains red. Scab present on left ear. Resident has shown no indication of discomfort this shift. Nurses Note from 8/16/21 at 2:10 PM, states, Fluid filled blister on back of left heel has reabsorbed and healed. Right bunion is pink and blanchable. POA notified of findings from weekly wound rounds and all questions answered. On 8/16/21, Weekly Pressure Ulcer Progress Report, states in part . Right heel. [NAME]. Pain: 0/10. Stage 2. Size: 2.9 x 3.4. Description of Peri-Wound: Blood blister remained intact and is now dry and hard. Skin around blister is pink and blanchable . On 8/16/21, Weekly Pressure Ulcer Progress Report, states in part . R buttock. [NAME]. Stage: Unstageable. Size: 6.3 x 5.5 with moderate amount of purulent foul smelling exudate. Description of peri wound: Dark purple tissue present in middle of wound with white slough on perimeter. Periwound is red and blanchable. Inferior portion of the wound has pink wound bed. No warmth noted. Pain: 4/10 . Nurses Notes from 8/16/21 at 6:29 PM, state, Resident seen by NP for special visit r/t wound. Orders received for Right buttock wound unstageable: 1. Remove dressing/packing 2. Rinse wound with normal saline 3. Pack with coarse gauze moistened with Dakin's 0.25% 4. Vaseline to periwound. 5. Cover with ABD 6. Change packing BID, change ABD BID & (and) PRN. See full dictation when available. NP Note from 8/16/21 states in part . The DTI on the right buttock has an eschar over the entire base with the exception of an open spot at the most interior aspect of the eschar that is 0.4cm. The eschar is irregularly shaped and is 6.3cm x 5.5cm. There was copious amounts of creamy tan drainage from the open area with a palpable cavity beneath it. The area was extended to 1.1cm in length. There is tunneling towards 2 o'clock 1.5cm - 7 o'clock 1cm - 4 o'clock 2cm. The depth is now measurable - 1cm. Periwound there is redness extending out about 0.5cm circumferentially. The redness is blanchable. R57's quarterly MDS (Minimum Data Set) assessment, with an assessment review date of 8/16/21, indicates R57 has two Stage 2 and 1 unstageable PI's. R57 has a BIMS (Brief Interview of Mental Status) of 5, indicating severe cognitive impairment. R57 requires extensive assistance of two staff for bed mobility, toileting, transfers and hygiene; Section H indicates R57 is frequently incontinent of urine. (It is important to note that R57 is not on a toileting program.) NP Note from 8/17/21, states in part . Call placed to resident guardian/daughter. Daughter would like care at NH and NP to complete [MEDICATION(S)]. Daughter understand that given residents chronic health issues, full healing of her wounds may not be attainable despite all of the best efforts of NH staff. Plan to do debridement later this week. Nurses Note from 8/18/21 at 5:24 PM, states, NP notified of resident's increase in drainage - brown soaked through dressing and into brief. Provider say ABD can be changed more frequently if saturated. Nurses Note from 8/19/21 at 1:42 PM, states, Treatment completed to buttocks as ordered this shift. Old ABD was covered with a large amount of brown drainage. Wound is open with tunneling present. Peri-wound area is black. Foul odor noted to wound and drainage. Resident had no c/o (complaints of) pain during treatment. Nurses Note from 8/19/21 at 11:13 PM, states, Tx done to right buttock at 2130 (9:30 PM) and was well tolerated. Old dressing was saturated with copious amt (amount) of brown serous drainage, along with soaking the brief. Drainage was very foul smelling. Wound was packed with 2, 4x4 gauze. Periwound is necrotic with pink outlining. NP Note from 8/20/21, states in part . NP Note: Seen for debridement today, right buttock. Pressure injury of the right buttock. There was a partial soft eschar over the superior portion of the wound. This was removed. Skin opening W1.5cm, L 6.2cm, D 1.5cm, there is tunneling at 11 o'clock position that extends in 8cm. There is also tunneling at 5 o'clock extended in 3cm. There is a necrotic odor and a large amount of necrotic tissue in the superior portion of the wound. The wound base continued to have a film of slough. Small amount of pink granulation tissue in the inferior portion of the wound where it was debrided previously. Some discomfort when the packing was removed and with cleansing of the wound. On 8/23/21, Weekly Pressure Ulcer Progress Report, states in part . Right heel. [NAME]. Pain: 0/10. Stage 2. Size: 2.9 x 3.4. Description of Peri-Wound: Blood blister remained dry and hard. Peri-wound is red and blanchable. Dried blister is beginning to peel off. Nutrition/Hydration Status: Below ideal body weight, losing weight and intake below 50%. Response to treatment/preventative measures: [MEDICATION(S)] BID. Progress: Deteriorated. Pressure Relieving Pads: Yes, type: air mattress, foot cradle, and foam boots. Supplements: High Protein Supplement. Notification: Physician, Dietary, and Resident/Resident Representative Notified on 8/30/21. Note: The Physician, Dietary and Resident/Resident Representative were not notified of the deterioration of the right heel for 7 days. On 8/23/21, Weekly Pressure Ulcer Progress Report, states in part . Right buttock. [NAME]. Stage 3. Size: 12 o'clock: 9 cm, 2 o'clock 9.6 cm, 3 o'clock 1.5 cm, 6 o'clock 2 cm, 6-11 o'clock non tunneling. Depth 2.5cm. Copious amounts of serosanguineous exudate with foul odor. Description of peri wound: Wound base is red and beefy. Edges are irregular and tunneling is mostly in superior portion of wound. Periwound is pink and blanchable. Strong found (sic) odor from wound. Nutrition/hydration: Below ideal body weight, weight stable, intake 50-75%. Treatment: Right buttock unstageable. 1. Remove dressing/packing. 2. Rinse wound with normal saline. 3. Pack with coarse gauze (should be (4) 4x4's) moistened with Dakin's 0.25%. 4. Apply [MEDICATION(S)] ointment to periwound with each dressing change and prn for skin irritation. 5. Cover with ABD (Abdominal Pads). 6. Change packing BID, change ABD BID and PRN. Special Instructions: Document the amount of 4x4's being applied into the wound bed. Progress: UTA (Unable to Assess) d/t (due to) wound being debrided since last assessment. Pressure relieving pad: Air Mattress. Supplement: High protein supplement. Notifications: Physician, Dietary, and Resident/Resident Representative Notified. Dietary Note from 8/25/2021 at 9:20 AM states, Nutrition Update: [Resident] has had significant wt (weight) loss of 21 lbs (12%) in 90 days. Current wt: 158 lbs (8/24) vs 179 (5/24). R57 continues on a regular diet with mech (mechanical) soft textures and thin liquids. Intakes have been poor, with 0-50% of meals consumed. Receives nutritional shakes TID with all meals. Noted that [MEDICATION(S)] was started (8/24) for appetite stimulant. Will monitor to ensure that intakes improve with this medication. Will also contact provider to start daily [MEDICATION(S)] for wound healing of stage 2 pressure ulcer on buttock. Will monitor wt status and supplement intake/tolerance. Nurses Note from 8/25/21 at 10:49 AM, states, Staff noticed resident has purple triangle shape to left hip area. Measures 4.1 x 3.9cm. Purple discoloration is non-blanchable. Noted dark pink discoloration surrounding the purple area. Dark pink skin is blanchable. Pink skin is 7.9 x 9.1cm. DON aware. Daughter notified. Note: The area on the left hip is the sixth [NAME] PI for R57. Progress Note from 8/26/21 at 9:04 AM, states, IDT reviewed skin event; found purple non-blanchable area to left hip. Resident was repositioned to take pressure off of area. Will obtain order for bordered foam dressing. Will continue to monitor for healing. Nurses Note from 8/26/21 at 9:48 AM, states, Nursing assistants brought this writer in because they found this skin problem while dressing resident. Upon inspection this writer found a small pressure related wound to her left lateral foot. Area is reddened, and raised slightly, tender to the touch, and semi-blanchable. At the center of the reddened area is a small, black area that is not blanchable. Resident does not c/o pain to the area, upon palpation. Area is not open, no s/s (signs or symptoms) of infection. Progress Note from 8/26/21 at 1:05 PM, states, IDT reviewed new discoloration found on left lateral foot found 8/26/21. Possibly from foam boots which were removed. Provider feels resident may be going into skin failure. Resident has air mattre [TRUNCATED]

Based on interview and record review, the facility did not promptly consult with resident's physician or extender when 1 of 22 residents (R120) had a significant change in his medical condition. On [DATE], at 4:30 AM and 8:00 AM, R120 had emesis and, at 9:00 AM, R120 had 3 large loose black foul-smelling bowel movements. This was a significant change in his condition. The facility did not immediately call R120's physician or NP C (Nurse Practitioner). On [DATE] at 12:45 PM, R120 had a further Change in Condition when staff was unable to get vital signs. Sometime after 1:00 PM, as the time was undocumented, RN E (Registered Nurse) called NP C to notify her of R120's Change of Condition. NP C gave the order to send R120 to the ER (emergency room ) for evaluation. R120 was transported to the ER where he expired. As a result of the physician/extender not being contacted for direction, R120 had to wait greater than 4 ,[DATE] hours for medical care when he had a significant change in his condition. The facility's failure to timely contact R120's physician/extender, when he had a significant change in his condition, created a finding of Immediate Jeopardy (IJ) beginning on [DATE]. On [DATE] at 4:42 PM, NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were informed of the IJ. The IJ was removed on [DATE] when the facility implemented an action plan related to notification of physician/extender when a resident has a Change in Condition. The deficient practice continues at a scope/severity of D (potential for harm/isolated) as the facility continues to implement its action plan. Evidenced by: The facility's Change in Resident's Condition policy, dated ,[DATE], includes, in part, the following: Notification of Changes. 1. A facility must immediately inform the resident, the resident's provider or on-call provider; and notify the resident's representative: d. a significant change in the resident's physical, mental or psychosocial status (i.e. deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications). The facility uses the INTERACT II TOOL pathways to direct staff when confronted with given signs and symptoms. Under Diarrhea the INTERACT II TOOL directs nursing to call the physician immediately when a resident has Acute onset of 3 or more episodes of loose stools. R120's [DIAGNOSES REDACTED]. R120 was his own decision maker. R120's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of [DATE] indicated R120 was cognitively intact, understood and understands, needed extensive assistance of two for transferring and toileting, and was frequently incontinent of bowel and bladder. R120's care plan problem: Comfort Care r/t (related to) declining condition m/b (manifested by) need for increased assistance with positioning and ADL's (Activities of Daily Living), need for intervention to relieve pain, respiratory, and emotional distress, dated [DATE], includes, in part, the following: Monitor condition closely and alert MD/GNP (Medical Doctor/Geriatric Nurse Practitioner) to any significant changes. R120's Patient Progress Notes include, in part, the following entries: [DATE], 5:00 (AM): Status: 4:30 (AM) resident noted to have lrg (large) liq (liquid) emesis. T (temperature) 98.3, O2 (oxygen) Sats (saturations) 95%, HOB (head of bed) (up). Will cont (continue) to monitor. [DATE], 1445 (2:45 PM): Change of Condition: Was notified by CNA (Certified Nursing Assistant) that Hall Nurse needed assist in res (resident) room. Upon arriving, res pale, cyanotic (bluish/purplish discolouration), diaphoretic (sweating heavily), cold (with) mottling (smearing of color) on extremities (sic) noted. Unable to obtain manual BP (blood pressure), O2 Sat reading or radial pulse. Asked res if he was able to say what was wrong & he responded, My back hurt. Hall Nurse stayed (with) res while Charge RN (Registered Nurse) initiated transfer. Unable to reach POA (Power of Attorney) (POA's Name), emergency contact, but did reach nephew (nephew's name) who agreed to transport. Obtained order from (NP C) for eval in ER. Placed call to (Ambulance Company) who arrived for transport at 1425 (2:25 PM). Res brother-in-law (brother-in-law's name) did call back & he was informed of the situation & will meet res in the ER @ (at) (hospital name). [DATE] 1700 (5:00 PM): Status Days: Administered AM meds (medications) to resident, which he swallowed without problem. Approximately 10 min (minutes) later this nurse could hear resident coughing, then vomiting. Assisted resident, cleaned up medium, liquid emesis. HOB elevated, Resident recovered from this, but was found by staff a short while later having a very large liquid loose stool over the bedding and onto the floor. Two assist (with) resident for cleanup, then he was assisted to chair. Temp (temperature) 97.3, O2 92% / 2L. Resident stayed in room through lunch watching his game shows per usual. Resident fed himself @ lunch. This nurse went into room early afternoon to change O2 tubing, noted that resident was very pale, diaphoretic; asked resident if he knew me and he acknowledged with yes. He could not remember my name, but said yes again when asked if he knew me. He was also able to recall the day of the week, was unable to get reading for BP, P (pulse), O2. Called for assist of Charge RN. We both attempted BP from both arms and got nothing. ADON (Assistant Director of Nursing) also took BP with unreliable results, due to pulse being inaudible; radial pulse very weak. Resident eyes open, became unresponsive. Dr (doctor), POA, then ambulance called. Resident left facility about 1430 (2:30 PM) via ambulance to (hospital name). The facility's Meal Intake, Unit 3, dated [DATE], indicates, in part: R120 refused his breakfast and had a sick tray for lunch. There is no information on whether R120 ate lunch or not. The facility provided Surveyor with the following statements: Statement signed by RN D, dated [DATE]: Statement of (RN D) as given to (DON B) on Friday, (MONTH) 2, (YEAR): I got shift report and found out that (R120) had a large liquid emesis at 0430 (4:30 AM). He had no loose stools and his patch was on. At about 0730 - 0740 (7:30 AM - 7:40 AM), I gave him his morning meds. He takes his meds whole with prosource. He gagged one time, which is not unusual; he otherwise had no problem swallowing. About 0800 (8:00 AM), I heard (R120) cough. I went into the room and he had a medium emesis one time. It was dark reddish, it looked like Kool Aide (sic). No pills came up. There were some particles noted, but the substance was unknown to me. He was able to hold the basin to his upper chest without difficulty. I then cleaned him up. I spent about 20 minutes trying to administer medications to his roommate. I did not hear any further cough or gagging. Between 0830 0900 (8:30 AM - 9:00 AM) CNA notified me that liquid stool was in (R120's) room on the floor next to the bed. It was very foul, black. (RN E) was helping to clean it up and questioned me about it. I told her he takes iron. (CNA and RN E) cleaned (R120) up and it took about 45 minutes. 1000 (10:00 AM) Checked (R120) temp and oxygen saturation. (a full set was not completed). Reason for not getting full set of vitals - he looked fine and was acting his normal self, temp and SpO2 (peripheral capillary oxygen saturation) were okay. Upon return at 1130 (11:30 AM), I gave . (R120) his [MEDICATION NAME]. He swallowed okay, looked okay, was talking without difficulty. At about 1245 - 1300 (12:45 PM - 1:00 PM), I was changing (R120's) oxygen tubing and humidifier bottle. I noticed he was pale and his tongue was thick. I asked him if he was okay. He verbalized Yeah. I left the room to go get the vitals kit from my med cart and heard the oxygen concentrator beeping. I returned to the room and turned the concentrator off for 10 - 15 seconds, then turned it back on. It was working. I checked for BP on the left with the automatic machine. (R120) verbalized owe, owe. The machine read error. I knew that something was wrong with the way the machine was trying to read his blood pressure. I asked (CNA) to go get the Charge Nurse. His SpO2 flashed 82% then I couldn't get it to register. His hands were ice cold. He was diaphoretic. He verbalized that he was hot. I asked him if he wanted a blanket removed, he stated, no. I noted a thick tongue speech. On [DATE] at 11:30 AM, Surveyor interviewed RN D. RN D stated on [DATE] she was told in report that R120 had a large emesis around 4:30 AM and she assisted R120 when he had a second emesis at around 8:00 AM. That emesis was medium amount, but could not remember what it looked like. RN D stated R120 had a large loose BM (bowel movement) around 9:00 AM, which RN E had assisted with. RN D stated RN E had asked her to get a full set of vital signs on R120 after she was came out of his room, after helping clean him up. RN D stated she did not get into R120's room to get his vital signs until after lunch and he was not the same. He looked pale, diaphoretic; however, he was still talking to me. RN D stated she attempted to get R120's vital signs; however, was unable to get them. She asked a CNA to get the Charge RN. Statement signed by RN E, dated [DATE]: Resident (R120) Condition Change. It was reported that res had large loose incontinent BM (after) an emesis. I went to assist CNA cleaning up the resident & that situation, which took approximately ,[DATE] hour. The time was approximately 9 - 9:30 (9:00 AM - 9:30 AM), during that time res was noted to be pale and slightly diaphoretic. He was verbally responsive. After helping with the situation I asked the Hallway Nurse if she had gotten a set of vitals. She told me his temp and I asked her if she would get a full set. I continued to go about my daily duties at the charge desk and between units. At approx (approximately) 1330 (1:30 PM) the CNA came to get me stating the Hall Nurse needs me right away. I immediately went to room (R120 room number). Res was in his w/c (wheelchair). Pale, cyanotic, diaphoretic (with) mottling of extremities noted, I asked if he could tell me what was wrong & all he stated was my back hurts. Attempted to obtain & was unable to get a manual BP. Radial pulse absent. Unable to get an O2 Sat to register. Hall Nurse then tried to get BP. I told Hall Nurse that he needs to be sent in immediately & I left her (with) the resident to begin the transfer process. (Ambulance company name) arrived at approx. 1410 (2:10 PM). On [DATE] at 11:00 AM, Surveyor interviewed RN E. RN E stated on [DATE] she was the Charge RN and she assisted the CNA with cleaning up R120 after he had a large loose BM. RN E stated that R120 had a large loose BM in his bed, another large loose BM on the floor, as he was being transferred to the bathroom, and a third large loose BM while on the toilet. RN E stated R120 looked pale and pasty. RN E stated she asked RN D to get a full set of vital signs on R120 and then returned to the Nurse's Desk. RN E stated she did not follow-up with RN D regarding the vital signs until she was called to R120's room, around 1:00 PM. RN D states she had not gotten a full set earlier and was having difficulty getting a set of vital signs now. RN E stated R120 was not responding verbally. RN E stated she went back to the Nurse's Station to call NP C, then the family and then an ambulance to send R120 to the ER. RN E stated she would have expected RN D to get a full set of vital signs when she requested them around 9:45 AM and give them to me as I was the Charge RN. On [DATE] at 4:42 PM, Surveyor interviewed DON B. DON B stated the facility uses the INTERACT TOOL for guidance on when to call a physician or NP. DON B stated she would have expected R120's physician or NP to be informed of his Change in Condition when he had the 2 emesis. On [DATE] at 11:00 AM, Surveyor interviewed NP C via telephone. NP C stated she would have expected R120 be fully assessed with [REDACTED]. R120 was having an emergency situation. RN D and RN E did not fully assess or notify R120's physician or NP C immediately when R120's had a significant change in his condition. Without immediately notifying R120's physician or NP C, the facility was unable to provide appropriate medical care to R120. The facility's failure to notify R120's physician or NP C with a Change in Condition created a situation of IJ, which was removed on [DATE], when the facility began implementing the following action plan: 1. Education to all CNA and Nurse Staff regarding the Change of Condition Policy and Procedure was initiated, to be completed by DON or other designated RN. All Nurse Staff will be educated prior to the start of their next scheduled shift on the following: * Charge Nurses will immediately report the findings regarding the acute change in resident condition to the resident's provider or provider on-call. * How to use INTERACT II Pathway Tool effectively. * INTERACT II Pathway Tool available on all med carts and at each Nurse Station. 2. Audit Process: The Director of Nursing or designee will audit every Change in Condition report for appropriate follow through daily for 10 days, then 2 times per week for 4 weeks, then 2 times per month for 3 months, then 1 time per quarter. 3. Evaluation Process: The QAPI (Quality Assurance and Performance Improvement) Team will review and assess the audits completed by DON at monthly QAPI meeting x 4 months. After 4 months, the Change of Condition Policy and Process will be reviewed each quarter through QAPI. Ongoing education will be provided as necessary. Modification to the Change of Condition Policy and Process will be made as necessary utilizing the QAPI process.

Based on interview and record review, the facility did not ensure that 1 of 22 sampled residents (R120) received a RN (Registered Nurse) Assessment and appropriate medical care when R120 had a significant change in his medical condition. On [DATE] at 4:30 AM, R120 had a large liquid emesis, at 8:00 AM had a medium dark reddish emesis, and at 9:00 AM had 3 large loose, foul smelling, black bowel movements (BM). R120 looked pale and pasty. R120 was transferred to his wheelchair (w/c) and left in his room. RN E, who is the Charge Nurse, asked RN D, R120's nurse, to get vital signs. At 10:00 AM, RN D got R120's temperature, 97.3 and oxygen saturation, 92% on 2 L (liters) of oxygen, but did not get a full set of vital signs, because she thought R120 looked fine. At 12:45 PM, RN D noticed R120 looked pale and his tongue was thick, R120 was diaphoretic, his hands were cold, and had mottling (smears of color) of his extremities. RN D was unable to obtain any vital signs. At 1:30 PM, RN D asked RN E to assist with obtaining R120's vital signs. Around 1:45 PM, R120 was transferred to his bed and RN F was called to assist with obtaining R120's vital signs. RN E called NP C (Nurse Practitioner), received an order to have R120 evaluated at the ER (emergency room ), ambulance arrived and R120 left the facility at 2:25 PM. R120 expired at the ER at 3:25 PM. Because nursing did not obtain a full set of vital signs and complete a full RN Assessment, the facility did not recognize R120 was having a significant change in his medical condition. There was no ongoing documented monitoring or assessment of R120 and R120 had to wait over 4 hours for medical care after having had a significant change in his condition. R120's Change in Condition began at 4:30 AM. The facility did not call NP C until after 1:00 PM and R120 was not transported to the hospital until 2:25 PM. R120 expired at the ER at 3:25 PM. The facility's failure to complete an RN Assessment, including the monitoring of vital signs for R120, and to provide him with appropriate medical care during a significant Change in Condition, created a finding of Immediate Jeopardy (IJ) beginning on [DATE]. On [DATE] at 4:42 PM, NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were informed of the IJ. The IJ was removed on [DATE]. The deficient practice continues at a scope/severity of D (potential for harm/isolated) as the facility continues to implement its action plan. Evidenced by: The facility's Change in Resident's Condition policy, dated (MONTH) (YEAR), includes, in part, the following: All changes in the resident's condition shall be noted on the resident's chart by the nurse caring for the resident. iv. Prior to notifying the provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the INTERACT II TOOL. ix. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. x. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition. The INTERACT II TOOL directs nursing to take vital signs (temperature, blood pressure, pulse, respirations and oxygen saturation when a resident experiences New or Worsening GI (Gastrointestinal Illness) Symptoms or Signs (to include nausea and/or vomiting), diarrhea (3 or more loose or liquid bowel movements per day .). Based on results, nursing may need to notify the Physician/Nurse Practitioner (NP)/Physician's Assistant (PA) or continue with further nursing evaluation. R120's [DIAGNOSES REDACTED]. R120 was his own decision maker. R120's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of [DATE] indicated R120 was cognitively intact, understood and understands, needed extensive assistance of two for transferring and toileting, and was frequently incontinent of bowel and bladder. R120's care plan problem: Comfort Care r/t (related to) declining condition m/b (manifested by) need for increased assistance with positioning and ADL's (Activities of Daily Living), need for intervention to relieve pain, respiratory, and emotional distress, dated [DATE], includes, in part, the following: Monitor condition closely and alert MD/GNP (Medical Doctor/Geriatric Nurse Practitioner) to any significant changes. R120's Patient Progress Notes include, in part, the following entries: [DATE], 5:00 (AM): Status: 4:30 (AM) resident noted to have lrg (large) liq (liquid) emesis. T (temperature) 98.3, O2 (oxygen) Sats (saturations) 95%, HOB (head of bed) (up). Will cont (continue) to monitor. [DATE], 1445 (2:45 PM): Change of Condition: Was notified by CNA (Certified Nursing Assistant) that Hall Nurse needed assist in res (resident) room. Upon arriving, res pale, cyanotic (bluish/purplish discolouration), diaphoretic (sweating heavily), cold (with) mottling on extremities (sic) noted. Unable to obtain manual BP (blood pressure), O2 Sat reading or radial pulse. Asked res if he was able to say what was wrong & he responded, My back hurt. Hall Nurse stayed (with) res while Charge RN (Registered Nurse) initiated transfer. Unable to reach POA (Power of Attorney) (POA's Name), emergency contact, but did reach nephew (nephew's name) who agreed to transport. Obtained order from (NP C) for eval in ER. Placed call to (Ambulance Company) who arrived for transport at 1425 (2:25 PM). Res brother-in-law (brother-in-law's name) did call back & he was informed of the situation & will meet res in the ER @ (at) (hospital name). [DATE] 1700 (5:00 PM): Status Days: Administered AM meds (medications) to resident, which he swallowed without problem. Approximately 10 min (minutes) later this nurse could hear resident coughing, then vomiting. Assisted resident, cleaned up medium, liquid emesis. HOB elevated, Resident recovered from this, but was found by staff a short while later having a very large liquid loose stool over the bedding and onto the floor. Two assist (with) resident for cleanup, then he was assisted to chair. Temp (temperature) 97.3, O2 92% / 2L. Resident stayed in room through lunch watching his game shows per usual. Resident fed himself @ lunch. This nurse went into room early afternoon to change O2 tubing, noted that resident was very pale, diaphoretic; asked resident if he knew me and he acknowledged with yes. He could not remember my name, but said yes again when asked if he knew me. He was also able to recall the day of the week, was unable to get reading for BP, P (pulse), O2. Called for assist of Charge RN. We both attempted BP from both arms and got nothing. ADON (Assistant Director of Nursing) also took BP with unreliable results, due to pulse being inaudible; radial pulse very weak. Resident eyes open, became unresponsive. Dr (doctor), POA, then ambulance called. Resident left facility about 1430 (2:30 PM) via ambulance to (hospital name). The facility's Meal Intake, Unit 3, dated [DATE], indicates, in part: R120 refused his breakfast and had a sick tray for lunch. There is no information on whether R120 ate lunch or not. The facility provided Surveyor with the following statements: Statement signed by RN D, dated [DATE]: Statement of (RN D) as given to (DON B) on Friday, (MONTH) 2, (YEAR): I got shift report and found out that (R120) had a large liquid emesis at 0430 (4:30 AM). He had no loose stools and his patch was on. At about 0730 - 0740 (7:30 AM - 7:40 AM), I gave him his morning meds. He takes his meds whole with prosourde. He gagged one time, which is not unusual, he otherwise had no problem swallowing. About 0800 (8:00 AM), I heard (R120) cough. I went into the room and he had a medium emesis one time. It was dark reddish, it looked like Kool Aide (sic). No pills came up. There were some particles noted, but the substance was unknown to me. He was able to hold the basin to his upper chest without difficulty. I then cleaned him up. I spent about 20 minutes trying to administer medications to his roommate. I did not hear any further cough or gagging. Between 0830 0900 (8:30 AM - 9:00 AM) CNA notified me that liquid stool was in (R120's) room on the floor next to the bed. It was very foul, black. (RN E) was helping to clean it up and questioned me about it. I told her he takes iron. (CNA and RN E) cleaned (R120) up and it took about 45 minutes. 1000 (10:00 AM) Checked (R120) temp and oxygen saturation. (a full set was not completed). Reason for not getting full set of vitals - he looked fine and was acting his normal self, temp and SpO2 were okay. Upon return at 1130 (11:30 AM), I gave . (R120) his [MEDICATION NAME]. He swallowed okay, looked okay, was talking without difficulty. At about 1245 - 1300 (12:45 PM - 1:00 PM), I was changing (R120's) oxygen tubing and humidifier bottle. I noticed he was pale and his tongue was thick. I asked him if he was okay. He verbalized Yeah. I left the room to go get the vitals kit from my med cart and heard the oxygen concentrator beeping. I returned to the room and turned the concentrator off for 10 - 15 seconds, then turned it back on. It was working. I checked for BP on the left with the automatic machine. (R120) verbalized owe, owe. The machine read error. I knew that something was wrong with the way the machine was trying to read his blood pressure. I asked (CNA) to go get the Charge Nurse. His SpO2 flashed 82%, then I couldn't get it to register. His hands were ice cold. He was diaphoretic. He verbalized that he was hot. I asked him if he wanted a blanket removed, he stated, No. I noted a thick tongue speech. On [DATE] at 11:30 AM, Surveyor interviewed RN D. RN D stated on [DATE] she was told in report that R120 had a large emesis around 4:30 AM and she assisted R120 when he had a second emesis at around 8:00 AM. That emesis was medium amount, but could not remember what it looked like. RN D stated R120 had a large loose BM around 9:00 AM which RN E had assisted with. RN D stated RN E had asked her to get a full set of vital signs on R120 after she was came out of his room after helping clean him up. RN D stated she did not get into R120's room to get his vital signs until after lunch and he was not the same. He looked pale, diaphoretic; however, he was still talking to me. RN D stated she attempted to get R120's vital signs; however, was unable to get them. She asked a CNA to get the Charge RN. Statement signed by RN E, dated [DATE]: Resident (R120) Condition Change. It was reported that res had large loose incontinent BM (after) an emesis. I went to assist CNA cleaning up the resident & that situation, which took approximately ,[DATE] hour. The time was approximately 9 - 9:30 (9:00 AM - 9:30 AM), during that time res was noted to be pale and slightly diaphoretic. He was verbally responsive. After helping with the situation I asked the Hallway Nurse if she had gotten a set of vitals. She told me his temp and I asked her if she would get a full set. I continued to go about my daily duties at the charge desk and between units. At approx (approximately) 1330 (1:30 PM) the CNA came to get me stating the Hall Nurse needs me right away. I immediately went to room (R120 room number). Res was in his w/c (wheelchair). Pale, cyanotic, diaphoretic (with) mottling of extremities noted, I asked if he could tell me what was wrong & all he stated was my back hurts. Attempted to obtain & was unable to get a manual BP. Radial pulse absent. Unable to get an O2 Sat to register. Hall Nurse then tried to get BP. I told Hall Nurse that he needs to be sent in immediately & I left her (with) the resident to begin the transfer process. (Ambulance company name) arrived at approx. 1410 (2:10 PM). On [DATE] at 11:00 AM, Surveyor interviewed RN E. RN E stated on [DATE] she was the Charge RN and she assisted the CNA with cleaning up R120 after he had a large loose BM. RN E stated that R120 had a large loose BM in his bed, another large loose BM on the floor, as he was being transferred to the bathroom, and a third large loose BM while on the toilet. RN E stated R120 looked pale and pasty. RN E stated she asked RN D to get a full set of vital signs on R120 and then returned to the Nurse's Desk. RN E stated she did not follow-up with RN D regarding the vital signs until she was called to R120's room, around 1:00 PM. RN D states she had not gotten a full set earlier and was having difficulty getting a set of vital signs now. RN E stated R120 was not responding verbally. RN E stated she went back to the Nurse's Station to call NP C, then the family and then an ambulance to send R120 to the ER. RN E stated she would have expected RN D to get a full set of vital signs when she requested them around 9:45 AM and give them to me as I was the Charge RN. On [DATE] at 4:42 PM, Surveyor interviewed DON B. DON B stated the facility uses the INTERACT II TOOL for guidance on when to call a physician or NP. DON B stated she would have expected R120's physician or NP to be informed of his Change in Condition when he had the 2 emesis. On [DATE] at 11:00 AM, Surveyor interviewed NP C via telephone. NP C stated she would have expected R120 to be fully assessed with [REDACTED]. When R120 was having a possible emergency situation, RN D and RN E did not assess R120 timely to determine if he was having a significant change in his condition. Without a RN Assessment and identification of R120's significant change in his condition, the facility was unable to provide appropriate medical care to R120. On [DATE], DON B had a discussion with RN D regarding complete vital sign assessment. The following is the written education provided to Surveyor on [DATE]. This form is signed by DON B only. Following the acute status change of (R120) (RN D) was educated on the importance of complete vital sign assessment being done in a timely manner with report of said vital signs and any further assessment being given to the Charge Nurse for follow-up with provider immediately following obtaining the vitals. Furthermore, it was discussed with (RN D) the critical role vital signs plays in gathering data assessment of a resident's status and subsequent determination of decline or improvement. It is important to know RN D was the only staff educated regarding completing vital sign assessment and that RN D was not educated on completing a full assessment with any Change of Condition. The facility's failure to ensure an RN Assessment, which includes monitoring of a resident's vital signs with a Change in Condition, created a situation of IJ, which was removed on [DATE], when the facility implemented the following action plan: 1. Education to all CNA and Nurse Staff regarding the Change of Condition Policy and Procedure was initiated, to be completed by DON or other designated RN. All Nurse Staff will be educated prior to the start of their next scheduled shift on the following: * How to recognize an acute Change of Condition. * Hall Nurse must inform the Charge Nurse of a resident that presents with an acute Change in Condition following a full system assessment, including a full vital sign assessment. * How to complete a full system assessment when a Change in Condition is recognized. * Nurse designating assessments and / or vital signs must follow-up immediately when an acute Change in Condition occurs in a resident. * How to use INTERACT II Pathway TOOL effectively. * INTERACT II Pathway TOOL available at all med carts and at each Nurse Station. All CNA Staff will be educated prior to the start of their next scheduled shift on the following: * How to use the STOP AND WATCH Tool. * Importance of thorough AND immediate completion of STOP AND WATCH Tool when a change in resident condition is recognized. * Any delays in completing the tool, delays nursing assessment, potential intervention and treatment for [REDACTED]. STOP AND WATCH Tool distributed to all CNA Staff and are available at all Nurse Stations and med carts. 2. Audit Process: The Director of Nursing or designee will audit every Change in Condition Report for appropriate follow through daily for 10 days, then 2 times per week for 4 weeks, then 2 times per month for 3 months, then 1 time per quarter. 3. Evaluation Process: The QAPI (Quality Assurance and Performance Improvement) Team will review and assess the audits completed by DON at monthly QAPI meeting x 4 months. After 4 months, the Change of Condition Policy and Process will be reviewed each quarter through QAPI. Ongoing education will be provided as necessary. Modification to the Change of Condition Policy and Process will be made as necessary utilizing the QAPI process.

Based on interview, medical record review, facility documentation review and facility policy and procedure review, the facility did not ensure Residents are free of significant medication errors, for 1 of 1 resident reviewed for significant medication errors. (R23). R23 was given 100 units of [MEDICATION NAME] (long acting insulin). R23 was to have received 15 units of [MEDICATION NAME]. The facility did not thoroughly investigate the significant medication error and had not identified what nurse actually had prepared and administered the incorrect dose of insulin. The facility had not taken steps to educate all nurses or change their policy, procedures or practices related to insulin administration, to prevent this type of error from re-occurring. This is evidenced by: The 01/2016 facility policy entitled Medication Administration using MatrixCare emar (electronic medication administration record) read in part: It is the policy of .Facility to provide medications as ordered, accurately and safely, to all residents. And 14. Medication is to be given as order and documented in the Matrix Care system. On 4/10/18 at approximately 11:15 AM, Surveyor requested the facility policy and procedure for insulin administration. On 04/10/18 at 2:20 PM, DON B told Surveyor, they have no insulin administration Policy & Procedure, but she is working on one and will have it done by Thursday (4/12/18). On 4/10/18 at 9:19 AM, Surveyor read a progress note dated 4/5/18 at 10:10 AM, written by SW (Social Worker) G, that identified R 23 was sent to the hospital on [DATE] due to an incorrect insulin dose being given. R23 returned from the hospital on [DATE]. R23 has [DIAGNOSES REDACTED]. Surveyor reviewed the Medication Error Report for R23 for 4/2/18. This report read in part: Time of Error: 09:05 A.M. Medication Given [MEDICATION NAME]. Dosage Given 100 units. Rte (route) of Admin (administration). Sub Q (subcutaneous). What was physician's orders [REDACTED]. Reason for making error: .Feeling overwhelmed & rushed, did not double check order amount. Could the error have endangered the life or welfare of the patient? Yes. Explain: Resident could have developed [DIAGNOSES REDACTED] and/or shock. What is the actual effect of the error made on the patient? Resident was hospitalized for [REDACTED]. How was the error discovered? Immediate recognition of error. By whom? (Registered Nurse (RN) F) When? 4/2/18 09:10 (AM). Who notified the physician? (RN F). When? 4/2/18 09:20 (AM). Has he seen the patient since the error was made? Yes. What precautions can you take to prevent a similar error? Double check insulin order with order on vial and in MAR (Medication Administration Record) before & after insulin administration. Establish a task in MAR indicated [REDACTED] Signature: Nurse making error: (Signed and dated by RN F on 4/3/18). A note dated 4/3/18, written by DON (Director of Nursing) B, attached to the Medication Error Report read in part: Following the incorrect medication administration dosage of (R23's initials) on 4/2/2018, (RN F's name and title) immediately contacted myself, (DON B's name and title). (RN F) explained and took responsibility for the error. I (DON B) informed her (RN F) that (NP C (Nurse Practitioner) name) and provider to (R23) had entered the building prior to my coming down to talk with her. I would send (NP C) down to talk with her (RN F) and (RN F) could explain the situation to (NP C). It would be her responsibility in inform (NP C) of all the necessary information and to complete a medication error report. I (DON B) followed up with (RN F) at 1530 (3:30 PM) on 4/2/18 to check in on how she (RN F) was doing . prior to leaving for the day. She (RN F) verbalized being upset with herself for making the medication error and not double checking the dose. She (RN F) stated that No one gets 100 units of [MEDICATION NAME]. I should know better than that. On 4/11/18, Surveyor reviewed R23's MAR for 4/2/18, and noted it was RN K (not RN F) who had signed as the nurse who had administered R23's [MEDICATION NAME] on the morning of 4/2/18. The [MEDICATION NAME] had a computerized time stamp of 9:38 AM on 4/2/18. The MAR for the [MEDICATION NAME] on 4/2/18, included an entry at 9:38 AM, that read: Late Administration: Administered late. by RN K. Surveyor questioned RN K signing for R23's [MEDICATION NAME] on the morning of 4/2/18, as RN F had identified herself as the nurse who made the error on the Medication Error Report. R23's MAR indicated [REDACTED]. On 4/11/18, beginning at 1:51 PM, Surveyor interviewed RN K. Surveyor asked RN K to explain how the [MEDICATION NAME] error occurred for R23 on 4/2/18. RN K said she and RN F were at the med cart and RN K was logged in to the computer. RN K said RN F told RN K to draw up 100 units of [MEDICATION NAME] for R23. Surveyor asked RN K if they had R23's MAR indicated [REDACTED]. RN K said, yes. Surveyor asked RN K if she personally had read the MAR for R23's [MEDICATION NAME] order. RN K said she read the top portion that was showing the 100 units/ml (milliliter), but not the underneath part that was highlighted in yellow with the actual amount to be administered, (the 15 units of [MEDICATION NAME]). RN K said she did not scroll down on the screen to see the full order. RN K stated she drew up the 100 units of [MEDICATION NAME] for R23. RN K said, after that, we went to R23's room to administer the insulin with a CNA (Certified Nursing Assistant) also, because R23 does not like needles and often refuses by saying no and pulling away. RN K said that day, R23 let them give her insulin after explaining why she needed it. While giving the insulin the CNA said, I don't think that was her normal dose. Surveyor asked, what prompted the CNA to say that. RN K said because, it took longer to go in than usual. After giving the insulin RN F went to the computer and checked the order and realized they had given the wrong dose. Surveyor asked what they did after realizing the error. RN K said RN F alerted the charge nurse, the DON and the NP who was on her way into the facility. RN K said, they held R23's [MEDICATION NAME] (an oral blood sugar lowering agent). Surveyor asked RN K if she checked R23's blood sugar after the [MEDICATION NAME] was given. RN K said, she did not. On 04/11/18, beginning at 2:51 PM, Surveyor interviewed RN F, and asked RN F to clarify who had administered the 100 units of [MEDICATION NAME] to R23 on 4/2/18. RN F said when she took over orienting RN K, RN K was logged into the MAR. RN F said she told RN K to draw up the 100 units of [MEDICATION NAME] and administer it to R23. Surveyor asked RN F, what time the [MEDICATION NAME] was given to R23, because the Med Error Report reads 9:05 AM, but the computer entered a time of 9:38 AM on 4/2/18. RN F said she did not actually go in and look at the MAR indicated [REDACTED]. RN F said the time on the Med Error Report is wrong then. Surveyor asked RN F what she was doing while RN K was giving R23 the [MEDICATION NAME]. RN F said she was in R23's room with RN K while RN K was giving the insulin. RN F said she thought it didn't seem right and a CNA said something like, that seems like more than her normal amount. Surveyor asked RN K, how long was it between RN K giving the [MEDICATION NAME] and realizing the error? RN F said, almost immediately, going from R23's room after giving it, to the computer and immediately checking the MAR, we realized the error. Surveyor asked what she did after realizing the error. RN F said, she told RN K, not to give R23 her morning dose of [MEDICATION NAME]. RN F directed the CNA to stay with R23 and have her eat as much as possible. RN F said she told DON B about the error and within five minutes of the error, RN F told NP C. On 04/11/18, beginning at 2:51 PM, RN F said, before the NP got there, she told the CNA with R23, the signs and symptoms of [DIAGNOSES REDACTED] and to let the nurse know immediately if R23 had any signs of symptoms. Surveyor asked RN F, the reason they did not check R23's blood sugar after the [MEDICATION NAME] 100 units was given. RN F said, they were monitoring her and at that time it was not warranted and R23 hates, hates her blood sugar and insulin being done. Surveyor asked RN F is she knew what time R23 left by ambulance for the hospital. RN F said, (RN EE) handled the transfer. RN F said she thought it was very quickly. RN EE also took care of contacting R23's POAHC (Power of Attorney for Health Care). On 04/12/18 at 11:05 AM, Surveyor conducted a phone interview with NP C. Surveyor asked NP C the reason R23 needed to be admitted to the hospital. NP C said because she didn't think they could manage it here. R23 needed very close monitoring for the next 24-72 hours, because [MEDICATION NAME] can last up to 72 hours. On 4/12/18, Surveyor reviewed R23's hospital progress notes for 4/2/18-4/5/18. These notes identified, on arrival to hospital, R23 was hemodynamically stable. R23's initial BG (blood glucose) at hospital was 304. The note identified [MEDICATION NAME] as being a long acting insulin and the plan was to check R23's BG every hour and give R23 an IV (intravenous) of D50 ([MEDICATION NAME] 50%) and half normal saline and or additional D50 if needed. R23's hospital note identified on the morning of 4/4/18, R23 was mildly hypoglycemic. Her BG was 65 at 6:44 AM and that resolved with juice. R23's BG was 84 at 7:12 AM on 4/4/18. The progress note identified R23's BG's started to trend up and R23's BG's were covered with SS (sliding scale) insulin. R23 returned to the facility on [DATE]. On 4/11/18 at 12:47 PM, Surveyor interviewed DON B and NHA (Nursing Home Administrator) A. Surveyor asked if they had completed education with all nurses regarding insulin administration, to prevent this type of significant error from re-occurring. DON B said, RN F and RN K have been re-educated but they have not done education with other nurses since this error occurred. Surveyor asked if the facility has changed their policy and procedure or practices related to insulin administration. DON B said they have not yet as of this point. We plan to make it a QAPI (Quality Assurance Performance Improvement) plan, making double checks and look at timing of the insulin. Surveyor asked DON B when they had decided to do that. DON B said last night, when they realized they did not have an insulin administration policy and procedure. For clarification, Surveyor asked if they had addressed the insulin administration error with their QAPI committee and had they developed an QAPI plan. DON B said it has not gone to the QAPI committee yet and they do not have a QAPI plan for it just yet.

Based on observation, record review and interview, the facility did not ensure that residents who currently have pressure ulcers received the necessary treatment to promote healing and to prevent pressure ulcers from developing and did not implement appropriate interventions to prevent pressure ulcers from occurring for 2 of 7 residents (Resident #1 and #6) reviewed for pressure ulcers. 1. Resident #1 had a decline in wounds and the facility did not implement appropriate interventions to promote healing or ensure appropriate infection control measures were taken during wound care. Resident #1 was noted to have changes in condition to skin during personal cares and staff did not report to nurse on skin changes. 2. Resident #6 is at high risk for pressure ulcers and the facility did not ensure the plan of care to reduce pressure ulcers was followed. As evidenced by: 1. On 01/25/16 at 1:40 p.m., Surveyor reviewed the medical record for Resident #1 and noted the following: - Resident #1 has [DIAGNOSES REDACTED]. - Minimum Data Set (MDS), dated [DATE] and 11/20/15, states Resident #1 was at high risk for pressure ulcers and no pressure ulcers present at this time. - Comprehensive Nursing care plan for impaired skin integrity, received 01/25/16, states Resident #1 is at risk for impaired skin due to urinary incontinence, and splint to the right hand/arm. The care plan states barrier cream is to be applied as needed, staff are to clean, dry and moisturize skin, especially over bony prominences, twice daily or as indicated by incontinence or sweating, encourage adequate nutrition and hydration, staff are to follow any positioning/repositioning directions from therapy, reassess the skin often and whenever the resident's condition or treatment plan results in an increased number of risk factors, skin is to be inspected each shift while providing care, Certified Nursing Assistants (CNAs) are to report changes in skin alteration to the licensed nurse specifically assess skin over bony prominences (e.g. sacrum, trochanter, scapulae, elbows, heels, inner and outer malleolus, inner and outer knees and back of head), and use lift sheet to move resident in bed. Surveyor noted the care plan did not indicate Resident #1 had a pressure ulcer and did not provide new interventions when pressure ulcer occurred. - CNA care plan, received 01/25/16, states staff are to reposition Resident #1 every two hours and as needed, reposition Resident #1 side to side while in the bed and Resident #1 is not to be positioned on her back (this intervention was dated on the care plan on 01/18/16) and offer toileting every two hours (which is dated 01/06/16 on the care plan). On 01/25/16 at approximately 2:00 p.m., Surveyor reviewed wound notes for Resident #1 and noted the following: - 12/25/15: Wound to coccyx: 1.8 cm x 1.0 cm x 0.1 cm. No tunneling, wound bed has red center, no exudate, no odor and surrounding skin is pink and blanchable. - 12/28/15: Wound to coccyx: 1.8 x 1.0 cm. No odor and surrounding skin is pink. Wound documentation for this date is blank for depth, tunneling, wound bed description and exudate description. - 01/04/16: Wound to coccyx: 2.4 cm x 1.4 cm x 0.5 cm, no tunneling, wound bed is gray, pink and red, serosangieoous drainage noted, no odor and surround skin is pink. - 01/11/16: Wound to coccyx: 4.0 cm x 1 cm x 0.5 cm. No tunneling, wound bed is yellow and red, serosangineous drainage noted, no odor and surrounding skin is pale and pink. - 01/19/16: Wound to coccyx: 3.0 cm x 1.0 cm x 0.3 cm. No description for tunneling noted on wound sheet. Wound bed is yellow, serosangineous drainage noted, no odor and surrounding skin is pale and pink. Surveyor noted on the wound documentation sheet the facility had checked Pressure: Suspected deep tissue Injury .Stage III. Surveyor noted a date next to this in parentheses to state 01/04/16. Surveyor noted a start date for the wound documentation which was 12/21/15. On 01/27/16, Surveyor received all weekly wound reports for Resident #1 and noted the following: - 12/31/15: Location of wound: Coccyx; Description of wound progress: Resident has been declining, refuses to eat most of the time, does not tolerate having periods of being up in wheelchair. Is most comfortable in bed. Protective devices in place: standard mattress of pressure reducing foam and roho cushion. Refuses nutritional supplement. - 01/07/16: Location of wound: Coccyx: Recently changed treatment to area, resident has been having loose stools. Medications were adjusted, however, appetite continues to be very poor, reapproaching ineffective. Daughter also observing poor appetite. Nursing care plan change: Mattress. Protective devices in place: Specialty mattress: low air mattress; roho cushion in wheelchair, foot cradle in bed, and body pillow. [MEDICATION NAME] supplement in place. - 01/14/16: Area appears clean and is red. Appetite continues to be very poor and is refusing to eat. No changes to care plan indicated. Protective devices in place: Low air loss mattress, roho cushion to wheelchair, foot cradle, turn and reposition schedule and body pillow. - 01/20/16: Over all status declining. Resident's appetite remains poor. There has been noted signs and symptoms of maceration to the wound. Appears clean. Will continue with current plan of care. Nursing care plan updated to reflect change in treatment. Protective devices in place: Low air loss mattress, roho cushion to wheelchair, foot cradle on bed and limited time up in wheelchair. [MEDICATION NAME] for nutritional supplement. On 01/25/16, Surveyor requested a copy of an outline describing the details of Resident #1's wounds from Registered Nurse (RN) F, who is the certified wound nurse for the facility. On 01/26/16, Surveyor received a copy of the above noted wound outline from RN F, which was dated 01/05/16, and noted the following: - (Resident #1) is at risk for skin breakdown because of her limited mobility, incontinence and prior intake. Barrier ointment was applied to her coccyx BID (twice daily) since 11/05/15. (Resident #1) has had a ROHO cushion in her w/c (wheelchair) and a Panacea mattress on her bed which is good for pressure relief through stage 2. Has been on a turning and repositioning schedule and supplements are ordered and offered but she often refuses them .On 12/07/15, (Resident #1) developed a pustule/blister on coccyx and had MASD (moisture related skin damage). Skin condition gradually eroded and became an open area. On 12/30/15, Tx (treatment) was changed to Allevyn and on 01/04/16 it was again changed to [MEDICATION NAME] and Allevyn. Are measuring site weekly. Family is aware along with provider. Did change mattress on 01/05/16. (Resident #1) is [AGE] years old and complete care are in place .has had weight loss and weight is currently 111.1 lbs. (Resident #1)'s main [DIAGNOSES REDACTED]. Presently has an open area on coccyx that measures 2.4 cm x 1.4 cm x 0.5 cm. Area was unavoidable because preventative measures were in place and risk factors were identified. Tx changes as needed. Will monitor wound daily and keep provider and family informed. On 01/27/16 at 9:16 a.m., Surveyor interviewed RN F in regard to the above noted time line. RN F stated on 12/07/15, Resident #1 developed a pustula (blister). Staff used house stock barrier cream. RN F stated the blister looked like a hard pimple prior to the pustula from developing. Resident #1 had a roho cushion in her wheelchair, was repositioned every two hours and had a standard foam mattress to aid in the prevention of pressure ulcers. RN F stated the floor nurses continued to monitor the pustula and eventually it opened up and she was then requested to assess the wound. RN F stated on 12/10/15 the wound was a superficial open area to the coccyx. A flow sheet was implemented (Surveyor requested a copy of the flow sheet and none was provided), was put on a skin assessment record and the physician was notified. RN F stated she did not take measurements of the wound at this time. RN F stated no treatment, other than barrier cream, was implemented until 12/30/15. RN F stated she does assist the nursing staff to help direct treatment and felt the wound on 12/10/15 was superficial and barrier cream was sufficient. RN F stated no interventions other than barrier cream were implemented due to already having a Roho cushion, turning schedule and was up for meals only. RN F indicated when the wound showed no improvement, nursing staff notified her on 12/21/15 and 12/28/15 that the wound had actually opened. RN F stated barrier cream was the only intervention implemented and no physician was notified. RN F stated on 12/30/15 the wound was not improving and looked worse than on 12/28/15. RN F stated she did not measure the wound at this time stating, I don't measure every time I look at it .already open .don't need to measure. RN F stated on 12/30/15 she requested nursing staff to treat the wound with Allevyn. RN F stated she staged Resident #1's pressure on 12/30/15 as a stage III pressure ulcer. RN F stated on 01/04/16 she did not feel the Allevyn was the right treatment so she consulted with a nurse practitioner who then ordered [MEDICATION NAME] and Allevyn to treat the wound. RN F stated she felt moisture was contributing to the change in the wound and noted Resident #1 to be having loose stools, so she requested a change in her medication be ordered to decrease the loose stools. RN F stated on 01/05/16, Resident #1's mattress was changed to a Panacea mattress, which is considered an alternating pressure low air loss mattress design, which is appropriate for stage III pressure ulcers. RN F stated on 01/19/15 the wound was still not getting better and appeared bigger in size so the treatment was again changed to [MEDICATION NAME], cover with gauze and is to be completed twice daily. On 01/27/16 at approximately 3:00 p.m., Surveyor received a copy of both the foam mattress and the Panacea mattress guidelines and noted the following: - Panacea Foam Mattress: Direct Supply Panacea foam mattresses are intended to be used as part of your care plan for your residents to help treat or prevent decubitus ulcers (bed sores) by providing a pressure-redistributing support surface. Guidelines did not indicate which stage of pressure ulcers it was appropriate for. - Lumex AltaDyne Plus Mattress: An ideal, portable air flotation system offers both alternating pressure and low air loss. Suitable for use in the prevention and treatment of [REDACTED]. On 01/27/16, Surveyor reviewed the physician orders [REDACTED]. - 12/30/15: treatment for [REDACTED]. Discontinue orange barrier cream, apply phytaplex with guard. - 01/04/16: Change [MEDICATION NAME] to Monday and Thursday and continue with same dosage. New treatment to coccyx: [MEDICATION NAME] to wound bed and cover with Allevyn dressing and change daily. - 01/19/16: Cleanse wound with normal saline, pat dry, cut [MEDICATION NAME] to fit, cover with 2x2 gauze, secure with mepliex tape. Treatment is to be changed twice daily and as needed. On 01/27/16 at approximately 10:00 a.m., Surveyor reviewed the nursing notes for Resident #1 from 12/01/15 - 01/25/16 and noted the following nursing entries: - 12/01/15: Orange top barrier cream applied to coccyx. Skin intact. - 12/02/15: Coccyx area looked good today. - 12/03/15: Bottom looks good. Orange barrier to site. - 12/07/15: Coccyx area noted one hard pustula. Orange barrier cream applied .continue to monitor for any changes and continue with comfort and healing. Surveyor noted no physician notification within the medical record for the change in condition for this date. - 12/08/15: No change to buttocks. Orange barrier cream applied. - 12/08/15: No change to buttocks, orange barrier cream applied. Repositioned every 2 hours and as needed. Resident is frequently incontinent of bowel and bladder and is on toileting program. - 12/10/15: Open area to coccyx is superficial open area. Orange barrier cream to treat. - 12/08/15: Area on coccyx remains open. Cleaned and barrier cream applied. Continue to monitor for any changes. - 12/16/15: Two small superficial open areas remain to residents coccyx area. Orange barrier cream applied. Repositioned every 2 hours and as needed. Surveyor was unable to identify physician notification or any new interventions to promote healing for this change in condition within the medical record. - 12/17/15: Barrier cream to buttocks. Center of wound opening remains and small sluff area on right buttock cheek noted. - 12/19/15: Has two small open areas to coccyx. Orange barrier cream applied. - 12/20/15: Resident has open area on right buttock. Orange to cream applied. was positioned on side when in bed to keep pressure off bottom. Laying down between meals today. - 12/21/15: Noted area on coccyx to be a little larger - 1.8 cm x 1 cm. Wound was previous 1 cm x .4 cm in circle. Orange barrier cream applied. Surveyor was unable to identify a physician notification for this change in condition and was unable to identify a new intervention to promote healing within the medical record. - 12/22/15: Orange barrier cream applied to coccyx area. - 12/23/15: Orange barrier cream applied to buttocks which continues to be open. - 12/25/15: Open area to coccyx. No drainage noted. Orange barrier cream applied. - 12/26/15: Barrier cream to coccyx and buttocks, area remains open was bleeding today and appears to be getting bigger. No odor noted. Orange barrier cream applied per order and repositioned every 2 hours while in bed. Surveyor was unable to identify physician notification and a new intervention to promote healing within the medical record for this change in condition. - 12/27/15: Orange barrier cream applied to buttocks. - 12/28/15: Open area on buttocks is large today and did relay to charge nurse to assess and if to see if another treatment was needed. Surveyor was unable to identify physician notification or a new intervention to promote healing with the medical record for this change in condition. Surveyor was unable to identify a comprehensive nursing assessment from charge nurse for this change in condition. - 12/29/15: Redness to coccyx persists. Orange barrier cream to area. Charge nurse alerted of need to assess. - 12/30/15: No nursing entry for this date within the nursing notes. - 01/01/16: Treatment ordered for buttocks. Allevyn dressing. - 01/02/16: Dressing changed to coccyx due to bowel movement. Open area has red wound bed of approximately 75% with 25% brown center. Area cleansed and dressing reapplied. - 01/03/16: Dressing changed to coccyx this shift due to soiled with bowel movement. Wound bed red, bleeding small amount with cleaning. Area has 2 small areas brown/black in color. Area cleansed and dressing replaced. - 01/04/16: Resident was seen by GNP (General Nurse Practitioner) today for special visit due to coccyx wound. Area assessed and new treatment implemented. - 01/05/16: Replaced Panacea mattress with an alternating pressure, low air loss mattress to relieve pressure sore. - 01/07/16: Coccyx dressing changed. Had a small amount of yellow greenish drainage. - 01/10/16: Dressing to coccyx, remains clean and nice pink tissue. - 01/13/16: Treatment to coccyx area. Clean and pink tissue center of area. Yellow pinpoint in middle. - 01/16/16: Dressing to coccyx covered with bowel movement this shift and was changed. Wound bed red/tan with pinpoint area deeper than remaining wound bed. - 01/18/16: Fax sent to physician to update regarding wound status. Slight odor noted. Area appears to have tunneling in center of wound bed. Requested to have frequency of wound care increased. (Note physician order [REDACTED]. - 01/20/16: Treatment to coccyx completed. Clean and no odor. - 01/21/16: Appetite remains very poor. Overall status continues to decline. Open area to coccyx remains clean with moderate amount of exudate even with increase in dressing changes. - 01/24/16: Coccyx appears pink with an odor noted. Treatment done per order. Will continue to monitor. - 01/25/16: Dressing removed and area cleaned. Noted to have some yellow sluff on the top part of opening, is pink and looks healthy. On 01/27/16 at 11:00 a.m., Surveyor interviewed the Director of Nursing (DON) in regard to the above noted wound for Resident #1. The DON stated the wound initially started out as a moisture related wound and eventually opened up and is now a stage III pressure ulcer. The DON stated she had observed the wound on 01/04/16 and determined it was a stage III pressure ulcer. Surveyor discussed concerns with the DON in regard to RN F staging the wound as a stage III pressure ulcer on 12/30/15. The DON stated she was not aware RN F had staged it on that date. The DON stated the wound opened up on 12/21/15 due to moisture related issues and she observed it on 01/04/16 and staged it a stage III pressure ulcer. Surveyor discussed concerns with the DON in regard to no interventions, other than barrier cream, were implemented until 12/30/15. Also discussed concerns in regard to no physician notification was implemented when changes to the wound were identified as noted above in the nursing notes. The DON stated the facility did implement a new mattress on 01/05/16 and felt the area to the coccyx prior to 12/30/15 was moisture related so the facility's main goal was to protect the skin by using barrier cream. The DON stated Resident #1 is complicated and end of life, remains on a repositioning schedule, is toileted per care plan and has supplements. On 01/26/16 at 8:21 a.m., Surveyor observed RN F provide wound care to Resident #1's coccyx. RN F washed her hands for four seconds and dried them and donned gloves. CNA D assisted in rolling Resident #1 onto her right side exposing Resident #1's dressing to the coccyx region which contained bowel movement. RN F removed the soiled dressing and with the same gloves grabbed the normal saline bottle and poured it onto a 4x4 gauze. RN F then cleaned the wound bed with the wet gauze. RN F then grabbed two 2x2 clean gauze pads and dried the wound. RN F removed her gloves and washed her hands for three seconds, gloved and finished wound care. On 01/27/16 at 11:00 a.m., Surveyor interviewed the DON and discussed concerns in regard to RN F not washing her hands according to current standards of practice and not changing her gloves prior to cleaning the wound. On 01/26/16 at 7:36 a.m., Surveyor observed CNA D provide personal cares for Resident #1. While washing Resident #1's upper left extremity, CNA D stated, It looks like she has a small sore under her arm by her armpit .this is new to me .will notify the nurse. CNA D continued with cares and noted Resident #1's heels to be flat on the mattress. CNA D and Surveyor observed Resident #1's right heel and noted the heel to be red in color. CNA D stated she would notify the nurse to assess. CNA D continued with cares and rolled Resident #1 over onto her right side and both CNA D and Surveyor noted Resident #1's skin to the right side to be very red. CNA D stated this was new and would notify the nurse. On 01/26/16 at 3:25 p.m., Surveyor interviewed RN E in regard to Resident #1 and asked RN E if the day shift nurse had reported any changes in condition for Resident #1. RN E stated she was not aware of any changes in condition for Resident #1 other than having an open area to the coccyx which was not new. RN E stated she was the nurse that would be taking care of Resident #1 during the PM shift on this date. On 01/27/16 at 7:00 a.m., Surveyor reviewed the nursing notes for 01/26/16 and 01/27/16 and noted no nursing entry for the above noted areas. Surveyor was unable to identify a comprehensive nursing assessment for Resident #1's sore to left armpit, red back and red heel which was identified on 01/26/16 during personal cares by CNA D. On 01/27/16 at 9:35 a.m., Surveyor interviewed Licensed Practical Nurse (LPN) V in regard to Resident #1's above noted changed in condition with personal cares. LPN V stated CNA D did tell her about the open area to the armpit on 01/26/16 but became very busy and forgot about it. LPN V stated, I'm sorry about that .should have assessed it yesterday .I assessed it now and it has been charted. LPN V stated she was not notified by CNA D on the red heel or the redness to the back of Resident #1. On 01/27/16 at 11:00 a.m., Surveyor interviewed the DON and discussed concerns in regard to CNA D not reporting the red heel or redness to the right back skin of Resident #1 and also discussed concerns in regard to LPN V not assessing the sore to the left armpit until the next day. 2. On 01/25/16 at 12:40 p.m., Surveyor reviewed the medical record and noted the following: - MDS, dated [DATE], states Resident #6 is at high risk for pressure ulcers. - CNA care plan, received 01/25/16, states Resident #6 is to have a dermasaver brief applied at all times. On 01/26/16 at 11:53 a.m., Surveyor observed CNA D and CNA H provide personal cares for Resident #6. Resident #6 was lying in bed and had a dermasaver brief on the chair next to the bed. The CNAs exposed Resident #6's lower extremity and it was noted Resident #6 had an incontinent brief on only and no dermasaver brief. Surveyor interviewed both CNAs in regard to the missing dermasaver brief. Both CNAs stated Resident #6 did not have a dermasaver brief on and should have had one on. CNA H stated they would be placing a dermasaver brief on after personal cares were completed. Both CNAs stated the dermasaver brief was used to prevent pressure ulcers due to Resident #6 having fragile skin and being at risk for pressure ulcers. The CNAs repositioned Resident #6 onto her right side and it was noted that Resident #6's coccyx was red. CNA D stated, Her coccyx is not always red like this. On 01/27/16 at 9:30 a.m., Surveyor interviewed RN F in regard to Resident #6's dermasaver brief and the observation above. RN F stated the dermasaver brief is to be worn by Resident #6 at all times due to Resident #6 being at high risk for pressure ulcers. RN F stated the dermasaver brief is an intervention to protect the skin from developing pressure ulcers. RN F stated Resident #6 should have had the brief on and agreed the staff were not following the care plan. On 01/27/16 at 11:00 a.m., Surveyor interviewed the DON in regard to the dermasaver brief not being applied as noted in the above observation. The DON confirmed the dermasaver brief should have been applied at all times.

Based on interview, medical record review, policy review and self-report review, the facility did not ensure that a resident's physician was immediately consulted when there was an accident involving the resident which resulted in an injury, and had the potential for requiring physician intervention for 1 of 4 residents reviewed. Resident #1 was being transferred by two Certified Nursing Assistants (CNAs) who were using a sit-to-stand lift. One of the loops of the sling slipped off the lift, the resident started to fall, and she was lowered to the floor. Resident #1 immediately complained of pain in her right ankle, as well as in subsequent days, but a physician was not immediately consulted. Resident #1's ankle was not x-rayed for a week, and the x-ray revealed a [MEDICATION NAME] fracture. This is evidenced by: The facility's policy for physician notification, dated 10/2007, states, "A facility must immediately inform the resident; consult with the resident's physician; and, if known, notify the resident's legal representative or an interested family member when there is (A) an accident involving the resident which results in injury and has the potential for requiring physician intervention..." Resident #1's medical record states she is completely dependent on staff for all of her care needs. Her Minimum Data Set (MDS), dated [DATE], states that she required extensive assist of 2+ people for bed mobility and transfers, and that she was non-ambulatory. This MDS also states that she had bilateral upper extremity impairment. She receives the medication [MEDICATION NAME] for dementia, but is able to answer direct questions. According to Resident #1's nurse's note, dated 01/03/14, written by Licensed Practical Nurse (LPN) D at 5:30 p.m., "Resident being transferred from her lounge chair to her broda chair for supper c (with) a stand lift. The strap came off the stand lift on the Lt (left) side. Staff was able to assist Res (resident) down to the floor at that time. Res did not hit her head. Did c/o (complain of) R (right) ankle pain immediately after...R ankle examined, no bruises, redness or excess swelling noted @ (at) the time. Dtr (daughter) notified of the fall by writer. Son also came to the facility to check on his mother. Writer notified (name) GNP (Geriatric Nurse Practioner I) to (check mark) on next rounds. Writer had maintenance check the stand lift. New rubber tabs were placed on the handles as the ones on there slipped off easily. Will continue to monitor Resident for any signs of injury." LPN D wrote the following note in the facility's communication book for NP I. "(Resident #1's name) - transferring c stand lift. Strap came off a lift arm. Res assisted c staff to the floor. C/O R ankle pain immediately after. No injuries seen." This note was written on a Friday night and would not be read by the NP until the following Monday. Surveyor interviewed LPN D on 01/22/14 at 4:26 p.m. Surveyor asked LPN D to describe what she knew about Resident #1's incident of 01/03/14. LPN D stated that the CNAs came to her and told her that when they were transferring Resident #1 in the sit-to-stand lift, the lift sling loop came off the lift, and they had lowered her to the floor. LPN D stated that when she assessed Resident #1, who was on the floor, LPN D asked Resident #1 if she hurt anywhere, and Resident #1 told her that she had pain in her right ankle. LPN D stated that she checked with Resident #1 a couple of hours later and she gave her some Tylenol, because she was still having discomfort. Surveyor asked LPN D if she called the physician, and LPN D stated, "I passed it onto the charge nurse, (Registered Nurse - RN C) and she would have been the one to call. I put (the above) note in the NP book that the incident happened." The CNAs used a Hoyer lift to transfer Resident #1 from the floor to her bed before RN C assessed her. Surveyor interviewed the charge nurse, RN C, on 01/22/14 at 3:35 p.m. She stated, "I was here when it happened. It was on the p.m. shift. I assessed her (Resident #1) in her bed. There was no swelling or redness." RN C stated that the physician was not called, nor was NP I. She stated, "From my assessment there was no immediate injury." RN C stated that she knew that evening (Friday) that NP I would not be in the building until the following Monday. Surveyor asked RN C if she performed a range of motion on (ROM) Resident #1's foot, and RN C stated, "Not a full range of motion." Surveyor asked RN C if she took a set of vital signs for Resident #1, and RN C stated, "No, they were already done, and I was told that they were fine." Surveyor asked RN C if she documented her assessment in Resident #1's medical record, and RN C stated she did not. Surveyor asked RN C if Resident #1 had any pain during the assessment, and RN C stated that Resident #1 complained of right ankle pain, and when asked if she hurt anywhere else, Resident #1 told her that her right hand hurts (which was also not documented). RN C stated sometimes Resident #1 complains of right hand pain from time to time. Surveyor asked RN C if she notified the Director of Nursing (DON) or the Nursing Home Administrator (NHA) at the time of the incident, and RN C stated she did not. Subsequent nurse's notes state the following. 01/04/14 at 4:45 a.m.: Denied pain or discomfort when asked. R ankle monitored, no injury noted. 01/04/14 at 11:00 a.m.: resident c/o pain when R ankle area touched this am for cares. Upon assessment no redness, no bruising noted. R leg is larger than L leg, ankle - thigh..assessed this p (after) noon & discomfort c exam cont (continues) to be s (without) bruising/redness. Hoyer lift being used for transfers D/T (due to) pain & discomfort. Will continue to monitor closely. Will notify NP via comm (communication) book unless condition (delta sign for change)s. 01/4/14 at 9:00 p.m.: Res R ankle had c/o pain when inspecting. No bruising noted. Trace [MEDICAL CONDITION], but it is to both ankles. Res given 1000 mg APAP PRN (milligrams of [MEDICATION NAME] as needed ) and it was effective. Also applied ice X 1 this shift which was effective. Dorsal & pedal pulse present. No redness. ROM completed c treatment orders c no additional c/o pain. Family was here this shift and nurse spoke c them quite a while regarding R ankle status. 01/05/14 at 2:50 p.m.: Lg (large) emesis mid morning. Temp 97.3. No further emesis, sips of fluids continue with plan. Rt. ankle remains tender to touch. 01/05/14, 3 - 11 shift: Res stated that her R ankle is feeling "Poor". 01/06/14, 7 - 3 shift: Resident's right ankle is slightly swollen and lightly bruised. Bruising is a light green and blue in color. Area is tender to the touch. 01/06/14, 9:45 p.m.: R ankle is swollen when asked if this area was painful, res denied pain, however, when ankle was manipulated, res winced in pain. Note that 01/06/14 was the day that NP I would have been notified of Resident #1's fall and ankle pain, however, there is no documentation that she examined Resident #1 on this date. 01/07/14 at 12:40 p.m.: Res denied pain to R ankle at rest, but stated "ow" c movement. Res given scheduled 1000 mg APAP. Ankle has very light blue/gray bruising lateral aspect. 01/07/14, 3 - 11 shift: No c/o or indication of pain to right ankle light bruising and swelling remains. Elevated and floated once in bed. Transferred with EZ stand without any difficulty. Will continue to monitor. 01/08/14, 7 - 3 shift: Res denied pain to ankle c movement and at rest this shift. Light bruising remains. EZ stand used c transfers and it well well. 01/09/14 at 3:15 p.m.: Rt ankle remains tender to touch. No increased swelling. Continue with plan. 01/09/14 at 9:40 p.m.: R ankle is swollen, red with purple bruising. This ankle is painful when manipulated, but no pain noted at rest. Will monitor. 01/09/14 at 10:15 p.m.: Outlined red area on R ankle and notified charge nurse. (The charge nurse did not write a note, and the physician had not yet been consulted.) 01/10/14 at 4:50 a.m.: "3-11 nurse reported giving tyl 650 mg @ 10:45 pm for increased ankle discomfort. R ankle remains swollen & red. PM nurse outlined area c marker to monitor, reddness continued within lines. Tender to touch. Offered pain med @ 0400 (4:00 a.m.) but declined - denied pain when stationary. But stated 'yes' when asked if she had pain upon movement or when touching. Will continue to monitor." 01/10/14 at 2:35 p.m.: Assessed R ankle as compared to earlier in week there is increase swelling, [DIAGNOSES REDACTED] (redness), pain c touch (light). At rest, no distress or discomfort. Verbalized discomfort with movement. GNP I was notified, and ordered an x-ray of Resident #1's right ankle. The nurse wrote that the facility would then use a Hoyer lift for transfers until the results of the x-ray is in, and ice was applied to the ankle. 01/10/14, 3 - 11 shift: R ankle remains [DIAGNOSES REDACTED]tous inside marking. Warm to the touch. Res reports pain to ankle with touch. R ankle wrapped with ACE wrap per order to splint foot. 01/10/14, 3 - 11 shift: x-ray results show fracture of R ankle. (GNP I) was informed. She called ortho dept for directions...splint/immobilize ankle, use ice PRN, [MEDICATION NAME] 5/325 every 4 hours PRN for pain, ortho appointment made for Tuesday. 01/11/14, night shift: During rounds Res was grimacing and appeared to be in pain. When asked if her ankle hurt, she said "Yes." Administered [MEDICATION NAME] to palpate pulses due to ACE wrap... Subsequent nurse's notes stated that Resident #1 seemed to have less pain with the ankle stabilized and with the administration of the [MEDICATION NAME]. She was seen by the orthopedic department on 01/14/14, and a hard cast was placed on her lower right leg. GNP I wrote her first note on 01/10/14 regarding Resident #1's right ankle, which states, "Nursing home staff called to report (Resident #1) has been having increased pain in the right ankle. She had a fall last weekend. Any manipulation of the ankle results in quite a bit of pain. Xray was done today to further evaluate. The xray came back with [MEDICATION NAME] minimally offset [MEDICAL CONDITION] malleolus...she is to be non weight bearing until evaluated in Orthopedics." Surveyor interviewed NP I on 01/23/14 at 9:50 a.m. Surveyor asked NP I if she had been aware that Resident #1 was having ankle pain after her fall on 01/03/14. NP I stated that she had not been told of the ankle pain following the fall, until the following Friday when the nurses called her. Surveyor noted that the facility's incident report had been signed by NP I, and the back of the incident report states, "Res c/o R ankle pain after fall." NP I stated, "I must not have read the back." Also note that LPN K had written about the ankle pain in the communication book. Surveyor asked NP I if she assessed Resident #1's ankle during the week leading up to her ordering the x-ray, and NP I stated that she did not. NP I stated, "If you fall on your elbow, you'll have pain, but that doesn't mean you have to call the doctor. You just monitor it." Surveyor interviewed RN G, who is the unit's day charge nurse, on 01/22/14 at 9:45 a.m. RN G was asked why the facility waited a week to x-ray Resident #1's ankle. RN G stated that Resident #1 can answer you but she is not always reliable. And sometimes she said she had pain (usually with movement) and sometimes she did not (usually at rest). She stated that since Resident #1 is nonambulatory it would take longer to figure it out. RN G did not document any assessments of Resident #1's ankle during the week after her fall. She stated that she does not attend the morning stand up meetings, and the incident was probably discussed with the interdisciplinary team on the Monday following the incident. RN G stated, "If we knew the outcome right away, we would have acted quicker." Surveyor interviewed the facility's DON on 01/23/14 at 9:10 a.m., who stated that she was off the Monday following Resident #1's fall. She stated that she had put the incident report in NP I's mail box on 01/07/14, and showed Surveyor that NP I had signed the incident report. The DON provided information that all nursing staff were re-trained in how to ensure safety with the EZ stand lifts, however, she had not inserviced her nurses in immediately consulting with a resident's provider (physician or NP) after an accident which may require physician intervention.

Surveyor: Fulton, Peggy Based on observation, interview and medical record review the facility did not provide care and services to ensure that a resident who entered the facility without pressures ulcers does not develop avoidable pressure ulcers for 1 of 4 residents reviewed for pressure ulcers. Resident #11 was discovered to have a Stage III pressure ulcer on 08/08/12 in her left coccyx area. On 08/11/12 Resident #11 was discovered to have a pressure ulcer/blister on her right lateral heel. The facility had identified that Resident #11 had a decline in her mobility status yet had not implemented sufficient pressure ulcer prevention measures to prevent the development of these pressure ulcers. This is evidenced by: On 09/13/12 at 8:05 a.m. Surveyor visited with Resident #11 in her room for several minutes. During this conversation Resident #11 told Surveyor that she had a sore on her tailbone and one on her foot. Resident #11 stated she was not sure why they occurred. Beginning on 09/13/12 Surveyor reviewed Resident #11's medical record and identified the following information. Resident #11 was admitted to the facility on [DATE]. Resident #11's [DIAGNOSES REDACTED]. Resident #11's initial Minimum Data Set (MDS) assessment with the assessment reference date (ARD) of 05/01/12, Section G identified Resident #11 at that time to be independent with bed mobility, required limited assist of one person with transfers, supervision of one person to walk in her room and in the corridor with her wheeled walker. Section M of this MDS asked "Is this resident at risk for developing pressure ulcers? " No was answered. Under "Skin and Ulcer Treatments" the MDS read in part "Check all that apply." A. Pressure reducing device for chair-not checked. B. Pressure reducing device for bed-not checked. C. Turning/repositioning program-not checked. D. Nutrition or hydration interventions-not checked. Z. None of the above were provided-this was checked. Resident #11's quarterly MDS assessment with the ARD of 07/27/12 identified Resident #11 required extensive assistance of two persons physical assistance for bed mobility, transfers and walking in her room and in the corridor. On Resident #11's 07/27/12 MDS Section M now identified Resident #11 was assessed to be at risk for pressure ulcers. The section "Skin and Ulcer Treatments" this MDS read in part "Check all that apply." A. Pressure reducing device for chair- this was now checked. B. Pressure reducing device for bed-this was now checked. C. Turning/repositioning program-this was not checked even though section G identified she needed extensive assistance of two for bed mobility. D. Nutrition or hydration interventions-this was checked. H. Applications of ointments/medications other than to feet was checked. Resident #11's Braden scale, an assessment to determine pressure ulcer risk, was completed on 04/27/12 and scored a 20 which indicated she was not at risk; a 05/07/12 Braden scale was scored at a 19, also identifying Resident #11 was not at risk. The 08/08/12 Braden pressure ulcer risk assessment again was scored a 19, which identified Resident #11 was not at risk. On 08/08/12 Resident #11 was found to have a stage III pressure ulcer to the left coccyx area and on 08/11/12 a blister/pressure ulcer area to her right lateral heel. On 09/13/12 at approximately 10:20 a.m. Surveyor interviewed Certified Nursing Assistant (CNA) M who was familiar with Resident #11. CNA M was asked if she knew why the pressure ulcer on her coccyx that was discovered on 08/08/12 occurred. CNA M stated Resident #11 has a lot of bony prominences. CNA M was asked if she could recall if Resident #11 needed help with turning and repositioning before the coccyx area ulcer was found in August 2012. CNA M stated usually, everybody does especially if they ask. Surveyor asked CNA M if Resident #11 would lie down during the day before the pressure ulcer occurred. CNA M stated occasionally if she was tired, she likes to sit in her recliner. CNA M was asked if Resident #11 lays down now during the day. CNA M stated she lies down on her side after lunch, she is very agreeable with that. CNA M was asked what time Resident #11 usually gets up. CNA M stated around 8:00 a.m., sometimes she sleeps in later. CNA M was asked if Resident #11 had a history of [REDACTED]. CNA M stated not for me, she is very pleasant. During the above interview CNA M was asked by Surveyor if she was aware of why Resident #11 developed the blister/pressure ulcer on her right heel that was found 08/11/12. CNA M stated no, unless a lot of times they don't move their feet in bed. CNA M was asked if she could recall if prior to the right heel blister being found, were you putting her legs on a pillow to prop her heels up? CNA M replied if we see a red area start to happen, unless they refuse. Surveyor asked CNA M to be more specific related to Resident #11. CNA M stated she can't be specific but if we see bony prominences we put pillows under legs. CNA M was asked if they check the resident's skin every day with cares. CNA M stated yes, we are always looking. Surveyor asked if she looks really closely at heels as they can be difficult to see all of the heel areas. CNA M stated we try to look at the whole heel. Surveyor asked CNA M if she could recall Resident #11 being ill or having a change in her condition around July and or August, 2012, CNA M stated it was getting harder for her to stand. She still ambulates with a 4 wheeled walker and two staff. When asked if Resident #11 had the Roho cushion in her recliner prior to the coccyx area ulcer being discovered, CNA M was unable to recall. On 09/13/12 at 10:50 a.m. Registered Nurse (RN) O informed Surveyor Resident #11 did have a wheelchair cushion, but RN O did not know what kind it was, Resident #11 had a chair cushion from home in her recliner prior to the pressure ulcer on her coccyx area being discovered. RN O also told Surveyor she should have checked pressure reducing mattress on Resident #11's 05/01/12 MDS as Resident #11 had a standard pressure reducing mattress from the time she was admitted but it was not identified on the 05/01/12 MDS. At 11:07 a.m. RN O told Surveyor she had entered section G and M of the MDS on 08/08/12 and identified declines in Resident #11's mobility and measures were put in place. RN O stated I couldn't do anything different looking at the date. Surveyor had been informed by RN O that Resident #11 had a physician order [REDACTED]. A physician order [REDACTED]. Based on the therapy orders, the facility had identified in June and July 2012 that Resident #11 was having declines in mobility, which should have prompted an assessment of the need for further pressure ulcer prevention measures. This did not occur. On 09/13/12 Surveyor reviewed Resident #11's 08/2012 activities of daily living (ADL) flow sheet the CNA's chart on. A hand written entry read "Air mattress overlay to bed, Roho cushion to w/c (wheelchair) & recliner. Derma saver undergarment." A date of 08/08/12 was written near these entries. To the left of those a hand written note read "Sheepskin to foot of bed at all times (not on top of bed)." Below these on the ADL sheet a typed/computerized entry read "POSITIONING: (A) (assist) of 1-2 as requested." Written next to that it read (A) of 2. Reposition q (every) 2 hours and PRN (as needed). Encourage laying side to side. Roho cushion to recliner and w/c 08/08/12." The 08/2012 ADL sheet also identified from the beginning of the month that Resident #11 was an assist of two and the EZ Stand for transfers from bed, w/c, toilet and from recliner to raise chair up and use assist of two so ambulation program can continue. An entry dated 08/22/12 read "Only exception for not using EZ stand is recliner to standing when going for a walk with 4-w(wheeled)/walker." On 09/13/12 Surveyor reviewed Resident #11's July, 2012 ADL sheet and her treatment administration record and did not find interventions for pressure ulcer prevention such as floating heels or a turning and repositioning plan for Resident #11, even though Resident 11's mobility had declined. Surveyor discussed this with the DON on 09/13/12 at 10:35 a.m. and pointed out these things were not identified as being implemented until after the discovery of the pressure ulcer on Resident #11's coccyx area 08/08/12 and the right heel blister on 08/11/12. The DON stated that is probably true, they were started after the ulcers were found. On 09/13/12 the Director of Nursing (DON) informed Surveyor that until 08/08/12 Resident #12 had a regular pressure reduction mattress. It was a Direct Supply Panacea Original Plus Mattress. The manufacturer information sheet read "May be appropriate through Stage II wounds. Mattress wound stage ratings are general usage guidelines. Resident-specific assessment could alter your particular usage of these mattresses." Surveyor read a nurses' note on 09/13/12 dated 08/08/12 at 3:10 p.m. written by Licensed Practical Nurse (LPN) P that read in part "Will replace mattress to air overlay & cushion for w/c etc." A nurses' note written on 08/10/12 by LPN P read in part "did decline mattress at this point agreed to lay (arrow pointing down) /p (after) lunch on side." A nurses' note dated 08/11/12 time of 7-3 written by LPN P read in part "11-7 nurse noted 1 cm x 1.8 cm blister (R) (right) heel brownish fluid filled-intact. will float leg when in bed. Pt (patient) now agrees to triangle symbol (change) of mattress-will do on Mon (Monday) when maintenance is here." 08/11/12 was a Saturday. A nurses' note written on Monday 08/13/12 read in part "Air mattress added to bed." (This was two days after Resident #11 had agreed to it). On 09/13/12 Surveyor reviewed the weekly body audit sheets that are completed by the CNA's on residents' bath day. They are signed by the CNA and either the LPN or RN that is working on that hall. Resident #11's weekly body audit completed 08/03/12 did not identify any skin concern areas. A notation on the form read "All Good.!" The 08/10/12 weekly body audit identified "sore on butt." There was nothing identified on this date regarding Resident #11's heels. Resident #11's 08/17/12 weekly body audit did not identify any issues with her heels, despite having the right heel pressure ulcer that was discovered on 08/11/12 and was still present as of 09/07/12. On 09/13/12 Surveyor received a copy of Resident #11's Skin Assessment Record. This form identified the site of the pressure ulcer as the coccyx, the acquired date as 08/08/12 and cause of skin alteration-pressure was x'd. The Stage was identified as a III. The measurements were 1 cm (centimeter) by 0.8 cm. Depth-read full thickness. The bottom of this form defined a Stage III ulcer as full thickness tissue loss extending through dermis to involve subcutaneous tissue. Presents as a shallow crater unless covered by eschar. May include necrotic tissue, undermining sinus tract formation, exudate, and/or infection. Wound base is usually not painful. On 08/08/12 the coccyx area wound bed was described as yellow 100%. Exudate-none. Odor-no. Surrounding Skin (Peri-Wound)-normal. Pain-with touch. The above skin assessment record identified Resident #11 continued to have the coccyx pressure area as of 09/07/12 and at that time the measurements were Length-0.8 cm, Width-0.6 cm and Depth-0.3 cm. Resident #11's skin assessment record related to her right heel pressure ulcer dated 08/11/12 identified the cause of the skin alteration as pressure and suspected deep tissue injury. Resident #11's right heel ulcer was documented on 08/11/12, which identified: Length-1.8 cm, Width-1 cm and Depth as question mark. Wound bed described as maroon blister. On 08/22/12 Resident #11's right heel ulcer was documented on the skin assessment record as being Length-1.4 cm, Width-1.9 cm and as intact black eschar. On 09/07/12 the right heel ulcer was still present and described as; Length-1.2 cm, Width-1.4 cm, intact - maroon crusted. On 09/13/12 at 1:30 p.m. Surveyor observed Resident #11 in her bed laying on her right side. Surveyor was unable to determine if Resident #11's heels were being floated off the mattress surface. Surveyor requested RN A accompany Surveyor to Resident #11's room and check her positioning. RN A removed the blanket from Resident #11's feet and lower legs. Surveyor and RN A observed Resident #11's lower legs were on two pillows and her right heel was floated off the bed but her left inner heel was resting against the sheep skin on the bed. Surveyor verbalized that Resident #11's left heel was touching the bed and was not floated. RN A stated she may need another pillow. The above concerns were shared with facility management staff on 09/13/12.

Based on observations, resident and staff interviews, and record reviews, the facility did not have sufficient staff to meet the individual needs of each resident who lived on the 100 & 200 units (of 4 resident units) which included 4 of 17 sampled residents and 13 supplemental residents (Residents #2, #22, #56, #4, #20, #21, #1, #18, #24, #11, #34, #35, #31, #33, #38, #57, and #33.) Because of inadequate staffing: A) Nursing assistants were unable to answer call lights in a reasonable time frame - causing residents to have to wait for extended periods of time to get up or to be assisted into the bathroom. (Residents #2, #20, #1, #35, #31, #21, and #18.) Resident #2 stated, "It is easier for the staff to clean you up instead of taking you to the bathroom." Resident #1 and Resident #38 have been incontinent of stool because staff have not responded quickly enough to their calls for assistance. B) Nursing assistants were unable to answer call lights in a reasonable time frame - causing residents to have to wait for extended periods of time to get up or be transferred/repositioned. Resident #1 has sustained 6 falls because staffs were not able to respond quickly enough to her sounding alarm. The last of these falls resulted in a [MEDICAL CONDITION]. Additional residents needing to get up, be repositioned, or transferred. (Residents #22, #56, #18, #11 and #57.) C) Nursing assistants were unable to answer call lights in a reasonable time frame - causing residents to have to wait for extended periods of time to get feeding assistance and /or dining room assist. (Residents #4, #24, #21, #31, #33, and #38.) D) Nursing Assistants who were providing ADL's to residents were interrupted and the residents left so staff could assist with caring for another resident. (Residents #11, #34, and #21.) This failure to provide adequate/timely ADL's to residents because of insufficient staff placed residents at high risk for pressure areas, falls, inadequate nutrition etc. This created a situation of immediate jeopardy, beginning 6/13/11. The lack of staff had the potential to affect all 40 residents living on the 100 and 200 Units. The facility was informed of the immediate jeopardy on 6/23/11 at approximately 2:50 p.m. by Surveyor . The facility removed the immediate jeopardy on 6/29/11, however, the deficient practice continues at a scope /severity level of E (potential for harm that is not immediate jeopardy/pattern) because all portions of the facility's plan have not been completely implemented. This is evidenced by: Surveyor held the resident group interview on 6/20/11 from 1:00 p.m.-2:15 p.m. with 12 residents attending (Residents #10, #13, #21, #25, #36, #40, #41, #42, #43, #44, #45, and #46.) When asked how long it takes for staff to answer their call lights, Resident #40 stated that 30 minutes was not uncommon, Resident #25 stated it could be over 30 minutes, and Resident #13 also stated "30 minutes." Resident #36, who was seated in a wheelchair, stated that she had to sit in feces on 2 separate occasions when her call light was not answered within 45 minutes. None of the residents stated that they could pin point a time of day or a day of the week that was worse than others, except for Resident #36, who stated that "a.m.'s" were the worst. Surveyor interviewed Resident #13 individually on 6/21/11 from 5:10-5:30 p.m. Resident #13 stated that when answering residents ' call lights staff will come into the room, shut off the call light, and say "be right back", but then don't return until "20 to 30 minutes later." On 6/20/11, Surveyor reviewed the minutes of the last 3 Resident Council meetings. Review of the minutes dated 4/27/11 read, "two residents commenting 'not enough staff', 'we're always short 1-2 people'-long waits for assist; when asked if staff explain why the wait, res (resident) comment 'heard every story in the book'; res comment 'large # (number) of us need assist of 2, if only 2 are on, what do you think happens to the rest of us?'" Review of the minutes dated 6/8/11 read, "one res with concern that there is not enough staff for assist on her unit-explained that with the increase in census, Nsg (nursing) is hiring & working staff schedules to have 3 CNA (certified nursing assistants) on that unit; res comments 'it's not working, I waited 30 min (minutes) for help just b/4 (before) coming down here'; did acknowledge that 2 on unit today d/t (due to) a call in." 200 Unit The completed CMS Resident Census and Condition of Residents Report for the 200 Unit noted the following; Total Residents = 21 Bathing - 19 need assist of 1-2 staff and 2 dependent. Dressing - 3 independent, 16 need assist of 1-2 staff and 2 dependent. Transferring - 6 independent, 12 need assist of 1-2 and 3 dependent. Toilet Use - 4 independent, 14 need assist of 1-2 and 3 dependent. Eating - 16 independent, 3 need assist of 1-2 and 2 dependent. The Unit 200 Report Sheet noted that 10 of 21 residents used alarms and 8 of these 10 residents used 2 or more alarms on their bed and/or wheelchair; Resident #2 - 3 alarms - Tab alarm in wheelchair and 2 beam alarms in bed. Resident #3 - 4 alarms - Tab alarm in wheelchair, and 1 pressure and 2 beam alarms in bed. Resident #14 - 2 alarms - Tab alarm in wheelchair and 1 beam alarm in bed. Resident #23 - 2 alarms - Pressure alarm in wheelchair and pressure alarm in bed. Resident #48 - 4 alarms - Pressure & Tab alarm in wheelchair, and 1 pressure and 1 beam alarm in bed. Resident #49 - 4 alarms - Pressure & Tab alarm in wheelchair and 1 pressure and 1 beam alarm in bed. Resident #50 - 2 alarms - Pressure alarm in wheelchair and 1 beam alarm in bed. Resident #51 - 2 alarms - Tab alarm in wheelchair and 1 beam alarm in bed. The facility schedule for Unit 200 dated 6/21/11 noted that two nurse aides are scheduled - CNA H is scheduled to work 6:00 a.m.-2:30 p.m. and CNA VV is scheduled to work from 6:30-3:00 p.m. and another- CNA Y is scheduled to work from 6:30-12:45 p.m. 1. On 6/21/11 at 7:05 a.m., Surveyor observed Resident #2 who lives on Unit 200 seated in his wheelchair in the door of his room and the call light was on. He reported it was his call light and he had to go to the bathroom and was waiting for someone to help him. Resident #2 reported that the facility is short of staff and he can't wait until he is able to walk so he can get himself to the bathroom. Surveyor asked the resident why he has a clip alarm on. Resident #2 stated the facility never asked him if he wanted it. He stated that he was given a suppository and put in a "gerichair." He had to go to the bathroom and no one responded so he tried to get up and fell . He further stated it is easier for the staff to clean you up instead of taking you to the bathroom. No staff were responding to Resident #2's call light so surveyor approached CNA Y at 7:08 a.m. and told her Resident #2 needed to use the bathroom. Resident #2's most current annual MDS with an assessment reference date of 5/4/11 notes that Resident #2's Brief Interview for Mental Status (BIMS) score was 10 indicating moderate cognitive impairment, however, the MDS notes that Resident #2 is able to make himself understood and is able to understand others. 2. On 6/20/11 at 10:32 a.m., Surveyor observed CNA F and CNA G enter Resident #22's room and transfer Resident #22 from his bed to the recliner chair in the room. Surveyor noted that there was not a pressure redistribution cushion in the seat of the recliner and Resident #22's heels rested directly on the footrest. CNA F reported that Resident #22 stays up in his recliner till second shift. Surveyor observed Resident #22 to be sitting up in his recliner with his heels resting on the footrest and a tray table positioned over the recliner at 1:50 p.m., 2:41 p.m., 2:59 p.m., and 3:19 p.m. Resident #22's record directs staff to use pressure relieving heel lift foam boots to bilateral heels every shift. (Cross reference F314) 3. On 6/22/11, at 8:24 a.m., Surveyor observed CNA FF deliver a breakfast tray to Resident #56 who lives in room [ROOM NUMBER]. room [ROOM NUMBER] is the last resident room on the 200 Unit. Surveyor asked CNA FF if the resident needed assistance with eating and CNA FF reported "she can eat by herself but I have to find someone to help boost her." Surveyor noted that CNA FF had to walk from the end of the 200 Unit to halfway down the 100 Unit to find CNA W to help her boost Resident #56 up in bed to eat. 4. On 6/22/11, at 8:30 a.m., Surveyor observed CNA Y deliver a breakfast tray to Resident #4 who lives in room [ROOM NUMBER] and ask the resident if she was comfortable. CNA Y stated "I'm going to go get CNA FF to help reposition you." CNA Y left the room and went to room [ROOM NUMBER] where CNA FF was assisting Resident #3 with breakfast. CNA FF stopped assisting Resident #3 and joined CNA Y in the hall and both CNAs entered Resident #4's room where they boosted Resident #4 up in bed for breakfast. CNA Y began assisting Resident #4 with breakfast. At 8:37 a.m., Assistant DON (ADON) A entered Resident #4's room and closed the door. Shortly thereafter, CNA Y left Resident #4's room and stated to Surveyor that ADON A is taking over assisting resident with breakfast as she has to go get Resident #20 off the toilet. CNA Y entered Resident #20's room at 8:39 a.m. to assist CNA FF transfer the resident off the toilet. At 8:50 a.m., Surveyor observed CNA Y and CNA W enter room [ROOM NUMBER] to assist Resident #56 to the bedside commode. After Resident #56 was assisted to the commode both nurse aides left the room and CNA W entered Resident #4's room to assist her with breakfast, becoming the third person to assist. 100 Unit On 6/21/11, ADON A completed a CMS Resident Census and Condition of Residents Report for the 100 Unit that noted the following; 100 Unit - Total Residents =19 Bathing - 18 need assist of 1-2 staff and 1 dependent. Dressing - 1 independent resident, 17 need assist of 1-2 staff and 1 dependent. Transferring - 2 independent, 16 need assist of 1-2 staff and 1 dependent. Toilet Use - 2 independent, 16 need assist of 1-2 staff and 1 dependent. Eating - 16 independent, 2 need assist of 1-2 staff and 1 dependent. The Unit 100 Report Sheet noted that 8/19 residents used alarms and 7/19 residents used two or more alarms on their bed and/or wheelchair; Resident #1 - 4 alarms - Pressure and Tab alarm in her wheelchair, pressure alarm on her bed and a bed beam alarm. It should be noted that Resident #1's safety care plan identifies the use of a beam alarm to the entrance of the room door to alert staff to resident entering room alone as well as a wall beam alarm. Resident #18 - 3 alarms - Pressure and Tab alarm in wheelchair and pressure alarm in bed. Resident #26 - 4 alarms - Pressure and Tab alarm in wheelchair, pressure alarm in bed and 1 beam alarm. Resident #28 - 3 alarms - Tab alarm in wheelchair and 2 beam alarms in bed. Resident #30 - 2 alarms - Tab alarm in wheelchair and 1 beam alarm in bed. Resident #31 - 3 alarms - Tab alarm in wheelchair and 2 beam alarms in bed. Resident #33 - 3 alarms - Tab alarm in wheelchair and and 2 beam alarms in bed. On 6/20/11, at 10:12 a.m., CNA F reported she was scheduled to work from 6:30 - 12:45 p.m. and was assigned to care for 7 residents. CNA F indicated that she also helped out on the 100 Unit as they were "working short." On 6/20/11, at 5:50 p.m., Surveyor interviewed CNA M who is assigned to the 100 Unit. CNA M reported there are two nurse aides assigned to the 100 Unit. The facility schedule for Unit 100 for the following day (6/21/11) noted that two nurse aides - CNA G and CNA I are scheduled to work from 6:30-3:00 p.m. and one nurse aide - CNA O is scheduled to work from 6:30-12:45 p.m. 5. On 6/21/11, at 7:36 a.m., Surveyor noted that a call light was sounding for an extended period of time. At 7:55 a.m., Surveyor and Surveyor started tracking the call light that was sounding and continued to sound at the nurses station for Resident #21 who resides in room [ROOM NUMBER]. At 8:19 a.m., Surveyor entered Resident #21's room and asked the resident if she had her call light on as two residents reside in this room. Resident #21 stated she had put her call light on and was waiting for someone to help get her up. At 8:21 a.m., Surveyor spoke with CNA G who was standing inside the doorway of room [ROOM NUMBER]. Surveyor asked CNA G who was assigned to Resident #21. CNA G reported that CNA I was assigned to Resident #21 but CNA I was currently in the tub room giving a bath right now. At 8:23 a.m., Surveyor told Licensed practical Nurse (LPN) Q that Resident #21's call light has been on for an extended period of time and Resident #21 requests assistance getting up. LPN Q went to room [ROOM NUMBER] and said something to CNA G. Surveyor observed CNA G exit room [ROOM NUMBER] and enter room [ROOM NUMBER]. Shortly after CNA G entered room [ROOM NUMBER] the call light was turned off. At 8:27 a.m., Surveyor spoke with Resident #21 who reported that CNA G came in her room, turned off her call light and said "they will be in shortly to help her." At this time Resident #21 stated "That will be about an hour." It had been 51 minutes since Resident #21 had put on her call light and she had still not been assisted. 6. On 6/24/11, at 10:15 a.m., at the request of the facility, Surveyors and met with Social Worker (SW) T from Western Wisconsin Care (WWC). SW T reported she speaks Hmong and usually visits Resident #1 on a weekly basis. SW T reported that Resident #1 told SW T that her biggest concerns are constant pain and her inability to get the help she needs because staff can't understand her and she can't get help when she wants to go back to bed after sitting up in her wheelchair for a long time or when she has been lying down for a long time. SW T reported Resident #1 used to be a very clean person before she came to the nursing home. SW T reported that Resident #1 has had occasional loose stools and doesn't want to be incontinent and staff don't respond when needed which is quite upsetting to Resident #1. SW T further reported that Resident #1 uses gestures to communicate with staff but staff are not understanding her. On 6/23/11, Surveyor reviewed Resident #1's record which noted the following in the Professional Progress Notes dated 3/22/11 noted " IPSN team review of residents behaviors and continued attempts of self transfers. On 3/21 @ ~ 1040 CNA walking past residents room observed resident standing at her closet rummaging through her clothing. Staff found that resident had turned off her pressure & beam alarms on her bed. Resident had also pushed the mattress on the floor next to her bed away. It appeared that once resident pushed away mattress that she had walked to her closet w/o (without) her w/walker (wheeled walker) ... Staff initiated 15 min(ute) checks while resident was in bed. T/P (Temporary Problem) started to monitor safety. Resident has numerous safety devices in place which are no always effective as she turns them off. Resident has had a significant amount of falls since her admission on 6/24/10. Facilities ability to keep resident safe d/t (due to) her unwillingness to use call light and make safe decisions. Have notified WWC that safety approaches have been exhausted. At this time will add 30 minute checks to poc (plan of care) as 15 min checks are not feasible with amount of staff on residents hallway ... " Patient Progress Notes dated 5/28/11at 1800 noted "Res(ident) yelling @ staff loudly because she wasn't able to get a staff member to take her to the bathroom. Continuously set off door alarm to her room after being told to wait patiently for staff who were helping other res. When staff member attempted to shut alarm off & closed the door to prevent res from entering her room, res swung @ staff member. Res started laughing when she missed. Spoke with res about incident, res cont'd (continued) to laugh & stated "well they kept making me wait." Reminded res to not do that in future...." Resident #1 has four alarms. During the meeting with facility management staff on 6/21/11 at 3:30 p.m., Surveyor asked the facility what was the purpose of the alarms used for Resident #1. The DON and Social Worker (SW) C stated that the alarms are used to notify staff of the resident's movement. Resident #1 has had six falls (9/10/10, 12/2/10, 2/4/11, 4/13/11, 5/2/11, 6/13/11) where alarms had sounded but staff were not able to respond quickly enough to the alarm to prevent Resident #1 from falling. The fall on 6/13/11 resulted in a [MEDICAL CONDITION]. According to a federal hearing decision (Bethel Center vs. CMS, 9/18/06), " ...the alarm is useless as an assistive device if the staff member is too far from the resident when the alarm sounds to come to the resident ' s assistance and prevent the resident from falling. Consequently, in every case where an alarm is used as an assistance device, facility staff must be no more than, at most, a few seconds and just paces away from the resident in order for the resident to be protected adequately. " On 6/23/11 at 9:39 a.m., Surveyor interviewed SW C regarding Resident #1's frequency of falls and ineffectiveness of alarms. SW C reported that there have been occasions where the staff have gotten to the resident before she has fallen. Surveyor asked SW C if the facility had ever considered putting Resident #1 on one-one supervision. SW C stated "We don't offer one to one supervision." Cross reference F323. 7. On 6/20/11, at 3:27 p.m., Surveyor observed Resident #18 sitting up in his wheelchair in the dining room. Resident #18 was poorly positioned with his body slumped down and his chin resting on the right side of his chest. At 5:09 p.m., Surveyor observed Resident #18 sitting slumped over in his wheelchair in the hall outside the dining room and across from the lobby entrance. At 5:31 p.m., Surveyor observed Resident #18 sitting in his wheelchair outside his room. He was slumped to the right with his chin resting on his chest. During these observations, numerous facility staff walked by Resident #18 and did not address his poor positioning. Resident #18 lives on Unit 100. (Cross reference F241) Surveyor reviewed the facility's daily assignment sheet for staff on the 100 wing, day shift, on 06/22/11 and identified that Certified Nursing Assistant (CNA) VV and CNA AA were to work from 6:30 a.m. to 3:00 p.m. and be in the dining room at 7:30 a.m. and 11:00 a.m. (to assist residents during mealtime). Another CNAs name was crossed off who was to work from 6:30 a.m. to 12:45 p.m. and was replaced with CNA Z. At 7:10 a.m., CNA VV and CNA AA were the only CNAs noted to be working on the 100 wing at that time. CNA Z was not present as identified on the daily assignment sheet and at 7:25 a.m., CNA VV stated, "It will be a crazy morning with 2 (CNAs). CNA VV stated the census on the 100 wing had increased over the previous week. CNA Z arrived on the unit at 7:27 a.m. and stated she had been sent over to assist from the 300 wing, adding that she did not usually work the 100 wing. 8. Resident #24 was observed sitting in his wheelchair toward the end of the hall near the nurses' station at 7:10 a.m., at 7:38 a.m., and at 7:41 a.m. Resident #24 stated he was waiting to be weighed which had to be done prior to his eating breakfast, adding that breakfast started at 7:30 a.m. Resident #24 waited for over 31 minutes before staff obtained his weight so he could go to breakfast. This observation identified there was insufficient staff to adequately assist all residents in a timely manner with necessary activities such as obtaining weights. 9. Surveyor observed CNA AA providing morning cares to Resident #30 at 7:24, 7:28, and 7:33 a.m. and assisting CNA VV with Resident #11 at 7:41 and 7:44 a.m. Resident #11's significant change Care Area Assessment Summary (CAAS), dated 05/27/11, stated the resident was no longer ambulatory and required extensive to total assistance with ADL's, was frequently incontinent of bowel and bladder, had a weight loss of 10% in the previous 6 months and refused all supplements, and had ongoing skin breakdown on his buttocks since his admission. Surveyor observed CNA VV providing morning cares to Resident #11 at 7:28, 7:34, and 7:48 a.m. Surveyor observed CNA Z providing morning cares to Resident #34 at 7:28 and 7:37 a.m. (left this resident from 7:38 to 7:47 a.m. to assist another resident as directed by the Director of Nursing (DON).) 10. It was identified on the facility's Census and Condition report that 17 to18 residents on the 100 wing required the assistance of 1 or more staff for dressing, transferring, and toileting. At 7:31 a.m., the bathroom call light went on for Resident #35, however, there was no staff in the area to immediately respond as all 3 CNAs on the unit were involved in providing personal care to residents. At 7:32 a.m., CNA Z came out of Resident #34's room to get supplies, and upon return to Resident #34's room walked by Resident #35's room looking at the flashing call light but having an arm full of supplies, returned to Resident #34's room without responding to the call light for Resident #35. At 7:34 a.m., Resident #31's alarm sounded and CNA AA responded to find Resident #31 attempting to get out of bed, stating he needed to use the bathroom. Surveyor observed that the above CNAs provided direct care to residents but it was difficult to impossible for them to respond timely to call lights and alarms during that time. 11. At 7:45 a.m., Surveyor observed Resident #34 lying in bed with a towel over his chest and a washbasin next to the bed. Resident #34 stated that CNA Z had to leave because another resident needed help. "She just started to wash me. I don't know when she'll be back." (CNA Z left the room at 7:38 when the DON directed her to assist another resident). At 7:47 a.m., Surveyor observed CNA Z return to assist Resident #34, having left him in the middle of his morning cares for approximately 9 minutes. CNA Z apologized to Resident #34 and stated that she knew why there had to be more than 2 staff on the 100 wing. At 7:50 a.m., CNA W arrived on the 100 wing and stated she was pulled from the 200 wing and was directed to stay on the 100 wing "until the work is done." This observation identified there was insufficient staff to adequately assist residents in a timely manner with necessary activities such as bathing and dressing. 12. From 7:57 to 8:00 a.m., Surveyor observed Resident #38 asleep in bed and Resident #21 awake in the recliner (they were roommates). Resident #21 stated both she and Resident #38 ate breakfast in the room, usually between 7:30 and 8:00 a.m. and added that both of them required staff to feed them (Resident #21 because of physical disability and Resident #38 because of cognitive deficit). Resident #21 stated she was putting her call light on (8:00 a.m.) because she needed to go to the bathroom. From 8:03 a.m. to 8:18 a.m., Surveyor observed CNA's VV, W, AA, and Z answer call lights and assist residents (#19, #33, #34). At 8:11 a.m., Resident #21 stated to Surveyor that CNA VV told her they were short of staff and would get her on the bedpan as soon as she could get CNA AA to help her. Resident #21 stated she had put her call light on earlier (to go to the bathroom), at approximately 7:00 a.m. and was told she would have to wait. Resident #21 stated she usually goes to the bathroom at approximately 10:00 p.m. and then did not normally use the bathroom during the night but had to go to the bathroom by about 7:00 a.m. the following morning (9 hours). Resident #21 identified this was her routine as it was usually "hard to get help" during the night, adding that staff must use the mechanical lift to transfer her from the recliner (where she sleeps) to the bed where she is placed on the bedpan. Resident #21 stated she had never been incontinent of urine because she had to wait for staff to assist her, but approximately 3 months earlier, was incontinent of stool because she had to wait. Resident #21 stated the incident made her feel bad. At 8:20 a.m., Surveyor heard CNA W ask CNA VV if she needed help with Resident #21 and CNA VV stated, "Oh, yeah," and they proceeded into Resident #21's room with a mechanical lift. These observations and interviews identified there was insufficient staff to adequately assist residents in a timely manner with toileting needs. 13. At 8:00 a.m., Surveyor observed Resident #18 in bed (a low bed with a mattress on the floor next to the bed), but awake. At 8:26 a.m., Surveyor observed Resident #18 in his room lying on his right side on the mat next to his bed. A pillow was noted behind his head and his body was pressed against the metal frame of the bed. There was no alarm sounding. Surveyor immediately summoned CNA Z and asked her to get a nurse for Resident #18. At 8:27 a.m., CNAs Z and AA, and Registered Nurse (RN) BB, all responded to assist Resident #18. RN BB stated the resident did not utilize an alarm when in bed because he didn't usually attempt to get up (later review of the resident's record identified falls onto the mat on 05/09/11 X 2, 05/25/11, and 06/11/11). RN BB checked range of motion for Resident #18 and the resident complained of back pain. This observation identified that even with an additional CNA added to the unit (CNA W), there was insufficient staff to adequately assist all residents in a timely manner with morning cares. 14. From 8:20 a.m. to 8:30 a.m., Surveyor observed that Residents #28, #31, and #33 were all awake and still waiting to get up for breakfast. Breakfast was scheduled to start in the dining room at 7:30 a.m. and room trays arrived on the unit at approximately 8:30 a.m. From 8:37 a.m. to 8:59 a.m., Surveyor observed CNAs Y, Z, AA, and VV distribute and/or set up breakfast trays to residents (#21, #28, #31, #33, #35, #37, #38). CNA VV and AA did not report to the dining room to assist residents during breakfast as directed on the daily assignment sheet which identified there was insufficient staff to adequately meet the needs of all residents. 15. At 8:34 a.m., Surveyor observed from the hallway, that a breakfast tray had been set in the room for Resident #33 (room trays arrived on the 100 wing on an open cart at approximately 8:30 a.m.). The resident was asleep and the motion sensor alarm sounded when Surveyor stepped into the room and made a closer observation of the tray next to the bed. At 8:36 a.m., approximately 1 and 1/2 minutes later, RN CC entered the room and turned off the alarm. The resident remained in bed, but did awaken with the sound of the alarm and would have had enough time to attempt an unsafe transfer out of bed. 16. At 8:49 a.m., Surveyor observed that CNA VV took Resident #38's breakfast tray into room [ROOM NUMBER] and set it on the overbed tray. Resident #21 was lying almost flat in bed covered by a small blanket and her breakfast tray had been placed on a table at the foot of the bed (placed at 8:43 by CNA AA). CNA VV stated that she could not feed both of the residents (both required to be fed by staff). CNA VV told Resident #21 that her tray included a sandwich and Resident #21 stated she would probably be able to eat that on her own. CNA VV left the room. Resident #21 stated that she had been told earlier that she would have to wait to eat. Resident #21 identified that she was off the bedpan but still had her pants down, adding that staff had not fixed them when they removed the bedpan. At 8:52 a.m., CNA VV and CNA AA came in and boosted Resident #21 up in bed. Resident #21 asked to have her pants pulled up. CNA AA questioned as to why this had not already been done. CNA VV responded that there had not been time to do it (when taken off the bedpan). Resident #21 stated it was "crazy like this every day." CNA AA and CNA VV assisted Resident #21 with her pants and CNA AA left the room at 8:55 a.m. This observation identified there was insufficient staff to adequately assist residents in a timely manner with necessary activities such as eating and toileting. 17. At 8:59 p.m., CNA VV set up the breakfast tray for Resident #38 who was asleep in bed. Due to the amount of time the tray had been sitting since it came from the kitchen (approximately 1/2 hour), Surveyor requested that CNA VV obtain a new breakfast tray and proceeded to take temperatures of foods and fluids on the tray. Abnormal temperatures included milk at 62 degrees Fahrenheit (above the safe temperature for milk products) and cooked cereal at 100 degrees Fahrenheit (Surveyor tasted the cereal and it was identified as not palatable). At 9:05 a.m., CNA VV returned with a new tray for Resident #38. Resident #21 stated to CNA VV that she was still not boosted up in bed so that she could eat. CNA VV responded that she understood, but stated, "We still need to feed these residents." CNA VV proceeded to assist Resident #38 at that time. This observation identified there was insufficient staff to adequately assist residents in a timely manner with necessary activities such as eating and the lack of timeliness resulted in inadequate temperatures for foods and fluids. 18. Surveyor made the following observations on 06/22/11 at 12:33 p.m. Resident #29 sat in her wheelchair in a nearby room where her spouse, Resident #11, resided (was seated in his gerichair). Resident #29 asked CNA W to assist Resident #11 (from his chair into bed). CNA W stated to Resident #29, "We don't have any help right now." CNA W went in and out of Resident #36's room, and then left the unit. Surveyor observed Resident #29 caught in the corner of Resident #11's room where Resident #11's gerichair and television set were in close proximity. Resident #29 asked Resident #11 to hand her the television remote which both were unable to reach. Resident #29 was able to get out of the corner with some difficulty and appeared frustrated. Activity Assistant (AA) EE came by and Surveyor asked if she could assist the two residents. AA EE went into the room and assisted the residents to change the television channel. This observation identified there was insufficient staff to adequately assist residents in a timely manner with necessary activities such as transferring and repositioning. 19. On 06/24/11 at 8:00 a.m., Surveyor heard Resident #57 calling out, "Hey, Hey!" Surveyor entered the resident's room and CNA WW soon followed and asked Resident #57 what he wanted. The resident was wearing a hospital gown (not dressed) and indicated he wanted to get up when CNA WW responded, "I can't get you up right now but I will be back in 15 minutes to get you up." CNA WW told the resident she would be taking him to the dining room when she returned and then recalled, "Oh wait, you eat in your room. I will bring you your breakfast." This observation identified there was insufficient staff to adequately assist residents in a timely manner with necessary activities such as dressing and eating. On 6/20/11, at the daily exit meeting from 4:10-4:30 p.m., Surveyor asked the Director of Nursing (DON) if the facility had a policy/procedure on how to replace absent staff. The DON said that the facility had no written policy/procedure. She stated that there is a list of who is off; and that she, or in her absence, the charge nurse, would try to replace an absent staff member. The facility removed the immediate jeopardy on 6/29/11 by which time the facility had: 1) Began hiring additonal certified nursing assistant staff. 2) Placed additional CNA staff on the working schedule for the day and evening shift on the 100and 200 Unit. 3. Asked current staff to work additional shifts to ensure staffing is adequate. 4. Social Worker will complete survey with alert residents on the 100 / 200 hallway by 6/29/11 to determine if their needs are being met. 5. DON monitoring call lights and alarm response times.

Based on observations, interviews, and record reviews, the facility did not ensure that the resident environment remained as free of accident hazards and did not ensure that each resident received adequate supervision and assistance devices to prevent accidents for 2 of 17 sample residents (#1, #8) and 3 supplemental residents (#18, #20, #39). Resident #1's most current comprehensive assessment identified Resident #1 as being at risk for falls. The facility did not comprehensively assess this resident's risk for falls and develop an appropriate care plan. Resident #1 fell 12 times from mid-September 2010 through mid-June 2011. The last fall on 6/11/11 resulted in a fractured hip. Even though it was well documented that Resident #1 did not understand English and would not use her call light when directed to do so, staff continued to encourage Resident #1 to use her call light. Resident #1 has had four falls (9/28/10, 10/9/10, 1/18/11, 2/20/11) where the alarms were turned off. Resident #1 has had eight falls (9/10/10, 12/2/10, 2/4/11, 4/13/11, 4/14/11, 4/21/11, 5/2/11, 6/11/11) where alarms had sounded but staff were not able to respond quickly enough to the alarm to prevent Resident #1 from falling. Six of the twelve falls (9/28/10, 2/21/11, 4/13/11, 4/21/11, 5/2/11, 6/11/11) occurred because Resident #1was trying to get herself to the bathroom or commode. Despite this, staff did not assess and develop a toileting schedule to reduce the number of attempts at independent transfer. Staff continued to rely on alarms even though these had proven to be ineffective because the resident could disconnect them or because staff was not able to respond quickly enough. The failure to provide the supervision that Resident #1 required created a finding of immediate jeopardy beginning 6/13/11. Surveyor # informed the NHA of this finding on 6/23/11 at 2:50 p.m. The facility removed the immediate jeopardy on 6/29/11, however the deficient practice continues at a scope/severity of E (potential for harm that is not immediate jeopardy/pattern) as evidenced by the following examples; Resident #8 is a [AGE] year old admitted to the facility in January, 2010, following hospitalization . He has moderate cognitive deficits, and uses a wheelchair for mobility due to his inability to ambulate. On admission, the facility assessed Resident #8's risk for falls (a 24, with a 10 being at risk.) As of 6/24/11, Surveyor identified that Resident #8 had at least 3 falls at the facility since his admission, yet he has had no comprehensive fall assessment or Care Plan developed to ensure proper supervision/equipment to prevent future falls. Resident #18 was assessed to be at risk for falls and had a recent history of falls off the bed. The resident had a care plan in place which required a pad alarm and a floor mat to be used in bed. On 06/22/11, Resident #18 had another fall out of bed and the pad alarm did not sound due to physical damage to the alarm cord. The resident was found on the floor mat by the surveyor with subsequent complaints of back pain. Facility staff did not assess each fall out of bed and make care plan changes to prevent serious injury with ongoing falls. Resident #20's most current quartely MDS assessment with an Assessment Reference Date of 5/13/11 notes that Resident #20 has moderate cognitive impairment, requires two person assist with bed mobility, transfers, toilet use and his balance is not steady and he is only able to stabilize his balance with assistance when moving on and off the toilet. The current CNA care plan does not direct staff to remain with Resident #20 while on the toilet. On 6/22/11, Resident #20 was left unattended on the toilet from 8:28 a.m. - 8:39 a.m. Resident #39 was seated in a wheelchair where her feet did not touch the floor and when she leaned forward she was at risk for falling out of her wheelchair. This is evidenced by: 1) Resident #1 is a [AGE] year-old Hmong resident who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A facility Fall Risk Assessment was completed 6/24/10 and noted the following risk factors; History of Falls , Impaired Vision, Problems with mobility, Balance problems, Needs assistance with elimination, Health Conditions, and Language barrier. Each risk factor was assigned a numeric value and the total score was noted to be 22. A score of 10 or more indicates a risk for falls. The most current comprehensive assessment dated [DATE] triggered Resident Assessment Protocol (RAP) Problem Areas to include but not limited to Cognitive Loss, Vision, Communication and Falls. The Cognitive Loss RAP Assessment documentation notes " ...She is primarily Hmong speaking and communication barrier could be contributing factor. Resident has been alert and oriented. No indication of memory impairment this reference period. Resident does generally use her call light when needing assistance, however, has on occasion not used ...Will proceed to care planning ... " The Vision RAP Assessment documentation notes " Does not read. Can not read English and can not read Hmong. Is able to see adequately for normal everyday ADLs. No concerns at this time. " The Communication RAP Assessment documentation notes "Is able to communicate in Hmong. Does not speak English. Family helps interpret for her when here. Staff who speak Hmong assist when at Mulders. Has a Social Worker (SW) that visits her to assist with needs. Mulder SW and her SW are working to make a picture book or communication board with pictures to help with communication of needs. Will initiate a care plan. " The care plan dated 7/5/10 includes the problem "Patient has difficulty making self understood R/T (related to) speaks Hmong. Does not speak English. " Approaches include; Provide non-hurried, quiet environment free of distractions for communication, encourage resident to use gestures, communication board, flash cards, etc. as provided, allow resident time to express self. Avoid interrupting the resident, observe for non-verbal signs of distress, assist with communication using family and Mulder staff when available. Contact social service as needed." The Falls RAP Assessment documentation dated 7/7/10 noted "Has had 3 falls since admission. Refer to IPSN for further information. Has history of occasional dizziness. Is on an antidepressant. Proceed to care plan." The RAP Assessment documentation did not address the risk factors identified in the completed Fall Risk assessment dated [DATE] to determine if the risk factors caused or contributed to Resident #1 falling. (Cross reference F272) The care plan dated 7/5/10 includes the problem "Patient has a history of falling since admission. Approaches include; give reminders not to ambulate / transfer without assistance, provide toileting assistance as indicated in CNA care plan, provide with safety device / appliance as indicated in CNA care plan (add sensor to doorway was hand written on care plan with no date or author), follow PT (physical therapy)guidelines, equip with device that monitors rising as may be indicated in CNA care plan, provide an environment free of clutter, keep call light in reach at all times, provide proper, well maintained footwear, assure the floor is free of glare, liquids, foreign objects, and follow all mobility guidelines in CNA care plan. a. Professional Progress Notes dated 09/13/10 noted " ISPN-team review of un-witnessed fall that occurred 09/10/10 ~ 1350. PTA (Physical Therapy Assistant) was walking by room and heard alarms sound. Resident found sitting on the in room. Interpreter (LPN) present and came to interpret. Resident reported she heard someone knocking and got up to see who/what it was ...Resident reported her left leg gave out and she went down on her knee ... Interpreter discussed need for resident to use call light and wait for help ... Will initiate use of special bed with large mats to floor on each side ... " . In this instance, an alarm had sounded, but staff had not been able to respond quickly enough to keep the resident from falling. b. Professional Progress Notes dated 09/28/10 noted " IPSN team review of un-witnessed fall that occurred 09/27/10 ~ 2230. Resident was heard calling out in her room at that time. Staff entered to find resident on the mattress mat on the window side of her bed holding her beam alarm from foot of bed in her hands. Alarm had been turned off. Resident apparently was heading to the BR (bathroom) and did not use her call light for assist. Resident was toileted after assessment and back to bed ...Staff report resident is able / knows how to turn beam alarm off. Will add bed pressure alarm as additional safety measure ... " Facility staff added an additional alarm but did not address the reason why Resident #1 got up (toileting). c. Professional Progress Notes dated 10/09/10 noted " Found on the mattress mat by her bed - sitting position this AM. Laughing when nurse approached. Unwitnessed. No apparent injury. No change. ISPN team to review on Mon 10/11/10. It should be noted that this note was written by RN CC who does not speak Hmong. Therefore RN CC could not interview Resident #1 to determine how she ended up on the mattress mat or what she had been trying to do. d. Professional Progress Notes dated 10/11/10 noted " IPSN team review of an un-witnessed fall that occurred on 10/09/10 at 0940. ... It is unclear why resident was self transferring ... Resident had lowered bed beam alarms that were not sounding when found. Resident is able to turn alarms off. Will add a bed pressure alarm to resident bed. " It should be noted that the intervention to add a bed pressure alarm should have already been placed per the 09/28/10 Professional Progress Notes. e. Professional Progress Notes dated 12/03/10 noted " IPSN Review: Resident suffered an un-witnessed fall on 12/2/2010 ~ 1800. Resident was found on the floor after CNA responded to an alarm. Resident was sitting on buttocks in her room. ...Resident inconsistent with call light use and hx (history) of impulsivity. Side beam alarms remain in place. " It should be noted that side beam alarms were not identified on Resident #1 ' s Fall Risk care plan. There was no assessment of what the resident was trying to do (e.g,, if she was trying to toilet herself). This is also the second fall that occurred when staff was not able to respond quickly enough to a sounding alarm. Professional Progress Notes dated 12/7/2010 noted " Clarification of IPSN note: After further follow up with nurse on duty by DON; resident did attempt to self transfer; however the alarm sounded during the act of self transfer from wheelchair to bed. Maintenance alerted to fact that Resident should have sensor placed on her doorway so that staff know if she should self propel herself back into her room. Resident remains unpredictable care plan to be updated. " Resident #1's quarterly MDS with an assessment reference date of 12/10/10 notes that Resident #1 had 2 or more falls without injury since prior assessment. f. Professional Progress Notes dated 1/18/11 noted " IPSN team review of an unwitnessed fall that occurred today ~ 0910. Resident was found wedged between w/c (wheelchair ) foot pedals. Tab alarm was pulled but not sounding. Housekeeper summoned nearby DON. DON required additional assistance from other staff. Foot pedals had to be removed and bed had to be moved to un-wedge Resident. Resident back in w/c (wheelchair) and replaced tab alarm ... Resident told Hmong speaking staff that she was trying to turn her radio on. Encouraged to use call light for help & not to transfer w/o (without) A (assistance) ... New tab alarm added. " It should be noted that on 12/7/10 Professional Progress Notes indicated that maintenance was going to put a sensor on Resident #1 ' s doorway so staff would know if Resident #1 self propelled herself back to her room. Professional Progress Notes dated 02/01/11 noted " IPSN team review of residents alarms and safety devices per staff request. Staff suggest that residents bed beam alarm be moved and attached to the wall. Resident turns off alarms multiple times during the night. Hmong speaking staff continually remind not to turn off her alarms. Have asked maintenance to place bed beam against wall out of residents reach. If resident did attempt to reach for alarm it would sound. Resident ' s bed is against wall and cannot exit at the end of her bed. Will add wall beam to POC (plan of care) ... " g. Professional Progress Notes dated 02/07/11 noted " IPSN team review of an unwitnessed fall that occurred on 02/04/11 at 1350. Staff responded to resident ' s alarms and found resident on the floor. Resident explained to Hmong speaking staff that she had walked from her bed to the bathroom in order to get a glass of water. Upon returning she got weak and fell to the floor .... It is unclear if residents account of the incident is factual as her left knee historically buckles when bearing weight. It is unlikely that resident was able to make it to her bathroom. Resident has mats to the floor bed pressure and beam alarms for safety. Will continue with these safety interventions. Resident continues to make attempts to self transfer despite safety team efforts and interventions. No changes made to POC at this time ... " This is the third fall that occurred when staff was not able to respond quickly enough to an alarm. h. Professional Progress Notes dated 2/21/11 noted " IPSN team review of an unwitnessed fall that occurred on 2/20 @ ~ 2215. Staff report resident was found sitting on floor next to bed, her mat was moved away from location next to bed. Residents alarms were turned off. Pressure alarm cord was pulled out of box. New alarm placed. ... Two staff assisted resident with gait belt onto the commode as this is where she was trying to transfer to. Staff demonstrated call light ... This is the second time Resident #1 has fallen because she was trying to toilet herself yet there was no individualized assessment of her toileting needs. i. Professional Progress Notes dated 3/22/11 noted " IPSN team review of residents behaviors and continued attempts of self transfers. On 3/21 @ ~ 1040 CNA walking past residents room observed resident standing at her closet rummaging through her clothing. Staff found that resident had turned off her pressure & beam alarms on her bed. Resident had also pushed the mattress on the floor next to her bed away. It appeared that once resident pushed away mattress that she had walked to her closet w/o (without) her w/walker (wheeled walker) ... Staff initiated 15 min(ute) checks while resident was in bed. T/P (Temporary Problem) started to monitor safety. Resident has numerous safety devices in place which are no always effective as she turns them off. Resident has had a significant amount of falls since her admission on 6/24/10. Facilities ability to keep resident safe d/t (due to) her unwillingness to use call light and make safe decisions. Have notified WWC that safety approaches have been exhausted. At this time will add 30 minute checks to poc (plan of care) as 15 min checks are not feasible with amount of staff on residents hallway ... " Professional Progress Notes written and dated 3/24/11 by Staff C - Social Worker noted the following; WWC SW T at facility to talk with resident about behaviors. SW T explained to resident she needs to call for assistance and not to turn off alarms. This writer explained to SW T that all current interventions are in place for resident safety. 1:1 (one to one) is not feasible at this facility. Will continue to monitor and update WWC on resident behaviors." j. Professional Progress Notes dated 04/13/11 noted " IPSN team review of an unwitnessed fall that occurred at 0230 this am. Staff responded to resident ' s pressure alarm sounding. Resident was found sitting on her mattress next to her bed. Resident communicated to Hmong speaking staff that she was going to use the commode. Resident verbalized she landed on her bottom. All alarms were functioning ... " This is the fourth fall in which staff was not able to respond quickly enough to an alarm to keep the resident from falling. It is also the third time that she fell trying to toilet herself, but there was no assessment of her toileting needs. k. Patient Progress Notes dated 4/14/11 at 1820 noted " O: Resident in MDR (main dining room) at 1600. W/C (wheelchair) alarm sounding. Resident (should state Staff) heard yell out & then fall after they had gotten to her. She was laying on her back & immediately c/o (complained of) pain in back of head. W/C facing in opposite direction, next to another resident. Because of language barrier, staff unable to determine cause of fall. Neuro(ological) checks initiated (pin-pong ball sized bump). Ice pack placed & held to bump. MD informed of fall ... Another resident told nurse Resident was leaning forward in her chair as if trying to reach something. Another resident the bumped into Resident #1 ' s w/c causing her to fall out. " This is the fifth fall when staff was not able to respond quickly enough to the resident ' s sounding alarm. l. Professional Progress Notes dated 4/22/11 noted " IPSN team review of a witnessed fall that occurred on 4/21 ~ 3:20 a.m. LPN responded to resident ' s alarms sounding in her room. Resident was noted to be standing between the head of her bed and the commode. LPN reports than resident was startled upon her entering the room and resident lost her balance. Resident landed on her left side and did not hit her head. ... MD was faxed. LPN also informed MD that resident has had some difficulty sleeping and has frequent voids ...Resident is continuously reminded by WWC team and staff that she cannot transfer without assistance. Resident continues to self transfer which inevitably results in a fall. Will continue to work with resident and WWC team to make resident safe and possibly look into alternate placement as facility may not be able to meet resident ' s needs ... " Even though facility staff informed the MD that Resident #1 was having frequent voids and difficulty sleeping, no changes were made to her plan of care to address these issues. This is the fourth time the resident apparently fell because she was trying to toilet herself. m. Professional Progress Notes dated 05/03/11 noted " IPSN team review of an unwitnessed fall that occurred on 5/2 ~ 1350. Staff responded to resident ' s alarms sounding in room. Upon entry resident found sidding (sitting) on floor next to her bed facing the window ... Resident appeared as if she needed to use the BR (bathroom). " This is the sixth fall when staff was not able to respond quickly enough to the resident ' s sounding alarm and the fifth time that she fell while trying to toilet herself. Patient Progress Notes dated 5/28/11 at 1800 noted "Res(ident) yelling @ staff loudly because she wasn't able to get a staff member to take her to the bathroom. Continuously set off door alarm to her room after being told to wait patiently for staff who were helping other res. When staff member attempted to shut alarm off & closed the door to prevent res from entering her room, res swung @ staff member. Res started laughing when she missed. Spoke with res about incident, res cont'd (continued) to laugh & stated "well they kept making me wait." Reminded res to not do that in future...." Professional Progress Notes dated 06/07/11 noted " IPSN team review of safety concerns made by staff. Resident continues to turn off her alarms and transfer without the assistance of staff. She is very impatient and will yell at the staff. She likes to enter her room and fidget around with personal belongings. Resident is not allowed to be in her room in w/c unsupervised d/t past falls ... Resident ' s need for one on one attention is something this facility cannot offer ... " n. Professional Progress Notes dated 6/13/11 noted " IPSN team review of an unwitnessed fall that occurred on 6/11 ~ 0445. Staff responded to resident ' s alarms as they sounded and then stopped. Concerned, staff entered resident ' s room to find resident lying beside her mat on her back groaning. Resident was noted to be rubbing her left hip ... Staff assisted resident to the commode where she had a medium sized BM. Hmong speak(ing) CNA came and translated for staff. Resident reported she was having great pain in her left hip ... On call MD notified and ordered to transfer to ER. ... Res was DX (diagnosed ) with a left hip FX (fracture) ... Team feels that this will be a " wake up call " for resident as she was seriously injured this fall .... This is the seventh fall when staff was not able to respond quickly enough to the resident ' s sounding alarm and the sixth fall when the resident was trying to toilet herself. Resident #1 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 6/22/11, Surveyor requested and received from Assistant DON a copy of the current care plan and CNA care plan for Resident #1. The current care plan continues to be the care plan initiated 7/5/10 with the addition of Resident #1's Safety Care Plan which is not dated and notes the following; 1/2 SR (side rail x (times) 2), W/C (wheelchair) with cushion, W/C tab alarm, 1 bed beam alarm, Pressure alarm to bed, Auto lock brakes to w/c, Demonstrate & remind how to use call light with each interaction, 30 minute checks when in building-all shifts, W/C pressure alarm, Lipped mattress, Low bed, 1 mattress to floor on exit side, gripper socks @ h.s. (hour of sleep), NOT to be left alone in room when up in w/c, Beam alarm to entrance of room door to alert staff to resident entering room alone, May use regular w/c for dialysis, Only exiting side of bed beam alarm needs to be parallel to floor, Wall beam alarm, Mattress is to be Velcroed to the floor to prevent resident from kicking it out of the way, and use alternative w/c for dialysis so drivers can get her in and out of van appropriately. The most current CNA Care Plan known as the ADL Flowsheet dated 6/1/11 - 6/30/11 directs staff to transfer the resident with an EZ Stand and assist of 2 but does not address how often the resident will be toileted. The CNA Care Plan notes the following; BOWEL: Continent BLADDER: Usually continent - urgency FREQUENCY: Voids small amts D/T (due to) renal dialysis, will alert staff. On 6/20/11 Surveyor observed Resident #1 remain seated in her wheelchair without benefit of toileting from 1:28 p.m. through 5:53 p.m. On 6/23/11 at 8:46 - 9:31 a.m., Surveyor interviewed the DON regarding Resident #1's frequency of falls related to the need to use the toilet. The DON referred Surveyor to speak with SW C. On 6/23/11 at 9:39 a.m., Surveyor interviewed SW C regarding Resident #1's frequency of falls and ineffectiveness of alarms as well as 7/13 falls were related to Resident #1 needing to use the toilet / commode. SW C reported that there have been occasions where the staffs have gotten to the resident before she has fallen. Surveyor # asked SW C if the facility had ever considered putting Resident #1 on one-one supervision. SW C stated "We don't offer one to one supervision." Surveyor # showed Staff C that the care plan notes "Provide toileting assistance as indicated in the CNA care plan" but Surveyor unable to determine how often staff are to toilet resident. Staff C stated that Resident #1 is toileted every 2 hours. Surveyor asked SW C to show surveyor where the frequency of toileting is addressed in the CNA Care Plan. Staff C reviewed the June 2011 CNA Care Plan which did not direct staff to toilet resident every 2 hours. Surveyor informed Staff C that based on Surveyor observations on 6/20/11; Resident #1 was not toileted every 2 hours. On 6/24/11 at 10:15 a.m., at the request of the facility, Surveyors and met with Staff T-Social Worker for Western Wisconsin Care. SW T reported she speaks Hmong and usually visits Resident #1 on a weekly basis. SW T reported that Resident #1 told SW T that her biggest concerns are constant pain and her inability to get the help she needs because staff can't understand her and she can't get help when she wants to go back to bed after sitting up in her wheelchair for a long time or when she has been lying down for a long time. SW T reported Resident #1 used to be a very clean person before she came to the nursing home. SW T reported that Resident #1 has had occasional loose stools and doesn't want to be incontinent and staffs don ' t respond when needed which is quite upsetting to Resident #1. SW T further reported that Resident #1 uses gestures to communicate with staff but staff do not understand her. Nursing failed to assess Resident #1 ' s individual toileting needs as a means to prevent independent ambulation, despite at least five falls that occurred while the resident was trying to toilet herself. Additionally, nursing continued relying on alarms as a means of supervision, despite the facts that the resident would remove them or that staff were not always able to respond quickly enough to a sounding alarm. A federal hearing decision (Bethel Center vs. CMS, 9/18/06) has noted that, " ...the alarm is useless as an assistance device if the staff member is too far from the resident when the alarm sounds to come to the resident ' s assistance and prevent the resident from falling. Consequently, in every case where an alarm is used as an assistance device, facility staff must be no more than, at most, a few seconds and just paces away from the resident in order for the resident to be protected adequately. " The failure to meet the supervision needs of Resident #1 created a finding of immediate jeopardy. The facility removed the immediate jeopardy on 6/29/11 by which time the facility had implemented the following; *On 6/27/11 the facility instituted a 3 day voiding diary to evaluate Resident #1's voiding frequency and pattern.Upon completion of the voiding diary, a care plan will be developed. *Facility assigned bilingual LPN to care for Resident #1. *The facility obtained interpreter services that became effective on 6/30/11 from Certified Languages International. *Social Worker is updating Communication Board to be more specific such as washing with hand sanitizer, brushing teeth, wanting kleenex, as well as toileting. *O.T. and Resident #1 went over Resident #1's room arrangement and how to make it efficient for her. *Fifteen minute checks for Resident #1 instituted. *Added additional staff on 100 hallway by asking existing staff to work extra shifts. *DON monitoring call lights and alarm response times. *Interviews scheduled for hiring additional staff began 6/24/11 *Began inservicing licensed staff as to what information needs to be collected on falls / accidents to include environment and need to get to root cause of the fall/accident. 40% of licensed staff were inserviced 6/29/11 and all licensed staff will be inserviced before they start work. *In process of negotiating consultant services with SMS consulting service. Scope/severity continues at an E level (potential for harm that is not immediate jeopardy/pattern) as evidenced by the following examples. 2) Resident #20 - On 6/22/11 at 8:28 a.m., Surveyor observed CNA W and CNA FF transfer Resident #20 from the wheelchair to the toilet using an EZ-Stand lift. As soon as the transfer was completed CNA FF left the room. At 8:37 a.m., Surveyor observed Assistant Director of Nursing (ADON) A enter Resident #4's room and close the door while CNA Y was assisting the resident with her meal. Shortly thereafter, CNAY left the room and told Surveyor that she had to go get CNA FF to help transfer Resident #20 off the toilet. At 8:39 a.m., CNA Y and CNA FF entered Resident #20's room where Resident #20 was sitting unattended on the toilet. On 6/23/11, Surveyor reviewed Resident #20's record that included a Fall Risk assessment dated [DATE] that noted a score of 26. The form notes "A score of 10 or above indicates at risk for falls." The most current quartely MDS assessment with an Assessment Reference Date of 5/13/11 notes that Resident #20 has moderate cognitive impairment based on a BIMS Summary Score of 9, requires two person assist with bed mobility, transfers, toilet use and his balance is not steady and is only able to stabilize his balance with assistance when moving on and off the toilet. The Care Plan dated 9/15/10 notes "Res is limited in ability to maintain grooming/hygiene/dressing/mobility - provide staff assistance as indicated in CNA care plan for ADLs - monitor for and report any safety concerns. The CNA care card titled ADL Flowsheet dated 6/1/2011-6/30/2011 notes; TRANSFERS: EZ Stand @ all times. Has prosthetic right leg-below the knee amputation. TOILETING: EZ Stand. The CNA care card does not direct staff to remain with or near Resident #20 while he is on the toilet. On 6/29/11 at 9:30 a.m., Surveyor spoke with DON and ADON A via conference call and shared surveyor's concerns about staff leaving Resident #20 unattended on the toilet and requested any information that would indicate that it was acceptable for the resident to sit unattended on the toilet. On 6/30/11 at 12:57 p.m., Surveyor received the following information from Assistant DON A via FAX; "He does not have a WC (wheelchair) safety device (alarm). Residents without alarms are allowed to be on the toilet unassisted. He appears to have adequate upper body strength to keep him upright although we do recognize that he tends to lean. I talked with our Occupational Therapist (OT ZZ) because they are working with him currently. As of March he was able to sit on the mat for 40 minutes unassisted. OT will recheck sitting balance in near future. Will install toilet bars on his toilet to improve stability. He has not had a fall from the WC or toilet recently..." 3) Resident #39 - On 6/21/11 at 7:43 a.m., Surveyor observed Resident #39 seated in a wheelchair in the dining room near Table #3. Resident #39's feet did not touch the floor and her feet were dangling. The wheelchair was not positioned close to the table and Resident #39 was leaning forward and trying to reach the table. A clip alarm was attached to the back of Resident #39's clothing and was not sounding even though Resident #39 was leaning forward in her wheelchair. Surveyor alerted Social Worker C who was walking through the dining room as it looked like Resident #39 would fall forward out of her wheelchair. The facility did not provide a safe environment for Resident #39. On 6/29/11 at 9:30 a.m., Surveyor spoke with DON and Assistant DON A via conference call and shared surveyor's concerns about surveyor observation on 6/21/11 and appropriateness of wheelchair. Surveyor requested facility provide any information about Resident #39's wheelchair. On 6/30/11 at 10:18 a.m., Surveyor received a document with information about Resident #39 via FAX from Assistant DON A. The document noted "When Resident #39 is in her WC (wheelchair) she is not to have any foot pedals because she has sustained injuries to her legs. She has RLS (Restless Leg Syndrome) and receives Pramipexole for this condition. When she is in the wheelchair she has almost continuous movemenr (swinging) of her feet. She does have a tab alarm on the WC and she hasn't had any fall from the WC over the past year. She doesn't attempt to self transfer from the WC. She transfers with a mechanical lift. On 1/23/10, her feet were able to touch the floor in the WC she had at the time (see nurses notes). I am unable to locate docuentation that the WC was changed for any certain purpose since now she is in a regular height WC and feet aren't touching the floor. This morning we did place her in a low WC and feet are touching the floor. She is comfortable and feet appeared stationary. Will observe how she does in this low WC and continue with this if tolerated." 4) Resident #18 had resided at the facility for several years. [DIAGNOSES REDACTED].

Based on observations, interviews and record reviews, the facility did not provide the necessary care and services for 2 of 17 (#1, #9) sample residents to attain or maintain their highest practicable physical, mental and psychosocial well-being. Resident #1 - The facility did not provide Resident #1 with effective pain management services consistent with current standards of practice. Resident #1's 12/10/10 quarterly MDS and 3/11/11 quarterly MDS identified the presence of constant daily pain at an intensity of 10 on a 0-10 scale that made it hard for Resident #1 to sleep at night and limited her day-to-day activities. The facility did not further assess her pain beyond the information on the MDSs and did not develop a care plan to address her pain. Facility staff characterized her restlessness and [MEDICAL CONDITION] as being behavioral issues rather than pain issues. On 6/11/11, Resident #1 fell at the facility and was hospitalized with a [MEDICAL CONDITION]. Resident #1 re-entered the facility on 6/15/11 after surgical repair of her left hip. The facility did not assess Resident #1 for pain on readmission and did not develop a care plan that addressed Resident #1's pain until 6/22/11. The care plan did not address Resident #1's language barrier and how facility staffs were to assess her pain as she does not speak English. The resident's medication regime included the use of as needed pain medication. Facility staff consistently documented that Resident #1 experienced severe reocurring pain with movement however no changes in the plan of care were implemented to include but not limited to scheduling the pain medication to prevent pain from reoccurring. Resident #9 - When admitted to the facility after a fracture of her pelvis, facility staff did not appropriately assess Resident #9's pain according to standards of practice. Resident #9 then demonstrated behaviors with cares and transfers (movement) and her behaviors were not appropriately assessed. Due to her behaviors, the facility then discharged Resident #9 to another facility without all available/appropriate interventions tried prior to her discharge. This is evidenced by: 1) Resident #1 - Surveyor reviewed this resident's record from 6/20-6/24/11. Resident is a [AGE] year-old Hmong resident who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's most current comprehensive assessment with an assessment reference date of 07/01/10 notes that Resident #1 experiences moderate pain on a daily basis. The pain sites are noted as headache, joint pain other than hip and other. The MDS triggered 12 Resident Assessment Protocols to include but not limited to Cognitive Loss/Dementia and Vision. The Cognitive Loss/Dementia Resident Assessment Protocol (RAP) Summary documentation noted that Resident #1 is primarily Hmong speaking and communication could be a contributing factor in making decisions. She is alert and oriented and has poor vision. The Visual Function RAP Summary documentation notes that Resident #1 does not read and cannot read English or Hmong. The Communication RAP Summary documentation notes that Resident #1 is able to communicate in Hmong but does not speak English. A review of the document titled Patient Problem List with an onset date of 6/25/10 does not identify pain as a problem. Resident #1's quarterly MDS with an assessment reference date of 12/10/10 notes that Resident #1 experiences pain recorded at an intensity of 10 almost constantly and the pain makes it hard to sleep at night and limits her daily activities. The MDS notes that Resident #1 receives prn pain medications and no scheduled pain medication. Resident #1's quarterly MDS with an assessment reference date of 3/11/11 notes that Resident #1 experiences pain recorded at an intensity of 10 almost constantly and the pain makes it hard to sleep at night and limits her daily activities. The MDS notes that Resident #1 receives both scheduled and prn pain medication. On 6/21/11, Surveyor was unable to find a comprehensive assessment of Resident #1's pain as well as a care plan with interventions that addressed Resident #1's pain.. Patient Progress Notes noted the following: 3/13/11 at 2110 - "Knee Pain - Residents family visiting. Family was asked if resident was having pain. She does c/o (complain of) knee pain. [MEDICATION NAME] given with good results. No yelling this shift..." 3/15/11 at 0140 - " NOC Charting -Res(ident) is I (independent) for repositioning in bed and assist of 1 for transfers. She is continent of B&B (bowel and bladder) with use of commode. Frequent unsafe actions with several attempts to self transfer each NOC (night) with very restless behavior. Will continue to monitor." 3/18/11 at 0430 - "Behavior - Res was up to commode and to eat x 5 during the NOC. She turned off her beam alarm and pressure alarm each time she needed to toilet. PRN [MEDICATION NAME] 5/500 ii given at 0130 with no eff(ect) for comfort. Will continue to monitor." 3/19/11 at 0705 - "Behaviors - Client awake most of noc. Up to commode x's (times) 10. Continually setting off alarms, turning them off & self transferring or attempting to self transfer. Increased [MEDICAL CONDITION] & behaviors noted. Will continue to monitor." 3/20/11 at 0445 - "Behaviors - Client up to commode x's 13 this shift. Self transferred or attempted to each time. Commode placed in BR (bathroom) much to residents dismay, became behavioral, screaming & kicking @ staff. Commode moved to prevent resident from self transfers. Slept very little, continually setting off alarms. Increased behaviors & [MEDICAL CONDITION] cont." Physician Clinic Notes dated 3/29/11 noted "...Nurses have also noticed that Resident #1 seems to be anxious and has noted difficulty with [MEDICAL CONDITION]. When asked about these symptoms she acknowledges being irritable and feels a lot of this is due to loss of freedoms and the constraints of living in a nursing home. Feels like difficulty sleeping is related to the pain in her left lower extremity. She is willing to take a medication for these symptoms." The physician progress notes [REDACTED]. Left lower extremity neuropathic pain. I will add [MEDICATION NAME] 100 at bedtime in addition to her 100 milligrams in the morning. She also has [MEDICATION NAME] scheduled in the evening." It should be noted that up until the time that Resident #1 was seen by her physician on 3/29/11, facility staff characterized her restlessness and [MEDICAL CONDITION] as being related to behavioral issues despite the fact that the 3/11/11 quarterly MDS noted Resident #1 to experience severe pain almost constantly that interrupted her ability to sleep and limited her activities. Patient Progress Notes dated 6/11/11 at 0445 noted that Resident #1 fell landing on her left hip and complained of significant pain. Resident #1 was transported via ambulance to the hospital. Subsequent Patient Progress Notes indicated that Resident #1 was admitted to the hospital for a [MEDICAL CONDITION] and would have surgery. On 6/15/11 at 12:20 p.m., Registered Nurse (RN) CC who does not speak Hmong completed the document titled Nurse's Admission Assessment and noted a [DIAGNOSES REDACTED]. The pain intensity via resident self-report, quality and duration of the pain as well as what makes the pain better and what makes it worse was not indicated. Many areas on this form that require a response from the resident are blank to include but not limited to; Headache, Ear aches, Soar throat, Chest pain, Dysuria Abdominal pain, Nausea, Muscle pain, Back pain, Stiffness, and Neck pain. A Care Plan for pain was not developed until 6/22/11. The care plan problem is identified as Alteration in Comfort: Pain with a goal of Pain needs will be met. Resident will be maintained at optimal pain relief level. Approaches are noted as follows; Assess for characteristics of pain: location, severity on a scale of 1-10, type, frequency, precipitating factors, relief factors. Offer comfort measures such as: distraction, back rubs, readjusting position, heat, or cold. Administer pain meds as ordered. Assess for nonverbal signs of pain Contact physician as needed for pain concerns The care plan does not address Resident #1's language barrier and how facility staffs are to assess Resident #1's pain characteristics when Resident #1 does not speak or read English. The care plan goal is not specific and does not identify Resident #1's individual comfort goal. Resident #1's Medication Flowsheet dated 6/1/11-6/30/11 identified the following medications for pain that were restarted on 6/15/11; [MEDICATION NAME] ([MEDICATION NAME]) Medicated Adhesive Patch (700mg/patch) once a day, [MEDICATION NAME] 100 mg twice a day and [MEDICATION NAME]-[MEDICATION NAME] 5-500mg ([MEDICATION NAME])1 tablet every 4 hours prn (as needed) for pain Patient Progress Notes dated 6/15/11 at 1430 noted "Returned from hospital by Mulder Van ~ 12:20. Alert. Ate lunch after arrival. No family present. Interpreter spoke with her reminding her to ask for assist when she wants to get out of w/c (wheelchair) or bed. Informed interpreter that she has left hip pain ([MEDICATION NAME] given)..." The pain intensity via resident self-report was not noted. The document titled PRN Medication Notes noted that Resident #1 received [MEDICATION NAME] 1 tablet at 1400 for left hip pain. The pain intensity via resident self report was not noted. According to numerous standards of practice to include the American Geriatrics Society, American Medical Directors Association, and the American Pain Society, the resident's self-report is considered the gold standard of pain assessment. Patient Progress Notes dated 6/15/11 at 2400 noted that Resident #1 complained of pain in her left leg with movement and was medicated with [MEDICATION NAME] 1 tablet with "relief & sleep." According to the PRN Medication Notes, Resident was medicated on 6/15/11 for left leg pain at an intensity level of 10 at 1800 and result was noted as "slept 3." Resident #1 was not remedicated for left leg pain until 0100 (7 hours later) and the pain intensity level via self report was not noted before and after the medication was given. Even though Resident #1 had recent surgery to repair her hip and experienced pain with movement, facility staff did not identify the need to routinely administer her pain medication to prevent her from experiencing severe reoccurring pain. Patient Progress Notes dated 6/16/11 at 0500 noted "... She used the bed pan with no success and requested to use the commode. She was transferred with assist of ii (2) and EZ stand. She yelled out in pain during the transfer. PRN [MEDICATION NAME] given at that time with good relief." The PRN Medication Notes indicated that she was medicated with [MEDICATION NAME] at 0600 (which is 5 hours from previous pain medication) for "yelling in pain" and the result of the medication was listed as "eff(ective)." Patient Progress Notes dated 6/17/11 at 0445 noted "Slept at intervals. Assisted up to the commode with use of EZ stand and 2 assist. Yelled loudly during transfer up to commode. Yelling & talking loudly @ 0315, [MEDICATION NAME] given for pain...Repositioned...Appears to be resting comfortable at this time." The PRN Medication record documented that Resident #1 received [MEDICATION NAME] @ 0315 for "leg pain (8-9?) yelling" and result was recorded as "eff(ective).". Resident #1's last dose of pain medication was recorded as given on 6/16/11 at 1740 for leg pain at a "6" with no recording of its effect. The PRN Medication record noted that Resident #1 received [MEDICATION NAME] on 6/17/11 at 0735 for leg pain 8/10 and "eff." Patient Progress Notes dated 6/18/11 at 2330 noted "Leg Pain O: C/o leg pain - [MEDICATION NAME] given x (time) 2 with some relief. Using EZ-stand for transfers." The PRN Medication record noted that Resident #1 received [MEDICATION NAME] at 1545 for leg pain at a 6-7 and the result was noted as "1800 - resting quietly 3." Patient Progress Notes dated 6/19/11 at 2140 noted "O: Extensive assist of 2-3 staff are used for repositioning & boosting in bed. C/o leg pain with any type of movement. E-Z stand was used for transfers to [MEDICATION NAME] given x 1 for her leg pain...Tries very hard to explain her wants & needs. Some English used..." The PRN Medication record noted that resident was medicated with [MEDICATION NAME] at 2045 for leg pain of 6-7 with no resident self-report of effectiveness noted. The PRN Medication record noted that she received her previous dose of pain medication on 6/19/11 at 0745. Patient Progress Notes dated 6/20/11 at 0450 noted "Assisted up to commode x's (times) 3. 0400 T 99. Yelling out in pain upon movement, [MEDICATION NAME] given @ that time. Ez stand used for transfers. Sleeps comfortably when lying still in bed. Will cont(inue) with poc (plan of care). The PRN Medication record noted that she received her previous dose of pain medication on 6/19/11 at 2045. On 6/20/11 at 11:01 a.m., Surveyor observed CNA H and CNA I in Resident #1's room as they had just transferred Resident #1 back into her wheelchair. CNA H reported that resident recently fell and broke her hip and "she's in a lot of pain" with cares. According to the PRN Medication record, Resident #1 was last medicated for leg pain at 0400. On 6/20/11 from 2:25 p.m.- 2:37 p.m., Surveyor observed Resident #1 seated in her wheelchair in the Therapy Department. Physical Therapy Aide (PTA) HH asked resident to stand and stated "I know it hurts just try." Resident brought to a standing position with a wheeled walker and Resident #1 stated "hurt" and PTA HH responded "do you want to sit?" Staff HH began asking and gesturing for Resident #1 to scoot her butt back and stated "you OK." Shortly thereafter PTA HH asked Resident #1 "Can we try one more stand" as PTA HH brought the resident to a standing position and Resident #1 stated "My leg hurt." PTA HH told Surveyor that Resident #1's hip has been bothering her and she had a pain pill before coming to therapy. At no time did Surveyor observe PTA HH use communication tools to communicate with Resident #1 in her own language to provide instructions to her and to determine her pain intensity level during therapy. Surveyor reviewed the document titled PRN Medication Notes that documented Resident #1 received [MEDICATION NAME] 5/500 1 tab at 1200 noon. The reason for giving the pain medication was noted as "Pre PT Session." There was no documentation of a pain intensity level via resident self-report before and after the medication was given. On 6/20/11 at 5:53 p.m., Surveyor spoke with CNA M who reported that Resident #1 likes to go to bed after supper. CNA M reported she tried using the Communication Board with Resident #1 but it doesn't really work. At 5:56 p.m., Surveyor and Surveyor observed CNA M and CNA N wheel resident into her room where they transferred Resident #1 using an EZ-Stand Lift from her wheelchair to the toilet. Resident #1 appeared to be trying to tell CNA M and CNA N something about her incontinent brief but both staff members reported they were unable to understand what Resident #1 was trying to say. CNA M and CNA N transferred Resident #1 off of the toilet and onto the side of her bed but did not pull up her incontinent brief prior to lowering her to the bed. The aides were trying to have resident stand up so they could pull up her incontinent brief but Resident #1 started screaming and the aides put her back down. Both aides attempted to lie resident down with one aide trying to lift her legs but again resident started screaming. At approximately 6:14 p.m, CNA M left the room with the lift and walked down the hall. CNA M returned to the room shortly thereafter stating she went to ask the nurse if Resident #1 could have something for pain but was told resident already had something. CNA M and CNA N again tried to lie resident down and she started screaming. CNA M and CNA N remained standing at the resident's bedside. At approximately 6:18 p.m., both surveyors left the room and as soon as the door was closed resident was heard screaming. At 6:20 p.m, CNA M exited the room and stated "She is very hard headed, she wants it her way in her order and then we can't understand what she wants." The PRN Medication record noted that Resident #1 received [MEDICATION NAME] at 5:30 p.m. on 6/20/11. On 6/21/11 at 8:30 a.m., Surveyor observed CNA G and CNA O transfer Resident #1 out of her wheelchair onto the toilet and then back into the wheelchair. Resident grimaced during the transfers and stated "my leg hurt" when CNA G elevated her left leg to place a pillow under her left calf. At approx 8:45 a.m., CNA G wheeled Resident #1 out of her room into the hall and parked her wheelchair outside her room. At no time during this observation did Surveyor observe CNA G or CNA O use communication tools to try to determine Resident #1's pain intensity level. At 8:45 a.m, Surveyor approached Licensed Practical Nurse (LPN) Q who speaks Hmong and asked her when Resident #1 was last medicated for pain. LPN Q told Surveyor that Resident #1's pain ranges 8-9 and she was medicated with [MEDICATION NAME] 1 tab at 5 AM. Surveyor had LPN Q introduce Surveyor to resident and then ask Resident her current pain intensity level. Resident responded a "10" but she planned to take her next pill before [MEDICAL TREATMENT] which was later in the morning. Surveyor had LPN Q ask resident why she is waiting to take her next pain pill if her pain is a "10." LPN Q reported that Resident has changed her mind and will take her pain pill now. Surveyor noted that LPN Q recorded the following in the Patient Progress Notes dated 6/21/11 at 1530; "When asked @ start of shift regarding res pain, res reported "I have pain but I can wait for the pain pills." Res last received pain meds @ 0500. After breakfast when asked again, res reported "I have more pain now to my hip "pointing to L hip area." Rated pain @ "10" on 1-10 scale. Offered [MEDICATION NAME] @ that time, res accepted PRN [MEDICATION NAME] was eff for PT session. Left for [MEDICAL TREATMENT]. Will cont to monitor." On 06/22/11 at 12:40 p.m., Surveyor observed CNA Y and another unidentified CNA transfer Resident #1 from her wheelchair into bed using a sit to stand lift. Resident #1 called out when the staff lifted her legs onto the bed. According to the PRN Medication Notes, Resident #1 received [MEDICATION NAME] 1 tablet on 6/22/11 at 7:30 a.m. for pain - "It hurts" pointing to left hip. There was no documentation of a pain intensity level via resident self-report before and after the medication was given to determine if the medication is reducing Resident #1's pain to a level acceptable to the resident. On 6/24/11 at 10:15 a.m., at the request of the facility, Surveyors and met with Social Worker (SW) T from Western Wisconsin Care. SW T reported she speaks Hmong and usually visits Resident #1 on a weekly basis and also attends care conferences. SW T reported that Resident #1 told SW T that her biggest concerns are constant pain and her inability to get the help she needs because staff can't understand her and she can't get help when she wants to go back to bed after sitting up in her wheelchair for a long time or when she has been lying down for a long time. SW T reported that she has asked facility staff to put Resident #1 on scheduled pain medications due to her constant pain. SW T further reported that Resident #1 uses gestures to communicate with staff but staff are not understanding her. On 6/24/11, Surveyor reviewed the facility's undated pain management policy on. It reads in its entirity, "We will identify any resident that is having pain by white "dotting" and "red coding" so that such is documented on each shift and by the Teamleaders leaving the Charge Nurse (s) a note regarding new pain problems. The Charge Nurse will assess all monthly QA's for pain done by the Teamleaders on each resident, will assess all temporary problems for pain and the MDS for pain indication." On 6/24/11 at 1:55 p.m., Surveyor spoke with Physical Therapist GG who reported that Resident #1 attends physical therapy five times a week after breakfast and before she goes to [MEDICAL TREATMENT] and attends occupational therapy three times a week on her non-[MEDICAL TREATMENT] right before or after lunch. On 6/29/11 at 9:30 a.m., Surveyor shared concerns regarding pain assessment and scheduling of medications with the DON and Assitant DON (ADON) A and requested any information facility may have regarding Resident #1's pain management. On 7/19/11 at 8:25 a.m., Surveyor spoke with the DON by phone and told DON Surveyor wanted to make sure facility provided any information facility may have regarding Resident #1's pain management. At 10:07 a.m., Surveyor received a fax that contained a copy of Resident #1's Alteration in Comfort care plan that had been annotated by ADON A on 7/1 and 7/2/11 and a copy of Physician Clinic Notes dated 3/29/11. The care plan annotations included; use pain card to ease communication, administer routine and PRN pain meds as ordered, monitor for effectiveness of pain meds & overall level of discomfort, keep MD informed of pain level / pain management & suggest changes as needed. (Cross reference F500) 2. Resident #9 - Surveyor reviewed the medical record of Resident #9 from 6/21-6/24/11. Resident #9 is an [AGE] year old admitted to the facility in 5/2011 after hospitalization for a fall that resulted in a pelvic fracture. Resident #9 also is diagnosed with [REDACTED]. Other [DIAGNOSES REDACTED]. Resident #9's Minimum Data Set (MDS) with a reference date of 6/1/11 shows that the facility coded Resident #9's cognition as a 3, meaning they were aware of her severe impairment in cognitive abilities. Resident #9's MDS with a reference date of 6/1/11 showed that behaviors triggered. The Behavior Care Area Assessment summary reads, "CAA triggers due to resident rejecting care 1-3 days in the past 7 days and presence of at least one behavioral symptom is indicated. Resident is combative and yells out almost daily when staff attempts cares, transferring or repositioning resident. Resident strikes out at staff in which she attempts to hit, scratch or push staff members. This behavior has been notably worse or occurs more often at night. Resident has alzheimer's and dementia which she is prescribed [MEDICATION NAME] for. Resident is A (alert): O (oriented) X (times) 1-2 and experiences confusion. Resident is in pain d/t (due to) a fx (fracture) and complains of pain when being transferred. Will proceed to care planning..." Review of Appendix C : CAA Resources states at C-3, Step 2, "For any triggered care area(s) conduct a thorough assessment of the resident using the care-area specific resources." Review of the specific resources for the care area of behaviors shows a number of areas, specific to Resident #9, that should have been considered and used in the CAA summary as part of a comprehensive assessment. Examples would include: effects of [MEDICAL CONDITION](stroke), a new admission, [DIAGNOSES REDACTED]. The 6/1/11 MDS shows at J0100, that Resident #9 received PRN (as needed) pain medication during the assessment period, and that she received non-medication interventions for pain during the assessment period, as well. Review of the pre-admission nursing note dated 5/25/11 reads, "Has pain issues R/T (related to) fx (fractured) pelvis." Review of Resident #9's admit note shows that Resident #9 arrived at 12:30 p.m. The note reads,"Can be combative, striking out & (and) yelling when transferred, repositioning, or when cares are done... [MEDICATION NAME] given for pain at 2130 (9:30 p.m.) for pain Resident #9 rated a 8 out of a possible 10. The PRN (as needed) Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The pain was described as hip pain, headache pain and back pain. Pain was rated from 5 to 9 on a scale of 1-10 during these times. The PRN (as needed) Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Pain was described as hip and back pain. resident #9 rated the pain from 4 to 9 on a scale of 1-10. A 6/11/11 note entitled, "Pain Management QA for May 2011" which reads, "Resident rec'd (received (no) scheduled meds 7 rec'd prn [MEDICATION NAME] 5/500 1 x 7, 7 Tylenol 650 mg. x 1. These have been effective. Cont. (continue) POC (plan of care.)" The 6/1/11 MDS did not trigger the care area assessment for pain , but the MDS did identify risk factors, diagnoses, and behaviors that should have prompted the facility to further evaluate Resident #9 for pain. Resident #9 had a fracture and behaviors-both verbal, physical, and others associated with Activities of Daily Living (ADL's). The 6/1/11 MDS triggered the behavior care area assessment due to Resident #9's behaviors associated with being transferred or having cares done, and also said that Resident #9's behaviors had a pattern- they were worse at night. This should have prompted the facility to determine a root cause for the behaviors. Section 4.6 of the RAI Manual notes "Therefore, facilities are responsible for assessing and addressing all care issues that are relevant to individual residents, regardless of whether or not they are covered by the RAI." Section 4.6 also notes, "the process of completing the MDS and related portions of the RAI does not constitute the entire assessment that may be needed to address issues and mange the care of individual residents. " Review of Resident #9's full Care Plan shows no pain management problem. Under behavior, as of 6/13/11, an approach is written as "When resident begins to become combative/disruptive, provide comfort measures for basic needs (e.g., pain, hunger, toileting, too hot/cold etc.) Under "Resident is a threat to self and/or others, the above approach is again written as of 6/20/11. There is nothing to prevent Resident #9's pain. On 6/22/11, Surveyor reviewed Resident #9's Certified Nursing Assistant (CNA) Care Plan last generated on 5/25/11. There is nothing on the CNA Care Plan about pain. The plan does read, "Can be combative, striking out and yelling when transferred, repositioned, or staff performs cares." Review of Resident #9's "Patient Problem List" shows no problem of pain management. On 6/29/11 at approximately 9:30 a.m., Surveyor spoke with the DON and ADON A via conference call and shared concerns about the facility's process for identifying pain issues. The DON and ADON A indicated they would review information provided and get back to Surveyor . Information from the DON on 6/30/11 stated that "Nursing judgement is used in determining when pain meds should be scheduled. It is suggested to the practitioner when it is evident that a resident has a pattern of pain med need at a certain time or when it is assessed that it would be beneficial for any logical reason." The DON also shared that PT (physical therapy)documented that "Pain was primarily expressed when she was standing and with activity involving pelvic area" (Note: a certain time and a logical reason.) Review of physical therapy notes by Surveyor showed: The PT note of 6/2/11 read, "c/o (complaint of) pain c (with) movt (movement) (R) (right) hip & (and ) standing." The PT note of 6/16/11 read, "c/o pain c activity,..." Review of the behavior monitoring sheets by Surveyor showed: 5/27/11: "Went to change product wouldn't roll, when changing punches aides and scratched them. Also screamed at the top of her lungs when changing." 5/28/11: "While putting to bed rolling resident to get product under her, she scratched and hit with her fist." 5/29/11: "Changed (Resident #9's name) product very combative. hit me with fists and dug nails in my arm." 5/30/11: "Tried to change product, got her half done, had to leave because she was hitting when we tried to roll her." 5/31/11: "Couldn't change her product...she was hitting and punching." 6/1/11: "She indicated pain and would not let us do a full change of product..." 6/1/11 at 0400: "we changed her but was angry and tried swinging at us but we were able to slide the product under her..." 6/3/11: "While changing product she punched aides." 6/4/11: "Resident punching and screaming while changing wet product." 6/5/11: "Combative during cares." 6/8/11: "Combative during cares." 6/10/11: "Combative during cares hitting and kicking." Review of nursing notes also showed Resident #9's pain:with movement and subsequent behaviors: 5/26/11: "Resident yells out c (with) cares when changing her product... yelling out during cares. hitting & (and) kicking when turning on side to give good bathing of buttocks..." 5/27/11: "Has (R) (right) pubic bone rami fx (fracture) & (and) has PRN pain meds available, [MEDICATION NAME] be agitated, loud, or combative c cares/transfers..." 5/27/11 at 1:15 p.m. "EZ stand transfer when (went) ok, but then pt (patient) became upset...2 in BR (bathroom) as pt hitting a little." 5/28/11: "...accepted pain med @ (at ) hs (bedtime). Warm pack applied to back area she stated hurt & was helpful....became combative during cares." 5/29/11: "Can have c/o (R) hip, 7 takes prn pain meds" 5/29/11 at 2:10 p.m.: "Res (resident) received bath thisam. Received PRN [MEDICATION NAME] tab for c/o hip pain "oh my hips". Min (minimal eff (effect) warm pack/compress to (R) hip area c eff (effect). Worked c (with) PT (physical therapy) this a.m. PT reported res tol (tolerated) well c [MEDICATION NAME] prior. Tyl (Tylenol) 650 mg. given this p (after) noon for c/o (complaint of) HA (headache)...no combative behaviors..." 5/30/11 "Combative c staff while giving cares." 5/30/11 at 11 a.m. "X (times) 1 pain med, very pleasant with cares, transfers..." 5/30/11 at 9:45 p.m. "[MEDICATION NAME] x 1 effective for pelvic pain.." 5/31/11 at 9:45 p.m. "[MEDICATION NAME] given @ (at) suppertime & eff (effective) for c/o of back/pelvic pain...cooperative c (with) HS (bedtime) cares." 6/1/11"...CNA put blue sheet under her. Did start swinging c both hands..." 6/1/11 at 3:00 p.m. "[MEDICATION NAME] 5/500 mg 1 tab given for c/o of (R) hip pain. Eff...." 6/1/11 at 9:30 p.m. "No aggressive/combative [MEDICATION NAME] given prior to evening transfers with good effect." 6/2/11 "Yells out c changing product or repositioning." 6/3/11 "Yells out with repositioning." 6/12/11 "Combative during cares. Three staff required to change product. Attempts made by res to bite and hit staff." 6/12/11 (3-11 shift) "...combative at approx (approximately) 4:00 p.m. while being assisted with cares." 6/21/11 at 4:00 a.m. "Combative c staff while giving cares." 6/21/11 at 3:00 p.m. "unable to complete body check. Combative kicking and yelling 6/23/11 "She was combative during cares but was pleasant during all other interactions." Surveyor reviewed the facility's undated pain management policy on 6/24/11. It reads in its entirety, "We will identify any resident that is having pain by white "dotting" and "red coding" so that such is documented on each shift and by the Teamleaders leaving the Charge Nurse (s) a note regarding new pain problems. The Charge Nurse will assess all monthly QA's for pain done by the Teamleaders on each resident, will assess all temporary problems for pain and the MDS for pain indication." On 6/23/11 and 6/24/11, Surveyor requested any/all pain assessments the facility had on Resident #9 from her admission forward. None were given to Surveyor . Surveyor reviewed the facility's policy entitled, "Resident Behavior Record" dated 9/2006, on 6/21/11. The entire policy reads, "A resident behavior record is initiated for all residents at the time of admission. Behaviors to be documented are listed on the following page (534). (These are duplicates of the mood/behaviors found on the Minimum Data Set (MDS). Any staff member observing and intervening in behavior should record the date, time, behavi

Based on observation, interviews, record review and a review of the facility's policy and procedure related to pressure ulcers, the facility did not ensure 1 (#12) of 2 sample residents out of a total sample of 17 who entered the facility without pressure ulcers did not develop pressure ulcers. The facility did not ensure 4 (#4, #7, #11, #12) of 17 sampled residents and 1 (#22) supplemental resident received the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing. Resident #12, who has a [DIAGNOSES REDACTED]. The facility knew Resident #5 refused to wear her heel protectors while in bed but did not revise the plan of care until 6/28/11. Resident #11 was admitted with multiple open areas on both buttocks, some of which were identified on the admission assessment as stage 2 pressure ulcers. The resident was at risk for developing subsequent pressure ulcers in other areas due to specific disease processes. Resident #11's pressure ulcers/open areas healed and reopened numerous times sometimes causing the resident discomfort. Facility staff did not address risk factors for developing subsequent pressure ulcers; promptly implement a pressure relieving device in the bed and in the gerichair, an individualized repositioning schedule and more frequent toileting or incontinence care, all to prevent delayed or non-healing as well as deterioration and to prevent new pressure ulcers from developing; and, did not follow accepted standards of care related to repositioning as observed on 1 of 5 days of survey. Resident #7 was admitted with [DIAGNOSES REDACTED]. Facility staff did not follow the care plan for positioning. Resident #22 who is at risk for the development of pressure ulcers was transferred from his bed to a personal recliner (Lazy Boy type) that did not have a pressure redistribution seat cushion, was not turned and repositioned every 2 hours and his heels were not elevated. Resident #4 who has [DIAGNOSES REDACTED]. This is evidenced by: The NPUAP (National Pressure Ulcer Advisory Panel) - EPUAP (European Pressure Ulcer Advisory Panel) Clinical Practice Guideline for Pressure Ulcer Prevention, 2009, notes the following; Repositioning for the Prevention of Pressure Ulcers Repositioning the Seated Individual 4.3 Limit the time an individual spends seated in a chair without pressure relief. Support Surfaces 3. The use of support surfaces to prevent heel pressure ulcers. "...The reduction of pressure and shear at the heel is an important point of interest in clinical practice. Because the heel is covered with a small subcutaneous tissue volume, mechanical loads are transmitted directly angular to the bone. Given the small surface area of the heel, it is challenging to try to redistribute load from the heel through the use of pressure-redistributing devices." 3.1. Ensure the heels are free of the surface of the bed. Ideally, heels should be free of all pressure - a state sometimes called "floating heels." Support surfaces usually fail to increase the total contact area of the heel zone, which would spread the load and reduce pressure. To reduce the pressure at the heels to 0 mmHg, elevate the heels from the mattress by placing a pillow under the lower legs. Consequently, the heels will no longer be subjected to any pressure and the pressure will instead spread to the lower legs. 3.2. Heel-protection devices should elevate the heel completely (offload them) in such a way as to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon. The knee should be in slight flexion. 3.3. Use a pillow under the calves so that heels are elevated (i.e., "floating"). 4. Use of support surfaces to prevent pressure ulcer while seated. When a person is seated, his/her body weight is supported by a relatively small surface area (buttocks, thighs and feet), leading to high interface pressures combined with limited opportunities to redistribute body weight to other anatomical sites. Prolonged sitting results in a strong predisposition to pressure ulcer development. 4.1 Use a pressure-redistributing seat cushion for individuals sitting in a chair whose mobility is reduced and who are thus at risk of pressure ulcer development. 4.2 Limit the time an individual spends seated in a chair without pressure relief. 1. Resident #12 has [DIAGNOSES REDACTED]. Resident #12's most current comprehensive assessment dated [DATE] notes at MO150 that resident is at risk of developing pressure ulcers but currently has no pressure ulcers. The MDS notes the facility is using a pressure reducing device for the chair and bed as well as application of nonsurgical dressings and ointments/medications other than to feet. The MDS triggered the Pressure Ulcer Care Area. The Pressure Ulcer Care Area Assessment (CAA) documentation completed by the facility notes "No current or recent pressure ulcers. Has a current Risk for Skin Impairment care plan. Because of limited mobility and incontinence will continue current care plan." This documentation demonstrates the facility did not identify all pertinent risk factors to include [DIAGNOSES REDACTED]. (Cross reference F272) The most current quarterly MDS dated [DATE] notes at MO150 that the resident is at risk of developing pressure ulcers but currently has no pressure ulcers. Resident #12's care plan has the problem of Resident is at risk for skin breakdown R/T limited mobility, incontinence and HX (history) of breakdown with a start date of 2/9/10. Approaches do not include protection of resident's feet or elevation of resident's heels. The facility document titled Treatments Flowsheet dated 6/1/11-6/30/11 notes "Heel protectors while in bed." There are numerous instances noted that resident has refused. On 6/23/11 at 6:57 a.m., Surveyor observed Resident #12 lying in bed on her side and a pink heel protector was laying on the floor between the head of the bed and the night stand. On 6/23/11 at 9 a.m., Surveyor observed cares for Resident #12. Surveyor observed a pink heel protector lying on the floor during the entire observation that ended at 9:25 a.m. On 6/29/11 at 9:30 a.m., Surveyors , and spoke with the DON and Assistant DON via conference call. Surveyor shared concerns that pressure ulcer care area assessment documentation does not identify [DIAGNOSES REDACTED].#12 was not wearing her heel protectors. Surveyor asked facility to provide any information regarding these concerns. On 6/30/11 at 10:36 a.m., Surveyor received a FAX from Assistant DON with additional information. Assistant DON noted "Resident had an order from 6-01 stating to wear heel protectors in bed. The treatment book indicates she refused to wear them most of the time. Also see nurses' notes 6-22 and 6-29 regarding the refusals. When it was observed on 6-23 that the heel protector was on the floor, she had probably removed it. On 6-27, received order to use pillows instead of boots. She is being more compliant with this. Her right heel ulcer was reviewed on 6-29 (see note), a new care plan was made and Braden scale was done. Ischemic foot care protocol is in place since she has [MEDICAL CONDITION]. See the * entries on the ADL flow sheet and the treatment flow sheet. See attached 13 pages." Surveyor reviewed the Ischemic foot care protocol on the ADL Flowsheet with a start date of 6/29/11. Assistant DON sent a copy of a physician order [REDACTED]. heel protectors while in bed." Surveyor reviewed the following Patient Progress Notes; 6/22/11 with a time recorded as 3-11. "..Res (Resident) usually refuses heel protectors..." 06/29/11 with a time recorded as 1220 "Dressing changed. No drainage, no redness or warmth to periskin wound base 100% pink/red. Resident tolerated procedure well. Resident encouraged to float heel stated "I use the pillow." Resident does not care for foam boot... Assistant DON sent a copy of a physician order [REDACTED]. Paint right heel with [MEDICATION NAME] and allow to dry. The PROGRESS NOTES portion of the physician order [REDACTED]. Needs appointment with MD in Podiatry and MD in Vascular Surgery. 2. Resident #11 was admitted to the facility on [DATE] with diagnoses/ conditions that included impaired or decreased mobility, diabetes mellitus, cerebral vascular disease, [MEDICAL CONDITIONS] and pressure ulcers on the buttocks. Initial and ongoing treatments included creams, duoderm and [MEDICATION NAME] AG/[MEDICATION NAME]. Resident #11's significant change comprehensive assessment with a reference date of 05/27/11, identified moderate cognitive impairment; decline with activities of daily living (ADLs) including ambulation and eating; bowel and bladder incontinence; occasional moderate pain; and, 5 Stage II pressure ulcers, with history of resolved pressure ulcers (per the quarterly comprehensive assessment with a reference date of 02/25/11). Skin treatments included a pressure-relieving device for the chair and for the bed, a turning/repositioning program and ulcer care. No foot problems were identified. Resident #11's significant change Care Area Assessment Summary (CAAS), dated 05/27/11, stated the resident was no longer ambulatory and required extensive to total assistance with ADLs, was frequently incontinent of bowel and bladder, had a weight loss of 10% in the previous 6 months and refused all supplements and had ongoing skin breakdown on his buttocks since his admission. The CAAS did not address risk factors (such as diabetes mellitus and [MEDICAL CONDITION]) and how these [DIAGNOSES REDACTED]. The facility did not identify the resident was at risk for developing another pressure ulcer in the same area or possibly on a different area of the body. Resident #11's current nursing care plan with a start date of 06/22/10 included regular assessment of the resident's skin integrity, providing good skin care after each incontinence episode and "pressure relieving devices as indicated." Repositioning was not specifically addressed in the nursing care plan, but referred to the Certified Nursing Assistant (CNA) care plan. The current CNA care plan stated positioning in the wheelchair and in bed was to be done by 2 staff (not identified how often) and the resident was to be offered to go to bed in the early afternoon and at bedtime. The resident's care plan did not include any pressure-relieving devices for the bed or chair. Because the pressure ulcers were not healing and the resident was at risk for a subsequent pressure ulcer, expectations for care would include measures beyond basic skin care, such as pressure-relieving devices on the bed and in the chair, an individualized repositioning schedule, appropriate protective devices and nutrition and hydration interventions. Resident #11's record identified multiple open areas on the buttocks at the time of admission (nurses' notes on 06/04/11 identified the resident complained of discomfort from the open areas on the buttocks, his heel was hurting, he had a backache from the mattress and a wheelchair cushion was in place). The nurses' notes identified open areas that persisted on the buttocks (healed in December 2010 and reopened) that progressed to a bleeding open area on the left buttock on 02/15/11 when the resident complained of the area being "very painful." The resident was hospitalized for [REDACTED]. Nurses' notes identified the open areas improved during April 2011, but then on 05/04/11, bilateral open areas were identified. A nurse's note on 05/25/11 identified the geri recliner (gerichair) was being trialed for positioning due to left side leaning. It was stated the geri recliner was ineffective. A nurse's note on 05/28/11 identified the resident complained of discomfort on his bottom. The most recent progress note related to Resident #11's skin, dated 06/15/11, stated the resident continued to refuse dietary supplements with a slow decline in weight, that his open areas were decreasing in size and he preferred the recliner over the bed making position changes limited. The resident's pressure ulcer report sheet, dated 06/17/11, identified a Stage II pressure ulcer to the right buttock and 3 pinpoint areas to the left buttock. The care plan was not changed related to the pressure ulcers since 06/22/10, except for the trial of the geri recliner. Staff did not revise the care plan with additional approaches to ensure another pressure ulcer did not develop in the same area or in another site. On 06/22/11 at 7:41 a.m., Surveyor observed CNA AA in Resident #11's room providing morning cares. At 8:20 a.m., it was noted Resident #11 was in his gerichair in the dining room. Subsequent observations throughout the morning including observations at 6:07 and 11:04 identified Resident #11 remained up in his gerichair. On 06/22/11 at 12:50 p.m. (4 to 5 hours after staff assisted him up for breakfast), Surveyor observed CNA VV and AA transfer Resident #11 from the gerichair into bed using the Hoyer lift. It was noted there was no pressure-relieving cushion in the gerichair nor was there a pressure-relieving mattress on the bed. CNA AA stated the last incontinence care/toileting was done earlier that morning when the resident was assisted up for breakfast and confirmed there had been no incontinence care or toileting since that time. CNA VV stated staff used to toilet the resident more often when he was more continent. CNA AA stated this is all they have time to do now, before breakfast and after lunch. Surveyor observed incontinence care. It was confirmed the incontinence pad was wet with urine. Both the resident's buttocks areas were dark red in color (a half softball-sized area on each buttock proximal to the buttock crease). Duoderm dressings, partially intact were noted over the left and right buttock areas. A small open area was noted on the right buttock, distal to where the duoderm was placed. CNA AA stated the residents open areas start like the area on the right buttock, heal, then reopen, then heal and reopen again. CNA VV confirmed this was the case over the past 2 months. Surveyor asked if Resident #11 had been repositioned from the time he got up in the morning to the present time. CNA VV stated she and CNA AA had "boosted him" once in the morning before lunch because he was sliding down in the gerichair. Surveyor asked CNA VV if Resident #11 was on any special repositioning schedule. CNA VV stated he was to go to bed after lunch and be positioned on his side. Surveyor suggested a nurse check the resident's new open area and the partially dislodged duoderm dressings. At 1:07 p.m., Surveyor observed Licensed Practical Nurse (LPN) Q change the duoderm to the right and left buttocks. One small open area near the right hip bone was noted on the right buttock and at least 5 open areas (confirmed by LPN Q) were noted on the left buttock with the 2 largest being approximately the size of a pencil eraser and the other a slightly larger in an elongated shape. Following the dressing change, which had several breaks in aseptic technique (see F441), Resident #11 was positioned onto his left side. His left heel was positioned so it was off the mattress; however, the resident's right heel was left resting directly on the mattress. Surveyor interviewed the DON and ADON A during a conference call on 06/29/11 at 9:30 a.m. It was requested they provide any information to demonstrate the facility identified and evaluated all appropriate risk factors to determine if these did or did not cause or contribute to skin breakdown/pressure ulcers for Resident #11 and how this information was addressed on the care plan. On 07/01/11, Surveyor received and reviewed additional information from the facility regarding Resident #11. The facility's statements included that Resident #11's repositioning and toileting occurred simultaneously. "He is transferred with the mechanical lift into bed where he is checked and changed at least every two hours since he is totally incontinent of bladder." It was also stated the CNA care plan was updated to more accurately reflect how the staff was providing care to Resident #11 and a ROHO cushion was added to the geri-recliner. The information provided did not demonstrate the facility had appropriately addressed risk factors for developing subsequent pressure ulcers, had promptly implemented a pressure relieving device in the bed and in the gerichair with an individualized repositioning schedule and more frequent toileting or incontinence care and did not follow accepted standards of care related to repositioning as observed on 06/22/11. 3. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician progress notes [REDACTED]. He cannot move either his right upper or lower extremity at all. His left lower extremity and left upper extremity do have some weakness..." and the current physician orders, dated 06/07/11, included to elevate the resident's heels off the bed to prevent (pressure) sore, especially the right since he could not position that one independently. Resident #7's annual assessment with a reference date of 03/04/11 identified moderate cognitive impairment; extensive assistance required with ADLs; bowel and bladder incontinence; occasional moderate pain; and, a history of resolved pressure ulcers (a Stage II pressure ulcer present on admission). Skin treatments included a pressure-relieving device for the chair and for the bed, a turning/repositioning program and nutrition/hydration intervention. No foot problems were identified. Resident #7's annual CAAS, dated 03/04/11, stated the resident was almost completely nonverbal and rarely or never understood with dependence on others for decision-making; required extensive to total assistance with ADLs, was incontinent of bowel and bladder, required monitoring for skin integrity and had occasional pain that limited day to day activities. The CAAS did not address risk factors (such as CAD and [MEDICAL CONDITION]) and how these [DIAGNOSES REDACTED]. The facility did not identify the resident was at risk for developing another pressure ulcer in the same area or possibly on a different area of the body. Resident #7's current nursing care plan with a start date of 03/18/10 included an ADL deficit. Interventions included to check the resident every 2 hours and assist with toileting as needed and to assess skin integrity with cares. Repositioning was not specifically addressed in the nursing care plan, but was addressed on the CNA care plan. The current CNA care plan included that the resident required 2 staff for repositioning, his right arm was to be supported by a pillow in bed and in the wheelchair and his heels were to be elevated off the bed (especially the right as he could not reposition it independently). The resident's care plan did not include any pressure-relieving devices for the bed or chair. On 06/24/11 at 8:00 a.m., Surveyor observed Resident #7, asleep, lying on his right side in his bed with his right arm supported on a pillow. Surveyor observed the resident had a regular mattress with no air overlay nor alternating pressure mattress. CNA WW checked the resident's positioning of the resident's lower extremities and Surveyor observed Resident #7 had an unfolded white blanket between his knees with both heels firmly pressed into the mattress. CNA WW repositioned Resident #7 by folding the blanket and placing it back between the resident's knees. Surveyor observed Resident #7 remained positioned on his right side with his left heel supported slightly off the mattress and the right heel firmly pressed into the mattress. CNA WW stated Resident #7 usually had more pillows in his room for positioning purposes but added she could not find any at that time. On 6/24/11 at 9:20 a.m. - 9:30 a.m., Surveyor observed Resident #7 lying in bed on his back. CNA WW stated Resident #7 was on a 2 hour toileting schedule and he was repositioned at that time. CNA XX stated she gives Resident #7 the bedpan and the urinal every 2 hours when he is in bed and repositions him at that time. CNA XX checked positioning of the resident's lower extremities and Surveyor observed Resident #7's heels were not elevated off the mattress but firmly pressed into the mattress. Surveyor asked CNA XX if there was anything on Resident #7's care plan regarding positioning of his lower extremities. CNA WW stated Resident #7 should have his heels elevated. CNA WW and CNA XX then proceeded to place a pillow under the resident's lower legs. CNA XX stated the resident's heels were still not floated off the mattress and CNA WW commented about the resident's pillows that were usually there for positioning were missing. A folded blanket was added by CNA WW and CNA XX to the pillow that had been placed and the heels were observed to then be floated off the mattress. On 07/01/11, the facility provided and Surveyor reviewed information related to Resident #7's physician order [REDACTED]. The facility maintains the elevation of the resident's heels was a physical therapy (PT) recommendation and "NOT" a physician order [REDACTED]. The facility also included a recent PT evaluation, dated 06/30/11, that stated, "Bed positioning remains appropriate (with) pillow under LE's (lower extremities) - could add foot cradle to decrease pressure to heels as prevention..." 3. Resident #22's most current annual MDS dated 1-/17/10 notes that Resident #22 is at risk for the development of pressure ulcers and triggered the Pressure Ulcer Care Area Assessment (CAA). The pressure ulcer care area assessment documentation written on a Professional Progress Note dated 10/28/10 notes the following; #16 pressure - Resident is at risk for pressure areas because of severe limited mobility & [MEDICAL CONDITION]. Skin is currently intact. ... pressure relieving mattress on the bed + cushion in wc. Often rests in lg (large) personal recliner in room too. Nutrition is adequate. He is T/R (turned and repositioned) routinely + skin is monitored closely every shift. Incontinence products are used to keep skin clean + dry + are changed routinely. Will proceed / continue with Risk for Impaired Skin Integrity care plan." The most current quarterly MDS dated [DATE] notes at Section MO150 that resident is at risk of developing pressure ulcers. The facility form titled ADL Flowsheet also known as the nurse aide care plan dated 06/01/11-06/30/11 notes the following approaches; TOILETING: Uses Incontinent products. FREQUENCY: Check & change product every 2 hours & PRN. SKIN CARE: Notify nurse of any skin concerns. Heel lift pads to feet. POSITIONING W/C & Bed: (A) (assist) of 2 to turn.... Turn & position at least every 2-3 hours while in bed. It should be noted that the CNA care plan does not direct nurse aides to reposition Resident #22 while sitting up in his personal recliner. The facility form titled Treatments Flowsheet dated 6/1/2011 -6/30/2011 notes "Pressure relieving heel lift foam boots bil(ateral) feet Q (every) Shift - Every Shift 06/03/11 - Open Ended." On 6/20/11 at 10:32 a.m., Surveyor observed CNA F and CNA G transfer Resident #22 from his bed to his personal recliner. Surveyor observed the seat of the recliner to be without a pressure redistribution cushion. Surveyor asked both CNA's if the resident uses anything in the seat of the recliner and they said "no". Once the CNA's had Resident #22 seated and semi-reclined in his recliner, Surveyor noted that Resident #22's heels were resting directly on the foot rest of the recliner. Surveyor asked CNA F to notify Surveyor when the resident is transferred back to bed. CNA F reported that the resident stays up in his recliner until second shift. Surveyor observed Resident #22 seated in his personal recliner with his heels resting directly on the foot rest at 1:50 p.m., 2:41 p.m., 2:59 p.m., 3:19 p.m. It should be noted that on 6/20/11 nurses signed off for all three shifts that Resident #22 was wearing his pressure relieving heel lift foam boots. On 6/29/11 at 9:30 a.m., Surveyors , and spoke with the DON and Assistant DON via conference call. Surveyor shared observations of Resident #22 seated in his personal recliner without a pressure redistribution cushion, with his heels resting directly on the foot rest and no turning/repositioning or incontinence care. Surveyor requested provide any additional information regarding these concerns. On 6/30/11 at 12:02 p.m., Surveyor received a FAX from Assistant DON with the following information. Attached is the pressure CAA from October 2010. The foam heel lift pads were a nursing suggestion it appears. The directions for use were not specific in the C.N.A. care plan. Attached is a copy of his physician orders [REDACTED]. recliner because they are generally so plush. The C.N.A. care plan was corrected to state that he should be turned and repositioned every 2-3 hours while in bed and in his personal recliner. His incontinent care/product check is also done at that interval. See attached 7 sheets. Patient Progress Notes dated 6/30/11 submitted by Assistant DON via FAX noted "1130 - Reviewed the heel lift pads with LPN & CNA. Both feel that pads aren't effective because eggcrate "fingers" actually indent somewhat on his skin. Preferred method is to use a pillow under lower legs & elevate heels from surface. Will utilize this as much as possible when in bed & personal recliner. CNA care plan updated & correct that he should be T/R while in recliner also. 4. Resident #4's most current comprehensive assessment with a completion date of 8/19/10 triggered Pressure Ulcers. The Pressure Ulcer RAP (Resident Assessment Protocol) Summary documentation noted "Resident has MS ([MEDICAL CONDITION]) and comes to us with pressure ulcers. She has one stage 4 on her left ischium that was debrided and a wound vac was placed. She does [MEDICAL CONDITIONS] in this wound....She is to remain in bed per MD orders so she can stay off the wound. MD recommends that resident get up in the chair for 1-2 hours per day. Often resident refuses to get out of bed. she also has other ulcers that include a stage 2 on her upper back and a previous stage 3 on her right knee that is now just a scab....Healing may be more difficult since she is a diabetic. She has an alternating pressure air mattress on her bed that is hers from home. Staff do reposition her routinely at least every 2 hours and PRN (as needed)... Resident #4's most current quarterly MDS dated [DATE] notes that Resident #4 is at risk of developing pressure ulcers and she has 1 or more unhealed pressure ulcers. The facility document titled Treatments Flowsheet dated 6/1/11-6/30/11 notes the following; Suspend heels at all times 8/6/10 - Open Ended." The CNA care plan books contains pictures of how to position Resident #4 in bed with her heels suspended. On 6/20/11 at 4:18 p.m., Surveyor observed CNA R and CNA OOO reposition Resident #4. When the sheet was pulled back Surveyor observed that Resident #4's heels were on the bed and not suspended. On 6/29/11 at 9:30 a.m., Surveyors , and spoke with the DON and Assistant DON via conference call. Surveyor shared observations of Resident #4's heels not suspended off the bed.

Based on observation, interviews, record review, and a review of the facility's policy and procedure related to pressure ulcers, the facility did not ensure 1 of 3 sampled residents at risk for pressure ulcers did not develop an avoidable pressure ulcer and that the resident received necessary treatment and services to promote healing, prevent infection, and prevent new pressure ulcers from developing. Resident #23 was admitted with open areas/pressure ulcers that included the right heel which subsequently healed. He then developed a new avoidable facility acquired left heel pressure ulcer which was not healing and due to arterial insufficiency and stasis, required a left [MEDICAL CONDITION] (BKA). Following the BKA, the resident developed a new avoidable facility acquired right heel pressure ulcer. Resident #23 experienced functional decline following the BKA due to even more limited mobility with the development of the right heel pressure ulcer. Resident #23's right heel pressure ulcer deteriorated and became infected. Resident #23 developed new pressure ulcers bilaterally on the buttocks which were healing and the resident was at risk of developing subsequent pressure ulcers. The facility did not: *promptly implement and/or consistently utilize a pressure relieving device to prevent deterioration of an existing pressure ulcer and/or to reduce the risk of developing an avoidable pressure ulcer; *reassess and provide appropriate interventions for the care and treatment of [REDACTED]. *explain adequately why they could not address risk factors when the resident refused specific care or treatment; *adequately implement aseptic technique when providing care and treatment to the pressure ulcer. Findings include: 2010 WOCN Guideline for Prevention and Management of Pressure Ulcers notes the following standards: III. Interventions: Prevention A. Reducing Risk of Developing Pressure Ulcers Heel Pressure Ulcers: Heel protection devices should completely offload (float) the heel (NPUAP/EPUAP, 2009; Fowler et al., 2008) Padding devices such as synthetic sheep skin, bunny boots, and rigid splints protect the heels and remove friction and shear but do not remove the pressure (Fowler et al., 2008). Pillows under calves decrease heel interface pressures as well as foam cushions under calves. However, there are many varieties of pillows and the method of pillow placement varies. The recommended method is to place the pillow longitudinally underneath the calf with the heel suspended in air. However, maintaining alignment may be difficult if the patient moves. In addition, pillows do not prevent plantar flexion contracture or lateral leg and foot rotation. See the attached document titled NPUAP-EPUAP PU CPG Excerpts - See section 3 - 3.4 regarding prevention of heel ulcers. The 2009 NPUAP-EPUAP Pressure Ulcer Prevention & Treatment Clinical Practice Guideline notes the following; Treatment Category/Stage III, IV, and Unstageable Pressure Ulcers of the Heel 1. Place the leg in a device that elevates the heel from the surface of the bed, completely offloading the pressure ulcer. At various times during 09/19/11 to 09/30/11 Surveyor reviewed records and policies related to Resident #23 including the facility medical record, the facility "Skin Alteration Policy and Procedure," and hospital/wound clinic records with the following noted: Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Open areas were identified on the coccyx and right heel. The resident had a history of [REDACTED]. Resident #23's admission Resident Assessment Instrument (RAI), dated 02/03/11, identified the need for extensive staff assistance with activities of daily living including bed mobility, transfers, and ambulation; occasional urinary incontinence; height and weight, respectively, at 74 inches (6 feet, 2 inches tall); and two Stage II pressure ulcers. Foot problems included infection and application of dressings. Treatments did not include a pressure reducing device for the bed. The associated Care Area Assessment Summary (CAAS) related to nutrition identified a renal diet with both sodium and fluid restriction, significant [MEDICAL CONDITION] treated with a diuretic, a long history of diet non-compliance, [MEDICATION NAME] for wound healing, and supplements to increase protein. The CAAS related to pressure ulcers did not identify the resident's risk factors, but did identify two Stage II pressure ulcers (the right heel and the left buttock). The CAAS related to dehydration identified the resident had [MEDICAL CONDITION] (MRSA) "infection of wounds." The facility's "Skin Alteration Policy and Procedure," dated 07/28/11, was signed by the facility's Medical Director and included the following, "Use pillows or foam wedges to keep bony prominences from direct contact with surfaces...Use devices that totally relieve pressure on the heels...Eliminate or reduce cause of pressure...A Temporary Care Plan is initiated upon identification of an open area or added to the care plan if a skin alteration care plan already exists...In the event the development of a pressure ulcer may be unavoidable despite the provision of appropriate care, the interdisciplinary team assesses the situation, and notifies the attending health care provider. Nursing staff will request that the health care provider document the nature of the condition, attesting to or disputing this assessment and conclusion...Skin rounds will be reviewed by the DON (Director of Nursing) weekly..." On 02/09/11, Resident #23's nursing care plan related to impaired skin integrity was initiated and identified risk for current pressure ulcers increasing in size and for the development of new pressure ulcers. The care plan included interventions related to food and fluid, regular assessment of the resident's skin integrity, keeping skin clean and dry as much as possible, assisting with repositioning, and providing pressure-relieving devices "as needed/indicated." The nursing care plan referred to the Certified Nursing Assistant (CNA) care plan which was also not specific related to pressure relieving devices for the resident's lower extremities. Contrary to the 2010 WOCN and the 2009 NPUAP-EPUAP guidelines, staff did not implement a pressure relieving device for the resident when in bed and when up in the wheelchair. On 03/17/11 and 03/30/11, Resident #23's physician's hospital/wound clinic notes identified unstageable, deep tissue injury (DTI) pressure ulcers bilaterally on the heels and on the sacrum. The note stated, "Has offloading foam boots, per patient and air bed as well..." The physician's hospital/wound clinic note, dated 05/25/11, included the following, "...not a reliable historian...Pressure ulcer - Unstageable - improving. Dorsal right ankle looks slightly worse ?new pressure problems. Patient came wearing post op podiatric boots, not foam booties." Treatment and/or dressings were applied bilaterally to the heels. Contrary to the 2010 WOCN and the 2009 NPUAP-EPUAP guidelines, staff did not consistently utilize a pressure relieving device for the resident's right heel pressure ulcer which was present on admission or for the left heel which developed an avoidable pressure ulcer. On 06/10/11, Resident #23's readmission Minimum Data Set assessment following a hospitalization identified the resident was independent for bed mobility, had increased urinary incontinence, and had two Stage II pressure ulcers. Treatments did not include a turning/repositioning program. Contrary to the 2010 WOCN and the 2009 NPUAP-EPUAP guidelines, staff did not reassess and revise the care plan related to the increase in incontinence and how the resident could safely be independent with bed mobility without staff's assistance or encouragement with a turning/repositioning program, and what the resident would utilize for pressure relief of the lower extremities. On 07/07/11, Resident #23's physician's hospital/wound clinic notes identified an ischemic left heel ulcer with significant necrotic tissue. It was stated the resident had an arterial insufficiency ulcer and a left BKA was recommended. Contrary to the 2010 WOCN and the 2009 NPUAP-EPUAP guidelines, staff did not provide appropriate interventions including a pressure relieving device for the left and right lower extremities both when in and out of bed as well as other specific interventions to adequately protect the lower extremities. On 07/09/11, the facility's skin/pressure ulcer forms for Resident #23 identified the resident's Stage II pressure ulcer on the right heel was healed and there was no evidence of a current pressure area on the left buttock. It was also identified the resident had two non-healing pressure ulcers on the left heel. Contrary to the 2010 WOCN and the 2009 NPUAP-EPUAP guidelines, staff did not provide appropriate interventions including a pressure relieving device for the left and right lower extremities both when in and out of bed as well as other specific interventions to adequately protect the lower extremities. Resident #23's record identified he was admitted to the hospital for a left BKA on 07/21/11 due to a non-healing arterial insufficiency left heel ulcer. Resident #23's wound consult note, ordered by the surgeon and written by Wound Clinic Nurse (WCN) QQQ on 07/21/11, identified the resident was seen following his left BKA. It was stated the resident had a "dry appearing ulcer in the anterior ankle region..." It was stated the resident had "mild [MEDICAL CONDITION] of the right lower extremity (RLE)...likely has mixed venous/arterial insufficiency. Will use mild compression with comperm, a moisturizer, and simple wound cares for the remaining superficial ulcer." Treatment was implemented to the resident's posterior buttock region and it was stated risk of further breakdown on the buttocks was higher since the BKA..."Mobility and education related to pressure ulcer prevention will be essential components of his care. Will need to maximize interventions to prevent further breakdown..." It was stated the resident would likely be wheelchair bound and a ROHO cushion was recommended. Resident #23's wound consult note dated 07/22/11 written by WCN QQQ, identified skin breakdown on the right ischial (buttocks) area "...Will need to maximize pressure ulcer prevention interventions..." It was also identified the resident had a chronic area on the right heel where he had a pressure ulcer with eschar at one time. It was noted the area was currently a darker pink color and intact, but quite tender to touch..."Will use a heel suspension boot to offload the area." On 07/25/11, Resident #23's record identified he returned to the facility following the left BKA. The hospital discharge summary included recommendations for a non adhering dressing and elevation related to a right anterior "foot" wound. There was no reference to any open area or pressure ulcer on the right "heel." It was identified the resident was at high risk for skin breakdown with recommendations including repositioning, suspending the (right) heel, and padding to protect bony prominences. The facility's Treatment Administration Record (TAR) identified bony prominences should be padded and protected. Contrary to the 2010 WOCN and the 2009 NPUAP-EPUAP guidelines, staff did not provide appropriate interventions including a pressure relieving device for RLE both when in and out of bed as well as other specific interventions to adequately protect the RLE. On 07/25/11 to 07/31/11, nurses' notes for Resident #23 identified the resident required two staff for repositioning, transferred with staff assist and the sit-to-stand lift (having only the right foot to bear weight), and self propelled his wheelchair. On 07/26/11, a weekly pressure ulcer note identified the resident had a draining open area on the right foot but there was no documentation of a problem with the right heel. On 07/28/11, a nurse's note stated the resident refused to wear "booties" in bed. Nurses' notes from 07/25/11 to 07/31/11, nor the care plan, addressed any kind of protective or pressure relieving device for the RLE either when in bed or when up in the wheelchair. Contrary to the 2010 WOCN and the 2009 NPUAP-EPUAP guidelines, staff did not provide appropriate interventions including a pressure relieving device for the RLE both when in and out of bed as well as other specific interventions to adequately protect the RLE. Staff did not consistently address the resident's risk factors when he refused to elevate his legs. On 08/01/11, Resident #23's CAAS related to a significant change RAI identified Stage II pressure ulcers on the anterior and posterior of the right foot and on the buttock. The RAI identified the resident had moderate cognitive impairment with most other assessment areas consistent with the admission RAI. Skin treatments included pressure-relieving device for chair and bed, turning/repositioning program, nutrition or hydration intervention, and ulcer care. Foot problems included infection and application of dressings. The CAAS stated the CNA care plan addressed positioning and the resident was involved in both physical therapy and occupational therapy but was not ambulating. The right heel was to be kept off the bed to decrease pressure. "Needs increased assist with mobility...Ulcers are recorded weekly on skin alteration assessment record...Has [DIAGNOSES REDACTED]." Contrary to the 2010 WOCN and the 2009 NPUAP-EPUAP guidelines, staff did not provide appropriate interventions including a pressure relieving device for the RLE both when in and out of bed as well as other specific interventions to adequately protect the RLE. Staff did not address the resident's risk factors when he refused to elevate his legs. On 08/01/11 to 08/03/11, nurses' notes stated Resident #23 could reposition himself independently in the bed and/or in the wheelchair, but still required staff assist and the sit-to-stand lift for transfers. It was stated the resident had a small open area remaining on top of the ankle but no open areas on the heel. On 08/04/11, a nurse's note stated the resident was able to transfer with two staff assist and a wheeled walker with a "platform." On 08/05/11, nurses' notes identified Resident #23's right foot wound had increased redness, swelling, and warmth. Orders by the Nurse Practitioner identified an antibiotic was initiated for [MEDICAL CONDITION] of the right foot. Contrary to the 2010 WOCN and the 2009 NPUAP-EPUAP guidelines, staff did not provide appropriate interventions to include devices for pressure relief of the heel and adequate protection of the RLE. On 08/06/11, nurses' notes identified Resident #23 fell during the night out of his wheelchair and "scooted" over to the bed to turn the call light on to alert staff. It was not identified what the resident was wearing on his RLE at the time of the fall. On 08/08/11, nurses' notes identified there were no open areas on the right heel but it continued to be tender to touch with pain medication given for "heel pain," and the resident refused to elevate the RLE. Orders written on 08/08/11 by the Nurse Practitioner included to "elevate the RLE as much as tolerated, a heel 'protector' to the right foot when in bed, and monitor the right heel for breakdown." New entries were added to the nurses' TAR on 08/08/11 for elevation of the RLE and for a heel protector to the resident's right foot when in bed. Contrary to the 2010 WOCN and the 2009 NPUAP-EPUAP guidelines, staff did not address what type of heel "protector" would be used when in bed nor what the resident was supposed to wear when up in the wheelchair. Staff did not address the resident's risk factors when he refused to elevate his legs. Surveyor interviewed the DON on 09/23/11 at 4:40 p.m. The DON stated the Nurse Practitioner probably did not realize, when she ordered the protective boot on 08/08/11, that Resident #23 already had a pressure relieving boot. On 08/09/11, nurses' notes identified Resident #23 was up in the wheelchair all night and wore a "sock" to the right foot...on days, the right heel was red and tender to touch with the resident refusing the "pressure relief boot" but agreeing to lay in bed and float his heel, expressing worry about his foot "getting bad..." on p.m.'s, refused the "protective boot." Contrary to the 2010 WOCN and the 2009 NPUAP-EPUAP guidelines, staff did not identify what type of pressure relief boot the resident was wearing, where it came from, or when it was supposed to be worn. Surveyor observed Resident #23 on 09/19/11 at 3:15 p.m. and on 09/21/11 at 2:50 p.m. The resident was sitting up in his wheelchair wearing a whitish colored, semi-rigid boot to his right foot. The boot fastened with Velcro in the front and had a hole cut in the rigid back of the boot at the area of the heel. Resident #23's spouse, Family Member (FM) RRR, was present during the observation on 09/21/11 who stated the resident wore the semi-rigid boot for support when he was up and pointed to a softly padded plaid boot adding he usually wore that boot when he was in bed. Surveyor observed Resident #23 on 09/20/11 at 9:45 a.m., just prior to a dressing change. The resident wore a light blue moderately thick padded protective boot to the right foot, heel, and ankle which was fastened with Velcro in the front. A pillow was placed horizontally under the resident's right lower leg, but the resident had slid down in the bed and the right foot with the boot was resting with the right heel against the wooden rim of the footboard of the bed. Following the dressing change, Registered Nurse (RN) J covered the kerlix bandage with a foot sock followed with the light blue protective boot. The resident's right heel again rested against the wooden rim of the footboard of the bed. RN J placed her hand under the resident's right heel and stated, "There's no pressure," (with the protection of the boot). RN J did reposition the resident's right heel off the bed using the pillow present under his right lower leg. Contrary to the 2010 WOCN and the 2009 NPUAP-EPUAP guidelines, staff did not provide appropriate interventions including a pressure relieving device for the RLE when in bed as well as other specific interventions to adequately protect the RLE. Surveyor interviewed the DON on 09/21/11 at 4:00 p.m. at which time she stated Resident #23 utilized a "Rooke" boot initiated by therapy, and provided manufacturer's information regarding the boot. The information included, "...ideal for patients being treated for [REDACTED]." Surveyor interviewed the DON on 09/23/11 at 4:40 p.m. at which time she stated the pressure relieving boot worn by Resident #23 when he was up in the wheelchair was not a Rooke boot, but a "heel suspension boot," and added she had forwarded printed information related to the boot. The DON stated the boot had not been initiated by therapy and "probably came from home." Surveyor reviewed, on 09/29/11 and 09/30/11, the printed information related to the heel suspension boot sent by the DON. The boot was identified as a "Heelift AFO" by DM SYSTEMS, INC. Company information for the Heelift AFO identifies the boot as a yellowish foam boot with a large, horizontal, elongated hole cut into the foam in the back of the boot and the semi- rigid brace runs vertically over the back of the boot and the hole which is positioned at the area of the heel (not consistent with the boot observed by this writer on 09/19/11 and 09/21/11). Surveyor interviewed the DON on 09/26/11 at 8:50 a.m. The DON stated the resident brought in the heel suspension boot from home at the time of admission which he had received from the wound clinic. The DON stated it was the wound clinic's recommendation the resident wear the boot as much as possible. Surveyor interviewed FM RRR on 09/26/11 at 3:30 p.m. FM RRR identified Resident #23 " had numerous boots at the facility. FM RRR stated she was unsure where the whitish semi-rigid boot with the hole came from, but thought he must have received it either from the wound clinic or from the nursing home. FM RRR identified the resident's other boots included two foam boots he sometimes wore when up in the wheelchair, a yellow boot that came from home and a peach boot that came either from the wound clinic or from the nursing home. FM RRR stated there were other boots and some he wore only in bed such as the soft blue plaid boot (that she pointed out on 09/21/11) and the light blue padded boot (observed by this writer on 09/20/11) which she thought might have come from the hospital. FM RRR stated the resident "has so many boots!" Surveyor interviewed the DON on 09/23/11 at 4:40 p.m. The DON stated when nurses documented a pressure relief boot, they were referring to the "heel suspension boot" and when they documented a protective boot, they were referring to the soft padded quilt boot or another moderately padded protective boot such as that observed by this writer on 09/20/11. Nurses' notes identified the following: On 08/10/11 during the night, "Sock in place to (right) foot." On 08/11/11, on days heel remained red, no open areas, on p.m.'s complained of right foot pain. On 08/12/11, slept in bed all night but refused to wear "boot" on right foot and on p.m.'s, was up in wheelchair entire shift but declined to elevate or wear "protective boot" to right leg with consequences discussed. On 08/13/11 on days, refused to reposition or lay down to elevate right foot with 2+ [MEDICAL CONDITION] noted and on p.m.'s, right leg slightly elevated but refused to wear "protective boot." On 08/14/11 on nights, elevated right foot but refused to wear "protective boot." On days, up in wheelchair and elevated right foot, 3+ [MEDICAL CONDITION] with right heel tender to touch and moderately red. On 08/15/11 on nights, staff encouraged the resident to sleep in bed and elevate his extremities and on days, small "crack" noted on right heel. On 08/16/11 on days, no open area noted on right heel, "pad" applied to the heel, wore the "boot." Contrary to the 2010 WOCN and the 2009 NPUAP-EPUAP guidelines, staff did not consistently identify what type of "boot" the resident wore in bed and in the wheelchair or if the resident refused to wear a particular boot. Staff did not consistently address risk factors with the resident related to his refusal to elevate the right foot or wear a protective boot. On 08/17/11, a nurse's note stated, "Wore protective boot" during the night. A physician order [REDACTED]. On 08/18/11, the resident's impaired skin integrity documentation form identified a Stage II pressure ulcer measuring 3 by 3 centimeter (cm) on the right heel with treatment that included [MEDICATION NAME] and an [MEDICATION NAME] dressing. On 08/18/11, a weekly pressure ulcer note written by RN K stated there was "redness" noted to the resident's right heel on 08/17/11 and the wound was assessed by the surgeon with the order received for [MEDICATION NAME]. On 08/18/11, nurses' notes identified the resident's right leg was elevated with a pillow. Contrary to the 2010 WOCN and the 2009 NPUAP-EPUAP guidelines, staff did not provide appropriate interventions to include devices for pressure relief of the heel, adequate protection of the RLE, and consistent treatment, and the resident developed an avoidable right heel ulcer. Nurses' notes identified the following regarding Resident #23: On 08/19/11, right leg elevated in bed during the night and "boot on as ordered" during the day. On 08/20/11, RLE elevated during the night and [MEDICATION NAME] intact during the day. On 08/21/11, [MEDICATION NAME] changed on right heel pressure area, superficial with improvement noted and surrounding skin looking "good." On 08/22/11, dressing intact on right heel. On 08/23/11, resident complained of RLE pain "8/10" and requested [MEDICATION NAME]. It was stated the resident was encouraged to elevate his RLE but he declined. Contrary to the 2010 WOCN and the 2009 NPUAP-EPUAP guidelines, staff did not implement a consistent pressure relief device to the right heel and did not consistently address risk factors with the resident related to his refusal to elevate the right foot or wear a protective boot. On 08/24/11, a nurse's note written by the facility's wound care nurse, RN V, identified the floor nurse reported Resident #23's right heel pressure ulcer was "malodorous" with a dark center. It was stated the area was red with a dark purple color from 12 to 3 o'clock and "macerated" around the wound margin in that area as well. The resident was seen by the Nurse Practitioner on 08/24/11 and the progress note included the resident had a slightly malodorous Stage II pressure area 0.8 cm round and 0.1 cm depth, wound edges pale and macerated, heel tissue soft with heel pain, and 3-4+ pedal [MEDICAL CONDITION]. It was stated the resident should get to the wound clinic as soon as possible. Orders included a daily dressing change with cleansing, [MEDICATION NAME], and an [MEDICATION NAME] dressing. It was also ordered to hold ambulation until seen by the wound clinic, change leg coverings to ace wraps, and culture the wound if odor persisted. Contrary to the 2010 WOCN and the 2009 NPUAP-EPUAP guidelines, staff did not implement a consistent pressure relief device to the right heel and the pressure ulcer deteriorated. Nurses' notes identified the following: On 08/25/11, night shift, wore a "padded boot" to right foot in bed, on day shift, right heel painful to touch, wore a "pressure relief boot." On 08/26/11, night shift, wore a "boot" to right foot in bed, day shift, heel wound "enlarging." On 08/27/11, area around pressure ulcer moderately red with light brown discoloration on lateral sides of heel. On 08/28/11, received "deep creases" on RLE from ace wraps on day shift and p.m. shift. On 08/29/11, Nurse Practitioner recommended to schedule for the wound clinic and ordered [MEDICATION NAME] and ace wrap to be applied loosely to protect leg from irritation, heel not addressed. On 08/29/11, continued to be small to moderate creases in RLE. Contrary to the 2010 WOCN and the 2009 NPUAP-EPUAP guidelines, staff did not implement a consistent pressure relief device to the right heel. On 08/30/11, measurements were taken of Resident #23's right heel ulcer and documented on the pressure ulcer form. It was measured at 2.2 by 1.5 (cm) with a superficial depth, small serosanguinous drainage, and red in color. Staff did not take measurements again of the pressure ulcer until 09/17/11. Staff did not follow their policy/procedure related to ensuring wound rounds were reviewed by the DON weekly with the identification of an avoidable pressure ulcer and implementing a device that would "totally" relieve pressure on the resident's right heel. On 08/31/11, a nurse's note identified Resident #23 had a scant amount of bloody drainage on the old dressing. On 09/01/11, the resident was seen by the surgeon related to the left BKA. The right heel was also evaluated by the surgeon, thus not seen by the wound clinic. The surgeon's orders included, "Protect right heel from pressure with foam boots or what ever was used previously. Continue with pillow under right calf to keep heel off of the bed." Contrary to the 2010 WOCN and the 2009 NPUAP-EPUAP guidelines, staff did not revise the care plan to include the use of the "foam boots," did not ensure the boot used was a pressure relief boot, and did not ensure a pressure relief boot was used consistently when in bed and when up in the wheelchair. On 09/03/11, a nurse's note identified Resident #23's right heel pressure ulcer had serosanguinous drainage, foul odor, was red in color with a bluish discoloration around the open area, and was tender when touched. On 09/04/11 and 09/05/11, nurses' notes identified the resident experienced respiratory signs/symptoms with fever and the right heel was open and draining a small amount of bloody drainage. On 09/06/11, nurses' notes identified an antibiotic was ordered for probable pneumonia per x-ray and it was noted the right heel had a dark purple area on the outer side of the heel. Contrary to the 2010 WOCN and the 2009 NPUAP-EPUAP guidelines, staff did not ensure a pressure relief boot was used consistently when in bed and when up in the wheelchair. On 09/07/11, the Nurse Practitioner assessed the right heel and identified it was a pressure ulcer and was worse, 2 cm in diameter with irregular edges, slightly malodorous with a small amount of drainage, and tender to touch with the resident stating it was "quite painful." An order to culture was given due to the odor. It was stated the resident was at risk for osteo[DIAGNOSES REDACTED] and it was recommended he be seen at the wound clinic. The new dressing order was for [MEDICATION NAME] and [MEDICATION NAME], to be changed every three days or more often with drainage. A nurse's note on 09/07/11 stated the resident wore a "bootie" on the foot. Contrary to the 2010 WOCN and the 2009 NPUAP-EPUAP guidelines, staff did not ensure a pressure relief boot was used consistently when in bed and when up in the wheelchair. On 09/10/11, nurses' notes identified the right heel pressure ulcer was positive [MEDICAL CONDITION] (antibiotic ordered). The dressing was changed with the open area noted to be moist, a blackened patch at the side of the open area, a slight odor, and tenderness noted. On 09/11/11, nurses' notes identified the dressing was intact (not changed). Nurses' notes did not address what the resident wore on his right heel in bed or in the wheelchair. Contrary to the 2010 WOCN and the 2009 NPUAP-EPUAP guidelines, staff did not ensure a pressure relief boot was used consistently when in bed and when up in the wheelchair. On 09/12/11, Resident #23 was seen at the wound clinic by the physician who identified an unstageable DTI pressure ulcer of the right heel. "I think wound needs to be dried out and promote epidermolysis and prevent more secondary infection." The orders for the right heel were changed to painting once daily with [MEDICATION NAME] iodine, to keep it dry, and to cover with a dry kling for protection. The antibiotic was to be continued longer and the treatment of [REDACTED]. From 09/12/11 to 09/17/11, nurses' notes for Resident #23 did not address whether or not he was wearing any kind of boot on his right foot or if staff were regularly encouraging and assisting with elevation of the right heel. Contrary to the 2010 WOCN and the 2009 NPUAP-EPUAP guidelines, staff did not ensure a pressure relief boot was used consistently when in bed and when up in the wheelchair. On 09/17/11, a nurse's note identified Resident #23's right heel pressure ulcer consisted of a small area superficially open with another dark purple area noted. Measurements on the pressure ulcer form identified a 2 cm area at the back of the heel and a dark purple area 7 cm long by 1.5 cm wide above the outer heel. Contrary to the 2010 WOCN and the 2009 NPUAP-EPUAP guidelines, staff did not put appropriate interventions in place to prevent deterioration of the right heel ulcer. On 09/18/11, a nurse's note identified two superficial open areas on the buttocks. Measurements on the pressure ulcer form identified two stage II pressure ulcers, 0.5 cm (round) superficial, and the other 1.0 by 0.5 (cm) superficial, with stoma adhesive applied to both. Contrary to the 2010 WOCN and the 2009 NPUAP-EPUAP guidelines, staff did not put appropriate interventions in place to prevent new ulcers from developing. On 09/19/11, a nurse's note on the day shift stated the resident's heel continued to have the dark purple areas with a superficial open area on the bottom back of the heel. It was stated the re