Every finding on record at Oak Park Nursing and Rehab Center

Based on record review, interview and policy review, the facility failed to thoroughly investigate an allegation of abuse for 1 (R3) of 3 abuse allegations reviewed in a sample of 13 residents. Facility did not complete a thorough investigation regarding R3's allegation of abuse. Findings include: Review of facility policy titled, Abuse, Neglect and Exploitation, dated 08/01/26, indicated, 4. Identifying and interviewing all involved persons, including persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations;.6. Providing complete and thorough documentation of the investigation. Review of R3's admission Record, located under the Profile tab in the electronic medical record (EMR), indicated that R3 was re-admitted to the facility on [DATE] with a diagnosis of diabetes mellitus, anxiety disorder, and major depressive disorder (MDD). Review of R3's facility provided Brief Interview for Mental Status (BIMS), dated 05/04/26, indicated, a score of 15 out of 15, which indicated she was cognitively intact. During an interview on 08/11/26 at 10:50 AM, R3 stated in May, a staff member called her fat and grabbed her vagina. R3 remembered the incident and stated that it hurt several days afterwards. R3 stated she was glad that she did not get an infection, because she is prone to urinary tract infections (UTI). She described the staff member as young with dark short hair; dark skin but not black; chunky lady with a mouthy, squeaky voice; and was strong with long nails. She did not recall if the staff member had any tattoos. Review of the Misconduct Incident Report (initial report), dated 05/13/26, indicated, On 05/13/26 during a complaint survey at the facility state surveyor reported to administration that during an interview with R3, she reported that during cares or changing of her brief, a Certified Nursing Assistant (CNA) cut her vagina with her fingernail. R3 was unable to tell the surveyor when it happened and was also unable to identify a staff member. R3 did state that it was some time ago. Review of facility provided R3's interview dated 05/13/26, indicated, .R3 was not able to recall that she had any wounds to her vagina and was unable to recall the event that she described to surveyors. During our conversation, R3 did mention that she had a wound on her arm at one time. It should be noted that there are no wounds on her arm. Writer asked R3 if she felt safe in the facility and R3 stated yes. Review of the unlabeled, and undated (final report) indicated, revealed only R3 was interviewed by Registered Nurse Consultant (RNC) related to the alleged incident. There was no evidence of staff interviews completed during the investigation. During an interview on 08/11/26 at 12:40 PM, the RNC indicated that no staff were interviewed in this investigation because she looked through all R3's skin assessments and there were no findings and R3 could not remember any findings. No interviews were conducted with the current Administrator and the Director of Nursing (DON) as they were not employees of the facility at the time of the incident.

Based on record review, interview and policy review, the facility failed to report an allegation of physical abuse for 1 of 3 Residents reviewed for abuse allegations (R3) out of a sample of 13 residents. Allegations involving R3 were not reported to the appropriate entities including law enforcement. Findings include: Review of the facility policy titled, Abuse, Neglect and Exploitation, dated 08/01/26, read as, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. VII. Reporting/Response: 1. Reporting of all alleged violations to the Administrator, Director of Housing, state agency, and to all other required agencies (e.g., law enforcement when applicable) within regulatory timeframes. Review of R3's admission Record, located under the Profile tab in the electronic medical record (EMR), indicated that R3 was re-admitted to the facility on [DATE] with a diagnosis of diabetes mellitus, anxiety disorder, and major depressive disorder (MDD). During an interview on 08/11/26 at 10:50 AM, R3 stated in May, a staff member called her fat and grabbed her vagina. R3 remembered the incident and stated that it hurt several days afterwards. R3 stated she was glad that she did not get an infection, because she is prone to urinary tract infections (UTI). She described the staff member as young with dark short hair; dark skin but not black; chunky lady with a mouthy, squeaky voice; and was strong with long nails. She did not recall if the staff member had any tattoos. Review of R3's Brief Interview for Mental Status (BIMS), dated 05/04/26, indicated a score of 15 out of 15, which indicated she was cognitively intact. Review of the Misconduct Incident Report (initial report), dated 05/13/26, indicated, On 05/13/26 during a complaint survey at the facility state surveyor reported to administration that during an interview with R3, she reported that during cares or changing of her brief, a Certified Nursing Assistant (CNA) cut her vagina with her fingernail. R3 was unable to tell the surveyor when it happened and was also unable to identify a staff member. R3 did state that it was some time ago. Review of R3's interview (as part of the investigation) dated 05/13/26, indicated, .R3 was not able to recall that she had any wounds to her vagina and was unable to recall the event that she described to surveyors. During our conversation, R3 did mention that she had a wound on her arm at one time. It should be noted that there are no wounds on her arm. Writer asked R3 if she felt safe in the facility and R3 stated yes. Review of the unlabeled, and undated (final report) indicated, .Investigation: The incident was immediately reported to department health services facility initiated a full internal investigation. Investigation Findings: R3 was interviewed by Registered Nurse Consultant (RNC) related to the alleged incident. R3 could not recall that she had any wounds to her vagina and was unable to recall the event described to surveyors. R3 did mention that she had a wound on her arm at one time. All R3's skin records were reviewed and there were no findings consistent with the alleged wound/incident. It was mentioned upon her return from the hospital that there was redness from use of a pure wick. It is plausible that R3 may have had some sensitivity to this area during cares following hospitalization. R3 reported feeling safe and happy at the facility. R3 had a skin check completed on the day of the allegation and there were no findings. A complete skin sweep was conducted on the memory care unit and there were no findings of new wounds or of wounds aligning with the alleged incident. Conclusion: Upon interdisciplinary team (IDT) review of the incident, investigation and findings, the facility believes the allegation to be unsubstantiated. Out of an abundance of caution, staff have been educated on the facility policy for nail length and audits will be conducted at random. [name of the facility] is committed to providing the highest quality of care and service to all residents. During an interview on 08/12/26 at 11:00 AM, the Administrator indicated the police, family/POA, and/or Ombudsman (if resident rights are involved) are to be contacted during any abuse investigation; however, not in this case. The Administrator stated that it was reported to the state agency (SA) and a skin sweep was completed with all residents on the memory care unit at the time. R3's skin assessments were reviewed without any negative findings, and re-education to staff about nail length. He said that Administration is always looking at staff's nail length which is to be kept short. Police were not notified regarding R3's allegation.

Based on record review, and interviews, the facility did not ensure to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 13 sampled Residents (R4). R4 was administered the wrong transdermal patch resulting in a medication error. Findings include:Review of R4's electronic medical record (EMR) located under the Profile tab revealed of the resident was admitted to the facility on [DATE], with diagnoses of Parkinson's disease, cognitive communication deficit, and dementia in other diseases classified elsewhere. Review of R4's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/06/26 and located under the Resident Assessment Instrument (RAI) tab of the EMR, revealed R4 had a Brief Interview of Mental Status (BIMS) score of 00 out of 15, which indicated R4 had severely impaired cognition.Review of R4's order summary report located under the Orders tab of the EMR revealed an order for Rivastigmine (Exelon) Transdermal Patch 24H (hour) 9.5 milligram (MG) every twenty-four hours.During an interview on 08/12/26 at 8:46 AM, the complainant stated she wanted it to be noted that a medication error was made. The complainant stated that the facility already had investigated the medication error. The complainant stated that the only change R4 had was he seemed a little tired and did not smile. During an interview on 08/12/26 at 9:40 AM, the Director of Nursing (DON) stated that a Registered Nurse (RN) inadvertently placed a nitroglycerin patch on R4 instead of the Exelon patch. The DON stated the facility notified the provider, the resident representative, and the nursing staff caring for R4. The DON stated that R4 was monitored for any adverse reactions without any negative outcomes. During an interview on 08/13/26 at 10:40 AM, RN2 stated that she was busy and when it came time to replace R4's transdermal patch for dementia, I made a mistake and placed a transdermal nitroglycerin patch on R4. RN2 stated that R4 was monitored for any adverse reactions to the nitroglycerin patch without any negative outcome.

Based on interview and record review, the facility did not ensure each resident received the necessary care and services in accordance with professional standards of practice to meet each resident's physical needs for 1 of 5 sampled residents (R1).R1's surgical dressing was not monitored or assessed. R1's surgical wound was not care planned.This is evidenced by:The facility's policy Acute Condition Changes - Clinical Protocol, dated 3/18, includes: 5. The physician and nursing staff will review the details of any recent hospitalization and will identify complications and problems that occurred during the hospital stay that may indicate instability or the risk of having additional complications. 1. The staff will monitor and document the resident/patient's progress and responses to treatment.The facility's policy Charting and Documentation, dated 7/17, includes: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. 2. The following information is to be documented in the resident medical record: a. Objective observations; c. Treatments or services performed. 7. Documentation of procedures and treatments will include care-specific details, including: c. the assessment data.R1 admitted to the facility on [DATE] with a diagnosis of pain in left hip after a fall at home. R1 was sent to the emergency room for an evaluation of pain in his left hip on 3/17/26. R1 was hospitalized until 3/23/26.R1 was readmitted to the facility on [DATE] with diagnosis of fracture of left hip.R1's hospital discharge instructions, dated [DATE], includes: Procedure: ORIF (Open Reduction and Internal Fixation, a surgical intervention to fix R1's left hip fracture) 3/18/26. Leave Dressing on - Keep it clean, dry and intact until clinic visit.R1's Admit/Readmit Screener, dated 3/23/36, includes: C. Skin Integrity site: left external hip. Type: Surgical Incision. Comments: Left surgical hip incision covered with grey hydrocolloid dressing.R1's physician orders, printed 5/14/26, does not have an order for R1's left hip surgical site until 4/20/26.On 4/20/26, R1's physician order states monitor left hip dressing each shift for drainage, shadowing, rolling or pealing [sic] edges.Of note, R1's hospital discharge orders to Leave Dressing on - Keep it clean, dry and intact until clinic visit was not entered into R1's physician orders.R1's comprehensive care plan, printed 5/14/26, does not address R1's left hip surgical site until 4/20/26.R1's March Treatment Administration Record (TAR) does not address R1's left hip surgical site.R1's April TAR does not address R1's left hip surgical site until 4/20/26.On 4/20/26, R1's TAR includes monitor left hip dressing each shift for drainage, shadowing, rolling or pealing [sic] edges.R1's nurse progress notes do not include an assessment or monitoring of R1's left hip surgical site.On 5/14/26 at 10:07 AM, Surveyor interviewed RN N (Registered Nurse). RN N indicated wound care and dressing orders should be entered into the resident's physician orders and would show up on the TAR. RN N indicated if a resident had an order to leave the dressing intact, a nurse would assess for swelling, redness, signs of infection and assess around the wound. RN N indicated the nurse would document the assessment in a progress note.On 5/14/26 at 10:13 AM, Surveyor interviewed RN O (Registered Nurse). RN O indicated wound care orders are placed on the resident's TAR. RN O indicated if a resident had an order to keep the dressing in place, the nurse would assess for infection and monitor the dressing.On 5/14/26 at 10:18 AM, Surveyor interviewed RN F (Registered Nurse). RN F indicated the nurse should be monitoring R1's left hip surgical site dressing every shift. RN F indicated the nurse should enter a progress note into R1's medical record detailing the assessment. RN F indicated a resident's care plan should reflect treatments that are ordered. RN F indicated R1's care plan should have been updated.On 5/14/26 at 1:26 PM, Surveyor interviewed DON B (Director of Nursing) regarding R1's left hip surgical site and dressing. DON B indicated R1's hospital discharge order to Leave Dressing on - Keep it clean, dry and intact until clinic visit should have been entered into R1's physician orders. DON B indicated the order should have been on R1's TAR. DON B indicated the nurses should have been monitoring the site daily, if not every shift, and should have documented the findings in R1's medical record. DON B indicated R1's care plan should have been updated to reflect R1's left hip surgical site.

Based on interview and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 5 sampled residents (R1). R1 had multiple wounds on his feet with physician orders for dressing changes and treatment. These treatments were not completed on the AM (morning) shift of 1/18/26. This is evidenced by:The facility policy entitled, Wound Care, dated October 2010, states, in part: . Documentation. The following information should be recorded in the resident's medical record. 2. The date and time the wound care was given. 9. If the resident refused the treatment and the reason(s) why. 10. The signature and title of the person recording the data.R1 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes with diabetic polyneuropathy (nerve damage in multiple sites), neutropenia (low white blood cell count, which are cells that fight infection), venous insufficiency (damage to blood vessels that causes fluid to build up in legs), and obesity. R1's Medication Administration Record on 1/18/26 indicates the following treatments were not administered:Calmoseptine External Ointment 0.44-20.6% (moisture barrier cream). Apply to buttocks, groin and folds topically every morning and at bedtime for skin protection/erythema (redness). Prior to applying peri care (cleaning of the genital area and buttocks) should be done and skin patted dry. Also apply after each toileting episode. Start Date: 9/12/25.Keep high bilateral tubi grips (elastic, tubular compression bandage) (extra long so they cover from base of toes to below knees with enough fabric to fold over foot). On AM (Morning). Off at bedtime for edema (swelling) two times a day for edema. Start date: 9/12/25.Wound Care - L (Left) Foot Toes: apply betadine/povidone (antiseptic) to areas BID (twice a day). Two times a day for wound care. Start date: 1/13/25.WOUND CARE - Left Lower Extremity: 1) remove old dressing 2) cleanse w/ (with) normal saline, pat dry 3) apply Calcium Alginate (wound drainage absorber dressing), 4) cover area w/ ABD pad (absorbent dressing) 5) secure w/ kerlix (sterile gauze roll) and knee-high tubi grip to be changed BID and PRN (as needed) if saturated/dislodged. Two times a day for wound care. Start date: 1/13/26.WOUND CARE - R (right) Foot, b/w (between) 1st and 2nd dig (digit), b/w 2nd dig and 3rd: 1) remove old dressing 2) cleanse between toes w/ normal saline (sterile sodium chloride solution) 3) weave calcium alginate w/ silver, between and around toes 4) cover w/ ABD pad 5) secure w/ kerlix and knee-high tubi grip to be changed BID and PRN if saturated/dislodged. Two times a day for wound care. Start date: 1/13/26.WOUND CARE - Right Lower Extremity: 1) remove old dressing 2) cleanse w/ normal saline, pat dry 3) apply Calcium Alginate over intact and open blistered areas 4) cover are w/ ABD pad 5) secure w/ kerlix and knee-high tubi grip. To be changed BID and PRN if saturated/dislodged. Two times a day for wound care. Start date: 1/13/26.On 1/24/26 at 2:50 PM, Surveyor interviewed RN C (Registered Nurse). Surveyor asked RN C how long he has been working for the facility. RN C indicates he is a new nurse graduate and has been working for the facility for one month. Surveyor asked RN C who is responsible for conducting wound treatments or dressing changes. RN C states, the nurses. Surveyor asked RN C if an ordered dressing change or wound treatment is conducted, should those treatments be signed out in the electronic health care record. RN C states, yes. On 1/24/26 at 3:00 PM, Surveyor interviewed RN D. Surveyor asked RN D how long she has been working for the facility. RN D indicates around 4 years. Surveyor asked RN D who is responsible for conducting dressing changes or wound treatments. RN D states the nurses. Surveyor asked RN D if an ordered dressing change or wound treatment is conducted, should those treatments be signed out in the electronic health care record. RN E states, yes On 1/24/26 at 3:29 PM, Surveyor interviewed RN E and DON B (Director of Nursing). Surveyor asked RN E how long she has been working for the facility. RN E indicates around 5 years. Surveyor asked DON B how long he has been working for the facility. DON B indicates a few weeks. Surveyor asked RN E if she works directly with the facility's wound physician when he does weekly rounds at the facility. RN E states, yes. Surveyor asked RN E and DON B who is responsible for conducting dressing changes or wound treatments. RN E and DON B state the nurses. Surveyor asked RN E and DON B if an ordered dressing change or wound treatment is conducted should those treatments be signed out in the electronic health care record. RN E and DON B state, yes, and that they would expect staff to indicate if the resident refuses their treatment.No further documentation was provided regarding R1's wound care treatments for the AM shift on 1/18/26.

Based on observation, interview, and record review, the facility did not ensure all drugs and biologicals were disposed of in accordance with currently accepted professional principles for 1 of 3 residents (R2) observed. Surveyor observed R2 in their wheelchair with a nitroglycerin patch stuck to the wheel. R2 does not have an order for a nitroglycerin patch.Evidenced by:According to Enokon article titled How Should a Nitroglycerin Patch Be Disposed of? A Step-By-Step Safety Guide dated 12/2025 states in part .The Step-by-Step Removal and Disposal ProcessFollowing a precise procedure for removing your nitroglycerin patch is essential for safety and consistent treatment. Each step is designed to protect you and others from unintended contact with this potent medication.Step 1: Peel the Patch from the SkinPress down on the center of the patch with one finger. This action should cause the outer edges to lift slightly, making it easier to grab. Gently peel the patch away from your skin.Step 2: Fold and Neutralize the PatchImmediately after removal, fold the patch in half so that the sticky, medicated sides press firmly together. This action seals in any active medication left on the patch.Step 3: Dispose of it SafelyPlace the folded patch in the trash. Ensure the disposal location is secure and completely out of the reach of children and pets who might be drawn to it.Step 4: Cleanse the Application SiteAfter disposing of the patch, wash the area of skin where the patch was applied. Use simple soap and water to remove any adhesive or medication residue. https://painplaster.com/faqs/how-should-a-nitroglycerin-patch-be-removed-and-disposed-of The facility's policy titled Discarding and Destroying Medications dated 4/2019 states in part Medications will be disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste, and controlled substances.R2 was admitted to the facility on [DATE] with diagnoses that include dementia, major depressive disorder, and schizophrenia. R2's most recent Minimum Data Set (MDS) dated [DATE] indicates that a Brief Interview of Mental Status (BIMS) was not completed due to R2 being rarely/never understood.On 2/4/26 at 9:20 AM, Surveyor was making observations in the unit's dining area. Surveyor noted that R2 had an oval shaped, paper-tape like substance on the wheel of their wheelchair. Surveyor looked at R2's wheelchair wheel and noted that the object attached to the wheel stated Nitroglycerin. and appeared to be a nitroglycerin patch. On 2/4/26 at 9:33 AM, Surveyor interviewed RN C (Registered Nurse). Surveyor asked RN C if they could see what the object attached to R2's wheel is, RN C observed the object and reported that it was a nitroglycerin patch dated 2/3. Surveyor asked RN C if R2 had an order for a nitroglycerin patch, RN C stated no, and that there is only one resident on the unit that has an order for one. RN C reported that the patch would have been removed from the other resident last night. Surveyor asked RN C what the facility's policy is for disposing of a nitroglycerin patch, RN C stated that the patch should be folded on itself (folded in half), and placed in the sharps container, or wrapped in gloves, placed in the resident's garbage can, and then the garbage has to be taken out at that time. Surveyor asked RN C if they would say that the patch was properly disposed of, RN C stated no.Surveyor reviewed R2's physician's orders. R2 does not have an order for nitroglycerin.On 2/4/26 at 2:46 Am, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what their expectation is for the removal and disposal of a nitroglycerin patch, DON B stated that the patch should be folded on itself and placed in the sharps container. Surveyor asked DON B if they would expect the staff to follow that practice, DON B stated yes. Surveyor reviewed the observation of R2, and the nitroglycerin patch stuck to their wheelchair wheel. Surveyor asked DON B if they would consider the nitroglycerin patch to have been disposed of properly, DON B stated no.

Based on observations, interviews, and document review, the facility failed to designate a qualified infection preventionist (IP) to develop, implement, and monitor the facility's infection prevention program. This has the potential to affect all 70 residents residing at the facility.The facility failed to monitor residents and staff with signs and symptoms of an acute respiratory illness and protect residents and staff from contracting an acute respiratory illness during a concurrent outbreak of influenza, RSV and COVID in January 2026 The facility's failure to have an infection preventionist who developed, implemented and monitored infectious illnesses placed 70 of 70 residents and facility staff at risk for development of an infectious illness which could result in serious harm and/or death, thus leading to a finding of immediate jeopardy. The facility's Administrator and Regional Nurse Consultant were informed on 01/09/26 at 4:45 PM that Immediate Jeopardy existed at F882 (Infection Preventionist Qualifications/Role) related to the failure to employ a qualified Infection Preventionist to initiate, direct and manage the facility's infection prevention program and failed to employ a qualified back-up trained Infection Preventionist to act in the event the primary Infection Preventionist is not available. The Immediate Jeopardy began on 01/02/26 when the facility was determined to be in an active outbreak of influenza, respiratory syncytial virus (RSV) and COVID and the facility IP (infection preventionist) was not available to properly monitor, track and trend infections during a current outbreak to prevent the spread of COVID, Influenza and RSV. The facility provided an Immediate Jeopardy Removal Plan that was accepted on 01/10/26 at 2:40 PM. The survey team could not validate implementation of the removal plan prior to survey exit on 01/10/26. Findings include:Review of the facility policy titled Infection Preventionist- Policy Statement, which lacked a review date, indicated: The infection preventionist is responsible for coordinating the implementation and updating of the infection prevention and control program. Responsibilities included The infection preventionist coordinated the development and monitoring of the infection prevention and control program. the infection preventionist collects, analyzes any infection data and trends, and provides education and training on infection prevention and control practices.On 01/07/26 at 8:30 AM, the facility reported they were in outbreak status with COVID-19, influenza, and RSV. Three residents were identified with COVID-19 and/or RSV, and three residents were positive for influenza. The facility identified a Regional Nurse as the facility's IP and reported the IP worked at the facility 20 hours per week. Review of the Regional Nurse job description, which was not signed or dated, had a Job Description of The primary purpose of your job position is to plan, organize, develop and direct the overall operations of the facility. The job description included follow established infection control procedures.During an interview with the Director of Nursing (DON) on 01/08/26 at 1:00 PM, the DON confirmed the facility's IP was in the facility half-time (20 hours per week). The DON confirmed she and the ADON were responsible for managing the facility's infection control program, including the current outbreak, when the IP was not present in the building or available to analyze and review the facility's outbreak status. The DON stated neither she nor the ADON were able to access the facility's EMR Infection Tracking Program and stated they would not be able to read and understand the information in the system if they did obtain access to it. The DON stated she had only received basic training related to infection control and was not sure she was going to be able to provide comprehensive information or data related to the current outbreak.During interviews on 0l/08/26 at 10:30 AM, and again at 1:00 PM, and 4:00 PM, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) confirmed that neither were trained as the facility's IP and could not interpret the IP's information nor act on her behalf.The facility's designated IP was not present in the facility on 01/08/26, 01/09/26 or 01/10/26 and was not able to be interviewed related to the facility's current outbreak status.On 01/09/26 at 11:30 AM, the facility identified nine residents with illness and five staff off work from illness.The survey team requested the facility's documentation related to the tracking and management of the facility's current influenza and COVID outbreak on 01/08/26 at 10:30 AM, again on 01/08/26 at 1:00 PM, again on 01/08/26 at 4:00 PM, and again on 01/09/26 at 9:15 AM. Requested documentation included the facility's current staff and resident line listing documentation related to each outbreak, the facility's outbreak management plan, and evidence of respiratory symptom tracking for non-infected residents to ensure potential new cases of influenza, RSV and COVID were detected. The facility could not provide evidence of an Outbreak Management Plan related to the outbreaks or documentation to show the facility was tracking non-infected residents to ensure new infections were caught and treated timely. The facility provided documentation printed from the facility's Point Click Care (PCC) Infection Control Management System to the surveyors on 01/09/26 at 10:30 AM. The documentation indicated the facility's current outbreak status had not been evaluated, tracked, or updated since 01/05/26. The documentation indicated the facility IP began contact tracking of symptoms of respiratory illness on 12/30/25, however nothing had been documented on the contact tracking documentation since 12/30/25 when the document was initiated. 1. Review of R8's admission Record, located in the Electronic Medical Record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included history of stroke. Review of R8's Progress Notes, dated 01/05/26 and located in the EMR under the Notes tab, revealed the resident began presenting symptoms of respiratory illness, including coughing and runny nose, on that date. Review of R8's laboratory result documentation, dated 01/06/26 and provided directly to the survey team, revealed R8 tested positive for both influenza and RSV on that date. 2. Review of R9's admission Record, located in the EMR (electronic medical record) under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Parkinson's Disease. Review of R9's Progress Notes, dated 12/31/25 and located in the EMR under the Notes tab, revealed the resident began presenting symptoms of respiratory illness on that date. Review of R9's laboratory result documentation, dated 01/02/26 and provided directly to the survey team, revealed R9 tested positive for influenza on that date. 3. Review of R18's admission Record, located in the EMR (electronic medical record) under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included atrial fibrillation and recent fracture of right pubic bone. Review of R18's Progress Notes, dated 01/06/26 and located in the EMR under the Notes tab, revealed the resident began exhibiting symptoms of respiratory illness on that date. Review of R18's laboratory result documentation, dated 01/06/26 and provided directly to the survey team, revealed R18 tested positive for COVID on that date. On 01/08/26 at 9:45 AM, it was determined that the facility failed to post signage (personal protective equipment/isolation precaution type) outside the doors of R8 and R11, residents with RSV and/or influenza. Observations made on 01/08/26 at 10:01 AM revealed a visitor entered R8's room without performing hand hygiene or putting on personal protective equipment (PPE). The visitor remained in the room briefly and then exited the room without performing hand hygiene, carrying a drinking glass, and asking for water. A staff member accompanied the visitor off the unit to obtain a glass of water. The visitor re-entered R8's room without PPE or performing hand hygiene. The visitor exited the room to ask if R8 had something and was it contagious. Certified Nurse Aide (CNA) 9 and CNA10 responded to the visitor's question with Yes. When the visitor had additional questions, the CNAs directed her to the nurse. During an interview on 01/08/26 at 10:30 AM, Housekeeper (HK)2 and the Housekeeping Manager (HKM) revealed they were unaware of the resident's infective illness and were unaware of the PPE required to wear to enter the residents' rooms. HK2 and HKM confirmed there were no signs at the doorway of the room directing them on what to do prior to entering the residents' rooms. Cross reference F880.The facility's failure to ensure it employed a qualified Infection Preventionist to initiate, direct and manage the facility's infection prevention program and its failure to employ a qualified back-up trained Infection Preventionist to act in the event the primary Infection Preventionist is not available created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The survey team was unable to confirm removal of the jeopardy by the conclusion of the survey.

Based on record review, observations, interviews, and facility policy review, the facility failed did not establish and maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable disease and infections. This has the potential to affect all 70 residents. The facility failed to ensure adequate infection control processes were followed to ensure containment of Influenza, Respiratory Syncytial Virus (RSV), and COVID during a concurrent facility outbreak of all three infections. This failure created the potential for all residents, staff, and visitors to the facility to become infected with one or more of these viruses, potentially leading to serious illness, hospitalization, and or/death, thus leading to a finding of immediate jeopardy. The facility's Administrator and Regional Nurse Consultant were informed on 01/09/26 at 4:45 PM that Immediate Jeopardy existed at F880 (Infection Control) related to the failure to ensure appropriate orders and care plans were in place to address influenza/RSV/COVID infection for 6 of 70 Residents (Residents (R)8, R9, R21, R18, R17 and R16) currently infected with the virus(s), failure to ensure proper signage was in place to indicate isolation procedures for two Residents (R8 and R9) currently infected with influenza and RSV, and failure to ensure accurate and timely monitoring and management of the current outbreak of influenza, COVID and RSV. The Immediate Jeopardy began on 01/02/26 when the facility was determined to be in an active outbreak of influenza, RSV and COVID and an adequate facility plan was not in place to address the outbreak. The facility provided an Immediate Jeopardy Removal Plan that was accepted on 01/10/26 at 2:40 PM. The survey team could not validate implementation of the removal plan prior to survey exit on 01/10/26.Findings include:CDC (center for disease control and prevention) indicates: . Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection.setting specific. Nursing Homes : Assign one or more individuals with training in IPC to provide on-site management of the IPC program. Stay connected with the healthcare-associated infection program in your state health department, as well as your local health department, and their notification requirements. Report SARS-CoV-2 infection data to National Healthcare Safety Network (NHSN) Long-term Care Facility (LTCF) COVID-19 Module. See Centers for Medicare & Medicaid Services (CMS) COVID-19 reporting requirements. Placement of residents with suspected or confirmed SARS-CoV-2 infection. Ideally, residents should be placed in a single-person room as described in Section 2. If limited single rooms are available, or if numerous residents are simultaneously identified to have known SARS-CoV-2 exposures or symptoms concerning for COVID-19, residents should remain in their current location.Responding to a newly identified SARS-CoV-2-infected HCP or resident. When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission.Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Due to challenges in interpreting the result, testing is generally not recommended for asymptomatic people who have recovered from SARS-CoV-2 infection in the prior 30 days. Testing should be considered for those who have recovered in the prior 31-90 days; however, an antigen test instead of a nucleic acid amplification test (NAAT) is recommended. This is because some people may remain NAAT positive but not be infectious during this period.Empiric use of Transmission-Based Precautions for residents and work restriction for HCP are not generally necessary unless residents meet the criteria described in Section 2 or HCP meet criteria in the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, respectively. However, source control should be worn by all individuals being tested.In the event of ongoing transmission within a facility that is not controlled with initial interventions, strong consideration should be given to use of Empiric use of Transmission-Based Precautions for residents and work restriction of HCP with higher-risk exposures. In addition, there might be other circumstances for which the jurisdiction's public authority recommends these and additional precautions.If no additional cases are identified during contact tracing or the broad-based testing, no further testing is indicated. Empiric use of Transmission-Based Precautions for residents and work restriction for HCP who met criteria can be discontinued as described in Section 2 and the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, respectively.If additional cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing should continue on affected unit(s) or facility-wide every 3-7 days until there are no new cases for 14 days.If antigen testing is used, more frequent testing (every 3 days), should be considered.Indoor visitation during an outbreak response: Facilities should follow guidance from CMS about visitation. Visitors should be counseled about their potential to be exposed to SARS-CoV-2 in the facility. If indoor visitation is occurring in areas of the facility experiencing transmission, it should ideally occur in the resident's room. The resident and their visitors should wear well-fitting source control (if tolerated) and physically distance (if possible) during the visit. Review of the facility's policy titled, Outbreak of Communicable Disease Policy, revised in 09/2022 read, in pertinent part, Outbreaks of communicable diseases within the facility are promptly identified and managed;.and An outbreak is defined as one of the following: a. One case of an infection that is highly communicable or has serious health implications; b. Trends that are ten (10) percent (or more) above the historical rate of infection for the facility; or c. Occurrence of three. (3) or more cases of the same infection over a specified period of time and in a defined area; .and An outbreak of influenza is defined as anything exceeding the endemic rate, or a single case if unusual for the facility; and The administrator is responsible for: a. communicating data about reportable diseases to the health department; b. establishing temporary policies to contain transmission, including: (1) new admissions; (2) visitation; (3) group activities; and (4) staff cohorting; .c. communicating with the infection control committee; and d. notifying families; and The infection preventionist and director of nursing services are responsible for a. managing surveillance data; b. monitoring ill residents and staff; c. initiating transmission-based precautions, as appropriate; and d. communicating with the medical director and attending physicians; and The nursing staff is responsible for: a. notifying the director of nursing services of newly symptomatic residents; b. providing infection surveillance data in a timely manner; and c. obtaining laboratory specimens as directed; and All employees/staff: a. follow standard precautions at all times, and transmission-based precautions as indicated; and b. report any symptoms relating to the current disease outbreak to their supervisor. Review of the facility's policy titled, Isolation - Categories of Transmission-Based Precautions Policy revised 09/2022 revealed, Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents; and When a resident is placed on transmission-based precautions; appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution; and Droplet Precautions: 1. Droplet precautions are implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets that can be generated by the individual coughing, sneezing, talking or by performance of procedures such as suctioning; and Masks are worn when entering the room; and Gloves, gown and goggles are worn if there is risk of spraying secretions. Review of the facility's policy titled, Influenza, Prevention and Control of Seasonal Policy revised 03/2022 revealed, Surveillance: 1. When there is influenza activity in the local community, or one laboratory-confirmed influenza case is identified in the facility, active daily surveillance for influenza illness is conducted among all new and current residents, healthcare personnel and visitors; and Visits to residents on precautions for influenza are scheduled and controlled to allow for: b. providing instruction, before visitors enter residents' rooms, on hand hygiene, limiting surfaces touched, and the use of personal protective equipment (PPE) while in the resident's room. 1.Review of R8's admission Record, located in the Electronic Medical Record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included history of stroke.Review of R8's admission Minimum Data Set (MDS), assessment with an Assessment Reference Date (ARD) of 12/16/25 and located in the EMR under the MDS tab, indicated a Brief Interview for Mental States (BIMS) score of four out of 15 which indicated the resident had severe cognitive impairment.Review of R8's Progress Notes, dated 01/05/26 and located in the EMR under the Notes tab, revealed the resident began presenting symptoms of respiratory illness, including coughing and runny nose on that date.Review of R8's laboratory result documentation, dated 01/06/26 and provided directly to the survey team, revealed R8 tested positive for both influenza and RSV on that date.Review of R8's comprehensive Physician Order Set, dated 01/08/26 and located in the EMR under the Orders tab, revealed no orders related to the management of R8's influenza or RSV infection, including orders for the resident to be placed on Transmission-Based (Droplet) Precautions (TBP).Review of R8's Comprehensive Care Plan, dated 01/08/26 and located in the EMR under the Care Plan tab, revealed no care planning related to the resident's influenza or RSV infection.Observations on 01/08/26 between 9:30 AM and 9:45 AM and again between 10:00 AM and 10:45 AM revealed R8 (influenza positive and observed with a frequent cough) was observed in her room. There was no signage on the resident's door to indicate the resident's positive influenza/Droplet Precautions status. Observations and interviews on 01/08/26 between 10:00 AM and 10:45 AM, revealed R8's daughter visiting with the resident in her room. Observations made on 01/08/26 at 10:01AM revealed a visitor entered R8's room without performing hand hygiene or putting on personal protective equipment (PPE). The visitor remained in the room briefly and then exited the room without performing hand hygiene carrying a drinking glass and asking for water. A staff member accompanied the visitor off the unit to obtain a glass of water. The visitor re-entered R8's room without PPE or performing hand hygiene. The visitor may have overheard the conversations of staff outside room [number] and exited the room to ask if R8 had something and was it contagious. Certified Nurse Aide (CNA)9 and CNA10 responded to the visitor's question with yes. When the visitor had additional questions, the CNAs directed her to the nurse. Facility staff Housekeeper (HK)2, Housekeeping Manager (HKM), CNA 8, and CNA9 confirmed the lack of signage indicating what PPE was needed and what precautions to take when entering R8's room to protect themselves, visitors, and other residents.2.Review of R9's admission Record, located in the EMR (electronic medial record) under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Parkinson's Disease.Review of R9's quarterly MDS, assessment with an ARD of 12/28/25 and located in the EMR under the MDS (minimum data set) tab, indicated a BIMS (brief interview of mental status) score of 10 out of 15 which indicated the resident had severe cognitive impairment.Review of R9's Progress Notes, dated 12/31/25 and located in the EMR under the Notes tab, revealed the resident began presenting symptoms of respiratory illness on that date.Review of R9's laboratory result documentation, dated 01/02/26 and provided directly to the survey team, revealed R9 tested positive for influenza on that date.R9's Nurses note, dated 1/6/25 at 14:43 (2:43PM) states in part: LATE ENTRY note text: writer noted to have spoken with residents NP (nurse practitioner) regarding the start of Tamiflu for the resident. Writer noted that the residents symptoms of Influenza had since resolved and that per NP orders, resident could be taken off isolation as of 1/7/26 since their symptoms began on 12/31/25. Writer notes that per NP Tamiflu was still indicated for the resident despite resolution of symptoms d/t (due to) residents age, living scenario, and comorbidities. Writer noted to proceed with placing order for prescribed Tamiflu doses. Author: (RN2). R9's Order details indicate: 1/6/26, patient tested positive for influenza A on 1/5/26à needs to be on droplet precautions at facility for 7 days since symptoms started (symptoms started on 12/31/25, at least until 1/7/26) or until after 24 hours after resolution of symptoms (whichever is longer)Review of R9's comprehensive Physician Order Set, dated 01/08/26 and located in the EMR under the Orders tab, revealed no orders related to management of R9's influenza, including orders for the resident to be placed on TBP.Review of R9's Comprehensive Care Plan, dated 01/08/26 and located in the EMR under the Care Plan tab, revealed no care planning related to management of the resident's influenza infection.Observations on 01/08/26 between 9:30 and 9:45 AM and again between 10:00 and 10:45 AM revealed R9 (influenza positive and with a 01/08/26 physician's order to begin receiving Tamiflu (an anti-viral medication) related to his symptoms of influenza on that date) in his room. There was no signage on the resident's door to indicate the resident's positive influenza/Droplet Precaution) status. 3.Review of R21's admission Record, located in the EMR (electronic medical record) under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included dysphagia and history of sepsis.Review of R21's admission MDS, (minimum data set) with an ARD (assessment reference date) of 12/19/26, located under the MDS tab in the EMR revealed the resident's cognition was not assessed at the time of the assessment. The resident's record indicated the resident had mild cognitive impairment.Review of R21's Progress Notes, dated 01/08/26 and located in the EMR under the Notes tab, revealed the resident began exhibiting symptoms of respiratory illness on that date.Review of R21's laboratory result documentation, dated 01/08/26 and provided directly to the survey team, revealed R21 tested positive for influenza on that date.Review of R21's comprehensive Physician Order Set, dated 01/08/26 and located in the EMR under the Orders tab, revealed no orders related to the management of R21's influenza, including orders for the resident to be placed on TBP.Review of R21's Comprehensive Care Plan, dated 01/08/26 and located in the EMR under the Care Plan tab, revealed no care planning related to management of the resident's influenza infection.4.Review of R18's admission Record, located in the EMR (electronic medical record) under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included atrial fibrillation and recent fracture of right pubic bone.Review of R18's admission MDS, (minimum data set) with an ARD (assessment reference date) of 01/05/26 and found in the EMR under the MDS Tab, revealed a BIMS score of 15 out of 15 which indicated the resident was cognitively intact.Review of R18's Progress Notes, dated 01/06/26 and located in the EMR under the Notes tab, revealed the resident began exhibiting symptoms of respiratory illness on that date.Review of R18's laboratory result documentation, dated 01/06/26 and provided directly to the survey team, revealed R18 tested positive for COVID on that date.Review of R18's comprehensive Physician Order Set, dated 01/06/26 and located in the EMR under the Orders tab, revealed orders for R18 to be placed on Droplet Precautions related to her COVID infection as of that date.Review of R18's Comprehensive Care Plan, dated 01/08/26 and located in the EMR under the Care Plan tab, revealed no care planning related to management of the resident's COVID infection.5.Review of R16's admission Record, located in the EMR (electronic medical record) under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included vascular dementia and dysphagia.Review of R16's admission MDS, (minimum data set) with an ARD (assessment reference date) of 12/09/25 and located in the EMR under the MDS tab, revealed a BIMS score of five out of 15 which indicated the resident had severe cognitive impairment.Review of R16's Progress Notes, dated 01/01/26 and located in the EMR under the Notes tab, revealed the resident began exhibiting symptoms of respiratory illness on that date.Review of R16's laboratory result documentation, dated 01/01/26 and provided directly to the survey team, revealed R16 tested positive for COVID on that date.Review of R16's comprehensive Physician Order Set, dated 01/08/26 and found in the EMR under the Orders tab, revealed no orders for R16 to be placed on Droplet Precautions related to her COVID infection prior to that date.Review of R16's Comprehensive Care Plan, dated 01/08/26 and located in the EMR under the Care Plan tab, revealed no care planning related to management of the resident's COVID infection as of that date.During an interview with Registered Nurse (RN)2 on 01/08/26 at 9:45 AM, she stated she thought R8 was supposed to be on droplet precautions, and she was not sure if R9 was supposed to be on droplet precautions. RN2 stated staff relied on the signage posted on each infected resident's door to determine whether that resident was on any type of precautions (including droplet precautions). The facility's designated Infection Preventionist (IP) was not present in the facility on 01/08/26, 01/09/26 or 01/10/26 and was not able to be interviewed related to the facility's current outbreak status. During an interview with the Director of Nursing (DON) on 01/08/26 at 1:00 PM, the DON confirmed the facility's IP was in the facility half-time (20 hours per week). The DON confirmed she and the Assistant Director of Nursing (ADON) were responsible for managing the facility's infection control program, including the current outbreak, when the IP was not present in the building or available to analyze and review the facility's outbreak status. The DON stated neither she nor the ADON were able to access the facility's EMR Infection Tracking Program and stated they would not be able to read and understand the information in the system if they did obtain access to it. The DON stated she had only received basic training related to infection control and was not sure she was going to be able to provide comprehensive information or data related to the current outbreak. The DON stated she was not tracking residents currently infected with influenza, RSV or COVID in any organized way and was not tracking respiratory symptoms in well residents to ensure newly developing infection was caught in a timely manner. The DON stated she was not sure whether the IP was tracking the current outbreak status as the IP was in another facility and was not available to this facility to review. The DON stated she would have to go to each unit and check with staff on the unit to see what was going on related to active infection, symptom tracking, isolation status, and family notification of illness. During an interview with the Administrator and the DON on 01/08/26 at 4:00 PM, neither was able to provide an outbreak management plan related to the current influenza and COVID outbreaks. The DON stated she did not know why there was no signage to indicate Droplet Precautions on the doors of R8 or R9. She stated her expectation was signage would be present on room doors to indicate if anyone was on precautions. During an interview with the DON on 01/09/26 at 10:00 AM, she confirmed isolation and droplet precaution orders had not been entered for any of the residents currently on droplet precautions for influenza, COVID, and RSV. The DON confirmed care plans had not been entered for any of the residents related to the management of influenza, COVID, or RSV. The DON stated she was not sure why the orders and care plans had not been initiated. She stated the information was being added to each record that day (01/09/26). The DON additionally stated symptom tracking for respiratory illness was also initiated for all residents in the facility that day (01/09/26) as this had not been happening prior to that. During an interview with the Regional Nurse Consultant on 01/09/26 at 10:30 AM, he confirmed his expectation was any facility outbreak would be appropriately managed and documentation would be in place related to this management, including line listing of residents with symptoms of illness and/or positive for illness such as influenza, RSV or COVID infection, a functioning outbreak management plan, evidence of symptom tracking in staff and residents and family notification of infection and facility outbreak status. The survey team requested the facility's documentation related to the tracking and management of the facility's current influenza and COVID outbreak on 01/08/26 at 10:30 AM, again on 01/08/26 at 1:00 PM, again on 01/08/26 at 4:00 PM, and again on 01/09/26 at 9:15 AM. Requested documentation included the facility's current staff and resident line listing documentation related to each outbreak, the facility's outbreak management plan, and evidence of respiratory symptom tracking for non-infected residents to ensure potential new cases of influenza, RSV and COVID were detected. The facility could not provide evidence of an Outbreak Management Plan related to the outbreaks or documentation to show the facility was tracking non-infected residents to ensure new infections were caught and treated timely. The facility provided documentation printed from the facility's Point Click Care (PCC) Infection Control Management System to the surveyors on 01/09/26 at 10:30 AM. The documentation indicated the facility's current outbreak status had not been evaluated, tracked, or updated since 01/05/26. The documentation indicated the facility IP began contact tracking of symptoms of respiratory illness on 12/30/25, however nothing had been documented on the contact tracking documentation since 12/30/25 when the document was initiated. The facility provided a Resident Symptom Management Log dated 01/09/26 to the survey team on 01/09/26 at 12:30 PM. The document indicated five residents with positive COVID infection and four residents with current positive influenza infection had been identified in the facility between 12/30/25 and 01/09/26. The facility provided a Symptom Management Log dated 01/09/26 to the survey team on 01/09/26 at 12:30 PM to indicate the following staff reported respiratory illness symptom reporting by staff: Activity Aide (AA1) reported she was feeling Feverish on 01/01/26.AA2 reported a cough and nausea on 01/02/26.Houskeeper (HK1) reported a cough and nausea on 01/02/26.Certified Nursing Assistant (CNA)5 reported a cough, sore throat, and headache on 01/04/26.CNA3 reported nausea and vomiting on 01/04/26.CNA10 reported vomiting and fever on 01/05/26.CNA11 reported chills and a sore throat on 01/05/26.RN4 reported a sore throat, runny nose, and congestion on 01/09/26. The facility's failure to implement a plan to track infections, isolate ill residents, develop care plans to manage ill residents, and to implement procedures to prevent the spread of three concurrent infections (influenza, RSV, and COVID) created a reasonable likelihood for serious resident harm, thus leading to a finding of immediate jeopardy. The facility submitted a removal plan; however, the survey team could not confirm the removal of the jeopardy by the conclusion of the survey.

Based on interview, record review, and facility policy review, the facility failed to protect 2 of 22 sampled residents' (R2 and R3) right to be free from verbal abuse by a Registered Nurse (RN1). RN1 referred to R2 as a (drug) addict and told R3 to Stop your damn crying while administering the resident's eye drops. Findings include: The facility's Abuse, Neglect, Exploitation or Misappropriation Prevention Program Policy dated most recently revised in 04/2021 read, in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation; and The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a facility staff;. 1.Review of R2's admission Record, located in the Electronic Medical Record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included acute and chronic respiratory failure and heart disease. Review of R2's significant change Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/10/25 and located 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. 2.Review of R3's admission Record, located in the EMR (electronic medical record) under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included hypertensive heart disease and generalized anxiety disorder. Review of R3's quarterly MDS, assessment with an ARD of 10/29/25 and located in the EMR under the MDS tab, indicated a BIMS score of 6 out of 15 which indicated the resident was severely cognitively impaired.The facility is R3's home. A reasonable person would expect that he/she is safe and will be treated with respect and dignity while being free from intimidation within their own home. Review of the facility's incident reporting and investigation documentation revealed an investigation related to reported potential verbal abuse of R2 and R3 was initiated on 12/14/25. The report indicated that R2 reported on the morning of 12/14/25, RN1 had been verbally abusive to R3 on the evening of 12/13/25 when RN1 told R3 to Stop your Damn crying when R3 cried while RN1 administered eye drops. In addition, R2 reported RN1 was abusive to her (R2) during the early morning of 12/14/25 when R2 requested her ordered narcotic pain medication. RN1 responded by referring to her (R2) as Addicted. During an interview conducted with R2 as part of the investigation into alleged verbal abuse of R2 and R3 by RN1, R2 confirmed she witnessed RN1 telling R3 to Stop your Damn crying and had referred to herself (R2) as addicted when she requested her ordered pain medication on the evening/night of 12/13/25-12/14/25. The facility investigation into the incident resulted in RN1 being immediately removed from the facility and placed on the facility's Do Not Return List. The investigation summary revealed the facility did not substantiate verbal abuse of R2 and R3 by RN1, however the facility concluded the matter was a breach of proper customer service. During an interview with R2 on 01/07/26 at 12:30 PM, R2 indicated she remembered the incident and stated she felt like she was verbally abused by RN1 when RN1 referred to her as addicted and she felt R3 was verbally abused by RN1 when she witnessed R3 being told to Stop her Damn Crying by RN1 when RN1 was administering her eye drops.R3 could not be interviewed during the investigation due to her poor cognition. During an interview with the Administrator and the Regional Nurse Consultant (RNC) on 12/10/26 at 1:13 PM, the Administrator stated he did not feel R2 or R3 were abused by RN1. He stated he felt the reported abuse came down to a He Said/She Said situation and abuse was not substantiated.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported to the administrator and other officials in accordance with State law through established procedures for 1 of 3 residents (R1) reviewed for abuse.On 10/22/25, an allegation of verbal abuse toward R1 from a family member was reported to the facility and the facility did not thoroughly investigate the allegation of abuse.This is evidenced by:The facility's policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 4/21, includes: Residents have the right to be free from abuse. This includes but is not limited to freedom from .verbal.abuse. 1. Protect residents from abuse.by anyone including, but not necessarily limited to: f. family members; 2. Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents; 8. Identify and investigate all possible incidents of abuse. 9. Investigate and report any allegations within timeframes required by federal requirements. 10. Protect residents from any further harm during investigations.The facility's policy Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated 9/22, includes: All reports of resident abuse.are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Investigating Allegations 1. All allegations are thoroughly investigated. The administrator initiates investigations. 5. The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility. 7. The individual conducting the investigation as a minimum: d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; f. interviews the resident. l. documents the investigation completely and thoroughly. Witness statements are obtained in writing, signed and dated.R1 admitted to the facility on [DATE].R1's BIMS (Brief Interview for Mental Status) completed on 10/17/25 has a score of 13, indicating R1 is cognitively intact.On 10/29/25 at 12:30 PM, Surveyor interviewed R4. R4 indicated she had been discharged home and was no longer at the facility. R4 explained on 10/22/25, she heard FM E (Family Member) in R1's room. R4 stated FM E was screaming and using profanity toward R1. R4 indicated it seemed FM E was mad and yelling at R1. R4 had a visitor in her room at the time, RV D (Resident's Visitor). R4 stated hearing the interaction between FM E and R1 was scary and sickening. R4 stated It tore me up to hear the way R1 was being treated. R4 indicated she reported the abuse to SS C (Social Services).On 10/29/25 at 12:35 PM, Surveyor interviewed RV D regarding the interaction between FM E and R1. RV D indicated she was visiting R4 when she heard screaming next door. RV D indicated she left R4's room and was standing outside of R1's room. RV D indicated she saw FM E standing at the foot of R1's bed screaming and yelling. RV D indicated FM E had a hanger in her hand and while she was yelling at R1, FM E threw the hanger across the floor and the hanger hit the wall. RV D stated nobody should be treated that way and she was furious that someone would treat another person like that. RV D stated That's abuse. It was awful. It's elder abuse. I'm glad she not at home with her. RV D indicated SS C came into R4's room and asked about the incident. RV D indicated she told SS C what happened.On 10/29/25 at 10:28 AM, Surveyor interviewed SS C (Social Services) regarding R1 and FM E (Family Member). SS C stated on 10/22/25, R4 and RV D reported the incident to her. SS C stated FM E was yelling and swearing at R1 and FM E threw a hanger against the wall in R1's room. SS C stated she reported this to the previous NHA (Nursing Home Administrator), NHA F. SS C stated she did not talk to R1 regarding the incident because FM E is R1's activated power of attorney and FM E instructed the staff they cannot speak to R1 without FM E being present. SS C indicated FM E visits daily. SS C indicated FM E will go into R1's room and shut the door and when FM E comes out, she appears frustrated. SS C indicated she feels the incident on 10/22/25 is considered abuse and that is why she reported it to NHA F. SS C indicated she is not aware of any plan or interventions the facility has put in place to keep R1 safe and free from further abuse.On 10/29/25 at 10:48, Surveyor interviewed NHA A (Nursing Home Administrator) regarding R1 and FM E. NHA A indicated the interaction on 10/22/25 between R1 and FM E could be considered abuse. NHA A indicated the facility has not interviewed R1 because FM E is R1's activated power of attorney and has to be present for staff to talk with R1. NHA A indicated staff want the residents to be safe and staff are encouraged to report and document any incidents. NHA A indicated staff try to monitor the interactions, but FM E frequently closes the door. NHA A indicated the facility did not implement a plan or any interventions to ensure R1 is kept safe and free from further abuse. NHA A indicated the facility did not report nor do a thorough investigation into this incident.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the appropriate agencies for 1 of 1 abuse allegations involving a resident (R1).On 10/22/25, an allegation of verbal abuse toward R1 from a family member was reported to the facility and the facility did not report the allegation of abuse.This is evidenced by:The facility's policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 4/21, includes: Residents have the right to be free from abuse. This includes but is not limited to freedom from .verbal.abuse. 1. Protect residents from abuse.by anyone including, but not necessarily limited to: f. family members; 2. Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents; 8. Identify and investigate all possible incidents of abuse. 9. Investigate and report any allegations within timeframes required by federal requirements. 10. Protect residents from any further harm during investigations. The facility's policy Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated 9/22, includes: All reports of resident abuse.are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. 1. If resident abuse.is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. R1 admitted to the facility on [DATE]. R1's BIMS (Brief Interview for Mental Status) completed on 10/17/25 has a score of 13, indicating R1 is cognitively intact. On 10/29/25 at 12:30 PM, Surveyor interviewed R4. R4 indicated she had been discharged home and was no longer at the facility. R4 explained on 10/22/25, she heard FM E (Family Member) in R1's room. R4 stated FM E was screaming and using profanity toward R1. R4 indicated it seemed FM E was mad and yelling at R1. R4 had a visitor in her room at the time, RV D (Resident's Visitor). R4 stated hearing the interaction between FM E and R1 was scary and sickening. R4 stated It tore me up to hear the way R1 was being treated. R4 indicated she reported the abuse to SS C (Social Services).On 10/29/25 at 12:35 PM, Surveyor interviewed RV D regarding the interaction between FM E and R1. RV D indicated she was visiting R4 when she heard screaming next door. RV D indicated she left R4's room and was standing outside of R1's room. RV D indicated she saw FM E standing at the foot of R1's bed screaming and yelling. RV D indicated FM E had a hanger in her hand and while she was yelling at R1, FM E threw the hanger across the floor and the hanger hit the wall. RV D stated nobody should be treated that way and she was furious that someone would treat another person like that. RV D stated That's abuse. It was awful. It's elder abuse. I'm glad she not at home with her. RV D indicated SS C came into R4's room and asked about the incident. RV D indicated she told SS C what happened.On 10/29/25 at 10:28 AM, Surveyor interviewed SS C (Social Services) regarding R1 and FM E (Family Member). SS C stated on 10/22/25, R4 and RV D reported the incident to her. SS C stated FM E was yelling and swearing at R1 and FM E threw a hanger against the wall in R1's room. SS C stated she reported this to the previous NHA (Nursing Home Administrator), NHA F. SS C stated she did not talk to R1 regarding the incident because FM E is R1's activated power of attorney and FM E instructed the staff they cannot speak to R1 without FM E being present. SS C indicated FM E visits daily. SS C indicated FM E will go into R1's room and shut the door and when FM E comes out, she appears frustrated. SS C indicated she feels the incident on 10/22/25 is considered abuse and that is why she reported it to NHA F. SS C indicated she is not aware of any plan or interventions the facility has put in place to keep R1 safe and free from further abuse. On 10/29/25 at 10:48, Surveyor interviewed NHA A (Nursing Home Administrator) regarding R1 and FM E. NHA A indicated the interaction on 10/22/25 between R1 and FM E could be considered abuse. NHA A indicated the facility has not interviewed R1 because FM E is R1's activated power of attorney and has to be present for staff to talk with R1. NHA A indicated staff want the residents to be safe and staff are encouraged to report and document any incidents. NHA A indicated staff try to monitor the interactions, but FM E frequently closes the door. NHA A indicated the facility did not implement a plan or any interventions to ensure R1 is kept safe and free from further abuse. NHA A indicated the facility did not report the allegation.

Based on interview and record review, the facility did not implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 3 residents (R1) reviewed for abuse.The facility did not implement their Abuse policy when the facility was made aware R1 was verbally abused by a family member. The facility did not put interventions in place to prevent further abuse, the facility did not report nor investigate the allegation of abuse.This is evidenced by:The facility's policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 4/21, includes: Residents have the right to be free from abuse. This includes but is not limited to freedom from .verbal.abuse. 1. Protect residents from abuse.by anyone including, but not necessarily limited to: f. family members; 2. Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents; 8. Identify and investigate all possible incidents of abuse. 9. Investigate and report any allegations within timeframes required by federal requirements. 10. Protect residents from any further harm during investigations. R1 admitted to the facility on [DATE]. R1's BIMS (Brief Interview for Mental Status) completed on 10/17/25 has a score of 13, indicating R1 is cognitively intact. On 10/29/25 at 12:30 PM, Surveyor interviewed R4. R4 indicated she had been discharged home and was no longer at the facility. R4 explained on 10/22/25, she heard FM E (Family Member) in R1's room. R4 stated FM E was screaming and using profanity toward R1. R4 indicated it seemed FM E was mad and yelling at R1. R4 had a visitor in her room at the time, RV D (Resident's Visitor). R4 stated hearing the interaction between FM E and R1 was scary and sickening. R4 stated It tore me up to hear the way R1 was being treated. R4 indicated she reported the abuse to SS C (Social Services).On 10/29/25 at 12:35 PM, Surveyor interviewed RV D regarding the interaction between FM E and R1. RV D indicated she was visiting R4 when she heard screaming next door. RV D indicated she left R4's room and was standing outside of R1's room. RV D indicated she saw FM E standing at the foot of R1's bed screaming and yelling. RV D indicated FM E had a hanger in her hand and while she was yelling at R1, FM E threw the hanger across the floor and the hanger hit the wall. RV D stated nobody should be treated that way and she was furious that someone would treat another person like that. RV D stated That's abuse. It was awful. It's elder abuse. I'm glad she not at home with her. RV D indicated SS C came into R4's room and asked about the incident. RV D indicated she told SS C what happened.On 10/29/25 at 10:28 AM, Surveyor interviewed SS C (Social Services) regarding R1 and FM E (Family Member). SS C stated on 10/22/25, R4 and RV D reported the incident to her. SS C stated FM E was yelling and swearing at R1 and FM E threw a hanger against the wall in R1's room. SS C stated she reported this to the previous NHA (Nursing Home Administrator), NHA F. SS C stated she did not talk to R1 regarding the incident because FM E is R1's activated power of attorney and FM E instructed the staff they cannot speak to R1 without FM E being present. SS C indicated FM E visits daily. SS C indicated FM E will go into R1's room and shut the door and when FM E comes out, she appears frustrated. SS C indicated she feels the incident on 10/22/25 is considered abuse and that is why she reported it to NHA F. SS C indicated she is not aware of any plan or interventions the facility has put in place to keep R1 safe and free from further abuse. On 10/29/25 at 10:48, Surveyor interviewed NHA A (Nursing Home Administrator) regarding R1 and FM E. NHA A indicated the interaction on 10/22/25 between R1 and FM E could be considered abuse. NHA A indicated the facility has not interviewed R1 because FM E is R1's activated power of attorney and has to be present for staff to talk with R1. NHA A indicated staff want the residents to be safe and staff are encouraged to report and document any incidents. NHA A indicated staff try to monitor the interactions, but FM E frequently closes the door. NHA A indicated the facility did not implement a plan or any interventions to ensure R1 is kept safe and free from further abuse. NHA A indicated the facility did not report nor do a thorough investigation into this incident. The facility did not implement their written policies and procedures that prohibit and prevent abuse, neglect, and exploitation for R1.

Based on interview and record review, the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 out of 19 residents (R74) reviewed for change of condition.R74 had orders to update the physician with pulse greater than 119. R74 had a pulse of 140 and the facility did not complete a nursing assessment, recheck the pulse, consult with the physician, or complete ongoing monitoring of R74. R74 was found pulseless and non-breathing. The facility's failure to recognize a change in condition and perform a thorough nursing assessment along with ongoing assessments and monitoring of a resident created a finding of immediate jeopardy that began on [DATE]. Surveyor notified the NHA A (Nursing Home Administrator) of the immediate jeopardy on [DATE] at 2:03 PM. The immediate jeopardy was removed on [DATE]; 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. Evidenced by:The facility's Change in a Resident's Condition or Status policy, dated 2/2021, states in part: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., (example) changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): .d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly;.i. specific instruction to notify the physician of changes in the resident's condition.3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR (Situation, Background, Assessment, and Recommendation-a standardized tool used by nurses to communicate critical patient information to other healthcare providers) Communication Form.8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s (Licensed Practical Nurse) or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis.R74 was admitted to the facility on [DATE] with diagnoses to include Other Cardiomyopathies (a disease of the heart muscle which causes the heart to have a harder time pumping blood to the rest of the body); Type 2 Diabetes Mellitus with ketoacidosis without coma (a condition when the body can't make enough insulin to regulate blood sugars which can cause heart concerns due to electrolyte imbalances); morbid obesity; and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.)R74's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident is cognitively intact. R74's Physician's Orders include:*Order date [DATE] CPR (cardiopulmonary resuscitation-indicating full code status; a medical directive instructing healthcare providers to perform life saving measures in the event of a cardiac or respiratory arrest.)R74's Hospital Discharge summary dated [DATE], states in part: PHMx (past medical history).s/p (status post-a condition after a specific past event) cardiac arrest (when the heart suddenly and unexpectedly stops beating) with defibrillator in place (a device that provides electric shock to the heart).primary familial cardiomyopathy (a genetic heart condition where the heart muscle thins and weakens, causing inefficient pumping).R74's Progress Note dated [DATE] at 12:34 PM, states in part: Elevated heart rate noted when obtaining VS (vital signs). Apical pulse rate (pulse point on the chest at the tip of the heart) is 105 and regular.called the on-call.advised that patient be evaluated in the ER (Emergency Room) with previous cardiac history, resident refused x3 (three times), education of importance was provided, resident still declined.R74's Physician's Orders include: Order date [DATE] VS every shift for monitoring.R74's Progress notes include:*[DATE] 11:26 am message left with NP (Nurse Practitioner) regarding continued elevated HR (heart rate) 110. Continues to deny heart palpations, SOB (shortness of breath), or chest pain.*[DATE] 11:39 am NP updated and meeting with resident today. *[DATE] 2:56 am . update left with NP of elevated HR of 114 and need for parameters of when to call MD.R74's Physician's Orders include:*Order date [DATE] Update NP in 1 week with heart rates one time only for Tachycardia (a condition where the heart beats abnormally fast, over 100 beats a minute) start date [DATE]*Order date [DATE] VS every shift, update provider for HR > (greater than) 119 and/or HR>100 with other symptoms, every shift for tachycardia*Order date [DATE] Update provider for HRs sustained >119 (for HR in 120s) or HR>100 with associated symptoms [dyspnea (difficulty breathing), CP (chest pain), dizziness, diaphoresis (sweating) and/or palpitations (sensation of feeling your heart beat abnormally)] every shift for TachycardiaR74's Weights and Vitals Summary for Pulse includes:*[DATE] 12:34 PM 105 bpm (beats per minute)*[DATE] 3:33 PM 102 bpm*[DATE] 5:06 AM 115 bpm*[DATE] 10:40 AM 110 bpm*[DATE] 3:14 PM 113 bpm*[DATE] 11:48 PM 114 bpm*[DATE] 7:59 AM 116 bpm*[DATE] 4:40 PM 111 bpm*[DATE] 12:10 AM 115 bpm*[DATE] 9:04 AM 117 bpm*[DATE] 8:56 PM 109 bpm*[DATE] 11:34 PM 116 bpm*[DATE] 10:38 AM 116 bpm*[DATE] 4:57 PM 115 bpm*[DATE] 2:45 AM 102 bpm*[DATE] 2:35 PM 108 bpm*[DATE] 9:17 PM 88 bpm*[DATE] 2:15 AM 99 bpm*[DATE] 1:52 PM 103 bpm*[DATE] 3:58 PM 104 bpm*[DATE] 9:17 PM 105 bpm*[DATE] 12:14 AM 102 bpm*[DATE] 9:32 AM 100 bpm*[DATE] 2:18 PM 100 bpm*[DATE] 9:35 PM 140 bpmImportant to note: there are no pulses documented on the vitals record after [DATE] at 9:35 PM. Additionally, there are no further cardiorespiratory assessments of R74 despite a pulse of 140. R74's Medication Administration Record (MAR) for the evening shift of [DATE] indicates a pulse of 140.R74's Progress Notes include:*[DATE] 6:55 AM Resident deceased *[DATE] 7:35 AM writer entered patient's room at approximately 4:30am.found pt pulseless and not breathing. Pt full code, writer and CNA (Certified Nursing Assistant) pulled pt from bed to floor where writer began chest compressions and CNA called 911. EMS (Emergency Medical Services) arrived, took over compressions.EMS attempted compressions for approximately 40 min when decision was made to cease attempts.Important to note: There are no progress notes or nursing assessments documented on [DATE] or [DATE] prior to R74's death.On [DATE] at 9:01 AM, Surveyor interviewed CNA U (Certified Nursing Assistant) and asked if anything had been shared about R74's pulse in shift report on [DATE]. CNA U stated no, but I had told the nurse a week or so earlier as I had noticed an elevated pulse .anything above 110 you are supposed to notify. If I remember right R74 was like 140 or something. Actually, I remember R74 being 147 .I had never seen anyone with a heart rate that high when resting.I could understand if they were in a marathon. CNA U indicated telling the nurse about the pulse and the nurse telling CNA U to recheck. CNA U stated the next pulse check was just as high.not higher, maybe 3 points less. CNA U indicated no recollection of who the nurse was or if there was any intervention for resident following the report of continued high pulse.On [DATE] at 9:50 AM, Surveyor interviewed LPN R (Licensed Practical Nurse) who indicated no recollection of R74. Surveyor asked if LPN R had any recollection of a resident having a pulse of 140. LPN R stated no. Reviewed the documentation of R74's VS report and MAR. LPN R stated no, that must be a typo.if a resident had a pulse of 140 I would notify the doctor.On [DATE] at 2:53 PM, Surveyor interviewed NP T (Nurse Practitioner) and asked if continued monitoring would be expected for a resident with a pulse of 140. NP T stated yes, vital signs with heart rate and monitoring for dizziness, shortness of breath, and altered mental status. NP T stated that if a resident refused to go to the ER, NP T would question the refusal and contact the resident/family to discuss risks and benefits.On [DATE] at 3:20 PM, Surveyor interviewed RN V (Registered Nurse) who indicated that no information had been shared at shift change regarding R74, but there were tasks in the charting regarding watching R74's pulse. RN V indicated peeking at resident at change of shift but having no contact with R74 until finding R74 pulseless/non-breathing, stating that R74 didn't like to be disturbed and preferred to call for assist as needed.On [DATE] at 11:55 AM, Surveyor interviewed IDON B (Interim Director of Nursing) and asked about interpretation of an order to update physician for sustained pulse >119. IDON B stated it would be dependent on the resident's activity level at the time of the pulse. If the resident was active, they may be elevated. Staff would need to recheck in a few minutes to see if it was an anomaly (something that deviates from what is normal/expected). After the recheck, if still above, call the physician. IDON B indicated being unfamiliar with R74 and would need to review. At 5:05 PM, IDON B stated that no documentation of assessment or physician update was found regarding the pulse of 140 and IDON B would have expected there to be.On [DATE] at 1:31 PM, Surveyor interviewed MD Q (Medical Director) and asked about a pulse of 140. MD Q stated that at 140, that is real tachycardia. MD Q stated this is abnormal and would need to be investigated: EKG (electrocardiogram-a non-invasive test that records the electrical activity of the heart), blood work, VS every 10-15 minutes; may need to call 911. MD Q stated we expect staff to document, that is unacceptable.The failure to complete a nursing assessment and implement continued monitoring created a reasonable likelihood for serious harm which created a finding of immediate jeopardy. The facility removed the immediate jeopardy on [DATE]; however, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement the following action plan: * A house sweep of all current residents to identify any changes of condition within the last 24 hours that require MD notification, and one resident was noted to have a change of condition, however standard of nursing practice and proper notification procedure were followed.*Facility DON /NHA initiated education for all scheduled licensed nursing staff regarding:o Policies and procedures-change in a resident's condition or status, medication and treatment orders, charting and documentation, standards of nursing practice (nursing process, including assessment and evaluation). Education provided emphasized the importance of documentation, clear and concise communication, identifying a change in resident condition, provider notification, and clinical follow-up. o Provider notification, standards of practice are based on the facility policy. Notifications will be made within 24 hours of the change of condition, except in medical emergencies, or resident injury. Education on the Standards of Nursing Practice included the use of Einteract for comprehensive and concise communication. Education on assessments and change of condition included review of clinical protocol for resident change of condition, as well as focused nursing assessments.o All licensed nursing staff will receive the above mentioned education by [DATE] or before the start of their next shift. *The facility will contract with an outside consultant to monitor compliance with abatement strategies *Quality assessment and assurance to ensure ongoing compliance. *Director of Nursing/designee will complete audits on change of conditions [sic] including documentation, follow-up, and provider notification. These audits will occur 3 times weekly for 3 weeks, monthly for 4 months then randomly thereafter.*Results of these reviews will be reviewed by the facility Quality Assurance Performance Improvement committee for patterns, trends and continued recommendations for process monitoring and improvement.

Based on interview, and record review, the facility did not ensure a resident's environment remained free of accidents and hazards for 1 of 3 residents reviewed for falls (R48) and 1 of 3 residents reviewed for supervision (R37). R48 is being cited at severity level 3 (actual harm). R48 sustained three falls. The facility failed to identify a root cause analysis (RCA) or patterns with R48's three falls. Without identifying the RCA, the interdisciplinary team (IDT) did not implement resident specific interventions or identify patterns which could have contributed to her falls and/or prevent future falls, such as a plan to anticipate her toileting needs when she stated she was trying to go to the bathroom. R48 was found to have a C1 fracture (a break in the first vertebra or the cervical spine, located at the base of the skull) and left seventh rib fracture after the second fall. R48's third fall resulted in a closed fracture of her right femur. There was no evidence of an RN assessment prior to R48 being moved after the third fall. Surveyor observed R37 put crafting pom poms in his mouth during mealtime while unsupervised and observed chemicals, lotions, and aerosol cans in an unlocked cabinet on a R37's unit. R37 is known for wandering, being confused, and rummaging. This is evidenced by: Facility policy, titled Falls – Clinical Protocol, revised March 2018, states in part, .Cause Identification 1. For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. Treatment/Management 1. Based on the preceding assessment, the staff and provider will identify pertinent interventions to try to prevent subsequent falls and to address the risk of clinically significant consequences of falling . Facility policy, titled Falls and Fall Risk, Managing, revised March 2018, states in part, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. Resident-Centered Approaches to Managing Falls and Fall Risk: .5. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. 6. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable.8. Position-change alarms will not be used as the primary or sole intervention to prevent falls but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. Monitoring Subsequent Falls and Falls Risk: .3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending provider will help the staff reconsider possible causes that may not previously have been identified. Example 1 R48 initially admitted to the facility on [DATE] following a hospital stay for acute hypoxic respiratory failure and pneumonia. R48 had a left femur trochanteric fracture (a break in the bone that connects the hip joint to the thigh) and left distal radius fracture (a break in the lower end of the long bone (thumb side) of the forearm) in 2/2025. R48 has diagnoses that include, in part: Other secondary Parkinsonism (condition that presents with symptoms such as tremors). R48's Minimum Data Set (MDS) with a reference date of 5/6/25, indicates R48's cognition is severely impaired, with a Brief Interview for Mental Status (BIMS) score of 7 out of 15. Section GG of this assessment indicated R48 uses a manual wheelchair for mobility and is dependent for chair/bed-to chair transfers, toilet transfers, and toileting hygiene. R48's admission Morse Fall Risk Assessment, dated 5/1/25, indicates R48 is at a high risk for falls, with a score of 75 (high risk is a score of 45 or higher). Section F. Mental Status states, Mental status measures the residents [sic] self-assessment of his/her own ability to ambulate. Ask the resident, 'Are you able to go to the bathroom alone, or do you need assistance?' Does the resident's response to the above indicate they know the limits of their abilities to ambulate safely? Response 1 is checked: Knows own limits.-It is important to note that R48 has a severe cognitive impairment; due to this, R48 may no longer be able to accurately judge her own limitations. R48's Care Plan, dated 5/1/25, states in part: .Focus: [R48] is at high risk for falls r/t (related to) impaired mobility secondary to Parkinson's Disease. Goal: [R48] will not sustain serious injury through the review date. Interventions/Tasks: All staff to monitor that [R48] is wearing appropriate footwear or non-skid socks when ambulating or mobilizing in w/c (wheelchair). Anticipate and meet [R48's] needs as much as possible to prevent unsafe self-initiation. Assess/observe regularly for a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; personal items within reach. Be sure call light is within reach and encourage [R48] to use it for assistance as needed. Educate [R48], family, and her other caregivers about safety reminders and what to do if a fall occurs. Encourage [R48] to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Follow fall protocol if a fall occurs. Pt (physical therapy) evaluate and treat as ordered or PRN (as needed). .Focus: Alteration in sleep pattern or sleep pattern disturbance.Interventions/Tasks: Encourage urination just before bedtime. .Focus: The resident has bladder incontinence r/t decreased mobility.Interventions/Tasks: Assist with routine and PRN toileting.Ensure the resident has an unobstructed path to the bathroom. .Focus: [R48] has impaired cognitive function or impaired thought processes – has activated HCPOA (Health Care Power of Attorney). SLUMS (St. Louis University Mental Status) score of 15/30 (examination for detecting cognitive impairment and dementia – a score of 0-20 indicates dementia).Interventions/Tasks: Ask yes/no questions to determine needs.Communication: Use the resident preferred name. Identify yourself at each interaction. Face [R48] when speaking and make eye contact. Reduce any distractions.The resident understands consistent, simple, directive sentences. Provide necessary cutes – stop and return if agitated. .Focus: [R48] has ADL (activities of daily living) self-care performance deficits.Interventions/Tasks: Ambulation: therapy only. Mobility/Locomotion: [R48] is mobile via manual wc (wheelchair) with assist of 1 staff. Toilet use: [R48] is able to perform stand pivot with 1A (one person assist) with grab bar or 2WW (two-wheeled walker). Fall #1:R48's Fall Un-Witnessed WITH Injury report, dated 6/4/25 at 5:00 AM, includes in part: .Nursing description: While doing rounds, CNA (certified nursing assistant) heard patient calling out 'help me, help me!' Upon entering patient's room, CNA found patient lying on the floor next to the wall across from the bathroom. Patient noted to have a large skin tear to left forearm that is actively bleeding but no other visible injuries noted. Patient c/o (complained of) chest and rib pain, telling writer it was hard to breathe. Writer offered to either have patient assisted back into bed or be sent to ER (Emergency Room) for further evaluation of the chest pain. It is this writer's opinion the skin tear did not warrant sutures.decision made to sent [sic] patient to.Hospital. Resident description: When queried regarding details of fall, patient tells writer, 'I tripped while on my way to the bathroom.'R48's Emergency Department after visit summary, dated 6/4/25, indicates that shoulder, elbow, and wrist x-rays were taken and a CT (computerized tomography) scan (an imaging procedure to look at cross-sectional images of the body) was completed. Discharge orders state, in part: .We found: Your fall did not result in any serious injuries; a comprehensive scan of your body (pan scan) showed no fractures or internal injuries. You were diagnosed with a urinary tract infection (UTI), for which you have been prescribed an antibiotic. Surveyor reviewed the Interdisciplinary Team (IDT) notes for R48's fall: 6/5/2025 24-hour note: IDT team reviewed this fall. Immediate intervention is to place reminders in resident's room to use call light when in need of assistance. CP (Care Plan) and CC (Care Card) updated. 6/9/2025 72-hour note: IDT team reviewed this intervention and found it to be effective. No additional falls were noted at this time. An updated Morse Fall Risk assessment was completed for R48 on 6/4/25. The updated assessment indicates R48 is at a high risk for falls, with a score of 80. Section F. Mental Status states, Mental status measures the residents [sic] self-assessment of his/her own ability to ambulate. Ask the resident, 'Are you able to go to the bathroom alone, or do you need assistance?' Does the resident's response to the above indicate they know the limits of their abilities to ambulate safely? Response 2 is checked: Overestimates or forgets limits. The following fall risk interventions/tasks were added to R48's care plan: Reminders placed in resident's room to use call light for assistance. Date initiated: 06/09/2025. [R48] will have a sign up in her room as a reminder to use her call light for assistance. Date initiated: 06/10/2025. It is important to note:-The fall report and the IDT review notes do not include documentation of a root cause. -Staff are educating R48 as an intervention for fall prevention, despite R48's BIMS score of 7 out of 15, indicating severe cognitive impairment, and her diagnosis of Parkinson's disease. Fall #2:R48's Fall Un-Witnessed WITHOUT Injury report, dated 6/11/25 at 6:00 AM, includes in part, .Nursing description: Writer called to resident room by CNA staff who reported resident was on the floor next to bed. She was sitting with [sic] floor with legs extended out. Resident unable to state why she was attempting to get out of bed on her own. VSS (vital signs stable), moves all extremities w/o (without) complaints of pain. No injuries observed. Resident description: Resident unable to give description.Immediate Action Taken – Description: DON (Director of Nursing), POA (Power of Attorney), and NP (Nurse Practitioner) updated. Resident encouraged to use call light for all transfers. R48's Progress Notes, dated 6/11/25, include in part:7:26 AM – RN (Registered Nurse): POA updated regarding unwitnessed fall. Resident reported that she had hit her head when she fell. Neuros and vitals WNL (within normal limits). POA did request for resident to be sent to hospital to be evaluated. 8:30 AM – RN: Received orders to send resident out to ER for evaluation. Resident sent out.POA and DON updated. 3:44 PM - RN: Per report from POA, resident has a broken bone in her neck and ribs.resident will be transferred.for further evaluation. DON updated. Surveyor reviewed the IDT notes for R48's fall: 6/12/2025 24-hour note: IDT team reviewed this fall. Resident already had a care plan in place for low bed, however, she did not have fall mats. At this time the immediate intervention will be to add fall mats to the resident's interventions. CP and CC updated. 6/16/2025 72-hour note: Resident still remains in hospital at this time. IDT finished out this fall and intervention. An updated Morse Fall Risk assessment was completed for R48 on 6/11/25. The updated assessment indicates R48 is at a high risk for falls, with a score of 80. Section F. Mental Status states, Mental status measures the residents [sic] self-assessment of his/her own ability to ambulate. Ask the resident, 'Are you able to go to the bathroom alone, or do you need assistance?' Does the resident's response to the above indicate they know the limits of their abilities to ambulate safely? Response 2 is checked: Overestimates or forgets limits. The following fall risk interventions/tasks were added to R48's care plan: Low bed. Date initiated: 06/09/2025 / Cancelled date: 06/12/2025. Low bed and falls mat. Date initiated: 06/12/2025. Bed against wall for spatial awareness. Date initiated: 06/17/2025. [NAME] alarms (a monitoring system that uses sensors to track movements and sends a silent alert to staff members): restless in room, out of bed alarm. Date initiated: 06/17/2025. Soft touch disc call light to be placed by resident's thigh while in bed. Date initiated: 06/17/2025. R48's hospital inpatient Discharge summary, dated [DATE], indicates, in part: .Briefly, [R48] presented following a mechanical fall out of bed resulting in C1 fracture and L (left) 7th rib fracture. Recommended a PMT collar (neck brace) to allow C1 fracture to heal. R48's Progress Notes, dated 6/17/25, include in part:3:53 PM – RN: Resident arrived to unit at approximately 1315 (1:15 PM) .6:29 PM - RN: Resident's daughter conveyed concerns for resident's safety regarding risk for falls. She did not want to leave her mother as she felt she needed further monitoring in order to ensure she didn't fall from bed. Writer attempted to locate a bed mat (out of bed alarm) but was unable to find one in the closets or ancillary. Writer notified nurse of inability to find and to pass along to staff to request one tomorrow from the ancillary. Writer also left voicemail for ancillary requesting more mats. Writer reassured resident's daughter/POA that staff is doing everything they can to mitigate falls and make the environment as safe as possible. Writer was able to brainstorm a few ideas that helped the daughter feel more at ease with resident being in room tonight. Daughter agreed for resident to have bed against wall, low bed, fall mat, soft touch disc call light by thigh, and restless in room ([NAME] system) to be an adequate start to ensuring her mom's safety for tonight.Staff were told to try to pay close attention for the call light alerts from her room due to her high fall risk.It is important to note:-This is R48's second fall without using the call light for assistance.-The fall report and the IDT review notes do not address potential root causes of why R48 was trying to get out of bed at 6:00 AM.-Without a true root cause there is no way of knowing if these interventions are appropriate. -R48 indicated after her first fall on 6/4/25 at 5:00 AM that she was trying to go to the bathroom. There is no evidence the facility ruled out a potential relationship between toileting and this fall, as it occurred at a similar time of 6:00 AM.-When R48 was readmitted to the facility on [DATE], not all the equipment needed for the new interventions recommended by the IDT were available for use.-Staff are educating R48 as an intervention for fall prevention, despite R48's BIMS score of 7 out of 15, indicating severe cognitive impairment, and her diagnosis of Parkinson's disease. Fall #3:R48's Progress Notes, dated 8/2/25, include in part:1:14 AM – LPN (Licensed Practical Nurse): Writer was called by the CNA while conducting rounds in the skilled nursing to attend to Resident [R48] that fell. Upon arrival at the resident's room, writer found the resident lying on the floor. VS (vital signs) were obtained.and head to toe assessment was immediately completed. On assessment, the resident was found to have sustained a skin tear with active bleeding to her right elbow. Resident reported a severe pain (10/10) to her right hip. The resident stated she was attempting to transfer herself to the toilet when she lost balance and fell. With the assistance from the CNA, resident was safely transferred back to the bed with a Hoyer (type of full body lift). Writer contacted 911 due to resident's pain level and potential injury. Writer left a voicemail for the on-call nurse manager [ADON N] (Assistant Director of Nursing) .and resident's POA.was contacted and informed. Resident was transported via EMS (emergency medical services) to.hospital for further evaluation and treatment. It is important to note that the LPN left a message for the ADON and did not discuss moving R48 before getting her back into bed with a Hoyer lift. LPN's are not able to complete nursing assessments and can only gather data then must wait for further instructions from a RN or physician prior to moving a resident. R48's Fall Un-Witnessed WITH Injury report, dated 8/2/25 at 3:00 AM, was completed by ADON N. The time on the report is approximately two hours after the fall occurred. ADON N copied the progress note written by the LPN at 1:14 AM and pasted it into the incident description section on the fall report for both the nursing description and the resident description. R48's Progress Notes, dated 8/2/25, include in part: 8:59 AM - RN: Call placed to [Hospital]; resident admitted for closed fx (fracture) of right femur.Surveyor reviewed the IDT note for R48's fall, dated 8/3/2025. The note was text copied from the fall report summary. No root causes were identified for this fall.An updated Morse Fall Risk assessment was completed for R48 by ADON N on 8/2/25. The updated assessment indicates R48 is at a moderate risk for falls, with a score of 25 (moderate risk is a score from 25-44). (Of note: This assessment was completed after R48's third fall, 2 of 3 falls with fractures, and the score decreased from 80 to 25, indicating R48's fall risk as moderate and not high.) R48's hospital Discharge summary, dated [DATE] indicates, in part: Reason for Hospitalization: .Pt [patient] reports she has been residing in a rehab for her recent fall and reportedly tripped over her other foot landing on the right side. Imaging is remarkable for mildly displaced right femoral fracture.She reports pain in her right hip from the fall.Hospital Course: .Parkinson's disease .Suspect she has associated dementia and cognitive impairment which is becoming more obvious with acute stressors. R48's Progress Notes, dated 8/8/25, include in part:5:48 PM – LPN: Resident readmitted to facility from [hospital].A&O (alert and oriented) x 1.Resident able to make needs known. Educated/shown how to use call light, resident demonstrated back. R48's Progress Notes, dated 8/9/25, include in part: 7:12 AM (staff position not listed in notes): Resident continues on skilled observations as ordered. NO acute events overnight. She noted [sic] to be restless and attempting to transfer from bed. Redirected and reoriented multiple times. Will continue monitoring for safety. An updated Morse Fall Risk assessment was completed for R48 on 8/8/25. The updated assessment indicates R48 is at a high risk for falls, with a score of 90. Section F. Mental Status states, Mental status measures the residents [sic] self-assessment of his/her own ability to ambulate. Ask the resident, 'Are you able to go to the bathroom alone, or do you need assistance?' Does the resident's response to the above indicate they know the limits of their abilities to ambulate safely? Response 2 is checked: Overestimates or forgets limits. No new fall risk interventions/tasks were added to R48's care plan. The following care area was added, and includes, in part: Focus: The resident has an alteration in musculoskeletal status r/t (related to) neck fracture (right femoral neck fracture – a break in the bone that connects the top of the thigh bone to the hip joint). Interventions/Tasks: Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. Date initiated: 08/08/2025 . It is important to note:-This is R48's third fall without using the call light for assistance.-This is R48's second fall during the early morning hours where she indicated she was trying to get to the bathroom. The facility has not shown evidence of addressing toileting interventions with R48, given 2 of 3 falls were known to be related to toileting. There is no evidence of completion, for example, of a toileting diary, to look for patterns in R48's toileting needs and potentially decrease future falls. -The fall report and the IDT review notes do not include documentation of a root cause. -Without a true root cause there is no way of knowing if these interventions are appropriate. -Staff are educating R48 as an intervention for fall prevention, despite R48's BIMS score of 7 out of 15, indicating severe cognitive impairment, and her diagnosis of Parkinson's disease. -There is no evidence of an RN assessment/consult by the LPN prior to moving R48. On 8/26/25 at 3:42 PM, Surveyors interviewed DON B regarding R48's falls. DON B indicated he was unable to pick out the particular root cause of the falls without more information but said he would review IDT notes to see what was found. IDT notes are part of QAPI (Quality Assurance Performance Improvement) and not in residents' progress notes. DON B reviewed R48's fall on 6/4/25 along with the IDT notes. DON B pointed out this fall was related to trying to use the bathroom. DON B indicated the notes reflect that R48 not using the call light was the root cause of this fall and the 72-hour IDT fall review determined placing a call light reminder was effective because there were no more falls during that time frame. DON B reviewed R48's fall on 6/11/25 along with the IDT notes. DON B indicated the notes address injury reduction instead of the fall itself. DON B indicated that he would expect to see more information investigating why the fall happened, such as the position the resident was in after the fall and whether or not R48 had been toileted recently. DON B reviewed R48's fall on 8/2/25 along with the IDT notes. DON B pointed out R48 was attempting to transfer herself to the bathroom, had an injury, and was sent out for further evaluation. DON B indicated the IDT notes did not determine the root cause. DON B reviewed R48's care plan. He indicated the care plan addresses routine and PRN (as needed) toileting and having an unobstructed pathway. Having an unobstructed pathway to the bathroom is standard in all care plans. R48's care plan indicates she shouldn't transfer to the bathroom herself. DON B indicated there should be something more in the care plan to address her toileting needs. DON B stated that he has a concern with R48's falls and interventions not properly being put into place. DON B indicated the expectation would be that the facility would have a clear indicator of what the root cause was for each fall. Surveyors asked DON B if educating the resident on call light use and placing signs in her room to remind her to use the call light are appropriate interventions, given her BIMS score indicates severe cognitive impairment. DON B indicated that educating R48 on using the call light is not an acceptable intervention. On 8/26/25 at 5:02 PM, Surveyors interviewed DON B and NHA A (Nursing Home Administrator). DON B and NHA A agreed that they would expect their team to determine the root cause for falls. NHA A indicated the facility consults with the medical director and pharmacist after three falls to discuss possible interventions. She said she would pull the records for review. On 8/27/25 at 5:31 PM, Surveyors interviewed DON B and NHA A. NHA A stated they had documentation from the facility's medical director stating that R48's falls were unavoidable. Surveyors reviewed the documentation from the facility's medical director pertaining to R48's falls that was signed and dated on 8/27/25. No further information was provided related to a pharmacist consult. NHA A also indicated interventions were put into place and they increased her [NAME] alarms, which track movements in resident rooms. It is important to note: The facility did not determine root causes for R48's falls and therefore it cannot be determined if the falls were unavoidable and/or if the interventions put into place were appropriate. Example 2 Facility policy, titled safety and Supervision of Residents, revised 7/2017, includes: Our facility strives to make the environment as free from accidents and hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Implementing interventions to reduce accident risks and hazards shall include the following: communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions, providing training as necessary, ensuring that interventions are implemented, and documenting interventions. Monitoring effectiveness of interventions shall include the following: ensuring that interventions are implemented correctly and consistently, evaluating the effectiveness of interventions, modifying or replacing interventions as needed, and evaluating the effectiveness of new or revised interventions. R37 admitted to the facility on [DATE] with the following diagnoses: unspecified dementia, anxiety, and major depressive disorder. R37's Care Plan, initiated 1/28/22, includes: 1/28/22 Feeding assistants- do not assist due to high risk for choking/aspiration. 1/28/22 Monitor/document/report as needed any signs or symptoms of dysphagia, coughing, water eyes, runny nose, drooling, pocketing, choking, holding food in mouth, several attempts at swallowing, refusing to eat,. 5/2/23 needs assistance with meals. 3/25/24 R37 has potential for alteration in nutrition related to diagnoses including aftercare following fall, dementia, hypertension, chronic obstructive pulmonary disease, and a history of weight loss. R37 has potential for choking/aspiration related to chewing/swallowing difficulty and edentulous (no teeth) status and chooses not to wear dentures and history of not attempting to consume trial upgrades therefore interdisciplinary team in agreement for order consistency. 5/18/23 Provide supervision, cues, and physical assist as needed. 5/18/23 Encourage to come to dining room for assist/supervision during meals. 3/25/24 R37 has difficulty self-feeding due to dementia and is able to maximize independence with dining by having foods in separate bowls. Speech Therapy Discharge, dated 6/22/22, includes diagnosis: Dysphagia- oral phase He demonstrates ability to safely swallow pureed solids and thin liquid diet using compensatory strategies from trained staff or caregivers demonstrating under 2 signs/symptoms of aspiration and greater than 80% oral clearance . Least restrictive diet is pureed . R37's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 8/8/25, indicates R37 is rarely or never understood in section C, but in section B it indicates R37 is understood by others and makes himself understood. (It is important to note the conflicting information in this one assessment. It is also important to note R37 resides on the memory care unit at the facility.) On 8/20/25 at 10:15 AM, Surveyor observed crafting supplies, aerosol cans, cleaner, and lotions in the activity cabinet on the unit. Activity Aide II began removing some of the items from the cabinet. During an interview, Activity Aide II indicated there are residents on the unit who wander and rummage in the cabinet and the lotions, aerosol cans, and cleaners should be locked up. On 8/20/25 at 12:58 PM, during the dining observation Surveyor observed that no staff were in the room while residents were eating meals. Two of the residents had pureed food in front of them, including R37. Surveyor observed R37 to have pureed food on his tray and two plastic covers. One of the plastic covers had crafting pom poms on it that appeared to be wet. The pom poms varied in size. Surveyor observed R37 place some of the pom poms in his mouth and Surveyor asked R37 what the pom poms were. R37 stated, I don't know, as he placed a few more in his mouth. Surveyor observed R37 take the plastic cover with the remaining pom poms and dump them into his mouth. RN W (Registered Nurse) entered the dining room and stood at her nurse cart with her back to the residents. Surveyor called to RN W and asked her if R37 should be eating crafting balls. RN W indicated he should not be and asked R37 to spit the pom poms out. R37 seemed confused by the request at first and hesitated, but with some encouragement by RN W R37 spit out 8 pom poms. On 8/20/25 at 1:16 PM, CNA M (Certified Nursing Assistant) indicated R37 has a history of placing nonfood items in his mouth. CNA M indicated she is not sure when the last time was that she saw R37 do this, but she sees him rummaging through drawers and cabinets at times. On 8/20/25 at 1:31 PM, DON B (Director of Nursing) indicated he is unsure if R37 has a history of placing nonfood items in his mouth. DON B indicated staff are to be supervising R37 while he is eating and they should have chemical cleaning products, aerosol cans, crafting supplies, and lotions in a locked cabinet because residents wander and rummage. On 8/20/25 at 3:13 PM, Activity Aide II stated, One time I laid out some sorting bears and he went to put them in his mouth. He does rummage through drawers. He could have gotten them (pom poms) out of here. I did pull some pom poms out of here today. Activity Aide II showed Surveyor a drawer at wheelchair height that R37 may have gotten the pom poms out of. On 8/20/25 at 3:22 PM, CNA FF indicated R37 rummages through drawers and cabinet that are at his reach. CNA FF also indicated staff are to supervise R37 when he is eating and offer cues, redirection, and/or assistance with meals. On 8/20/25 at 3:24 PM, Surveyor observed R37's room to have a bulletin board at wheelchair height with a sign pinned on it. The sign stated R37's name and around the name were glued on crafting pom poms. The sign also had glue spots with colored pom pom fuzz attached to it where pom poms were previously glued to the paper. On 8/20/25 at 3:40 PM, CNA GG stated, I see R37 rummaging in activity area and in dining room. I think those things he put in his mouth should be kept out of reach. Surveyor and CNA GG observed the sign in R37's room. Surveyor asked if R37 could have gotten the pom poms off of this sign. CNA GG indicated this was likely due to some of them being missing. On 8/20/25 at 3:44 PM, RN HH (Registered Nurse) stated R37 is known to rummage around looking for food. RN HH indicated staff should keep crafting supplies,

Based on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect 67 of 68 residents.Surveyor observed food that was not sealed or labeled with a use by date in the main kitchen freezer.Surveyor observed food that was not labeled or dated in a kitchenette refrigerator.Surveyor observed microwaves in the three kitchenettes to have several multi-colored dried on splatters and stains on the inside microwaves.The refrigerator and freezer temperatures in two of the kitchenettes are not being consistently monitored or recorded.Evidenced by:Example - Unsealed and unlabeled packages of food in main kitchen freezerFacility policy entitled, Food Receiving and Storage with a revision date of April 2019 states, in part: .8. All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date) .On 8/20/25 at 9:24 AM, during the initial tour of the kitchen, Surveyor and DM J (Dietary Manager) observed an opened bag of turkey sausage links and an opened bag of sliced salami in the walk-in freezer that weren't sealed or dated. Surveyor asked DM J if opened bags of food should be sealed and have a use by date; DM J stated yes. On 8/25/25 at 3:15 PM, Surveyor interviewed NHA A (Nursing Home Administrator), DON B (Director of Nursing), and RDM K (Regional Dietetic Manager). Surveyor asked if they would expect policies to be followed for food storage and labeling; they stated yes. Example - Unlabeled food in Kitchenette refrigeratorFacility policy entitled, Food Receiving and Storage with a revision date of April 2019 states, in part: .14. Food items and snacks kept on the nursing units must be maintained as indicated below: .b. All foods belonging to residents must be labeled with the resident's name, the item and the use by date.On 8/21/25 at 2:50 PM, Surveyor toured the kitchenette on the 100 hall. Surveyor observed a clear sandwich bag containing an opened package of sausage sticks and a snack pack of cheese cubes, nuts, and dried cranberries in the kitchenette refrigerator that did not have a name or date on it.On 8/21/25 at 3:02 PM, Surveyor interviewed CNA L (Certified Nursing Assistant) and asked if she knew whose food that was and how long it has been in the refrigerator. CNA L indicated she didn't know, couldn't tell because there was no name or date on it.On 8/25/25 at 2:32 PM, Surveyor interviewed DM J and AFSD I (Assistant Food Services Director) who indicated food in the kitchenette refrigerator should be labeled and dated. On 8/25/25 at 3:15 PM, Surveyor interviewed NHA A (Nursing Home Administrator), DON B (Director of Nursing), and RDM K (Regional Dietetic Manager). Surveyor asked if they would expect policies to be followed for food storage and labeling; they stated yes. Example - Kitchenette microwaves not being cleanedFacility policy entitled, Food Preparation and Service with a revision date of April 2019 states, in part: .4. Appropriate measures are used to prevent cross contamination. These include:.d. cleaning and sanitizing work surfaces and food-contact equipment between uses.On 8/20/25 at 12:22 PM, Surveyor toured the kitchenette on the 200 hall - Skilled (non-Memory Care) and observed multiple dried on substances of different colors inside the microwave.On 8/20/25 at 12:37 PM, Surveyor interviewed CNA M and asked who is responsible for cleaning the microwaves in the kitchenette. CNA M stated housekeeping cleans them. Surveyor showed CNA M the inside of the microwave on 200 hall (Skilled side) and CNA M indicated it was dirty and had several dried-on splatters on the inside.On 8/21/25 at 3:05 PM, Surveyor interviewed HKG O (Housekeeping Aide/CNA) and asked who is responsible for cleaning the microwaves in the kitchenettes. HKG O indicated housekeeping cleans the microwaves and kitchenette areas.On 8/21/25 at 2:50 PM, Surveyor toured the Kitchenette on the 100 hall and observed several multi-colored splatters on the inside of the microwave.On 8/21/25 at 3:02 PM, Surveyor interviewed CNA L and asked who was responsible for cleaning the microwave. CNA L stated housekeeping cleans it and CNA L observed microwave with Surveyor, and she indicated it was dirty with dried on splatters on it.On 8/21/25 at 3:05 PM, Surveyor interviewed HKG O and asked who is responsible for cleaning the microwaves in the kitchenettes. HKG O indicated housekeeping cleans the microwaves and kitchenette areas. Surveyor showed HKG O the microwave and stated she had cleaned it earlier that morning, indicated it was dirty and began cleaning it while Surveyor was still present.On 8/21/25 at 3:10 PM, Surveyor toured the kitchenette on the Memory Care unit and observed the microwave to have several multi-colored dried on splatters, brown stains on the inside and some brownish-reddish spots on the inside of the door.On 8/21/25 at 3:17 PM, Surveyor interviewed RDM K (Regional Dietetic Manager) and asked her to look at the inside of the microwave. RDM K indicated housekeeping cleans the microwaves and verified the inside of the microwave looked dirty, should have been cleaned, and stated she thought the brown stains were burn marks and thought the spots on the inside of the door were rust. RDM K unplugged the microwave, pulled it away from the wall and said they would remove it and replace it. Surveyor observed a different microwave there the next visit to the kitchenette on 8/25/25.On 8/25/25 at 2:32 PM, Surveyor interviewed DM J (Dietary Manager) and AFSD I (Assistant Food Services Director) who indicated food in the kitchenette microwaves should have been clean.On 8/25/25 at 3:15 PM, Surveyor interviewed NHA A (Nursing Home Administrator), DON B (Director of Nursing), and RDM K (Regional Dietetic Manager). Surveyor asked if they would expect policies to be followed for food preparation and service; they stated yes. Example - Kitchenette refrigerator and freezer temperatures not being consistently monitored and recordedFacility policy entitled, Food Receiving and Storage with a revision date of April 2019 states, in part: .14. Food items and snacks kept on the nursing units must be maintained as indicated below:.c. Refrigerators must have working thermometers and be monitored for temperature according to state-specific guidelines.On 8/20/25 at 12:22 PM, Surveyor observed the temperature log for August 2025 for the refrigerator and freezer temperatures in the kitchenette on the 200 hall (Skilled). Surveyor observed only 2 days recorded for August: 8/5/25 and 8/12/25. Surveyor also reviewed the temperature logs for the months of May, June, and July 2025. May temperature log has the following days missing for both the refrigerator and freezer: May 1, 3, 4, 6, 9, 10, 13, 14, 24, and 25. June has the following days missing for temperature recording: June 9, 12, 16, 17, 20, 22, 23, 24, 25, 26, and 27.On 8/21/25 at 3:10 PM, Surveyor observed the temperature log for August 2025 for the refrigerator and freezer temperatures in the kitchenette on the Memory Care unit on the 200 hall. Surveyor observed only 4 days recorded for August: 8/5, 8/6, 8/11, and 8/12/25. Surveyor also reviewed temperature logs for the months of May, June, and July 2025. May temperature log has the following days missing for both the refrigerator and freezer: May 1, 4, 5, 9, 10, 13, 24, 25, 26, and 27. June temperature log has the following days missing for recording: June 7, 8, 9, 12, 16, 17, 20, 22, 23, 24, 25, 26, and 27. July log has the following day missing of temperature recording: July 6, 7, 11, 18, 19, 20, 21, 22, 23, 24, 25, 28, 29, 30, and 31.On 8/21/25 at 3:17 PM, Surveyor interviewed RDM K (Regional Dietetic Manager) and asked who is responsible to monitoring the temperatures of the refrigerator and freezer in the kitchenettes. RDM K stated she wasn't sure but indicated the temperatures should have been completed and indicated there were several dates missing on the August log.On 8/21/25 at 3:30 PM, Surveyor interviewed ADON N (Assistant Director of Nursing) and asked who was responsible for recording the temperatures of the refrigerator and freezer in the kitchenettes. ADON N stated the night shift nursing staff take the temperatures and record them. ADON N observed the August temperature log with Surveyor and verified there were several dates missing and stated they should have been filled out.On 8/25/25 at 2:32 PM, Surveyor interviewed DM J (Dietary Manager) and AFSD I (Assistant Food Services Director) who indicated kitchenette refrigerator and freezer temperatures should have been taken and recorded.On 8/25/25 at 3:15 PM, Surveyor interviewed NHA A (Nursing Home Administrator), DON B (Director of Nursing), and RDM K. Surveyor asked if they would expect policies to be followed for Food Receiving and Storage; they stated yes.

Based on observation, 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 had the potential to affect all 68 residents. Three staff members returned to work too soon after experiencing gastrointestinal (GI) symptoms. The facility's infection control line lists for staff and residents are incomplete and inaccurate. The facility did not ensure daily infection control surveillance for staff and residents. The facility failed to recognize commonalities with staff who called in with similar symptoms in February 2025 and did not rule out a GI or COVID-19 outbreak. The facility did not perform testing, per Centers for Disease Control and Prevention (CDC) guidelines, after a resident tested positive for COVID-19 at the facility in February 2025. The facility had COVID-19 outbreaks in February 2025 and April 2025 and did not have complete outbreak summaries. The laundry room was observed to be dirty. Surveyor observed a staff member handling R45's indwelling catheter bag without utilizing Enhanced Barrier Precautions (EBP) or performing proper hand hygiene. This is evidenced by: The facility policy, Employee Work Exclusion Policy, effective 7/19/24, states in part: .Purpose: It is the policy of [Facility Name] to exclude healthcare workers that put patients/residents at risk due to their infection status in accordance with the CDC guidelines, and state and federal regulations. For the purposes of this policy, healthcare workers include all employees to reduce the spread of infection. Universal Source Control Measures: Universal source control is to be implemented on a unit or area of the facility experiencing SARS-CoV-2 (COVID-19) outbreak if an unknown source with prevalent high-risk exposure could impact safety AND contact tracing cannot be reliably completed. Contact Tracing Source Control Measures: If contact tracing is conducted immediately following discovery of a positive case of SARS-CoV2 then source control is to be implemented only by those persons identified in contact tracing. Disease / Exclusion/Work Restriction Duration: Diarrheal disease (i.e. (for example) Norovirus or other GI illness) / Exclude until 48 hours after symptoms resolve. The facility policy, Infection Prevention and Control Program, revised in December 2023, states in part: Policy Statement: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the transmission of communicable diseases and infections. Elements of the IPCP: .3. Surveillance and reporting: a. Process surveillance (adherence to infection prevention and control practices) and outcome surveillance (incidence and prevalence of healthcare acquired infections) are used as measures of the IPCP effectiveness. b. Surveillance tools are used for identifying the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring employee infection, monitoring adherence to infection prevention and control practices, and detecting unusual pathogens with infection control implications. 5. Data Analysis: a. Data gathered during surveillance is used to oversee infections and spot trends. 6. Outbreak Management a. Outbreak management is a process that consists of: (1) determining the presence of an outbreak; (2) managing the affected residents; (3) preventing the spread to other residents; (4) documenting information about the outbreak; (5) reporting the information to appropriate public health authorities; (6) educating the staff and the public; (7) monitoring for recurrences; (8) reviewing the care after the outbreak has subsided; (9) recommending new or revised policies to handle similar events in the future. 7. Prevention of infection a. Important facets of infection prevention include: (1) identifying possible infections or potential complications of existing infections. (5) screening for possible significant pathogens. (8) following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC) . The facility policy, Outbreak of Communicable Diseases, revised in September 2022, states in part: Policy Statement: Outbreaks of communicable diseases within the facility are promptly identified and managed. Policy Interpretation and Implementation: 1. An outbreak is defined as one of the following:. c. Occurrence of three (3) or more cases of the same infection over a specified period of time and in a defined area. 6. The infection preventionist and director of nursing services are responsible for: a. managing surveillance data; b. monitoring ill residents and staff; c. initiating transmission-based precautions, as appropriate; and d. communicating with the medical director and the attending physicians. ADON N (Assistant Director of Nursing) is the facility's Infection Preventionist and had worked in this position for approximately a month from the date of this survey. DON B (Director of Nursing) has been helping her acclimate to this role. Example 1: Surveyors reviewed the staff line list provided by the facility for the past three months (June, July, and August 2025) and for February 2025 and April 2025, when COVID-19 outbreaks occurred at the facility. The line list has columns labeled as follows: Employee Name / Title/Dept (Department) / Date of Call In / Date of Symptom Onset / Time of Symptom Onset (if known) / Date of Last Symptom / Time of Last Symptom / Date Allowed to Return / Time allowed to return (48 hr (hours) after last symptom of NVD (nausea, vomiting, or diarrhea) or 24 hr after fever w/o (without) medication) / COVID/Flu/RSV (respiratory syncytial virus) Exposure: Yes/No / COVID/Flu/RSV Testing Needed? The list also has columns with symptoms that can be checked (examples: nausea, vomiting, diarrhea, fever, chills.) Surveyors noted several staff members with nausea, vomiting, and/or diarrhea symptoms had a date allowed to return to work that was the day after the date of last symptom. Surveyors requested timecards for five of these staff members to see when they returned to work. Three of the five staff members returned to work in a time frame that was less than 48 hours after the last symptom of nausea, vomiting, and/or diarrhea. MAA Z (Medication Administration Aide): Symptoms: vomiting and diarrhea; Date of call in: 2/5 for 2/6; Date of symptom onset: 2/5/2025; Time of symptom onset: 11:20 p (PM); Date of last symptom: 2/6/2025; Time of last symptom: noon; Date allowed to return to work: 2/7/2025; Time allowed to return to work: after noonMAA Z's timecard indicated he worked on 2/7/25 from 3:00 PM to 6:30 PM. DA BB (Dietary Aide): Symptom: diarrhea; Date of call in: 4/20/2025; Date of symptom onset: 4/17/2025; Time of symptom onset: AM; Date of last symptom: late 4/20; Time of last symptom: 11:30 p; Date allowed to return: 4/21/2025; Time allowed to return: AM DA BB's timecard indicated he worked on 4/21/25 from 5:42 AM to 2:54 PM. Additionally, the line list notes that the date of symptom onset was 4/17/25, but DA BB's timecard also shows that he worked on 4/17, 4/18, and 4/19. Housekeeper AA: Symptom: diarrhea; Date of call in: 6/3/2025; Date of symptom onset: 6/3/2025; Time of symptom onset: 4 AM; Date of last symptom: 6/4/2025; Time of last symptom: AM; Date allowed to return: 6/5/2025; Time allowed to return: blank Housekeeper AA's timecard indicated she worked on 6/5/25 from 5:48 AM to 2:18 PM. On 8/26/25 at 4:48 PM, Surveyors interviewed DON B and asked how long staff members with GI symptoms should be off work. DON B reviewed the facility's policy and indicated staff should be off for 48 hours after the time of the last symptom. Surveyors identified staff members who returned to work too soon. DON B stated, That would be a concern if they're coming back to work the next day. Example 2: Surveyors reviewed the staff and resident line lists provided by the facility for the past three months (residents: May, June, and July 2025 / staff: June, July, and August 2025) and for February 2025 and April 2025, when COVID-19 outbreaks occurred. The staff line lists contain the following columns: Employee Name / Title/Dept (Department) / Date of Call In / Date of Symptom Onset / Time of Symptom Onset (if known) / Date of Last Symptom / Time of Last Symptom / Date Allowed to Return / Time allowed to return (48 hr (hours) after last symptom of NVD (nausea, vomiting, or diarrhea) or 24 hr after fever w/o (without) medication) / COVID/Flu/RSV (respiratory syncytial virus) Exposure: Yes/No / COVID/Flu/RSV Testing Needed? The list also has columns with symptoms that can be checked (examples: nausea, vomiting, diarrhea, fever, chills.)The logs do not indicate when staff members worked last or what unit or shift they were on. Staff February log indicates:5 occurrence dates that have no explanation or symptoms listed.9 occurrence dates that have no date or time of last symptom listed. Two of these are listed as ongoing.7 occurrence dates that have no date allowed to return to work listed.4 occurrence dates that have nausea, vomiting, and/or diarrhea symptoms checked, but the date/time allowed to return to work is less than 48 hours after the date/time of last symptom. Staff April log indicates:2 occurrence dates that have no explanation or symptoms listed.5 occurrence dates that have no date or time of last symptom listed.1 occurrence date that has no date allowed to return to work listed.2 occurrence dates that have nausea, vomiting, and/or diarrhea symptoms checked, but the date/time allowed to return to work is less than 48 hours after the date/time of last symptom. Staff June log indicates:1 occurrence date that has no explanation or symptoms listed.3 occurrence dates that have no date or time of last symptom listed.1 occurrence date that has no date allowed to return to work listed.4 occurrence dates that have nausea, vomiting, and/or diarrhea symptoms checked, but the date/time allowed to return to work is less than 48 hours after the date/time of last symptom. Staff July log indicates:3 occurrence dates that have no date or time of last symptom listed.2 occurrence dates that have nausea, vomiting, and/or diarrhea symptoms checked, but the date/time allowed to return to work is less than 48 hours after the date/time of last symptom.The resident line lists contain the following columns: Resident name, MRN (medical record number), Most recent/relevant admission date, Location in facility, Antibiotic start date, Symptom onset date, Data U/A (urinalysis) ordered, Type of infection criteria met, Other: identify infection type, CAI/HAI (community-acquired infection / hospital-acquired infection), Culture result, Specimen collection date, Organism 1, Organism 2, MDRO (multidrug-resistant organism) type,.Signs and Symptoms, Antibiotic(s) prescribed, Indication/dose/duration documented, Provider name, Antibiotic verified after culture, Precautions type, Precautions start, Precautions end, Additional notes. Resident February log indicates :26 occurrences listed: no admission dates are listed, CAI/HAI column is not completed, only 3 occurrences verify the type of infection criteria was met, 9 occurrences are missing residents' location in facility. On 8/27/25 at 2:45 PM, Surveyors interviewed DON B. Surveyors went over the February line lists and asked if all the blanks should be filled in. DON B said yes. DON B indicated line lists should be complete or they should not be on there at all. DON B indicated staff members on the line list were being mixed up with staff members who called in for reasons such as family emergencies. DON B stated the facility has a new tracking system that is better and cleaner. Resident COVID line list:R62: Onset date: 2/7/25, Positive lab test: 2/7/25. Droplet isolation placed: 2/7/25. Notes: admitted to hospital 2/7R93: Onset date: 2/12/25, Positive lab test: 2/12/25. Droplet isolation placed: 2/8/25. Notes: Sent to ED (emergency department) and returned 2/8 at 1:00 AM, tested positive at hospital On 8/27/25 at 3:01 PM, Surveyors interviewed DON B and NHA A (Nursing Home Administrator). Surveyors reviewed the February 2025 line list and asked about the information on the list for R93, as it did not match information in her health record. DON B confirmed R93 did not go to the hospital on 2/8 and she tested positive for COVID on 2/12, so the droplet isolation date on the list was also wrong. DON B indicated the information on the line for R93 matched information for R62, who was listed on the line above. DON B stated, This is a mess. DON B indicated, my biggest concern is we have all of these pieces and none of them are communicating. Surveyors asked if line lists should be accurate. DON B said yes, they should be. Example 3: Surveyors reviewed the staff and resident line lists provided by the facility for the past three months (residents: May, June, and July 2025 / staff: June, July, and August 2025) and for February 2025 and April 2025, when COVID-19 outbreaks occurred. The facility completed separate COVID line lists for residents in February and April 2025. Surveyors compared these line lists to the infection-tracking maps provided by the facility for February 2025 and April 2025. The maps have the following labels: Respiratory, Skin mucosal, UTI (urinary tract infection), GI, Blood, Bone, Other. The February 2025 map had five rooms on the second floor highlighted in blue, which indicated a respiratory infection. The April 2025 map had one room on the first floor and four rooms on the second floor highlighted in blue, which indicated a respiratory infection On 8/26/25 at 11:34 AM, Surveyors interviewed ADON N (Assistant Director of Nursing) and DON B (Director of Nursing). ADON N indicated maps are tracked in real time, so nothing is missed. February COVID-19 line list vs. map:-Six residents tested positive for COVID-19 in February 2025 but were not tracked on the facility's surveillance map for having a respiratory illness: R93, R94, R66, R95, R14, and R96. April COVID-19 line list vs. map:-Six following residents tested positive for COVID-19 in April 2025 but were not tracked on the facility's surveillance map for having a respiratory illness: R37, R97, R57, R38, R17, and R65. On 8/26/25 at 4:48 PM, Surveyors interviewed DON B and showed him the discrepancies between the maps and line lists. DON B agreed that there were discrepancies. DON B indicated the facility has recently switched to a new infection control program in July 2025 that tracks residents and staff members together. They are still working on learning the new system. -Staff February log:2/2: Call in with symptoms of nausea and diarrhea / Onset date:2/22/2: Call in with symptoms of vomiting / Onset date: 2/22/4: Call in with nausea / Onset date: 2/32/5: Call in with vomiting and diarrhea / Onset date: 2/52/6: Call in with vomiting and diarrhea / Onset date: 2/69 occurrence dates do not have a yes or no response to the COVID/Flu/RSV exposure column.10 occurrence dates do not have a yes or no response to the COVID/Flu/RSV testing needed? column. On 8/27/25 at 2:45 PM, Surveyors interviewed DON B. Surveyors pointed out the pattern of staff members that had CDC-listed COVID symptoms when they called in, yet they were not listed as needing to be tested. DON B indicated they try to identify if there was a significant exposure. When staff members call in, they are asked if they've had a COVID exposure, as testing is not recommended for everyone. Surveyors pointed out that the list does not say what unit staff members worked on and when they worked last. They suggested this might make surveillance easier. DON B indicated it would be easier if all the information was in one place. On 8/27/25 at 5:31 PM, Surveyors interviewed NHA A (Nursing Home Administrator) and DON B. Surveyors asked if people have GI symptoms that are similar, would this be a commonality? DON B replied yes. Surveyor asked if DON B would expect commonalities to be looked at if staff members are calling in with the same symptoms. DON B replied yes. Surveyors asked once this was identified, should the facility have done contact tracing or broad-based testing? DON B indicated this would have warranted further testing and the facility should have done tracking and trending. The facility did not perform testing, per CDC (Centers for Disease Control and Prevention) guidelines, after a resident tested positive for COVID-19 at the facility in February 2025. -Resident July log: No MDROs were documented on any of the resident logs until July 2025. On 8/26/25 at 11:34 AM, Surveyors interviewed DON B and ADON N. Surveyors asked how the facility tracks MDROs. ADON N indicated MDROs are in resident care plans. The new tracking list the facility is using has a column for that. -Summary by infection category lists 0 Urinary tract/kidney infections On 8/26/25 at 11:34 AM, Surveyors interviewed DON B and ADON N. Surveyors had noted that R48 had a UTI in July 2025 but noted that the infection category summary on the facility's infection surveillance monthly report was showing the facility had no UTIs in July 2025. DON B pointed out that R48 was listed on the report. Under the Infection category for R48, Unknown was listed, so it didn't show up on the summary. DON B indicated they are still working on learning the new system. On 8/27/25 at 5:31 PM, Surveyors interviewed NHA A and DON B. Surveyors commented that the facility's infection control program wasn't able to be looked at in a comprehensive way. DON B agreed with this statement and indicated that the overall program was being treated as three or four separate programs, when it should have been treated as one. Example 4: The CDC lists symptoms of COVID-19 on their website: https://www.cdc.gov/covid/signs-symptoms/index.html. The list was last updated on 3/10/25. Symptoms include: fever or chills, cough, shortness of breath or difficulty breathing, sore throat, congestion or runny nose, new loss of taste or smell, fatigue, muscle or body aches, headache, nausea or vomiting, and diarrhea.Surveyors reviewed the February 2025 resident line list. According to the line list, the facility's first COVID-positive resident (R62) was identified on 2/8. On 8/27/25 at 3:01 PM, Surveyors interviewed NHA A (Nursing Home Administrator) and DON B. DON B indicated the R62 tested positive while she was out at the hospital and the facility was notified upon her return to the facility. Surveyors asked what the facility's protocol is when a resident tests positive for COVID. DON B indicated staff is to call the DON, which was done. Surveyors asked if isolation and PPE (personal protective equipment) are used. DON B indicated enhanced droplet precautions are put into place with an N-95 mask. DON B and NHA A indicated all staff and resident testing was initiated on 2/12 after three residents were found to be COVID-positive. Surveyors asked if the facility does house-wide or contact tracing. DON B indicated the facility attempts to do contact tracing. On 8/27/25 at 5:31 PM, Surveyors interviewed NHA A and DON B. Surveyors stated there was no evidence of broad-based testing or contract tracing being done after the first resident in the facility tested positive for COVID. DON B indicated this should have been done, but they do not have any evidence showing that it was done.Surveyors reviewed the staff line list for February 2025:2/2: Call in with symptoms of nausea and diarrhea / Onset date:2/22/2: Call in with symptoms of vomiting / Onset date: 2/22/4: Call in with nausea / Onset date: 2/32/5: Call in with vomiting and diarrhea / Onset date: 2/52/6: Call in with vomiting and diarrhea / Onset date: 2/62/6: Call in with no symptoms listed / Onset date: 2/6 – date of last symptom listed as ongoing2/7: Call in with nausea and chills / Onset date: 2/7 (Of note: Nausea, Vomiting and Diarrhea in 3 or more staff or residents within 72 hours would meet criteria for an outbreak. These symptoms can be due to Gastrointestinal (GI) illness or COVID-19. Neither of which were ruled out for the staff indicated above.) On 8/27/25 at 2:45 PM, Surveyors interviewed DON B. Surveyors pointed out the pattern of staff members that had CDC-listed COVID symptoms when they called in, yet they were not listed as needing to be tested. DON B indicated they try to identify if there was a significant exposure. When staff members call in, they are asked if they've had a COVID exposure, as testing is not recommended for everyone. Surveyors pointed out that the list does not say what unit staff members worked on and when they worked last. DON B indicated it would be easier if all the information was in one place. DON B was asked what date would be considered the start of the facility outbreak. DON B reviewed the information and indicated he would guess it started on 2/7. Surveyors asked if staff should be considered when determining an outbreak. DON B answered yes. Surveyors pointed out that staff members were on the line list in early February with COVID symptoms, but they were not tested. Surveyors asked what symptoms require testing. DON B indicated cold symptoms and respiratory symptoms and indicated they test for nausea, diarrhea, and vomiting if the CDC recommends it. DON B indicated testing everyone is not recommended. Surveyors asked if the facility should be testing based on symptoms alone. DON B indicated they probably should be. Surveyors asked if the facility can determine the actual start date for the outbreak without knowing if staff members were positive for COVID. DON B indicated the facility would not know for sure. On 8/27/25 at 5:31 PM, Surveyors interviewed NHA A (Nursing Home Administrator) and DON B. Surveyors asked why the facility was not doing COVID-19 testing for all symptoms that are listed on the CDC's website (such as nausea, vomiting, diarrhea). DON B indicated that COVID testing should be done if symptoms are not easily explained by another reason. Surveyors asked if people have GI symptoms that are similar, would this be a commonality? DON B replied yes. Surveyor asked if DON B would expect commonalities to be looked at if staff members are calling in with the same symptoms. DON B replied yes. Surveyors asked once this was identified, should the facility have done contact tracing or broad-based testing? DON B indicated this would have warranted further testing and the facility should have done tracking and trending. Example 5: On 8/26/25 at 11:34 AM, Surveyors interviewed ADON N and DON B. Surveyors asked if the facility had any outbreaks. ADON N and DON B indicated there had been no outbreaks in the last few months.After reviewing the facility's infection surveillance maps, Surveyors requested line list documentation from February 2025 and April 2025. The February 2025 map had five rooms on the second floor highlighted in blue, which indicated a respiratory infection. The April 2025 map had one room on the first floor and four rooms on the second floor highlighted in blue, which indicated a respiratory infection. On 8/26/25 at 3:42 PM, Surveyors interviewed DON B. DON B indicated they had discovered there was a COVID-19 outbreak in February 2025 and in April 2025 after looking at the line lists for those months. DON B and NHA A (Nursing Home Administrator) provided the facility summaries for both months. The facility completed separate COVID line lists for residents in February and April 2025. The line list contained the following information for residents: Room number, Resident with COVID signs/symptoms, Onset date, Positive lab test, Symptoms, Last symptom date, Droplet isolation placed, Date resolved, Notes. The February summary listed the following information for residents: Date, Event – [NAME] (opportunistic pathogen) timeline COVID-19, Response/Action. A separate resident summary was not provided for April. The facility noted no staff members had tested positive for COVID during the February 2025 outbreak. The summary listed the following information for staff members in April 2025: Date, Event – [NAME] timeline COVID-19, Response/Action. Nothing in the summaries included an overall description of the facility's response or lessons learned. It was not obvious when each outbreak started or ended. Surveyors wouldn't have known about the outbreaks if they hadn't asked for the line lists for February and April. On 8/27/25 at 2:45 PM, Surveyors interviewed DON B. DON B was asked what date would be considered the start of the facility outbreak. DON B reviewed the information and indicated he would guess it started on 2/7. Surveyors asked if staff should be considered when determining an outbreak. DON B answered yes. Surveyors pointed out that staff members were on the line list in early February with COVID symptoms, but they were not tested. Surveyors asked what symptoms require testing. DON B indicated cold symptoms and respiratory symptoms and indicated they test for nausea, diarrhea, and vomiting if the CDC recommends it. DON B indicated testing everyone is not recommended. Surveyors asked if the facility should be testing with the symptoms alone. DON B indicated they probably should be. Surveyors asked if the facility can determine the actual start date for the outbreak without knowing if staff members were positive for COVID. DON B indicated the facility would not know for sure. On 8/27/25 at 3:01 PM, Surveyors interviewed DON B and NHA A. NHA A indicated the facility called an outbreak on 2/12. NHA A indicated when staff call in with nausea, vomiting, and/or diarrhea, they ask if they've had a COVID exposure. If they haven't, they do not require testing. Surveyors asked how long the facility continues to test residents during an outbreak. NHA A indicated until there are 14 days of no positive tests. DON B indicated the end of the February outbreak was 3/4. Surveyors pointed out that a staff member had called in at the end of February with nausea and vomiting but had not been tested. Surveyors asked if she should have been tested, and would this have changed the end date of the outbreak? DON B responded, possibly. Example 6: On 8/25/25 at 11:10 AM, Surveyors toured the laundry room with HD CC (Housekeeping Director). Surveyors noted a thick layer of dust on top of the pipes above the clean laundry folding area. Some of the dust was hanging down from the pipes and there was air circulating in the room, causing it to blow. The positioning of the pipes created the potential for dust to fall on the clean laundry being folded. On 8/26/25 at 2:20 PM, Surveyors toured the laundry room again. Two housekeeping staff members were working in the laundry room. Surveyors pointed out the dust on top of the pipes above the clean laundry folding area and asked who oversees cleaning the pipes. Both staff members indicated they didn't know who cleans the pipes. On 8/26/25 at 3:39 PM, Surveyors interviewed HD CC and told her about the dust on the pipes in the laundry room. HD CC indicated the maintenance department oversees cleaning pipes and the vents around the facility. HD CC stated she would put a request in to have the laundry room pipes cleaned. Example 7: The facility policy titled, Catheter Care, Urinary, dated 2001, states, in part: Purpose: The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Infection Control: 1. Use aseptic technique when handling or manipulating the drainage system. The facility policy titled, Handwashing/Hand Hygiene, dated 2001, with a Revision Date of October, 2023, states, in part: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Policy Interpretation and Implementation: Administrative Practices to Promote Hand Hygiene . 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents and visitors . Indications for Hand Hygiene: 1. Hand Hygiene is indicated: . c. after contact with blood, body fluids, or contaminated surfaces . 4. Single-use disposable gloves should be used: . c. when in contact with a resident, or the equipment or environment of a resident, who is on contact precautions . R45 was admitted to the facility on [DATE] with diagnoses that include, in part: Other Neuromuscular Dysfunction of Bladder. R45's Comprehensive Care Plan, dated 8/11/25, states, in part: Focus: Resident is on Enhanced Barrier Precautions related to (r/t) indwelling catheter. Goal: Enhanced Barrier Precautions will be followed when coming into contact with. catheter. Interventions: Utilize gown and gloves when coming into contact with. catheter. On 8/20/25 at 12:44 PM, Surveyor observed R45 in the dining room eating lunch with his catheter bag uncovered. On 8/20/25 at 12:51 PM, Surveyor interviewed RN H (Registered Nurse) about R45's catheter bag not being covered. RN H indicated that they do have catheter bags in the facility, and that she would get one to cover R45's catheter bag. Surveyor observed while RN H went to a storage closet in the hallway and retrieved a catheter bag. Surveyor observed RN H return to the dining room and proceed to cover R45's catheter bag with the privacy bag. RN H did not wear gloves, or gown, or perform any hand hygiene before or after handling R45's catheter bag. Surveyor asked RN H if R45 was on Enhanced Barrier Precautions. RN H stated that he was. Surveyor asked RN H what Enhanced Barrier Precautions should be in place for someone that had a catheter. RN H stated that she should have worn gloves and performed hand hygiene after handling R45's catheter bag. On 8/26/25 at 3:17 PM, Surveyor interviewed DON B (Director of Nursing) and shared the observation of R45's catheter bag being handled without Enhanced Barrier Precautions or proper hand hygiene. Surveyor asked DON B if it was his expectation that staff followed Enhanced Barrier Precautions for a resident with an indwelling catheter. DON B stated yes, that was his expectation and that it was concerning that a staff member handled a catheter bag without gloves or performing hand hygiene.

Based on observation, resident interview, staff interviews, and record review, the facility did not ensure Minimum Data Set (MDS) assessment information accurately reflected resident's status for 3 residents (R) of 19 sampled residents (R8, R23, R37) and 1 supplemental resident (R48).R8's, R23's, R37's, and R48's MDS (Minimum Data Set) assessments have conflicting data and are inaccurate as section C indicates they are rarely or never understood, while section B indicates they are understood, have clear speech, and make themselves understood by others.R48's MDS indicates she discharged with return anticipated and that she had a fall with major injury. R48's emergency department notes indicate she had a fall with fracture. Her reentry assessment indicates she did not have a fall with major injury.Evidenced by:The facility did not provide a policy related to the completion of resident MDS.Example 1R8 admitted to the facility on [DATE] Type 2 diabetes, hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), chronic kidney disease, gastro-esophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining), and depressive episodes (periods of intense sadness),On 8/20/25 at 10:14 AM, Surveyor interviewed R8. R8 was able to have a complete conversation and spoke about the food at the facility, the residents who live at the facility, and her experience with previously being sent out to the hospital. She spoke clearly and was able to make herself understood.R8's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 8/21/25 indicates in section B that R8's speech is clarity is clear, her ability to hear is adequate, she makes herself understood, and she understands others with clear comprehension. R8's section C indicates R8 is rarely or never understood.(It is important to note that section B and section C do not support each other, and the assessment does not accurately reflect R8's cognition.)Example 2R23 admitted to the facility on [DATE] with the following diagnoses: Type 2 Diabetes Mellitus, congestive heart failure, hyperlipidemia (a condition in which there are high levels of fat in the blood), dementia, and depression.On 8/20/25 at 12:55 PM, Surveyor observed R23 interact with staff members and residents during lunch. Surveyor noted that R23 speaks fluent Spanish. Some staff members were able to communicate in Spanish back to her. Surveyor also noted that R23 can point and use her hands to makes her needs known if staff members are unable to understand Spanish.R23's most recent MDS, with ARD of 8/6/25, indicates in section B that R23 makes herself understood, has clear speech with distinct intelligible words, and understands others. R23's MDS, section C indicates that she is rarely to never understood.(It is important to note that R23 is assessed to be understood and to understand and to rarely or never be understood. This is contradicting and does not reflect R23's cognitive status.)Example 3R48 admitted to the facility on [DATE] with the following diagnoses: polyneuropathy (peripheral nervous system disorder that impacts nerve function), chronic obstructive pulmonary disease, and chronic kidney disease.On 8/20/25 at approximately 1:00 PM, Surveyor observed R48 interact with staff members and residents during lunch. Surveyor was able to communicate with R48 and asked how lunch was going. R48 spoke clearly and was able to make herself understood.On 8/27/25 at 11:25 AM, Surveyors interviewed NHA A (Nursing Home Administrator) regarding R48. NHA A indicated R48 can articulate and have conversations with staff members.R48's MDS, with ARD of 8/13/25, indicates in section B that R48 has clear speech with distinct intelligible words, adequate hearing, has the ability to make herself understood, and has the ability to understand others with clear comprehension.(It is important to note the discrepancy recorded within this assessment.)Example 4R37 admitted to the facility on [DATE] with the following diagnoses: emphysema ( condition of the lung marked by abnormal enlargement), unspecified dementia, anxiety, major depressive disorder, and chronic kidney disease stage 3.R37's MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 8/8/25, indicates R37 is rarely or never understood in section C, but in section B it indicates R37 is understood by others and makes himself understood.(It is important to note the conflicting information in this one assessment.)Example 5Minimum Data Set 3.0 Resident Assessment Instrument, includes in part: Steps for Assessment The period of review is 180 days (6 months) prior to admission, looking back from the resident's entry date (A1600). 1. Ask the resident and family or significant other about a history of falls in the month prior to admission and in the 6 months prior to admission. This would include any fall, no matter where it occurred. 2. Review inter-facility transfer information (if the resident is being admitted from another facility) for evidence of falls. 3. Review all relevant medical records received from facilities where the resident resided during the previous 6 months; also review any other medical records received for evidence of one or more falls. Coding Instructions for J1700A, Did the Resident Have a Fall Any Time in the Last Month Prior to Admission/Entry or Reentry? Code 0, no: if resident and family report no falls and transfer records and medical records do not document a fall in the month preceding the resident's entry date item (A1600). Code 1, yes: if resident or family report or transfer records or medical records document a fall in the month preceding the resident's entry date item (A1600). Code 9, unable to determine: if the resident is unable to provide the information or if the resident and family are not available or do not have the information and medical record information is inadequate to determine whether a fall occurred. DEFINITION FALL Unintentional change in position coming to rest on the ground, floor or onto the next lower surface (e.g., onto a bed, chair, or bedside mat). The fall may be witnessed, reported by the resident or an observer or identified when a resident is found on the floor or ground. Falls include any fall, no matter whether it occurred at home, while out in the community, in an acute hospital or a nursing home. Falls are not a result of an overwhelming external force (e.g., a resident pushes another resident). An intercepted fall occurs when the resident would have fallen if they had not caught themself or had not been intercepted by another person - this is still considered a fall. CMS understands that challenging a resident's balance and training them to recover from a loss of balance is an intentional therapeutic intervention and does not consider anticipated losses of balance that occur during supervised therapeutic interventions as intercepted falls. CMS's RAI Version 3.0 Manual CH 3: MDS Items [J] October 2024 Page J-32 J1700: Fall History on Admission/Entry or Reentry (cont.) Coding Instructions for J1700B, Did the Resident Have a Fall Any Time in the Last 2-6 Months prior to Admission/Entry or Reentry? Code 0, no: if resident and family report no falls and transfer records and medical records do not document a fall in the 2-6 months prior to the resident's entry date item (A1600). Code 1, yes: if resident or family report or transfer records or medical records document a fall in the 2-6 months prior to the resident's entry date item (A1600). Code 9, unable to determine: if the resident is unable to provide the information, or if the resident and family are not available or do not have the information, and medical record information is inadequate to determine whether a fall occurred. Coding Instructions for J1700C. Did the Resident Have Any Fracture Related to a Fall in the 6 Months prior to Admission/Entry or Reentry? Code 0, no: if resident and family report no fractures related to falls and transfer records and medical records do not document a fracture related to fall in the 6 months (0-180 days) preceding the resident's entry date item (A1600). Code 1, yes: if resident or family report or transfer records or medical records document a fracture related to fall in the 6 months (0-180 days) preceding the resident's entry date item (A1600). Code 9, unable to determine: if the resident is unable to provide the information, or if the resident and family are not available or do not have the information, and medical record information is inadequate to determine whether a fall occurred. page 31: Steps for Assessment 1. If this is the first assessment/entry or reentry (A0310E = 1), review the medical record for the time period from the admission date to the ARD. 2. If this is not the first assessment/entry or reentry (A0310E = 0), the review period is from the day after the ARD of the last MDS assessment to the ARD of the current assessment. 3. Review all available sources for any fall since the last assessment, no matter whether it occurred while out in the community, in an acute hospital, or in the nursing home. Include medical records generated in any health care setting since last assessment. 4. Review nursing home incident reports, fall logs and the medical record (physician, nursing, therapy, and nursing assistant notes). 5. Ask the resident and family about falls during the look-back period. Resident and family reports of falls should be captured here whether or not these incidents are documented in the medical record.R48 initially admitted to the facility on [DATE] following a hospital stay for acute hypoxic respiratory failure (low oxygen levels in the blood) and pneumonia. She had a left femur trochanteric fracture (hip fracture) and left distal radius (radial bone (arm bone)) fracture in 2/2025. R48 has diagnoses that include other secondary Parkinsonism (clinical syndrome characterized by tremor, bradykinesia, rigidity, and postural instability), chronic pain syndrome, and difficulty in walking, not elsewhere classified. R48's Comprehensive Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/6/25 indicated R48's cognition is severely impaired, with a Brief Interview for Mental Status (BIMS) score of 7 out of 15. Section GG of this assessment indicated R48 uses a manual wheelchair for mobility and is dependent for chair/bed-to chair transfers, toilet transfers, and toileting hygiene. R48's Fall Un-Witnessed With Injury report, dated 6/11/25 at 6:00 AM, includes in part, .Nursing description: Writer called to resident room by CNA (Certified Nursing Assistant) staff who reported resident was on the floor next to bed. She was sitting with [sic] floor with legs extended out. Resident unable to state why she was attempting to get out of bed on her own. VSS [vital signs stable], moves all extremities w/o [without] complaints of pain. No injuries observed. Resident description: Resident unable to give description.Immediate Action Taken - Description: DON [Director of Nursing], POA [Power of Attorney], and NP [Nurse Practitioner] updated. Resident encouraged to use call light for all transfers. R48's Emergency Department after visit summary indicates, in part, .Briefly, [R48] presented following a mechanical fall out of bed resulting in C1 fracture and L [left] 7th rib fracture. Recommended a PMT collar (neck brace) to allow C1 fracture to heal. R48's MDS, with ARD of 6/11/25, indicates R48 discharged on 6/11/25 with return anticipated. It also indicates R48 had one fall with major injury since last entry, reentry, or scheduled PPS (Prospective Payment System) or OBRA (Omnibus Budget Reconciliation Act) assessment. R48's MDS, with ARD of 6/25/25, indicated R48 readmitted into the facility on 6/17/25 and she has had no falls since entry, reentry, or since prior scheduled PPS or OBRA assessment. R48's Fall Un-Witnessed With Injury report, dated 8/2/25 at 3:00 AM, includes in part, .Nursing description: [NAME] [sic] was called by the CNA while conducting rounds in the skilled nursing to attend to [R48] that fell. Upon arrival at the resident's room, writer found the resident lying on the floor. VS [vital signs] were obtained.and head to toe assessment was immediately completed. On assessment, the resident was found to have sustained a skin tear with active bleeding to her right elbow. Resident reported a severe pain (10/10) to her right hip. The resident stated she was attempting to transfer herself to the toilet when she lost balance and fell.With the assistance from the CNA, resident was safely transferred back to the bed with a Hoyer [type of lift]. Writer contacted 911 due to resident's pain level and potential injury. Writer left a voicemail for the on call nurse manager.and resident's POA.was contacted and informed. Resident was transported via EMS [emergency medical services] to.hospital for further evaluation and treatment. R48's Emergency Department after visit summary, dated 8/2/25, includes, in part, Reason for Hospitalization: .Pt [patient] reports she has been residing in a rehab for her recent fall and reportedly tripped over her other foot landing on the right side. Imaging is remarkable for mildly displaced right femoral fracture.She reports pain in her right hip from the fall.Hospital Course: .Parkinson's disease .Suspect she has associated dementia and cognitive impairment which is becoming more obvious with acute stressors. R48's MDS with ARD of 8/2/25 indicated R48 discharged with return anticipated. It also indicates R48 had one fall since admission with major injury. R48's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 8/13/25, indicates R48's hearing is adequate with no difficulty in normal conversations, social interactions, and listening to television, R48's MDS also indicates her speech clarity is clear with distinct intelligible words and her ability to express ideas and wants is understood by others. R48's MDS indicates her ability to understand others or understand verbal content is understands with clear comprehension. R48's MDS also indicates R48 had no falls since entry, reentry, or prior scheduled PPS or OBRA assessment. On 8/26/25 at 2:37 PM, MDS Coordinator JJ indicated falls are only counted if they occurred after the reentry. MDS Coordinator JJ indicated if section B states resident is understood by others and understands others then section C should be completed with an interview.On 8/26/25 at 3:15 PM, DON B (Director of Nursing) stated, They need to be accurately filled out. We will have to educate. If sections are completed with interview we should be able to do section C. DON B indicated staff should follow the RAI manual instructions for entering data.

Based on observation, interview and record review, the facility did not ensure each resident had a safe, clean, comfortable and homelike environment or ensure housekeeping provided necessary services to maintain a sanitary, orderly and comfortable area for 3 of 22 sampled residents (R33, R37, and R47), 4 supplemental residents (R57, R76, R26, R30) and 1 of 4 units.R33 and R26 voiced concerns related to the cleanliness of the unit.Surveyor observed R33's, R37's, R57's, R76's, and R30's rooms to be unclean with dirt and debris build up in the corners, urine dried around floor and bottom of toilet, and food and paper particles spattered on floor throughout room.Surveyor and staff observed dried dripping substance on the walls and the ceiling, dirt and debris gathered in the corners, in the windowsills, along the baseboards, and behind doors in the hallways of the unit, in the activity room, and in the dining room.Surveyor observed R47's wheelchair armrest to have the padding and leather/plastic covering to be peeled away and/or missing, exposing the hard structure and screws. Staff indicated they were aware of this concern but thought it was the family's responsibility to fix and did not attempt to put anything in place to make the chair comfortable for R47 while she used it.Surveyor observed R37's wheelchair to have hardened and black colored food on it throughout survey.Evidenced by:Facility policy, titled Resident Room Cleaning Procedure, undated, includes: . Spray the outside of the toilet with (named cleaner) . wipe down horizontal surfaces with (named cleaner) . dust on Wednesdays . sweep the entire floor- floors should we swept corner to corner in a circle around the room and ending in the bathroom . mop the entire floor- be sure to place wet floor signs before beginning . Floor should be mopped corner to corner . Example 1R33 admitted to the facility on [DATE] with the following diagnoses: major depressive disorder, anxiety, type 2 diabetes mellitus, and acute and chronic respiratory failure with hypoxia.R33's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 4/6/25 indicates R33's ability to express needs and wants is understood by others and her ability to understand others is she understands with clear comprehension.On 8/20/25 at 9:52 AM, R33 stated, They could do a better job at cleaning my room. There is dirt in the corners and corn on the floor in the bathroom that has been there a couple days. Surveyor observed debris, hair, and dirt to be gathered in the corners, along the baseboard, and next to the heating register. Surveyor observed 3 pieces of dried corn on the floor near where the floor and shower meet and dried urine on the bottom of R33's toilet.On 8/25/25 at 9:54 AM, Surveyors observed R33's room to still have dirt, dust, debris, and hair built up in the corners of her room, next to her register, behind the doors, and along the baseboards. R33 indicated someone did come in and clean up the hard dried corn after she showed it to them, but they haven't done much to get the floor cleaned in other places.On 8/25/25 at 10:07 AM, Housekeeper EE and Surveyor walked together observing R33's room and bathroom. Surveyor and Housekeeper EE observed dirt and debris built up in the corners, along the baseboards, next to the register, behind the doors, and urine splatters around the base of R33's toilet. I can definitely do better. Sometimes I don't do my best because I have so many rooms to do. Housekeeper EE indicated he only deep cleans the room when someone asks or there is a discharge/room change.On 8/25/25 at 10:36 AM, Housekeeping Manager CC and Surveyor observed R33's room noting dirt and debris built up in the corners, along the baseboards, and along the register. Housekeeping Manager CC and Surveyor observed R33's wall to have brown dried dripping marks on it near the garbage can and observed the bathroom. Housekeeping Manager CC indicated R33's bathroom should not have dirt built up in the corners and urine splatters on the floor and on the bottom of the toilet from last week. Housekeeping Manager CC indicated she would educate and get staff cleaning these areas as soon as possible. Housekeeping Manager CC indicated there is no set schedule for deep cleaning, but they are to do it upon discharges. Housekeeping Manager CC indicated there should be a schedule for deep cleaning the rooms for the long term care residents.Example 2R26 admitted to the facility on [DATE] with the following diagnoses: alcohol abuse, major depressive disorder, generalized anxiety, and chronic pain.R26's most recent MDS with ARD of 6/10/25, indicates her ability to express needs and wants is understood by others and her ability to understand others is she understands with clear comprehension.On 8/20/25 at 10:03 AM, R26 indicated she has a concern that the housekeeping staff do not come on the weekends to clean.Example 3 R37 admitted to the facility on [DATE].R57 admitted to the facility on [DATE].R76 admitted to the facility on [DATE].R30 admitted to the facility on [DATE].On 8/20/25 from 9:52 AM until 1:14 PM, Surveyors observed R37's, R57's, R76's, and R30's rooms to have dust, hair, and debris built up in the corners, behind the doors, along the baseboards, and in the windowsills. Surveyors observed R76's bathroom to have urine on and around the bottom of the toilet and a dirty mop head to be lying on the floor. Surveyor observed a dried gray spill mark next to R37's bed.On 8/25/25 at 9:54 AM, Surveyors observed R37's room, R57's room, R76's room, and R30's room to still have dust, debris built up in the corners, behind the doors, and along the baseboards. Surveyors observed R76's bathroom to still have urine splatter on the floor and bottom of his toilet. Surveyor observed the same gray dried on liquid spill mark next to R37's bed.On 8/25/25 at 10:07 AM, Housekeeper EE observed R37's, R57's, R76's, and R30's rooms, noting dust, hair, and debris built up in the corners, behind the doors, along the baseboards, in the windowsills, and urine splatters around the toilet in R76's room. Housekeeper EE stated, I can definitely do better. Sometimes I don't do my best because I have so many rooms to do. On 8/25/25 at 10:36 AM, Housekeeping Manager CC indicated she oversees several buildings and is not always at this location. Housekeeping Manager CC indicated the department has two open positions and the current staff is working short staffed. Housekeeping Manager CC and Surveyor walked through the unit together noting in rooms (R33's, R57's, R76's, R37's) dirt and debris built up in the corners, in the windowsills, and along the baseboards. Housekeeping Manager CC indicated the cleanliness of the unit does not meet her expectations. Housekeeping Manager CC indicated she will re-educate the housekeeping staff on the issues. Housekeeping Manager CC indicated it is not homelike to have dried brown dripping on the ceilings, walls, or doors. Housekeeping Manager CC indicated staff should clean spills on the spot, when they happen. Housekeeping Manager CC indicated there should not be cobwebs, paper debris, food debris, and dried dripping in the windowsills. Housekeeping Manager CC observed along the baseboards, in the corners, and behind the doors in R37's room, R57's room, R76's room, and R30's room. Housekeeping Manager CC indicated these areas are unclean and they should be cleaned. Example 4On 8/20/25 from 9:52 AM, Surveyors observed on the memory care unit brown dried liquid dripping down the walls in the hallway, activity room, and the dining room. Surveyors observed brown dried liquid on the ceiling in the activity room and on two doors in the activity room. Surveyors observed cobwebs, dust, hair, and debris in the windowsills of the activity room.On 8/25/25 at 9:54 AM, Surveyors observed the same units walls to still have brown dried liquids dripping on them in multiple areas, dust and debris to be gathered in the corners of the activity room and the dining room, and along the baseboards in the hallway, in rooms, in activity room, and in dining room. Surveyors observed a brown substance dripping on two doors in the activity room, and dust, cobwebs, hair, and debris to be gathered in the windowsills of the activity room.On 8/25/25 at 10:07 AM, Housekeeper EE and Surveyor walked together observing the unit. Housekeeper EE indicated he sees a brown liquid dried to the walls and ceiling in the dining room and activity room. Housekeeper EE indicated there are cobwebs, hair, food wrappers, and dried spills in the windowsills of that activity room. Housekeeper EE indicated he sees brown dried substance dripping down two doors in the activity room and brown dried substance dripping in several areas in the hallway. Housekeeper EE indicated the nursing staff could also assist in cleaning up the spills when they happen, but they do not always do this. Housekeeper EE indicated the department is working short staffed as they have 2 positions not filled. Housekeeper EE stated, I can definitely do better. Sometimes I don't do my best because I have so many rooms to do. On 8/25/25 at 10:36 AM, Housekeeping Manager CC indicated she oversees several buildings and is not always at this location. Housekeeping Manager CC indicated the department has two open positions and the current staff is working short staffed. Housekeeping Manager CC and Surveyor walked through the unit together noting the following: In the dining room- dust and debris built up along the baseboards and behind the door, brown dried dripping on the walls in multiple areas and on the doors. In the activity room- dust and debris built up along the baseboards and in the corners and brown dried dripping on the doors, ceiling, and walls in multiple areas, and dried spills on the floor. In the hallways of the unit- brown dried dripping in multiple areas, dust gathered in the corners, along the baseboards, in doorways, and behind doors. Housekeeping Manager CC indicated the cleanliness of the unit does not meet her expectations. Housekeeping Manager CC indicated she will re-educate the housekeeping staff on the issues. Housekeeping Manager CC indicated it is not homelike to have dried brown substance dripping on the ceilings, walls, or doors. Housekeeping Manager CC indicated staff should clean spills on the spot, when they happen. Housekeeping Manager CC indicated there should not be cobwebs, paper debris, food debris, and dried substance dripping in the windowsills of the shared activity room. Housekeeping Manager CC observed along the baseboards, in the corners, and behind the doors in the activity room, dining room, and indicated she would have staff come and clean these areas.Example 5R47 admitted to the facility on [DATE] with diagnoses including schizophrenia, anxiety disorder, macular degeneration, glaucoma, and major depressive disorder.R47's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 6/25/25 indicates R47 requires assistance to meet her needs in the following areas: toileting, bathing, dressing, putting on footwear, rolling in bed, and transfer.On 8/21/25 at 12:30 PM, Surveyor observed R47's wheelchair armrest to have a hard plastic structure and a screw exposed. Surveyor observed the leather/plastic casing that used to cover the structure to be hanging alongside the armrest and missing the padding. R47 had a short-sleeved shirt on and was propelling herself on the unit, rubbing the inside of her elbow along the exposed hard structure. Surveyor observed R47's arm and did not observe an injury. On 8/21/25 at 12:57 PM, RN W (Registered Nurse) indicated R47's wheelchair armrest is ripped and folded over. RN W indicated R47's wheelchair has been like this for several days and it is the family's responsibility to maintain the chair because they own in. Surveyor asked RN W if there was potential for R47 to get an injury due to the exposed hard plastic structure or screws. RN W indicated there is potential for this as R47 propels herself on the unit. Surveyor asked RN W if R47's chair in this condition is safe and homelike. RN W indicated it is not.On 8/21/25 at 1:01 PM, DON B (Director of Nursing) indicated he was unaware of R47's chair being damaged and the facility should put something in place on R47's wheelchair arm rest to prevent R47 from obtaining an injury. DON B indicated the broken armrest of R47's wheelchair is not safe and homelike. DON B indicated the facility would get her a different wheelchair until her family can repair hers.Example 6R37 admitted to the facility on [DATE] with the following diagnoses: unspecified dementia, anxiety, and major depressive disorder.On 8/20/25 at 12:58 PM, Surveyor observed R37's wheelchair to have hardened food substance on it that resembled hardened brown candle wax. The substance was on the arm of his chair, the side of his chair, in the braking mechanism of the chair, on the seat of his chair and on the bars underneath the chair. Surveyor observed R37 drop food from his mouth onto the chair including orange pureed fruit and a red and white pudding/cheesecake dessert. During an interview, RN W indicated it is the night shift CNAs (certified nursing assistants) who clean wheelchairs. RN W indicated R37's wheelchair needs to be cleaned.On 8/25/25 at 10:07 AM, Surveyor and Housekeeper EE observed R37's wheelchair noting the brown, white, red, and orange substances that are layered on the arm, side, seat, on the braking mechanism, and on the bars. Housekeeper EE indicated the nursing department is responsible for cleaning resident wheelchairs. On 8/25/25 at 10:36 AM, Housekeeping Manager CC indicated it is the nursing department's responsibility to clean the wheelchairs and R37's wheelchair needs to be cleaned. Housekeeping Manager CC indicated R37's wheelchair has not been cleaned in some time.

Based on observation, interview and record review, the facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature. This has the potential to affect 4 (R82, R51, R3 and R1) of 19 sampled residents and residents eating in 1 of 3 dining rooms (10 residents out of a census of 68). R82 and R51 voiced concerns with hot foods not being hot. R3 and R1 voiced concerns regarding food temperatures. Surveyor conducted 1 test tray for the dining room which was not palatable. Evidenced by: Example 1 On 8/20/25 at 2:38 PM, Surveyor interviewed R82 during the initial screening process. During the interview R82 was asked if there were any concerns with meals. R82 indicated about 5 times a week the food is dry, tasteless, has no spices and the hot foods are not hot. Example 2 On 8/21/25 at 9:16 AM, Surveyor interviewed R51 during the initial screening process. During the interview R51 was asked if there were any concerns with meals. R51 indicated that about 5 times a week the hot foods are not hot. Example 3 R3 admitted to the facility on [DATE]. Her most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/4/25 indicates R3's cognition is intact with a Brief Interview of Mental Status (BIMS) score of 15 out of 15. On 8/20/25 at 11:48 AM, Surveyor interviewed R3 about the food at the facility. R3 stated that the food was terrible. R3 indicated that the food was not hot and very often she has to eat cold eggs in the morning. R3 stated that she eats breakfast in her room, and that she usually doesn't get her breakfast tray until 9:00 o'clock. Of note: the posted mealtimes provided by the facility indicate that breakfast for the hallway that R3 resides in is 7:40 AM. Example 4 R1 admitted to the facility on [DATE]. Her most recent MDS with an ARD of 7/30/25 indicates R1's cognition is intact with a BIMS score of 15 out of 15. On 8/20/25 at 12:05 PM, Surveyor interviewed R1 about the food at the facility. R1 stated that she eats in her room, and that the food is not always hot. R1 indicated that the majority of the time the food is cold, and that while she loves oatmeal for breakfast, when she gets hers in the morning it is cold. R1 stated that she doesn't like cold oatmeal. Surveyor asked R1 if the staff would warm up her oatmeal for her so she wouldn't have to eat it cold. R1 stated that they would, but that she has gotten tired of asking them to warm it up every day. Example 5 Facility policy, entitled Food Preparation and Service with a revision date of April 2019 states, in part: .Food Preparation, Cooking and Holding Time/Temperatures 1. The danger zone for food temperatures is between 41- and 135-degrees Fahrenheit.PHF (Potentially Hazardous Foods) must be maintained below 41 degrees Fahrenheit or above 135 degrees Fahrenheit. On 8/21/25 at 12:55 PM, Surveyor conducted a test tray from the 200 Skilled Unit dining room. Surveyor took the temperature of the items on the tray. The temperatures were as follows: Hamburger on a bun– 126.7 degrees Fahrenheit Sweet Potato fries – 122.8 degrees Fahrenheit Dill pickle spear – 115 degrees Fahrenheit Milk – 38.9 degrees Fahrenheit Water – 42.9 degrees Fahrenheit Surveyor tasted the food and drink on the tray. The hamburger and fries were not as hot as they should have been. The pickle was very warm from sitting on the plate from preparation to service and should have been a cold item. The tray was not palatable and at a safe and appetizing temperature. On 8/25/25 at 2:32 PM, Surveyor interviewed DM J (Dietary Manager) and AFSD I (Assistant Food Service Director) who indicated the hot food should have been above 135 degrees and the cold food should be below 41 degrees Fahrenheit. On 8/25/25 at 3:15 PM, Surveyor interviewed NHA A (Nursing Home Administrator), DON B (Director of Nursing), and RDM K (Regional Dietetic Manager). Surveyor asked if they would expect policies to be followed for food preparation and service; they stated yes.

Based on observation, interview, and record review the facility did not ensure that residents were ensured a dignified existence and self-determination for 2 of 17 sampled residents (R45 and R37). R45 voiced concerns that his catheter bag was not covered, including when he went to the dining room for meals. R37's wheelchair was observed to be dirty and undignified. As evidenced by: The facility policy titled, Resident Rights, dated 2001, states, in part: .Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. to be treated with respect, kindness, and dignity. e. self-determination. h. be supported by the facility in exercising his or her rights. The facility policy titled, Dignity, dated 2001, states, in part: Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation: 1. Residents are treated with dignity and respect at all times. 2. The facility culture supports dignity and respect for residents by honoring residents goals, choices, preferences. 5. When assisting with care, residents are supported in exercising their rights. For example, residents are: a. groomed as they wish to be groomed. e. provided with a dignified dining experience. 12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: a. helping the resident to keep urinary catheter bags covered. Example 1 R45 was admitted to the facility on [DATE]. R45's Minimum Data Set (MDS) dated [DATE] indicates, in part: a Brief Interview of Mental Status (BIMS) score of 6 out of 15, indicating R45 has a severe cognitive impairment. R45's Comprehensive Care Plan, dated 1/14/25, states, in part: .Focus: The resident has a Suprapubic catheter related to (r/t) Neuro muscular dysfunction of bladder. Intervention: Position catheter bag and tubing below the level of the bladder and away from entrance room door or cover for privacy. On 8/20/25 at 10:59 AM, Surveyor interviewed R45 in his room and noted that he had a catheter bag that was uncovered. Surveyor asked R45 about his catheter bag. R45 stated that he didn't mind it being uncovered while in his room, but that he liked it to be covered when he was out of his room. On 8/20/25 at 12:44 PM, Surveyor observed R45 eating lunch in the dining room with his catheter bag uncovered. Surveyor interviewed R45 about his catheter bag, who stated that that there should be a black or blue bag covering it. R45 indicated that his catheter bag should be covered and that he likes it to be covered when he is out of his room. On 8/20/25 at 12:51 PM, Surveyor interviewed RN H (Registered Nurse) and asked her about R45's catheter bag not being covered. RN H stated that they do have catheter bags and that she would get him one. Surveyor asked RN H if she would consider the catheter bag uncovered to be a violation of R45's dignity. RN H stated yes, she considered the uncovered catheter bag to be a dignity issue. On 8/20/25 at 12:57 PM, Surveyor interviewed CNA D (Certified Nursing Assistant) and asked her about R45's catheter bag. CNA D stated that she didn't think that R45 had a bag to cover his catheter, but that some of the other residents have them. Surveyor asked CNA D if she would consider the catheter bag uncovered to be a violation of R45's dignity. CNA D stated yes, that possibly R45 would feel bad if he wanted it covered and it wasn't. On 8/25/25 at 8:18 AM, Surveyor observed R45 in the dining room eating breakfast again with his catheter bag not covered. On 8/26/25 at 3:16 PM, Surveyor interviewed DON B (Director of Nursing) and shared with him the observations of R45's catheter bag being uncovered in the dining room. Surveyor asked DON B if he would consider the catheter bag uncovered to be a violation of R45's dignity. DON B stated that yes, if a resident is requesting their catheter bag to be covered and it wasn't, then he would consider that to be a violation of their dignity. Example 2 On 8/20/25 at 12:58 PM, Surveyor observed R37 sitting in his wheelchair. Surveyor observed R37's wheelchair to have dried brown, yellow, red, and orange food substance on the arm of the chair, in the braking mechanism, along the side of the chair, and on the edge of the seat of the wheelchair. Some of the food substance had hardened into a brown wax-like form representing a dripping candle. Other food substance was colorful and could be identified by the menu for the week, including cheesecake/Jello desert and mandarin oranges. On 8/21/25 at 12:52 PM, RN W (Registered Nurse) and Surveyor observed R37's wheelchair. RN W stated, This is not clean. There is food on here from more than one meal. RN W indicated the night shift CNAs (Certified Nursing Assistants) are to clean the residents' wheelchairs. On 8/25/25 at 10:07 AM, Housekeeper EE and Surveyor observed R37's wheelchair while he was seated in it, in the unit's dining/activity room, noting the food substance to be hardened like candle wax and in the form of a spill with dripping patterns. Housekeeper EE indicated it is the nursing department's responsibility to clean resident wheelchairs. Housekeeper EE indicated the food appears to have fallen at different times with the oldest food being brown in color and the newer food to be hardened but still holding some color. Housekeeper EE indicated R37's wheelchair was not clean, and it should be. Surveyor observed R37's wheelchair to have the same food substance on it as last week, noting brown hardened food substance dripping down the side of the wheelchair on the arm, the side panel, in and on the braking handles, and on the seat of the wheelchair. The food varied in color from white, red, orange, brown, and it varied in hardness (some of the food could be wiped off while others were hardened onto the chair). On 8/25/25 at 10:36 AM Housekeeping Manager CC indicated cleaning of spills is everyone's responsibility, not just housekeeping department. Housekeeping Manager CC observed R37's wheelchair and indicated it is dirty, and nursing should clean this. Housekeeping Manager CC indicated R37's chair should be cleaned regularly, but it has not been.

Based on interview and record review, the facility did not provide care consistent with professional standards of practice to prevent pressure injuries (PI) from developing or worsening for 2 of 5 residents reviewed for PIs (R68 and R66.) R68 was admitted to the facility with a stage 2 PI on his spine. The facility did not complete weekly wound assessments and measurements and R68's PI worsened. The facility did not ensure an initial assessment, weekly measurements, and interventions were in place to prevent the PI from developing or worsening for R66's left buttock pressure injury. Evidenced by: The facility's policy titled, Pressure Injuries Overview last revised March 2020, states in part, .Pressure Ulcer/ Injury (PU/PI) refers to localized damage to the skin and/ or underlying soft tissue usually over a bony prominence or related to a medical or other device .Debridement is the removal of devitalized/ necrotic tissue and foreign matter from a wound to improve or facilitate the healing process . Eschar is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color; and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound. Slough is a non-viable yellow, tan, gray, green, or brown tissue; usually moist; can be soft, stringy, and mucinous in texture. Slough may ne adherent to the base of the wound or present in clumps throughout the wound bed .Stage 2 Pressure Injury: Partial- thickness skin loss with exposed dermis .*The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum- intact blister .*Granulation tissue, slough, and eschar are not present .Stage 3 Pressure Injury: Full- thickness skin loss *Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. *Slough and/ or eschar may be visible .*If slough or eschar obscures the wound bed, this is an Unstageable PI:Unstageable Pressure Ulcer: Obscured full- thickness and tissue loss *Full- thickness skin and tissue loss in which the extent of the tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar .*Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed . Example 1 R68 was admitted to the facility on [DATE] with diagnoses that include: left intertrochanteric hip fracture, aspiration pneumonia, CHF (Congestive heart Failure), Kyphoscoliosis, and a stage 2 pressure injury to his spine. R68's most recent Minimum Data Set (MDS) dated [DATE] states that R68 has a Brief Interview of Mental Status (BIMS) of 11/15, indicating that R68's cognition is moderately impaired. R68's MDS also states that R69 requires extensive assistance and 2 staff for bed mobility, transfers, toileting, and personal hygiene. R68's PI measurements are as follows: 3/16/23: 2.3cm (centimeters) x 1.5 cm- no documentation of PI characteristics, such as what the wound bed looked like or if there was any drainage. PI was documented as a stage 2. R68's physician's orders dated 3/16/23: Spine wound: Cleanse area with soap and water, pat dry, apply mepilex to area until resolved every day and as needed. R68's PI measurements dated 3/28/23: 1.3cm x 1.5cm- slough present in 50% of the wound bed, light serous (thin, watery fluid), progress: deteriorating. Wound continues to be documented as a stage 2. R68's physician's orders dated 3/28/23: Spine wound: Cleanse area with soap and water, pat dry, apply medihoney, cover with mepilex; change daily until resolved (also available as needed). Nurse's notes dated 3/28/23 state, Notified NP (Nurse Practitioner) that spine wound is worsening. NP added medihoney to wound care regimen daily. NP also ordered Q2 (every 2 hours) turns and a pillow to be placed behind his back when in wheelchair. (It should be noted a PI with 50% slough would be considered a St 3.) (It should be noted there was no assessment or measurements for the week of 4/3/23) 4/11/23: 1.3cm x 2.0cm- slough present in 20% of the wound bed, light serous drainage. Wound continues to be documented as a stage 2. (It should be noted there was no assessment or measurements for 14 days between 3/28 and 4/11.) On 4/13/23 at 8:03 AM, Surveyor observed RN D (Registered Nurse) perform R68's wound care. Surveyor observed R68's spine PI and noted that the peri wound was approximately the size of a baseball and was a reddish-purple color. R68's wound bed had slough that covered approximately 1/3 of the wound bed. Surveyor asked RN D if she would say there is slough in the wound bed, RN D stated yes. On 4/17/23 at 12:40 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what the process is for when a resident is admitted with or develops a PI, DON B stated that the floor staff complete a head-to-toe assessment and would update herself and the NHA (Nursing Home Administrator), and then they would assess the area. DON B stated that she would expect floor staff to document everything, including the measurements, appearance, and location. Surveyor asked DON B who is responsible for staging the wounds, DON B stated that the wound nurse will stage the wound when she assesses the wound. Surveyor asked DON B if a stage 2 wound develops slough, is it still a stage 2, DON B stated no, it would not be a stage 2. Surveyor asked DON B if R68's wound stage should have been updated, DON B stated yes. Surveyor reported to DON B that R68 only had wound measurements completed on 3/16/23, 3/28/23, and 4/11/23. Surveyor asked DON B if R68 should have had weekly wound measurements and assessments, DON B stated yes. It is important to note that R68 did not receive weekly wound measurements and assessments and the wound deteriorated, developed slough and was slightly bigger during this time. 39849 Example 2 R66 was admitted to the facility on [DATE] with diagnoses that include, in part: Displaced fracture of base of neck of left femur; Type II Diabetes; Other Lack of Coordination; Cognitive Communication Deficit; and Delerium . R66's admission Minimum Data Set (MDS) dated [DATE] documents the following: Section C: Brief Interview for Mental Status (BIMS) of 10, indicating R66 has a moderate cognitive impairment. Section G: Indicates R66 requires Extensive assistance with two + person physical assist for bed mobility, transfer, and toileting. Extensive assistance with one-person physical assistance for locomotion on and off the unit. R66's Care Plan, states, in part: Focus: R66 has potential impairment to skin integrity r/t decreased mobility. Date Initiated: 2/23/23. Revision on: 3/2/23. Goal: R66 will maintain or develop clean and intact skin by the review date. Date Initiated: 2/23/23. Revision on: 3/2/23. Interventions: Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration, etc, to MD. Date initiated: 2/23/23. Focus: R66 has an ADL (Activities of Daily Living) self-care performance deficit .Date initiated 2/23/23; Revised 3/22/23. Goal: R66 will improve current level of function in his ADLs through the review date. Date Initiated and Revision on: 2/23/23. Interventions: Bed Mobility: The resident requires 2 staff to turn and reposition in bed and as necessary. Date Initiated: 2/23/23. Revision on: 3/20/23. Focus: R66 has potential for malnutrition, potential for altered hydration status d/t increased nutrient needs d/t femur fx c/b (complicated by) oropharyngeal dysphagia with history of aspiration PNA (pneumonia) .hx of weight loss and variable intake .R66 has increased PRO/kcal needs r/t risk for malnutrition and hx of significant weight loss .Date initiated: 2/23/23. Revision on: 4/12/23. Goal: R66 will consume at least 50% of most meals through next review date. Date initiated: 2/23/23. Revision on 2/24/23. Interventions: Diet Type is: Regular diet, Pureed textures, Honey liquids. Date Initiated: 2/23/23. Revision on 3/22/23. Offer snacks if intake is low or as needed. Date Initiated: 2/23/23. Administer supplements as orders. Date Initiated: 2/24/23. Encourage high PRO snack at HS (bedtime). Date Initiated: 3/10/23. Assure adequate assistance is provided. Date initiated: 4/12/23. Encourage favorites - Hot Cocoa, Magic Cups. Date Initiated and revised: 4/12/23. Focus: R66 is at risk for falls r/t (related to) Gait/balance problems, delirium, history of falls. Date initiated and revised: 2/23/23. Goal: [NAME] will not sustain serious injury through the review date. Date initiated and revised: 2/23/23. Interventions: Air mattress with Bolsters. Date initiated: 3/7/23. Revision on 4/9/23. Check and Change every 2-3 hours and PRN (as needed). Date Initiated: 3/6/23. Revision on: 4/12/23. Encourage resident to lay down after dinner. Date Initiated: 3/24/23. Encourage resident to sit in recliner in the lounge area when restless. Date initiated 3/30/23. R66's Certified Nursing Assistant (CNA) Care Card includes, in part: Bed Mobility: 2A (Assist). Continence: Incont. B/B (Bowel/Bladder) Check and change Q2-3 hrs and PRN. Turn and position: Every 2-3 hrs and prn. Mattress: Air-3 w/bolsters. Special Notes: Encourage pt to sit in recliner after meals R66's Skin & Wound Evaluation. include, in part: 2/23/23: .1. Type: .12. Moisture Associated Skin Damage (MASD) .12a. 1. IAD Incontinence Associated Dermatitis .22. Location: Sacrum. 23. Acquired: .2. Present on Admission .B. Wound Measurements: 1.0cm x 0.7cm. No depth. 3/14/23: .1. Type: .12. Moisture Associated Skin Damage (MASD) .12a. 1. IAD Incontinence Associated Dermatitis .22. Location: Sacrum. 23. Acquired: .2. Present on Admission .B. Wound Measurements: None listed. C. Wound Bed: 1. Epithelial. 1a. %Epithelial. 1. 100% of wound covered, surface intact .I. Progress: .7. Resolved . R66's Skin Observation Weekly, include, part: 3/15/23: .2. Notes: No new or worsening skin impairments noted. 3/29/23: .2. Notes: No new or worsening skin impairments noted. 4/12/23: .2. Wounds to heel and sacrum remain . R66's Electronic Treatment Administration Record (eTAR) for March 2023, includes, in part: Start Date: 3/31/23 - Apply foam dressing or mepilex to open are on buttock weekly, change if becomes soiled or wet. as needed for skin integrity. Of note there is no measurements or asssessment of this open area from 3/31/23. Start Date: 4/7/23 7:00AM - Apply foam dressing or mepilex to open area on buttock weekly, change if becomes soiled or wet. One time a day every Fri for Skin Integrity. R66's physician orders, indicate, in part: Order and Start Date: 3/31/23: Apply foam dressing or mepilex to open area on buttock weekly, change if becomes soiled or wet. As needed for skin integrity. Order Date 3/31/23. Start Date: 4/7/23: Apply foam dressing or mepilex to open area on buttock weekly, change if becomes soiled or wet. One time a day every Fri for Skin integrity Of note there is no measurements or asssessment of this open area from 3/31/23. Order Date 4/14/23. Start Date: 4/15/23: Left buttock wound: Cleanse are with NS (normal saline), pat dry, apply lotion to healed, intact skin. Cover open areas with Mepilex AG (silver) every day shift for skin condition . R66's Nurses notes, include, in part: 3/31/23 6:59PM: Return call received from PCP (Primary Care Provider) .apply foam dressing or mepilex to open area on buttock weekly and PRN (as needed) if becomes soiled or wet . Of note, Surveyor noted no evidence of documentation of the wound description, measurements, or other characteristics for 3/31/23 until 4/13/23. R66's Wound Evaluation, dated April 13, 2023 at 10:42AM includes, in part: Pressure - Stage 2; Body Location: Left Buttock; New - 14 days old; Acquired: In-House Acquired .Dimensions: Length: 4.49cm; Width 4.47cm .Wound Bed: .Other: Pink or red. Exudate: Amount: Light; Type: Serous . Of note, the wound bed, when observed, was covered in off-white/tan material. An interview with RN C (Regional Nurse), the wound care certified nurse for the facility, note her assessment of 60-75% slough. On 4/13/23 at 9:25AM Surveyor accompanied RN D (Registered Nurse) to R66's room to observe wound care. There is a dressing to the left buttock that was removed by RN D. After removal an open area is noted. RN D indicated the last time she did this treatment the area was closed. Surveyor asked RN D how she would describe the open area. RN D indicated a stage II PI (Pressure Injury) with slough. RN D indicated, she is not the wound care certified nurse and that she would be requesting RN C to assess the wound. Open area to left buttock has a light tan to off-white slough like covering greater than 90% of the wound bed. Peri area is red. Surveyor asked RN D what nursing responsibilities are when finding a pressure injury. RN D indicated, we are just supposed to describe the wound and the WCC (Wound Care Certified) nurse should do the staging. So, I would say stage II with slough but RN C will have to look at it. RN D indicated, they will contact the doctor and POA (Power of Attorney) regarding the change and get new orders. On 4/13/23 at 9:54AM Surveyor interviewed RN J and asked what interventions are in place for R66's pressure injuries. RN J indicated, an air mattress, last she was aware they were putting mepilex on his buttock for protection. Surveyor asked RN J how long it had been since she had completed care to the are on R66's bottom. RN J indicated she did not recall. R66's Nurses notes indicate, in part: 4/13/23 at 11:20AM Nurses Note (Documented by RN D) Note Text: Today, writer was performing wound care treatment to resident when an open area was uncovered to buttocks. It was noted that resident has MASD (Moisture Associated Skin Damage) to the right buttocks and an open area (roughly the size of a half dollar) that appears to be a Stage 2 pressure sore with slough at the center. After completing wound care, writer updated DON (Director of Nursing) and wound nurse. Floor nurse also made aware. Floor nurse to fill out skin packet and notify family. Writer called and left message with resident's PCP (Primary Care Provider) to notify them of open area and obtain treatment orders. Waiting for a call back. Writer also returned and obtained pictures of the areas. 4/13/23 at 2:08 PM Nurses Note (Documented by RN C) Assessed left buttock and gluts, area blanches, open area has zero depth. Granulation under wound, 10% slough center with epithelization on wound. R66 has a low air loss mattress, positioned off left glut. On 4/17/23 Surveyor was provided with R66's patient instructions from his wound care appointment on 4/14/23. These include information for multiple wounds including the Left Buttock Wound. Visit Diagnoses include, in part: Primary: Pressure injury of left heel, unstageable; Pressure injury of left buttock, stage 2; Traumatic open wound of right lower leg, initial encounter; Sloughing of wound . On 4/17/23 at 2:46 PM, Surveyor attempted to contact the wound clinic provider to clarify which wound was diagnosed as sloughing. No return call was received. On 4/13/23 at 1:28 PM Surveyor spoke with CNA E (Certified Nursing Assistant) and asked how she knows what interventions are in place for current pressure injuries (PI's) and/or prevention of PI's. CNA E indicated, the staff get a new care card every day and they can also look in the computer under the CNA charting for interventions. CNA E provided a copy of a current care card to the Surveyor. Surveyor reviewed the information for R66 with CNA E. Surveyor asked CNA E how she would know to use a pressure relieving device in R66's wheelchair or other surfaces. CNA E showed Surveyor in the electronic health record CNA charting where it indicates to monitor chair - pressure relieving device. On 4/17/23 at approximately 9:35AM Surveyor interviewed, CNA E and asked how often R66 sits in the green recliner in living room area. CNA E indicated, we try to get him in there after lunch, but if he is having a good time in activities, like doing ROM (Range of Motion), then we will leave him in his wheelchair so he can continue. Surveyor asked CNA E how long R66 stays in the recliner. CNA E indicated around an hour and a half to two hours is the longest. Surveyor asked what the shortest amount of time would be. CNA E indicated, Forty-five minutes to an hour. Surveyor asked CNA E if she puts anything in the recliner prior to R66 sitting in it. CNA E indicated, no. Surveyor asked CNA E if she has been trained to move his pressure relieving cushion from his wheelchair to the recliner when he is in the recliner. CNA E indicated, no, I have not. On 4/17/23 at 9:21AM Surveyor interviewed CNA K and asked if she has ever assisted R66 to sit in the green recliner in the living room and how often. CNA K indicated, yes, sometimes we try to put him in there after meals. Surveyor asked CNA K, how long R66 stays in the recliner. CNA K indicated, it depends on his mood, could be thirty minutes, sometimes an hour. Surveyor asked CNA K if she places anything in the recliner prior to moving R66 to it. CNA K indicated, no, sometimes I do grab his cushion from his wheelchair and then pillows to get his heels up. On 4/17/23 at 12:40 PM Surveyors interviewed DON B (Direcot of Nursing) and asked what the process is if a resident comes into the facility with a PI (Pressure Injury) or develops one while in the facility. DON B indicated, with admissions, the floor staff will tell me or the NHA (Nursing Home Administrator) and the IDT (Interdisciplinary Team) and then we would assess it. If we were still in the building, we like to get the pictures on admission. We do expect them to document everything. If we can't get the picture that day, we do get it the next day. Surveyor asked DON B, what the documentation should include. DON B indicated, measurements, appearance of the wound, location. Surveyor asked DON B what is done for in-house acquired PIs. DON B indicated, call the physician, complete risk management in PCC (electronic health record), skin packet - includes what they found, who they notified, what they think happened, then the IDT and myself all review it at our daily meeting. We figure out the root cause and put in place any interventions and then care plan and care card are updated. Surveyor asked DON B, where we find the measurements for a new wound. DON B indicated, they are in risk management and that we do not have access to this. Surveyor asked for any information regarding wound measurements prior to 4/13/23 for R66's Left Buttock Wound that was found on 3/31/23. Surveyor asked DON B, if wound measurements should be done when the PI/wound is found. DON B indicated, yes. Surveyor asked DON B when staging is completed. DON B indicated, staging is typically done by our wound nurse when she assesses it. Surveyor asked DON B what the process is if it is the weekend, or the wound care nurse is not at the facility. DON B indicated, they would call me and the doctor and explain what they found. Surveyor asked DON B if staging the wound would not be done until they actually came in and saw it. DON B indicated, yes. Surveyor asked DON B who the wound care nurse is. DON B indicated RN C is wound care certified and she is involved in the wounds and reviews wound care documentation weekly. RN D, is not wound care certified, and does the initial assessment and then RN C will go in and put another note in regarding the wound. Surveyor asked DON B if wounds are measured and assessed weekly. DON B indicated, yes. RN C, RN D, and myself do this. Surveyor asked DON B if R66 should have a pressure relieving device when he is in the recliner in the living room. DON B indicated, yes. Surveyor asked DON B if she was aware of the wound on R66's left buttock. DON B indicated she was not aware of it until last week. Surveyor asked DON B to clarify if she was not aware of it until the wound care was observed by the Surveyor last week with RN D. DON B indicated, yes. Surveyor asked DON B if there should have been a wound description and measurements on the 3/31/23 when there is a note indicating it was first found. DON B indicated, yes. Surveyor asked DON B if measurements should have been done weekly. DON B indicated, yes. Surveyor asked DON B if the wound develops slough is it a stage II. DON B indicated, no, not if you can't see through it. Surveyor showed DON B the picture of R66's wound that was taken on 4/13/23 and asked how she would stage the wound. DON B indicated, that there are red dots and a small line of epithelial tissue you can see and so it would be a stage II. The wound care team deemed it a stage II as well. On 4/17/23 at 1:43PM Surveyor interviewed RN C (Regional Nurse) and asked how she decided the staging of R66's Left Buttock Wound. RN C indicated, I did go in and look at the wound after it was staged and assessed by RN D. My question to RN D was is that slough. You can't have slough in the wound of a stage II. We had the discussed that it was not slough and that it was granulation tissue. Surveyor asked for clarification from RN C and asked if she is saying they decided the area that was off white to tan wasn't slough. RN C indicated, no, that is not correct and requested to review her notes and then come back. Surveyor asked RN C if she has been monitoring R66's wounds his entire admission. RN C indicated she was off during the week of 3/27 but otherwise yes and that she completed his admission assessment. Surveyor asked RN C what standard of practice they follow. RN C indicated, WCEI (Wound Care Education Institute) and NPIAP (National Pressure Injury Advisory Panel). On 4/17/23 at 4:00PM RN C indicated she wanted to provide further information from our previous discussion. RN C stated she would stage R66's left buttock pressure injury as a Stage 3. Surveyor and RN C reviewed wound picture from 4/13/23. Surveyor asked RN C about her documentation from the same day that states the wound was 10% slough. Surveyor asked RN C how she is differentiating that 10% from the rest of the wound bed. RN C indicated, I would say it is closer to 60-75% slough. Surveyor asked RN C how she would stage a wound with 60-75% slough. RN C indicated, unstageable.

Based on observation, interview and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 3 residents (R1 and R4) reviewed for supervision and accidents out of a total sample of 5. R1 is moderately cognitively impaired, and requires extensive assist of one staff with sit to stand transfers. Staff assisted R1 with a transfer that resulted in R1 falling and sustaining a laceration above the left eye requiring stitches. R4 sustained falls at the facility, the facility did not consistently complete root cause analysis or implement fall interventions or update the plan of care after the fall/s. This is evidenced by: The facility's Fall Policy and Prevention Program, dated 6/29/21, states as follows: Intent: All residents will receive adequate supervision, assistance, and assistive devices to aid in the prevention of falls. Each resident will be evaluated for safety risks including falls and accidents. Care plans will be created and implemented based on the individual's risk factors to aid in the prevention of falls. All falls are to be investigated and monitored. Program Steps: I. Investigative Guidelines. I. Complete Incident Report in Risk Management. L. Obtain detailed statements from resident any witnesses as soon as possible following the event. Statements must be signed with the correct date and time for falls with serious injuries. M. xi. Use the Fall Intervention for possible immediate approaches to use in care of the resident. II. Quality Assurance/Risk Management Guidelines. B. The interdisciplinary Plan of Care (IPOC) team will meet within the same period of time and discuss the causative factors, interventions to prevent another fall, make therapy referral as necessary and revise the care plan if necessary. Example 1 R1 was admitted to the facility on [DATE] with diagnoses that include in part . [CONDITION(S)] ([CONDITION(S)]), [CONDITION(S)], diastolic heart failure, and [CONDITION(S)]. R1's Significant Change MDS (Minimum Data Set) dated 7/27/21, indicates R1's BIMS (Brief Interview of Mental Status) is 12 indicating moderate cognitive impairment. R1 is responsible for herself and makes her own decisions. Section G0110, Functional Status Transfers: Extensive assistance of one staff, Toileting: Extensive assistance of one staff. Section G0300 Balance During Transitions and Walking, Moving from seated to stand position: Not steady, only able to stabilize with human assistance; Surface to Surface transfers (transfer between bed and chair or wheelchair): Not steady, only able to stabilize with human assistance. R1's Comprehensive Care Plan, initiated 4/19/21, revised 7/30/21 states in part . Problem: R1 has an ADL (Activities of Daily Living) self-performance deficit r/t [related to] increased weakness. Interventions: Ambulation: 2ww (2-wheeled walked) is used for walking/ambulating with assist of 1 staff, initiated 4/19/21, revised 8/24/21. On 8/24/21, R1 was changed to 2WW with 2 staff assist. Transfer: R1 is able to transfer with 2ww and 1 staff assist, initiated 4/19/21, discontinued 8/24/21. On 8/24/21, R1 was changed to a transfer with 2WW and 2 staff assist. Encourage the resident to use bell to call for assistance, initiated 4/19/21, revision 4/19/21. R1's Comprehensive Care Plan, initiated 4/19/21, 8/30/21 states in part . Problem: R1 is at risk for falls r/t increased weakness. Interventions: anti rollback installed on the wheelchair/low profile cushion, initiated 4/23/21, revision 8/30/21. Personal items to be within reach, initiated 8/18/21, revision 8/30/21. R1's CNA (Certified Nursing Assistant) Care Plan indicates the following in part . Locomotion: 1A (1 assist) w/c (wheelchair) w/ (with) anti rollback device. Transfers: 2A (2 assist) w/ 2WW. Special Instructions: Keep personal items within reach. Note: The facility uses a word document to create their CNA Care Plans. When the facility makes changes to the CNA Care plan they do not keep the previous care plan to show what changes are made. Note: Maintenance Record shows that the installation of anti-rollback brakes was applied on 4/22/21, the day prior to the initiation of the plan of care. Fall Un (Unwitnessed) 8/01/21 On 8/01/21 at 00:00 (12:00 AM) Incident Description: Nursing Description: Heard her saying Help me and went into her room and saw her sitting on the floor by the other bed leaning more to her right side and between her wheelchair and the bed. Resident Description: I was trying to get to the bathroom and someone moved my chair and I fell trying to get into it. She did not think that she hit her head. Immediate Action Taken: Able to move all extremities and bend wrists as previous to incident. PEARL (pupils equal and reactive to light). Small lump noted back of her head, is not bruised or abraded, nor is it tender. She is unclear if it is new. Does c/o (complain of) pain in her shoulder but said that is not new. Gotten up with Hoyer and 2 assist. VSS (vital signs stable). Level of Pain: 8 Mental State: Orientated to person, place and time. Predisposing Environmental Factors: Poor Lighting Predisposing Physiological Factors: Incontinent Predisposing Situation Factors: Improper Footwear and Ambulating without Assist. Notes: 8/02/21, 24 hour: IDT (Interdisciplinary Team) reviewed fall. Neuro checks remains WNL (within normal limits), no change in LOC (level of consciousness) or ROM (range of motion). New intervention anti-roll back to w/c. Note: This is not a new intervention. Anti-rollback brakes were to have been applied on 4/22/21. Resident Fall Data Collection: What appears to be the root cause(s) of the fall based on contributing factors: Had to have a BM (bowel movement) and got up without calling for assistance. What is the initial intervention to prevent further falls implemented immediately after fall? Remind her to use her call light, low bed and fall mat implemented. Note: Fall mat and low bed were never placed on the care plan or the CNA care card. Fall Un 8/18/21 On 8/18/21 at 21:50 (9:50 PM) Incident Description: CNA saw resident lying on the floor next to her bed and called nurse. Resident Description: I was trying to hang up the phone behind me and slid out of my chair. Immediate Action Taken: Resident assessed, sling slid underneath her and she was Hoyer lifted to bed. Level of Pain: 0 Mental State: Orientated to person. Predisposing Environmental Factors: None Predisposing Physiological Factors: Confused, Gait Imbalance, Impaired Memory. Predisposing Situation Factors: None. Notes: 8/19/21, 24 hour: Res (Resident) remains at baseline, no change in LOC, ROM post fall. Neuro checks WNL. New intervention put into place, all personal items to be within reach. Resident Fall Data Collection: What appears to be the root cause(s) of the fall based on contributing factors: Left empty. What is the initial intervention to prevent further falls implemented immediately after fall? She was put to bed and personal items were within reach. Fall Witnessed 8/21/21 On 8/21/21 at 10:30 AM Incident Description: Resident was being assisted by CNA to her w/c when she fell forward hitting her head on the foot rail of her roommate's bed. Injury to the skin above the left eye with bleeding. Resident was supported on the floor by staff and pressure placed on head wound. This writer applied a pressure dressing and called Daughter to inform her of the fall and this writer felt it appropriate to send her to ER (emergency room ) for eval (evaluation). 911 called and resident taken to Hospital. While at the hospital resident received stitches above the left eye. RN states they should dissolve on there [sic] own. Resident on her way back to facility. Resident Description: Resident was able to answer questions but states she doesn't know what happened. Immediate Action Taken: 911 called to transport to Hospital. Daughter called to report situation and agreed she should be sent to ER. Level of Pain: 0 Mental State: Orientated to person, place and time. Predisposing Environmental Factors: None Predisposing Physiological Factors: Confused, Gait Imbalance, Weakness/Fainted. Predisposing Situation Factors: Recent Room Change. Witnesses: CNA E: Both CNA's were in resident's room in the morning around 7:20 AM on 8/21/21. I was helping resident up with w/c locked and on her side. Other CNA went to help roommate with TV [television]. As R1 was reaching for handle on w/c she was quickly falling forward as I was trying to grab her and alert other CNS [sic] in room. She went to get nurse outside the room and treated the wound and Hoyered her into bed. Witnesses: CNA D: I was in res (resident) room with other CNA. We got res sat up on side of bed and applied gait belt. Res stood up and I went to help other res in room with TV. We then used the Hoyer to transfer her back to bed. Notes: 8/21/21: Resident was being assisted by CNA to her w/c when she fell forward hitting her head on the foot rail of her roommate's bed. Injury to the skin above the left eye with bleeding. Resident was supported on the floor by staff and pressure placed on head wound. This writer applied a pressure dressing and called Daughter to inform her of the fall and this writer felt it appropriate to send her to ER (emergency room ) for eval (evaluation). 911 called and resident taken to Hospital. While at the hospital resident received stitches above the left eye. RN states they should dissolve on there (sic) own. Resident on her way back to facility. Notes: 8/22/21, 24 hour: IDT reviewed fall, new intervention to change transfer status to 2A w/2ww. Resident denies pain or discomfort, area noted to head no s/sx (signs or symptoms), bruising noted. Neuro checks remain WNL. Will continue to monitor. Resident Fall Data Collection: What appears to be the root cause(s) of the fall based on contributing factors: Left blank by facility. What is the initial intervention to prevent further falls implemented immediately after fall? She was put to bed and personal items were within reach. ED (Emergency Department) Provider Notes state in part . CC (Chief Complaint): Fall, Head Laceration HPI [History of Present Illness]: Patient has a 2 cm (centimeter) laceration over the left eyebrow. Bleeding is controlled. Mild swelling at this region. Patient denies any significant tenderness. Denies pain or injury to her neck, back, chest, abdomen, or extremities. CT HEAD W/ O IV CONSTRAST: Impression: 1. Small left supraorbital frontal scalp contusion-hematoma complex, without evidence of underlying fracture or acute intracranial injury. 2. [CONDITION(S)] changes of the paranasal sinuses, incidentally noted; recommend correlation for clinical signs of sinusitis. End of impression. CT HEAD W/ O IV CONTRAST: Impression: 1. No acute osseous injury of the cervical spine. End of impression. Laceration Repair: Face location: L (left) eyebrow. Length (cm): 2; Depth (mm) (millimeter): 5; Repair method: Sutures; Number of Sutures: 7 MDM (Medical Decision Making): R1 presented with a forehead laceration after a witnessed mechanical fall this morning. Workup for major injury secondary to fall reassuring with negative CT scans. Laceration repaired by PA (Physician's Assistant) as documented above. Screening medical evaluation overall reassuring. Patient appropriate for discharge back to facility and agreeable with this plan. On 8/30/21 at 1:43 PM, Surveyor interviewed Regional Nurse C and DON B (Director of Nursing). Surveyor asked Regional Nurse C and DON B the facility process for falls and fall interventions. DON B stated, We have an IDT process, someone makes notes and someone else might care plan new interventions. We change the immediate interventions put into place from the nurses notes or the fall packet, if we think they are not appropriate. Regional Nurse C states, If sent to ER (emergency room ) that would be the immediate intervention. Team would look at it when the resident comes back and put something into place. Surveyor asked Regional Nurse C and DON B interventions put into place for R1's falls on 8/01/21, 8/19/21 and 8/21/21. DON B states, According to the 'Resident Fall Data Collection' form the intervention for the fall on 8/1/21 was remind R1 to use call light, low bed and fall mat. The IDT team then put into place on 8/2/21 new intervention of anti-roll back to w/c. The fall on 8/19/21 was to keep personal items in reach and the last fall on 8/21/21 was to change R1 from a 1A with 2WW to 2A with 2WW. Note: The floor mat and keep bed low were never care planned as an intervention for the fall on 8/01/21 and anti-roll back brakes were an intervention placed on the care plan on 4/23/21. Note: The IDT changed R1 from a 1A to a 2A on 8/22/21 but this was not put on the care plan as an intervention until 8/24/21. On 8/30/21 at 3:15 PM, Surveyor interviewed CNA D via phone. Surveyor asked CNA D to review R1's fall from 8/21/21. CNA D stated, Me and another CNA went into the room. We were working on transferring R1 with 1A pivot with gait belt. I turned around to help R1's roommate and R1 lost balance and fell forward, hit her head on floor near other residents bed. Since then we have been using an EZ Stand (sit to stand lift) for transfers with R1. On 8/30/21 at 3:26 PM, Surveyor interviewed CNA E via phone. Surveyor asked CNA E about R1's fall from 8/21/21. CNA E stated, CNA D and I were in room together and getting her up. CNA E went to help roommate. R1 is technically a 1A but we were both in there. We were using a gait belt and attempting to pivot. On the CNA Kardex it states R1 is a 1A with a walker but from report we always did pivot. I don't think she has a walker in her room. Note: Care Plan and CNA Care Card both indicate R1 transfer with 1A and 2WW walker. Staff were transferring R1 with 1A pivot without walker thus not following R1's care plan at the time of the fall on 8/21/21. R1 fell and received a laceration requiring sutures due to the fall. On 8/30/21 at 3:26 PM, Surveyor interviewed DON B. Surveyor asked DON B if she was able to provide information on when anti-roll back brakes were applied to R1's wheelchair. DON B states, The anti-roll brakes were put on for this resident on 4/22/21. The information from that fall is incorrect. The fall data collection sheet from 8/1/21, to remind R1 to use call light was implemented. Surveyor and DON B reviewed care plan which indicates a reminder to use call light was initiated on 4/19/21 and not revised since that date. DON B had no further comments regarding this. On 8/30/21 at 4:21 PM, Surveyor interviewed Regional Nurse C and DON B. Surveyor asked if any follow-up interviews were conducted with staff regarding the fall from 8/21/21. DON B stated, No, just the initial statements in the fall investigation. Surveyor asked what assistance R1's needs with transfers. DON B stated, R1 is a 1A with a walker and staff should follow the care plan. Surveyor asked Regional Nurse C and DON B if they were aware that at the time of the fall CNA E states she was completing a pivot transfer without a walker. Regional Nurse stated, No. Surveyor also reported to Regional Nurse C and DON B R1 did not have a walker in her room and at the time of the transfer CNA D had walked away to assist R1's roommate and did not assist with the transfer according to their interviews with Surveyor. The facility staff failed to follow R1's care plan for transfers resulting in R1 receiving a laceration to her forehead which required sutures. Fall care planned interventions were not placed on the plan of care. Example 2 R4 was admitted to the facility 2/24/21, and has diagnoses that include [CONDITION(S)] Disease, [CONDITION(S)] and Collapse, and [CONDITION(S)]. R4's Quarterly Minimum Data Set (MDS) assessment, dated 7/10/21, indicated R4 has a BIMS (Brief Interview of Mental Status) of 8 indicating moderate cognitive impairment. Section G shows that R4 requires extensive two assist with transfers and bed mobility. R4's Comprehensive Care Plan, initiated 2/24/21, revised 8/10/21, states in part .Focus: R4 has an ADL (activities of daily living) self-care performance deficit r/t (related to) syncopal event, [CONDITION(S)], nearing end of life. Goal: R4 will receive assistance with ADLs through the review date. Transfer: R4 is able to: pivot transfer with 2 assist using the bedside grab bar. Date Initiated: 2/24/21` Revision: 3/3/21. Toilet Use: R4 requires moderate assistance by 2 staff to stand pivot transfer using toilet grab bar for toileting. Offer toileting upon rising, before meals and at HS (hours of sleep) plus once during night Date Initiated: 2/24/21 Revision on 9/1/21 . R4's Comprehensive Care Plan, initiated on 2/24/21, revised 9/2/21, states in part: Focus: R4 is at risk for falls r/t balance problems, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], anxiety, [CONDITION(S)], DMII (Diabetes Mellitus type 2), history of falls, poor safety awareness, incontinence, nearing end of life with sarcopenia, use of cathartics and narcotics. Date Initiated: 2/24/21 Revision on: 9/2/21.Goal: R4 will not sustain serious injury through the review date. Date Initiated: 2/24/21 Revision Date: 8/10/21. *Fall Unwitnessed 7/6/2021 On 7/6/2021 at 22:00 (10:00 PM) Incident Description: Nursing Description: Writer called to resident's room by CNA (Certified Nursing Assistant) who reported resident was on the floor. Resident was sitting on fall mat with feet extended out. Resident denies pain moves all extremities w/o (without) complaints of pain. Resident hoyered back into bed. VS (vital signs) and Neuro WNL (within normal limits). Resident Description: Resident reports trying to get up from bed. Unable to state why. Immediate Action Taken: Neuro and VS WNL. RN (Registered Nurse) manager, POA (Power of Attorney) and Hospice updated. Resident assisted back into bed. Injuries Observed at Time of Incident: No injuries observed at time of incident. Predisposing Environmental Factors: None Predisposing Physiological Factors: Confused, Gait Imbalance, and Impaired Memory Predisposing Situation Factors: None Note: During the investigation the facility did not identify a root/cause through the fall report, nurse documentation or the Resident Fall Data Collection Sheet and no interventions put into place for this fall. Note: No additional fall information received upon request from Surveyor. *Fall Unwitnessed 8/8/2021 On 8/8/2021 at 20:00 (8:00 PM) Incident Description: Nursing Description: Writer called to room by CNA saying R4 is on the floor. Writer found patient lying on mat on floor next to bed. RN called to assess; no apparent injuries found. Vital signs: BP (Blood Pressure) 111/71 T (Temperature) 96.4 tympanic P (Pulse) 105 R (Respirations) 18 O2 Sat (saturation) 94% RA (Room Air) POA called to inform of unwitnessed fall. Hospice called to inform of unwitnessed fall. Resident Description: Resident Unable to give Description Immediate Action Taken: Patient had loose stool on mat; cleaned and returned to bed. Vital signs taken, found to be at baseline. No apparent injury noted. POA and Hospice notified. Mental Status: Oriented to Person. Predisposing Environmental Factors: Note: Not completed Predisposing Physiological Factors: Note: Not completed Predisposing Situation Factors: Note: Not completed Note: During the investigation the facility did not put into place a fall intervention based on root/cause through the fall report, nurse documentation or Resident Fall Data Collection. Note: No additional fall information received upon request from Surveyor. On 8/30/21 at 5:35 PM, Surveyor interviewed DON B and asked with each fall incident should there be a root cause analysis and fall intervention put into place. DON B indicated yes there should be. Surveyor asked DON B if each intervention should be on care plan to correlate with each fall and DON B indicated yes they should be.

Based on observation, interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents in 2 of 5 residents (R4 and R2) reviewed for fall concerns. On 3/24/18 the facility had documentation of R4 self-transferring. Starting on 3/31/18 to 4/5/18 the facility documented daily that R4 was self-transferring multiple times a day. The facility did not ensure that adequate supervision or assistive devices were in place to prevent her from falling. The facility did not fully assess if R4 was attempting to use devices, if her alarm was sounding when she self-transferred, or increase her supervision. R4 sustained a subarachnoid hemorrhage due to trauma or fall on 4/6/18. R2 fell on Friday 4/13/18 and the facility did not ensure a new intervention was in place to keep her safe over the weekend until the Interdisciplinary team could review it the following Monday. Evidenced by: The facility policy and procedures titled Falls and Fall Risk, Managing revised 12/15/16 states: Purpose: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Statement of Policy: It is the policy of this facility to identify residents at risks for falls, develop plans of care that address the risk and implement procedures to assist in preventing falls. The facility will also review accidents involving residents sustaining falls to identify possible cause and develop approaches and interventions to assist in preventing repeated falls. Procedure: 1. The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of the resident's fall risk identified several possible interventions, the staff may choose to prioritize interventions . Example 1 R4 was admitted to the facility for rehabilitation on 3/6/18 after a fall with a [MEDICAL CONDITION]. Her [DIAGNOSES REDACTED]. Her admission progress note on 3/6/18 included her plan to discharge to independent living following rehab. The Morse Fall Risk assessment completed for R4 on 3/6/18 states she scored 70. A score of 45 or higher indicates a high risk for falls. The facility created a care plan as of 3/6/18 for R4 that included the following: The resident has impaired cognitive function/dementia or impaired thought process due to impaired decision making. She was on an anticoagulant medication due to post-surgical hip repair. And R4 has a right [MEDICAL CONDITION] due to a fall and included interventions to monitor that R4 is wearing appropriate footwear, anticipate needs as much as possible to prevent unsafe self-initiation, as well as others. On 3/18/18 the facility added a Vigil alarm to be on her bed at all times. It is a pressure alarm to alert staff if she attempts to get out of bed. A 3/13/18 MDS assessment noted this resident required 2-person physical assist with bed mobility, one-person physical assist with transfers (staff provide weight bearing support) and 2+ physical assist with toilet use. Walk in room under Self-performance notes limited assistance - resident highly involved in activity. Staff provide guided maneuvering of limbs or other non-weight bearing assistance. Under Support it notes one-person physical assist. R4s progress notes are as follows regarding her self-transferring prior to her fall on 4/6/18: 3/24/18 at 9:31 PM Resident was howling, Help, help. every 5 minutes even though staff answered her call light. Resident repeated the same questions, where is my husband. said Go to hell. to staff and her husband. Her husband came and saw her several times tonight. Resident was mean to staff and swear at staff. Resident tried to stand up from her bed and walked down the hall way and redirected by staff . Resident denied pain, will continue to monitor (sig) 3/25/18 at 9:38 PM . tonight she has been restless screaming help, turning lights on for bathroom, but will not go. Do not want to stay in bed or chair. (sig) 3/27/18 at 5:19 PM resident noted with increased agitation with care, threw a towel at therapy during therapy session, negative statements and verbal abuse towards staff and family, increased impulsiveness, getting OOB (out of bed) without help, calling out, help, help me. Resident offered reassurance, a snack, fluids, calm and quite (quiet) environment, soft music, dim lighting, husband reassurance without effectiveness noted . (sig) 3/28/18 at 10:18 PM (R4) Frequent calling out Help continues. Is oriented to self only with no short-term memory so is unable to retain information given. Got PRN (as needed) trazadone x 2 this shift with slight improvement and did sleep about 45 minutes before calling out again. Can get herself OOB (out of bed) and has no safety awareness. Frequently requests toileting then doesn't void. (sig) 3/29/18 at 4:02 PM (R4) has been getting in and out of bed without assistance. Staff have assisted her several times helping her in and out of bed. Almost immediately she will begin to do the opposite. If she was assisted into bed, then she would be trying get back out of bed. Her memory seems to be only minutes long e/b asking the same question over and over within minutes of the previous question. She was given her 1600 (4:00 PM) Trazadone but it took several attempts to get her to actually allow meds. She initially tried to spit meds out at writer. Who are you and where is my husband? Being somewhat resistive with cares which actually puts her at great risk for falling. (sig) 3/31/18 at 7:51 AM Resident was calling out for help, walking through the unit, disrupting and disturbing other resident, was verbally inappropriate. Tried different intervention non-pharmaceutical and with medicines with no success. (sig) 4/1/18 at 10:43 PM Resident was howling, help, help. 5-6 times during the pm (evening) shift. Resident was redirected. Staff noted that resident self transferred from bathroom to her bed. (sig) 4/2/18 at 4:06 AM Resident transferred self with walker to the toilet throughout noc (night) shift q5-10 minutes (q means every). No voiding on toilet. No c/o's (complaints) pain/discomfort noted. (sig) 4/3/18 at 12:26 AM Resident continues to get up without assistance. Continues to yell out where is my husband. Unable to redirect. Gave PRN trazedone. (sig) 4/4/18 at 10:13 AM NP (nurse practitioner) updated this shift on resident condition . resident noted with increase in activity level, resident self-transferring from bed to toilet, multiple times daily . (sig) 4/4/18 at 11:34 AM Family meeting held today . She appears stronger as she is able to walk . Although R4's mobility has increased she does not like to walk. (sig) (This note includes that the family agreed to a referral to Geripsych which the NP later called in orders for.) 4/5/18 at 2:46 AM Resident self-transferring from her bed to wheelchair. Resident going into bathroom multiple times during noc and not voiding on toilet. Resident is argumentative with staff when staff is assisting with cares, resident stating, Go to hell, and Just shoot me when staff is attempting to assist with cares. (sig) At 3:25 PM NP gave new DX (diagnosis) of dementia with behavior disturbance .(sig) The facility did provide documentation that an anti-rollback device was added to R4s wheelchair on 4/5/18 however the self-transfer on 4/5/18 was the only time that it is mentioned that she self-transferred to her wheelchair. The other self-transfers are to the bathroom or do not include documentation that she attempted to use her wheelchair. 4/6/18 at 5:40 AM Resident found out of bed sitting on the floor with arms to sides and legs in front . (Charted at 5:35 AM) Bump noted to Right side of forehead, approx. (approximately) 6cm x 6cm. Yellow colored skin discoloration noted. Right elbow skin discoloration noted approx. 2cm x 2cm. (sig) The facility fall investigation for R4 on 4/6/18 states in addition to the progress notes on 4/6/18 that she was unable to explain how she fell on the floor. It indicates the fall alarm was in place but does not state if it was sounding and does not mention if she attempted to use any assistive device. R4 was sent to the hospital for eval. The hospital discharge notes include: The CT of the head without contrast on 4/6/18 states the impression of a New, small 5 to 6 mm curvilinear high attenuation focus at the gray-white matter junction of the right precentral gyrus is suspicious for a small amount of cortically-based hemorrhage. This could be posttraumatic or related to the patient's amyloid angiopathy. Short interval follow-up CT or MRI is recommended for further assessment. 2. Right frontal scalp hematoma. However the Discharge [DIAGNOSES REDACTED]. 1. Subarachnoid hemorrhage due to trauma 2. Fall 3. Advanced dementia The hospital notes include that hospice for R4 was discussed and would be arranged for R4 while she was in the hospital. On 4/16/18 at 12:40 PM Surveyor viewed R4 and interviewed R4s Husband C. R4's right side of her face, forehead, and eye looked to be covered with dark purple bruising. R4s Husband C stated that she got up to use the bathroom and fell on to the wardrobe hitting her head on the wardrobe. He stated that prior to her fall the plan was to admit her to a facility in Stoughton (Geri psych) but now after the fall he had decided with his family to have her admitted to hospice to just keep her comfortable. Hospice was in place for R4 when she was admitted back to the facility on [DATE]. On 4/16/18 at 2:10 PM Surveyor interviewed Director of Nursing (DON) B who stated that if a resident is self-transferring the facility would review it in the interdisciplinary team meeting. Surveyor requested any evidence of additional assessments and interventions the facility put in place due to R4s increased self-transferring prior to her fall on 4/6/18. Example 2 R2 was admitted to the facility on [DATE] with a dementia diagnosis. The facility put a care plan in place noting she was at risk for falls due to deconditioning and was unaware of safety needs. R2 fell on Friday 4/13/18 at 7:45 PM. R2 stated she was trying to get into her bed and had not called for assistance. The facility fall investigation includes that she was in her wheelchair when she attempted to self-transfer into bed. The witness statements included, suggested having resident put to bed after being toileted to reduce risk of self-transferring. and Suggest to have her go to bed after being toileted in the evening to reduce the risk of self transferring. (sig) It is important to note that on 4/16/18 when Surveyor reviewed R4s care plan no new interventions had been put in place. On 4/16/18 at 2:10 PM Surveyor interviewed Director of Nursing (DON) B who agreed that nursing staff should put a new intervention immediately after a fall. She stated if it happens on the weekend they can still update the care plan and when the Interdisciplinary team reviews it the following Monday they may change it. DON B stated that she would have reviewed R2's fall on this date, but agreed that the staff should have put an intervention in place over the weekend.

Based on record review and interview the facility failed to immediately consult with the resident's physician where there was a significant change in the resident's physical, mental or psychosocial status or a need to alter treatment significantly for 2 of 6 residents (Residents 1 and 4). Resident 1 was found to be unresponsive after having been without an ordered [MEDICAL CONDITION] machine the night following the resident's admission. The facility did not immediately consult with the physician for treatment orders, thus delayed treatment. Resident 1's respiratory status continued to decline. The failure to immediately consult with the physician created a finding of immediate jeopardy. The immediate jeopardy began on 11/24/15. The Nursing Home Administrator was notified of the immediately jeopardy on 12/8/15. The facility removed the jeopardy on 12/7/15, however the deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) as the facility continues to implement its action plan and as evidenced by the following example: Resident 4's anti blood clotting medication [MEDICATION NAME] was not available and the physician was not consulted for a change in treatment. This is evidenced by the following: : Example 1 The American Medical Directors Association (AMDA) Guidelines for physician notification include the following for immediate notification: Sudden change in level of consciousness or responsiveness Resident 1 was admitted to the hospital and treated for [REDACTED]. Other [DIAGNOSES REDACTED]. The facility completed a pre-admission assessment on Resident 1 on 11/19/15. On the assessment form the facility notes Resident 1 requires oxygen 2-3 liters and a [MEDICAL CONDITION] machine (a device that provides pressure support during non-invasive ventilation) from home. Resident 1's goal was to return to her assisted living apartment. Resident 1 was admitted to the facility on [DATE] at 2:45 PM. Resident 1 was alert and oriented and her own person. Resident 1 has a Power of Attorney document listing Family Member F and Family Member G as agents. However, the Power of Attorney document had not been activated. Resident 1's social service note, written 11/25/15, as an admission note late entry, indicates Resident 1 is her own decision maker, alert and oriented, able to make her needs known and signed the admission agreement. Resident 1 was admitted for short term rehabilitation and her goal is to return to assisted living apartment after rehabilitative care. Resident 1's hospital discharge orders, dated 11/23/15, include: Continue home [MEDICAL CONDITION] or [MEDICAL CONDITION] per home settings, 12/6 with 2 liter oxygen bleed. Due to a transcription error, however, the facility did not provide Resident 1 with a [MEDICAL CONDITION] (bilevel positive airway pressure) machine, which the resident typically used from 10 PM until 6 AM every night. (Cross reference F309.) Resident 1 was not on a [MEDICAL CONDITION] machine the night of 11/23 - 11/24/15. Resident 1's nursing notes include: 11/23/15, 5:21 PM, shortness of breath or trouble breathing with exertion, respirations regular at rest, lungs are clear, wheezing heard bilateral lower lobes, Resident 1 cannot take deep breaths due to acute condition. -5:49 PM, pulse 89 normal, respiratory rate 22, blood pressure 112/69, oxygen saturation 92% on oxygen. 11/24/15, 3:31 AM, pulse 71, respiratory rate 20, blood pressure 127/56, oxygen saturation 92%. -9:49 AM, pulse 93, respiratory rate 26, blood pressure 140/77, oxygen saturation 93% on 3 liters of oxygen. -4:25 PM, late entry for 9:50 AM, at approximately 9:50 AM floor nurse informed writer that resident has a change in responsiveness. This writer found resident sitting in wheelchair, not responsive to verbal stimuli and minimal response to painful stimuli. Respirations 36-40, oxygen saturation 93% on 3 liters oxygen, blood pressure and pulse stable. Informed staff to transfer resident back into bed. Per CNA (Certified Nursing Assistant) and nurse report, resident had been awake and alert all morning, taking her medications, informing nurse how she takes her medications, informing staff how upright she prefers to sit in bed. Resident had last been seen when CNA set her up for breakfast, resident had been awake and talking at this time. Lung sounds diminished throughout. Bilateral rhonchi to upper lobes. Heart sounds distant though RRR (regular rate and rhythm). Color good, no cyanosis noted. Nails blanchable. Lips pink. Writer then went to review chart and notified both daughters of change in condition. Family Member F informed writer that she would be on her way to facility. Approximately 10:10 AM DON B (Director of Nursing) with writer in room. Respiratory status continued to decline. Family Member F had not arrived. Decision was made to call 911. At 10:20 AM Family Member F in room with rescue response team. Approximately 10:45 AM Resident 1 was transferred out of facility to hospital. GNP E (Geriatric Nurse Practitioner) updated in person.-written by Registered Nurse (RN) C. The facility did not promptly consult with a physician/call 911 for 30 minutes, during which time Resident 1's respiratory status continued to decline. Per hospital documentation, Resident 1 presented to the hospital with altered mental status. She is obtunded (refers to less than full alertness typically as a result of a medical condition or trauma) and does not awake to loud voice or noxious stimuli. Her daughter is present and tells me Resident 1 has not been on [MEDICAL CONDITION] for greater than 36 hours. Daughter feels this might be the reason why she is so obtunded. Hospital findings include arterial blood gas abnormal with PCO2 of 85 (normal range is 35-45 mm Hg). Resident 1 elected for comfort cares and to be weaned off the [MEDICAL CONDITION] machine. Resident 1 passed away on 11/27/15. On 12/7/15, at 10:53 AM, Surveyor interviewed RN C. RN C is the floor manager. RN C stated on 11/24/15 the nurse came and got her stating Resident 1 was experiencing altered mental status. RN C responded to Resident 1's room and noted she was up in her chair and the CNAs were checking her vitals and they were fine. RN C stated Resident 1 did not respond to a sternal rub and she would not open her eyes. RN C then instructed the CNAs to use the mechanical lift and transfer Resident 1 into bed. There was still no change in her mental status. RN C stated Resident 1 did have oxygen on in the room. RN C then reviewed Resident 1's chart and called Family Member G who wanted Resident 1 sent to the hospital and to call Family Member F as she is in town. RN C called Family Member F who stated she would be there in 5 minutes. During this call Family Member F stated Resident 1 should be on a [MEDICAL CONDITION] machine. RN C looked this up and noted the [MEDICAL CONDITION] machine was at her apartment. RN C contacted DON B who sent someone across the street to get the [MEDICAL CONDITION] but that it took time. During this time RN C and DON B decided to call 911 even though Family Member F was not at the facility as Family Member G had said to send her. When the paramedics arrived at the facility they asked facility staff to assist with putting Resident 1's [MEDICAL CONDITION] on as they were not familiar with her machine. RN C also stated during the time the paramedics were here there was a conversation with the paramedics doctors as Resident 1 is her own person but Family Member F did not want her sent to the hospital but then agreed. RN C stated GNP E was in the building and they spoke with her around the same time they decided to send Resident 1 out to the hospital. Surveyor asked why the family was called and not the physician or 911 immediately. RN C stated both, herself and DON B, were in the room and it was never discussed to call the physician. RN C stated she called Resident 1's daughters because they had been talking comfort care and she wanted to make sure everyone was on the same page when she called the physician. On 12/7/15, at 11:34 AM, Surveyor interviewed DON B. DON B stated it is her expectation that if a resident is experiencing a change of condition the nurse is to do an assessment and update the family and physician. DON B stated the physician would be updated as soon as possible after the assessment. Surveyor asked if the physician or family should be notified first. DON B stated it depends on the situation if the resident's wishes are clear. If family is involved or if there are questions would ask the family first if they would want the resident sent out. DON B stated GNP E was in the building and she was updated probably about the same time 911 was called. DON B stated she thought that if a person was incapacitated they could go to the person listed on the POA document for decisions. On 12/7/15, at 2:20 PM, Surveyor interviewed GNP E. GNP E stated she had never seen or treated Resident 1 prior to 11/24/15. GNP E stated she was in the building on 11/24/15 and when she came to the floor she was informed 911 was contacted and was on the way. GNP E did not consult on Resident 1's care. On 12/7/15, at 2:25 PM, Surveyor interviewed DON B again who confirmed the facility follows the AMDA Guidelines for physician notification. The failure to immediately consult with the physician or call 911 when Resident 1 experienced a change in mental status and was unresponsive thus delaying treatment created a finding of immediate jeopardy. The facility removed the immediate jeopardy on 12/7/15 when they began education with all nursing staff, prior to working their shift, on proper physician notification with resident change of condition using the AMDA guidelines. Example 2 Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 4's physician orders [REDACTED]. Resident 4's record indicates the [MEDICATION NAME] 150 mg was not available until 11/8/15 morning dose. Resident 4 missed 5 doses of this medication. Resident 4's physician was not notified when then medication was not available or regarding the missed doses. Resident 4's record also indicates the [MEDICATION NAME] was not available until 11/15/15. Resident 4 missed 4 doses of this medication. Resident 4's physician was not notified when the medication was available or regarding the missed doses. On 12/7/15, at 1:03 PM, Surveyor interviewed Registered Nurse (RN) C. RN C stated if a medication is unavailable and they cannot get it from the pharmacy timely the nurse should call the physician to let them know the medication is not available and request if there is a different medication available or what the physician would like the facility to do. RN C stated she was not aware Resident 4 did not receive the [MEDICATION NAME] or [MEDICATION NAME]. RN C stated the physician should have been called and updated on the missed medications.

Based on record review and interview the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 of 6 residents (Resident 1). Resident 1 required the use of a [MEDICAL CONDITION] machine at night. Because of a transcription error, the facility did not ensure this device was available for Resident 1 on admission and Resident 1 was not on the [MEDICAL CONDITION] machine that night. Resident 1 became unresponsive the following morning after not having the [MEDICAL CONDITION]. Resident 1 was sent to the emergency room and died at the hospital three days later. The failure to provide the necessary care by providing the [MEDICAL CONDITION] machine created a finding of immediate jeopardy. The immediate jeopardy began on [DATE]. The Nursing Home Administrator was notified of the immediately jeopardy on [DATE]. The facility removed the jeopardy on [DATE]; however, the deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) as the facility continues to implement its action plan. This is evidenced by the following: [MEDICAL CONDITION] is a term used to refer to bilevel positive airway pressure (BPAP). A [MEDICAL CONDITION] machine is a breathing apparatus that helps its user get more air into his or her lungs. Unlike a [MEDICAL CONDITION] machine however, a BPAP machine uses variable levels of air pressure instead of continuous pressure. Both of these devices are used to help treat breathing difficulties. A BPAP machine allows the air that is delivered through the mask to be set at one pressure for inhaling and another for exhaling. This makes it much easier for the user to adapt to the apparatus and allows a person who has a neuromuscular disease to use the device. These dual settings also allow the user to get more air in and out of his or her lungs. Resident 1 was admitted to the hospital and treated for [REDACTED]. Other [DIAGNOSES REDACTED]. Prior to hospitalization Resident 1 lived in an assisted living apartment owned by the facility corporation. The facility completed a pre-admission assessment on Resident 1 on [DATE]. On the assessment the facility notes Resident 1 requires oxygen ,[DATE] liters and a [MEDICAL CONDITION] machine from home. Resident 1's goal was to return to her assisted living apartment. Resident 1 was admitted to the facility on [DATE] at 2:45 PM. Resident 1 was alert and oriented and her own person. Resident 1 has a Power of Attorney document listing Family Member F and Family Member G as agents. The Power of Attorney has not been activated. Resident 1's social service note, written [DATE], as admission note late entry, indicates Resident 1 is her own decision maker, alert and oriented, able to make her needs known and signed the admission agreement. Resident 1 was admitted for short term rehabilitation and her goal is to return to assisted living apartment after rehabilitative care. Resident 1's hospital discharge orders, dated [DATE], include: Continue home [MEDICAL CONDITION] or [MEDICAL CONDITION] per home settings, ,[DATE] with 2 liter oxygen bleed. Please note there is no order for continuous oxygen via nasal cannula. Resident 1's physician orders while in the assisted living were for [MEDICAL CONDITION] ,[DATE] with oxygen at ,[DATE] liters night and evening. Nursing Home Administrator (NHA) A spoke with the assisted living director and Resident 1 typically wore the [MEDICAL CONDITION] from about 10:00 PM to 6:00 AM. Resident 1's physician orders that were transcribed at the hospital and entered into the facility computer did not include orders for the [MEDICAL CONDITION] machine. On [DATE], at 11:10 AM, Surveyor interviewed RN (Registered Nurse) D with DON (Director of Nurses) B present. RN D confirmed she is the admissions nurse and is the one who transcribed Resident 1's physician orders. RN D stated when there is a new admission she reviews the orders and enters them into the computer. Then the nurse manager double checks the orders to ensure they are accurate. RN D stated she and the nurse manager sign the bottom of the physician orders indicating they were checked. Surveyor noted Resident 1's physician orders did not have two signatures. DON B stated Resident 1's original orders that were signed by the nurses cannot be found. DON B stated she printed the orders off today and RN D signed them today. Surveyor asked about the [MEDICAL CONDITION] order. RN D stated she missed them and they should have been on the orders in the computer. RN D also stated she implements the temporary care plan on admission and she did not initiate a care plan for oxygen use for Resident 1. On [DATE], at 11:34 AM, Surveyor interviewed DON B. DON B stated it is her expectation that orders are checked by the admissions nurse and then double checked by the PM or floor nurse. DON B stated neither nurse saw the order for [MEDICAL CONDITION] but Resident 1 should have had the [MEDICAL CONDITION]. On [DATE], at 2:25 PM, Surveyor interviewed NHA A who stated if a resident needs a [MEDICAL CONDITION] machine the facility's pharmacy will provide one however most residents prefer to bring their own from home as they are already set up. Because of the transcription error, Resident 1 was not on a [MEDICAL CONDITION] machine the night of admission [DATE] - [DATE]. Resident 1's nursing notes include: [DATE], 5:21 PM, shortness of breath or trouble breathing with exertion, respirations regular at rest, lungs are clear, wheezing heard bilateral lower lobes, Resident 1 cannot take deep breaths due to acute condition. -5:49 PM, pulse 89 normal, respiratory rate 22, blood pressure ,[DATE], oxygen saturation 92% on oxygen. [DATE], 3:31 AM, pulse 71, respiratory rate 20, blood pressure ,[DATE], oxygen saturation 92%. -9:49 AM, pulse 93, respiratory rate 26, blood pressure ,[DATE], oxygen saturation 93% on 3 liters of oxygen. -4:25 PM, late entry by RN C for 9:50 AM, at approximately 9:50 AM floor nurse informed writer that resident has a change in responsiveness. This writer found resident sitting in wheelchair, not responsive to verbal stimuli and minimal response to painful stimuli. Respirations ,[DATE], oxygen saturation 93% on 3 liters oxygen, blood pressure and pulse stable. Informed staff to transfer resident back into bed. Per CNA (Certified Nursing Assistant) and nurse report, resident had been awake and alert all morning, taking her medications, informing nurse how she takes her medications, informing staff how upright she prefers to sit in bed. Resident had last been seen when CNA set her up for breakfast, resident had been awake and talking at this time. Lung sounds diminished throughout. Bilateral rhonchi to upper lobes. Heart sounds distant though RRR (regular rate and rhythm). Color good, no cyanosis noted. Nails blanchable. Lips pink. Writer then went to review chart and notified both daughters of change in condition. Family Member F informed writer that she would be on her way to facility. Approximately 10:10 AM DON B (Director of Nursing) with writer in room. Respiratory status continued to decline. Family Member F had not arrived. Decision was made to call 911. At 10:20 AM Family Member F in room with rescue response team. Approximately 10:45 AM Resident 1 was transferred out of facility to hospital. GNP E (Geriatric Nurse Practitioner) updated in person. Per hospital documentation, Resident 1 presented to the hospital with altered mental status. She is obtunded (refers to less than full alertness typically as a result of a medical condition or trauma) and does not awake to loud voice or noxious stimuli. Her daughter is present and tells me Resident 1 has not been on [MEDICAL CONDITION] for greater than 36 hours. Daughter feels this might be the reason why she is so obtunded. Hospital findings include arterial blood gas abnormal with PCO2 of 85 (normal range is ,[DATE] mm Hg). Resident 1 elected for comfort cares and to be weaned off the [MEDICAL CONDITION] machine. Resident 1 passed away on [DATE]. On [DATE], at 10:53 AM, Surveyor interviewed RN C. RN C is the floor manager. RN C stated on [DATE] the nurse came and got her stating Resident 1 was experiencing altered mental status. RN C responded to Resident 1's room and noted she was up in her chair and the CNAs were checking her vitals and they were fine. RN C stated Resident 1 did not respond to a sternal rub and she would not open her eyes. RN C then instructed the CNAs to use the mechanical lift and transfer Resident 1 into bed. There was still no change in her mental status. RN C stated Resident 1 did have oxygen on in the room. RN C then reviewed Resident 1's chart and called Family Member G who wanted Resident 1 sent to the hospital and to call Family Member F as she is in town. During this call Family Member F stated Resident 1 should be on a [MEDICAL CONDITION] machine. RN C looked this up and noted the [MEDICAL CONDITION] was at her apartment. RN C contacted DON B who sent someone across the street to get the [MEDICAL CONDITION] but that it took time. During this time RN C and DON B decided to call 911 even though Family Member F was not at the facility as Family Member G had said to send her. When the paramedics arrived at the facility they asked facility staff to assist with putting Resident 1's [MEDICAL CONDITION] on as they were not familiar with her machine. Cross reference F309. The failure to provide Resident 1 with the necessary [MEDICAL CONDITION] machine created a finding of immediate jeopardy. The facility removed the immediate jeopardy on [DATE] when they began education on a thorough review of the admission paperwork for order accuracy and completeness, admission process was changed to include a third check of admission orders [REDACTED].

Based on observation, interview and record review, the facility did not ensure that each resident's environment remained free of accident hazards as possible for 7 (Residents 1, 7, 5, 4, 8, 3 and 2) of 8 residents reviewed falls and use of supportive devices. Resident 1 sustained a fall from her bed on 6/6/15. Resident 1 ' s head got caught on the grab bar as she fell , which prevented the top portion of her body from falling. This cut off her air supply and Resident 1 was not breathing when found. The facility had not thoroughly assessed whether Resident 1 needed a grab bar and had not assessed the safety of the grab bar for Resident 1. The grab bar for Resident 1 was not used or needed. This, combined with the fact that the resident had a history of [REDACTED]. Immediate jeopardy began on 6/4/15, the date when Resident 1 fell from her bed and another fall prevention device was added without an assessment of the grab bar. The NHA was notified on 6/23/15 that immediate jeopardy existed. The immediate jeopardy had been removed on 6/22/15. The deficient practice continues at a scope/severity of E (potential for harm that is not immediate jeopardy/Pattern) as all portions of the corrective action plan have not been fully implemented and as evidenced by the following. Residents 7, 5, 4, 8, 3 and 2's grab bars were not assessed to be safe prior to applying the grab bar to the bed permanently for their use. Residents 7, 5, 4, 8, 3 and 2's grab bars were not reassessed when other supportive devices were added to their beds. This is evidenced by: Facility bed assist bar policy dated 5/2014, revised 6/2015: Purpose: bed assist bars are available for resident who require them to increase independence with bed mobility. Policy: (facility name) will provide bed assist bars to the beds of residents who have been assessed to likely benefit from them for increased independence in bed mobility and transfers. Guidelines: 1. Prior to adding bars to a bed, a resident will be assessed for risk versus benefits. Assessment can be completed by registered nurse and/or PT/OT. 2. Resident assessed to likely benefit from assist bars for bed mobility and/or transfers will be permitted to have them installed. 3. Once the assessment is completed, maintenance will be notified of placement and installation completed. 4. Continued use of assist bars will be assessed periodically to determine continued benefit. 5. Upon resident discharge, all assist bars will be removed prior to another resident occupying the room. Fixed assist bar for head end manufacturer assembly guidelines, undated: Warning: When assessing the Risk for Entrapment, you need to consider your bed mattress, head and foot boards, half rails, assist rails and other accessories as an entire system. All bed systems are evaluated for compliance to the hospital bed system Dimensional and Assessment Guidance to Reduce Entrapment guidelines. A resident's condition could lead to resident entrapment. It is extremely important to review the resident physical and mental condition and initiate an appropriate individual care plan to address any entrapment risk. On 6/22/14 at approximately 9:30 AM Director of Nursing (DON) B presented Surveyor a complete resident roster of all the residents in the facility. DON B stated the highlighted residents currently have grab bars. The resident census on 6/22/15 was 79. 61 residents were highlighted to indicate on 6/22/15 those residents all had grab bars on their beds. On 6/22/15 at 3:45 PM Surveyor interviewed DON B regarding grab bar assessments for all residents using grab bars. Surveyor reviewed Residents 1, 2, 4, and 5 ' s grab bar assessments. The grab bar assessments identified three areas on the form. 1. Mental status. 2. Comatose/unresponsive. 3. Confused at night. Surveyor asked DON B according to this assessment where does it identify if the resident can use the grab bar or if the grab bar is safe for use for these residents. DON B stated the facility assessment only identifies the three areas. DON B stated she is changing the program to include resident use and grab bar safety. DON B stated they had just reviewed all residents in house for grab bar use and assessments last week. Surveyor requested the updated assessment. DON B stated they did not do a new assessment or a form they documented their checks on a resident roster for all those who currently were to keep their grab bars. DON B stated all other grab bars were removed. No further grab bar assessments were presented to Surveyor . Example 1 Resident 1 was admitted to the facility on [DATE] due to fracture vertebrae resulting from a fall at home. Resident 1 [DIAGNOSES REDACTED]. Medications include in part: Lorazepam 0.5 milligrams (mg) three times a day (TID), Trazodone 50 mg every bedtime (qHS), Mirtazapine 30 mg q HS, Oxycodone 5 mg as needed (PRN) q 4 hours (hr), Plavix 75 mg everyday (qd), Gabapentin 100 mg qHS, Levothyroxine 25 mg qd. Hospital Therapy note, dated 5/25/15, History of present illness. Patient presents as a Level II trauma, involved a fall. Patient was found in her bedroom after falling out of bed. Patient was down for an unknown period of time. Patient alert and oriented. Resident 1's fall risk assessment dated [DATE] total score result is 16 indicating Resident 1 is a fall risk. Resident 1's Side rail assessment, dated 5/27/15, Mental status: Alert and oriented times 3 during the day. She is not comatose or unresponsive. She is not confused at night. (The assessment does not indicate if she can use the grab bar, if she can use the grab bar safely, and does not include the risks and benefits of the grab bar usage.) Resident 1's Hospice visit note, dated 6/1/15 at 11:10 AM, Current mental status: Lethargic, slowed thought process. Observable mood/affect: Anxious, frustration, helpless. Inquired about her mood and coping with recent events: she replied, could be better when I get on the road. Writer inquired where she may be going, but she fell asleep. Resident 1 had a repeat fall risk assessment completed on 6/4/15; the total score was 14 again indicating Resident 1 was a fall risk. The accuracy of this assessment is questionable since Resident 1 went from being legally blind on the assessment of 5/17/15 to having Adequate (with or without glasses) vision on 6/4/15. Resident 1's admission MDS, dated [DATE], Resident 1 has moderate difficulty with hearing and does not wear a hearing aide, Vision is highly impaired, Cognitive status (BIMS) 11 indicating she does have some memory impairment. Bed mobility is extensive assist of 2 people. Transfer status is extensive assist of 2 people. She has full range of motion. Resident 1's care plan problem extensive assist with activities of daily living, dated 6/3/15, Approach: Assure safety. Not to be alone in room in wheel chair. Left eye legally blind. (Resident 1's care plan does indicate the use of grab bars.) Resident 1's care plan problem at risk for major falls, dated 6/3/15, related to injuries due to decreased mobility. Approaches (dated 6/8/15): Low bed, fall mat, wedge cushion. (Resident 1's care plan does indicate the use of the grab bar.) Nursing notes reviewed: *6/4/15 at 3:00 PM, Writer found resident on floor saying help at 6:45 AM, found lying on right side with feet toward bathroom and head next to bed. No injury. Possible cause: Resident wanted to get out of bed. New intervention initiated: Fall mat, wedge applied to bed to prevent rolling out of bed. Mental status: Poor recall, judgment, safety awareness. On 6/22/15 at 1:55 PM Surveyor interviewed Registered Nurse (RN) C. RN C stated Resident 1 had a wedge added to her bed after her fall on 6/4/15. The wedge was a single wedge and it was placed under the sheet behind Resident 1's back. RN demonstrated applying the wedge. Surveyor observed the wedge that placed in Resident 1's bed. The wedge was a blue wedge of soft foam covered with a plastic type material. The wedge was approximately 3 ft long and 10 to 12 inches wide. RN C placed the wedge onto a bed and lifted the sheet. RN C stated the wedge goes under the bottom sheet to keep it in place. RN C stated we should use bolsters they go across the bed and cannot fall off of the bed. On 6/22/15 at 3:05 PM, RN C stated she did not train or show the staff how to place the wedge in Resident 1's bed. RN C stated it was just to go at the edge of the bed behind her back to her knee area. RN C stated she did not consider the use of the wedge with the grab bar or do an assessment of the grab bar with the use of the wedge cushion. RN C did not look to see how much space was between the wedge and grab bar and did not instruct staff to keep the wedge in any certain place in relation to the grab bar. Physical Device review, dated 6/5/15: Purpose of note: Assessment for use. Supportive device: Bed in low position/falls mat. Decrease risk of injury related to falls. Device does not restrict movement or reaching a body part. Resident can easily remove or maneuver around device. Supportive device: Wedge cushion: decrease risk of injury related to falls. Enable better sitting balance and positioning. Reduce the risk of rolling/falling from bed. Device does not restrict movement or reaching a body part. Resident can easily remove or maneuver around the device. *6/5/15 at 9:29 AM, Review of incident: Fall, Resident rolled out of bed. She likes to lie in the fetal position up near the right side enabler bar. Bed wedge in place on her right side to help her with boundaries, provide comfort and security and prevent rolling out of bed. Fall mat and low bed in place as well. *6/6/15 at 6:25 AM nursing note: LPN working upstairs, alerted writer that resident was on the floor and needed to be assessed. LPN reported what she saw. Writer assessed, resident not responding to verbal commands, was not breathing and had a pulse. LPN completing sternal rub on resident trying to get her to respond. Pupils are fixed and non-reactive. 911 was called to get resident off the ground to assess neck/spine for possible injuries and take to hospital to be further evaluated. Resident started breathing while writer was on the phone but still remained unresponsive. *6/6/15 at 11:33 AM nursing note: Description of incident: Resident found by CNA and alerted writer. Writer found resident with legs on floor on fall mat next to bed and upper body on bed with head against grab bar. Writer supported head and shoulders and directed CNA to direct feet to lower resident completely to ground. Resident was unresponsive, not breathing, pulse of 20, pupils fixed. Writer performed sternal rub while calling for resident. After approximately 30 to 60 seconds, resident took a few irregular, gasping breaths. Still unresponsive but started to breath more normally. Cough noted with gurgling and clear sputum. Still unresponsive to questions of alertness. Resident tried to grab for grab bars from floor, attempting to get back to bed. Writer had last seen during med pass at 5:50 AM. Injury: Skin discoloration approximately 2.5 cm by 1.5 cm front of Resident neck and 1.5 cm by 1.5 cm left side of neck. The Fire department Paramedic note, dated 6/6/15, dispatched at 6:22 AM and arrived at the scene at 6:27 AM, Engine 13 was dispatch to Facility for a [AGE] year old female. Staff reported they found her hanging between the bed and the railing of the bed. They assisted her to the pad on the ground next to her bed. The staff was not familiar with the patient so we did not have a normal baseline for her mental status. The patient would respond to some questions but would not elaborate as to what had happened. Patient care was transferred to the hospital. Trauma: Mechanism of injury: Fall. Height of the fall: 2 feet. emergency room note, dated 6/6/15, Comments: [AGE] year old female. Assumed mental status change. trapped between bed and railing hanging there. Unknown baseline mental status. History and Physical: Chief complaint: Altered mental status. According to nursing facility staff, the patient was found in bed and her head hanging off the side, not felt breathing, but had a pulse. She was able to arouse with sternal rub. There was some concern she may have sustained a neck injury, there seems to be some red marks noted on her neck. In summary, presented in emergency room for altered mental status noted this morning. Shortly after patient arrived, patient's Hospice staff also present - they state that she is a do not resuscitate and would not want further intervention at this time. They requested she be discharged back to the nursing home. Aware that her work up is not complete and could have potentially reversible etiology. Plan to discharge to nursing home. emergency room registered nurse note, dated 6/6/15, Call placed to facility and talked to nursing staff that cares for patient. Per staff had been checked on and was fine, then within 20 minutes staff came back and she had her head out of the bed side railing and was not breathing but had a pulse. Staff states I thought she was dead. Pt was removed right away and placed on the floor where staff gave patient sternal rubs and she started to breathe again. Patient had several red marks around her neck line. Staff reportedly concerned of a neck injury. Per staff patient baseline is mostly oriented but is a little off unable to further elaborate on the specifics. On 6/6/15 at 7:21 AM, while in the emergency room , Resident 1's Troponin level 0.08 (normal 0.00 - 0.05) 0.06 - 0.49: Suspicious for myocardial injury, Serial measurements may be necessary to confirm or exclude DX of acute coronary syndrome, repeat testing in 2 hours.) 0.50 results or greater. Consistent with MI. Facility investigation included a statement by LPN: what do you feel contributed to the fall? Restless, rolling about in bed. What do you believe could have prevented the fall from occurring? Removing the side rails from the bed of residents that do not meet the criteria for needing them. Vigil possibly? On 6/23/15 at 8:55 AM, Surveyor interviewed CNA H regarding Resident 1's fall. CNA H stated she found Resident 1 on the floor. She was alone in the room. CNA H stated found her with her head on the bed against the grab bar and her feet on the floor. CNA H stated she did not move her or help move her that morning. CNA H stated she yelled out for CNA I and she came into the room. CNA H then left and went to get the nurse. When CNA H came back into the room she was on the floor. Surveyor asked CNA H where the wedge cushion was when she first found Resident 1. CNA H stated the wedge cushion was on top of her torso part way around her. Surveyor asked to describe how the wedge was on the resident to get a clearer picture of the event. CNA H paused and stated I don't recall. On 6/23/15 at 2:05 PM, Surveyor interviewed CNA I regarding Resident 1's fall. CNA I stated her and another CNA entered the room together and found the resident hanging on the edge of the bed her feet were dangling off the bed. Resident 1's neck was going into the rail (grab bar). Resident 1's head was inside of the rail and her neck was between the bed and the grab bar. Her head was still on a pillow on the bed. She did not fall all the way to the ground due to her head got caught into the rail and it would not let her fall. CNA I ran to get the nurse and the other CNA stayed in the room. CNA I stated she did not help Resident 1 get to the floor I. On 6/22/15 at 2:15 PM Surveyor interviewed Licensed Practical Nurse (LPN) D regarding Resident 1's fall from the bed. LPN D stated Resident 1 had a knee on the floor and her back against the bed. Her body was completely twisted around. Her neck was stuck in the bed in between to the bed and the rail (grab bar). Her body could not come down to the floor because she of the rail. LPN D had to physically support her shoulder and neck to get the pressure off her neck from the rail. The wedge cushion was in place when LPN D seen her at 6:00 AM or so to give her medication (Levothyroxine). Resident 1 was lying in bed in and covered, did not look like she was attempted to move. LPN D raised her head to give her some meds and then lowered her head. LPN D stated during the fall the wedge cushion was under the bed. LPN D stated she remembered that because LPN D thought that was an unusual place for the wedge to have fallen. LPN D had another Certified Nursing Assistant (CNA) help her move Resident 1. I had to get her head out from being pressed against the rail. LPN D had the CNA lift her legs and back toward the bed. LPN D then removed her neck from the rail. Yes her neck was pressed into the rail. Her head was facing out her chin was in the rail and her neck was pressed into the grab bar. Resident 1 was not breathing and LPN D and her pulse was 20 she was ashen in color. LPN D gave her sternal rub to wake her she took a few gasping breaths then she was trying to reach for the grab bar from the floor. On 6/23/15 at approx. 1:00 PM Surveyor re- interviewed LPN D via the phone regarding the incident with Resident 1. LPN D stated that she was at the nurse ' s station for report and a CNA came in to tell us that Resident 1 was on the floor. I was on my way out for the day and I called for an RN to come and assess. LPN D went to Resident 1 ' s room expecting to find her on the floor and she was not. LPN D saw that her legs were off the bed with her back against the mattress her chest was pointing out and her head on side rail. LPN D noticed pressure from the side rail on her neck and head and grabbed her around the shoulders and pulled her up and away from the side rail to get her neck off the rail and release the pressure on her neck. Resident 1 was unresponsive and limp. A CNA was there and she grabbed Resident 1 ' s legs so that Resident 1 was horizontal with the bed and was able to slide her down the bed to get passed the side rail. We then laid her on the ground and I did the sternal rub after about 2 minutes she took a very deep breath. Then she coughed and coughed. The pressure on her neck from the rail cut off her air off she was ashen, not red or blue but ashen. Her pulse was 20 when I found her. If the rail was not there she would have fallen out of bed. On 6/22/15 at 3:00 PM Surveyor and RN C observed the type of grab bar used by Resident 1. The grab bar was approximately 12 to 14 inches high and approximately 8 to 10 inches wide. The bar had 2 outer bars with a top bar making it look like a rectangle shape. In between the 2 bar there were 2 cross bars (made the bar resemble a ladder shape). The grab bar was secured to the bottom of the bed. On 6/22/15 at 3:45 PM Surveyor interviewed DON B regarding Resident 1's bed grab bar assessment. DON B reviewed the assessment and stated the assessment only indicates if the resident was alert or not alert. Surveyor asked DON B if the assessment indicates if Resident 1 was able to use the grab bar and if the grab bar was safe. DON B stated the assessment does not directly indicate if Resident 1 can use the grab bar and also does not state the grab bar was safe to use. DON B stated all of the assessments for all of the grab bars in the facility do not address the use of the grab bar. DON B stated the assessment asks only 3 to 4 questions related to level consciousness and confusion. DON B stated she is currently changing the assessment to address the use of the grab bar. Surveyor reviewed Resident 1's plan of care with DON B. DON B stated the grab bar is not on the plan of care. On 6/22/15 at 6:20 PM, Surveyor spoke with CNA G regarding Resident 1's use of the grab bar. CNA G stated Resident 1 did not use the grab bar to reposition; she would just hold onto it at times but did not grab it to move or use it to assist us with moving her. CNA G stated she would assist to reposition Resident 1 in bed and Resident 1 never used the grab bar. 6/23/15 at 8:45 AM, Surveyor interviewed Certified Nursing Assistant (CNA) Regarding Resident 1's fall. CNA F stated she did work with Resident on 6/6/15 in the morning. She was in the room at 5:30 or 5:45 AM and she was fine. CNA F was doing night shift to day shift rounds. CNA F stated Resident 1 was just found on the floor. CNA F stated she did not go into the room or see how she was laying. CNA F stated Resident did not use the grab bar to reposition or to help reposition in the bed. CNA F stated Resident 1 likes to lie close to the grab bar. She liked to lay on her right side, it was comfortable. CNA F stated Resident 1 did not grab the grab bar to help me reposition. She did not grab the bar at all during repositioning. She always liked to lie toward the grab bar. 6/7/15 at 12:00 AM nursing note: Bed in low position/fall mat, a regular body pillow at edge of bed. Hospice brought a new bed without side rails. Continue to monitor every 15 minutes. On 6/8/15 Nurse Practitioner note, seen today for a follow up emergency room visit due to a fall with mental status changes. Resident 1 is negative for findings except for the following: fell out of bed times 3 over the weekend. Fall on 6/6/15 resulted in head wedged between bed and table with concern of neck injury, reduce responsiveness. Nursing note on 6/9/15 at 10:42 AM, Level of consciousness: Lethargic (responds slow to verbal stimuli. Hand grasp: Right weakness and left weakness, pupils difficult to assess, keeps eyes closed. Speech: Rambling, repetitive. Nursing note on 6/10/15 at 6:46 AM Level of consciousness: Lethargic (responds slow to verbal stimuli. Hand grasp: Right weakness and left weakness. Speech: Rambling. A nursing note on 6/15/15 at 1:09 PM indicated that Resident 1 passed away. On 6/22/15 at 7:00 PM, Surveyor spoke with Nursing Home Administrator (NHA) A regarding employee education on grab bars after Resident 1 had fallen. NHA A stated he cannot find any evidence of a written in-service or sign in sheet related to Resident 1's incident or the use and/or assessment of the grab bars. According to the US Food and Drug Administration, Between January 1, 1985 and January 1, 2013, FDA received reports of 901 incidents of patients caught, trapped, entangled, or strangled in hospital beds. The reports included 531 deaths, 151 nonfatal injuries, and 220 cases where staff intervened to prevent an injury. Most of the affected patients were frail, elderly, or confused says (Joan) Todd (a senior nurse consultant with the FDA). 'But health care facilities, as well as patient caregivers, are urged to take a careful look at hospital beds. They need to determine if there are large openings that present an entrapment risk, and to take steps to minimize this risk.' ¿Any type of rail or grab bar attached to a bed, as well as the fit of the bed mattress, should be assessed for entrapment risks, ' she adds. Ms. Todd notes, Patient entrapment is uncommon .but when it occurs, it's often fatal. <http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm 6.htm> The facility's failure to assess, evaluate fall interventions for Resident 1 created an immediate jeopardy situation which began 6/4/15. The facility removed the immediate jeopardy on 6/22/15 by taking the following actions: 1. All nurses will be educated on the need to complete a thorough assessment of any resident needing the use of a bed device. Assessment will include safety issues, functional mobility, whether the device is a restraint or not. Education to be completed immediately. Education will be completed prior to an employee's next shift worked. 2. 100% review/assessment will be completed on all residents with any bed device. 3. All nursing/maintenance staff will be educated to the need to remove bed devices upon discharge and prior to another resident being admitted to the bed. Education to be completed immediately. Education will be completed prior to an employee's next shift worked. 4. Based on the assessment above, bed devices will be removed if deemed no longer necessary or beneficial. 5. All bed devices that are assessed to be beneficial will be care planned. 6. Continued use of bed devices will be periodically reviewed for appropriateness for residents with bed devices. 7. Bed rail assessment was revised to capture pertinent information. The deficient practice continues at a scope/severity level of E (potential for harm that is not immediate jeopardy/pattern) as evidenced by: Example 2 Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 7's Minimum Data Set (MDS) was not completed due to recent admission. Resident 7 is not her own decision maker and was deemed incapacitated on 6/13/15. Comprehensive care plan review, on 6/22/15 at approximately 4:00 PM, Surveyor reviewed Resident 7's comprehensive care plans. Resident 7's comprehensive care plan included, Falls, Self care deficit, Cognitive loss, Mobility and Activities of daily living. Resident 7's use of the grab bars was not located within the comprehensive care plan. Resident 7's side rail assessment, dated 6/18/15: Mental status is not alert/oriented times 3 during the day. Is not comatose/unresponsive. Is confused at night and has a history of falls at night. Additional note added: Grab bar on left side to assist in repositioning and transfer in and out of bed. (The side rail assessment does not indicate if Resident 7 can safely use the grab bar.) Physical device review, dated 6/18/15, Bed in low position/ fall mat. Risk: An (X) is placed in the box identified as Other. (There are no identifying words for what the word Other means.) Benefits: Decreased risk of injury related to falls. Nursing note, dated 6/19/15 at 12:49 AM, Resident 7 found out of bed lying on the floor on her back. Resident 7 unable to vocalize what she was doing on the floor. Skin tear noted on her right elbow area. Nursing note, dated 6/19/15 at 3:06 PM, Resident 7 has her strong left side - facing out of the bed. She likes to use her left side to promote bed mobility but is unaware of boundaries. Writer applied a scoop mattress and bolster to help her stay in bed when she is moving to her left side. It is likely she got her left side too close to the edge of the bed and she rolled out. She already has a low bed and fall mat in place. Physical device review, dated 6/19/15, Scoop mattress, bolster. Risk: An (X) is placed in the box identified as Other. (There are no identifying words for what the word Other means.) Benefits: Reduce risk of rolling out of bed, Resident comfort and sense of security. On 6/22/15 at 3:15 PM Surveyor and Registered Nurse (RN) C observed the type of bolster used by Resident 7. RN C entered the room and stated Resident 7 fell out of bed and RN C applied a bolster to the side of her bed. Resident 7's bed was placed against a long wall with the end of the bed toward the top wall. Resident 7's left side would be toward the open side of the bed. RN C explained the bolster to Surveyor . The bolster was light blue in color and consisted of 2 bolsters one for each side of the bed. The two bolster where connected by a sheet of material. The bolster were approximately 2 1/2 to 3 feet long by 8 to 10 inches wide. The bolster were secured to the bed with a strap. RN C stated the bolster will not move or fall off the bed. RN C pushed on the bolster and it fell level with the edge of the bed. The bolster was placed approximately 5 inches down from the grab bar. On 6/22/15 at 3:15 PM Surveyor interviewed RN C regarding the use of the other fall prevention devices with the Grab bars. RN C stated she did not assess the grab bar and the bolster together. RN C stated she did a risk form for the bolster and the scoop mattress. Surveyor and RN C observed the scoop mattress and bolster. The bolster filled in the cut off of the scoop mattress. RN C stated she did not assess the grab bar after applying the new devices. Surveyor asked RN C if Resident 7 rolled out of bed prior to adding the bolster to the bed. RN C stated yes she was found on the floor and likes to lie on her side near the door. (This is also the side where the grab bar is present.) RN C stated she did not consider the grab bar or the items placed near the grab bar when adding the additional supportive devices. On 6/22/15 at 6:30 PM Surveyor spoke with DON B regarding Resident 7's grab bars and assessment. DON B stated none of the resident assessments are complete to identify if the resident can use the grab bar or if the grab bar is safe. DON B stated she has changed the program to identify if the resident can use the grab bar and that the grab bar is safe. Example 3 Resident 5 has a [DIAGNOSES REDACTED]. Resident 5 ' s quarterly Minimum Data Set ((MDS) dated [DATE] indicates Resident 5's Brief Interview for Mental status (BIMS) is a 3, indicating Resident 5 is severely cognitively impaired. Resident needs extensive assist of 1 with bed mobility and extensive assist of 2 with transfers Resident 5's side rail assessment, dated 3/14/15: Mental status is not alert/oriented times 3 during the day. Is not comatose/unresponsive. Is confused at night and has a history of falls at night. (The side rail assessment does not indicate if Resident 5 can safely use the grab bar. On 6/22/15 at 8:50 AM Surveyor observed Resident 5's bed. Resident 5's bed was observed with grab bars on both sides of her bed. On 6/22/15 at 9:30 AM Surveyor was presented by Director of Nursing (DON) B a list of Residents who are currently using grab bars in the facility. The list did not include Resident 5. On 6/22/15 at 2:30 PM Surveyor spoke with DON B regarding Resident 5's grab bars and assessment. DON B reviewed the grab bar assessment and the list of Residents using Grab bars. DON B acknowledged Resident 5 was not on the grab bar list. DON B stated Resident 5's grab bar assessment does not indicate Resident 5 can use the grab bar or if the grab bar is safe. DON B stated the assessment need to be more thorough and is currently changing the system. On 6/22/15 at 3:30 PM Resident 5's comprehensive care plan was reviewed by Surveyor . Resident 5's comprehensive care plan did not indicate the use of the grab bar. On 6/22/15 at 6: 00 PM Surveyor spoke with DON B regarding Resident 5's care plan. DON B stated I do not believe the grab bars are on any of the care plans currently. DON B stated she would look into the facility process on care planning grab bars. Example 4 Resident 4 has the following [DIAGNOSES REDACTED]. Resident 4 admission Minimum Data Set ((MDS) dated [DATE] indicates Resident 4's Brief Interview for Mental Status (BIMS) is a 9, indicating Resident 4 has cognitive impairment. Resident needs extensive assist of 2 with bed mobility and extensive assist of 2 with transfers. Resident 4's side rail assessment, dated 3/14/15: Mental status is alert/oriented times 3 during the day. Is not comatose/unresponsive. Is sometimes confused at night. (The side rail assessment does not indicate if Resident 4 can safely use the grab bar.) On 6/22/15 at 8:35 AM Surveyor Observed Resident 4's bed. Resident 4's bed was observed with grab bars on her bed. On 6/22/15 at 2:30 PM Surveyor spoke with DON B regarding Resident 4's grab bars and assessment. DON B reviewed Resident 4's grab bar assessment. DON B. DON B stated Resident 4's grab bar assessment does not indicate Resident 4 can use the grab bar or if the grab bar is safe. DON B stated the assessment needs to be more thorough and she is currently changing the system. On 6/22/15 at 4:00 PM Resident 4's c

Based on interview and record review, the facility did not ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents reviewed (Resident 4). On 12/18/14 Resident 4 was observed in the hallway of the unit without her walker. Resident 4 asked Certified Nursing Assistant (CNA) D for milk. CNA D left Resident 4 without her walker and proceeded to get the requested milk. Resident 4 fell and fractured her pelvis. Resident 4 sustained an additional fall on 12/22/14 during the night shift. Resident 4 was to be toileted every one to two hours during the night. This was not completed. The facility did not complete an investigation related to the failure to follow Resident 4's plan of care. Resident 4 developed a deep vein thrombosis (DVT) to her right lower leg due to inactivity, after the falls. Resident 4 was placed on an anticoagulant medication related to this diagnosis. This is evidenced by: The facility's policy titled "Falls and Falls Risk Managing" dated 12/15/11 states in part, "Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. It is the policy of this facility to identify residents at risk for falls, develop plans of care that address the risk and implement procedures to assist in preventing falls. The facility will also review accidents involving residents sustaining falls to identify possible cause and develop approaches and interventions to assist in preventing repeated falls." Resident 4 is a long-term resident of the facility who lives on the facility's memory care unit. Resident 4 has [DIAGNOSES REDACTED]. According to "Face Sheet", Resident 4 has an activated Power of Attorney for Health Care. The facility completed an annual Minimum Data Set (MDS) assessment, with a reference date of 10/6/14. This assessment states that Resident 4 scored four points on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. This assessment also notes that Resident 4 used a walker for mobility and had one fall since the previous assessment. The facility completed a "Fall Risk Assessment" dated 11/17/14. This assessment states, "Mental Status: Alert, oriented, reliably aware of safety. Mobility/Continence: Ambulatory/continent. Gait/Balance: Gait/balance normal. Vision Status: Adequate (with or without glasses). Orthostatic BP (Blood Pressure) (Systolic): No drop from lying to standing. # of falls in the past 3 months: None. Medications: None. Med/Dose change: None. Predisposing Disease/Condition: Dementia 1-2 conditions. A score of 10 or (SIC) may represent a high risk for falls." It is important to note that this assessment is not scored. Resident 4's "Physical Therapy Discharge Summary" dated 7/29/14 states, "Ambulation: Independent with gait without device in room and with a 4 wheeled walker on the memory care unit. Participated in longer distance gait training throughout the building independently, on outdoor surfaces with 4 wheeled walker and SBA (stand by assist) and up/down carpeted incline with 4 wheeled walker independent. Recommend use of the 4 wheeled walker for all gait activities out of her room." Resident 4's "Resident Care Card" in place on 12/28/14 states, "Mobility/Positioning: Locomotion: I (independent) 4 WW (wheeled walker). Locomotion: I. Ambulation: I with walker, check for non-skid footwear. Toileting: X 1A (one assist) empty colostomy with every toileting to prevent resident from trying to empty. **Toilet q (every) 2-3 hrs (6am to 6 pm), toilet q 1-2 hrs (6pm-6am)." Resident 4's comprehensive care plan, in place from 12/18/14 to the time of survey (2/2/15) states in part, "1/21/14: Nurse Aide----Call button in reach. Allow time to complete tasks Encourage independence Provide cues as needed Encourage rest periods Report pain indicators Avoid fatigue Toileting schedule, toilet resident Q 2-3 hrs start approx. between 6am to 6 pm. Wake if necessary. Toilet Q 1-2 hrs between 6 pm and 6 am ...9/29/14: Locomotion: 4 WW. Transfers: I 4WW. 11/03/14: Ambulation: I with walker, check for non-skid footwear." Resident 4's "CNA Charting" states, in part, the following: "12/13/14: PM walk in hall: independent. Assistive Device: walker used." "12/14/14: PM Move on unit: independent. Mode/Supportive Device: walker used." "12/15/14: PM Walk in hall. Independent. Assistive Device: walker used." "12/18/14: PM Walk in hall: Independent. Assistive Device: walker used. PM Move on unit: Independent. Assistive Device: walker used." "Nurse's Notes" dated 12/18/14 state, "Date of Incident: 12/18/14. Time of Incident: 1500 (3:00 PM). Incident Type: Fall. Descrip of Incident: resident walked down the hallway without (SIC) and asked CNA to get her a carton of milk. When CNA turned around to go get the milk the resident fell to the floor. CNA did not see the fall happen. Resident states that she did not hit head but her head was leaning against the wall. Resident complaining of pain in her right butt/hip area. When staff got resident up she was having a hard time bearing weight on her right hip. Location: Hallway. Injury: pain to right hip. Resident position: standing. Mental state: normal for resident, Activity at the time: walking. Equipment involved: none. Did resident hit head? Neuro (neurological) assessment initiated. First Aid: none needed. Possible Cause: none obvious. Staff involved: CNA nurse. Witnesses: none. Neuro Checks: Pupils equal, round and react to light (immediately after). Physician Notification: physician notified (Doctor name). Family notification: family notified (name). Actions: continue to observe. New Intervention Initiated: Ensure that patient has walker at all times when ambulating. Teaching Done: None/N/A. Shift: PM shift. Day of Week: Thursday. Physician Contact: spoke with attending physician. Regarding: resident fall. Result: Physician requests that we send patient to ER to have xrays as well as vitals monitored due to high blood pressure. Time: 1800 (6:00 PM) Resident left for (hospital) via paratech ambulance, daughter to follow in her own vehicle ...Spoke with MD at ER. X rays results were negative for any obvious fracture. Resident still unable to bare (SIC) wt (weight) at this time. MD is going to order CT scan to rule out any further fracture. MD states if she comes back she will be an assist to the restroom. 23:40 (11:40 PM) Resident returned to (facility) via ambulance @ approx. 2330 (11:30 PM) with pubic rami fx (fracture) WBAT (weight bearing as tolerated)-foley cath in place. Need to follow up with (Resident 4's primary care physician) tomorrow. New orders received for Oxycodone 5 mg (milligrams) q4 hrs (hours) prn (as needed) pain/discomfort and Miralax 17 g (grams) by mouth BID (twice per day) prn. Resting comfortably in bed at this time." Hospital documentation titled "Information About Your Visit" dated 12/18/14 states, "Your [DIAGNOSES REDACTED]. Home Care Instructions: You should be on bed rest for as long as directed by your caregiver. Change positions of your legs every 1-2 hours to maintain good blood flow...SEEK IMMEDIATE CARE IF: ...There is swelling in one or both legs." Resident 4 was assessed and care planned to require the use of a walker when in the hallway. CNA D did not ensure that Resident 4 had her walker while in the hallway. CNA D did not assist in retrieving Resident 4's walker, but rather left Resident 4 without her walker to get milk. The facility completed an investigation into Resident 4's fall on 12/18/14. This investigation includes the following: "Misconduct Incident Report; Date Occurred: 12/18/14; Time Occurred: 1500 ...Incident Investigation of (Resident 4) Fall; Incident. On 18 December 2014 at approximately 1500, (Resident 4) was noted laying down on the floor while in the hallway. She was assessed and sent to the ER at 1800 where she was diagnosed with [REDACTED]. Investigation: (Resident 4) was originally admitted to (facility) on 30 October 2012. She is [AGE] years old. She is a long term resident on the memory care unit with SLUMS (St. Louis University Mental Status) score of 7 out of 30. She had primary [DIAGNOSES REDACTED]. Some of these include vitamin and mineral deficiencies. On the memory care unit where she is an independent person with transfers and ambulation using a four wheeled walker, she is often found in her room or in the hallway. It has been observed that the resident as times, forgets to use her walker. She does not have a history of falls. In the interview of the staff member (CNA D), she stated that the resident was standing in the hallway while she went to go get her milk. The resident was independent and having no issues with walking at this time. Even though she was not with her walker she was steady against the side rail of the hallway. Other staff were interviewed and no one observed (Resident 4) immediately prior to her being noted on the floor. On 19 December 2014, I went to interview (Resident 4) on the events. When asked what had happened the previous day she stated ' ...I don't think I remember ...' She stated that she was not in any pain at the time when asked if she needed anything, she stated 'A diamond ring, a new car ...' Her mood was pleasant and she was smiling. During the time of the incident, the camera system was doing an upgrade. There is not any photographic evidence of what happened. This incident happened on the memory care unit and none of the residents are interviewable for any information relevant this this case. Conclusion: (Resident 4) is a long term resident of memory care unit with multiple medical comorbidity issues. While it is unfortunate that she fell and had a fracture, there is no sign of abuse or neglect for this resident. The resident frequently was walking with and without her walker about the unit. When she is without her walker she is reminded to use it. There was one staff member (CNA D) to interview she stated there was no issue with the resident before the incident. The resident received medical attention; she was not in further pain when interviewed and was screened and treated by physical therapy. Her mentation is back to her baseline without issue or long term effects. She continues therapy and is doing well. Pain medication provided as needed. (Signed) (Director of Nursing (DON) B). The facility submitted their investigation to the State Agency on 12/24/14. The facility provided a statement written by CNA D to Surveyor on 2/2/15. This states, "I was educated that if a resident that is in need of an assistive device is noted to not have an assistive device, resident should be made safe by providing a seat until assistive device is returned." The facility did not include in their investigation, evidence that all staff were educated on the importance of prioritizing resident safety, ensuring that safety devices are provided and that care plans are followed. "Nurse's Notes" dated 12/22/14 state, "Date of Incident: 12/22/14. Time of Incident: 00:50 (12:50 AM). Incident type: Fall ...Descrip of Incident: Resident found sitting on floor in bathroom with arms to sides and legs in front. RN (Registered Nurse) assessed resident and able to move all extremities. Resident said that she bumped her head. No apparent bruising or abrasions noted to head. Resident grimaced and says ouch when she was picked up from floor. Resident as able to bear weight when transferring to bed ...Injury: no apparent injury. Mental state: confused. Activity at time: walking. Equipment involved: none. Did resident hit head? No Neuro Assessment Initiated. First Aid: none. Possible Cause: Transferring self from toilet and slipped on the floor. Staff involved: none. Witnesses: None ...New Intervention Initiated: Toilet schedule q 2-3hrs. Teaching done: none. Shift: NOC (night) shift ...Review of incident: Additional information: Resident found sitting on the floor in her bathroom near toilet with arms to sides and legs in front of her. Resident said she bumped her head. No apparent bruising or abrasions noted to head. Resident stated she had pain when being assisted off the floor. Resident is alert and oriented X2-3. Resident ambulates independently with a walker and brought herself to the bathroom. Resident was last toileted at 10pm with staff." It is important to note that the facility did not analyze that Resident 4 was last toileted at 10:00 PM on 12/21/14 and the fall occurred at 12:50 AM on 12/22/14. The facility did not ensure that Resident 4 was toileted in accordance of her plan of care, every one to two hours, and did not investigate this incident as it relates to Resident 4's toileting schedule. "Nurse's Notes" dated 1/1/15 state, "16:30 (4:30 PM) Spoke with (Resident 4's physician) regarding red streak down R (right) calf. R calf swollen, warm and tender to touch. New orders received and noted 1/01/2015 16:35 (4:35 PM) Obtain STAT venous Doppler to RLE (right lower extremity) or send patient to ER if unable to obtain venous Doppler. 16:39 (4:39 PM) (imaging provider) called to schedule STAT venous Doppler ...stated they 'don't do STAT Doppler's.' Would put in the order and the tech would let nurse know if Doppler would be able to be done tonight. No call received from tech. Nurse called ...for transport to (hospital) ER for Doppler of RLE at 16:50 (4:50 PM). 21:34 (9:46 PM) Resident returned for (hospital) ER with dx (diagnosis) of DVT (deep vein thrombosis) (blood clot). New orders Xarelto BID. Elevate R leg. Apply warm heat to R leg. Encourage fluids." Hospital documentation dated 1/1/15 states, "Information About Your Visit; Your [DIAGNOSES REDACTED]." "physician progress notes [REDACTED]. First s/p (status [REDACTED]. Unfortunately patient was not ambulating regularly & developed RLE swelling and found to have DVT on 1/1/15. Currently denies pain but poor historian ...A/P (assessment/plan): 1. RLE DVT (1/1/15) d/t (due to) pelvic fracture/immobility. Xarelto 15 mg BID X 21 days then 20 mg daily X 3-6 months ..." "CNA Charting" for December, 2014 notes the Resident 4 consistently ambulated on each shift until 12/19/14. After Resident 4's fall on 12/18/14, "CNA Charting" for Resident 4 indicates a significant decrease in ambulation for Resident 4. Surveyor spoke with CNA F on 2/2/15 at 12:35 PM. CNA F stated that she had not had training related to (Resident 4's) fall. CNA F stated that she had taken care of (Resident 4). CNA F stated that (Resident 4) is a one assist with transfers and walking. CNA F stated that (Resident 4) was independent with her walker before her falls. CNA F stated that she used her walker before and does now as well. Surveyor spoke with CNA G on 2/2/15 at 12:40 PM. CNA G stated that she takes care of (Resident 4) and that Resident 4 always used her walker before her fall and does so now as well. CNA G stated that she has not been educated recently related to use of assistive devices. Surveyor spoke with CNA D and Nursing Home Administrator (NHA) A on 2/2/15 at 2:00 PM. CNA D stated that (Resident 4) was in the hallway on 12/18/14 by the living room area. CNA D stated that (Resident 4) would not go into the living room because it was too loud. CNA D stated that she wanted milk, so she went and got (Resident 4) some milk. CNA D stated that the nurse was in the living room at this time. CNA D stated that she then heard that someone had fell and she thought it was another resident. CNA D stated that it was (Resident 4). CNA D stated that when (Resident 4) requested the milk, she did not have her walker. CNA D stated that any other time she had seen (Resident 4) without her walker, she would take her hand. CNA D stated that (Resident 4) was always without her walker and she thought she was safe. CNA D stated that normally, when (Resident 4) leaves her room, she does not have her walker so she would then take her hand. CNA D stated that this time, she was right by the living room, so she thought she was safe. CNA D stated that the nurse manager did education with her and she thought she (Resident 4) was stable because she was near the railing. CNA D then stated that there was no one else around and that the unit nurse was in the nurse's station. Surveyor spoke with Director of Training (DOT) E on 2/2/15 at 1:50 PM. DOT E stated that she was told today that they were looking for education related to this fall. DOT E sated that she does not do all of the education. DOT E stated that she was not involved in (Resident 4's) case. DOT E sated that there was not training specific to this situation. DOT E sated that she had done some ADL (Activities of Daily Living) training in the past, but this was "not referring to this occurrence whatsoever." Surveyor asked DOT E about the training process when a situation, such as this occurs. DOT E stated that remedial education is done right away and then this is passed onto the next shifts so that all can be educated. Surveyor spoke with DON B on 2/21/5 at approximately 1:55 PM. DON B stated that he was trying to find education related to this. DON B stated that education was completed with the CNA right away. DON B stated that the incident was very unfortunate as the resident was very independent. DON B stated that (Resident 4) would walk all over the unit. DON B stated that this was an isolated incident and he believes it was addressed. Surveyor asked DON B about his expectations for staff that see residents without their assistive devices. DON B stated that they should make sure the resident is safe first. At 2:35 PM, Surveyor asked DON B about Resident 4's fall on 12/22/14. DON B stated that he did not identify the toileting schedule as a problem related to the fall. Surveyor asked DON B who was responsible for ensuring that the falls are looked at for root cause and a thorough investigation is completed. DON B stated that the VP of Clinical Services is in charge of this, and she is not in today. DON B stated that the chain of events regarding (Resident 4's) falls, DVT and additional medication (Xarelto) was concerning to him.

Based on observation, interview and record review, the facility did not ensure that each resident received adequate supervision to prevent accidents for 1 Resident (6) of 4 Residents reviewed for fall risk. Resident 6 fell 11 times in the facility in a 3-month period including one fall with a fractured femur. The facility did not add new interventions after each fall and did not ensure adequate supervision to prevent future falls. This is evidenced by: Facility Policy entitled "Falls and Fall Risk, Managing" with effective date of 12/15/11 states: "Purpose: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Statement of Policy: It is the policy of this facility to identify residents at risk of falls, develop plans of care that address the risk and implement procedures to assist in preventing falls. The facility will also review accidents involving residents sustaining falls to identify possible cause and develop approaches and interventions to assist in preventing repeated falls. Procedure: 1. The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls...4. If falling recurs, despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant..." Resident 6 was admitted to the facility 6/15/12 with [DIAGNOSES REDACTED]. Resident 6's Admission Minimum Data Set (MDS) listed a Brief Interview for Mental Status (BIMS) score of 05 which indicates severe impairment of cognitive function. The MDS also indicated that Resident 6 needs Extensive Assistance for toileting with a Two+ persons physical assist. Resident 6 sustained 11 falls in the facility from 6/15/12 through 9/14/12 as follows: 6/15/12 -2 falls- 5:30 PM and 8:30 PM Resident 6 was admitted to the facility on this day at 2:30 PM. Resident 6 was admitted with a left hip fracture that he had sustained in a fall prior to admission. Resident 6 had a "Fall Risk Assessment" completed 6/15/12 which indicates a score of "24." Scores of 20-29 are a Moderate Risk for falls per the scoring key. Per the facility summary (e-mailed to Surveyor on 10/10/12), a chair alarm was placed at the time of admission. Resident 6 had an unwitnessed fall from his wheelchair in his room on 6/15/12 at 5:30 PM. He was found kneeling on the floor in front of the wheelchair. The alarm was sounding. There was no injury. The Resident Incident report shows "Immediate Actions Taken" were "Chair alarm applied (this had already been in place and was sounding during the fall), Bed alarm applied, Bed in low position, and floor mat." Resident 6 then had an unwitnessed fall from his bed at on 6/15/12 at 8:30 PM. Resident 6 rolled out of bed and was found lying on the floor mat with his feet straight out in front of him. Resident 6 stated he hit his head. Neuro checks were already in place from the previous fall. Nurse's Notes on 6/15/12 at 8:58 PM state: "Updated wife about (Resident 6's) restlessness and a need for someone to watch him. She hasn't slept and can't come in. Will attempt to give pain medication and if still trying to get out of bed will need to bring to nurse's station where he can be more closely watched." The intervention to bring Resident 6 to the Nurse's Station if restless was short-term--it was not added to the plan of care or noted as a fall intervention. The Resident Incident Report of 6/15/12 also has 3 witness statements attached. Certified Nursing Assistant (CNA) E answered the question "...describe what resident was doing at the time of the fall?" and noted that (Resident 6) was "constantly trying to get up." Note: The Interdisciplinary (IDT) fall review team did not meet regarding these 2 falls until 6/18/12. 6/17/12 at 3:16 PM- Unwitnessed fall from wheelchair in Resident room. The Resident Incident Report for this fall states: "resident was found on floor in BR (Bathroom), chair alarm was sounding, resident denied hitting head, resident is an unreliable witness due to advanced dementia, resident had been seen by staff 20 minutes before and was sitting in w/c (wheelchair) in room, resident stated he did not need to use the toilet and was not soiled at time of fall, he stated he needed to clean the shower, shower was not dirty." Immediate Actions Taken section states: "continue to observe, pain level monitored, moved closer to nurse's station." Resident 6 was moved to another room on the same hallway closer to the nurse's station on 6/17/12. The IDT team met to review all 3 falls on 6/18/12. Intervention noted for the 1st fall on 6/15/12 is "will have therapy do some cognitive testing." It had already been noted that Resident 6 has advanced dementia and delusions (i.e. the dirty shower). Intervention noted for the 2nd fall on 6/15/12 is "will consult with MD for anxiety medication." Per the 10/10/12 summary, the Nurse's Notes on 6/17/12 indicated that the "MD was consulted regarding the medications resident was on and could they be contributing to falls. MD did not think so and recommended resident be moved to the Dementia Unit or closer to the nurse's station." This was done 2 days after the 6/15/12 falls (after Resident 6 had fallen a third time). The Resident Plan of Care showed the following entries: 6/15/12 Bed alarm Chair alarm when not in line of sight 6/18/12 Fall Mats/Low Bed in place when in bed 6/19/12 Toilet after dinner and prior to bed, toilet every 2-3 hours at night (this was based on the admission Bowel and Bladder Assessment that was completed on 6/19/12--it was not a fall intervention). Nurse's Notes 6/19/12 at 10:51 PM state: "Resident was trying to get up from wheelchair several times this shift, residents alarms remain on...Resident was put in wheelchair after toileting and sat by nurses' station for an hour or two until put to bed..." 6/26/12 at 8:30 PM - Resident slid down while trying to transfer from wheelchair to toilet. Resident 6 was "slowly going down on one knee trying to urinate." A CNA had entered the room and witnessed the fall. The Resident Incident Report notes Immediate Actions Taken as: "continue to observe, items placed within reach, bed alarms and chair alarms remain on, bed in low position, fall mat down, put into bed, candy given, toileted." No changes were made to the plan of care. The IDT team met 6/28/12 (2 days later). The notes of that meeting state: "...Reportedly resident indicated several times during the shift that he needs to void. staff report that resident has noted frequency. (Resident 6) was taken off cipro due to negative test (Urinalysis) results. Therefore it is felt that this is not an infectious process..." IDT Follow-up states: "PVR (Post Void Residual) through weekend, call if over 250 ml for st cath (straight catheterization) orders." Surveyor asked to see bladder scan results and the consult with the Physician. The 10/10/12 e-mail summary states: "The nursing intervention of obtaining PVR's was completed but the results were so little amount remaining in the bladder that there was no need for change as it determined there was not urinary retention." Therefore, the facility ruled out retention and infection as causes for the urinary frequency and related fall. However, they did not reassess to add new interventions based on this information. No new interventions or changes to the care plan were made after this fall. Nurse's Notes 6/29/12 at 10:31 PM state: "Resident still confused and urinating often. Resident has one on ones when staff is available. In wheelchair in hall most of the time due to resident needing to be watched..." Nurse's Notes 7/1/12 at 10:34 PM state: "Residents urine is clearing up, less cloudy. Resident urgency is decreasing. Resident stays in wheelchair and roams the hall to have as many eyes on him as possible for his safety..." Nurse's Notes 7/2/12 at 3:31 AM state: "...Alarms are in place. Pt has made several attempts to get OOB. Assisted him to w/c and had him sit with nurse at nurse's station earlier..." 7/5/12 - 9:15 PM - Resident was found on floor outside a restroom (on his hallway) with no apparent injury. The alarm was sounding. According to the Nurse's Notes dated 7/5/12: "Resident stated he was trying to open the bathroom door to go to the bathroom. He needed to have a bowel movement..." Immediate Actions Taken states: "continue to observe, resident was toileted and taken to go to bed for the night. The Resident Incident Report has witness statements. CNA F completed a witness statement. In the section asking for suggestions to prevent further incidents like this from occurring CNA F wrote: "1:1(one on one) 8-10 PM?" On 7/6/12 the IDT team met to review the fall. The recommendations noted from this meeting are: "Change toileting to q (every) 2-3 hours." Since the Care Plan already had instructions to toilet Resident 6 after dinner and before bed (added to care plan 6/19/12), it is unclear whether this new care plan update would have added any extra toileting to the evening schedule. No mention was made of the witness statement (by direct care staff) regarding extra supervision in the 8-10 PM period. The Care Plan was updated on 7/6/12 with the entry "Toilet q 2-3 h and prn (as needed) at NOC (night shift), toilet after dinner and before bed, remind res to void, provide privacy, change clothes PRN, observe void pattern, report changes in voiding pattern or appearance of urine, enc. to empty bladder." 7/8/12 6:40 PM - Resident was in his room in his w/c. A CNA witnessed resident get out of chair and fall to the floor. The computerized fall report states: "Preventive Devices in Use: tabs alarm was sounding." Immediate actions taken noted as: "Tabs alarm applied continue to observe." A witness statement completed by a CNA (unable to read signature/name) states the following: "What do you feel contributed to the fall?" Answer: "Resident's wife had just gone home. Whenever alone the resident is a constant fall risk and persistently tries to stand on his own..." and "What interventions do you think could be initiated to prevent further falls with this resident?" Answer: "Supervision." On 7/9/12, the IDT team met to review the fall. The IDT note states: "...Resident was on cipro and it was stopped on 7/5. He is not sleeping well at night, according to his wife this increases his confusion. Frequent urination is occurring and resident indicates he was on his way to the bathroom when fell . A urine dip is being done and PCP is being contacted to inquire about a sleep aid." No mention is made of the CNA suggestion for more supervision and no care plan changes were made to protect the resident while the urine testing and medication changes were being considered. Nurse's Notes 7/10/12 at 2:32 PM states: "Reported that resident was up all night, resident wheeling around unit when I came on the floor. Resident was sleeping on and off throughout shift (mainly in chair), later transferred himself from wheelchair to chair while (name of staff member) from transport was trying to get him to stop. He became biligerent for us trying to keep him in his chair. Once back in his wheelchair he was trying to get back up to sit on the bed. Resident is becoming more confused. Will continue to monitor." On 7/10/12 there is a Physician Telephone order for: "UA C&S (culture and sensitivity) if indicated." On 7/11/12 there is a Physician Telephone order for: "Cipro 500 mg (milligrams) BID (twice a day) x 5 days. Also on 7/11/12 there is a telephone order for: "send out to ER for eval-possible sepsis" Nurse's Notes 7/11/12 at 10:47 PM indicate that Resident was not feeling well, temperature was elevated, Blood Pressure was high and Resident was vomiting. Notes state: "...talked to on call (name of doctor) and decided to send in since it was OK with wife (POA) due to possible sepsis and chronic UTI, hypertension and febrile state due to UTI." Resident 6 was hospitalized from [DATE] to 7/21/12. Nurse's Notes at readmission on 7/21/12 state: "admitted from Acute Care Hospital (name of hospital) s/p (status [REDACTED]." Note: Resident was admitted to a new room on the facility Dementia Care Unit. Resident 6 had a "Fall Risk Assessment" completed upon re-admission 7/21/12 which indicates a score of "24." Scores of 20-29 are a Moderate Risk for falls per the scoring key. The scoring on this assessment may have under-estimated Resident 6's fall risk. In the area for "History of Falls" Resident 6 is scored as "2" which indicates 1-2 falls in the past 90 days. Resident 2 had "3 or more falls" in the past 90 days (as noted above) and should have received a score of "4" in this section. In the area of "Balance" Resident 6 was given a score of "0" indicating that he can "maintain position as required." This is inconsistent with his [DIAGNOSES REDACTED]. that when "moving from sitting to standing" that Resident 6 is "not steady, able to stabilize with human assistance. Resident 6 could have scored an additional 1- 4 points in this section that would have placed him in or borderline to the "High Risk" score of 30-40. Also, this fall assessment was only completed on 2 dates--6/15/12 and 7/21/12. No new fall assessments were completed after multiple falls. Nurse's Notes 7/22/12 at 8:50 PM state in part: "...staff called this nurse to residents room, this nurse found that resident had twisted off IV tubing from site and was bleeding from IV site...resident was brought to living room for supervision until IV abx was completed. Wife came to visit and when IV was completed wife took resident off unit to spend time. Resident has been trying to exit seek most of shift and front double unit doors. Resident at times difficult to re-direct, especially when looking for wife..." 7/22/12 at 11:10 PM - Resident 6 fell from his bed, no injuries were noted. The computerized fall report states: "Resident was found OOB (out of bed) in sitting position on landing strip. CNA alerted to room with bed alarm sounding...Resident told staff that he was trying to get to the airport..." "Immediate Actions Taken state: continue to observe placed in w/c, sitting at nurse's station with staff." On 7/23/12 the IDT team met to review the fall. The recommendations noted from this meeting are: "Place bed vigil alarm." There is an addition to the Care Plan on 7/23/12 which notes: "Vigil door and Bed alarm, chair alarm when not in line of sight. Fall mat/Low bed in place when in bed." On 10/9/12 at 3:55 PM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding the vigil alarm. NHA A stated that the difference between a vigil alarm and the pad alarm (that Resident 6 had prior to 7/23) is that the vigil alarm plugs into the call light system and the alarm does not ring sound inside the room, but rather sends a page to the CNAs pager alerting them when the Resident moves off the sensor. There are also Vigil "door" sensors placed in the ceiling, the main doorway, and the bathroom doorway (of all rooms in the memory care unit). NHA A stated that these can be programmed to send a page to the nursing staff when the resident enters the room, when the Resident leaves the room, or when the resident enters the bathroom. There is different programming for each. When asked, NHA A stated he would have to check the programming to see which modes were set for Resident 6. On 10/9/12 at 4:00 PM, NHA A and Surveyor went to Resident 6's room to observe the alarms that are currently in place. Resident 6 was not in his room at this time. Resident 6's bed has both a pad alarm sensor (which sounds in the room) and a vigil alarm pad (which sends a page to the nursing staff) on his bed. An observation of Resident 6's room also shows that not all of Resident 6's room is visible from the hallway. There is a short corridor at the entrance to each Resident room before the room opens up to its full width. You can see the left 1/4 to 1/2 of the resident room when facing the room from the doorway. The view of the right 1/2 of the room is blocked by the wall that separates the short entrance corridor from the bathroom. In Resident 6's room, the bed is along the right wall of the room and the bathroom door is around the right corner of the short entrance corridor. Neither the bed nor the bathroom door is visible from the hallway. Nurse's Notes for Resident 6 indicate a pattern of restlessness and agitation especially on the PM and night shift as follows: 7/28/12 7:30 PM - "Resident has been anxious most of shift. wife here this afternoon and stated she wanted to leave early because her husband was too difficult to converse with. Difficult for resident to stay in one place for more than a few minutes at a time and would become angry with staff when attempts were made to redirect..." 7/31/12 2:27 AM - "Resident assisted into bed and just a few after resident was in bed resident started yelling out, went into room and resident wanted a flashlight so he could see if he needed to get up during the night...resident started scooting closer to edge of bed to get up, another staff member called into room to assist in getting resident back to w/c. Resident is now at nurse's station for supervision." 8/5/12 9:31 PM - "The past two days resident has become confused and disoriented after wife leaves which is around 4 PM. Resident thinks he is at work at the paper mills and is the boss of the staff...Resident is unable to be redirected and does become angry when staff uses different redirection attempts. These behaviors go on until resident goes to bed which is usually on the night shift." 8/6/12 6:43 AM - Resident is restless and sitting on edge of bed with feet dangling. CNA assisted with using urinal x 5 and assisted to bathroom x 2. Resident slept approx. 2 hours during noc's (night shift)." 8/7/12 8:03 PM - Pt. has been increasingly agitated before supper, trying to take things off the med cart and shaking door handles trying to get out. Calmed down after speaking to wife on phone." 8/9/12 9:22 PM - Resident is confused, staff keeps re-directing him to keep him from wandering d/t him being a high fall risk. Resident has been fixated on finding his shoes and putting things in order in his room." 8/10/12 2:31 AM - Resident was up for half the night. Went to sleep at 0200. He did not show any signs of agitation this shift. Sat and watched TV in the family room.." 8/14/12 at 7:30 PM - Resident 6 was found on the floor in the resident bathroom. The computerized fall report states "minor injury." Note: Resident 6 was later sent out to the emergency room and found to have a fractured femur. The fall report states: "This nurse heard w/c alarm sound and went to answer alarm. Entered resident's room and found resident sitting on buttock next to toilet with pants down. Noted that urine was in the toilet. Resident did complain of some left knee pain, but could move extremities...Immediate Actions Taken: "continue to observe assisted into bed." Nurses Notes dated 8/14/12 at 9:30 PM state in part: "...Resident was in bed after fall and was trying to sit on side of bed to get up, but was having more pain to left leg. Pain was now in left hip and groin area and to lower back. Resident tried to stand and was unable to bear weight on left leg...Order received to send to (Name of Hospital) ER for eval..." Nurse's Notes dated 8/15/12 at 3:58 AM state in part: "...Resident returned from (Name of Hospital) at approximately 3:30 AM with Discharge instructions for Nonweightbearing left lower extremity...There is a midshaft left femur fracture that is new, compared to prior X-rays..." On 8/15/12 the IDT team met to review the fall. The recommendations noted from this meeting are: "Place on toileting after meals along with current toileting schedule of every 2-3 hours and therapy to screen." However, Resident 6 already had "toileting after dinner" on his care plan (since 6/19/12). The 8/14 fall occurred after dinner. Presumably toileting had already been done if the care plan was followed. This is not a new intervention for the timeframe that has been problematic (PM and NOC shift). Upon review of the "Resident Incident Report" forms for all 11 falls, only the 8/14/12 fall had no witness statements attached. The witness statements provide information about what fall interventions were in place at the time of the fall, what time the witness had last seen the resident, what the resident was doing when last seen, at what time the resident had last been toileted, etc. None of this information was available in the Incident Report as viewed by Surveyor on 10/9/12. The IDT team review did not address these issues. The IDT review also did not address the issue of how long it took for staff to respond to the alarm (the resident stood from his wheelchair, already had his pants down, and had completed urinating in the toilet prior to the fall.) Nurse's Notes 8/15/12 at 5:00 PM states in part: "After wife left resident was trying to get up out of w/c without assist in bathroom. Staff assisted resident with urinal. Resident then was stating he need to get on the air plane and go...Resident continued to become agitated and demanding staff give him his plane tickets. Had RN manager 1:1 with resident..." After consulting with the Physician an order for [REDACTED]. There were no changes made to the resident care plan. On 8/15/12 there is a physician telephone order for "lorazepam 1 mg po (by mouth) Q 8 hours prn (as needed) for agitation." On 8/16/12, Resident 6 was sent out to ER for pain management and surgery to left femur. Resident 6 returned to the facility on [DATE] at 2:30 PM. The Hospital "Internal Medicine Admission History and Physical" dated 8/16/12 states in part: "(name of resident) is an 86 y.o. male who is here today for left leg pain. The patient is unable to give a history. Full history is taken from the patient's spouse. He is currently residing at a nursing facility. He fell Tuesday and was noted to have a new fracture of the mid-shaft of the femur. He was discharged with anticipation of a screw being placed. However, yesterday his pain increased per spouse. He will not admit pain but was shouting and very agitated...Impression: 1. New, mildly displaced spiral fracture of the midshaft of the left femur as described. 2. Intertrochanteric fracture of the left femur, unchanged...Assessment and Plan...1. Hip fracture - pain not well controlled, pain medications, try to avoid over sedation, plan for OR in am, patient should go forth with surgery..." Nurse's Notes on 8/20/12 at 4:30 PM state: "Resident was found trying to get self OOB without assistance, attempted to explain that he could not put any weight on left leg due to surgery...Resident continued to try to put weight on left leg..." Lorazepam 1 mg was given for agitation. 8/21/12 at 3:00 PM - Resident 6 fell in his room and was found on the floor with no apparent injury. Description of Incident states: "resident was found leaning on his right side on floor between bathroom and bedroom...there was a bag of popcorn on the toilet, resident had been in activity room for observation to prevent falls, resident left activity room without activities noticing, he was found on floor when w/c alarm was heard by staff...right pupil was fixed at 5 mm...MD stated resident should be seen in ED (Emergency Department) due to condition of pupils...resident was transported to (name of hospital) ED...after staff performed a CT scan of his head and noted no abnormalities resident was sent back to (name of facility) at 2000 (8:00 PM.)" ED (Emergency Department) Provider Notes dated 8/21/12 state: (Resident 6's name) is a 86 y.o. male who presents for evaluation after a fall. He was just discharged to his SNF yesterday after recent admission for left femur fracture which was treated by a rod placement. Per report his chair alarm was heard and he had gotten up and fallen between the chair and wall?...His right pupil was noted to be larger and thus he was sent here for evaluation...ER Diagnostics: CT scan of head showed no acute process..." On 8/22/12 the IDT team met to review the fall. The recommendations noted from this meeting are: "A tabs alarm to be placed to give staff an alert the he is attempting to get out of the chair. He was last toileted at 2:30." Note: This is the 7th fall from the wheelchair. An alarm has sounded in every fall. The 7/8/12 fall had already indicated that a tab alarm was in place and was sounding. This is not a new intervention. Nurse's Note indicates continued restlessness and agitation: 8/25/12 1:58 PM: "PRN Med given-Lorazepam 1 mg given for agitation angry affect, confused to time and place, requesting to toilet himself, attempting to get up out of w/c unassisted, 1:1 provided.." 8/26/12 12:30 PM - "Staff states more difficulty with slide board transfers, due to resident's mentation and cognition due to Dementia, resident becomes angry with staff, wants to transfer himself, does not follow directions, etc..." The care plan was updated on 8/22/12 to say: "Q 2-3 hours and after meals encourage pt to void-MUST have urinal with pt in bag when in WC and next to bed when in bed." 9/3/12 at 1:55 PM - Resident 6 fell in Resident bathroom with no apparent injury. Description of incident states: "Called to resident's room by CNA, states, 'resident is on the floor.' found resident sitting up on buttocks to the side of his toilet, denies hitting his head...witnesses: none...activity at the time: sitting in w/c attempted to toilet self...w/c sensor alarm was sounding." Note: the description does not mention tabs alarm (the intervention after 8/22/12 fall.) Immediate Actions Taken are: "continue to observe." The "Resident Incident Report" for the 9/3/12 fall has 3 witness statements attached. CNA G's statement states that Resident 6 was last seen in the dining room eating lunch. CNA G notes in the section for suggestions to prevent further incidents: "need one on one most all the time cause he is confused many times, we need to watch closely to him." CNA H's witness statement states that Resident 6 was last toileted "before lunch." Resident 6's care plan and previous fall interventions state that Resident 6 should be toileted after meals. Resident 6 was in his room alone after lunch and, according to this witness statement, had not been toileted after lunch. Resident 6 then fell trying to self-toilet. On 9/4/12 the IDT team met to review the fall. No additional interventions are noted on the IDT team computerized charting dated 9/4/12 at 10:17 am. The (hard copy) "Resident Incident Report", which is signed by IDT team members on 9/6/12, states that IDT Follow-up is: "Educate staff on placement of urinal." PT (Physical Therapy) Progress notes dated 9/5/12 at 6:14 PM state in part: "...Pt is doing as well as can be expected with dementia and WBing (weight bearing) restrictions. Pt has not had a fall since having his urinal in the bag attached to his WC and is asking to use it instead of trying to get up by himself." Note: This statement is incorrect. The bag with the urinal was added to the care plan on 8/22/12 and Resident 6 sustained another fall on 9/3/12. 9/14/12 at 12:45 AM - Resident 6 was found on the floor in his room. Description of Incident in computerized fall charting states: "Resident found OOB and sitting on the floor with his back leaning against the wall...denies hitting his head..." The "Resident Incident Report" states: "Resident ambulated from the bed and found in the middle of his room sitting on floor and leaning his back against wall." IDT follow-up is noted as: "Check function of vigil bed alarm." Witness statement attached from CNA I states: "We gave him a new alarm bc (because) the vigil was not working effectively." Relevant Nurse's Notes from 9/14/12 to 10/9/12 include: 9/15/12 4:52 PM - "PRN Med Given: Lorazepam 1 mg tablet given for anxiety. 9/16/12 8:04 PM - "PRN Med Given: Lorazepam 1 mg tablet given for anxiety. Resident looking for the keys to the offices to get to work." 9/23/12 9:36 PM - "PRN Med Given: Lorazepam 1 mg tablet given for agitation, insisting on going home, asking for wife, difficulty staying on task, anxiety." 10/3/12 8:44 AM- "OT (Occupational Therapy) weekly note" late entry from paper copy for note dated 8/25/12. Pt seen 4/5 times this note period for skilled OT. Pt's dementia is advanced and he continues to finds it difficult to recall NWBing precautions. Pt. has had several falls specifically around attempting to self-toilet. Therapy has attached a bag to R (right) w/c arm rest to hold urinal. Therapy is hoping physical presence of urinal will remind pt to ask for assistance in toileting. The bag is also to serve as a reminder for CNAs that toileting pt with urinal is fastest and safest method...Functional status is as follows:....Short Term Goal 2: (W)Goal amended due to change in WBing status. New goal: Complete toilet transfer with slide board and 2 assist. Short Term Goal 3:...Locate urinal in bag 25% of the time when prompted...Toileting: min. assist with use of urinal; mod-max assist x2 with verbal cues..." 10/3/12 3:17 PM - "OT (Occupational Therapy) weekly note" late entry from paper copy for note dated 9/1/12. Pt seen 5/5 times this note period for skilled OT. Treatment focus has been on environmental changes and task simplification for increased safety during toileting..Pt has responded to use of urinal and has not had a fall this week...Pt recognizes urinal bag for correct purpose but at this point is able to locate urinal ) 0% of the time if prompted..." 10/4/12 4:55 PM - "OT (Occupational Therapy) weekly note" late entry from paper copy for note dated 9/15/12. Pt seen 5/5 times this note period for skilled OT...Pt's progress is slowing an therapy will continue for one additional week with a treatment focus on the following: use of urinal with set-up only..." 10/05/12 11:44 PM - "Lorazepam 1 MG Tablet given for anxiety, difficult to redirect." 10/7/12 4:01 PM - "PRN Med Given: Lorazepam 1 mg tablet given for anxiety behavior. Trying to find a way out to go home or to work. Difficult to redirect after needs met. Pushing staff away." 10/8/12 4:49 PM - "PRN Med Given: Lorazepam 1 mg tablet given for anxiety." 8:07 PM - "PRN Med Result: Improved but still present." On 10/9/12, Surveyor had the following observations during survey: 8:45 AM - Initial Tour - Resident 6 was in his room with the door closed. A strong smell of urine was noted in the hallway outside room. An aide exited the room and stated that they were currently providing AM cares to Resident 6. 10:10 AM - Resident 6 was in the Resident lounge watching TV with 7 other Residents and CNA J. There was a pad alarm noted in the wheelchair and Resident 6 was wearing gripper socks. Surveyor spoke with the CNA J who stated that Resident 6 usually uses a urinal for toileting and that he is continent of bowel. CNA J stated that Resident 6 can ask for assistance with toileting. 12:45 PM - Resident 6 was at dining table for lunch. 1:40 PM - Resident 6 was in the Resident lounge. CNA K asked Resident 6 if he needed to go to the bathroom. Resident 6 stated "no, not right now." CNA K showed Resident 6 a puzzle on the table (2 board puzzles with large pieces partially finished) and encouraged him to put it together. CNA K told Resident 6 that the Occupational Therapy would like him to work on the puzzle. Resident 6 was pleasant and cooperative and worked for 10-15 minutes on the puzzle while Surveyo

Based on observation, interview and record review, the facility did not ensure that each resident receives assistive devices and adequate supervision to ensure that accidents do no occur for 1 of 7 residents reviewed (Resident 6). Resident 6 was left alone in while on the toilet and fell , suffering a head laceration. Resident 6's alarm was observed to be unplugged while seated in his wheelchair. This is evidenced by the following: The facility's policy titled, "Falls and Fall Risk, Managing" (Effective 12/15/11), states, "Purpose: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. Statement of Policy: It is the policy of this facility to identify residents at risk for falls, develop plans of care that address the risk and implement procedures to assist in preventing falls. The facility will also review accidents involving residents sustaining falls to identify possible cause and develop approaches and interventions to assist in preventing repeated falls..." CNA (Certified Nursing Assistant) Orientation Check List states, "...Safety; 1. Applies and checks functioning of all fall prevention devices. A. never leave resident with any fall prevention device alone in bathroom (ex. Toilet, shower chair, etc.) i.e. falls mat, low bed, bed alarm, chair alarm, scoop mattress..." Resident 6 was admitted to the facility on [DATE], according to "Face Sheet". According to Cumulative "[DIAGNOSES REDACTED]. The facility completed Care Area Assessment (CAA) for falls, in conjunction with Resident 6's admission Minimum Data Set (MDS) assessment. CAA 11-Falls states, "balance problems during transition...resident has fallen at least one time since admission or the prior assessment...Res (resident) was recently admitted to SNF (skilled nursing facility) on 8/15/12 after hospital for aftercare of left hip fx (fracture) s/p (status [REDACTED]. Res also has dx (diagnosis) of dementia, pain, HTN (high blood pressure), [DIAGNOSES REDACTED], BPH (benign prostatic hyperplasia), hyperactive bladder, A fib (atrial fibrillation)...Res receives pain meds per MD orders for dx mentioned above. Res needs extensive assistance of 2 with most ADL (activities of daily living) tasks. Res is able to communicate needs verbally. Res has fall hx (history). Res has fall risk fall of 24. Has had 2 falls with no injury since admitted to SNF. Res has bed & w/c (wheelchair) alarms, falls mat and bed in low position in place for safety...Care Plan: will develop care plan to prevent complications. To maintain res with minimal to no falls and no injuries r/t (related to) falls through." The facility completed a "Fall Risk Assessment" on 7/21/12. Resident 6 scored 24 points, indicating that Resident 6 was at moderate risk for falls. The facility completed a quarterly MDS assessment dated [DATE]. This assessment indicates that Resident 6 scored 6 points on the Brief Interview for Mental Status (BIMS) which denotes that Resident 6 has severe cognitive impairment. This assessment notes that Resident 6 required total dependence and two person physical assist for transfers, did not ambulate, and used a wheelchair for mobility. This assessment states that Resident 6 has sustained 2 falls (no injury) since that prior assessment. Resident 6's care plan for falls states the following: "7/6/12: Problem: potential for injury-trauma-falls; Related to: decline in cognitive status, unsteady gait, incontinence, decline in functional status, hip fracture; Manifested by: history of falls; Nurses: Observe, record, and report all unsafe conditions and situations. Encourage to ask for assistance, monitor closely, and assess change in level of consciousness. Instruct on safety...10/31/12: Temporary Care Plan: Problem: potential for falls...Approaches: Fall assessment completed per facility protocol. Nurse implements fall protocol. Nurse-falls mat/bed in low position. CNA/Nurse-bed and/or chair alarms. CNA/Nurse-call light in reach; All-call light in reach. All staff instruct on safety. Nurse/CNA other: toilet resident q (every) 2-3 hours @ noc (night), bed wedge in place. 11/7/12:...new intervention: add to care plan not leave resident in bathroom alone. 11/12/12: Bed in low position. Encourage to ask for assistance, call light in reach. Assist in ambulating, transferring, toileting. Anticipate needs; falls mat bed and w/c alarms in place for safety. Bed and room Vigil alarms, attempt recliner in living room-tabs alarm on resident when in recliner, large TV on in living room at night, leave light on in living room at night." Interdisciplinary Notes dated 11/7/12 state, "Time of occurrence: 20:05 (8:05 PM) Date of occurrence: 11/7/12; Shift: evening; Resident aware of incident: yes; Incident type: fall: found on floor; Level of injury: moderate injury; Type of injury: laceration 2 areas to left eyebrow 1 cm long; Description of incident: This nurse was in room (other resident's room) giving resident medications when family member called to me that someone needed help. When I exited room family member stated that she heard the resident fall. I entered room (Resident 6's room) to find resident lying toward left side, but starting to raise self up to sitting position. Noted resident was bleeding from eyebrow and called for nurse manager. Witness: none; Staff/others involved (Registered Nurse (RN) D)(Certified Nursing Assistant (CNA) E); Location: bathroom. Activity at time: toileting; Position found: lying on left side; Mental state/behavior: confused; Preventive devices in use: no one while in bathroom; Vitals: blood pressure 138/64 pulse: 65 respirations 18 temperature 98.3 Neuro Checks: bil (bilateral) hand grasps firm left pupil small nonreactive, right pupil larger that left nonreactive; First Aid: immediately applied pressure to left eyebrow and then ice, then to emergency room ...New intervention initiated: other add to care plan to not leave resident alone in bathroom..." emergency room report dated 11/7/12 states, "Diagnoses: [REDACTED]." Interdisciplinary Notes dated 11/8/12 at 1:08 AM state, "Resident returned to (Facility Name) @ (at) approx (approximately) 0045 (12:45 AM) via ambulance from (Hospital name) ER with seven sutures applied above left eye. Bandage intact..." Interdisciplinary Notes dated 11/8/12 state, "IDT follow-up: IDT met to review incident of 11/7/12 Resident found at 8:05 PM on the floor of the bathroom. Previously resident was seen sitting on the toilet. All interventions remain appropriate and available to staff, interventions were not followed by one individual CNA. The interventions continue to be appropriate. Individual did not follow care plan. All staff are currently receiving re-education regarding fall precautions. Individual CNA personal education and counseling." The facility investigated Resident 6's fall on 11/7/12 and obtained the following staff statements and interviews: Interview- Director of Nursing (DON) B and CNA E: DON B: Explain what happened last night. CNA E: pushed him in his room, (staff member) said something; I put (Resident 6) on the toilet left him and went to see what (staff member) wanted. When I came back a couple of minutes later the nurse said he was on the floor. I am really sorry about that. DON B: Did you put him on the toilet by yourself? CNA E: Yes. DON B: Did you read your care card? CNA E: No, I guess I didn't. I neglected to look at the care card; I thought my experience with him earlier let me know how to care for him. I am really sorry this happened." Interview-DON B and Licensed Practical Nurse (LPN) F: "11/08/12; what did you observe-resident in living rm (room) had to go to BR (bathroom), I got (CNA E) take him to BR after that I went to (another resident room) to admin (administer) some meds, as I was going towards (room number) I passed (family member) in the hall. I had just arrived to (room number) and I heard (family member) calling for help. I finished c (with) (room number) and came out of room at which time (family member) pointed to (Resident 6's room) and stated I heard him fall. I entered the room his w/c was just outside the BR. Resident was half laying/sitting propped up on L (left) arm in front sink in BR, he had obvious BM in toilet and has cleansed himself & pulled pants up. Approx time 10 to 15 min (minutes). When I spoke to (CNA E) I stated you can never leave a pt (patient) c an alarm unattended. (CNA E) stated I didn't know (Resident 6) could not be left alone." The facility re-educated nursing staff related to leaving resident supervision and safety following Resident 6's fall on 11/7/12. Surveyor spoke with DON B on 11/13/12 at 10:30 AM. DON B stated that she expects staff to not leave residents in the bathroom alone if they have alarms and that this now shows up on the care card sheets. Resident 6's "Resident Care Card" dated 11/12/12 states, "Vigil door and bed alarm, chair alarm when not in line of sight...Residents with alarms may NOT be left alone in the bathroom ..." On 11/13/12 at 1:23 PM, Surveyor observed CNA C transfer Resident 6 from a dining room chair to the wheelchair. Surveyor noted that Resident 6's alarm on his wheelchair was not plugged in. CNA C did not ensure that Resident 6's alarm was plugged in after completing the transfer. Resident 6 was pushed into the living room area. Surveyor noted, at 1:30 PM that Resident 6 was left alone in the living room area for two minutes. Staff did not have Resident 6 in line of sight and Resident 6's alarm remained unplugged. Surveyor spoke with CNA C, who was in the dining room clearing tables at 1:37 PM. Surveyor asked CNA C if Resident 6 is to have the alarm on when seated in his wheelchair. CNA C stated that the alarm should have been plugged in and then she just hits the button on the alarm to ensure that it is on. Surveyor and CNA C examined Resident 6's alarm. CNA C plugged in Resident 6's alarm. Surveyor spoke with DON B at approximately 1:50 PM. DON B stated that if Resident 6 is in the dining room then he does not need the alarm if he is in line of sight of staff. Surveyor asked DON B if she would expect staff to check function of an alarm if the resident moved out of line of sight. DON B stated that she would expect staff to check the alarm and that it does not matter if staff is not in the room for only minutes as residents can fall during those minutes.

Based on observation, interview, and record review the facility did not ensure that the facility provided each resident with sufficient fluid intake to maintain proper hydration and health for 1 resident out of 9 reviewed. (Resident 4). The facility stated they would measure I&O (intake and output) and monitor I&O in Resident 4's CAA (care area assessment) dated 1/13/11, however, this was not performed on a regular basis. Resident 4's fluid intake did not meet Resident 4's estimated fluid needs. The physician was not updated on Resident 4 not meeting estimated fluid needs. A care plan was not implemented to identify Resident 4 as at risk for hydration. The Resident was admitted to the hospital with [REDACTED]. This is evidenced by: The facility policy and procedure titled Hydration with date 10/ 0 states but not all inclusive: It is the policy of this facility to provide each resident with sufficient intake to maintain proper hydration. Sufficient fluid means th at amount of fluid needed to prevent dehydration and maintain health status. Resident's intake and output is recorded per physician's orders [REDACTED]. A facility memorandum dated December, 2010 with a subject of Hydration to discuss our new hydration procedure states (but is not all inclusive). 1. Nursing assistants, ensure your residents are consuming the fluids on their tray. If resident consumes 50% or less of the fluid served at meals, notify your nurse after dining is completed. 2. Nurses will notify dietary around ONE PM (24 hour report sheet) and the PM shift will notify dietary by documenting on the 24 hour report sheet between 7-8 PM of any resident that may have a condition that places them at risk for fluid depletion or electrolyte imbalance. Resident 4 was admitted to facility on 1/6/11 with [DIAGNOSES REDACTED]. Resident 4's initial nutrition assessment dated [DATE] states that Resident 4's total fluid needs is 1738 cc. Resident 4 requires assistance for eating, although is able to feed herself some. Her current level of intake at meals is not adequate for needs. Ensure TID (three times a day) has been ordered, if all is consumed of nutrition supplement oral intake should be adequate. Will monitor intake via MAR (medication administration record), to assure adequate intake and request weekly weights x 4 weeks. Resident 4's recorded intakes are as follows: 1/15/11 water 200 cc, brk (breakfast) 240 cc, lunch 0 cc, supper 240 cc. Total 680 cc Resident did not meet required needs and took no fluids for lunch there is no mention in nursing notes stating nursing was updated that resident consumed 50% or less of fluids served. 1/16/11 brk 360 cc, lunch 60 cc, supper 480 cc. Total 900 cc. Again Resident did not meet needs and there is not mention of this in the nursing notes. 1/17/11 brk 360 cc, lunch 620 cc, supper 240 cc, ensure supplement 480 cc. Total 1700. Again Resident did not meet needs. Nurses' notes state: Large emesis at lunch. Resident very thirsty likely filled out with too much water and reason vomited. Vital signs stable. 1/18/11 No record of fluid intakes were provided to Surveyor for this day. Ensure intake 440. Unable to tell if met needs. Nursing notes state Resident more sleepy than usual self. 1/19/11 brk 0 cc, lunch 240 cc, supper 240 cc, ensure intake 720 cc. Total 1200. Again Resident 4 did not meet needs and no mention in nurses' notes about no fluid intake at brk. 1/20/11 no record for brk, lunch 240 cc, supper 240 cc, ensure intake 720 cc. Total 1200 cc. Again did not meet needs. 1/21/11 brk 260 cc, lunch 150 cc, supper 240 cc, ensure 720 cc. Total 1370 cc. Again did not meet needs. Third consecutive day of being 500 cc under assessed needs physician was not updated. 1/22/11 brk and lunch not recorded supper 240 cc and ensure 600 cc. Total 820. 1/23/11 supper only meal recorded 180 cc, ensure intake 460 cc. Nurses' notes Resident 4 had temperature of 100.5. 1/24/11 No records of meal intakes provided to Surveyor . Total ensure intake 190 cc. Although the facility provided more information after the survey to show that the resident's daily fluid intake may have been greater than what was documented, there is no documentation to support the water pass totals or med pass totals that were submitted. Nor is there information in the record to show that staff questioned or acted upon the daily totals that were documented, in accordance with facility policy, to ensure that Resident 4 was adequately hydrated. On 2/24/11 Resident 4's nursing note states, Resident was sent to hospital emergency room related to unresponsive episode at 1:20 PM with labored respirations. Nurse manager called 911. MD (medical doctor) notified, recent lab reports sent along and faxed to MD's office. Temperature 100.2, pulse 136, respirations 48 labored, blood pressure 120/70 oxygen sat on room air 80%. Per the Long Term Care Nursing Desk Reference 2005 signs and symptoms of dehydration that Resident 4 had are: Elevated Temp 100.2 Mental confusion Dry mucous membranes Weakness Increased pulse 136 Abnormal lab values elevated sodium 146 normal 135-144, elevated BUN 68 (baseline 26-30) and elevated creatinine of 1.8 (baseline 0.8) Ratio 37% per MD history and physical this placed Resident 4 in an acute kidney injury. By the time signs and symptoms appear most residents are already dehydrated and aggressive interventions are essential. Per ER (emergency room ) notes dated 1/24/11, chief concern: altered mental status. Resident 4 was found slumped over in her wheelchair and minimally responsive. Labs revealed AKI (acute kidney injury) with a creatinine of 1.8 (baseline is 0.8) and a BUN of 68 (baseline 26-30). Resident 4 was started in normal saline per IV at 250 ml/hr. Pulse 127 [MEDICAL CONDITION] Resident 4 obtunded does not respond to voice or follow commands. Mucous membranes dry. Lab sodium 146 (high) [MEDICAL CONDITION]- suspect poor oral intake treatment IV fluids. Mild hypercalcemia likely due to dehydration treatment IV fluids. Resident 4's chest x-ray appears to show atelectasis rather than pneumonia, so it seems unlikely to be an active infection, but given that she appears dehydrated, a pneumonia could become more apparent after hydration. Resident 4's lactic acidosis is concerning as well. It may be due to hypoperfusion in the setting of dehydration. Per Hospital history and physical dated 1/28/11 Resident 4 was admitted with dehydration and altered mental status. Resident 4 was given IV fluid resuscitation and her creatinine normalized with IV fluid administration. Her mental status began to improve with hydration and correction of her underlying metabolic derangements. Per the Long Term Care Nursing Desk Reference 2009, decreased fluid intake or increases fluid loss can quickly lead to fluid imbalance. Conservatively, the minimum acceptable fluid intake in the elderly should be no less than 1,500 ml - 1,800 ml per day. Less than 1,500 ml is unacceptable for most residents.