Every finding on record at Oak Ridge Care Center

Based on observation, interview, and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 3 of 3 residents (R1, R2, and R3) reviewed for pressure injuries. R1 admitted to the facility without any pressure injuries and was assessed as being at risk for pressure injuries. R1 developed a blister on the left buttock 10 days after admission that was not assessed by a Registered Nurse and the facility failed to revise R1's skin impairment care plan or pressure injury care plan after the area declined. Aggressive interventions including repositioning were not implemented even after R1 refused an air mattress. The wound continued to decline, eventually becoming infected, requiring antibiotics, and requiring surgical debridement. After debridement, the pressure injury was staged at a 4. The facility's failure to provide care to prevent the development of pressure injuries (PIs), failure to complete an RN assessment upon discovery of the PI, implement aggressive interventions, revise the plan of care and promote the healing of pressure injuries created a finding of Immediate Jeopardy (IJ) that began on 8/25/25. Surveyor notified Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, Executive Director (ED)-C, and Assistant Administrator (AA)-O of the immediate jeopardy on 10/21/25 at 12:12 p.m. The immediate jeopardy was removed on 10/21/25, however, the deficient practice continues at a scope and severity of D (potential for harm/isolated) as the facility implements its action plan and due to the following examples: *R2 was observed not being repositioned on 10/16/25 and 10/20/25. On 10/20/25, R2's family member informed Surveyor they visit during the evening shift from approximately 1:00 p.m. to 9:00 p.m. and do not see R2 being repositioned. *R3 was readmitted to the facility on [DATE]. There was not a comprehensive assessment for R3's pressure injury until 9/29/25. On 10/20/25, R3 was observed without heels being offloaded and was not repositioned according to R3's plan of care. Findings include: The facility's policy titled, Wound Management and reviewed 9/2025 under Policy Guidelines documents: (Name of facility) is committed to providing a comprehensive wound management program to promote the resident's highest level of functioning and well-being and to minimize the development of in-house acquired pressure injuries, unless the individual's clinical condition demonstrates they are unavoidable. Any resident with a wound receives treatment and services consistent with the resident's goals of treatment. Typically, the goal is one of promoting healing, prevent development of additional pressure injuries, and preventing the infection unless a resident's preferences and medical condition necessitate palliative care as the primary focus. A commitment to the Wound Management Program is demonstrated by implementation of processes founded on accepted standards of practice, research-driven clinical guidelines, and interdisciplinary involvement. Under section B. admission Wound Assessment and Management documents 2. Wounds are assessed within 8 hours of admission. A. Comprehensive assessment of any wound. This may include: Location of wound. Length, width, and depth measurements recorded in centimeters. Direction and length of tunneling and undermining. Appearance of the wound base. Type and percentage of tissue in wound. Drainage amount and characteristics including color, consistency, and odor. Appearance of wound edges. Description of the peri-wound condition or evaluation of the skin adjacent to the wound. Presence or absence of new epithelium at wound rim. Under section F Documentation and Care Planning 2. The wound management program documentation requirements include: a. Each hall's nurse manager and the Wound Care Nurse will assist in updating the care plan as needed. B. The care plan will be reviewed at the resident's quarterly care plan meeting. c. All care planning will follow the facilities care plan policy (see the care plan policy for a detailed description of care planning at name [name of facility]). 3. Resident risk factors and interventions are documented including but not limited to: a. Impaired mobility. b. Need for pressure relief such as support surfaces, repositioning, pressure relieving devices. c. Nutritional status. d. Incontinence. e. Skin condition. f. Complications such as infection and pain. g. General treatment regimen (delineating specific treatment is not necessary). 1.) R1 admitted to the facility on [DATE] with diagnoses that include right hip fracture, atrial fibrillation (irregular and rapid heart rate), chronic kidney disease (kidneys are damaged and cannot filter blood and waste effectively), morbid obesity, lymphedema (tissue swelling often in an arm or leg), congestive heart failure (heart doesn't pump enough blood to meet the body's needs), diabetes mellitus (high blood sugar), and hypertension (high blood pressure). R1's skin/wound note dated 5/20/25 written by Licensed Practical Nurse/Wound Nurse Manager (LPN/WNM)-G includes R1's right shin, right knee, left breast, right breast, right shoulder, left hand, left forearm, left inner elbow, right forearm, back, right ankle, left leg, left shin, right hand, and right and left heels. There is no documentation regarding R1's buttocks and no documentation of any open areas/pressure injuries. R1's Braden assessment dated [DATE] has a score of 17, which indicates at risk for pressure injury (PI) development. R1's impairment to skin integrity care plan initiated 5/22/25 and revised 7/31/25 documents the following interventions: *Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Initiated 5/22/25. *Encourage good nutrition and hydration in order to promote healthier skin. Initiated 5/22/25. *Follow facility protocols for treatment of injury. Initiated 5/22/25. *Use a draw sheet or lifting sheet to move resident. Initiated 5/22/25. *Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Initiated 5/22/25. *Use alcohol prep pad to help remove therapy tape. Initiated 8/9/25 and resolved 10/1/25. R1's care plan indicates resident has stage 4 pressure injury to the left buttocks initiated 5/22/25 and revised 6/23/25 and documents the following interventions: The resident has an unstageable pressure injury to left buttock r/t (related to) limited mobility initiated 5/22/25 & revised 6/23/25 was revised to The resident has stage 4 pressure injury to left buttock r/t limited mobility initiated 5/22/25 & revised 9/8/25 documents the following interventions: *Follow facility policies/protocols for the prevention/treatment of skin breakdown. Initiated 5/22/25. *Monitor nutritional status. Serve diet as ordered, monitor intake and record. Initiated 5/22/25. *The resident requires the bed as flat as possible to reduce shear. The resident prefers to be repositioned with bariatric slide sheet. Initiated and revised 5/30/25. *Signed risk agreement for no air mattress. Initiated 6/26/25. *Ensure my Roho cushion is in my chair and properly inflated. Initiated 6/27/25. *Encourage resident to off load pressure to buttock, turn from side to side, don't stay up in chair too long. Initiated 7/28/25. *Staff to provide education on offloading and remind resident to turn from side to side when lying in bed. Initiated 8/18/25. *Ensure air mattress is inflated, functioning, and set on proper settings: Proactive proteckt aire 8000 set to 420 pounds, alternating every 10 minutes. Initiated 8/25/25 and revised 8/27/25. *Elevate heels while in bed with pillows. Initiated 10/16/25. *Ensure resident has w/c (wheelchair) cushion. Initiated 10/16/25. *Offer food choices to promote nutrition. Initiated 10/16/25. *RD (registered dietitian) consult, if recommendations are made update MD/NP/POA (medical doctor/nurse practitioner/power of attorney). *Use a draw sheet or lifting device to move resident. Initiated 10/16/25. *Use a minimum of two people assisting plus draw sheet in repositioning/boosting the resident up in bed. Initiated 10/16/25. R1's admission MDS (Minimum Data Set) with an assessment reference date of 5/24/25 has a BIMS (Brief Interview for Mental Status) score of 15 which indicates intact cognition. R1 is assessed as not having any behaviors including refusal of cares. R1 is assessed as requiring set up or clean up assistance for eating, and is dependent for toileting, roll left and right, chair/bed to chair transfer, and toilet transfer. R1 is frequently incontinent of urine and always incontinent of bowel. R1 is assessed for being at risk for pressure injuries and has no pressure injuries. R1's Braden assessment dated [DATE] has a score of 18 which indicates at risk for PI development. R1's pressure injury CAA (Care Area Assessment) dated 5/28/25 was triggered but not completed. Under analysis of findings for nature of problem/condition and care plan considerations, for describe impact of this problem/need on the resident and your rationale for care plan decisions are blank. R1's Braden assessment dated [DATE] has a score of 14 which indicates moderate risk for PI development. R1's nurses note dated 5/30/25, at 1624 (4:24 p.m.), written by LPN-P documents: new skin area on patients left buttock measuring 3 x (times) 3.5 blister caused by friction. Tx (treatment) entered into TAR (treatment administration record) HUCU (HIPPA compliant messaging app) message sent. Patient self-responsible and updated with plan of care. Care plan updated. Surveyor noted LPN-P did not specify details regarding the blister to indicate if it was fluid filled, what type of fluid (clear or blood), etc. Surveyor noted there is no Registered Nurse (RN) or Medical Doctor (MD) comprehensive assessment or evidence an RN reviewed LPN-P's assessment until 6/2/25 when the left buttock's skin impairment declined. R1's progress note dated 5/30/25 written by Dietitian-Q documents RD (registered dietitian) f/u (follow up): intakes continue to be good mostly 75-100% on supplement surgical areas improving weight is stable no recommendations. Wound MD-K's initial wound evaluation dated 6/2/25 under review of system for additional system documents: refused air bed despite education. Wound MD-K documents non-pressure wound of the left buttocks full thickness. Etiology is trauma/injury and further etiology detail is abrasion. Wound size is 4 x 3.5 x 0.1 cm (centimeters). Exudate is moderate serous. Slough is 20% and granulation tissue is 80%. Treatment is alginate calcium followed by gauze island with border dressing daily. The facility did not revise R1's skin impairment care plan or pressure injury care plan after R1's left buttock's skin impairment declined. The facility did not implement any aggressive interventions including repositioning and how often staff should reposition R1 to help heal or prevent the decline of R1's left buttocks skin impairment. Additionally, the facility did not assess to determine how friction to R1's skin was being prevented or if interventions were being appropriately implemented to prevent further decline in skin integrity. R1's Braden assessment dated [DATE] has a score of 17 which indicates R1 is at risk for PI development. Wound MD-K's wound evaluation and management summary dated 6/9/25 under review of system for additional system documents: refused air bed despite education. Wound MD-K documents non-pressure wound of the left buttocks full thickness. Etiology is trauma/injury and further etiology detail is abrasion. Wound size is 4 x 3.5 x 0.1 cm. Exudate is moderate serous. Slough is 20% and granulation tissue is 80%. Wound progress is at goal and Wound MD-K continued the same treatment for R1. The facility still did not revise R1's skin impairment care plan or PI care plan. The facility did not implement any aggressive interventions or assess alternatives beyond an air mattress to include repositioning and how often staff should reposition R1 to help heal or prevent the decline of R1's left buttocks skin impairment. R1's continued risk for friction was not further assessed. Wound MD-K's wound evaluation and management summary dated 6/16/25 under review of system for additional system documents: refused air bed despite education. Wound MD-K documents non-pressure wound of the left buttocks full thickness. Etiology is trauma/injury and further etiology detail is abrasion. Wound size is 4 x 4 x 0.1 cm. Exudate is moderate serous. Slough is 50% and granulation tissue is 50%. Wound progress is not at goal due to increased exudate and Wound MD-K changed R1's treatment to leptospermum honey followed by gauze island border dressing daily. Surveyor noted although R1's left buttocks skin impairment continued to decline the facility still did not revise R1's skin impairment care plan or PI care plan. The facility did not implement any aggressive interventions. The facility was aware R1 declined an air mattress and did not have an intervention to reposition and how often staff should reposition R1 to help heal or prevent the decline of R1's left buttocks skin impairment. R1's continued risk for friction was not further assessed. R1's skin/wound note dated 6/16/25 at 1759 (5:59 p.m.), written by LPN/WNM-G includes documentation of: client now agreeable to air mattress, requested air mattress to be ordered. R1's nurses note dated 6/19/25, at 1810 (6:10 p.m.), written by LPN/WNM-G documents: Client is now refusing to have the air mattress I had one in the past they are just noisy, and I am afraid I won't be able to sleep. Resident would like to try a couple more weeks of no air mattress and will try to offload more often to help improve the wound. Risk and benefits explained to resident. Resident understands the wound could get worse but resident at this time continues to decline the air mattress. Surveyor noted there was no revision made to R1's skin integrity or PI plan of care to address R1 declining continued use of an air mattress and providing interventions to help with R1 offloading and preventing pressure and friction. Wound MD-K's wound evaluation and management summary dated 6/23/25 under review of system for additional system documents: refused air bed despite education. Wound MD-K documents unstageable (due to necrosis) of the left buttocks full thickness. Etiology is pressure (changed from non-pressure) and further etiology detail is abrasion. Wound size is 4 x 4 x 0.1 cm. Exudate is moderate serous. Necrotic tissue is 80% and granulation tissue is 20%. Wound progress is exacerbated due to noncompliant. Wound MD-K changed R1's treatment to Santyl followed by gauze island border dressing daily. R1's nurses note dated 6/23/25, at 1558 (3:58 p.m.), written by LPN/WNM-G documents: Writer and wound care MD in to see resident. Resident wound has deteriorated. Risk and benefits of offloading were explained to resident. MD stated, I want to (sic) to know how serious this can be, if you don't want an air mattress and you don't offload you can get an infection, your wound will get worse could get to the bone and it could lead to death. Resident then stated, Well I wouldn't mind if I died. MD educated resident that death is preventable and offered help with the resident to be able to talk about her feelings. Resident stated, I would be better off dead because everything is so expensive. Writer and MD provided 1 to 1 with resident and before we left the room resident was no longer making statements. Writer updated IPC manager and SS (Social Service) on resident statement. On 6/25/25, R1 signed a Negotiated Risk Agreement which was dated 6/24/25. Under identify the cause for concern documents: Resident has a pressure wound to the buttocks that has shown signs of deterioration. Three weeks ago, an air mattress was recommended to assist with pressure redistribution and promote wound healing. At that time the resident declined the recommendation, stating the mattress was too noisy. The wound was stable initially, but during the following week, deterioration was noted. The air mattress was again suggested as part of the treatment plan. The resident initially agreed but later refused its use, again citing concerns about the noise level. Resident has been reeducated on the importance of pressure relief in wound healing, and the risks of further decline, including infection and delayed healing, have been explained. Alternative pressure relief strategies will continue, and the resident's decision has been documented. Under agreement documents: Resident to continue using standard facility mattress per preference. Pressure offloading strategies remain in place, including regular repositioning, use of pillows or wedges to reduce pressure on bony prominences, and close monitoring of skin integrity. Staff will continue to implement alternative pressure relief methods to support wound healing and prevent further breakdown. Although facility staff were aware R1 was refusing an air mattress on her bed the facility did not revise R1's impairment of skin integrity care plan or pressure injury care plan to include repositioning and how often R1 should be repositioned. R1's care plan was revised on 6/26/25 with signed risk agreement for no air mattress and ensure my Roho cushion is in my chair and properly inflated on 6/27/25. Wound MD-K's wound evaluation and management summary dated 6/30/25 under review of system for additional system documents: refused air bed despite education. Wound MD-K documents unstageable (due to necrosis) of the left buttocks full thickness. Etiology is pressure and further etiology detail is abrasion. Wound size is 4 x 3.5 x 0.1 cm. Exudate is moderate serous. Necrotic tissue is 80% and granulation tissue is 20%. Wound progress is improved evidenced by decreased surface area. Wound MD-K continued R1's same treatment. Wound MD-K's wound evaluation and management summary dated 7/7/25 under review of system for additional system documents: refused air bed despite education. Wound MD-K documents unstageable (due to necrosis) of the left buttocks full thickness. Etiology is pressure and further etiology detail is abrasion. Wound size is 3.5 x 3 x 0.1 cm. Exudate is moderate serous. Necrotic tissue is 80% and granulation tissue is 20%. Wound progress is improved evidenced by decreased surface area. Wound MD-K continued R1's same treatment. Wound MD-K's wound evaluation and management summary dated 7/14/25 under review of system for additional system documents: refused air bed despite education. Wound MD-K documents unstageable (due to necrosis) of the left buttocks full thickness. Etiology is pressure and further etiology detail is abrasion. Wound size is 3.5 x 3 x 0.1 cm. Exudate is moderate serous. Necrotic tissue is 80% and granulation tissue is 20%. Wound progress is at goal. Wound MD-K continued R1's same treatment. Wound MD-K's wound evaluation and management summary dated 7/21/25 is the same as 7/14/25, however, under additional wound detail documents: educated on offloading, non-compliant. Wound MD-K's wound evaluation and management summary dated 7/28/25 is the same as above except for: Necrotic tissue is 100%. Wound progress is exacerbated due to noncompliant with offloading. Wound MD-K changed R1's treatment to Santyl, alginate calcium followed by gauze island with border dressing. Surveyor reviewed R1's medical record including progress notes and Certified Nursing Assistant (CNA) documentation under the task tab for roll left and right (bed mobility). There is no evidence in R1's medical record R1 refused to be repositioned. R1's impaired skin integrity care plan and pressure injury care plan do not address repositioning. There is not a refusal care plan nor are there any interventions addressing R1's refusal to reposition in any of R1's care plans. R1's nutrition note dated 7/29/25 written by Dietitian-Q documents: RD (Registered Dietitian) review r/t (related to) wound; resident with a pressure injury unstageable to her Lt (left) buttock which has shown a decline. Stable wt (weight). Diet is CCD (carbohydrate-controlled diet). Intakes 76-100%, with a few 51-75% over the last month. Glucerna 237 ml (milliliters) once daily after breakfast, 50-100% intakes. Est (estimated) needs: 2781 kcal/day (kilocalorie per day) Adj BW, 111-120gPro/day (grams protein per day) based on 1.2-1.3 gPro/kg Adj BW. Good glycemic control based on BGL (blood glucose level). Recommend increase Glucerna to 237 ml twice daily between meals. Also start Protein liquid 30ml once daily. Gradual wt (weight) loss acceptable to improve BMI. Wound MD-K's wound evaluation and management summary dated 8/4/25 under review of system for additional system documents: refused air bed despite education. Wound MD-K documents unstageable (due to necrosis) of the left buttocks full thickness. Etiology is pressure and further etiology detail is abrasion. Wound size is 3.5 x 2.5 x 0.1 cm. Exudate is moderate serous. Necrotic tissue is 100%. Wound progress is improved evidenced by decreased surface area. Wound MD-K continued R1's same treatment. Wound MD-K's wound evaluation and management summary dated 8/11/25 is the same as 8/4/25 with the exception of wound size. Wound size is 3 x 2 x 1 cm. Wound MD-K's wound evaluation and management summary dated 8/18/25 documents the same as 8/11/25 except for: Wound size is 3 x 3 x 2 cm. Necrotic tissue is 90% and 10% granulation. Wound progress is exacerbated due to noncompliant with offloading despite weekly education, refused air bed again. Wound MD-K changed R1's treatment to 1/2 strength Dakin's, alginate calcium followed by gauze island with border dressing. Surveyor reviewed R1's medical record including progress notes and Certified Nursing Assistant (CNA) documentation under the task tab for roll left and right (bed mobility). There is no evidence in R1's medical record R1 refused to be repositioned. R1's impaired skin integrity care plan, pressure injury care plan, and CNA Kardex does not address repositioning. There is not a refusal care plan nor are there any interventions addressing R1's refusal to reposition in any of R1's care plans. R1's Braden assessment dated [DATE] has a score of 16 which indicates at risk for PI development. R1's skin/wound note dated 8/18/25 at 15:04 (3:04 p.m.), written by LPN/WNM-G documents: [Wound MD-K's name] and writer educated resident on risk and benefits of air mattress, offloading and importance of eating well. Resident continues to refuse air mattress. Risk agreement remains on file. Resident stated she will try to offload more and will focus on consuming protein. R1's quarterly MDS with an assessment reference date of 8/21/25 has a BIMS score of 15 which indicates intact cognition. R1 is assessed as not having any behaviors including refusal of care. R1 is assessed as being independent for eating, partial/moderate assistance for toileting, substantial/maximal assistance for roll left and right, and dependent for chair/bed to chair transfer, and toilet transfer. R1 is frequently incontinent of urine and always incontinent of bowel. R1 is at risk for pressure injury development and has one unstageable pressure injury. R1's nurses note dated 8/22/25 at 10:59 a.m., written by Licensed Practical Nurse/Unit Manager (LPN/UM)-M documents: Resident is her own person and re-signed risk agreement for refusing air mattress at quarterly care conference. Resident was educated on the risk vs benefits of refusing air mattress r/t (related to) wound healing. Wound MD-K's wound evaluation and management summary dated 8/25/25 under review of system for additional system documents: refused air bed despite education. Offloading with education while husband in room. Wound MD-K documents unstageable (due to necrosis) of the left buttocks full thickness. Etiology is pressure and further etiology detail is abrasion. Wound size is 3 x 3 x 5 cm. Exudate is moderate serous. Necrotic tissue is 100%. Wound progress is exacerbated due to noncompliant with offloading despite education. Infection assessment documents one or more sign(s) of clinical infection. Under expanded evaluation performed documents: The progress of this wound and the context surrounding the progress were considered in greater detail today. Patient requiring an increase in the level of care. Cellulitis: doxycycline 100mg (milligram) po (by mouth) bid (twice daily) x 14 days, probiotics 2 tabs daily x 30 days. Wound MD-K changed R1's treatment to 1/2 Dakin's followed by gauze island with border dressing two times daily. Surveyor reviewed R1's medical record including progress notes and Certified Nursing Assistant (CNA) documentation under the task tab for roll left and right (bed mobility). There is no evidence in R1's medical record R1 refused to be repositioned. R1's impaired skin integrity care plan, pressure injury care plan, and CNA Kardex does address repositioning. There is not a refusal care plan nor are there any interventions addressing R1 refusal to reposition in any of R1's care plans. Surveyor also noted despite the documentation of R1 refusing use of an air mattress, there is no indication an alternate support surface was discussed, assessed or offered beyond an air mattress or the facility standard mattress. R1's skin/wound note dated 8/26/25 at 07:20 (7:20 a.m.) written by LPN/WNM-G documents: DX (diagnosis) of cellulitis on [wound company name] note, wound to left buttock is hot, red, increased drainage noted, foul odor. [Wound MD-K's name] ordered wound culture f/b (followed by) ATB (antibiotic) therapy to begin once wound culture was obtained. New orders for ATB placed, CP (care plan) created, TAR (Treatment Administration Record) updated. Client responsible and aware of new orders. Surveyor noted the date of Wound MD-K's note is 8/25/25. Wound MD-K's wound evaluation and management summary dated 9/1/25 under review of system for additional system documents: refused air bed despite education. Offloading with education while husband in room. Wound MD-K documents unstageable (due to necrosis) of the left buttocks full thickness. Etiology is pressure and further etiology detail is abrasion. Wound size is 3 x 3 x 5 cm. Undermining is 6 cm at 2 o'clock. Exudate is moderate serous. Necrotic tissue is 100%. Wound progress is exacerbated due to infection, noncompliant. Infection assessment documents: No sign(s) of infection. Surface culture of unstageable (due to necrosis) of the left buttock demonstrates enterococcus faecalis, MRSA (methicillin-resistant staphylococcus aureus) on 8/26/25. Wound MD-K continued with the same treatment. Under expanded evaluation performed documents: The progress of this wound and the context surrounding the progress were considered in greater detail today. Patient requiring an increase in the level of care. Spoke extensive [sic] with patient and husband on a nonhealing wound, history of noncompliance, and infected wound on oral antibiotics. Family agrees with sending to ER (emergency room) for further evaluation. R1 was hospitalized on [DATE] and returned to the facility on 9/5/25. R1's hospitalist Discharge summary dated [DATE] under discharge diagnoses documents principal problem: Wound of sacral region, initial encounter. admission condition is documented as poor. Discharge condition is documented as stable. Under hospital course for hospital summary documents past medical history of hip fracture with surgery in May 2025 after fall at [Name], diabetes mellitus, chronic kidney disease, obstructive sleep apnea on CPAP (continuous positive airway pressure), atrial fibrillation, morbid obesity, osteoporosis who was admitted for sacral wound infection and developing abscess. She has been mostly bed bound at the facility since her hip surgery. She was started on PO (by mouth) antibiotics in the outpatient setting; however, wound was worsening therefore she was brought here for evaluation. She was admitted and started on IV (intravenous) antibiotics. General surgery was consulted, and she underwent surgical debridement in the OR (operating room) on 9/2. Cultures are positive for staph aureus, likely MRSA (methicillin-resistant staphylococcus aureus). Infectious disease consulted and have recommended Zyvox (an antibiotic) for 7 additional days at discharge. Wound care consulted and she had a wound VAC (vacuum-assisted closure) placed in house which has since been removed with the recommendations being to continue daily wet to moist dressings. She will need to offload for the wound to heal. discharged to SNF (skilled nursing facility). R1 returned to the facility on 9/5/25 with a Stage 4 left buttock pressure injury. R1's skin only evaluation dated 9/5/25 created by LPN-R and revised by Director of Nursing (DON)-B, dated as still in progress, under skin note documents: back of left thigh wound Measurements: length 7cm Width: 3 1/2 cm no tunneling depth: 5 cm. Bruises noted on left arm: L (left) upper 1 inch long, forearm 1 inch long. Bruise on Right hand 2 inches long. Bruise on Right forearm 1 inch long. Under other education notes documents: Resident is aware of turning every 2 hours to stay of [sic] (off) wound site. Wedges in place. Surveyor noted LPN-R documented R1's left buttock as left thigh. This skin only evaluation is not a comprehensive assessment as there is no stage, no description of the wound bed with percentages of the wound bed tissue, no documentation regarding drainage, etc. R1's Braden assessment dated [DATE] has a score of 18 which indicates R1 is at risk for PI development. R1's physician order dated 9/5/25 documents: document on resident's noncompliance with turning and repositioning and if any education was provided. Wound MD-K's wound evaluation and management summary dated 9/8/25 under review of system for additional system documents: refused air bed despite education. Offloading with education while husband in room. Wound MD-K documents Stage 4 pressure wound of the left buttock full thickness. Etiology is pressure and further etiology detail is abrasion. Wound size is 7 x 4 x 5.5 cm, undermining is 1 cm at 2 o'clock, and exudate is moderate serious. Necrotic tissue is 40% and granulation is 60%. Wound progress is exacerbated due to recent return from hospital. Wound MD-K ordered a treatm

Based on interviews and record review, the facility did not have documentation of completion of 12 hours of required in-service training for 5 of 5 Certified Nursing Assistants (CNAs) reviewed potentially affecting all 71 residents in the facility.CNA-W, CNA-X, CNA-Y, CNA-Z, and CNA-AA did not have documentation of completing the 12 hours of required in-service training.Findings include:The Facility assessment dated [DATE], last reviewed 8/6/2025, documents: Staff Training/Education and Competencies .-Required in-service training for nurse aides. In-service training must: Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year.CNA-W was hired on 7/18/2023 so the review of training was 7/18/2024-7/18/2025.CNA-X was hired on 12/26/2022 so the review of training was 12/26/23-12/26/2024.CNA-Y was hired on 5/22/2024 so the review of training was 5/22/2024-5/22/2025.CNA-Z was hired on 7/26/2023 so the review of training was 7/26/2024-7/26/2025.CNA-ZZ was hired on 2/6/2024 so the review of training was 2/6/2024-2/6/2025.On 10/28/2025 at 10:37 AM, Surveyor requested from Executive Director (ED)-C and Director of Nursing (DON)-B employee files for review of training and education for CNA-W, CNA-X, CNA-Y, CNA-Z, and CNA-AA. ED-C shared the request with Assistant Administrator (AA)-O. AA-O asked for clarification of what was requested. Surveyor shared with AA-O, ED-C, and DON-B that CNAs need to have documentation of receiving 12 hours of education annually per their hire date. DON-B stated DON-B would look for that information and provide what DON-B could locate.ED-C provided to Surveyor an undated document with employee names and number of hours of training. The document did not denote what type of education or when the education was provided. Surveyor shared with ED-C the need to see when the education was provided, what education was provided, and the length of the education to show CNA-W, CNA-X, CNA-Y, CNA-Z, and CNA-AA had the required 12 hours yearly of education based on their date of hire. Surveyor shared with ED-C the education was based on the month of hire and was a rolling year depending on that date; an example was given if an employee was hired on 2/1/2023 then the training hours and topics that would be reviewed would be from 2/1/2024 to 2/1/2025 since that would be the most recent year based on the hire date. ED-C acknowledged understanding of what was requested.DON-B provided to Surveyor multiple sign-in sheets attached to in-service trainings. DON-B provided written quizzes completed by CNA-W, CNA-X, CNA-Y, CNA-Z, and CNA-AA. Some of the quizzes were not dated and the CNA that completed a quiz did not consistently sign the in-service sign-in sheet. Surveyor asked DON-B if CNA-W, CNA-X, CNA-Y, CNA-Z, and CNA-AA had documentation of what trainings had been received and when. DON-B stated no, they did not keep individual records. Surveyor asked DON-B how DON-B knew if each employee had the training that was required annually. DON-B stated DON-B would have to look at each in-service sign-in sheet to see if the employee had attended.On 10/28/2025 at 3:30 PM, Surveyor shared with ED-C, DON-B and AA-O the concern CNA-W, CNA-X, CNA-Y, CNA-Z, and CNA-AA did not have the documentation of completing required training in the timeframe based on the hire date of the employee. DON-B agreed there was not a system in place to monitor the training completed or required for employees.On 10/29/2025 at 12:04 PM via email, ED-C provided a spreadsheet with staff education topics, dates provided, and hours per topic. The spreadsheet had an initial date of 10/9/2024 and a final date of 10/10/2025. The spreadsheet did not incorporate the rolling 12 months from the CNA dates of hire to show training was completed during the individual timeframes.

Based on observation and interview, the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 1 (R3) of 3 residents.*During wound care, hand hygiene was not performed prior to placing a clean dressing on R3's stage 4 sacral pressure wound.Findings include:The facility policy titled Wound Management with effective date 10/2020 and reviewed date 9/2025 documents: . committed to providing a comprehensive wound management program to promote the resident's highest level of functioning and well-being and to minimize the development of in-house acquired pressure injuries, unless the individual's clinical condition demonstrates they are unavoidable. Any resident with a wound receives treatment and services consistent with the resident's goals and treatment. A commitment to the Wound Management Program is demonstrated by implementation of processes founded on accepted standards of practice, research-driven clinical guidelines, and interdisciplinary involvement. Wound care/dressings:-general infection control practices are maintained during wound care and dressing changes.The facility policy titled Wound Dressing Change with effective date 4/19/19 and reviewed date 9/2024 documents: The purpose of this procedure is to provide guidelines for the approved method of removing, cleaning, and applying wound dressings . Procedure: -gather all necessary supplies.-perform hand hygiene and put on personal protective equipment (PPE), if indicated.-place a waste receptacle or bag at a convenient location for use during the procedure.-put on clean, disposable gloves and loosen tape on old dressings.-carefully remove the soiled dressings.-place soiled dressings in the appropriate waste receptacle.-remove gloves and dispose of them in an appropriate waste receptacle.-perform hand hygiene.-open supplies needed to re-dress the wound.-put on gloves.-clean the wound.-pat the wound dry if ordered. Apply ointment or perform other treatments as ordered.-apply ordered dressing over the wound.-remove and discard gloves.The Centers for Disease Control guideline titled Clinical Safety: Hand Hygiene for Healthcare Workers dated 2/27/24, documents hand hygiene should be performed . immediately before touching a patient . before moving from work on a soiled body site to a clean body site on the same patient . after contact with blood, body fluids, or contaminated surfaces . immediately after glove removal. The guideline documents gloves should be changed and hands cleaned if gloves become soiled with blood or body fluids after a task . if moving from work on a soiled body site to a clean body site on the same patient.R3 admitted to the facility on [DATE] with diagnoses including pressure ulcer of sacral region (lower back), stage 4, osteomyelitis (infection of the bone), anxiety, Type 2 Diabetes Mellitus, depression, pressure ulcer of left lower back, stage 3, and pressure ulcer of right heel, unstageable. R3's Significant Change Minimum Data Set (MDS) dated [DATE] documents R3 has a pressure ulcer, is at risk of developing a pressure ulcer, and has one stage 4 pressure ulcer which was present upon admission. R3's physician order dated 9/29/25 for wound treatment to the sacrum documents: Clean wound with wound cleanser or normal saline, pat dry, apply calcium alginate to wound bed, followed by bordered island dressing . every day shift.On 10/16/25, at 10:57 AM, a Surveyor observed wound treatment performed by Registered Nurse (RN)-F for R3's stage 4 sacral pressure wound. A Surveyor observed RN-F wash hands and don PPE prior to beginning wound treatment. At 11:01 AM, A Surveyor observed RN-F remove R3's old dressing on R3's sacrum, remove gloves, wash hands, and don new gloves. At 11:10 AM, a Surveyor observed RN-F cleanse sacral wound with wound cleanser, dab the wound with gauze, remove the gauze, apply calcium alginate, then cover the wound with a border dressing. A Surveyor noted RN-F did not change gloves or perform hand hygiene prior to applying a new border dressing after coming in contact with the wound when applying wound cleanser and calcium alginate. On 10/20/25, at 3:00 PM, Surveyor shared concern with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Executive Director (ED)-C that proper hand hygiene was not observed during R3's wound treatment. No further information was provided. On 10/21/25, at 9:28 AM, Surveyor interviewed Licensed Practical Nurse Wound Nurse Manager-G who stated when performing wound treatments, staff would be expected to perform hand hygiene before starting treatment, anytime after coming in contact with dirty dressings, and when completing wound care. On 10/21/25, at 9:47 AM, NHA-A and DON-B stated education has been provided regarding proper hand hygiene during wound dressing changes. No additional information was provided.

Based on observation, interview, and record review, the facility did not ensure the environment remained free of accident hazards and residents received adequate supervision to prevent accidents for 3 (R34, R29, and R50) of 5 residents reviewed for accidents. *R34 was given a handled cup of hot chocolate with the handle placed towards the right hand. R34 had limited movement of the right hand and, while transferring the cup from the right hand to the left hand, the scalding liquid spilled onto R34's left side/hip/buttock area causing a third degree burn that measured 34 cm x 30 cm. The facility staff did not place the cup in a safe manner for R34 to manage the cup independently and the water was at a temperature hot enough to cause a third degree burn. The facility did not investigate or monitor the temperature of the water used when making the hot chocolate to prevent other residents from potentially being burned if a spill occurred. *R29 had a fall on 2/17/2025 when being transferred. R29 was not being transferred per care plan. *R50 had a fall on 3/8/2025 that was not thoroughly investigated to determine a root cause and implement appropriate interventions to prevent future falls. Findings include: *R34 was admitted to the facility on [DATE] with diagnoses of cervical disc disorder with myelopathy (the spinal cord is compressed in the neck region that causes pain, loss of sensation, and problems with movement or fine motor skills), paraplegia (the inability to move the lower extremities), and dementia. R34's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R34 had mild cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 9 and had an active diagnosis of paraplegia. R34's Care Plan documented R34 could not complete cares independently and needed the assist of one staff to provide setup or clean-up with eating. R34 used a soft touch call light and needed adaptive equipment for eating. Surveyor noted R34's Care Plan did not address R34's limited movement of the right hand/arm and the need to have items placed for R34 to use the left hand. The State Operations Manual has the following chart: Time and Temperature Relationship to Serious Burns that shows the water temperature and the time required for a third degree burn to occur: 155 degrees F - 1 second 148 degrees F - 2 seconds 140 degrees F - 5 seconds 133 degrees F - 15 seconds 127 degrees F - 1 minute 124 degrees F - 3 minutes 120 degrees F - 5 minutes 100 degrees F - safe temperatures for bathing Note: burns can occur even at water temperatures below those identified in the table, depending on an individual's condition and the length of exposure. On 12/17/2024 at 11:25 PM in the progress notes, Licensed Practical Nurse (LPN)-H documented R34 spilled hot chocolate and has a reddened area on the left hip/side/buttock with a couple scattered blisters. LPN-H documented the Physician Assistant was contacted. LPN-H applied SSD (Silver Sulfadiazine) cream (a cream that is used to treat and prevent infection in second and third degree burns) to the affected area that measured 35 cm (centimeters) x 22 cm. On 12/18/2024 at 4:19 PM in the progress notes, Director of Nursing (DON)-B documented an assessment of R34's burn to the left posterior back. The burn was a partial thickness (second degree burn) reddened area measuring 34 cm x 30 cm with blistering in some places. The etiology of the wound was dropping hot chocolate onto the skin. DON-B documented R34's burn would be assessed by the wound physician. On 12/23/2024, R34 was seen by the wound physician for an initial assessment. The wound physician documented the full thickness (third degree) burn measured 30 cm x 28 cm x 0.1 cm with 70% thick adherent devitalized necrotic tissue, 20% dermis, and 10% intact skin. The wound physician surgically debrided the area to a depth of 0.2 cm and as a result of the procedure, the nonviable tissue in the wound bed decreased from 70% to 50%. The wound physician continued to assess and treat the burn on a weekly basis. The most recent assessment was on 5/5/2025; the wound physician documented the full thickness burn measured 17 cm x 2 cm x 0.1 cm with 50% granulation and 50% intact skin. The facility initiated an investigation on 12/18/2024 into R34's burn on 12/17/2024 and provided a recap of the investigation to Surveyor. R34 had been placed on the UTI (urinary tract infection) tracker due to R34's family member noticing R34 was more confused than normal with burning with urination and lower abdominal pain. The facility interviewed staff that were involved in R34's care on the second shift of 12/17/2024. Through those interviews it was discovered R34 had requested hot chocolate from the second shift staff and when R34's dinner tray was being removed from R34's room, the hot chocolate was found spilled on R34. R34 had a black mug at that time from the dinner tray. R34 has left hand contractures that needed adaptive equipment for silverware from a previous Occupational Therapy (OT) evaluation. R34 was interviewed and was able to tell what happened with the hot chocolate and how R34 dropped it when trying to move the cup from one hand to the other. R34 stated R34 had never spilled drinks before this incident nor had an issue with drinking independently. The Nurse Practitioner was consulted and agreed to have R34 evaluated by OT for different adaptive equipment. The Ad Hoc QAPI (Quality Assurance and Performance Improvement) team met on 12/18/2024 to discuss the isolated incident that occurred with R34. The discussion included R34 had been displaying symptoms of altered mental status based off R34's family member's observation, R34 could normally eat independently, and the OT screen that was ordered to determine different adaptive equipment. OT completed a screen and recommended Kennedy cups based off contractures and upper extremity movements. A Kennedy cup is a lightweight drinking cup with a spillproof lid designed for ease of use and accessibility for individuals that have difficulty gripping or manipulating standard cups. Kennedy cups were added to R34's meal ticket for communication between dietary staff and nursing. Surveyor noted the facility did not investigate the temperature of the hot chocolate that was served or address the placement of the cup handle so R34 could pick up the cup with the left hand and not have to pass the cup from the right to the left hand. R34's Significant Change MDS assessment dated [DATE] documented R34 was cognitively intact with a BIMS score of 14 and had impairment to one arm and both legs. Surveyor noted R34 had fluctuations in cognition with improvement from R34's Quarterly MDS assessment dated [DATE] with a BIMS score of 9. On 5/5/2025 at 9:27 AM, Surveyor asked R34 if R34 had any pain. R34 stated R34 had boiling hot chocolate spilled on R34's back that was still causing R34 pain. Surveyor asked R34 when did the spill happen and how did it happen. R34 stated the spill occurred maybe in November 2024 or sometime close to that. R34 stated R34 was switching the cup from one hand to the other when the hot cocoa spilled. R34 denied anyone else was present when the spill occurred. Surveyor noted R34's hands to be malformed and contracted. R34 showed Surveyor how the right hand cannot grasp while the left hand had slightly more mobility. R34 stated R34 can only use the left hand to pick things up or grasp them. On 5/7/2025 at 7:50 AM, Surveyor talked with R34 again to get a clearer picture of what happened on 12/17/2024 when the hot cocoa was spilled and R34 was burned. R34 stated R34 had to ask for the hot chocolate when the dinner tray was brought to R34's room. R34 stated R34 always eats in bed. R34 stated the aide put the cup down with the handle facing the right hand and R34 needed it facing the left hand, so R34 picked up the cup with the right hand and while switching it to the left hand, the hot chocolate spilled all over the left side of R34's body. R34 stated R34 yelled out and staff came fairly quickly. R34 denied pushing the call light because they heard R34 yelling. R34 stated the staff changed R34's clothes and bedding but could not recall if a cream was applied to the burned area. R34 stated R34 overheard staff questioning the person who brought in the hot cocoa, Why did you get it from there? R34 thought they got the hot chocolate from the boiler or something; it was very hot. R34 stated since then, the staff give R34 a Kennedy cup, and it does not spill. On 5/7/2025 at 8:39 AM, Surveyor went to the kitchen and requested a cup of hot chocolate. Food Service Manager (FSM)-J dispensed hot water from a coffee/hot water machine in the kitchen. The machine has three spigots. The spigots on the left and right dispense hot coffee and hot decaffeinated coffee. The middle spigot dispenses hot water. FSM-J took a surface temperature of the hot water after it was dispensed from the machine. The surface temperature ranged from 145-150 degrees F. FSM-J thought the water was 195 degrees F when it comes out of the machine, but did not know for sure because there was no gauge indicating the water temperature. Surveyor asked FSM-J who has access to the kitchen and the hot water dispenser. FSM-J stated the kitchen is always open and staff has access at any time. The hot chocolate was brought to the conference room and the temperature of the hot chocolate was 149 degrees. On 5/7/2025 at 8:49 AM, Surveyor observed R34 in bed, finishing eating breakfast. R34 had built up eating utensils and two Kennedy cups with beverages in them on the tray. The Kennedy cup had one handle and a tight fitting lid with a straw coming out of the center. Surveyor asked R34 if R34 had anything hot to drink in the Kennedy cup. R34 stated R34 did not have any hot drinks that day, but when R34 does have a hot drink, the staff uses the Kennedy cup. Surveyor stated to R34 that Surveyor would have thought the straw would melt if used with a hot beverage. R34 stated surprisingly the straw does not melt, because R34 thought the same, that it would melt. In an interview on 5/7/2025 at 9:52 AM, Surveyor asked Certified Nursing Assistant (CNA)-L where CNA-L would get hot chocolate for a resident if a resident made such a request. CNA-L stated CNA-L would go to the kitchen and ring the doorbell at the kitchen door. CNA-L stated the kitchen staff makes the hot chocolate and gives it to CNA-L to bring to the resident. In an interview on 5/7/2025 at 9:59 AM, Surveyor asked CNA-M where CNA-M would get hot chocolate for a resident if a resident requested hot chocolate. CNA-M stated the kitchen has the hot water and then CNA-M mixes the hot chocolate into the cup. Surveyor asked CNA-M if CNA-M ever tests the temperature of the hot beverage. CNA-M stated CNA-M feels the warmth of the cup and sometimes it is steaming so CNA-M warns the resident that it is hot. CNA-M stated sometimes CNA-M takes a straw and gets a little on CNA-M's wrist, but usually it is not scalding. In an interview on 5/7/2025 at 10:09 AM, LPN-I stated LPN-I was told it was a freak accident that R34 spilled hot chocolate on themselves. LPN-I stated LPN-I got the wound physician involved. Surveyor observed the burn to R34 at that time and the wound extended from the left iliac crest down to the left outer hip. The burn was consistent with hot liquid spilling and pooling on the left side while R34 was in bed. On 5/7/2025 at 10:28 AM, Surveyor attempted to call LPN-H. LPN-H was the nurse on duty at the time R34 sustained the third degree burn to the left side. A message was left to return the call. No return call was received. In an interview on 5/7/2025 at 10:42 AM, Surveyor asked DON-B to describe the events of 12/17/2024 regarding R34 sustaining a third degree burn from hot chocolate. DON-B stated DON-B was informed by the nurse the next day that at dinner time, R34 had asked for hot chocolate. DON-B stated the CNA went to the kitchen to get hot chocolate during the meal service. The CNA was given a black mug with the hot chocolate in it and the CNA gave it to R34. R34 switched the mug from hand to hand and spilled the hot chocolate. DON-B stated after dinner when the staff was collecting dinner trays, they found the hot chocolate had spilled onto R34 and found R34 had been burned. DON-B stated the Nurse Practitioner and family member were notified of the burn. Surveyor asked DON-B if R34 had been sent to the emergency room for evaluation and treatment. DON-B stated no, R34 was not sent out at all. Surveyor asked DON-B what the process was for residents who request hot chocolate. DON-B stated during dinner time, staff cannot go into the kitchen; they are given the hot water, and the CNA mixes the drink in the dining area. Surveyor asked DON-B if, during their investigation, they found out how hot the water was that was used to make the hot chocolate. DON-B stated no, DON-B did not know how hot the water was. DON-B stated they have not had any other complaints or burns from the water being too hot. DON-B stated since March 1, 2025, when they started using a different computer charting system, they now do a hot liquid beverage assessment on admission and quarterly. Surveyor asked DON-B if anyone since the incident in December 2024 has tested the temperature of the hot water. DON-B stated no one has tested the temperature of the hot water that DON-B was aware of. Surveyor shared with DON-B that Surveyor had tested the temperature of hot chocolate that was made that morning by FSM-J and the temperature was 145-150 degrees surface temperature. Surveyor asked to speak to the CNAs that were working on R34's unit when the incident happened. DON-B stated the CNA that delivered the hot chocolate is no longer employed at the facility, but CNA-K would be in for the second shift that day and DON-B would have CNA-K talk to Surveyor. On 5/7/2025 at 11:16 AM, Surveyor went to the kitchen to test the water temperature from the hot water dispenser with an immersion thermometer, rather than the surface temperature thermometer that was used earlier. FSM-J greeted Surveyor in the kitchen and stated someone had been in the kitchen earlier to get the phone number off of the hot water machine to have it serviced because the facility does not own the machine and therefore cannot change the settings. Surveyor requested FSM-J make a cup of hot chocolate and we would get temperatures throughout the process to determine what the temperature of the hot chocolate could have been at the time R34 spilled the hot chocolate. FSM-J dispensed the hot water into a plastic mug. The water was steaming as it was coming out of the dispenser. FSM-J measured the temperature of the hot water right after it was dispensed from the machine into a plastic mug with an immersion thermometer. The water was 170 degrees F. FSM-J mixed the hot chocolate packet into the hot water and put a plastic lid on it. We walked down to R34's room, took off the lid, and FSM-J measured the hot chocolate temperature. The beverage measured 160 degrees F. FSM-J put the lid back on the mug and we walked back to the kitchen. We waited five minutes and had FSM-J measure the temperature of beverage. When FSM-J removed the lid, the beverage was still steaming. FSM-J measured the temperature, and the beverage was 150 degrees F. On 5/7/2025 at 11:35 AM, Nursing Home Administrator (NHA)-A stated NHA-A called the company that services the coffee/hot water dispenser to turn down the temperature of the machine. NHA-A stated for lunch, the kitchen staff will be temping the hot beverages and adding ice to the hot beverages. NHA in training-C stated maintenance was done about a year ago on that machine where they had to turn up the temperature because it was not warm enough. In an interview on 5/7/2025 at 2:32 PM, CNA-K stated another CNA had given R34 hot chocolate that caused R34 to get burned. CNA-K stated after all the dinner trays had been collected that day, R34 complained that R34's side hurt. CNA-K stated CNA-K was not involved with caring for R34 that day but had thought the CNA heated up a cup of hot chocolate in one of the microwaves in the kitchen. CNA-K did not have any other information about the incident. Surveyor noted this was the only report of the use of microwave to heat up the hot chocolate. On 5/7/2025 at 4:00 PM, Surveyor shared with NHA-A, DON-B, and NHA in training-C the concern R34 did not have in the Care Plan to place items to the left because of R34's inability to use the right hand and the Care Plan was not revised after the incident to address this. R34 was served hot chocolate on 12/17/2024 and staff did not turn the handle towards the left hand causing R34 to have to use the right hand get the cup into the left hand. R34 spilled scalding liquid onto the left side while trying to transfer the cup from one hand to the other causing a third degree burn that to the left side. Surveyor shared the concern the facility did not do any investigation into the temperature of the water that was dispensed by the machine in the kitchen and the staff continued to use the hot water without any regulating or monitoring of the temperature of water until Surveyor brought it to the facility's attention during survey, potentially causing harm to any other resident that accidentally spills a hot beverage. 47094 2) R50 was admitted to the facility on [DATE] and has diagnoses that include moderate protein-calorie malnutrition, moderate dementia with other behavioral disturbance, peripheral vascular disease, mood affective disorder, macular degeneration, muscle weakness, and rhabdomyolysis. R50's quarterly minimum data set (MDS) dated [DATE] indicated R50 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 4 and the facility assessed R50 needing maximal assist with one staff member for repositioning, and total assist with one staff member for toileting hygiene, upper and lower body dressing. R50 transferred with assist of two staff and a gait belt to move between surfaces. R50 is incontinent of bowel and bladder and wears adult briefs for protection. R50's care plan documents risk for injury, have the potential to fall down and hurt self -care plan initiated on 2/5/2025 with the following interventions: I (R50) need my nurses to: - Request a therapy screen if needed and collaborate with therapy. - Remind to ask for help. - Anticipate fall times. - Ensure proper positioning. I (R50) need my aides to: - Remind to ask for help. - Soft touch call light within reach. - Offer to get up between 0600 - 0745 (600 AM-7:45 AM) . - Ensure grippy socks are on when in bed. - Place fall mat on floor next to bed. - Offer to toilet between 2030 - 2230 (8:30 PM - 10:30 PM), then offer assistance to bed. - Ensure grippy socks or shoes are on at all times . - Soft touch call light within reach. On 3/10/2025, at 11:00 AM, in the progress notes nursing documented medical doctor (MD) and physician assistant (PA) updated on R50's fall with no injury on 3/8/2025, no new orders. Surveyor noted there was no documentation in R50's progress notes on 3/8/2025 regarding R50 falling. Surveyor requested the fall investigation for R50's fall on 3/8/2025. Surveyor reviewed the facility's fall investigation completed on 5/8/2025 at 20:58 (8:58 PM) which documented R50 was found sitting on the fall mat next to R50's bed with an aide by R50's side when nursing entered R50's bedroom. R50 was unable to describe what happened. Surveyor noted no staff statements were documented. There is no documentation as to when staff last observed or assisted R50 to the bathroom or what R50 was doing prior to R50's fall. An interdisciplinary team (IDT) note dated 3/10/2025 documents root cause analysis determined by IDT team using fall report and staff statements. R50 was lying in bed and then observed sitting on fall mat next to bed. R50 denies hitting head and no injuries noted at time of fall. Intervention: bolster cover over mattress to define edge of bed for resident. On 5/7/2025, at 9:37 AM, Surveyor asked Director of Nursing (DON)-B if all the information from R50's fall on 3/8/2025 was provided. DON-B stated all the information was provided. Surveyor asked what expectations were of staff if a resident fell . DON-B stated staff should assess the resident, complete a fall report, fall assessments, initiate neurological check if unwitnessed, update administration, medical providers, and emergency contacts, put on 24 hour board for monitoring. Surveyor shared the concern there was no documentation in R50's medical record regarding R50's fall, no indication if medical providers were notified, and no staff statements indicating when R50 was last observed or toileted or what R50 was doing prior to R50 falling on 3/8/2025. DON-B stated medical providers, emergency contacts, and administration was contacted but noted it was not documented in progress notes or the fall investigation so when the IDT reviewed the fall on 3/10/2025, a progress noted was documented. DON-B understood concern there was not documentation or staff statements indicating when R50 was last observed, checked on, or toileted or what R50 was doing prior to R50's fall on 3/8/2025 to indicate if R50's fall could have been prevented. 49435 3) R29 requires extensive assistance by 2 staff using a gait belt and non-mechanical transfer device to move between surfaces. On 2/17/25, 2 staff members were transferring R29 and did not use the non-mechanical transfer device correctly. R29 fell . The facility did not thoroughly investigate the fall to identify an accurate root cause for R29's fall. The facility implemented a new fall intervention of educating staff on correct use of the transfer device. The facility did not educate all staff members involved in R29's fall. The facility policy revised 5/2024, titled Fall prevention and Management Program, documents, in part: . The goal of this program is to enhance each resident's mobility and encourage independence by removing the risk of falls where possible and reducing both the incidence of falls and the injuries that may occur. It is the policy of this facility to provide the highest quality care in the safest environment for the residents residing in the facility. The program identifies the factors that place residents at risk for falls, promotes proactive healthcare practices for resident care planning using the least restrictive method possible to keep the resident safe and identifies the main components of an effective fall prevention program. These components include fall risk assessment, identifying risk factors, implementing interventions, documentation, evaluation, regular reassessment and re-evaluation . The Fall prevention and management program identifies staff participation and accountability to include . Expectation of all caregivers to observe resident transfer status, environmental hazards, and any other factor that may lead to falls during the daily provision of the resident's personal care . Post fall assessment: .Transfer resident per safe patient handling policy. Utilize lift unless the resident is able to rise independently . A comprehensive Post fall Nursing Report must be completed in [name of electronic medical record] . Care plans must be reviewed and revised at the time of the fall. A new intervention must be added to prevent further falls The [Interdisciplinary Team (IDT)] will complete a post-fall evaluation as soon as possible to assure that appropriate measures are in place in order to prevent falls. The post-fall evaluation should include factors specific to the resident. General factors affecting the resident's falls will be considered . The facility policy reviewed/updated 2/2024, titled Safe Patient Handling, documents, in part: . Goals: Reduce the injury potential for both the resident and caregiver . Ensure staff competency in the safe use of transfer and mobility-related equipment. Outline roles and responsibility of staff members. New resident's transfer status will be determined by therapy. Stand Aid with gait belt- A stand Aid may be used with one or two caregivers as care planned. The resident must be able to bear weight and pull themselves into a standing position. Resident must be able to hold on with at least one hand during the entire transfer. Each caregiver participating in a transfer will be required to abide by this policy. It is the responsible of all nurses and management to ensure this policy is followed. Non-compliance with the policy will result in disciplinary action (this includes employment termination) and retraining. Training specific to the safe patient handling policy and all equipment will be provided before employee uses any equipment to transfer resident. All caregivers will receive training on all transfer status and use of mechanical lifts . It is required that the safe patient handling policy will be followed at all times. If this policy is not followed, disciplinary action, including termination of employment, will be taken. The undated manufacturer's operation manual for [name brand] non-mechanical stand assist device documents, in part: . The [name brand] stand assist is a manual standing aid that requires patients to assist themselves in preparation for transport. Functionally, the Stand Assist is positioned between a traditional walker and a battery powered sit-to-stand lift. The Stand Assist is a convenient toileting alternative to a wheelchair. Once the resident has positioned themselves on board, the split seat can be positioned to allow the resident to sit comfortably while a caregiver performs the transport. The [name brand] Stand Assist's intended use is as a transport assistance unit. R29 was admitted to the facility on [DATE] with diagnosis that includes acquired absence of right leg below knee, Type 2 Diabetes with foot ulcer and chronic peripheral venous insufficiency. R29's Admission Minimum Data Set assessment dated [DATE] documents R29 is cognitively intact. R29 has a lower extremity impairment on one side. R29 requires substantial/maximal assistance for toileting hygiene, shower/bathing, and dressing. R29 is dependent in the ability to come to a standing position from a sitting position. R29 is dependent for transfers. R29 is frequently incontinent of bladder and always incontinent of bowel. R29 has not had a fall in the last 6 months prior to admission. R29's fall risk assessment completed on 12/10/24 documents a score of 17 which indicates R29 is at risk for falls. R29's potential to fall care plan dated 12/10/24, documents the following pertinent interventions: remind me to ask for help, frequently check on me, assist me with transfers, remind me to get up and move slowly, encourage me to use assistance. My goal is to stay safe while I'm moving about to avoid injury. R29's Certified Nursing Assistant (CNA) Kardex documents: The resident requires extensive assistance by 2 staff using a gait belt and [non-mechanical transfer device] to move between surfaces as necessary. Keep a Hoyer sling in resident chair in case resident refuses [non-mechanical transfer device] transfer. R29's fall report dated 2/17/25, at 3:01 PM, documents, in part: Date of fall: 2/17/25. Time of fall: 1:15 PM. Location of Fall: Resident's Room . While transferring resident from bathroom to wheelchair via [non-mechanical transfer device], resident's legs gave out causing resident to be assisted to the floor. No injury noted. Mobility status: Resident is an assist of two via [non-mechanical transfer device], non-ambulatory. What was the resident wearing? Personal well-fitting clothes, prosthesis to right lower extremity. Gait belt used? N/A. Lift used correctly: Yes . Care plan followed: Yes . Intervention: Therapy to re-assess transfer status, using Hoyer for safety at this time. Surveyor noted R29's fall report documents the fall occurred because R29's legs gave out. The fall report does not document that a gait belt was used according to R29's care plan. The fall report documents the lift was used correctly. R29's post-fall evaluation note dated 2/18/25, at 10:00 AM, documents, in part: Location of fall: Resident's room/bathroom . Equipment issues: none noted . Contributing factors: none identified . Appliance used correctly: Yes . Cause: Became weak during transfer with staff using [non-mechanical transfer device] . Root cause analysis determined by IDT team using fall report and staff statements. Resident being transferred with staff from [non-mechanical transfer device] to wheelchair when resident became weak/legs gave out and resident was lowered to the floor by staff. No injury noted at time of fall. New intervention: Floor nurse intervention discontinued. New intervention: staff education on correct use of [non-mechanical transfer device] and therapy to work with resident on [non-mechanical transfer device] transfers. Surveyor noted R29's post-fall evaluation documented there were no contributing factors, the appliance was used correctly and there were not any equipment issues. This contradicts the new intervention of staff education on correct use of transfer device. Surveyor noted the root cause analysis identifies R29 became weak but does not identify or document what staff did incorrectly with the transfer device and why staff needed education. Surveyor noted staff statements were not included in the post-fall evaluation. R29's potential to fall care plan dated 2/17/24 documents, in part: I have fallen .I need my nurses to have therapy re-assess transfer status, use Hoyer for safety at this time. On 3/3/25, at 9:40 AM, Surveyor interviewed R29 about the fall. R29 stated R29 fell while 2 staff members were transferring R29 from the toilet to R29's wheelchair. R29 was on the transfer device when a staff member was pushing the device to get over the thresh hold bump from the bathroom to the resident's room where R29's wheelchair was located. R29 stated both seats of the transfer device were not down as they should have been. R29 stated R29 was not wearing a gait belt. R29 stated the staff member pushing the transfer device could not get the transfer device over the little bump. R29 stated the staff member pushed hard to get over the bump. That is when R29's leg gave out and R29 fell off the device on the side the seat was not down. Surveyor noted R29 is cognitively intact and R29's account of the fall was not included in the facilities fall report or post fall evaluation. Surveyor noted R29 indicated the non-mechanical transfer device was not used correctly and noted R29 was not wearing a gait belt as care planned. On 5/6/25, at 12:56 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-D, who was the nurse assisting R29 with the transfer on 2/17/25. LPN-D stated LPN-D and a Certified Nursing Assistant (CNA) were helping R29 from the bathroom to the wheelchair located right outside of the bathroom when R29 lost R29's balance and fell . LPN-D stated LPN-D was at the lift and the CNA was getting the wheelchair to put it in the correct position. LPN-D stated LPN-D did not remember which CNA was helping. LPN-D indicated the seats of the non-mechanical transfer device were being lifted while the wheelchair was being placed. That is when R29 lost balance and LPN-D, and the CNA assisted R29 to the floor. Surveyor asked if any education was completed after this incident. LPN-D stated LPN-D did not recall any education provided after this incident. On 5/6/25, at 1:18 PM, Surveyor interviewed CNA-F, who was the other staff member helping LPN-D transfer R29 on 2/17/25. CNA-F indicated CNA-F and LPN-D were moving the non-mechanical transfer device from the bathroom to right outside of the bathroom where R29's wheelchair was located. CNA-F stated as they were turning the device to position it in front of the wheelchair, R29 let go of the device and both staff members

Based on interview and record review the facility did not ensure 3 (R51, R8, R63) of 15 residents care plans were revised. * R51's behaviors care plan was not patient centered or specific to R51's behavior concerns/needs. * R8's care plan was not revised to monitor for emotional well-being after R8 was involved in a resident to resident altercation on 4/2/2025. * R63's care plan documented R63 was in contact isolation related to an UTI (urinary tract infection). R63 was to be on contact isolation for Clostridium difficile (C-Diff, bacteria in the colon) not an UTI. Findings include: The facility policy titled Care Plan Changes and Updates reviewed 9/2024 documents: It is the policy of [Facility name] to make necessary changes and updates to resident plans of care when needed as soon as possible. The facility also strives to effectively and efficiently communicate care plan changes and updates between staff. Procedure: 1. Anytime a care plan change is need [sic], the nurse will make the appropriate change in the electronic health record. Overall, the care plan is to be a person - centered approach to provide the necessary care and services in order to ensure the resident attains or maintains the highest practicable physical, mental, and psychosocial well-being in a manner that is consistent with the resident's needs and choices. It should be directed towards assisting the resident in maintain and/or achieving independent functioning, dignity, and well-being to the extent possible in accordance with the resident's own needs and preferences. Procedure: Goals of Care Planning: . 5. Ensure all staff members are well informed of the resident's plan of care and facilitate communication of care expectations to direct care staff. 6. Ensure that the resident is reassessed to continually deliver high quality care. Overview of Key Factors: . 1. The process should be constructive and focused on the development of the individual. 2. It should be person centered and contribute to the enhancement of the individual's quality of life. 1) R51 was admitted to the facility on [DATE] and has diagnoses that include Schizophrenia, Persistent mood disorder, anxiety disorder, Parkinsonism, intermittent explosive disorder, dysphagia, and severe intellectual disability. R51's quarterly minimum data set (MDS) dated [DATE] indicated R51 had severely impaired cognition with a Brief interview for Mental Status (BIMS) score of 1. R51 did not have an upper or lower range of motion extremity impairment and was able to self-propel in a manual wheelchair. The facility documented in section E of the MDS that R51 did not have any behavior concerns. R51 was taking antipsychotic, antianxiety, and antidepressant medications. R51 discharged from the facility on 5/5/2025. R51's behavior problem care plan documents; crying, yelling, kicking or hitting staff/other residents, throwing things related to severe intellectual disabilities, schizophrenia, mood disorder, anxiety, and intermittent explosive disorder, initiated on 3/19/2024 with the following interventions: - Administer medication as ordered. Monitor/document for side effects and effectiveness. - Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. - Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. R51's mood problem care plan related to disease processes of schizophrenia and intermittent explosive disorder, initiated on 3/6/2025 with the following interventions: -Behavioral health consult as needed (psycho-geriatric team, psychiatrist, etc.). -Monitor/record/report to medical doctor (MD) as needed (PRN) mood patterns signs/symptoms of depression, anxiety, sad mood, as per family behavior monitoring protocols. R51's psychosocial well-being care plan related to inability to problem solve, ineffective coping and disease process of schizophrenia was initiated on 3/11/2025 with the following interventions: -Encourage participation from resident who depends on others to make own decisions. -When conflict arises, remove residents to calm, safe environment and allow to vent/share feelings. On 3/17/2025, at 13:54 (1:54 PM), in the progress notes nursing documented, Behavior Review Summary note: .Mood: pleasant at this time, Cognition: impaired, Behavior patter: 1-2 behaviors noted per week. Precipitating factors and/or events: [R51] gets upset when things do not go as [R51] hopes such as winning at bingo. Interventions that help mood/ behaviors: reorientation, offer activity, quiet environment, distraction. Frequency of mood/ behaviors: 1-2 noted per week. On 4/2/2025, at 1700 (5:00 PM), in the progress notes licensed practical nurse (LPN)-E documented . R51 became upset after seeing R50's slipper and thought they were R51's slippers. R51 went up to R50, grabbed R50's shirt sleeve, R51 then turned and grabbed R8's sleeve. staff able to separate residents and gave R51 a soda as a diversion and 1 on 1 time. Surveyor noted R51's care plans did not specify what activities or interventions worked best for R51 to help redirect R51 when R51 is having an episode or to prevent an episode. Surveyor noted R51's care plan was not revised after the incident on 4/2/2025 when R51 grabbed R50's and R8's shirt. On 5/6/2025, at 12:46 PM, Surveyor interviewed LPN-E who stated LPN-E was at the nurse's station when R51 came up and noticed R50 and said R50 was wearing R51's slippers. LPN-E stated there had been no concerns LPN-E was aware of related to R51 and R51 was in a pleasant mood until R51 looked down and thought R50 was wearing R51's slippers. LPN-E stated by the time LPN-E got around the nurse's station R50 had already grabbed R50's shirt and in the process of doing that, ended grabbing R8's arm also. LPN-E stated LPN-E and another nurse were able to separate the residents. LPN-E took R51 and sat with her a little bit until R51 calmed down, then kept her 1 on 1 for the remainder of the shift. Surveyor asked LPN-E what interventions are in place for R51's behaviors. LPN-E stated R51 really enjoys being around people, so R51 will attend a lot of activities, and the activity staff will do a lot of one on one activities with R51. LPN-E stated R51 typically had behaviors where R51 would cry or yell if R51 was missing a colored pencil or could not find the exact one R51 was using the prior day, but never grab or try to hit anyone. Surveyor asked LPN-E who usually will revise the care plan when needed. LPN-E stated nursing staff would or the Director of Nursing (DON)-B. On 5/7/2025, at 9:37 AM, Surveyor interviewed DON-B who stated the facility switched over to using point click care (PCC, Healthcare software) in March and were still working on how to use it. Surveyor shared the concern R51's care plan was not patient centered to R51's needs and did not identify specific interventions that were more directed for R51. DON-B stated R51's behavior care plans should have been more patient specific to R51's concerns and needs and should have been documented as such when transferring from the old healthcare software to the new healthcare software. 2) R8 was admitted to the facility on [DATE] and has diagnoses that include vascular dementia, parkinsonism, epilepsy, schizophrenia, tremor, major depressive disorder, and encephalopathy. R8's quarterly minimum data set (MDS) dated [DATE] indicated R8 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 4. R8 did not have an upper or lower extremity range of motion impairment and was able to self-propel in a manual wheelchair. The facility documented in section E of the MDS R8 did not have any behavior concerns. On 4/2/2025, at 1700 (5:00 PM), in the progress notes licensed practical nurse (LPN)-E documented (R8) was involved in a resident to resident altercation due to another resident (R51) being agitated and unable to be redirected. (R51) approached (R8) and grabbed R8's sleeve. R8's care plan initiated on 3/26/2025 for being at risk for increased sadness, emotional distress, upsetting thoughts, loss of interest, memory loss, and/or trouble concentrating with the following interventions: - Encourage resident to express feelings. - Use calm and understanding approaches. R8's mood problem care plan related to schizophrenia and major depressive disorder diagnoses was initiated on 3/12/2025 with the following interventions: - Behavioral health consults as needed (Psychogeriatric team, psychiatrist, etc.). - Monitor/record mood to determine if problems seem to be related to external causes. - Monitor/record/report to medical doctor (MD) as needed mood patterns/signs and symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols. Surveyor noted R8's care plan was not revised to monitor for emotional well-being after R8 was involved in a resident to resident altercation with R51. On 5/7/2025, at 9:37 AM, Surveyor interviewed Director of Nursing (DON)-B who stated R8 was at the nurse's station and sitting by R50 when R51 came and accused R50 of wearing R51's slippers. DON-B stated R8 happened to be in the middle of the situation. Surveyor shared concerns R8's care plan was not revised to monitor for emotional well being from the resident to resident altercation on 4/2/2025. DON-B stated DON-B was sure R8 was being monitored because it was being documented, but understood that it should have been care planned. 22692 3) R63 was admitted to the facility on [DATE]. On 5/6/25, R63's progress notes dated 5/1/25, at 5:14 PM, were reviewed and documented: Called the hospital for results of R63's stool sample for possible Clostridium difficile (C-Diff) infection. Results C-Diff toxin but Glutimate Dehyrdogenase (GDH) antigen positive. This most likely represents bacterial colonization and does not warrant treatment. Soap and water precautions (Contact isolation precautions with the need to use soap and water for handwashing and not alcohol based sanitizer) required. On 5/6/25, at 7:57 AM, A sign was observed on R63's door indicating she was on contact isolation. On 5/6/25, R63's current care plan for contact isolation with a start date of 5/3/25 was reviewed and documented: R63 is on contact precautions related to a urinary tract infection. Follow contact precaution protocol. On 5/07/25, at 8:40 AM, Director of Nursing (DON)- B was interviewed and indicated R63's care plan is wrong for contact isolation and should be for loose stools with concerns for C-Diff not for a urinary tract infection. The above findings were shared with Nursing Home Administrator-A and DON-B on 5/6/25, at 3:00 PM. Additional information was requested if available as to why R63's care plan was inaccurate as to the source of infection requiring contact isolation. None was provided.

Based on observation, interview, and record review the facility did not ensure staff performed proper hand hygiene and infection control for 2 (R9, R63) of 4 residents observed during the medication pass observation. * R63 was in contact isolation and Licensed Practical Nurse (LPN)-D took R63's blood pressure and then used the same blood pressure cuff on R9 without sanitizing it. Findings include: On 5/6/25, at 7:57 AM, LPN-D was observed administering medication to R63. R63 was observed to have a sign on her door indicating she was on contact isolation. LPN-D put on a gown and gloves and took R63's blood pressure with the blood pressure machine from the medication cart. After taking R63's blood pressure LPN-D took off her gown and gloves sanitized her hands and placed the blood pressure machine on the medication cart in the hall. LPN-D did not sanitize the blood pressure machine. LPN-D then took the same blood pressure machine and took R9's blood pressure. R9 had a sign on his door indicating he was on enhanced barrier precautions. After LPN-D took R9's blood pressure she placed it on a cart that held PPE (personal proactive equipment). LPN-D did not sanitize the blood pressure machine. On 5/6/25, at 10:30 AM, LPN-E, who is the facility's Infection Control Preventionist, was interviewed and indicated R63 is on contact isolation for Clostridium difficile and if a nurse uses a blood pressure machine with R63 the machine should be sanitized before being used on another resident. On 5/6/25, R63's current care plan for contact isolation with a start date of 5/3/25 was reviewed and documented: R63 is on contact precautions related to a urinary tract infection. Follow contact precaution protocol. On 5/7/25, the facility's policy titled PPE Precautions Policy dated 12/19 was reviewed and documented: Contact precautions: use disposable or dedicated patient-care equipment. If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient. The above findings were shared with Nursing Home Administrator-A and DON-B on 5/6/25, at 3:00 PM. Additional information was requested if available as to why a contaminated blood pressure cuff was used on R9. None was provided.

Based on interviews, record review, and facility policy review, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 1 of 8 sampled residents. On [DATE], R4 reported being depressed and having thoughts that he would be better off dead or of hurting himself almost daily. The facility did not provide R4 with support or services to address these concerns. Approximately 8 hours later, R4 was found pulseless and non-breathing with a plastic bag over his head and the oxygen tubing wrapped around his neck. The facility's failure to provide support and monitoring to R4 after making statements that he was depressed and had thoughts that he would be better off dead nearly every day created a finding of immediate jeopardy that began on [DATE]. NHA A (Nursing Home Administrator) was notified of the finding on [DATE] at 2:07 PM. Findings include: Review of the facility's policy titled, Facility Investigations of Resident Threats to Harm Self dated ,d+[DATE], stated .1. Should resident voice intent or attempt to harm themselves in any way staff will immediately intervene in order to stop negative behavior and to assure safety .2. Based on the severity of the occurrence immediate nursing interventions to consider would be .a. assure no bodily harm has occurred (i.e. redness, bruising, swelling, etc.) through a body check .b. initiate 1:1 care .c. initiate 15 minute checks .d. consider sending resident out to the hospital if dangerous behavior continues .e. remove items from room that which resident could potential harm themselves with .f. inform dietary should resident need plastic utensils .3. Nurse must notify the following people of the incident: .a. the on call Nurse Manager; the on call Nurse Manager is then responsible for notifying the Administrator or designee .b. the resident's primary physician . c. the resident's family . d. third parties such as Hospice or Partnership .e. the resident's facility Social Worker .4. The resident's Social Worker or designee is responsible for completing a thorough and immediate investigation of the situation by: a. interviewing the resident .b. interviewing any potential witnesses (i.e. other residents if cognitive, staff, visitors) .5. Social Services must attempt to determine reasons for the threat. Reasons to consider may include: a. diagnosis (i.e. Depression, Anxiety, Bipolar disease, etc.) .b. adjustment or grieving issues . c. attention seeking behavior . d. lack of family/friends . e. medication changes . f. overall decline in health; loss of independence . 6. Upon determining potential reasons for the threat Social Services or the designee must then update the resident's plan of care. Resident's care plan goal and interventions must include a review date and end date. Based on the reason for the threat possible. Social Service interventions to consider may include: a. increase of 1:1 visits with resident by Social Services .b. consider recommending consult with in-house psychologist if not already seeing .c. if already seeing in-house psychologist, contact to inform of situation . d. consider recommending consult with outside psychiatrist . 7. Social Services and Nursing to work together to communicate any new interventions to staff via: a. verbally communicating with C.N.A.'s on resident's hall . b. written documentation on 24 hr. board . 8. Social Services must document their investigation and submit to the Administrator for review. R4 was admitted to the facility on [DATE] with diagnoses which included other fracture of upper and low-end fibula, subs for closed fracture with routine heal. Review of the undated diagnosis list provided by the facility revealed no diagnosis of depression, anxiety, or other mental health issues. Review of R4's Care Plan, dated [DATE] at 7:47 PM indicated R4 had the potential to feel anxious, scared, angry, sad, alone, or isolated. The care plan indicated that R4 needed nurses to ask me how I am feeling, identify my patterns of behavior, provide me with clear explanations, assess my medication. I need social services to establish a quiet environment for me, provide me with regular counseling. Review of R4 physician orders, dated [DATE] and provided by the facility, revealed medication orders for risperidone (anti-psychotic medication) 0.5 MG (milligram) tablet by mouth every 12 hours for tremors. Review of nurse's note dated [DATE] at 1:34 PM and provided by the facility, revealed R4 had a diagnosis of dementia, was his own decision maker, alert and oriented with confusion. Review of R4's Patient Health Questionnaire (PHQ), provided by the facility, was completed by AA C (Admission Assistant) on [DATE], at 2:56 PM. The PHQ revealed that R4 answered yes to thoughts that he would be better off dead, or hurting himself in some way, nearly every day. When asked if he was depressed, R4 answered yes. During an interview on [DATE], at 6:25 PM, AA C (Admissions Assistant) stated she told APSW (Advanced Practice Social Worker) right away that R4 answered yes to being depressed, having thoughts that he would be better off dead, or of hurting himself in some way. AA C stated R4 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he was cognitively intact. During an interview on [DATE], at 6:45 PM, APSW E stated that AA C told her on [DATE] that R4 had answered yes to the question that he would be better off dead. APSW E stated, Since it was the end of the day, I figured I would just take care of it the next day. When asked if she documented this conversation, APSW E stated that she typically does not document conversations between coworkers; only when the resident tells her directly. APSW E stated she was not made aware the resident answered yes to being depressed. She stated if she was aware that there were additional yes answers on the PHQ, she would have done something about the resident at the time. When asked why she did not take action after the admissions assistant informed her of the assessment, APSW E responded, It was the end of the day. Review of nurse's note dated [DATE] at 3:37 PM and provided by the facility, noted R4's mood: Did not indicate concern with R4 making any negative statements or verbalized self-worthlessness in the past month. During an interview on [DATE], at 6:13 PM, CNA D (Certified Nursing Assistant) stated that he was doing his final check on [DATE] at 11:25 PM and he was going up and down the hallways. He stated that he went into R4's room, and it was dark, so he turned on his light to check on him. He stated that observed R4 had a clear plastic trash bag over his head. He stated that he could tell that R4 was not breathing, so he ran quickly to get a nurse. CNA D stated that they ran back down to R4's room, the nurse removed the bag from over his head and checked his vitals. He stated R4 had a Do Not Resuscitate (DNR) bracelet on his wrist, and cardiopulmonary resuscitation (CPR) was not initiated. He stated that he wrote a statement for the facility and a statement with the police. CNA D stated, The oxygen tubing was wrapped around the bag that was over R4's head and R4 did not have the oxygen tubing in his nose. During an interview on [DATE] at 1:55 PM, the AA C stated that she had a discussion with NHA A, ANHA F (Assistant Nursing Home Administrator), APSW E, and AC G (Admission Coordinator) on [DATE]. She stated that she did not recall the time that the meeting was held. She stated that the group discussed and decided to archive the PHQ because R4's statements were taken out of context. When asked what it meant that the statement was taken out of context AA C indicated they said it was because he was cheerful, he was [AGE] years old, has lived his life, and if it happens it happens. During an interview on [DATE] at 2:25 PM, the ANHA F that on [DATE], the team met to discuss the incident and the assessment that was conducted. She stated that based off the way the resident had responded to the questions, they were taken out of context. She stated that R4 did not directly state he would hurt himself. Review of Facility Reportable Death Determination-F62470, dated [DATE], revealed R4's cause of death was probable suicide by asphyxiation per Medical Examiner. According to the documented assessment on the PHQ, R4 indicated he was depressed and nearly every day had thoughts of being better off dead or of hurting himself. This is not the same as thinking about death daily and accepting it when it comes, as facility staff have since interpreted the resident's demeanor. Failure to recognize the resident's responses as a cry for help, to further assess the responses, and to immediately implement medically-related social services to address these concerns created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy.

Based on record reviews, interviews, and facility policy review, the facility failed to ensure that 1 of 3 sampled residents reviewed for Coumadin usage (R2) received ongoing laboratory testing to monitor the therapeutic dose the resident received. R2 was admitted to the facility with an order for Coumadin (an anticoagulation medication). Use of this medication requires frequent laboratory testing to ensure a person is receiving the correct dose to remain in therapeutic range. The last test that was completed was on [DATE]. R2 began to develop multiple bruises, which can be a sign of over anticoagulation (too much Coumadin). Neither nursing nor pharmacy identified there were no orders for labs and that R2 was not being monitored. On [DATE], R2 developed hematuria (blood in urine) and labs were ordered. Results found that R2 had critical low hemoglobin and hematocrit and critical high prothrombin and INR (International Normalization Ratio). These results are indicative of bleeding and R2 being over anticoagulated. R2 was sent emergently to the hospital where he later died . The failure to regularly monitor labs while receiving Coumadin created a finding of immediate jeopardy that began on [DATE]. NHA A (Nursing Home Administrator) was notified of the immediate jeopardy on [DATE] at 4:15 PM. The immediate jeopardy was determined to be removed and the deficiency corrected on [DATE]. Findings include: Review of facility's policy titled, Anticoagulation dated ,d+[DATE] and provided by the facility, indicated that .orders for Coumadin are received weekly by the Provider. Nursing staff will follow orders for drawing labs and giving medication as prescribed. Recommendations from the Provider will be implemented and communicated with the pharmacy also. Any abnormal lab results will be communicated with the Provider. Pharmacy completes monthly medication reviews and makes recommendations. These medication reviews are sent to the facility and reviewed by the Nurse Practitioner or Medical Director. R2 was admitted to the facility on [DATE] with diagnosis of congestive heart failure (CHF). Review of R2's diagnosis list provided by the facility revealed additional diagnoses of hypokalemia, hyperlipidemia, epilepsy, chronic obstructive pulmonary disease, unspecified intellectual disabilities, and major depressive disorder. Review of R2's Admission Weekly Skin Assessment form, dated [DATE] and provided by the facility, revealed bruising on the right posterior hand, right anterior forearm, left posterior hand, right chest, right shin, and left biceps. At the time of R2's discharge from the facility, Facility Physician Discharge Orders, dated [DATE], revealed R2 had orders for Coumadin (an anticoagulant medication) 2.5 mg (milligrams) po (by mouth) one time a week on Wednesday evening and 4 mg po daily in the evening which was started on [DATE]. Record review revealed a Physician Order, dated [DATE], for a PT/INR (Prothrombin/International Normalization Ratio), which is a test that determines how many seconds it takes a blood clot to form, to be drawn on the morning shift. Record review of Laboratory Results, dated [DATE] and provided by the facility, ordered by APNP H (Advanced Practice Nurse Practitioner), revealed no notation regarding the next PT/INR test. There was no evidence of a standing order for PT/INR and no additional labs were ordered after this date. Review of R2's Weekly Skin Assessment form, dated [DATE] and provided by the facility, revealed bruising on the right and left wrist, left bicep, left knee, and the right groin area. The MD I (Medical Doctor) was notified. Unusual or excessive bruising with no other cause identified is considered an adverse reaction with Coumadin and would indicate lab work should be completed. Review of R2's Weekly Skin Assessment form, dated [DATE] and provided by the facility, revealed that R2 had bruising inside the right cheek and bruising on the left foot. This is the second week that R2 has experienced unusual bruising. APNP H was notified. Review of R2's Nurses' Note, dated [DATE] and provided by the facility, revealed R2 was experiencing hematuria (bright red blood in the urine), yelling out, striking out at staff, refusing care, and had increased bruising with multiple etiologies. Review of a Physician Order, dated [DATE] and provided by the facility, indicated a new order for STAT (immediately) PT/INR, CBC (complete blood count), and BMP (basic metabolic panel) laboratory tests received. Review R2's Laboratory Report, dated [DATE] and provided by the facility, revealed: ~low critical hemoglobin (protein that carries oxygen through the blood) result of 6.0 g/dl (gram/per deciliter) (Hemoglobin normal range: 13XXX,d+[DATE].5), ~low critical hematocrit (the volume or percentage of red blood cells in blood) of 19% (Hematocrit normal range: ,d+[DATE]%) ~high critical prothrombin time greater than 90.0 (Prothrombin normal range: 9XXX,d+[DATE].8) ~INR (international normalized ratio) of greater than 10 (INR normal range: 2XXX,d+[DATE].5- intensive anticoagulation). Review of R2's Nurses' Note, dated [DATE] and provided by the facility, revealed the physician was notified and the physician ordered R2 be transferred to the hospital where he died on [DATE]. During an interview on [DATE] at 10:00 AM, DON B (Director of Nursing) confirmed there was no specific order for Coumadin side effect monitoring and confirmed that the January - [DATE] Medication Administration records presented by the facility did not indicate side effect monitoring for Coumadin. DON B stated she did not know why there were no orders to monitor the Coumadin with lab work. She stated as the DON, her expectation would be that the facility would ensure that residents on Coumadin were monitored with lab work and that staff would also monitor for Coumadin side effects such as bruising and bleeding. During an interview on [DATE] at 10:05 AM, the RPh J (Registered Pharmacist) stated that she was aware that R2 was on Coumadin and had seen this medication noted on his medication list. RPh J stated she had not noticed that laboratory work had not been done for the Coumadin medication. RPh J stated that she was made aware of the lack of Coumadin lab work by the facility after R2 died . RPh J stated that once she learned of the incident, there had been policy changes within the pharmacy regarding ordering and processing Coumadin medication refills because the pharmacy staff were refilling the Coumadin prescription without approval, and they were not catching that the order was old or there were no dose changes. During an interview on [DATE] at 10:18 AM, MedDir K stated that he was not aware that R2 did not have orders to monitor the Coumadin medication. MedDir K stated R2 was being followed by Nurse Practitioners at the facility. MedDir K stated that R2 had been seen by multiple clinicians and that this was a system failure. When asked what the expectation was going forward, MedDir K stated there needed to be better checks and balances for residents on Coumadin with standing orders for monitoring labs unless their Coumadin was being managed by outside clinics. MedDir K stated that he was aware that the facility had revised their anticoagulation policy after this incident. During an interview on [DATE] at 1:45 PM, APNP H stated she could not remember if she had ordered a standing lab for R2 after the [DATE] order. APNP H stated that when the results were called to the on-call physician, she may not know what the result was. During an interview on [DATE] at 3:21 PM, MD I stated that she was familiar with R2 and acknowledged that she was part of the care team. MD I confirmed she had received a report regarding R2's bruising on [DATE] but did not recall a reference to the Coumadin at the time she received the report. MD I stated that the lab work orders for Coumadin were missed by multiple people. During an interview on [DATE] at 9:30 AM, NHA A stated he did not know why the Coumadin lab work was missed. He stated that his expectation going forward was to remain on high alert for residents on Coumadin and continue to evaluate the new system for Coumadin monitoring to ensure that it was working. He stated that since the incident, there had been residents residing in the facility and the new system worked. The failure to regularly monitor residents who received Coumadin created a finding of immediate jeopardy. The facility removed the immediacy and corrected the deficiency on [DATE] by which time they had completed the following: 1. On [DATE] the facility began an investigation and identified all residents in the building who could potentially be affected and ensured that all labs and medications were up-to date and accurate. 2. On [DATE] the leadership team, including the NHA A, DON B, ADON L (Assistant Director of Nursing) ANHA F (Assistant Nursing Home Administrator), MedDir K, Nurse Manager, and Quality Care Coordinator conducted an Ad-Hoc (for this purpose) Quality Assurance and Performance Improvement (QAPI) meeting. The passing of the resident was reviewed. 3. The anticoagulation policy was reviewed and updated to ensure resident safety. The policy was adjusted to include standing orders for residents on Coumadin for weekly PT/INR draws upon admission to the facility. 4. During the Ad-Hoc QAPI meeting, the team also decided to add new monitoring orders upon admission, including monitoring for signs or symptoms for bleeding. 5. A Coumadin log was initiated by the nurse manager team for daily review during clinical meetings. At each clinical meeting, the clinical team reviews all residents who are prescribed Coumadin. 6. After discussing with MedDir K, the facility's pharmacy was contacted and a medication audit for all residents in the facility was completed. No other medication issues were discovered during this facility-wide medication audit. The pharmacy continues with monthly audits for all residents, and the residents on Coumadin are being monitored routinely by the pharmacy. 7. New admissions to the facility will have a prospective medication review completed by the pharmacy and the pharmacy will make note of medication that requires close monitoring. The consultant pharmacist will evaluate residents on Coumadin and clinically determine if INRs are being monitored routinely. Clinical judgement with regard to past stability of patient INR's will determine if consultant pharmacist recommends an INR for a resident for that month. 8. DON B began education on Coumadin with the nursing staff on [DATE]. All nursing staff were educated and provided with information about Coumadin. After reading and having a discussion, staff independently completed a quiz to show competency. The DON held small groups to complete this education with the nurses; additionally, the nurses were informed that if they had additional questions or concerns, they should seek out information from DON B or the ADON L accordingly. The staff were then informed about the changes being implemented regarding Coumadin. 9. The nursing staff's admission checklist and requirements include standing orders for weekly PT/INR draws for residents with Coumadin prescribed. Education began on [DATE] and all staff were educated before they began working their next shift on the floor. By [DATE], the nursing department had been educated about Coumadin and informed of the Anticoagulation policy and procedure. Upon hire, new staff members are now trained on this policy during their training period at orientation. 10. By the end of the day on [DATE], the team had contacted all parties involved to address the issue and make needed corrections. The plans put in place have thus far ensured that this mistake is prevented from occurring again. No other residents were affected, and the updated policy and procedure will keep residents safe. The facility made the necessary corrections and began monitoring immediately. 37283

Based on interview, record review, and review of facility policy, the facility failed to thoroughly investigate the death that occurred for 1 of 3 sampled residents R4 reviewed for abuse and/or neglect of eight sample residents. R4 died of a presumed suicide. The facility did not thoroughly investigate the death Findings include: Review of the facility's policy titled, Investigation and Reporting of Alleged Incidents of Abuse, Neglect, and Misappropriation, dated ,d+[DATE], stated All abuse, neglect, and exploitation of residents and misappropriation of resident property are prohibited at [Name of facility]. All alleged violations will be taken seriously and investigated and reported as necessary .1. All alleged violations involving mistreatment, neglect, abuse, injuries of unknown source and misappropriation of resident property shall immediately be reported to the Administrator (or designee), the employee's supervisor, or nurse who will immediately report to the Administrator (or designee) .e. Examples of neglect include, but are not limited to: ignoring a resident's need for help, not providing food or water, or withholding care . Review of R4's Face Sheet, dated [DATE] and provided by the facility, indicated R4 was admitted to the facility on [DATE], with diagnoses which included other fracture of upper and low-end fibula, subs for closed fracture with routine heal. Thorough review of facility documentation and R4's medical record indicated nothing to show that a thorough investigation had been conducted related to the resident's death, to include all staff and resident interviews about possible causes of the death. Review of R4's Reportable Death Determination, dated [DATE] and provided by the facility, indicated Nurse last saw resident at 10:45 PM on [DATE] sleeping in his bed with his oxygen on. The nurse stated that he could see the resident's chest rise and fall, ensuring that he was breathing. At 11:25 PM on [DATE], CNA D (Certified Nurse Aide) completed last rounding and checked on resident. CNA saw a plastic bag over the resident's head. CNA ran to get nurses, and nurses responded immediately. Resident had the plastic bag over his head and his oxygen tubing tightly wrapped around his neck. The nurses tore the bag off of the resident's head and unwrapped the tubing, but resident was nonresponsive and not breathing. He was pale with no pulse. Resident is a DNR [Do Not Resuscitate] and had a bracelet on; CPR [cardiopulmonary resuscitation] was not given. DON B (Director of Nursing, ANHA F (Assistant Nursing HOme Administrator) NHA A (Nursing Home Administrator) were notified. Police were called; case number provided. The Medical Examiner was called in. Medical Examiner stated that the cause of death of probable suicide. The Administrator called family contact to update on incident. During an interview on [DATE] at 2:15 PM, ANHA F confirmed that the information that she provided was all that had been done related to R4's death investigation. She stated she arrived at the facility on [DATE] at 2:00 AM, and took statements from CNA D, Licensed Practical LPN N (Licened Practical Nurse and LPN M. She stated that residents were observed to ensure their safety, but no statements were taken from the residents. She stated that the Sheriff gathered statements from the three staff members that were with R4.

Based on interview and record review, the facility failed to ensure that 1 of 3 residents (R1) received accurate medication administration resulting in a significant medication error of eight sample residents. R1 received another resident's anti-seizure and laxative medications in error placing R1 at risk for discomfort and a potential risk to his health and safety. Findings include: Review of R1's undated Face Sheet provided by the facility, revealed an admitted [DATE] with an admission diagnosis of unspecified dementia. Review of R1's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/18/24, revealed R1 did not have a Brief Interview for Mental Status (BIMS) conducted and was assessed as having cognitive skills for daily decision making that was severely impaired. Review of a Medication/Treatment Error Report, dated 03/19/24 and provided by the facility, indicated that R1 received Depakote (an anti-seizure medication) 875 mg po (by mouth), Keppra (an anti-seizure medication) 500 mg po (by mouth), and lactulose 45 ml (milliliters)/30 g (grams) po (by mouth) in error given by a student nurse. The physician action was to monitor for drowsiness and aspiration in AM (morning) and PM (afternoon/evening). Review of Progress Notes, dated 03/19/24 and provided by the facility, revealed that R1 did not have an adverse reaction. During an interview on 06/25/24 at 1:00 PM, DON B (Director of Nursing) stated the student nurse was with her instructor at the time of the medication administration and that since the incident the nurse instructor was not allowed back in the facility.

Based on observation, interview, and record review, the Facility did not provide the necessary care and services to prevent development of pressure injuries and promote healing of pressure injuries for 1 (R1) of 3 Residents reviewed with pressure injuries. R1 had a Stage 4 pressure injury and was observed to be in bed with her air mattress unplugged for 2 hours and 10 minutes. Findings include: R1 was admitted to the facility on [DATE] with diagnoses that Dementia. R1 receives hospice services that started on 12/21/22. On 3/28/24 at 10:00 AM R1 was observed in bed and her air mattress was observed to be unplugged from the wall and no power to the air mattress. On 3/28/24 at 12:10 PM Director of Nurses (DON)-B came into R1's room with the Surveyor and verified R1's mattress did not have power. DON-B plugged R1's air mattress in and it inflated. On 3/28/24 R1's pressure injury measurements to her coccyx were reviewed and indicated it was facility acquired and was declining rapidly as R1 only was eating for pleasure feeding. R1 was last seen by the Wound Physician-C on 3/25/24 and coccyx pressure injury was assessed 9 centimeter (cm) long by 5 cm wide and 4 cm deep, stage 4. The start date for the pressure injury was noted as 1/27/24 when it presented as moisture associated dermatitis and measured 1.5 cm wide by 0.5 cm long with no depth. On 4/1/24 at 9:36AM R1's coccyx pressure injury was observed. Per observation it appeared as large deep pressure injury which appeared clean and had a large area of surrounding redness. On 4/1/24 Wound Physician-C was interviewed and indicated because of R1's condition and rapid deterioration he felt the wound was a [NAME] Ulcer with the goal being to keep R1 as comfortable as possible. On 3/28/24 R1's current care plan for pressure ulcer (injury) dated 3/19/24 was reviewed and read: make sure air mattress is plugged in and set on 150 pounds. The above findings were shared with Administrator-A and DON-B on 3/28/24 at 3:00 PM. Additional information was requested if available. None was provided.

Based on observation, record review and interview, the facility did not ensure a resident received the appropriate treatment during medication administration through a g (gastrostomy)-tube to prevent possible complications. This was observed with 1 (R3) of 1 residents with a G-tube. R3 received medications without ensuring the g-tube was appropriately placed in the stomach prior to the water flush and medication administration. On 1/30/24, LPN (Licensed Practical Nurse)-F did not auscultate or aspirate the g-tube prior to administering the medication. Findings include: The facility policy and procedure entitled, Feeding Tube Management dated January 28, 2019, states: Management . Feeding tube placement verification prior to each instillation into the tube is based on current standards of practice which include: a. Auscultate an air bolus in the stomach. Verify a whoosh, [NAME], bubbling sound or b. Aspirate gastric content (none may exist if stomach is empty). c. Other alternatives include: measure gastric pH ranges from 1-6 or check length of g-tube prior to each instillation. On 01/30/24, at 08:27 AM, Surveyor observed R3 during the medication pass task. LPN-F dispensed one glycopyrrolate 1 mg (milligram) pill into a medication cup and informed the Surveyor you need to wait 30 minutes to start the tube feed, LPN-F stated they need to come back after 9 to start the enteral feeding. LPN-F then added one famotidine 20 mg pill to the same medication cup and proceeded to crush both medications and return them to the medication cup. LPN-F then dispensed a capful of Miralax powder into a plastic water cup. R3 was seated in a low pedal Broda chair. R3 was not receiving any enteral feeding at the time of the medication pass. LPN-F drew up 60 ml of water into the 60 ml syringe. LPN-F removed the plug of R3's g-tube and inserted the syringe and pushed the water through the tube. Surveyor noted LPN-F did not check placement of R3's g-tube prior to flushing the tube with water. After the syringe was empty, LPN-F added water to the medication cup with the two crushed medications in and added water to the syringe and drew up the medications as well. LPN-F then administered the medications with a 60 ml water flush to follow. Water was added to the Miralax and it was drawn into the syringe and administered. A 60 ml flush was done and the plug was placed back on R3's g-tube. LPN-F stated that a 60 ml flush should be done before and after each medication. Surveyor verified through record review that there is a physician order for 60 ml of water before and after each medication administration. On 01/30/24, at 11:15 AM, Surveyor interviewed LPN-F. LPN-F stated that for feedings you need to check residual and if over 100 cc hold. LPN-F also stated there is no expectation to check for placement before administering medications, you just need to make sure the flush goes in and resident is in an upright position. On 01/30/24, at 11:48 AM, Surveyor spoke with DON (Director of Nursing)-B. DON-B shared the expectation is to check the orders, check the parameters, and assess resident before giving medication or enteral feedings. If there are no signs of adverse reactions or emesis, the nurse should check for placement by withdrawing gastric contents, doing a pH test or instilling air through the tube and auscultate with stethoscope. DON-B confirmed this should be done before an enteral feeding as well as medication administration. On 01/30/24, at 03:04 PM, during the end of day meeting with facility this Surveyor shared with: Nursing Home Administrator-A, DON-B, Interim DON-I, Quality Care-G, Assistant Director of Nursing-H, , and Assistant Administrator-J the above observation. No further information was provided.

Based on observation, interview and record review, the facility staff did not utilize the appropriate (personal protective equipment) PPE for residents on droplet isolation. This was observed with 2 (R162 and R160) of 2 residents in droplet isolation. -R162 and R160 have a respiratory illness requiring droplet isolation. The required PPE was noted on their doorway, along with PPE supplies outside of the room. Staff was observed to not don the required PPE when entering the room. Findings include: Surveyor reviewed the facility's policy and procedure PPE (personal protective equipment) Precautions Policy dated 12/2022. Under section C. Enhanced Droplet Precautions: Enhanced Droplet Precautions are used for patients known or suspected with covid-19. The following is indicated: - perform hand hygiene when entering and exiting room; -Don a N95, gown, gloves, and eye protection upon entry into a patient room/space. 1.) On 01/29/24, at 9:52 AM, Surveyor observed Certified Nursing Assistant (CNA)-D answer R162's call light. R162 has a sign on their door indicating a need for droplet isolation. The PPE indicators are: Clean hands, gown, N95, eye protection, and gloves. CNA-D was observed with a surgical mask for PPE when they entered R162's room. CNA-D was not observed going into another resident room and was in the Nurses station area. Surveyor queried CNA-D regarding PPE requirements. CNA-D indicated they know they are supposed to go into R162's room with gown, gloves and wear a N95 mask. CNA-D had no reason for not donning the required PPE and indicated there are supplies available. Surveyor observed R162 had a cart outside of their room with PPE supplies. On 01/30/24, at 08:24 AM, Surveyor observed CNA-C delivery a breakfast tray into R160's room. R160 has a sign on their door indicating a need for droplet isolation. The PPE indicators are: Clean hands, gown, N95, eye protection, and gloves. Surveyor observed CNA-C don a gown, gloves, eye protection and a surgical mask. CNA-C then delivered the meal tray into R160's room. CNA-C removed all their PPE when exiting R160's room and preformed hand hygiene. Surveyor queried CNA-C regarding the required PPE for R160. CNA-C indicated they did not don a N95 mask and did not wear a N95 in the room. CNA-C is aware they are supposed to be wearing a N95 mask and just forgot. Surveyor observed there were N95 masks available in the isolation cart outside of R160's room. On 01/30/24, at 1:26 PM, Surveyor spoke with the Infection Preventionist (IP)-E regarding the staff PPE observations with R162 and R160. IP-E indicated they do monitor staff and educate on PPE requirements. There has been no supply concerns with PPE. Staff are fit tested for N95 masks. R162 and R160 droplet precautions include a N95 mask, gown, gloves and eye protection. On 01/30/24, at 3:05 PM, at the facility Exit Meeting with Administration. Surveyor shared the concerns with staff not utilizing PPE appropriately with residents on droplet precautions. No further information was provided.

Based on interview and record review, the facility did not ensure 3 (R34, R40 and R46) of 3 sampled residents reviewed for a facility initiated discharge received a written transfer/discharge notice that included the date of transfer, reason for transfer, location of transfer, appeal rights and contact information of the State Long-Term Care Ombudsman. R34 was transferred to the hospital on 9/15/23. R34 and their representative was not given a transfer notice. R40 was transferred to the hospital on 11/28/23 and 12/25/23. R40 and their representative was not given a transfer notice. R46 was transferred to the hospital on 10/17/23. R46 and their representative was not given a transfer notice. Findings include: On 1/30/23 a policy and procedure for transfer notices was requested and none provided by the facility. 1.) R34 was admitted to the facility on [DATE]. On 1/30/23, the Surveyor reviewed R34's medical record and it indicated R34 was transferred to the hospital on 9/15/23. The resident's medical record did not include documentation that a transfer notice had been given to the resident and their representative for the hospitalization . 2.) R40 was admitted to the facility on [DATE]. On 1/30/23, the Surveyor reviewed R40's medical record and it indicated R34 was transferred to the hospital on 11/28/23 and 12/25/23. The resident's medical record did not include documentation that a transfer notice had been given to the resident and their representative for the hospitalization s. 3.) R46 was admitted to the facility on [DATE]. On 1/30/23, the Surveyor reviewed R40's medical record and it indicated R34 was transferred to the hospital on 10/17/23 . The resident's medical record did not include documentation that a transfer notice had been given to the resident and their representative for the hospitalization . On 1/30/23, at 1:15 PM, the Surveyor interviewed Director of Nurses (DON)-B who indicated they could not find a transfer notice for R34's, R40's and R46's transfers to the hospital. On 1/30/23, at 1:30 PM, the Surveyor interviewed Social Worker (SW)-K regarding resident transfer notices. Social Worker-K indicated the facility does not provide a transfer notice at the time of discharge but do notify the residents representative that the resident is being transferred. On 1/30/24, at 3:00 PM, the above findings were shared with Administrator-A and Director of Nurses-B. Additional information was requested if available. None was provided.

Based on interview and record review the facility did not ensure 3 (R34, R40 and R46) of 3 residents received a written notice of the facility's bed hold policy and procedure when they were transferred to the hospital. -R34 was transferred to the hospital on 9/15/23. R34 and their representative was not given a bed hold notice. -R40 was transferred to the hospital on 11/28/23 and 12/25/23. R40 and their representative was not given a bed hold notice. -R46 was transferred to the hospital on 10/17/23. R46 and their representative was not given a bed hold notice. Findings include: On 1/30/23 a policy and procedure for bed hold notices was requested and none provided by the facility. 1.) R34 was admitted to the facility on [DATE]. On 1/30/23, the Surveyor reviewed R34's medical record and it indicated R34 was transferred to the hospital on 9/15/23. The resident's medical record did not include documentation that a bed hold notice had been given to the resident and their representative for the hospitalization . 2.) R40 was admitted to the facility on [DATE]. On 1/30/23, the Surveyor reviewed R40's medical record and it indicated R34 was transferred to the hospital on 11/28/23 and 12/25/23. The resident's medical record did not include documentation that a bed hold notice had been given to the resident and their representative for the hospitalization s. 3.) R46 was admitted to the facility on [DATE]. On 1/30/23, the Surveyor reviewed R40's medical record and it indicated R34 was transferred to the hospital on 10/17/23 . The resident's medical record did not include documentation that a bed hold notice had been given to the resident and their representative for the hospitalization . On 1/30/23 at 1:15 PM, the Surveyor interviewed Director of Nurses (DON)-B who indicated they could not find a bed hold notice for R34's, R40's and R46's transfers to the hospital. On 1/30/23 at 1:30 PM, the Surveyor interviewed Social Worker (SW)-K regarding resident bed hold notices. Social Worker-K indicated the facility does not provide a bed hold notice at the time of discharge but that they wait to see if the resident is admitted to the hospital. On 1/30/24 at 3:00 PM the above findings were shared with Administrator-A and Director of Nurses-B. Additional information was requested if available. None was provided.

Based on staff interview and record review, the facility did not ensure a Power of Attorney for Healthcare (POAHC) was notified regarding a change in fluid consistency for 1 (R1) of 3 residents reviewed. Licensed Practical Nurse (LPN)-C did not notify R1's activated POAHC when R1's dietary fluid consistency was changed to honey-thickened liquids. Findings include: The facility's Change in a Resident's Condition or Status policy, updated 10/2022, contained the following information: Oak Ridge Care Center shall promptly notify the resident, his or her provider, and representative (power of attorney or guardian) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, medical condition etc.). On 4/14/23, Surveyor reviewed R1's medical record and noted R1 had an activated POAHC. Surveyor reviewed a copy of a therapy consent form, dated 12/8/22, that contained a physician's order for Speech Therapy to evaluate R1 as well as a verbal consent from R1's POAHC. Speech Therapy evaluation notes indicated R1 was at risk for aspiration on thin liquids related to dementia, and a dietary change of honey-thickened liquids was recommended on 12/8/22. On 4/14/23 at 12:15 PM, Surveyor interviewed LPN-C regarding the change in R1's fluid consistency order. LPN-C stated LPN-C noted R1 was coughing during a meal while drinking fluids on or around 12/6/22. LPN-C requested a Speech Therapy consult. LPN-C could not recall if LPN-C updated R1's POAHC regarding the consultation request and the reason for the request. R1's medical record did not indicate R1's POAHC was updated on the final recommendation from Speech Therapy for honey-thickened liquids. On 4/14/23 at 12:33 PM, Surveyor interviewed Director of Nursing (DON)-B regarding DON-B's expectation for updating residents and/or their representatives regarding dietary changes. DON-B verified R1's medical record did not contain documentation that R1's POAHC was updated regarding the change in R1's fluid consistency. DON-B stated we dropped the ball on that one and indicated the facility should have updated R1's POAHC.

Based on observation, record review and staff interview, the facility did not ensure residents were assessed promptly with a weight loss and quarterly nutritional assessments. This was observed with 3 (R16, R45 and R50) of 4 residents with nutritional concerns. * R16 had a weight loss and the RD (Registered Dietitian) and Physician were not notified. * R45 did not have a nutritional assessment completed with a Significant Change in Status and Quarterly MDS (minimum data set) assessments. * R50 had a weight loss and the RD and Physician were not notified. Findings include: The facility's policy and procedure Nutrition and Weight Management, dated 11/2017, was reviewed by Surveyor. The procedures include the following: The RD will perform a comprehensive nutritional risk assessment with any significant change in condition. If a significant or severe weight loss occurs despite interventions, the Nurse Practitioner/Physician and the RD shall be notified. 1.) On 11/01/22 at 9:22 AM Surveyor observed R16 laying in bed appearing to be asleep. Surveyor observed the breakfast tray meal is untouched on the over-bed table. On 11/01/22 at 11:59 AM Surveyor observed R16 in their bed. Surveyor observed, staff had set-up the lunch meal on R16's over-bed table. R16 was involved with meal prep decisions and did not want to go to the dining room. Surveyor observed the meal to look appealing and as ordered. R16's medical record was reviewed by Surveyor. On 10/14/22 a comprehensive RD (Registered Dietitian) assessment for a new admission was completed. R16's hospital weight on 9/30/22 was 147 pounds (#) and their admission weight on 10/7/22 in the facility was 147#'s. R16's nutritional parameters were assessed and they do have an average of 58% for meal intakes. The assessment indicates R16 will be monitored for meal intakes and weights to determine if a supplement is necessary. R16's weight record documents: weight of 147#'s on 10/7/22; 10/28/22 was 136#'s and 10/30/22 was 136#'s. This indicates a severe weight loss of 7.48% in 1 month. On 10/27/22 the RD added a house supplement due to meal intake refusals, there is no mention of a weight loss in the nutritional note. R16's medical record does not indicate the RD or physician was notified of the severe weight loss. On 11/02/22 at 2:29 PM Surveyor called RD-C. RD-C indicated they would be notified by email if a resident has a weight loss. RD-C indicated they would review their notes and call Surveyor back. On 11/02/22 at 2:57 PM RD-C called Surveyor. RD-C was not aware of R16's weight loss and requested another weight. RD-C indicated they increased the house supplement to 3 times a day. On 11/2/22 at 3:00 PM at the Facility Exit Meeting Surveyor shared the concerns regarding R16's weight loss. R16 was re-weighed: R16's weight on 11/2/22 and 11/3/22 was 133#'s. 2.) On 11/01/22 at 12:03 PM Surveyor observed R45 eating in their room R45 chose to eat in their room and the meal was as ordered. On 11/02/22 at 8:56 AM Surveyor observed R45 dressed and sitting in their wheelchair. R45 ate breakfast in their room. R45's medical record was reviewed by Surveyor. Review of weights indicates R45 has had no weight loss the past few months. R45's most recent MDS (minimum data set) assessment was a Quarterly assessment dated [DATE]. R45 has a SCS (Significant Change in Status) MDS completed with a date of 5/16/22. R45 does receive Lasix 20 mg daily for edema, Vitamin D3 25 mcg every day for deficiency, potassium Chloride 10 meq every day. Thiamine 100mg daily for alcoholism anemia. R45's diet is a general diet with a house supplement daily. Review of R45's medical record indicates there has not been a comprehensive nutritional assessment since 2/3/2022 when R45 was newly admitted to the facility. There is no nutritional assessment for the Quarterly and SCS MDS assessments. R45 is a nutritional risk due to medications and variations in intakes that prompt a daily nutritional supplement. On 11/02/22 at 9:52 AM Surveyor spoke with AA-F (Assistant Administrator) and RN-D (Registered Nurse) regarding nutritional assessments. They indicated they will look for more assessment information. On 11/02/22 at 10:43 AM AA-F provided Surveyor RD- C's (Registered Dietitian) phone number. AA-F indicated there has been no changes with R45. The RD will typically complete an assessment on admission, annual and with changes. On 11/02/22 at 2:57 PM RD-C called Surveyor. RD-C indicated they complete a comprehensive nutritional assessment with the Annual, Admission and Change of Condition MDS assessments. The Dietary Manager conducts the quarterly assessments. RD-C was not made aware of R45's Significant Change in Status assessment in May. On 11/2/22 at 3:00 PM at the Facility Exit Meeting Surveyor shared the concerns regarding R45's nutrition assessments. On 11/03/22 at 10:42 AM Surveyor spoke with the DM-E (Dietary Manager). The DM-E indicated they have been with the facility for a year. DM-E indicated they get a list of residents from AA-F once a week, that AA-F was not in the facility when R45 assessment was due. DM-E is aware of requirement of completing nutritional assessments. They do not know why R45 did not have a quarterly assessment completed. 22692 3.) R50 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included colitis, depression and cerebral infraction. On 11/2/22 R50's nutritional assessment dated [DATE] was reviewed and indicated R50 was on a mechanical soft diet, ate an average of 52% of his meals and was started on a magic cup supplement twice a day as of 10/14/22. On 11/2/22 R50's weight records were reviewed and were recorded as follows: 10/6/22 163 pounds 10/28/22: 143 pounds (a severe weight loss of 20 pounds or 12.2% in less than 30 days) 11/3/22 at 8:15 AM: 139.4 pounds. This was a surveyor observed weight indicating a 23.6 pound weight loss or a severe weight loss of 14.4% in less than 30 days. On 11/2/22 at 2:37 PM Dietitian-C was interviewed and indicated that she and R50's physician should have been notified of R50's weight loss on 10/28/22 and was not. Dietitian-C also indicated a reweigh should have been completed and it was not done. On 11/2/22 R50's care plan for Potential for unintended weight loss related to history of Depression and Cerebral Vascular Accident dated 10/11/22 was reviewed and indicated: follow my diet plan, offer something else if I don't like the meal. On 11/2/22 R50's appetite percentages for the timeframe of 10/6/22 to 11/2/22 were reviewed and documentation indicated during that timeframe R50 refused 12 meals and consumed 25% of 29 meals, 50% of 25 meals, and 75%-100% of 14 meals. R50's medical record was reviewed and there was no evidence R50's physician was called on 10/28/22 with his 20 pound weight loss at the time it was found. Medical records indicate R50 has suffered no loss in status as his pressure injuries are healing and he is progressing in therapy. The above findings were shared with the Administrator and Director of Nurses on 11/2/22 at 3:00 PM. Additional information was requested if available. None was provided.

Based on observation, record review and staff interview, the facility did not ensure a residents oxygen orders were implemented. This was observed with 1 (R42) of 1 residents with oxygen use in the facility. R42 was observed without a humidifier with oxygen use and their oxygen tubing was not dated per physicians orders. Findings include: The facility's policy and procedures for Changing Oxygen Cannula, Tubing and Bubbler, dated 5/2017, was reviewed by Surveyor. Procedures #2 indicates that the facility prefers to change cannula, oxygen tubing and bubbler weekly and with application of date. On 11/01/22 at 09:35 AM Surveyor observed R42 in their bed. R42 had oxygen at 2 LPM (liters per minute) via a nasal cannula. Surveyor observed the oxygen cannula tubing has no apparent date and no humidifier attached to the oxygen. R42's medical record was reviewed by Surveyor. R42's signed physician orders, dated 11/2/22 indicate to administer oxygen at 2-5 LPM per nasal cannula to keep saturations above 89%. Change humidifier and tubing every week and as needed. On 11/02/22 at 08:55 AM Surveyor observed R42 has oxygen on per nasal cannula at 2 LPM and there is no date of use on oxygen tubing and no humidifier. On 11/2/22 at 3:00 PM at the facility Exit Meeting Surveyor shared the concerns regarding R42's oxygen management. 11/03/22 at 08:03 AM Surveyor spoke with RN-D (Registered Nurse) manager who indicated they have labeled the tubing and by mistake the humidifier got tossed. There is no additional information for why the oxygen tubing was not labeled during observations and no humidifier in use. On 11/03/22 at 8:20 AM Surveyor observed R42. R42 is observed to have a humidifier and oxygen tubing dated 11/2/22. R42 indicated they changed the tubing yesterday and added the humidifier.

Based on observation, interview, and record review the facility did not ensure 1 (R200) of 3 residents reviewed with or at risk for pressure injuries received the necessary care and services for prevention and healing of pressure injuries/wounds R200 was at risk for developing pressure injuries. There is no indication the facility identified a pressure injury for R200 until it was discovered as stage 3 pressure injury. Upon discovery there was no comprehensive assessment or change in the plan of care. This pressure injury required debridement by the wound physician. During the survey R200 was observed to not have her heels being offloaded despite ongoing risk for pressure injuries. Additionally, it was determined R200 did not have a pressure reducing mattress on the bed appropriate for an individual with a stage 3 pressure injury. Findings include: R200 was admitted to the facility 4/28/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R200's Quarterly MDS with an ARD date of 8/13/21 documents a BIMS score of 8, indicating R200 is moderately cognitively impaired and was not interviewable. R200 requires extensive assistance of 2 staff with bed mobility, transfers and dressing. R200 is at risk for development of pressure injuries and requires pressure relieving devices for their wheelchair and bed. On 9/14/21 at 10:30 AM, Surveyor requested a list of residents who have acquired or were admitted to the facility with pressure injuries since 8/24/21. The facility pressure injury list indicates R200 developed a pressure injury to the coccyx on 8/26/21. On 9/14/21 at 12:15 PM, Surveyor observed R200 lying in bed, positioned on their back. R200's feet were noted directly on the mattress. Surveyor did not observe a pressure relieving mattress on R200's bed. A gel wheelchair cushion was noted in R200's wheelchair. On 9/14/21 at 12:20 PM, Surveyor reviewed R200's medical record, including Physician Orders, Progress notes, Care Plans, Treatment Administration Record and Wound Assessments. On 8/26/21, RN-I documented on R200's skin condition: New area: Yes, Location: Buttock, Etiology: Moisture .Update Skin Care Plan: Nurses- treat as ordered. Keep clean and dry. Nurse Aide- gentle cleaning of area to remove previous layer of cream before applying a new layer. Surveyor did not note any measurements related to R200's skin condition at this time. Surveyor did not note any other documentation of a pressure injury to the coccyx on 8/26/21. On 8/30/21, RN-F documented on R200's skin condition: Initial assessment 8/30/21. Onset/Discovery Date: 8/26/21, Area: upper coccyx. Pressure Ulcer: Has full thickness of skin lost, exposing the subcutaneous tissues-presents as a deep crater (Pressure Stage 3), Wound type: Stage 3, Tissue Type: Slough 20%, Granulation 80%.Mattress type: alternating pressure .Area: 3.0 cm x 2.0 cm x 0.1 cm. A treatment order was given by Wound Physician- D to apply [MEDICATION(S)] and a foam dressing to R200's coccyx daily. Surveyor reviewed R200's skin integrity care plan with an initiation date of 10/21/17 which lists the following interventions: Gel Cushion in Wheelchair, Elevate heels off of mattress when in bed, with Pillows, Assess skin condition weekly and prn (as needed) and note any changes, Treat as ordered, Keep clean and dry, Assist with hygiene and general skin care,use moisture barrier cream with each incontinence episode, encourage resident to assist with rolling and using grab bars, allow extra time as resident moves slowly, Apply [MEDICATION(S)] to closed skin in high risk shear areas each shift, Treat as ordered, Keep clean and dry, Gentle cleaning of area to remove previous layer of cream before applying a new layer, Keep skin clean and dry, Keep nails clean and trimmed. Surveyor noted no changes or revisions to the care plan despite R200 developing a stage 3 pressure injury. Surveyor reviewed the wound evaluation assessment from Wound Physician-D from 9/6/21 and 9/13/21. On 9/6/21, Wound Physician-D documented Stage 3 pressure wound of the upper coccyx full thickness, Wound size: 2.8 cm x 1.5 cm x 0.1 cm. Surveyor noted that Wound Physician-D had performed [MEDICATION(S)] of R200's stage 3 pressure injury on 9/6/21. On 9/13/21, Wound Physician-D documented Stage 3 pressure wound of the upper coccyx full thickness, Wound size: 3.5 cm x 1.2 cm x 0.1 cm. Surveyor noted that Wound Physician-D had performed [MEDICATION(S)] of R200's stage 3 pressure injury on 9/13/21. On 9/14/21 at 12:45 PM, Surveyor conducted interview with RN-I. RN-I told Surveyor that R200 had some moisture associated [CONDITION(S)] with some shallow breaks in skin. Surveyor asked RN-I how they would differentiate between moisture associated [CONDITION(S)] and a pressure injury. RN-I continued, I learned the hard way .I am not a wound specialist or very good at staging wounds and anatomy .I'm not sure floor nurses should be staging wounds. Surveyor asked RN-I what the process would be if they found a resident with a wound or pressure injury. RN-I responded When you see it, you clean it and assess the wound bed, measure and document a skin assessment. Surveyor asked if they were aware that R200 developed a stage 3 pressure injury on 8/26/21. RN-I responded that they had mistakenly thought the pressure area to be moisture associated [CONDITION(S)]. Surveyor asked if R200's pressure injury should have been measured on and assessed on 8/26/21. RN-I responded that they would have measured the area if they could do it over again. On 9/14/21 at 1:15 PM, Surveyor conducted an interview with LPN-J and RN-K. LPN-J was working as a CNA at the time of interview due to staffing. Surveyor asked LPN-J whether or not R200's heels should be floated when they are in bed. LPN-J responded Yes. Surveyor asked LPN-J whether or not they were aware of if R200 has a pressure relieving air mattress on their bed. LPN-J and RN-K said that they would need to go check. Surveyor waited in the doorway of R200's room as LPN-J and RN-K checked R200's bed. RN-K confirmed that R200 does not have a pressure relieving air mattress in place on their bed. Surveyor asked LPN-J if a resident with a stage 3 pressure injury should have a pressure relieving air mattress in place on their bed. LPN-J responded Definitely. Taking care of the resident is the most important thing. RN-K agreed with LPN-J and told Surveyor they would find R200 a pressure relieving air mattress. On 9/14/21 at 1:40 PM, Surveyor conducted interview with RN-F and DON-B. RN-F is a manager at the facility and is part of the wound team. Surveyor asked RN-F if they were aware of R200's stage 3 pressure injury. DON-B responded that RN-F was at a wound certification class on 8/26/21 and had not seen the initial wound. Surveyor asked RN-F how they would be able to differentiate moisture associated [CONDITION(S)] from a pressure injury. RN-F responded that the skin would need to be intact to not be a pressure injury and pressure injuries are on bony prominences. RN-F told Surveyor that they did wound rounds with Wound Physician-D on 8/30/21 and that it was the first time they measured the pressure injury. Surveyor asked if RN-I should have measured R200's pressure injury on 8/26/21 when it was first discovered. DON-B responded that the floor nurses have been instructed to make managers aware of wounds so they can be staged appropriately and RN-F would have measured the wound if they had been in the facility on 8/26/21. On 9/14/21 at 2:52 PM, Surveyor met with NHA-A and DON-B. Surveyor asked DON-B if a resident with a stage 3 pressure injury should have a pressure relieving air mattress on their bed. DON-B responded Yes. Surveyor made NHA-A and DON-B aware that they did not observe a pressure relieving air mattress on R200's bed. NHA-A responded that they will look into this further. On 9/14/21 at 3:20 PM, Surveyor shared concerns related to the development of R200's stage 3 pressure injury on 8/26/21, including lack of wound measurements and assessment until 8/30/21. Surveyor shared concerns of observations made on 9/14/21 of R200 with their heels not being floated and lack of a pressure relieving air mattress on R200's bed. NHA-A responded that R200 now has a pressure relieving air mattress on their bed.

Based on observation, interview and record review the facility did not ensure that 1 (R1) of 5 residents reviewed had an environment that remained free from accident hazards and received adequate supervision to prevent accidents. R1 has fallen 8 times in the past 6 months. 6 of the falls have occurred in R1's room. 5 of the falls have resulted in injuries to R1 including but not limited to lacerations to the forehead and bruising/hematomas to the forehead, leg, arms and hand. The facility did not ensure R1 received adequate supervision to prevent further accidents. Findings include: R1 was admitted to the facility on [DATE] with diagnoses that include: dementia with behavioral disturbance, cerebral infarct, anxiety disorder, [CONDITION(S)] disorder and [CONDITION(S)]. R1's Readmission Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 7/13/21, documents: A Brief Interview of Mental Status (BIMS) score of 0, indicating R1 has severely impaired cognitive skills for daily decision making; Patient Health Questionnaire (PHQ-9) score of 1, indicating minimal depressive symptoms- identifying feeling tired and having little energy; behavior symptoms that disrupt cares or the living environment 1-3 days over the last 7 days; requires extensive assist of 2 staff for bed mobility, transfers, dressing and toilet use, extensive assist of 1 staff for locomotion on and off the unit and personal hygiene, not steady and only able to stabilize with staff assistance when moving from seated to standing, moving on and off the toilet and surface to surface transfers; always incontinent of bladder and frequently incontinent of bowel. R1's Care Plan, dated 12/25/18, documents: At risk for Trauma-Falls; injury. Internal factors, decline in cognitive status, appliance or device used, [CONDITION(S)] ([CONDITION(S)] Accident), unsteady gait, incontinence, decline in functional status, arthritis or joint pain, previous fracture RLE (Right Lower Extremity. Interventions include: -Observe for function decline due to [CONDITION(S)] use, initiated: 12/25/18; -Encourage to ask for assistance, assist with ambulating, transferring, toileting; Check comfort level every 2 hours; toilet resident every 2 hours and as needed; toilet resident before and after meals, offer bed pan/check brief; call light in reach; non-slip sheet in wheelchair; assure that resident is using proper footwear when in w/c (wheelchair); bed in lower, locked position; floor mat on floor beside bed when resident is in the bed; uses soft touch call light, initiated: 12/25/18 -Be attentive of report unsafe conditions, initiated: 12/25/18; -History of falls, use of psychotropics, impaired sense of balance, poor leg control, unsteady gait, initiated: 4/25/19; -Stay in bathroom while resident is on toilet, date initiated: 11/11/19; -If fire alarm rings, reassure resident. After alarm, ensure she is one of the first ones seen by staff d/t (due to) her anxiety, initiated: 11/21/19; -When checking on resident on NOC (Night Shift) rounds, remind/reorient her it is still nighttime and she can go back to sleep, initiated: 6/2/20; -If resident is seen trying to make her bed assist her with making her bed, initiated: 11/14/20; -Check and change resident between 2100 (9:00 PM) and 2230 (10:30 PM), offer toilet, if awake remind her what time it is and that she can get some sleep, initiated: 12/1/20; -Offer to lay resident down for a nap after breakfast, initiated: 3/9/21; -After visiting with family, reassure resident of safety, related to anxiety, initiated: 4/16/21; -After visiting with family/returning to room from off-unit visits, reassure and reorient resident, initiated: 4/19/21; -Offer to help resident get ready for and into bed between 1900 (7:00 PM) and 2100 (9:00 PM) nightly, initiated: 4/23/21; -Reposition resident in wheelchair when sitting her up for meals, initiated: 5/18/21; -Encourage resident to eat meals in the dining room, initiated 6/21/21 -Offer resident activities between meals. offer baby doll to resident to hold after supper, likes to wrap it in a blanket. Offer music for resident to listen to, PT (Physical Therapy), evaluate, treat as indicated; OT (Occupational Therapy) Evaluate, treat as indicated, pedal Broda chair, initiated: 7/14/21; -Anticipate fall times, PT/OT eval (evaluation) and treat for positioning and safety, initiated: 7/20/21; -Med (Medication) review by MD (Medical Doctor) and pharmacy; attempt to keep in direct line of sight when up and in common areas, initiated: 7/21/21; -At shift changes, ensure resident's floor is clear of items she may have dropped, initiated: 9/15/21. R1's Care Plan does not address the level of supervision R1 requires when awake and in her room. R1 has had 8 falls in the last 6 months. All 8 falls occurred while R1 was up in a wheel chair or in a pedal Broda chair. 6 of the falls occurred in R1's room and were unwitnessed by staff. 2 of the falls occurred while R1 was in her room and was reaching for objects. On 9/7/21, at 15:10 (3:10 PM), R1's Fall Report documents: R1 was found on the floor next to bed; just prior to the incident the resident had been toileted; Injury: hematoma to forehead; Cognitive status: cognitively impaired; Gait Problem: yes; Was the resident trying to toilet self when the fall occurred: No; At the time of the fall: Resident was continent of Bowel and Bladder; Resident's activities prior to fall: attempting to pick things off the floor; What was resident sitting in: Broda chair; Time resident was last toileted: 1445 (2:45 PM); Resident's mood/bx (behaviors) prior to fall: usual self and mentation; What was the resident wearing: non-skid socks; incontinent at the time of the fall: no; call light in use: no; nurses recommended intervention: when resident is out of bed, she should be wheeled close to central desk. R1's Fall Report dated 9/7/21 does not document what R1 was attempting to pick up off the floor at the time of the fall, if R1's call light was within reach at the time of the fall and if R1's Broda chair was in the upright or reclined position at the time of the fall. R1's Interdisciplinary Team Fall Investigation, dated: 9/15/21, documents: [Resident's Name] had minor injury; Location of fall: Resident's room; Environmental clues: Resident was reaching for items, clutter on floor; health status/care status clues: Recent weight loss, resident reaching for items; Equipment issues: none; New medications in the last week : none; Medication status: antihypertensive, diuretic, cardiac [CONDITION(S)], laxative; Contributing factors: none; Shift fall occurred on : Shift change; # (number) of falls in the past 3 months: 3; Cane/walker used: no; Geri or wheelchair used: yes, in good repair; Appliance used correctly: yes; call light in reach: Yes, call light not used; Cause: reaching for item on floor. What Happened & (and) Root Cause: Root cause analysis determined by the IDT (Interdisciplinary Team) using fall report and staff statements. Resident was in pedal Broda chair in room, was reaching forward to pick up and item off the floor and fell out of Broda chair. New Interventions: At shift change, ensure resident's floor is clear of items she may have dropped. Date of fall: 9/7/21; time of fall: 15:10. (3:10 PM). Surveyor noted the nursing recommended intervention on the 9/7/21 fall report to wheel R1 close to the central desk when the resident is out of bed is not addressed or explained why it is not added to the care plan. Surveyor also noted the intervention to check the floor at shift change does not prevent R1 from reaching for items that may have fallen or that she wants throughout the shift. On 9/15/21, at 12:57 PM, Surveyor observed R1 to be in her room, sitting in a low, pedal Broda chair that is slightly tilted back, feeding herself the noon meal. R1's lunch tray is in front of R1 sitting on an over the bed table. R1's call light is on the far side of the bed up against the wall with R1's doll resting across some of the call light cord and the call light is out of R1's reach. R1 is observed to have a quarter side, raised, discoloration to the center of the forehead. On 9/16/21, at 9:05 AM, R1 is observed sitting in low, pedal Broda chair next to main nursing station. R1 is observed with a baby doll in her lap. R1 has her head down and is leaning off to the right side of the pedal Broda chair with her eyes closed. R1 remains up at the nursing station until 9:48 AM when Activity Staff-N offers to take R1 outside. Activity Staff-N proceeds to wheel R1 outside. At 11:29 AM, Activity Staff-N is observed bringing R1 back inside and asks at the nursing station if R1 should go to her room or stay at the nursing station. Staff at nursing station instruct Activity Staff-N to leave R1 up at the nursing station. On 9/16/21, at 12:27 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-M who stated the staff does not like to keep R1 in her room because R1 tends to fall asleep and lean forward and fall forward out of the chair. CNA-M stated if R1 looks tired the staff then put R1 to bed to rest but otherwise R1 is to be kept out of her room. CNA-M stated she was going to assist R1 with lunch as staff need to guide R1 or she will use her hands to feed herself. At this time, Surveyor observed R1's call light to be out of R1's reach as it was at the foot of R1's bed and against the far side of the bed, up against the wall. On 9/16/21, at 1:56 PM, Surveyor interviewed Director of Nursing (DON)-B and Registered Nurse (RN) Manager-C, who stated the nurse on duty at the time of a resident's fall is responsible for completing the Fall Investigation form when a fall occurs. RN Manager-C stated the IDT will then review the nurse's completed Fall Investigation form to determine the root cause of the fall. NM-C stated then the IDT will determine the most appropriate fall prevention intervention as related to the IDT root cause analysis of the fall. Surveyor asked why the Fall Investigation form for R1's fall on 9/7/21, documents a nurse recommended intervention that is different from the IDT fall prevention intervention that is added to R1's care plan. RN Manager-C stated the IDT will review the nurse completed Fall Investigation form, determine the root cause of the fall and the IDT will determine if the nurse recommended intervention on the Fall Investigation form is appropriate for the resident or not. RN Manager-C stated the IDT reviewed R1's fall on 9/7/21 and determined the fall was caused by R1 reaching for something on the floor and the fall prevention intervention the IDT felt was most appropriate was: At shift change the staff would ensure R1's floor was clear of items she may have dropped. RN Manager-C stated this intervention was then added to R1's care plan. RN Manager-C stated the IDT did not feel the Nurse Recommended Intervention on R1's Fall Investigation form dated 9/7/21, which identified the intervention of: wheeling R1 close to the central desk when awake, was the most appropriate fall prevention intervention and that is why the IDT identified a different intervention that was added to R1's care plan. RN Manager-C stated R1 only needs to be within the line of sight of the staff when in common areas. RN Manager-C stated this intervention was added to R1's care plan following a recent fall when R1 fell in the hallway. Surveyor informed DON-B and RN Manager-C of Surveyor's interview with staff that did identify staff's understanding of R1's need for supervision to be different from that of RN Manager-C and DON-B. On 9/16/21 at 2:28 PM, Surveyor informed Nursing Home Administrator- A, DON-B, RN Manager-C and Executive Director-L of the concern R1 had multiple falls and R1's care plan does not address the level of supervision R1 requires when awake and in her room to prevent further falls and concerns that the safety plan of care to ensure the call light is in reach was not implemented during the survey. On 9/17/21 the facility submitted additional information for review indicating the observations of R1's call light not being in reach should not be considered an issue as the facility indicates R1 is able to propel her wheelchair and reach for items she may want. Surveyor noted upon review of R1's falls and care plans that while R1 may be able to propel her wheelchair there are safety concerns identified on the plan of care with her ability to do so safely. Additionally, the plan of care also identifies concerns with R1 reaching for items and includes interventions to try to keep her from slipping forward in her Broda chair which would make it important to ensure the call light is within R1's immediate reach as the facility has identified as a safety precaution for R1. The facility shared that the comments made by CNA-D indicating R1 should not be left alone in her room is not what the plan of care indicates. Surveyor noted R1 has had multiple falls that have occurred in her room and there is no indication the facility has assessed R1's needed supervision for safety when her room to prevent future falls.

Based on observation, interview, and record review the facility did not ensure 4 (R5, R19, R60 and R33) of 4 residents with pressure injuries received the necessary care and services for prevention and healing of pressure injuries/wounds. -R5 has a history of skin impairment. On 4/9/21 R5 was noted to have a skin impairment to the right hip, documented as being from the window handle. There is no documentation of resolution of this area or update to R5's plan of care to prevent skin impairment from the window handle. On 4/18/21 R5 was noted to have a skin impairment to the right outer buttock from pressure. There is no documentation of resolution of this area. There is no documentation of assessment or resolution to a skin impairment to R5's right hip or right outer buttock. On 5/12/21 R5 was noted to have a shear wound to the right posterior upper thigh measuring 8 x 7 x 0.1cm with 60% necrotic tissue, 20% slough, and 20% granulation tissue. Treatment to this area was not always completed as ordered by the physician, and as of 7/26/21 the area remains to the right posterior upper thigh measuring 2.5 x 2.9 x 3 cm with 10% thick adherent devitalized necrotic tissue, 10% slough, and 80% granulation tissue. On 4/14/21 R5 was noted to have a shear wound to the left buttock. Treatment to the left buttock was not always completed as ordered by the physician. During the time the treatment was not done as ordered by the physician the wound deteriorated, requiring oral antibiotics. As of 7/26/21 the left buttock wound remained measuring 6.5 x 8.6 x 4cm with 40% thick adherent devitalized necrotic tissue, 30% granulation, and 30% other viable tissue (bone, muscle). -R19 developed a shearing wound to the left buttock. R19's plan of care did not include interventions to prevent or address shearing. R19's shearing wound was not treated as ordered by the physician. R19's shearing wound required surgical excisional debridement and developed slough. -R60's moisture areas to the right buttock and left gluteal fold wounds did not always have complete, weekly assessments. R60's coccyx wound was not assessed or treated when found on 7/24/21 until brought to the attention of the facility by the surveyor on 7/26/21 when it was noted to have necrotic tissue. -R33 developed 3 facility acquired deep tissue injuries, some with brown adherent tissue, the facility did not ensure wounds were comprehensively assessed and monitored according to standards of practice. Examples involving R5, R19 and R60 are being cited at the scope and severity of G (actual harm/isolated). Findings include: The facility SKIN CARE AND PRESSURE INJURY MANAGEMENT policy and procedure, effective 10/28/20 and reviewed by the facility on 7/22/21 states 2. Nurses will conduct a weekly skin assessment to identify changes 3. Identify cause and contributing factors such as friction, shear, pressure, malnutrition, dehydration, trauma, immobility, medications, disease, and moisture/incontinence .a. Wound nurse or designee to place resident on weekly wounds rounds b. Wound nurse or designee in collaboration with the MD will make recommendations for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 1.) R5 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/15/21 R5 began hospice services. R5 has a history of pressure injuries, moisture associated skin damage, fissures, and shear wounds. R5's significant change MDS (Minimum Data Set) assessment, with an assessment reference date of 4/14/21 documents R5 is at risk for the development of pressure injuries, has open lesion(s) other than ulcers, rashes, cuts and moisture associated skin damage. R5's plan of care includes a problem area of Impairment of skin integrity initiated on 12/24/20, related to urine and or bowel incontinence, Internal factors, Immobility, Disease process, Decreased safety awareness, paraparesis of BLE [bilateral lower extremity], Altered nutritional state, Dehydration, Incontinence. Interventions initiated on 12/24/20 include Assess skin condition weekly and prn [as needed] and note any changes, Measure area, Treat as ordered, Provide Ulcer Care, Follow turning schedule, Encourage to reposition at least every 2 hours, Encourage resident to make small shifts in position, Minimize pressure on bony prominences, Use pillow for positioning, and Use lift sheet when moving resident in bed. Interventions added to the plan of care on 12/29/20 include ROHO cushion when up in wheel chair and alternating air mattress. A Weekly Skin Assessment note on 4/9/21 documents yes to new area, documenting the location as the right hip. The note documents the etiology as Got this from the window handle on his window and how he sometimes lays in bed. The assessment documents the wound as 1.5 cm x 0.5 cm and 6 cm x 0.5 cm. The description documents Small reddened area that is next to a longer reddened area on hip. The assessment documents the physician and skin manager were notified. On 4/9/21 R5's TAR (treatment administration record) documents to Monitor reddened areas on right hip for any s/sx [signs/symptoms] of infection f/b [followed by] bordered foam q. [every] shift until healed The monitoring was discontinued on 4/10/21. R5's medical record does not contain documentation of resolution of the area. On 4/10/21 R5's TAR indicates an order was entered for WOUND CARE: right hip-cleanse with NS [normal saline], protect periwound with skin prep, apply bordered foam 3x wk [three times a week]. This order is documented as being discontinued on 4/14/21. R5's medical record did not contain documentation of resolution of the area. On 4/14/21 progress notes document a shear wound to the left buttock, 100% granulation, 10.5 x 15 x 0.1. Under healing progress is documented N/A (new area). The description documents wound care MD at bedside. Moderate exudate noted. Nontender to the touch. Surrounding tissue excoriated and red. Resident is known to be incontinent most of the time and refuses to reposition. Treatment placed per MD order. Under root cause of wound is documented pressure, The wound physician ordered collagen powder with a foam border dressing three times per week and recommended to off-load wound and reposition per facility protocol. The wound physician's assessment does not contain documentation related to R5's wound to the right hip. On 4/18/21 progress notes document a new area to the right outer buttock document the etiology as pressure. Under TYPE OF INJURY the assessment documents Unable to determine pressure injury. The measurements are documented as 5 cm x 11 cm and description states Closed intact skin, pink surrounding skin, area in total measure 5 cm x 11 cm. Purple area in center measure 3 cm x 4 cm. TX [treatment] in place see TAR [treatment administration record]. The assessment documents the physician and skin manager were notified. On 4/18/21 R5's TAR indicates a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] .i.d [three times a day]. This treatment is documented as being completed 4/18/21-4/27/21. R5's medical record does not contain documentation of the area being resolved when the order was discontinued on 4/27/21. A progress notes on 4/19/21 documents New area to buttock noted by desk RN [registered nurse] 4/18/21. Resident has known wounds to bilateral buttocks. To be evaluated by wound care MD 4/21/21. On 4/21/21 R5 was seen by the wound physician who documents a shear wound to the left buttock measuring 7 x 13 x 0.1 cm, 100% granulation. The wound physician does not document on a right outer buttock or right hip wound. On 4/28/21 R5 was seen by the wound physician who documents a shear wound to the left buttock 4.5 x 7 x 0.1cm 20% slough and 80% granulation tissue. The wound physician does not document on a right outer buttock or right hip wound. On 5/5/21 R5 was seen by the wound physician who documents a shear wound to the left buttock measuring 3 x 5 x 0.1, 20% slough and 80% granulation tissue. The wound physician does not document on a right outer buttock or right hip wound. On 5/12/21 R5 was seen by the wound physician who documents a shear wound to the left buttock measuring 1.5 x 5 x 0.1cm, 20% slough and 80% granulation. The wound physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR does not indicate the treatment ordered for the leptospermum honey was implemented as ordered on 5/12/21. Review of R5's TAR documents the previous order to apply collagen powder to the wound bed and cover with bordered foam 3 times a week continued until 6/2/21 when the order was put into the TAR to apply [MEDICATION(S)] and cover with bordered foam daily. On 5/12/21 the wound physician also notes a shear wound to the right posterior upper thigh measuring 8 x 7 x 0.1cm 60% necrotic tissue, 20% slough, 20% granulation tissue, and orders Santyl with a gauze island with border dressing applied daily. This is the first documentation by the wound physician related to an area to R5's right thigh. R5's medical record did not contain documentation of an assessment or resolution of the area previously noted on 4/9/21 to R5's right hip or the area noted on 4/18/21 to the right outer hip. On 7/27/21 at 1:35 pm the surveyor interviewed RN Manager-G and RN Manager-C. RN Manager-G informed the surveyor the previous wound nurse had put in the order for the collagen and had left working at the facility on 5/27/21. RN Manager-G stated RN Manager-C had rounded with the wound physician the following week on 6/2/21 and realized the treatment was incorrect and changed it to the [MEDICATION(S)] as ordered right away. The surveyor asked what the process is for changing treatment orders. RN Manager-C informed the surveyor the wound physician immediately uploads his summaries into the system, and the wound manager reviews for changes and updates the treatment record. On 7/27/21 at 12:20 pm the surveyor interviewed DON (Director of Nursing)-B and RN Manager-G. DON-B informed the surveyor she believes the previous wound nurse, who no longer works at the facility, had looked at the wrong area for R5's wound after it was first noted, as the previous nurse had described it as right hip and another nurse described it as the right out buttocks, so she speculates the wound nurse went and looked at the wrong area and didn't see anything. The surveyor shared the documentation indicating the initial area to the right hip was from the window. The surveyor asked what was done to prevent that from happening again. RN Manager-G informed the surveyor R5 used to be very particular about where his bed height was. DON-B stated that is a good question and would look for more information. DON-B did not provide the surveyor any additional information for an intervention that was put into place related to preventing skin impairment from R5's window. The surveyor informed DON-B of the concern of no documentation of resolution or assessment to R5's right hip wound from 4/18/21-5/12/21 when it was noted to contain necrotic tissue and slough. On 5/19/21 R5 declined to be seen by the wound physician. On 5/26/21 R5 was seen by the wound physician who documents the shear wound to the left buttock has deteriorated, 2.5 x 5 x 0.1cm, 20%slough 80% granulation. The wound physician documents the shear wound to the right posterior upper thigh has improved with 80% thick adherent devitalized necrotic tissue. Both wounds received surgical excisional debridement. On 6/2/21 R5 was seen by the wound physician who documents the shear wound to the left buttock as deteriorated, 4 x 4.5 x 0.1cm, 20% slough, 80% granulation tissue. The shear wound to the right posterior upper thigh is documented as 5 x 5 x 0.3cm, 70% thick adherent devitalized necrotic tissue, 10% slough, 20% granulation tissue. The wound MD recommends a treatment change to the right posterior upper thigh wound to apply Dakins with a gauze island every shift. Both wounds are documented as receiving surgical excisional debridement. On 6/9/21 the wound physician documents R5's shear wound to the left buttock as deteriorated, 5.6 x 8 x 0.1cm and 100% thick adherent devitalized necrotic tissue. The wound physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R5'2 TAR indicates the treatment was not implemented as ordered. R5's TAR indicates the treatment to apply [MEDICATION(S)] and cover with bordered dressing daily continued until 6/23/21, and not the Dakins as ordered. The wound physician documents the shear wound to the right posterior upper thigh as improved, 4.7 x 4.5 x 1.5 cm, 70% thick adherent devitalized necrotic tissue, 10% slough. Both wounds are documented as receiving surgical excisional debridement. On 7/27/21 at 1:35 pm the surveyor interviewed RN Manager-G and RN Manager-C. RN Manager-G informed the surveyor the previous wound nurse had put in the order for the collagen and had left working at the facility on 5/27/21 and RN Manager-C had rounded with the physician the following week on 6/2/21. The surveyor informed RN Manager-G of R5's treatment was not changed as ordered on 6/9/21. RN Manager-G reviewed R5's documentation and confirmed the treatment was not changed as ordered. On 6/16/21 R5 declined to be seen by the wound physician. On 6/21/21 a late entry for 6/17/21 in R5's progress notes documents the left buttock wound as being full-thickness, 100%necrotic/eschar, no deterioration, no infection, and being 6 x 9 x not measurable. The root cause of wound is documented as being shear/moisture. The right posterior upper thigh is documented as being a full-thickness wound, 70% necrotic/eschar, 20% slough, and 10% granulation. On 6/23/21 the wound physician documents R5's shear wound to the left buttock as deteriorated, 5.6 x 10 x 0.1cm, with 100% thick adherent devitalized necrotic tissue and recommends [MEDICATION(S)] 300 mg every 8 hours for 10 days. The wound physician documents the shear wound to the right posterior upper thigh as improved, 4 x 4 x 2.5 cm, 40% thick adherent devitalized tissue, 10% slough, and 50% granulation tissue. Both wounds are documented as receiving surgical excisional debridement. On 6/30/21 the wound physician documents the shear wound to R5's left buttock as improved, 5.7 x 10 x 1.7cm, and 90% thick adherent devitalized necrotic tissue and 10% granulation tissue. The wound physician documents the shear wound to the right posterior upper thigh as improved, 3.5 x 3.5 x 3 cm, 20% thick adherent devitalized necrotic tissue, 10% slough, and 70% granulation. Both wounds are documented as receiving surgical excisional debridement. On 7/7/21 the wound physician documents R5's shear wound of the left buttock as improved, 7 x 9 x 2.5 cm, 70% thick adherent devitalized necrotic tissue and 30% granulation tissue. The wound physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound physician documents the shear wound to the right posterior upper thigh as improved, 2.5 x 3.3 x 2.7 cm, 10% thick adherent devitalized necrotic tissue, 10% slough, and 80% granulation tissue. Both wounds are documented as receiving surgical excisional debridement. On 7/12/21 the wound physician documents R5's shear wound of the left buttock as improved, 6.2 x 9.3 x 3.9 cm, 70% thick adherent devitalized necrotic tissue and 30% granulation tissue. The wound physician documents the shear wound of the right posterior upper thigh as deteriorated, 2.5 x 4.3 x 3 cm. Both wounds are documented as receiving surgical excisional debridement. On 7/19/21 the wound physician documents R5's shear wound to the left buttock as improved, 6.1 x 8.6 x 3.2 cm, 50% thick adherent devitalized necrotic tissue. The wound physician documents the shear wound to the right posterior upper thigh as improved, 2.5 x 2.9 x 3 cm, 10% thick adherent devitalized necrotic tissue, 10% slough, and 80% granulation tissue. Both wounds are documented as receiving surgical excisional debridement. On 7/26/21 at 12:25 PM the surveyor observed Wound Physician-D and RN (registered nurse)-E enter R5's room to complete an assessment and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/26/21 the wound physician documents R5's shear wound of the left buttock as improved, 6.5 x 8.6 x 4 cm, 40% thick adherent devitalized necrotic tissue, 30% granulation, and 30% other viable tissue (bone, muscle). The wound physician documents no change for the wound progress to the shear wound of the right posterior upper thigh, 2.5 x 2.9 x 3 cm, 10% thick adherent devitalized necrotic tissue, 10% slough, and 80% granulation tissue. Both wounds are documented as receiving surgical excisional debridement. On 7/26/21 at 2:57 PM the surveyor interviewed RN-F. The surveyor asked how R5's wounds were doing. RN-F informed the surveyor the right thigh wound is improving and the left buttock wound is about the same. The surveyor asked why the wounds are considered shearing. RN-F stated she believed that is how the wound first started. RN-F informed the surveyor R5 is hospice and a palliative approach is in place, and R5 does not want antibiotics or to go to the hospital so Wound Physician-D is treating him in house. RN-F informed the surveyor both wounds were into the muscle and cartilage. On 7/27/21 at 1:46 PM the facility provided the surveyor with a Past Non-Compliance Checklist initiated during the survey documenting [The facility] failed to prevent and appropriately document skin injuries. The assessment documents a plan of correction was implemented including 1. AMT reference for wound documentation distributed to all nurses with a quiz via (name of) survey on 7/23/21. 2. Review and update skin care management and wound dressing. 3. Written read and signed education of updated skin care management, wound dressings, and screen shot how to update skin care plans put out to all nurses 7/23/21. 4. All CNA's sent via e-mail education related to repositioning and off-loading and documentation with corresponding quiz on 7/23/21. 5. In depth power point and worksheet education of skin care and wounds sent to all nurses early AM on 7/24/21. 6. Skin pocket care cards for reference to all nurses made and distributed 7/26/21. 7. New Braden assessments completed on every resident 7/23/21 and 7/24/21. 8. Full skin assessment completed on all residents on 7/24/21, new treatments and interventions implemented as necessary. 9. New wound nurse hired on 7/19/21 and signed up to complete WCC [wound care certification] on 7/22/21. Course starts August 2021. She completed her first wound rounds with wound MD 7/26/21. The surveyor informed DON-B and NHA (nursing home administrator)-A of the concern related to R5's treatments not being completed as ordered, intervention not put into place to prevent R5 from having skin impairment from his window, and lack of documentation related to R5's right thigh wound resolving or assessment of the area between 4/18/21-5/12/21 when the area is noted to be necrotic and contain slough. 2.) R19 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R19 has a history of skin impairment including pressure injuries. R19's plan of care includes a problem area of Impairment of skin integrity RELATED TO: Immobility, contractures bilateral lower extremities, Bedfast implemented on 11/19/19. Interventions include Report any skin issues to nurse implemented 12/13/19, Assess skin condition weekly and prn [as needed] and note any changes implemented 3/4/19, New skin treatment see TAR [treatment administration record]. Implemented 6/20/21. R19's plan of care does not include documentation of interventions to address and prevent shearing. On 7/7/21 the wound physician documents a shear wound of the left lateral buttock measuring 1.3 x 1 x 0.1cm, 100% granulation, and duration greater than 2 days. The surveyor was unable to find documentation of the area prior to 7/7/21. R19's TAR does not contain documentation of a treatment to this area prior to 7/7/21. The wound physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/7/21 R19's TAR documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . 3x [times] week. Tuesday Wednesday, Saturday PM (per resident's request). The surveyor noted the treatment was not put into the TAR to be completed daily as ordered by the physician. Surveyor noted there was no documentation to indicate if the physician was notified of a requested change in frequency of treatment. On 7/12/21 the wound physician documents the shear wound to the left lateral buttock as being 1.2 x 0.9 x 0.1 cm, 30% slough and 70% granulation tissues, and improved evidenced by decreased surface area. The wound physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R19's TAR continued to document to do the treatment three times a week. On 7/19/21 the wound physician documents the shear wound to the left lateral buttock as improved, 1.1 x 0.9 x 0.1 cm, 30% slough and 70% granulation tissue, and orders Dakins solution with a gauze island dressing with border to be applied twice daily. R19's TAR does not document this treatment as be transcribed onto the TAR or completed as ordered. R19's TAR indicates the [MEDICATION(S)] continued as ordered. On 7/26/21 at 1:02 PM the surveyor observed RN (registered nurse)-E, RN-F and Wound Physician-D perform treatment and assessment to R19's wounds. The surveyor observed a smaller than a dime sized reddened/pinkish area to R19's left buttock. The surveyor observed Wound Physician-D do surgical incisional debridement of the area. The surveyor asked how often the treatment was being done. RN-F stated she thinks it was three times a week, Tuesday, Thursday and Saturday but she would check if that is what Wound Physician-D wants. On 7/16/21 at 3:03 PM the surveyor interviewed RN-E. The surveyor informed RN-E about the wound treatment being ordered by the physician to be done daily, and R19's TAR indicating the treatment was only being done three times a week. RN-E stated no, it should be done daily, that medi-honey should be done daily and not three times a week. RN-E stated she had just checked with Wound Physician-D and he wanted to change the treatment to medi-honey and wants it done daily. On 7/26/21 the wound physician documents the shear wound to the left lateral buttock as improved, 0.9 x 1 x 0.1 cm, 30% slough and 70% granulation tissue, and orders leptospermum honey with a gauze island with border dressing to be done daily. On 7/27/21 at 11:05 AM the surveyor interviewed DON (Director of Nursing)-B. The surveyor informed DON-B of R19's treatment not being completed as ordered and care plan not including interventions related to addressing/preventing shearing. DON-B stated it was a transcription error and that they will be doing education, and a new plan for the unit managers are doing skin checks and correlating the treatment and interventions. 3.) R60 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Significant Change Minimum Data Set (MDS) assessment dated [DATE] coded R60 as being completely dependent for bed mobility, toileting, hygiene, and bathing. R60 had a Brief Interview for Mental Status (BIMS) score of 8 indicating moderate cognitive impairment and R60 had an activated Power of Attorney. R60's Skin Integrity Care Plan was in place 2/16/2012 and the following interventions were in place on 4/16/2021: -assist with hygiene and general skin care -provide diet as ordered -treat as ordered, monitor med effect -keep clean and dry -monitor vital signs as needed -encourage to apply lotion to extremities and assist to apply as needed -keep linen clean, dry, and wrinkle free -use incontinence pads -report any redness to suprapubic site -float heels when in bed -(R60) often refuses to lay down after meals, offer to lay down, inform nurse of refusals -assess skin condition weekly and as needed and note any changes, bandage as appropriate, change dressing -reposition every two hours -assess heels every day -use pillows for positioning -heel protector to both feet at all times -dietary consult as needed -(R60) uses pressure relieving mattress on bed -barrier cream to peri-area as needed and after incontinent episode -gentle approach when using Hoyer lift, remove all obstacles from space when using lift -new skin treatment see Treatment Administration Record LEFT GLUTEAL FOLD On 4/16/2021 at 7:22 AM in the progress notes, nursing charted R60 had moisture from incontinence and two blisters on the left gluteal fold opened. The open areas measured 1.5 cm x 0.5 cm and 1.25 cm x 1.0 cm. The physician and POA were notified of the open areas. No further documentation was found regarding the open areas to the left gluteal fold. On 7/26/2021 at 10:16 AM, Surveyor observed R60's left gluteal fold with Registered Nurse (RN)-E and RN-F. No wound was observed. In an interview on 7/27/2021 at 10:56 AM, Surveyor asked Director of Nursing (DON)-B if the facility had any more wound documentation of R60's left gluteal fold after it was discovered on 4/16/2021. DON-B stated the assessment documented on 4/16/2021 was the only documentation of the left gluteal fold. DON-B stated the area healed at some time, but did not know when. RIGHT BUTTOCK On 4/23/2021 at 9:16 PM in the progress notes, nursing charted R60 had incontinence associated skin damage to the right buttock that measured 1.0 cm x 1.5 cm x 0.1 cm with full-thickness 100% granulation tissue. The physician and POA were notified of the new open area. The wound was comprehensively assessed weekly from 4/23/2021 to 5/7/2021. On 5/7/2021 at 9:53 PM in the progress notes, nursing charted the full-thickness wound measured 1.5 cm x 1.0 cm x 0.3 cm with 70% granulation and 30% eschar versus Deep Tissue Injury. Nursing charted the round shaped full thickness injury was mostly granulated with one area that was dark which alluded to deep tissue injury within the wound versus necrotic tissue. The physician and POA were notified of the deterioration of the wound. The Skin Integrity Care Plan was revised with the following intervention: encourage R60 to reposition every hour when up in Broda chair. The wound was not comprehensively assessed from 5/7/2021 to 5/18/2021, eleven days. On 5/18/2021 at 5:57 PM in the progress notes, nursing charted the full-thickness wound measured 1.2 cm x 1.1 cm x 0.2 cm with 100% granulation. On 5/25/2021 at 4:20 PM in the progress notes, nursing charted the full-thickness wound measured 1.2 cm x 1.1 cm x 0.2 cm with 100% granulation. On 6/3/2021 at 7:35 PM in the progress notes, nursing charted the full-thickness wound measured 1.3 cm x 1.0 cm x 0. cm with slough occurring. No percentage of the slough was documented. From 6/10/2021 to 7/14/2021, the wound was assessed weekly. Measurements were documented. The wound had granulation to the base with no percentage documented. On 7/14/2021 at 3:17 PM in the progress notes, nursing charted the full-thickness wound measured 0.5 cm x 0.5 cm x 0.1 cm with granulation. No percentage of the granulation was documented. On 7/20/2021, a referral was made to the wound physician. On 7/22/2021, Surveyor requested from the facility all wound documentation for R60's right buttock wound. The right buttock wound had no documentation after 7/14/2021. On 7/26/2021, the facility provided further documentation of R60's right buttock wound: on 7/24/2021 at 10:13 AM in the progress notes, nursing charted the right buttocks wound had resolved. On 7/26/2021 at 10:16 AM, Surveyor observed with RN-E and RN-F R60's right buttock. No wound was observed. In an interview on 7/26/2021 at 3:18 PM, DON-B stated when Surveyor asked for wound documentation for R60, DON-B discovered wound documentation had room for improvement so the facility did a skin sweep on 7/24/2021 and noted R60 did not have a wound at that time to the right buttock. DON-B did not know when the wound had healed and agreed it should have been assessed prior to 7/24/2021. In an interview on 7/27/2021 at 10:56 AM, DON-B stated RN Manager-C had written the documentation of R60's right buttock wound and had forgotten to put in the percentages when assessing the wound base. DON-B agreed the percentages should have been documented. DON-B stated RN Manager-C was under the impression that wounds had to be charted on once every week per calendar week, but not necessarily every seven days. Surveyor asked DON-B what standard of practice was used for wounds. DON-B stated the National Pressure Injury Advisory Panel; that standard states wounds should be assessed every seven days or more often as indicated. COCCYX On 6/15/2020 at 5:51 AM in the progress notes, nursing charted R60 had a wound caused by pressure to the coccyx. The wound had two open areas that were described as fissures. The proximal fissure measured 1.5 cm x 0.2 cm with a pink wound bed; the distal fissure measured 1.5 cm x 0.2 cm with a pink wound bed. The two fissures had tunneling between that measured 0.2 cm x 0.2 cm x 0.4 cm. The wound was determined to be a Stage 3 pressure injury. The coccyx wound healed on 9/10/2020 leaving a deep crater to the area per nursing documentation. On 10/8/2020 at 3:44 PM in the progress notes, nursing charted a dimple to the coccyx remained and was closed. A treatment was initiated to cleanse and pat dry the dimple on the coccyx and apply skin prep for protection three times daily. On 7/24/2021 at 11:37 PM in the progress notes, nursing charted R60 had a fissure caused by moisture to the coccyx that measured 1.0 cm in length. No other measurements or wound description was documented. The physician was notified. No change in treatment was obtained; the treatment ordered on 10/8/2020 continued of skin prep to the area. In an interview on 7/26/2021 at 9:27 AM, Surveyor asked RN-E if R60 had a wound to the coccyx. RN-E stated RN-E would have to review the documentation, but was not aware of any wound to the coccyx. RN-E stated this is the first time the wound team was assessing R60 with Wound Physician-D. On 7/26/2021 at 10:16 AM, Surveyor observed with RN-E and RN-F R60's coccyx wound. RN-E stated Wound Physician-D had just been in to assess the wound and debrided the slough and cauterized the wound. Surveyor observed the wound on the coccyx to measure approximately 3 cm x 1 cm with dark tissue from the cauterization with a small open area in the center of the dark tissue that presented as a divot. RN-E stated the wound was caused by friction according to Wound Physician-D. Wound Physician-D stated the coccyx wound was from moisture and superficial with a depth of 0.3 cm after being cleaned out. Wound Physician-D stated the wound did not look like a pressure wound because the area around the wound is healed. RN-E stated the facility had been monitoring the area that looked like a dimple. The Initial Wound Evaluation and Management Summary completed by Wound Physician-D on 7/26/2021 documented the wound to the sacrum was caused by shearing and measured 0.4 cm x 0.2 cm x 0.3 cm with 100% granulation tissue. [MEDICATION(S)] was ordered to the wound base daily. Chemical cauterization of hypergranulation tissue had been performed on the sacrum wound to facilitate healing. In an interview with DON-B, RN-E

Based on interview and record review the facility did not ensure each resident received the necessary care and services in accordance to professional standards of practice to meet each residents' physical needs for 1 (R35) of 6 sampled residents. R35 experienced a change in condition indicating symptoms of a stroke which included slurred speech. The facility did not immediately notify a RN of new onset of slurred speech so the RN could conduct a thorough assessment and determine what course of action should be taken. R35 experienced a stroke and was unable to receive treatment due to the delay in hospitalization . R35 has right sided weakness from the stroke. The facility's failure to provide the necessary care and services when R35 was noted to have symptoms of a stroke created a finding of immediate jeopardy. The immediate jeopardy began on 12/27/17. Administrator-A was notified of the immediate jeopardy on 2/14/18 at 3:37 pm. The facility removed the immediate jeopardy on 2/14/18, however, the deficient practice continues at a severity/scope level of D (potential for harm that is not immediate jeopardy/isolated) as the facility continues to implement its removal plan. Findings include: The FAST guideline put out by the American Heart Association and the American Stroke Association direct individuals to call 911 immediately if someone shows any of these symptoms, even if the symptoms go away .to help get the person to the hospital immediately. Time is important! Don't delay . The S in FAST represents Speech difficulty. - Is speech slurred? Is the person unable to speak or hard to understand? Ask the person to repeat a simple sentence, like The sky is blue. Is the person able to correctly repeat the words? Unsure. Call 9-1-1 immediately. Don't wait! http://www.strokeassociation.org/STROKEORG/WarningSigns/Stroke-Warning-Signs-and-Symptoms_UCM_ 8_SubHomePage.jsp R35 was admitted to the facility on [DATE] from another skilled nursing facility with a medical history that included a previous stroke with residual left sided weakness, and [DIAGNOSES REDACTED]. R35's Occupational Therapy Plan of Care with a start of care date of 12/23/17 document treatment [DIAGNOSES REDACTED]. The reason for referral is documented as Transfer from another SNF (skilled nursing facility)-to be nearer to family- for short term rehab and return home. On 12/24/17 at 12:23 am LPN (licensed practical nurse)-K documented R35's mental state as alert, speech is normal. On 12/24/17 at 12:28 am LPN-K documented R35's pupils as equal, round, reactive to light. On 12/24/17 at 12:45 am LPN-K documented COMMUNICATION: Communicates with speech, CLARITY: Speech is clear, with distinct and intelligible words. UNDERSTANDING: Understands others, COMMUNCIATION PROB (problem): no drooling, no frustration with communication, no shortness of breath or slowness to express needs. On 12/24/17 at 11:44 am progress notes document speech is normal. On 12/26/17 at 5:20 am RN (registered nurse)-L documented Speech is clear, with distinct and intelligible words. On 12/26/17 R35 was seen by ST (speech therapist)-M. ST-M's initial assessment documentation on 12/26/17 does not include documentation of slurred speech. On 2/14/18 at 12:15 PM the surveyor interviewed ST-M, who is also the facility's Rehab Director. ST-M informed the surveyor that the first time she had seen R35 (on 12/26/17) he had transferred here from another facility, not the hospital. ST-M stated that the 12/26/17 visit was for 35's cognition. The surveyor asked ST-M if a patient has slurred speech would she document that. ST-M stated R35 had a history of [REDACTED]. ST-M stated R35 on that first date (12/26/17) he was intelligible. The surveyor asked ST-M if she recalled R35 having any slurred speech on 12/26. St-M stated no, not until he went out to the hospital (on 12/28/17). On 12/27/17 at 3:20 pm progress notes document speech is normal, alert. On 12/28/17 at 5:37 pm LPN-K documented a late entry for 12/27/17 at 8:30 pm. LPN-K documented Aide stated Resident was having slurred speech. Upon assessment resident was able to follow simple commands such as smile and puff out cheeks. Upon puffing out cheeks and smiling resident's face was symmetrical with no signs of drooping. Resident was able to stick out tongue and move it from right to left without any complications. Resident was able to hold himself up with his right hand while using the sit to stand lift. Upon taking medications and eating dinner he did not have any difficulty swallowing. BP (blood pressure) was 142/82. This is the first time that R35 is documented to have slurred speech in the medical record. On 2/13/18 at 12:42 pm the surveyor interviewed LPN-K. The surveyor asked LPN-K if she recalled R35 and his condition on 12/26/17. LPN-K stated she remembered she was doing the med pass and the aide reported to her R35 was having slurred speech. LPN-K stated she had R35 smile that the smile was symmetrical, she had him stick out his tongue and that was symmetrical. LPN-K stated she helped toilet R35 and he was at his baseline. LPN-K stated R35 seemed to be doing just fine, but just had a little bit of slurred speech. The surveyor asked if the slurred speech was different then his normal speech. LPN-K stated yes, the slurring was more pronounced. LPN-K stated that R35 was able to eat dinner fine and take his meds ok and he was able to smile. LPN-K stated she did tell the third shift nurse in report and that she (LPN-K) had assessed him. The surveyor asked LPN-K if she had checked to see if R35 had weakness in his extremities. LPN-K stated his other side was fine. The surveyor asked LPN-K how she determined that. LPN-K stated R35 was able to hold himself up on the sit-to-stand. The surveyor asked LPN-K if there an RN that she reports to. LPN-K stated she reported to third shift. LPN-K stated she does not recall if an RN was in the building. The surveyor asked LPN-K if she had told an RN at the time (of the change in condition). LPN-K stated not at the time, that she reported to RN-L at shift change. LPN-K stated she was not sure if an RN was on that night. The surveyor asked LPN-K if there is not an RN on at night what the expectation for her to do is. LPN-K stated I guess I just deal with it myself, if there are any significant changes I fax the doctor and carry out his orders. The surveyor asked LPN-K if she notified the physician about R35's slurred speech. LPN-K stated no, I did not. The surveyor asked LPN-K if there was anything else she wanted the surveyor to know, LPN-K stated she was doing med pass and the desk that night so she was a little more strapped for time than usual. LPN-K stated usually 2 people do that job. The surveyor asked LPN-K if she hadn't been doing both the med pass and the desk that night is there something more that she would have done. LPN-K stated she would have been able to take her time more, and that she was not sure if she also had an admission. LPN-K stated she couldn't remember but recalled being strapped for time. LPN-K then stated honestly it was a little bit more slurred speech, wasn't that significant, and when I assessed him wasn't any other stroke symptoms noted. LPN-K did not mention the use of the interact tool to the surveyor. On 2/13/18 at 4:15 pm the surveyor interviewed DON (Director of Nursing)-B. The surveyor asked what an LPN should do if a resident has a change in condition, and there is not an RN in the building. DON-B stated there is usually always a RN in the building; otherwise have on RN on call that is noted on the schedule. The facility's Job Description for an LPN states This individual, a licensed practical nurse, is assigned to work under the direction of the registered nurse. Under Duties, Responsibilities, and Limitations the job description states Report to the registered nurse if there is a change in resident's condition and Seek the consultation and judgment of the registered nurse in situations which are beyond the range of these criteria. This is consistent with the Wisconsin Nurse Practice Act N6, which notes that a licensed practical nurse (LPN) can collect data, but a registered nurse must assess, plan, intervene and evaluate. The facility's 24 hour nursing report sheet for 12/27/17 documents for PM shift for R35 -slurring words -monitor. The report for Noc (third) shift documents (R35 ) monitor speech. Took AM meds (without) difficulty ' slurred speech continues - see charting. (Physician-J) saw this AM-No new orders @ (at) this time-monitor for now. On 12/28/17 at 7:06 am RN-L documented Resident noted to have slurred speech this AM; slurred speech was also noted per PM shift 24 hour report note. Resident woke easily this AM, alert, responsive, took AM medications without difficulty. Resident states 'All of a sudden I just lost my voice.' No other complaints offered at present. Pupils equally small bilaterally and reacting to light equally. (Physician-J) in facility and saw resident; continue to monitor at this time per (Physician-J). R35's condition continued to deteriorate over the course of the morning and he was subsequently sent to the emergency room (ER). Physician-J's progress note, dated 12/28/17, documents Pt (patient) had an acute event overnight where he was weaker on the right side with right facial droop and dysarthria. Pt was able to from (sic) words during interview. Patient unable to recount other history due to cognitive deficit .Patient also [MEDICAL CONDITION] left sided weakness .No new focal neurologic deficits since admission to facility. Physician-J documents under Assessment/Plan Probable left hemispheric [MEDICAL CONDITION]- D/W (discussed with) staff at length. Given uncertain onset of symptoms overnight, pt may not be a candidate for TPA/ Will have pt evaluated in ER. Pt seen at 6am and within next hour, pt's speech more slurred. On 2/15/18 the facility provided the surveyor with a typed out statement signed by Physician-J, dated 2/14/18. The statement states I came in early the morning of (MONTH) 28th (YEAR) and was informed that resident (R35) had an episode of slurred speech the previous evening. It was reported to me that the slurred speech had gone away. I visited the resident between 530-600 and did not notice any slurred speech. At that time I instructed the staff to continue to monitor the resident. I continued my rounds and was notified approximately one hour later that the resident's condition had declined and I instructed the resident and staff that (R35) could go the Emergency Department for further evaluation if it was his wishes. R28 was admitted to the hospital on [DATE] after being found to have a new acute infarction (a stroke). The hospital medical record documents .presented from Nursing home for slurred speech since last night. (Emphasis added.) Patient is a poor historian and due to speech, history is difficult to obtain. Per ED (emergency department) NH (nursing home) reported slurred speech since 11 pm last night, along with more weakness seen on right side. (Emphasis added.) Patient has history of [MEDICAL CONDITION]([MEDICAL CONDITION]/stroke) with residual left sided weakness. In ED he was found to have slurred speech, ams (altered mental status), left facial droop. Initially having right sided weakness but later was able to raise his right arm against gravity. Not a candidate for tPA given time line. According to the Stroke Association, A stroke occurs when a vessel in the brain is blocked by a blood clot or ruptures. A stroke caused by a clot is called an ischemic stroke; about 85 percent of all [MEDICAL CONDITION] in the United States are ischemic. The only FDA-approved treatment for [REDACTED]. Alteplase IV r-tPA works by dissolving the clot and improving blood flow to the part of the brain being deprived of blood flow. If administered within three hours (and up to four-and-a-half hours in certain eligible patients), Alteplase IV r-tPA may improve the chances of recovering from a stroke. A significant number of stroke victims don't get to the hospital in time for Alteplase IV r-tPA treatment; this is why it's so important to identify a stroke immediately. http://www.strokeassociation.org/STROKEORG/General/Why-Getting-Quick-Stroke-Treatment-Is-Important_UCM_ 0_Article.jsp Progress notes on 12/30/17 at 11:45 pm document Resident was found to have new acute infarction on MRI. Overall deconditioned and has weakness bilaterally. Resident was started on ASA (aspirin) 325mg and statin in hospital .Resident is to continue with OT (occupational therapy) PT (physical therapy) and now ST (speech therapy). Resident continues with slurred speech, received nectar thick liquids and dysphagic diet. On 2/14/18 at 9:05 am the facility provided the surveyor with a timeline of events that occurred. The timeline states 2230 (10:30pm)(This time was later clarified by the facility to be 8:30 pm)-Aide (not family) notified (LPN-K) that (R35) was having slurred speech. Upon assessment resident was able to follow simple commands such as smile and puff out checks. Upon puffing out cheeks and smiling resident's face was symmetrical with no signs of drooping. Resident was able to stick out tongue and move it from right to left without any complications. Resident was able to hold himself up with his right hand while using the sit to stand lift this is normal for resident as he has a history of left sided weakness. Upon taking medications and eating dinner, he did not have any difficulty swallowing. The (CNA-S) stated she heard another CNA state that (R35) 'was not making sense.' (CNA-S) went to (R35's) room to investigate. She also noted that he was 'not making sense.' (CNA-S) stated resident's speech wasn't necessarily slurred, but seemed different. (CNA-S) shared that her great grandmother had had a mini stroke in the past and she though that (R35's) speech was different but not like her great grandmother.(CNA-S) remembers that the LPN then assessed (R35) asking him to puff out his checks and complete other tasks. (CNA-S) watched as the assessments took place. After the assessments were completed LPN stated to (CNA-s) that the assessments showed that he was okay but to let her know right away if anything changed. (CNA-S) reported that nothing else was noted regarding (R35) for the rest of the night and that the LPN reported (R35's) speech to the RN during shift change. On 2/22/18, after the facility had been notified of the immediate jeopardy, the facility provided an additional timeline. The timeline states Clarification: On the original timeline it is stated that (CNA-T) first noted the speech change and spoke to (CNA-S) It was clarified by both (CNA-S ) and (CNA-T) that (CNA-S) was the only one to notice the change in speech on their shift. The timeline continues to state 2140 (9:40 pm)- Pain screening assessment was completed. Per charting -RESIDENTS ABILITY TO COMMUNICATE: able to communicate. Temp 98.4, Pulse 70. Respiratory Rate 18. (LPN-K) decided not to notify as resident's baseline was occasionally slurry, resident had had a long day, and resident's family had not noticed a change during their visit. (LPN-K) decided to place it on the 24 hour board to monitor. The surveyor noted there was no documentation of R35 having slurry speech prior to 12/27/17. LPN-K did not reference the interact tool in her interview with the surveyor. The timeline continues to state that at 11 PM LPN-K gave report to RN-L. (RN-L) completed rounds on resident and he appeared at his baseline. At 1 am (RN-L) checked on rounds as usual at 0100 (1am) Resident awoke easily. He was alert and responsive. Pupils were equally small bilaterally and reactive to light. No complaints were offered by resident. As per resident's usual, resident was not talkative during noc and slept at long intervals. Resident was able to answer simple questions and follow simple commands as usual. Resident appeared at baseline through cares. At 3 am (RN-L) check on rounds as usual at 0300 (3am). Resident awoke easily. He was alert and responsive. Pupils were equally small bilaterally and reactive to light. No complaints were offered by resident. As per resident's usual, resident was not talkative during noc and slept at long intervals. Resident was able to answer simple questions and follow simple commands as usual. Resident appeared at baseline through cares. (Note: There is no contemporaneous documentation of these assessments.) On 2/13/18 at 11:57 AM the surveyor attempted to contact RN-L. A voicemail was left. No return call was received. On 2/14/18 at 11:2 AM the surveyor attempted to contact RN-L. A voicemail was left. No return call was received. On 2/15/18 at 9:50 AM, after the facility had been notified of the immediate jeopardy, the surveyor interviewed RN-L. The surveyor asked RN-L why she had not documented her assessments noted in the timeline in the medical record. RN-L stated we had not noted anything unusual. The surveyor asked RN-L if she only charts if something is unusual. RN-L stated more often than not we are charting by exception than by the norm. The surveyor asked RN-L of what she was informed of in report. RN-L stated she recalled being told that 35's speech had been slurred, and that she believed it had first been noted at the end of the shift. The surveyor asked if she recalled when she first saw R35 on that shift. RN-L stated between 11 and 12:30 pm. On 2/22/18 the facility sent in additional information, obtained after being informed of the immediate jeopardy. Additional information provided on 2/22/18 included a signed statement by CNA-S dated 2/21/18. The statement states From the previous experiences I had had with (R35), he did not talk much. Mostly he only spoke when he needed something. The first time I remember working with (R35) on 12/27/17 was around 530 pm when I delivered his dinner. I believe his son was visiting. Something after dinner I noticed that (R35's) speech seemed different. I spoke so the other CNA on the hallway, (CNA-T) and asked her to check on (R35) to see if his speech was different. (CNA-T) stated that she did not see a difference. I told the nurse (LPN-K) and she stated that she had passed his medications earlier and had not noticed any speech slurring. However, she went to the room to evaluate him. Additional information provided from the facility on 2/22/18 included a typed statement from CNA-T dated 2/21/18, not signed, that stated (CNA-T) stated that she worked as a CNA on second shift on 12/27/17. She recalled that one of (R35's sons was visiting him during dinner time and no issues were reported. At around 8:30pm (CNA-S) asked her to go to (R35's) room to see if his speech seemed different. She remembered that she seemed tired, but he could speak to them and it was understandable. She stated that her shift on 12/27/17 was the first shift that she had worked with (R35), and she was not aware of his normal behaviors. She told (CNA-S) this, and (CNA-S) said that she would tell (LPN)-K just in case. Additional informed provided from the facility on 2/22/18 included a typed statement from LPN-K, dated 2/21/18. The statement states (CNA-S) came to me during med pass around 8:30pm on 12/27/17 and stated something seemed off about his speech. I recall that (R35's)son was visiting him earlier in the shift and no issues were reported to me from the family. I had just given (R35( his medications a few minutes prior, and he had swallowed his pills with no issues. I hadn't noted any changes at that time, but regardless I went to his room and evaluated him. He puffed out his cheeks, was able to support himself on the sit-to-stand lift, was able to grasp hand rails, dad normal pupil response, had normal vital signs, his face was symmetrical, and he was not drooling or had any facial drooping. I assisted (CNA-S) with his transfer from the toilet to the bed, and I could clearly understand him at the time. I did not feel that he had a significant change in speech. (The surveyor noted that on 2/13/18 at 12:42 pm the surveyor asked LPN-K if the slurred speech was different then his normal speech. LPN-K stated yes, the slurring was more pronounced.) I had completed a pain evaluation during the evening med pass prior to my change in condition evaluation. I noted that his speech was clear, and charted this in his pain evaluation at approximately 9:40pm. (The surveyor noted that LPN-K's pain screening assessment documentation on 12/27/17 at 9:40 pm documents 'RESIDENTS ABILITY TO VERBALLY COMMUNICATE: Able to Communicate.' The assessment does not document 'speech was clear'.) I checked (R35) later in the shift around 10:00pm, and he was sleeping. During shift change I reported to N[NAME] nurse (RN-L) that earlier in the shift a CNA reported he had a slight change in his speech. I wrote on 24 hour board to continue to monitor so that the nurses on the following shift would continue to monitor so that the nurses on the following shifts would continue to check on him. RN nurse manager (RN-Q) spoke to me on 12/28/17 at the beginning of my shift. (RN-Q) asked me what had occurred the previous night and I told her that a CNA had reported to me that (R35's) speech seemed different. I told her that I evaluated him and did not note any issues. (The surveyor noted that on 2/13/18 at 12:42 pm the surveyor asked LPN-K if the slurred speech was different then his normal speech. LPN-K stated yes, the slurring was more pronounced.) (RN-Q) educated me that I should chart any evaluation that I complete even if the evaluation indicates no issues. (RN-Q) instructed me to enter a late entry note so I entered a late entry regarding my data collection from the previous night . The facility's failure to provide the necessary care and services when R35 had signs and symptoms of stroke, created a finding of Immediate Jeopardy for R35 beginning on 12/27/17. Administrator-A was informed of the immediate Jeopardy on 2/14/18. The Immediate Jeopardy was removed on 2/14/18 when the facility implemented the following action plan. The deficienct practice continues at a scope and severity of a D (potential for harm/isolated) as the facility implements the following: ~ The facility assessed R35 for change in condition and initiated a facility assessment of all residents for changes in condition. ~ The facility reviewed the notification of changes policy and procedure and initiated education for all nursing staff on the use of INTERACT, when to report to the MD/NP/PA. ~ The medical director reviewed the facility's policy for consultation and contact with the physician and initiated training to all nursing staff. ~ The facility reviewed their nursing supervisor on call policy and procedure with staff and initiated training. ~ Each LPN and RN was educated on license parameters for each position. ~ The facility established an audit process to ensure implementation of plan and assessment and notification of residents experiencing changes in conditions and review through the facility QAPI process.

Based on observation, interview and record review the Facility did not ensure that 2 (Resident's #1 & #13) of 13 sampled Resident's received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with their comprehensive assessment and plan of care. · Resident #1 was observed to be in pain which he rated a 10 out of a scale of 1-10 during treatment of [REDACTED]. When given pain medication Resident #1 was not always reassessed as to the effectiveness of the medication. A comprehensive assessment for pain was not completed for Resident #1 on 7/28/15 per the facility's policy. This resulted in actual harm to Resident #1. · Resident #13 did not have a bowel movement documented in the medical record for 13 days and was assessed at being at risk for constipation. Findings include: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/6/15 at 10 a.m. Surveyor # observed Registered Nurse (RN)-K complete dressing changes to several wounds under Resident #1's abdominal folds and left and right groin. RN-K removed the old dressings to Resident #1's abdominal fold and groin wounds and applied a Dakin's solution (a type of hypochlorite solution. It is made from bleach that has been diluted and treated to decrease irritation. Chlorine, the active ingredient in Dakin's solution, is a strong antiseptic that kills most forms of bacteria [MEDICAL CONDITION]) soaked gauze to the wounds. RN-K then washed the left side wounds with sterile water. Resident #1 moaned loudly 3 times during the washing of the left side wounds. RN-K did not stop the treatment or question Resident #1 as to his pain when he was moaning so Surveyor # asked Resident #1 to rate his pain on a scale of 1-10 with 10 being the highest. Resident #1 stated it's at least a 10. RN-K stated that Resident #1's pain had been worse with the treatment the last couple of days. RN-K then proceeded to wash Resident #1's right side wounds with sterile water. Resident #1 moaned and yelled god help me and recited the Lord's Prayer which RN-K recited with him. RN-K stated that's the worst part when I have to dab. RN-K then stated, You're toughing it out, doing awesome. RN-K then applied the dressing to Resident #1's left groin and Resident #1 stated, I don't know how much more I can take. RN-K stated, We didn't hit the right time today for Resident (#1's) pain medication. RN-K then applied a dressing to Resident #1's right groin and abdominal fold. Resident #1 stated, Bring in that [MEDICATION NAME]. RN-K stated that Resident #1 got [MEDICATION NAME] at 5:30 a.m. and can have [MEDICATION NAME] very hour. RN-K then went to the treatment cart and told the nurse in the hall to bring Resident (#1) [MEDICATION NAME]. RN-K stated she would wait to do Resident #1's sacral treatment until the medication had time to take effect. On 8/6/15 at 11:45 a.m. Surveyor # observed Resident #1 receive treatment to his stage 4 sacral pressure ulcer. Upon entering the room RN-K asked Resident #1 what his pain level was on a scale of 1-10. Resident #1 stated it was a 10 but stated he wanted to get the treatment done. RN-K removed the old dressing and placed the Dakin's soaked gauze in the pressure ulcer. Resident #1 stated he was ok. RN-K then washed the pressure ulcer with sterile saline and Resident #1 stated that's enough. RN-K continued to dry the pressure ulcer with gauze. Resident #1 then stated to RN-K, Don't you want to give me any more medication? RN-K stated I can't. RN-K then packed Resident #1's pressure ulcer with the silver dressing, applied a foam top dressing and tape. During the placement of the dressing Resident #1 moaned loudly 3 times. After the observation Surveyor # Reviewed Resident #1's Medication Administration Record [REDACTED] On 8/6/15 Surveyor # reviewed Resident #1's current physician's orders [REDACTED]. On 8/6/15 at the 10 a.m. treatment according to Resident #1's orders he could have been given 2 [MEDICATION NAME] and an additional 10 milligrams of [MEDICATION NAME] for pain relief. On 8/6/15 at the 11:45 a.m. treatment according to Resident #1's orders he could have been given an additional 20 milligrams of [MEDICATION NAME] for pain relief. Review of Resident #1's most recent quarterly Minimum Data Set ((MDS) dated [DATE] indicates that Resident #1 is on scheduled and PRN pain management and also received nonmedication interventions for pain. The interview for the MDS with Resident #1 indicates that the pain is occasional at the time of the MDS but that it has affected Resident #1's functioning including his sleep and day-to-day activities. The numeric rating scale for Resident #1's pain on the MDS is 8 on a scale of 0-10. On 8/6/15 Surveyor # reviewed Resident #1's current care plan for pain dated 6/18/13 which read: Pain related to stage 4 pressure ulcer. Goal: expressed feelings of comfort or pain relief within reasonable time after pain medication administration. Approach: Administer pain medication per order, monitor/record medication effectiveness, document pain level using pain scale, note characteristics of pain, be attentive to nonverbal communication, encourage resident to ask for pain medication when needed. On 8/10/15 Surveyor # reviewed Resident #1's Comprehensive pain assessment dated [DATE] which read location: Sacrococcygeal open area. Pain at its worst: 4. What relieves pain oral [MEDICATION NAME]: rest. On 8/10/15 Surveyor # reviewed the pain medication notes for Resident #1 which indicated: · 7/30/15 at 5:49 a.m. 2 [MEDICATION NAME] administered for all over pain rated an 8. No documentation as to the effectiveness of the medication could be found. · 7/30/15 at 10:08 a.m. 2 [MEDICATION NAME] administered for all over pain rated a 10. No documentation as to the effectiveness of the medication could be found. · 7/30/15 at 10:30 a.m. 10 mg of [MEDICATION NAME] administered for all over pain rated a 10. No documentation as to the effectiveness of the medication could be found. · 7/31/15 at 5:40 a.m. 2 [MEDICATION NAME] administered for all over pain rated a 7. No documentation as to the effectiveness of the medication could be found. · 8/1/15 at 6:02 a.m. 2 [MEDICATION NAME] administered for pain. No documentation as to the effectiveness of the medication or the level of pain/location before administration could be found. · 8/1/15 at 9:55 a.m. 2 [MEDICATION NAME] administered for all over pain rated a 10. No documentation as to the effectiveness of the medication could be found. · 8/1/15 at 7:48 p.m. 2 [MEDICATION NAME] administered for all over pain rated a 10. No documentation as to the effectiveness of the medication could be found. · 8/3/15 at 3:59 a.m. 2 [MEDICATION NAME] administered for pain. No documentation as to the effectiveness of the medication or the level of pain/location before administration could be found. · 8/1/15 at 5:30 a.m. 10 mg of [MEDICATION NAME] administered for pain. No documentation as to the effectiveness of the medication or the level of pain/location before administration could be found. · 8/5/15 at 5:30 a.m.10 mg of [MEDICATION NAME] administered for all over pain rated an 8. No documentation as to the effectiveness of the medication could be found. · 8/5/15 at 7:37a.m. 2 [MEDICATION NAME] administered for all over pain rated a 10. No documentation as to the effectiveness of the medication could be found. · 8/5/15 at 9:38 a.m. 10 mg of [MEDICATION NAME] administered for pain. No documentation as to the effectiveness of the medication or the level of pain/location before administration could be found. · 8/5/15 at 8:22p.m. 2 [MEDICATION NAME] administered for back pain rated an 8. No documentation as to the effectiveness of the medication could be found. · 8/6/15 at 5:33 a.m. 2 [MEDICATION NAME] administered for all over pain rated a 7. No documentation as to the effectiveness of the medication could be found. On 8/10/15 at 12:05 p.m. Surveyor # interviewed Director of Nurses (DON)-C who stated that the nurses are not always documenting the pain medication effectiveness for Resident #1 after administering pain medication and they should be. On 8/10/15 Surveyor # reviewed the facility policy and procedure titled Pain Management, undated, which read: The screening pain screening form will be performed quarterly and if a score of 5 or greater is scored a comprehensive is needed. All as needed [MEDICATION NAME] will be documented on the pain flow sheet and follow up on pain control documented after 1 hour and again after 3 hours. On 8/10/15 Surveyor # reviewed Resident #1's Pain screening assessment dated [DATE] which was scored a 5. No follow up comprehensive pain assessment could be found in Resident #1's medical record per the facility pain management policy above. On 8/10/15 at 3:00 p.m. DON-C stated that a comprehensive pain assessment for Resident #1's pain screening of a 5 on 7/28/15 could not be found and should have been done. The above findings were shared with Adminstrator-B and Director of Nurses-C on 8/10/15 at 3:00 p.m. at the daily exit meeting. Additional information was requested if available. None was provided. 2.) Resident #13 has been residing in the facility since 05/14 with several admissions to the hospital with returns back to the facility. Per clinical record, Resident #13 is identified to be alert and oriented and able to make her needs known. Resident #13 receives several medications that can produce constipation such as [MEDICATION NAME] for pain, multivitamins and antidepressants. Resident #13 also receives medications to alleviate constipation, such as Senna tablets twice daily, Polyethylene [MEDICATION NAME] Powder twice daily and [MEDICATION NAME] suppositories as needed. A review of resident #13's clinical record noted per documentation of the progress notes dated 07/23/15 at 3:50 p.m.: Resident has not had a recorded bowel movement in 13 days. Resident was asked if she had any bowel movements at [MEDICAL TREATMENT]. Resident stated, no, I haven't and I haven't had a bm (bowel movement) for a week. Per Registered Nurse (RN)-K assessment: bowel sounds hyperactive in upper left and right quadrants. Bowel sounds hypoactive in lower right quadrant and absent in lower left quadrant and absent in lower left quadrant. upon palpation, distended, firm all quadrants and nontender. Per documentation, Resident #13 refused a suppository and an enema until tomorrow, tomorrow I will. A review of the Laxative Sheet that the certified nurse aide (CNA) document residents bowel movements, did show evidence that Resident #13 indeed has not had any bowel movements recorded back to June of 2015. The laxative sheet notes that the week of 06/29/15, no recorded bowel movements for 6 days. For the week of 07/06/15, no recorded bowel movements for 6 days. For the week of 07/13/15, no recorded bowel movement for 7 days. For the week of 07/20/15, no recorded bowel movement for 4 days. The days between 06/29/15 through 07/24/15 shows evidence that Resident #13 has not had a bowel movement recorded for a total of 24 days. A review of the facility undated, unsigned policy titled Bowel Regiment provided by Nursing Home Administrator (NHA)-B on 08/10/15 at 12:10 p.m. CNA's are to record bowel movements for each resident every shift on laxative sheet located in the CNA binder. CNA's should inform their nurse if any resident has not had a bowel movement in 3 days. All nurses are responsible for checking and reviewing the laxative sheet for any resident who has not had a bowel movement in 3 days. The policy further directs nursing to first offer milk of magnesia. If that is not effective, to administer a [MEDICATION NAME] suppository. If that is not effective the nurse is to obtain an order for [REDACTED].#5, Residents who frequently experience constipation should be reviewed for scheduling laxative medications or possible other dietary interventions such as prune juice, power pudding, etc. It was noted that Resident #13 was refusing suppository, however there was no evidence that the resident was offered nutritional interventions to assist in her constipation. It was noted that the [DIAGNOSES REDACTED].#13's care plan. The facility did not ensure that Resident #13 received the necessary treatment related to her bowel evacuation. There was no evidence that the physician was contacted to consult with regarding Resident #13's refusal of the suppositories and enemas or any nutritional interventions. This was shared with Director of Nursing (DON)-C and NHA-B.