Every finding on record at Oakwood Health Services

Based on interview and record review, the facility did not ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 7 of 7 residents reviewed (R7, R11, R39, R41, R44, R70, and R74).There was no documentation of non-pharmacological interventions for pain for R7, R11, R39, R41, R44, R70, and R74.Facility ran out of pain medications for R44.Findings include: Facility Policy titled, Pain Management, last revised on 08/09/2022, reads in part: The facility must ensure that pain management is provided to residents who require such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.Non-pharmacological interventions will include but are not limited to: Environmental comfort measures.loosening restrictive clothing.cold compress, warm shower/bath, massage.music, relaxation techniques, activities, diversions. Example 1 R74 was admitted to the facility on [DATE]. Most recent Minimum Data Set (MDS) reflects a Brief Interview for Mental Status (BIMS) score of 15/15 indicating R74 is cognitively intact. Pertinent diagnoses include hypertension, chronic kidney disease with heart failure, congestive heart failure, lymphedema, peripheral venous insufficiency, and dependence on other enabling machines and devices. Pertinent physician orders include lidocaine external patch, acetaminophen, tramadol, and document any non-pharmacological pain interventions attempted. 1. Heat 2. Cold 3. Positioning 4. Massage 5. Environmental Control 6. Imagery 7. Music 8. Distraction 9. Gentle Range of Motion (ROM) 10. Tens 11. Other- Specify in progress note 12. NA- Denies Pain Care plan includes focus of pain in the knees and hips with a goal of will express that pain management is within acceptable limits, and interventions including administer pain medication per orders and encourage/assist to reposition frequently to position of comfort. On 03/09/26 at 1:02 PM, Surveyor interviewed R74. R74 reported he has chronic pain in both knees and legs. R74 reported it sometimes takes a long time to receive pain medication when requested. R74 stated that no non-pharmacological interventions have been offered/tried since admission. Surveyor reviewed R74's Electronic Health Record (EHR). Physician orders for documenting non-pharmacological interventions in the treatment administration record (TAR) are blank since admission, indicating none were offered. Surveyor did not find any documentation of non-pharmacological interventions offered in progress notes when pain levels were obtained. Example 2 R44 was admitted to the facility on [DATE]. Most recent MDS reflects a BIMS score of 15/15 indicating R44 is cognitively intact. Pertinent diagnoses include peripheral vascular angioplasty with implants and grafts, polyneuropathy, history of stroke, and history of circulatory surgical procedure. Pertinent physician orders include oxycodone, acetaminophen, tizanidine, diclofenac sodium external gel, gabapentin, and document any non-pharmacological pain interventions attempted. 1. Heat 2. Cold 3. Positioning 4. Massage 5. Environmental Control 6. Imagery 7. Music 8. Distraction 9. Gentle ROM 10. Tens 11. Other- Specify in progress note 12. NA- Denies Pain Care plan includes a focus of pain in left leg related to fasciotomy and polyneuropathy with a goal of reduce episodes of breakthrough pain through next review date, and interventions including administer pain medication per orders and notify provider if pain frequency/intensity is worsening or if current analgesia regimen has become ineffective. On 03/09/26 at 1:46 PM, Surveyor interviewed R44. R44 reported the facility ran out of his oxycodone and needed to wait for a new script and delivery. R44 reported the facility does not offer any non-pharmacological interventions for pain. R44 reported R44 was not aware of the order for diclofenac topical pain gel, as R44 was never informed it was available and was never offered any. Surveyor reviewed R44's EHR. Physician orders for documenting non-pharmacological interventions in the TAR are blank since admission, indicating none were offered. Surveyor did not find any documentation of non-pharmacological interventions offered in progress notes when pain levels were obtained. The medication administration record (MAR) indicated that R44's diclofenac pain relieving gel was never administered. Progress note from 03/08/26 reads in part: Patient is currently out of Oxycodone and awaiting provider approval for new script. On 03/11/26 at 7:46 AM, Surveyor interviewed Registered Nurse (RN) D. RN D stated to monitor a resident's pain they ask the resident each shift to rate it. If unable to do so, they have the PAINAD assessment for non-verbal residents. RN D stated if giving as needed medication, they also do a follow up pain level and enter the number in the charting. RN D stated they do offer non-pharmacological interventions and believes they would just add that in a progress note. RN D stated if the interventions were ineffective, RN D would check on other options or readdress non-pharmacological. RN D stated if all of those interventions were still not effective, RN D would call the provider to have it addressed. RN D stated if RN D noticed a trend in continuous pain, RN D would call and update the provider after a week at most. RN D stated the facility does not run out of pain medications, but if they did, RN D would contact the provider, see if the medication is available in contingency, and if not, get a rush order from pharmacy. RN D stated the facility's main pharmacy delivers twice a day, so an urgent need would come from a local pharmacy. On 03/11/26 at 7:56 AM, Surveyor interviewed Medication Aide (MA) E. MA E stated to monitor/assess a resident for pain, MA E would ask the resident to rate their pain out of 10 if able. If not able, MA E would watch for body language and other non-verbal indications of pain. MA E stated that when giving an as needed medication they wait approximately an hour and return to follow up on the pain level and sooner if warranted. MA E stated if pain medications are not effective, MA E would inform the nurse and see if there are other options including a warm compress or creams for pain and that information would get documented in the progress note. MA E stated MA E has not come across pain medications that have run out, but MA E would inform the nurse and contact the pharmacy right away. On 03/11/26 at 9:57 AM, Surveyor interviewed Director of Nursing (DON) B. DON B stated it would be the expectation that nurses would complete a pain assessment, the MDS Coordinator would complete a pain interview, and daily the nurses would ask the resident or assess a resident for pain. DON B stated if a PRN medication was administered, they would wait about an hour or so and reassess the resident's pain level and this would be documented she believed in either the MAR or TAR. When asked if this was being completed, DON B stated, I would like to believe that. Non-pharmacological and gels and creams for pain management should also be offered. DON B stated that if a trend is noticed, the doctor will be updated on rounds or sooner if urgent. DON B stated they try to get medication scripts on time but if they don't, they will call pharmacy, see if the medication is available in contingency, or ask the doctor if there is an alternative until their medication is available. DON B stated the facility does have a fast run option for pharmacy if not available in house. Example 3 R11 was admitted to the facility on [DATE] with diagnoses that include unsteady on feet, heart failure, and stroke. R11 was hospitalized after a fall at home. R11 had a Brief Interview of Mental Status (BIMS) score of 11 out of 15 completed on 2/20/26 that indicated that R11 had moderate impaired cognition. On 03/09/26 at 3:06 PM, Surveyor interviewed R11 who reported that s/he has pain from when s/he fell at home. A pain assessment was completed by the facility on 02/23/26. The pain assessment notes R11's pain is occasional and ranges from 3 - 9 on a 0 to 10 scale and the location is in the neck and back. R11's care plan dated 02/20/26 identifies the following: ~Pain to spine evidenced by verbal complaints r/t fall at home ~Administer pain medication per MD orders ~Notify MD if pain frequency/intensity is worsening or if current analgesia regimen has become ineffective. Surveyor reviewed R11's physician orders, dated 02/20/26, which noted: Document any non-pharmacological pain interventions attempted. 1. Heat 2. Cold 3. Positioning 4. Massage 5. Environmental Control 6. Imagery 7. Music 8. Distraction 9. Gentle ROM 10. Tens 11. Other- Specify in progress note 12. NA- Denies Pain Surveyor reviewed R11's March 2026 medication and treatment records and found no documentation of nonpharmacological interventions tried. All areas were blank. There were number recorded under pain assessment where R11 reported pain 6 out of 10 days in March and rated the pain 2 or 4 and one time a 5 out of a 0 to 10 scale. Example 4 R39 was admitted to the facility on [DATE] with a diagnosis that included fracture of the sacrum, unsteadiness on feet, and age-related osteoporosis. Most recent MDS dated [DATE] indicated R39 had a BIMS score of 12 out of 15 that indicated that R11 had moderate impaired cognition. On 3/09/2026 at10:18 AM, Surveyor interviewed R39 who reported that she has pain from when she fell at home. R39 stated she has not been offered anything for pain relief besides occasionally ice, occasionally repositioning, and her pain medications. A pain assessment was completed by the facility on 02/13/26. The pain assessment notes R39's pain is daily pain and ranges from 4 to 7 on 0- 10 pain scale and the location is the sacrum. R39's care plan dated 2/13/26 identifies the following: -Pain to sacrum evidenced by facture.-Will express that pain management is within acceptable limits -Administer pain medication per MD orders-Implement non-drug therapies to assist with pain and monitor for effectiveness.-Notify MD if pain frequency/intensity is worsening or if current analgesia regimen has become ineffective.-Report nonverbal expressions of pain such as moaning, striking out, grimacing, crying, thrashing, change in breathing, etc. Surveyor reviewed R39's physician orders, dated 02/13/26, which included: -Tramadol HCL 25 mg by mouth every 6 hours as needed for severe pain-Lidocaine external patch 4%- Apply to buttock topically at bedtime for pain and remove in AM.-Document any non-pharmacological pain interventions attempted. 1. Heat 2. Cold 3. Positioning 4. Massage 5. Environmental Control 6. Imagery 7. Music 8. Distraction 9. Gentle ROM 10. Tens 11.Other- Specify in progress note 12. NA- Denies Pain Surveyor reviewed R39's medication and treatment records since her admission and found no documentation of nonpharmacological interventions offered. All areas were blank. R39's pain level was assessed every shift and with Tramadol given. Surveyor noted assessment of R39 reported pain a 5 or greater daily on a 0 to 10 scale since her admission. On 3/10/26 at 11 AM, Surveyor interviewed Licensed Practical Nurse (LPN) H, who stated non-pharmacological pain interventions might get documented in the progress notes. LPN H stated that when R39 is offered ice or any other non-pharmacological intervention, it probably doesn't get documented. Example 5 R70 was admitted to the facility on [DATE] with a diagnosis that included surgical after care following surgery on the digestive system, diverticulitis of the large intestine with perforation and abscess, intestinal bypass, fracture of the upper end of the right radius, and displaced fracture of the right ulna. Most recent MDS indicated R70 had a BIMS score of 12 out of 15 completed on 3/10/26 that indicated that R11 had moderate impaired cognition. On 3/10/2026 at 7:28 AM, Surveyor interviewed R70 who reported her pain is in her right wrist. R70 has a hard cast on her fractured right wrist and winces in pain when it is moved. R70 reported her pain has been as high as a 10 on a scale of 0-10 pain scale. Surveyor asked if any non- pharmacological interventions were offered to her. R70 replied that she usually tries to keep it elevated but could not say if other interventions have been offered besides her pain medications. Surveyor noted a pain assessment was completed by the facility on 3/6/26. The pain assessment notes R70's pain is occasional and ranges from 2 to 7 on a o-10 pain assessment scale. R70's care plan dated 3/5/26 indicated the following:-Pain [right upper extremity] RUE evidenced by rating/potential for pain [related to] r/t [right] R wrist [fracture]fx -Will express that pain management is within acceptable limits.-Administer pain medication per MD orders -Notify MD if pain frequency/intensity is worsening or if current analgesia regimen has become ineffective. Surveyor did not find non-pharmacological interventions for pain not addressed in care plan or Kardex. Surveyor reviewed R70's physician orders, dated 3/5/26, which included:-oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) *Controlled Drug*, give 5 mg by mouth every 6 hours as needed for pain rated 7-10/10 -Document any non-pharmacological pain interventions attempted. 1. Heat 2. Cold 3. Positioning 4. Massage 5. Environmental Control 6. Imagery 7. Music 8. Distraction 9. Gentle ROM 10. Tens 11. Other- Specify in progress note 12. NA- Denies Pain-Resident pain level every shift. Surveyor reviewed R70's medication and treatment records since her admission and found no documentation of nonpharmacological interventions offered. Surveyor noted R70 rated her pain a 7 out of 10 on three days since her admission. On 3/10/26 at 7:34 AM, Surveyor interviewed LPN H, who when asked if R70 was offered non-pharmacological interventions for R70's pain, LPN H replied R70 usually keeps her arm elevated and takes pain medication but was unsure if any other interventions were offered. Example 6 R7 was admitted to the facility on [DATE], and has diagnoses that include anxiety disorder, major depression, adult failure to thrive, pulmonary nodules, anemia, hypothyroidism, viral hepatitis, peripheral vascular disease, high blood pressure, unsteadiness of feet. R7's MDS assessment, dated 2/4/26, states that R7 is cognitively intact, has clear speech and understands what is being said. R7 can ambulate with therapy only, needs assist of one in a wheelchair for locomotion, and assist of 2 for all transfers and bed mobility. R7 care plan, dated 2/11/26, states: Focus: opioid use for pain management, with the intervention administering medications as ordered. R7's care plan does not include non-pharmacological pain interventions. R7's Treatment Administration Record (TAR) reviewed December 2025 through March 2026, states, Document nonpharmacological pain interventions attempted. 1. Heat 2. Cold 3. Positioning 4. Massage 5. Environmental Control 6. Imagery 7. Music 8. Distraction 9. Gentle ROM 10. Tens 11. Other- specify in progress notes. 12. NA- [NAME] pain as needed. This order is on the TAR starting 11/21/25 and discontinued on 1/27/26, 1/30/26 and discontinued 2/2/26 and started 2/3/26 and still active. On November 2025, December 2025, January 2026, February 2026, and March 2026 TAR reports, no documentation related to this order was completed. There is no order or documentation available in Certified Nursing Assistant (CNA) Kardex (plan of care) or Point of Care charting either. On 3/9/26 at 1:18 PM, Surveyor interviewed R7 who stated R7 gets pain medication for leg pain. R7 stated he was on a scheduled pain medication before R7 went into the hospital. R7 stated it changed when I got back, now it is when R7 asks. R7 states, I don't know why they changed it. If I don't watch the clock and wait, then my pain gets intolerable. R7 states I have to ask all the time. R7 stated right now my pain is tolerable but usually it is worse. R7 stated R7's pain is usually an 8 on a scale of 1-10, with 10 being the worst. On 3/11/26 at 7:53 AM, Surveyor interviewed CNA F who stated that CNA F does nothing related to pain management, there are no non-pharmacological pain interventions for R7, except reporting pain to the nurse. On 3/11/26 at 8:11 AM, Surveyor interviewed RN H who stated pain assessment is at least once a shift, sometimes that is on the Medication Administration Treatment Record (MAR) and sometimes the TAR for documentation. RN H stated that the high chronic pain residents will have scheduled analgesia like Tylenol by mouth or topical like diclofenac or lidocaine, we try those things first. RN H stated that we have people like R7 who are always an 8 and have oxycodone every 4 hours as needed. RN H stated R7 watches the clock and requests his oxycodone on the dot. Surveyor asked if R7 had any non-pharmacological pain interventions. RN H opened the MAR and identified there are non-pharmacological interventions on the MAR. RN H stated there is nowhere to document in the MAR so we should document in progress notes. RN H paused and read the order closer and stated, wait specify in charting is for the option titled other, there are numbers (way documentation happens in the MAR). RN H opened the order and identified that it was listed as PRN and does not pull up every shift. RN H stated RN H guesses it would just be documented if people are thinking of looking in PRN. RN H stated that orders are expected to be done, and actions are expected to be charted. RN H stated she is going to fix that in the MAR so it pulls up every shift. Example 7 R41 was admitted to the facility on [DATE] and has diagnoses that include polyosteoarthritis (arthritis of many joints), chronic pain syndrome, adult failure to thrive, high blood pressure, major depression, anxiety, restless legs and type 2 diabetes with diabetic neuropathy (nerve pain). R41's MDS assessment, dated 2/19/26, states that R41 is cognitively intact with clear speech and can understand what is being said. R41 needs the assistance of 2 for bed mobility, dressing, toileting, and requires an assist of 2 with a mechanical lift for transfers. R41 can feed herself after set-up and requires the assistance of 1 for hygiene and grooming. R41's care plan dated 12/26/25 states: Focus: Pain as evidence by reported generalized pain, restless leg syndrome. Date initiated 6/14/24 Revision 11/21/24. Intervention: Implement non-drug therapies (hot or cold therapy, repositioning) to assist with pain and monitor for effectiveness. Dated Initiated 11/21/24 Revision on 11/21/24. R41's MAR and TAR for December 2025, January 2026, February 2026, March 2026 do not have an order for non-drug therapies. On 3/11/26 at 8:04 AM, Surveyor interviewed CNA G who stated that R41 complains of pain when rolling, states our (CNA's) fingers feel pointy. R41 complains about her legs and one shoulder but only mentions it when we roll her. CNA G stated that R41 does not have non-pharmacological interventions as far as CNA G knows. CNA G stated if R41 complains of pain, we tell the nurse. On 3/11/26 at 8:11 AM, Surveyor interviewed RN H regarding non-pharmacological pain interventions for R41. RN H looked up R41's orders in the computer and stated no. Surveyor asked RN to look at R41's pain related care plan. RN H looked at care plan and stated it is on her care plan but not on her MAR. RN H is not sure how that happened. RN H opened the care plan history and identified a box was not checked that puts a care planned intervention on the MAR or TAR. RN H stated we have not been offering non-pharmacological interventions to R41; honestly, she wouldn't have accepted them anyway. On 3/11/26 at 10:25 AM, Surveyor interviewed Nursing Home Administrator (NHA) A who stated that non-pharmacological interventions sometimes are not going to suffice; in a perfect world we will try these interventions and then a med. NHA A stated it depends on the residents, whether they are open to attempting them, or are they going to push for pharmacological interventions. Surveyor told NHA A there are non-pharmacological interventions on the care plan or part of the MAR and no documentation for months that any were attempted. Surveyor asked what is your expectation for staff in response to the care plan. NHA A stated they follow the plan of care. Surveyor asked how do you know if they are following the care plan. NHA stated the expectation is that they document what tasks they are completing.

Based on interview and record review, the facility did not ensure ongoing assessment of the resident's condition and monitoring for complications before dialysis treatments for 2 of 2 residents reviewed (R1, R6).R1 and R6 did not have pre-dialysis weights performed. Previous dialysis day's weights utilized for majority of assessments.Findings include:Facility Policy titled, Hemodialysis, last revised on 09/10/23, reads in part: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis.This will include: The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments.nutritional/fluid management including documentation of weights.Example 1R1 was admitted to the facility on [DATE].Most recent Minimum Data Set (MDS) indicates a Brief Interview for Mental Status (BIMS) score of 14/15 indicating intact cognitive function.R1's pertinent diagnoses include hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end state renal disease, and dependence on renal dialysis.R1 has scheduled dialysis outside the facility on Mondays and Fridays.R1's orders include completing pre-dialysis assessment prior to treatments, and post-dialysis assessments upon return from treatment. Order in place to obtain weight prior to and after dialysis treatments on Monday and Friday.Surveyor reviewed R1's Electronic Health Record (EHR). Weights were not obtained prior to dialysis appointments. The previous dialysis day's weight was used in place of obtaining a new one. The weights were obtained upon return post-dialysis.Example 2R6 was admitted to the facility on [DATE].Most recent MDS indicates a BIMS score of 13/15 indicating intact cognitive function.R6's pertinent diagnoses include hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end state renal disease, type 2 diabetes mellitus with diabetic chronic kidney disease, and dependence on renal dialysis.R6 has scheduled dialysis outside the facility on Monday, Wednesday, and Friday.R6's orders include completing pre-dialysis assessment prior to treatments, and post-dialysis assessments upon return from treatment. Order in place to obtain weight prior to and after dialysis treatments on Monday, Wednesday, and Friday.Surveyor reviewed R1's Electronic Health Record (EHR). Weights were not obtained prior to dialysis appointments. The previous dialysis day's weight was used in place of obtaining a new one. The weights were obtained upon return post-dialysis.On 03/10/26 at 8:32 AM, Surveyor interviewed Certified Nursing Assistant (CNA) C. CNA C stated CNA C was not sure when the dialysis residents got weighed but was pretty sure it was before they leave for the appointment. CNA C stated the nurses just tell them when they need a weight obtained and they get weights on everyone the first of the month and on shower days.On 03/10/26 at 8:43 AM, Surveyor interviewed Registered Nurse (RN) D. RN D stated for dialysis residents, vitals signs are checked before and after dialysis. RN D stated there is a pre-dialysis and post dialysis assessment that is to be completed. RN D stated RN D wasn't sure if one or both residents required a weight before dialysis but they both required weights after returning from dialysis.On 03/10/26 at 8:38 AM, Surveyor interviewed Director of Nursing (DON) B. DON B stated the expectation for dialysis residents would be for the nurses to complete a full set of vitals including weights, before and after dialysis appointments. DON B stated the nurses would obtain the vitals and may ask the CNAs to obtain the weight. DON B acknowledged Surveyor's record review of unobtained weights prior to dialysis appointments.

Based on observations, interviews, and record reviews, the facility did not ensure that a resident receives appropriate treatment and services to prevent urinary tract infections to the extent possible for 1 of 3 reviewed. (R20)-R20 has a suprapubic catheter, and it was not kept below the bladder level.The facility policy titled, Catheter Care, dated 03/15/23, indicates drainage bags are to be located below the level of the bladder to discourage backflow of urine. There is no mention of proper tubing placement. R20 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, retention of urine, dysfunction of bladder, cystostomy, and history of MRSA. R20's Minimum Data Set (MDS), dated [DATE], indicated that R20 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 indicating that R20 had moderately impaired cognition. R20's care plan dated 08/15/25 notes, Use of indwelling urinary catheter suprapubic needed due to neurogenic bladder secondary to MS. R20 is dependent on staff for eating, bed mobility, transfers using a mechanical lift, and toileting/bed pan and catheter management. On 03/09/2026 at 1:53 PM. Surveyor interviewed R20's family member who was concerned that R20 gets frequent urinary tract infections (UTI). Surveyor observed R20's catheter tubing was above bladder level while R20 was up in Broda chair and hanging down in a coil that would not allow proper drainage. On 03/10/2026 at 6:42 AM, Surveyor observed R20's Foley catheter tubing below the bladder level and looped off the side of the bed hanging down. (It was not looped on top of the bed to allow adequate drainage.) The clip was not secured to anything. On 03/10/2026 at 8:04 AM, Surveyor observed Certified Nursing Assistant (CNA) I and CNA J providing care on R20. Both CNAs assisted with morning care that included suprapubic catheter care. Surveyor asked the CNAs about the catheter tubing. CNA J stated it is supposed to be coiled on the bed. CNA J then moved the tubing onto the bed, and a significant amount of urine began pouring into the drainage bag. After the cares were finished, CNAs applied a Hoyer sling under R20, hooked up sling to the lift, then attached the urinary drainage bag to the top hook on the lift that was approximately 1 1/2 feet above R20's bladder. CNAs finished the transfer and lowered R20 onto a Broda chair. CNA J then took the drainage bag and clipped it by the foot of the Broda chair. The tubing was coiled in a downward loop. Surveyor asked the CNAs if they felt the urine would drain well with the tubing positioned that way. CNA J stated it probably would not, then clipped the bag under the seat of the chair and ensured the tubing was positioned to allow the urine to flow freely into the bag. Surveyor reviewed R20's physician orders since admission and found R20 was treated for a UTI from 1/9/26 to 1/19/26 with Cipro for UTI. There were no other UTIs found in the record. On 03/10/2026 at 9:21 AM, Surveyor interviewed Director of Nursing (DON) B and asked what should be done with tubing when a resident with a catheter is in bed or chair. DON B stated the tubing should be on the bed and clipped to the sheet and tubing should always be placed to allow the urine to flow into the bag. Surveyor then asked where the catheter bag should be during a transfer with a Hoyer lift. DON B stated it should be hooked low on the lift and below the bladder level. Surveyor explained what was observed and DON B stated that was not proper and will educate the staff.

Based on observations, interviews, and record review, the facility did not provide special eating equipment and utensils for residents who need them when consuming meals for 1 of 17 residents reviewed. (R14)R14 requires the use of a divided plate, built up utensils, and a nosey cup. R14 was not provided with built up utensils or the nosey cup during lunch.R14 was admitted on [DATE] with diagnoses that include dementia, stroke, abnormal posture, dysphagia, and diabetes. R14's most recent Brief Interview of Mental Status (BIMS) score was 0 of 15 which indicates R14 had severe cognitive impairment. R14's care plan with a revision date of 01/27/26 notes R14 is at risk for nutritional status due to diabetes and dementia. Interventions include set up assistance and to encourage to use divided plates, nosey cup, built-up utensils and clothing protector. On 03/09/26 at 12:17 PM, Surveyor observed R14 in the dining room using a divided plate, and regular cup and utensils. Certified Nursing Assistant (CNA) K was feeding R14. At 12:46 PM, Surveyor reviewed R14's dietary card that noted adaptive equipment needed was divided plate, nosey cup, and built-up utensils. Surveyor asked CNA K if R14 was to have the adaptive equipment of the nosey cup and built-up utensils, and CNA K said yes and she will go grab them. CNA K then retrieved the nosey cup and gray handled built-up silverware. On 03/10/26, Surveyor interviewed Dietary Manager L and asked what the expectation would be for staff to provide adaptive equipment at mealtime. Dietary Manager L stated that all staff should be following what is on the residents' tickets.

Based on observation, record review, and interview, the facility did not ensure drugs and biologicals were labeled with an open date/expiration date in accordance with currently accepted professional principles for 1 of 1 resident (R) (R11).Facility did not have an open/expiration date label on R11's opened bottle of Roxanol.Findings include:On 03/10/2026 at 9:38 AM, Surveyor observed medication cart on Aspen unit. Surveyor observed in narcotic box R11's Roxanol 20mg/ml liquid bottle. Surveyor observed R11's Roxanol liquid bottle opened with no open date label. Surveyor asked Medication Aide (MA) E if it is normal process for liquid controlled substances to not be labeled once opened. MA E reported that R11's Roxanol bottle should have been labeled with an open date label. Surveyor asked MA E when MA E's last dose was given. MA E reported after looking at R11's Medication Administration Record (MAR), R11 received Roxanol second dose today on 03/10/26 at 3:00 AM. On 03/10/2026 at 3:52 PM, Surveyor interviewed Director of Nursing (DON) B and asked DON B for expectation of open liquid-controlled substance such as Roxanol being labeled. DON B reported to Surveyor that all staff are to label any liquid bottles that are opened with the open date so that staff know when it will expire and to reconcile appropriately with controlled substances. DON B reported that someone should have labeled R11's bottle once opened. DON B reported to Surveyor that DON B will discard the open unlabeled bottle and replace it with a new one.

Based on observations, interviews, and record review, the facility did not determine safe self-administration of medications for 1 out of 17 residents (R) reviewed (R39).Surveyor observed R39 to have a cup of medications on the bedside table sitting in front of her while she was sleeping in her chair. R39 did not have an assessment for self-administration of medications, and R39 did not have a physician's order for self-administration.This is evidenced by: The facility's policy titled, Medication Administration, Section 7.3, Self-Administration by Resident dated 1/26, states in part, . Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the medications are appropriate and safe for self-administration. The facility's policy titled, Medication Administration, Section 7.1, General Guidelines dated 1/26, states in part, 13. Explain to resident the type of medication being administered and the procedure. R39 was admitted to the facility on [DATE] with diagnoses that included: fracture of the sacrum, age-related osteoporosis, and unsteadiness on her feet. R39's Minimum Data Set (MDS), dated [DATE], indicates a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating R39 is cognitively intact. On 3/10/2026 at 10:25 AM, Surveyor was walking past R39's room and noted R39 had medication in a med cup on a tray table in front of her. R39 was asleep and did not wake up when Surveyor knocked on her open door. On 3/10/2026 at 10:27 AM, Surveyor interviewed Licensed Practical Nurse (LPN) H, who reported doing the medication administration for hall B. LPN H reported there were no residents in hall B that would be considered able to self-administer their medications. Surveyor asked LPN H how she would know when it is appropriate to leave medications in a resident's room. LPN H stated it would be in the medication administration record (MAR). LPN H stated did med pass in B hall and she thought all residents took their medications. LPN H and Surveyor together went to R39's room. R39 had three pills in the medication cup in front of her on the table. LPN H woke R39 and asked why she hadn't taken her medications. R39 stated she was concerned and wanted to know what the medications are because some are making her dizzy. LPN H identified R39's medications as vitamin D, Senna plus (stool softener), and her torsemide (diuretic). R39 then took her medications one at a time. On 3/10/2026 at 11:00 AM, Surveyor interviewed LPN H who stated she had not gone through R39's medications when giving them this morning. LPN H stated she had watched R39 put her med cup up to her mouth to take her medications. Surveyor asked if LPN H thought R39 had spit them out. LPN H stated, she didn't know but, I probably should have stayed and watched her to make sure she swallowed them. On 3/10/26 at approximately 11:30 AM, Surveyor interviewed R39 who stated she is frustrated with the nurses and wants to know what she is taking for her medication because she's not sure if they are giving her medications that she does not want. R39 stated she has told several nurses this and they don't listen to her. R39 also reported she prefers to take her medications with applesauce and takes one pill at a time. On 3/11/2026 at 10:17 AM, Surveyor interviewed DON B who stated residents who request to self-administer meds would require a provider order and an assessment to self-administer. DON B agreed that nursing staff should be providing residents the knowledge on what type of medication they are being given if the resident asks. Surveyor informed DON B that LPN H admitted she did not explain the medications given or ensure R39 swallowed her oral medications safely. DON B replied, yes, the nurse should have ensured that residents take their medications.

Based on interview and record review, the facility did not ensure 1 resident (R39) of 5 medication administration observations was fully informed of but not limited to; resident rights and required medication information with options as requested by R39 prior to administering R39's medications during medication administration. Registered Nurse (RN) N did not provide information as requested by R39 before administering questionable medications that R39 had concern for.Findings include: Facility policy titled Medication Administration, last revised 01/26, stated in part, .medication administration #13. Explain to resident the type of medication being administered and the procedure. On 03/11/2026 at 7:14 AM, Surveyor observed RN N entering R39's room. RN N placed medications on the table. R39 asked RN N where R39's applesauce is as R39 takes medications with applesauce. RN N reported that kitchen did not have applesauce, but RN N brought chocolate pudding instead. R39 reported that R39 did not want chocolate pudding. R39 complained of not wanting to take medications because R39 does not know what medications R39 is on. R39 stated, They have changed my medications so much that I don't know what I am on anymore, and it's frustrating. Something is causing me to be dizzy. I reported this to staff the other day, and it keeps happening, so I really want to know what medications I am on before taking them. RN N reported to R39 that RN N was unaware that R39 was complaining of being dizzy. RN N stated to R39, I can make a list of medications for you explaining what you are taking, but I cannot leave the room until you take medications. R39 seemed discouraged, looked at RN N, and looked at medication cup. R39 then proceeded to take one pill out at a time to swallow. R39 took two pills then accidentally dropped two more pills on the floor. RN N stated, I will need to go get new meds for you since these dropped. R39 grabbed another pill out of medication cup and asked RN N what the medication was. RN N stated, I am not entirely sure, but I think it is your losartan blood pressure med. R39 looked confused and stated, Oh, ok I guess. During medication administration, R39 began to have a nosebleed. RN N handed R39 a Kleenex. R39 stated, Yea I am having a bad nosebleed, I guess. RN N observed R39 finish medications. RN stated to R39, I am going to get a set of vitals since you have a nosebleed. Surveyor observed RN N exit R39's room. On 03/11/2026 at 7:21 AM, Surveyor observed RN at medication cart. Surveyor made RN N aware that RN N did not prepare R39's medications with losartan in the medication cup and the order for losartan is at bedtime not morning time. Surveyor asked RN N to clarify where the losartan medication came into play during medication administration observation. RN N stated to Surveyor, Oh you're right I did not administer losartan. The pill must be torsemide then that I administered. RN N then walked into R39's room with Lidocaine patch and other medications that had dropped on the floor. RN N administered medications to R39 and exited room. Surveyor did not observe RN N explain medications to R39 or identify the accuracy of what medication R39 took that was potentially called losartan. On 03/11/2026 at 7:27 AM, Surveyor interviewed RN N and asked what RN N's process is for educating R39 on medications that R39 does not know she is taking or correcting the misinformation about the losartan given. RN N reported that RN N will need to write a list for R39 down to show R39 what she is taking. RN N reported that RN N should have probably completed the education to R39 prior to having R39 taking medications but did not. On 03/11/2026 at 10:47 AM, Surveyor interviewed Director of Nursing (DON) B and asked expectation of RN N to educate R39 on medications prior to making R39 take medications when R39 did not want to due to concern of dizziness. DON B reported that RN N should have printed the MAR and educated R39 before administering medications. DON B reported to Surveyor that Assistant Director of Nursing (ADON) O will print a MAR and explain medications to R39 right away. Surveyor observed ADON O print R39's MAR and exit DON B's office.

Based on record review and interview, the facility did not ensure employees were screened for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 1 of 8 employees reviewed.The facility did not ensure their abuse policy was implemented when one employee's background information disclosure (BID) was not obtained before employee started working at facility. (LPN M).Findings include:The facility policy, titled Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, last revised 01/26, stated in part, .Employee screening and training: a. Before new employees are permitted to work with residents' board registrations and certifications regarding prospective employees' backgrounds will be checked. d. A criminal background check will be conducted on all prospective employees as provided by the facility's policy on criminal background checks.On 03/11/26 at 10:14 AM, Surveyor reviewed 8 random staff Background Information Disclosures (BID).Licensed Practical Nurse (LPN) M was hired on 01/29/26. Surveyor found BID dated 09/13/24 with question #4 answered, Yes, lived in Minnesota from 2001-2021. Surveyor did not find a background performed for the state of Minnesota prior to LPN M working at facility. Surveyor did not find an updated BID form for facility to run an updated background upon LPN M's hire. On 05/06/25 at 11:42 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked where LPN M's BID, DOJ, and IBIS were. NHA A indicated that somehow LPN M's Minnesota background was missing when there were role changes in the facility. NHA A reported to Surveyor that the background will be completed today right away since it was not performed upon LPN M's hire date.

Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 out of 3 residents (R) observed for wound care (R70) Staff did not change gloves or perform hand hygiene during observation of wound care.R70's wound suction tubing was unplugged, and the open end of suction vacuum tubing was touching the floor. Staff did not clean or disinfect the tubing end prior to reconnecting to clean wound suction dressing. Findings include:The facility policy titled, Personal Protective Equipment, revised 3/17/2023, states in part, 4. Indications/considerations for PPE use: a. Gloves:. iv. Change gloves and perform hand hygiene between clean and dirty tasks, when moving from one body part to another, when heavily contaminated, or when torn.The Center for Disease Control (CDC) wound care guidelines states in part, Emphasize strict infection control through hand hygiene, proper use of personal protective equipment (PPE), and aseptic techniques to prevent cross-contamination. Ensure clean environments for wound care and prevent exposure to dirty water or surfaces.R70 was admitted to the facility on [DATE] with a diagnosis that included, encounter for surgical after care following surgery on the digestive system. R70's orders included, Wound Vac - Apply vacuum-assisted closure device at 125 mmHG with green foam to abdomen, without bridge dressing, and transparent semipermeable cover dressing every day shift every Tue, Thu, Sat and as needed.On 3/10/26 at 6:54 AM, Surveyor observed Licensed Practical Nurse (LPN) H, perform R70's surgical wound change. During R70's wound care dressing change, Surveyor observed LPN H wipe stool from R70's uncovered colostomy stoma, and then without changing gloves or performing hand hygiene, LPN H proceeded to grab R70's suction tubing that had remained attached to the suction machine on one end but the other, unattached end had been lying on the floor under R70's bed. LPN H proceeded to plug the unattached end to the newly applied wound vacuum tubing. On 3/10/26 at 7:25 AM, Surveyor interviewed LPN H, who stated she didn't realize the open tubing had touched the floor.On 3/10/26 at 9:22 AM, Surveyor interviewed Director of Nursing (DON) B, who stated the expectation would be that the suction hose end that had touched floor would have been cleaned off with an alcohol prep pad before reconnecting to the resident's wound vac. DON B agreed LPN H should change gloves and use hand hygiene after cleaning stool from R70's colostomy stoma site and before reconnecting suction tubing.

Based on record review, observation and interview, the facility did not ensure the residents remain free of possible accidental hazards. Facility did not ensure staff were applying the correct size Hoyer (mechanical full body lift) sling to prevent accidents for 1 of 10 residents (R) reviewed. (R3). Certified Nursing Assistants (CNA) used a size large instead of the care planned size medium Hoyer sling for R3. This occurred after nursing staff received education and skill checks within the last month. Findings include: Facility policy titled, NSG-Save Resident Handling and Transfers, dated 08/05/22, states: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Resident lifting and transferring will be performed according to the resident's individual plan of care. R3 was admitted to the facility on [DATE] with diagnoses including right sided paralysis following a stroke, right hand contracture, neglect syndrome, and dementia. R3's care plan, dated 04/28/25, indicates that R3 is cognitively impaired and is rarely/never understood. R3 requires the use of a purple (medium) sized sling for all Hoyer transfers. R3 is dependent on staff for all position changes and transfers. R3's medical record, dated 06/02/25, indicates R3's weight was 134.4. R3's weight according to manufacturer's guidelines identifies that only a purple (medium) sling should be used. On 06/03/25 at 12:16 PM, Surveyor observed R3 sitting in the dining room in a broda chair with a green sling under him. Surveyor asked CNA C to identify R3. Survey asked if CNA C were training, where would a new staff member go for directions on how to care for R3. Surveyor followed CNA C down to R3's room and opened the closet to show Surveyor the plan in the closet. Surveyor asked CNA C to read how to transfer R3. CNA read from the plan, Assist of 2, Full body mechanical lift, size medium Purple full body or divided split leg sling. CNA C also stated another place to look is on the computer in the hallway where the CNAs chart. CNA C demonstrated the plan there also stated the same as mentioned above. Surveyor asked CNA C to follow her to the dining room, look at R3, and asked if there were any concerns. CNA C stated, Oh no! It's green! Surveyor asked CNA C if education and skill checks were done. CNA C stated they were just done in the last month or so and did not know how this could have happened. At 12:32 PM, Surveyor interviewed Nursing Home Administrator (NHA) A. Surveyor asked NHA A how they ensure staff are competent and follow the plan of care. NHA stated they just educated and completed skill checks on the nursing staff. Surveyor then informed Nursing Home Administrator (NHA) A on the finding noted above. On 06/03/25 at 1:12 PM, NHA A informed Surveyor that all residents that require Hoyer lifts were checked for correct sling size, and all but R3's sling were correct.

Based on interview and record review, the facility failed to protect the resident's right to be free from mental abuse by staff. This affected 1 of 3 residents (R1) reviewed for mental abuse. Staff held R1 down and forced R1 to be catherized against her wishes. As a result, R1 experienced severe trauma and fear, stating she did not feel safe in the facility and requested to be removed from the facility. The facility's failure to ensure R1 was free from abuse created a finding of immediate jeopardy that began on 2/01/25. Nursing Home Administrator (NHA) A, Director of Nursing (DON) B and [NAME] President of Success (VPS) G were notified of the immediate jeopardy on 2/12/25 at 3:32 PM. The immediate jeopardy was removed 02/01/25 and corrected on 02/03/25. Based on this determination, this citation is being cited as past noncompliance. This is evidenced by: Surveyor requested and received the facility policy titled Abuse, Neglect and Exploitation dated 7/15/2022. The facility policy states in part, Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse. Abuse means the willful infliction of injury, unreasonable confinement. Resulting in .pain or mental anguish .Instances of abuse for all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict harm. Mistreatment means inappropriate treatment .of a resident. Policy Explanation and Compliance Guidelines: The facility will develop and implement policies and procedures that: ~Prohibit and prevent abuse . Identification of abuse . ~The facility will have written procedures to assist staff in identifying abuse . ~Possible indictors of abuse include .physical abuse of a resident observed .psychological abuse of a resident observed .sudden unexplained changes in behavior and/or activities such as a fear of a person or place . R1 was admitted to the facility on [DATE] with primary diagnosis of Parkinson's disease. R1 was her own decision maker. R1's most recent significant change in status Minimum Data Set (MDS) conducted 1/21/25, noted resident understands, is understood and has unclear speech. R1 is cognitively intact with indicators of depressed mood. R1 had no behavioral symptoms, no hallucinations and no delusions. R1 required substantial assistance for bed mobility, transfers and hygiene. R1's care plan noted focus areas as follows: ~Resistive/non-compliant with treatments/care (refusing to reposition self while in recliner) r/t (related to) belief treatment is not needed. Interventions: Provide education about risks of not complying with therapeutic regimen. Initiated: 9/23/24. ~Difficulty communicating r/t Parkinson's disease. Goal: Needs will be met with comfort and dignity. Initiated: 8/09/24 Interventions: Provide reassurance and patience communicating with resident, repeat information as needed. ~At risk for changes in mood r/t situational depression. Goal: Will maintain involvement with adl (activities of daily living) performance and social activities. Initiated: 8/09/24 Interventions: Mood assessment is indicating 5/mild depression. Resident does not have a diagnosis of mental health condition . Assess for physical/environmental changes that may precipitate change in mood. Offer choices to enhance sense of control. ~Added on 2/03/25: At risk for re-traumatization of past event or experience where reminders/triggers of event may cause behavioral changes or emotional distress. Other: having a medical procedure done to her that she did not want done. Initiated 2/03/2025. Goal: Reminders/triggering events will be avoided with minimal impact during her stay within the facility. Approaches: Provide a safe environment. Remove/avoid situations that may trigger re-traumatization. R1's Psychosocial/Trauma Informed Care Assessments/Observations since R1's admission note the following in part, 8/09/24: Prior Trauma or hx/dx (history/diagnosis) pstd (post-traumatic stress disease)? None of the above. Other concerns: none. 10/28/24: Prior Trauma or hx/dx (history/diagnosis) pstd (post-traumatic stress disease)? None of the above. Other concerns: none. R1's trauma screen, dated 1/20/25, states in part, (check all those that apply) Does resident have any of the following that may affect her approach to care? Dx or Hx (diagnosis or history) of PTSD: unchecked Prior trauma: unchecked Newly identified trauma: unchecked None of the above: checked. Surveyor reviewed the Facility Reported Incident (FRI) with the following noted: Date occurred: 2/01/2025 Time occurred: 2:00 PM Briefly Describe the Incident: On 2/01/2025 it was reported [RN C] allegedly performed a straight catheterization on resident [R1], who was not in agreement. [RN C] directed two CNA's to assist her in the procedure [CNA D and CNA E]. An investigation was immediately begun. The accused employees have been suspended pending investigation. [R1] has a BIMS (brief interview of mental status) of 15 (cognitively intact) and is her own healthcare decision maker. [R1] is currently safe in the center and free from injury. Police department was contacted at 3:21 PM. Re-education of staff regarding abuse began on 2/01/2025. R1's trauma screen, dated 2/03/25, states in part, (check all that apply) Description: [R1] had a medical procedure done to her Saturday February 1, that she did not want done. [R1] reported that the nurse did that to me and those 2 girls held me down. [R1] reported she does not feel safe. Writer suggested a move to another hall and [R1] stated, That would probably help. Experience: Did any of these events bother you? Yes Comment on events resident was bothered by: [R1] is currently feeling unsafe due to the recent event that happened to her. Treatment: [R1] was happy with the idea of a room move. She feels that will help her feel safer. Additional comments: This is a new event for [R1], she will have her mood monitored for any significant changes . R1's nurse's notes from 1/29/25 at 12:42 PM state in part, Resident questioning if meds (medications) were given after given, repeatedly asking for duloxetine (antidepressant) and calling staff liars when 1:1 provided and reassured medications were given. Asking for pain meds for right arm pain. Offered Tylenol-refused. Voltaren gel applied, resident wiped off volteran gel with Kleenex. Weepy at times. Repositioned for comfort. Added to MD list of residents to be seen at next visit regarding right arm pain. Trying to use communication board. Several nurses offering meds-making suspicious comments 'no you didn't you are lying.' Nurse's note from 1/30/25 at 5:37 AM state in part, Resident assisted to the bathroom and after toileting said something inaudible, so writer asked resident to use communication board and she pin pointed HURTPEE, asked how she rates her pain and pin pointed. Tylenol given Voided a good amount and has not been frequenting the bathroom this shift .Encouraged to drink cranberry juice did not show any behavior such as crying or anger .AM nurse will be made aware . Nurse's note from 1/30/25 at 8:43 AM states in part, Provider contact: Reporting dysuria (discomfort when urinating), weepy with bathroom use/transfer this am, VSS (vital signs stable). Incontinent of urine. Provider response: Call back to request order to check for UTI. Physician Order dated 1/30/25: U/A (urinalysis), UC (urine culture) if positive due to dysuria for possible UTI (urinary tract infection) (may cath (catheter) if unable to do a clean catch) Situation/Change in condition: BP (blood pressure): 116/58, Pulse: 81, RR: 16.0, Temp: 98.8, increased confusion, other behavioral symptoms, painful urination Nurse's note from 1/30/25 at 7:00 PM states in part, On follow up for resident complaint of burning with urination. Status: VSS afebrile (vital signs stable without fever) has been pleasant and cooperative with staff this shift, no frequency, urgency or foul odor with urination. Attempt at urine catch was contaminated. No noted discomfort with void. Nurse's note form 1/31/25 at 6:54 PM states in part, Awaiting UA cultures, WBC (white blood cells) present, negative for bacteria and nitrates .refused dinner .trying to stand by self .witnessed fall . Nurse's note from 1/31/25 at 10:57 PM states in part, UA results received .nitrates negative, no bacteria, WBC's 21-50 awaiting culture Nurse's note from 2/01/25 at 7:20 AM states in part, UA sent and positive for WBC, no bacteria or nitrates, awaiting culture results. No urinary complaints noted on noc (night) shift. Nurse's note from 2/01/25 at 1:55 PM states in part, Tele-Health Visit (physician visit): RN reporting urine culture grew 10-15,000 mixed genital flora likely contamination and this was culture result report. Patient was having some dysuria on Thursday not on antibiotics. Spoke with patient on the phone today having some dysuria but no urgency/frequency, no fever, chills or abdominal pain. Discussed with RN to get another UA with urine culture, no need antibiotics in the meantime. Surveyor reviewed the facility Criteria for Infection Form-Urinary Tract Infections which notes: Residents without an indwelling Catheter: Resident Exhibits: Fever greater than 100.0 of 2.4 degrees over baseline for 2 instances in past 12 hours And 1 or more: Dysuria, urgency, frequency, suprapubic pain, gross hematuria, flank pain, urinary incontinence, shaking/chills Resident meets criteria to order urine culture or does not meet Criteria. Of note, nurse's notes show no evidence R1 had a fever thus she did not meet criteria to order a urine culture and have the need for a straight catheterization procedure. Surveyor noted no nurse's note for the event that occurred on 2/01/24 at 2:00 p.m., that was described in the facility self report. Nurse's note from 2/01/24 at 8:59 PM states in part, Behavior as usual, no increased pain levels noted. Nurse's note from 2/02/25 at 1:08 AM states in part, Vital signs stable, rates pain at a 4 per communication board but did not want Tylenol, resting in recliner. Nurse's note from 2/02/25 at 6:06 PM states in part, Toilet without complaints of burning .no increased pain. UA returned from lab-final report says negative . Nurse's note from 2/03/25 at 11:18 PM states in part, Follow up to room change, VSS moved to a new room today with a new roommate, adjusting well to change. Nurse's note from 2/04/25 at 4:44 AM states in part, Has been sleeping well so far tonight in her new room . no complaints of pain or discomfort noted . Nurse's note from 2/04/25 at 9:53 PM states in part, Resident crying that she doesn't like room and does not want to be in it. Late entry nurse's note written by Director of Nursing (DON) B: Effective 2/05/25 at 5:26 PM states in part, Writer informed by [VPS (Vice President of Success) G]: resident stated she desired to go to the hospital to be in a place she felt safe. Resident told writer and MSW (Social Worker) earlier in the day that she feels safe in the facility, however this evening she wishes to be removed and be sent to the hospital. I did speak with resident before call to EMS (emergency medical services), I asked her again if she wished to go, to which she said yes. I asked if ok to accompany her to ED (emergency department) for continuity of care .resident clearly indicated it was ok with her transferred via a stretcher and EMS . Surveyor received and reviewed R1's skin assessments post incident which noted no new skin impairments. Surveyor reviewed R1's Hospital Internal Medicine Admission Note which states in part, On 2/05/25 at 7:34 PM: Chief Complaint: Generalized pain all over, patient has dementia that has worsened over past few months. History of present illness: patient having dementia with progressive delirium, starting to have intermittent hallucinations, but is still technically her own person. Patient accompanied by nurse at the nursing home, she is extremely familiar with the patient, they have a very good relationship, however, there has been increasing behaviors and increasing paranoia recently. Because of this they did a UA the mid-stream was unfortunately contaminated, so the doctor ordered a clean cath (catheter) sample, this was performed, and patient is alleging that she tried to refuse this, and it was forced on her anyway. Because of this APS (Adult Protective Services) was involved, they have completed in this investigation, they state patient states she feels uncomfortable and needs to be removed from the nursing home as soon as possible. Patient states that she feels comfortable in the nursing home as long as the nurse is there, however when the nurse goes home for the day she makes multiple statements about feeling uncomfortable, which triggered APS to advise removal from the nursing home today, which prompted her visit here .Nurse states that they did attempt to modify the patients living situation including moving contact with staff members she has poorly interacted with, changing to different room, however patient continues to make statements about feeling unsafe .Patient does have slurred speech but is intermittently able to be understood .she is refusing repeat urine. Nurse states patient with intermittently had hallucinations over last week, including children tickling her feet underneath her wheelchair and hearing giggling . Assessment/Plan: Patient presents for further evaluation of concerns about her safety at her home, patient having increased hallucinations and delusions over past week but not currently. Head CT (computed tomography) and basic labs .No explanation for symptoms identified, patient admitted for placement . On 2/05/25 at 7:53 PM: Hospital Internal Medicine Admission Note states in part, Chief Complaint: Feels unsafe at the [facility] History of present illness: .presented to hospital today with complaints she was being mistreated, apparently patient has had worsening progressive dementia thought to be secondary to her Parkinson's and there were concerns that patient may have a UTI. A midstream clean catch urine was tested and was abnormal. A cathed urinalysis was ordered and patient had reported that when this was obtained, she refused but staff obtained it despite her refusal. Patient had complained to the director and reported this to Adult Protective Services. Adult Protective Services documented that the patient felt uncomfortable and unsafe at the nursing home. General Physical exam: no acute distress. Plan: admit for observation. Surveyor reviewed the police report for R1 which states the following in part, Incident Nature: Assault Date: 2/01/2025 at 3:22 PM Disposition: Arrest Brief Summary of Activity: Officer responded to an information case from a local assisting [sic] living. DHS (Department of Health) was contacted and informed of a possible elder abuse case. Details: On Saturday February 1, 2025, at approximately 3:30 PM officer was requested by dispatch to make contact with director from [facility name] . [NHA A] told me a nurse was ordered to collect a urine sample from a resident. She stated that the resident did not want to be subjected to a catheter. The nurse requested help from CNA's who held the residents' legs down and used the catheter. [NHA A] stated the resident [R1] was crying and asking them to stop. I arrived at [facility name] to speak with [R1] about what had occurred. I was greeted by another director at the building [DON B] .[DON B] stated that multiple other staff members could hear yelling and crying from [R1's] room when the incident took place .[DON B] told me she received the report and returned to work, she found [R1] in her room with her pants still around her lower legs. I met with [R1] in her room to speak with her about what happened. [R1] said that she was in bed when a nurse came in to take a urine sample. [R1] said that during the urine sample she asked them to stop several times and never consented for the sample to be taken. [R1] stated she tried to fight but her hands and legs were held down and out of the way of the procedure. [R1] stated she was in pain during the procedure and was still in pain. I called and spoke with [CNA E] to speak with her about what happened. [CNA E] stated .around 1:55 PM she was asked by [RN C] to assist with getting a urine sample. When she entered the room, [RN C] was going over the procedure with [R1]. [RN C] began cleaning [R1's] vaginal area and [R1] was saying no several times .was instructed to assist holding one of [R1's] legs to open the vaginal area. [R1] began resisting and crying. [RN C] then told [CNA E] to get help to hold [R1]. [CNA E] went into the hallway .and asked [CNA D] to come into the room. [CNA E] said her and [CNA D] each took a side of [R1] and held her down while [RN C] inserted the catheter. When both [CNA D] and [CNA E] held her down [R1] began to cry and yell louder. [CNA E] said she felt bad and quickly realized it was wrong. However, she felt she was in a tough spot because she was instructed to do so from the nurse. I then called [CNA D] to speak about what happened. [CNA D] said she was just starting her shift when [CNA E] came and asked her to help with [R1]. When [CNA D] entered the room, she stated [R1] was very worked up and crying. [CNA D] did what she was told by [RN C] and held one of [R1's] legs down .[R1] was yelling leave me alone, let me go . I called [RN C] asked her to provide accounts of what happened. [RN C] stated she received an order from a doctor to collect a urine sample. The previous sample was contaminated therefore the doctor ordered a new sample. The new sample was to be straight catheter. [RN C] went into [R1's] room and explained the procedure to her. I asked if [R1] said anything about the procedure and [RN C] said no. I asked if she appeared upset at all and [RN C] stated she did not think so. [RN C] told me [R1] is often upset and paranoid. [RN C] stated she only requested help to hold [R1's] legs down so she could administer the catheter. [RN C] said she never heard [R1] say anything and did not notice her face being upset. I asked [RN C] why she never heard [R1], and she said she was only focused on what she was doing and did not realize anything was wrong until she was notified of the report. Findings: Through my investigation, I learned two individuals held a resident down while a nurse used a catheter to get a urine sample. The resident appeared to be resisting and telling the nurse to stop according to the CNAs in the room. On 2/11/25 at 12:39 PM, Surveyor spoke with CNA D via phone about the facility reported incident. CNA D reported being on staff since 7/27/23 and familiar with R1. CNA D reported being a certified nursing assistant for almost [AGE] years. CNA D reported she had been asked by CNA E to come to R1's room. R1 was in bed when she entered the room with her pants and brief pulled down. In the room was RN C with catheter supplies prepared at bedside. Upon entering R1's room, R1 appeared distressed. CNA D reported R1 was physically upset with red face and starting to cry. RN C instructed CNA D and CNA E to hold R1's legs open with the CNAs on both sides of R1's bed. With CNA D and CNA E holding R1's legs open, R1 started to vocalize louder, yelling and trying to prevent nurse from doing procedure. CNA D used one hand to stop R1 from hitting RN C and grabbing catheter supplies as she held her leg with her other hand. CNA D reported R1 was in obvious distress as CNA D tried to console her. R1 started saying, Leave me alone, Don't touch me. R1 continued yelling until RN C finished procedure. R1 was yelling, crying, pushing at staff and the supplies. After the procedure the CNAs tried pulling R1's pants up and she did not want anyone to touch her. Surveyor asked CNA D why she did not stop RN C from doing the procedure when R1 was objecting and crying. CNA D responded she had just come on shift; she was told what to do and she thought the nurse would stop/quit the procedure and she did not. CNA D stated, I should have stopped the nurse, resident did not want the procedure, resident was refusing. It did not feel right and needed to report the incident to the director of nursing. On 2/11/25 at 12:59 PM, Surveyor spoke with CNA E about the facility reported incident. CNA E indicated she has been on staff since 10/04/24 and is familiar with R1. CNA E reported being a certified nursing assistant about 3 years. CNA E reported just before 2:00 PM she was asked by RN C to assist her in getting a urine sample from R1. R1 was in bed as she had laid her down 20-30 minutes before. RN C was already in the room at bedside with catheter supplies prepared when CNA E entered the room. CNA E assisted RN C with pulling R1's pants and brief down. RN C was explaining the procedure to R1 and R1 said no, consistently no. CNA E said she was thinking RN C would stop. CNA E stated she even offered to come back another time, but RN C either didn't hear or ignored the comment. RN C directed CNA E to place her hands on R1's inner thighs. R1 was not resisting until RN C started swabbing, then R1 started to squeeze her legs shut, using her muscles against CNA E's hands and stating No. RN C directed CNA E to get help. CNA E stepped out of the room and asked CNA D to come help. Both CNA E and CNA D went to each side of R1's bed to hold R1's legs open with RN C at end of the bed. R1 was resisting RN C at bottom of the bed, grabbing at the nurse and supplies and stating No. RN C pushed R1's arms up and the CNAs blocked her arms and held her arms up to keep her from grabbing at the nurse and catheter supplies. R1 stated, Let go, let go of my hands, get off me, as nurse was inserting the catheter. Surveyor asked CNA E why she did not stop the nurse and the procedure. CNA E responded, Honestly, I walked off. I was emotional and told my co-workers I needed to self-report myself as resident was refusing and we continued anyways. It was emotional. It felt wrong. CNA E indicated CNA D was also very uncomfortable with the incident. CNA E expressed looking back she didn't expect it; she felt stuck after the comment to try again another day was ignored by RN C. CNA E expressed she recognized R1 did not want it. The incident was reported to DON immediately and an investigation was started within a few minutes. On 2/11/25 at 3:39 PM, Surveyor spoke with Family Member (FM) H via the phone. FM H reported she had been in to visit R1 earlier the day of the incident. Later that day, R1 called. R1 was hard to understand, more so than usual, she was upset. R1 reported to FM H she was held down by staff for a catheter. The DON called FM H after talking with R1. DON B told her R1 had been straight cathed (catheterized) by a nurse and 2 CNAs. R1 said no and it hurts, and R1 could be heard from people down the hall. R1 had told DON B what had happened. DON B reported that the police were called, and staff were suspended. FM H explained R1 had been slowly declining since her admission to the nursing home. R1 had some pain issues, was more paranoid with behavioral concerns and a progressive cognitive decline. All thought to be related to her Parkinson's. FM H stated after the incident, she could see changes in R1. The facility tried room changes in the facility a few times but R1 still reported she felt unsafe and wanted to go to the hospital. Once at the hospital, a total decline began and R1 spiraled down. FM H indicated she was not sure if the decline was from all the quality-of-life changes in the past year, but the incident was part of it. FM H stated the incident was traumatic, and R1 can't communicate. FM H stated the plan was for R1 to return to the facility; however, R1 has not eaten for 5 days and family has made the decision for comfort cares. FM H reports it is not realistic for R1 to return, and she expects she will soon expire. On 2/11/25 at 3:58 PM, Surveyor spoke with CNA F. CNA F indicated she had worked for the nursing home many years and works the PM shift. CNA F expressed she works R1's hall and is familiar with R1. CNA F indicated on the day of the incident she entered the facility by the back door by the timeclock for her PM shift. Upon entering she could hear R1 screaming from her room (108) which is up the hall from timeclock, around the nurse's station and halfway up hall A. CNA F indicated R1 was very loud but the words could not be understood. CNA F asked CNA D and CNA E what was going on as they exited R1's room. CNA F expressed the CNAs said R1 was upset with catheter procedure she did not want. CNA F told CNA E and CNA D to report the situation. It was obvious R1 was very upset and continued to be upset until about 3:30-4:00 PM, when she settled down. CNA F reported the next day R1 transferred to another hall. CNA F expressed she did not hear R1 say she felt unsafe after the incident. On 2/12/25 at 8:15 AM, Surveyor spoke with RN C via the phone. RN C reported working at the facility [AGE] years. RN C reported working the AM shift and the wing where R1 resided. RN C reported R1 had an overall decline in the past few months. R1 was not as active, lowering herself to the floor, had increased complaints of discomfort and behavioral changes. RN C reported R1 had urinary incontinence at end of January which was unusual and R1 reported it hurt with urination. R1's physician was contacted and gave an order for a urine sample. Surveyor asked RN C if R1 had any fever with her complaints. RN C indicated R1 did not have a fever. Surveyor discussed the facility's criteria for obtaining a urine culture included reports of a fever. RN C indicated she was not aware the criteria specified a fever as part of the criteria. RN C indicated a clean catch urine was obtained for R1 by another staff nurse. On Saturday 2/01/25 the culture results showed contamination with WBCs and the on-call MD (physician) was called and discussed resident symptoms. MD spoke with resident who said burns. MD explained the 1st clean catch specimen was contaminated and the need to collect another one. RN C gathered supplies for a straight catheter to obtain the specimen, entered R1's room and assisted with lowering R1's blankets and pants. RN C explained she assisted R1 with peri care with wipes and saw no issues. R1 was calm. With swabbing, R1 became kind of rigid and RN C instructed CNA E to spread her legs. RN C said she knew it was not going to be easy due to R1's rigidness and asked CNA D to get help. CNA D got CNA E. The two CNAs were on each side of R1's bed with RN C at the foot of bed. RN C instructed the CNAs to spread R1's legs. RN C said it was quiet in the room and she had an issue with the first catheter and had another kit there to try. RN C said she has cathed many people and the second one filled, was removed and the CNAs were trying to re-dress R1 when she noticed she was weepy. RN C expressed she did not notice any objection from R1, did not see resident moving away and did not see any non-verbal cues resident was upset. RN C expressed, The CNAs are there to watch the patient and their comfort. The CNAs did not alert her to any issues. RN C expressed she did not know there was an issue until contacted later that day by DON B. RN C stated she would have stopped had she known R1 was objecting. On 2/12/25 at 11:37 AM, Surveyor spoke with Adult Protective Services (APS) I who indicated she received a report of incident on 2/03/25 by law enforcement. APS I reported to the facility on [DATE] and spoke with R1. R1 indicated she told staff she did not want straight catheter procedure when the nurse was explaining the procedure, as in the past it hurt. The nurse (RN C) had 2 CNA staff (CNA D and CNA E) hold her down by her arms and legs to do the catheter even though she said no several times. R1 said it hurt very bad and she did not consent to the procedure. R1 said she wanted to press charges as she doesn't want it to happen to another resident. R1 requested to move, as she did not feel safe. The facility moved her to another room but R1 requested a move as she continued to not to feel safe at the facility regardless of the change in room and the fact that the alleged staff had been suspended. APS I expressed she informed R1's managed care organization coach about the request to move; as well as facility administrator for R1's safety and wellbeing. R1 was transferred to the hospital that day. On 2/12/2025 at 1:13 PM, Surveyor spoke with DON B about the incident on 2/01/25 with R1. DON B indicated she was called by CNA E just after 2:00 PM stating she was uncomfortable with R1's straight catheter procedure. CNA E reported R1 did not want the procedure, and the procedure was done anyway. DON B said she came into the facility immediately and called NHA A when in route. Once at the facility she asked RN C about the straight catheter procedure and if R1 consented to the procedure. RN C said she did not decipher R1 did not want it done and she did not hear no but R1 was tearful. RN C was asked to leave the building and informed an investigation would be conducted. RN C did not note the incident in the nurse's notes. DON B stated she talked to CNA D next. CNA D explained she was asked to assist with the procedure. R1 was tearful and did not want the procedure done. CNA D said she was told to hold R1 in a position to obtain catheter urine. R1 was tearful. CNA D was asked to leave the facility was and informed of investigation. DON B said she then went to speak with R1. R1 said she wanted a clean catch and questioned why a straight catheter was done. DON B explained the specimen was contaminated and the provider gave an order for straight catheter. R1 did not want it done and did not give consent. R1 said no and no means no. Resident rights were violated by not being allowed to refuse treatment. Based on facility policies abuse occurred. DON B stated the facility immediately began training staff on resident rights and provided training to all staff before they reported to work. On 2/12/25 at 1:59 PM, Surveyor spoke with NHA A about the incident with R1 on 2/01/2025. NHA A indicated she was called by DON B around 2:15 PM on 2/01/2025 reporting CNA E said she was part of getting a urine sample from R1 when R1 said no and that R1 was upset. NHA A indicated she called law enforcement right away and started reporting to the state of Wisconsin Department of Health Services. NHA A reported DON B talked with RN C. NHA A indicated APS came in on 2/05/25 and reported to her R1 did not feel safe in the building, R1 wanted to press charges and APS I was going to contact the MCO regarding placement. VPS G spoke with R1 who stated she did not feel safe because staff were putting toys in pillowcases and on her bed making her lay on them. R1 was saying a little girl was under her wheelchair which was new for her. R1 was transferred to the hospital 2/05/25 around 5:30 PM and has not returned to the facility. On Monday 2/03/25 the facility continued staff education related to abuse, definitions, who to contact, allegations, reporting and resident rights. Specifically, what to do when someone says no. Surveyor asked NHA A if R1's rights were violated. NHA A responded R1's right to refuse treatment was violated as the CNAs held her legs down to obtain urine sample that resident said she did not want. The facility's failure to protect vulnerable residents from mental abuse created serious harm which led to a finding of immediate jeopardy. The immediate jeopardy was removed on 02/01/25 when involved staff were removed from work. In addition the deficiency was corrected on 02/03/25 after the facility completed the following: - Re-education was immediately given to staff on duty and in [NAME] [TRUNCATED]

Based on observation, interview and record review, the facility did not establish an Infection Control Program under which it investigates, controls, and prevents infections in the facility, or a system for recording incidents identified under the facility's Infection Control Program, including corrective action in a timely manner, for both residents and staff. This has the potential to affect all 39 residents in the facility. The facility did not have an adequate surveillance in place for tracking and monitoring infection and communicable disease for staff and residents. The facility did not ensure proper fitting N95 mask for staff with facial hair of a full beard. Facility staff did not dispose of contaminated Personal Protective Equipment (PPE) before exiting COVID positive rooms. The facility did not initiate Enhanced Barrier Precautions (EBP) upon R91's admission to the facility with an indwelling urinary catheter. R35 was placed on contact precautions after having one incident of vomiting. Staff did not practice proper hand hygiene during cares for R4. This is evidenced by: Example 1 Facility policy titled, Infection Surveillance, with a most recent reviewed date of 03/08/23 stated in part: Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections . Infection surveillance refers to an ongoing systematic collection, analysis, interpretations, and dissemination of infection-related data .6. The facility will collect data to properly identify possible communicable diseases or infections before they spread by identifying: a. Data to be collected, including how often and the type of data to be documented, including: i. summary and analysis of the number of residents (and staff, if applicable) who developed infections; ii. Observations of staff including the identification of ineffective practices, if any; and iii. The identification of unusual or unexpected outcomes, infection trends and patterns .9. Resident infections will be tracked . Surveyor reviewed the facility's infection control program. The facility did not utilize a data collection tool for surveillance for early detection of symptomatic residents and staff that will identify, track, and monitor for possible communicable disease and outbreaks. Surveyor reviewed the facility's monthly infection control logs from 12/23 - 12/24. The infection control logs were not completely filled out to include symptom date of onset and resolution, map identifying trends and patterns, start or end date of cautionary measures, diagnostic results including organism, summary of analysis of infections, all residents being monitored for infection, and observations of staff. On 12/18/24 at 10:00 AM, Surveyor interviewed Director of Nursing (DON) B regarding infection surveillance. DON B stated that new leadership took over a couple of months ago and recognized that the facility's infection surveillance was not being logged and monitored appropriately. DON B stated that prior to 11/24, no procedure had been in place for consistent documentation of infection surveillance. DON B stated she has been involved in extensive training in how to properly log and monitor infection surveillance data and has since been attempting to fix the process of tracking and monitoring infections for staff and residents. DON B stated there is currently no written process of improvement plan in place but is actively working to correct this issue as it has the potential for harm for all the residents and staff. 44863 Example 2 On 12/17/24, Surveyor reviewed R35's progress notes and noted the following: On 10/04/24, R35 had a single episode of vomiting and was placed on TBP. From 10/05/24-10/09/24, progress notes indicated R35 had no further vomiting and no other signs of illness. Two rapid Covid tests determined R35 was negative for the virus. On 10/27/24, R35's progress notes indicated he was removed from TBP. On 12/17/24, Surveyor reviewed the facility's surveillance and infection line list. Surveyor noted the facility was not in outbreak status for gastrointestinal related infections during the month of October. On 12/17/24 at 9:13 AM, Surveyor interviewed R35. R35 was not able to recall if he was placed on precautions and did not have concerns related to being isolated to his room. Surveyor interviewed nursing staff; however, staff were not able to recall the duration of R35's precautions. On 12/18/24 at 9:37 AM, Surveyor interviewed [NAME] President of Success (VPS) C and DON B. VPS C and DON B reviewed R35's record and agreed R35 was placed on contact precautions for an undetermined amount of time and exceeded the 48-hour recommended time for gastrointestinal symptoms. VPS C and DON B acknowledged the facility's surveillance data was not completed accurately. VPS C stated R35 would not have been involuntarily secluded to his room during this time, as the facility policy is to encourage residents on TBP to isolate or wear appropriate PPE. However. a resident has the right to leave their room if they choose to do so. 31086 Example 3 The facility's policy titled, COVID-19 Prevention, Response and Reporting, dated 05/18/23, documented, in part. 15. HCP (Healthcare Personnel) who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection should adhere to transmission-based precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection. R16 has current diagnoses of COVID-19 as of 12/14/24, Alzheimer's disease, type 2 diabetes mellitus, anxiety disorders, and major depression disorder. Surveyor observed at the entrance of R16's room a sign from the Centers for Disease Control and Prevention (CDC) stating, Stop droplet Precautions, Everyone must: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before entry. Remove face protection before room exit. Surveyor observed outside of R16's door a bin with PPE supplies of gowns, gloves, N95 masks and surgical masks. On 12/16/24 at 10:06 AM, Surveyor observed Certified Nursing Assistant (CNA) D apply PPE of a gown, gloves, goggles, and N95 mask and entered R16's room to assist with a Hoyer lift transfer. Surveyor observed CNA D having a full beard with the facial hair being over an inch long and the N95 not having a tight seal to CNA D's facial skin. At 10:12 AM, CNA D exited R16's room wearing the contaminated PPE of the gown, gloves, and N95 mask. In the hallway CNA D removed the contaminated PPE and brought the contaminated PPE across the hall to R31's room and placed the contaminated PPE into R31's garbage can. R31 is not COVID positive and is not on any precautions. R28 has current diagnoses of COVID-19 as of 12/12/24 and hemiplegia affecting right dominant side, cerebrovascular disease, and major depression. Surveyor observed at the entrance of R28's room a sign from the CDC stating, Stop droplet Precautions, Everyone must: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before entry. Remove face protection before room exit. Surveyor observed outside of R28's door a bin with PPE supplies of gowns, gloves, N95 masks and surgical masks. On 12/16/24 at 12:44 PM, Surveyor observed CNA D apply PPE of gloves, gown, and applied N95 and entered R28's room to deliver R28's meal tray. Surveyor observed CNA D's N95 mask not having a tight seal on CNA D's facial skin. CNA D exited R28's room wearing the contaminated PPE. CNA D removed the contaminated PPE in the hallway. CNA D brought the contaminated PPE across the hall and disposed of the contaminated PPE into R191's garbage can. R191 is not COVID-19 positive and is not on precautions. R15 has current diagnoses of COVID-19 as of 12/13/24, dementia, anxiety, and chronic kidney disease. Surveyor observed at the entrance of R15's room a sign from the CDC stating, Stop droplet Precautions, Everyone must: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before entry. Remove face protection before room exit. Surveyor observed outside of R15's door a bin with PPE supplies of gowns, gloves, N95 masks and surgical masks. On 12/16/24 at 12:51 PM, Surveyor observed CNA D bring R15's meal tray into R15's room. CNA D wore PPE of a surgical mask. CNA D did not apply the required COVID-19 PPE of a gown, gloves, eye protection, and an N95 mask. On 12/18/24 at 8:07 AM, Surveyor interviewed CNA D about resident units CNA D worked on 12/16/24. CNA D indicated working all units and will work as transport and maintenance. Surveyor asked how often he is fit tested for the N95 and training for COVID-19 personal protective equipment. CNA D indicated training is completed in the computer system and receives fit testing for N[AGE] yearly. CNA D indicated he was fit tested with a beard and had passed but the beard was shorter at that time. CNA D indicated no current fit testing was completed with the length of his beard currently and it is now longer. Surveyor reviewed with CNA D of Surveyor's observation of exiting positive COVID-19 resident's room with contaminated PPE and disposing of the PPE in a non-COVID positive resident room and entering R15's room to delivery meal tray with only a surgical mask. CNA D indicated he did not know where the garbage was in the room and prior they had the garbage right outside of the resident's room. CNA D indicated the PPE should not have been disposed in another resident's room. CNA D indicated PPE should have been worn when delivering meal tray to a COVID positive resident's room. On 12/18/24 at 10: 42 AM, Surveyor interviewed DON B about proper personal protective equipment to be used in COVID-19 positive room, and when staff fit testing is to be completed. DON B indicated fit testing should be completed annually and if there are changes to their body size. Surveyor asked if appropriate for staff to wear N95 with facial hair that is a full beard. DON B indicated facial hair should be shaved to appropriately fit an N95. Surveyor reviewed with DON B of CNA D having large amount of facial hair. Surveyor reviewed with DON B the observation of CNA D exiting R16 and R28's rooms with PPE and disposing of the PPE across the hall into a resident room that is not COVID positive. Surveyor reviewed with DON B of CNA D entering R15's room with a surgical mask and no N95, gown, gloves, goggles to deliver a meal tray. DON B indicated PPE should be disposed of inside the resident's room before exiting and the appropriate PPE needs to be used to enter a COVID positive room. Example 4 The facility's policy titled, Enhanced Barrier Precautions, dated 08/08/24, documented, in part. 1. Prompt recognition of need: .2. b. An order for enhanced barrier precautions .will be initiated for residents with any of the following: i .and/or indwelling medical devices (e.g., .urinary catheters .) .even if the resident is not known to be infected or colonized with a MDRO .3. a. Make gowns and gloves available immediately near or outside of the resident's room. R91 was admitted to the facility on [DATE] with diagnoses of enlarged prostate with lower urinary tract symptoms, acute cholecystitis, and retention of urine. R91 has an indwelling catheter for urinary retention. Review of R91's care plans did not document to use EBP related to R91's indwelling urinary catheter. On 12/16/24 at 10:31 AM, Surveyor observed R91 having a urinary catheter and no sign or bin of PPE at the entrance of R91's room for the use of EBP. On 12/18/24 at 10:45 AM, Surveyor interviewed DON B about R91 having an indwelling catheter and if EBP should be in place on admission. DON B indicated R91 should have been put on EBP at the time of admission and was not completed until 12/16/24. 51095 Example 5 On 12/17/24 at 8:15 AM, Surveyor observed a sign on R4's door indicating Transmission Based Precautions. R4 was admitted on [DATE] with multiple medical diagnoses, including hypertensive chronic kidney disease with stage 5 (or end stage) chronic kidney disease. On 12/17/24 at 8:16 AM, Surveyor observed personal cares for R4. CNA I donned gloves and using a wet washcloth, provided bathing cares for R4, including peri area cleaning where visible drainage and soiling was noted. CNA I did not remove/change gloves or perform hand hygiene throughout R4's cares. CNA I continued with same gloves by assisting Registered Nurse (RN) F with peri area treatment, holding skin folds, wiping, and touching skin area around R4's stoma opening while RN F replaced ostomy/stoma ring. CNA I continued providing cares with same contaminated gloves and without washing or sanitizing her hands, placing R4's oxygen tubing back in nose, brushing R4's hair, handled oxygen concentrator, moving motorized wheelchair, and transferring R4 via mechanical lift into wheelchair. After R4 was in her wheelchair and before leaving the room, CNA I then removed her gloves and washed her hands. On 12/17/24 at 8:47 AM, Surveyor interviewed CNA I about facility's infection control training and appropriate hand hygiene with R4's cares. CNA I admitted she did not change her gloves, wash or sanitize her hands and states she should have done so. On 12/17/24 at 1:47 PM, Surveyor interviewed Assistant Director of Nursing (ADON) H. ADON H reported hand hygiene education is provided monthly to CNAs. ADON H reported the expectation is that gloves are changed, and hand hygiene is to be performed after peri area or ostomy cares are performed.

Based on observation, interview and record review, the facility did not use a gait belt to promote safe transfer for 1 of 2 residents. (R9) This is evidenced by: Surveyor reviewed the facility's policy titled, NSG-Safe Resident Handling and Transfers. Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risk for injury and provide and promote a safe, secure, and comfortable experience .in accordance with standards and guidelines. The following numbers of sections relate to the numbered section in the policy. 1. The interdisciplinary team or designee will evaluate and assess each resident's individual mobility needs, taking into account other facts as well, such as weight and cognitive status. 2. The resident's mobility needs will be addressed on admission and reviewed quarterly, after a significant change in condition or based on direct care staff observations or recommendations. 4. Handling aids may include gait belts, transfer boards, and other devices. 11. Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire. R9 was admitted to the facility on [DATE]. Current diagnoses include but not limited to anxiety disorders, (osteo)arthritis, a right artificial knee, abnormalities of gait and mobility, and generalized muscle weakness. R9's Minimum Data Set (MDS) assessment date is 11/22/24. R9's Brief Interview of Mental Status (BIMS) scored an 11 out of 15, indicating moderate cognitive impairment. R9 requires the assist of 1 staff member with transfers and change of position. R9 requires partial/moderate assist of staff to dress self, complete ADL, and roll in bed, or complete any position changes. R9's care plan dated 09/06/24 includes two related sections. One is the need for assistance with ADLs and self-care due to weakness and the second area planned is R9's risk for falls due to history of falls. The interventions outlined in these two areas include but are not limited to, assist of one staff when completion of ADLs, and when transferring or moving. R9 is to be encouraged to move slowly and have appropriate footwear on when transferring. On 12/17/24 at 10:27 AM, Surveyor observed Certified Nursing Assistant (CNA) K provide cares to R9. CNA K assisted R9 to a sitting position on the bed. CNA K raised bed and adjusted wheelchair so that the wheelchair was closer to bed on R9's left side. CNA K assisted R9 to stand. CNA K held R9's pant waist band to assist to stand. R9 pivoted into her wheelchair. R9 was assisted to the bathroom where R9 was kindly instructed to grab the handrail and again assisted to stand. CNA K's hands were on R9's back/under arm while assisting up and with stabilization. While R9 was standing and holding bar, CNA K pulled down R9's pants and brief. R9 finished pivoting to toilet and sat down onto the toilet. CNA K kindly instructed R9 again to grab hold of bar. CNA K assisted R9 to stand again using the grab bar. CNA K's hands were placed under R9's arms. While R9 was standing, CNA K provided appropriate toilet hygiene followed by hand hygiene. CNA K assisted R9 to pivot to sit in wheelchair. CNA K did not use a gait belt on R9 for the entire encounter. On 12/17/24 at 10:45 AM, Surveyor interviewed CNA K about gait belt use. CNA K indicated she does not use a gait belt normally with R9. CNA K stated, I wasn't told to. We use a gait belt when she walks? CNA K indicated she uses a gait belt when it is care planned. Surveyor's review of R9's care plan states transfer with assist of 1 (staff member), with no documentation to use or not use a gait belt. On 12/18/24 at 9:00 AM, Surveyor interviewed CNA K. CNA K indicated she should have used a gait belt for transfers without prompting. CNA K expressed she has now corrected her practice. 12/18/24 at 9:05 AM, Surveyor interviewed Occupational Therapy (OT) L regarding transfers and gait belt use. OT L indicated assessments are completed as part of MDS process quarterly and annually. The outcome, including the transfer process, is documented in the care plan. OT L specified that the cna(s) and staff are to follow the care plan. A copy is posted in patient's room on inside door of closet. OT L expressed that gait belts are to be used with any assistive transfers, unless the resident signs risk benefit and declines the use of the gait belt. On 12/18/24 at 10:24 AM, Physical Therapy (PT) M brought paper copy of therapy recommended plan of care to Surveyors. During discussion with PT M, she indicated the expectation is that staff follow care plan and use gait belt with any transfer or assist. On 12/18/24 at 10:42 AM, Surveyor interviewed Director of Nursing (DON) B regarding transfers and gait belt use. DON B indicated that transfer assessment would be completed and found in the MDS and transferred into the care plan. Expectation is to use a gait belt with any transfer assist.

Based on interview and record review, the facility did not ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 2 residents (R28) reviewed. The facility did not implement R28's Range of Motion (ROM) developed plan of care. This is evidenced by: R28 was admitted to the facility on [DATE]. R28's diagnoses, that include but are not limited to, are hemiplegia affecting right dominant side, rheumatoid arthritis, and right shoulder contracture. R28's Minimum Data Set (MDS) annual assessment dated [DATE] and quarterly assessment dated [DATE] were reviewed. R28's Brief Interview of Mental Status (BIMS) score is 15 out of 15, indicating cognition is intact. R28 requires the assist of 1 staff member with transfers and bed mobility. R28's ROM is impaired on one side of upper extremity and both sides of lower extremities. R28 requires substantial/maximal assistance with activities of daily living (ADLs), bathing, and dressing upper extremities. R28 is dependent on staff for dressing lower extremities, toilet transfer, and toileting hygiene. Surveyor reviewed R28's care plan with revision date of 02/21/22, which documented nursing restorative program should include ROM exercises to include but not limited to yellow therapy band exercises, shoulder extensions, elbow flexions, and rowing 20 reps x 2 for upper body extremities and heel slides, ankle pumps for lower extremities. Surveyor reviewed R28's electronic medical record for evidence of care plan completion related to ROM exercises. No documentation was found in R28's electronic medical record regarding ROM exercise to either upper or lower extremities as outlined in plan of care were completed. Surveyor reviewed documentation of therapy's restorative plan for R28. R28's therapy's plan matches R28's current care plan. On 12/18/24 at 9:00 AM, Surveyor interviewed Certified Nursing Assistant (CNA) K regarding ROM exercises with R28. CNA K reported she does ROM with R28 during morning cares. Especially since they did away with restorative. Surveyor asked if there is enough staff to do the restorative. CNA K stated, It is easier right now when [R28] has COVID. I can do it while I am in there waiting. CNA K knows what needs to be done because it is on the care plan. CNA K stated she documents in computer. Surveyor could not find documentation of exercise completion. Surveyor asked for copy of documentation and did not receive a copy. On 12/18/24 at 10:42 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and Director of Nursing (DON) B about documentation of evidence ROM exercises were completed and assessed for needed changes to the plan. DON B stated, Restorative binder is only care plans, there is no documentation. NHA A indicated the facility had a change in leadership and in process realized there were holes in the restorative programs. They are working on changes. Surveyor asked for clarification on expectations for the ROM plan of care. DON B stated, That they be done and documented every day, daily.

Based on observation, interview and record review, the facility did not develop a person-centered care plan for 1 of 12 sampled residents (R35). The facility did not identify R35's individual choices and daily routines, which had the potential to negatively impact R35's quality of care and quality of life. During the comprehensive assessment, R35 indicated a desire to smoke. R35's comprehensive care plan did not address R35's preferences for smoking, which resulted in R35 complaining of not being able to smoke, feeling frustrated with staff, and expressing negative behaviors. Findings include: Review of the facility's policy titled Smoking Policy read, .Any resident who is deemed safe to smoke, with to without supervision, will be allowed to smoke in designated smoking areas (weather permitting), at designated times, and in accordance with his/her care plan . Review of the facility's policy titled Comprehensive Care Plan read, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . Person-centered means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives .The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: e. The resident and the resident's representative, to the extent practicable. R35 was admitted to the facility on [DATE]. Diagnoses included dementia, anxiety, and depression. R35's Minimum Data Set (MDS) assessment, dated 11/07/24, indicated R35 scored 15/15 during Brief Interview for Mental Status (BIMS), indicating intact cognition. R35's care plan included a focus are for: Verbal/physical agitation/aggression with yelling out at staff and swearing at staff when educated on leaving the medication cart alone related to cognitive impairment, dated 07/01/24. Interventions included: -Administer medications per physician orders. -May be verbally abusive. -Give R35 clean, concise explanation of anything about to occur. R35's smoking care plan identified R35 is at risk for smoking related injury related to impaired cognition, dated 10/08/24. Interventions included: -Assist to and from designated smoking area, remain with R35 while he is smoking. -Assure smoking material is extinguished prior to resident leaving smoking area. -Complete nicotine assessment per facility policy. -Observe resident for unsafe smoking behaviors or attempts to obtain smoking material from outside sources. Immediately inform facility management of concerns. -R35 is not to have cigarettes or smoking material on person. -Storage of smoking materials per facility policy. On 12/16/24 at 11:04 AM, Surveyor interviewed R35. R35 reported he does smoke cigarettes and he does not desire to quit or seek nicotine alternatives. R35 stated, I would like to go out to have a cigarette whenever I want, but I'm lucky if I go once a week. Someone has to go with me. There are certain staff that I ask but most of them give me tough time about it or pretend they don't know what I am talking about. R35 expressed this is frustrating for him and he feels staff don't listen to him. R35 reported staff are aware of his desire to smoke but was unable to report if his smoking preferences had been discussed with him, stating, They don't care. R35 reported he would be satisfied with designated smoking times and going out to smoke 3-4 times per day. During interviews with certified nursing assistants (CNAs), CNAs reported R35 requests smoking materials from licensed nursing staff, as his cigarettes are locked in the medication cart. On 12/16/24 at 11:53 AM, Surveyor interviewed Registered Nurse (RN) E. RN E stated R35's cigarettes are locked in the medication cart and R35 requests cigarettes from staff. RN E stated, He asks all the time to smoke, but he requires supervision, and we don't have the time to watch him. He is a smoker, but he only has one every couple of months. On 12/16/24 at 12:08 PM, Surveyor observed R35 ask another Surveyor if he could go outside to smoke. Surveyor told R35 she did not work at the facility and was not able to take him outside. This Surveyor observed R35 propel himself to his room and did not ask any other staff to take him outside to smoke. Surveyor asked R35 why he did not ask staff to take him outside to smoke. R35 raised his arm waving and pointing towards the hallway in an angry manner and did not respond to this Surveyor's question. On 12/16/24, Surveyor did not observe R35 go outside to have a cigarette. On 12/17/25 at 9:45 AM, Surveyor interviewed RN F. RN F stated when R35 requests his cigarettes, the staff accommodate R35's request as soon as they can. Surveyor asked RN F if she could be more specific as to what that means, and RN F stated, They just get to him as soon as they can. On 12/17/24 at 12:30 PM, Surveyor interviewed [NAME] President of Success (VPS) C and Social Worker (SW) G. SW G reported R35 would go outside to smoke every 15 minutes if he was allowed. Surveyor asked VPS C if the facility had scheduled smoking times per the facility policy. VPS C stated when a resident requests to smoke staff will accommodate that time to smoke as best they can, and scheduled smoking times are only applied when there is a concern. On 12/17/24, Surveyor observed staff assist R35 outside to smoke, on one occasion. Surveyor noted on 07/01/24, R35's care plan was updated to reflect R35's behaviors of trying to get into the medication cart where his smoking materials are stored. There were no new interventions added to indicate R35's smoking preferences. Surveyor noted on 10/08/24, R35's care plan was updated to reflect R35's risk for a smoking related injury. There were no new interventions added to indicate R35's smoking preferences.

Based on observation, interview, and record review, the facility did not ensure each resident receives cares consistent with professional standards of practice to prevent pressure injuries (PIs) for 2 of 4 sampled residents (R)1 and R3. On admission 5/20/24, staff identified R1 had a suspected deep tissue injury (DTI) from the coccyx to the peri area. Physician, Director of Nursing, or wound nurse were not notified of this suspected DTI. No care plan or interventions were put in place for the pressure injury. Pressure injury assessments were not completed after the identification of the DTI on 5/20/24. As a result, R1 developed an unstageable pressure injury and sepsis. R1 required hospitalization and surgical debridement of the PI. The PI was staged as a stage 4 pressure injury. The facility's failure to implement pressure injury interventions and assess R1's pressure injury, created a finding of immediate jeopardy that began on 05/27/24. Nursing Home Administrator (NHA) A, Director of Nursing (DON) B and [NAME] President of Success (VPS) J were notified of the immediate jeopardy on 08/21/24 at 12:16 PM. The immediate jeopardy was removed on 8/21/24; however, the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan and as evidenced by the following example: R3 was admitted to the facility 08/09/24 with a PI on the left heel. R3's care plan included float heels as able; use pillows and/or positioning devices as needed. R3's heels were not being floated during numerous observations by survey team. Example 1: Based on the National Pressure Injury Advisory Panel (NPIAP), Pressure Injury Prevention Points dated April 2016, stated in part, RISK ASSESSMENT .5 Develop a plan of care based on the areas of risk, rather than on the total risk assessment score .SKIN CARE 1 Inspect all of the skin upon admission as soon as possible 2 Inspect the skin at least daily for signs of pressure injury, especially nonblanchable erythema. 3 Assess pressure points, such as the sacrum, coccyx, buttocks, heels, ischium, trochanters, elbows, and beneath medical devices. 4 When inspecting darkly pigmented skin, look for changes in skin tone, skin temperature and tissue consistency compared to adjacent skin . 8 Avoid positioning an individual on an area of erythema or pressure injury .REPOSITIONING AND MOBILIZATION . 5 Avoid positioning the individual on body areas with pressure injury. R1 was admitted to the facility on [DATE] from an acute care hospital. R1 had a documented Brief Interview of Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. R1 has diagnoses of malnutrition, multiple myeloma (also known as Kahler's disease, an uncommon blood cancer that affects the bone marrow, the body's blood-forming system), left hip fracture of iliac wing (to heal with conservative measures), pain control, and therapy for non-weight bearing to the left lower extremity (NWBLLE). R1's Minimum Data Sets (MDS) assessment, dated 05/27/24, included the following: Mobility: Partial/moderate assistance with roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, tub/shower transfer. Substantial/maximal assistance with toilet transfer. Skin: Does resident have a pressure injury: No Is resident at risk of a pressure injury: Yes Pressure reducing device for chair and bed: Yes Turning/Repositioning: No Pressure ulcer care: No Application of nonsurgical dressing: No On 8/20/24 at 11:00 AM, Surveyor reviewed R1's CNA Kardex (patient care summary). The Kardex indicated R1 was assist of 1 with bed mobility, personal hygiene, toileting bathing and showering. Transfer assist of one with gait belt. Record review identified a Braden Scale (a standardized, evidence-based assessment tool commonly used in health care to assess and document a client's risk for developing pressure injuries) was completed on 05/20/24 at 4:53 PM, with a score of 21, which meant R1 was not at risk for skin breakdown. Of note, R1 needs assistance to roll left and right, and partial to moderate assistance for all transfers. A weekly skin assessment completed on 05/20/24, at 9:09 PM, indicated R1 had a pressure injury to coccyx, From coccyx to peri area is dark purple and appears to be a DTI. No open area noted. Surveyor was unable to find any documentation in R1's medical record showing a physician, the wound care nurse or the DON was notified of this suspected DTI. Further review of R1's medical record identified there was no care plan for actual skin breakdown. R1 had a care plan focus, stating, At risk for alteration in skin integrity related to: impaired mobility. Interventions for this care plan included: Barrier cream to peri area/buttocks as needed, diet and supplements per Medical Doctor (MD) orders, observe skin condition with Activities of Daily Living (ADL) care daily and report abnormalities. The skin integrity care plan did not include any individualized pressure interventions for R1's coccyx DTI. There was no turning schedule despite R1 needing partial/moderate assistance with turning. Doctor's orders: NWB LLE started 05/20/24. Complete initial skin assessment and document in point click care every shift. Weekly skin review every Wednesday start 05/22/24 revision date 05/20/24. On 5/26/24, there was a weekly skin review in the medical chart, with a box checked for bruises under the skin conditions section. Nothing is documented under the site or description sections of the document. This weekly skin review has no documentation on the coccyx DTI. On 5/27/24 at 5:29 PM, the next progress note states in part: .Daughter came up to desk at shift change and stated that [R1] was admitted to the hospital for surgical procedure on her buttock. Surveyor was unable to identify information about how or why R1 was sent to the hospital in the medical record. Surveyor requested documentation. Director of Nursing (DON) B provided Surveyor with the Situation, Background, Assessment, and Recommendation (SBAR) and transfer to hospital form. The SBAR communication form reads in part on 05/27/24 at 7:32 AM: .BP 122/65, Pulse 148, RR 18, temp, 98.1, Skin evaluation: Pressure ulcer Does the patient have pain: Yes the pain is new Description of pain/location: New wound measuring at 3.7 x 2.2 x 0.7 with foul smelling purulent drainage noted coccyx. Intensity: 6 Called on call physician for acute care hospital and spoke with Medical Doctor (MD) G who gave orders to send to ER for evaluation and treatment. R1's Daughter notified 05/27/24 at 7:32 AM. Surveyor reviewed the ambulance report. On 05/27/24 at 8:15 AM, the ambulance record states the staff report that R1 had been feeling unwell, complaining of fatigue, lower back pain and fevers for the past two days. Staff checked a pressure ulcer located on the patient's coccyx and stated that it was black and oozing. Staff report the patient had a low-grade fever yesterday of 100 degrees Fahrenheit. Ambulance record indicates temperature of 99.5, HR of 136, 120, BP stable. On 08/20/24 at 9:48 AM, Surveyor phone interviewed R1's family member for any new or pertinent information. R1's daughter informed Surveyor that R1 required surgery for the wound on the butt, and the acute care facility that did the surgery staged the wound as a stage 4 pressure injury. R1 was still in another nursing home. R1 has not been home for 3 months now and her cancer treatments were put on hold until the wound could heal. On 08/20/24 at 12:45 PM, Surveyor interviewed Certified Nursing Assistant (CNA) D regarding cares for R1. CNA D did recall caring for R1. CNA D did not recall being informed that R1 had any skin issue or wounds at the time of admission to the facility. CNA D did not recall that R1 had any special turning or repositioning plan. CNA D did recall that R1 had a standard bed mattress and a cushion in the wheelchair. CNA D remembered one day, but was unsure of which day, when caring for R1 there was drainage from R1's bottom and on R1's depends. CNA D noted redness on R1's bottom and called Registered Nurse (RN) E to assess R1's skin. CNA D does not remember what or if any new interventions were started after this observation of redness and drainage. On 08/20/24 at 2:27 PM, Surveyor asked Assistant Director of Nursing (ADON) C (the facility's wound nurse), about the process of being notified if a resident has a PI. ADON C indicated on admission to the facility, if a resident has a PI, staff open up a wound tracker and that triggers ADON C to look at it on wound rounds on Wednesdays. On 08/20/24 at 2:40 PM, Surveyor interviewed Registered Nurse (RN) E. Surveyor asked RN E about being called in to assess an open wound on R1. RN E indicated the original wound was red and wasn't open, so barrier cream was applied and no dressings were in place at that time. RN E did not think that it needed any further treatment because it was red and not open. RN E indicates she would have notified the wound nurse if the area was open. Surveyor could not find any documentation in R1's medical record identifying RN E's assessment of the redness and drainage that was reported by CNA D. On 08/20/24 at 3:59 PM, Surveyor interviewed RN F regarding pressure relieving devices for R1. RN F indicated that R1 had a pressure relieving chair cushion in the wheelchair, and the facility provides those for all residents' wheelchairs. R1's mattress was a standard mattress. RN F also indicated that R1 was not started on a turning or repositioning schedule. RN F informed Surveyor that every time R1 went to the bathroom skin barrier cream was applied to the purple area and this area remained intact until R1 went to the hospital. RN F was asked about assessments that were performed on this area. RN F informed Surveyor that CNAs saw R1's bottom every time they took R1 to the bathroom and they never reported any open areas. On 08/21/24 at 8:50 AM, Surveyor interviewed via phone Medical Doctor (MD) G regarding care for R1's pressure injury. MD G informed Surveyor there was a hospital follow up visit completed on May 23, 2024, and there was no mention of or complaints of any skin issues. MD G informed Surveyor R1 did not complain of skin issues at the time of admission. Surveyor asked MD G if MD G was informed of the DTI to R1's bottom. MD G indicated, the first time I was notified was when the facility was sending R1 to the emergency roiagnom on [DATE]. On 08/21/24 at 10:21 AM, Surveyor interviewed ADON C about the suspected DTI to R1's bottom on admission. ADON C denied knowing anything about it. ADON C informed Surveyor that ADON C was never notified of the DTI. On 08/21/24 at 10:32 AM, Surveyor asked DON B about the suspected DTI to R1's bottom on admission. DON B informed Surveyor that DON B was never made aware of the DTI on 5/20/24. The failure to ensure each resident receives cares consistent with professional standards of practice to prevent pressure injuries created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy that began on 05/27/24. On 08/21/24, the facility took steps to correct the deficient practice and ensure compliance. The immediate jeopardy was removed on 08/21/24 when the facility implemented the following: 1. Facility in-house residents had their skin inspected by RN on 08/21/24 and no unidentified pressure injuries were discovered, current interventions were reviewed and verified in place as per care plan, and treatment orders are in place, accurate, and completed as ordered as of 08/21/24. 2. Re-education to licensed nursing staff (RNs and LPNs) was initiated on 08/21/24 for aggressive pressure injury prevention including visually inspecting resident's skin upon admission or readmission to identify skin impairments, notifying physician to obtain orders for treatment, notifying responsible party of resident, and interdisciplinary team (IDT) re-educated on pressure injury and non-pressure injury, need to review new or worsening skin impairments to ensure interventions are reviewed and care plan updated. 3. Re-education to nursing staff on 08/21/24 to monitor skin for injuries or changes with cares to ensure current he nurse if noted. 4. DON or designee to review facility charting for 2 weeks to ensure new admissions, readmissions, and current residents have skin impairments properly documented, orders implemented, and notifications completed and documented. This review will then be completed 5 days per week for 6 weeks or until substantial compliance maintained. 5. Audits will be completed for 8 weeks by DON or IDT to ensure in house residents with pressure injuries have established wound process in place including care plan review and evaluation. 6. Quality Assurance Performance Improvement (QAPI) meeting held on 08/21/24 to review pressure injury incident, discuss implementation of actions items as stated above. 40181 Example 2: R3 was admitted to the facility on [DATE] after an acute care hospital stay with the following diagnoses, in part, Parkinson's disease, polyosteoarthritis, and long term use of antibiotics. R3's admission assessment, dated 08/09/24, identified R3 had a Braden risk assessment score of 18, which indicated R3 was at risk for the development of a pressure injury. The admission assessment also identified R3 had a pressure injury on the left heel. The assessment did not identify the stage of the pressure injury or any measurements or description of the wound condition. R3's Minimum Data Set (MDS) assessment, dated 08/16/24, identified R3 was at risk for development of a pressure injury and had one unhealed stage 1 pressure injury. All of the subsequent Weekly Skin Review documents identified R3 had no skin impairments. Surveyor was unable to identify any other documentation of assessment of the left heel pressure injury, or documentation stating the left heel pressure injury was resolved. R3's care plan included the following focus areas, in part: The resident has a pressure ulcer (left heel) r/t [related to] recent hospitalization . Date initiated: 08/09/2024. Goal: The resident's Pressure ulcer will show signs of healing and remain free from infection by/through review date. Date initiated: 08/09/2024. Interventions/Tasks: Administer treatments as ordered and monitor for effectiveness. Date initiated: 08/09/2024. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Date initiated: 08/09/2024 .Actual pressure wound at left heel r/t recent hospitalization /immobility. Date initiated: 08/09/2024. Goal: Show no signs of infection. Interventions/Tasks: Encourage and assist as needed to turn and reposition; use assistive devices as needed. Float heels as able. Follow up care with MD as ordered. Use pillows and/or positioning devices as needed. R3's order summary did not contain any treatment orders for care or treatment of the left heel pressure injury. On 08/20/24 at 11:40 AM, Surveyor observed R3 seated in a wheelchair in R3's room. R3 was dressed and had gripper socks on both feet. R3's heels were resting directly on the floor. R3 stated they thought they had a sore on their heel. On 08/20/24 at 12:38 PM, Surveyor observed R3 seated in a recliner in R3's room. The footrest on the recliner was elevated and R3's heels were resting directly on the foot rest. R3 had gripper socks on both feet and her heels were not floated. On 08/20/24 at 12:45 PM, Surveyor interviewed Certified Nursing Assistant (CNA) D and asked if R3 had any wounds or skin issues. CNA D was not aware of any wounds or skin issues for R3. Surveyor asked CNA D if they had any interventions for positioning or pressure relief for R3. CNA D stated they tried to encourage R3 to reposition every 2 hours. Surveyor asked if they were supposed to float R3's heels. CNA D was not aware of any interventions to float R3's heels. On 08/20/24 at 12:56 PM, Surveyor interviewed Registered Nurse (RN) H, who was caring for the residents on R3's hall, and asked if R3 had any wounds or pressure injuries. RN H stated they were not aware of any skin issues for R3. On 08/20/24 at 2:30 PM, Surveyor interviewed Assistant Director of Nursing (ADON) C, who stated they were the facility's wound nurse. Surveyor asked if there was additional documentation of assessments of R3's left heel pressure injury that was identified on admission to the facility. ADON C stated they were not aware of R3's pressure injury. ADON C stated when a staff member identifies a new wound on a resident, they are supposed to inform ADON C. ADON C will then assess the wound and open a weekly wound tracker and do weekly wound assessments and documentation until the wound is healed. On 08/20/24 at 2:40 PM, Surveyor interviewed RN I, who stated R3 did have a previous pressure injury to the left heel when admitted from the hospital, but it had subsequently healed. RN I stated R3 did not have a current pressure injury to the left heel, but they neglected to update the care plan to reflect this. Surveyor asked RN I if there was documentation of an assessment of the left heel that showed the pressure injury had resolved. RN I stated they did not document an assessment of R3's heel showing the pressure injury had resolved. Surveyor asked if R3 was still at risk for development of pressure injuries. RN I stated R3 was still at risk for pressure injuries and staff should still follow the care plan and float R3's heels to prevent the recurrence of pressure injuries to R3's heels. Surveyor informed RN I of two observations of R3 seated without heels floated. RN I stated staff would be reeducated.

Based on interview and record review, the facility failed to notify resident's physician about a change in condition for 1 of 4 sampled residents (R)1. The facility did not inform physician about a deep tissue injury and change in vital signs for R1. Findings: The facility's policy titled, Change in Condition of the Resident, revised 09/20/2022, states in part: . When a resident presents with a possible change of condition, after a fall or other possible trauma, or noted changes in mental or physical functioning: 1. Assess the resident's need for immediate care/medical attention. Provide emergency care as needed. 2. Assess/evaluate the resident. This assessment/evaluation could include, but is not limited to the following: a. Vital signs . R1 was admitted to the facility on [DATE] with a Brief Interview of Mental Status (BIMS) of 11 which indicated a moderate impaired cognition, from an acute care hospital with diagnoses of malnutrition, multiple myeloma (also known as Kahler's disease, is an uncommon blood cancer that affects the bone marrow, the body's blood-forming system), left hip fracture of iliac wing (to heal with conservative measures), pain control, and therapy for a resident that was Non Weight Bear to the Left Lower Extremity (NWBLLE). Record review identified a Braden Scale (a standardized, evidence-based assessment tool commonly used in health care to assess and document a client's risk for developing pressure injuries) was completed on 05/20/24 at 4:53 PM, with a score of 21, which meant R1 was not at risk for skin breakdown. A weekly skin assessment was completed on 05/20/24 at 9:09 PM, which indicated R1 had a pressure injury to coccyx - from coccyx to peri area is dark purple and appears to be a Deep Tissue Injury (DTI). No open area noted. Surveyor was unable to find any documentation in R1's medical record showing a physician was notified of this suspected DTI. R1 developed tachycardia (a rapid heart rate) starting on 05/25/24 at 5:43 PM with a reading of 100 beats per minute. On 05/26/24 at 2:07 AM, R1 had a heart rate of 105, at 7:08 AM, 124, at 6:30 PM, 100. On 05/27/24 at 3:55 AM, R1's heart rate was 122, and at 6:44 AM, 148. R1's blood pressure dropped to 92/58 on 05/26/24. There was no documentation of physician notification when abnormal blood pressure and heart rates were noted. Both of the changes are possible signs of sepsis. A daily skilled note, dated 05/26/24 at 6:02 PM, identified the following statement in part, .Resident reported concern about her heart and on auscultation she is regular despite tachycardia. Surveyor unable to identify information about how or why R1 was sent to the hospital and requested documentation. DON B provided Surveyor with the Situation, Background, Assessment, and Recommendation (SBAR) and transfer to hospital form. On 05/27/24 at 7:32 AM, the SBAR communication form reads in part: . BP 122/65, Pulse 148, RR 18, temp, 98.1, Skin evaluation: Pressure ulcer Does the patient have pain: Yes the pain is new Description of pain/location: New wound measuring at 3.7 x 2.2 x 0.7 with foul smelling purulent drainage noted coccyx. Intensity: 6 Called on call for [hospital] and spoke with [Medical Doctor (MD) G] who gave orders to send to ER for evaluation and treatment. R1's Daughter notified 05/27/24 at 7:32 AM. On 05/27/24 at 8:15 AM, the ambulance record states the staff reports that R1 had been feeling unwell, complaining of fatigue, lower back pain and fevers for the past two days. Staff checked a pressure ulcer located on the patient's coccyx and stated that it was black and oozing. Staff report the patient had a low-grade fever yesterday of 100 degrees F. Ambulance record indicates temperature of 99.5, HR of 136, 120, BP stable. On 08/21/24 at 8:50 AM, Surveyor interviewed via phone MD G regarding R1's care to the pressure injury. On 08/21/24 at 9:08 AM, Surveyor asked MD G via phone if MD G was informed of the DTI to R1's bottom. MD G indicated the first time MD G was notified was when the facility requested to send R1 to the emergency roiagnom on [DATE]. Surveyor asked MD G if staff notified MD G with any change of condition related to elevated heart rate on 05/25/24 and noted decreased blood pressures. MD G indicated did not see anything documented for notification of this.

Based on interview and record review, the facility did not establish an Infection Control Program under which it investigates, controls, and prevents infections in the facility, and a system for recording incidents identified under the facility's Infection Control Program, including corrective action in a timely manner, for both residents and staff. This has the potential to affect all 51 residents in the facility. The facility did not have a tracking program in place for the early detection of infected and exposed residents (R) and staff for scabies. Multiple nursing staff members worked when they had scabies and were being treated, then worked on multiple other resident units, thus exposing other residents to scabies. The facility did not have a tracking program in place for the early detection of exposed residents on these other units. This is evidenced by: According to the Centers for Disease Control and Prevention (CDC) standard of practice, .suggestions for developing guidelines for preventing, detecting, and responding to multiple cases of non-crusted scabies in an institution. Surveillance .Have an active program for early detection of infested patients and staff. Maintain a high index of suspicion that scabies may be the cause of undiagnosed skin rash; suspected cases should be evaluated and confirmed by obtaining skin scrapings . Control [and] Treatment .Maintain records with patient name, age, sex, room number, roommate(s) name(s), skin scraping status and result(s), and name(s) of all staff who provided hands-on care to the patient before implementation of infection control measures: symptoms can take up to 2 months to appear in exposed persons and staff .Identify and treat all persons (e.g. staff .patients, etc.) having prolonged, direct skin-to-skin contact with an infected person before he/she was treated CDC (2023, December 23) Single Case. Retrieved from https://www.cdc.gov/scabies/php/public-health-strategy-crusted/index.html On 07/08/24, the following number of residents resided on each facility units and halls: -Aspen unit: A hall-twenty-three residents -[NAME] unit: B hall-six residents -Cedar unit: C hall-twenty-two residents On 07/08/24 at 9:47 a.m., Surveyor received and reviewed the facility timeline for a current scabies (a condition caused by tiny insects, or mites, which infest and irritate the skin) outbreak amongst staff and residents. The timeline indicates: -Certified Nursing Assistant (CNA) F had symptoms of abdominal rash with no onset date documented of when the symptoms occurred but then was evaluated on 06/07/24 and started scabicide (Permethrin cream) on 06/12/24. CNA F worked on Aspen Hall. -Resident (R) R8 located on Cedar Hall had symptoms of right upper quadrant rash with onset date of 06/09/24. R8 was not placed on contact precautions until 06/23/24 and then began scabicide (Permethrin cream) on 06/25/24. -CNA G had onset symptoms of abdominal rash on 06/08/24 and was evaluated by a physician in urgent care which then CNA G was prescribed to start scabicide (Permethrin cream) on 06/11/24. CNA G worked on Aspen Hall. - CNA H had onset symptoms of arms and chest rash on 05/15/24 approximately and was evaluated by a physician in urgent care which then CNA H was prescribed to start scabicide (Permethrin cream) on 06/19/24 and 06/26/24. CNA H worked on Aspen Hall. - Registered Nurse (RN) I had onset symptoms of arm rash bilaterally on 06/12/24 and was evaluated by a physician which then RN I was prescribed to start scabicide (Permethrin cream) on 06/12/24. RN I worked on Aspen Hall. - CNA J had onset symptoms of abdominal rash on 06/16/24 and was evaluated by a physician on 06/16/24 in which then CNA J was prescribed to start scabicide (Permethrin cream) on 06/16/24. CNA J worked on Aspen, [NAME], and Cedar Hall. -R9 located on Aspen Hall had symptoms of a rash on hands with onset date of 06/17/24, scrapings were ordered that resulted in a positive result for scabies placed on contact precautions, and then began scabicide (Permethrin cream) on 06/17/24. -From 06/17/24-06/26/24, 14 more residents R3, R4, R5, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, and R20 became infected with scabies and was placed on contact precautions and scabicide (Permethrin cream). Review of the outbreak timeline did not indicate when any of the staff or residents' contact precautions ended. There is no documentation of skin scraping to test for scabies and why the test was not completed. Surveyor reviewed a note from MDS (Minimum Data Set) Coordinator C dated 06/12/24 that indicated that staff brought concerns to administration's attention in regard to rashes on Aspen Hall. Director of Nursing (DON) B and Assistant Director of Nursing (ADON) K began a full body review on 06/12/24 at 10:00 a.m. of all current residents on Aspen Hall. There was no documentation that [NAME] and Cedar Hall were assessed for skin rashes. On 07/08/24 at 12:51 p.m., Surveyor interviewed Nursing Home Administrator (NHA) A and Director of Nursing (DON) B and asked about CNA F and CNA G reporting to DON B that CNA F and CNA G had scabies. DON B indicated that CNA F and CNA G came forward and reported to DON B that they had scabies. DON B indicated that DON B didn't think the staff members were positive for scabies as it was not brought to DON B's attention until after the fact, so DON B did not do anything about the staff members reporting the scabies infection amongst the two staff members. DON B indicated that DON B only knew about 2 of the 6 staff members on the line list that possibly had scabies until after it was too late. Surveyor asked NHA A and DON B when NHA A and DON B calculated that start of the scabies outbreak. DON B indicated the outbreak started on 06/20/24. NHA A indicated that NHA A started calling employee list to surveillance the scabies outbreak on 06/21/24. DON B indicated that through calling down the employee list four more staff members came forward and reported staff members had a scabies outbreak. DON B indicated that the four staff members had worked on all three halls throughout the facility but it was too late to try and mitigate scabies from spreading as it was after the outbreak was deemed active that the staff members came forward. On 07/08/24 at 2:52 p.m., Surveyor interviewed DON B and asked about scrapings category on the line list and why some of the residents were not tested for scraping results. DON B indicated that it was the choice of the physicians, and they did not want scrapings completed and to treat residents as rash presents. Surveyor asked DON B why skin assessments were not completed for [NAME] Hall and Cedar Hall after a resident down Cedar Hall had symptomatic rash down Cedar Hall and staff members that became symptomatic shortly after. DON B indicated the first 3 staff members only worked down Aspen Hall and the facility didn't think the facility needed to assess other halls. DON B indicated that staff should have performed skin sweeps on [NAME] and Cedar Hall along with Aspen Hall. Surveyor asked if the 3 staff members also float to dining room and help with feeding and delivery of trays. DON B indicated that yes, all staff members float to dining room, and activities area. On 07/09/24 at 8:16 a.m., Surveyor interviewed DON B and asked what conditions/diseases staff are required to report to DON B and Infection Preventionist (IP) once staff members become ill. DON B handed Surveyor the Employees Notice of Reportable Conditions. Surveyor reviewed and the list included: -#7 Scabies, - #9 Skin rashes, poison ivy/oak, impetigo, or staph. DON B indicated that all staff are trained on hire at orientation about the proper conditions and diseases that are reportable to administration to mitigate the spread of infections. DON B indicated that 4 of the 6 staff members did not report the staff's rashes until it was too late. .Concurrent treatment of contacts [i.e. staff] and individuals diagnosed with scabies is important, as the onset of symptoms is often delayed and therefore contacts may have active scabies while they are asymptomatic of pruritus. Family members that co-habit, including domestic workers, nurses, social workers, volunteers, therapists, assistants .and visitors .Identified contacts should be treated with the same regimen used for classic scabies .Restriction of staff rotation in the care facility has been identified as one of the steps of the successful control of outbreaks .Nurses who are caring for symptomatic patients and residents in the same ward are required to examine themselves regularly . Ong, C. & Fakhrudin, F. (2018) Infected with Scabies Again? Focus in Management in Long-Term Care Facilities. doi: 10.3390/diseases7010003. There were no resident line lists, to monitor for rashes or signs and symptoms of scabies, for the [NAME] and Cedar Halls, who were potentially exposed to scabies by nursing staff. There were no skin assessments to identify if rashes were present for the residents on [NAME] and Cedar Halls, after R8 who resides on Cedar Hall was found to have a rash on upper quadrant began, on or after 06/09/24. The facility did not actively treat all exposed residents on Aspen Hall, [NAME] Hall, and or on Cedar Hall when the facility knew they had scabies in staff members on 06/11/24. There were three residents (R8, R18, and R19) on Cedar Hall who became infected with scabies after the initial outbreak began. Facility had staff that did not report scabies infection to proper administration to mitigate the spread of scabies infection.

Based on interviews and record reviews, the facility did not calculate 1 of 3 sampled residents' (R2) fluid intakes who are at high risk for dehydration, in order to determine if meeting a sufficient fluid intake to maintain or improve proper hydration and health. This is evidenced by: The facility policy, entitled Hydration, dated 07/26/22 states, The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. Sufficient fluid means the amount of fluid needed to prevent dehydration (output of fluids far exceeds fluid intake: and maintain health. The amount needed is specific for each resident and fluctuates as the resident's condition fluctuates (i.e., increase fluids if resident has fever or diarrhea). Both the American Medical Director Association and the American Dietary Association Guidelines recommend a minimum fluid intake of 1500 cc's (cubic centiliters)/day for adults regardless of body weight. This is based on a healthy adult. Some individuals may need additional fluids based on health conditions. These minimum calculations are taken by calculating 30 ml/kg (milliliters/kilogram) of the resident's weight. 30 ml is equal to one ounce. R2 was admitted to facility 06/18/24 to 06/22/24, with a diagnosis of compression fracture of T9-T10 vertebra and history of constipation. R2 was ordered and received Furosemide 40 mg one time daily (a diuretic that helps body get rid of extra fluid). R2's Minimum Data Set (MDS), dated [DATE], indicated that R2 had a BIMS of 13 (cognitively intact), dependent on staff for toileting and chair/bed transfer. MDS was marked not applicable for toilet transfers. R2'2 MDS dated [DATE] section J1550 indicates no dehydration. R2's care plan, dated 06/19/24, indicated at risk for nutritional status related to pain but does not address fluid needs. R2's dehydration risk assessment completed by facility, dated 06/29/24, indicated R2 had predisposing factors of medical history and medication that would place at risk for hydration. The assessment did not include fluid intake recommendations. A hydration risk care plan was not developed. On 07/08/24, Surveyor reviewed R2's documentation of R2 receiving daily fluid intakes of: 06/18/24 = 480 cc 06/19/24 = 1060 cc 06/20/24 = 520 cc 06/21/24 = 700 cc 06/22/24 = 240 cc On 07/08/24 at 1:43 PM, Surveyor interviewed Director of Nursing (DON) B and Registered Nurse (RN) C requested documentation to support facility assessed fluid intake to assure R2 was taking at a minimum the recommended 1500 cc of fluids daily to prevent dehydration. Both DON B and RN C confirmed not having assessments completed to monitor for dehydration and recommended fluid intakes. On 07/09/24 at 9:29 AM, Surveyor interviewed Dietary Manager (DM) D, who stated assessments are usually completed within 7 days but has up to 14 days to complete. DM D stated an assessment was not completed on R2's nutritional /fluid needs but reviewing chart would have recommended 2100 - 2500 cc of fluids daily.

Based on interviews and record review, the facility did not ensure 1 of 3 residents (R2) were provided care and services to promote regular bowel movements (BM) that are in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. Findings include: The facility stated they did not have a policy or procedure on bowel management. R2 was admitted to facility from a hospital 06/18/24 to 06/22/24, with a diagnosis of compression fracture of T9-T10 vertebra and history of constipation. R2's last known BM was 06/16/24 and did not have a BM during admission to facility. R2's Minimum Data Set (MDS), dated [DATE], indicated that R2 had a BIMS of 13 (cognitively intact), dependent on staff for toileting and chair/bed transfer. MDS was marked not applicable for toilet transfers. R2 was ordered and received MiraLAX 17 grams mixed with 8 ounces of water daily for constipation. R2 was ordered and received Senna Plus 2 tablets at bedtime for constipation. R2 was ordered and received Furosemide 40 mg one time daily (a diuretic that helps body get rid of extra fluid). R2 was ordered and received 4 doses of Oxycodone HCL 5mg as needed for pain (an opioid which slows down the movement of stool) during admission to facility. R2's base line care plan, dated 06/18/24, indicated last known BM was on 06/16/24. R2's care plan, dated 06/19/24, stated: Opioid use r/t vertebral compression fracture with a goal to not experience prolonged constipation, ileus, or impaction while taking opioids. Interventions include to monitor bowel habits and implement bowel regimen as ordered. On 06/20/24, standing orders were signed by provider that include: Milk of Magnesia (MOM) 30 cc 1x every other day for constipation. Bisacodyl 10mg suppository rectally 2x daily as needed for constipation. Fleets enema 2x weekly rectally as needed for constipation. On 06/19/24 at 1:20 PM, nurses notes state in part .Bowel patterns: regular elimination - 1 BM every 1-2 days On 06/21/24 at 11:12 AM, nurses notes state in part .[R2] explained that he felt constipated, like he had not had a decent BM in weeks. An enema was ordered but R2 was concerned about not being able to stand and move to the restroom or commode. R2 was offered a bed pan and refused this option. RN offered another dose of MOM and a suppository. R2 stated would rather try those options. On 06/22/24 at 1:41 PM, nurses notes state in part .Bowel incontinence: No bowel activity. Bowel patterns: subject to constipation-BM every 2-3 days, uses laxatives, suppositories, enema. On 06/22/24 at 4:22 PM, nurses notes state that R2's daughter requested transfer to hospital due to not having a BM for 4 days. On 07/08/24, Surveyor reviewed R2's medical record which shows no documentation of R2 having a bowel movement during admission from 06/18/24 to transfer to hospital on 06/22/24. On 07/08/24, Surveyor reviewed R2's medical record and was unable to locate a bowel assessment completed by facility to gather information of last bowel movement, usual elimination pattern, bowel sounds, palpation for distention, hydration status or recommendations and medications. On 07/08/24 at 11:30 AM, Surveyor reviewed R2's medication administration record which shows no documentation of R2 receiving MOM, enema, or suppository during the entire stay at facility from 06/18/24 to transfer to hospital on 06/22/24. On 07/08/24 at 2:32 PM, Surveyor interviewed Director of Nursing (DON) B and Registered Nurse (RN) C, who confirmed there was no policy, assessment or documentation to support that R2 received the as needed MOM, enema or a suppository and the expectation would be for nurses to provide MOM and/or prune juice and if no BM by next day to give a suppository. On 07/08/24, DON B and RN C confirmed there was no formal bowel assessment completed by facility. On 07/09/24 at 7:59 AM, Surveyor interviewed MD E who stated the expectation would be to call if complications of pain, nausea or vomiting or fever and would have expected facility would have provided MOM and suppository as documented or offered other laxatives for the constipation.

Based on observation, interview and record review, the facility did not ensure the resident's environment remains as free of accident hazards as possible, and each resident receives adequate supervision and assistive devices to prevent accidents. This occurred for three of five residents (Residents (R) 68, 45 and 23) who were reviewed for falls. R68 was receiving a blood thinner, and was a high fall risk. The resident sustained [REDACTED]. The facility did not provide adequate supervision for R68, to prevent falls from reoccurring. The facility did not develop a baseline care plan after R68 was initially admitted , and did not include all fall prevention interventions on the comprehensive care plan. R23 is at risk for falls and fell on [DATE], a thorough investigation and new interventions were not put into place. R45, identified as a fall risk, sustained four documented falls at facility since readmission on 7/13/19. The facility did not identify a root cause for each documented fall, revise the care plan or implement individualized, resident-centered interventions to reduce risk of future falls. This is evidenced by: 1. On 08/22/19 at 10:45 a.m., Surveyor received and reviewed a facility policy entitled, Fall Prevention and Management Guidelines. The policy, which was revised on 05/20/19, states the following, in part: .Fall Prevention and Management Guidelines Objectives: Appropriate fall management needs to result in reducing fall, minimizing injuries, and ultimately improving the quality of life of residents. Limit and/or prevent the occurrence of falls within the parameters that can be controlled through structured program interventions . Details of Key Elements: [NAME] Assessments. 1. Clinical (Nursing) assessment .1. Admission fall risk assessment .completed within 24 hours of admission .3. Frequency of reassessment. 1. Upon a fall-complete post fall assessment .3. Continence protocol as indicated .Toilet schedule: implement as needed .4. Mental status assessment .1. Recall assessment. 2. Judgment (safety awareness) .7. Pharmacological assessment and review .8. Environment assessment .B. Dynamic Treatment Plan. 1. Specific interventions based on results of fall assessments and individual resident's preferences. The interdisciplinary team members must address: a. Resident, staff, and family teaching .c. Resident's daily routines. d. Mental status/behaviors. e. Physical limitations .Continence .8. Non-pharmaceutical interventions in place .2. As information is updated, it needs to be communicated to the staff, resident and family. 0. Staff 1. Identify the resident's potential to fall .3. Individual care plan developed, communicated with staff and implemented. 4. Give staff verbal and written reports as needed . C. Evaluation. 1. Complete post fall evaluation after every fall .Actions of the interdisciplinary team 1. Timely modifications to the treatment plan and re-inservicing of staff .3. Collective review, identification, and analysis of trends in resident falls throughout the facility . On 08/20/19, Surveyor reviewed R68's medical record. The resident's [DIAGNOSES REDACTED]. The resident was legally blind. The resident was admitted to the facility, from a hospital following a stroke and dehydration, on 06/27/19. A physician progress notes [REDACTED].NEUROLOGY NOTE .She had a 'busy' night, requiring one-to-one monitoring .ASSESSMENT/PLAN .She continues to have confusion at night. I suspect that this is a sundowning phenomenon (late-day confusion) .She is still awaiting placement (for nursing home) pending 48 hours of not needing a one-to-one monitor . A hospital After Visit Summary, note, dated 06/27/19, states the following, in part, .Safety Considerations .Cognition: Appropriate for developmental age, Impulsive, Poor safety awareness, Short term memory loss . The facility medical record identifies R68 had short and long term memory deficits and had severely impaired decision making abilities. The resident had an activated Power of Attorney for Healthcare (POAHC), who was Family Member (FM) GG. The resident's Minimum Data Set (MDS), dated [DATE], indicated the resident did not have hallucinations or delusions. The MDS indicated R68 was continent of bowel function, but was frequently incontinent (having seven or more episodes of incontinence, but at least one episode of continent voiding) of bladder function. The assessment identified the resident required two staff for bed mobility, transfers and toileting. The resident did not ambulate and required a mechanical lift for transfers. R68 was taking the following medications, in part, as of 06/27/19: -Eliquis (an anticoagulant/blood thinner) 2.5 milligrams (mg), twice a day (AM and PM) -Aspirin 81 mg, daily (AM) -[MEDICATION NAME] (an antipsychotic) 12.5 mg at bedtime (newly prescribed while in the hospital) -[MEDICATION NAME] (a diuretic) 12.5 mg, daily (AM) -[MEDICATION NAME] (laxative) 10 mg tablet and 10 mg suppository, both twice a day as needed -[MEDICATION NAME] (stool softener) 283 mg/5 milliliters, one enema rectally, twice a day as needed The 2019 Eliquis Box Warning states the following, in part, You may have a higher risk of bleeding if you take ELIQUIS and take other medicines that increase your risk of bleeding, such as aspirin .selective serotonin reuptake inhibitors (SSRIs) .and other medicines to help prevent or treat blood clots .While taking ELIQUIS, you may bruise more easily and it may take longer than usual for any bleeding to stop . [MEDICATION NAME] is an SSRI medication. It is noted, taking blood thinners can worsen the effects of a fall, which may cause internal or external bleeding, or a bone fracture. Bleeding after a fall when taking a blood thinner can be life threatening, and can lead to changes in a person's blood pressure and/or breathing pattern. R68's Care Delivery Guide, which was initiated on 06/27/19, states the following, in part, .Hoyer (full body mechanical lift) until therapy evals (evaluates) .Bladder: Incontinent .Bowel: Incontinent .Vision: (Left blank) .Communication Problems: very HOH (Hard of Hearing) .Cognitive: Alert, Confused .Give short 1-step instructions .Safety Devices: (Left blank) .Resting/Sleeping Preferences: (Left blank) .Fall Risk (describe): self-transfer attempts, forgetful, confused . The Care Delivery Guide does not identify the resident has visual impairments, and does not identify any initial fall prevention interventions for the resident. The facility did not develop a baseline care plan for the resident, within the first 48-hours of admission, for the resident's potential fall risk and fall interventions. On 08/22/19 at 10:42 a.m., the Director of Nursing (DON) confirmed there was no baseline care plan completed for R68. The DON stated baseline care plans for falls are developed upon a resident's admission to the facility by the unit manager and the MDS Coordinator. Surveyor reviewed R68's fall assessments, post fall reports, and nurses' notes, from 06/27/19 to 07/05/19. The assessments and notes state the following, in part: -Thursday, 06/27/19, written by Registered Nurse (RN) Z: .Resident is alert but appears only oriented to self and close family. Resident didn't seem to be fully grasping orientation to facility and her room (phone, bed remote, call light) .mental status changes [MEDICAL CONDITION](stroke) 'multifactoral [MEDICAL CONDITION]' .and [MEDICATION NAME] was started to treat this. Safety issues: Resident's confusion and delerium (sic) may likely make her a serious fall risk. Will need to be monitored closely. -06/27/19: .confused, poor safety awareness, high fall risk, unable to bear weight on legs .legally blind, hoh .tries to self transfer . -06/27/19, Admission/Readmission Evaluation: .Vision: Severely impaired .Bladder: Incontinent (for) longer than a year .How often is the resident wet? Once or more per shift .Resident is wet during: Day and Night time .Bowel: Continent of Stool? No .Fall Risk Assessment: Fall History: Last 30 Days .No falls .Last 60 Days .No Falls .Last 180 days .No Falls .Medication taken more than 3x/week, including PRNs (as needed): Diuretic, Antihypertensive, [MEDICAL CONDITION] medication .Wandering, verbally abusive, physically abusive, socially inappropriate .Behavior occurred daily or more .(specific behavior is not identified on the assessment) .Resident is at risk for falls? Yes .Fall Care Plan (Checked as complete) . -Friday, 06/28/19, nurses' note: Resident attempted to self transfer out of bed this shift and slide out of bed on to the floor. Resident was observed sitting next to her bed with no injury noted .Bed placed in low position and touch pad call light placed in resident's reach. Personal belongings in resident's reach. Resident reeducated to use call light for assistance from staff. Resident has poor eyesight and is hard of hearing . .Background: new admit to facility for [MEDICAL CONDITIONS], multiple falls, hard of hearing, poor eyesight, noted confusion .needs reminders to use call light for assistance from staff. resident was dry at the time of fall. Assessment: resident has confusion and does not understand the need to wait for assistance from staff. prior to coming to the facility resident had been living in an apartment independently .Recommendations: bed in low position, frequent reminders to use call light .personal items in reach, grippy socks on feet, monitor resident. Response: resident voices understanding regarding reminders to use call light but will call out loud, make noise by hitting her call light on side rail or attempt to get out of bed on her own . -06/28/19, Post Fall Analysis/Plan: .Time (of fall): 1:40 a.m Subjective or patient states: stated had to go to bathroom then stated looking for clothes then wanted to know what time breakfast was .Specify Recommendations/Interventions taken to prevent reoccurrence: Bed in low position, touch pad call light, personal belongings in reach, snack before bed, offer toileting .Care plan updated: (Left blank) . There was no documentation in the medical record, a care plan, or the Care Delivery Guide as to when or how often toileting would be offered to R68. -06/28/19, Fall Risk Assessment: .Fall History: Last 1 Month: Multiple Falls .Last 3 Months: Multiple Falls .Last 6 Months: Multiple Falls .Medication Use: Antihypertensives (Diuretics and [MEDICAL CONDITION] are not identified) .Continence in Last 14 Days: Frequently Incontinent: bladder incontinent daily .bowel 2-3 x/week .Confined to chair and disoriented .Gait Analysis: Unable to independently come to a standing position .Care Plan Updated: Yes. List New Immediate Interventions .bed in low position, touch pad call light, personal items in reach, reoriented to current facility . There was no baseline or a comprehensive care plan completed for R68, as of 06/28/19, which identified these fall interventions, including the risks involved of receiving an anticoagulant. -Saturday, 06/29/19, written by RN X .Resident had been restless and c/o (complained of) being cold. (due to history of falls), was brought out into the hall in her wheel chair where it was warmer till supper. (Had her in view for safety). Resident went to supper and was assisted back by another hall nurse. That person did not know she was a fall risk. The nurse had placed her in her room and put her call light on and left for her own wing. Less than 5 minutes later heard a crash and resident was found on the floor face down. Large hematoma (bruise) over left eyebrow small skin tear seen. Resident was hoyer lifted into bed .Md (Doctor of Medicine) was notified .then called the son to get permission to send her in for a C-T (computed tomography) scan. Resident was sent out (to hospital) and came back after the scan was negative for changes .[MEDICAL CONDITION] and bruising had already spread to whole eye orbit and the hematoma was protruding over her eye . .Pain Evaluation: Yes .6 (out of 10) Acute Headache Persistent nagging headache .Neurological Evaluation .dizziness and lightheaded . On 08/22/19 at 11:03 a.m., Surveyor interviewed RN X, and asked about the circumstances of this fall. RN X explained a nurse on a different unit wheeled R68 into the resident's room after supper, the nurse activated the call light, and left the room with the resident alone. RN X stated she does not remember the name of the other nurse. RN X stated at this time, the pharmacy arrived to the facility to deliver medications, and the RN went to assist with this delivery. RN X stated she was aware at the time R68 was left alone in the room with the activated call light, but the RN indicated she did not tell any staff members to remove the resident out of the room. RN X said R68 fell a few minutes later. During the continued interview, RN X stated she implemented the fall intervention of having the resident in constant visual line of sight on the PM shift, due to R68's history of falls, and the resident liked to fiddle around with things. The RN stated 15-minute safety checks would not have stopped R68 from falling. RN X further stated she believed whenever the resident fell , the resident needed to use the bathroom. The RN stated she did not update R68's care plan, on or after 06/29/19, with this new fall intervention, since RN X is not familiar with how to update resident's care plans in the computer. RN X stated she did not notify the DON or unit manager the resident's care plan needed to be updated. The RN stated the resident's bruising after the fall extended from R68's forehead down to almost the chin. R68's fall assessments, post fall reports, and nurses' notes, continue to state, in part: -06/29/19: A Skin Assessment indicates the following, in part, Comments: (Areas above R68's left eyebrow) small abrasion (and) skin tear from fall-hematoma 1 1/2 (inches) x 2 (inches) . There is no documentation in R68's medical record or in the fall reports the nurse from the other wing or other staff members were educated on the resident's high risk for falls, or fall prevention interventions. -06/29/19, Post Fall Analysis/Plan: .Time: (6:55 p.m.) Fall Details: attempted self transfer, leg tangles in w/chr (wheelchair) legs .trying to get out of w/chr to toilet .Time last toileted .: (4:30 p.m.) .Specify Recommendations/Interventions taken to prevent reoccurrence: Check and change or toilet q (every) 2 (hours) and when in w/chr have her out in hall within sight. gripper socks at all times .Care plan updated: Yes .IDT (Interdisciplinary Team) Review and Recommendations: Intervention not to be left alone in room. Signatures: (Report signed by the DON, on 07/01/19) . -06/29/19, Fall Risk Assessment, completed by RN X: .Fall History: Last 1 Month: Multiple Falls .Last 3 Months: Multiple Falls .Medication Use: (None identified) .Continence in Last 14 Days: Frequently Incontinent: bladder incontinent daily .bowel 2-3 x/week .Confined to chair and disoriented .Gait Analysis: Unable to independently come to a standing position, Requires hands-on assistance to move from place to place .Care Plan Updated: Yes. List New Immediate Interventions .When in wheel chair needs to be out in hall and be within sight the whole time .Comments: resident noncompliant with use of call light due to stroke . This assessment was signed by RN X on 07/11/19, 13 days after the resident's fall. There was no baseline or a comprehensive care plan completed for R68, as of 06/29/19, which identified these specific fall interventions, including the risks involved of receiving an anticoagulant. On 08/21/19 at 1:45 p.m., Surveyor interviewed the DON, and asked if the facility educated this nurse and/or other staff members of R68's high falls risk, including the fall interventions which were implemented. The DON stated she did not know the nurse from the other unit was not aware of R68's fall risk, until 08/21/19. The DON stated no education was provided to the nurse from the other wing or other staff members, regarding R68's fall interventions or the resident was a high fall risk. Surveyor asked the DON about the fall interventions identified in the resident's Post Fall Analysis/Plan as well as the Fall Risk Assessment, of having R68 to be within sight and having the resident in the hallway when up in the wheelchair. The DON replied the facility did not have R68 within line of sight supervision, since the facility did not have enough staff for this. The DON stated the staff instead kept the resident close to staff members while in the wheelchair, kept the resident in sight, and would keep eyeballs on R68 as much as they could. On 08/26/19 at 8:11 a.m., the DON stated on 06/29/19, RN X was not able to get into the facility computer to complete the Fall Risk Assessment, so this assessment was not completed until RN X returned from vacation, on 07/11/19. The DON stated the intervention of having the resident toileted every two hours, was not documented on the resident's care plan. The DON stated the intervention of having the resident not to be left alone in the room, was a temporary intervention, implemented by RN X, which only lasted over the weekend. The DON further stated the charge nurses do not update resident care plans. It is noted, there is no documentation the intervention of not leaving R68 alone in the room was a temporary intervention, or only lasted that weekend. R68's fall assessments, post fall reports, and nurses' notes, continue to state, in part: -Sunday, 06/30/19 at 12:55 a.m., nurses' note: .instructions from ER (emergency room ) not to take eliquis tonight restart all other current medications tomorrow keep her wound clean and dry return to the emergency department if develops any worsening headache, vomiting, confusion or if worse in any other way. Surveyor reviewed R68's Medication Administration Record [REDACTED]. The anticoagulant was otherwise held, from 06/30/19 to 07/05/19. R68's fall assessments, post fall reports, and nurses' notes, continue to state, in part: -06/30/19: Resident has swollen and bruised left eye from her recent fall on 6-29-19 . -06/30/19: .Falls .Resident found on the floor next to her bed. Has rolled out of low bed unto mat on floor. No new noted injuries . -06/30/19, Post Fall Analysis/Plan: .Time: (5:00 p.m.) Fall Details: (Left blank) .Time last toileted .: (4:00 p.m.) .Dry .Recap of resident activities during the three hours prior to the fall: Came back from lunch, toileted, then was put in hall so we could watch her-because of fall the night before. Was toileted around 3:30 (p.m.) and wanted to lye down. Laid her down around 4:00 (p.m.)-was hanging off edge of bed so bed was repositioned with Right side against the wall-found on floor at 4:30 (p.m.) .Specify Recommendations/Interventions taken to prevent reoccurrence: Turned bed against wall .Care plan updated: (Left blank) . There is no root cause identified for this fall. -06/30/19, physician consult note: Received call from nurse (name of facility) .ER placed eliquis on hold until Monday. I extended the hold until (name of other physician) reviews the situation as patient has fallen 3 days in a row now and is at high risk for negative outcome. This may need to be discussed with neurologist . There is no documentation this was discussed or follow-up with a neurologist. On 08/26/19 at 8:11 a.m., Surveyor interviewed the DON about this fall, and asked if the facility considered or implemented having R68 toileted more frequently than every two hours. The DON replied she could not remember if this intervention was discussed with the IDT. R68's fall assessments, post fall reports, and nurses' notes, continue to state, in part: -07/01/19: .Left eye is bruised and swollen shut, Right eye bruising noted as well, left forehead swollen and bruised. family concerned about the condition of resident, wanted to send resident to hospital to be evaluated again, after RN (name of RN Z) talked to dr. and per drs. recommendations educated family on the process of bruising due to being on an anticoagulant and that a trip to the ER would be unnecessary. Family was agreeable .Confusion noted (by resident) . -07/02/19: .Resident fall in last 3 months: Yes Abrasion to forehead, bruising and swollen to forehead. Rt. (Right) elbow abrasion, bruises and hematoma to left arm . -07/02/19, fax to the physician: .Concern(s)/Reason for Fax: Resident has been more sedated per Family report/Care Conference today. Son/POA .requests d/c (discontinue) [MEDICATION NAME] 12.5 mg .daily. Can we get this ordered . The physician ordered R68's [MEDICATION NAME] to be discontinued. -07/03/19: .Resident confused and hard to redirect .calling out in her room and had to be reminded not to get out of bed by herself. resident was reminded to use her call light to obtain staff assistance, needs close supervision, and lots of time and attention . -Friday, 07/05/19 at 1:15 a.m.: .Continues to have facial bruises and swelling. No adverse reaction from serquel (sic) being discontinued. Resident does continue with behaviors of yelling out and not using her call light. Continue to monitor . -07/05/19, written by RN Z: Resident was noted to have fallen (at 8:30 p.m.). Resident was in hall near nurses cart d/t (due to) recent hx (history) of freq (frequent) falls in room/out of bed attempting to self-transfer/ambulate. At a point when nurse and CNAs' (Certified Nursing Assistants) were assisting other residents in their rooms, resident again attempted to stand from w/c and fell forward to floor. Fall was unwitnessed but resident cried out as she was (falling) and staff attended (to) her immediately. Resident c/o R sided head pain and R elbow pain. No bleeding anywhere noted but superficial abrasion noted to R elbow. Gently moved upper and lower extremities, which ellicited (sic) no pain. Resident then assisted in to wc w/ (with) hoyer .Resident was alert and confused per baseline. Immediately called to report fall to on call physician .and son/POA . .Pain Evaluation: Yes .Occasional moan or groan. Low-level of speech with a negative or disapproving quality .Acute Headache .Per order from on-call physician .and desire of POA/son .resident transported to (name of hospital) .via ambulance . R68 was hospitalized until 07/11/19 and did not return to the facility. -07/11/19, written by RN X: .Send to ER for C-T scan (on 07/05/19) to R/O (Rule Out) more trauma due to blood thinners and recent stroke . -07/05/19, Hospital Note: .Principal Problem: [MEDICATION NAME] force eye trauma, bilateral (both) .Hospital Course .is here after several falls .I did note (name of other physician's) concerns. Her trauma could be considered consistent with a single large contusion with 'flow' of the subcutaneous blood and ecchymosis (bruising) as her left side is more prominent than the right. Although, this is very significant, it is not completely out of the norm with a hematoma on blood thinners with spreading ecchymosis .Physical Exam: Significant bruising of the entire forehead down around her eyes . -07/05/19, Post Fall Analysis/Plan: .Time: (8:30 p.m.) Fall Details: (Left blank) .Time last toileted .: (Left blank) .Recap of resident activities during the three hours prior to the fall: In w/c being observed as closely as possible in hall by CNAs and nurse .Possible Causal/Contributing Factors and Observations: Attempted to stand unassisted from wc in hall. Resident is forgetful and confused since [MEDICAL CONDITION] forgets she is weak on L side (and) can't stand up/ambulate .Specify Recommendations/Interventions taken to prevent reoccurrence: Resident hit her head in fall and c/o R sided head pain after. Sent to (hospital) ED (Emergency Department) for eval and (treatment) .Care plan updated: (Left blank) . There is no documentation in R68's medical record or the fall reports as to what time the resident was last toileted prior to the fall. On 08/26/19 at 11:31 a.m., Surveyor interviewed RN Z, and asked about the circumstances of this fall. The RN stated R68 was seated in a wheelchair in the hallway, and RN Z was seated approximately ten feet away from the resident at the nurses' station (which is located at the center of the facility). RN Z explained the other nurse was providing care to another resident, when R68 stood up from the wheelchair, and made an ugly sound when the resident's head hit the floor. RN Z stated she was not one-to-one with R68, but looked over at the resident once-in-awhile. RN Z stated she did not see R68 stand up or fall, and the RN did not know when the resident was last toileted. During the continued interview, RN Z stated on PM shift, R68 was antsy, and tried to get up a lot out of the wheelchair and move around. Surveyor asked what interventions staff implemented to prevent R68 from falling. RN Z replied the bed was kept in a low position with a fall mat, staff attempted to keep the resident at the nurses' cart, regular cares were provided, and keeping the resident within line of sight as best as staff could which was the whole point in keeping the resident out in the hallway. On 08/21/19 at 1:45 p.m., Surveyor asked about the circumstances regarding this fall. The DON stated staff turned away from R68, turned back and the resident was already on the floor. The DON further indicated R68 was very restless on the PM shift. On 08/26/19 at 8:11 a.m., Surveyor asked the DON when R68 was last toileted prior to this fall, and if this was investigated by the facility; in order to determine if the previous fall intervention (from 06/29/19) was being followed. The DON stated she would have to look into this. At approximately 8:30 a.m., the DON informed Surveyor there is no documentation in R68's record or fall report as to when the resident was last toileted. On 08/21/19 at 2:50 p.m., the DON provided Surveyor with a copy of R68's CNA care plan. Surveyor asked the date in which the CNA care plan was effective, and the DON replied the care plan would have been the most current. R68's undated CNA care plan states the following, in part, .Repo (Reposition) q 2hrs (hours) .Fall Interventions: bed in lowest position, keep her items within her reach, when in bed place touch pad call light on her night gown, gripper socks .RES IS BLIND . The fall prevention interventions of offering R68 a snack before bed (06/28/19), toileting every two hours (06/29/19), not to be left alone in room and to be kept within line of sight in the hall (06/29/19), having the bed against the wall (06/30/19), and a fall mat (nurses' note from 06/30/19), are not identified on the CNA care plan. Surveyor reviewed R68's comprehensive care plan. The care plan states the following, in part, Resident is at risk for falls r/t (related to) Cognition-unaware of safety needs, Deconditioning/weakness, Gait balance problems, History of falls, Incontinence, Recent illness. Date Initiated: 07/05/2019. Goal: Fall related injuries will be minimized through care plan review date. Date Initiated: 07/05/2019 .Interventions: Anticipate and meet the Resident's needs. Encourage the Resident to always call for assistance .clip call light to her night gown at night, bed against the wall with mat on the floor .Ensure that the Resident is wearing appropriate footwear (specify) .Follow Therapy recommendations for transfers, mobility and ambulation .Place bed at lowest position .Place call light or communication device within reach. Answer call light promptly-always .Review information on past falls and attempt to determine cause of falls for prevention and to minimize injuries . All interventions are documented as being initiated on 07/05/19. The interventions of offering R68 a snack before bed (06/28/19), toileting every two hours (06/29/19), not to be left alone in room and to be kept within line of sight in the hall (06/29/19) are not identified on the comprehensive care plan. The care plan does not identify the resident is at a higher risk of bleeding and and sustaining injuries when falling due to the anticoagulant. The resident's comprehensive care plan was not developed until 07/05/19, eight days after the resident's admission, after the resident sustained [REDACTED]. On 08/21/19 at 1:45 p.m., Surveyor interviewed the DON. The DON indicated the facility knew R68 was a fall risk upon admission to the facility, and the resident was in one of the first rooms which was closest to the nurses' station on one of the units. Surveyor asked the DON if the facility normally develops a comprehensive care plan for falls, after a resident is admitted to the facility. The DON replied a fall care plan is usually developed on the resident's baseline care plan after an admission. The DON stated the Care Delivery Guide is the initial, short-term CNA care plan and the facility should have developed a baseline care plan for the resident. Surveyor showed the DON R68's comprehensive care plan, which the DON confirmed was developed on 07/05/19, and did not identify all of the resident's fall interventions. On 08/26/19 at 8:11 a.m., the DON stated staff review the fall reports every morning during an IDT meeting. The DON further stated staff discussed R68 during the WAR meetings (Weekly At Risk), on 07/01/19, and 07/08/19. The DON provided the WAR meeting notes, from these two dates, and the DON stated she does not keep good notes as the WAR notes are just an outline. The 07/01/19 WAR Meeting Key Indicators notes, state the following, in part, .Falls: (Name of R68)-freq. falls since admit . The 07/08/19 WAR Meeting Key Indicators notes, state the following, in part, .Falls: (Name of R68)-to ER/(illegible word) . On 08/20/19 at 4:45 p.m., Surveyor interviewed CNA Y, and asked about R68. CNA Y stated the resident was a high fall risk and would often lean forward while in the wheelchair, and reach for things that were not there. The CNA stated, she was one you always kept an eye on. CNA Y stated he believed R68 was supposed to be kept within line of sight, but the CNA stated this was not identified on the CNA care plan. The CNA further stated after R68's falls, the resident's face was all bruised. On 08/21/19 at 10:47 a.m., Surveyor interviewed Social Services Director (SSD) [MI] Surveyor noted R68's care conference with the POAHC was held on 07/02/19, and Surveyor asked SSD L what was discussed at the resident's care conference meeting. SSD L stated therapy provided an update on the resident's progress, and nursing discussed fall interventions regarding R68's recent falls. Surveyor asked if facility staff were supposed to have R68 within line of sight to help prevent falls. SSD L replied staff had R68 at the nurses' station for the nurses to see the resident. SSD L stated she did not document what was discussed at R68's care conference in the resident's medical record. On 08/22/19 at 9:22 a.m., Surveyor interviewed R68's FM GG. FM GG stated after R68's fall on 06/29/19, the resident had a golf ball sized knot above the resident's left eye along with significant bruising from the forehead down to the resident's chin. FM GG stated he was told this fall occurred at dinner time when staff was gone for a few minutes. During the continued interview, FM GG stated during R68's care conference, which was held on 07/02/19, staff informed the FM the resident was restless, agitated and not respecting safety issues. Staff further info

Based on observation, interview and record review, the facility did not ensure pain management was provided to residents who require such services, which are consistent with professional standards of practice, the person-centered care plan, and the resident's goals and preferences. This occurred for one of six residents (Resident (R) 16) who were reviewed for pain. R16 was observed to have excruciating, breakthrough pain during two personal care observations. Nursing staff did not stop performing cares and notify the charge nurse of the resident's pain. The facility did not pre-medicate the resident to prevent pain prior to performing personal cares and transfers. The facility did not adequately assess and treat the resident's pain, did not identify a pain level goal according to the resident's goals and preferences and did not notify the physician regarding the amount of pain the resident had been experiencing. This is evidenced by: According to the Journal of the American Medical Directors Association, It is essential that physicians and midlevel practitioners who care for residents in long-term care facilities be proficient in the recognition, assessment, and treatment of [REDACTED]. pain. (Winn, Peter A. S., Dentino Andrew N. (2004) Effective Pain Management in the Long-Term Care Setting. Volume 5 (Issue 5), pp. 342-352). On 07/31/18, Surveyor reviewed R16's medical record. The resident has [DIAGNOSES REDACTED]. According to the Mayo Clinic, Cervical spondylosis is a general term for age-related wear and tear affecting the spinal disks in (the) neck. As the disks dehydrate and shrink, signs of [MEDICAL CONDITION] develop, including bony projections along the edges of bones (bone spurs) .Sometimes, cervical spondylosis results in a narrowing of the space needed by the spinal cord and the nerve roots that pass through the spine to the rest of your body . The resident has short and long term memory deficits and has a legal guardian. According to the medical record, the resident is able to verbalize most of his needs to staff. R16's medical record indicates the resident requires the assistance of two staff members for bed mobility, transfers, dressing, and personal hygiene. The resident requires a full-body mechanical Hoyer lift for all transfers. The resident uses a Broda (brand name) wheelchair with footrests. The resident's most recent Minimum Data Set (MDS), dated [DATE], indicates the resident is always incontinent of bowel and bladder function. The resident's comprehensive care plan states the following, in part: Focus: (R16's first name) has pain or the potential for pain r/t (related to) or evidenced by: Decreased mobility Date Initiated: 11/27/2017 Revision on: 04/24/2018 . Goal: The Resident will communicate needs for pain medication and will verbalize adequate relief of pain or ability to cope with pain as specified by pain level goal-see pain assessment. Date Initiated: 11/27/2017 Revision on: 05/08/2018 . Interventions: Administer [MEDICATION NAME] per MD (Doctor of Medicine) orders. Give prior to treatments, therapy or cares Date Initiated: 11/27/2017 .Explore non pharmacological pain alleviating interventions such as heat, ice, massage, elevation, relaxation, repositioning and food Date Initiated: 11/27/2017 .Monitor/document for side effects of pain medication .Observe Resident during cares for signs of pain i.e. facial grimacing, hesitancy with movement, furrowed brows, saying 'Ouch', refusing to move or transfer. Always ask Resident about their pain with each encounter. Date Initiated: 11/27/2017 .Update Physician on effectiveness of [MEDICATION NAME] and pain treatments as necessary Date Initiated: 11/27/2017 . Focus: (Activities of Daily Living) self care deficit .Interventions: offer to lay down after meals .reposition every 2 hours and (as needed) .check and change every 2 hours and (as needed) . R16's care plan does not identify the resident has chronic pain, chronic pain related to cervical spondylosis, nor does the care plan identify the location of the resident's pain. R16 is currently taking the following medications for pain: -[MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]; a narcotic) 5-325 milligrams (mg) every six hours; 7:00 a.m., 1:00 p.m., 7:00 p.m. and 1:00 a.m. -Tylenol 325 mg, as needed (PRN), every four hours for pain level 1 or 2 -Tylenol 650 mg, PRN, every four hours for pain level 3-5 A physician's progress note, dated 07/25/17, identifies R16 has been taking [MEDICATION NAME] for chronic pain, every six hours, since this time. According to the resident's medical clinic, on 08/01/18, the resident has been taking scheduled [MEDICATION NAME] for chronic pain, since (MONTH) (YEAR). A physician's progress note, dated 10/24/17, states the following, in part, .Present History .(R16) also mentions some lower extremity pain which is nothing different from his baseline. Discussed with nursing staff if (R16's first name) had fallen recently or had any sort of trauma. This does not seem to (be) the case and there is report that (R16's first name) does periodically report lower extremity pain throughout the day .Assessment & Plan .4. Chronic Pain related to cervical spondylosis . On 07/30/18 at 11:24 a.m., Surveyor was standing in a hallway, three rooms down from R16's room. This is approximately half-way down the hallway from R16's room. At this time, Surveyor heard a resident moaning loudly, as if in pain, and yelling, Ow! Ow! Ow! from behind a closed door. Surveyor approached R16's closed room door and heard a staff member say, I'm sorry .Do you want to change your pants? Surveyor then heard a resident yelling, Ow! .Ouch my back hurts! At 11:28 a.m., Surveyor entered R16's room, and observed R16 dressed, and lying on his back in bed. A Hoyer sling was located beneath the resident. At this time, Surveyor observed Certified Nursing Assistants (CNAs) C and D roll R16 onto the resident's right side. As the resident rolled onto his side, the resident yelled out, Ow! The CNAs then rolled the resident onto his back, and hooked up the Hoyer sling hooks to the mechanical lift bar. At 11:29 a.m., R16 was lifted up with the full-body Hoyer lift from the bed. At this time, the resident was moaning loudly and said, My feet hurt! Surveyor observed the resident's back slightly hit the bedside table, and R16 yelled, Ow! Goddammit let me down! As the resident was transferred in the sling, from the bed to the wheelchair, Surveyor heard R16 yell out Ow! five times. As the CNAs were lowering the resident into the Broda wheelchair, R16 yelled, Ow! It hurts! At 11:31 a.m., the CNAs explained to the resident they were going to assist R16 to change his shirt. At this time, the resident leaned slightly forward in the wheelchair and CNAs C and D removed R16's shirt. As the CNAs were removing R16's shirt, the resident said, I can't move! Ow! Ow, It hurts! Goddammit! Ow! Ow! It hurts! This observation ended at 11:35 a.m. At 11:38 a.m., Surveyor interviewed CNA C, and asked if R16 is usually in this much pain during personal cares. CNA C replied R16's back and feet usually hurt, and the resident is usually in that much pain, even when the resident is lying in bed. The CNA stated the resident's pain is constant, and the resident always has pain when transferred. According to the resident's medical record, the resident was not pre-medicated prior to cares and this transfer. Nursing staff did not stop personal cares, and did not notify the charge nurse of the resident's pain. On 07/31/18 at approximately 9:27 a.m., Surveyor observed R16 sitting in a Broda wheelchair in the resident's room. At this time, CNAs E and F entered the resident's room with a Hoyer lift. At 9:30 a.m., CNA F hooked up the Hoyer sling hooks (sling was located behind the resident) to the mechanical lift bar. As R16 was lifted from the wheelchair with the lift, the resident yelled, Ow! Ow! That's my back! Resident was observed to be moaning loudly as if in pain, while transferring in the lift from the wheelchair to the bed. The resident was lowered to the bed from the lift, and CNA F removed R16's shoes. Both CNAs then rolled the resident onto the resident's right side, and the resident yelled out, Ow! The CNAs then rolled R16 onto his back. CNA F lowered the resident's pants from R16's waist to his knees, and the resident yelled, Ow! Goddammit! Son-of-a-[***] ! At 9:36 a.m., the CNAs rolled R16 onto the resident's left side, and the resident yelled, Ow, my back! Ow, my back! Ow! Goddammit! My back hurts! At this time CNA F removed the resident's soiled incontinence brief and informed R16 the aides were going to wash up the resident. Surveyor turned away, in order to give R16 privacy. Surveyor was able to hear R16 yell out, My back's sore. Ow! CNA F replied, I have to wash it. Resident was then heard yelling, Ow, it hurts! At approximately 9:41 a.m., Surveyor observed the CNAs turn R16 onto the resident's right side in bed. At this time, the resident yelled, Ow! Ow! CNA E said, You're ok to the resident. At this time, CNA F continued to provide incontinence cares to R16, in which Surveyor turned away to give the resident privacy. Surveyor was able to hear CNA F inform the resident the aide was going to put protective cream on the resident's buttocks. At this time, Surveyor heard R16 yell, Ow! Ow! The aides then placed a clean incontinence brief on R16, and rolled the resident onto his back in bed. At this time, R16 stated he wished to lie in bed and wanted his pants completely removed. The resident's pants were now located around the resident's lower calves/ankles. As CNAs E and F removed the resident's pants, Surveyor observed R16 to have both hands clenched in fists, a clenched jaw/teeth, closed eyes, facial grimacing, and an arched back. The resident was also crying out and moaning loudly for approximately five to ten seconds, during and after the resident's pants were removed by staff. After the resident's pants were removed, CNAs E and F slightly turned R16 to the side, and removed the sling from beneath the resident. The resident yelled out, Ow! Ow! At 9:46 a.m., CNA E placed a Heel's Up device beneath R16's legs, and the CNA stated the resident was not lying straight in bed. At this time, CNA E repositioned the resident in bed, and the resident yelled, Ow! Ow! This observation ended at 9:48 a.m. At 9:49 a.m., Surveyor interviewed CNA F, and asked about R16's pain. CNA F stated the resident's back is always in pain, all the time. The CNA further stated R16 is always crying out and moaning during cares. According to the resident's medical record, the resident was not pre-medicated prior to cares and this transfer. Nursing staff did not stop personal cares, and did not notify the charge nurse of the resident's pain at the time the resident was experiencing the pain. At 9:51 a.m., Surveyor observed CNA E inform Registered Nurse (RN) B R16 was having pain during cares. At this time, Surveyor asked RN B about R16's pain. RN B stated the resident has chronic pain, and further indicated she believes R16 has a fear of pain with movement, during cares. RN B stated she was planning on giving the resident a PRN Tylenol for pain. At 10:01 a.m., Surveyor observed RN B enter the resident's room and the nurse administered medications, including Tylenol 650 mg, to the resident. At this time, R16 was heard telling RN B, the resident's back hurt. At 10:04 a.m., R16 was lying in bed, on his back, and was alone in the room. Surveyor was noted to be the only staff in the hallway, outside of the resident's line of vision. Surveyor heard the resident moaning loudly and repeatedly saying for two minutes, Oh, my back hurts! My back! My back hurts! At 10:06 a.m., Surveyor interviewed R16, and asked how often the resident has pain. The resident rubbed his left groin area, had a furrowed brow, moaned loudly and said, It hurts! Surveyor asked if R16's back hurt, which the resident replied, Yes. Surveyor asked the resident how often R16's back hurt, to which the resident replied, It makes it hard to sleep at night. It is noted, no sleep assessments, from the last three months, were located in the resident's medical record. At 3:48 p.m., Surveyor informed the Director of Nursing (DON) and RN A of the above observations. The DON indicated she was not aware R16 was experiencing any pain. The DON indicated a full pain assessment will be completed on R16, and the physician will be updated. On 08/01/18 at 7:15 a.m., the DON stated a pain assessment was completed for R16, by the DON. Surveyor reviewed the pain assessment, from 07/31/18 at 4:36 p.m., which states the following, in part: .A. Breathing .Occasional Labored Breathing (episodic bursts of harsh, difficult, wearing respirations) or Short Periods of Hyperventilation-characterized by intervals of rapid, deep breaths [MEDICATION NAME] short periods of time .B. Negative Vocalization .Occasional moan or groan-characterized by mournful or murmuring sounds, wails or laments. Low-level speech with a negative or disapproving quality .C. Facial Expression .Sad-unhappy, lonesome, sorrowful Frightened-look of fear, alarm or heightened anxiety. Frowning .D. Body Language .Tense-strained apprehensive or worried appearance . Surveyor reviewed R16's PRN Tylenol use, from (MONTH) (YEAR) to (MONTH) (YEAR). The resident received the following PRN medications for pain: -May (YEAR): No PRNs pain medications were administered -06/25/18: Tylenol 650 mg administered for back pain/moaning, while the resident was in bed at 4:55 a.m. There is no documented pain rating scale prior to the pain medication, or after the pain medication was given. -06/30/18: Tylenol 650 mg administered for back pain, while the resident was in bed at 4:30 a.m. There is no documented pain rating scale prior to the pain medication, or after the pain medication was given. -07/15/18: Tylenol 650 mg administered for all over pain, while the resident was in bed at 4:30 a.m. R16 rated the pain at 5 out of 10 prior to the pain medication being administered. The resident's pain was a zero out of ten after the PRN was administered. No time was documented when this pain rating was received. The facility has not been pre-medicating R16 with PRN Tylenol prior to personal cares and transfers. Surveyor reviewed R16's nurses' notes, from 05/01/18 to 07/30/18. There is no documentation the resident experiences pain, or has received PRN pain medication during this time. There is no documentation the resident's physician has been notified regarding the resident's pain. Nurses' notes, dated 07/31/18, state the following, in part: -Situation .Pain (uncontrolled) .Pain Evaluation .Persistent back pain not responding to existing or progressive order with no new abnormal neurological signs Progressive or more frequent pain .Summary of observation .He states that he does not have any pain until he is being moved or repositioned then he says 'ow' (R16's first name) is easily distracted by voice. -Writer (RN A) completed head to toe assessment with resident on this day. Resident reports that he does not have any noted pain but upon movement and repositioning he says, ow. No other clinical changes in condition noted. Resident was calm and cooperative during assessment. He was breathing normally but unable to adequately rate pain d/t (due to) [DIAGNOSES REDACTED]. Surveyor reviewed the resident's most recent pain assessment. R16's pain assessment, completed by RN L on 05/11/18, indicates the resident did not report having any pain or hurting within the last five days. The assessment indicates the resident had no difficulties sleeping due to pain within the last five days. RN L was not available for an interview to determine how and what time of the day this pain assessment was completed with the resident, or if RN L had ever observed the resident's personal cares or transfers. The resident's MDS, dated [DATE], indicates R16 received scheduled pain medications within the last five days. This MDS indicates R16 did not receive any PRN medications for pain, and did not receive any non-pharmacological pain interventions, within the previous five days. The staff assessment for R16's pain was completed for this MDS. According to this staff assessment, the resident was not observed to have any non-verbal signs of pain (i.e. groaning, moaning), verbal signs (i.e. saying ouch that hurts), facial expressions of pain (i.e. facial grimacing, furrowed brow, clenched teeth or jaw), or protective body movements, within the previous five days of the MDS. According to R16's comprehensive care plan, the resident's pain assessments would identify a pain level goal. Neither pain assessment identifies a pain level goal, which identifies the resident's goals and preferences for pain management. On 08/01/18 at 4:09 a.m., Surveyor interviewed MDS Coordinator G, who completed R16's staff pain assessment for the resident's 05/12/18 MDS. MDS Coordinator G stated she interviewed staff and reviewed R16's nurses' notes, to determine if the resident experienced any pain. MDS Coordinator G was not able to remember which staff she interviewed regarding R16's pain but stated she usually interviews RN B for other resident's pain assessments. MDS Coordinator G stated she, at times, will observe a resident's personal care or transfer as part of her MDS pain assessment. The MDS Coordinator stated she has not observed R16's personal cares or transfers to determine if the resident has pain. At 4:18 p.m., Surveyor interviewed Licensed Practical Nurse (LPN) H. The LPN stated R16 is able to make the resident's needs known to staff, and is able to report when the resident is having pain. Surveyor asked LPN H if the resident experiences pain. The LPN replied the resident has pain sometimes, but it's more of a behavioral thing. When Surveyor asked LPN H how R16's pain is a behavior, the LPN replied the resident will report having pain but after sitting and talking to R16 for five to ten minutes, the resident will be fine. On 08/01/18, the DON informed Surveyor there were no sleep assessments completed for R16 within the last three months. The sleep assessments may determine if the resident is getting adequate sleep, or is having pain during the night. On 08/02/18 at 10:39 a.m., Surveyor interviewed CNA K, and asked about R16's pain. CNA K stated the resident has pain about half the times, during personal cares and transfers. The CNA stated the resident usually has pain when rolling in bed or while sitting up too long in the wheelchair. CNA K stated R16 will express pain by saying, Ow, moaning, or having a clenched face. At 10:47 a.m., Surveyor stood in a hallway outside of R16's room, and observed a CNA enter the resident's room. The privacy curtain was pulled around the foot of the resident's bed, which is closest to the room door. The CNA left the room door ajar. Surveyor was able to hear R16 request to get out of bed. About five minutes later, Surveyor heard the CNA inform R16, We're going to put cream on your buttocks .now (inaudible) help get your pants on . At 10:53 a.m., CNA K entered R16's room with a Hoyer lift. CNA K left the room door ajar. At 10:54 a.m., Surveyor heard what sounded like a mechanical lift squeaking, and heard a CNA say to the resident, Up, up and away! R16 laughed and replied, Up, up! Surveyor again heard R16 laughing. At 10:55 a.m., Surveyor heard R16 say, Ow! Ow, my back! It is noted, this is the first and only time R16 was heard to report any pain during this personal care. After R16 verbalized pain, Surveyor then heard the resident laughing. At 10:56 a.m., CNA K opened the resident's room door, and R16 was dressed and sitting up in the wheelchair. The resident was smiling and laughing, at this time. Surveyor reviewed R16's Medication Administration Record [REDACTED]. The physician ordered a [MEDICATION NAME] 5% (pain patch) for R16, on 08/01/18. The patch was ordered to be applied to R16's lower back, daily. The MAR indicated [REDACTED]. This observation was reported to the DON, RN A, and the Nursing Home Administrator.