Every finding on record at Resolve at West Allis Respiratory and Rehab

Based on interviews and record review, the facility did not ensure residents received adequate supervision and assistance devices to prevent accidents for 3 (R1, R2, and R3) of 6 residents reviewed for accidents. *R1 fell out of bed while receiving cares on 6/24/2026 and sustained a left lower leg laceration that required sutures. *R2 fell out of bed while receiving care on 6/21/2026 and 7/5/2026. The investigations did not thoroughly document whether R2 was positioned correctly or whether staff had control over R2's body before being rolled. There were no care plan revisions to include interventions to prevent future falls after R2's falls on 6/21/2026 and 7/5/2026. *R3 fell out of bed while receiving care on 8/13/2026. The investigation did not thoroughly document whether R3 was positioned correctly in bed or whether staff had control over R3's body before being rolled. Findings include: The facility policy titled Turning and Repositioning last reviewed/revised 93/5/2026 [sic] documents: This policy establishes responsibilities and protocols for turning and repositioning. Policy Explanation and Complete Guidelines: 2. Turning and repositioning is a primary responsibility of nursing assistance, However, all nursing staff are expected to assist with turning and repositioning. 5. Use the appropriate number of staff to perform the tasks safely. 1.) R1 was admitted to the facility on [DATE] with diagnoses that included adult failure to thrive, cognitive communication deficit, muscle weakness, and anxiety disorder. R1's Quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15. The MDS documents that R1 was assessed as having impairment to one side of R1's upper body and impairment to both sides of R1's lower body. The MDS documents that R1 required maximal assist of 1 staff for repositioning side to side and was dependent on 2 staff for transfers with a Hoyer lift. R1's assistance with Activities of Daily Living (ADLs) related to weakness care plan was initiated on 7/31/2026 with interventions that included: - Bed Mobility Assist: (weight-bearing assistance) bilateral side rails to assist with bed mobility (revision 1/21/2026) - R1 refuses cares at times and will wait until saturated to be changed at times (revision: 2/24/2026) - R1 requests to wear an extra brief at times (revision: 2/24/2026) - Toileting hygiene assist: (total dependance) assist of 1 (2/24/2026) R1's at risk for falls related to deconditioning, incontinence, and psychoactive drug use care plan was initiated on 7/21/2024 with interventions that included: - Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. (R1) needs prompt response to all requests for assistance (revision: 2/24/2026) - Educate (R1)/family/and caregivers about safety reminders and what to do if a fall occurs. - Keep call light within reach - Keep commonly used items within reach. - Physical Therapy (PT) to evaluate and treat as ordered or as needed R1's Care Kardex used by Certified Nursing Assistants (CNAs) has the following care interventions in place: - Bed Mobility: (Weight-bearing Assistance), Bilateral side rails to assist with bed mobility. - Safety: Care in pairs, staff are allowed to go in a Buddy system to provide care to (R1) due to presentation of false accusations. Observe R1 for safety, R1 taking anti-anxiety medication which is associated with increased risk for confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia and increases risk of falls, broken hips and legs. R1's medical record documented a fall from bed occurred on 7/24/2026, at 2:17 AM. The fall investigation documented: CNA-H was providing care to R1, R1 was laying on the left side and CNA-H was on opposite side of the bed and pulled the draw sheet towards CNA-H and R1 started to fall out of the bed. R1 landed into a praying position with R1 landing on R1's knees and R1's upper body leaning on the bed. CNA-H went over and lowered R1's upper body onto the floor so R1 was laying in the prone position (on stomach.) Registered Nurse (RN)-C entered room to assist, blood was noted coming from R1's ostomy bag. 911 called and R1 was transported to the hospital for further evaluation. Vital signs, pain assessment, and a complete skin assessment could not be obtained prior to emergency medical services (EMS) arrival, R1 remained on the floor and was not moved by staff. The Interdisciplinary Team (IDT) review of the fall reviewed and root cause documented: R1 slid towards the edge of the bed during repositioning while incontinence cares were being completed. Contributing factors: - Decreased trunk control and inability to maintain a safe position during bed mobility. - R1's movement occurred while the draw sheet was being adjusted. - Dependence on staff for safe repositioning during personal care. - High fall risk related to impaired mobility and physical limitations. Interventions: - Immediately implement a 2 person assist for all repositioning, bed mobility, and incontinent care, regardless of R1's ability to assist using repositioning bars. - Reinforce staff education on maintaining physical control and support of the resident throughout repositioning and avoiding repositioning from the opposite side of the bed without adequate assistance. Surveyor noted R1's fall investigation did not indicate what safety measures were in place prior to R1 from falling out of bed during cares. On 8/3/2026, Surveyor requested and reviewed R1's hospital admission records and noted R1 required sutures to R1's left lower leg laceration. There was no additional documentation regarding the specific location or measurement of R1's left leg laceration. Surveyor noted x-rays were completed to left lower extremity due to R1 voicing pain in the left leg with no conclusive results. Surveyor sent a request to the hospital and requested to view all hospital documents and findings related to R1's hospitalization on 7/24/2026. On 8/4/2026 at 8:40 AM, Surveyor interviewed RN-C who stated RN-C was called to R1's bedroom. RN-C stated R1 was lying on R1's stomach when entering R1's bedroom and R1 stated they fell onto their knees before getting placed onto the floor. RN-C stated R1 just moaned when asked if had any pain. RN-C called 911 and did not want to move R1, so RN-C was not able to assess R1, however, RN-C noted there was blood by R1's colostomy area which was common for R1. Surveyor asked RN-C what level of assistance R1 required when receiving incontinence cares or being repositioned in bed. RN-C stated R1 was a 1-2 staff assist, it depended on what R1 wanted. Surveyor asked how staff determined if 1 or 2 staff were required to provide care for R1. RN-C stated R1 would always say either 1 staff to 2 staff, but usually 1 staff is enough because R1 could assist and use the bar to help. On 8/4/2026 at 10:15 AM, Surveyor interviewed Director of Rehab (DOR)-F who stated R1 was last evaluated by physical therapy on 3/13/2026 but refused additional therapy sessions. On 3/13/2026, R1 was assessed to be moderate assistance with 1 staff for repositioning side to side. R1 also had enabler bars on both the right and left side of the bed to assist R1 with being able to assist during repositioning. Surveyor asked if the weight of a resident was considered when determining level of assistance with a resident since R1's weight was in the 300 pounds range. DOR-F stated weight is not considered when determining level of assistance for a resident. DOR-F stated staff did not indicate a need for a reevaluation for R1 due to a decline in functioning so R1 would still be considered moderate assistance of 1 staff member for repositioning side to side. On 8/4/2026 at 10:46 AM, Surveyor interviewed CNA-H who stated they were called in to R1's bedroom to do incontinence care. CNA-H stated when R1 was cleaned, CNA-H noted R1's bed sheet was wet so they were going to complete a bed change. CNA-H stated R1 rolled and CNA-H pulled the draw sheet towards them and R1's feet started to slide off the bed, but CNA-H was not able to grab them right away and R1 continued to slide down to the ground and landed on R1's knees. CNA-H was not able to assist R1 to a standing position and lowered R1 down to the ground and called for assistance and stayed with R1 until EMTs arrived. CNA-H stated at that time, CNA-H went out into the hallway so CNA-H was not sure if R1 was bleeding from anywhere. Surveyor asked what level of assistance R1 required when receiving incontinence cares or when repositioned. CNA-H stated they did not usually work that unit and R1 told them usually 1 staff assists with cares. Surveyor asked where staff would look for that information. CNA-H stated staff would look at the resident's care Kardex or care plan, however CNA-H did not look to see and went based off of what R1 said. On 8/4/2026 at 11:43 AM, Surveyors interviewed Director of Nursing (DON)-B who stated residents' care plans and status are reviewed and discussed as a team which includes therapy department. DON-B stated even if a resident is dependent on staff, it does not necessarily mean they require 2 staff to assist, and it would depend on the person and their individual assessment to determine how much help is needed. On 8/4/2026 at 1:07 PM, Surveyor informed NHA (Nursing Home Administrator)-A that R1 fell out of bed on 7/24/2026 while receiving cares with a CNA resulting in a left leg laceration that required stitches. NHA-A denied R1 having a laceration and did not have solid evidence R1 received the laceration while in the facility on 7/24/2026. Surveyor shared in review of the hospital documentation with NHA-A that stated R1 had a left lower extremity laceration that required stitches which were done in the ER (Emergency Room). DON-B stated R1 likes to pick at scabs, and it could have been something R1 picked prior to R1's fall. NHA-A stated nursing did not note any skin concerns when R1 was assessed after the fall and does not believe the laceration was obtained at the facility. Surveyor shared that interviews with nursing staff that were involved in R1's fall revealed that staff did not complete a comprehensive skin assessment on R1 due to being in the prone position and staff did not roll R1 over to do an evaluation of R1's skin. NHA-A stated staff was following R1's care plan and resident's fall and was unsure how R1's fall could have be prevented and did not see concerns regarding non-compliance. Surveyor informed NHA-A that R1 rolled out of bed, with staff present, and sustained a left leg laceration requiring stitches. Surveyor also informed NHA-A that x-rays were obtained due to R1 reporting left leg pain, however, did not see results documented. Surveyor submitted request to get EMS (Emergency Services Report) report from 7/24/2026 regarding R1's fall. On 8/4/2026 at 2:06 PM, Surveyor informed NHA-A and DON-B that Surveyor requested additional information and would review once received, however with the current information available, R1 fell out of bed while receiving cares and sustained a lower left leg laceration that required sutures. Surveyor informed NHA-A and DON-B that R1's fall investigation did not indicate what safety measures were put into place to prevent R1 from falling out of bed during cares. Surveyor noted that R1 was being provided cares by one CNA. The CNA was standing on the opposite side of R1 when the CNA pulled the drawsheet toward herself while R1 was repositioning, causing R1 to fall out of bed. On 8/5/2026, Surveyor received the EMT report from 7/24/2026 which documents: -2:29 AM-EMTs arrive at the scene, noted R1 lying in prone position on stomach. EMTs rolled R1 over and noted a 6-8 inch deep laceration to R1's left lower leg just beneath the knee, not actively bleeding at time of discovery. On 8/5/2025, Surveyor received the R1's hospital documentation for when R1 was admitted on [DATE] due to R1's fall. The documentation stated a CT scan to the left knee was performed at the hospital on 7/24/2026 with the following findings: Impression: - Internally fixated, healing fracture of the femur. - Additional mildly impacted fracture of the proximal tibial metaphysis with suggestion of some changes of osseous healing, favored subacute in chronicity. - Additional nondisplaced fracture of the proximal left fibula. - Extensive subcutaneous soft tissue edema. Surveyor noted that R1 fell out of bed while receiving cares on 7/24/2026, landing on both knees and was guided by CNA-H to the floor. R1 sustained a lower left leg laceration measuring 6-8 inches deep that required sutures and CT scan showed a left tibial and left fibula fracture. 2.) R2 was admitted to the facility on [DATE] with diagnoses that include obstructive hydrocephalus, spondylolisthesis, and history of a cerebral infarction requiring placement of a tracheostomy and g-tube. R2's Quarterly Minimum Data Set (MDS) dated [DATE] indicated R2 has intact cognition with a Brief Interview for Mental Status (BIMS) score of 15. The MDS documents that R2 was assessed as being dependent on staff for all Activities of Daily Living (ADLs). The MDS documents that R2 is always incontinent of urine and bowel and transferred using a Hoyer lift with 2 staff. R2's ADL self-care performance deficit related to weakness care plan was initiated on 3/18/2026 with the following interventions: Bed Mobility: (R2) is partial/moderate assist (revised 3/31/2026) R2's at risk for falls related to weakness, use of hypnotic's care plan was initiated on 3/18/2026 with the following interventions: - Be sure (R2's) call light is within reach and encourage (R2) to use it for assistance as needed.- Bed in the lowest position as (R2) tolerated and can self-adjust.- Ensure (R2) is wearing appropriate footwear when ambulating or wheeling in wheelchair.- Keep needed items, water, etc in reach.- Physical Therapy (PT)/Occupational Therapy (OT), Speech Language Pathologist (SLP) evaluation and treat as order. R2's Care Kardex used by Certified Nursing Assistants (CNAs) has the following care interventions in place: -Bed Mobility: ADL-Bed Mobility Surveyor noted that the CNA Care Kardex does not specifically document what R2's bed mobility assistance is. R2's medical record documented a fall from bed that occurred on 6/21/2026 at 9:15 AM. CNA-D's statement documents: CNA-D was performing cares on R2 who was also on the phone. CNA-D asked R2 to roll over onto the left side and R2 kept rolling and slid off the bed onto R2's bottom. The Interdisciplinary Team (IDT) review of R2's fall documents: R2's recent fall when R2 was talking on the phone while staff was providing care. Root cause determined to be R2's inability to safely focus on repositioning while simultaneously participating in a phone conversation. The distraction contributed to decreased attention to staff instructions and body positioning during care. IDT interventions include: - PT/OT to evaluate and work with resident on turning and repositioning.- Educate R2 on the importance of ending phone calls and minimizing distractions during personal cares, repositioning, and transfers. Surveyor noted R2's fall care plan focus section had a revision on 6/21/2026 documenting:-6/21, PT/OT to evaluate and work with (R2) on turning and repositioning. However, the care plan did not revised interventions to include staff to educate R2 on importance of ending telephone calls as documented in the IDT review of R2's fall on 6/21/2026. On 8/4/2026 at 9:36 AM, Surveyor interviewed CNA-D who stated CNA-D was providing cares to R2 on 6/21/26. CNA-D stated R2 did not want to get off the phone so CNA-D asked R2 to roll to the side so CNA-D could clean R2 up. CNA-D stated R2 just kept rolling and CNA-D did not have a chance to try and catch R2. Surveyor asked if R2 is one or two person assist. CNA-D stated R2 is a one person and can assist with rolling themselves and holding themselves on their side. Surveyor asked if any education was provided on safe bed mobility of residents. CNA-D could not recall if education was provided to staff or R2. On 7/5/2026 at 1845 (6:45 PM,) R2's medical records documents a fall. CNA-E's statement documents: R2 had emesis and CNA-E was cleaning up R2's clothes and bedding. CNA-E asked R2 to roll towards the window, R2 usually rolls on their own so CNA-E did not hold onto R2 and R2 kept rolling over and off the bed. CNA-E tried to catch R2 but R2 rolled too fast. The IDT review of the fall documents: R2 stated they were turning toward the window, swung their legs over the side of the bed and then landed on the ground. Root cause determined to be R2 sliding from the bed while independently assisting with repositioning during care. Contributing factors include R2's tendency to independently assist with bed mobility, R2's legs moving beyond the edge of the bed during repositioning and reduced stability while positioned on an air mattress. IDT interventions include:- Removal of the air mattress and replaced with a standard mattress to provide a more stable sleeping surface. On 8/4/2025 at 9:49 AM, Surveyor interviewed CNA-E who stated R2 had an episode of emesis. CNA-E was helping R2 get cleaned up and CNA-E asked R2 to roll over and CNA-E stated R2 just kept going. Surveyor asked how many staff are usually required to assist R2 with cares. CNA-E stated when R2 requires a boost up in bed, 2 staff are required, otherwise one staff member for anything else because R2 is able to reposition themselves. Surveyor asked if education was provided to staff after R2 rolled out of bed. CNA-E stated education was provided to staff regarding how to safely handle residents while repositioning them. Surveyor noted there were no care plan revisions to indicate R2's air mattress was removed or any other interventions related to R2 rolling out of bed for after R2's second fall on 7/5/2026. On 8/4/2026 at 11:43 AM, Surveyors interviewed Director of Nursing (DON)-B who stated residents' care plans and status are reviewed and discussed as a team which includes therapy department. DON-B stated even if a resident is dependent on staff, it does not necessarily mean they require 2 staff to assist, and it would depend on the person and their individual assessment to determine how much help is needed. On 8/4/2026 at 1:07 PM, Surveyor informed Nursing Home Administrator (NHA)-A and DON-B that R2 rolled out of bed on 6/21/2026 with CNA-D, and 7/5/2026 with CNA-E during cares and no care plan revisions or safety measures were put in place to prevent R2 from rolling out of bed. NHA-A stated R2 was on the phone for the first fall and for the second fall, R2 lifted their legs out of bed. Surveyor shared concern no safety measures were in place such as waiting to do cares until R2 was off phone or being safely positioned as R2 is known for overturning at times. Surveyor informed NHA-A and DON-B that interventions were not put in place after R2's second fall on 7/5/2026. 3.) R3 was admitted to the facility on [DATE] with diagnoses that included traumatic brain compression with herniation, subdural hematoma status post decompression craniotomy, chronic respiratory failure dependent on ventilator, heart failure, diabetes mellitus type 2, and congestive heart failure. R3's Quarterly MDS (Minimum Data Set) dated 6/16/26 documents that R3 assessed to be dependent (helper does all of the effort, resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) for the following: Roll left and right; the ability to roll from lying on back to left and right side and return to lying on back on the bed. R3's falls care plan dated 12/4/25 documents the following interventions Dependent on staff for transfer, ensure bed in lowest position. Re-educate staff on safe positioning techniques for residents on air mattresses (initiated 7/13/26), ensure residents remain centered in bed throughout personal care and repositioning (initiated 7/16/26). R3's care plan dated 12/14/15 documents: ADL (activity of daily living) self-care deficit r/t (related to) limited mobility, limited range of motion, dependent on staff for all bathing needs, dependent on staff for bed mobility, dependent on staff for all hygiene and dressing needs. R3's medical record documented a fall from bed occurred on 7/13/26 at 10:05 AM. The fall investigation documented: Resident receiving bed bath/personal care at the time of witnessed fall. The CNA (Certified Nursing Assistant) statement documented that the CNA was giving a bed bath and the bed was wet, the CNA pulled the resident closer to where the CNA was standing before turning R3, when R3 started coughing and noticed R3 was rolling off the other side of the bed. The NP (Nurse Practitioner) completed an assessment and R3 was sent to the emergency room. R3 returned to the facility during the night and the following day the respiratory therapist noted R3's oxygen levels were low. R3 was sent to the ER and subsequently admitted to the hospital. R3's hospital records revealed no new fractures or injuries related to the fall. The IDT (interdisciplinary team) root cause documented: The fall occurred during staff assisted personal care and repositioning. Contributing factors include the movement associated with repositioning and the instability created by the air mattress, which increased the risk of the resident rolling toward the edge of the bed during care. Immediate interventions: Re-educate staff on safe repositioning techniques for residents on air mattresses. Ensure the resident remains centered in the bed throughout personal care and repositioning. On 8/3/26 at 12:50 PM, Surveyor asked CNA-P to describe what happened with R3's fall. CNA-P told Surveyor CNA-P was giving R3 a bed bath and pulled R3 over toward CNA-P with the sheet before turning R3. Surveyor asked which way CNA-P turned R3, CNA-P stated, away from me on his side. CNA-P stated, he started coughing and I noticed he was rolling out the other side of the bed and with his contractures I couldn't stop him. Surveyor confirmed that CNA-P was alone when providing cares and asked if R3 is 1 assist for bed mobility, to which CNA-P replied yes. CNA-P told Surveyor the DON (Director of Nursing) provided R3 with education after the fall and bolsters were added to R3's bed. On 8/3/26 at 1:25 PM, Surveyor asked Physical Therapist (PT)-S how much assistance R3 needs for bed mobility. PT-S stated, When I'm in with him doing any kind of change of position, I like to have 2 people. If they were incontinent or such, I'd want them cleaned up right away. Surveyor asked PT-S if he thought R3 is safe with 1 person to roll in bed and do cares. PT-S stated, I'd say go with 2 people, so that 1 person is on the other side that can hold him over while the other person cleans him up. Surveyor asked what therapy has assessed R3 to be for bed mobility. PT-S stated, I would think 2 people, but that would be a question for the therapy director. On 8/3/26 at 3:10 PM, Surveyor spoke with Director of Rehab (DOR)-F who reported R3 is assist of 1 person for bed mobility. Surveyor asked how the facility determined R3 to be 1 assist for bed mobility and asked for the most recent therapy evaluation. DOR-F provided an evaluation dated 6/25/26 which did not include an assessment for bed mobility. DOR-F told Surveyor that R3 was probably assessed a couple days later because he was up in the Broda chair and DOR-F would look for the assessment. Surveyor asked how it is determined if R3 is safe to be a 1 person assist or needs 2 persons assist for bed mobility. DOR-F stated, I don't know, I don't do the assessment; I'm a PT assistant. Surveyor asked DOR-F if, after R3's fall on 7/13/26, therapy was consulted to do an assessment for bed mobility to determine if R3 was safe with 1 person assist. DOR-F stated, No, but we talked about it in the risk meeting on Tuesday. The intervention was to use bolsters. On 8/3/26 at 3:20 PM, Surveyor spoke with Registered Nurse (RN)-Q, who reported she has worked for the facility for 2 years and works with R3 every day. RN-Q told Surveyor R3 needs 2 person assist for turning and repositioning. Surveyor asked if R3 has always needed 2 persons assist, RN-Q stated yes, as long as he's been here. Surveyor asked RN-Q if she would be able to safely turn and reposition R3 by herself, she replied Hell no. Not only is he severely contracted, but he balls up and tightens up, making it really hard to turn him by yourself, I would not say that would be safe. On 8/4/26 at 8:20 AM, DOR-F provided Surveyor with a therapy note completed by PT-S dated 7/10/26 which documented: L/R (left/right) roll 2-3 in side lying for pressure relief. Repositioning and sit-supine max assist 100%. Surveyor asked DOR-F how much assist is needed if residents are dependent for bed mobility. DOR-F stated, We look at their weight, if they're able to bear weight at all and those factors. Surveyor told DOR-F that R3 is dependent for bed mobility and asked how many people are needed for his bed mobility. DOR-F told Surveyor R3 is 1 person assist. Surveyor was not provided with a therapy or facility assessment to determine how much assistance (1 or 2 persons) R3 requires for bed mobility, turning and repositioning. On 8/4/26 at 8:30 AM Surveyor asked for R3's CNA documentation in PCC (point click care) tasks for bed mobility and assistance provided. Nursing Home Administrator (NHA)-A told Surveyor they are unable to print information for June, as it was not initiated for documentation and that they can only print the last 30 days. Surveyor noted the PCC information entered from 7/23/26 through 8/3/26 documented: Bed mobility - total dependence. 1 person assist provided 25 times and 2 person assist provided 6 times. On 8/4/26 at 11:25 AM, Surveyor asked PT-S about his documented note on 7/10/26. Surveyor asked if he was alone during his therapy session and turning/repositioning of R3. PT-S told Surveyor he did not remember. PT-S stated that each resident is different, with R3 I think it depends, can he be done with 1 person? – Sure, but there may be times when a 2nd person is needed for some reason; if he's harder that day or to make it easier to clean when on his side. Surveyor asked Nursing Home Administrator (NHA)-A if education was provided to staff On 8/4/26 at 11:43 AM, Surveyor asked DON (Director of Nursing)-B who is responsible for assessing and determining if a resident requires 1 or 2 persons assist for bed mobility. DON-B stated, We always discuss it as a team with therapy also. Just because a resident is dependent on staff does not necessarily mean they need 2-assist, it depends on the person and their individual assessment to determine how much help is needed. Surveyor informed DON-B that R3 is dependent on staff for bed mobility and there was no documentation that was provided to Surveyor that an assessment was completed to determine the safest intervention (use of 1 or 2 people) needed for R3's cares and turning/repositioning. R3 sustained a fall from bed during cares provided by 1 person and R3 was not re-assessed after the fall to determine if he is safe to use only 1 person for cares and turning and repositioning. Surveyor informed DON-B that staff documentation indicates at times R3 requires 2-person assistance. Staff interviews report R3 needs 2-person assistance and is not safe with 1 person.

Based on observation, interview and record review, the facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 4 (R1, R8, R10 and R25) of 7 residents reviewed for pressure injuries. *R1 was readmitted to the facility on [DATE] with an unstageable Deep Tissue Injury (DTI) to R1's left heel. Surveyor observed R1's heels to not be offloaded on 3 separate occasions (4/26/2026, 4/27/2026 and 4/28/2026). On 4/27/2026, R1's wound has nearly doubled in size since initial assessment. The example regarding R1 is being cited at a scope and severity of a G (actual harm/isolated). The examples regarding R8, R10, and R25 are examples at the scope and severity of a D (potential for harm/isolated). *R8 had a Stage 4 pressure injury to the sacrum that developed osteomyelitis due to the Nurse Practitioner intervention recommendation not being implemented. *R10 had a weight loss from 190.2 pounds on 10/2/24 to 176.9 pounds on 4/7/25. The facility did not reassess the effectiveness of R10's interventions to reduce risk of developing a pressure injury after the weight loss, and R10 developed a pressure injury on 5/2/25 to the left buttock which progressed to a stage 4 pressure injury on 8/18/25. *R25 was admitted with a pressure injury that developed an infection and required hospitalization and antibiotic administration. Findings include: The facility's policy, with no date and titled Pressure Injury Prevention Guidelines documents: 1. Individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). 2. The goal and preferences of the resident and/or authorized representative will be included in the plan of care. 3. Interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used and, for tasks, the frequency for performing them. 4. Prevention devices will be utilized in accordance with manufacturers' recommendations (e.g., heel flotation devices, cushions, mattresses). 8. The effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound. Considerations for needed modifications include: a. Development of a new pressure injury. b. Lack of progression towards healing or changes in wound characteristics. c. Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights. 1.) R1 was admitted to the facility on [DATE] with diagnoses including respiratory failure (a life-threatening condition where the lungs cannot adequately oxygenate the blood or remove carbon dioxide), hemiplegia (complete paralysis of one side of the body), hemiparesis (a neurological condition causing mild-to-moderate weakness on one side of the body) and pain. R1's Annual Minimum Data Set (MDS), dated [DATE], indicates R1 was assessed to have severely impaired cognition, does not exhibit behaviors, has impairment in both upper and lower extremities, always incontinent of bowel and bladder, is at risk for pressure injuries, has current unhealed pressure injuries including one stage 4 pressure injury (PI) and one Unstageable (PI) presenting as a Deep Tissue Injury (DTI). R1's Care Plan Report with revisions, documents that R1 has impaired skin integrity and is at high risk for further skin breakdown with the following interventions: -SPECIALTY MATTRESS: with the setting at P2. -Bed rest. -Apply house moisturizing lotion as needed to keep skin hydrated. Avoid applying between toes and other moist areas. Staff will not apply lotion to buttocks. -Attempt to off load bony prominences by turning and using pillows, wedges, or other positioning devices as resident allows and tolerates. -Heel boots on at all times for skin protection. - Perform thorough diabetic foot check daily at bedtime. Check all surfaces, including between toes. Notify primary physician and Wound Care Team of any skin abnormalities. - Wound assessment/measurement performed weekly/as needed by Wound Care Team. If unavailable, assessment will be completed at earliest availability. - Wound care treatment to be performed by Wound Care Team/Nursing as ordered - When positioning medical devices ( ex- foley, tubing , 0 2 tubing). Attempt to avoid positioning medical devices over a bony prominence. On 04/26/2026, at 2:00 PM, Surveyor observed R1 in R1's bed. Surveyor noted R1's heel boots laying in R1's wheelchair. Surveyor noted that R1 did have any offloading to R1's lower extremities while in bed. On 04/27/2026, at 3:22 PM, Surveyor observed R1 in bed without R1's heel boots on and noted R1's heel boots in R1's wheelchair. Surveyor noted that R1's heels were not offloaded to reduce pressure per R1's plan of care. On 04/28/2026, at 7:45 AM, Surveyor observed R1 in bed without offloading or heel boots on R1's lower extremities. Surveyor observed R1's heel boots in R1's wheelchair. Surveyor noted that R1's heels were not offloaded to reduce pressure per R1's plan of care. On 04/28/2026, at 7:51 AM, Surveyor asked Nurse Manager-N and Certified Nursing Assistant (CNA)-O about R1's heel boots. CNA-O informed Surveyor that CNA-O started at 6:30AM and has not been in to see R1 until now. CNA-O pulled back R1's covers to expose R1's lower body. Surveyor noted a pillow under R1's left side and a pillow under R1's upper thighs. Surveyor observed R's heels directly on the bed and heels were not offloaded to reduce pressure. Surveyor asked CNA-O how staff know what interventions should be in place for R1's skin protection. CNA-O indicated the information is on the care plan and everything is in the computer. Surveyor asked Nurse Manager-N if R1 should have heel protectors on, Nurse Manager-N informed Surveyor Nurse Manager-N will have to confirm how often R1 needs heel boots on, but does not currently have the heel boots on at this time. On 04/28/2026, at 8:11 AM, Nurse Manager-N came back to R1's room and put R1's heel boots on R1. Nurse Manager-N informed Surveyor that according to R1's care plan, heel boots should always be on R1, which protects R1's heels from pressure and prevent R1's DTI from worsening. On 04/28/2026, at 8:47 AM, Surveyor interviewed Wound Registered Nurse (RN)-I. Wound RN-I indicated that R1's DTI to the left heel was discovered on 4/23/2026 after being readmitted to the facility following a hospital stay, unrelated to wounds. R1's current interventions include a restorative program for upper and lower extremities i.e. repositioning every 2-3, specialty mattress, Prevalon heel boots to bilateral lower extremities, protective dressings in place, pain management as needed, arms and elbows off loaded, only supposed to be on a chuck pad to reduce moisture and skin break down, therapy and make sure R1 is not laying on any medical devices. Wound RN-I informed Surveyor that on 4/23/2026, when left heel DTI was first discovered, it measured in centimeters (cm) 2.5 x 2.5 intact, dark purple in color with no depth just intact skin. On 4/27/2026, R1's left heel DTI measured (in cm) 4 x 3 x not measurable- intact skin with purple/maroon discoloration which was an increase in the wound size Wound RN-I indicated if interventions are not being implemented, there is potential for a decline or deterioration in the wound. Wound RN-I informed Surveyor that if heel boots are unavailable, due to being washed, heels can be off loaded with pillows until boots are available. Surveyor reviewed the facility provided documents, titled Weekly Wound Documentation for R1 and noted the following: 4/23/2026- admitted with: Left lateral foot wound- 100% dark purple, non-blanchable, boggy. Measurements in cm: 2.5 x 2.5 x N/A intact skin. Wound MD-H to assess 4/27/2026. Surveyor reviewed the Facility provided (name of medical group) wound notes for R1 and noted the following: 4/27/2026- Unstageable DTI of the left heel- undetermined thickness Etiology- pressure Detail- trauma from patient chewing on lip Stage- Unstageable DTI with intact skin Wound size- 4 x 3 x not measurable Surface area- 12.00cm2 Skin- intact with purple/maroon discoloration Surveyor noted since the discovery of R1's left heel DTI, the wound has increased in size. On 04/29/2026, at 12:50 PM, Surveyor interviewed Director of Nursing (DON)-B. DON-B informed Surveyor that R1 is to have heel boots always on. R1's heel boots can only be taken off while providing care and should be put back on right away and is the responsibility of everyone caring for R1 to ensure those interventions are being implemented. On 04/29/2026, at 1:01 PM, Surveyor informed Nursing Home Administrator (NHA)-A regarding concerns involving R1 not having heel boots in place as care planned and R1's left heel DTI increasing in size. No additional information was provided. 2.) R8 was admitted to the facility on [DATE] and had diagnoses of chronic respiratory failure, persistent vegetative state, diabetes, and a Stage 4 pressure injury to the sacral region. R8's Annual Minimum Data Set (MDS) dated [DATE] documented R8 was assessed to be in a vegetative state with a tracheostomy, an indwelling urinary catheter, a feeding tube for all nutrition, and a Stage 4 pressure injury. R8's Actual Skin Impairment Care Plan was initiated on 8/7/2023. Some of the interventions in place on 4/11/2025 were: -Bed rest. -18Fr Foley catheter for wound healing. -Specialty mattress: Air Ranger Pro air mattress per orders – function and setting checked per shift. -Address pain prior to treatment to improve resident tolerance/acceptance of wound care; address pain as needed for resident comfort to encourage adherence to interventions to maintain skin integrity. -Apply lotion to bilateral lower extremities every day with cares. -Attempt to off load bony prominences/heels by urning and using pillows, wedges, heel boots or other positioning devices as resident allows and tolerates. -Change clothes/linens when damp or wet to prevent prolonged moisture to skin; incontinence briefs to be left off when resident in bed; keep abdominal folds dry. -Nursing to monitor dressing integrity with each resident encounter and replace dressing if soiled/loose/missing. -Provide incontinence care as needed to keep skin as clean and dry as possible; utilize barrier cream as ordered/needed to protect skin from incontinence. -Provide assistance with repositioning every 2-3 hours; utilize draw sheet when available for repositioning to reduce risk of friction/shear. R8 was seen weekly by the wound Nurse Practitioner (NP) for a comprehensive assessment of the Stage 4 pressure injury to the coccyx. The pressure injury had been present since December 2023. On 4/11/2025, the wound NP documented: R8's Stage 4 pressure injury to the coccyx measured 6.5 cm x 6 cm x 3.5 cm with circumferential undermining with the deepest measurement of 3.6 cm at 9 o'clock with 100% granular tissue and exposed bone. On 4/12/2025 at 5:12 PM in the progress notes, nursing documented R8 was having loose stool/diarrhea at least once within eight hours. R8 was on continuous tube feeding resulting in soft stool, not loose stool. On 4/18/2025, the wound NP documented R8's Stage 4 pressure injury to the sacrum measured 9 cm x 6 cm x unable to determine depth with 80% necrotic tissue and 20% granular tissue. The wound NP noted a decline in the status of the pressure injury. The wound NP changed the treatment to the wound at that time. On 4/23/2025 at 10:15 AM in the progress notes, the facility NP documented R8 had chronic loose stools for which R8 was being treated with banana flake, however, R8 had frequent hyperkalemia so banana flakes frequency of administration was decreased. Staff were to continue to monitor for loose stools, hyperkalemia and wound status. The facility NP documented R8 needed frequent bed changes to prevent wound breakdown. Surveyor noted the frequent bed changes were not added to R8's Care Plan. On 4/25/2025, the wound NP documented: R8's Stage 4 pressure injury to the sacrum measured 9 cm x 15 cm x unable to determine depth with 70% necrotic tissue and 30% granular tissue. The wound NP documented the wound had a large amount of seropurulent drainage with the surrounding tissue being red and hot to the touch. The wound NP documented there was concern for an acute infection and R8 was transferred to the hospital for further evaluation and treatment. R8 was diagnosed in the hospital with osteomyelitis, an infection of the bone, requiring intravenous antibiotics. The wound NP that had been assessing R8's Stage 4 pressure injury was no longer employed by the facility and unavailable for interview. On 4/27/2026, R8 was seen by Wound Physician (WP)-H. WP-H documented: R8's sacral Stage 4 pressure injury measured 5 cm x 6 cm x 2 cm with tunneling at 4 o'clock that measured 3 cm with 40% necrotic and 60% granulation tissue. In an interview on 4/28/2026 at 1:42 PM, Surveyor asked Licensed Practical Nurse (LPN)-K how often R8 received incontinence care. LPN-K stated R8 was repositioned every two hours and R8 has bowel movements a lot. LPN-K stated R8 has bladder spasms with catheter leakage where they had to put stents in. Surveyor asked LPN-K if R8 had loose stools. LPN-K stated it was very common for R8 to have loose stools and R8 gets banana flakes to try and make the stools less watery and that is why they cannot get R8's wound on the coccyx to heal; R8 is constantly stooling, and the stool gets in the dressing. In an interview on 4/29/2026 at 10:22 AM, Surveyor asked Wound Registered Nurse (WRN)-I how often R8 gets incontinence care. WRN-I stated R8 has frequent stools, especially in the morning. WRN-I stated R8 received incontinent care three times in three hours the other day and that is typical for R8. WRN-I stated Certified Nursing Assistant (CNA)-F would have a good estimate of how often R8 is changed per shift since CNA-F often works with R8. CNA-F stated R8 is changed 4-5 times per shift because R8's stool is extremely loose, and the stool gets into the wound. WRN-I stated they offered R8's POA to get an ostomy with a gastrointestinal (GI) consult but R8's POA did not think R8 was medically stable for surgery. WRN-I stated R8 was seen by a plastic surgeon in March 2026 for a flap to cover the wound to help with healing, but the appointment was cancelled because that surgeon did not handle wounds. WRN-I stated they have tried stool supplements to help stop the liquid stool and the wound is drastically better than what it had been. In an interview on 4/29/2026 at 11:53 AM, Surveyor asked WP-H how R8 developed osteomyelitis in April 2025. WP-H stated with the location of the wound, it is hard to keep it from getting osteomyelitis. WP-H stated R8 has an indwelling urinary catheter, but stool gets in the wound and with tube feeding, the stool is very liquid. WP-H stated often, when WP-H is assessing the wound, as soon as R8 is rolled over, R8 has a stool and that contaminates the wound. WP-H stated R8 is immunocompromised with comorbidities and even though R8 is getting supplemental protein, since it is in liquid form for the gastrostomy tube, the protein is not absorbed as well. On 4/29/2026 at 1:09 PM, Surveyor shared with Director of Nursing (DON)-B and WRN-I the concern the facility NP documented to increase changing of linens on 4/23/2025 and the care plan was not revised to incorporate that recommendation. R8 developed osteomyelitis on 4/25/2025 requiring intravenous antibiotics. DON-B agreed the care plan was not revised to reflect the NP recommendation. No additional information was provided. 3.) R10 was admitted to the facility on [DATE] with diagnoses including quadriplegia (weakness of all four extremities), neurogenic bowel (loss of normal bowel function caused by a nerve problem), and neuromuscular dysfunction of bladder (loss of bladder control due to a nerve problem). R10's quarterly Minimal Data Set (MDS) dated [DATE] documents that R10 was assessed to have no current pressure ulcers and that R10 is at risk for pressure ulcers. The MDS documents that R10 was assessed to have a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R10's pressure injury Care Area Assessment (CAA) dated 11/10/24 documents: [R10] is at risk for development of pressure ulcers due to impaired mobility, diagnosis of quadriplegia and dependent on staff for bed mobility and repositioning. Other risk factors include incontinence of bowel. Pressure relieving device to bed and chair, pericare for incontinence, repositioning every 2-3 hours and as needed (PRN), receiving Pro-Mod to assist with skin integrity. Will proceed to care plan with interventions to reduce risks for development of pressure ulcers. R10's turning/repositioning program care plan initiated 8/24/21 documents the following intervention:-assist with turning/repositioning every 2 hours, revised date 5/21/24 R10's impairment to skin integrity care plan initiated 6/3/24 documents the following interventions:-avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, revised date 11/12/24-educate resident/family/caregivers of causative factors and measures to prevent skin injury, revised date 11/12/24-encourage good nutrition and hydration in order to promote healthier skin, revised date 11/12/24-heels offloaded with pillows when in bed, document compliance and effectiveness every shift, revised date 11/12/24-identify/document potential causative factors and eliminate/resolve where possible, revised date 11/12/24-nursing will assess skin upon admission, weekly on day of scheduled shower, PRN, and with any change in condition. Any abnormalities will be documented in chart and reported to primary physician and wound care team for follow up, revised date 11/12/24-pillows used to offload bony prominences when in bed. Document compliance and effectiveness every shift, revised date 11/12/24-provide incontinence care as needed to keep skin as clean and dry as possible. Utilize barrier cream as needed to protect intact skin from incontinence. Change linens and clothing when wet to prevent prolonged moisture to skin, revised date 11/12/24-suprapubic catheter per orders, revised date 11/12/24 -support surfaces for pressure reduction: alternating pressure mattress and electric wheelchair with pressure reduction cushion. Evaluate for effectiveness/proper function with each resident encounter, revised date 11/12/24 R10's resistive to care and frequently refuses prescribed medications care plan initiated 1/2/25 documents the following interventions:-allow [R10] to make decisions about treatment regime to provide sense of control, date initiated 1/2/25-educate [R10] of the possible outcome(s) of not complying with treatment or care, date initiated 1/2/25 R10's Braden Scale assessment dated [DATE] documents a score of 17.0 indicating R10 is at risk for pressure injury development. In an interview on 4/28/26 at 10:05 AM, R10 confirmed R10 still has a pressure injury on R10's left buttock which opened in May 2025. R10 stated R10 previously had a pressure sore on R10's bottom in 2018 which healed by June 2019, and R10 has not had any pressure injuries since 2019. R10 stated R10 thinks it developed because R10 lost weight at the end of 2024 before the wound opened and because R10 is incontinent of bowel. R10 stated R10 has a tilt in space electric wheelchair which R10 uses during the day and can independently maneuver. R10's electronic health record (EHR) documents the following weights:10/2/24: 190.2 pounds (lbs)11/6/24: 186.6 lbs12/5/24: 189.6 lbs1/2/25: 181.0 lbs2/10/25: 175.2 lbs3/5/25: 176.6 lbs4/2/25: 175.4 lbs4/7/25: 176.9 lbs R10's weights and vitals note dated 2/13/25 documents [R10] triggered for gradual weight loss, refuses meals at time with meal intake variable 0-100%. [R10] has goal of weight reduction toward body weight in the 180s. [R10] reported eating most meals and food from the kitchen is hit and miss. [R10] reported [R10] will refuse meals at times due to them being cold and refuses to let staff reheat them. [R10] refused supplements, on Pro-Med twice per day, also orders food from outside the facility frequently and has food in the fridge in [R10]'s room. Recommended to have snacks at bedside for resident to access. Weight stability recommended. R10's physician orders documents the following order: ProMod Liquid (nutritional supplement), give 30 milliliters (mL) orally two times a day related to quadriplegia, with a start date documented as 11/28/2020. Surveyor was unable to locate any evidence that the facility reassessed the effectiveness of R10's interventions to prevent the development of pressure injuries after R10 experienced weight loss to ensure interventions in place were appropriate for R10's new weight. A progress note in R10's EHR dated 5/2/25 documents [R10] has a pin sized open area in old scar on left buttock. On 4/28/26 at 9:11 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who confirmed LPN-E was working on 5/2/25 when R10's wound was discovered. LPN-E stated the open area was initially the size of a pinprick on the day it was found, then it gradually kept getting bigger and bigger because R10 refused to do what the wound team told R10 to do to help the wound heal. LPN-E stated R10 was told not to stay in the wheelchair for longer than 2 hours at a time, but R10 always gets in the wheelchair around 11:30 AM and does not lay back in bed until 5:30 PM every day. LPN-E stated R10 was turned religiously every 2 hours on the dot in bed before the area opened and continues to be turned every 2 hours in bed. R10's interdisciplinary team review note dated 5/5/25 documents clinical review of new skin integrity alteration. [R10] with pinhole sized open area to left buttocks, no signs or symptoms of infection. Skin alteration/risk and interventions reviewed and remain appropriate. [R10] is provided incontinence cares PRN and currently has low air-loss mattress in place. Site of pinhole opening is to already fragile/weakened area of scar tissue as scar tissue is not as elastic or strong as surrounding skin. Area is also subject to moisture at times with being provided incontinence cares as [R10] is incontinent of bowel. Intervention: encourage right sided and back positioning with intermittent positioning to left until wound resolution, ensure skin/backside dry after performing incontinence cares. R10's skin observation tool dated 5/5/26 documents an open area to left buttock 0.5 centimeters (cm) x 0.5 cm x 0.1 cm, no drainage noted, smooth red skin. A wound nurse practitioner (NP) note dated 5/9/25 documents a stage 2 pressure injury to R10's left buttock measuring 0.3 cm x 0.4 cm x 0.1 cm with 100% smooth red tissue, scant serosanguinous drainage. A wound NP note dated 5/16/25 documents an unstageable pressure injury to R10's left buttock measuring 1 cm x 1.5 cm x 0.3 cm with 60% slough and 40% granular tissue, moderate serosanguinous drainage. A wound NP note dated 6/6/25 documents a stage 3 pressure injury to R10's left buttock measuring 2 cm x 1.7 cm x 1.4 cm with undermining 1.4 cm at 2 o'clock with 100% granular tissue. The wound continued to be comprehensively assessed on a weekly basis without significant changes. A wound NP note dated 8/15/25 documents a stage 3 pressure injury to R10's left buttock measuring 1.5 cm x 0.8 cm x 0.8 cm with 2 cm undermining at 1 o'clock with 100% granular tissue. The wound NP that had been assessing R10's Stage 3 pressure injury was no longer employed by the facility and unavailable for interview. R10's initial assessment by Wound Physician (WP)-H dated 8/18/25 documents a stage 4 pressure injury to the left buttock measuring 3.5 cm x 1.5 cm x 2.0 cm with 50% granulation tissue and 50% slough. On 4/28/26 at 11:13 AM, Surveyor interviewed wound registered nurse (WRN)-I who stated every wound professional is going to look at a wound and interpret the wound differently, so WP-H may have seen different things on WP-H's initial assessment than the wound NP saw a few days prior, or the wound could have been measured from a different perspective by WP-H, which is likely why the wound is described differently within a short timeline. The wound continued to be comprehensively assessed on a weekly basis without significant changes. R10's weekly wound documentation dated 9/22/25, documents damage education was provided to [R10] related to being up in the wheelchair with risk of new wound development, worsening of current wound, infection and up to and including death were shared with [R10]. R10's weekly wound documentation dated 10/6/25 documents a stage 4 pressure injury to the left buttock measuring 4.0 cm x 1.0 cm x 1.5 cm with 70% granulation tissue and 30% slough. A nursing note dated 10/6/25 documents order for x-ray of coccyx and sacrum placed by wound care team to rule out osteomyelitis due to worsening wound. X-ray results negative for evidence of osteomyelitis. In an interview on 4/28/26 at 11:22 AM, WRN-I stated an x-ray was ordered on 10/6/25 because WP-H felt bone and there was increased drainage. The wound continued to be comprehensively assessed on a weekly basis without significant changes. R10's weekly wound documentation dated 11/3/25 documents a worsening stage 4 pressure injury to the left buttock measuring 4.0 cm x 2.0 cm x 4.0 cm with 10% granulation tissue, 70% necrosis, and 20% bone. WP-H obtained bone biopsy due to concern for acute osteomyelitis. [R10] was encouraged to refrain from being up in the wheelchair for extended periods of time to promote wound healing and offloading. [R10] reluctant to education. R10's physician orders document the following:-Ciprofloxacin HCl oral tablet 500 milligrams (MG), give 1 tablet by mouth every morning and at bedtime for osteomyelitis until 12/1/25-Doxycycline Hyclate Oral Tablet 100 MG, give 1 tablet by mouth every morning and at bedtime for osteomyelitis until 12/1/25. In an interview on 4/28/26 at 11:29 AM, WRN-I stated R10's bone biopsy results came back showing acute osteomyelitis. WRN-I stated R10 was extremely noncompliant with any of the wound team's recommendations, especially about being up in the wheelchair for prolonged periods of time and the need for offloading. WRN-I stated R10 is compliant with repositioning in bed, but WP-H recommended R10 only be up in the wheelchair for 1-2 hours per day which R10 does not comply to. WRN-I stated R10 is up in the wheelchair for 5-6 hours and goes outside in the warm heat in the summertime which contributes to moisture in the area of the wound. WRN-I stated R10 also does not have good nutritional intake which impacts wound healing. WRN-I stated you can tell the damage to R10's wound is from sitting upright in the wheelchair because the wound is straight up and down. On 4/29/26 at 11:49 AM, Surveyor interviewed WP-H via phone call. WP-H stated R10's wound location is easily compromised with stool. WP-H stated R10 is R10's own person and dictates R10's own care, and WP-H can only recommend and suggest to R10 to stay off the wound and limit the time spent in the wheelchair, but R10 has a right not to follow WP-H's recommendations. WP-H stated R10 has a history of being up all day in the wheelchair especially on the weekends. WP-H stated R10's wheelchair does some repositioning but the tilt in space wheelchair does not offer the same offloading as being in bed and repositioned to truly offload the wound. WP-H stated R10 cannot feel when R10 stools or sweats when up in the wheelchair and does not want to get changed if R10 is up in the wheelchair. WP-H stated these things contribute to bacteria in the wound and R10's comorbidities make R10 immunocompromised, which contributed to R10 developing osteomyelitis. WP-H stated R10's wound is improving with the bone no longer exposed and there is healthy granulation tissue present now. R10's MRI (magnetic resonance imaging) report dated 12/3/25 documents left ischial soft tissue defect extending to the underlying bone and resulting in osteomyelitis of the ischial tuberosity. R10's physician orders document the following:-Cipro oral tablet 500 MG, give 1 tablet by mouth 2 times per day for continued osteomyelitis as seen on MRI for 6 weeks-Doxycycline Hyclate oral tablet 100 MG, give 1 tablet by mouth 2 times per day for continued osteomyelitis as seen on MRI for 6 weeks. The wound continued to be comprehensively assessed on a weekly basis without significant changes. R10's most recent weekly wound documentation dated 4/27/26 documents a stage 4 pressure injury to the left buttock measuring 3.0 cm x 2.0 cm x 1.5 cm with 90% granulation tissue and 10% slough. In an interview on 4/29/26 at 11:02 AM, R10 stated yes, the wound team tells R10 to limit time up in the wheelchair, but R10 stated it is difficult to get in and out of the wheelchair, so R10 prefers to just stay in the wheelchair during the day. R10 confirmed R10 requests to get put in the wheelchair around 11:30 AM every day, then R10 asks staff to put R10 back in bed between 5:20-5:30 PM every day. R10 stated R10 must go outside every day because R10 cannot stay in R10's room all day long. On 4/29/26 at 1:09 PM, Surveyor shared concern with WRN-I and Director of Nursing (DON)-B that R10 had weight loss between October 2024 and April 2025, but there is no evidence the facility reassessed R10's interventions to prevent the development of a pressure injury after this weight loss to ensure their effectiveness at R10's new weight. DON-B and WRN-I stated they were not working in the facility at the time of R10's weight loss, so they cannot speak to why interventions were not readdressed or re-evaluated when R10 lost weight. No additional information was provided. 4.) R25 was readmitted to the facility on [DATE] with diagnoses that include Retention of Urine, Cerebral Infarction, Neuromuscular Dysfunction of Bladder and Malnutrition. R25's Quarterly MDS (Minimum Data Set) dated 8/12/25 documents that R25 was assessed to have no impairment to lower or upper extremities and is fully dependent on staff for R25's transfer and rolling left to right while in bed (bed mobility). The MDS documents that R25 was assessed to not have any pressure injuries at the time of the assessment but at risk for the development of pressure injuries. R25's pressure injury CAA (Care Area Assessment) dated 11/19/25 documents under the Analysis of Findings section: [R25] has a stage 4 pressure ulcer on her left buttock that was house acquired. She is at risk for further pressure ulcer development due to impaired mobility . Extensive assist for bed mobility. Weekly skin assessments by license

Based on interview and record review, the facility did not ensure it completed accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to the Centers for Medicare & Medicaid Services (CMS). This had the potential to affect all 79 residents residing in the facility.Staffing information for Quarter 1 (October 1 - December 31, 2025) of the Payroll Based Journal (PBJ) was not accurately submitted to CMS.Findings include:The CMS Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, indicates: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS .1.2 Submission Timelines and Accuracy. Direct care staffing and census data will be collected quarterly and is required to be timely and accurate .Report Quarter: staffing and census data will be collected for each fiscal quarter. Staffing data includes the number of hours paid to work by each staff member each day within a quarter. Census data includes the facility's census on the last day of each of the three months in a quarter. The fiscal quarters are as follows: Fiscal Quarter, Date range: (quarter) 1 October 1-December 31, (quarter) 2 January 1-March 31, (quarter) 3 April 1-June 30, (quarter) 4 July 1-September 30.Surveyor reviewed the facility's PBJ Staffing Data Report, CASPER Report 1705D, for Fiscal year 2026 (run on 4/20/2026) which documented the facility had excessively low weekend staffing and a one-star staffing rating for the 1st Quarter (October 1 - December 31, 2025). Surveyor reviewed the facility's weekend schedules from October 2025 through December 2025. Surveyor noted licensed nurses and certified nursing assistants present on each shift, for each unit. Surveyor noted these schedules indicated call ins, agency staff and staff who picked up shifts. Surveyor noted there were numerous call-ins, however the shifts were filled by staff or agency.On 04/28/2026, at 1:04 PM, Surveyor interviewed Scheduler-D and asked to verify nursing staff per shift scheduled in October to December of 2025. Per Scheduler-D, the minimum scheduled on 1st floor was three nurses and three Certified Nursing Assistants for day shift and two nurses with three Certified Nursing Assistants on the NOC shift. On second floor they scheduled three nurses with four Certified Nursing Assistants on the AM shift, two nurses on PM shift with four Certified Nursing Assistants and on the NOC shift one nurse with three Certified Nursing Assistants.Per Scheduler-D the second half of last year was an adjustment period. With a new company coming in, staff was calling in because they didn't want to work. Staff were upset about the new expectations so quit or went prn (as needed). This was an adjustment period. It was a scramble to call in staff or get agency to fill in the gaps, however with agency the gaps were filled. Scheduler-D uses an application called Cover that alerts staff when there is an opening, if the opening isn't picked up then uses agency.Surveyor noted the schedules documented many staff calling in and the openings being filled by staff or agency.On 4/29/2026, at 09:36 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding the facility's low ratings for staffing on the Payroll-Based Journal. NHA-A stated staffing fluctuates and is based on census and acuity. Surveyor discussed the schedules and gave a list of dates that didn't meet the number of staff to schedule given by Scheduler-D. NHA-A stated will review the dates.On 4/29/2026, at 12:30 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-E regarding staffing and was told it is decent. There are a lot of call ins, replacements are usually found. On 4/29/2026, at 12:42 PM, Surveyor interviewed Certified Nursing Assistant-F who stated staffing is okay, been here awhile and it has gotten better over time. Call ins are replaced and weekends are well covered.On 4/29/2026, at 12:45 PM, Surveyor interviewed NHA-A and Chief Nursing Officer-C regarding staffing during October to December and was shown how they reviewed each date given and compared to the census. On days that were questionable staffing, there was lower census in the building so less staff were needed. The census and number of staff working correlated. The problem they have identified is that the supervisor should be allocating their hours to what they were doing for the shift. Often, they help out on the floor and do not allocate time to show floor coverage so time is recorded as supervisory. They will do education in order to make a change for the future. They have also hired a consulting company to help with Payroll Based Journal reporting.On 4/29/2026, at 01:08 PM, Surveyor let NHA-A know of the concern with Payroll Based Journal reporting being inaccurate for the first quarter of the 2026 fiscal year.No additional information was provided as to why the facility did not accurately submit staffing information for Quarter 1 (October 1 through December 31, 2025) for the Payroll Based Journal (PBJ).

Based on observation, interview and record review the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 4 resident unit refrigerators in the facility and 1 of 1 meat/dairy cooler. *Observations of black, moldlike substances in the kitchen walk in cooler.*Ice buildup in the kitchen freezer*Condiments in kitchen walk in cooler were expired and/or not dated.This deficient practice has the potential to affect 62 of 79 residents whom receive food from main kitchen. Findings:The facility's undated policy, titled Food Safety Requirements documents: 1. Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process include the following: . b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms.On 04/26/2026, at 8:03 AM, Surveyor did an initial walk through the kitchen. Surveyor noted that in the kitchen's meat/dairy cooler, was an opened container of Sweet Baby Ray's Barbeque Sauce with no open date and expired on 10/8/2025. Surveyor also observed a container of [NAME] Apple Sauce with no open date. Surveyor noted the wall near the back corner of the cooler, near the door to the freezer, has a black, moldlike substance. Surveyor entered the freezer section of the cooler and noted ice chucks on the ground, and ice built up on a pipe on the ceiling. Surveyor spoke with Dietary Lead-S and asked who is usually responsible for the maintenance of the coolers/freezers, Dietary Lead-S informed Surveyor that the cooks are usually responsible for ensuring logs are completed but indicated Kitchen Director-R would be able to answer Surveyors questions better. On 04/26/2026, at 1:05 PM, Surveyor met with Kitchen Director-R to do the tour of the kitchen. Surveyor noted the kitchen cooler was reorganized and the expired condiments were gone. Kitchen Director-R informed Surveyor that Kitchen Director-R went through the kitchen cooler, removed the expired condiments and indicated the cooks should be checking the cooler for expired foods, every night, when time allows. Surveyor asked Kitchen Director-R about the substance on the wall in the cooler, Kitchen Director-R indicated that has been there for a while and has not mentioned it to anyone but indicated it looks to be mold and Kitchen Director-R scrapped it off with the paint, moved all the stuff, and ran soap on the concrete. Surveyor asked about the ice buildup in the freezer, Kitchen Director-R informed Surveyor that the defrost is leaking and built up. Kitchen Director-R indicated the AC unit wasn't working last summer, and it was hot and when the door opened moisture would get in and believe that may have been how it started. The former Maintenance Director was aware but there is a new Maintenance Director and Kitchen Director-R would inform him.On 04/26/2026, at 3:37 PM, Surveyor interviewed Maintenance Director-Q, who started working for the facility at the end of March 2026. Maintenance Director-Q indicated that he was not aware of the mold in the cooler or build up of ice in the freezer and would need to hire out for the maintenance of cooler/freezers in kitchen. Maintenance Director-Q indicated expecting to be made aware of mold in the kitchen cooler and to be made aware of the ice buildup in the freezer to be able to trouble shoot and address it properly. On 04/29/2026, at 10:26 AM, Surveyor observed the resident refrigerator on the 1 South/Vent unit with Nurse Manager-N. Surveyor observed condensation on the inside back of the refrigerator, a plastic bag with food items not labeled or dated, breaded chicken on a plate with no labeled or date. Surveyor reviewed the temperature log for April and noted on 4/18/2026, 4/19/2026, 4/20/2026, 4/21/2026, 4/25/2026, 4/26/2026, 4/27/2026 and 4/29/2026 all had temperature ranges above 41 degrees Fahrenheit, with no corrective action taken. Nurse Manager-N informed Surveyor she would need to look into the concern further and get back to Surveyor.On 04/28/2026, at 3:23 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. Surveyor was informed that the facility hired a restoration/remediation company, who is coming at the end of the week to look more into the black, mold like substance in the kitchen cooler and the ice buildup in the freezer. NHA-A indicated she expects to be notified, as well as maintenance, right away of these types of concerns so a proper intervention and follow up can occur.On 04/29/2026, at 12:46 PM, Surveyor informed NHA-A and DON-B of the concerns with the 1 South Vent unit refrigerator for resident food. Surveyor was informed that the food in fridge should be dated and labeled with resident name. Any concerns with fridge temperatures should be brought to DON-B and maintenance should be notified to evaluate. DON-B indicated that the 1 South Vent unit refrigerator has a different log than the other refrigerators on the units which are managed by the kitchen. Will update 1 south log for all refrigerators to be uniform and have ranges listed. No additional information was provided.

Based on interview and record review, the facility did not ensure all alleged violations of neglect were reported immediately to the State Agency, but not later than 24 hours after the allegation was made for 1 of 2 Facility Reported Incidents (FRI) reviewed. The facility received notification that R10 made an allegation of neglect on 1/23/26 at 7:00 PM and did not report the allegation to the State Agency until 1/26/26 at 3:14 PM. Findings include: The facility policy, entitled Abuse, Neglect and Exploitation, with no implemented or revised date documents: 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, neglect, exploitation and misappropriation of resident property. reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes: . not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.On 4/27/26, Surveyor reviewed the FRI (facility reported incident) with an initial submission date of 1/26/26 to the State Agency, which documents: On 1/26/26, an email was reviewed by the facility administrator containing an allegation of neglect. The FRI investigation documents an investigation was initiated immediately upon review of the grievance. After a thorough investigation of all potential witnesses, the facility was unable to substantiate the allegation of neglect. The alleged staff member discontinued employment at the facility prior to the grievance being received. On 4/27/26 at 3:06 PM, Surveyor requested the email Nursing Home Administrator (NHA)-A received from R10 on 1/26/26. On 4/28/26 at 7:43 AM, NHA-A provided Surveyor with a copy of the email contents that R10 sent to NHA. Surveyor noted there is no date provided on the email contents and NHA-A stated NHA-A was having issues printing the actual email and was only able to print the contents of the email for Surveyor to review. Surveyor notes the email included a grievance form which documents date submitted as 1/14/26. On 4/29/26 at 8:41 AM, Surveyor asked NHA-A when NHA-A received the email from R10 with a grievance alleging neglect from a staff member. NHA-A stated NHA-A received the email from R10 on 1/23/26 at 7:00 PM. NHA-A stated R10 always emails any grievances to NHA-A because NHA-A is the grievance officer for the facility and R10 prefers to send the grievances in email form due to physical limitations limiting R10's ability to write. NHA-A stated NHA-A often receives emails from R10 with grievances on the weekends or overnight after NHA-A has left the facility for the day. NHA-A stated NHA-A was out of town the weekend NHA-A received the email from R10 on 1/23/26, so NHA-A did not check NHA-A's email until returning to work on 1/26/26. NHA-A stated once NHA-A read the email from R10 on 1/26/26, NHA-A realized R10 was making an allegation of neglect and reported the alleged neglect to the State Agency on 1/26/26.Surveyor shared the concern with NHA-A that R10 notified NHA-A of an allegation of neglect on 1/23/26, but it was not reported to the State Agency until 1/26/26, which is later than 24 hours of receiving the allegation. NHA-A stated R10 should have called NHA-A with any concern about potential abuse or neglect, but R10 emailed NHA-A instead, and NHA-A does not check NHA-A's email 24 hours a day.No additional information was provided regarding why the facility did not report R10's allegation of neglect within 24 hours of receiving notification of the alleged violation.

Based on observation, interview, and record review, the facility did not ensure staff followed infection control procedures for 1 (R25) of 2 residents reviewed with an indwelling catheter.* R25's catheter bag was observed lying directly on the ground without a barrier. R25 is considered high risk for infection with a history of urinary tract infections (UTIs) with sepsis.Findings include:R25 was admitted to the facility on [DATE] and has diagnoses that include Multiple Sclerosis (autoimmune disease of the central nervous system affecting the brain, spinal cord, and eye nerves) , Alzheimer's Disease, obstructive and reflex uropathy (blockage in the urinary tract that stops urine from flowing), anxiety disorder, metabolic encephalopathy (brain dysfunction) , neuromuscular dysfunction of the bladder, retention of urine and history of urinary tract infections with Sepsis.R25's annual Minimum Data Set (MDS) dated [DATE] documents that R25 was assessed to have intact cognition with a Brief Interview for Mental Status (BIMS) score of 13 and needing extensive assist with 1 staff member for Activities of Daily Living (ADLs). The MDS also assessed R25 to have an indwelling catheter with a history of Urinary Tract Infections (UTIs) and always incontinent of bladder. R25's chronic indwelling foley catheter related to neurogenic bladder, . and is at risk/ has a history of UTI's care plan initiated on 1/11/2023 has the following interventions:- CATHETER: (R25) has a 16F coude (angled tip on catheter tubing instead of a straight tip) catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door.- Check tubing for kinks every shift.- Observe for pain/ discomfort due to catheter.- Observe as needed for signs/ symptoms of UTI: .- Change Catheter bag as needed (Initiated: 10/3/2023).- Change foley catheter when occluded (blocked) or unable to flow freely as needed for patency. - Provide foley catheter care every shift and as needed.- Secure indwelling catheter tubing using an anchoring device to prevent movement and urethral traction every shift.On 4/26/2026, at 11:04 AM, Surveyor observed R25 lying in bed watching TV. Surveyor observed R25's catheter bag hanging off the right side of the bed, viewable from the room entrance doorway and the bottom of the catheter bag was touching the ground directly without a protective barrier. Surveyor asked R25 how often facility staff provide care to R25's catheter and how often they empty the catheter bag. R25 stated staff just emptied the bag and was unable to recall how often staff provided cares or emptied R25's catheter bag. Surveyor asked if the catheter has been in place for a while and if R25 ever got UTI's. R25 stated having the catheter for a very long time and frequently got UTI's but was unable to provide when R25 last had a UTI. On 4/29/26 at 1:11 PM, Surveyor informed WRN-I and DON (Director of Nursing)-B, of the observation of R25's catheter bag lying on the ground without a protective barrier and R25 is already considered a high risk for developing UTI's. No additional information was provided.

Based on observation, interview and record review, the facility did not ensure 1 (R25) of 18 residents received treatment and care in accordance with professional standards of practice.*R25 had a peripherally inserted central catheter (PICC) line placed on 4/13/26. R25 has an MD order for the PICC line dressing to be changed every 7 days. Surveyor observed R25's PICC line dressing on 4/26/26 and 4/28/26. During observation, R25's PICC line dressing was dated 4/13/26, indicating that R25's PICC line dressing was not changed from 4/13/26 to 4/28/26. R25's IV medication care plan was not initiated until 4/27/26, which is 2 weeks after the PICC line was placed. Findings include:The facility policy dated 10/2024 and titled, Dressing change for vascular access devices, documents, in part: Purpose-To prevent local systemic infection related to the IV catheter. Policy- A sterile dressing is maintained on all peripheral and central vascular access devices to protect the site, provide a microbial barrier and to provide vascular access device securement. Central venous access device and peripheral midline dressings are changed every 7 days and immediately if the integrity of the dressing is compromised, if moisture, drainage or blood is present, or for further assessment if infection is suspected. Central venous access device dressing change procedure. Remove old dressing. Assess site. Clean an area larger than dressing to be applied. Apply transparent dressing. Secure catheter and IV tubing. Apply label on dressing with date and nurse's initials.R25 was admitted on [DATE] and had diagnosis that include Stroke (an instance where blood flow to the brain is blocked), Alzheimer's disease (progressive irreversible brain disorder that destroys memories), Pulmonary embolism (life threatening blockage in a lung artery), Pressure ulcer (localized skin and tissue damage caused by prolonged pressure, friction, or shear, usually over bony areas) and Osteomyelitis (serious bone infection).R25's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documents that R25 is cognitively intact.R25's progress note dated 4/13/26 documents: Per new orders [R25] needs PICC line for IV [antibiotics] therapy and new IV [antibiotics]. [Nurse Practitioner] to place orders.R25's progress note dated 4/13/26 documents: Dynamic access placed 44cm single lumen PICC to right brachial [vein].R25's MD order with a start date of 4/13/26 documents: Intermittent IV medication infusion- Flush using [saline-administer-saline] technique with 10 [milliliters (ml)] normal saline before med and 10 ml after med. Two time a day for PICC patency.R25's MD order with a start date of 4/14/26 documents: Change catheter site dressing with site change [Every] 7 days and [as needed]. Label with date/time/initials. One time a day every 7 days.R25's IV Medication care plan initiated 4/27/26 documents the following pertinent interventions, in part: If IV is infiltrated: stop infusion and thoroughly examine the site. If the catheter appears to be lodged in the tissues, an attempt to aspirate any fluid remaining in the catheter can be made in order to lessen the amount of drug at the site. IV dressing: Observe dressing with each med administration. Change dressing and record observations of site per order, [as needed]. Monitor/document/report [as needed] [signs and symptoms] of infection at the site: drainage, inflammation, swelling, redness, warmth. Monitor/document/report [as needed] [signs and symptoms] of leaking at the IV site.Surveyor noted that facility staff initiated an IV care plan on 4/27/26, which is 2 weeks after R25 had R25's PICC line placed.On 4/26/2026 at 10:44 AM, Surveyor observed R25. R25 had antibiotic medication running into right arm PICC line. The date on the PICC line dressing is 4/13/26.On 4/28/26 at 1:13 PM, Surveyor observed R25. R25's PICC line dressing is dated 4/13/26.Surveyor noted that R25's MD order documented that R25's PICC line dressing should be changed every 7 days and labeled with date, time and initials. Surveyor noted that during observations, R25's date on R25's dressing was labeled with the date of 4/13/26 indicating that R25's dressing had not been changed and re-labeled from 4/13 through 4/28/26.On 4/28/26 at 1:15 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-G. Surveyor asked what is needed if a resident has a PICC line. LPN-G indicated that the resident would have orders for a PICC line dressing change every 7 days and would have a care plan.On 4/29/2026 at 9:21 AM, Surveyor observed R25. The date on R25's PICC line dressing is 4/28/26. Surveyor noted that facility staff changed and re-labeled R25's PICC line dressing after Surveyor's observation on 4/28/26.On 4/29/26 at 9:33 AM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked what the expectation is for nursing staff regarding PICC lines. DON-B stated that there is an order for a dressing change every 7 days. When it is due, if there is an LPN working, the LPN will let the Registered Nurse (RN) Supervisor know that the dressing is due for a change. The RN Supervisor will change the dressing and document that. Surveyor asked if there should be a care plan and asked if DON-B would expect staff to follow the MD order. DON-B indicated that there should be a care plan, and staff should follow the MD order. Surveyor shared the following concerns that R25 had a PICC line placed on 4/13/26. A care plan was not initiated until 4/27/26. Surveyor observed on 4/26/26 and 4/28/26, that R25's PICC line dressing was dated 4/13/26. R25's MD order states that the dressing should be changed and dated with the date of change. When Surveyor observed R25's PICC line today 4/29/26, the dressing was dated 4/28/26 indicating that R25's dressing was changed after Surveyor's observation on 4/28. R25 went from 4/13/26 to 4/28/26 without a dressing change. DON-B understood the concerns.On 4/29/26 at 2:45 PM, Surveyor informed Nursing Home Administrator (NHA)-A of the above concerns. No additional information was provided.

Based on observation, interview and record review, the facility did not ensure dependent residents received the necessary services to maintain nail care for 1 (R5) of 5 residents reviewed for activities of daily living (ADLs).R5, an ADL dependent resident, was observed with long and dirty fingernails from 4/26/26 to 4/28/26.Findings include: The facility's undated policy, titled Nail Care, documents: Policy: The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health. Policy Explanation and Compliance Guidelines: .2. Identify conditions that increase risk for foot or nail problems, such as diabetes, peripheral vascular disease, heart failure, renal disease, or stroke. 3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 4. Routine nail care, to include trimming and filing, will be provided on a regular schedule. Nail care will be provided between scheduled occasions as the need arises.R1 was admitted to the facility on [DATE] with diagnoses that include diabetes, atrial fibrillation, chronic obstructive pulmonary disease, depressive and anxiety disorder.R5's Minimum Data Set (MDS) annual assessment, dated 1/10/26, documents a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. The MDS documents that R5 was assessed to be dependent for performing oral hygiene, toileting, shower/bathe, upper/lower body dressing and personal hygiene. On 04/26/2026 at 12:05 PM Surveyor observed R5's fingernails long at approximately 1/2 inch in length and dirty under the nails. Surveyor asked R5 if staff cut R5's fingernails and R5 stated, no one has ever cut them or offered to cut them.R5's Care Plan, dated 2/23/25, documents R5 requires assistance with ADL's r/t (related to) weakness, decreased mobility, pain. The goal is R5's risks for decline inADL abilities will be minimized through review date. Interventions include, in part. Dressing Assist: (Total Dependence) Assist of 1. Personal Hygiene Assist: (Total Dependence) Assist of 1, Showering Assist: (Total Dependence) Assist of 1, Toileting Hygiene Assist: (Total Dependence) Assist of 1.R5's Physician Orders, dated 4/13/26, documents, SHOWER DAY (sic): Monday PM; Document refusals. Nurse to perform Skin Observation in Evaluations and verify shower was completed. Document any skin concerns and update MD/management/Wound Team if needed; every evening shift every Mon (sic) for Shower.R5's Skin Monitoring Comprehensive Certified Nursing Assistant (CNA) Shower Review Sheets, dated 11/3/25 through 4/20/26, documents: Nail Care Completed: Yes, No or Not needed at this time. None of the sheets have documented a Yes or a nurse documenting nail care was provided under the comment section. Surveyor noted, six months of shower sheets were reviewed with R5 receiving a shower every Monday evening. On 04/28/2026 at 7:50 AM, Surveyor observed R5 sleeping in bed supine with hands visible. R5's fingernails were long and dirty and several of R5's fingernails were at least 1/2 inch long. On 04/28/2026 at 7:53 AM Surveyor interviewed Licensed Practical Nurse (LPN)-L who stated, if a resident is diabetic, the nurses have to trim the residents' fingernails. Surveyor asked LPN-L, when does fingernail trimming occur. LPN-L stated this typically occurs when the CNA's shower the residents and the need to cut fingernails is evaluated at that time. If the resident's fingernails need trimming, the CNA's tell the nurse and the nurse will trim the fingernails or if the nurse notices a need for fingernail trimming, it will done at that time. Surveyor asked where fingernail trimming is documented and LPN-L stated, it is not documented.Surveyor asked LPN-L if LPN-L noticed R5's fingernails were long and dirty and LPN-L stated LPN-L had not noticed. Surveyor asked LPN-L if LPN-L could accompany Surveyor to R5's room to observe fingernails. LPN-L and Surveyor entered R5's room together and observed R5's fingernails to be long and dirty underneath the nail. LPN-L acknowledged that R5's fingernails were long and dirty, and LPN-L stated LPN-L would be taking care of trimming R5's fingernails today. Surveyor asked if LPN-L would also be cleaning underneath the fingernails and LPN-L stated, LPN-L will clean with an orange stick that is used to specifically clean underneath the nails.On 04/28/2026 at 1:16 PM, Surveyor observed R5 lying in bed supine watching TV with trimmed and clean fingernails.On 04/28/2026 at 3:31 PM, Surveyor asked Director of Nursing (DON)-B what the process for trimming fingernails for diabetic residents. DON-B stated that the CNA's can file the fingernails but cannot cut but the nurses can only cut the fingernails of diabetic residents. The CNA's will notify the nurses on shower days if a diabetic resident fingernails need to be trimmed. The nurse should also be doing the skin assessment after every resident shower and determine if fingernails need to be trimmed as well. On 04/28/2026 at 3:32 PM Surveyor notified Nursing Home Administrator (NHA)-A and DON-B of concerns regarding observations of R5's fingernails long and dirty. LPN-L has since cut and cleaned nails.No additional information was provided.

Based on interview and record review, the facility did not ensure 2 (R25 & R57) of 2 residents were notified of the reason for transfer/discharge & bed hold policy in writing to the resident & their representative and the rate to reserve the resident's bed was not documented in the Transfer, Bed hold Notice form. * There is no evidence R25 and/or R25's representative was provided a copy of the bed hold/ transfer notice for R25's hospitalization on 7/19/2025 and the bed hold notice did not document the bed hold rate for R25's hospitalization on 10/27/2025. * R57 was transferred to the hospital on 3/25/2026 and 4/10/2026. The bed hold and transfer notices for the two separate transfers were combined and not individualized for each transfer. Findings include: The facility policy titled Bed Hold Notice with no initiated or reviewed/revised date documents: It is the policy of this facility to provide written information to the resident and/ or the resident representative regarding bed hold practices both well in advance, and at the time of, a transfer for hospitalization or therapeutic leave. Policy Explanation and Compliance Guidelines:1. at the time of transfer to the hospital . the facility will provide a resident and/ or resident representative written information that specifies:a. The duration of the State bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility.b. The reserve bed payment policy in the state plan policy.2. In the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed-hold policies to the resident and/ or resident representative within 24 hours. The facility will document multiple attempts to reach the resident's representative in cases where the facility was unable to notify the representative. 3. The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file and/ or medical record. 1.) R25 was admitted to the facility on [DATE] and has diagnoses that include Multiple Sclerosis (autoimmune disease of the central nervous system affecting the brain, spinal cord, and eye nerves), Alzheimer's Disease, anxiety disorder, and metabolic encephalopathy (brain dysfunction). R25's annual Minimum Data Set (MDS) dated [DATE] documents R25 was assessed to have intact cognition with a Brief Interview for Mental Status (BIMS) score of 13. R25's power of attorney (POA) was activated. R25 was transferred and admitted to the hospital on [DATE] and re-admitted to the facility on [DATE]. Surveyor reviewed R25's bed hold/ transfer forms for R25's hospitalization on 7/19/2025. Surveyor noted there is no evidence R25 and/or R25's activated POA signed or received a copy of the bed hold/ transfer form for R25's hospitalization on 7/19/2026. R25 was transferred and admitted to the hospital on [DATE] and re-admitted to the facility on [DATE]. Surveyor reviewed R25's bed hold/ transfer forms for R25's hospitalization on 10/27/2025. Surveyor noted there is no evidence R25 and/ or R25's activated POA signed the forms, were notified of the bed hold rate, or were provided copies of the bed hold/ transfer forms for R25's hospitalization on 10/27/2025. On 4/28/2026, at 3:23 PM, Surveyor shared concerns with nursing home administrator (NHA)-A concern R25 and R25's activated power of attorney was not provided the bed hold rate, provided bed hold/ transfer forms to sign, and was not provided a copy of the bed hold/ transfer forms for R25's transfer and admission to the hospital on 7/19/2026 and 10/27/2025. NHA-A replied during those months the facility was not providing a copy to the resident and/or the resident representative. NHA-A was not sure why the rates were not provided or documented for R25's transfers to the hospital on 7/19/2025 and 10/27/2025. 2.) R57 was admitted to the facility on [DATE] with diagnoses of acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, diabetes, Barrett's esophagus, cerebral infarction, dysphagia, and history of cardiac arrest. R57's admission Minimum Data Set (MDS) assessment dated [DATE] documented that R57 was assessed to be cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and had a feeding tube where the majority of nutrition was provided and on a mechanically altered diet. The MDs documents that R57 was assessed to require suctioning from the tracheostomy and received Speech, Occupational, Physical, and Respiratory Therapies. R57 had an activated Power of Attorney (POA). On 3/25/2026 at 6:09 PM in the progress notes, nursing documented they were called into R57's room by Respiratory Therapy (RT). RT told the nurse R57 was choking on Jello and they needed to bag R57 and increase oxygenation to 10 liters with oxygen saturation at 90%. The nurse contacted the physician, and an order was obtained to send R57 to the hospital for evaluation and treatment. The nurse called R57's POA to provide an update with a verbal confirmation to hold the bed and send R57 to the hospital. A Bed Hold Notice form was completed by the nurse that sent R57 to the hospital. The form indicated the POA gave verbal authorization on 3/25/2026 at 5:35 PM. The facility staff signed the form on 3/26/2026, the following day. The Notice of Resident Transfer or Discharge form was completed on 3/25/2026 documenting R57's needs could not be met by the facility for decreased oxygenation with episodes of choking. The form was signed by R57's POA and dated 3/21/2026, four days before the transfer. On 4/9/2026 at 2;44 AM in the progress notes, nursing documented R57 complained of nausea and dizziness. Vital signs showed an elevated heart rate and low oxygenation. R57 was coughing up clear frothy sputum. R57 was given their scheduled medications and breathing treatment as needed. R57's oxygen saturation would not remain stable even after oxygen was increased to 10 liters. The nurse called the on-call physician and received an order to send R57 to the hospital for evaluation and treatment. The Bed Hold and Notice of Resident Transfer forms were scanned into R57's medical record. The forms were from R57's 3/25/2026 transfer with the addition of R57's POA signing the Bed Hold Notice on 4/12/2026. All other information written on the forms was from 3/25/2026 including R57's POA signature on the Notice of Resident Transfer dated 3/21/2026. In an interview on 4/27/2026 at 3:05 PM, Surveyor asked Director of Nursing (DON)-B what the facility process was for the Bed Hold and Notice of Resident Transfer paperwork. DON-B stated the nurse on the unit who is sending the resident out to the hospital gets a verbal confirmation from the POA for the bed hold and transfer notice. DON-B stated the nurse will then scan the original form to the resident's medical record and when the form comes back with a signature from the POA, they add the second form to the record. Surveyor shared with DON-B the concern R57's Bed Hold and Notice of Resident Transfer forms for 3/25/2026 and 4/9/2026 were the same documents scanned in twice. DON-B stated the nurse uploaded the form from the first hospitalization for both dates and the night nurse put the wrong date on the form originally since R57 went out earlier in the shift when it was 3/25/2026 and later in the shift it was 3/26/2026 since it was then after midnight. DON-B stated the POA signed the completely wrong date and could not explain why that had been done or why it had not been corrected. DON-B agreed R57's second hospitalization did not have the correct forms completed. Nursing Home Administrator (NHA)-A was present at the time of the interview and understood the concern with not having the notices completed correctly. No additional information was provided.

Based on observation and interview, the facility did not ensure a safe, clean, comfortable, and homelike environment for 1 (R49) of 18 residents.*The facility experienced water damage to the ceiling in R49's room causing R49 to be concerned of ceiling integrity and organic growth. The facility did not remediate the water damage to R49's ceiling in a timely manner.Findings include:On 04/26/2026, at 9:40 AM, Surveyor interviewed R49. R49 informed Surveyor that water has leaked from ceiling multiple times over last month causing water damage to the ceiling tiles. Surveyor noted brown stained blotches on the ceiling above R49's bed, and above R49's doorway. R49 stated R49 mentioning the concerns to Director of Nursing (DON)-B multiple times but feels it has been shrugged off. R49 informed Surveyor that R49 has also talked to maintenance and they are having a hard time finding tiles. R49 is concerned for the integrity of the ceiling and would like the tiles taken down.On 04/27/2026, at 10:37 AM, Surveyor interviewed Maintenance Director-Q who indicated being newer to his role. Maintenance Director-Q informed Surveyor there have been no leaking pipes over the last month but due to a toilet overflowing on occasions, the ceiling tiles need to be replaced in R49's room due to water damage. Maintenance Director-Q indicated that today is the first Maintenance Director-Q knew of the concern. Maintenance Director-Q stopped by R49's room about an hour ago to say hello, when R49 pointed out the ceiling tiles. Maintenance Director-Q indicated that the facility should be getting replacement tiles for R49's room soon. On 04/27/2026, at 11:13 AM, Surveyor interviewed Maintenance-P who has worked at the facility for 12 years. Maintenance-P indicated being aware of the water damage to the ceiling in R49's room, explaining that an overflowing toilet upstairs came down to R49's room which happened about 2 weeks ago. Maintenance-P was notified by one of the maintenance technicians after the fact and indicated R49's ceilings would need new tiles. Maintenance-P stated the facility now has tiles but Maintenance-P has not got to it yet and that caulk was used previously in some of the areas that had water damage from previous times. Maintenance-P stated none of the new tiles have been taken down or replaced yet, and that Maintenance-P is just waiting for the time to get in there to do it. On 04/28/2026, at 9:13 AM, Surveyor went into R49's room and noted the water damaged ceiling tiles have been taken down. R49 was resting in bed and expressed being very happy that maintenance had now started working on the ceiling.On 04/28/2026, at 3:23 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B and was informed that the water damage to the ceiling tiles in R49's room were from a recent leak and that the facility was waiting for it to dry out, before putting nails in to replace the tiles. No additional information was provided.

Based on observation, interview and record review, the facility did not ensure the medication error rate was below 5% for 1 resident (R5) of 3 observed receiving medications. The facility medication error rate was 6.89%. *R5 received one ergocalciferol oral capsule 1.25mg. R5's physician order documents ergocalciferol oral capsule 1.25mg, give 2 capsule by mouth in the morning every Wed (Wednesday) for vitamin D deficiency. *R5 received one zinc 50mg tablet. R5's physician order documents zinc-220 oral capsule, give 1 capsule by mouth one time a day. Findings include: On 1/28/26, at 7:32am, Surveyor observed medications being administered to R5. Medication Technician (MT)-G prepared 18 medications to administer to R5. Surveyor observed MT-G add one ergocalciferol oral capsule 1.25mg and one zinc 50mg tablet to the medication cup that R5 was to receive. Surveyor noted upon review of the Physician Orders the order for ergocalciferol oral capsule 1.25mg documents ergocalciferol oral capsule 1.25mg, give 2 capsule by mouth in the morning every Wed (Wednesday) for vitamin D deficiency and MT-G gave one. Also, R5 received one zinc 50mg tablet from the house stock and R5's physician order documents zinc-220 oral capsule, give 1 capsule by mouth one time a day., this is 170mg less than prescribed. On 1/28/26, at 9:47am, Surveyor interviewed MT-G and confirmed that one ergocalciferol oral capsule 1.25mg was given. MT-G showed Surveyor the medication card and on it was typed to give one capsule, Surveyor asked MT-G to look at the order in the computer and MT-G confirmed the physician order is for two capsules. Surveyor asked MT-G to look at the bottle for the zinc medication that was given. A 50mg bottle of zinc was shown. Surveyor asked MT-G to review the order in the computer and explained that zinc-220 indicates 220 mg of zinc per capsule and that only 50mg was given. On 1/28/25, at 10:47am, Surveyor interviewed Director of Nursing (DON)-B about the medication error rate being 6.89% with 29 opportunities. Surveyor explained the concerns of one ergocalciferol oral capsule being given and zinc 50 mg given, not the physician order of zinc-220. DON-B replied that pharmacy is following with medication pass once per month to audit the medication pass. No further information was provided regarding the medication errors observed.

Based on observation, interview and record review the facility did not ensure 1 (R1) of 3 residents reviewed for falls received adequate supervision and assistive devices to prevent accidents.R1 was admitted to the facility on [DATE] with recommendations to wear a helmet when out of bed or chair to prevent brain injury from falling or head trauma after having a craniotomy (a surgical procedure in which a neurosurgeon temporarily removes a section of the skull). R1's care plan for activities of daily living (ADLs) identifies the need for R1 to wear a helmet; dated 1/2/26. The facility assessed R1 being at risk for falls and did not place orders for R1's helmet until 1/20/26. The facility did not verify recommendations/orders with the physician to determined when R1 is to wear a helmet until 1/27/26.Findings include:The facility's undated policy titled, Use of Assistive Devices, documents the following:The purpose of this policy is to provide a reliable process for the proper and consistent use of assistive devices, or those residents require equipment to maintain or improve function, dignity and quality of life.The use of assistive devices will be based on the resident's comprehensive assessment, in accordance with the resident's plan of care.The facility will provide assistive devices, as indicated, for residents who need them. Nursing, dietary, social services, and therapy departments will work together to ensure availability of devices, such as for ordering and/or replacement.Facility staff will provide appropriate assistance to ensure that the resident can use the assistive devices safely. This may include assessment, education or therapy sessions for training on the use of the device, set up assistance, supervision, or physical assistance as needed.A nurse with a responsibility for the resident will monitor for the consistent use of the device and safety in the use of the device. Refusals of use, or problems with the device, will be documented in the medical record. Modifications to the plan of care will be made as needed.The facility's undated policy titled, admission Orders documents the following:A physician, physician assistant, nurse practitioner or clinical nurse specialist must provide written and/or verbal orders for the resident's immediate care and needs.The orders should allow facility staff to provide essential care to the resident consistent with the residents' mental and physical status on admission.The orders for providing information to maintain or improve the resident's functional abilities until staff can conduct a comprehensive assessment and developed in interdisciplinary care plan.R1 is a [AGE] year-old resident who was admitted to the facility on [DATE]. R1's diagnoses include chronic respiratory failure (low oxygen levels due to lungs not working properly), intracerebral hemorrhage (a type of stroke caused by ruptured blood vessel within the brain), dysphagia (difficulty swallowing from problems with the mouth and lips), muscle weakness, cognitive deficit (problems with thinking abilities like memory, attention, learning, reasoning, and judgment), cerebral infarction (stroke), Type 2 Diabetes (the body resists the effects of insulin leading to high blood sugar levels), aphasia (communication disorder caused by brain damage or a stroke), and hemiplegia (paralysis affecting one side of the body).R1's admission Minimum Data Set (MDS) completed on 12/28/25, assesses R1 requires substantial/maximal assistance with rolling right to left, and is dependent with toileting, showering, dressing, and transfers. R1 uses a manual wheelchair, has an indwelling catheter and is always incontinent of bowel. R1 requires insulin injections 7 days a week and is taking an anticonvulsant. R1 has had a fall in the last 2-6 months. R1 was assessed as having a Brief Interview for Mental Status (BIMS) score of 0, indicating that R1 has severe cognitive impairment.R1's admission MDS dated [DATE], documents the following Care Area Assessment (CAA):Falls CAA - R1 is at risk for falls related to history of falls prior to hospitalization, use of antidepressant, anti anxiety medication, and impaired mobility. R1 had a fall with his Cerebral Vascular Accident (CVA) prior to admission. R1 is receiving Sertraline for depression, alprazolam for anxiety, and opioids for pain. R1 is dependent upon staff for transfers via Hoyer due to a recent craniotomy. R1 is receiving therapy for strengthening and rehabilitation. R1 has had no falls since admission. Cognitive Loss/Dementia CAA - R1 is able to communicate by using thumbs up or down and pointing. This is not helpful during the BIMS assessment. There is no memory concerns, just lack of vocal ability.On 1/27/26, Surveyor reviewed R1's hospital discharge paperwork dated 12/22/25, which documents the following: Make sure to wear your helmet whenever you are out of bed or chair - if there are any falls or head trauma there is a risk of brain injury.Surveyor reviewed R1's orders which document the following:R1 to have helmet on when doing activity and out of bed (ordered date 1/20/26). Surveyor notes R1 was admitted on [DATE] and it did not have orders until 1/20/26 for R1's helmet. Surveyor also notes R1's orders did not reflect recommendations from R1's hospital discharge documents and R1's care plan did not get updated or reflect order written on 1/20/26.R1's care plan, dated 12/22/25, documents:*R1 has an Activities of Daily Living (ADL) self-care performance deficit related to stroke, hemiplegia, respiratory failure with stroke, and weakness (date initiated 12/22/25, revision 1/2/26).Interventions:Bed mobility - R1 is maximum assistance with bed mobility. R1 must have helmet on when on left side due to craniotomy (date initiated 1/2/26). Bed mobility - R1 is maximum assistance with bed mobility. R1 must have helmet on when on left side due to craniotomy, when out of bed and activities (revised on 1/27/26).Transfer - R1 requires mechanical lift Hoyer with two staff assistance for transfers (date initiated 12/22/25).*R1 demonstrates impaired safety awareness related to status post craniotomy, evidenced by intermittent removal of protective helmet after repositioning and transfer to wheelchair (date initiated 1/27/26).Interventions:R1 intermittently removes the helmet due to impaired safety awareness. Staff apply the helmet during repositioning and transfers, provide redirection and education, and monitor for safety (date initiated 1/27/26).Anticipate and meet R1's needs (date initiated 1/27/26).Explain all procedures to R1 before starting and allow R1 time to adjust to changes (date initiated 1/27/26).Provide calm verbal redirection and cueing regarding helmet use and safety risks (date initiated 1/27/26).Reapply helmet as tolerated (date initiated 1/27/26).R1's spouse educated on behavior, associated risks, and helmet use exceptions; spouse verbalized understanding and stated awareness and acceptance of behavior once R1 is seated (date initiated 1/27/26).*R1 is at risk for falls related to weakness (date initiated 12/22/25).Interventions:Be sure R1's call light is within reach and encourage R1 to use it for assistance as needed (date initiated 12/22/25).Ensure R1 is wearing appropriate footwear when ambulating or wheeling in wheelchair (date initiated 12/22/25).Keep needed items, water, etc. in reach (date initiated 12/22/25).*R1 has potential impairment to skin integrity related to immobility (date initiated 12/22/25).*R1 has potential impairment to skin integrity related to immobility, history of pressure injury to right ear and surgical incision scar to left lateral scalp (date revised on 1/12/26).Interventions:Surgical scar to skull. R1 must wear helmet when on left side (date initiated 1/12/26).Surgical scar to skull. R1 must wear helmet when on left side, out of bed and with activities (date revised on 1/27/26).Surveyor notes the following after reviewing R1's care plan:R1 did not have a bed mobility care plan until 1/2/26, which is 11 days after R1 was admitted on [DATE]. R1's care plan was updated on 1/27/26 with further instructions on how and when R1 is to wear R1's helmet. R1 transfers using a Hoyer lift, putting R1 at risk for head trauma while using the lift, and R1's care plan did not include R1 wearing a helmet during transfers until R1's care plan was revised on 1/27/26.The facility documents on 1/27/26, R1 having impaired safety awareness as evidence by R1 removing R1's helmet.R1's Kardex dated 1/27/26, documents the following:Bed Mobility - R1 is maximum assistance with bed mobility. R1 must have helmet on, when on the left side due to craniotomy.Dressing - R1 is totally dependent on 1 staff member for dressing and has a surgical scar to R1's skull. R1 must wear a helmet when on the left side.R1's Kardex dated 1/28/26, documents the following:Bed Mobility - R1 is maximum assistance with bed mobility. R1 must have helmet on, when on the left side due to craniotomy, when out of bed and activities.Dressing - R1 has a surgical scar to the skull. R1 must have helmet on, when on the left side, out of bed and with activities.Surveyor asked for copy of R1's Kardex at end of the day meeting on 1/27/26, at 2:06 PM. The facility provided Surveyor with a copy of R1's Kardex on 1/28/26 and Surveyor notes R1's Kardex was updated to reflect changes, on when R1 is to wear his helmet.On 1/27/26, at 12:12 PM, Surveyor interviewed R1 and R1's spouse. R1 was lying in bed supine with head of the bed at 45 degrees and grab bars present on both sides of R1's bed. Surveyor noted R1's bed to be in the middle of the room with both sides open and only the head of bed pushed up to the wall. Surveyor noted R1's helmet laying on R1's bedside table in the corner of R1's room out of reach. Surveyor asked R1 how R1 was doing and R1 nodded at Surveyor and gave a thumbs up. Surveyor asked R1 when R1 is supposed to wear R1's helmet. R1's spouse stated R1 is to wear a helmet with any movement such as rolling, being up out of bed, and during Hoyer lifts. R1's spouse stated R1 does not have part of R1's skull and it is just skin over R1's brain which is why R1 has the helmet. R1's spouse stated R1 went to the hospital via ambulance for scheduled doctor appointments on 1/19/26. R1's spouse met R1 at the hospital and was notified by ambulance staff that R1 had fallen when R1 was placed into a hospital wheelchair from the ambulance gurney. The seat on the hospital wheelchair fell forward with R1 being escorted down to the floor by ambulance staff with R1 being placed on R1's buttocks on to the floor. R1's spouse stated R1 did not sustain any injuries but then stated R1 did not have R1's helmet on at the time of the ambulance ride and fall. R1's spouse stated R1 will remove R1's helmet on their own and will often take off the helmet when sitting in the wheelchair. R1's spouse stated R1 and the family is ok with R1 removing the helmet when sitting in the wheelchair due to R1 having enough trunk strength. R1's spouse then stated R1 knows when R1 needs to wear the helmet but then stated R1 forgets to ask for the helmet because of the brain injury.On 1/27/26, at 12:49 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-F and asked CNA-F how she knows how a resident transfers and if equipment is needed. CNA-F states she refers to the care plan but was unable to locate the care plan binders at the nursing station. CNA-F stated she has worked at the facility for a while and is familiar with the residents. Surveyor asked CNA-F when R1 is to wear R1's helmet. CNA-F stated R1 is to wear a helmet when rolling in bed, during transfers, and during cares. CNA-F stated she got R1 ready on 1/19/26 for R1's doctor appointments and the ambulance staff transport. CNA-F stated she got R1 dressed and put on R1's helmet, and next thing she knew, the ambulance staff transferred R1 to the gurney and R1 was gone. Surveyor asked CNA-F if she witnessed ambulance staff transfer R1 to the gurney and CNA-F stated she did not see ambulance staff transfer R1 and then stated R1 can take on and off R1's helmet independently. CNA-F stated she is unsure if ambulance staff checked in with nursing staff prior to leaving the facility.On 1/28/26, at 10:01 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E by phone who stated she is familiar with R1 and recalls caring for R1 on 1/19/26. LPN-E stated CNA-F provided cares to R1 prior to ambulance staff showing up on 1/19/26. LPN-E stated CNA-F always makes sure R1 has R1's helmet on. LPN-E stated R1 will pull off the helmet all the time. LPN-E stated R1 will slide off R1's helmet independently and knows how to do it. LPN-E then stated it's not appropriate for R1 to remove R1's helmet if R1 is up in the wheelchair because R1 is supposed to have it on. LPN-E stated R1 is to have the helmet on when R1 is out of bed and up in the wheelchair. LPN-E stated R1 does not need a helmet on when R1 is in bed. Surveyor asked LPN-E where she would look to verify instructions on when R1 is to wear a helmet. LPN-E stated she will get report from the previous nurse, look at the 24-hour board, and look at orders. LPN-E stated the Treatment Administration Record (TAR) and/or Medication Administration Record (MAR) should indicate how and when R1's helmet is to be on. Surveyor noted to LPN-E that there were no orders for R1's helmet on 1/19/26 and asked how LPN-E knew when R1 was to wear R1's helmet. LPN-E stated she was told in report when R1 was admitted , and she carried on those same instructions when she cared for R1 and again referred to looking at R1's orders. LPN-E stated ambulance staff verified with LPN-E where R1 was going. LPN-E stated R1 had R1's helmet on and she's not sure when R1 removed the helmet. Surveyor asked LPN-E if she notified ambulance staff that R1 had a helmet and LPN-E stated she did not mention it to the ambulance staff because R1 had the helmet on when she last saw R1. LPN-E then stated she was passing medications to other residents within the facility at the time of R1 being transferred out by ambulance staff. LPN-E stated she was not aware of any falls when R1 was with ambulance staff on 1/19/26, and did not get report from the ambulance staff after R1 returned to the facility. Surveyor asked LPN-E who manages care plans and LPN-E stated care plans are not managed by floor staff. LPN-E indicated she does not know who enters in care plans for residents.On 1/27/26, at 2:06 PM, Surveyor asked Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B, about the process when ambulance staff take residents to a scheduled appointment. NHA-A stated ambulance staff will check in at the front desk and the receptionist at the front desk will hand over the paperwork to the ambulance staff and call the nursing unit to let nursing staff know that transportation is at the facility. Ambulance staff will speak with the nursing staff prior to the resident leaving the facility. Surveyor asked NHA-A and DON-B when R1 is supposed to wear their helmet. DON-B stated the facility reviewed the referral from the hospital prior to R1 arriving at the facility. DON-B stated the referral indicated R1 was to wear the helmet when being repositioned to R1's left side. DON-B then stated the facility was not provided an actual order with the hospital discharge paperwork and stated there were only recommendations in the patient education portion of the hospital discharge paperwork. DON-B stated we communicated with staff to tell them what family had instructed the facility to do with R1's helmet. DON-B indicated R1's spouse doesn't want a helmet on when R1 is in the wheelchair. DON-B stated R1 and/or R1's spouse will take off R1's helmet once R1 is transferred into the wheelchair. DON-B then stated best practice is for R1 to have the helmet on when sitting in the wheelchair and stated again there were no discharge orders given by the hospital specifying R1's helmet, there were only recommendations. Surveyor asked what the current orders are for R1's helmet. DON-B stated R1's helmet should be on when up in the chair or if repositioning. Surveyor asked if the facility contacted R1's physician or the hospital to clarify the recommendations or to specify orders on when R1 is to wear a helmet. No further information was provided by NHA-A and DON-B regarding contacting R1's provider to specify orders.On 1/28/26, Surveyor reviewed R1's Progress Notes which document the following:Effective date 1/27/26, at 3:11 PM, created on 1/28/26, at 9:13 AM, DON-B contacted R1's Neuroscience Department to follow up on the instructions for R1's helmet and directions/orders for upcoming appointments and surgery.On 1/28/26, at 9:03 AM, Surveyor observed R1 in a high back wheelchair in the facility hallway waiting at the elevator with another staff member. Surveyor observed R1 not wearing a helmet and the facility staff member holding R1's helmet in his hand.On 1/28/26, at 10:43 AM, Surveyor interviewed DON-B who states R1's hospital paperwork had instructions on R1's helmet and did not have orders. DON-B stated there was no specific order to say when R1 was to wear R1's helmet. DON-B then stated she contacted R1's provider on 1/27/26, to get clarification on orders for R1's helmet. DON-B stated R1's provider indicated R1 is to wear a helmet when up in a chair and during activities, but the helmet is not needed when R1 is in bed. DON-B stated if there is no way R1 is going to fall, R1 won't need the helmet and stated the helmet is to be used during transfers, sitting in the chair, and during activities. DON-B stated the purpose of the helmet is in the event of a fall, to provide protection. DON-B indicated R1 does not like wearing the helmet and will take it off frequently. DON-B stated the facility was initially notified of R1 needing the helmet when turning R1 on the left side. Surveyor asked DON-B if she was aware of R1 having a fall during transport. DON-B stated R1's spouse notified the facility of R1 having a fall with ambulance staff while at R1's appointments outside of the facility. DON-B stated the facility contacted the ambulance company and obtained ambulance records which document R1 was assisted to the floor by ambulance staff when transferring to a wheelchair and R1 did not sustain any injuries. Surveyor asked DON-B if R1 was wearing a helmet at the time of the fall and DON-B stated she can't confirm if R1 was wearing a helmet at the time of R1's fall with ambulance staff outside of the facility. Surveyor shared the following concerns with DON-B: R1 is assessed as being at high risk for a brain injury with a fall after having a recent craniotomy. R1 was admitted on [DATE] with no orders for R1's helmet and the facility did not contact R1's provider to clarify recommendations or get orders for R1's helmet. R1's helmet was not care planned until 1/2/26. R1 did not have an order placed at the facility until 1/20/26. R1 was observed sitting in R1's wheelchair at the elevator without a helmet and a facility staff member was holding R1's helmet in their hand. The facility did not clarify orders/recommendations with R1's providers until 1/27/26. R1 was escorted out of the facility by ambulance staff on 1/19/26 and sustained a fall with ambulance staff. R1's spouse indicated R1 was not wearing a helmet at the time of the fall and facility staff cannot confirm what was shared with the ambulance staff to ensure R1's safety with what the expectations were for R1 wearing their helmet on 1/19/26.

Based on observations, interviews, 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 (R11) of 3 residents reviewed for medication administration via Enteral Tube (ET) (a tube that is connected to the digestive system and is used to deliver hydration, nutrition, or medications.) R11 was on Enhanced Barrier Precautions (EBP), a staff member placed a graduated cylinder and syringe, from R11's room that's used for R11's ET cares, on the nurse's medication cart leaving residual fluid on the cart. The staff member did not sanitize the cart but then began preparing the next medication administration for another resident by placing cups on the contaminated cart/fluid. R11 is on EBP, a staff member did not maintain EBP after providing cares to R11. The staff member did not remove Personal Protective Equipment (PPE) before grabbing a spoon from the shared container off of the nurse's medication cart (that all residents use) with contaminated gloves. A staff member wiped off a syringe with a contaminated glove multiple times that would be used to deliver and remove fluid from R11's digestive tract. Findings Include: The facility policy, titled Medication Administration, with no date, review date, and revision date; states in part:Keep medication cart clean. The facility policy, titled Enhanced Barrier Precautions, with no date, review date, and revision date; states in part: Enhanced Barrier precautions (EBP) referred to an infection control intervention designed to reduce transmission of multidrug resistant organisms that employs targeted gown and gloves to use during high contact resident care activities.In order for enhanced barrier precautions will be obtained for residents with any of the following:. And/or indwelling medical devices (e.g., .urinary catheters, Feeding tubes, tracheostomy/ ventilator tubes.). PPE for EBP is only necessary when performing high contact care activities.Position the trash can inside of the resident room and near the exit for discarding PPE after removal, prior to the exit of the room or before providing care for another resident in the same room.High contact resident care activities include:device care or use: urinary catheter, feeding tubes, tracheostomy/ ventilator tubes. R11 was admitted to the facility on [DATE] with diagnoses of Acute respiratory failure with hypoxia (the lungs cannot get enough oxygen to the blood requiring oxygenation through a ventilation system), tracheostomy status (a medical opening in the neck that has a tube placed to assist with breathing), and gastronomy status (a tube inserted into the stomach).R11's Quarterly Minimum Data Set (MDS) dated [DATE] documented R11 is rarely or never understood, has short, long term memory impairment, and severely impaired skills for daily decision making. R11 has range of motion impairment of both sides of the body and upper and lower body. R11 is dependent on staff for hygiene, showers, bed mobility, and transferring. R11's Kardex as of 1/14/26, (which indicates to staff how to care for R11) documents:Resident is NPO (nothing by mouth) and requires continuous tube feedingcatheter: the resident has (specify size 16 French 10CC.)Perform trach care is ordered R11's Care Plan as of 1/14/26 documented:The resident has a tracheostomy R/T (related to) impaired breathing mechanics. Date initiated: 7/23/25use universal precautions as appropriate. Date initiated 7/23/25The resident has indwelling catheter: neurogenic bladder data initiated 7/23/25, revision on 7/30/25 On 1/14/26, at 12:05 PM, Surveyor observed Licensed practical Nurse (LPN)- J administer R11's medications through R11's ET. On the outside of R11's door is a sign indicating EBP and staff must perform hand hygiene and wear a gown and gloves to perform cares. All other visitors must perform hand hygiene. LPN-J was outside of R11's room, preformed hand hygiene applied a gown and gloves and recorded R11's vital signs. LPN-J removed gloves and gown, then preformed hand hygiene. LPN-J verified R11's medication that were due, crushed the medication, and placed the medication in a cup. LPN-J preformed hand hygiene, walked into R11's room, grabbed (without gloves) R11's graduated cylinder and syringe that is prefilled with water (this is used to push fluids, medications, and remove residual stomach fluids for R11) and placed the graduated cylinder on the medication cart. The graduated cylinder left a puddle of water with unknown contaminates on the nurse's cart.LPN-J preformed hand hygiene, donned a gown, and gloves and provided for privacy. LPN-J brought the medication and the graduated cylinder into the room and next to the bedside of R11. LPN-J stopped R11's tube feeding machine and disconnected the line from R11's ET. LPN-J confirmed R11's ET placement with 10cc of air (by pushing air into the ET with a syringe and listening on R11's stomach to hear a woosh sound). LPN-J then pulled water into the syringe from the graduated cylinder and pushed the remaining air out of the syringe with a small amount of water dripping down the side of the syringe to measure 30 mL of water. LPN-J wiped off the syringe with the contained gloved hand, including the tip of the syringe that goes into R11's ET. LPN-J connected the syringe and attempted to flush the ET, but was unsuccessful and disconnected the syringe. LPN-J pulled more water into the syringe from the graduated cylinder, pushed out the remaining air and some water, to measure 30 mL, causing water to drip down the syringe. LPN-J wiped off the syringe with the contained gloved hand including the tip that goes into R11's ET. LPN-J connected the syringe and flushed the ET successfully. LPN-J pulled 30 mL of water into the syringe, pushed out the remaining air and some water (to measure 30 mL) causing some water to spill over the syringe. LPN-J wiped off the syringe with the contaminated gloved hand, including the tip that connects to R11's ET. LPN-J put the water into R11's crushed medication cup and began to mix the medication to get it to dissolve. LPN-J pulled the medication and water mixture into the syringe, and attempted to push the air out, but LPN-J voiced difficulty as the syringe was clogged. LPN-J pushed the water and medication mixture in and out of the syringe using the cup it was mixed in - in attempt to free the clog. LPN-J freed the clog from the syringe, pushed the air out, noted there was water dripping down the syringe, and wiped the syringe including the tip that gets connected to R11's ET with a contaminated gloved hand. LPN-J connected the syringe to R11's ET and attempted to flush, but LPN-J noted there was resistance and does not continue. LPN-J attempted to free the clog again by pushing the water and medication mixture into the cup that was used to mix the medication. LPN-J stated a spoon is needed. LPN-J did not remove PPE and opened the door to R11's room, and grabbed a spoon out of the shared spoon container on the nurses cart that is shared amongst all residents on the unit. LPN-J comes back into the room and closed the door. LPN-J did not remove PPE or preform hand hygiene. LPN-J used the spoon to mix the medication mixture. LPN-J drew up the mixture into the syringe and freed the clog. LPN-J pushed the remaining air out of the syringe and connected the syringe to R11's ET. LPN-J had resistance with pushing the medication and water mixture and stopped. LPN-J disconnected the syringe and discarded the medication mixture and the syringe and informed surveyor that LPN-J will re-attempt the medication administration for R11. LPN-J ran warm water in the sink, informing surveyor warmer water will be easier to dissolve the medication in. LPN-J removed gloves, and gown and preformed hand hygiene.LPN-J exits R11's room and retrieved another syringe. LPN-J preformed hand hygiene, pulled another medication for R11, and verified the medication. LPN-J crushed the medication and placed it into a cup. LPN-J preformed hand hygiene, applied a gown and gloves and entered R11's room and provided for privacy. LPN-J dumped out the previous water from the graduated cylinder and filled the graduated cylinder with warm water from the sink. LPN-J placed the medication and water at the bedside of R11. LPN-J checked R11's ET placement with 10cc of air, and confirmed placement. LPN-J filled the new syringe with water from the graduated cylinder and pushed the air and some water syringe out to measure 30 mL, some water flows over the syringe. LPN-J wiped off the syringe with a contained glove including the tip that is connected to R11. LPN-J connected the syringe to R11 and flushes the ET. LPN-J pulls water from the graduated cylinder into the syringe and pushed water and air out to measure 30 mL of water, and pushed the water into the cup with the crushed medication. LPN-J mixes the water and medication. LPN-J pulls the medication mixture into the syringe and pushed out the residual air. LPN-J connected the syringe to R11's ET and administers the mixture. LPN-J filled the syringe with 30 mL of water from the graduated cylinder and pushed out the air and some water, causing some to flow over the syringe. LPN-J wiped off the syringe with the contaminated glove, including the tip of the syringe that connects to R11's ET. LPN-J connected the syringe to R11 and flushes the ET. LPN-J connected the tube feeding line back to R11's ET and starts the machine. LPN-J dumps the remaining water in the graduated cylinder into the sink. LPN-J removes gloves and gown and preformed hand hygiene. LPN-J wiped off the stethoscope used on R11 and places the stethoscope into the water puddle on the nurse's cart from R11's graduated cylinder. LPN-J moves the medication cart in front of the next resident's room to begin another medication administration. LPN-J placed the stethoscope, that is contained from the water puddle on the nurse's cart, around the back of LPN-J's neck. LPN-J did not wipe down the nurse's cart. On 1/14/26, at 1:28 PM, Surveyor Interviewed LPN-J. Surveyor asked LPN-J if it's standard practice to bring the graduated cylinder from a resident's room and put it on the medication cart. LPN-J stated no, but LPN-J was so nervous and would not do that normally. LPN-J stated that the graduated cylinder should not leave the room. Surveyor asked LPN-J if there is a standard of practice to wipe off a syringe with a contaminated gloved hand prior to administration of fluids or medication to a resident with a ET. LPN-J stated no, and that LPN-J was nervous and does not recall wiping off the syringe prior to administering a medication. Surveyor asked LPN-J if LPN-J normally grabs items off of the cart while in contaminated PPE. LPN-J stated that LPN-J did not touch anything, so it was not an issue. Surveyor asked LPN-J if that is an infection control standard of practice. LPN-J stated no, and that LPN-J was nervous. On 1/14/26, at 2:02 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-N. Surveyor asked ADON-N if ADON-N is the infection preventionist in the building. ADON-N stated yes. Surveyor asked ADON-N if it is an expectation if a nurse has PPE on a room that has EBP, should the nurse remove PPE and preform hand hygiene before accessing the nurse's cart and anything outside of the room. ADON-N stated a nurse would need to remove PPE before exiting a room and before accessing anything outside of the room, especially a shared medication cart. Surveyor asked ADON-N if the graduated cylinder from a resident's room should be removed and placed on communal surfaces - like the nurse's cart. ADON-N stated no, a graduated cylinder is a care item specific to residents' and should not be removed from the room. Surveyor asked ADON-N if there is a standard of practice to wipe off a syringe, including the tip that is connected to a resident. ADON-N stated no, the nurse may wipe the outside with a paper towel or rinse in the sink, but nothing should be touching the tip of the syringe that connects to the resident. On 1/14/25, at 2:20 PM, Surveyor interviewed Director of Nursing (DON)-B with Nursing Home Administrator (NHA)-A present. Surveyor asked DON-B if it is a standard of practice to wipe off a syringe with a contained gloved hand prior to administering a medication through a resident's ET. DON-B stated no, the syringe should not be wiped off. DON-B also stated if the nurse felt it needed to be rinsed, the nurse should use the water from the graduated cylinder, wipe the outside with a paper towel, or rinse in the sink. Surveyor asked DON-B if the graduated cylinder from a resident's room should be removed and placed on communal surfaces - like the nurse's cart. DON-B stated the graduated cylinder should not leave the resident's room, and medications should be prepared at the bedside with the graduated cylinder or at the nurse's cart with another source of water. Surveyor asked DON-B if it is an expectation if a nurse has PPE on a room that has EBP, should the nurse remove PPE and preform hand hygiene before accessing the nurse's cart and anything outside of the room. DON-B stated any time staff exit the room with EBP the staff are expected to remove PPE and preform hand hygiene. DON-B stated if a nurse needed to access something on the nurse's cart that is just outside of the resident's room, the nurse is expected to remove gloves and preform hand hygiene but may leave on the gown since the nurse is not fully out of the room. DON-B stated the nurse after obtaining an item from the nurse's cart must perform hand hygiene and apply gloves before resuming resident care. On 1/14/25, at 2:25 PM, Surveyor shared concerns about infection control during the administration of medication for R11. The facility has no further information to provide at this time.

Based on observation, interview and record review the facility did not ensure 1 (R7) of 1 resident were free of significant medication errors.R7 was admitted to the facility on [DATE]. R7's has an order for Acetaminophen 1000 mg (milligrams) by mouth every 6 hours for pain/discomfort with a start date of 8/21/25. This order was not entered correctly, and Acetaminophen 1000 mg did not appear on R7's monthly medication administration records resulting in R7 not receiving Acetaminophen 1000 mg every six hours daily. R7 missed 48 doses in August 2025, 120 doses in September 2025, 124 doses in October 2025, 120 doses in November 2025, 124 doses in December 2025, and 53 doses in January 2026. R7 was not administered 589 doses of Acetaminophen 1000 mg.Findings include:The facility's policy titled, Medication Orders and not dated under Policy Explanation and Compliance Guidelines documents for 4. Documentation of Medication Orders: a. Each medication order should be documented with the date, time and signature of the person receiving the order. The order should be recorded on the physician order sheet, and the Medication Administration Record (MAR). f. Transcribe newly prescribed medications on the MAR or treatment record or ensure the order is in the electronic MAR.R7 was admitted to the facility on [DATE] with diagnosis which include left periprosthetic distal femur fracture (a break in the thigh bone occurring near a hip replacement prosthesis).R7's physician orders include Acetaminophen Oral Tablet (Acetaminophen). Give 1000 mg (milligrams) by mouth every 6 hours for Pain/Discomfort. Do not exceed more than 4g (grams) of acetaminophen from any source with an order & start date of 8/21/25.Advanced Practice Nurse Prescriber (APNP)-I progress note dated 8/22/25 under subjective documents [R7's name], [AGE] year old female, is seen today for follow-up evaluation on day 2 of her SNF (skilled nursing facility) stay. She was admitted yesterday following hospitalization for a left periprosthetic distal femur fracture that was treated with retrograde intramedullary nail fixation on 8/14/2025. Patient is seen sitting up in bed, awake and alert. She reports pain is overall controlled. Appetite and sleep are stable. She continues on Tylenol, oxycodone, and Zanaflex for pain management.R7's Orthopaedic Clinic after visit summary dated 11/26/25 under continue taking these medications documents acetaminophen 500 mg tablet Commonly known as: Tylenol. Take 2 tablets (1,000 mg total) by mouth every 6 hours. This was noted by Licensed Practical Nurse (LPN)-C on 11/26/25.On 1/14/26, at 11:02 a.m., Surveyor reviewed R7's August 2025 MAR (Medication Administration Record), September 2025 MAR, October 2025 MAR, November 2025 MAR, December 2025 MAR, and January 2026 MAR. Surveyor noted R7's order for Acetaminophen Oral Tablet (Acetaminophen). Give 1000 mg by mouth every 6 hours for Pain/Discomfort. Do not exceed more than 4 grams in not listed on any of R7's MARs.On 1/14/26, at 11:24 a.m., Surveyor asked LPN-C if she is going to administer any medications to R7 this afternoon. LPN-C informed Surveyor R7 gets a blood sugar and eye drops usually after 12:00 p.m. On 1/14/26, from 12:20 p.m. to 12:24 p.m., Surveyor observed LPN-C administer R7's medication which consisted of Prednisolone Acetate Ophthalmic Suspension 1% and Humalog 10 units. At 12:25 p.m., Surveyor asked LPN-C if this is all of R7's medications to be administered. LPN-C replied yes doesn't get anything else.On 1/14/26, at 12:44 p.m. Surveyor asked Nurse Manager/Licensed Practical Nurse (NM/LPN)-E if she could explain the facility's process regarding medication for a new admission. NM/LPN-E informed Surveyor when a resident is admitted they receive an admission packet from the hospital. NM/LPN-E explained they put the orders in off the hospital AVS (after visit summary). NM/LPN-E informed Surveyor they do three checks explaining if she puts the order in, the supervisor on the next shift and one of the nurses will review the orders. Surveyor asked NM/LPN-E if the physician orders under the order tab are the resident's current orders. NM/LPN-E replied yes. Surveyor asked NM/LPN-E if she could pull up R7's orders on her computer screen. Surveyor asked NM/LPN-E if she sees an order for Acetaminophen 1000 mg every six hours. NM/LPN-E replied yes. Surveyor informed NM/LPN-E R7's Acetaminophen 1000 mg every six hours is not listed on any MAR and R7 has not received this medication since admission. NM/LPN-E reviewed R7's order in the computer and informed Surveyor she sees why the nurses aren't seeing the medication. NM/LPN-E explain when the order was initially entered the order type was entered as pharmacy and it's supposed to say standard medication MAR. NM/LPN-E informed Surveyor it's not popping up for the nurses. NM/LPN-E informed Surveyor she can't answer how the order was put in because she wasn't employed at the facility at the time. NM/LPN-E informed Surveyor she just fixed it and is going to tell LPN-C to give R7 the Acetaminophen. On 1/14/26, at 2:06 p.m., Surveyor asked Director of Nursing (DON)-B how the facility ensures resident's medication are entered correctly so the resident receives their medication as ordered by the physician. DON-B explained they have a three-person check. DON-B informed Surveyor they also have [name of pharmacy company] who checks remotely and will send pharmacy recommendations. Surveyor informed DON-B R7 has not received Acetaminophen 1000 mg every six hours according to physician orders since admission as the order type was incorrectly entered as pharmacy and did not appear on any MAR. Surveyor asked DON-B if she has received a pharmacy recommendation for R7. DON-B replied no not for Tylenol.

Based on observation, interview, and record review the Facility did not ensure there was a medication error rate below 5 percent. There were 2 medication errors in 31 opportunities which resulted in a medication error rate of 6.45%. Medication errors were identified for R7 & R9.*R7's Prednisolone Acetate Ophthalmic Solution 1% was not shaken prior to administration.*R9 was administered two drops of Cromolyn Sodium 4% eye drops into each eye without waiting one minute between drops.Findings include:The facility's policy titled, Administration of Eye Drops or Ointments and not dated under Policy documents Eye medications are administered as ordered by the physician and in accordance with professional standards of practice to lubricate the eye or treat certain eye conditions.1.) On 1/14/26, at 12:16 p.m., Surveyor observed Licensed Practical Nurse (LPN)-C remove a glucometer and a clear bag containing R7's Prednisolone Acetate Ophthalmic Solution 1% from the medication cart. Surveyor observed the clear bag containing this eye drop is affixed with a blue sticker instructing to shake well. On 1/14/26, at 12:17 p.m., Surveyor observed LPN-C enter R7's room with a glucometer and the bag containing R7's Prednisolone Acetate 1% eye drops. LPN-C informed R7 she was going to check R7's blood sugar and administer her eye drops. After checking R7's blood sugar, LPN-C removed her gloves, and cleansed her hands.On 1/14/26, at 12:20 p.m., Surveyor observed LPN-C place gloves on and hand R7 a Kleenex. LPN-C removed Prednisolone Acetate 1% eye drops from the bag, removed the eye drop bottle top, and administer 1 drop into R7's left eye. Surveyor did not observe LPN-C shake Prednisolone Acetate 1% eye drops. After administering R7's eye drop, LPN-C removed her gloves, went into the bathroom, and washed her hands. After administering R7's eye drops, LPN-C prepared and administered Humalog 10 units according to physician orders.On 1/14/26, at 1:03 p.m., Surveyor asked LPN-C why she didn't shake R7's Prednisolone Acetate 1% eye drops. LPN-C informed Surveyor she did, making the motion of tipping the bottle down and then upright. Surveyor informed LPN-C R7's Prednisolone Acetate 1% should be shaken well before administration not tipped over and back up.On 1/14/26, at 1:13 p.m., Surveyor asked Nurse Manager/Licensed Practical Nurse (NM/LPN)-E if there is a label on an eye drop container to shake well how should the nurse shake the eye drops. NM/LPN-E showed Surveyor by moving her hand back & forth quickly multiple times. Surveyor informed NM/LPN-E R7's Prednisolone Acetate 1% eye drops bag was affixed with a blue sticker instructing to shake well. Surveyor did not observe LPN-C shake R7's eye drops prior to administration. This observation resulted in a medication error for R7.2.) On 1/14/26, at 1:37 p.m., Surveyor observed Certified Medication Aide (CMA)-D cleanse her hands and start to prepare R9's medication which consisted of Acetaminophen 500 mg (milligrams) 2 tablets, Clonidine HCL 0.2 mg one tablet, Cromolyn Sodium Ophthalmic Solution 4 %, Oxycodone HCL 5 mg one tablet, and Tizanidine HCL 2 mg one tablet.On 1/14/26, at 1:41 p.m., Surveyor verified the number of pills in the medication cup with CMA-D. CMA-D then placed gloves and a gown on, entered R9's room and asked R9 if R9 was ready to take the medication.On 1/14/26, at 1:44 p.m., CMA-D administered R9's medication whole with water.On 1/14/26, at 1:45 p.m., CMA-D informed R9 she has his eye drops and handed R9 a Kleenex. CMA-D instilled two drops of Cromolyn Sodium 4% eye drops into R9's left eye, stating one, two while instilling the eye drops. CMA-D then administered two drops of Cromolyn Sodium 4% into R9's right eye, stating one, two while instilling the eye drops. CMA-D did not wait any time between R9's eye drops in either eye.This observation resulted in one medication error for R9.On 1/14/26, at 2:03 p.m., Surveyor asked Director of Nursing (DON)-B how long the nurse should wait between drops when administering eye drops to a resident. DON-B informed Surveyor one minute between drops of the same eye medication and three to five minutes between different eye medication. Surveyor informed DON-B Surveyor observed CMA-D administer two drops of Cromolyn Sodium 4% into R9's right & left eye without waiting one minute in between drops.

Based on interview and record review the facility did not ensure 3 (R2, R3, and R4) of 3 residents and/or representative were notified of the reason for transfer/discharge in writing and the rate to reserve the residents' bed was not documented in the Bed Hold and Notice of Transfer. *R2 was discharged to the hospital on [DATE] and 12/28/25. The facility's transfer and discharge notice was not provided in writing and in a language understood to R2 and/or R2's representative. R2's bed hold notices did not document the facility per diem daily rate. *R3 was discharged to the hospital on [DATE], 12/2/25, 12/7/25 and 12/11/25. The facility's transfer and discharge notice was not provided in writing and in a language understood to R3 and/or R3's representative. R3's bed hold notices did not document the facility per diem daily rate. *R4 was discharged to the hospital on [DATE]. The facility's transfer and discharge notice was not provided in writing and in a language understood to R4 and/or R4's representative. R4's bed hold notices did not document the facility per diem daily rate. Findings include: The facility's policy titled, Bed Hold Notice and reviewed/revised 8/2025 documents: Policy: . It is the policy of this facility to provide written information to the resident and/or representative regarding bed hold practices both well in advance, and at the time of, a transfer for hospitalization or therapeutic leave. Policy Explanation and Compliance Guidelines: . 1. As part of the admission packet and at the time of a transfer to the hospital or therapeutic leave, the facility will provide the resident and/or the resident representative written information that specifics: a. The duration of the State bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility. b. The reserve bed payment policy in the state plan policy, if any. c. The facility policies regarding bed-hold periods to include allowing a resident to return to the next available bed. d. Conditions upon which the resident would return to the facility: The resident requires the services which the facility provides; The resident is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. 2. In the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed-hold policies to the resident and/or the resident representative within 24 hours. The facility will document multiple attempts to reach the resident's representative in cases where the facility was unable to notify the representative. 3. The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file and/or medical record. 4. The facility will provide this written information to all facility residents, regardless of their payment source. 1.) R2 was admitted to the facility on [DATE] with diagnoses of Quadriplegia (partial or complete loss of function in all four limbs), Epilepsy (disorder in which nerve cell activity in brain is disturbed causing seizures), Dysphagia (difficulty swallowing foods), Insomnia (sleep disorder characterized by difficulty falling asleep), Anxiety Disorder (mental health disorder characterized by feelings of worry, fear that interfere with daily activities), and Major Depressive Disorder (persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities). R2 was discharged to the hospital on [DATE] and has not returned to the facility. R2's Quarterly Minimum Data Set (MDS) completed 11/5/25 documents R2's Brief Interview for Mental Status (BIMS) score to be 15, indicating R2 is cognitively intact for daily decision making. R2 was transferred to the hospital on [DATE]. The facility's Notice of Resident Transfer or Discharge documents: Dear [R2], the intent of this notice is to remind you of this facility's admission agreement. A resident may be transferred/discharged when the facility determines that this action is necessary. This is to meet the resident's needs should we not be able to. The facility has determined that a transfer/discharge is necessary on this date: 12-9-25. Reason(s) for transfer/discharge: The transfer is necessary for the resident's welfare and the resident's needs cannot be met by the facility. Specify: Sent out for NP (nasal prongs) The location to be transferred/discharged to is documented for R2. Surveyor notes the transfer notice documents the required agencies to contact for the appeal process. R2's transfer notice is signed by a facility employee but is not acknowledged by R2 or R2's representative. R2's Bed Hold Notice documents: . This notice is presented to you because of the following: Select One: -admission to the hospital -Temporary therapeutic leave from the facility. Surveyor notes there is no above reason checked for R2's need for a bed hold. There are 2 different options to choose from on the facility bed hold notice: -Request for bed hold -Release of bed The facility bed hold notice documents: . I, [R2] a resident of this facility, hereby request that the facility hold a bed during my absence from the facility. I understand that by making this request I am responsible for payment of the basic per diem rate. Surveyor notes that the facility basic per diem rate is not filled out. R2's bed hold notice documents R2's POA agrees to bed hold. R2's electronic medical record (EMR) does not contain documentation that R2 and/or R2's representative was notified in writing in a language they understand and acknowledged R2's transfer deemed necessary along with appeal rights. R2 was transferred to the hospital again on 12/28/25. The facility's Notice of Resident Transfer or Discharge documents: Dear [R2], the intent of this notice is to remind you of this facility's admission agreement. A resident may be transferred/discharged when the facility determines that this action is necessary. This is to meet the resident's needs should we not be able to. The facility has determined that a transfer/discharge is necessary on this date: 12-28-25. Reason(s) for transfer/discharge: The transfer is necessary for the resident's welfare and the resident's needs cannot be met by the facility. Specify: Surveyor notes this is blank. The location to be transferred/discharged to is documented for R2. Surveyor notes the transfer notice documents the required agencies to contact for the appeal process. R2's transfer notice is signed by a facility employee but is not acknowledged by R2 or R2's representative as having received the transfer notice in writing. R2's Bed Hold Notice documents: . This notice is presented to you because of the following: Select One: -admission to the hospital -Temporary therapeutic leave from the facility. Surveyor notes admission to the hospital is checked. There are 2 different options to choose from on the facility bed hold notice: -Request for bed hold -Release of bed The facility bed hold notice documents: . I, representative of R2 request that the facility hold a bed during my absence from the facility. I understand that I will be responsible for payment of the basic per diem rate. Surveyor notes the facility basic per diem rate is not filled out. R2's bed hold notice documents that R2's representative was provided a verbal notice for the bed hold. R2's electronic medical record (EMR) does not contain documentation that R2 and/or R2's representative was notified in writing in a language they understand and acknowledged R2's transfer deemed necessary along with appeal rights. On 1/14/26, at 2:16 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A in regard to the facility's notice of resident transfer or discharge and bed hold notice. NHA-A verified the facility only gets verbal acknowledgement by a resident and/or representative of the bed hold notice and transfer or discharge notice. NHA-A states the facility per diem differs depending on basic, private, trach, or vent care. If there is a concern, NHA-A would clarify. Surveyor shared the concern with NHA-A that R2's transfer or discharge notice was not provided to R2 and/or representative in written form in a language understood. Surveyor shared the facility per diem rate to hold the bed after 15 days was blank on R2's 12/9 and 12/28/25 bed hold notices. NHA-A confirmed R2 would have the vent facility per diem rate. NHA-A understands the concerns. Surveyor requested the transfer or discharge notice policy. The facility has not provided the facility at this time. No further information has been provided by the facility at this time. 2). R3 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia (a condition where the lungs cannot get enough oxygen in the blood leading to oxygen deprivation in tissues), tracheostomy status (a breathing tube placed into the neck), and cognitive communication deficit. R3's admission Minimum Data Set (MDS) dated [DATE] documents R3 has short-term and long-term memory problems, and R3 is rarely understood and rarely understands others. R3 has a guardian. R3 was hospitalized on [DATE] due to respiratory distress. R3 returned to the facility on [DATE]. Surveyor reviewed R3's electronic health record (EHR) and located a notice of transfer and bed hold notice document dated 10/31/25. Surveyor notes on the bottom of the notice of transfer document there is a blank line for the resident or resident representative to sign and date acknowledging receipt of the notice of transfer. Surveyor notes there is no signature of R3's guardian on the notice of transfer dated 10/31/25. Surveyor notes on the bed hold notice dated 10/31/25, Licensed Practical Nurse (LPN)-G, employed by the facility, consented to holding R3's bed, and there is no evidence that R3's guardian consented to holding R3's bed during this hospitalization on the bed hold notice document. Surveyor notes there is no daily rate documented on the bed hold form dated 10/31/25. R3 was hospitalized on [DATE] due to altered mental status. R3 returned to the facility on [DATE]. Surveyor reviewed R3's EHR and located a notice of transfer and bed hold notice document dated 12/2/25. Surveyor notes on the bottom of the notice of transfer document there is a blank line for the resident or resident representative to sign and date acknowledging receipt of the notice of transfer. Surveyor notes there is no signature of R3's guardian on the notice of transfer dated 12/2/25. Surveyor notes on the bed hold notice dated 12/2/25, Licensed Practical Nurse (LPN)-H, employed by the facility, consented to holding R3's bed, and there is no evidence that R3's guardian consented to holding R3's bed during this hospitalization on the bed hold notice document. Surveyor notes there is no daily rate documented on the bed hold form dated 12/2/25. R3 was hospitalized on [DATE] due to abnormal vitals. R3 returned to the facility on [DATE]. Surveyor reviewed R3's EHR and located a notice of transfer and bed hold notice document dated 12/7/25. Surveyor notes the bottom of the notice of transfer documents verbal consent was obtained from R3's guardian, however, there is no evidence that the notice of transfer was provided in writing to R3's guardian. Surveyor notes there is no daily rate documented on the bed hold form dated 12/7/25. R3 was hospitalized on [DATE] due to abnormal vitals and difficulty breathing. R3 returned to the facility on [DATE]. Surveyor reviewed R3's EHR and located a notice of transfer and bed hold notice document dated 12/11/25. Surveyor notes the bottom of the notice of transfer documents verbal consent was obtained from R3's guardian, however, there is no evidence that the notice of transfer was provided in writing to R3's guardian. Surveyor notes there is no daily rate documented on the bed hold form dated 12/11/25. In an interview on 1/14/26 at 8:55 AM with Nursing Home Administrator (NHA)-A, NHA-A stated the nurse on duty is responsible for obtaining and filling out the notice of transfer and bed hold notice when a resident goes to the hospital. NHA-A stated verbal consent is obtained from a resident representative if the resident is not their own person. NHA-A was not sure if the notice of transfer and bed hold notice is provided to the resident representative in writing but would further look into it. In an interview on 1/14/26 at 2:16 PM with NHA-A and Director of Nursing (DON)-B, NHA-A confirmed only verbal consent is obtained on the notice of transfer and bed hold notice and no copy is sent to a resident representative in writing. NHA-A confirmed consent to hold a resident's bed should be obtained from the resident or the resident's representative and not from a facility nurse. NHA-A stated the daily bed hold rate is listed in the admission paperwork that is signed by the resident or their representative on admission. Surveyor shared concern with NHA-A and DON-B that R3's notice of transfer on dates 10/31/25, 12/2/25, 12/7/25, and 12/11/25 does not document evidence that the notice of transfer was provided to R3's guardian in writing. Surveyor shared concern with NHA-A and DON-B that R3's bed hold notice on dates 10/31/25 and 12/2/25 documents LPN-G and LPN-H providing consent to hold R3's bed and there is no evidence of R3's guardian providing consent to holding R3's bed. Surveyor shared concern with NHA-A and DON-B that the daily bed hold rate is not specified on R3's bed hold notice on dates 10/31/25, 12/2/25, 12/7/25, or 12/11/25. No further information was provided. 3.) R4 was admitted to the facility on [DATE] with diagnoses of chronic respiratory failure (not enough oxygen or too much carbon dioxide in the body), dependence on respirator (ventilator) (dependence of a machine to breathe), encephalopathy (altered brain function due to toxin/trauma/infection), dysphagia (difficulty swallowing that is hazardous and can cause choking or inhalation of liquids), Tracheostomy status (a medical opening in the throat to provide another way of breathing), and Traumatic subdural hemorrhage (bleeding in the brain). R4 has a legal guardian. R4 was hospitalized on [DATE] due to Pneumonia, increased heart rate, fever, and increased secretions on the respiratory tract. R4 returned to the facility on [DATE]. Surveyor reviewed R4's electronic health record (EHR) and located a notice of transfer and bed hold notice document dated 10/29/25. Surveyor noted on the bed hold notice Licensed Practical Nurse (LPN)-O signed on the resident's representative signature line, consenting to holding R4's bed. Surveyor noted there is no daily rate documented on the bed hold form and R4's legal guardian did not sign the bed hold form. R4 was hospitalized on [DATE] due to respiratory distress. R4 returned to the facility on [DATE]. Surveyor reviewed R4's EHR and located a notice of transfer and bed hold notice document dated 12/2/25. Surveyor noted on the bottom of the notice of transfer document there is a blank line for the resident or resident representative to sign and date acknowledging receipt of the notice of transfer. Surveyor noted there is no signature of R4's guardian on the notice of transfer. Surveyor noted on the bed hold notice there is no evidence that R4's guardian consented to holding R4's bed on the bed hold notice document. Surveyor noted there is no daily rate documented on the bed hold form. On 1/14/26, at 8:55 AM, A Surveyor interviewed Nursing Home Administrator (NHA)-A, NHA-A stated the nurse on duty is responsible for obtaining and filling out the notice of transfer and bed hold notice when a resident goes to the hospital. NHA-A stated verbal consent is obtained from a resident representative if the resident is not their own person. NHA-A was not sure if the notice of transfer and bed hold notice is provided to the resident representative in writing but would further look into it. On 1/14/26, at 2:16 PM, A Surveyor interviewed NHA-A and Director of Nursing (DON)-B. NHA-A confirmed only verbal consent is obtained on the notice of transfer and bed hold notice and no copy is sent to a resident representative in writing. NHA-A confirmed consent to hold a resident's bed should be obtained from the resident or the resident's representative and not from a facility nurse. NHA-A stated the daily bed hold rate is listed in the admission paperwork that is signed by the resident or their representative on admission. Surveyor shared concern with NHA-A and DON-B that R4's notice of transfer on dates 12/2/25 and 11/3/25 does not document evidence that the notice of transfer was provided to R4's guardian in writing. Surveyor shared concern with NHA-A and DON-B that R4's bed hold notice on dates 10/29/25 documented LPN-O providing consent to hold R4's bed and there is no evidence of R4's guardian providing consent to holding R4's bed. Surveyor shared concern with NHA-A and DON-B that the daily bed hold rate is not specified on R4's bed hold notice on dates 10/29/25, and 11/2/25. No further information was provided from the facility at this time.

Based on observation, record review, interview and document review, the facility failed to follow infection control guidelines during a wound care observation for two of three residents (Resident (R)1 and R4) observed out of five sampled residents. This failure had the potential for R1 and R4 to be exposed to infections.Findings include:1.Review of R1's updated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R1 was admitted to the facility on [DATE] with the diagnosis of quadriplegia, and pressure ulcer to left buttock.Review of R1's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 08/13/25 indicated R1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 was cognitively intact. R1 was also coded as having a stage three pressure ulcer that was unhealed.Review of R1's Physician Orders located under the Orders tab in the EMR indicated an order dated 10/06/25 for Left buttock PI [pressure injury] Cleanse with 1/2 [half] strength dankins [sic] f/b [followed by] pat dry f/b calcium alginate AG [silver] f/b bordered foam dressing every day [sic] shift for wound care and as needed for soiled or misplaced dressing.During a wound care observation on 10/15/25 at 6:35 AM, the Wound Care Nurse (WCN) placed a barrier on the overbed table and then placed the unopened wound care supplies on it. WCN then proceeded to don a pair of clean gloves on and helped the Certified Nursing Assistant (CNA) to reposition R1 in bed. The WCN did not remove the dirty gloves and sanitize her hands and apply a clean pair of gloves on prior to removing the old dressing. The WCN did not remove the dirty gloves, sanitize her hands and apply a new pair of clean gloves prior to opening the 4x4 package and then cleaned the wound with Dankins Solution. WCN removed her gloves, sanitized her hands then don another pair of clean gloves on. The WCN then opened the package of clean 4x4's and patted R1's wound dry with the 4x4. The WCN removed the dirty gloves and donned clean gloves but did not sanitize her hands between glove changes. WCN opened the calcium alginate AG package and removed the clean dressing supply then applied this to R1's wound. The WCN then applied the bordered dressing to R1's wound.2.Review of R4's undated Face Sheet located under the Profile tab in the EMR indicated R4 was admitted to the facility on [DATE] with the diagnosis of respiratory failure and anoxic brain injury.Review of R4's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 08/22/25 indicated R4 was coded as having short- and long-term memory problems and being severely impaired in making daily decisions. R4 was also coded as having an unhealed stage three pressure ulcer.Review of R4's Care Plan located under the Care Plan tab in the EMR indicated R4 had a Focus dated 05/16/25 for Actual Skin Impairment [sic] and high risk for further impairment r/t [related to] Pressure Ulcers [sic], limited mobility, incontinence, altered nutrition [sic]. Interventions included, .Measure wounds at least weekly. Inform MD [medical doctor] if area is worsening. Treatment as ordered.Review of R4's Physician Orders located under the Orders tab in the EMR indicated an order dated 09/15/25 for Sacrum PI [pressure injury]: cleanse [sic] wound with normal saline f/b [followed by] pat dry f/b xeroform [sic] f/b bordered gauze dressing every day [sic] shift for wound care and as needed for soiled or misplaced dressing.During an observation on 10/15/25 at 7:10 AM, the WCN applied a clean barrier down on the overbed table and placed the unopened wound care supplies and scissors on the barrier. WCN then proceeded to don a pair of clean gloves on and helped the Certified Nursing Assistant (CNA) to reposition R4 in bed. The WCN removed the old dressing, opened the 4x4 package and cleaned the wound with Normal Saline. WCN removed her gloves, sanitized her hands then don another pair of clean gloves on. The WCN then opened the package of clean 4x4's and patted R4's wound dry with the 4x4. The WCN removed the dirty gloves and donned clean gloves but did not sanitize her hands. WCN opened the Xeroform package, cut the Xeroform and place this in the wound bed. The WCN did not sanitize the scissors prior to use of cutting the Xeroform dressing. The WCN the opened the bordered dressing package, removed it, and applied it to R4's wound.During an interview on 10/15/25 at 8:15 AM, the WCN was asked what should be done after she removes the dirty gloves and before she dons the clean gloves. The WCN stated, I should sanitize my hands. The WCN was then asked what she had should have done to the overbed table prior to placing the clean barrier down on the overbed table. The WCN stated, I should have cleaned it with a disinfectant wipe, and I should have opened the dressing supply packages prior to performing the wound care.During an interview on 10/15/25 at 3:51 PM, the Infection Preventionist (IP) nurse stated, The nurse should have sanitized the overbed table prior to placing the barrier on the overbed table, should have opened the wound care dressing packages or changed gloves after opening these packages, and sanitized her hands after removing the dirty gloves and before applying clean gloves.During an interview on 10/15/25 at 4:52 PM, the Director of Nursing (DON) confirmed the nurse should have wiped the overbed table with a disinfectant wipe prior to putting the barrier on the overbed table, changing her gloves after opening the dressing packages, and sanitizing her hands after removing her dirty gloves and before applying clean gloves.Review of the undated facility's policy Wound Treatment Management did not indicate the infection control guidelines to follow during the wound care of the resident.

Based on observation, record review, interview and document review, the facility failed 1. to prime an unused insulin pen prior to the injection of insulin as well as 2. failed to ensure the insulin was administered as ordered for one of five sampled residents (Resident (R)5). This failure had the potential for R5 not to receive the physician ordered amount of insulin to R5 and the potential to have uncontrolled blood sugars as a result of this action.Findings include:Review of R5's Review of R5's undated Face Sheet located under the Profile' tab in the electronic medical record (EMR) indicated R5 was originally admitted to the facility on [DATE] with the diagnosis which included type two diabetes mellitus, hypertension, and transient ischemic attack.Review of R5's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 07/23/25 indicated R5 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R5 was cognitively intact.Review of R5's Physician Orders located under the Orders tab in the EMR indicated an order dated 04/23/25 for Lantus Solostar Subcutaneous Solution Pen-Injector 100 unit/ml [unit per milliliter] (Insulin Glargine) Inject six unit subcutaneously in the morning for (DM2) [diabetes mellitus type two].1. During an observation on 10/15/25 at 10:00 AM, Licensed Practical Nurse (LPN)1 was observed opening a new insulin pen and connecting a needle to the injector pen. LPN1 proceeded to take the Lantus insulin pen into R5's room and administered six units of the insulin to R5. LPN1 was asked if she primed the insulin pen prior to administering the insulin to R5. LPN1 stated, No, I didn't but I should have.During an interview on 10/15/25 at 11:30 AM, the Director of Nursing (DON) stated, You always have to prime the injector pen of insulin each time prior to the administration of insulin. That way you know the resident will receive the proper amount of insulin that was ordered by the physician.Review of the undated facility's policy Insulin Pen indicated, .Insulin pens will be primed prior to the use to avoid collection of air in the insulin reservoir. Prime the insulin pen.Dial 2 [sic] units by turning the dose selector clockwise. With the needle pointing down, push the plunger, and watch to see at least one drop of insulin appears [sic] on the tip of the needle. If not, repeat until at least one drop appears.2. Review of the Medication Admin Audit Report provided by the facility indicated:On 10/01/25: scheduled for 8:00 AM and was documented as being administered at 12:22 PM. Lantus Solostar Subcutaneous Solution Pen-injector 100 UNIT/ML [unit per milliliter] (Insulin Glargine) Inject 6 unit subcutaneously in the morning for DM2 [diabetes mellitus, type two]. The administration was three hours and 22 minutes late.On 10/07/25: scheduled for 8:00 AM and was documented as being administered at 1:47 PM. Lantus Solostar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 6 unit subcutaneously in the morning for DM2. The administration was four hours and 47 minutes late.On 10/08/25: scheduled for 8:00 AM and was documented as being administered at 12:31 PM. Lantus Solostar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 6 unit subcutaneously in the morning for DM2. The administration was three hours and 31 minutes late.On 10/10/25: scheduled for 8:00 AM and was documented as being administered at 12:14 PM. Lantus Solostar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 6 unit subcutaneously in the morning for DM2. The administration was three hours and 14 minutes late.On 10/12/25: scheduled for 8:00 AM and was documented as being administered at 2:09 PM. Lantus Solostar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 6 unit subcutaneously in the morning for DM2. The administration was five hours and nine minutes late.During an interview on 10/14/25 at 1:44 PM, Licensed Practical Nurse (LPN)2 stated, We have an hour and an hour after the scheduled time before it is considered being given late to the resident.During an interview on 10/15/25 at 4:52 PM, the Director of Nursing (DON) stated, the nurses are taught they have an hour before and an hour after that the medication is considered being given late to the residents. The staff received education on this began in August, with the latest education provided was on 10/06/25 and 10/07/25.Review of the Journal and Family Medicine and Primary Care article titled, Errors in diabetic insulin therapy and the vitality of proper precautions in Bangladesh: Real-life insights from the developing world indicated, .Insulin is considered a high-alert medication (HAM), which means that mistakes with this medication, either in preparation or administration, can have very serious consequences .

Based on record review, interviews, and facility policy review, the facility failed to ensure medication administration was timely for two of three residents (Resident (R)1 and R5) reviewed for late medications out of five sampled residents. This failure had the potential to interfere with the medication effectiveness.Findings include:1.Review of R1's updated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R1 was admitted to the facility on [DATE] with the diagnosis of quadriplegia, and pressure ulcer to left buttock.Review of R1's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 08/13/25 indicated R1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 was cognitively intact. R1 was also coded as having a stage three pressure ulcer that was unhealed.During an interview on 10/13/25 at 2:55 PM, R1 stated he either received his medications too early or late. R1 reported the medications were Tylenol, Gabapentin, Baclofen, and Tizandine. R1 reported these medications are ones that he receives four times a day and if they are late in being administered to him affects the next doses that he receives would be too close together.Review of the August Medication Admin Audit Report, provided by the facility, revealed:On 08/03/25: scheduled for 8:00 AM and documented as being administered on 08/03/25 at 9:50 AM. Gabapentin 800 mg [milligrams] Give 1 tablet orally four times a day for pain. The administration was 50 minutes late.On 08/03/25: scheduled for 11:00 AM and documented as being administered on 08/03/25 at 1:42 PM. Tylenol Tablet 500 mg Give 2 tablets by mouth four times a day for pain. The administration was one hour and 42 minutes late.On 08/03/25: scheduled for 11:00 AM and documented as being administered at 1:43 PM. Tizanidine Tablet 2 mg Give 3 tablets by mouth four times a day for muscle spasm. and Baclofen Tablet 20 mg Give 1 by mouth four times a day for muscle spasm. The administration was one hour and 43 minutes late.On 08/03/25: scheduled for 12:00 PM and documented as being administered at 1:43 PM. Gabapentin Tablet 800 mg Give 1 tablet orally four times a day for pain. The administration was 43 minutes late.On 08/05/25: scheduled for 4:00 PM and documented as being administered at 6:00 PM. Gabapentin Tablet 800 mg Give 1 tablet orally four times a day for pain. The administration was one hour late.On 08/07/25: scheduled for 8:00 AM and documented as being administered at 9:42 AM. Gabapentin Tablet 800 mg Give 1 tablet orally four times a day for pain. The administration was 42 minutes late.On 08/07/25: scheduled for 11:00 AM and documented as being administered at 1:08 PM. Tylenol Tablet 500 mg Give 1 tablet by mouth four times a day for pain. The administration was one hour and eight minutes late.On 08/07/25: scheduled for 11:00 AM and documented as being administered at 1:07 PM. Baclofen Tablet 20 mg Give 1 tablet by mouth four times a day for muscle spasm. and Tizanidine Tablet 2 mg Give 3 tablets by mouth four times a day for muscle spasms. The administration was one hour and seven minutes late.On 08/13/25: scheduled for 11:00 PM and was documented as being administered at 3:08 AM on 08/14/25. Tylenol Tablet 500 mg -Give 2 tablets by mouth four times a day for pain, Tizanidine Tablet 2 mg- Give 3 tablet by mouth four times a day for muscle spasm. and Baclofen Tablet 20 mg- Give 1 tablet by mouth four times a day for muscle spasm. The administration was three hours and eight minutes late.On 08/15/25: scheduled for 11:00 PM and was documented as being administered at 3:16 AM on 08/16/25. Tylenol Tablet 500 mg-Give 2 tablets by mouth four times a day for pain, Tizanidine Tablet 2 m- Give 3 tablet by mouth four times a day for muscle spasm, and Baclofen Tablet 20 mg- Give 1 tablet by mouth four times a day for muscle spasm. The administration was three hours and sixteen minutes late.On 08/25/25: scheduled for 8:00 PM and documented as being administered at 10:35 PM. Gabapentin Tablet 800 mg Give 1 tablet orally four times a day for pain. The administration was an hour and 35 minutes late.On 08/26/25: scheduled for 20:00 (8:00 PM) and documented as being administered at 22:26 (10:26 PM). Gabapentin Tablet 800 mg-Give 1 tablet orally four times a day for pain. The administration was an hour and 26 minutes late.On 10/02/25: scheduled for 11:00 AM and documented as being given at 1:12 PM. 11:00 AM and documented as being administered at 1:07 PM. Baclofen Tablet 20 mg-Give 1 tablet by mouth four times a day for muscle spasm, and Tizanidine Tablet 2 mg-Give 3 tablets by mouth four times a day for muscle spasms, and Tylenol Tablet 500 mg-Give 1 tablet by mouth four times a day for pain. The administration was one hour and twelve minutes late.On 10/06/25: scheduled for 11:00 AM and documented as being given at 1:47 PM. Baclofen Tablet 20 mg-Give 1 tablet by mouth four times a day for muscle spasm, Tizanidine Tablet 2 mg- Give 3 tablets by mouth four times a day for muscle spasms, and Tylenol Tablet 500 mg-Give 1 tablet by mouth four times a day for pain. The administration was one hour and 47 minutes late.On 10/07/25: scheduled for 12:00 PM and documented as being given at 2:46 PM. Gabapentin Tablet 800 mg-Give 1 tablet orally four times a day for pain. The administration was an hour and 26 minutes late.On 10/12/25: scheduled for 11:00 AM and documented as being given at 1:23 PM. Baclofen Tablet 20 m- Give 1 tablet by mouth four times a day for muscle spasm, Tizanidine Tablet 2 mg -Give 3 tablets by mouth four times a day for muscle spasms, Tylenol Tablet 500 mg-Give 1 tablet by mouth four times a day for pain. The administration was one hour and 23 minutes late.Review of the staff meeting for 10/06/25 and 10/07/25, indicated, To ensure all nursing staff, including agency nurses, understand the importance of timely medication administration and effective communication of resident-specific medication preferences during report, orientation, and throughout the shift. Medications must be administered within the facility's approved administration time frame per physician in orders and facility policy (typically within one hour before or one hour after the scheduled times unless otherwise specified). Resident medication preferences. must be honored when clinically appropriate.

Based on observation, record review, observation, and policy review, the facility failed to determine one of five sampled residents (Resident (R) 5) was safe in the self-administration of physician ordered medications. This failure had the potential for R5 not to take his medication and experience adverse effects of not taking the physician ordered medications.Findings include:Review of R5's undated Face Sheet located under the Profile' tab in the electronic medical record (EMR) indicated R5 was originally admitted to the facility on [DATE] with the diagnosis which included type two diabetes mellitus, hypertension, and transient ischemic attack.Review of R5's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 07/23/25 indicated R5 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R5 was cognitively intact.Review of R5's Physician Orders located under the Orders tab in the EMR indicated the following orders:-08/29/25 Amlodipine 10 mg (milligrams) Give one tablet by mouth on time a day. Hold for SBP (systolic blood pressure) < (less then) 100.-08/29/25 Aspirin 81 mg (Chewable) Give one tablet by mouth in the morning.-08/29/25 Atropine Solution 1% (percent) Instill one drop in left eye one time a day.-08/29/25 Hydrochlorothiazide 50 mg Give one tablet by mouth in the morning. Hold for SBP < 100.-04/23/25 Lantus Insulin 100 unit/ml (unit per milliliter) Inject six units subcutaneously in the morning-08/29/25 Lisinopril 40 mg Give one tablet by mouth in the morning. Hold for SBP < 100.-08/28/25 Carvedilol 6.25 mg Give one tablet by mouth in the morning and at bedtime. Hold for SBP < 100 or HR (heart rate) < 60.-08/28/25 Prednisolone Instill one drop in both eyes every morning and at bedtime.-08/28/25 Sodium Bicarbonate 650 mg Give two tablets by mouth three times a day.During an observation on 10/15/25 at 10:00 AM, Licensed Practical Nurse (LPN)1 took R5's morning medications into the resident's room and laid the medicine cup which contained the medications on the resident's overbed table. LPN1 exited the room and walked down the hallway to the next medication cart and then returned to R5's room and administered the medications to R5.During an interview on 10/15/25 at 10:20 AM, LPN1 was asked if R5 has been approved for to self-administer medications. LPN1 stated, I really don't know. LPN1 was then asked if she could view the medications when she left R5's room. LPN1 confirmed that she could not. LPN1 stated, I should have taken the medications with me when I left the room.During an interview on 10/15/25 at 4:52 PM, the Director of Nursing (DON) stated, If a nurse needs to leave the room, the nurse should have taken the medication with her and not leave the medications in the room with the resident. The DON confirmed R5 had not been approved for self-administration of medications.Review of the undated facility's policy Resident Self-Administration of Medication indicated, . A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely.Review of the undated facility's policy Medication Administration indicated, .Observe resident consumption of medication.

Based on observation, interview and record review, the facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 1 (R3) of 4 residents reviewed for pressure injuries. *R3 is dependent for all cares and mobility, is at high risk for developing pressure injuries and has a history of pressure injuries. On 5/2/25, facility documented that R3 had developed a pressure injury to R3's left ear. The pressure injury was not comprehensively assessed and there is no documentation that R3's MD was contacted until 5/4/25 when a treatment order was put in place. From 5/7/25 through 5/14/25, R5 was admitted to the hospital for a different change of condition. The initial skin evaluation on readmission to the facility documented that R3 had a stage 2 pressure injury of the left ear, and a treatment was ordered to be completed every Monday, Wednesday and Friday. On 5/16/25, the facility's Wound Nurse Practitioner (NP)-C documented that R3 has a full thickness stage 3 pressure injury to the left ear. NP-C recommended daily treatment for this pressure injury. Facility staff continued to complete treatments every Monday, Wednesday and Friday. On 5/30/25, the pressure injury doubled in length and the wound NP recommended again that treatments should be done daily. The facility did not reevaluate the need for additional interventions after the wound worsened. Facility staff continued to complete treatments every Monday, Wednesday and Friday. On 6/6/25, R3's wound was evaluated by NP-C and NP-C recommended a new treatment to be completed daily. The new recommendations were followed by facility staff and by 6/20/25, the stage 3 pressure injury was healed. On 5/4/25, facility staff entered a care plan intervention that R3 should have a neck pillow around neck at all times to ensure ear offloaded. While on survey, Surveyor observed R3 multiple times without his neck pillow on and direct pressure on R3's left ear. Findings include: The facility policy, with a last reviewed date of 11/7/24, titled Skin Integrity and Wound Policy documents, in part: Based on the comprehensive assessment of a resident, the facility must ensure that A resident receives care, consistent with professional standards of practice to prevent pressure ulcers/injuries and does not develop pressure ulcers/injuries unless the individual's clinical condition demonstrates that they were unavoidable and a resident with pressure ulcers/injuries receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers/injuries from developing . R3 was admitted to the facility on [DATE] with diagnosis including non-traumatic intracranial hemorrhage (bleeding within the skull), Tracheostomy (a surgically placed breathing tube in the windpipe), Gastrostomy (a tube inserted through the abdominal wall into the stomach to provide a way to deliver nutrition and fluids), Epileptic seizures, Chronic Kidney disease, Chronic Respiratory failure. R3's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documents R3 is severely cognitively impaired and is rarely/never understood. R3 is dependent for all cares, mobility and transfers. R3 is at risk for pressure injuries but has no unhealed pressure injuries. R3 Care Area Assessment for pressure ulcers/injuries dated 9/19/24 documents, in part: Resident is at risk for pressure ulcer development [related to] history of [pressure injuries], impaired mobility, feeding tube, trach with oxygen, incontinence. Due to respiratory failure, [R3] is dependent upon staff for bed mobility, incontinence care . R3's Braden scale for predicting pressure ulcer risk dated 2/19/25 documents a score of 10 indicating that R3 is at high risk for developing pressure ulcers. R3's potential for skin impairment care plan initiated on 9/21/23 documents the following pertinent interventions: Attempt to off load bony prominences by turning and using pillows, wedges, or other positioning devices as resident allows and tolerates. Nursing will assess skin upon admission, weekly on day of scheduled shower, [as needed], and with any change of condition. Any abnormalities will be documented in chart and reported to primary physician and Wound Care team for follow up. Reposition every 2-3 hours when in bed. R3's actual impairment to skin integrity care plan initiated on 6/11/24 documents the following pertinent interventions: Air mattress to bed. Function checked every shift. Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Follow facility protocols for treatment of injury. Identify/document potential causative factors and eliminate/resolve where possible. Reposition every 2 hours and [as needed]. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. R3's Skin observation tool assessment entered by wound nurse LPN-E, dated 5/2/25 documents: site-Left ear, type-pressure. Surveyor noted that the fields for measurement of the wound, stage of the wound and notes were all left blank. Surveyor noted that a comprehensive assessment with measurements, description of wound including type of tissue and staging was not completed when the pressure injury was found on 5/2/25. Surveyor reviewed R3's electronic medical record (EMR) for evidence that a provider was notified on 5/2/25, a treatment was completed and that an order for treatment was obtained. Surveyor did not locate any of this documentation. On 6/26/25 at 2:29 PM, Surveyor interviewed LPN-E and Nursing Home Administrator (NHA)-A. NHA-A informed Surveyor that LPN-E was not working at the facility on 5/2/25. LPN-E stated that LPN-E was working at a different building. NHA-A stated that NHA-A is looking into who entered the charting under LPN-E's name. NHA-A instructed LPN-E to change passwords to ensure this doesn't happen again. NHA-A indicated that NHA-A would let Surveyor know if anything was found. Surveyor was not informed who was using LPN-E's sign in to document the finding of a new pressure injury. R3's Change in condition evaluation entered by Licensed Practical Nurse (LPN)-D dated 5/3/25 documents, in part: Change in skin color or condition started on 5/3/25 . The primary care clinician was notified on 5/3/25 at 5:30 AM .Site-Left ear. Description-pressure area. R3's progress note entered by LPN-D, dated 5/3/25 at 6 AM documents: Writer awaiting on call back [in] regards to new open area found to left ear pressure related. Resident shows no discomfort or complaints of pain. Little clear drainage to open area. On 6/26/25 at 2:29 PM, Nursing Home administrator informed Surveyor that a New Pressure Injury form was submitted on 5/3/25. This form does not appear in the EMR. R3's New Pressure injury form submitted by LPN-D, dated 5/3/25 documents, in part: Awaiting on call back from NP, voicemail left for family. Cleansed area with normal saline. Neck pillow in place and ears offloaded. Left ear 0.8 centimeters (cm) x 0.5 cm x 0.1cm. Skin intact, scant serous drainage . [Power of Attorney (POA)] aware . Surveyor noted that measurements of the wound were obtained but a comprehensive assessment including the description of the type of tissue and staging was not completed by LPN-D. On 6/26/25, Surveyor attempted to interview LPN-D by phone. LPN-D did not return Surveyor's phone call. Surveyor noted that there is no further documentation on 5/3/25 stating that R3's NP returned a call or gave treatment orders. R3's Change in Condition evaluation dated 5/4/25 documents, in part: Skin wound or ulcer started on 5/4/25 . During AM cares, noted dried blood on pillowcase. Upon body assessment, noted a dried abrasion to left ear. NP was updated and new orders received for wound care . Primary care clinician notified on 5/4/25 at 10 AM. Wound [treatment] (floor nurse to complete): Left ear- Cleanse with [normal saline, pat dry, apply calcium alginate. Cover with a border gauze dressing. Change [Monday, Wednesday, Friday and as needed] . Site-left ear. Description-abrasion noted to area . POA aware . R3's progress note dated 5/4/25 at 1:05 PM documents, in part: . During cares, abrasion was noted to Left Ear. NP was updated. New orders received for wound care and message left for wound nurse in the am to assess. Resident tends to always lay on his Left ear. Head was positioned with a pillow to keep pressure off Left ear. POA aware of new abrasion to Left ear and new treatment orders. Surveyor noted that a comprehensive assessment with measurements, description of wound including type of tissue and staging was not completed when the pressure injury was documented on 5/4/25. Surveyor noted that the documentation on 5/4/25 does not refer to any of the documentation of the wound from 5/2 or 5/3/25 and actually documents that the left ear wound was found on 5/4/25. R3's MD order with a start date of 5/5/25 documents: . Left ear cleanse with [Normal saline], pat dry. Apply calcium alginate. Cover with a border gauze dressing. Change [Monday, Wednesday, Friday and as needed]. R3's actual impairment to skin integrity care plan has an added intervention initiated on 5/4/25: Neck pillow around neck at all times. Ensure ear offloaded. R3's Certified Nursing Assistant (CNA) Kardex documents: Neck pillow around neck at all times. Ensure ear offloaded. R3's late entry Interdisciplinary Team (IDT) note dated 5/5/25 at 8:45 AM documents: IDT clinical review of new open area to left ear. Resident with no pain behaviors or [signs and symptoms] of infection to site. Medical history includes non-traumatic intracranial hemorrhage, [hypertension], cognitive communication deficit, dysphagia, seizure, presence of cerebrospinal fluid drainage device, [chronic kidney disease] and chronic respiratory failure. Resident is dependent on staff for repositioning [every] 2-3 hours . Resident is frequently turned side to side for offloading and perspires due to medications and with being warm. Neck pillow to be used at all times ensuring ears are offloaded. Maintain a comfortable temperature in resident room to prevent increased perspiration. Surveyor noted that the IDT team reviewed R3's new ear pressure injury and still no comprehensive assessment of the wound was completed and documented. R3's potential for skin impairment care plan has an added intervention initiated on 5/5/25: Ensure room at a comfortable temperature for resident to reduce perspiration. R3's progress note dated 5/7/2025 at 1:30 PM documents, in part: Abnormal lab results received and reported to NP. Left foot was cool to touch, no pedal pulse was felt. NP attempted to find a pulse with doppler and was unable. Order received to send to [local hospital] for Eval and treat. POA was called and gave permission to send to ER . Surveyor noted that R3 was hospitalized on [DATE] through 5/14/25 with a Left lower extremity occlusion. Surveyor noted that the facility did not complete a comprehensive assessment of R3's left ear pressure injury anytime between 5/2 and 5/7/25 before R3 went to the hospital. R3's admission re-admission nursing evaluation dated 5/14/25 documents, in part: . Skin integrity: Left ear pressure 1 cm x 0.5 cm x 0.1cm stage II. Surveyor noted that admission skin evaluation did not include a description of the pressure injury, or the type of tissue visualized on assessment. On 6/26/25, Surveyor interviewed NHA-A. NHA-A informed Surveyor that the admission assessment was incorrectly staged. NHA-A stated that the pressure injury on R3's left ear should have been staged a 3. R3's MD order initiated on 5/14/25 documents: Wound [treatment]: Left ear cleanse with [Normal Saline]. Pat dry. Apply calcium alginate. Cover with a border gauze dressing. Change [Monday, Wednesday, Friday and as needed]. R3's Wound evaluation by NP-C dated 5/16/25 documents, in part: . Left ear stage 3 pressure injury. Full thickness wound measuring 0.5 cm x 0.5 cm x 0.1cm. 100% granular tissue. Moderate serosanguineous [fluid discharge from a wound that contains both blood and serum] drainage. Peri wound is dry, intact. No [signs and symptoms] of infection . Plan: silver alginate and bordered foam daily and [as needed]. Surveyor noted NP-C recommended that the treatment of R3's ear pressure injury be completed daily. Surveyor reviewed R3's MD orders and the previous treatment order was not changed. From 5/16/25 to 5/23/25, facility staff completed the treatments every Monday, Wednesday and Friday and not daily as recommended by NP-C. Surveyor reviewed R3's EMR for a Wound evaluation by NP-C for the week of 5/23/25. None was found. R3's Wound observation tool, completed the Wound nurse at the facility, dated 5/23/25 documents, in part: . Left ear. Pressure ulcer stage 3. Granulation tissue present (beefy red) . Moderate Serosanguineous drainage. 0.5 cm x 0.5 cm x 0.1 cm. No signs and symptoms of infection . Treatment: [Normal Saline], Silver alginate bordered foam dressing daily and [as needed]. Surveyor noted that the treatment of R3's ear pressure injury was again recommended to be completed daily. Surveyor reviewed R3's MD orders and the treatment order was not changed. From 5/23/25 to 5/30/25, facility staff completed the treatments every Monday, Wednesday and Friday and not daily as recommended by the facility wound nurse. R3's wound note dated 5/30/25, entered by a wound NP covering for NP-C while NP-C was on vacation, documents, in part: . Left ear stage 3 pressure injury. Full thickness wound measuring 1.0 cm x 0.5 cm x 0.1cm. 100% granular tissue. Moderate serosanguineous drainage. Peri wound is dry. No [signs or symptoms] of infection . Plan: silver alginate and bordered foam daily and [as needed]. Surveyor noted that length measurement in the wound doubled in size. The pressure injury went from 0.5 cm which was measured last on 5/23/25 to 1 cm. Surveyor reviewed R3's care plan for an additional intervention after R3's ear wound worsened. No intervention was found. Surveyor noted the wound NP recommended that the treatment of R3's ear pressure injury be completed daily. Surveyor reviewed R3's MD orders and the treatment order was not changed. From 5/30/25 to 6/6/25, facility staff completed the treatments every Monday, Wednesday and Friday and not daily as recommended by the wound NP. R3's wound note dated 6/6/25, entered by NP-C, documents, in part: Left ear stage 3 pressure injury. Full thickness wound measuring 1.0 cm x 0.5 cm x 0.1cm. 80% granular tissue, 20% slough. Moderate serosanguineous drainage. Peri wound is dry. No [signs or symptoms] of infection. Plan: Medi honey and bordered foam daily and [as needed]. R3's MD order with a start date of 6/7/25 documents: Wound treatment (floor Nurse to complete): Left ear cleanse with [normal saline], pat dry. Apply Medi honey to wound. Cover with a border foam dressing. From 6/7/25 through 6/20/25, facility staff completed the daily recommended treatment for R3's left ear wound. On 6/20/25, NP-C documented that the stage 3 left ear pressure injury had healed. On 6/26/25 at 9:13 AM, 9:52 AM, 10:46 AM, and 11:55 AM Surveyor observed R3 in bed, laying on R3's back. The head of the bed is raised 30%. R3's head is resting on a regular pillow. R3's head is tilted to the left. R3's left ear is not visible. Surveyor noted that R3 is not wearing a neck pillow as care planned. Surveyor noted R3 had direct pressure on R3's left ear. Surveyor noted multiple observations of R3 in the same position and with pressure on R3's left ear. On 6/26/25 at 12:38 PM, Surveyor observed R3 in bed, laying on R3's back. The head of the bed is raised 15%. R3's head is resting on a regular pillow. R3's head is tilted to the right. Surveyor observed R3's left ear and noted a healed pressure injury. Surveyor noted that R3 is not wearing a neck pillow as care planned. Surveyor noted multiple observations of R3 without a neck pillow on at all times as care planned. On 6/26/25 at 12:45 PM, Surveyor interviewed LPN-H, CNA-I and CNA-J who were at the nurse's station together. Surveyor asked what interventions are in place for R3's skin. LPN-H stated that repositioning is completed. R3 has an air mattress. The nurses follow treatment orders. CNA-I stated again that repositioning is completed and R3 uses regular pillows. Surveyor asked if R3 had a neck pillow. LPN-H and CNA-I both stated no. Surveyor asked if R3 had ever had a neck pillow in the past. All 3 staff members stated no. LPN-H stated that LPN-H was not sure that a neck pillow would be beneficial because he coughs and moves his head. On 6/26/25 at 11:45 AM, Surveyor interviewed LPN-E. LPN-E stated that LPN-E has been the wound nurse at the facility for one month and is still training. Surveyor asked what the process is when a new pressure injury is found. LPN-E stated the floor nurse will report the wound to the wound nurse. The floor nurse will assess the wound. The assessment includes measurements and description of the wound. The MD/NP will be notified as well as the resident/resident representative will be notified. The floor nurse will do the initial assessment and then the Assistant Director of Nursing (ADON) and the wound nurse would assess the wound that day or the next time they are in the building. On 6/26/25 11:57 AM, Surveyor interviewed floor nurse, LPN-G. Surveyor asked what the process is when a new pressure injury wound is found on a resident. LPN-G stated that there are multiple forms that need to be filled out including the risk for and change of condition form. LPN-G would notify the resident or resident representative and notify the residents physician. LPN-G would get an order for treatment. LPN-G stated that measurements would be taken but the full assessment is done by a Registered Nurse (RN). The assessment would include a description of the wound tissue, the measurements and the kind of wound it is, like pressure or trauma. On 6/26/25 at 12:03 PM, Surveyor interviewed Register Nurse (RN)-F. Surveyor asked what the process is when a new pressure injury is found on a resident. RN-F indicated that the nurse caring for the resident would fill out the risk management form and change of condition form. The nurse would complete a pain assessment. The wound would be measured and fully assessed and staged. RN-F indicated the facility has a book of recommended treatments that they will use for an initial treatment and then will reach out to the provider for full treatment orders. The care plan should be updated, and the wound team notified to be added to the wound rounds. On 6/26/25 at 1:55 PM, Surveyor interviewed Wound NP-C. NP-C informed Survey that NP-C comes to the facility every Friday to assess residents on the wound list. Surveyor asked if NP-C was aware that facility staff documented that R3 had developed an ear pressure injury on 5/2/25. NP-C looked back in documentation and NP-C was not aware on 5/2/25. NP-C stated that NP-C first evaluated R3's ear wound on 5/16/25 after R3 returned from the hospital. Surveyor asked what caused R3's ear wound. NP-C indicated that R3 always likes to lay R3's head to the left and the pressure on the ear caused the injury. Surveyor asked what interventions NP-C would expect to be in place. NP-C stated R3 is on an air mattress. NP-C stated a neck pillow is sometimes used, as well as other pillows; repositioning is important and NP-C stated that facility staff were doing that for R3. Surveyor asked if NP-C was aware that NP-C treatments were not followed as recommended, and the treatments were completed every Monday, Wednesday and Friday instead of daily from 5/16/25 through 6/6/25. NP-C was not aware. NP-C stated that NP-C will typically order a daily treatment on ears because the dressings fall off so easily but stated that 3 times a week could be appropriate. Surveyor asked if the 3 times a week treatment could have led to the decline in the ear wound noted on 5/30/25. NP-C stated it could've contributed but it is hard to say that is solely responsible for the change in the wound size. On 6/26/25 at 2:34 PM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked what is the expectation when staff find a new pressure injury. DON-B indicated that RN would measure, do the comprehensive assessment and stage the wound. DON-B stated that the nurse supervisors are the point person and are also on call on weekends are available to consult. Surveyor shared the concerns that R3's ear pressure injury was found on 5/2/25. A comprehensive assessment was not completed by facility staff before the resident went to the hospital on 5/7/25. There is no documentation that a MD was aware of the pressure injury until 5/4/25 when a treatment order was obtained. When R3 returned to the facility after the hospital stay, NP-C recommended daily treatments be completed. Facility staff continued to complete 3 times a week treatment from 5/16/25 through 6/6/25 despite NP-C recommendations. Surveyor asked DON-B if DON-B would expect provider orders to be followed. DON-B indicated that DON-B would expect that they be followed. On 5/30/25, the wound doubled in length. No additional interventions were put in place when the wound worsened. During survey, R3 has been observed multiple times without a neck pillow on and 3 staff members interviewed stated that R3 has never had a neck pillow. DON-B stated that DON-B has personally adjusted R3's neck pillow and knows that that intervention has been in place. DON-B indicated that maybe the neck pillow is in the wash so DON-B will look for the pillow. Surveyor asked if the neck pillow should have been in place at all times, DON-B indicated yes. On 6/6/26 at 3:15 PM, Surveyor informed NHA-A of the above concerns.

Based on interview and record review, the facility's Quality Assurance and Performance Improvement (QAPI) program failed to ensure systems are in place and actions implemented with the intention to improve performance, including the prioritizing of pressure injury prevention and treatment, addressing the prevalence and the severity of the problem, and implementation of corrective actions, analysis of data, measuring success, and tracking performance to ensure improvements are sustained. The QAPI program's failure to ensure systems are in place to implement action plans to improve performance regarding pressure injury prevention and treatment resulted in 6 of 6 residents (R95, R101, R107, R100, R68, R88) reviewed developing facility acquired pressure injuries which included multiple unstageable pressure injuries, stage 3 and stage 4 pressure injuries. Additionally, R95 and R101required hospitalization s for sepsis and osteomyelitis and R100 required inhouse IV antibiotics for infection. At the start of the survey, the facility had identified: Deep Tissue Injuries (DTI) - 1 community acquired and 5 facility acquired. Unstageable Pressure Injuries- 2 community acquired and 7 facility acquired. Stage 3 Pressure Injuries- 4 community acquired and 7 facility acquired. Stage 4 Pressure Injuries- 14 community acquired and 6 facility acquired. Review of the facility's compliance history indicates the following regarding concerns related to proving care to residents with pressure injuries. The facility was cited at F686 on the following surveys including this most recent survey: ND9511 - 6/8/23 - F686 J (immediate jeopardy/isolated); G22E11 - 12/12/22 - F686 G (actual harm/isolated); PYPL11 - 6/28/22 - F686 D (potential for harm/isolated). The facility's failure to develop and implement appropriate plans of action to correct identified quality deficiencies created a situation of immediate jeopardy that began on 11/27/23. The Nursing Home Administrator (NHA)-A, [NAME] President of Clinical Operations-J, [NAME] President of Operations-AA, and Medical Director- BB were notified of the immediate jeopardy on 12/6/23 at approximately 3:50 pm. The immediate jeopardy was removed on 12/8/23, however; the deficient practice continues at a scope and severity level of F (potential for more than minimal harm/widespread) as the facility continues to implement and monitor their action plan. Findings include: Surveyor reviewed the facility's Quality Assurance and Performance Improvement (QAPI) Plan 2001 Med-Pass, Inc (Revised April 2014) includes in part: Program Statement: This facility shall develop, implement, and maintain an ongoing, facility wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems. Policy Interpretation and Implementation: The objectives of the QAPI Plan are to: Provide a means to identify and resolve present and potential negative outcomes related to resident care and services; Reinforce and build upon effective systems and processes related to the delivery of quality care and services; Provide structure and processes to correct identified quality and/or safety deficiencies; Establish and implement plans to correct deficiencies, and to monitor the effects of these action plans on resident outcome; Help departments, consultants, and ancillary services that provide direct or indirect care to residents to communicate effectively, and to delineate lines of authority, responsibility, and accountability; Provide systems and processes to maintain documentation relative to the QAPI Program, as a basis for demonstrating that there is an effective ongoing program. Authority: The owner and/or governing board (body) of our facility shall be ultimately responsible for the QAPI Program. The Administrator is responsible for assuring that the facility's QAPI Program complies with federal, state, and local regulatory agency requirements. Implementation: The QAPI Committee shall oversee implementation of our QAPI Plan. A QAPI Coordinator shall coordinate QAPI Committee activities, including documentation. This committee shall meet monthly to review reports, evaluate the significance of data, and monitor quality-related activities of all departments, services, or committees. The QAPI Committee shall oversee and authorize QAPI activities, including data-collection tools, monitoring tools, and the basis for and appropriateness and effectiveness of QAPI activities. The committee shall approve of any corrective actions, including changes in policies and/or procedures, employment practices, standards of care, etc. and shall also monitor all corrective activities for appropriateness and/or the need for alternative measures . Individual departments or services shall develop quality indicators for programs and services in which they are involved, and which affect their function. Departments, services, and committees shall submit their reports to the QAPI Committee as directed by the committee. Evaluation: The facility shall evaluate the effectiveness of its QAPI Program at least annually and shall present their conclusions to the owner/governing board for review. The QAPI Committee, Administrator, and the governing board shall review and approve a summary of problems and corrective measures. Coordinator: The QAPI Coordinator will help other committees, individuals, departments, and/or services develop quality indicators, monitoring tools, criteria, and assessment methodologies, and help them identify and evaluate concerns impacting resident care and safety. Review of the facility history and offsite preparation for the recertification survey that started on 11/27/23 indicates the following: The facility has been identified as a special focus facility (SFF) since 6/30/2021. The facility has a history with deficiencies cited in the areas of pressure injury prevention and treatment, which includes the following: * F686 (J) - Pressure injury prevention and treatment was cited during a recertification survey event: ND9511 dated 6/8/23 at immediate jeopardy/isolated. * F686 (G)- Pressure injury prevention and treatment was cited during a recertification survey event: G22E11 dated 12/12/22 at harm level/isolated. * F686 (D)- Pressure injury prevention and treatment was cited during a recertification survey event: PYPL11 dated 6/28/22 at potential for harm/isolated. On 11/27/23 (first day of survey), Surveyors were provided with a Master Wound List for the week of 11/21/2023 to 11/28/2023. The list included 25 residents with pressure injuries, noting that some of these residents had multiple pressure injuries. The list indicated a total of 46 pressure injuries (total wounds) with the following noted: Deep Tissue Injuries (DTI) - 1 community acquired and 5 facility acquired. Unstageable Pressure Injuries- 2 community acquired and 7 facility acquired. Stage 3 Pressure Injuries- 4 community acquired and 7 facility acquired. Stage 4 Pressure Injuries- 14 community acquired and 6 facility acquired. During this recertification and complaint survey, Surveyors reviewed a sample of 6 of 6 residents (R95, R101, R107, R100, R68, R88) with facility acquired pressure injuries. This sample of residents developed multiple unstageable pressure injuries, stage 3 and stage 4 pressure injuries, and including R95, R101, and R100, requiring hospitalization s for sepsis, osteomyelitis, and/or infection. R95 was admitted into the facility to the facility on [DATE] without pressure injuries. R95 sustained a skin tear to her sacral area which significantly declined with large amounts of necrotic tissue requiring debridement due to pressure. R95 was hospitalized from 7/21/23 to 8/11/23 due to sepsis from the infected wound, which was debrided and assessed to be a stage 4. R101 developed an unstageable pressure injury to the coccyx with a root cause determined to be heavy incontinence (including loose stools). R101 was hospitalized with osteomyelitis involving the distal sacrum and coccyx and was treated with antibiotics while hospitalized . R107 was admitted with a stage 3 pressure injury to the left ear which healed on 10/12/23. On 11/10/23 R107 developed an unstageable pressure injury to the right ear from immobility and moisture. The pressure injury to the right ear healed on 11/10/23; however during the survey, R107 was observed multiple times with his left ear directly on his pillow contrary to physician orders. R100 developed multiple pressure injuries which included a stage 4 pressure injury to the sacrum (suspected abscess complicated by pressure), stage 3 pressure injury to the right posterior scalp, unstageable pressure injuries to the right and left trochanter, a suspected deep tissue injury to the left ischium, and suspected deep tissue injury to the right heel. R100 received an IV antibiotic for the right hip (right trochanter). R68 developed pressure injuries to her right hand (unstageable pressure injuries to the 3rd and 4th fingers, right dorsal hand stage 3), unstageable left ear, and unstageable left posterior scalp/back of head. R88 developed a stage 3 pressure injury to the right lateral ankle. (Cross-reference F686). On 11/30/23 at 11:33 am, Surveyors interviewed RN Wound Nurse -O regarding the facility's wound care process, who stated in part, if a resident comes in after 1:00 pm, she will look at the resident the next day, that she reviews the nurse charting and does a head-to-toe assessment of the resident. RN-O reported she will glance at admission paperwork if available for a resident who will be admitted into the facility with pressure injuries and if she knows beforehand will get an air mattress. RN-O stated the nurse will get the treatment and will leave RN-O a note. RN-O stated a number of individuals can become involved with care planning such as nursing (including herself, MDS nurse), dietary etc. Surveyors asked RN-O as to why assessments of pressure injuries did not always consist of percentage of tissue types within a wound bed. RN-O stated the computer system allows only for the selection of the worst tissue type observed in the wound bed even if the wound bed consisted of other tissue types. RN-O stated if a wound bed consisted of some necrotic tissue, she would have to select necrotic. RN-O stated if she was able to create her charting, she would allow more options. RN-O stated there is a narrative component in the system and the Nurse Practitioner usually has a percentage in her wound notes, so that she does not have to do it. RN-O stated she is made aware of issues, interventions at daily clinical meetings. RN-O stated she and the nurse practitioner evaluate the effectiveness of interventions by exception, but does not look at everything involved, such as restless legs, kicking boots off etc. RN-O stated she reports to the QAPI committee the status of the wounds and where things are at. RN-O stated she also attends the weekly Skin, Nutrition, and at Risk (SNAR) meetings along with the nurse managers, ADON, and at times the Administrator has been present. During this interview, Surveyors shared concerns regarding sampled residents with pressure injuries. Surveyors noted RN-O was identified as part of the facility's QAPI process. On 11/30/23 at 3:09 pm, [NAME] President of Regulatory Services - I provided Surveyors a Wound Performance Improvement Plan (PIP), with a date of Wed November 1, 2023, 1:35 pm on it. This plan included Investigative findings pertaining to a specific resident in the facility who was identified on 10/31/23 to have facility acquired, deep tissue injuries to their left foot. The facility's skin/wound action plan dated 10/31/23 identified the issue as Pressure Ulcer. The facility's PIP addressed in part the following 4 step process: 1. Steps to complete or completed to correct issues: Head to toe assessment completed on resident with MD/POA notification. See Skin only assessment completed 10/31/23, Treatment orders updated, and care plan updated. 2. Steps to complete to identify others at risk. Complete a skin sweep with assessments completed on current facility residents. If any new areas are identified, wound nurse to assess, risk completed notify MD/POA, new treatment orders implemented and update the care plan. Review changes of condition (COC) and progress notes on current residents with wounds for the past 30 days to review for MD/RP notification of areas, treatment orders in place, and timeliness of notification. Review incontinent residents to assure barrier cream is in place. Review all residents for DM dx to assure diabetic foot checks are implemented. Review skin assessments to ensure timely evaluation. Refer any new wounds to therapy. 3. Process/Systemic Change. Licensed nurses will be re-educated on the facility's skin/wound policy, timely completion of evaluation and documentation of wounds, notification to MD for proper treatment, implementing an intervention, notification to family, and reviewing/updating the care plan with each wound. Nurses will also complete a skin assessment competency. IDT will review the 24-hour report for progress notes and COC at daily morning clinical to identify any new skin concerns and ensure timely completion of evaluation and documentation of wounds, notification to MD for proper treatment, implementing an intervention notification to family, and reviewing/updated the care plan with each wound. The IDT will have weekly wound management meetings . will assure that current residents with wounds have appropriate interventions in place to include proper mattress, w/c cushions, and nutritional interventions are in place, IDT will evaluate review the care plan and discuss if current interventions effective. IDT will review and revise the care plan as indicated. 4. QI Monitoring: The Director of Nursing or designee will perform Quality Assurance Review for residents who experience a wound to ensure a risk cause analysis has been completed with appropriate interventions implemented, the care plan was reviewed and updated and every shift, documentation is completed for a minimum of 72 hours after the wound identification. This will be completed weekly for four weeks then monthly. Areas of concern will be addressed immediately. Findings will be reported to the Executive Director and the Quality Assurance Performance Improvement Committee monthly. The Nurse Management team will perform monthly skin sweeps for residents to ensure all skin concerns have been identified. Any findings not previously identified will have a risk cause analysis completed with appropriate interventions implemented, the care plan is updated, and documentation is completed for a minimum of 72 hours after the wound identification. This will be completed monthly x3 months. Areas of concern will be addressed immediately. Findings will be reported to the Executive Director and the Quality Assurance Performance Improvement Committee. On 11/30/23 at 2:57 pm and on 12/4/23 at 1:52 pm, Surveyors met with the facility administrative staff including Nursing Home Administrator (NHA)-A, Medical Director-BB, [NAME] President of Regulatory Services-I, [NAME] President of Clinical Operations-J, and [NAME] President of Operations-AA, Consultant-U, and Director of Nursing-B, sharing with them concerns involving sampled residents with pressure injury prevention and treatment including in part; prevention, assessment, treatment and care plan revisions. Director of Nursing - B and administrative staff stated that previously the regional ombudsman recommended training through Meta Star. Administrative staff stated they partnered with Meta Star who also recommended they obtain an outside consultant. Administrative staff stated they had the services of Consultant-U. Administrative staff informed the survey team that in late September the facility conducted a mock survey and identified concerns with their wound program, such as falling behind with care plans. Surveyor was informed the facility conducted a wound/skin sweep on 10/31/23. At the time, the NHA-A was not available, and the interdisciplinary team put together a Performance Improvement Plan (PIP). Administrative staff identified the facility's wound nurses as Wound RN-O and the facility also had the services of an outside Consultant-U. Administrative staff reported that they spoke to Wound RN-O regarding wound care plans and that the care plans were still under construction. Administrative staff stated they started a PIP which was still in progress getting through with wound care plans. Administrative staff stated the facility PIP consisted of a 4-step process: Identification of Risk, Education, Skin Assessment, and Competencies. Medical Director-BB stated there were multiple components with wound assessments as they fix things, they did not back date, so timelines won't make sense. Administrative staff stated Meta Star chose to do staff training on site October 3rd and 4th with all facility staff including Certified Nursing Assistants and Managers. Consultant-U stated she has been coming to the facility since August 10 and that she provides education, chart review as well as auditing different records every week. Consultant-U stated she provides support to the team. During the 11/30/23 discussion with Administrative staff, Consultant-U shared with surveyors the concept of micro-reposition and indicated she wants to teach individualized positioning. When asked about care planning for individualized positioning, Consultant-U stated that care planning speaks to off-loading and off pressure daily; however, the decision as to how much micro repositioning is conducted would be a decision dependent upon how the resident is doing on a daily basis. During the 12/4/23 discussion with Administrative staff, Consultant-U clarified she does not use the term micro-reposition, reiterating her intent is to teach individualized repositioning. On 12/5/23 at 1:05 pm, Surveyors interviewed NHA-A regarding the facility's QAPI program. NHA-A reported she started with the facility in January 2023. NHA-A stated the QAPI committee meets monthly having had QAPI meetings in January, February, March, April, May, June, July, and in August. NHA-A stated they did not have a QAPI meeting in September or in October as they could not get those scheduled. NHA-A stated they had a QAPI meeting in November and will have one in December. NHA-A stated the QAPI Committee is made up of each Department head, along with the Medical Director, Director of Nursing, the wound nurse, Minimum Data Set nurse, and herself. NHA-A stated she sets the agenda for QAPI, discussing previous QAPI issues, discussing for instance such things as grievances, significant weight loss, number of people on restorative, falls, med errors, staff education through Relias. NHA-A reported they discuss the number of wounds, the number of wounds healed and the number of facility acquired wounds. NHA-A stated they have had pressure issues since June 9, 2023. NHA-A stated we did an inhouse audit, educated all staff including post testing, conducted audits, assigning each person with an angel round individual (nurse manager, certified nursing assistant, etc.) who had the resident's Kardex conducting daily rounds ensuring the directions on the Kardex were being followed, such as head of bed elevated, etc. NHA-A stated they would review audits weekly then 2 times a month then 1 time a month. NHA-A showed surveyor a sample of the treatment audits that were conducted at the time which included audits on the accuracy of assessments, treatment orders obtained, and treatment orders completed. NHA-A stated they conducted staff education right after the last survey (June 8, 2023, survey where F686 was cited at an Immediate Jeopardy.) NHA-A stated Meta Star conducted education, regarding proper positioning of residents, what CNAs should look for, prevention of wounds. NHA-A stated they discussed moisture associated skin conditions if residents are not changed timely, and care planning. During this interview, NHA-A telephoned Consultant U who stated she conducted training along with Meta Star. Some of the topics that were reviewed included shearing and prevention of shearing, repositioning, how to identify new areas with showers, discussed boggy heels and deep tissue injuries, measure of wounds, staging, diabetic foot checks, moisturizing, Consultant-U stated Meta Star went over staging and measurements. Surveyor asked Consultant-U if Meta Star discussed documenting wound bed percentages of a pressure injury as part of an assessment which was noted missing in some of the pressure injury assessments viewed by the survey team. Consultant-U indicated there was discussion regarding wound bed coloring but could not remember if percentages of the wound bed such as percent of granulation was discussed. Consultant-U indicated CNAs following care plans was discussed but was not sure how much care planning was discussed. Consultant-U indicated there was an agenda that Meta Star put together in a binder. After discussion with Consultant-U, NHA-A went on to say she was not available when the IDT team developed a PIP regarding wounds and conducting a house sweep. NHA-A and [NAME] President of Clinical Operations-J stated wound prevention has come up at QAPI. [NAME] President of Clinical Operations-J stated when they identified an individual who had a change in condition, they instituted the Stop and Watch Interact tool. Surveyor noted [NAME] President of Clinical Operations-J left the meeting with NHA-A and [NAME] President of Operations-AA then joined in on the interview with NHA-A. Surveyor informed NHA-A and [NAME] President of Operations-AA that the survey team identified issues with pressure injuries and questioned why there were these issues. [NAME] President of Operations-AA stated they had a great plan of correction (referring to the June 8, 2023, survey) with audits for only 3 months. Vice President of Operations-AA reported they stopped doing the audits after 3 months and maybe things fell apart. [NAME] President of Operations-AA stated the audits were going great and so they started looking at other components of the program. On 12/5/23 at 4:15 pm, Surveyors met with facility administration including Nursing Home Administrator (NHA)-A, Medical Director-BB, [NAME] President of Regulatory Services-I, [NAME] President of Clinical Operations-J, and [NAME] President of Operations-AA, Consultant-U, and Director of Nursing-B, discussing what RN (wound nurse)-O brings forth to QAPI. Administrative staff stated RN-O addresses the total number of wounds and the results of wounds, number of facility acquired wounds, new and resolved and at the end of the month how many active wounds there are. They also discuss whether the wounds are avoidable and unavoidable. Administrative staff also stated the multiple interdisciplinary team members attend the Skin, Nutrition and at Risk (SNAR) meetings which occur weekly. The interdisciplinary team members include wound nurse-O, dietary, and nurse managers. Surveyors asked Administrative staff about components of the PIP that continue to not be implemented such as development and revision to care plans. [NAME] President of Clinical Operations-J indicated they continue to develop care plans but that it takes time. When asked what the barrier was with getting the care plans updated as there did not seem to be a sense of urgency with updating care plans despite developing a PIP on 10/31/23, Administrative staff indicated a PIP has multiple components with systemic issues and that cares are being done even if care plans are not updated. Surveyors noted the facility seems to identify root cause factors that may contribute to the development of pressure injuries for individual residents but then does not take the next step to address the causal factors through care plan and interventions to assist with healing and preventing new pressure injuries from developing. Surveyors noted the lack of care plan updates and implementing interventions to prevent pressure injuries were noted for all the sampled residents with pressure injuries reviewed during the survey. In addition, the facility's training on pressure injuries as well as the staff posttest included reference to the care planning process. Surveyors noted that while the facility presented information pertaining to staff education for pressure injuries and while the facility presented a PIP pertaining to wounds, a review of the facility's QAPI program binder indicated the following: The July QAPI minutes indicate the wound RN was not present at this meeting, nor was there a discussion regarding pressure injuries. The August QAPI notes the number of facility acquired wounds. The QAPI minutes do not specify what the issues are. There are audits from the 6/8/23 survey with the F686 IJ. The audits involved MD treatment orders and turning and reposition and preventions in place however there is no plan identified that comes from the audit information. According to NHA-A there was no QAPI meeting for September and October, and therefore no QAPI meeting minutes. There was no QAPI meeting even though the facility developed a PIP involving wounds in October. The November QAPI meeting discussed the number of wounds but nothing further. Surveyor noted in reviewing data provided to Surveyors the facility's QAPI program is documenting raw data pertaining to the number of pressure injuries but is not following through on analyzing this data, implementing effective actions, measuring the success of the action plans, and tracking performance to ensure improvements are achieved and sustained. Surveyors also noted the facility has implemented training to staff regarding pressure injury care that the QAPI committee is not ensuring is based upon current standards of practice but also the QAPI committee is not ensuring that staff can implement as interventions and systems are not in place to support training expectations. Given the facility's history, its failure to implement an effective QAPI program pertaining to pressure injuries created a reasonable likelihood for serious harm, thus creating a finding of immediate jeopardy. The immediate jeopardy was removed on 12/8/23 when the facility implemented the following: The QAPI Committed reviewed the pressure injuries for R68, R95, R107, and R88. R100 and R101 are currently in an acute care hospital. A root cause analysis (RCA) was performed for each (identified) resident's wound (s) and care plan interventions were implemented related to findings of the RCA for each resident. An audit of wounds on all residents in the facility was completed by the Director of Nursing, Assistant Director of Nursing, and [NAME] President of Clinical Services, Care plans were reviewed for residents who experienced a wound to ensure an appropriate intervention was in place to decrease the risk of development of wounds. Correction actions were completed as indicated. The Executive Director, Director of Nursing, and Medical Director through the QAPI Committee initiated a performance improvement project (PIP) sub-committee comprised of the Director of Nursing, Assistant Director of Nursing, Unit Manager, Charge Nurse, Certified Nursing Assistant, Director of Rehab Services, and Activity Director. The Executive Director charged this team with analyzing the wound data, completing a trending of the data, completing a root cause analysis of wounds in the facility, utilizing audit results and information to develop a plan, and report findings and the plan to the QAPI Committee. The plan to decrease the number of wounds, therefore the risk of injury from wounds will be initiated. Education was provided for by the Executive Director, Director of Nursing, and Medical Director by the [NAME] President of Operations regarding the requirement to develop, implement and maintain an effective, comprehensive, data driven Quality Assurance Performance Improvement program that focuses on indicators of the outcomes of care and quality of life. Included in the education was the 5 elements of QAPI and making the process an active part of identifying concerns and initiating performance improvement projects to collect data, analyze data, complete a root cause analysis, develop a plan, and monitor the effectiveness of the plan. Ad Hoc Quality Assurance Process Improvement meeting was held by the Executive Director, the Director of Nursing, Infection Preventionist, and with the Medical Director to discuss the plans initiated to decrease the risk of wounds.

Based on observation, record review, and interview, the facility did not ensure residents at risk for pressure injuries, and with pressure injuries, were comprehensively assessed in order to implement an individualized plan of care. This was observed with 6 (R95, R101, R107, R100, R68, and R88) of 6 residents reviewed with pressure injuries and at risk for pressure injuries. * R95 was admitted to the facility on [DATE] and identified as being high risk for pressure injuries. R95 was not comprehensively assessed in order to implement an individualized plan of care for prevention of pressure injuries or implement care plan revisions with pressure injury onset. R95 developed a facility acquired unstageable pressure injury to the sacrum on 6/15/23 which deteriorated. On 7/21/23, R95 was hospitalized with sepsis secondary to sacral wound infection with a stage 4 pressure injury to the sacrum. This resulted in immediate jeopardy to R95. * R101 was admitted to the facility on [DATE] with a SDTI (suspected deep tissue injury) and identified as being high risk for pressure injuries. R101 was not comprehensively assessed in order to implement an individualized plan of care for prevention of pressure injuries or implement care plan revisions with pressure injury onset. R101 developed a facility acquired unstageable pressure injury to the sacrum on 8/16/23 which deteriorated. On 9/15/23, R101 was hospitalized with a stage 4 pressure injury to the sacrum with osteomyelitis. This resulted in immediate jeopardy to R101. * R100 admitted to facility with no pressure injuries and was identified to be very high risk. R100 developed 6 facility acquired pressure injuries: -Sacrum abscess 9/19/23. Progressed to stage 4 PI (pressure injury) on 10/20/23. -Posterior scalp unstageable 10/5. Stage 3 on 10/20 -Right Trochanter unstageable 10/23 -Left Trochanter SDTI (suspected deep tissue injury)10/30. Unstageable 11/10 -Left Ischium SDTI 11/10. Unstageable 11/17 -Right heel SDTI 11/27 Wounds were not comprehensively assessed in order to implement individualized care plan interventions to prevent pressure injuries and implement care plan revisions to promote healing. R100 was observed on 11/28/23 positioned only on his back with legs positioned to the left side and on 11/29/23 to be positioned only on his back with legs positioned to the left side for a 4-hour period. R100 was observed during the survey to not always have a neck pillow in place. This resulted in immediate jeopardy to R100. * R68 was identified to be very high risk for pressure injuries and developed 4 unstageable pressure injuries: -Right 3rd & 4th fingers unstageable 10/9 -Right dorsal hand stage 3 10/12 -Posterior scalp SDTI 11/6. MASD (moisture associated skin dermatitis) left ear -Left ear unstageable/necrotic 11/10 Wounds were not comprehensively assessed in order to implement individualized care plan interventions to prevent pressure injuries and implement care plan revisions to promote healing. R68 was observed during survey to not be off-loaded to reduce pressure. This resulted in immediate jeopardy to R68. The facility failure to comprehensively assess resident pressure injury risks and implement individualized plans of care, utilize wound percentages of characteristics to determine changes, and revise the plans of care with the development of a pressure injury created a finding of immediate jeopardy that began on 7/21/23. Surveyor notified Administrator-A and (Vice President of Operations) VPO-AA of the immediate jeopardy on 12/5/23 at 12:10 PM. The immediate jeopardy was removed on 12/7/23 however, the deficient practice continues at a scope/severity of G (actual harm /isolated) as evidenced by the following examples: * R107 was readmitted to the facility on [DATE] with a stage 3 pressure injury to the left ear that was not comprehensively assessed in order to implement individualized preventative measure to their ears. On 11/10/23, R107 developed a facility acquired stage 3 pressure injury to their right ear. R107 was observed with left ear against their pillow during survey due to head deviation. R107 had no revisions to their plan of care to prevent ear off-loading. This resulted in immediate jeopardy to R107. * R88 had a history of pressure injuries to the right medial heel, left lateral ankle, and left medial foot that healed 6/2023. On 9/7/2023, R88 developed a facility acquired open area to the right lateral ankle caused by friction from a heel boot. On 9/28/2023, the facility determined the wound was an Unstageable pressure injury. No interventions were implemented to prevent the pressure injury from developing and the wound was not comprehensively assessed until 11/10/2023. This resulted in actual harm to R88. Findings include: Surveyor reviewed the facility's policy and procedure for Pressure Injury Risk Assessment revised March 2020. The Purpose of the procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing new pressure injuries or worsening of existing pressure injuries (PIs). The General Guidelines under 2. Risk Factors that increase a resident's susceptibility to develop or to not heal PIs include: b. Impaired/decreased mobility and decreased functional ability. c. The presence of previously healed PI. d. The presence of an existing PI. e. Exposure of skin to urinary and fecal incontinence or other source of moisture. i. Conditions, such as end stage renal disease, thyroid disease or diabetes mellitus. l. Impaired sensory perception. 6. Once the assessment is conducted and risk factors are identified and characterized, a resident-centered care plan can be created to address the modifiable risks for pressure injuries. 7. Repeat the risk assessment weekly for the first four weeks, if there is a significant change in condition, or as often as is required based on the resident's condition. STEPS IN THE PROCEDURE 4. Conduct a comprehensive skin assessment with every risk assessment. 5. Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals: a. The interventions must be based on current, recognized standards of care. b. The effects of the interventions must be evaluated. c. The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate. Surveyor reviewed the facility's policy and procedure for Repositioning revised May 2013. The Purpose is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed or chair bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. The General Guidelines include: 1. Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and proving pressure relief. 2. Evaluation of a resident's skin integrity after pressure has been reduced or redistributed should guide the development and implementation of repositioning plans. Such plans should be addressed in the comprehensive plan of care consistent with the resident's needs and goals. 3. Repositioning is critical for a resident who is immobile or dependent on staff for repositioning. INTERVENTIONS 1. A turning/repositioning program includes a continuous consistent program for changing the resident's position and realigning the body. A program is defined as a specific approach that is organized, planned documented, monitored and evaluated. 2. Frequency of repositioning a bed or chair bound resident should be determined by: a. The type of support surface, b. The condition of the skin. c. The overall condition of the resident. d. The response to the current repositioning schedule; and e. Overall treatment objectives. 1. On 11/27/23 at 9:25 AM, Surveyor observed R95 in bed. R95 has a Foley catheter, tube feeding, a LAL (low air loss) mattress, and is ventilator dependent and non-verbal. Surveyor reviewed R95's medical record. R95 was admitted to the facility on [DATE] with diagnoses of Chronic respiratory failure (vent dependent), diabetes mellitus, flaccid hemiplegia, and cardiac arrest. Surveyor reviewed R95's Plan of Care. The Plan of Care for Impaired Skin Integrity related to limited mobility and incontinence has an initiated date of 5/19/23. The interventions created on 5/19/23 are the following: -Observe skin during care and report any concerns to the nurse. -Turn and reposition to promote healing of current areas. R95's Admission MDS assessment completed on 5/25/23 indicates: always incontinent of bowel and bladder, at risk for pressure injury, non-verbal, receives tube feeding, and dependent on staff for all care needs. The Admission MDS assessment does not indicate R95 is on a turning/repositioning plan for pressure ulcer preventions. On 11/29/23 at 10:49 AM, Surveyor spoke with (Minimum Data Set) (Registered Nurse) MDS RN-N, who assessed R95's Skin Section, regarding R95 not being assessed for a turning/repositioning plan for pressure ulcer prevention. MDS RN-N did not know and would look for further information. On 11/29/23 at 11:15 AM, MDS RN-N indicated R95 would need a program to be documented and probably nursing would do that. It was not coded for pressure ulcer preventions because there was no documentation for a repositioning program. The plan of care for Impaired Skin Integrity was revised on 5/30/23 to identify an actual area of skin impairment. This identifies a skin tear on the coccyx on 5/29/23. There were no revisions to the interventions with the new development of a pressure injury to the coccyx on 6/15/23. Surveyor reviewed R95's Skin Assessments, and noted the following: -6/1/23 a skin tear on the coccyx measuring 2.6 cm by 2.7 cm by 0.1 cm. -6/8/23 a skin tear on the coccyx measuring 2.3 cm by 1.3 cm by 0.1 cm. - Then CHANGED to an unstageable pressure injury on 6/15/23 measuring 2.5 cm by 1.3 cm by 0.1 cm, skin base covered in slough with progression into pressure injury . The root cause is immobility and contamination from heavy, frequent incontinence. Resident to be side to side positioning and Foley requested for wound healing. The above skin assessments did not include a description of the wound characteristics including tissue type present or the percentage of tissue present to determine if there was any progression or deterioration of the wounds. There were no revisions to the care planned interventions with the new development of a pressure injury to the coccyx on 6/15/23. This facility uses a computer generated system. Any care plan entries will automatically generate a Kardex for staff to reference for care needs. There was no revision with the plan of care when R95 developed an unstageable pressure injury on the coccyx on 6/15/23. R95's medical record did not contain a comprehensive bowel and bladder assessment. R95's physician plan of care includes an order on 6/20/23 for a Foley catheter size 16 French with a 10cc balloon related to diagnosis of wound care. R95's Skin Assessments by Wound (Registered Nurse) RN-O are as follows: -6/28/23 US (unstageable) PI (pressure injury) on coccyx measuring 3.5 cm by 2.9 cm by 0.1 cm. The Notes indicate the wound area is larger and wound bed almost completely slough. NP (Nurse Practitioner) to see on 7/7 for possible debridement. -7/7/23 US PI on coccyx measuring 2.9 cm by 2.7 cm by 0.4 cm. The Notes indicate the coccyx has slightly improved and was debrided. And incontinent briefs to be left off in bed. -7/14/23 US PI on coccyx measuring 3.4 cm by 3.3 cm by 0.7 cm. (This indicates a deterioration/decline in the wound). -7/21/23 US PI on coccyx measuring 5.5 cm by 5 cm by 1.9 cm. The Notes indicate the coccyx wound declined despite all interventions. The wound is larger with increased necrotic tissue. An X-ray was negative for osteomyelitis. The wound dressing frequently contaminated with loose stool. R95 was sent to the hospital due to symptoms of infected coccyx wound on 7/21/23 and returned on 8/11/23 with a diagnosis of septic shock secondary to infected sacral wound. Surveyor noted R95 did not have a comprehensive skin assessment upon readmission to the facility. NEXT Skin Assessment is: -8/14/23 now has a stage 4 PI to sacrum measuring 8.7 cm by 4.5 cm by 1.7 cm. Coccyx wound was an US PI before hospital visit. The coccyx wound was debrided in the hospital and is now a stage 4 PI. The treatment changed to a wound vac. On 8/18/23, the Notes indicate improvement; 8/25/23 improvement; 9/1/23 improvement; 9/8/23 improvement. -9/15/23 PI Stage 4 on coccyx measuring 6.3 cm by 3.5 cm by 1.3 cm. The Notes indicate the wound is improving. R95 is having frequent loose stools again. The (Registered Dietician) RD and NP are reviewing TF (tube feeding) formula. The coccyx PI is measured weekly with no changes until - -10/20/23 PI stage 4 on coccyx has declined. Measuring 4.5 cm by 3.7 cm by 1 cm. The wound bed is darker, and peri wound has mild fraying. R95 made bedrest as sitting up in chair suspected as causing a decline in the wound. -10/27/23 improved -11/3/23 improved -11/10/23 PI stage 4 on coccyx measuring 4 cm by 3.2 cm by 1.2 cm. The Notes indicate the coccyx wound declined, R95 was up in a chair with poor posture. -11/17/23 PI stage 4 on coccyx measuring 3 cm by 2.4 cm by 1 cm. -11/24/23 PI stage 4 on coccyx measuring 3.1 cm by 2 cm by 0.9 cm. Surveyor reviewed R95's RD Nutritional Assessment completed on 5/23/23 which indicates Jevity 1.2 feeding. The Nutritional Assessment does not include an assessment of loose stool. The next RD Assessment is 8/14/23 (after hospital stay) and indicates Glucerna 1.2 feeding, has antibiotic for wound infections, has wound vac. The assessment does not indicate any incontinence concerns with loose stools. The next RD Assessment is 8/22/23 (for Quarterly) and indicates Glucerna 1.2 feeding. The Note Section indicates R95 continues with loose stool and no tube feeding concerns. The next RD Assessment is 11/21/23 (for Quarterly) indicates Jevity 1.2 for feeding. The Note Section indicates R95 continues with loose stool (banana flakes and loperamide ordered). (Banana flakes are used to reduce watery diarrhea and thicken stool consistency.) On 11/30/23 at 8:44 AM, Surveyor spoke with (Registered Dietician) RD-R. RD-R was aware of R95 having loose stools. They adjusted the tube feeding formula and added banana flakes. RD-R indicated Wound RN-O talks about concerns in morning meeting. RD-R could not recall when they were made aware of R95 having loose stools. According to the RD Assessments, with Physician Orders, the banana flakes were added 10/23/23 and the tube feeding formula change d in October. R95's Physician Plan of Care indicates an order for Banana Flakes 2 times a day started on 10/23/23. This was increased to three times a day on 11/29/23 for loose stools. On 11/30/23 at 11:31 AM, Surveyor spoke with Wound RN-O regarding the skin assessment process who indicated the floor nurse conducts the admission skin assessment. The floor nurse will do the Skin Observation form for the resident readmissions. Wound RN-O does a head-to-toe assessment the next day. The Wound RN will get admission paperwork for residents with wounds upon admission. The floor nurse will get the treatment orders and notify the WCT (wound care team) regarding a wound. Everybody does the resident care plan. Nursing starts the plan of care and revises it as needed. The resident care plan recommendations, or interventions, could be added by a number of people. The Wound Assessment is in PCC (point click care). Wound RN-O will pick the worst tissue type from a drop-down box. There are no drop-down boxes for wound characteristic percentages. The NP will have percentages in their notes that are completed weekly on Friday. Wound RN-O reports findings at clinical meetings daily. Then the staff would take the responsibility from there to revise and implement the care plan. On 11/30/23 at 12:36 PM, Surveyor spoke with Wound RN-O regarding preventative interventions. The tube feeding formula was changed. They did share the concerns with loose stool. R95's sacral wound started as a shear injury and they were following it, then after a weekend the wound had slough. On 11/30/23 at 3:32 PM, at the facility exit meeting, Surveyor shared the concerns with R95's pressure injury development, and care plan interventions. On 12/04/23 at 8:05 AM, (Vice President of Clinical Operations) VPCO-J and (Director of Nurses) DON-B spoke with Surveyor. They indicated on 5/19/23, R95 had a PR (pressure reducing) mattress, turning and repositioning 2-3 hours, and was provided incontinence care. On 6/2/23, a LAL (low air loss) mattress was added. On 6/15/23, the NP (Nurse Practitioner) requested a Foley catheter for wound healing, which started 6/20/23. On 8/11/23 and 8/25/23, there were bowel and bladder assessments. The Foley was implemented for wound healing. On 12/04/23 at 10:36 AM, VPCO-J and DON-B spoke with Surveyor. They indicated on 5/30/23, R95 developed a skin tear on the coccyx that changed to a PI on 6/15/23. R95 was on Jevity tube feeding upon admission. R95's blood sugars were in the 400 range. On 5/26/23, the Jevity changed to Glucerna. R95's insulin was changed with increased Lantus to 12 units on 5/26/23 and added Humalog insulin s/s (sliding scale) on 5/31/23. R95's blood sugars improved. R95's blood sugars and tube feeding were changed during the development of skin issues. On 12/04/23 at 12:27 PM, Surveyor observed R95's wound treatment. R95 was incontinent of loose stool. R95's wound dressing does include an absorbent dressing plus border foam. On 12/04/23 at 1:51 PM, the Survey Team met with Nursing Home Administrator (NHA)-A, (Medical Director) MD-BB, (Vice President of Operations) VPO-AA, (Vice President Regulatory Services) VPRS-I, (Consultant) C-U, and VPCO-J. They reported the facility did a mock survey and found problems with the wounds. They did a skin sweep of residents. They discovered the care plans were behind. The Wound Nurse is employed by [name] and MD-BB is aware of care plan issues. In July, the facility brought in C-U to assist with training, monitoring, and recommendations for wounds. The Corporate direction wanted the care plans to be combined and not separated. The facility has lots of complex wounds. They wanted a consultant from the outside to help. The facility feels things were being done and just the documentation was behind. VPO-AA indicated on 10/31/23 they went through care plans for wounds. They talked with Wound Nurse RN-O about being consistent across the board with either 1 or 2 care plans for skin. On 10/31/23, they did the whole building skin sweep so they could see what was happening. The care plan portion of addressing wounds is still under process. C-U indicated they are here about 10 hours a week doing education, observations, chart reviews, and whatever needs to be done to support the team in any way that she can. C-U wants to teach the staff individualized positioning; each resident gets different care depending on the person. C-U stated offloading needs to be individualized because some people do not tolerate large movement, but by putting or moving pillows in slightly different ways to offload in any way you can is all the resident can tolerate. They are always trying to teach about repositioning, making sure pillow, bolster, or Foley is moved as needed to get pressure off. On 12/4/23 at 4:15 PM at the facility exit meeting, VPCO-J indicated the Admission MDS (minimum data set) was coded wrong for repositioning for R95. VPCO-J provided a documentation tracker regarding repositioning for the month of June. The tracker review does not include prompted time frames and shows more than 3 hours between turning. The facility conducted a Skills Fair from 8/21/23 - 8/25/23 for all staff. The Skills Fair included incontinence care, repositioning, and keeping wound dressings dry. On 12/05/23 at 10:17 AM, Surveyor spoke with (Certified Nursing Assistant) CNA-S who cares for R95. CN A-S stated they usually turn residents every 2 hours and all the residents are incontinent of bowel and bladder unless they have a Foley. On 12/05/23 at 10:20 AM, Surveyor spoke with CNA-Q who cares for R95. CNA-Q stated they usually turn residents every 2 hours and that all the residents are incontinent of bowel and bladder unless they have a Foley. 2. On 11/27/23 at 9:15 AM, Surveyor observed R101 lying in bed. R101 has a LAL (low air loss) air mattress, Prevalon boots, wrist splints, ventilator, Foley catheter, and tube feeding. R101 was admitted on [DATE] with diagnoses of chronic respiratory failure, diabetes mellitus, and cardiac arrest. R101 is non-verbal, on a ventilator, tube fed, and totally dependent on staff for activities of daily living. R101's Admission (minimum data set) MDS assessment completed on 8/10/23 indicates R101 is a pressure injury risk with a suspected deep tissue injury on right 5th toe. R101 developed an unstageable pressure injury to the coccyx on 8/16/23. The Admission MDS assessment does not indicate R101 is on a turning/repositioning plan for pressure ulcer prevention. On 11/29/23 at 10:49 AM, Surveyor spoke with (Minimum Data Set) (Registered Nurse) MDS RN-N, who assessed R101's Skin Section, regarding R101 not being assessed for a turning/repositioning plan for pressure ulcer prevention. MDS RN-N did not know and would look for further information. On 11/29/23 at 11:15 AM, MDS RN-N indicated R101 would need a program to be documented and probably nursing would do that. It was not coded for pressure ulcer preventions because there was no documentation for a repositioning program. On 11/30/23 at 12:29 PM, Surveyor spoke with Wound RN-O. They indicated they are not involved with MDS assessments. R101's coccyx wound started as MASD (moisture associated dermatitis), then over the weekend, wound bed had slough. Surveyor reviewed R101's plan of care. R101 has a plan of care for Impaired Skin Integrity as evidenced by: A stage 4 (previously unstageable) pressure injury to coccyx, acquired in facility and discovered 8/16/23; debrided in hospital 9/18/23; surgical wound to left buttock status post excision of abscess in hospital 9/18/23. The date initiated indicates 8/7/23 with a revision date of 11/25/23. The electronic plan of care for Point Click Care electronically tracks the date history of care plans. The creation of the plan of care is 9/18/23. The Goal is, R101 will not experience complications from skin condition requiring hospitalization until wound is resolved. This has a date initiated 8/7/23 however, the creation date is 9/18/23. There were no pressure ulcer interventions created until 9/18/23. This was after the development of an unstageable pressure injury on 8/16/23. There are no interventions to address the suspected deep tissue injury the right 5th toe and prevent skin breakdown. The interventions are as follows: -Initiated date 8/16/23 with actual date 9/18/23 - incontinence briefs to be left off when resident in bed. May put on if resident gets up in wheelchair. -Initiated date 8/16/23 with actual date 9/18/23 - nursing to monitor dressing integrity with each resident encounter and replace dressing if soiled/loose/missing. Dressing location: coccyx. -Initiated 8/16/23 with actual date 9/18/23 - provide vitamin therapy to aid wound healing. This facility uses a computer generated system. Any care plan entries will automatically generate a Kardex for staff to reference for care needs. There was no revision with the plan of care when R101 developed an unstageable pressure injury on the coccyx on 8/16/23. Surveyor reviewed R101's Skin Assessments. The Skin Assessments do not consistently include the characteristics of the wound to determine changes. The Skin Assessments include: -8/16/23 developed an US (unstageable) PI (pressure injury) to their coccyx measuring 2.9 cm by 1.4 cm by 0.1 cm. The root cause is heavy incontinence, friction and contamination from loose stool and positive for UTI (urinary tract infection). Foley requested short-term. -8/25/23 US PI on coccyx measures 3.4 cm by 1.5 cm by 0.1 cm. -9/1/23 US PI on coccyx measures 5.5. cm by 3.9 cm by 1.5 cm. The coccyx wound is declining despite all interventions. Frequent loose stools causing contamination. Loose slough debrided and x-ray ordered, the treatment is changed, and suspected skin failure as resident's overall status declining. -9/8/23 US PI on coccyx measuring 6.5 cm by 4 cm by 2.4 cm. The coccyx continues to show decline with frequent contamination from stool. The treatment was changed. The x-ray was negative for osteomyelitis. R101 has suspected skin failure. - 9/15/23 US PI on coccyx measuring 7.9 cm by 4.6 cm by 2.4 cm. The coccyx wound is larger with significant amount of slough in wound base. There is firm indurated area palpated in left buttock and purulent drainage seen in wound when pressed. There is frequent contamination from loose stool. R101 will be sent to ER (emergency room ) for suspected abscess vs osteomyelitis. HOSPITAL: 9/15/2023 with concern for sacral wound infection. Upon arrival to the ED (emergency department) R101 met sepsis criteria as they were febrile, tachycardic with leukocytosis. CT (computed tomography) of the pelvis with contrast revealed large sacral ulcer with developing abscess/phlegmon along the right inferior border. Findings suggestive of osteomyelitis involving the distal sacrum and coccyx. R101 was treated with Doxycycline, vancomycin, cefepime, meropenem de-escalated to meropenem only while in the hospital. The final recommendations on discharge to start ertapenem 1 gram daily to treat for a total of 2 weeks with end of treatment date 9/29/23. The Skin Assessment from the hospital on 9/27/23 addresses the coccyx wound only and not the other DTI (deep tissue injury) areas. R101 returned to the facility on [DATE] at 4:30 PM. No comprehensive skin assessment was completed upon return from the hospital on 9/27/23. Assessments continued: -9/28/23 PI is now a stage 4 on the coccyx with left buttock communicates at 4 o'clock measures 8.8 cm by 7.7 cm by 3.6 cm with LT(left) buttock measuring 3.3 cm by 1.9 cm by 1.2 cm; DTI (deep tissue injury) left 1st finger measuring 1 cm by 0.6 cm; DTI left 5th finger measuring 0.6 cm by 1.3 cm; DTI right middle finger measures 0.7 cm by 0.8 cm; DTI right 4th finger measures 0.6 cm by 0.5 cm; right medial heel DTI measures 1.5 cm by 1.1 cm; RT posterior heel measures 1.2 cm by 1.3 cm; RT lateral 5th toe DTI measuring 0.5 cm by 0.7 cm. -10/6/23 stage 4 PI to coccyx measuring 8.5 cm by 8.9 cm; DTI left 1st finger 0.4 cm by 0.3 cm; RT 4th finger 0.3 cm by 0.3 cm; RT medial heal DTI 1.1 cm by 1 cm; RT posterior heal DTI 0.9 cm by 1.1 cm; RT lateral 5th toe 0.3 cm by 0.5 cm; LT buttock(surgical/abscess) 3.1 cm by 1.6 cm by 0.2 cm. DTI's to LT 5th finger and RT middle finger resolved. -10/13/23 PI stage 4 to coccyx measuring 8.3 cm by 5.5 cm by 3.4 cm; LT buttock(abscess) 3 cm by 0.9 cm by 0.2 cm; RT medial heal DTI 0.4 cm by 0.5 cm; RT posterior heal DTI 0.9 cm by 1.1 cm; DTIs to LT 1st finger, RT 4th finger, RT 5th toe resolved. Other areas improving. -10/20/23 the LT buttock (abscess) 2.4 cm by 0.9 cm by 0.2 cm; coccyx stage 4 7.9 cm by 5.5 cm by 3.3 cm; DTI to RT(right) medial and posterior heel resolved. Other areas improving. -10/23/23 new DTI as of today: LT great toe DTI 0.5 cm by 1.3 cm; and LT 2nd toe DTI 0.5 cm by 0.8 cm. Root cause is increased edema and friction from foot rotation within heel boot. Heel boots on with each encounter. -10/27/23 LT great toe DTI 0.5 cm by 1.1 cm; LT 2nd toe DTI 0.4 cm by 0.5 cm; LT buttock (abscess) 1.9 cm by 0.6 cm by 0.2 cm; coccyx stage 4 7.7 cm by 5.5 cm by 3 cm. The areas are improving. R101 had a hospital stay from 10/29/23 - 11/14/23. No comprehensive skin assessment was completed upon return from the hospital on 11/14/23. -11/15/23 LT lateral ankle DTI 1 cm by 0.6 cm; LT buttock (abscess) 2.4 cm by 1.2 cm by 2.5 cm; coccyx stage 4 9.1 cm by 8.8 cm by 2.3 cm. 11/15/23 stage 4 pressure injury to coccyx (previously unstageable w/ abscess beneath- debrided in hospital), surgical incision left buttock that communicates w/coccyx wound, and DTI to left lateral ankle, present on re-admission 11/14/23 (coccyx & left buttock present prior to). -11/17/23 coccyx stage 4 measuring 9.1 cm by 8.2 cm by 2.1 cm; LT buttock (abscess) 1.8 cm by 0.9 cm by 1.6 cm; LT lateral ankle DTI 0.6 cm by 0.4 cm. The coccyx, left buttock, and left lateral ankle are improving; coccyx and left buttock still communicate. -11/24/23 coccyx stage 4 measuring 8.5 cm by 7.7 cm by 2.1 cm; LT buttock (abscess) 1.1 cm by 0.5 cm by 1.4 cm. The coccyx and left buttock are improved and left lateral ankle is now resolved. On 11/29/23 at 1:57 PM, Surveyor observed R101's wound treatment by Wound RN-O. R101 has a stage 4 PI on the coccyx with a left buttock open area. R101 had pillows, Prevalon boots, and a Foley catheter. On 11/30/23 at 8:44 AM, Surveyor spoke with (Registered Dietician) RD-R. RD-R indicated they were not aware of R101 having loose stools contributing to their pressure injury. They added banana flakes at some point. RD-R could not recall any details. RD-R provided their Nutritional Assessments. On 8/8/23, an Admission Nutritional Assessment was conducted. R101 receives Osmolyte 1.2 tube feeding and is on stool softeners and insulin. R101 was admitted from Select Hospital. There is no notation related to high risk factors for PI and stool incontinence. The next Nutritional Assessment is a reentry on 9/28/23. This assessment indicates Prostat daily supplement, Osmolyte 1.2 tube feeding; readmit from hospital due to wound infection; has multiple wounds present upon admission with edema. There is notation about loose stools. The next Nutritional Assessment is a reentry on 11/17/23. This assessment has Prostat supplement increased to twice a day, Osmolyte 1.2 tube feeding, includes wounds with infections. This Nutritional Assessment does not address any loose stool concerns. On 11/30/23 at 11:31 AM, Surveyor spoke with Wound RN-O regarding the skin assessment process. Wound RN-O indicated the floor nurse conducts the admission skin assessment. The floor nurse will do the Skin Observation form and for the resident readmissions. Wound RN-O does head-to-toe assessment the next day. The Wound RN will get admission paperwork for residents with wounds upon admission. The floor nurse will get the treatment orders and notify the WCT (wound care team) regarding a wound. Everybody does the resident care plan. Nursing starts the plan of care and revises it as needed. The resident care plan recommendations, or interventions, could be added by a number of people. The Wound Assessment in PCC (point click care) is where Wound RN-O documents the assessment. Wound RN-O will pick the worst tissue type from a drop-down box. There are no drop-down boxes for wound characteristic percentages. The NP will have percentages in their notes that are documented weekly on Friday. Wound RN-O reports findings at clinical meetings daily. Then the staff would take the responsibility from there to implement them in the care plan. On 11/30/23 at 3:32 PM at the facility exit meeting, Surveyor shared the concerns with R101's pressure injury development and care plan interventions. On 12/04/23 at 8:05 AM, (Vice President of Clinical Operations) VPCO-J and (Director of Nurses) DON-B spoke with

Based on observation, record review, and interviews, the facility did not ensure residents were comprehensively assessed for bowel and bladder function to prevent infections and skin impairment. This was observed with 4 (R101, R95, R100, and R15) of 5 residents reviewed with bowel and bladder incontinence upon admission to the facility. -R101 was admitted to the facility with both bowel and bladder incontinence. An individual assessment of R101's continence status was not completed to develop an individualized plan of care. On 8/14/23, R101 was determined to have a urinary tract infection (UTI). On 8/16/23, R101 was determined to have an unstageable pressure injury and was started on antibiotics for the UTI. On 8/18/23, a Foley catheter was placed for R101 without an individualized plan of care or for clear justification for the use of the Foley catheter. R101 developed multiple urinary tract infections while continuing to use a Foley catheter without ongoing assessment or clear indications for use. R101 was hospitalized with infection to their pressure injury and a UTI while using a Foley catheter without an individualized plan of care. The example regarding R101 rises to the level of a G (actual harm/isolated). -R95 was admitted with bowel and bladder incontinence, which evolved to an indwelling Foley catheter for bladder, and developed a pressure injury with infection. -R100 was incontinent of bowel and bladder and dependent on staff for incontinence care. He developed a stage 4 pressure injury on the sacrum, an unstageable pressure injury on the right trochanter, and a suspected deep tissue injury on the left trochanter. A Foley catheter was placed on 10/30/23 for wound healing, and although the facility reported incontinence as a contributing factor that would affect wound healing, the facility did not complete a comprehensive bowel and bladder assessment to determine a pattern or if R100 needed more frequent checking and changing prior to the Foley being placed. -R15 was admitted with bowel and bladder incontinence and was not comprehensively assessed, along with voiding patterns. Findings include: Surveyor reviewed the facility's policy and procedure for Urinary Continence and Incontinence-Assessment and Management dated August 2022. The Policy Statement includes the following: -The physician and staff will provide appropriate services and treatment to help residents restore and improve bladder function and prevent urinary tract infection to the extent possible. -Indwelling urinary catheters will be used sparingly, for appropriate indications only. The Policy Interpretation and Implementation for Relevant Information includes the following: -History of urinary incontinence; factors precipitating incontinence; and associated symptoms. -Previous treatment/management attempts and response to interventions. -Pertinent diagnosis -Observations, including wet bed or clothing, use of a urinary catheter and use of diuretics. -Functional and/or cognitive limitations. -Voiding patterns; types of incontinence. Surveyor reviewed the facility's policy and procedure for Bowel and Bladder Management dated 4/15/2020. This policy includes the following: -Each resident will be assessed for bowel and bladder functioning on admission/readmission, quarterly and any change in condition. -Upon completion of the bowel and bladder evaluation, a plan of care will be developed. -The plan of care may include a bladder retraining program, prompted voiding, scheduled voiding or check and change program. 1.) R101 was admitted to the facility on [DATE] with diagnoses of chronic respiratory failure and cardiac arrest. R101 is ventilator dependent, receives nutrition via gastrostomy tube (g-tube), is non-verbal, and dependent on staff for all activities of daily living. The Admission MDS (minimum data set) completed on 8/10/23 indicates R101 is frequently incontinent of bowel and bladder. R101 had an Admission Nursing Evaluation completed on 8/4/23. The Section for Bowel is a physical assessment. Bowel continence is checked no, factors indicate diet. The Bladder Section indicates incontinent, large amounts, once or more per shift and day and night. R101's medical record, electronic and paper, did not contain a comprehensive bowel and bladder assessment for incontinence to include a pattern or type of incontinence. On 12/04/23 at 4:15pm at the facility daily meeting, [NAME] President of Clinical Operations (VPCO) J provided Surveyor with R101's Task record from admission. The Task Record indicates Bowel and Bladder 3-day tracking starting at 6:00am 8/5/23. There is no documentation on 8/6/23 from 7:00pm - 9:00pm; On 8/7/23, there is no documentation from 6:00am to 2:00pm; On 8/8/23, there is no documentation from 12:00am - 6:00am and 2:00pm - 9:00pm; On 8/10/23, there is no documentation from 12:00am - 6:00am and 2:00pm - 9:00pm. R101 did not have a comprehensive bowel and bladder assessment completed on admission of since admission on 8/4/23. R101 developed an unstageable pressure injury on the coccyx on 8/16/23 (cross reference F686.) R101's Skin/Wound assessments were reviewed by Surveyor. On 8/16/23, R101 developed on their coccyx an unstageable pressure injury measuring 2.9 cm by 1.4 cm by 0.1 cm. The assessment includes: Assessed buttocks at request of nursing. Upon assessment, shear injury noted to right medial buttock and superficial unstageable pressure injury to coccyx. Root cause is heavy incontinence, friction, and contamination. Loose stool and (+) (positive) for UTI (urinary tract infection). Foley requested short-term. Braden score 9. Risk factors include age, trach dependence, morbid obesity, immobility, moisture d/t (due to) habitus, incontinence (loose stool), and pain. Receives enteral nutrition and blood sugars are not well-controlled. R101's medical record did not contain a comprehensive bowel assessment to develop appropriate interventions to prevent skin breakdown and infection. R101's medical record did not contain a comprehensive bladder assessment prior to use of an indwelling catheter, nor after the Foley catheter was placed and in use. R101's care plan for bladder incontinence created on 8/17/23 identifies bladder incontinence (no type specified) related to immobility. The interventions started on 8/17/23 include: -Risk for septicemia will be minimized/prevented via prompt recognition and treatment of symptoms of urinary tract infection. -Cleanse peri-area with each incontinence episode -Monitor and document intake and output Surveyor noted the interventions were not individualized for R101. R101's plan of care was reviewed by Surveyor on 11/29/2023 in the morning and no bowel incontinence care plan was found On 8/18/23, there is an order for a 12 French Foley catheter with no diagnosis. There are no orders for care and maintenance of the catheter. R101's bladder status changed to using a Foley catheter on 8/18/23 for bladder output. Surveyor noted there was no revision made to R101's bladder/incontinence care plan at that time. R101's care plan for the Foley catheter was created on 8/22/23 and identifies a catheter is being used (no type or size identified) for pressure ulcer. No interventions were initiated with the development of the care plan on 8/22/23. Interventions were initiated on 10/3/23 and include: -Secure indwelling catheter tubing using anchoring device to prevent movement and urethral traction. -Foley cath care every shift and as needed Surveyor noted the interventions were not individualized for R101. On 9/30/23, there is an order for a Foley catheter, size 16 French with 30cc balloon related to a diagnosis of Neurogenic bladder. Surveyor noted there is no indication an evaluation or assessment had been completed confirming R101 had a Neurogenic bladder. This order is discontinued on 11/29/23 and changed to Foley catheter, size 16 French with 30cc balloon for wound healing secondary to a stage 4 pressure injury. Surveyor noted no assessment was completed to determine the need for a Foley catheter on 8/18/23, no documentation was found showing other interventions were attempted to address incontinence and to clearly explain the assessment and the need for a Foley catheter due to a Stage 4 pressure injury. Surveyor noted this was not identified until 11/29/2023 after Surveyor had discussed care plan concerns with facility staff. Continued review of R101's record indicates R101 was prescribed antibiotics for urinary tract and/or infection to pressure injuries during the following timeframes: -Cipro 500mg via G-tube twice a day from 8/16/23 - 8/21/23. -Doxycycline Hyclate 100mg twice a day from 8/16/23 - 8/21/23. -Doxycycline Hyclate 100mg via G-tube twice a day from 9/12/23- 9/22/23. R101 was hospitalized from 9/15/23 - 9/27/23 with osteomyelitis in their sacral wound and UTI. -Ertapenem sodium injection use 1 gram IV once a day for 2 administrations from 9/27/23- 9/30/23 -Doxycycline Hyclate 100mg via G-tube morning and evening from 10/21/23 - 10/29/23. -Ertapenem sodium injection use 1 gram IV once a day from 10/20/23 - 10/30/23. -Cipro 500mg via G-tube twice a day from 11/15/23 - 11/20/23. On 11/29/23 at 12:40 PM Surveyor spoke with the facility (Infection Preventionist) IP-EE. R101's infection and antibiotic use was obtained. IP-EE provided a printout of R101's antibiotic use in the facility. IP-EE indicated R101's wound infection antibiotic was switched. R101 was on antibiotics in the hospital for a wound and urinary tract infection. IP-EE did not have any further information and indicated R101 was a sick woman. On 11/29/23 at 2:18 PM, Surveyor spoke with (Licensed Practical Nurse) LPN-P who is also the Unit Manager for R101. LPN-P indicated the staff know the heavy wetters and need to check and turn them. There is a bowel and bladder form in PCC (Point Click Care). LPN-P indicated there is no other bowel and bladder assessment form. They do the PCC bowel and bladder forms quarterly. R101's electronic record was reviewed at this time. There was no comprehensive bowel and bladder assessment. On 11/29/23, a plan of care was created for bowel incontinence related to impaired mobility and impaired cognition after Surveyor questioned staff regarding a bowel incontinence care plan. The now created care plan included a goal to have less than two episodes of incontinence per day. The interventions created 11/29/23 indicate the following: -Check resident every two hours and assist with toileting as needed. -Provide peri care after each incontinence episode. On 11/30/23 at 3:32 PM at the facility daily meeting, shared concerns regarding no bowel and bladder assessments. On 12/04/23 at 10:36 AM (Vice President of Clinical operations) VPCO-J and (Director of Nurses) DON-B spoke with Surveyor. They indicated R101 is repositioned every 2 -3 hours in the Task section (Kardex) in PCC, which applied to times of incontinence care. It was indicated the care plan does not have time frames for this; however, the Task documentation is also not considered part of the care plan. On 8/14/23 R101 had a UTI that was being treated with two antibiotics on 8/16 - 8/21. It was shared with Surveyor R101 had a decline due to this infection. A Foley was placed on 8/18/23 for the wound. 2.) R95 was admitted to the facility on [DATE] with diagnoses of chronic respiratory failure (vent dependent), diabetes mellitus, flaccid hemiplegia, and cardiac arrest. R95 is non-verbal, on a ventilator, receives nutrition via a gastrostomy tube (g-tube) and totally dependent on staff for all activities of daily living. The Admission MDS (Minimum data set) assessment completed on 5/25/23 indicates they are always incontinent of bowel and bladder. On 12/4/23 at 4:15 PM at the facility daily meeting VPCO-J provided Surveyor with R95's May 2023 Task Documentation for Bowel and Bladder incontinence tracking. This begins May 19th at Noon and ends May 31st. There is no documentation on: 5/20/23 from 2:00 PM - 12:00 AM; 5/21/23 12:00 AM - 12:00 PM; 5/25/23 2:00 PM - 12:00 AM; 5/26/23 2:00 PM - 7:00 PM and 12:00 AM - 5:00 AM; 5/27/23 6:00 AM - 12:00 AM; 5/28/23 12:00 AM - 12:00 PM; 5/29/23 6:00 AM - 2:00 PM. R95 did not have a comprehensive bowel and bladder assessment completed on admission. R95's physician plan of care includes an order on 6/20/23 for a Foley catheter, size 16 French with a 10cc balloon related to diagnosis of wound care. R95's medical record, electronic and paper, did not contain a comprehensive bowel and bladder assessment for incontinence or the reason for an insertion of an indwelling Foley catheter for the bladder. R95 had a hospital stay from 7/21/23 - 8/11/23 for septic shock secondary to an infected sacral wound. R95's medical record did not have a comprehensive bowel and bladder assessment before, or after, the use of a Foley catheter. R95's plan of care was reviewed by Surveyor on 11/29/23 in the morning and no bowel incontinence care plan was found. On 11/29/23 a plan of care was created for bowel incontinence related to impaired mobility and impaired cognition after Surveyor questioned staff regarding a bowel incontinence care plan. The newly developed care plan included a goal to have less than two episodes of incontinence per day. The interventions created 11/29/23 indicate the following: -Check resident every two hours and assist with toileting as needed. -Provide pericare after each incontinence episode. R95's plan of care was reviewed by Surveyor on 11/29/23 in the morning and no bladder incontinence care plan or Foley catheter care plan was found. After Surveyor questioned staff regarding urinary care plans for R95 on 11/29/23, a plan of care was created for bladder incontinence (no type indicated) related to impaired mobility with the following interventions: -Clean peri-area with each incontinence episode. -Monitor for urinary tract infections. R95's plan of care for Catheter (no type or size) for skin breakdown was created 11/29/23. Then REVISED on 11/29/23 to Indwelling catheter for wound healing secondary to a stage 4 pressure injury. The interventions created 11/29/23 include: -Will remain free from catheter related trauma. -Position catheter bag and tubing below the level of the bladder and away from entrance room door. -Check tubing for kinks each shift. -Monitor and document intake and output as per facility policy. -Monitor for pain/discomfort. R95 did not have a comprehensive plan of care developed to implement individualized interventions. Surveyor noted R95 had a change in bladder status on 6/20/23 with the use of a Foley catheter and a care plan was not created until 11/29/2023 after being brought to the facility's attention by Surveyor. On 11/29/23 at 10:28 AM (Vice President of Regulatory Services) VPRS-I provided Surveyor with R95's Bowel and Bladder assessment from the medical record. R95 has one bowel and bladder form from 8/25/23 that indicates Foley care every shift and incontinent of stool daily. This evaluation indicates R95 is incontinent of bowel and bladder, Foley care every shift and no additional information related to their bowels. The evaluation did not include patterning of bowel elimination or the consistency of the bowel movements. On 11/29/23 at 2:18 PM, Surveyor spoke with (Licensed Practical Nurse) LPN-P who is also the Unit Manager for R95. LPN-P indicated the staff know the heavy wetters and need to check and turn them. There is a bowel and bladder form in PCC (Point Click Care), there is no other bowel and bladder assessment form. They do the PCC bowel and bladder forms quarterly. R95 electronic record was reviewed at this time. There was no comprehensive bowel and bladder assessment. On 11/30/23 at 3:32 PM at the facility daily meeting, Surveyor shared concerns regarding no bowel and bladder assessments. On 12/4/23 at 1:51 PM the Survey Team met with VPCO-J, Nursing Home Administrator (NHA)-A, Medical Director-BB, (Vice President of Regulatory Services) VPRS-I, (Vice President of Operations) VPO-AA and Outside Consultant-U. VPCO-J indicated they are doing an education component with a 4-step process related to pressure injury care. VPCO-J indicated they are still working on getting it all in place but it is definitely underway. The process includes internal education and consultant education. The QA (Quality Assurance) tool for that is reviewed in morning clinical meetings and that they use the tool to make sure it is working for them. Surveyor asked if the new tool included bowel and bladder assessments. VPCO-J stated the bowel and bladder assessments in the computer have not been changed, but they have been reviewing the assessments to see if they are being done quarterly with the MDS assessment. Bowel and bladder only have a box for free-typing in the assessment in PCC and they are working on getting something that was more comprehensive for the nurses to complete. 38146 3.) R100 admitted to the facility on [DATE] and has diagnoses that include Castleman's Disease, Acute Respiratory Failure with hypoxia, Tracheostomy, Cerebrovascular Disease, Gastroparesis, chronic embolic CVA (cerebrovascular accident) leading to obstructive hydrocephalus, Occipital craniotomy and C1 laminectomy for decompression on 5/28/23 F/B (followed by) shunt placement 6/14/23. R100's Admission/Re-admission Nursing Evaluation dated 9/8/23 documents: Bladder continence: Incontinent - No control; multiple daily incontinent episodes. How often is the resident wet? 1-2x (times) daily. Resident is wet during: Day and Nighttime. Amount of urine: Large (puddles/soaks, clothes, bed, floor). Continent of Stool - No. Bowel pattern - Normal formed stool, rarely/never depends on laxative. Surveyor located no comprehensive bowel and bladder assessments in R100's medical record. R100's Care plan documents: (Resident) is at risk for impaired skin integrity related to: Immobility, incontinence, and cachetic state. Interventions include: - Incontinence care every shift and as needed for incontinence episodes - date initiated 10/12/23. - Provide peri care after each incontinent episode - date initiated 10/3/23. (Resident) has (SPECIFY: FUNCTIONAL) bladder incontinence r/t (related to) Impaired Mobility, communication impairment - date initiated 9/26/23. Interventions include: - Clean peri-area with each incontinence episode. On 11/30/23 at 12:32 PM Surveyor spoke with Wound RN (Registered Nurse)-O. Surveyor asked why a Foley catheter was placed on 10/30/23 for wound healing. Wound RN-O stated: He is incontinent, we thought that could have been contributing to the pressure injuries and would affect healing. Surveyor asked if a comprehensive bowel and bladder assessment was completed to determine if R100 needed more frequent check and change for incontinence. Wound RN-O stated: He was totally incontinent and had no control. Surveyor verbalized understanding and asked if the facility believed incontinence may have contributed to his pressure injuries and healing of the pressure injuries, did the facility complete a bowel and bladder assessment to determine if there was a pattern or need for more frequent checking and changing of the resident. Wound RN-O stated: I don't think so. R100 was incontinent of bowel and bladder and dependent on staff for incontinence care. R100 developed a stage 4 pressure injury on the sacrum, an unstageable pressure injury on the right trochanter and a suspected deep tissue injury on the left trochanter. A Foley catheter was placed on 10/30/23 for wound healing, and although the facility indicated incontinence as a contributing factor and would affect wound healing, the facility did not complete a comprehensive bowel and bladder assessment to determine a pattern or if R100 needed more frequent checking and changing prior to the Foley catheter having been placed. No additional information was provided. (Cross-reference F686). 46214 4.) R15 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease, vascular dementia, hemiplegia, sequelae following unspecified cerebrovascular disease, depressive disorder, heart failure, peripheral vascular disease, paralytic syndrome and a history of urinary tract infections and urosepsis. R15's Quarterly Minimum Data Set (MDS) dated [DATE] indicates R15 is moderately cognitively impaired and is totally dependent with transfers, needs extensive assistance with bed mobility and is always incontinent of bladder and bowel. R15's Braden Scale for Predicting Pressure Ulcer Risk completed on 10/7/23 is assessed that R15 high risk for developing a pressure injury. R15's Care Plan for bladder and bowel incontinence due to inability to recognize bladder/bowel cues, started 2/7/21 documents the following interventions: establish voiding patterns, date initiated 2/7/21 and check Q2 (every 2 hours) and as required for incontinence. Wash rinse, dry perineum. Change clothing PRN (as needed) after incontinence episodes. Check and change on predetermined scheduled - nurse and aide to discuss and plan, date initiated 2/7/21 and revised on 4/3/23. On 11/27/23, at 10:25 AM, during the screening process, R15 informed Surveyor that they are supposed to be checked and changed every 2 hours, however they have experienced times when they lay in their urine for more than 2 hours and do not get their brief changed on a regular basis. R15 explained that they do use the call light and verbally tell staff that they have voided and need to be changed, however staff leaves the room and do not return timely. R15 states they had a urinary tract infection (UTI) about a month ago and was on antibiotics. Surveyor reviewed the Bladder and Bowel assessment which was completed on 3/31/23, 6/29/23 and 9/27/23. All three assessments document that R15 is sometimes mentally aware of need to toilet, incontinent of stool daily and always incontinent. Surveyor notes that this quarterly bladder and bowel assessment is not comprehensive and does not include a voiding pattern. On 11/28/23 at 11:22 AM, Surveyor spoke with R15 who stated that they were changed around 1230 AM and the aide never returned that shift. R15 stated that they were pretty wet on this morning when R15 was finally changed after breakfast. On 11/29/23 at 01:27 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-L who stated that she is familiar with R15 and that R15 is to be checked and changed every 2 hours. CNA-L explained that she usually changes R15 multiple times per shift. CNA-L informed Surveyor that she did not change R15 as of yet this shift and that R15 was on leave out of the facility currently. On 11/29/23 at 01:31 PM, Surveyor interviewed CNA-K who informed Surveyor that R15 uses a bed pan and briefs. She explained that R15 is not on a toileting schedule since R15 tells them when they need to be changed. CNA-K stated that she did provide incontinent care prior to R15 leaving around 10:45 AM. On 11/30/23 at 07:43 AM, Surveyor spoke with R15 who stated that they had not been changed since 1:30 AM. R15 verbalized that they were wet and that the bed sheets were wet. R15 stated, I feel like I'm in a pool and my rear end is just so sore. R15 stated that they did tell the aide, however the aide stated that it was R15's shower day so she would just clean them up later when she came back to do the shower. On 11/30/23 at 09:23 AM, CNA-K came to R15's room and informed Surveyor that she was assigned to work with R15. CNA-K stated that she had not provided incontinence care yet for R15. CNA-K stated she was ready to give R15 a shower. Surveyor stayed in the room while R15 was prepped for transport to the shower room. During this time R15's brief was removed. The brief removed was saturated with urine and appeared yellow. CNA-K confirmed that the brief was saturated with urine. On 11/30/23 at 08:49 AM, Surveyor spoke with RN Unit Manager-D and asked if the facility ever did a voiding pattern for R15. RN Unit Manager-D stated that she didn't think that the facility did voiding patterns and would have to look into it. RN Unit Manager-D did inform Surveyor that R15 uses a call light and verbally tells staff when they need to be changed. She was not aware of a toileting schedule for R15 and stated that staff just go in often to check on the resident throughout the day. The medical record does not indicate R15 had a comprehensive bowel and bladder assessment and there are inconsistencies noted in R15's incontinence and toileting care plan. Care plan continues to reference a commode however R15 states that they use a bed pan regularly. The facility did not create an individualized toileting schedule for R15. On 11/30/23 at 03:37 PM during the end of day meeting with Nursing Home Administrator-A, Assistant Executive Director (AED)-F And VP of Clinical Operations-J, Surveyor expressed concerns with the lack of a comprehensive bowel and bladder assessment for R15 and requested voiding patterns for R15. On 12/04/23 at 08:23 AM, Surveyor spoke with Director of Nursing (DON)-B and VP of Clinical Operations-J. DON-B informed Surveyor that best practice is to check and change every 2 hours for bed bound individuals. She explained that the expectation is for staff to go and check every 2 hours. If a resident is verbal and can tell staff if they voided, then staff should be checking and changing at that time and not waiting. Surveyor expressed concerns of R15 being verbal and not being checked and changed per verbal request after voiding and or after every 2 hours. DON-B states they will have to go back in and update the care plan and educate staff. Surveyor asked if they completed a voiding pattern with R15 and she was not aware and stated we will need to figure out a toileting system. If a resident is incontinent and they are telling us they voided, then our staff should be checking and changing them. DON-B continued to say that if R15 is verbal then they should have a self-directed plan of care. The DON stated that they will go upstairs and talk with the resident, update the care plan and document that R15 is self-directed for toileting. VP of Clinical Operations-J stated that they will also refer R15 to therapy to assess if R15 is eligible for a toileting program. On 12/04/23 at 02:10 PM, VP of Clinical Operations-J informed Surveyor that they did look at the quarterly Bladder and Bowel assessments however they were only checking them to make sure they were being completed. She stated that establishing voiding patters was not being done and that they have brought the issue to corporate informing them that PCC Bladder and Bowel assessment doesn't have a comprehensive assessment which would include a voiding pattern. No additional information was provided.

Based on observation, interview, and record review the facility did not ensure that residents with pressure injuries received necessary treatment and services, consistent with professional standards of practice, to promote healing, and prevent new pressure injuries from developing for 2 of 5 (R58 and R77) residents reviewed for pressure injuries. The facility assessed R58 to be at risk for the development of pressure injuries. The facility did not implement a turning and repositioning program despite R58's assessed risk. R58 developed a facility acquired stage 3 pressure injury to the right knee that was assessed to have necrotic tissue. The facility identified the root cause of this pressure injury to be immobility, heavy perspiration, and pressure. The facility did not revise R58's care plan with interventions to address the identified root cause. The facility did not complete treatments per physician orders. R58 also developed a stage 4 pressure injury to the right elbow with bone exposed. R58 had a prior Suspected Deep Tissue Injury (SDTI) to the right elbow that healed. The facility identified the root cause of the pressure injury to be increased moisture from perspiration and upper extremity edema. The facility did not revise R58's care plan with interventions to address the identified root cause of the right elbow pressure injury. The facility did not complete treatments per physician orders. Surveyor observed R58's pressure injury care plan interventions not in place and R58 was not repositioned per care plan. The facility's failure to provide prescribed treatments and implement care plan interventions to prevent new pressure injuries created a finding of immediate jeopardy that began on 5/12/23. Surveyor notified Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the immediate jeopardy on 6/1/23 at 2:42 PM. The Immediate Jeopardy was removed on 6/2/23 when the facility implemented its action plan. The deficient practice continues at a D (potential for harm/isolated) based upon the following example and the residents at risk for pressure injuries residing in the facility. -R77 did not have heels offloaded for 2 days of survey. Findings include: 1.) R58 admitted to the facility on [DATE] and has diagnoses that include chronic respiratory failure, ventilator status, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, osteomyelitis of vertebra, sacral and sacrococcygeal region, severe protein-calorie malnutrition, intracranial hemorrhage, vascular dementia, and atherosclerotic heart disease. R58's Quarterly Minimum Data Sets (MDS) dated [DATE] and 1/25/23 indicate R58 requires extensive assist of two staff for bed mobility. R58 is at risk for pressure injuries having unhealed pressure injuries. R58's Quarterly Minimum Data Set, dated dated dated [DATE] documents bed mobility as total dependence 1 person assist. Functional Limitation in Range of Motion impairment 1 side left upper and left lower extremity. The MDS indicates R58 is at risk for pressure injuries with unhealed pressure injuries. Surveyor noted for all MDS assessments there is no indication of a turning and repositioning program for R58 despite risk for pressure injuries, range of motion impairment and total dependence for bed mobility. R58's Braden Scale for Predicting Pressure Ulcer Risk, dated 12/1/22 documented a score of 10, indicating R58 is at High Risk. R58's Brief Interview for Mental status score dated 3/12/23 was 00 - indicating severe cognitive impairment R58's care plan documents: (Resident) is at risk for further impaired skin integrity r/t (related to) impaired mobility, impaired cognition, history of pressure injuries, and incontinence - Date Initiated 7/15/22. Interventions include: - Apply house moisturizing lotion as needed to keep skin hydrated. Avoid applying between toes and other moist areas. - Nursing will assess skin upon admission, weekly on day of scheduled shower, PRN (as needed), and with any change in condition. Any abnormalities will be documented in chart and reported to primary physician and Wound Care Team for follow up. - Offload resident to reduce direct pressure on bony prominences. Utilize heel boots and/or pillows to keep heels floated as resident allows. Monitor offloading devices with each encounter to ensure proper positioning. Avoid positioning devices directly over wounds/bony prominences. - Provide resident assistance with repositioning every 2-3 hours when in bed. Avoid positioning resident on back when possible. Utilize draw sheet when available for repositioning to reduce risk of friction/shear. Verify residents' body is free from contact with environmental hazards (not pressing into side rails or foot board, not laying on tubes, etc.). - Support surfaces for pressure reduction: standard pressure reduction mattress. Evaluate for effectiveness/proper function with each resident encounter. R58's care plan documents: (Resident) has impaired skin integrity, as evidenced by stage 3 (previously unstageable) pressure injury to right knee, acquired at facility 1/4 - Date Initiated 1/4/23, revised 4/10/23. Interventions include: - Nursing to monitor dressing integrity with each resident encounter and replace dressing if soiled/loose/missing. Dressing location: right knee - Staff to ensure pillow between legs when repositioning. - Wound assessment/measurement performed weekly/PRN by Wound Care Team. If resident is unavailable, assessment will be completed at earliest availability. - Wound care treatment to be performed by Wound Care Team/Nursing as ordered by MD/NP (Medical Doctor/Nurse Practitioner). R58's care plan documents: (Resident) has impaired skin integrity, as evidenced by unstageable pressure injury to right elbow (lateral), present on return from LOA (Leave of Absence) 3/6 - initiated 3/7/2023 (Resident) has impaired skin integrity, as evidenced by unstageable pressure injury to right elbow, acquired at facility 1/13. Now 2 separate areas upon return from LOA (leave of absence) 3/6, site is now right elbow (medial). On 5/5, 2 elbow wounds communicate as slough breaking down (anticipated) and will be followed as 1 - Date Initiated 1/13/23, revised 5/16/23. Interventions include: - Nursing to monitor dressing integrity with each resident encounter and replace dressing if soiled/loose/missing. Dressing location: right elbow - Resident's arms to be elevated on pillows with repositioning - Sharps debridement to be performed as needed by [named clinic] NP (Nurse Practitioner) for wound bed preparation. - Wound assessment/measurement performed weekly/PRN by Wound Care Team. If resident is unavailable, assessment will be completed at earliest availability. Record review of R58's pressure injuries: Current stage 4 pressure injury to coccyx present on admission. Current stage 3 pressure injury right knee. Current stage 4 pressure injury right elbow. Previous SDTI (Suspected Deep Tissue Injury) right elbow - resolved 10/21/22. Previous left ear stage 4 pressure injury - resolved 4/28/23. The facility Skin Observation Tool completed by floor nurses on 12/29/22 and 1/12/23 had nothing marked under the body sites. Surveyor was advised the WCT (wound care team) weekly wound care assessments and measurements are documented on the Skin Only Evaluation form. R58's Skin Only Evaluation form, dated 1/4/23 documents: Right knee, unstageable 1.5 cm (centimeters) x 1.4 x 0.1 necrotic. Resident seen by Wound Care Team for scheduled treatments and head to toe skin check. New unstageable pressure injury noted to right medial knee. Root cause is immobility, heavy perspiration, and pressure from left knee. Pillow to be placed between knees at all times. Surveyor noted although R58's prior care plan included intervention to offload resident to reduce direct pressure on bony prominence's/monitor offloading devices with each encounter to ensure proper positioning, the specific care plan intervention of pillow between knees was not implemented until after the pressure injury was identified. The facility root cause of the pressure injury included heavy perspiration however, there were no care plan revisions related to R58's heavy perspiration. R58's Skin Only Evaluation form, dated 1/13/23 documents: Right elbow, unstageable 2 x 1.7 x 0.1 slough. Resident seen by Wound Care Team for weekly assessment. New superficial unstageable pressure injury to right elbow. Root cause is increased moisture from perspiration and UE (upper extremity) edema. Arms to be elevated on pillows and tx (treatment) order received. Surveyor noted R58's prior care plan included intervention to offload resident to reduce direct pressure on bony prominences/monitor offloading devices with each encounter to ensure proper positioning. The facility was aware R58 had a previous SDTI to the right elbow in October 2022, however the specific care plan intervention to elevate arms on pillows was not implemented until another pressure injury developed on the right elbow. In addition, the facility identified the root cause of the pressure injury to be from increased moisture from perspiration and upper extremity edema however, there were no care plan revisions related to moisture, perspiration, or edema. Weekly wound assessments and measurements were completed by the WCT weekly. Treatments were changed accordingly. R58's Skin Only Evaluation form, dated 3/3/23 documents: Right knee 1.9 x 2.1 x 0.2 slough, unstageable Right elbow 1.2 x 3.3 x 0.1 slough, unstageable Resident seen by Wound Care Team for weekly assessment. All wounds showing slight improvement. Eschar to right elbow & right knee unstable - debrided by NP and hydrofera blue added to right knee tx (treatment). R58's Skin Only Evaluation form, dated 3/7/23 (readmit from hospital) documents: Right knee 2.2 x 2.2 x 0.1 slough, unstageable R (right) elbow medial 1.2 x 0.8 x 0.1 slough, unstageable R elbow lateral 1.4 x 1.1 x 0.1 slough, unstageable Resident seen by Wound Care Team for skin assessment upon return from LOA (leave of absence-hospitalization ). Skin remains impaired, evidenced by stage 4 pressure injuries to coccyx & left ear, and unstageable pressure injuries to right elbow (medial/lateral), right 1st finger, and right knee, all present on re-admission. Surveyor noted the facility Skin Only Evaluation on 4/7/23 documented the right knee pressure injury was assessed to be a stage 3 pressure injury (full thickness skin loss with granulation tissue present) from prior assessments as an unstageable pressure injury. Measurements were 2.2 x 2.4 x 0.1. R58's Skin Only Evaluation form, dated 5/5/23 documents: Right knee 1.9 x 1.7 x 0.1, granulation Right elbow 1.8 x 3.1 x 0.3, slough Resident seen by Wound Care Team for weekly assessment. All wounds appear stable. Right elbow wounds now communicate d/t (due to) autolytic debridement of slough (anticipated) and will be followed as 1 wound. New tx order received. Surveyor noted the facility Skin Only Evaluation on 5/12/23 documented the right elbow was changed to a stage 4 pressure injury (full thickness tissue loss from prior unstageable assessments.) Surveyor noted despite the decline in the condition of the elbow pressure injury, the facility made no changes to the care plan to prevent worsening or to promote healing of the pressure injury. R58's Skin Only Evaluation form, dated 5/19/23 documents: Right knee stage 3, 1.9 x 1.5 x 0.1 Right elbow stage 4, 2.7 x 3 x 0.4 Weekly assessment completed by Wound Care Team. Right elbow wound larger with more bone exposed. No visible signs of infection- NP ordered xray to r/o (rule out) osteo (osteomyelitis). All remaining wounds improved. See Wound NPs visit note for further assessment details. WCT will continue to follow. Nursing to notify WCT of any new concern or change in skin condition. R58's Radiology report dated 5/22/23 documented: No radiographic evidence of osteomyelitis seen. R58's Skin Only Evaluation form, dated 5/26/23 documents: Right knee, stage 3, 2 x 2 x 0.1, slough Right elbow, stage 4, 2.7 x 3.6 x 0.3, slough Resident seen by Wound Care Team for weekly assessment. Right elbow is stable - undermining present d/t (due to) autolytic debridement of slough. Coccyx improving and right knee stable. No signs indicating possible infection noted. Braden score 9. Risk factors remain unchanged and include: Age, s/p (status post) ICH (intracranial hemorrhage) with left hemiplegia/hemiparesis, seizures, vascular dementia, ventilator dependence, immobility, contractures, incontinence, and pain. Interventions in place and include: every 2 hour turning/repositioning (dependent), offloading with pillows, heel boots as resident tolerates, alternating pressure mattress, pain management, incontinence cares, and weekly skin assessment by nursing. Resident does not appear receptive to any education at this time. WCT will continue to follow. Nursing to notify WCT of any new concern or change in skin condition. R58's Skin Only Evaluation, dated 6/2/23 documents: Right knee 2.2 x 1.9 x 0.1, slough Right elbow 2.5 x 3.3 x 0.3, slough On 5/30/23, at 9:54 AM, Surveyor observed R58 lying in bed on his back. Surveyor noted R58 to be on an air mattress and wearing Prevalon boots on both feet. R58's left arm was elevated on a pillow and his right arm was lying directly on the bed next to the residents' body. R58's right knee was bent and resting directly on his left knee with no pillow or offloading device to prevent pressure from bone on bone of the knees. Surveyor observed R58's right elbow wrapped with Kerlix dated 5/26 with the initials WCT. Surveyor observed a pink foam dressing on his right medial knee dated 5/26 with initials WCT. Surveyor observed the knee dressing had drainage shadowing 75% of the dressing. Surveyor noted R58 had not had a dressing change to these areas in 4 days despite stage of wounds and physician orders to complete treatments/dressing changes every Monday Wednesday and Friday and as needed. The facility did not complete treatments and dressing changes on Monday 5/29 as ordered. On 5/30/23, at 12:10 PM, Surveyor observed a facility Respiratory Therapist (RT) standing next to R58's bed for a few seconds before she left the room. Surveyor observed R58 to be in the same position as previously observed: Lying in bed on his back, left arm on pillow, right arm remains on bed next to body. Right knee bent and resting directly on the left knee with no pillow to prevent pressure of knees. Same Kerlix dressing on right elbow dated 5/26, same dressing on right knee dated 5/26. Although R58's care plan interventions include a pillow between legs and pillows under arms, R58 did not have these interventions in place and the RT did not reposition or ensure the interventions were in place before leaving the room. On 5/30/23, at 1:59 PM, Surveyor observed R58 to be in the same position as previously observed: Lying in bed on his back, left arm on pillow, right arm remains on bed next to body. Right knee bent and resting directly on the left knee with no pillow to prevent pressure of knees. Same Kerlix dressing on right elbow dated 5/26, same dressing on right knee dated 5/26. On 5/30/23, at 2:13 PM, Surveyor observed R58 to be in the same position as previously observed: Lying in bed on his back, left arm on pillow, right arm remains on bed next to body. Right knee bent and resting directly on the left knee with no pillow or offloading device to prevent bone on bone pressure of knees. Same Kerlix dressing on right elbow dated 5/26, same dressing on right knee dated 5/26. Review of R58's May 2023 Treatment Administration Record documents: Cleanse coccyx wound with Puracyn, apply collagen particles, gently pack with opticell, cover with super absorbent, and secure with bordered foam dressing. Change MWF (Monday, Wednesday, Friday) and PRN. One time a day every Mon, Wed, Fri. Cleanse right elbow wound with Puracyn, apply Anacept gel to wound bed, place oil emulsion over exposed bone, then cover with hydrofera blue foam, followed by super absorbent, and secure with bordered foam dressing and light kerlix. Change MWF and PRN. One time a day every Mon, Wed, Fri Cleanse right knee wound with Puracyn, apply collagen powder, cover with oil emulsion, followed by bordered foam dressing. Change MWF and PRN. One time a day every Mon, Wed, Fri. Surveyor noted the above treatments were not signed out as having been completed on Monday, 5/29/23. On 5/31/23, at 7:42 AM, Surveyor observed R58 lying in bed on his back, wearing Prevalon boots on both feet, a pillow between his knees and under his right arm, his left arm was resting on the bed. Surveyor noted a new Kerlix dressing on the right elbow and new pink foam dressing on the right knee, both dated 5/31 with initials WCT. On 5/31/23, at 9:32 AM, Surveyor observed R58 to be in the same position as previously observed: Lying in bed on his back, wearing Prevalon boots on both feet, pillow between knees and under right arm, left arm resting on the bed. On 5/31/23, at 11:13 AM, Surveyor observed R58 to be in the same position as previously observed: Lying in bed on his back, wearing Prevalon boots on both feet, pillow between knees and under right arm, left arm resting on the bed. Surveyor noted R58 continues to have a pressure injury to the coccyx that is not being offloaded On 5/31/23, at 11:30 AM, Surveyor observed R58's room door was closed. On 5/31/23, at 12:30 PM, Surveyor observed R58 lying on his back, slightly turned to left side, wearing a new gown. His right arm was elevated on a pillow, left arm was on the bed. Prevalon boots on both feet. Surveyor noted there was no pillow between his knees to prevent bone on bone pressure. R58's right knee was bent and resting directly on the left knee. On 5/31/23, at 12:51 PM, Surveyor spoke with facility Wound Care Nurse (WCN)-K to discuss R58's pressure injuries. Surveyor asked how she thought the right knee pressure injury developed. WCN-K stated: From knee-on-knee pressure and probably moisture from sweating. Surveyor asked how she thought the right elbow pressure injury developed. WCN-K stated: The same, from pressure and sweating, and also he gets increased edema in that arm when positioned on that side. Surveyor reviewed the care plan interventions of a pillow between the knees and pillow under arms were implemented after the pressure injuries was identified. Surveyor asked why a pillow was not utilized prior to the development of the pressure injuries? WCN-K stated: I can't say if one was used or not, I know it is now. Surveyor advised WCN-K of observations on 5/30/23 - no pillow between knees, with the knees resting directly on each other, right arm lying on bed/not offloaded, no change of position for greater than 4 hours. Surveyor asked how often R58 should be repositioned. WCN-K stated: Well anyone at risk we say every 2-3 hours, but for him, because he has wounds, he should be repositioned at least every 2 hours minimum. We have educated and told them (referring to aides and nurses) many, many times about repositioning, and that just because they're on an air mattress, they still have to be repositioned at least every 2 hours. WCN-K reported the wound care team does all treatments Monday through Friday, and nurses are responsible for doing treatments on weekends, holidays or if the dressing falls off. Surveyor advised WCN-K of observation on 5/30/23 of right elbow and right knee dressings dated 5/26. WCN-K stated: Apparently the treatment wasn't done on Monday (5/29). WCN-K reported she did the dressings this morning (5/31) and thought the wounds looked better. She reported decreasing the treatments to twice weekly dressing changes. Surveyor asked what time she did the treatment this morning. WCN-K stated: We usually try to get scheduled treatments done early. He was done probably between 6-6:30 AM. Surveyor advised WCN-K of observation R58 in same position from 7:42 AM - 11:13 AM. WCN-K stated: My guess is he's still in the same position as I left him this morning. On 5/31/23, at 3:10 PM, Surveyor advised Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of observations and concern related to R58 lack of repositioning, not having care plan interventions in place and treatment not completed as scheduled. On 6/1/23, at 11:28 AM, Surveyor spoke with NHA-A and DON-B. Surveyor asked who was responsible for skin checks in between weekly WCN assessments. DON-B reported the floor nurses and nurse managers can assist with skin checks. DON-B reported the expectation is the nurse generally looks for new issues and does not document existing issues. Surveyor asked if the facility would expect Certified Nursing Assistants (CNA) to do skin checks. DON-B reported shower sheets have an area to address skin, and CNAs should document any concerns, sign and give to the floor nurse who also signs, then give to Nurse Manager to review before they are scanned in (to the electronic medical record). Surveyor asked what the facility policy for overall assessment and monitoring of residents' skin is. DON-B reported a skin assessment is done on shower days, But everyone is of course looking at residents' skin when providing cares or turning/repositioning, essentially we are always assessing skin in a sense. If the aides find any areas concerning, they are to notify the nurse immediately. Surveyor was advised the facility identified the root cause of R58's elbow and knee pressure injuries to be from perspiration and/or edema and noted there were no care plan revisions related to the identified root cause. DON-B reported she would have to look. On 6/5/23, at 8:19 AM, Surveyor met with Medical Doctor (MD)-L with VP-F present. MD-L stated: As far as the moisture, we wouldn't want to pad or cover the area for protection - that would cause increase moisture. We would want to just offload bony prominences. Caring for the moisture and sweating would just fall under normal cares, keeping him clean and dry - we wouldn't specifically care plan this, it would be done with cares. Surveyor advised the facility root cause of the pressure injuries listed perspiration, heavy sweating, and moisture, yet there was no evidence of interventions to address this issue. MD-L stated: That's because it's not something we would normally care plan. It would fall under normal cares for the resident. On 6/5/23 the facility provided a statement written by MD-L regarding R58's pressure injuries and R58's comorbidities. MD-L indicates in this statement the most appropriate management for this patient to reduce risk of developing or worsening wounds is appropriate nutrition, air mattress, frequent turning/positioning and off-loading, and management of microclimate. MD-L goes on to indicate R58 is currently on a turning schedule and every 2-4 hours is appropriate. Surveyor noted this is not consistent with the wound practitioners' recommendations and is potentially an even greater amount of time for R58 to not be repositioned. Surveyor also noted if frequent repositioning is important for R58 this area was not individually assessed or implemented as an individualized intervention based upon assessment as the MDS did not assess or indicate a turning/repositioning program for R58 as part of the assessment. MD-L also indicates to manage R58's microclimate, no further or additional measures are recommended other than frequent turning and regular cares to keep skin dry. Surveyor noted with each facility skin only assessment the facility did not assess the surrounding skin tissue to determine if skin was impacted by the microclimate. Surveyor also noted there is no indication the facility assessed for moisture reducing bedding or hospital gowns, room temperature, etc. to alleviate moisture and perspiration. The facility's failure to treat and implement care plan interventions to prevent new pressure injuries created a finding of immediate jeopardy that began on 1/13/23. The Immediate Jeopardy was removed on 6/2/23 when the facility implemented the following: -R58 was immediately evaluated by the wound nurse and all ordered pressure relieving devices immediately put into place and a pain evaluation was competed. -Rounds were completed on all residents to ensure treatments have been completed per physician orders and all orders for pressure relieving devices were in place, and all residents have been turned and repositioned -A Braden assessment was completed on all Residents -All Residents identified to be at high risk for skin breakdown were reviewed to ensure appropriate preventative skin breakdown measure are in place. -Care plans were reviewed for all Resident at risk for skin breakdown or with actual skin breakdown to ensure appropriate interventions were in place. -An ad hoc QAPI meeting was held to review the Immediate Jeopardy removal plan. -Education was given to the Director of Nursing, nursing administration, Nursing Home Administrator, Assistant Administrator, and all managers on the facility policy and procedure on Pressure Ulcer Prevention and standards of practice for treatment and turning and repositioning with a follow up posttest. -Education was provided to all licensed nurses on the standards of practice related to following physician orders for treatments, ensuring residents plan of care is followed, resident turning and repositioning and pressure ulcer prevention policy and procedure. -Education was provided to all licensed nurses on how to appropriately complete weekly skin observations, identify new area with a posttest completed. -Education initiated for all Certified Nursing Assistance related to the facility policy and procedure for Pressure Ulcer Prevention, standards for practice for turning and repositioning, following resident Kardex to ensure preventive skin interventions are in place, and identification of any skin area noted and reporting to their nurse with a posttest required. -A Performance Improvement Tool was developed to monitor compliance with following physician orders, ensuring turning and repositioning is completed, and preventative devices are in place. -Nursing administration team will review weekly skin observations and the results will be forwarded to QAPI committee for review. -Department managers that participate in daily Angel Care rounds will monitor repositioning, ensuring pressure relieving devices are in place and visible dressings are clean, dry, and dated appropriately, during rounds. The deficient practice continues at a D (potential for harm/isolated) based upon the following example for R77 and the residents at risk for pressure injuries residing in the facility. 22692 2.) R77 was admitted to the facility on [DATE] with diagnosis that included Aphasia, and Schizophrenia. R77 was admitted to the facility with a stage 3 pressure injury which had healed at the time of the survey. R77's Quarterly Minimum Data Set (MDS) dated [DATE] was reviewed and indicated R77 was at risk for developing pressure injuries. R77's Brief interview for Mental Status was a score of 0, indicating she has a severe cognitive deficit. On 6/1/23 R77's Braden Scale for Predicting pressure Ulcer Risk dated 5/24/23 was reviewed and indicated R77 scored a 9 (very high risk). On 5/30/23 R77 was observed in bed at 10:30 AM, 12:30 PM and 2:15 PM. R77's heels were observed to be directly on the mattress and no device to elevate her heels was observed in her bed. In R77's closet a pair of pressure relief boots were observed on the floor of the closet. R77's heels were observed to be free from redness or pressure injuries. On 5/31/23 R77 was observed in bed at 8:30 AM, 10:30 AM and 2:00 PM. R77's heels were observed to be directly on the mattress and no device to elevate her heels was observed in her bed. In R77's closet a pair of pressure relief boots were observed on the floor of the closet. R77's heels were observed to be free from redness or pressure injuries. On 5/31/23 R77's current care plan titled Risk for impaired skin integrity related to limited mobility, incontinence and altered nutrition with a start date of 4/21/22. Interventions for R77 included: Offload resident to reduce direct pressure on bony prominence's. Utilize pillows to keep heels floated when possible start date 4/21/22. On 6/1/23 at 1:14 PM Director of Nurses-B was interviewed and indicated that R77 should have her heels offloaded while in bed. The above findings were shared with the Administrator -A and Director of Nurses-B at the daily exit meeting on 6/1/23 at 3:00 PM. Additional information was requested if available. None was provided.

Based on observation, interviews, and record review, the facility failed to protect the resident's right (R9's right) to be free from sexual abuse by R10 of 6 sampled residents reviewed. On 3/5/23 R10 was observed in R9's room, while R9 was sleeping and partially disrobed. R10 was observed to be standing next to R9's bed and watching her sleep. Licensed Practical Nurse (LPN) K wrote a nurses note of her observation and reported her concerns that R10 should not be in R9 room and questioned why was R10 watching R9 sleeping. LPN K told LPN J her concerns and LPN J, who was also concerned with R10's behavior, told LPN K to report it to the supervisor. LPN K reported this concern to RN Supervisor I. Certified Nursing Assistant (CNA) N, who also observed R10 in R9's room while R9 was sleeping was concerned with R10's behavior. RN Supervisor I stated she didn't find the behavior unusual and stated she couldn't prevent R10 from walking around the facility, RN Supervisor I did not report this incident to administration. The facility did not investigate this further to determine why R10 was on the second floor of the facility and in R9's room while R9 was sleeping. R10 resides on the 1st floor of the facility. On 3/26/23 R10 was observed to be sucking on R9's breast, in the activity room. The facility separated the residents and placed R10 on 15-minute checks. The facility investigation revealed R9 expressed she did not like R10's sexual behavior and did not want it to occur again. The facility investigation also revealed the police were not called until 3/27/23. The facility's failure to investigate the 3/5/23 incident to understand what happened on 3/5/23 when 3 staff expressed concern about the incident lead to a failure to potentially safeguard R9 and assess possible need for increased supervision of R10. The facility did not further assess to determine why R10 was in R9's room while she was sleeping and partially undressed. During the Survey, facility administration insisted R9 and R10 were friends and nothing unusual happed on 3/5/23 despite the facility not completing a thorough investigation or a root cause analysis into the incident. The facility did not further assess R9 or R10 following the 3/5/23 incident to determine their ability to consent or understand relationships or sexual relations despite the facility insisting they were friends. The facility did not keep R9 safe from sexual abuse on 3/26/23 when R10 engaged in sucking on R9's breast in the activity room. This created a finding of immediate jeopardy that began on 3/26/23. Surveyor notified NHA (nursing home administrator) A of the immediate jeopardy on 4/12/23 at 11:45 p.m. The immediate jeopardy was removed on 4/14/23. However, the deficient practice continues at a scope/severity of (scope/severity) E (potential for harm/pattern) as the facility continues to implement its action plan. Findings include: The facility's policy Protection of Residents during Abuse Investigations dated September 2022 indicates: Sexual Abuse 1. Sexual abuse is non-consensual sexual conduct of any type with a resident. Sexual abuse includes, but is not limited to: a. Unwanted intimate touching of any kind especially of breasts or perineal area; b. All types of sexual assault or battery, such as rape, sodomy, and coerced nudity; c. Forced observation of masturbation and/or pornography; and d. Taking sexually explicit photographs and/or audio/video recordings of a resident(s) and maintaining and/or distributing them (e.g posting on social media). This would include, but is not limited to, nudity, fondling, and/or intercourse involving a resident. 2. Generally, sexual contact is nonconsensual if: a. The resident appears to want the contact to occur, but lacks the cognitive ability to consent; b. The resident does not want the contact to occur; c. The resident is sedated, is temporarily unconscious, or is in a coma; or d. Consent is obtained through intimidation, coercion or fear, whether it is expressed by the resident or suspected by staff. 3. Any forced, coerced or extorted sexual activity with a resident, regardless of the existence of a pre-existing or current sexual relationship, is considered to be sexual abuse. 4. Residents have the right to engage in consensual sexual activity. However, anytime there is a reason to suspect that a resident may not have the capacity to consent to sexual activity, the facility will take steps to ensure that the resident is protected from abuse, including evaluation whether the resident has the capacity to consent to sexual activity. R9 was admitted to the facility on [DATE] with diagnoses of bipolar, CVA (cerebral vascular accident) dysphagia, aphasia and type 2 diabetes. R9 has a legal guardian appointed. R9's quarterly MDS (minimum data set) dated 2/22/23 indicate a BIMS (brief interview for mental status) score of 10, which indicates moderate cognitive impairment. It also indicates R9 needs extensive assistance with bed mobility, dressing and hygiene. R10 was admitted to the facility on [DATE] with diagnoses of incomplete quadriplegia, type 2 diabetes and alcohol abuse. R10 was his own decision maker. R10's significant change MDS dated [DATE] indicate R10 has a BIMS score of 15, which indicates R10 is cognitively intact. It also indicates R10 needed limited assistance with walking and bed mobility and needed supervision with dressing and hygiene. On 4/10/23, at 9:12 a.m., Surveyor observed R9 in her room dressed and in her Broda chair. R9 was not receptive to Surveyor attempts to speak to R9 and Surveyor was unable to understand R9. Surveyor observed on 4/10/23, R9's room is located down a long hallway and around the corner. R9's room is across from the activity/dining room for the 2nd floor. R9 resides in a room without a roommate. R10 resides on the first floor. Review of a nurse's note dated 3/5/23, 14:50 (2:50 PM) indicates R10 was observed, in R9's room, standing with his walker next to R9's bed, while R9 was sleeping in bed. The nurse's note indicates R9 had a sheet over her with gown partly off due to BM (bowel movement) being present on gown and R9 had a brief on. The note continues to indicate that R10 was told to leave the room and that R10 should not be in R9's room. R10 apologized and left the room. The nurses note indicates the supervisor was made aware. The nurse's note dated 3/26/23 indicates CNA H observed R9 and R10 in the dining room. CNA H indicated he observed R9 with her shirt up and R10 sucking on R9's breast. Surveyor reviewed the facility investigation into this sexual incident. The facility investigation dated 3/26/23 indicates on Sunday, March 26th, after the activity (word list) was completed in the [NAME] activity room on the 2nd floor (CNA H) during his rounds around 2:45 pm, found R9 and R10 in the [NAME] activity room on the second floor. CNA H stated as he walked in (R9's 2nd floor room), R9 was not in her room. CNA H began to look for R9 and later found her in the activity room on the second floor with R10. CNA H stated he saw R9 holding up her shirt and R10 was being inappropriate with R9, precisely sucking her breast. R9 saw CNA H and CNA H indicated R9 was smiling; CNA H stopped them and notified the nurse. The investigation indicates R9 and R10 were separated and R9 was moved to her room. The investigation indicates no other residents were in the activity room at the time. The investigation indicates R10 was placed on 15-minute checks immediately after the incident. The investigation indicates the police were not immediately called but were called the following day on 3/27/23. (Cross-reference F609). The medical record indicates R10 was taken by the police on 3/27/23 and released from jail on 3/31/23. The medical record indicates R10 was not allowed back to the facility. The facility conducted skin checks on all non interviewable residents and other residents were interviewed to determine if anyone else was harmed. Medical Director M was in the facility, on 3/26/23, at the time of the incident. Medical Director M's progress note dated 3/26/23 indicates she evaluated R9 shortly after the incident with R10. Medical Director M's note indicates R9 stated R10 was sucking on her breast and denies R10 touched any other part of her body. The note indicates R9 told Medical Director M that R9 did not like or want it and admits R9 did not ask R10 to stop. R9 stated she did not want it to occur again and did not want to see R10 again. The note indicates R9 denies feeling unsafe or afraid but did admit to feeling anxious, but it is unclear if R9 was anxious about the situation or the questions/conversations. R9 also indicated this had not happened prior. Medical Director M's examination revealed no bruising or physical trauma noted. Medical Director M's note also indicates R9 was able to recall the events consistently, but it is unclear at this time if she can consent to sexual activities as she may not fully comprehend the consequences of her actions. Interview with R10 indicates R10 denied sucking R9's breast and was just helping her pull her shirt down. On 4/11/23, at 10:45 a.m., Surveyor interviewed Social Service Director (SSD) L. Surveyor asked SSD L if an assessment was completed for R9 and/or R10 regarding their ability to consent to a sexual relationship prior to the 3/26/23 incident. SSD L stated an assessment for consent was not completed. SSD L stated she completed a BIMS on R9 after the 3/26/23 incident and R9 scored 13 (cognitively intact). SSD L stated not everyone knows how to communicate with R9 and they need to take their time when communicating with R9. SSD L stated she communicated with R9 after the incident and R9 indicated she was fine and had no trauma as a result of the 3/26/23 incident. The facility completed interviews with staff regarding R10's behavior. CNA N's statement dated 3/29/23 indicates: Question: Did you ever see resident go into anyone's room? CNA N answer: Caught him 2 weekends ago standing over (R9) on AM shift and she was sleeping. He didn't touch her just looking at her. Told (LPN K). After that next day (R10) came back up there and (CNA N) told him to go back downstairs. When aide addressed him, he (R10) acted like he couldn't speak English and went back downstairs. After that saw him in the hallway but not in anyone's room. Question: Have you ever heard of the resident talking or being inappropriate with staff or residents? CNA N answer: No Question: Do you have any concerns with this resident? CNA N answer: Absolutely Resident (R10) shouldn't be upstairs and he shouldn't be up there with her (R9) On 4/11/23, at 12:30 p.m., Surveyor interviewed CNA N regarding his 3/29/23 statement. Surveyor asked CNA N if he was concerned when he found R10 standing over R9's bed. CNA N stated he was concerned because R9 was sleeping and often disrobes/undresses so R10 had no business in R9's room. CNA N stated even after being caught standing over R9 while she was sleeping, R10 would sneak upstairs. Surveyor asked CNA N if R10 had friends upstairs. CNA N stated R10 did not have any friends but would sometimes hang out with a male resident from the 2nd floor. The male resident resided on the other side of the building far from R9's room. CNA N stated there was no reason for R10 to be near R9. Surveyor asked CNA N if he told anyone about his observation of R10 and CNA N stated he told LPN K. The facility did not obtain an interview with LPN K regarding R10's behavior. On 4/11/23, at 12:45 p.m., Surveyor interviewed LPN K. Surveyor asked LPN K if she remembers the incident where CNA N told her that R10 was observed standing over R9 while she was in bed. LPN K stated she doesn't remember CNA N speaking to her but remembers around March 5th, LPN K's own observation of R10 standing over R9 while she was in bed sleeping. LPN K stated R10 usually was found eating lunch on the 2nd floor dining room or just hanging out in the dining room. LPN K stated she didn't think anything of R10 being upstairs on occasion until she observed him in R9's room. LPN K stated when she observed him in R9's room she told R10 he needed to leave the room and that he shouldn't be in R9's room. LPN K stated after finding R10 in R9's room she kept a closer eye on R10 if he was on the 2nd floor. LPN K stated this incident created a red flag regarding R10's behavior. LPN K stated she told RN Supervisor I of her concerns immediately. The facility obtained LPN J's statement on 3/30/23 regarding R10's behavior Question: Did you ever see resident go into anyone's room? LPN J answer: Yes .knew from (name of staff LPN K), then I started watching him closer. Stays in dining room north hall Question: Have you ever heard of the resident talking or being inappropriate with staff or residents? LPN J answer: No Question: Do you have any concerns with this resident? Yes, he spent extended time down that hallway. I assumed everyone knew what was going on.It's creepy to me because why does he keep going down there especially with her (R9) taking off her clothes coming in the hallway like she does all the time. On 4/11/23 at 2:15 p.m. Surveyor interviewed LPN J. LPN J stated LPN K told her that she found R10 in R9's room just standing over R9 while she was sleeping. LPN J stated she told LPN K that she needs to report that to the supervisor. LPN J stated she works on the other hall (hall opposite R9's hallway) but when she heard about R10 being in R9's room, she paid more attention to him. LPN J stated R9 isn't in her right mind and is known to masturbate and disrobe so R10 doesn't need to be down the hallway R9 resides. The facility interviewed RN Supervisor I on 3/29/23 regarding R10's behavior Question: Did you ever see resident go into anyone's room? RN Supervisor I answer: No Question: Have you ever heard of the resident talking or being inappropriate with staff or residents? RN Supervisor I answer: No Question: Do you have any concerns with this resident? RN Supervisor I answer: No On 4/12/23, at 8:10 a.m. Surveyor interviewed RN Supervisor I. Surveyor asked RN Supervisor I if she remembers the sexual incident with R9 and R10 on 3/26/23. RN Supervisor I stated she didn't hear about this incident. Surveyor asked RN Supervisor I does she remember LPN K telling RN Supervisor I her concerns regarding observing R10 standing beside R9's bed while R9 was sleeping. RN Supervisor I stated she remembers that conversation. RN Supervisor I stated she felt it was harmless and felt LPN K just didn't want R10 up on the 2nd floor. RN Supervisor I stated R10 walks all over the facility and had no concerns with R10. Surveyor reviewed R10's care plan and it does not indicate any increase supervision after the 3/5/23 observation. The facility does not have any investigation or root cause analysis related to the 3/5/23 observations of R10 in R9's room. Surveyor reviewed R9's care plan and it does not indicate R9 tends to disrobe/remove clothes and masturbates. The care plan does not indicate any privacy or safety measures have been put in place because R9 disrobes and masturbates. On 4/11/23, at 2:30 p.m. during the daily exit meeting with Director of Nursing (DON) B, Nursing Home Administrator (NHA) A and VP of Operations D, Surveyor explained the concern that on 3/5/23 R10 was observed in R9's room and the three staff involved (CNA N, LPN K and LPN J) were concerned about R10's behavior. There is no evidence this incident was investigated, there was no facility self-report and there was no increase in supervision for R10, in turn R10 was able to roam the 2nd floor and sexually assault R9 on 3/26/23. Surveyor also explained the concern the police were not called immediately, and this self-report was not reported to the state agency within 2 hours of the discovery. Surveyor also explained there is no evidence R9 and R10 had an assessment regarding the ability to consent to a sexual relationship. R9 did not have a trauma history assessment performed prior to the incident or after the incident. (Cross-reference F745). VP of Operations D stated in their opinion R9 and R10 were friends and so an assessment to consent to a sexual relationship was not needed. Surveyor asked for evidence of this friendship. Surveyor explained the interviews conducted with staff indicate there was no friendship between R9 and R10. VP of Operations D indicated R9 was seen smiling during the incident, implying it was consensual. Surveyor explained R9 told Medical Director M that she did not like or want the interaction with R10 and did not want to see R10 again. VP of Operations D continued to indicate R10 was just a friendly guy and had many friends including R9 without providing or sharing any evidence of these friendships. VP of Operations D indicated she didn't feel the 3/26/23 incident was abuse because R9 had a smile on her face when found and VP of Operations D stated R9 didn't say no despite having no knowledge of what led up to R10 engaging a sexual event with R9. VP of Operations D stated that no staff indicated through interviews that they were concerned with R10's behavior on 3/5/23 when R10 was found in R9's room. Surveyor explained the facility interviews indicate LPN J and CNA N had concerns with R10's behavior when interviewed by the facility and no follow up/investigation into the documented concerns was noted. Surveyor also explained LPN K was not interviewed by the facility but indicated when interviewed by Surveyor she was concerned by R10's behavior and even wrote a nurses note indicating her concern. VP of Operations D continued to reiterate R9 and R10 were friends and it was not strange for R10 to be standing beside R9, while R9 was in bed sleeping. VP of Operations D indicated R10 probably was checking R9 to see if she was awake. VP of Operations D reiterated she did not feel any of this was abuse. Surveyor reviewed the police report dated 3/27/23. The police report indicates on 3/27/23, the police officer attempted to speak with R9. It indicates R9 was unable to communicate with me and was only able to making (sic) grunting noises. The police report indicates they spoke with R10. R10 told the police he did not have any specific friends or people that he's met in the past 10 months he was at the facility. R10 told the police he likes to go to the activities room upstairs to play games. The police report indicates R9 was initially reported to be nonverbal and non-communicative due to a stroke she previously suffered. She is also diagnosed with bipolar disorder, altered mental status and disruptive mood dysregulation disorder. Due to (R9's) medical and mental health conditions, it was believed she was in a position where she could not give consent for sexual contact. The police report indicates R10 admitted he does not know R9 well and only knows her from attending several activities together. Activities sometimes happen four days a week, but R9 does not attend them all. R10 admitted he does see R9 on a weekly basis and sometimes more than once a week. The statement from R10 to the police officer indicated R10 stated he knows (R9) as she goes to activities a lot and her room is next to activities. (R10) stated he believed her name is (R9's name). R10 was asked if he has ever talked to her before and he responded she cannot talk. R10 stated he was just in the room and wasn't doing anything else. The report continues to indicate: Police Officer V asked (R10) if something took place between him and the female that would make people think that something happened between him and the (R9) and he responded no. R10 stated they were just talking and that sometimes she sits next to him but she cannot talk and sits in a wheelchair. The detective's (Detective W's) narrative on 3/27/23 indicates (Detective W) asked (R10) if ever (sic) has any conversations with (R9). (R10) replied, she cannot talk and that someone needs to push her in her wheelchair. (Detective W) asked him if she (R9) can read or write, and he stated he did not know. (R10) has never had or attempted to have a conversation with (R9). (R10) then told me (R9) can talk but real slow. (R10) again confirmed that he has never talked with (R9). An interview on 3/27/23, at 1640 (4:40 PM) hours indicates (R10) stated he was in the room with a lady in a wheelchair (R9) and a guy named (name of guy) came in the room. R10 then said oh, okay. Bye (name of R9) and that he gave her a kiss on her cheek. (R10) claimed that was all that happened. (R9) is another resident (at the name of the facility) and R10 admitted this interaction took place in the activity room. After the activity residents attended was over, (R10) and (R9) stayed in the room and listened to the radio. (Detective W) asked who (the name of the other resident was named by R10), and he stated he was in the room with them, left to go to his room and then came back to the activity room. Surveyor noted there is no indication in the facility's investigation that they asked how R9 and R10 came to be in the activity room without supervision and when staff last saw the residents. Surveyor noted the facility investigation did not include details to determine if other residents were present or witness etc. The Detective W's interview continues indicating R10 was told an employee was accusing R9 of having her shirt up. (R10) stated she always have (sic) like this and lifted his shirt up to expose his belly. The report indicates R10 was told that an employee observed (R10's) mouth on (R9's) breast. (R10) stated the employee was lying and he has never had sexual contact with (R9). (R10) was asked if he knew that having sexual contact with (R9) would be wrong. (R10) stated Yeah. The detective goes on to tell R10 that she cannot communicate or consent and that she is confined to a wheelchair, (R10) agreed and that she does not have much mobility movement (sic). (R10) again denied kissing or placing his mouth on (R9's) breast and stated another resident named (name of resident) was there with them. (R10) believed (the name of other resident) may have observed him kissing (R9's) cheek. (R10) also claimed it was the first time he had kissed (R9) goodbye. The detective's (Detective W) note dated 3/27/23, at 5:30 p.m. indicates there was an interview with CNA H. It indicates CNA H confirmed he actually saw R10's mouth on R9's breast. CNA H stated when he walked in the room, he thought R10 would immediately stop but R10 did not remove his mouth from R9's breast until CNA H called out and confronted him. CNA H indicated there were no other residents in the room at the time. CNA H informed the detective R9 is able to communicate with someone she is comfortable with and R9 told CNA H that it was R10's idea to kiss R9's breast. The detective note indicates CNA H assisted the detective with R9 when answering the detective's questions. The note indicates with assistance of CNA H, R9 indicated she did not consent to having R10 touching her. R9 also indicated that this was not the first time R10 touched her. R9 again indicated she did not consent to R10 touching her. All of R9's responses were her shaking her head no and responded with saying no to the Detective W's questions. The failure to supervise R10, who had a history of being in R9's room, without R9 being aware R10 was in her room and subsequently on 3/26/23 R10 was observed to be sexually assaulting R9, created a finding of immediate jeopardy. The facility removed the jeopardy on 4/14/23 when it had completed the following: The facility initiated education on the facility's abuse policy and procedure including protecting residents during an investigation. Staff will be tested prior to staring their next shift. Residents with a BIMS score of 8 or above were interviewed. No allegations of abuse were received from residents. Skin evaluations were also completed on all residents with BIMS score of less than 8 with no negative findings. Social Service initiated a record review for all residents to ensure a Trauma informed care evaluation is completed and any triggers are appropriately care planned and added to nursing assistant kardex. Care plans will be updated as necessary. A sexuality screen will be completed on all current residents that are able to understand and able to answer the sexuality screening questions appropriately. Based on the outcome of the screening the facility will set up a care plan meeting with the resident's/participants guardian or other legal representative for health care decisions to discuss the resident's expression of sexuality along with the resident/participant. Residents who are incompetent or incapacitated or display diminished capacity to appraise personal conduct and also demonstrate an indicated need for additional sexuality screening based on factor including but not limited to resident interactions, relationship status, ongoing observations and history, the Social Worker/Designee will do an assessment of the residents/participants to consent to sexual activity using the guidelines in the facility Sexuality and Intimacy Policy. Once evaluations are completed a care plan will be developed for the staff to follow and kardex will be updated New admissions will have a trauma informed care evaluation completed by Social Services and a care plan will be initiated based on evaluation and kardex update. A sexuality screen will be completed on all new admissions that are able to understand and able to answer the sexuality screening questions appropriately. Based on the outcome of the screening the facility will set up a care plan meeting with the resident's/participants guardian or other legal representative for health care decisions to discuss the resident's expression of sexuality along with the resident/participant. New residents who are incompetent or incapacitated or display diminished capacity to appraise personal conduct and also demonstrate an indicated need for additional sexuality screening based on factor including but not limited to resident interactions, relationship status, ongoing observations and history, the Social Worker/Designee will do an assessment of the residents/participants to consent to sexual activity using the guidelines in the facility Sexuality and Intimacy Policy. Once the evaluation is completed a care plan will be developed for staff to follow and kardex will be updated. Assistant Administrator and DON were re-educated on the facility's Abuse Policy, including: abuse prevention; safeguarding the resident during a abuse investigation; reporting timeframes and requires under the Elder Justice Act; and timely reporting allegations to the appropriate agencies, including the state survey agency and local police. The Administrator was also educated on the procedure of notifying the [NAME] President of Operations and the Regional [NAME] President of Clinical Services with all allegations of Abuse. Facility staff will receive education on facility policy and procedure related to resident sexuality and intimacy to include any indicators that residents may be entering into a relationship and who and when to report any potential relationship to and when increased supervision may be needed to include a post test. A Performance Improvement Tool has been developed to monitor timely compliance of abuse reporting to state agencies and local law enforcement. The PI tool will be completed by the Director of Operations or the Regional [NAME] President of Clinical services with each state agency reportable to ensure timely notification of law enforcement and timely notification to state agencies for 3 months with results being forwarded to the QAPI committee for any further recommendations and/or resolution. A Performance Improvement Tool has been developed that will monitor compliance with Trauma Informed Care Evaluations for new admission, including care plan and Kardex updates. PI tool will be completed by the Administrator/Designee Monday through Friday with all new admissions for 30 days, then 2 times weekly for 30 days then monthly for 3 months to ensure Trauma informed evaluation, care plan and Kardex completed as necessary. Results will be forwarded to the QAPI for any further recommendations and/or resolution. A Performance Improvement Tool has been developed that will monitor compliance with newly admitted residents' ability to understand and consent to sexual activity. PI tool will be completed Monday through Friday by Administrator/Designee for 30 days, then 2 times weekly for 30 days then monthly for 3 months with results being forwarded to the QAPI committee for any further recommendations and/or resolution. A questionnaire has been developed and will be completed by 10 staff members to determine staff knowledge in regards to resident rights to have intimacy, identification of potential relationship, reporting of potential intimacy and increased supervision until capacity for intimacy has been determined, daily Monday through Friday for one month, then 2 times weekly for one month, then monthly for 3 months with results being forwarded to the QAPI committee for any further recommendations and/or resolution. New employees will receive resident sexuality and intimacy education upon hire.

Based on record review and interviews, the facility did not ensure 1 (R2) of 1 resident's reviewed receiving hospice services had effective coordination of care between the facility and hospice services to ensure care was provided as indicated. *R2 was admitted to hospice services on 7/21/2022. R2's hospice care plan and facility care plan were not similar resulting in lack or coordination between hospice and the facility. Hospice was not part of R2's care conferences to coordinate care for R2, and hospice staff did not communicate with facility staff upon exiting the building on 12/16/2022 to allow the facility to intervene when R2 was refusing to have their bed lowered resulting in R2 having an unwitnessed fall out of bed that resulted in a major injury. Findings include: The facility policy, entitled Falls and Fall Risk, managing, revised March 2018, states: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Fall Risk Factors 1. Environmental factors that contribute to the risk of falls include: . c. incorrect bed height or width . 2. Resident conditions that may contribute to the risk of falls include: . c. delirium and other cognitive impairment; d. pain; e. lower extremity weakness; f. poor grip strength; g. medication side effects; . i. functional impairments; j. visual deficits; k. incontinence. The HOSPICE SERVICES AGREEMENT, effective June 24, 2021, states: . 2. RESPONSIBILITIES OF FACILITY . h) Facility shall designate a member of facility's interdisciplinary team who is responsible for working with hospice to coordinate care provided by facility staff and hospice staff to any resident under hospice's care. Such interdisciplinary team member shall be responsible for the following: (I) collaborating with hospice and coordinating facility staff participating in the hospice care planning process for those residents who are under hospice's care; (II) communicating with hospice and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the resident and family; . (IV) obtaining the following information from hospice: (A) the most recent hospice plan of care specific to each resident. (V) ensuring the facility provides to hospice an orientation with respect to the policies and procedures of the facility, including resident rights, appropriate forms, and record keeping requirements. Facility shall notify hospice promptly of any change in the designated interdisciplinary team member. I) Facility shall ensure that each residents written plan of care includes both the most recent hospice plan of care if applicable and a description of the services furnished by the facility to attain or maintain the residents highest practicable physical, mental, and psychosocial well being . 3. COMMUNICATION a) General, hospice and facility shall communicate regarding the provision of care to each resident under hospice's care. b) Communication Protocol, Prior to admission of any resident to hospice, hospice and facility shall work together to develop a written communication protocol governing how they will communicate all information needed for residents care, ., including how such communication will be documented to ensure that the needs of residents are addressed and met 24 hours a day. The communication protocol shall include, . a procedure that that clearly outlines the chain of communication between the parties in the event . changes to the hospice plan of care are indicated c) Care Planning. Hospice and facility shall permit each other to attend care planning meetings involving any resident under hospice's care. Each party may reasonably request that a care planning meeting be held with the other . R2 was admitted to the facility on [DATE], R2 transitioned to hospice care on 7/21/2022 and passed away on 12/20/2022 in the facility. R2's diagnoses included muscle weakness, unspecified lack of coordination, unspecified protein-calorie malnutrition, pain, type 2 diabetes, . and a history of falling. R2's quarterly minimum data set (MDS) assessment dated [DATE] assessed R2 needing extensive assist with bed mobility, transfers, dressing, eating, toileting, hygiene cares, and bathing. R2 was immobile and used a Hoyer lift for transfers into a wheelchair. R2's Brief Interview for Mental Status (BIMS) and PHQ-9 were not assessed and R2 had no behaviors. R2 was always incontinent of bowel and urine and wore adult briefs. R2's Risk for falls care plan was initiated on 2/7/2021 with the following interventions: - Anticipate and meet R2's needs. - Be sure R2's call light is within reach and encourage R2 to use it for assistance as needed. R2 needs prompt response to all requests for assistance. - Follow fall protocol. - Provide R2 with mat on floor at bedside. - PT/OT evaluate and treat as ordered or as needed. - Review information on past falls and attempt to determine cause of falls. Record root causes. Alter any potential causes if possible. Educate resident/family/caregivers/interdisciplinary team (IDT) as to causes. - Therapy eval. (initiated 2/8/2021) - Fall mat bedside bed. (initiated 2/8/2021) - Bed in low position with wheels locked when not providing cares. (initiated 4/19/2021) - Bolsters applied to mattress. (initiated 7/2/2021) - Body pillow to left side to keep R2's body positioned in center of bed. Keep bed in low position when not performing cares- Notify nursing if R2 is refusing to allow staff to lower bed. (Initiated 12/16/2022) R2's Hospice Care plan was initiated on 8/16/2022 with the following interventions: - Administer medications as ordered. - Assess coping strategies and respect wishes. - Encourage R2 to express feelings, listen with non-judgmental acceptance and compassion. - Encourage support system to family and friends. - Honor resident and family preferences. - Hospice to provide Spiritual counseling to resident and family as needed. - Notify hospice of any changes in R2's condition. - Observe for pain and discomfort. - Provide education to resident and family as needed. On 12/16/2022 at 1:30 PM in the progress notes, nursing charted R2 had been found on the floor with a head injury. Nursing charted that R2 was lying on R2's right side, a hematoma (bruise) and bleeding was noted to R2's head. Nursing called hospice who stated hospice would be at the facility soon. The Nurse Practitioner (NP) assessed R2 and assisted putting R2 back into R2's bed using a Hoyer lift with the assistance of another registered nurse (RN) and two certified nursing assistants (CNA). RN-P from hospice arrived and called ambulance to transport to hospital per approval of R2's Power of Attorney. On 12/16/2022 at 9:32 PM in the progress notes, RN-G charted R2 returned from emergency department with three neck fractures and a cervical collar to wear at all times. R2 was screaming in pain upon arrival back to facility. RN-G wrote RN-G contacted hospice and obtained a verbal order for increased dose of morphine for R2's pain. RN-G charted safety precautions maintained with bed mobility and assist of one and safety mat at bedside. Surveyor reviewed R2's hospital records from 12/16/2022 visit to the emergency department. R2 had lab tests, chest x-ray, and CT of the cervical spine, and head completed. R2 was diagnosed with: -Closed nondisplaced fracture of the 6th and 7th vertebra (bottom of neck) - Compression fracture of T1 vertebra (top of the spine) On 12/19/2022 the IDT did a root cause of R2's fall and was determined to be poor safety awareness and weakness. Immediate intervention was to place body pillow to left side of R2 to keep R2 positioned in center of R2's bed. Staff was educated to keep beds in low position when not performing cares and notifying nursing if R2 is refusing to let staff lower bed. IDT wrote that upon further investigation and staff interviews it was determined that the hospice CNA-R left R2's bed in high position and left the facility without notifying facility staff of the positioning of R2's bed. On 12/20/2022 at 5:25 AM in progress notes, RN-G charted R2 was observed without a pulse or respirations. Hospice notified. On 4/11/2023 Surveyor reviewed R2's care plans from the facility and hospice. R2's facility care plan documented fall prevention interventions which included fall matt bedside bed initiated 2/8/21, Bed in low position with wheels locked when not providing cares (initiated 4/19/21, and bolsters applied to mattress (initiated 27/2/21). R2's hospice care plan did not identify the facility's safety precautions to prevent potential falls. There is no indication that Hospice services were aware of the facility's fall precautions for R2. Neither the facility or the hospice care plans indicate communication between hospice and nursing home staff when hospice staff are leaving for the day. Surveyor noted R2's care plans for the facility and hospice did not have consistency with interventions which resulted in lack of consistent care between the facility and hospice and staff having different interventions in place for R2. Surveyor also noted hospice was not present at R2's care conferences. On 4/11/2023, at 9:05 AM, Surveyor interviewed RN unit manager (RNUM)-O who stated RNUM-O does not recall what fall interventions were supposed to be in place for R2. RNUM-O stated when RNUM-O called the hospice RN-P who was on their way to the facility. RNUM-O stated did not recall how R2 was when found on the floor. RNUM-O could not recall if a floor mat was in place at the time of R2's fall. RNUM-O stated R2 was not restless while lying in bed but R2 did get squirmy at times but never attempted to get out of bed. RNUM-O recalled the hospice CNA-R was with R2 prior to R2's fall on 12/16/2022. RNUM-O stated the hospice CNA-R did not report off to RNUM-O when hospice CNA-R left. RNUM-O stated not all hospice staff report off when they leave. RNUM-O stated the facility is trying to work on better communication with other agencies for better consistency of care. On 4/11/2023, at 11:06 AM, Surveyor interviewed hospice RN-P who stated RN-P walked into R2's room after the fall to assess and R2 was already back in R2's bed. RN-P attempted to get vital signs on R2, but paramedics arrived to take R2 to the hospital. RN-P stated R2 appeared comfortable, lethargic, and was moaning per R2's baseline and the bleeding on R2's head had stopped. RN-P stated R2's demeanor was mostly laying in bed, very lethargic, not restless at all. RN-P stated R2 had been declining the last few months and diminished verbally. RN-P did not recall if a floor mat was in place at time of R2's fall. R2 had not had any falls prior while R2 was on hospice. On 4/11/2023, at 12:32 PM, Surveyor interviewed hospice CNA-R who stated CNA-R arrived at the facility at 11:15 AM to provide cares for R2. CNA-R stated CNA-R got assistance from a CNA at the facility to reposition R2 onto R2's left side. CNA-R cleaned up R2's room, finished up care for R2, and when CNA-R was lowering R2's bed CNA-R stated R2 told CNA-R not to lower it anymore. CNA-R stated there was not a fall mat in the room that CNA-R has ever seen and did not put a mat on the floor on 12/16/2022 before leaving the facility. CNA-R stated safety precautions were put in place and CNA-R did not recall if CNA-R reported off to staff from the facility at 12:00 PM when CNA-R left the facility. CNA-R stated CNA-R usually reports off to staff but could not recall if CNA-R reported off that day (12/16/2022 at 12:00 PM). Surveyor asked CNA-R to clarify what safety precautions were put in place. CNA-R stated on the hospice care plan for hospice, R2's safety precautions are: - Put items in easy reach of R2. - Use grab bars when showering or toileting R2. - Make sure R2's bed is against the wall. - Remove clutter from R2's room. - Keep R2's floor clean. - Use a wheelchair for transporting. - Check to make sure R2's air mattress was on correct setting and working. CNA-R stated there was nothing regarding keeping bed low or using floor mat for R2. Surveyor noted that R2's care plan for the facility and care plan for hospice were not consistent and did not have the same interventions in place that resulted in inconsistencies with coordination of care between the facility and hospice. Surveyor noted that R2 was admitted into hospice on 7/21/2022 but a significant change MDS was not done until 8/11/2022 and the facility did not initiate a hospice care plan until 8/16/2022. On 4/11/2023, at 1:30 PM, Surveyor interviewed MDS coordinator (MDSc)-S who state MDSc-S worked remotely and someone that is in-house set up a schedule for MDSc-S to follow. MDSc-S did not recall who set those schedules at the time. MDSc-S stated that MDSc-S will open the schedule, start at the bottom, and work up for the MDS assessments that need to be completed. MDSc-S will look through the residents' charts and fill information in based off the information found. If there is information MDSc-S is unable to find and email gets sent out. MDSc-S stated that Social Services will usually initiate care plans, but if MDSc-S sees a care plan that has not been initiated that should have been, MDSc-S will initiate the care plan. On 4/11/2023, at 2:09 PM, Surveyor interviewed Social Services Director (SSD)-L who stated SSD-L started at the facility on 8/8/2022 and had to go back and make up a bunch of care conferences for residents. SSD-L stated SSD-L usually communicates with hospice when care conferences are. Surveyor asked SSD-L regarding the care conference for R2 on 11/30/2022 if hospice was invited. SSD-L did not recall if hospice was called but is written on R2's form that hospice could not make. Surveyor confirmed with SSD-L that no other staff was present at the care conference for R2 on 11/30/2022 and that R2's code status was reviewed. SSD-L was not sure if hospice had access to the facility's care plans but stated hospice staff had access to point click care (healthcare software provider). On 4/11/2023, 2:33 PM, Surveyor interviewed hospice RN-P who states hospice staff did not have access to point click care at the facility R2 was residing at. RN-P stated they never were told or shown how to access point click care. Surveyor asked RN-P if hospice was ever told about or invited to R2's care conferences. RN-P denied being invited or being made aware of R2's care conferences. RN-P stated hospice sent care plans and visit notes to the facility monthly for R2 but did not receive information back from the facility. On 4/12/2023, at 7:21 AM, Surveyor interviewed RN-G who stated R2 returned to the facility on [DATE] from the emergency department following R2's unwitnessed fall out of bed. RN-G stated R2 had a neck brace on that needed to remain in place at all times. RN-G states RN-G put a fall mat in place by R2's bed and initiated hourly checks when R2 arrived back to the facility. RN-G did not recall what interventions were in place prior to R2's fall. RN-G state R2 squirmed a little in bed, R2 would always move to back if R2 was lying on R2's side, but R2 never attempted to get out of bed. On 4/12/2023 at 10:34 AM the Nursing Home administrator was informed of Surveyors concern regarding lack of communication and coordination of care plans between the facility and hospice. Surveyor was handed paperwork that showed trainings hospice did regarding R2's fall and an email between hospice and SSD-L. Surveyor expressed concern that the paperwork received showed how hospice communicated with the facility, but the facility had nothing in place to communicate with hospice. No further information provided at this time.

Based on observation, interview, and record review, the Facility did not provide the necessary care and services to prevent development of pressure injuries and promote healing of pressure injuries for 3 (R28, R78, & R50) of 10 Residents. * R28 was discovered to have a full thickness pressure injury to the left ischium without a treatment in place and without monitoring. * R78 sustained a deep tissue injury to the right medial hand after wearing protective mitts. This pressure injury deteriorated to an unstageable pressure injury with eschar. The Facility did not follow physician orders to discontinue the mitt use and use freedom splints. * R50 had a pressure injury to the right buttocks. The facility did not follow physician orders to limit time up in Broda chair to 2 hours. R50's pressure injury declined and became an unstageable pressure injury. Findings include: The facility policy, entitled Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised in April 2018, states, Assessment and Recognition . 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue Cause and Identification 1.The physician will help identify factors contributing or predisposing residents to skin breakdown; for example, medical comorbidities such as diabetes or congestive heart failure, overall medical instability, cancer or sepsis causing a catabolic state, and macerated or friable skin . Treatment and Management .3. The physician will help staff characterize the likelihood of wound healing, based on a review of pertinent factors, for example: a. Healing or Prevention Likely: The resident's underlying physical condition, prognosis, personal goals and wishes, care instructions, and the ability to cooperate with the treatment plan make wound healing and subsequent wound prevention realistic. b. Healing or Prevention Possible: Healing may be delayed or may occur only partially; wounds may occur despite appropriate preventive efforts. 1. R28 was admitted to the facility on [DATE] and has diagnoses that include: Unspecified paraplegia, Neuromuscular Dysfunction of Bladder with Suprapubic catheter placement, Spina Bifida, Pressure Ulcer of Left Hip and Pressure Ulcer of left Buttock, unspecified stage. R28's quarterly MDS (Minimum Data Set) Assessment with an ARD (Assessment Reference Date) of 09/02/2022 documents R28 has a BIMS (Brief Interview for Mental Status) of 14 indicating R28 is cognitively intact; documents R28 does not have a behavior of refusing cares; R28 needs extensive staff assistance with activities of daily living including needing the assistance of 2 plus staff for bed mobility and R28 is at risk for developing pressure ulcers but has no current pressure ulcers. The 12/03/2022 quarterly MDS indicates R28 has a BIMS of 12 indicating R28 is cognitively intact and continues to require extensive assist for ADL's including 2 plus staff for bed mobility. This MDS indicates R28 is at risk for pressure injuries and currently does not have a pressure injury. Additionally, this MDS indicates R28 did not demonstrate the behavior of rejecting cares. R28's most recent Braden score on 08/23/2022 was a 13, indicating R28 is at a moderate risk to develop pressure injuries. R28's Care Plan, last revised on 11/29/2022 with a target date of 02/27/2023, states: [name of resident] is at risk for impaired skin integrity r/t (related to): diagnosis of spina bifida, paraplegia, depression, pain, impaired sensation, impaired mobility, and incontinence. Resident is frequently non-compliant with interventions despite understanding of risks. Interventions include: Address pain as needed for resident comfort to encourage adherence to interventions to maintain skin integrity. (R28)'s pain is managed with repositioning, offloading, and medication. Apply house moisturizing lotion as needed to keep skin hydrated. Avoid applying between toes and other moist areas. Edema management--apply tubigrips (size E) or compression socks (provided by family) to BLE (Bilateral Lower Extremities) on in AM, off at HS (Hour of Sleep). Resident is frequently non-compliant with use of tubigrips despite frequent education on risks. Encourage resident to elevate BLE when at rest. Resident is frequently noncompliant with elevating BLE despite frequent education on risks. Encourage resident to keep head of bed below 30 degrees. May have head of bed elevated for meals. Moisture management--insure abdominal, groin, and chest folds are cleaned and thoroughly dried twice daily with AM/PM cares. Utilize Ultrasorb pads as needed for areas of high moisture. Monitor skin under/around medical devices (suprapubic catheter) once a shift and as needed. Utilize securement devices and cushion areas of contact to prevent skin irritation. Nursing will assess skin upon admission, weekly on day of scheduled shower, PRN (as needed), and with any change in condition. Any abnormalities will be documented in chart and reported to primary physician and Wound Care Team for follow up. Offload resident to reduce direct pressure on bony prominences. Utilize heel boots and/or pillows to keep heels floated as resident allows. Monitor offloading devices with each encounter to ensure proper positioning. Avoid positioning devices directly over wounds/bony prominences. Resident is frequently non-compliant with use of heel boots and floating heels despite frequent education. Provide resident reminders and assistance with repositioning every 2-3 hours when in bed. [name of resident] was educated regarding pulling down briefs rather than trying to tear them off. Re-educate as needed. Support surfaces for pressure reduction: alternating pressure/low air loss mattress and Roho cushion. Evaluate for effectiveness/proper function with each resident encounter. On 12/06/22 at 9:47 AM, Surveyor observed R28 lying in bed on back, HOB (head of bed) elevated less than 30 degrees, heel boots on to bilateral lower extremities. Surveyor interviewed R28 and asked if R28 had any open areas. R28 informed Surveyor there was an open area located on their bottom and staff were putting cream on it. Surveyor reviewed R28's medical record and noted the following active physician's order .After gentle cleansing and drying, apply Triad cream to posterior scrotum & buttocks . This order was scheduled for every shift and did not specify why the cream was being used. Surveyor reviewed R28's medical record and noted R28 had been readmitted to the facility on [DATE] after a hospital stay. The following was documented in a nurses progress note on 08/23/2022, Resident readmitted to facility from [name of hospital], transported by EMS (Emergency Medical Services) .Stage 2 pressure injuries to left ischium and peri-rectum noted on hospital discharge summary. Resident reports no awareness of skin breakdown and denied knowledge of any treatment in the hospital. WCT (wound care team) notified of reported skin issues .Resident also has orders in place for Triad cream and hygiene routine for past issues with MASD (moisture associated skin damage) to groin/buttock r/t (related to) poor hygiene and leaking suprapubic catheter . Surveyor reviewed the hospital discharge summary dated 08/23/2022 which documented, Stage ll to perineal wound, present on admission, continue with wound care. On 08/23/22 a Skin Only Evaluation documented, Resident deferred full assessment at this time--playing board games with brother; Per hospital report, resident has stage 2 pressure injuries to left ischium and peri-rectum. Surveyor reviewed additional Skin Only Evaluations and noted the following documented: On 08/26/2022 NO new skin issues as a result of this sliding from the bed. On 09/07/2022 No new bruises or injuries On 10/31/2022 Skin intact; On 11/07/2022 No new skin issues noted On 11/14/2022 No new skin concerns. Being followed by wound team for area to butt/scrotum. On 11/21/2022 Treatment to butt/scrotum in place. On 11/28/2022 Treatment to butt/scrotum in place. On 12/05/2022 No new skin issues noted Surveyor noted the most recent wound care team assessment was from 9/23/22 and documented, Weekly assessment completed by Wound Care Team .Triad cream to peri-rectal area MASD (Moisture Associated Dermatitis) with cares. Braden score 13. Risk factors unchanged from previous assessment. Recent weight is 171.2lbs. Intakes adequate and blood sugars not monitored. Interventions in place and include: every 2-hour turning/repositioning (refuses), offloading, heel boots (non-adherent), edema management (non-adherent with LE elevation), pain management, alternating pressure mattress, Roho cushion, incontinence cares, and weekly skin assessment by nursing. Resident educated on current skin condition, interventions, and risks of non-adherence- verbalized understanding, but often non-compliant and hangs leg over edge of bed. WCT (Wound Care Team) will no longer follow. Nursing to notify WCT of any concern or change in skin condition. Surveyor could not locate facility documentation of a pressure injury to the ischium area per hospital discharge summary. Surveyor also noted the Braden score referenced was the assessment from 8/23/22. On 12/08/22 at 7:39 AM, Surveyor observed R28 lying in bed, clean shaven, heel boots on to bilateral lower extremities. R28 gave Surveyor permission to view morning cares. On 12/08/22 at 7:44 AM, CNA (Certified Nursing Assistant)-M prepared to assist R28 with morning cares. CNA-M donned the appropriate PPE (Personal Protective Equipment) for enhanced barrier precautions and performed hand hygiene per professional standards. CNA-M gathered supplies and explained the procedure to R28. CNA-M could not find R28's tubigrips, doffed all PPE, performed hand hygiene and left the room to ask for another pair of tubigrips. On 12/08/22 at 7:54 AM, CNA-M returned, donned appropriate PPE, and performed hand hygiene per professional standards. CNA-M began assisting R28 with morning hygiene cares. Surveyor did not have any issues with cares. On 12/08/22 at 8:00 AM, CNA-M assisted R28 onto their left side and began washing R28's back and buttocks area. Surveyor did not have any issues with cares. During this time, Surveyor viewed R28's buttocks and perineal area. Surveyor noted a circular open area to the left posterior buttocks. The area appeared to have depth, with edges that appeared to have epiboly (rolled or curled-under closed wound edges that may be dried, callused or hyperkeratonic which can impede wound healing). The open area appeared clean, and Surveyor did not note any signs or symptoms of infection. Surveyor pointed to the area and asked CNA-M if the area was open. CNA-M confirmed the area was open. Surveyor asked CNA-M how long R28 had the open area. CNA-M informed Surveyor R28 has had the open area for a while, it clears up and then comes back. Surveyor asked CNA-M what was being done for the wound. CNA-M informed Surveyor the staff attempt to keep the area clean and dry and put a cream on it. CNA-M pointed to the Triad cream that was on R28's bedside dresser. CNA-M stated the area is getting better. On 12/08/22 at 8:05 AM, CNA-M applied a thin layer of triad wound cream to R28's buttocks including the open area. On 12/08/22 at 8:07 AM, R28 informed Surveyor the open area was a problem a month or so ago because the catheter (Suprapubic) was leaking; now the catheter does not seem to be leaking but being incontinent of bowels does not help. CNA-M continued assisting R28 with morning cares. Surveyor did not have any issues with how cares were performed or hand hygiene. On 12/08/22 at 8:13 AM, Surveyor asked CNA-M what she would do if she noticed any new skin conditions. CNA-M replied she would report it the nurse and if the wound care team was in the facility she would report it to them as well. On 12/08/22 at 10:33 AM, Surveyor interviewed Unit Manager, RN (Registered Nurse)-N and Unit Manager, RN-L. Surveyor asked both RN-N and RN-L if R28 had any skin issues. RN-N informed Surveyor R28 had excoriation/denuded skin to buttocks/scrotum. RN-N was not certain of the last time she had assessed R28's bottom. RN-N informed Surveyor the wound care team usually does the follow up for wounds but was uncertain when the wound care team last saw R28. Surveyor informed RN-N the last wound care team note documented in R28's chart was from 09/23/2022. RN-N thought maybe there was something documented in the progress notes and would look through R28's chart. Surveyor explained a concerning issue was noted during morning cares and asked if RN-N would view R28's buttocks with Surveyor. RN-N stated yes, and she would let Surveyor know when R28 was ready to lay down. On 12/08/22 at 11:52 AM, Surveyor asked RN-N if she had any additional information and when would be a good time to view R28's skin. RN-N informed surveyor she was on phone with the wound care team and needed to check downstairs and would touch base with Surveyor. On 12/08/22 at 1:51 PM, Surveyors observed R28 lying in bed. R28 gave permission for both Surveyors to be in the room with RN-N while she assessed R28's skin. RN-N proceeded to don the appropriate PPE and enter R28's room. On 12/08/22 at 2:01 PM, RN-N and Surveyors observed R28's buttocks. Surveyor pointed to the area observed previously and RN-N informed Surveyor the area is open and R28 has had open areas there previously. RN-N stated she will measure the wound and contact the NP (Nurse Practitioner) to obtain a treatment order. Surveyor asked RN-N to update Surveyor with measurements and wound care orders. On 12/08/22 at 3:25 PM, Surveyor interviewed RN-N. RN-N informed Surveyor the area looked like pressure and RN-N had given the measurements to DON (Director of Nursing)-B. Surveyor brought up concerns regarding the hospital discharge summary from 08/23/2022 that mentions a stage 2 pressure injury to the left perineum and lack of facility documentation acknowledging whether that wound was present or not. RN-N informed Surveyor the area has been opened before and it will heal and then reappear. Surveyor brought up concerns about not knowing how long R28 had the current open area with no treatment in place. Surveyor asked RN-N about the Triad cream and if a CNA or nurse should be applying the cream. RN-N informed Surveyor the wound care team did give permission for the CNAs to apply that cream since it was only for maceration. Surveyor asked RN-N when a nurse should assess the skin. RN-N informed Surveyor at some point during the shift, a nurse should apply the triad cream and assess the skin. Otherwise, the skin assessments are weekly during showers. Surveyor asked if there should be measurements for maceration and RN-N replied no, staff would not measure the macerated area. On 12/08/22 at 3:47 PM, Surveyor interviewed DON-B. DON-B informed Surveyor the measurements for the open area were 3cm (centimeters) x 3cm x 2cm. DON-B informed Surveyor she would stage it as a 3, however she will wait for the wound care team to assess and have an extra set of eyes. DON-B informed Surveyor she would not document the stage until the resident is seen by the wound care team. DON-B informed Surveyor there would be no measurements for maceration and the CNAs are allowed to apply the triad cream. DON-B stated the nurses would not need to assess the skin every shift because the cream was only for maceration and skin checks would be done weekly. DON-B informed Surveyor the CNAs may need additional training on recognizing the differences between maceration and an open area. Surveyor asked for any additional information on this wound. On 12/12/2022, Surveyor reviewed R28's medical record and noted the following physician's order, Cleanse wound to left posterior ischium with Puracyn. Place calcium alginate and secure with border foam dressing. Every day shift every Mon, Wed, Fri for Wound care. This order had a start date of 12/08/2022. Surveyor also noted the following documented in a Skin Only Evaluation by DON-B: Wound noted to left ischium, near scrotum. Wound appears clean and moist, with pink, granulated base. Moderate serous drainage noted. No odor . 3x3x2. There is no staging documented in this assessment. Surveyor could not locate an assessment from the wound care team. On 12/12/22 at 3:50 PM, Surveyor asked NHA (Nursing Home Administrator)-A if R28 was seen by the wound care and could Surveyor have a copy of the assessment. NHA-A was uncertain if R28 was seen by wound care but would find out and give Surveyor a copy of the assessment. Surveyor was not given this information prior to survey exit on 12/12/2022. On 12/20/22 the facility provided to Surveyor the assessment completed by the nurse practitioner/wound team. This assessment is dated 12/13/22 and indicates R28 has a full thickness wound measuring 2.5 x 2.1 x 1.5 cm with a wound bed with 100% moist pink with a small amount of hyper-granulation tissue - moderate serosanguinous drainage. Peri-wound is moist with blanchable erythema. The treatment is cleanse with wound cleanser, tuck calcium alginate into wound bed leaving tail out to facilitate removal, cover with bordered foam. Surveyor noted the facility did not specifically stage this pressure injury as part of their assessment. 2.) R78 was admitted to the facility on [DATE] and has diagnoses that include acute respiratory failure with hypoxia, dysphagia, and hypotension. R78's Quarterly Minimum Data Set (MDS) assessment, dated 10/19/22 documents a Brief Interview for Mental Status (BIMS) was scored at 0 indicating severe mental impairment. Section G: Personal Hygiene documents R78 requires total dependence for maintaining personal hygiene and 2+person's physical assist. Upper extremity documents impairment on both sides. It documents that resident is at risk for developing pressure ulcers and at the time of the assessment did not have any unhealed pressure ulcers present. Limb restraints documents daily use. On 12/06/22, at 10:34 AM, Surveyor observed R78 lying in bed wearing white bilateral padded mitts that tie at the wrist. On 12/06/22, at 2:16 PM, Surveyor observed R78 lying in bed wearing white bilateral padded mitts that tie at the wrist. On 12/07/22, at 3:43 PM, Surveyor observed R78 lying in bed wearing white bilateral padded mitts that tie at the wrist. On 12/07/22, at 10:53 AM, Surveyor interviewed Licensed Practical Nurse-S (LPN-S) and asked him what R78 was wearing on his hands. LPN-S stated he was not sure and was not sure why R78 was wearing them but would ask his supervisor. On 12/07/22, at 1:40 PM, Surveyor interviewed Rehabilitation Director-W (Rehab Director). Surveyor asked if the therapy department is usually involved in the assessment for restraint use. Rehab Dir-W stated that they usually are not involved. She stated that typically restraint use is driven by nursing department. We may participate in discussion with the team, but we alone do not make the decision. The Rehab Director informed Surveyor that the restorative aide usually gives residents who wear restraints a break from them when they are doing therapy or restorative services. Our therapist or restorative aide will remove the restraint and complete services and then reapply the restraint. Surveyor asked Rehab Director-W if the therapy staff and restorative aides were trained on the different restraint and splint devices used at the facility. She stated yes. On 12/08/22, at 7:36 AM, Surveyor interviewed LPN-Q. Surveyor asked her what R78 was wearing on his hands. LPN-Q informed surveyor that R78 was wearing protective mitts to protect his trach so he doesn't pull it out. She stated that they check his skin every shift and document it on the medication administration record (MAR). Surveyor asked LPN-Q to show Surveyor where this was being documented. LPN-Q pulled up R78 electronic MAR and pointed to the order for freedom splints and stated this is where we document he is wearing the mitts and the skin checks. Surveyor asked LPN-Q if she was aware of R78 having a DTI to his hand. LPN-Q stated that he has a very small wound on hand, however it is healing. Surveyor asked LPN-Q if it was okay for R78 to be wearing the mitts while the DTI is healing, and she stated yes. On 12/08/22, at 7:39 AM, Surveyor observed R78 lying in bed wearing white bilateral padded mitts that tie at the wrist. On 12/08/22, at 8:08 AM, Surveyor interviewed Certified Nursing Assistant-T (CNA). CNA-T informed Surveyor that R78 was wearing mitts to prevent him from pulling at his tubing. CNA-T stated that R78 wears the mitts almost all the time. Surveyor reviewed the most recent Braden assessment with a date of 11/14/22. The Braden scale for predicting pressure ulcer risk is scored at 11 indicating R78 is at moderate risk for the development of pressure injuries. Surveyor reviewed R78's medical record and noted an active physician's order documenting, Trial resident off of restraints, monitor for safety/behaviors; every shift. This order was dated12/5/2022. Another active physician order documents, Freedom splints to bilateral hands at all times to protect trach integrity; Nurse to check placement and skin integrity every shift. This order was dated 11/15/2022. Surveyor noted a discontinued physician order stating, Mitts to bilateral hands at all times to protect trach integrity; Nurse to check placement and skin integrity every shift. This order has a start date of 9/13/2022 and a discontinued date of 11/15/2022. Surveyor could not locate a current physician order for mitts. (Cross-reference F604). 12/08/22 Surveyor reviewed R78's current Care Plan, dated 7/13/22. Care Plan documents, Don/doff protective mitts to prevent pt (patient) from injuring self. This intervention was initiated on 08/10/2022. R78's Care Plan also documents, has impaired skin integrity, as evidenced by unstageable (previously DTI (device-related)) pressure injury to right lateral hand, acquired in facility. Date initiated was 11/14/2022 and revised on 12/06/2022. Interventions include, Mitt restraint dc'd (discontinued)- freedom splint to be used in place. This intervention was initiated on 11/14/2022. R78 uses bilateral freedom splints d/t (due to) pulling at medical devices such as trach, G (gastrostomy)-tube and vent tubing. This intervention was initiated on 7/19/2022 and revised on 11/15/2022. It also documents that R78 will have, Wound assessment/measurement performed weekly/PRN (as needed) by Wound Care Team. This intervention was initiated on 11/14/2022. Surveyor notes that this current Care Plan has not been updated consistently in all related sections to reflect that the protective mitts were discontinued on 11/15/22 and there are new orders for freedom splints to be use instead of protective mitts. Surveyor review R78 Kardex dated 12/7/22. It documents, Don bilateral resting hand splints daily for 6-8 hours to prevent contractures of digits and hands. Don/doff protective mitts to prevent pt (patient) from injuring self. Surveyor notes that the Kardex still documents the use of protective mitts when these mitts were discontinued on 11/15/22 due to R78 forming a deep tissue injury (DTI) to his right lateral hand and does not document the use of freedom splints. The Kardex does not document any current DTI and interventions. Surveyor reviewed R78's Medication Administration Record (MAR) for November and December 2022. November MAR documents, Mitts to bilateral hands at all times to protect trach integrity; nurse to check placement and skin integrity every shift. Start date 9/13/22 and discontinued date 11/15/22. Documentation of protective mitts is completed for 11/1/22 through 11/15/22. November MAR also documents, Freedom splints to bilateral hands at all times to protect trach integrity, nurse to check placement and skin integrity every shift. Start date 11/15/22 at 1400. Documentation of freedom splint is noted 11/15/22 through 11/30/22. December MAR continues to document the use of freedom splints. Documentation has been completed 12/1/22-12/7/22. Surveyor notes that through observation of R78 on 12/6/22, 12/7/22 and 12/8/22, R78 was wearing protective mitts and not the freedom splints. The December MAR however has staff documenting the protective mitt use under the freedom splints. This is inaccurate documentation of a restraint device. Surveyor reviewed the skin only evaluations for R78. The skin only evaluation dated 11/14/2022 documents a right lateral wrist with a stage of suspected deep tissue injury, depth unknown. Measuring 1 x 1.1. Wound bed is epithelial. Skin notes documents, Resident seen by Wound Care Team at request of nursing for reported bruising to right wrist. Upon assessment, DTI observed to right lateral hand near wrist (device related- mitt). Root cause is mitt restraint. Removed by nursing & freedom splint ordered. Braden score is 13. Surveyor reviewed the Nurse Practitioner progress notes dated 11/14/2022. It documents, Patient noted to have new DTI to right hand likely related to the mitt. Mitt currently off, hand is edematous-we will leave the mitt off to rest for a while. Unspecified open wound of unspecified hand, initial encounter: Deep tissue injury noted to right hand secondary to mitt. The mitt will remain off for a bit to rest. Wound care team following. make sure that the mitt is not too tight around the wrist-continue to monitor. Skin only evaluation dated 11/18/2022 documents a pressure ulcer/injury on right lateral hand with suspected deep tissue injury depth unknow. Measuring 0.8 x 0.9. Skin note documents, Resident seen by Wound Care Team for weekly assessment. Right hand DTI improved and reabsorbing. Braden score is 13. Nurse Practitioner progress note dated 11/21/1022 documents, Patient noted to have new DTI to right hand last week likely related to the mitt. Mitts were removed and Freedom splints placed. Respiratory status stable. No other concerns per nursing - Unspecified open wound of unspecified hand, initial encounter: Deep tissue injury noted to right hand secondary to mitt. The mitt will remain off and freedom splints were placed. Wound care team following. Resolving. Skin only evaluation dated 11/22/2022 documents a pressure ulcer/injury on right lateral hand that is unstageable. Measuring 0.4 x 0.3 x 0.1. Wound bed is necrotic. Skin note documents, Resident seen by Wound Care Team for weekly assessment. Right hand DTI now unstageable as area evolved and now dry eschar- improved/smaller. Braden score is 13. Skin only evaluation dated 11/29/2022 documents a pressure ulcer/injury on right lateral hand that is unstageable. Measuring 0.3 x 0.3 x 0.1 with necrotic tissue. Skin note documents, Resident seen by Wound Care Team for weekly assessment. Right lateral hand slightly improved- eschar edges lifting. Braden score is 13. Skin only evaluation dated 12/02/2022 documents a pressure ulcer/injury to right lateral hand that is unstageable. Measuring 0.3 x 0.3 x 0.1 with necrotic tissue. Skin note documents, Weekly assessment completed by Wound Care Team. Right lateral hand stable- dry eschar and OTA (open to air). Braden score 13. Skin only evaluation dated 12/09/2022 documents, Weekly assessment completed by Wound Care Team. Right lateral hand is now resolved. Braden score 13. On 12/08/22, at 8:32 AM, Surveyor interviewed Registered Nurse Manager-V (RN Manager-V). Surveyor and RN Manager-V spoke outside of R78's room. Surveyor asked RN Manager to identify what R78 was wearing on his hands noting observation on this date. RN Manager-V stated that they call them mitts. Surveyor asked RN Manager if she was familiar with freedom splints. RN Manger-V stated that she was familiar, and that freedom splint are like a plastic material and is applied around the elbow area to prevent the elbow from bending. Surveyor asked how often a resident wearing mitts are monitored. She stated that the skin is checked once per shift or whatever is in the physician order. RN Manager-V stated that residents wear the mitts 24 hours a day, but the skin is checked, and they may also be out of the mitts if they have restorative services and wear a comfy blue bilateral splint. Surveyor asked RN Manager-V if she was aware of R78 having a pressure injury to his hand. RN Manager-V stated yes. Surveyor asked RN Manager-V if there was a current order for the mitts. She stated that there should be an order for the mitts if we are using them. Surveyor asked RN Manager to clarify what an order that states trial resident off of restraints - monitor for safety/behaviors; every shift. RN Manager stated that if there is an order for a trial then I would expect to see no mitts on R78. On 12/08/22, at 3:24 PM, Surveyor interviewed the Director of Nursing (DON-B). Surveyor asked DON-B if she was aware that there currently is no physician order for the protective mitts and R78 was observed wearing protective mitts on 12/6/22, 12/7/22 and 12/8/22. DON-B informed Surveyor that she heard about this. She stated that R78 was switched to freedom splints after receiving a DTI to his hand, however the restorative aide saw the protective mitts in R78's room and continued to put them on him after services. Surveyor asked DON-B if staff are trained on restraint and splint devices at the facility. DON-B stated that staff should be trained and referred Surveyor to the Staff Development Coordinator (SDC-U). Surveyor asked DON-B if she was aware that staff are continuing to document the use of the padded mitts under in the MAR under the current physician order for the freedom splints. DON-B stated she was not aware. When asked who should be monitoring that documentation the DON-B stated the nursing supervisors and myself. On 12/12/22, at 9:45 AM, Surveyor interviewed the Nursing Home Administrator (NHA-A) regarding the above concerns. NHA-A was not sure why R78 would still be wearing protective mitts without a physician order. Surveyor asked NHA-A who was responsible to monitor restraint documentation. NHA-A informed Surveyor that it is everyone's responsibility, however the nursing supervisor should be reviewing nurse documentation. The NHA-A did recall discussing R78 at morning meetings with her staff and his protective mitts in the past but did not recall any concerns recently. No additional information was provided. 3.) R50 was admitted to the facility on [DATE], with diagnoses of acute respiratory failure, cognitive communication deficit, dysphagia, and chronic kidney disease. R50's Quarterly Minimum Data Set (MDS) dated [DATE], documents R50's Brief Interview for Mental Status (BIMS) score of 00 which indicates R50 is severely impaired. Section G: Personal Hygiene documents R50 requires extensive assistance for maintaining personal hygiene and one-person physical assist. Upper and lower extremities documents impairment on both sides. Section M: Skin, documents no pressure ulcer/injury at the time of the assessment and documents he is at risk of developing a pressure ulcer/injury. On 12/07/22, at 1:12 PM, Surveyor observed R50 in Broda chair. On 12/07/22, at 3:44 PM, Surveyor observed R50 in Broda chair asleep. On 12/07/22, at 4:44 PM, Surveyor observed R50 in Broda chair. On 12/08/22, at 1:40 PM, Surveyor observed R50 awake in Broda chair. On 12/08/22, at 3:41 PM, Surveyor observed R50 in Broda chair asleep. Surveyor review R50's medical record and Care Plan dated 3/4/2021 and revised on 11/08/22 documents, Impaired skin integrity, as evidenced by shear injury to right medial buttock, developed in facility. Intervention include, Limit time up in wheelchair to 2 hours at a time. Assist resident to shift weight while up in chair at least once an hour. Nursing to monitor dressing integr [TRUNCATED]

Based on observation, record review and interview, the facility did not ensure all treatment and care was provided to facility residents in accordance with assessment, professional standards of practice, the comprehensive care plan and resident choices in 4 of 4 residents (R55, R3, R17 and R25) reviewed. * On [DATE], R55 had a change in condition. On [DATE] at 6:00 am, R55 had STAT (immediate) orders for a CBC (Complete blood count) and a BMP (Basic Metabolic Panel). There was no evidence that the facility received the results of the STAT lab orders and no evidence that they followed up with the ordering nurse practitioner or the physician. R55 continued to experience a significant decline in condition and was hospitalized on [DATE] with severe sepsis due to a urinary tract infection. R55 expired while at the facility on [DATE] with cause of death as urinary tract infection. * On [DATE] R3 was noted to have Leukocytosis (a high level of white blood cells, indicating possible infection) with a Nurse Practitioner's note stating a UA (urinary analysis) will be sent. Surveyor did not locate any urinalysis results for R3 for [DATE]. Nurse Practitioner X responded she would expect about a 24-hour turnaround time. There was a delay in obtaining R3's urinalysis and was not obtained until [DATE]. * R17 had an unwitnessed fall on [DATE] and neurological checks were not fully completed. * R25 had 2 unwitnessed falls on [DATE] and [DATE]. Neurochecks were not competed. Director of Nursing (DON) B confirmed that neurochecks should been done. * R25's morning blood pressure on [DATE] was ,d+[DATE] and R25 received her morning dose of Amlodipine Besylate 2.5 mg, Metoprolol Succinate ER 25 mg & Clonidine HCL 0.1 mg. R25's physician orders document to hold these medications of R25's systolic blood pressure is less than 100. Surveyor asked RN Unit Manager-C if these medications should have been held on [DATE]. RN Unit Manager-C replied they should have been. Findings include: Surveyor reviewed the facility's Lab and Diagnostic Test Results-Clinical Protocol, Revised [DATE]; 2005, Med-Pass, Inc. Under Assessment and Recognition, the policy states, - The physician will identify, and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. - The staff will process test requisitions and arrange for tests. - The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. Surveyor noted this clinical protocol does not address STAT orders for lab testing, does not address STAT turnaround time, does not address staff follow-up when the results are not received and in such cases a time frame for physician notification. According to Laboratory Medicine Curriculum, Clinical Laboratory-Fundamentals, a STAT test is defined as a quick turnaround time, generally an hour or less from specimen receipt until test result reporting. Such STAT tests are usually ordered when the result is needed quickly for a decision regarding patient management. Such tests must be performed ahead of others in the queue . https://webpath.med.utah/EXAM/LabMedCurric/LabMed01_5.htm# 1.) On ,d+[DATE] and [DATE], Surveyor reviewed R55's medical record which documents in part: R55 was admitted into the facility on [DATE]. R55's diagnosis included in part: Chronic Obstructive Pulmonary Disease (COPD), Heat failure, Type 3 Diabetes Mellitus w/o complications, Essential Hypertension, Chronic Kidney disease stage 3A, Hyperlipidemia, Hypo-osmolality, and hyponatremia, etc. R55 is noted to have a legal guardian. R55's advanced directive indicates R55 is full code. R55's quarterly Minimum Data Set (MDS) dated [DATE] reflects R55 has adequate hearing, clear speech, is understood, understands, has impaired vision seeing large print. The MDS indicates R55 scored a 10 on the Brief Interview for Mental Status which indicates R55 is moderately impaired for daily decision-making skills. R55 requires supervision oversight encourage or cueing, set up help only for eating. The MDS also indicates R55 requires oxygen. R55's care plan includes in part: - R(55) has impaired cognitive function/impaired thought process related to impaired decision making, deemed incompetent by courts, long term (LT) and short-term (ST) memory impairment. Initiated [DATE] with revision on [DATE]. Interventions include: - Monitor/document/report PRN (as needed) any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. [DATE] - Has COPD and CHF (congestive heart failure) with altered respiratory status [DATE] Interventions include in-part: Give aerosol or bronchodilators as ordered, monitor/document/report PRN any signs and symptoms of respiratory infection; fever, chills, increased difficulty breathing XXX[DATE] - Has oxygen therapy related to respiratory illness [DATE] with interventions in-part to include Oxygen per MD orders, change resident position every 2 hours to facilitate lung secretion [DATE]. R's 55's medical record review includes the following progress notes: [DATE] Rapid Swab for Covid-19 performed today resident was negative. [DATE] Resident tested via Rapid Covid test due to Covid outbreak. Results negative. Vital signs obtained on [DATE] at 7:23 a.m. are Blood Pressure: ,d+[DATE] Temperature: 97.9 forehead Pulse: 77 Respiration: 16 [DATE] 03:30 psych follow-up Chart reviewed. Case staffed with treatment team and writer met with patient. Patient seen getting ready for breakfast. She states her mood is OK. She is unable to engage in meaningful conversation today. She is unable to or choosing not to answer further assessment questions. She appears disoriented. Nurse present and states the same. Patient recently tested negative for COVID. Nurse states she will monitor. [DATE]: PHQ9 (mood score): 10 (moderate depression); BIMS: 10 (Moderately Cognitively Impaired). General appearance and behavior: Pleasant, cooperative; Speech: low and slow in rate volume tone, Mood Ok Affect- Constricted, disoriented, Thought Process- Logical, longer time to process and respond, Cognition- Alert Ox,d+[DATE], Judgement/insight-fair. Assessment and Plan: Generalized anxiety disorder. Appears Stable. Does not present anxious .mild cognitive impairment, so stated: Appears more disoriented today and is unable to engage in conversations. Patient still takes time to process and respond to queries. Monitor for worsening behaviors. Nurse aware of symptoms and current medication. Continue to provide reassurance and supportive cares. Monitor closely. Patient is a [AGE] year-old woman with anxiety disorder being seen for a follow up visit. She appears very disoriented today. Nurse states she tested negative for COVID but will monitor. Psychiatric/Mental Health AA. On [DATE], R55 had a psych follow up. Surveyor noted this progress note references R55 as being very disoriented today and to monitor closely. Vital signs obtained on [DATE] at 6:45 p.m. are Blood Pressure: ,d+[DATE] Lying Right arm. Temperature: 98.0 Pulse: 77 Respiration: 18 On ,d+[DATE]/ 22, at 5:22 am, R55 has a temperature of 102.3 orally. R55's Medication Administration Record indicates on [DATE] at 0522 (5:22 am) R55 received Acetaminophen (Tylenol) Tablet 325 mg 2 tablet by mouth every 4 hours as needed for Fever-650 mg tablet. The [DATE] 5:55 (am) Nurses note indicates Writer in to see res d/t (due to) Certified Nursing Assistant (CNA) reports feels warm, res alert in bed responds appropriately, lungs with diminishes sounds, bilateral fields, no coughing noted, 02@3LPM (oxygen at 3 liters per minute) via NC, res given Tylenol 650mg and cooling measures in place. Call placed to on-call no answer informed by receptionist will call when available will notify supervisor and am nurse. Licensed Practical Nurse (LPN) N. There is no evidence of an RN assessment at this time. [DATE] 06:00 (am) Nurses note: (name) NP (X) returned call and updated, new orders STAT CXR (Chest X-Ray), CBC (Complete blood count), BMP (Basic Metabolic Panel), res and guardian (name) message left. On [DATE] Director of Nursing (DON) B provided Surveyor with a screen shot of documentation showing on [DATE] at 6:27 am an online order placed in the lab portal for the STAT CXR, CBC, and BMP that was ordered by NP X. R55's medical record continues: [DATE] 6:02 (am) Nurse note: Rapid Covid neg: LPN N. [DATE] 8:15 (am)-SNF Progress Note NP X acute: Chief complaint: fever, tachycardia, AMS (altered mental status). Patient is seen lying in bed. She has her eyes closed; she is slow to respond. Patient noted to have fever with tachycardia last evening rapid COVID test was negative labs and chest X-ray were ordered. No results as of yet. Oxygen saturation 89% on 3 L. Oxygen was increased to 6 L. Will have IV placed to start IV fluids. Await X -ray and lab results. Vital signs reviewed, stable, occasional soft BP, General No acute distress, comfortable, Cardiac regular rate and rhythm, respiratory clear, no wheeze, no edema, alert interactive . Assessment and Plan: Chronic obstructive lung disease: Oxygen saturation 89% on 3 L, will increase to 8L currently. AMS noted. Awaiting Chest X-ray and lab results. Maintain oxygen saturation greater than 90%. Continue DuoNeb treatments as needed and prescribed inhalers. Monitor closely Fever unspecified: Fever 102.3 last evening, currently afebrile, but feels warm. Tachycardia unspecified: rates is ,d+[DATE]s. Appears regular. Surveyor noted the lab order had been placed into the Lab portal on [DATE] at 6:27 am with the results not yet received. Surveyor was provided with a copy of R55's Chest Xray Radiology report which was electronically signed on [DATE] at 11:39 am. The Xray results documented Lungs: No focal consolidation. Pulmonary vasculature is within normal limits. Pleura: No pneumothorax. No pleural effusion. Conclusion: No acute cardiopulmonary process. Electronically signed by MD CC. The vital signs taken on [DATE] at 8:43 am includes: Blood Pressure: ,d+[DATE] lying left arm Temperature: 97.8 Forehead non-contact Pulse: 112 Respiration: 20 [DATE] 11:31 (am) Nurses Note Resident status has changed, blood pressure low and heart rate increased. No fever noted. Resident appears drained. COVID test negative, chest C-ray and labs completed waiting for results. Writer called Access RN to placed IV for dehydration. Normal Saline 100ml/hr. PRN Nebulizer treatment administered. Writer will continue to monitor for any new concerns. Surveyor noted this was written by LPN Q. [DATE] 13:55 (1:55 pm) Nurses Note Text: Access RN placed IV in resident's right forearm. Writer started Normal Saline @100ml/hr for a total of 1L for dehydration. Writer will continue to monitor. [DATE] 22:39 (10:39 pm) Nurses Note Text: Resident completed NS IV solution this PM shift. IV site dressing to right hand is clean, dry, intact. Resident continues to be lethargic and moderate body twitches, arousable and responsive to touch and verbal tactile. Resident denies any pain or discomfort. Resident fed by writer this shift and ate 75% of dinner tray. Resident vitals obtained this shift is stable, afebrile. This is documented by LPN JJ. Surveyor noted R55 is referenced as being lethargic with moderate body twitches and that R55 was fed by the staff member eating 75% of the dinner tray. R55's [DATE] MDS had indicated R55 only required supervision oversight with encouragement or cueing and set up help only. There is no indication the decline in ability or noted body twitching was discussed with the nurse practitioner or physician. Vital signs obtained on [DATE] at 2:24 a.m. are Pulse: 100 Respirations: 20 O2: 93% Vital signs obtained on [DATE] at 8:43 a.m. are Blood Pressure: ,d+[DATE] Lying Left arm. Temperature: 97.8 Forehead, non-contact Pulse: 112 Respirations: 20 O2: 96% Vital signs obtained on [DATE] at (6:48p.m. Blood pressure: ,d+[DATE] sitting left arm. Temperature: 96.9 oral Pulse: 109 Respirations: 20 O2: 96% Surveyor also was provided with a copy of the facility's 24-hour report/change of condition report dated [DATE] which documents: AM shift: [R55 as having] STAT CBC, BMP, CXR, Nebulizer treatment, call placed IV normal saline 150 ml/hr., decreased blood pressure, increased heart rate, no fever. PM shift: IV right hand, C, D, I, afebrile, VSS. Surveyor noted there is no follow up reference to the [DATE] 6:00 am STAT CBC, BMP, and CXR order. R55's medical record continues: [DATE] 03:46 (am) Nurses Note Text: Res easily aroused responds appropriately when questioned, lungs with diminished sounds, 02@8LPM via NC, no apparent resp. distress pox 93%, twitching noted entire body continuously, skin warm and dry, Tylenol given res denies pain, right wrist PIV intact no s/s of infiltration. This is documented by LPN N. Vital signs obtained on [DATE] at 5:39 a.m. are: Blood Pressure: ,d+[DATE] lying left arm Temperature: 102.2 Oral Pulse: 85 bpm Respiration: O2: 93.0 Oxygen via nasal cannula. [DATE] 05:46 (am) Nurses Note Text: Tylenol suppository given d/t res pocketing meds. This was documented by LPN N. Surveyor noted R55's oxygen was at 93% at 2 LPM via NC and R55's body was noted to have continuous twitching with skin warm and dry. Surveyor also noted R55 was given an Acetaminophen/Tylenol suppository verses tablet form. Additionally, Surveyor did not observe any lab results that had previously been ordered on [DATE] at 6:00 am. Surveyor noted no RN assessment and no call to the physician or NP. R55's medical record continues: [DATE] 07:15 (am) SNF Progress Note [DATE] . [NAME] Note ***CHIEF COMPLAINT*** fever, tachycardia, AMS, hypoxia ***SUBJECTIVE*** Patient is seen lying in bed. She remains lethargic with jerking body movements. She is minimally responsive. She continues to require increased oxygen levels. She is tachycardic and febrile. She was given 1 L NS last evening. CXR was unremarkable. Labs were not performed. Patient will be sent out to evaluation and treatment. ***LAB RESULTS*** Not Recorded ***MICROBIOLOGY RESULTS*** Not Recorded Chronic obstructive lung disease: Oxygen saturation 89% on 3 L, will increase to 8 L currently. AMS (Altered Mental Status) noted. Awaiting chest x-ray and lab results. Maintain oxygen saturation greater than 90%. Continue DuoNeb treatments as needed and prescribed inhalers. Monitor closely. CXR was unremarkable. Required 8L NC. Fever, unspecified: Fever 102.2 this am. Tachycardia, unspecified: rates in the 100s-110s. Appears regular. Related to fever likely. Altered mental status, unspecified: Lethargic with jerking body movements. Minimally responsive. Labs were not drawn and not sure when we can get them, so will send patient out for evaluation and treatment. ***FOLLOW-UP*** Time spent during visit today was 35 minutes, of which greater than 50% of the time was spent in confirming history, reviewing recent hospitalization records regarding multiple medical problems, assessing patient, reviewing facility EHR and collaboration of plan of care with patient/ nursing staff / collaborating providers as detailed above. Provider: (NP X), Signed Date: [DATE] 16:52:17 (4:52:17 pm). Surveyor noted on [DATE] at 07:15 am, NP X's progress note documents R55 remains lethargic with jerking body movements, is minimally responsive, continues to require increased oxygen and was febrile. The progress note also documents labs were not performed and that R55 would be sent out to evaluate and treat. R55's medical record continues: [DATE] 08:45 (am) Health Status Note Text: resident was sent to (name of) hospital, resident had a temp of 102.2, NP X notified, left voicemail for guardian ., bed hold obtained. [DATE] 15:35 (3:35 pm) Nurses Note Text: Writer received call from (name of) hospital and spoke with nurse . Writer informed that resident is being admitted to hospital for sepsis at this time. [DATE] 14:26 (2:26pm) Social Service Progress Note Text: . Later contacted (name of hospital); spoke to nurse; . admitted for severe sepsis, UTI (urinary tract infection), with acute renal failure, hyponatremia, and pneumonia versus a lung mass. Is going to have an ID consult. Social Services-J [DATE] 15:11 (3:11 pm) Nurses Note Text: Discharge summary of medications reviewed with NO n (sic) preparation for today's admit. All medications reviewed and changes made as ordered. PO ATB (antibiotic) to continue x 5 days. [DATE] 20:09 (8:09 pm) Nurses Note Text: Resident returned . (name of hospital) earlier this evening. Resident is alert and oriented baseline. Vitals obtained stable. Resident denies any pain or discomfort. Able to make needs known. Resident has two large dark purple bruises to bilateral AC space, light green bruises to bilateral dorsal hand. Abdomen soft non-tender, Bowel sounds active X4, Lungs clear. Resident is currently resting in bed watching TV, appears to be adjusting well to room. Call-light and water within reach. Surveyor reviewed the Hospitalist Discharge Summary dated [DATE] which indicated in-part: Discharge diagnosis: Severe Sepsis due to and UTI from Klebsiella (bacteria) Altered Mental Status: Improved Possible pneumonia/lung mass (ruled out) Hypernatremia: Improved Hyperkalemia: Improved Acute renal failure: Improved Peripheral artery disease status post intervention in 2019 Type 2 diabetes mellitus COPD Hospital Course/Synopsis: . [AGE] year-old female . alert and oriented X2. She was noted to have less responsive and had fever. The patient is unable to give history .patient arrived on 12 L oxygen. She was febrile with a temperature of 102.8, heart rate 118 but blood pressure has remained normal, was weaned off O2 in ER room, was saturated 93% room air, Chest Xray showed three patchy right perihilar opacity which may be due to an early infiltrate .UA is positive for UTI .Urine culture is positive Klebsiella, pneumonia. She was treated with IV Ceftriaxone. Creatinine and Hypernatremia improved with IV fluids. Her Mental status improved to baseline. CT chest negative for lung mass. R55's medical record continues: [DATE] 02:35 Nurse note: Re-admit-res easily aroused, lungs .resp. Even and non-labored, abd (abdomen) soft round non-tender bsX4, skin warm and dry no edema noted, purple bruise on AC from needle sticks, res denies pain at present time, left safe call light in reach. LPN N [DATE] 05:53 (am) Nurses note NP X and (name) guardian notified of res with no signs of life and 911 here at facility with resident. On [DATE] 7:18 am Surveyor interviewed Director of Nursing (DON) B. Surveyor shared that R55 was noted to be experiencing a change in condition. Surveyor reported R55's medical record indicated a STAT order was received on [DATE] at 6:00 am and as of [DATE] at 7:15 am (24 hours later) NP X's documentation indicates labs were not performed .Labs were not drawn . DON B reported on [DATE] the facility switched labs with the labs first day being [DATE]. DON B stated the order for CBC and BMP was created on [DATE] on the new labs online portal however there was some initial confusion. The new lab did not have their STAT lab set up yet and the lab was going to send out samples which would take longer to get results back. DON B reported she was not sure if anyone came to draw blood or not. DON B stated, in this situation it doesn't look like anyone came out. DON B stated the Phlebotomist now comes to the facility and the lab is working on getting equipment so that they can do the CBCs and BMPs. DON B stated since then, they have worked out wrinkles with the new lab. DON B stated once the problem was recognized they ran all STAT orders through their former Lab until the new lab could get set up. During this conversation, DON B stated she would ask the Phlebotomist to check to see if the lab was drawn on [R55] on [DATE]. DON B stated the STAT lab orders were discontinued on [DATE] when [R55] passed away. Surveyor spoke to DON B again on [DATE] at 11:52 am. Surveyor shared concerns with DON B that it appeared no one was following up on the STAT lab ordered on [DATE] at 6:00 am. DON B stated, the on-line portal information say no results, I haven't asked what happened to the blood draw as [R55] passed away. Procedures are for the nurses to get the result of the lab and call the NP even though the NP says she was checking. When blood work is STAT ordered, we put the order in, and it will go nurse to nurse until passed on in report. Generally, we have a routine lab day and NP X will look since she knows she ordered it, will keep an eye out for them. With the blood draw and them not resulted, doesn't know where the ball was dropped but yes shift to shift is the expectation and at some point, for someone to call the NP saying we haven't gotten the lab back and go on from there. On [DATE] 07:45 AM Surveyor interviewed NP X regarding the ,d+[DATE] STAT CBC and BMP order. NP X stated she saw [R55] twice (,d+[DATE] and ,d+[DATE]). NP X informed Surveyor We weren't sure what was expected from the lab what we needed to do to get the lab, the whole process wasn't really clear, we needed to work out kinks with the new lab and we knew everyone was aware of the new lab, most of time I keep track and check the labs because I see the patients daily, we didn't see anything, so I sent her out. I look at lab results and then I talk to nursing, so they don't always know, even with old lab can be common not to get the labs when we order them. I don't think any treatment was delayed as a result of not getting the STAT lab, we sent her out as soon as we could, saw [R55's] mentation wasn't getting any better. She did get IV first night I saw her. She had Sepsis from UTI (urinary tract infection). Labs at the hospital were high, normally [R55] is very stable so we don't have to check labs, rarely gets a UTI, wasn't first thing on my monitor. It would have been nice to know the labs because the labs were bad. I am here Monday through Friday mostly all day, not weekends. I work for Dr. Y who is the Medical Director here. On [DATE] 08:07 AM, Surveyor interviewed Phlebotomist FF who works for the new lab and who stated, this is her only facility. Phlebotomist FF reported, [R55's] orders were given to her, I came to do them. I did draw the patient [R55] on [DATE], I collected the specimen, and took it over to the lab. I personally dropped it off at the lab. The lab is a 3rd party that does STAT lab XXX[DATE] was a Friday (Surveyor noted it was actually a Thursday). There is usually about a 4 hour turn around. They (the facility) should have gotten results. I remember when I brought it to the lab it was almost closing time, I handed it (specimen) over to her. Usually, the results are not handled on our end, usually management's end. If asked I can call out, see what's going on. The lab was new to the facility that day, I'm not sure if there was a different process for STATs. Surveyor reinterviewed Phlebotomist FF on [DATE] at 02:30 PM. who stated, on [DATE], I took R55's blood draw more in the noonish, anytime between 1 and when I left around 3 pm. I took the specimen to the lab on 36th street. All STATs that come in I have it documented the time they bring it to me. I was here in building and given the STAT order by an RN can't recall the exact RN who gave the STAT order. I can go get the order for you .as the new lab Management agency has office upstairs. Anytime there is a STAT draw and UA the RN fills out form and they give it to lab upstairs. The RN gives it to me, the RN fills out a requisition form and gives it to me. I see what labs need to be drawn I collect the blood and I send out the UA if requested on a form. I will either get specimen packaged for pick up or if it is around the time I leave, I will drop it off. ,d+[DATE] was Thursday the first day I was here. On [DATE] 11:22 AM Surveyor interviewed Dr. Y. who stated, the facility switched Labs. Resident's (R55) fever was 102.2 and the best thing to do was to send her out on [DATE]. The labs are supposed to go directly into Point Click Care, but there is also a portal where lab results go in as well. Most of time we know labs before nurses know. For STAT labs, I allow 4 hours for draw and 4 hours to get back that's my understanding 8 hours. There have been new lab challenges with new lab. They kept me in loop with the lab challenges on the phone as to what was going on. After a few days got a hold of the lab and shared what the expectation is and what is in place to return lab in timely manner. [R55] went to hospital on ,d+[DATE] 8:45 am, she was slowly declining, could have sent her out earlier if we had the lab results however her BP was stable, we were able to manager her O2 in house, had IV fluids, treatment for [R55] already got started, it was a judgement call whether we could wait .reviewing the labs from hospital we could have sent her out earlier, we take critically ill residents, we treat in the hospital, we are used to sick people here. Knowing this patient [R55] and the stability of the patient, was younger we had time to watch, I would have loved to have had the labs and we could have started earlier, the former lab declined to come out to draw . Surveyor asked about the delay in treatment and MD Y stated, there was a delay because of labs however this delay did not cause [R55's] hospitalization , she was sick, the mentation worried us the most she was not eating and drinking .You need labs to make better decisions if the labs are not provided then send Resident out, mentation triggers something else. [R55] was pm 10 Liters (L) of O2, I usually like to send out when the Resident is between ,d+[DATE] L. Initially upon hospital admission, it states, [R55] was 98% on 12 liters, by 11:00 she was at 4 liters and by 1:00 pm, was at 2 liters. So did she really need the 12 liters. Her cause of death was a UTI and thinks the O2 was related to sepsis because you don't go from 12 L to 4 L in 12 hours. If we had the labs things may have been done differently, they tried to resolve the issue and when we couldn't resolve took steps. On [DATE] 02:24 PM, Dr. Y informed Surveyor NP X was capable of making the clinical judgement. If she had the labs, she may have thought differently regarding the delay however it was harder to say if harm occurred. Dr. Y stated if there was a point, we couldn't have waited we would have sent out earlier. The Tylenol brought the temps down, the O2 saturations went down, if NP X was physically in building it was not a concern. [R55] met the criteria for sepsis but there was no source .they (hospital) gave her pills, if we would have known the source (of the sepsis) we may have given her an antibiotic here, but we may have sent her out anyway due to mental status change and her O2 saturations was reason to send out as well as not having the labs. On [DATE] 01:56 PM, Surveyor spoke to Administrator A, DON B, Corporate Consultant H and I regarding R55's lack of having the [DATE] 6:00 AM STAT lab results for CBC and BMP lab orders. Corporate Consultant I stated, the Stat labs go to a lab located in the area. We are pretty sure the blood was drawn and was sent to the lab. Phlebotomist FF is here Monday through Friday from 5:00 am to 9:00 am, long enough to do the lab that is scheduled and after that she is available to come in to draw labs until 3 pm. I have no idea when she drew it, and we can get it from lab. She would have come back to do the lab draw. Corporate Consultant H stated they obtained the new lab because they couldn't get labs from old lab. The new lab is located out of state .We are their only customer in Wisconsin, they have an office upstairs in facility. The phlebotomist is a full-time employee of the lab. This was the only STAT lab on [DATE]. Corporate Consultant H was not aware of other residents with routine lab concerns occurring on [DATE]. DON B discussed sending a Resident out to the hospital for a STAT lab as back up if needed. Corporate Consultant I stated we would send our patient to the hospital for a lab draw. Corporate Consultant I stated, thinks they have 6 to 8 hours to report pm a STAT lab. Staff know if there is a change in condition and the phlebotomist is not here to do the draw staff would notify DON B or NP X or (name) Medical who is on ,d+[DATE] and they would discuss Resident going out to the hospital. In this case, there was no lab result, staff would call DON B or NP X, DON B would follow up with the lab or the NP would give an order to send out. We allow 6 to 8 hours to get the STAT lab. The STAT time would include the time to do the draw and processing time which would be 6 to 8 hours. After 6 to 8 hours would start investigation, would call MD/NP whoever is on call and the get order to send out, if they still would want resident sent. Surveyor shared that the STAT order was placed into the portal on [DATE] at 6:27 am, given 4 hours allowed to draw the lab and 4 hours to process and result the lab, the facility should have had the lab results on [DATE] by 2:30 pm. Facility staff should have started following up with the lab and consultation with the physician/NP on [DATE] by 2:30 pm, which was not done. Surveyor indicated if the phlebotomist would have drawn up the blood on [DATE] at 3:00 pm, 8 hours later would have been [DATE] at 11:00 pm. Surveyor informed the administrative team there was no follow up to this STAT CBC and BMP order while R55 was experiencing a change in condition. There was no consultation with the physician/NP on [DATE] to discuss that the lab results had not been received. Additionally, it is noted in the early morning of [DATE] R55 was demonstrating additional changes in her condition including continuous muscle twitching and pocketing of meds leading to a Tylenol suppository administration. There is no indication these changes were assessed by an RN or communicated with the nurse practitioner or physician for consultation. 42037 2. R3 was admitted to the facility on [DATE] with diagnoses of morbid obesity, urinary retention and muscle weakness. R3's Admission Minimum Data Set (MDS) dated [DATE] notes R3 requires extensive to total assistance with activities of daily living. R3 was admitted to the facility with a urinary catheter in place and is frequently incontinent of bowel. R3 has a history of UTI (Urinary Tract Infections). On [DATE] at 3:33 PM, Surveyor conducted an interview with R3. R3 told Surveyor that they have had UTIs in the past and they are scared they could get sick again if staff aren't paying attention and helping to monitor her catheter and toileting. R3 was alert and appeared to be free from obvious signs and symptoms of infection at the time of the interview. Surveyor reviewed R3's medical record, including Nurse Practitioner progress notes. Surveyor reviewed Nurse Practitioner X's progress note dated [DATE] reads: .Leukocytosis (a high level of white blood cells, indicating possible infection) was noted on today's labs at 17. UA will be sent. On [DATE], Surveyor reviewed R3's medical record, including lab work and urinalysis results for November and December of 2022. Surveyor did not locate any urinalysis results for R3 for [DATE]. Surveyor located urinalysis results for [DATE], indicating R3 was positive for urine abnormalities. On [DATE], R3 was started on antibiotic therapy for a urinary tract infection. On [DATE] at 11:50 AM, Surveyor conducted interview with Nurse Practitioner X. Surveyor asked Nurse Practitioner X if diagnost [TRUNCATED]

Based on interview and record review, the facility did not provide appropriate treatment and services to allow a resident to attain or maintain his or her highest practicable physical, mental and psychosocial well-being for 1 (R356) of 1 resident reviewed who has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The facility did not put effective interventions in place for the suspected root cause of R356's increased behaviors. When R356 had increased anxiety and [CONDITION(S)] resulting in multiple falls, including one with physical injury on admission, the resident was not assessed, provided appropriate interventions and only sent to the hospital. Staff were unaware of interventions to help address R356's increased behaviors. The resident was not assessed by Psychiatric Services in an appropriate manner and resident specific interventions were not put in place. Staff were unaware of how to address R356's behaviors. MDS assessments were not completed to reflect behaviors or dementia with behaviors. Psych medications were not put in place appropriately and were not discontinued when ordered to. After supposedly being discontinued, these medications were used and deemed effective but no assessment of the resident or medication usage was completed. Resident continued to have increased behaviors on an almost daily basis that were not addressed resulting in psychosocial harm. The resident made comments of self-harm that were not addressed by the facility and not monitored or reported to psych services. Findings include: Facility policy and procedure entitled: Behavioral Health Services, with a revision date of February 2019, documents: Policy Statement The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Policy Interpretation and Implementation 1. Behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care. 2. Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care. 3. Residents who do not display symptoms of, or have not been diagnosed with, mental, psychiatric, psychosocial adjustment, substance abuse or post-traumatic stress disorder(s) will not develop behavioral disturbances that cannot be attributed to a specific clinical condition that makes the pattern unavoidable. 4. Staff must promote dignity, autonomy, privacy, socialization and safety as appropriate for each resident and are trained in ways to support residents in distress. 5. Staff training regarding behavioral health services includes, but is not limited to: a. Recognizing changes in behavior that indicate psychological distress; b. Implementing care plan interventions that are relevant to the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] c. Monitoring care plan interventions and reporting changes in condition; and d. Protocols and guidelines related to the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 6. Behavioral health services are provided by staff who are qualified and competent in behavioral health and trauma-informed care. 7. Staff are scheduled in sufficient numbers to manage resident needs throughout the day, evening and night. Facility policy entitled: Behavior Assessment and Management, with an effective date of 6/25/17, documents: It is important to understand causes of behavior problems in our residents. Examples of behavior problems can include a depressed resident withdrawing from other people, an agitated resident shouting repeatedly, and agitated resident hitting someone, or a confused resident wandering from his or her unit. Behavioral health encompasses a residents whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Causes of these behaviors can be internal or external factors that combine to make a behavior happen or keep happening. Some internal factors could be emotion (despair, anxiety, fear), mediation, illness, confusion and pain. Some external factors could be lack of meaningful activity, unpleasant events, unpleasant actions of others, demands of others, light too bright or too dim, too much noise and being misunderstood by others. REMEMBER every problem behavior is likely to have both internal and external causes. Alzheimer's disease and related dementia's as well as mental illness diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Some become anxious or aggressive. Others repeat certain questions or gestures. Many misinterpret what they hear. These reactions can lead to misunderstanding, frustration and tension, particularly between the person with disease process and the caregiver. It is important to understand that usually the person is not acting that way on purpose. Behaviors may be related to physical discomfort, overstimulation, unfamiliar surroundings, complicated tasks and frustrating interactions. 1. Examine the behavior: - What was the behavior? Was it harmful to the individual or others? - What happened just before the behavior occurred? Did something trigger it? - What happened immediately after the behavior occurred? How did you react? - Could something be causing the person pain? - Consult a physician to identify any causes related to medications or illness. 2. Explore potential solutions: - What are the needs of the resident? Are they being met? - Can adapting the surroundings comfort the person? - How can you change your reaction or approach to the behavior? Are you responding in a calm and supportive way? 3. Try different responses: - Did your new response help? - Do you need to explore other potential causes and solutions? If so, what can you do differently? Assessment of resident behaviors: There are many tools available to assess resident behaviors. Information from resident and/or resident representative, nursing observations, comprehensive MDS assessment, behavior monitoring, nursing documentation, social service documentation, etc. Any resident receiving an antipsychotic medication, exhibiting behaviors, etc. should have behavior monitoring. The behavior monitoring assists in identifying the types of behaviors, time of day behavior occurred, how many times behavior occurs and can be utilized in determining potential dose reduction or discontinuation of antipsychotic, or other psychoactive medications. These behaviors may indicate unrecognized needs, preferences, or illness. Care planning of resident behaviors: Understanding the nature of the issue/condition and addressing the underlying causes have the potential to improve the quality of the resident's life and lives of those with whom the resident interacts. Once behaviors have been assessed, the next step is to develop a resident-specific care plan based directly on the conclusion/underlying cause. If behaviors place the resident or others at risk for harm, immediate action is required to prevent any harm. The focus of the care plan should be to address the underlying cause or causes, reversing the daily display of troubling behaviors, and preventing any harm from occurring. How do I handle different behaviors? Working in a long term care facility with many different personalities, disease processes and age differential can be challenging. There is a myriad of responses staff members can take when dealing with a resident exhibiting behaviors. What works one time may not work the next time. The goal is to identify what is causing behaviors and address that cause. Aggressive behavior: This can be verbal (shouting, name calling), or physical (hitting, kicking). May occur suddenly with no apparent reason or can result from a frustrating situation. How to respond: - Identify the immediate cause-what happened right before the event that may have triggered this behavior - Rule out pain - Focus on feelings-look for feelings behind the words or actions other than just details of event - Don't get upset - Try a relaxing activity or shift the focus to another activity- music, massage or activity may have unintentionally cause the event. If so try something different. Anxiety/Agitation A resident may become restless and need to move around or pace. Or, the resident may become upset in certain places and focused on specific details. How to respond: - Listen to the frustration - Provide reassurance-use calming phrases. Maintain your composure. - Involve the person in activities-art, music or whatever their specific interests are. - Modify the environment-decrease noise/distractions, or relocate to different area. - Find outlets for energy-resident may be looking for something to do. Go for a walk. Confusion Resident may not recognize familiar people, places or things. May call family members by other names or confused about where home is. Common items such as a pen or fork may also be forgotten. How to respond: - Stay calm- Not being recognized may be painful or frustrating. Try not to make this apparent. - Respond with brief explanation-Lengthy statements can overwhelm the resident. - Show photos and other reminders - Don't contradict the resident-avoid explanations that sound like scolding. Try I thought that was a fork vs. You know that is a fork and you use it to eat. - Try not to take it personally Repetition A resident may say or do something over and over again. (repeating words, say same phrase, ask same question) May pace or undo what was just done. These actions are rarely harmful to resident but rather stressful for the caregiver. How to respond: - Look for reason behind the repetition - Focus on emotion, not the behavior-do not react to what the resident is doing, respond to how their feeling - Turn action or behavior into an activity-if resident is rubbing his or her hand across a table, provide a cloth and ask for help dusting. - Stay calm and be patient - Provide an answer-give the resident an answer even if you have to repeat it several times. - Use memory aids-like notes, clocks, calendars or photographs - Accept the behavior and work with it-if it isn't harmful, don't worry about it. Suspicion Residents may become suspicious of those around them, accusing others of theft, infidelity or other improper behavior. Misinterpretation of what he or she sees and hears may occur. How to respond: -Don't take offense - Don't argue or try to convince-acknowledge residents opinion - Offer a simple answer-don't overwhelm with lengthy explanation - Switch the focus to another activity-ask for help with a chore, ask what resident did for a living, etc. - Duplicate any lost items-if resident searches for a specific item, have several available. For example, if the resident is always looking for wallet, purchase a few of the same kind. 10 Quick Tips for Responding to Behaviors 1. Remain flexible, patient and calm 2. Explore pain as a trigger 3. Respond to the emotion, not the behavior 4. Don't argue or try to convince 5. Try to identify the unmet need. 6. Acknowledge requests, and respond to them 7. Look for reasons behind each behavior 8. Consult a physician to identify any causes related to medications or illness 9. Don't take the behavior personally 10. Share your experiences with others. R356 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor reviewed R356's Progress Notes. Documented on 3/17/22, at 7:30 PM, was Resident admitted from [hospital name]. Upon arrival, [spouse/wife/Power of Attorney (POA)], present with resident. Resident pleasant and cooperative. Approximately 10 minutes after spouse left facility, resident became agitated, and began to complain of 15/10 pain. Resident demanding to be sent to the hospital, refusing to accept pain medication offered by staff. Resident has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident began to perseverate that his wife was cheating on him with a younger man. Writer called [POA] who wanted resident to remain at the facility. [POA] tried to talk to resident on the phone about staying, but resident continued to talk about relationship issues. Writer updated [Nurse Practitioner (NP)] to confirm admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Writer and [Registered Dietician (RD)] remained in room with resident and talked with resident, offering reassurance and building report (sic). Resident became much calmer, but remained very confused. Writer was able to get resident to openly accept and take Tylenol for pain, which resident had not mentioned again since initial conversation. [Executive Director (NHA)-A], updated on resident situation, and also came to talk with resident. Resident agreeable at this time to staying the night at the facility, but will require frequent monitoring and reassurance/redirection due to confusion. Bed in low position with wheels locked. Door open for staff to visualize resident. Personal items, water, call light, urinal, and remote within reach. Resident clean, dry, and appears comfortable with alternating pressure/[low air loss (LAL)] mattress in place and functioning appropriately. Writer assisted resident with using urinal prior to leaving room. Surveyor noted that staff identified spouse leaving as a trigger for anxiety and increased behaviors. Documented on 3/18/22, at 12:54 AM, was Patient is new admit day 2, patient is with increased confusion, stating that he needs to go to the hospital and requesting staff to call the police because he states he left the bar a few hours ago and while he was there someone spiked his drink. Called to the patients room by [Respiratory Therapist (RT)], patient on the floor laying aside the bed, bed in low position, call light attached to patients gown, patient states he fell out of the bed to get someone's attention, patient complaint of hitting his head at time of fall, states his neck hurts, there is a laceration to the right head and left lower leg, [NP] updated and to send patient to [name of hospital] for eval and treat, left message for patients wife to call for an update, [name of ambulance company] ambulance was called and on their way for pick up. The resident was sent to the hospital and returned. R356 suffered a head and leg laceration. R356's medical record documented on 3/18/22, at 1:13 PM, was Writer spoke with [POA] this morning to obtain a verbal consent for resident to be seen by [psych services] - [POA] gave verbal consent to writer over the phone. Surveyor reviewed R356's Referral for Psychiatric Services form. Documented under Reason for Referral was Depression. Surveyor reviewed R356's Comprehensive Care Plan with an initiation date of 3/18/20. Documented was: Focus: [R356] has a behavior problem (agitation, impulsiveness, paranoia) related to (r/t) vascular dementia. Refuses to take medications, respiratory treatments and to eat at times. Goal: [R356] will have fewer episodes of behaviors by review date. Interventions: - Administer medications as ordered. Monitor/document for side effects and effectiveness. - Anticipate and meet [R356's] needs. - Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him when passing by. - Explain all procedures to the resident before starting and allow the resident time to adjust to changes. - Minimize potential for the resident's disruptive behaviors by offering tasks which divert attention such as talking about family . (daughters) or work history. - Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. - Provide a program of activities that is of interest and accommodates resident's status . Focus: [R356] has impaired cognitive function and impaired thought processes r/t vascular dementia. Goal: - [R356] will maintain current level of cognitive function through the review date. Interventions: - Administer medications as ordered. Monitor/document for side effects and effectiveness. - Allow/encourage resident to verbalize feelings and fears. - Approach resident in a calm, friendly, non-rushed manner. - Assist resident per ADL (Activities of Daily Living) care plan. - Communicate with the resident/family/caregivers regarding residents capabilities and needs. - Cue, reorient, and supervise as needed. - Focus on resident's strengths. - Keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. - Let resident make as many daily decisions as possible. - Monitor with routine MDS interviews and [as needed (PRN)]. - Prefers to be called: [R356's name] - Provide a program of activities that accommodates the resident's abilities. - Psych. referral as needed. Surveyor noted spouse not present was not documented as a trigger for anxiety and increased behaviors in R356's care plan. The care plan was not updated to address the potential behavior trigger or to provide interventions to address resident specific behaviors during R356's stay at the facility. R356's medical record documented on 3/18/22, at 2:56 PM,: 0715 (7:15 AM): Writer received call from wife, wife wanted writer to take away resident's cell phone and room phone so he is unable to call her. Wife state he was constantly calling her throughout the night and she would like some rest. Writer warned wife, we are unable to comply with request at this time. Wife verbalized understanding. R356's medical record documented on 3/18/22, at 0820 (8:20 AM): Resident began whistling and yelling for help. Writer entered residence room to address concern. Resident wanted urinal to void. Writer handed resident urinal and reminded him to use call light instead of yelling and whistling for staff. Resident agreed. R356's medical record documented on 3/18/22, at 0900 (9:00 AM): Resident refused morning medication and stated writer was holding him against his will. R356's medical record documented on 3/18/22, at 1245 (12:45 PM): Resident began whistling and yelling for help once more demanding for staff to call wife, he refused his noon medication once again accusing writer of holding him against his will. Writer attempted to call wife however, call went straight to voicemail. Resident proceeded to ask writer to call daughter. Daughter answered phone and writer witness resident demanding daughter to call the District Attorney . R356's medical record documented on 3/18/22, at 3:27 PM, Writer visited resident this afternoon to complete assessment- resident appeared very flustered, he kept referring to his wife with all questions writer asked- resident had writer call his wife but the phone went straight to voicemail, resident proceeded to leave a message for about 5 minutes, when writer asked if he wanted the phone hung up, resident stated no and continued talking into the phone accusing his wife of abandoning him-[Former Psych (NP)-SS] is visiting resident now. Surveyor reviewed Psych NP-SS visit note from 3/18/22. Documented was .Pt (Patient) is seen today because of increased agitation, repeat phone calls to wife, paranoia about wife cheating on him, accusatory of staff. Staff reports that he has been inconsolable, he has refused cares from staff despite soiled clothing. He has refused medications, some of which are analgesics. Agitation may be associated with pain as well. The pt state he has never had [CONDITION(S)], never had mental health hospitalization . He states he used to work with [name of company] as a distribution manager and traveled widely, that could have all the beer he wanted, He states his brother is a doctor and accurately states where the clinic was, who set it up, and who the partner is. He states he did not disagree to take pills, and states he will take his pills right now. Nurse was able to administer medications to him. As pt is highly agitated and unable to achieve good rest, with ramping up of anxiety, we will trial [MEDICATION(S)] 0.5mg three times daily (tid) x (for) 4 days scheduled. Next week we will have it as as needed (PRN) every (q) 8 hours, and at the same time, help to acclimatize him to new environment. Surveyor noted there were no non-pharmacological interventions added to R356's care plan at this time. R356's medical record documented on 3/20/22, at 12:59 PM, Writer called in to the room by primary nurse stating the resident is highly anxious requesting to leave against medical advice (AMA) due to his wife cheating on him and taking all his money. On arrival to resident's room resident is A/O x4 (alert and orientated to person, place, time and event). Requesting to be transferred to [name of hospital] hospital because he don't feel good. Resident state his arm is not well and want to go to the hospital. Resident noted to be moving right arm during conversation, but lacks fine motor skills. Per wife since his fall 3 months ago and has requires feeding since the fall 3 months ago. Wife has been feeding resident d/t (due to) inability to coordinate . Surveyor reviewed R356's admission MDS (Minimum Data Set) with an assessment reference date of 3/23/22, which documents: a BIMS (brief interview mental status) score of 12, indicating moderate cognitive impairment. Documented under [CONDITION(S)], Acute onset mental status change: Is there evidence of an acute change in mental status from the resident's baseline? No. Inattention - Did the resident have difficulty focusing attention, for example, being easily distractable or having difficulty keeping track of what was being said? Behavior present, fluctuates (comes and goes, changes in severity). Documented under Behavior was Potential Indicators of [CONDITION(S)]: None of the Above . Overall Presence of Behavioral Symptoms: No . Behaviors not exhibited . Surveyor reviewed R356's Care Area Assessments (CAA) with an assessment reference date of 3/23/22. There was no assessment for [CONDITION(S)], Mood State or Behavioral Symptoms documented. R356's medical record documents on 3/23/22, at 11:14 AM, Resident currently being monitored for behaviors. Resident having some difficulty adjusting to facility. Resident continues to yell out asking help from staff. Needs are met by staff. Resident continue to express want to go home to be with family. Resident redirected several times throughout the day explaining the reason for stay. Surveyor reviewed Psych NP-SS visit note from 3/25/22. Documented was Psych NP f/u (follow up) CC: Paranoia, anxiety, disruptive behaviors Patient seen in room laying down in bed. Patient states his mood is pretty good. Patient denies feeling down, depressed or hopeless. Patient denies feeling anxious but reports he is wondering when he can go home. Patient states he is sleeping and eating well. Staff reports hypersexual verbal comments. Patient states he doesn't remember making any sexual comments but that he may have said it in his sleep. Spoke at length with [wife], pt started showing signs of forgetfulness about 2 years ago, but more evident of late now accusing her of extramarital affairs, now being more paranoid. Pt is in room, as well, he is eating a home cooked meal. He needs to be fed as he has pain to his extremities associated with C-spine O/A (open area), and stenosis. [Wife] stated that it seems [MEDICATION(S)] 0.5mg TID prn has calmed him down so he does not call her constantly or feeling increased paranoia about her . Surveyor noted no non-pharmacological interventions were added to R356's care plan and the behavior of making hypersexual verbal comments was not added to the care plan or addressed by the facility. Surveyor reviewed facility Unwitnessed Fall Report, dated 3/26/22 at 12:38 AM, which documents: [R356] had a fall in his room. Documented under Incident Description was Nursing Description: Called into patients' room by [Certified Nursing Assistant's name], patient found on floor on side of bed face first. Resident Description: Patient states he was trying to get everyone's attention so he put himself on the floor, call light was on, staff were in the room minutes prior changing him and upon fall he was dry. Immediate Action Taken: Assessed patient for injury, no injury seen, VSS (Vital Signs Stable), denies pain or discomfort. Patient was removed from the floor via the Hoyer and two other staff members, NP updated and attempted to notify the patients wife but no answer. R356's medical record documented on 3/26/22, 2:47 PM, Pt (Patient) stated wanted to die pt was transported to hospital reported shoulder was in pain. R356's medical record documented on 3/26/22, at 2:49 PM, RN (Registered Nurse) stated she found resident partially out of bed with right shoulder on the ground. Resident c/o (complained of) shoulder pain from fall on NOC (night shift) and is demanding to go to the emergency room . Writer spoke with on call NP, NP agrees to send resident the ER (emergency room ). In addition, resident stated he does not want to live anymore and has been refusing to eat, refusing RT (Respiratory Therapy) treatment, and refusing to take his medication. Writer requested a psych evaluation while resident is in hospital if possible. Wife was notified and is agreeable. [Name of ambulance company] ambulance arrive to take resident, resident left with no resistance. [R356' a name] was transported to the hospital on 3/26/22 around 3:00 PM. Surveyor reviewed Hospital Paperwork from 3/26/22 ER visit. There was no documentation of a psych evaluation occurring in the hospital. There was no documentation R356 was assessed for suicidal thoughts. Paperwork documented resident was sent to ER for Fall (uncertain cause), contusion (upper extremity) and back contusion. R356's medical record documented on 3/26/22, at 11:01 PM, Resident returned from [ER] for evaluation for fall, nno (no new orders) remains alert responsive no injury noted rom (range of motion) wnl (within normal limits) denies pain at this time. Will continue to monitor. Surveyor noted upon R356's return to the facility from the ER, there was no monitoring, assessments or interventions put in place to address R356 stating he does not want to live anymore. Surveyor reviewed Electronic Medical Record (EMR). There was no monitoring, documentation or assessments of R356's mood and behavior upon readmission. The next documentation in the EMR was completed 3/27/22, at 6:05 PM, by the Activities Director (AD)-ZZ which documented Resident was visited and appeared to be less anxious prior to his going to the hospital. Resident stated he did not need anything at this time and was watching TV. Staff will continue to visit for socialization. R356's medical record documents on 3/29/22, at 7:00 PM, resident refused dinner. yelling at CNA stating I'm having chest pain send me out nurse assessed resident, VSS and writer made aware of situation. lungs coarse, RR (Respiratory Rate) WNL, resident on [CONDITION(S)] collar 6 liters, 02 (oxygen level) in 90s. NP to be called. Resident was sent to the hospital and admitted [DATE] through 3/31/22. R356's medical record documented on 3/31/22, at 6:15 PM, EMS (Emergency Medical Services) returned to facility to drop off hospital paperwork. Resident was discharged from hospital due to noncompliance per DC (Discharge) summary. NP aware. Surveyor noted R356's care plan was not updated to reflect the noncompliance nor new interventions put into place to address R356's noncompliance. R356's medical record documented on 3/31/22, at 7:35 PM, writer called to room-resident laying on floor mat next to bed, fully dressed with gripper socks. bed in low position. resident yelling send me to hospital . I threw myself out of bed and hurt my right arm and shoulder. resident thrashing up and down from ground. CNA monitoring resident until EMS arrives. VSS, NP and wife updated . R356's medical record documented on 4/1/22, at 3:29 PM, Patient returned back to facility via ambulance on a stretcher at 0247 (2:47 AM) to room [room number], pt has been oriented to his room, bed and call light controls, pt went out because of right shoulder and arm pain and returned with negative x-ray results no fx (fracture). Patient is alert x 1-2, he knows that he is in a medical setting but then said not sure where, when asked where he is coming from he said I was at the bar having a drink with my guy . Surveyor noted there were no interventions added to R356's care plan to address his delusions and no behavior monitoring put into place assess R356's delusional behaviors. R356's medical record documented on 4/1/22, at 7:05 AM, Writer called to the room by the aides because [name of resident] was on the floor. Writer assessed [name of resident] and he complained of left hip pain and left thigh pain and stated, send me to the emergency room . Writer contacted [name of transport company] for transport . At 8:46 AM a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . For the pt's safety, we will trial [MEDICATION(S)] 25mg bid (twice a day) for a brief trial. Surveyor noted R356 was sent to the hospital and admitted from 4/1/22 through 4/15/22. The [MEDICATION(S)] was not started and R356 was discharged back to the facility with orders for [MEDICATION(S)] Sprinkles. Surveyor reviewed MD orders starting 4/15/22 from the hospital that documented [MEDICATION(S)] Sprinkles, Take 1 capsule (125 mg) by mouth every 6 hours as needed for agitation. [MEDICATION(S)], Take 0.5 tablets (5 mg total) by mouth nightly for dementia. [MEDICATION(S)], Take 1 tablet (5 mg total) by mouth nightly for dementia. Surveyor reviewed April 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Only 1 dose of [MEDICATION(S)] as needed was given for agitation on 4/18/22 and the effectiveness was documented as unknown. R356's medial record documented on 4/16/22, 1:10 AM, F/u readmit. Resident alert to name with confusion at time. Calling out for help me. wanting to get up to go home, wanting police to be call so they can take him to the hospital . R356's medical record documented on 4/16/22, at 12:23 PM, Resident noted to be screaming out psychotically all morning, all needs met by staff, denies pain. Redirection and other interventions offered and unsuccessful. Frequent checks completed on patient as patient is very impulsive and has decreased safety awareness. Patient noted to be found laying on the floor next to his bed, stating that he is trying to go home to tell my wife where I am. Patient awake and alert, denies hitting head but states that he hurt his neck and shoulder. VSS. [CONDITION(S)] in place and sating at 95% on RA (Room Air). Patient requesting to go to the hospital to be evaluated . Resident to be transferred to hospital . Surveyor noted R356 returned the facility on 4/16/22 with no monitoring or new interventions in place related to the documented psychotic behaviors. R356's medical record documents on 4/16/22, at 6:29 PM, Called to patients room by his nurse, patient on the floor, patient states that he put himself on the floor because he was trying to get some attention, VSS, patients wife updated and message left for case worker, call out to [name of medical

Based on interview, and record review, the facility did not ensure 1 (R4) of 5 residents reviewed received the necessary care and services for fall prevention. R4 had a fall from the bed to the floor with subsequent disconnection from the ventilator and inability to be reconnected causing respiratory distress and need to be transferred and admitted to the hospital. R4 did not have a fall risk observation completed on 8/4/21 upon admission in accordance with facility policy. R4 did not have a baseline care plan indicating R4's risk status for falls, specifying interventions to prevent falls. Findings include: The facility policy, Fall Management, dated 6/25/17, stated a fall risk observation is used to identify individuals who are at high risk for falls, as well as those individuals who have any risk factors for falls on a regular schedule including admission to the facility. Communicate residents risk status and interventions to care givers. Develop a plan of care which can include general and specific interventions to reduce falls risk. R4 was admitted to the facility on [DATE] and transferred to the ER (emergency room ) via 911 on 8/7/21 after a fall from the bed to the floor and disconnection from the ventilator. R4's diagnoses include ARF (Acute Respiratory Failure) due to [CONDITION(S)] (low oxygenation in the blood), CHF (Congestive Heart Failure), Pneumonia, Pulmonary Hypertension, [CONDITION(S)] (Chronic Obstructive Pulmonary Disease), [CONDITION(S)], Diabetes, and [CONDITION(S)]. R4's MDS (Minimum Data Set) which was discharge return anticipated, dated 8/7/21, indicated R4 required extensive assistance for bed mobility and toileting, total staff dependence for transfer. R4 was dependent on the ventilator for breathing and respiratory stability. R4's ventilator settings were AC (Assist Control) which submits a set number of breaths at a set volume of air which was 500 cc, and a PEEP (Positive End Expiratory Pressure) of 8 cm that is designed to help keep the airway open while the machine delivers R4's required and necessary breaths. R4's progress notes on 8/7/21 at 6:03 AM indicated R4 fell off the bed while CNA-E was changing R4. R4 was disconnected from the ventilator and the RT (Respiratory Therapist) was called into R4's room as R4's oxygen saturation started dropping and R4 was turning blue (due to lack of ventilation and oxygenation). RT began to manually provide breaths via an ambu bag and R4's oxygen saturation began to rise to 88%. 911 was called and R4 was transported to the hospital. On 9/1/21, at 1:44 PM, Surveyor received R4's records from NHA-A (Nursing Home Administrator) who stated the facility was unable to obtain a copy of the physician orders as R4 had been discharged from the system, R4 did not have a CNA Care Card, and she was unaware if there was a fall investigation follow up. On 9/2/21, at 6:15 AM, Surveyor interviewed RN-C (Registered Nurse) who works at the facility as the night shift supervisor. RN-C stated R4 was able to make needs known, move slightly in bed but could not roll self over, was alert with a [CONDITION(S)] (artificial airway) connected to the ventilator. RN-C stated she reviews the resident's and their care needs with the CNAs in a report at the beginning of the shift. RN-C stated she told CNA-E that R4 was a 2 person assist and transfer but CNA-E chose to care for R4 independently without asking for assistance. RN-C stated she was assisting another resident when she heard CNA-E yell for help. RN-C stated when she entered R4's room, R4 was lying on the floor with the top part of R4's body being held up by CNA-E with the bed at medium height. RN-C stated she could not get around to the other side of the bed to assist and CNA-E had to let go of R4. RN-C stated R4's [CONDITION(S)] did not come out but R4 had become disconnected from the ventilator as the machine was on the opposite side of the bed from where R4 had fallen. RT came to the room and began to manually provide breaths via an ambu bag as R4 had blue lips, 911 was called, and RT continued to manually provide breaths as R4 remained on the floor until the paramedics took over the care and transported R4 to the hospital. RN-C stated a fall incident report was entered into the computer as per procedure. Surveyor reviewed the fall incident report which indicated R4 was on the floor and incontinent of bowel and bladder. The report indicated that when the RT entered the room, R4 had to be turned on R4's back because RT was unable to reach the [CONDITION(S)] and R4's oxygen saturations were dropping to 60-70's and R4 was turning blue. RT was able to begin ambu bagging R4 via the [CONDITION(S)] and R4's oxygen saturation began to come up to 88%. R4 was admitted to the hospital following the respiratory distress. On 9/2/21, at 8:08 AM, Surveyor interviewed DON-B (Director of Nursing) stated we complete a baseline care plan within 48 hours but R4 was not in the facility long enough. DON-B stated she verified with RN-C that CNA-E knew how to care for R4 and the root cause of the fall was failure of the staff to follow the verbal supervisor report as R4 did not have a baseline care plan. DON-B stated the facility relies on verbal report until an established baseline care plan. DON-B stated the fall incident report is entered into the EMR (Electronic Medical Record) by the nurse and DON-B will close it out after completing education. On 9/2/21 at 8:14 am Surveyor noted the nursing admission assessment that would document information such as R4's activity of daily living needs for assistance and functional assessment was marked as in progress in the electronic medical record. Upon further review, Surveyor noted the form was blank at this time. Surveyor noted R4 did not have a fall risk observation completed on 8/4/21 upon admission in accordance with facility policy, and R4 did not have a care plan indicating the risk status and fall interventions for R4. On 9/2/21, at 3:00 PM, the Survey team conducted the facility exit and no further information was provided.

Based on observation, record review and interview, the facility did not ensure that 13 of 16 residents reviewed and at risk for developing pressure injuries received consistent measures to prevent the development of pressure injuries. * R9 developed an unstageable pressure injury at the facility as a result of wearing socks that put pressure on R9's skin. Noncompliance is being cited at severity level 3/actual harm. * R34, R35, R46, R48, R88, R5, R8, R41, R49, R66, R67 & R75 were all observed not to have their heels offloaded in order to prevent the development of pressure injuries. Findings include: Surveyor reviewed the facility's policy and procedure on Prevention of Pressure Injuries, Revised April 2020: Purpose The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Preparation Review the Resident's care plan and identify the risk factors as well as the interventions designed to reduce to eliminate those considered modifiable Mobility/Repositioning 1. Reposition all Residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team 2. Choose a frequency for repositioning on the Resident's risk factors and current clinical practice guidelines 3. Teach Residents who change positions independently the importance of repositioning. Provide support devices and assistance as needed. Remind and encourage Residents to change positions. Support Surfaces and Pressure Redistribution 1. Select appropriate support surfaces based on the Resident's risk factors, in accordance with current clinical practice Device-Related Pressure Injuries 1. Review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application and ability to secure the device 2. Monitor regularly for comfort and signs of pressure-related injury 3. For prevention measures associated with specific devices, consult current clinical practice guidelines Monitoring 1. Evaluate, report and document potential changes in the skin 2. Review the interventions and strategies for effectiveness on an ongoing basis In addition, The Prevention of Pressure Injuries policy and procedure 2001 Med-Pass, Inc. (Revised April 2020) under skin assessment documents; 3. Inspect the skin on a daily basis when performing or assisting with personal cares or ADL's (activities daily living). a. Identify any signs of developing pressure injuries (i.e., non-blanchable, erythema). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbow, ischium, trochanter, etc.); c. Wash the skin after any episodes of incontinence, using pH balanced skin cleanser; d. Moisturize dry skin daily; and e. Reposition resident as indicated on the care plan. Under Support Surfaces and Pressure Redistribution documents 1. Select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice. 1. R9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's Quarterly MDS (Minimum Data Set) dated 6/10/21 documents that R9 has short and long term memory problems. Section C1000 (Cognitive Skills for Daily Decision Making) documents that R9 has severely impaired cognitive skills for daily decision making. Surveyor noted R9 was not interviewable. Section G documents that R9 has total dependence on staff and requires a one person physical assist for her transfer mobility needs. Section G also documents that R9 requires extensive assistance and a two person physical assist for her bed mobility needs. Section G0400 (Functional Limitation in Range of Motion) documents that R9 has no impairment to either side of both her upper and lower extremities. Section M (Skin Conditions) documents that R9 had 1 unhealed unstageable pressure injury at the time of the MDS. Section M also documents that R9 is at risk for the development of pressure injuries. R9's Pressure Injury CAA (Care Area Assessment) dated 3/10/21 documents under the Analysis of Findings section, R9 admitted with a Stage 3 pressure ulcer to her coccyx and is at risk for development of further pressure ulcers. She has impaired mobility from prior CVA ([CONDITION(S)] Accident). She also suffers from Alzheimer's Disease. She is dependent upon staff for bed mobility, transfers, locomotion. She is incontinent of bowel and bladder. Weekly skin assessments are done by licensed staff. Pressure relieving device to bed and chair. She is being seen by in-house wound team. Will proceed to care plan with interventions to reduce risk for further development of pressure ulcers. R9's Braden Scale for Predicting Pressure Sore/Injury assessment dated [DATE] documents a score of 12, indicating that R9 is at high risk for the development of pressure injuries. R9's Skin Integrity plan of care dated as initiated on 3/3/21 documents under the Focus section, R9 has risk for further impaired skin integrity r/t (related to): age, CVA ([CONDITION(S)] accident), muscle weakness. Under the Interventions section it documents that as of 3/3/21, R9 had the following interventions in place: Offload resident to reduce direct pressure on bony prominences. Utilize heel boots and/or pillows to keep heels floated when possible. Monitor offloading devices with each encounter to ensure proper positioning. Avoid positioning devices directly over wounds/bony prominences. R9's Skin Only note and assessment dated [DATE] documents, Skin Issue: Pressure Ulcer / Injury. Skin issue location: Left Anterior Lower Leg Pressure Ulcer / Injury Stage: Unstageable. Length: 2.9 Width: 1.5 Depth: 0.1 Wound bed: Slough. Wound exudate: Serosanguineous. Peri wound condition: WNL (within normal limits). Dressing saturation: Minimal (<25%). Wound odor: No. Tunneling: No. Undermining: No. The Skin note (as part of this 5/14/21 assessment): Resident seen by WCT (wound care team) at request of nursing staff. New unstageable pressure injuries noted to bilateral anterior lower legs. Resident noted wearing tight ankle socks cutting into skin above ankle. Socks removed, protective dressings placed, and heel boots reapplied . Interventions in place to address risk factors remain appropriate. Resident unable to retain any education at this time. Care plans reviewed and updated. WCT will continue to follow. Nursing to notify WCT of any change in skin condition. Surveyor was unable to locate any documentation in R9's medical records that prior to the development of R9's unstageable pressure injuries, R9's socks were removed and or that R9's lower legs were offloaded for the prevention of pressure injuries per R9's plan of care. R9's Skin Only note and assessment dated [DATE] documents, Skin warm & dry, skin color WNL, mucous membranes moist, turgor normal. Resident has current skin issues. Skin Issue: Pressure Ulcer/ Injury. Skin issue location: Left Anterior Lower Leg Pressure Ulcer/ Injury Stage: Unstageable. Length: 1.8 Width: 1.2 Depth: 0.1 Wound bed: Slough. Wound exudate: None. Peri wound condition: WNL. Dressing saturation: None. Wound odor: No. Tunneling: No. Undermining: No. Skin Issue: Pressure Ulcer / Injury. Skin issue location: Right Anterior Lower Leg Pressure Ulcer/ Injury Stage: Unstageable. Length: 2 Width: 1.6 Depth: 0.1 Wound bed: Slough. Wound exudate: None. Peri wound condition: WNL. Dressing saturation: None. Wound odor: No. Tunneling: No. Undermining: No; Skin note: Resident seen by WCT for weekly assessment. Skin integrity remains impaired. All wounds are showing improvement with decrease in area. R9's medical record documents that R9 was transferred to the hospital on 5/25/21 and was readmitted to the facility on [DATE]. R9's medical record documents that upon R9's readmission to the facility on [DATE], R9's right lower leg unstageable pressure injury was healed. R9's Skin Only note and assessment dated [DATE] documents, Skin warm & dry, skin color WNL, mucous membranes moist, turgor normal. Resident has current skin issues. Skin Issue: Pressure Ulcer/ Injury. Skin issue location: Left Anterior Lower Leg Pressure Ulcer/ Injury Stage: Unstageable. Length: 2.3 Width: 1.9 Depth: 0.1 Wound bed: Slough. Wound exudate: Serous. Peri wound condition: WNL. Dressing saturation: Minimal (<25%). Wound odor: No. Tunneling: No. Undermining: No. The Skin note: Resident seen by Wound Care Team for skin assessment upon return from LOA (leave of absence). Skin integrity is impaired, as evidenced by stage 3 pressure injury to sacrum and unstageable pressure injury to left anterior lower leg, present upon readmission. Braden score is 12. R9's Skin Only note and assessment dated [DATE] documents, Skin warm & dry, skin color WNL, mucous membranes moist, turgor normal. Resident has current skin issues. Skin Issue: Pressure Ulcer/ Injury. Skin issue location: Left Anterior Lower Leg Pressure Ulcer/ Injury Stage: Unstageable. Length: 1.5 Width: 0.7 Depth: 0.1 Wound bed: Slough. Wound exudate: Serous. Peri wound condition: WNL. Dressing saturation: Minimal (<25%). Wound odor: No. Tunneling: No. Undermining: No. The Skin note: Resident seen by WCT for weekly assessment. Skin integrity remains impaired. Wound to left anterior lower leg is improving with decrease in area. R9's Skin Only note and assessment dated [DATE] documents, Skin warm & dry, skin color WNL, mucous membranes moist, turgor normal. Resident has current skin issues. Skin Issue: Pressure Ulcer/ Injury. Skin issue location: Left Anterior Lower Leg Pressure Ulcer/ Injury Stage: Unstageable. Length: 0.8 Width: 0.5 Depth: 0.1 Wound bed: Slough. Wound exudate: None. Peri wound condition: WNL. Dressing saturation: None. Wound odor: No. Tunneling: No. Undermining: No. The Skin note: Resident seen by WCT for weekly assessment. Skin integrity remains impaired. Both wounds are showing improvement with decrease in area. Treatment to left anterior lower leg changed to [MEDICATION(S)] due to desiccation of slough. Surveyor was unable to locate any documentation in R9's medical records that prior to the development of R9's unstageable pressure injuries, R9's socks were removed daily and that the skin beneath the socks were being monitored. On 6/17/21 at 1:05 p.m., Surveyor informed DON (Director of Nursing)-B of the above findings. Surveyor asked DON-B to confirm that the above pressure injury documentation was accurate and to confirm the origin of the unstageable pressure injury. DON-B directed Surveyor to speak with the wound care team to obtain additional information. On 6/21/21 at 10:53 a.m., Surveyor interviewed Wound RN (Registered Nurse)-E regarding R9's left anterior lower leg unstageable pressure injury. Surveyor asked Wound RN-E to confirm that the above pressure injury documentation was accurate and to confirm the origin of the unstageable pressure injury. Wound RN-E reviewed the above documentation and informed Surveyor that the documentation was accurate. Wound RN-E informed Surveyor that the initial cause of R9's left anterior lower leg unstageable pressure injury was due to the socks putting pressure on the area. Surveyor asked Wound RN-E if she was aware of any interventions that were put in place prior to R9's unstageable pressure injury formation regarding R9's sock use, as Surveyor was unable to locate any in R9's medical record. Wound RN-E informed Surveyor that she believed R9 was wearing pressure relieving boots prior to the formation of her unstageable pressure injuries, but that she was not aware of any specific intervention regarding R9's sock use. Wound RN-E informed Surveyor that she was unaware of any intervention that limited or monitored the use of socks by R9 prior to the formation of R9's unstageable pressure injury. Wound RN-E informed Surveyor that after the formation, the facility put in place an intervention to ensure that R9 was wearing larger slipper socks to prevent the formation of pressure injuries. Wound RN-E informed Surveyor that the facility had obtained a Doppler assessment of R9's left lower leg and that the area was found to have vascular circulation impairment. On 6/21/21 at approximately 11:00 a.m., Surveyor was provided with R9's Doppler Report dated 6/18/21 that documented, Doppler Report: Bilateral Duplex Lower Extremity Arterial- Conclusion: No focal hemodynamically significant stenosis and no occlusion. Generally decreased velocities are present suggest decreased flow to the lower extremities and may present proximal disease. No information was provided as to why the facility did not ensure that R9 received care, consistent with professional standards of practice, to prevent the development of pressure injuries. 2. R34 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R34's Admission MDS (Minimum Data Set) dated 4/8/21 documents that R34 has short and long term memory problems. Section C1000 (Cognitive Skills for Daily Decision Making) documents that R34 has severely impaired cognitive skills for daily decision making. Surveyor noted R34 was not interviewable. Section G (Functional Status) documents that R34 requires extensive assistance and a two person physical assist for her transfer and bed mobility needs. Section G0400 (Functional Limitation in Range of Motion) documents that R34 has impairment to one side of her upper and lower extremities. R34's Pressure Ulcer/Injury CAA (Care Area Assessment) dated 4/8/21 documents under the Analysis of Findings section, R34 is at risk for development of pressure ulcers due to impaired mobility. She requires assist with bed mobility and transfers. She is incontinent of bowel. Has Foley catheter for urinary control due to [CONDITION(S)] bladder. Has hx (history) of CVA ([CONDITION(S)] accident) with left [CONDITION(S)] . Pressure reducing mattress and cushion in chair. Pericare provided after each incontinent episode. Will proceed to care plan. R34's Braden Score for Predicting Pressure Sores/Injuries assessment dated [DATE] documents a score of 13, indicating that R34 is at moderate risk for the development of pressure injuries. R34's Pressure Ulcer/Injury care plan dated as initiated on 4/12/21 documents under the Focus section, The resident has potential for pressure ulcer development r/t (related to) Immobility, malnutrition, [CONDITION(S)], DM, abdominal binder. Surveyor noted that R34's care planned interventions did not directly address off loading of R34's heels, even though R34 was noted to be at moderate risk for the development of pressure injuries, required assistance with bed mobility and had functional limitations in range of motion to one side of her upper and lower extremity. On 6/14/21 at 11:58 a.m., Surveyor observed R34 laying supine in bed with her heels resting directly on the mattress and not offloaded to prevent the formation of pressure injuries. Surveyor observed R34 to have socks on her feet and was not wearing any pressure relieving boots. On 6/16/21 at 7:43 a.m., Surveyor observed R34 laying supine in bed with her heels resting directly on the mattress and not offloaded to prevent the formation of pressure injuries. Surveyor observed R34 to have socks on her feet and was not wearing any pressure relieving boots. On 6/17/21 at 1:20 p.m., Surveyor informed DON (Director of Nursing)-B of the above findings. Surveyor asked DON-B if R34 should have her heels offloaded to prevent the formation of pressure injuries. DON-B informed Surveyor that she would review R34's plan of care and let staff know that R34's heels are to be offloaded. No additional information was provided. 3. R35 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R35's Quarterly MDS (Minimum Data Set) dated 4/7/21 documents that R35 has short and long term memory problems. Section C1000 (Cognitive Skills for Daily Decision Making) documents that R35 has severely impaired cognitive skills for daily decision making. Surveyor noted R35 was not interviewable. Section G documents that R35 requires extensive assistance and a one person physical assist for his bed mobility needs. Section G0400 (Functional Limitation in Range of Motion) documents that R35 has impairment on one side of both his upper and lower extremities. R35's Pressure Ulcer/Injury CAA (Care Area Assessment) dated 1/5/21 documents under the Analysis of Findings section, At risk for development of pressure ulcers due to impaired mobility, incontinence. He requires staff assist for bed mobility. Is incontinent of bowel and bladder. Pericare is provided after each incontinent episode. Other risk factors include DM (Diabetes Mellitus), [CONDITION(S)], right [CONDITION(S)]. Weekly skin assessments by licensed staff. Pressure reducing device to mattress and chair. R35's Braden Score for Predicting Pressure Ulcers/Injuries assessment dated [DATE] documents a score of 12, indicating that R35 is at high risk for the development of pressure injuries. R35's Skin Impairment care plan dated as initiated on 12/30/20 documents under the Interventions section, Offload resident to reduce direct pressure on bony prominences. Utilize heel boots and/or pillows to keep heels floated when possible. Neck pillow Monitor offloading devices with each encounter to ensure proper positioning. Avoid positioning devices directly over wounds/bony prominences. On 6/14/21 at 11:59 a.m., Surveyor observed R35 laying supine in bed with his heels resting directly on the mattress and not offloaded as documented in R35's plan of care. Surveyor observed R35 to have socks on his feet and was not wearing any pressure relieving boots. On 6/14/21 at 2:45 p.m., Surveyor observed R35 laying supine in bed with his heels resting directly on the mattress and not offloaded as documented in R35's plan of care. Surveyor observed R35 to have socks on his feet and was not wearing any pressure relieving boots. On 6/15/21 at 1:41 p.m., Surveyor observed R35 laying supine in bed with his heels resting directly on the mattress and not offloaded as documented in R35's plan of care. Surveyor observed R35 to have socks on his feet and was not wearing any pressure relieving boots. On 6/15/21 at 4:08 p.m., Surveyor observed R35 laying supine in bed with his heels resting directly on the mattress and not offloaded as documented in R35's plan of care. Surveyor observed R35 to have socks on his feet and was not wearing any relieving boots. Surveyor observed R35's heel boots to be on the floor and not on R35's feet. On 6/16/21 at 3:12 p.m., Surveyor observed R35 laying supine in bed with his heels resting directly on the mattress and not offloaded as documented in R35's plan of care. Surveyor observed R35 to have socks on his feet and was not wearing any pressure relieving boots. Surveyor observed R35's heel boots to be on the floor and not on R35's feet. On 6/17/21 at 7:46 a.m., Surveyor observed R35 laying supine in bed with his heels resting directly on the mattress and not offloaded as documented in R35's plan of care. Surveyor observed R35 to have socks on his feet and was not wearing any relieving boots. Surveyor observed R35's heel boots to be on the floor and not on R35's feet. On 6/17/21 at 10:43 a.m., Surveyor observed R35 laying supine in bed with his heels resting directly on the mattress and not offloaded as documented in R35's plan of care. Surveyor observed R35 to have socks on his feet and was not wearing any pressure relieving boots. Surveyor observed R35's heel boots to be on the floor and not on R35's feet. On 6/17/21 at 1:20 p.m., Surveyor informed DON (Director of Nursing)-B of the above findings. DON-B informed Surveyor that she would speak with staff to ensure that R35's heel boots were on. No additional information was provided. 4. R46's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The at risk for impaired skin integrity care plan initiated 12/1/20 includes an intervention dated 12/1/20 of Offload resident to reduce direct pressure on bony prominences. Utilize heel boots and/or pillow to keep heels floated when possible. Monitor offloading devices with each encounter to ensure proper positioning. Avoid positioning devices directly over wounds/bony prominences. The Braden assessment dated [DATE] has a score of 13 which indicates is at moderate risk for pressure injury development. The quarterly MDS (Minimum Data Set) with an assessment reference date of 4/17/21 documents a BIMS (brief interview mental status) score of 9 which indicates moderately impaired. R46 requires extensive assistance with one person physical assist for bed mobility and doesn't ambulate. R46 is at risk for pressure injury development and is coded as not having any pressure injuries. On 6/14/21 at 10:43 a.m. Surveyor observed R46 in bed on his back with the head of the bed elevated, there is over bed table across him and the quarter side rail on the left side of R46's bed. R46 was wearing yellow gripper socks with his heels resting directly on the mattress. Surveyor asked R46 if he ever wears boots when he is in bed. R46 replied yes. Surveyor asked where the boots were. R46 replied they are in the closet. On 6/14/21 at 12:26 p.m. Surveyor observed R46 in bed on his back with the head of the bed up and a lunch tray on the over bed table. R46 is wearing yellow gripper socks and his heels are continuing to rest directly on the mattress. On 6/14/21 at 1:38 p.m. Surveyor observed R46 continues to be in bed on his back with the head of the bed elevated. R46's heels continue to be resting directly on the mattress and are not being offloaded. On 6/14/21 at 2:47 p.m. Surveyor observed R46 continues to be in bed on his back. R46 continues to be wearing yellow gripper socks and his heels are resting directly on the mattress. On 6/15/21 at 7:17 a.m. Surveyor observed R46 in bed on his back with the head of the bed elevated. R46 is wearing yellow gripper socks and his heels are resting directly on the mattress. On 6/15/21 at 8:58 a.m. Surveyor observed R46 in bed on his back. R46 is wearing bilateral ankle splints. On 6/16/21 at 7:18 a.m. Surveyor observed R46 in bed on his back with his head of the bed up. R46 has bare feet and his heels are resting directly on the mattress. On 6/17/21 at 7:38 a.m. Surveyor observed R46 in bed on his back and the head of the bed elevated. R46 has bare feet with his heels resting directly on the mattress and are not being offloaded. On 6/17/21 at 8:16 a.m. Surveyor observed R46 continues to be in bed on his back with the head of the bed elevated. R46 has bare feet with his heels resting directly on the mattress and are not being offloaded. On 6/17/21 at 9:42 a.m. Surveyor observed R46 continues to be in bed on his back with the head of the bed elevated high. There is a breakfast tray on the over bed table across R46. R46 continues to have bare feet and his heels are resting directly on the mattress. On 6/17/21 at 11:56 a.m. Surveyor observed R46 in bed on his back with the head of the bed elevated. R46's heels are resting directly on the mattress and are not being offloaded. On 6/17/21 at 11:59 a.m. Surveyor asked CNA (Certified Nursing Assistant)-EE when Residents are in bed how should their heels be. CNA-EE informed Surveyor they should be floated on a pillow and should not be on the mattress. On 6/17/21 at 2:34 p.m. Administrator-A, DON (Director of Nursing)-B and RN (Registered Nurse) Consultant-F were informed of the above. On 6/17/21 at 3:23 p.m. Surveyor observed R46 in bed on his back with the head of the bed elevated. R46's has bare feet and his heels are resting directly on the mattress. 5. R48's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R48 has a [CONDITION(S)], is on a ventilator, receives his nutrition via G (gastrostomy)-tube and has an indwelling catheter. The at risk for impaired skin integrity care plan initiated 1/12/21 & revised 6/16/21 includes an intervention dated 1/12/21 of Offload resident to reduce direct pressure on bony prominences. Utilize heel boots and/or pillows to keep heels floated when possible. Monitor offloading devices with each encounter to ensure proper positioning. Avoid positioning devices directly over wounds/bony prominences. The quarterly MDS (Minimum Data Set) with an assessment reference date of 4/18/21 documents a BIMS (brief interview mental status) score of 6 which indicates severe impairment. R48 requires extensive assistance with two plus person physical assist for bed mobility & transfer, and does not ambulate. R48 is at risk for pressure injury development and is coded as not having any pressure injuries. On 6/17/21 at 7:36 a.m. Surveyor observed R48 in bed on his back with the head of the bed elevated and two pillow under R48's head. R48 has gripper socks on his feet and R48's heels are resting directly on the mattress. Surveyor noted this is the first observation during the survey that R48 was not wearing pressure relieving boots while in bed. On 6/17/21 at 8:14 a.m. Surveyor observed R48 continues to be in bed on his back with the head of the bed elevated. R48 is wearing gripper socks with his heels resting directly on the mattress. R48's heels are not being offloaded and R48 is not wearing pressure relieving boots. On 6/17/21 at 9:40 a.m. R48 continues to be in bed on his back. R48 is wearing only gripper socks and his heels are resting directly on the mattress. On 6/17/21 at 10:50 a.m. R48 continues to be in bed on his back. R48 is wearing only gripper socks with his heels resting directly on the mattress. On 6/17/21 at 11:54 a.m. Surveyor observed R48 continues to be in bed on his back with the head of the bed elevated. R48 is wearing only gripper socks and his heels are resting directly on the mattress. On 6/17/21 at 2:34 p.m. Administrator-A, DON (Director of Nursing)-B and RN (Registered Nurse) Consultant-F were informed of the above. On 6/17/21 at 3:22 p.m. Surveyor observed R48 continues to be in bed on his back with the head of the bed elevated. R48 heels are resting directly on the mattress. 6. R88 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] & [CONDITION(S)], and dependence on respirator. R88 has a [CONDITION(S)], is on a ventilator, receives her nutrition via G-tube and has an indwelling catheter. The at risk for impaired skin integrity care plan initiated 12/1/20 & revised 12/23/20 includes an intervention initiated 12/1/20 & revised 12/15/20 of Offload resident to reduce direct pressure on bony prominences. Utilize heel boots and/or pillows to keep heels floated when possible. Monitor offloading devices with each encounter to ensure proper positioning. Avoid positioning devices directly over wounds/bony prominences. The Braden assessment dated [DATE] documents a score of 9 which indicates very high risk for pressure injury development. The quarterly MDS (Minimum Data Set) with an assessment reference date of 5/26/21 documents R88 has short & long term memory problems and is severely impaired for cognitive skills for daily decision making. R88 is dependent with two plus person physical assist for bed mobility & transfer and does not ambulate. R88 is at risk for pressure injury development and is coded as not having any pressure injuries. On 6/14/21 at 10:05 a.m. Surveyor observed R88 in bed on her back with a pillow under her right shoulder. Surveyor observed R88's heels are not being offloaded. On 6/14/21 at 11:33 a.m. Surveyor observed R88 in bed on her left side with the head of the bed elevated. R88 is wearing red gripper socks with her right heel resting directly on the pillow and the left heel is on the mattress. R88's heels are not being offloaded. On 6/14/21 at 2:50 p.m. Surveyor observed R88 in bed on her back. Surveyor observed R88's heels are not being offloaded. On 6/15/21 at 7:08 a.m. Surveyor observed R88 in bed on her back with the head of the bed elevated. There is a pillow under R88's lower legs and R88's heels are resting directly on the pillow. On 6/15/21 at 9:01 a.m. Surveyor observed R88 in bed on her left side with a pillow along R88's upper right side. There is a pillow under R88's lower legs and R88's heels are resting directly on the mattress. On 6/15/21 at 3:48 p.m. Surveyor observed R88 in bed on her back with the head of the bed elevated. There is a pillow under R88's legs. The right heel is being offloaded but the left heel is resting directly on the mattress. On 6/16/21 at 7:13 a.m. Surveyor observed R88 in bed on her back with the head of the bed elevated. R88 head is leaning towards the right. Surveyor observed R88's heels are not being offloaded. On 6/16/21 at 8:18 a.m. Surveyor observed R88 in bed on her back with a device under R88's head to keep her head straight. Surveyor observed R88's heels are not being offloaded. On 6/17/21 at 7:30 a.m. Surveyor observed R88 in bed on her back with the device to keep her head straight. R88's heels are not being offloaded and are resting directly on the mattress. On 6/17/21 at 8:13 a.m. Surveyor observed R88 continues to be on her back with her heels resting directly on the mattress. R88's heels were not being offloaded. On 6/17/21 at 9:39 a.m. Surveyor observed R88 continues to be on her back with her heels resting directly on the mattress. R88's heels were not being offloaded. On 6/17/21 at 10:48 a.m. Surveyor observed R88 continues to be on her back with her heels resting directly on the mattress. R88's heels were not being offloaded. On 6/17/21 at 11:53 a.m. Surveyor observed R88 continues to be on her back with her heels resting directly on the mattress. R88's heels were not being offloaded. On 6/17/21 at 11:59 a.m. Surveyor asked CNA (Certified Nursing Assistant)-EE when Residents are in bed how should their heels be. CNA-EE informed Surveyor they should be floated on a pillow and should not be on the mattress. On 6/17/21 at 2:34 p.m. Administrator-A, DON (Director of Nursing)-B and RN (Registered Nurse) Consultant-F were informed of the above. On 6/17/21 at 3:20 p.m. Surveyor observed R88 continues to be on her back with her heels resting directly on the mattress. R88's heels were not being offloaded. 7. R5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5 has an activated Health Care Power of Attorney(HCPOA). R5's Quarterly Minimum Data Set(MDS) dated [DATE] documents R5 to have a Brief Interview for Mental Status(BIMS) score of 12, indicating R5 demonstrates moderately impaired skills for daily decision making. R5's MDS documents that R5 required extensive assistance for bed mobility, total dependence for toileting, and transfers at the time of the MDS was not happening. The MDS documents that R5 is at risk for pressure areas but currently has none. Surveyor reviewed R5's Kardex Report as of 6/14/21 and notes the following i [TRUNCATED]

Based on interview and record review, the facility failed to ensure that 1 (R1) of 3 residents reviewed for anticoagulants was adequately monitored for therapeutic levels. R1 was admitted to the facility on [DATE] with orders for the anticoagulant [MEDICATION NAME] and [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) for monitoring of therapeutic level of 2 to 3. R1 was started on the medication [DATE]. The facility did not put in orders for PT/INR's to be drawn. The facility did not check with the physician about routine monitoring of PT/INR, did not implement the standing orders to monitor PT/INR on Mondays and Thursdays for anyone on [MEDICATION NAME], and did not begin an anticoagulant care plan for R1 to monitor for adverse signs and symptoms. The facility did not have a system for ensuring residents who received anticoagulant therapy were monitored. Beginning with the blood draw that should have occurred on [DATE], there was no subsequent monitoring of R1's PT/INR level. R1 received her scheduled [MEDICATION NAME] each day in [DATE]. On [DATE] Medical Director (MD)-J started this resident on an antibiotic for five days. Antibiotics can interact with [MEDICATION NAME] and potentiate its effect, thereby placing the individual at greater risk of bleeding. Despite this, the facility did not monitor R1's PT/INR or ask about reducing the dosage of [MEDICATION NAME]. The facility gave this antibiotic for three days from [DATE] through [DATE]. On [DATE] the resident was sent out 911 after uncontrolled bleeding from her [MEDICAL CONDITION] stoma and was admitted to the hospital with [REDACTED]. The facility's failure to monitor the resident's PT/INR causing uncontrolled bleeding and hospitalization created a finding of Immediate Jeopardy (IJ) that began on [DATE]. Surveyor notified Nursing Home Administrator (NHA-A) and Director of Nursing (DON-B) of the IJ on [DATE] at 10:20 AM. The IJ was removed on [DATE]; 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. Findings include: According to the National Institute of Health (Medline Plus), [MEDICATION NAME] may cause severe bleeding that can be life-threatening and even cause death. According to the article Bleeding Risks and Response to Therapy in Patients with INR Higher than 9, Close monitoring of INR is necessary to avoid both under and over-anticoagulation. INR higher than 4 has been associated with an increased risk of bleeding, and the risk of [MEDICAL CONDITION] increases approximately 2-fold for every 1 unit rise in INR. INR greater than 9 is associated with a particularly high risk of bleeding, with up to 20% of patients with INR higher than 9 bleeding within the next week, 20-fold higher than patients with INR lower than 9. This source also notes that Among inpatients (with an INR higher than 9) receiving [MEDICATION NAME], 35% had bleeding and 17% died . Factors associated with bleeding were older age, [MEDICAL CONDITION], and alcohol use. https://academic.oup.com/ajcp/article/[DATE]/ 21 The article Oral Anticoagulants and [MEDICAL CONDITION] notes, Anticoagulation . increases the risk of [MEDICAL CONDITION] 7- to 10-fold . Most (70%) anticoagulant-related [MEDICAL CONDITION] are [MEDICATION NAME] hematomas (approximately 60% are fatal); the bulk of the remainder are subdural hematomas. Predictors of anticoagulant-related [MEDICATION NAME] hematoma are advanced patient age, prior ischemic stroke, hypertension, and intensity of anticoagulation. In approximately half of anticoagulated patients with [MEDICATION NAME] hematoma the bleeding evolves slowly over 12 to 24 hours, and emergency reversal of anticoagulation is crucial. http://stroke.ahajournals.org/content/[DATE].full .[MEDICATION NAME] users require routine coagulation monitoring because of its narrow therapeutic range and interactions between [MEDICATION NAME] and diet or other medications. Bleeding associated with over-anticoagulation can occur in patients taking [MEDICATION NAME], the annual frequency of this complication reportedly being 15%-20%, including 1%-3% of fatal bleeding events. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 45/ Antibiotics may increase the clotting effects of [MEDICATION NAME]. Using [MEDICATION NAME] together with [MEDICATION NAME] may cause you to bleed more easily. You may need a dose adjustment based on your [MEDICATION NAME] time or International Normalized Ratio (INR). Call your doctor promptly if you have any unusual bleeding or bruising, vomiting, blood in your urine or stools, headache, dizziness, or weakness. It is important to tell your doctor about all other medications you use, including vitamins and herbs. Do not stop using any medications without first talking to your doctor. https://www.drugs.com/drug-interactions/[MEDICATION NAME]-with-[MEDICATION NAME]-[DATE]-0.html Surveyor reviewed facility's Anticoagulation policy with a revised date of [DATE]. Policy states, Policy Statement: Physician and staff shall follow appropriate approaches to anticoagulating residents/patients. Outcomes: 1. Residents/patients will be anticoagulated safely and effectively. 2. Complications related to anticoagulation will be minimized. 3. [MEDICAL CONDITION] events and related complications will be minimized. Procedure: Recognition: 1. The physician and staff will identify individuals who are currently anticoagulated; for example, those with a recent history of [MEDICAL CONDITIONS], heart valve replacement, [MEDICAL CONDITION], or recent joint replacement surgery. 2. The physician and staff will identify situations where an individual is not anticoagulated but where anticoagulation may be indicated; for example, new onset [MEDICAL CONDITION], or new or previously undiagnosed carotid artery stenosis or [MEDICAL CONDITION]. 3. The staff and physician will identify and address potential complications in individuals receiving anticoagulation; for example, a fall risk, a recent history of [MEDICAL CONDITION], or poorly controlled hypertension. - The physician will identify relative and absolute contraindications to anticoagulation. Diagnosis/Cause Identification 4. The physician will seek or verify underlying causes of conditions requiring anticoagulation (for example, [MEDICAL CONDITION] or [MEDICAL CONDITION] related to mitral stenosis). Treatment/Management 5. The physician will prescribe anticoagulation therapy (for example, low molecular weight [MEDICATION NAME], or another oral anticoagulant) appropriately, consistent with recognized guidelines (see References). - In general, long-term subcutaneous administration of [MEDICATION NAME] in chronically bed-bound individuals is not indicated or of proven benefit for [MEDICAL CONDITION]. 6. The physician will collaborate with the consultant pharmacist and nursing staff to identify potentially serious medication interactions with anticoagulants; for example, [MEDICATION NAME], and many antibiotics. - The physician should adjust the anticoagulant dose or stop, taper, or change medications that interact with the anticoagulant, and/or monitor the PT/INR very closely while the individual is receiving [MEDICATION NAME], to ensure that the PT/INR stabilizes within a therapeutic range. Monitoring 7. The physician will order appropriate lab testing to monitor anticoagulant therapy and potential complications; for example, periodically checking hemoglobin/hematocrit, platelets, PT/INR, and stool for occult blood. - If [MEDICATION NAME] is used, staff should use a [MEDICATION NAME] flow sheet or some comparable means to follow trends in anticoagulant dosage and response in individuals on [MEDICATION NAME]. 8. The physician will review the progress of individuals who are anticoagulated; for example, identify whether recent-onset [MEDICAL CONDITION] has resolved or to evaluate the status of any [MEDICAL CONDITION]. 9. The physician will periodically identify individuals whose anticoagulants can be discontinued or reduced (for example, resolved [MEDICAL CONDITION] or sufficient time has elapsed since resolution of a [MEDICAL CONDITION], and will document a rationale for continuing anticoagulation over time, including the medication and current dosage. 10. The staff and physician will monitor for possible complications in individuals who are being anticoagulated, and will manage related problems. - If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant. - The physician will order measures to address to address any complications, including holding or discontinuing the anticoagulant as indicated. - In individuals receiving [MEDICATION NAME] anticoagulation who are bleeding or who have a markedly elevated PT/INR, it may suffice to stop the anticoagulant and recheck the PT/INR if the individual is stable, there is no more than minor bleeding, and the INR is not greater than 9. Once Vitamin K is given to try to reverse the effects of [MEDICATION NAME], it can reduce the effectiveness of subsequently resumed anticoagulation for an extended time. R1 was admitted to the facility [DATE] after a hospitalization with [DIAGNOSES REDACTED]. Surveyor reviewed Hospital Discharge Summary with a date of [DATE]. Documented under Major medication changes and reasons was Stop abixaban, start of [MEDICATION NAME] . Documented under Specific issues for (Primary Care Physician (PCP)) or referring physician to follow up on was Monitor INR and [MEDICATION NAME]. Documented under Hospital Course was [MEDICAL CONDITION] Fibrillation with (rapid ventricular rate (RVR)); rate controlled. She went into RVR, likely secondary to (advanced diastolic heart failure (ADHF)) and physiological stress of bacteremia (fever) and UTI. (Heart rates (HR)) have been controlled. Given her obesity and (Creatinine), apixaban was stopped and she was started on [MEDICATION NAME]. She was bridged with [MEDICATION NAME] (due to history of PE). INR was 2.9 and [MEDICATION NAME] was stopped. INR at discharge was 3.1. Documented under Medication List: Take these Medications was [MEDICATION NAME] 2.5 mg tablet. Commonly known as: [MEDICATION NAME]. Take 1 tablet (2.5 mg total) by mouth every evening. Notes to patient: Please check INR ,[DATE] (sic) of note, was on 5 mg daily ,[DATE] - ,[DATE] and started 2.5 mg daily on ,[DATE]. Handwritten underneath this order was INR goal: 2 - 3. Surveyor reviewed MD orders with start date of [DATE]. Documented was [MEDICATION NAME] 2.5 mg (by mouth) in the evening. There were no orders for PT/INR lab draws. Surveyor reviewed R1's Comprehensive Care Plan with initiation date of [DATE]. There was no Anticoagulation care plan for monitoring for abnormal signs or symptoms or bleeding. Surveyor reviewed NP-F's visit note for R1 from [DATE]. Documented under Assessment/Plan for [MEDICAL CONDITION] with RVR was (Plan: (P)) continue [MEDICATION NAME], continue [MEDICATION NAME], monitor INR. Documented under Labs was Last lab draw: blank. Next lab draw: ,[DATE]. Surveyor reviewed Medical Director (MD)-J's visit note for R1 from [DATE]. Documented under Assessment/Plan for [MEDICAL CONDITION] with RVR was P: continue [MEDICATION NAME], continue [MEDICATION NAME], monitor INR. Documented under Labs was Last lab draw: ,[DATE]. Next lab draw: blank. Surveyor reviewed lab results with a date of [DATE]. Documented under Coagulation was INR 2.3. Handwritten next to the result by Nurse Practitioner (NP)-F was (No new orders (NNO)). On [DATE] at 10:00 AM, Surveyor interviewed NP-F and MD-J. Surveyor asked how often PT/INR's should be drawn for a resident on [MEDICATION NAME]. MD-J stated there are standing orders for all residents on [MEDICATION NAME] for Monday and Thursday PT/INR lab draws. On Thursday [DATE], Monday [DATE] and Thursday [DATE] there were no PT/INR labs drawn. Surveyor reviewed NP-F's visit notes for R1 from [DATE], [DATE] and [DATE]. Documented under Assessment/Plan for [MEDICAL CONDITION] with RVR was (Plan: (P)) continue [MEDICATION NAME], continue [MEDICATION NAME], monitor INR. Documented under Labs was Last lab draw: blank. Next lab draw: ,[DATE]. Surveyor reviewed Former NP-K's visit notes for R1 from [DATE]. Documented under Assessment/Plan for [MEDICAL CONDITION] with RVR was (Plan: (P)) continue [MEDICATION NAME], continue [MEDICATION NAME], monitor INR. Documented under Labs was Last lab draw: ,[DATE]. Next lab draw: ,[DATE]. On [DATE] there was no PT/INR lab drawn. Surveyor reviewed NP-F's visit notes for R1 from [DATE] and [DATE]. Documented under Assessment/Plan for [MEDICAL CONDITION] with RVR was (Plan: (P)) continue [MEDICATION NAME], continue [MEDICATION NAME], monitor INR. Documented under Labs was Last lab draw: ,[DATE]. Next lab draw: blank. On Monday [DATE] and Thursday [DATE] there were no PT/INR labs drawn. On [DATE] an MD order was received for [MEDICATION NAME] tablet 500 mg. Give 1 tablet by mouth at bedtime for UTI for 5 days. This medication was administered [DATE], [DATE] and [DATE]. On [DATE] a Progress Note was triggered when [MEDICATION NAME] was entered into the computer for the following alert/warning interaction with [MEDICATION NAME] for R1, [MEDICATION NAME] effects of [MEDICATION NAME] Sodium Tablet 2.5MG may be increased by [MEDICATION NAME] Tablet 500MG. Dosage reduction of [MEDICATION NAME] Sodium Tablet 2.5MG may be required. Surveyor reviewed MD-J's visit note for R1 from [DATE]. Documented under Assessment/Plan for [MEDICAL CONDITION] with RVR was (Plan: (P)) continue [MEDICATION NAME], continue [MEDICATION NAME], monitor INR. Documented under Labs was Last lab draw: ,[DATE] and ,[DATE] (urinalysis (UA)). Next lab draw: blank. Surveyor reviewed Progress Notes for R1. Documented on [DATE] at 11:10 PM was Did not get a blood draw earlier today for PT/INR. Phone call to on-call (physician.) Stated to give current dose of [MEDICATION NAME] and order PT/INR to be done [DATE]. On [DATE] a Laboratory Order Request form was sent to the lab from Former NP-K requesting Test(s) to be ordered: PT/INR. Frequency: x1. Start Date: [DATE]. End Date: [DATE]. Test(s) to be ordered: PT/INR. Frequency: Mon/Thurs. Start Date: [DATE]. End Date: blank. On Monday [DATE] and Tuesday [DATE] there were no PT/INR labs drawn. Surveyor reviewed Former NP-K's visit notes for R1 from [DATE]. Documented under Assessment/Plan for [MEDICAL CONDITION] with RVR was (Plan: (P)) continue [MEDICATION NAME], continue [MEDICATION NAME], monitor INR. Documented under Labs was Last lab draw: ,[DATE] and ,[DATE] (UA). Next lab draw: ,[DATE]. On Thursday [DATE] there was no PT/INR lab drawn. Surveyor reviewed Progress Notes for R1. Documented on [DATE] at 12:42 AM by Respiratory Therapy (RT)-M was .Resident was suctioned for a moderate amount of thick, blood tinged secretions via trach. Resident also coughed up a quarter sized bloody mucous plug x2 . On [DATE] at 1:33 PM Surveyor interviewed RT-M. Surveyor asked if blood tinged secretions and bloody mucous plugs were normal for R1. RT-M stated it had been for the past day or two. Surveyor asked if she reported this to the MD, NP or facility. RT-M stated she updated the nurse on that shift [DATE]. Surveyor reviewed Progress Notes for R1. Documented on [DATE] at 3:59 AM by RT-N was .Suctioned very large dried red mucous plugs x2 this shift .[MEDICAL CONDITION] completed with inner cannula changed and large amounts dried blood noted to cannula . On [DATE] at 2:59 PM Surveyor interviewed RT-N. Surveyor asked if large dried red mucous plugs and large amounts of dried blood to cannula were normal for R1. RT-N stated it had been for 1 or 2 days. Surveyor asked if he reported this to the MD, NP or facility. RT-N stated he updated the nurse on that shift [DATE]. RT-N stated he reports all unusual assessments to nursing and nursing updates the MD. Surveyor reviewed Progress Notes for R1. Documented on [DATE] at 7:30 AM was Called to (patient (pt)) room by (Licensed Practical Nurse (LPN)). Pt suction set bloody and pt stating after (RT-Q) changed her inner cannula that she started to cough up blood and clots. (Oxygen saturation) ,[DATE]% on 7L via trach. When split gauze removed, a large blood clot vs prolapsed stoma was noted. Pt in no distress. Notified (NP), she advised to send out via 911 . On [DATE] at 2:59 PM Surveyor interviewed RT-Q. Surveyor asked about the events on [DATE] with R1. RT-Q stated when he was rounding between 6:30 and 8:00 AM he assessed R1 twice. RT-Q stated he performed open suction the first visit and was suctioning out frank red blood. On the second visit RT-Q stated he performed open suction again and was suctioning out frank red blood again. RT-Q stated he told staff to get the nurse. When the nurse arrived he removed the cannula and noticed her stoma was bleeding profusely and would not stop. The nurse went to call 911 and he got R1 ready for transport. Surveyor asked if suctioning frank red blood was normal for R1. RT-Q stated no and that is why he got the nurse. Surveyor asked if bloody mucous plugs were normal for R1. RT-Q stated mucous plugs are normal but not bloody ones. R1 was transported via ambulance to the hospital and admitted on [DATE] with Bleeding from [MEDICAL CONDITION] Secondary to Supratherapeutic INR. On [DATE] at 10:00 AM during interview with NP-F and MD-J Surveyor asked what should be monitored for a patient on [MEDICATION NAME]. MD-J stated PT/INR on Mondays and Thursdays for a couple weeks and then reassess the frequency. Surveyor asked about R1 starting on an antibiotic and the warning of the effects on [MEDICATION NAME]. MD-J stated patients on [MEDICATION NAME] have an increased risk for bleeding and should be monitored closely if on an antibiotic. MD-J stated the INR at the hospital was 10 and probably that high because she was on an antibiotic. Surveyor asked what the risks are if you are not monitoring PT/INR's for a resident on [MEDICATION NAME]. MD-J stated there is an increased risk for bleeding. The facility's failure to monitor the resident's PT/INR causing uncontrolled bleeding and hospitalization created a finding of immediate jeopardy. The facility removed the immediate jeopardy on [DATE] when the facility implemented the following: R1 is currently hospitalized and [MEDICATION NAME] was discontinued on [DATE]. Currently the facility has 2 residents on [MEDICATION NAME]. Both residents had PT/INR orders completed as ordered on [DATE] with no new orders. Both residents have had their care plans reviewed to ensure anticoagulation care plans are in place. Licensed Nurses have been re-educated on Facility Policy & Procedure related to [MEDICATION NAME] use, dosing, lab monitoring and the use of [MEDICATION NAME] Flow Sheets which includes any orders for antibiotics and any need for increased monitoring. Licensed Nurses have been re-educated on Facility Policy & Procedure related to following Physician orders [REDACTED]. DON/Designee will bring [MEDICATION NAME] Flow Sheets to daily Clinical meeting to validate PT/INR was drawn, Physician will be notified and will verify that any new orders received have been completed. This will be a standing agenda item at daily clinical meeting. All new admission/ readmission charts will be reviewed in daily clinical meeting to determine if lab monitoring needs to be initiated for any resident on [MEDICATION NAME]. Physician orders [REDACTED].

Based on interview and record review, the facility failed to ensure that 1 (R1) of 3 residents reviewed for a change in condition received care based upon current standards of care and individual assessment. R1 was admitted to the facility on [DATE] with orders for the anticoagulant [MEDICATION NAME] which put R1 at high risk for bleeding. On 12/20/20 R1 was started on an antibiotic and the electronic medical record flagged for possible adverse drug interactions. Nursing did not address the flagged warning. R1 received 3 doses of the antibiotic with no indication the facility recognized the increased risk for bleeding or developed an individualized plan of care. On 12/24/20, R1 was seen by a Respiratory Therapist (RT) who noted blood tinged sputum. RT reported this to nursing who did not assess the resident. On 12/25/20, R1 was seen by a RT who noted blood tinged mucous plugs. RT reported this to nursing who did not assess the resident. Later on 12/25/20 the resident was sent out 911 after uncontrolled bleeding from her [MEDICAL CONDITION] stoma and was admitted to the hospital with [REDACTED]. The facility failed to assess the resident who was at high risk for bleeding and who was showing signs of internal bleeding. Without an assessment there was no nursing diagnosis, no planning and no intervention, leaving the resident at risk for the effects and consequences of continued bleeding. This created a finding of Immediate Jeopardy (IJ) that began on 12/24/20. Surveyor notified Nursing Home Administrator (NHA-A) and Director of Nursing (DON-B) of the IJ on 2/25/21 at 10:20 AM. The IJ was removed on 2/25/21; however, the deficient practice continues at a scope/severity level of E (potential for more than minimal harm/pattern) as the facility continues to implement its action plan. Findings include: The standard of practice for nursing care in Wisconsin is the Wisconsin Nurse Practice Act (N6), which requires registered nurses to follow the steps of the nursing process. These steps include: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.'s or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. Surveyor reviewed facility's Anticoagulation policy with a revised date of September 2017. Policy states, Policy Statement: Physician and staff shall follow appropriate approaches to anticoagulating residents/patients. Outcomes: 1. Residents/patients will be anticoagulated safely and effectively. 2. Complications related to anticoagulation will be minimized. 3. [MEDICAL CONDITION] events and related complications will be minimized . Procedure: .10. The staff and physician will monitor for possible complications in individuals who are being anticoagulated, and will manage related problems. - If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant. - The physician will order measures to address to address any complications, including holding or discontinuing the anticoagulant as indicated . R1 was admitted to the facility 11/30/20 after a hospitalization with [DIAGNOSES REDACTED]. Surveyor reviewed MD orders with start date of 11/30/20. Documented was [MEDICATION NAME] 2.5 mg (by mouth) in the evening. Surveyor reviewed R1's Comprehensive Care Plan with initiation date of 12/1/20. There was no Anticoagulation care plan for monitoring for abnormal signs or symptoms or bleeding. Surveyor reviewed Medication Administration Record [REDACTED]. On 12/20/20 an MD order was received for [MEDICATION NAME] tablet 500 mg. Give 1 tablet by mouth at bedtime for UTI for 5 days. This medication was administered 12/20/20, 12/21/20 and 12/23/20. Antibiotics may increase the clotting effects of [MEDICATION NAME]. Using [MEDICATION NAME] together with [MEDICATION NAME] may cause you to bleed more easily. You may need a dose adjustment based on your [MEDICATION NAME] time or International Normalized Ratio (INR). Call your doctor promptly if you have any unusual bleeding or bruising, vomiting, blood in your urine or stools, headache, dizziness, or weakness. It is important to tell your doctor about all other medications you use, including vitamins and herbs. Do not stop using any medications without first talking to your doctor. https://www.drugs.com/drug-interactions/[MEDICATION NAME]-with-[MEDICATION NAME]-1457-0-2311-0.html On 12/20/20 a Progress Note was triggered when [MEDICATION NAME] was entered into the computer for the following alert/warning interaction with [MEDICATION NAME] for R1, [MEDICATION NAME] effects of [MEDICATION NAME] Sodium Tablet 2.5MG may be increased by [MEDICATION NAME] Tablet 500MG. Dosage reduction of [MEDICATION NAME] Sodium Tablet 2.5MG may be required. Surveyor noted there is no indication nursing staff addressed the alert/warning that flagged in the electronic medical record. Surveyor reviewed Progress Notes for R1. Documented on 12/24/20 at 12:42 AM by RT-M was .Resident was suctioned for a moderate amount of thick, blood tinged secretions via trach. Resident also coughed up a quarter sized bloody mucous plug x2 . On 2/24/21 at 1:33 PM Surveyor interviewed RT-M. Surveyor asked if blood tinged secretions and bloody mucous plugs were normal for R1. RT-M stated it had been for the past day or two. Surveyor asked if she reported this to the MD, NP or facility. RT-M stated she updated the nurse on that shift 12/24/21. Surveyor reviewed R1's Electronic Medical Record (EMR). There was no Registered Nurse (RN) assessment in R1's EMR. Surveyor reviewed Progress Notes for R1. Documented on 12/25/20 at 3:59 AM by RT-N was .Suctioned very large dried red mucous plugs x2 this shift .[MEDICAL CONDITION] completed with inner cannula changed and large amounts dried blood noted to cannula . On 2/24/21 at 2:59 PM Surveyor interviewed RT-N. Surveyor asked if large dried red mucous plugs and large amounts of dried blood to cannula were normal for R1. RT-N stated it had been for 1 or 2 days. Surveyor asked if he reported this to the MD, NP or facility. RT-N stated he updated the nurse on that shift 12/25/21. RT-N stated he reports all unusual assessments to nursing and nursing updates the MD. Surveyor reviewed R1's Electronic Medical Record (EMR). There was no Registered Nurse (RN) assessment in R1's EMR. Surveyor reviewed Progress Notes for R1. Documented on 12/25/20 at 7:30 AM was Called to (patient (pt)) room by (Licensed Practical Nurse (LPN)). Pt suction set bloody and pt stating after (RT-Q) changed her inner cannula that she started to cough up blood and clots. (Oxygen saturation) 93-97% on 7L via trach. When split gauze removed, a large blood clot vs prolapsed stoma was noted. Pt in no distress. Notified (NP), she advised to send out via 911 . On 2/24/21 at 2:59 PM Surveyor interviewed RT-Q. Surveyor asked about the events on 12/25/20 with R1. RT-Q stated when he was rounding between 6:30 and 8:00 AM he assessed R1 twice. RT-Q stated he performed open suction the first visit and was suctioning out frank red blood. On the second visit RT-Q stated he performed open suction again and was suctioning out frank red blood again. RT-Q stated he told staff to get the nurse. When the nurse arrived he removed the cannula and noticed her stoma was bleeding profusely and would not stop. The nurse went to call 911 and he got R1 ready for transport. Surveyor asked if suctioning frank red blood was normal for R1. RT-Q stated no and that is why he got the nurse. Surveyor asked if bloody mucous plugs were normal for R1. RT-Q stated mucous plugs are normal but not bloody ones. R1 was transported via ambulance to the hospital and admitted on [DATE] with Bleeding from [MEDICAL CONDITION] Secondary to Supratherapeutic INR. On 2/24/21 at 3:46 PM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked what the expectation of staff was if a RT reports anything abnormal with a resident. DON-B stated the nurse should assess. Surveyor asked what was expected of staff if resident has blood in their sputum. DON-B stated an assessment and to call the MD. According to the National Institute of Health (Medline Plus), [MEDICATION NAME] may cause severe bleeding that can be life-threatening and even cause death. https://academic.oup.com/ajcp/article/138/4/546/ 21 On 2/24/21 at 10:00 AM, Surveyor interviewed Nurse Practitioner (NP)-F and Medical Director (MD)-J. Surveyor asked what should be monitored for a patient on [MEDICATION NAME]. MD-J stated PT/INR ([MEDICATION NAME] Time/International Normalized Ratio) on Mondays and Thursdays for a couple weeks and then reassess the frequency. Surveyor asked about R1 starting on an antibiotic and the warning of the effects on [MEDICATION NAME]. MD-J stated patients on [MEDICATION NAME] have an increase the risk for bleeding and should be monitored closely if on an antibiotic. MD-J stated the INR at the hospital was 10 and probably that high because she was on an antibiotic. Surveyor asked what the risks are if you are not monitoring PT/INR's for a resident on [MEDICATION NAME]. MD-J stated there is an increased risk for bleeding. The facility's failure to develop a care plan addessing R1's risk for bleeding, its failure to address the warning that flagged on 12/20/20 and its failure to assess a resident on [MEDICATION NAME] who is showing signs of internal bleeding created a finding of immediate jeopardy. The facility removed the immediate jeopardy on 2/25/21 when the facility implemented the following: RN Unit Managers (RN UM) have reviewed 24 hour reports, nurses notes and have conducted walking rounds with NP to assess all current residents for any change of condition. Respiratory Therapist, RN UM and NP completed rounds on all Vent [MEDICAL CONDITION] to review for any change of condition. Medical Director reviewed the center's policy on MD notification regarding change of condition. Licensed Nurses and Respiratory Therapists are being re-educated on facility Policy & Procedure related to change of condition, to include identification, notification of Physician and documentation in resident's medical record. Licensed Nurses were re-educated on their role in change of condition based on their scope of practice. Licensed Nurses and Respiratory Therapists will complete a Post Test to assess their knowledge prior to the start of their shift. As part of clinical daily clinical meeting residents' progress notes are reviewed for any change of condition and to ensure follow up has been completed. A Performance Improvement (PI) Tool has been developed that will monitor identification of change of condition, documentation of change of condition in the medical record and Physician notification. PI Tool will be completed by DON/Nursing Administration during walking rounds across all three shifts each unit daily for two weeks, then three times a week for two weeks, then weekly for one month, with results being forwarded to QAPI committee for any further recommendations and/or resolution.

Based on interview and record review, the facility failed to ensure the medical doctor (MD) for 1 (R1) of 3 residents reviewed for change in condition was consulted with regarding a significant change in condition. R1 was admitted to the facility on [DATE] with orders for the anticoagulant [MEDICATION NAME] which put R1 at high risk for bleeding. On 12/24/20, R1 was seen by a Respiratory Therapist (RT) who noted blood tinged sputum. RT reported this to nursing who did not report the abnormality to the MD. On 12/25/20, R1 was seen by a RT who noted blood tinged mucous plugs. RT reported this to nursing who did not report the abnormality to the MD. On 12/25/20 the resident was sent out 911 after uncontrolled bleeding from her [MEDICAL CONDITION] stoma and was admitted to the hospital with [REDACTED]. The facility's failure to immediately consult with a physician prevented the possibility of an earlier medical intervention, leaving the resident at risk for the effects and consequences of continued bleeding. This created a finding of Immediate Jeopardy (IJ) that began on 12/24/20. Surveyor notified Nursing Home Administrator (NHA-A) and Director of Nursing (DON-B) of the IJ on 2/25/21 at 10:20 AM. The IJ was removed on 2/25/21; however, the deficient practice continues at a scope/severity level of a E (potential for more than minimal harm/pattern) as the facility continues to implement its action plan. Findings include: Surveyor reviewed facility's Anticoagulation policy with a revised date of September 2017. Policy states, .10. The staff and physician will monitor for possible complications in individuals who are being anticoagulated, and will manage related problems. - If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant. - The physician will order measures to address to address any complications, including holding or discontinuing the anticoagulant as indicated. R1 was admitted to the facility 11/30/20 after a hospitalization with [DIAGNOSES REDACTED]. Surveyor reviewed MD orders with start date of 11/30/20. Documented was [MEDICATION NAME] 2.5 mg (by mouth) in the evening. Surveyor reviewed R1's Comprehensive Care Plan with initiation date of 12/1/20. There was no Anticoagulation care plan for monitoring for abnormal signs or symptoms or bleeding. Surveyor reviewed Medication Administration Record [REDACTED]. On 12/20/20 a MD order was received for [MEDICATION NAME] tablet 500 mg. Give 1 tablet by mouth at bedtime for UTI for 5 days. This medication was administered 12/20/20, 12/21/20 and 12/23/20. On 12/20/20 a Progress Note was triggered when [MEDICATION NAME] was entered into the computer for the following alert/warning interaction with [MEDICATION NAME] for R1, [MEDICATION NAME] effects of [MEDICATION NAME] Sodium Tablet 2.5MG may be increased by [MEDICATION NAME] Tablet 500MG. Dosage reduction of [MEDICATION NAME] Sodium Tablet 2.5MG may be required. Surveyor reviewed Progress Notes for R1. Documented on 12/24/20 at 12:42 AM by RT-M was .Resident was suctioned for a moderate amount of thick, blood tinged secretions via trach. Resident also coughed up a quarter sized bloody mucous plug x2 . On 2/24/21 at 1:33 PM Surveyor interviewed RT-M. Surveyor asked if blood tinged secretions and bloody mucous plugs were normal for R1. RT-M stated it had been for the past day or two. Surveyor asked if she reported this to the MD, NP or facility. RT-M stated she updated the nurse on that shift 12/24/20. Surveyor reviewed R1's Electronic Medical Record (EMR). There was no documentation of an update to MD in R1's EMR. Surveyor reviewed Progress Notes for R1. Documented on 12/25/20 at 3:59 AM by RT-N was .Suctioned very large dried red mucous plugs x2 this shift .[MEDICAL CONDITION] completed with inner cannula changed and large amounts dried blood noted to cannula . On 2/24/21 at 2:59 PM Surveyor interviewed RT-N. Surveyor asked if large dried red mucous plugs and large amounts of dried blood to cannula were normal for R1. RT-N stated it had been for 1 or 2 days. Surveyor asked if he reported this to the MD, NP (Nurse Practitioner) or facility. RT-N stated he updated the nurse on that shift 12/25/20. RT-N stated he reports all unusual assessments to nursing and nursing updates the MD. Surveyor reviewed R1's Electronic Medical Record (EMR). There was no documentation of an update to MD in R1's EMR. Surveyor reviewed Progress Notes for R1. Documented on 12/25/20 at 7:30 AM was Called to (patient (pt)) room by (Licensed Practical Nurse (LPN)). Pt suction set bloody and pt stating after (RT-Q) changed her inner cannula that she started to cough up blood and clots. (Oxygen saturation) 93-97% on 7L via trach. When split gauze removed, a large blood clot vs prolapsed stoma was noted. Pt in no distress. Notified (NP), she advised to send out via 911 . R1 was transported via ambulance to the hospital and admitted on [DATE] with Bleeding from [MEDICAL CONDITION] Secondary to Supratherapeutic INR. On 2/24/21 at 10:00 AM, Surveyor interviewed Nurse Practitioner (NP)-F and Medical Director (MD)-J. Surveyor asked what should be monitored for a patient on [MEDICATION NAME]. MD-J stated PT/INR ([MEDICATION NAME] Time/International Normalized Ratio) on Mondays and Thursdays for a couple weeks and then reassess the frequency. Surveyor asked about R1 starting on an antibiotic and the warning of the effects on [MEDICATION NAME]. MD-J stated patients on [MEDICATION NAME] have an increase risk for bleeding and should be monitored closely if on an antibiotic. MD-J stated the INR at the hospital was 10 and probably that high because she was on an antibiotic. Surveyor asked what the risks are if you are not monitoring PT/INR's for a resident on [MEDICATION NAME]. MD-J stated there is an increased risk for bleeding. On 2/24/21 at 3:46 PM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked what was expected of staff if resident has blood in their sputum. DON-B stated an assessment should be completed and to call the MD. Surveyor asked if RT's call the MD or only nursing. DON-B stated RT's and nursing can call the MD for a change in condition. Immediate medical intervention is needed when a person on anticoagulant therapy begins bleeding to reverse the condition and to prevent continued bleeding. According to UW Health, Any significant signs or symptoms of major bleeding or clotting should be referred to a primary care provider or urgent care/emergency department for evaluation. Common signs and symptoms of major bleeding and clotting include . Blood in sputum. https://www.uwhealth.org/files/uwhealth/docs/pdf2/[MEDICATION NAME].pdf. Antibiotics may increase the clotting effects of [MEDICATION NAME]. Using [MEDICATION NAME] together with [MEDICATION NAME] may cause you to bleed more easily. You may need a dose adjustment based on your [MEDICATION NAME] time or International Normalized Ratio (INR). Call your doctor promptly if you have any unusual bleeding or bruising, vomiting, blood in your urine or stools, headache, dizziness, or weakness. It is important to tell your doctor about all other medications you use, including vitamins and herbs. Do not stop using any medications without first talking to your doctor. https://www.drugs.com/drug-interactions/[MEDICATION NAME]-with-[MEDICATION NAME]-1457-0-2311-0.html According to the National Institute of Health (Medline Plus), [MEDICATION NAME] may cause severe bleeding that can be life-threatening and even cause death. https://academic.oup.com/ajcp/article/138/4/546/ 21 The facility's failure to immediately consult with a physician prevented earlier medical intervention, creating a finding of immediate jeopardy. The facility removed the immediate jeopardy on 2/25/21 when the facility implemented the following: Resident #1 was transferred to hospital on [DATE]. RN Unit Managers (RN UM) have reviewed 24 hour reports, nurses notes and have conducted walking rounds with NP to assess all current residents for any change of condition. Respiratory Therapist, RN UM and NP completed rounds on all Vent [MEDICAL CONDITION] to review for any change of condition. Medical Director has reviewed the center's policy around MD notification on change of condition. Licensed Nurses and Respiratory Therapists are being re-educated on facility Policy & Procedure related to change of condition to include identification, notification of Physician and documentation in resident's medical record. Licensed Nurses and Respiratory Therapists will complete a Post Test to assess their knowledge prior to start of shift. As part of daily clinical meeting, residents' progress notes are reviewed for any change of condition and to ensure follow up has been completed to include Physician Notification of change. A Performance Improvement (PI) Tool has been developed that will monitor identification of change of condition, documentation of change of condition in the medical record and Physician notification. PI Tool will be completed by DON/Nursing Administration during walking rounds across all three shifts each unit daily for two weeks, then three times a week for two weeks, then weekly for one month, with results being forwarded to QAPI committee for any further recommendations and/or resolution.

Based on record review and interview, the facility did not ensure residents were free of significant medication errors for 2 (R16 and R24) of 6 residents reviewed for medications. * R16 did not receive [MEDICATION NAME] or [MEDICATION NAME], anti-[MEDICAL CONDITION] medications, or Humalog insulin as ordered when admitted to the facility on [DATE] through 1/2/2021. R16 was hosptalized on [DATE] for multiple [MEDICAL CONDITION]. * R24 did not receive the right dose of [MEDICATION NAME] or [MEDICATION NAME] as ordered when admitted to the facility on [DATE] through 1/8/2021. Findings: The facility policy and procedure entitled Pharmacy Services Overview dated 4/2019 states: The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed consultant pharmacist. Policy Interpretation and Implementation: . 4. Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner. 5. Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration. 1. R16 was admitted to the facility on [DATE] after an extensive hospitalized from [DATE]-12/31/2020 for resection of an [DIAGNOSES REDACTED], a malignant [DIAGNOSES REDACTED], which resulted in a stroke post-operatively. R16 had a history of [REDACTED]. R16 developed post-operative [MEDICAL CONDITION] and medication was changed from [MEDICATION NAME] to [MEDICATION NAME] and the [MEDICATION NAME] dose was increased. Review of the hospital paperwork indicated R16 did not have any further [MEDICAL CONDITION] activity since 10/2020 post-operatively. R16 also had a [DIAGNOSES REDACTED]. The hospital discharge orders included: -lacosamide ([MEDICATION NAME]) 200 mg twice daily through the gastrostomy tube ([DEVICE]) -levetiracetam ([MEDICATION NAME]) 1,500 mg every 12 hours through the [DEVICE] -[MEDICATION NAME] 17 units nightly -Humalog 18 units three times a day with meals R16's medication orders were transcribed on 12/31/2020 as follows: -lacosamide 200 mg twice daily through the [DEVICE] -[MEDICATION NAME] 17 units daily at bedtime -[MEDICATION NAME] 18 units three times a day with meals (should have been Humalog) [MEDICATION NAME] was not transcribed from the hospital's discharge orders into R16's Medication Administration Record. No documentation was found indicating the medications had been reviewed or verified by a physician or nurse practitioner. [MEDICAL CONDITION] MEDICATION ([MEDICATION NAME] AND [MEDICATION NAME]) On 12/31/2020 at 7:00 PM, the nurse signed out [MEDICATION NAME] as being administered. On 1/1/2021 and 1/2/2021, the nurses documented [MEDICATION NAME] was not available and had not been delivered by the pharmacy. The nurse that signed out the [MEDICATION NAME] on 12/31/2020 was unavailable for interview during the survey to verify if that dose was given or not. The same nurse on 1/1/2021 documented [MEDICATION NAME] was not available for administration. R16 did not receive 4 of 5 doses of [MEDICATION NAME] due to not being delivered to the facility by the pharmacy. Nurses charted at each dosing time the medication was not available and the pharmacy was to send. No documentation was found that the pharmacy had been contacted to provide [MEDICATION NAME]. The order for [MEDICATION NAME] was never transcribed. R16 missed 5 doses of [MEDICATION NAME] on 12/31/202 (1 dose) 1/1/21 (2 doses) and 1/2/2021 (2 doses) in the 57 hours R16 was in the facility. R16 misseed 4 of 5 doses of [MEDICATION NAME] on 1/1/2021 (2 doses), 1/2/2021 (2 doses) in the 57 hours R16 was in the facility. R16 was transferred to the hospital on [DATE] at 8:33 PM due to multiple [MEDICAL CONDITION] and a heart rate of 140. INSULIN ([MEDICATION NAME] AND HUMALOG) On 12/31/2020 at 4:00 PM, R16 received 18 units [MEDICATION NAME]. Surveyor noted R16 should have received 18 units of Humalog. On 12/31/2020 at 8:40 PM, the nurse documented the evening dose of 17 units of [MEDICATION NAME] was not given because it was a duplicate order (indicating [MEDICATION NAME] had been given at 4:00 PM). Surveyor noted the [MEDICATION NAME] at 4pm should have been Humalog and not [MEDICATION NAME]. On 1/1/2021 at 8:00 AM and Noon, R16 received 18 units of [MEDICATION NAME] and not Humlog insulin. The 4:00 PM dose indicated no insulin was required because it was a duplicate order (indicating the evening [MEDICATION NAME] dose). On 1/1/2021 at 9:00 PM, R16 received 17 units of [MEDICATION NAME]. On 1/2/2021 at 8:00 AM, Noon, and 4:00 PM, R16 received 18 units of [MEDICATION NAME] and not Humalog insulin. R16 was transferred to the hospital on [DATE] at 8:33 PM. R16 received a total of 10 doses of [MEDICATION NAME] in 48 hours and did not receive the Humalog insulin. Blood sugars ranged from 113 to 309. In an interview on 1/21/2021 at 9:15 AM, Director of Nursing (DON)-B stated any nurse on the floor will put new admission orders [REDACTED]. In an interview on 1/21/2021 at 9:53 AM, Registered Nurse Unit Manager (RN UM)-D stated a resident is admitted from the hospital with a discharge packet and the orders are in that packet. RN UM-D agreed that RN UM-D had put in R16's admission orders [REDACTED]. No notation was found in R16's chart by RN UM-D. Licensed Practical Nurse (LPN)-E had documented in the progress notes the Nurse Practitioner (NP) was notified of R16's arrival to the facility. RN UM-D stated LPN-E verified the orders with the NP because LPN-E documented the notification to the NP. RN UM-D stated RN UM-D did not verify any orders with the NP or physician. Surveyor reviewed the transcription errors on R16's admission with RN UM-D. RN UM-D was unaware of R16 having any transcription errors on the medication orders. RN UM-D remembered hearing R16 had missed getting [MEDICATION NAME], but denied anything was said directly to RN UM-D about any errors made during transcription of the orders. In an interview on 1/21/2021 at 10:26 AM, LPN-E stated the unit manager does admission orders [REDACTED]. LPN-E stated on 12/31/2020, the NP was notified by LPN-E of R16's arrival to the facility, but did not go over any of the medication orders with the NP. LPN-E stated RN UM-D let LPN-E know the medication orders were taken care of and took that to mean the orders had been verified and entered into the computer system. LPN-E denied doing anything with the orders. In an interview on 1/21/2021 at 10:30 AM, NP-F stated NP-F was aware of R16 but had never seen R16 while R16 was at the facility. NP-F stated the other facility NP was supposed to see R16, but R16 was in the facility for only 3 days and didn't get a chance to see R16. Surveyor asked NP-F what the process was for a new admission in regards to medication verification. NP-F stated the medications are continued from the hospitalization and the facility has standing orders for general orders, such as laboratory tests every four weeks. NP-F stated if the resident has orders for narcotics or other controlled medications, the resident should have a script for those medications. NP-F stated individual medications are not verbalized with the facility nurses; the medications are reviewed when the resident is seen by the NP. NP-F stated they rely on the nurses to transcribe the orders from the hospital. Surveyor shared R16's discharge medications and the transcription errors with NP-F. NP-F was unaware of the medication errors. On 1/25/2021 at 9:35, Surveyor discussed the above findings with Nursing Home Administrator (NHA)-A and DON-B. R16 was sent to the hospital with multiple [MEDICAL CONDITION] after not receiving ordered anti-[MEDICAL CONDITION] medication while at the facility. NHA-A and DON-B agreed there were transcription errors and they were working on having nurses do second checks on new admission orders [REDACTED]. Surveyor noted the facility had already implemented a second check for new admission orders [REDACTED] Systemic Changes: Licensed nureses were re-educated on the following: Accurately transcribing a phyisician order. The 5 rights of medication administration. Two nurses to verify transcription of all hand written physician orders. Two nurses to verify transcription of all admission/readmission orders [REDACTED] Processing a physicians order to include timely pharmacy notification . This systemic corrective action plan was not implemented when R16 was admitted into the facility on [DATE]. 2. R24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R24 had been as a patient at a long term acute care hospital prior to coming to the facility. Discharge medication orders from the previous facility included: -[MEDICATION NAME] 37.5 mcg daily through the gastrostomy tube ([DEVICE]) -[MEDICATION NAME] 64.8 mg twice daily through the [DEVICE] R24's medication orders were transcribed on 1/5/2021 as follows: -[MEDICATION NAME] 375 mcg daily through the [DEVICE] (10 times the dosage ordered) -[MEDICATION NAME] 64.8 mg once daily through the [DEVICE] (should have been twice daily) On 1/8/2021, the medication orders were changed to match the discharge medication orders. R24 received the incorrect dose of [MEDICATION NAME] on 1/6/21, 1/7/21, and 1/8/21 (a total of three times.) R24 missed three doses of [MEDICATION NAME] on 1/6/21, 1/7/21, and 1/8/21. In an interview on 1/25/2021 at 8:52 AM, Registered Nurse Unit Manager (RN UM)-G stated RN UM-D put R24's admission orders [REDACTED]. RN UM-G stated Nursing Home Administrator (NHA)-A texted RN UM-G on 1/8/2021 to review and compare R24's medications in the computer system to the discharge medications. RN UM-G stated R24's chart had not been audited by RN UM-G yet, but was on the list of things to do. RN UM-G was unaware of how NHA-A discovered the medication errors and transcription errors. RN UM-G stated RN UM-G corrected the [MEDICATION NAME] and [MEDICATION NAME] orders. In an interview on 1/25/2021 at 9:35 AM, NHA-A stated NHA-A was reviewing new admission orders [REDACTED]. NHA-A notified RN UM-G of the situation and RN UM-G fixed the orders in the computer. DON-B initialed the administration of [MEDICATION NAME] 375 mcg on 1/6/2021. DON-B stated yes, that was the amount of medication that was administered. DON-B stated the medication came from the pharmacy in a bottle with the label reading [MEDICATION NAME] 375 mcg daily and that is what DON-B measured out of the bottle and administered the medication to R24. DON-B stated a [MEDICATION NAME] level was drawn on 1/7/2021 which showed it was in therapeutic range. DON-B stated a [MEDICAL CONDITION] hormone level would be drawn on this date, 1/25/2021. NHA-A and DON-B were aware of the medication errors. No further information was provided at that time.

Based on interview and record review, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident when emergency medical care and basic life support is needed. This deficient practice has the potential to affect 51 out of 107 residents residing at the facility who are full code, requiring basic life support, up to and including CPR. The facility was previously cited with an IJ (immediate jeopardy) level citation on [DATE] for failure to provide basic life support, up to and including CPR (cardiopulmonary resuscitation). Despite the facility's attempts to implement its plan of correction and educate staff, on [DATE], the facility failed to provide basic life support, up to and including CPR, to R101 after R101 experienced a change in condition. The facility administration was not aware, as of the time of this survey, of the above findings and failed to monitor, investigate and educate staff regarding R101's change in condition on [DATE]. The administration's failure to review what happened with R101 and its failure to implement procedures to ensure that residents facing a cardiac event are monitored and not left alone, that 911 is called, and that staff are prepared to begin CPR as soon as needed, created a finding of immediate jeopardy that began on [DATE]. The Nursing Home Administrator (Administrator-A) and Director of Nursing (DON-B) were notified of the immediate jeopardy on [DATE] at 4:09 p.m. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope/severity of [NAME] (potential for more than minimal harm/pattern) as the facility continues to implement its plan of correction. Findings include: 1.) On [DATE], the facility was cited at F678 at a scope/severity of J (immediate jeopardy/isolated) due to the facility's failure to provide basic life support, up to and including CPR. The facility alleged removal of the immediate jeopardy on [DATE], when it had completed the following: * Care staff was educated beginning [DATE] related to CPR policy to include immediate response to a code blue and CPR technique. * On [DATE] the facility ensured that employees were given education prior to or during their shift. * Care staff were educated prior to and or during their shift and have participated in a mock drill highlighting the immediate use of the backboard to ensure adequate compression and how to properly initiate a code blue. * The Facility reviewed the agency orientation packet to ensure all information regarding crash cart location and Policies and Procedures related to CPR are present. This information is now to be part of the agency orientation and education packet ongoing. * All nursing staff was re-educated to respond to all codes. The 1st nurse that arrives is the team lead in charge of the code. This nurse will assign duties to other responders who will assist with the code. The facility continues to complete mock code blue drills on every shift to ensure staff knowledge and competency. * A Performance Improvement continuous quality improvement (CQI) tool is being completed by a supervisor daily to monitor for compliance and to self-identify any ongoing areas that have an opportunity for improvement. The code will be paged overhead using a clear and concise voice to mitigate risk of staff not understanding message. * RN supervisors are responsible to ensure that crash carts and AED checklist are completed daily. In addition the Director of Nursing/Administrator will monitor the log and sign as a Quality Assurance (QA) process to monitor compliance related to crash cart and AED checks. * Code blue drills are being completed every shift until all nursing staff has attended and posttest completed. Facility will have ongoing continuous quality improvement (CQI) checks and complete code blue drills monthly across all shifts ongoing. 2.) On [DATE], R101 had a change a condition and was left unattended and found to be not breathing and without a pulse by EMS (Emergency Medical Services) personnel. Staff was aware of the change in condition in R101 but did not call for additional assistance. An RN (Registered Nurse) assessment was not performed, staff did not stay with and monitor the resident, and facility staff were not aware that R101 had become unresponsive and lifeless until EMS personnel arrived at the facility. The failure of staff to assess and monitor R101 and failure from facility staff to provide R101 with basic life support prior to EMS arriving at the facility and when R101 became pulseless and non-breathing, created a finding of immediate jeopardy that began on [DATE]. Cross reference F678. 3.) On [DATE] at 11:00 a.m., Surveyor interviewed DON (Director of Nursing)-B regarding R101's change in condition and subsequent death on [DATE]. Surveyor asked DON-B if she was present in the building on [DATE] when R101 experienced a change in condition. DON-B informed Surveyor that she was present in the building on [DATE] when R101 experienced a change in condition. Surveyor asked DON-B if she heard an overhead page or call from help from any facility staff regarding R101's change in condition on [DATE]. DON-B informed Surveyor that she did not hear an overhead page or call from help from any facility staff regarding R101's change in condition at any time on [DATE]. DON-B informed Surveyor that she was not aware of R101's change in condition and was under the impression that R101 coded (lost his pulse and stopped breathing) when the ambulance arrived to the facility and not prior. DON-B informed Surveyor that she was not aware of R101's change in condition, need for monitoring and or an RN assessment because staff did not communicate with her (DON-B). DON-B informed Surveyor that had staff informed her (DON-B) of what was occurring, she would have stepped in (taken over care) to care for R101. DON-B informed Surveyor that she would have assessed and monitored R101's change in condition and that staff should have called for assistance and or a supervisor when R101 experienced a change in condition. 4.) On [DATE] at 3:14 p.m., as part of the QAA (Quality Assurance and Assessment)/QAPI (Quality Assurance and Performance Improvement) facility task, Surveyor interviewed Administrator-A and Assistant Administrator-C regarding the above incidents. Surveyor asked Administrator-A how the facility had failed to be aware, prior to the survey findings, of R101's change in condition and failure of staff to provide R101 with basic life support on [DATE], especially as the facility had been cited for the same immediate jeopardy citation (F678) on [DATE]. Administrator-A informed Surveyor that the facility's goal with R101 was to get him home and on hospice. Administrator-A informed Surveyor that facility staff read LPN-MM's nursing note regarding R101 and assumed R101 had simply coded (pulseless and not breathing) and not that facility staff failed to monitor and or provide basic life support to R101. Administrator-A informed Surveyor that the facility failed to take a deeper dive in R101's change in condition and subsequent death as they took LPN-MM's nursing notes to be truth and had not obtained R101's EMS (Emergency Medical Services) report which detailed the immediate jeopardy findings. Surveyor asked Administrator-A why the facility had not educated staff and or audited R101's death prior to the survey findings, especially since the facility had implemented a plan of correction to prevent further deficiencies with the delivery of basic life support, including CPR documented in F678. Administrator-A informed Surveyor that again the facility was not aware of the issues with R101's change of condition and death, as the facility did not investigate further then LPN-MM's nursing notes. No additional information was provided as to why the facility was not administered in a manner that enables it to use its resources effectively and efficiently to ensure that that facility staff were educated and that R101's change in condition and death was monitored and audited to prevent further incidents. The facility removed the immediate jeopardy on [DATE], when it had completed the following: * The Vice President of Operations and Senior Vice President of Clinical Services conducted education with the Administrator and Director of Nursing relative to immediate reporting of any events and/or resident change of condition that could or did require CPR. * The Administrator and Director of Nursing will notify the Vice President of Operations and Senior Vice President of Clinical Services immediately upon events to include deaths, hospitalization s, unplanned discharges or resident acute/significant changes of condition to ensure a review is conducted for necessary intervention up to and including the need for CPR. * The Vice President of Operations, Senior Vice President of Clinical Services and Regional Nurse Consultant will review clinical documentation daily to ensure all events have been identified to include those that may require CPR. Events that have been identified will have a comprehensive review to ensue appropriate response. * There will be daily communication with staff to discuss any resident events or support needed. * Each week, a quality assurance meeting, in collaboration with the facility medical director and corporate representatives, will be conducted to review all events for trends and opportunities for further education and training. * The facility medical director will review each death and hospitalization in the facility in the weekly Quality Assurance and Performance Improvement (QAPI) meeting for appropriate response and provide recommendations as needed.

Based on a record review and interview, the facility did not ensure facility staff provided basic life support to 1 (R101) of 1 Residents who required Cardiopulmonary Resuscitation (CPR). Basic life support is defined in the State Operations Manual as a level of medical care which is used for victims of life-threatening illnesses or injuries until they can be given full medical care at a hospital . On [DATE], R101 experienced a significant change in condition such that one certified nursing assistant (CNA) thought the resident had passed. Staff left the resident unattended until found to be not breathing and without a pulse by EMS (Emergency Medical Services) personnel. LPN-MM was aware of the change in condition in R101 but did not call for additional assistance. An RN (Registered Nurse) assessment was not performed and facility staff were not aware that R101 had become unresponsive and lifeless until EMS personnel arrived at the facility. The failure of staff to assess and monitor R101 and failure from facility staff to provide R101 with basic life support prior to EMS arriving at the facility and when R101 became pulseless and non-breathing, created a finding of immediate jeopardy that began on [DATE]. The Nursing Home Administrator (Administrator-A) and Director of Nursing (DON-B) were notified of the immediate jeopardy on [DATE] at 4:09 p.m. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope/severity of [NAME] (potential for more than minimal harm/pattern) as the facility continues to implement its plan of correction for the 51 residents who are full code. Findings include: The facility's policy dated as revised (MONTH) (YEAR) and titled, The Emergency Procedure -Cardiopulmonary Resuscitation documents, Policy Statement: Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), included defibrillation, for victims of sudden [MEDICAL CONDITION]. Under the General Guidelines section it documents, 3. Victims of [MEDICAL CONDITION] may initially have gasping respirations or may appear to be having a [MEDICAL CONDITION]. Training in BLS includes recognizing presentations of SCA (sudden [MEDICAL CONDITION]); 4. The chances of surviving SCA may be increased if CPR is initiated immediately upon collapse; 7. IF the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's orders [REDACTED]. 8. If the first responder is not CPR certified that person will call 911 and follow the 911 operator's instructions until a CPR-certified staff member arrives. R101 was admitted on [DATE] with [DIAGNOSES REDACTED]. R101's Admission MDS (Minimum Data Set) dated [DATE] documents short and long term memory problems and severely impaired cognitive skills for daily decision making. Section G (Functional Status) documents that R101 had total dependence on facility staff and required a two person physical assist for his bed mobility and transfer needs. Section O (Special Treatment, Procedures and Programs) documents that R101 required oxygen therapy, suctioning and [MEDICAL CONDITION] care. R101's signed admission documentation dated [DATE], that was confirmed with R101's POA (power of attorney), documents that R101 wished to be a full code. R101's physician order [REDACTED]. R101's Advance Directive's Care Plan dated [DATE] documents, Full code has been activated, provide CPR as indicated. R101's nursing note by LPN (Licensed Practical Nurse)-MM dated [DATE] at 12:45 PM documents, CNA (Certified Nursing Assistant) called nurse to room to check resident to see if resident was breathing. RT (Respiratory Therapist) and writer went into room, RT checked SATS (oxygen saturation), SATS 100%. Resident was resting. Repositioned by staff, cares provided by staff per care plan. R101's nursing note written by LPN-MM dated [DATE] at 1:04 PM documents, Resident [MEDICAL CONDITION] and unresponsive at this time. Skin cool and clammy. Unable to get temp reading, unable to get blood pressure at this time. SATS (oxygen saturation) ranging from ,[DATE]% at this time on O2 (oxygen) [MEDICAL CONDITION]. Resident a full code. Call out to Dr. (doctor), NOR (new order received) send resident out to ER (emergency room ). Call out to resident's niece who is emergency contact. Niece aware of C[NAME] (change of condition) that resident will be going to FMH (Froedert Memorial Hospital) ED (emergency department). Niece states that she is on her way. Call out to [NAME] Ambulance for transportation. On hold with FMH to give report. Will monitor. R101's nursing note written by LPN-MM dated [DATE] at 1:45 PM documents, [NAME] ambulance here at facility and resident coded. Ambulance performed CPR (cardiopulmonary resuscitation) on resident for 20 minutes or so before pronouncing death at 1336 (1:36 PM). Call out to family to update, niece states that she is on her way to facility. Niece asked nurse why isn't resident at FMH like nurse said earlier. Writer explained that resident was going to FMH until ambulance noticed that resident coded and started CPR right away. Resident was soon to start hospice and was evaluated yesterday on [DATE]. Resident was not admitted into hospice yet. Resident was still a full code at this time. Will monitor. R101's nursing note dated [DATE] at 2:54 PM documents, Resident's family here in resident's room. Niece wants to speak with nurse regarding uncle's death. Nurse explained that hospice came out yesterday for evaluation but had not yet admitted patient at this time. Niece was aware of hospice. Niece had the idea that resident would be going home to be comfortable but was not intending death. Niece wants to speak with staff regarding an autopsy and what to do next. Writer says ok and will get as much information as possible. Will monitor. R101's [NAME] Ambulance Emergency Services report dated [DATE] documents: Dispatch Notify: 1:04 PM on [DATE]; Dispatched: 1:05 PM on [DATE]; At Scene: 1:18 PM on [DATE]; Narrative: Upon arrival a male pt. (patient) laying in bed supine, pt. is cool to the touch with no pulse and no spontaneous respirations, no rigor is noted and no lividity is present. HX (History)-[NAME] 485 dispatched for patient who per EMS (emergency medical services) noted looks dead with low spo2 (oxygen saturation). pt.(patient) is a full code. Nurse reports that 10 minutes before they called EMS (emergency medical services), patient barely breathing and had low SPO2 (oxygen saturation) saturations and did not look good. AX (Assessment) -pt. is cool to the touch, radical and central pulses are felt and are absent. pt. has no chest rise or fall and no lung sounds. pt. has no signs of trauma. pt. is moved from his bed to the floor where CPR is immediately started. RX (Treatment/Prescription)-BVM (bag valve mask) is attached to [MEDICAL CONDITION]. Continuous compressions are initiated and BVM breaths delivered every 6 seconds with good chest rise and fall. IO (intraosseous) access is obtained in the left medial tibial tuberosity and 1 mg (milligram) of [MEDICATION NAME] is administered continuous compressions are continued switching off every 2 minutes while minimally disrupting compressions, blood sugar obtained. Initial ETCO2 (End-Tidal Carbon [MEDICATION NAME]) is obtained in the high 70's and steadily drops to the 40's; 2nd [MEDICATION NAME] is delivered 5 minutes later and flushed; Medical control is contacted on the phone and Doctor is contacted. We discussed what is done and how the patient is presenting. She agrees that one more EPI ([MEDICATION NAME]) should be given and a pulse check after; patient remains in the asystole the whole time with no change. Doctor agrees to a time of death of 1336 (1:36 PM). CX (Outcome) - Call is cancelled, nursing staff contacts funeral home and family. Surveyor noted that LPN-MM called [NAME] Ambulance, a private ambulance company, at 1:04 PM on [DATE] and the ambulance did not arrive to the facility until 1:18 PM, 14 minutes later. A Google Maps search of the closest fire station, with a paramedic response, from the facility revealed that there are two fire stations within 1.5 miles from the facility and each have a 5 to 6 minute travel time to the facility. Surveyor was unable to locate any documentation or evidence in R101's medical record that documented R101 was assessed, monitored or provided with basic life support services when R101 experienced a change in condition on [DATE]. Surveyor was unable to locate any documentation of any vitals obtained by facility staff or LPN-MM during R101's change of condition on [DATE]. Surveyor noted that per the above documentation, LPN-MM recognized a change in condition in R101 but failed to monitor, assess and or provide basic life support services for R101. Per the documentation, LPN-MM left R101 alone when R101 was experiencing a change in condition, did not call for an RN (Registered Nurse) assessment or assistance and did not monitor R101 before he lost his pulse and stopped breathing. On [DATE] at 3:24 p.m., Surveyor interviewed LPN-MM, who was the LPN documented as caring for R101 on [DATE], regarding R101's change in condition and death on [DATE]. Surveyor asked LPN-MM to describe what occurred with R101 on [DATE]. LPN-MM informed Surveyor that CNA (Certified Nursing Assistant)-PP requested she check on R101, as per CNA-PP, R101 did not look well. LPN-MM informed Surveyor that she went into R101's room with RT (Respiratory Therapist)-NN and took R101's vitals, noted his SPO2 (oxygen saturation) was 100% and determined R101 was all right. LPN-MM informed Surveyor that she then left R101's room and went and gave other residents insulin while CNA-PP provided cares to R101. LPN-MM informed Surveyor that CNA-PP, after providing cares for R101, returned to her and again informed her that R101 did not look well. LPN-MM informed Surveyor that when she entered R101's room, she noted his SPO2 (oxygen saturation) was at 69% and R101's heart rate was fluctuating between 88 bpm (beats per minute) and 199 bmp. LPN-MM informed Surveyor that at this time, she was unable to obtain a blood pressure on R101 as the blood pressure machine kept cycling over and over. LPN-MM informed Surveyor that because R101's heart was racing she left R101's room and called R101's physician, who ordered R101 be sent out to the hospital right away. LPN-MM informed Surveyor that when she left R101's room, CNA-PP and RT-NN remained in R101's room. LPN-MM informed Surveyor that after calling R101's physician, she called for an ambulance for R101 and remained at the nurse's station getting R101's transfer paper work ready. LPN-MM informed Surveyor that in addition to preparing R101's transfer paper work, she called the hospital to give report on R101. LPN-MM informed Surveyor, that at the time, she was in a hurry to gather R101's transfer paper work and was not aware that R101 had lost his pulse or stopped breathing until ambulance personnel arrived and asked her (LPN-MM) if R101 was a full code or not. LPN-MM informed Surveyor that when she had initially left R101's room to call R101's physician, R101 still had a pulse and was breathing. Surveyor asked LPN-MM if she (LPN-MM) had called for 'crash' cart (containing emergency equipment), other staff assistance or had called for a code blue (code for unresponsive/pulseless not breathing/critical patient) when she noticed R101 had a change in condition. LPN-MM informed Surveyor that she did not call for a crash cart and did not get other nursing/staff assistance at the time of R101's change in condition. LPN-MM informed Surveyor that at the time, she (LPN-MM) felt R101 was still stable as R101 was still breathing. LPN-MM informed Surveyor that she only called for other staff assistance and had DON (Director of Nursing)-B paged only after EMS personnel alerted her that R101 had stopped breathing and had become pulseless. LPN-MM informed Surveyor that after she called for other staff assistance, via an overhead page, no other staff, including DON-B, came to assist her in R101's room. Surveyor asked LPN-MM why she had called a private ambulance company ([NAME] Ambulance) instead of 911, as 911 would have provided a faster response time for R101's change in condition. LPN-MM informed Surveyor that at the time, she felt R101 was still stable as R101 was still breathing. Surveyor asked LPN-MM if a RN (Registered Nurse) had performed an assessment on R101 or if she had documented R101's vitals when she noticed R101's change in condition. LPN-MM informed Surveyor that she was not sure if she documented R101's vitals and confirmed that no RN had performed an assessment on R101 when R101 experienced a change in condition. On [DATE] at 4:30 p.m., Surveyor interviewed CNA (Certified Nursing Assistant)-PP, who was the CNA documented as caring for R101 on [DATE], regarding R101's change in condition and death on [DATE]. Surveyor asked CNA-PP to describe what occurred prior to R101's death on [DATE]. CNA-PP informed Surveyor that on [DATE], she (CNA-PP) was in R101's room providing cares for R101 when she (CNA-PP) noticed that R101 looked different. CNA-PP informed Surveyor that at that time R101 was still breathing and had a pulse. CNA-PP stated that because of her concern, she went and asked LPN-MM to come check R101 out to make sure R101 was all right. Per CNA-PP, LPN-MM and RT (Respiratory Therapist)-NN went into R101's room and informed her (CNA-PP) that R101 was all right. CNA-PP informed Surveyor that once LPN-MM informed her R101 was all right, she went back into R101's room and finished providing care for R101. CNA-PP informed Surveyor that she again noticed that R101 was not looking well and that she (CNA-PP) again informed LPN-MM of this. CNA-PP informed Surveyor that she then observed LPN-MM go into R101's room and take R101's vitals. CNA-PP informed Surveyor that she then returned to R101's room to place heel boots on R101 and again noticed R101 was not looking well. CNA-PP informed Surveyor that she then left R101's room and began providing care to other residents. CNA-PP informed Surveyor that during this time, she did not observe anyone in R101's room, but that she (CNA-PP) believed RT-NN might have stayed in R101's room while she observed LPN-MM at the nurse's station and not in R101's room. CNA-PP informed Surveyor that shortly after this, she saw ambulance personnel arrive at the facility, to which she escorted them to R101's room. CNA-PP informed Surveyor that she then left to provide other residents with cares. CNA-PP informed Surveyor that she then heard an overhead call for assistance in R101's room and that when she walked to R101's room she saw ambulance personnel performing CPR on R101. CNA-PP informed Surveyor that she did not observe a facility crash cart (containing emergency equipment) or other nursing staff in R101's room, prior to EMS arriving or while ambulance personnel performed CPR on R101. On [DATE] at 9:13 a.m., Surveyor interviewed CNA -OO, who was also a CNA documented as caring for R101 on [DATE], about R101's change in condition and death on [DATE]. Surveyor asked CNA-OO to describe what occurred prior to R101's death on [DATE]. CNA-OO informed Surveyor that she and CNA-PP were providing R101 with care when CNA-PP observed that R101 was not looking well and went to get LPN-MM. CNA-OO informed Surveyor that when she was in R101's room, she observed R101 to be cold to the touch and that initially she thought R101 had passed/expired. CNA-OO informed Surveyor that when LPN-MM came into R101's room to check on R101, she (CNA-OO) left R101's room to go and obtain heel boots for R101. CNA-OO informed Surveyor that when she returned to R101's room, she did not enter R101's room but instead handed the heel boots to CNA-PP to place on R101. CNA-OO informed Surveyor that she then went into other resident rooms to provide care and that when she exited the resident rooms and was in the hallway, she (CNA-OO) was then confronted by EMS personnel and was asked by EMS personnel if R101 was a full code (requiring CPR). CNA-OO informed Surveyor that she told EMS personnel she was unsure if R101 was a full code and that she then observed EMS personnel began chest compressions on R101. CNA-OO informed Surveyor that she did not hear an overhead page for assistance in R101's room and that she (CNA-OO) did not observe a crash (containing emergency equipment) cart in R101's room when R101 had a change in condition or prior to R101 become unresponsive and lifeless. On [DATE] at 9:46 a.m., Surveyor asked Corporate Consultant-D if RT-NN was available to be interviewed. Corporate Consultant-D informed Surveyor that RT-NN was no longer employed at the facility and that there was no information to contact RT-NN. On [DATE] at 10:54 a.m., Surveyor interviewed LPN (Licensed Practical Nurse)-M, who was assigned to the ventilator unit on [DATE] when R101 experienced a change in condition, if she heard an overhead page or call from help from any facility staff regarding R101's change in condition on [DATE]. LPN-M informed Surveyor that she did not hear an overhead page or call from help from any facility staff regarding R101's change in condition at any time on [DATE]. On [DATE] at 11:00 a.m., Surveyor informed DON (Director of Nursing)-B of the above findings. Surveyor asked DON-B if she was present in the building on [DATE] when R101 experienced a change in condition. DON-B informed Surveyor that she was present in the building on [DATE] when R101 experienced a change in condition. Surveyor asked DON-B if she heard an overhead page or call from help from any facility staff regarding R101's change in condition on [DATE]. DON-B informed Surveyor that she did not hear an overhead page or call from help from any facility staff regarding R101's change in condition at any time on [DATE]. DON-B informed Surveyor that if LPN-MM had informed her that she needed assistance, she (DON-B) was CPR certified and would have responded and assisted LPN-MM. DON-B informed Surveyor that she was not aware of R101's change in condition and was under the impression that R101 coded (lost his pulse and stopped breathing) when the ambulance arrived to the facility and not prior. DON-B informed Surveyor that she was not aware of R101's change in condition, need for monitoring and or an RN assessment because LPN-MM did not communicate this to her (DON-B). DON-B informed Surveyor that had LPN-MM informed her (DON-B) of what was occurring, she would have stepped in (taken over care) to care for R101. DON-B informed Surveyor that she would have assessed and monitored R101's change in condition and that LPN-MM should have called for assistance and or a supervisor when R101 experienced a change in condition. No additional information was provided as to why LPN-MM left R101 alone when R101 was experiencing a change in condition, did not call for an RN (Registered Nurse) assessment or assistance and did not monitor R101 before he lost his pulse and stopped breathing. The facility removed the immediate jeopardy on [DATE], when it had completed the following: * The resident affected is no longer at the facility. * All licensed nurses working at the facility, including agency staff members, were educated related to identification of change in condition for residents, ensuring residents that experience an acute/significant change in condition have continuous monitoring, how and when to call for assistance from a Registered Nurse and/or Direction of Nursing, * Licensed nurses will be educated on instances where 911 should be called versus routine transport in addition to any situation that would warrant initiation of a code blue. Education was also provided on CPR policy to include immediate response to any situation that could potentiate the need for a code blue, including having emergency equipment accessible at the time on acute/serious change in condition. * Policies and procedures related to code blue and change in condition will be reviewed by the facility Quality Assurance Committee. Each week, a quality assurance meeting, in collaboration with the facility medical director and corporate representatives, will be conducted to review all events or trends and opportunities for further education and training. * The facility medical director will review each death and hospitalization in the facility in the weekly QAPI (Quality Assurance Performance Improvement) meeting for appropriate response and provide recommendations as needed.

Based on observation, interview and record review the facility did not ensure 1 (R14) of 7 sampled residents with limited range of motion received care and services to maintain or improve their range of motion. -R14's recommendations from therapy to receive PROM (passive range of motion) was not carried over into R14's plan of care. R14 had no documented evidence that range of motion was performed from 10/11/19-1/1/20. R14's contractures are documented as worsening. (Cross Reference F686). Findings include: R14 has [DIAGNOSES REDACTED]. R14's Admission Minimum Data Set assessment with an assessment reference date of 10/4/19 documents R14's cognitive skills for daily decision making is severely impaired, requires total dependence on two plus persons physical assistance for bed mobility, and has a functional limitation in range of motion on one side to both the upper and lower extremity. R14 was discharged from Occupational Therapy on 10/11/19. The OT (Occupational Therapy) Discharge Summary includes Discharge Recommendations: Nursing communication issued regarding PROM (passive range of motion) with AM/PM self cares and Pt. (patient) to be repositioned in bed every two hours. The Discharge Summary also documents Functional Maintenance Program Established/Trained=Range of Motion Program. The assessment documents R14 has contractures to her bilateral upper extremity. The surveyor reviewed R14's plan of care. R14 had no plan of care related to her contractures and preventing complications related to R14's contractures. R14 had no interventions on her plan of care related to providing passive range of motion until 1/1/2020 when the intervention to Provide Passive and or Active ROM (Range of Motion) during care was added. The surveyor reviewed R14's medical record and noted there was no documentation of range of motion being completed after R14 was discharged from therapy on 10/11/19-1/1/20. On 12/23/19 R14 was referred to occupational therapy due to worsening contractures. The surveyor observed R14 throughout the survey. The surveyor observed R14's bilateral upper extremities were contracted with her bilateral hands noted to be clenched into fists. On 01/09/20 at 12:06 PM the surveyor interviewed CNA (certified nursing assistant)-Q. The surveyor asked how CNA-Q knows if someone has daily range of motion. CNA-Q stated it would be on the care plan and therapy would let you know. The surveyor asked CNA-Q if R14 was currently receiving range of motion. CNA-Q stated she goes in about once a day and stretches her legs and arms and finger tips. The surveyor noted this was not in accordance to R14's plan of care to provide range of motion during cares. CNA-Q confirmed they document providing range of motion in the electronic health record. On 01/09/20 at 12:13 PM the surveyor interviewed RN (Registered Nurse) Manager-[NAME] The surveyor asked how staff know to perform range of motion on residents. RN Manager-J stated it is in their care plan. The surveyor asked how therapy communicates with nursing. RN Manager-J stated verbally and they will fill out a communication form with the recommendations being added to the care plan. The surveyor asked RN Manager-J if staff documents performing range of motion. RN Manager-J stated yes. The surveyor informed RN Manager-J of being unable to find intervention related to providing range of motion or documentation of range of motion being completed for R14 prior to 1/1/20. On 01/09/20 at 08:45 AM the surveyor interviewed Rehab Director-T. Rehab Director-T informed the surveyor R14 had been unable to tolerate hands splints so they had gone with the PROM to the hands. Rehab Director-T informed the surveyor R14 had not been clenching her fists as much as she currently is now. The surveyor asked how CNAs (certified nursing assistants) know they need to do PROM. Rehab Director-T stated we tell the nursing supervisors and they enter it into the system. The surveyor asked if R14 was able to do PROM to her hands. Rehab Director-T stated she (R14) was not able do range of motion to a normal end range, but staff should have been educated on how far she could go. Rehab Director-T stated we educate staff to still do PROM to her hands, just may not be to a normal end range. On 01/09/20 at 12:33 PM the surveyor informed Assistant Nursing Home Administrator-C of the concern of R14's recommendation from therapy for passive range of motion to be completed not being carried over into the care plan, and R14 not being documented as receiving range of motion.

Based on observation, interview and record review, the facility did not ensure that 3 (R32, R59 & R199) of 5 residents reviewed received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. * R32 did not have a comprehensive bowel assessment or bowel monitoring in place to prevent stool impaction and hospitalization . R32 was hospitalized from [DATE] to 5/21/19 for stool impaction/proctitis. * R59 did not have a comprehensive bowel assessment or bowel monitoring in place. R59 did not have a documented bowel movement from 12/30/19 to 1/11/2020. * R199 was admitted with a Foley Catheter. The MDS was incorrectly coded indicating R199 did not have a catheter upon admission and that R199 was incontinent of urine and always incontinent of bowel. There was no comprehensive assessment for the use of the Foley Catheter or justification for it's continued use. There was no care plan for the use of the Catheter and what appropriate care and services would be provided to prevent urinary tract infections and possible discontinuation of use. The Medication and Treatment Administration Records did not record catheter care every shift and did not document urinary output every shift as per physician's orders. Certified Nursing Assistants (CNAs) inconsistently documented R199 was incontinent of urine while at other times the catheter was noted. On 10/9/19, the Nurse Practitioner (NP) documented a plan for a voiding trial to be done on 10/7/19 which was not followed up on and the Nurse Practitioner documented the same plan for a voiding trial on 10/16/19 and on 10/18/19. A Progress note on 10/28/19 indicates Foley patent, urine clear yellow, complaint of pain at penis site due to tugging of Foley by resident unintentionally. A Progress note on 11/13/19 at 4:44 P.M., indicates R199 very agitated, complaining of pain. R199's Foley drainage bag was empty, no urine in tubing, only small amount of blood tinged muscus. The Foley was changed with an immediate return of urine. Prior to this, the last time the facility documented on R's urine output was on 11/11/19. The 11/13/19 progress note was the first entry about catheter care being provided since admission. A Progress note on 11/13/19 at 10:50 P.M. indicates R199 had approximately 100 red urine in Foley tubing. The Foley balloon was deflated and Foley advanced which produced 120 cc red urine with little relief. R199 was given [MEDICATION NAME]. On 11/14/19 at 5:47 [NAME]M. blood clotting was observed in R199's brief and he was in severe pain. The nurse attempted to advance the catheter but it was too painful. R199 was able to urinate without difficulty once the catheter was pulled out. The MD was contacted who ordered to hold the catheter reinsertion. On 11/14/19 at 3:07 P.M., R199 was observed with some blood on his bedding and incontinence product. R199 was seen by the NP. At 1445, R199 was observed in the bathroom with blood on the floor, on his legs and on the toilet seat. R199 was sent to the emergency room and was admitted into the hospital [MEDICAL CONDITION]. The facility did not ensure R199 had a comprehensive assessment and care plan for the use of the catheter, staff were documenting R199 was incontinent of urine and staff were not documenting R199's urinary output. Additionally, R199 who was assessed as always being incontinent of bowel did not have a comprehensive assessment or a 72 hour toileting diary conducted. The Nurse Practitioner's progress notes indicate R199's chief complaints of constipation with a plan for the use of Mirlax was documented, however R199 had no physician's orders for the use of Mirlax, nor was Mirlax administered. R199's care plan did not address R199's concerns with constipation. It was noted that R199 would go for days without a bowel movement without the physician being notified and the facility did not obtain an order for [REDACTED]. Examples #1 involving R32 and Example #3 involving R199 rises to a scope and severity level of G (Harm/Isolated.) Findings include: 1.) R32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R32's Annual MDS (Minimum Data Set) dated 1/17/19 documents a BIMS (Brief Interview for Mental Status) score of 15, indicating that R32 is cognitively intact. Section G (Functional Status) documents that R32 has total dependence on staff and requires a two person physical assist for his transfer and toileting needs. Section G0400 (Functional Limitation in Range of Motion) documents that R32 has impairment to both sides of both his upper and lower extremities. Section H (Bladder and Bowel) documents that R32 has an indwelling urinary catheter in place and documents that R32 is always incontinent of bowel. R32's Urinary Incontinence and Indwelling Catheter CAA (Care Area Assessment) dated 1/28/19 documents under the Analysis of Findings section, Resident with dx (diagnosis) of [MEDICAL CONDITION] .he has related [MEDICAL CONDITION] bowel and bladder . uses narcotic pain medication. R32's Altered Toileting care plan dated 11/19/18 documents under the Problem section, Altered Toileting as evidence by [DIAGNOSES REDACTED]. On 1/6/20 at 12:56 p.m., Surveyor interviewed R32 regarding the quality of care at the facility. Surveyor asked R32 is he had issues or concerns regarding his bowels and or suppository administration. R32 informed Surveyor that he has in the past had trouble getting his daily suppository and that in (MONTH) 2019 he had a bowel obstruction, which required hospitalization , due to not getting his daily suppository. On 1/7/20 at 1:34 p.m., Surveyor reviewed R32's medical record and noted that R32 did not have a documented bowel movement from 5/10/19 to 5/19/19. Surveyor noted that on 5/19/19, R32 was sent out to the hospital for stool impaction/proctitis. R32's physician assistant progress note dated 5/29/19 documents, (R32) was admitted to hospital from 5/19/19 to 5/21/19 for stool impaction/proctitis. Patient had not had a bowel movement for 9 days and developed an altered mental status. He was given enemas and started on a bowel regiment with good results .Patient reports daily BMs (bowel movements) since return from the hospital .Review of Matrix shows lack of documentation of BMs. R32's physician order dated 4/7/18 documents, Requires digital stimulation of rectum daily with ordered [MEDICATION NAME] suppository every AM -[MEDICAL CONDITION] bowel. Surveyor reviewed R32's (MONTH) 2019 MAR (Medication Administration Record) and noted that the above order was not administered from 5/9/19 to 5/19/19. R32's physician order dated 8/16/18 documents, [MEDICATION NAME] suppository; 10 mg (milligrams); Amount to Administer: 1 suppository; rectal. Diagnosis: [REDACTED]. Surveyor was unable to locate any documentation or evidence in R32's medical record that R32 had a comprehensive bowel assessment completed prior to being hosptalized on [DATE]. Surveyor was unable to locate any documentation or evidence in R32's medical record that R32's bowel movements were being monitored by facility staff. Surveyor was unable to locate any documentation or evidence in R32's medical record that R32's physician was notified that R32 did not have a bowel movement from 5/10/19 to 5/19/19, prior to R32 being hosptalized on [DATE]. On 1/8/20 at 8:49 a.m., Surveyor asked R32 if he had refused his scheduled suppository and or digital stimulation from 5/10/19 to 5/19/19. R32 denied having refused his scheduled suppository and or digital stimulation from 5/10/19 to 5/19/19. On 1/8/20 at 12:28 p.m., Surveyor informed Corporate Consultant-D of the above findings. Surveyor asked why R32 did not have his scheduled suppository and digital stimulation, per physician orders from 5/9/19 to 5/19/19, prior to R32 being hospitalized . Corporate Consultant-D informed Surveyor that she could not provide any information as to why R32 did not have his scheduled suppository and digital stimulation, per physician orders from 5/9/19 to 5/19/19. Surveyor asked Corporate Consultant-D if R32's bowel movements were being monitored and or if R32's physician was notified that R32 did not have a bowel movement from 5/10/19 to 5/19/19, prior to R32 being hosptalized on [DATE]. Corporate Consultant-D informed Surveyor that she could not provide any documentation and or evidence that R32's bowel movements were being monitored and informed Surveyor that she could not locate any documentation that R32's physician was notified that R32 did not have a bowel movement from 5/10/19 to 5/19/19, prior to R32 being hosptalized on [DATE]. On 1/9/20 at 8:02 a.m., Corporate Consultant-D informed Surveyor that she could not locate a comprehensive bowel assessment for R32 in R32's medical record. No additional information was provided as to why R32 did not receive appropriate treatment and services to restore as much bowel function as possible. 2.) R59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R59's Quarterly MDS (Minimum Data Set) 11/26/19 documents a BIMS (Brief Interview for Mental Status) score of 15, indicating that R59 is cognitively intact. Section G (Functional Status) documents that R59 has total dependence on staff and requires a two person physical assist for his bed mobility, personal hygiene and toileting needs. Section G0400 (Functional Limitation in Range of Motion) documents that R59 has impairment to both sides of both his upper and lower extremities. Section H (Bladder and Bowel) documents that R59 has no appliances in place and is frequently incontinent of bowel. On 12/5/19, a complaint was called into the Southeastern Regional office that alleged R59's bowel movements are not monitored, as R59 receives narcotics and often will refuse his tube feeding due to his abdomen being hard due to needing a suppository. On 1/13/19, Surveyor reviewed 59's medical record and was unable to locate any documentation or evidence that R59 had a comprehensive bowel assessment. A review of R59's bowel record documents that R59 did not have a documented bowel movement from 12/30/19 to 1/11/2020. Surveyor was unable to locate any documentation or evidence in R59's medical record that R59's bowel movements were being monitored by facility staff. On 1/13/20 at 10:23 a.m., Surveyor informed RN (Registered Nurse) Manager-J of the above findings. Surveyor asked RN Manager-J if R59 had a comprehensive bowel assessment completed and if R59's bowel movements were being monitored by facility staff, as Surveyor was unable to locate any documentation or evidence in R59's medical record. RN Manager- J informed Surveyor that she would review R59's medical record and let Surveyor know. On 1/13/20 at 1:47 p.m., RN Manager-J informed Surveyor that she was in the process of completing a bowel assessment for R59, which included monitoring of R59's bowel movements, and that she could provide no additional information. No additional information was provided as to why R59 did not receive appropriate treatment and services to restore as much bowel function as possible. 3.) On 01/08/20, Surveyor initiated a closed medical record review for R199. R199 was admitted on [DATE] with [DIAGNOSES REDACTED]. Admission progress note dated 09/27/2019 at 3:00 p.m. states that R199 arrived via ambulance at 12:30 p.m. A and O (alert and orientated) x's 3 pleasant and cooperative able to verbalize needs. ROM WNL (range of motion within normal limits) an assist of one with ADL's (activities of daily living) and transfers d/t (due to) condition along with weakness noted and reported. Wound team measured (sic) placed wound vac to right lower extremity. PICC to right upper arm double lumen intact and patent. Foley catheter 16fr 10cc draining clear yellow urine BS (bowel sounds) x4 hypoactive encourage fluids. General diet thin liquids IDDM (diabetes) showing no s/s of hypo/[MEDICAL CONDITION]. Skin intact dry dental partial intact wear glasses general diet thin liquids orientated to room call light at bedside will continue to monitor. Admission physician orders, dated 9/27/19 included the following treatment orders: General Catheter Care Every Shift and PRN (as needed) Special Instructions: Document catheter care as indicated Every Shift Noc 20:00 - 06:00, Days 06:00 - 14:00, Evenings 14:00 - 20:00 09/27/2019 Open Ended Treatments General Change Cath if Leaking or Not Functioning Special Instructions: Staff Note: check if changed at facility or other location Once A Day -PRN 1 09/27/2019 Open Ended Treatments General Change F/C (Foley catheter) Monthly and PRN Special Instructions: Document date F/C changed Once A Day on the 7th of the Month 06:00 - 10:00 09/27/2019 Open Ended Treatments General Document Output from Catheter every shift Every Shift Noc 20:00 - 06:00, Days 06:00 - 14:00, Evenings 14:00 - 20:00 09/27/2019 Open Ended Treatments Review of the ELC Clinical Admission Documentation dated 9/28/19 states that R199 has no obvious problems with bowel and for urinary elimination- incontinence and uses briefs/ urinal. Nurse Practitioner Progress Note, dated 9/30/19, states that R199 has [MEDICAL CONDITION] and Foley catheter is in place. The plan is to continue use of Foley and monitor input and output. Also continue Tamsulosin medication (medication for enlarged prostate). The Admission MDS (Minimum Data Set), dated 10/4/19, states that R199 has a BIMS (brief interview for mental status) score of 14 indicating R199 is cognitively intact, no behaviors noted, needs extensive assistance of 1 and 2 staff for ADL's, extensive 1 person assistance for toileting. The MDS states, catheter not present on admission, occasionally incontinent of urine and always incontinent of bowel. No toileting program for bowel and bowel patterns- constipation present- no. On 1/8/20 at 9:26 a.m., Surveyor interviewed Corporate Consultant (CC) D in regards to the inaccuracy of R199's admission MDS. CC- D was able to confirm that the MDS was coded wrong regarding R199 not having a catheter in place at the time of admission. CC-D stated that the MDS Coordinator that was responsible for completing the MDS's in this reference period is no longer at the facility. CC- D also stated that a comprehensive assessment and the care plan is based on the information gathered for the MDS. Surveyor conducted further review of the medical record and noted that there was no comprehensive assessment for the use of the catheter. There was no documentation as to why R199 had the Foley catheter in place and what was the medical justification for it's continued use. In addition, it was noted that there was not a care plan in place for the use of the catheter and what appropriate care and services would be provided to prevent urinary tract infections and possible discontinuation of the use of the catheter. On 01/13/20 at 7:43 a.m., Surveyor interviewed CC- [NAME] who was able to confirm that because the use of a catheter was not triggered on the admission MDS, a comprehensive assessment of the use of the catheter was not triggered or completed, nor was the development of a care plan regarding the use of the catheter for R199. Surveyor conducted a review of the Medication Administration Record and Treatment Administration Record for (MONTH) and October, 2019. It was noted that the above orders regarding catheter care that was to be done every shift including check to see if catheter is leaking or not functioning and document output from catheter every shift was not listed within these records. There was no evidence that these services were provided to R199 in the months of (MONTH) and October, 2019. It is noted that R199 still had the catheter in place until the date of discharge on 11/14/19. The (MONTH) 2019 Treatment Administration record did have documentation on 11/13/19 and 11/14/19 that catheter care was provided. From the admission date of [DATE] through date of discharge, there were only 2 days in which staff signed out that catheter care was provided. A review of the Vitals Report showed from 9/27/19- 9/29/19 that only 2 entries were made about the amount of urine output in R199's catheter. The order indicates this should be documented each shift. The (MONTH) 2019 vitals report was reviewed showing that documentation for urine output was only recorded on 10/1/19 (1 shift), 10/11/19 (1 shift), 10/13/19 (1 shift), 10/16/19 (1 shift), 10/18/19 (1 shift), 10/22/19 (1 shift), 10/23/19 (1 shift), 10/26/19 (1 shift), 10/27/19 (1 shift), 10/28/19 (1 shift), 10/30/19 (1 shift) and 10/31/19 (1 shift). A review of the (MONTH) 2019 Vitals Report shows that staff only documented urine output on 11/4/19 (1 shift), 11/11/19 (1 shift), 11/13/19 (2 times). A review of the Point of Care History, which is generated by the Certified Nursing Assistants entering data into the electronic record, showed that on several occasions staff documented that R199 was incontinent of urine and other entries stated that R199 had a catheter in place. This data had several inaccurate entries within it. On 10/9/19, the Nurse Practitioner visited R199 and conducted a follow-up assessment for multiple medical problems. A review of the progress note states that (R199) does have [MEDICAL CONDITION] and that a Foley catheter is present. The progress note states that the assessment of the Foley catheter was conducted and the plan is to continue Tamsulosin medication and will do a voiding trial on 10/7/19. On 10/16/19 and 10/18/19, a progress note was written by the Nurse Practitioner after R199 had been seen and evaluated. Both progress notes again state that a trial voiding was to take place on 10/7/19. Surveyor conducted a review of the medical record and there is no evidence that a trial voiding and discontinuation of the use of the Foley catheter took place for the entire time that R199 resided at the facility. Further review of the progress notes was conducted and the following was noted: 10/28/2019 at 11:25 p.m.: IV Double lumen PICC RUE (right upper extremity) unable to flush @ 1600, supervisor called, IV flushed and ABT (antibiotic) started by supervisor, IV/ABT with no adverse reaction, Foley patent, urine clear yellow, c/o pain @ penis site d/t tugging of Foley by resident unintentionally. Writer explained to writer about using call light for help when transferring so the tugging would not happen. No bleeding noted. 11/13/2019 at 4:44 p.m.: Resident (R199) very agitated, c/o pain this AM stated feels like I'm going to explode. Stated pain in butt, penis, abdomen. Pulse & BP (blood pressure) elevated at 170/108 (right arm), checked l (left) arm at 199/120, with pulse of 96. Foley drainage bag noted to be empty. Resident making many confused statements with regard to Foley. it was just emptied. I need that out so I can urinate I need a urinal, I have to pee. No urine noted in tubing, only small amount of blood tinged mucus at top of tubing. Message out for (name of), NP. Foley changed, immediate return of urine, totaled 800 within approx. 30 minutes. Resident calm, AM meds administered. BP rechecked later, was down to 116/78 with pulse of 88. Output in Foley bag up to 1200 when emptied shortly after. Resident asked to go to toilet at approx. 1400, CNA assisting him advised writer that Foley had come out. Another Foley placed at approx 1500, no return apparent initially. PM will monitor for output. Review of the medical record showed that the last time any documentation about the amount of urine output from the catheter was on 11/11/19 where they document 200 milliliters of output until the above note on 11/13/19. In addition, the first entry about catheter care being provided since admission is on 11/13/19. 11/13/2019 at 10:50 p.m.: Resident (R199) initially has approx 100 red urine in Foley tubing, writer deflated balloon and advanced Foley catheter which produced a 120cc red urine return, resident complained of pain since first Foley came out, reported little relief after writer advanced new Foley catheter. Was given [MEDICATION NAME] 5/325 mg for pain, repositioned due to being tense. Staff informed to monitor output. 11/14/2019 at 05:47 a.m.: writer called into pt room. moderate amt of blood with small amount of clotting observed in pt brief. pt stated he was in severe pain. writer attempted to advance cath. pt complained that it was too painful. a blood clot was observed at tip of cath. pt was able to urinate without difficulty once cath was pulled out. urine color dark yellow. pt c/o that he has small amt of discomfort. on call MD notified, N.O hold cath re-insert until MD follows up and monitor pt output. will continue to monitor. 11/14/2019 at 3:07 p.m.: Resident (R199) observed this AM with some blood on bedding and incontinence product. Seen by NP, this AM. Resident provided with clean urinal to monitor voiding. At approx. 1445, resident observed in bathroom, on toilet, with blood on floor, on his legs, and toilet seat. Some blood noted in toilet, no evidence of voiding in toilet, incontinence product, or urinal. NP contacted, NOR to send out to ER. 11/15/2019 at 15:58: F/U call to the hospital. Resident admitted for [MEDICAL CONDITION]. Nursing aware. On 1/13/20 at 9:50 a.m., Surveyor interviewed Director of Nursing-B (DON). DON-B stated that care plans are developed based on the MDS assessments as well as the admission assessment or any other comprehensive assessment. DON-B stated that sometimes there are orders for catheter care and sometimes there is not and it is up to the physician to write orders for the cares. DON-B was unable to provide any additional information as to why R199 did not have a comprehensive assessment for the use of the catheter, why R199 did not have a plan of care in place for the care of the catheter, why staff were documenting that R199 was incontinent when the catheter was in place during his entire stay and why staff was not documenting urine output, per physician orders. On 1/13/20 at 10:55 a.m., Surveyor interviewed LPN (Licensed Practical Nurse)-Y in regards to R199. LPN-Y stated that she was working when R199 was observed to not have any urine output in the catheter bag on 11/13/19. LPN-Y stated that staff just know to take care of a catheter when they see the patient has one when they walk in the room. LPN-Y stated that it may or may not be on the care plan or in the treatment record, we just know when we see one. LPN-Y stated that on 11/13/19 she changed the catheter, figuring that it was blocked. LPN-Y stated that she was surprised to hear that the replacement catheter had come out and doesn't know how it came out other than R199 must have tugged it out some how. LPN-Y stated that the amount of blood that was observed must have been from the trauma of pulling the catheter out. BOWEL MANAGEMENT: According to R199's 10/4/19 Admission MDS, R199 is always incontinent of bowel and that there is no bowel/ bladder toileting training plan in place. A review of R199's plan of care states that R199 has altered toileting as evidenced by occasional urinary incontinence/ bowel incontinence. Problem start date is 10/14/19. Approaches included administer medications as ordered, complete a 72 hour toileting diary, provide briefs as needed and provide incontinence care as needed. A review of R199's medical record did not show that a comprehensive assessment of R199's bowel management was conducted or a 72 hour toileting diary was conducted. NP Progress Note, dated 9/30/19, indicates that chief complaints for R199 include constipation. Assessment is intermittent and plan is to continue [MEDICATION NAME] scheduling. NP Progress Note, dated 10/9/19, states chief complaints for R199 include constipation and the assessment is that it is intermittent and the plan is to continue [MEDICATION NAME]. It is noted on the NP progress notes for 10/16/19, 10/18/19, 11/11/19, 11/13/19 and 11/14/19 that the same chief complaints of constipation and plan for use of [MEDICATION NAME] is documented. There is no indication the assessment referenced is based upon an actual voiding pattern. A review of the Physician Orders for September, (MONTH) and November, 2019 did not show that an order had been obtained for the use of the [MEDICATION NAME] for intermittent constipation. A review of the Medication Administration record for September, (MONTH) and November, 2019 also did not provide evidence that [MEDICATION NAME] was administered to R199 for intermittent constipation. It was noted that the plan of care also did not address that R199 had concerns with constipation. A review of the Vitals Report for September, (MONTH) and November, 2019 was conducted. It was noted that there was no BM (bowel movements) recorded from 10/11/19-10/17/19, 10/18/19-10/24/19, 11/5/19-11/9/19 and 11/11/19-11/14/19. On 1/13/20 at 9:50 a.m., Surveyor interviewed DON-B in regards to the facility's bowel management program. DON-B stated that there should be standing orders that if someone does not have a bowel movement over a 72 hour period, that nursing staff should be contacting the physician. DON-B also stated that constipation risk should be addressed on the individual care plan and bowels should be documented in the electronic record. DON-B was not able to state why R199 did not have an order for [REDACTED].

Based on observation, interview and record review the facility did not ensure 10 (R14, R200, R18, R46, R87, R47, R24, R82, R28 and R31) of 13 residents at risk for skin break down from a sample of 22 received care and services to promote the prevention of pressure injury development. - R14's recommendation from therapy for passive range of motion to be completed were not carried over to their plan of care and is not documented as receiving range of motion prior to development of R14 developing a stage 3 and two stage 4 pressure injuries to her left hand being documented as being caused from contractures. -R200 developed a pressure injury that was not noted until it was unstageable, did not have revisions to the plan of care as the pressure injury worsened, and the weekly skin assessments completed prior to pressure injury developing did not document the results of the skin assessment. - R46, R87, R82, R47, R24 heels were not offloaded of pressuer as indicated by their plan of care. -R18, R28, and R31 were not repositioned and did not have their heels offloaded of pressure as indicated by their plan of care. Examples #1 involving R14 and Example #2 involving R200 rise to a scope and severity level of a G (harm/isolated) Findings include: 1. R14 has [DIAGNOSES REDACTED]. R14 has a history of pressure injuries. R14's Admission Minimum Data Set (MDS) assessment with a reference date of 10/4/19 documents R14's cognitive skills for daily decision making is severely impaired, requires total dependence on two plus persons physical assistance for bed mobility, and has a functional limitation in range of motion (ROM) on one side to both the upper and lower extremity. R14's Care Area Analysis for Pressure Injuries, signed as completed on 10/17/19, documents Pressure CAA (care area analysis) triggered r/t (related to) pressure injuries present on admission. Unstageable area on Right buttocks. Treatment plan in place, followed by wound care team. Resident is on tube feedings for all nutritional needs, followed by dietary. Medications in use that increase risk of pressure injuries- blood thinners, anti-anxiety and anti-depressants. [MEDICAL CONDITION] CAA triggered to anti-depressant and anti-anxiety in use daily to manage depression/anxiety. Staff will continue to monitor resident and adjust care as needed. A Braden Scale For Prediction of Pressure Sore Risk Assessment completed on 12/20/19 scores R14 at 11, indicating R14 is at high risk for the development of pressure injuries. R14 was discharged from Occupational Therapy (OT) on 10/11/19. The OT Discharge Summary includes, Discharge Recommendations: Nursing communication issued regarding PROM (passive range of motion) with AM/PM self cares and Pt. (patient) to be repositioned in bed every two hours. The Discharge Summary also documents, Functional Maintenance Program Established/Trained=Range of Motion Program. The assessment documents R14 has contractures to her bilateral upper extremity. The surveyor reviewed R14's plan of care. R14 had no plan of care related to her contractures and preventing complications related to R14's contractures. R14 had no interventions on her plan of care related to providing passive range of motion until 1/1/2020 when the intervention to Provide Passive and or Active ROM during care was added. The surveyor reviewed R14's medical record and noted there was no documentation of range of motion being completed after R14 was discharged from therapy on 10/11/19-1/1/20. Progress notes on 12/20/19 document, Resident seen by Wound Care Team at request of nursing staff for change in skin integrity. Skin integrity is impaired, as evidenced by unstageable pressure injury to left lateral fourth finger, unstageable pressure injury to left lateral third finger, and stage 3 pressure injury to left medial second finger. Resident has contractures of left hand into fist causing knuckles to press together. Wounds cleansed and non-adhesive foam tucked between fingers to reduce pressure. Will see if therapy can evaluate for contracture management .Risk assessment completed. Braden score remains 10. Risk factors identified include: age (70),[MEDICAL CONDITION] [MEDICAL CONDITIONS], cerebral [MEDICAL CONDITION], CKD [MEDICAL CONDITIONS](hypertension), depression, impaired mobility, incontinence, and medications ([MEDICATION NAME], aspirin, eliquis, [MEDICATION NAME]) . Wound information documentation on 12/20/19 reflects a 0.6 x 0.7 x 0.1 stage 3 pressure injury to the left second finger, a 0.9 x 1.1 x 0.1 unstageable pressure injury with 80% slough and 20% granulation tissue to the left ring finger, and a 0.7 x 0.8 x 0.1 unstageable pressure injury with 90% slough and 10% granulation tissue to the left pinky. The wounds are documented as being R/t (related to) contractures. On 1/7/20 R14's pressure injuries are documented as being a 0.2 x 0.2 stage 3 pressure injury to her left second finger, a 1 x 0.8 stage 4 pressure injury to her left ring finger, and a 0.7 x 0.5 stage 4 pressure injury to her left pinky finger. On 01/09/20 the surveyor observed Wound Care RN-O and Wound Care RN-P provide wound care to the 3 pressure injuries on R14's left hand. The surveyor observed 3 pressure injuries on the left hand on the bony prominence of the knuckle. The surveyor observed R14's hands were contracted into a tight fist causing pressure to the knuckles. The surveyor observed the pressure injuries were beefy red. RN-P informed the surveyor the wounds were staged as a stage 4 related to visible fascia (connective tissue) on two of the wounds. On 01/09/20 at 12:33 PM the surveyor informed Assistant Nursing Home Administrator-C of the concern of R14's recommendation from therapy for passive range of motion to be completed not being carried over to the care plan, the resident not being documented as receiving range of motion, the resident being documented as having worsening contractures and developing multiple pressure injuries related to the contractures with no interventions in place prior to the areas developing to prevent complications or prevent the contractures from worsening. The Prevention of Pressure Ulcer/Injuries policy/procedure from 2001 Med Pass, Inc. (Revised (MONTH) (YEAR)) under risk assessment documents; 1. Assess the resident on admission (within eight hours) for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. 2. Conduct a comprehensive skin assessment upon admission including: a. Skin integrity - any evidence of existing or developing pressure ulcer or injuries; b. Tissue tolerance - the ability of the skin (and supporting structures) to endure the effects of pressure; and c. Areas of impaired circulation due to pressure from positioning or medical devices. 3. Use a screening tool to determine if resident is at risk for under-nutrition or malnutrition. 4. Inspect the skin on a daily basis when performing or assisting with personal care or ADL, (activity daily living). a. Identify any signs of developing pressure injuries (i.e. nonblanchable [DIAGNOSES REDACTED]). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.); c. Wash the skin after any episodes of incontinence, using pH balanced skin cleanser; d. Moisturize dry skin daily; and e. Reposition resident as indicated on the care plan. Under the section Prevention for Mobility/Repositioning documents; 1. Choose a frequency for repositioning based on the resident's mobility, the support surface in use, skin condition and tolerance, and the resident's stated preferences. 2. At least every hour, reposition residents who are chair-bound or bed-bound with the head of the bed elevated 30 degrees or more. 3. At least every two hours, reposition residents who are reclining and dependent on staff for repositioning. 4. Reposition more frequently as needed, based on the condition of the skin and resident's comfort. 5. Teach residents who can change positions independently the importance of repositioning. Provide support devices and assistance as needed. Remind and encourage residents to change position. 2. R200 was admitted to the facility on [DATE] and discharged on [DATE]. R200 was reviewed as a closed record. R200's [DIAGNOSES REDACTED]. The Braden assessment dated [DATE] has a score of 10 (10-12 high risk). The (MONTH) 2019 treatment record with a start date of 9/27/19 under order documents, Weekly Skin Check Completed: I=skin intact N=skin not intact and under special instructions documents add med note for I-intact and N-Not Intact. Surveyor noted on 9/30/19 there are only initials indicating a skin check was completed. There is no documentation either on the treatment record or in the nurses notes as to whether R200's skin is intact or not intact. Surveyor noted the wound note dated 9/30/19 indicates R200's skin is impaired as evidenced by a surgical wound to R200's right below knee amputation with 26 staples. The baseline skin care plan dated 9/30/19 has approaches all dated 9/30/19 of Provide assistance to reposition every 2-3 hours when in bed and at least hourly when in chair as needed. Utilize draw sheet when possible to reduce risk for friction/shearing. Address pain as needed for resident comfort to encourage adherence to interventions to maintain skin integrity. Apply house moisturizing lotion PRN (as needed) to keep skin hydrated. Monitor skin under medical devices (tracheotomy, feeding tube, hand mitt, abdominal binder) once a shift. Nursing will assess skin weekly with shower and with any change of condition. Any abnormalities will be documented in chart, and reported to primary physician and wound care team to follow up. Nursing will educate resident and family about primary risk factors (see problems) and preventions (see approaches). Re-education will be provided as needed. Offload resident using pillows to reduce pressure to bony prominences. Utilize heels boots or ensure heels are floated on pillow(s) to prevent breakdown when in bed. Monitor offloading devices with each encounter to ensure proper positioning. Patient followed by Oak Medical Wound Care Team. Wound assessment/measurements performed upon admission, weekly, and PRN at request of nursing staff. Perform thorough diabetic foot check daily at bedtime. Check all surfaces, including between toes. Notify WCT (wound care team) of any skin abnormalities. Pressure reduction mattress (standard foam). Provide diet as ordered. Consult dietitian as needed for nutritional review with any dietary concerns. Provide incontinence cares as needed to keep skin as clean and dry as possible. Utilize barrier cream as needed to protect intact skin from incontinence. Change linens and clothing when wet to prevent prolonged moisture to skin. Referral to PT/OT (physical therapy/occupational therapy) to improve mobility and prevent contractures. The wound note dated 09/30/2019 documents Resident seen by Wound Care Team for initial assessment. Skin integrity is impaired, as evidenced by surgical wound to right BKA (below knee amputation) site with 26 staples intact. See Observations for detailed wound assessment. Risk assessment completed. Braden score is 13. Risk factors identified include: age (66), [MEDICAL CONDITION], [MEDICATION NAME] hemorrhage, [MEDICAL CONDITIONS](hypertension), DMII (diabetes mellitus 2), [MEDICAL CONDITION], impaired mobility, incontinence, and medications (aspirin, [MEDICATION NAME]). Admission weight was 170 lbs. Resident receives enteral feedings. Blood sugars appear poorly controlled. Interventions initiated to address risk factors include: every 2 hour turns/repositioning, offloading, incontinence care, diabetic monitoring, pressure reduction mattress, and weekly skin assessment by nursing. Resident unable to retain education. Care plan initiated. WCT (wound care team) will follow. Nursing to notify WCT of any change in skin condition. The admission MDS (Minimum Data Set) with an assessment reference date of 10/4/19 documents R200 has short and long term memory problem and is severely impaired for daily decision making. R200 requires extensive assistance with two plus person physical assist for bed mobility, is dependent with two plus person physical assist for transfer & toilet use, and is dependent with one person physical assist for eating. R200 is always incontinent of bowel & bladder, is at risk for pressure injuries and is coded as not having any pressure injuries. The pressure injury CAA (care area assessment) dated 10/7/19 under analysis of findings documents Resident triggered CAA due to risk for skin break down r/t (related to) impaired mobility, incontinence. Please see Incontinence CA[NAME] Staff to assist with repositioning every 2-3 hours and PRN (as needed). Weekly skin checks by licensed staff. Pressure reducing mattress and w/c (wheelchair) cushion in use. Resident admitted with R AKA (right above knee amputation) surgical incision; monitor for complication. Observe for changes. Proceed to care plan. The urinary incontinence and indwelling catheter CAA dated 10/7/19 under analysis of findings documents, Resident triggered CAA due to be incontinent of bowel and bladder and requiring assistance with incontinence cares. Staff to check and change every 2-3 hours and PRN (as needed). Proceed to care plan. The wound note dated 10/7/19 documents, Resident seen by Wound Care Team for weekly assessment. Skin integrity is impaired, as evidenced by surgical wound to right BKA site with 26 staples intact. Wound is healing appropriately. See Observations for detailed wound assessment. Risk assessment completed. Braden score remains 13. Risk factors identified include: age (66), [MEDICAL CONDITION], [MEDICATION NAME] hemorrhage, [MEDICAL CONDITION], HTN, DMII, [MEDICAL CONDITION], impaired mobility, incontinence, and medications (aspirin, [MEDICATION NAME]). Most recent weight was 175.2 lbs, which is an increase from previous weight. Resident receives enteral feedings. Blood sugars appear poorly controlled. Interventions in place to address risk factors remain appropriate: every 2 hour turns/repositioning, offloading, incontinence care, diabetic monitoring, pressure reduction mattress, and weekly skin assessment by nursing. Resident unable to retain education. Care plan reviewed and remains appropriate. WCT will continue to follow. Nursing to notify WCT of any change in skin condition. The at risk for developing pressure ulcer care plan with a start date of 10/7/19 has approaches all dated 10/7/19 of Assess and record changes in skin status. Complete skin risk assessment at least quarterly. Educate resident and family about primary risk factors and preventions. Provide and monitor effectiveness of pressure relieving devices - chair/cushion. Provide diet as ordered. Report pertinent change in skin status to MD (medical doctor). Turn and reposition every 2-3 hours and PRN (as needed). The (MONTH) 2019 treatment record with a start date of 9/27/19 under order documents Weekly Skin Check Completed: I=skin intact N=skin not intact and under special instructions documents add med note for I-intact and N-Not Intact. Surveyor noted on 10/7/19 there are only initials indicating a skin check was completed. There is no documentation either on the treatment record or in the nurses notes as to whether R200's skin is intact or not intact. The nurse that initialed the skin assessment is no longer employed at the Facility. Surveyor noted the wound note dated 10/7/19 indicates R200's skin is impaired as evidenced by a surgical wound to R200's right below knee amputation with 26 staples. The Resident Profile, which is the CNA (Certified Nursing Assistant) care card, documents approaches with a start date of 10/11/19 for all approaches of Offload resident using pillows to reduce pressure to bony prominences. Utilize heel boots or ensure heels are floated on pillow(s) to prevent breakdown when in bed. Monitor offloading devices with each encounter to ensure proper positioning., Provide assistance to reposition every 2-3 hours when in bed and at least hourly when in chair as needed. Utilize draw sheet when possible to reduce risk for friction/shearing. and Provide incontinence cares as needed to keep skin as clean and dry as possible. Utilize barrier cream as needed to protect intact skin from incontinence. Change linens and clothing when wet to prevent prolonged moisture to skin. The wound note dated 10/11/19 documents, Resident seen by Wound Care Team at request of nursing staff for change in skin integrity to buttock. Skin integrity is impaired, as evidenced by large butterfly-shaped unstageable pressure injury to sacrum. Resident has impaired mobility and incontinence. Currently on foam pressure reduction mattress--requested alternating pressure mattress from materials manager. Surgical wound to right BKA site with 26 staples intact remains stable. Wound is healing appropriately. See Observations for detailed wound assessment. Risk assessment completed. Braden score remains 13. Risk factors identified include: age (66), [MEDICAL CONDITION], [MEDICATION NAME] hemorrhage, [MEDICAL CONDITION], HTN, DMII, [MEDICAL CONDITION], impaired mobility, incontinence, and medications (aspirin, [MEDICATION NAME]). Most recent weight was 175.2 lbs (no weight obtained since previous assessment), which is an increase from previous weight. Resident receives enteral feedings. Blood sugars appear poorly controlled--NP notified for review. Interventions in place to address risk factors remain appropriate: every 2 hour turns/repositioning, offloading, incontinence care, diabetic monitoring, and weekly skin assessment by nursing. Alternating pressure mattress to be placed ASAP. Resident unable to retain education. Care plan reviewed and updated. WCT will continue to follow. Nursing to notify WCT of any change in skin condition. The sacrum wound measurements dated 10/11/19 documents length as 6.9, width 8 and depth 0.1. Stage is Unstageable - Slough and/or eschar. Tissue type is slough. Percentage of wound covered by [MEDICATION NAME] tissue is 10 and percent of wound covered by slough tissue is 90. The skin care plan with a problem start date of 10/11/19 has approaches all dated 10/11/19 of Address pain as needed for resident comfort to encourage adherence to interventions to improve skin integrity/wound healing. Nursing to monitor dressing integrity with each resident encounter. Replace dressing if soiled/loose/missing. Notify WCT of any concerns. Nursing will assess skin weekly with shower, and with ay change in condition. Any abnormalities will be documented in chart, and reported to primary physician and Wound Care Team for follow up. Nursing will educate resident and family about primary risk factors (see problems) and preventions (see approaches). Re-education will be provided as needed. Offload resident using pillows to reduce pressure to bony prominences. Utilize heel boots ore ensure heels are floated on pillow(s) to prevent breakdown when in bed. Monitor offloading devices with each encounter to ensure proper positioning. Patient followed by Oak Medical Wound Care Team. Wound assessment/measurements performed upon admission, weekly, and PRN at request of nursing staff. Pressure reduction chair (Broda). Provide assistance to reposition every 2-3 hours when in bed and at least hourly when in chair as needed. Utilize draw sheet when possible to reduce risk for friction/shearing. Provide diet as ordered. Encourage food and fluid intake as appropriate to insure adequate nutrition. Vitamins/Protein supplements/nutritional supplements provided as ordered to improve nutritional status and aid wound healing. Consult dietitian as needed for nutritional review with any dietary concerns. Provide incontinence cares as needed to keep skin as clean and dry as possible. Utilize barrier cream as needed to protect intact skin from incontinence. Change linens and clothing when wet to prevent prolonged moisture to skin. Speciality mattress: alternating pressure/low air loss. Treatments performed by wound care team and nursing as ordered by MD. Surveyor noted there were no revisions made to this care plan after the start date of 10/11/19 and there is no care plan regarding R200 refusing cares. The wound note dated 10/14/19 documents, Weekly assessment completed by Wound Care Team. Skin integrity remains impaired, as evidenced by unstageable pressure injury to sacrum and right BKA site-approximated with staples intact. Sacral wound is healing appropriately. See Wound Management and Observations for detailed wound assessments. Braden score remains 13. Risk factors include: age (66), [MEDICAL CONDITION], [MEDICATION NAME] hemorrhage, [MEDICAL CONDITION], HTN, DMII, [MEDICAL CONDITION], impaired mobility, incontinence, and medications (aspirin, [MEDICATION NAME]). Resident receives enteral feedings. Blood sugars poorly controlled. Interventions in place and remain appropriate. These include: every 2 hour turning/repositioning, alternating pressure mattress, offloading, incontinence care, pain management, diabetic monitoring, and weekly skin assessment by nursing. Care plans reviewed and appropriate. WCT will continue to follow. Nursing to notify WCT of any concern or change in skin condition. The sacrum wound measurements dated 10/14/19 documents length as 6.5, width 8 and depth 0.1. Stage is Unstageable - Slough and/or eschar. Tissue type is slough. Percent of wound covered by slough tissue is 100. The sacrum wound measurements dated 10/21/19 documents length as 7.9, width 7 and depth 0.1. Stage is Unstageable - Slough and/or eschar. Tissue type is slough. Percent of wound covered by granulation tissue is 5. Percent of wound covered by slough tissue is 95. The sacrum wound measurements dated 10/28/19 documents length as 7.6, width 7 and depth 0.1. Stage is Unstageable - Slough and/or eschar. Tissue type is slough. Percent of wound covered by granulation tissue is 20. Percent of wound covered by slough tissue is 80. The sacrum wound measurements dated 11/4/19 documents length as 7.6, width 5.6 and depth 2.7. Undermining measurement is 2.7. Stage is Unstageable - Slough and/or eschar. Tissue type is slough. Percent of wound covered by granulation tissue is 80. Percent of wound covered by slough tissue is 20. Surveyor noted the sacral wound was debrided by Vohra wound physician, which causes an increase in depth and undermining. The sacrum wound measurements dated 11/11/19 documents length as 6.9, width 5 and depth 2.9. Undermining measurement is 5. Stage is IV(4). Tissue type is Granulation Tissue . Percent of wound covered by granulation tissue is 100. On 11/12/19 R200 was admitted to the hospital. On 1/9/20 at 11:56 a.m. Surveyor asked CNA (Certified Nursing Assistant)-GG if she remembered R200. CNA-GG replied yes. Surveyor asked what cares she provided to R200. CNA-GG informed Surveyor R200 just started to eat so she fed him, cleaned him up and rotated him side to side. Surveyor asked CNA-GG how R200 received the unstageable pressure injury on his buttocks. CNA-GG replied I don't know. CNA-GG explained she worked R200's section every blue moon and picks up time so she knows all the residents. On 1/9/20 at 12:34 p.m. Surveyor asked CNA-II if she took care of R200. CNA-II informed Surveyor a couple of times but doesn't remember the specific dates. Surveyor asked if R200 every refused any cares. CNA-II informed Surveyor he was a buddy system and could be combative. CNA-II informed Surveyor CNA-HH isn't working today but was always on R200's assignment and suggested Surveyor speak to CNA-HH. On 1/9/20 at 2:10 p.m. Surveyor asked CC (Corporate Consultant)-D who Surveyor should speak with regarding R200's sacrum pressure injury. CC-D informed Surveyor the wound nurse. Surveyor informed CC-D Surveyor has concerns regarding the development of R200's unstageable pressure injury. CC-D informed Surveyor there isn't a unit manager so Surveyor should speak to herself (CC-D) or DON (Director of Nursing)-B. On 1/9/20 at 2:33 p.m. Surveyor asked LPN (Licensed Practical Nurse)-I if R200 refused any cares. LPN-I informed Surveyor sometimes R200 would stare and not respond but never out right refused. LPN-I informed Surveyor R200 was npo (nothing by mouth) when he was first admitted and when he started eating he would sometimes refuse. Surveyor asked LPN-I how R200 developed the unstageable pressure injury. LPN-I informed Surveyor he wasn't sure and thought R200 came in with the pressure injury. LPN-I indicated he knew the wound team was following R200. Surveyor asked LPN-I if staff reported to him R200 refused to be repositioned. LPN-I informed Surveyor he didn't refuse. On 1/13/20 at 8:09 a.m. Surveyor spoke with Wound Care RN (Registered Nurse)-O to inquire about skin assessments. Wound Care RN-O explained the nurses do the initial skin check when a Resident is admitted and will either find them or leave a message to let her know the results. If they don't receive a message they will do a skin check to make sure nothing is missed. If the nurse see something on the skin assessment they will come in and consult. Surveyor asked about R200. Surveyor informed Wound Care RN-O Surveyor had noted R200 a surgical wound for his right above knee amputation and asked when they saw R200 did they assess his entire body. Wound Care RN-O replied no and explained they primarily focused on the amputation site. Surveyor asked Wound Care RN-O if they rely on the nurses to inform them of any new areas of skin impairment. Wound Care RN-O indicated they do. On 1/13/20 at 8:46 a.m. Surveyor spoke with APNP (advance practice nurse prescriber)-J[NAME] Surveyor informed APNP-JJ Surveyor had noted multiple progress notes for R200 but none of the notes spoke about his sacrum pressure injury. APNP-JJ informed Surveyor what she understands is that the pressure injury was not present on admission. APNP-JJ explained in her capacity at the Facility she doesn't do the full skin check like she did when she did wound care. APNP-JJ informed Surveyor she couldn't tell the Surveyor the time line of the pressure injury but thought it progressed rather rapidly. APNP-JJ informed Surveyor she thinks R200 was followed by the Vohra physician for wound care. APNP-JJ informed Surveyor she wasn't necessarily following R200 for his pressure injury and was managing him for other issues. On 1/13/20 at 9:54 a.m. Surveyor spoke with DON-B regarding R200. Surveyor informed DON-B Surveyor didn't understand how R200 developed an unstageable pressure injury without it being identified until it as unstageable. Surveyor asked what the weekly skin assessments entail and what documentation is completed. DON-B informed Surveyor the nurse looks over the skin to make sure there are no new skin alterations. Surveyor showed DON-B the skin assessments completed on R200 TAR (treatment administration record) with just initials and asked why there isn't any documentation if the skin is intact or not. DON-B informed Surveyor she couldn't answer that as that would be a matrix question. Surveyor noted matrix is the Facility's computer program. On 1/13/20 at 10:29 a.m. Surveyor asked CNA-HH if she took care of R200. CNA-HH informed Surveyor she used to have him. Surveyor asked what CNA-HH had to do. CNA-HH replied, Everything, he was a complete total. Surveyor asked CNA-HH if he would refuse anything. CNA-HH replied, Yes sometimes he would when it came to eating. Surveyor asked if R200 had to be repositioned. CNA-HH replied, Yes every two hours. Surveyor asked CNA-HH how she thought R200 developed the unstageable pressure injury on his sacrum. CNA-HH informed Surveyor if she wasn't mistaken R200 came in with it and that she didn't work with R200 that much as she works part time. Surveyor noted R200 developed a pressure injury that was not noted until it was unstageable, did not have revisions to their plan of care as the pressure injury worsened, and the weekly skin assessments completed prior to pressure injury developing did not document the results of the skin assessment. 3. R18's [DIAGNOSES REDACTED]. R18 started receiving hospice services on 10/4/19. The Resident Profile, which is the CNA (Certified Nursing Assistant) care card, documents an approaches with a start date of 12/11/19 of Offload resident using pillows to reduce pressure to bony prominences. Utilize heel boots or ensure heels are floated on pillow(s) to prevent breakdown when in bed. Monitor offloading devices with each encounter to ensure proper positioning. and Provide assistance to reposition every 2-3 hours when in bed and at least hourly when in chair as needed. Utilize draw sheet when possible to reduce risk for friction/shearing. The significant change MDS with an assessment reference date of 10/11/19 documents a BIMS (brief interview mental status) score of 11 which indicates moderately impaired. R18 is coded as not having any behaviors including rejection of care. R18 requires extensive assistance with one person physical assist for bed mobility & toilet use, does not ambulate, and is always incontinent of bowel and bladder. R18 is at risk for pressure injuries and is coded as not having any pressure injuries. The pressure injury CAA (care area assessment) dated 10/21/19 under analysis of findings documents, ADL (activities daily living) CAA triggered r/t (related to) resident requires extensive staff assist of 1 with most ADL. PMH (primary medical history)- [MEDICAL CONDITIONS], chronic [MEDICAL CONDITIONS], chronic [MEDICAL CONDITION] with [MEDICAL CONDITION]- on O2 (oxygen), [MEDICAL CONDITION], depression, diverticulitis, [MEDICAL CONDITIONS](hypertension), [MEDICAL CONDITION], anxiety, constipation, blind in both eyes. Resident signed onto hospice care on 10/4. Overall a decline is anticipated. Resident able to make needs known. HOB (head of bed) remains at least 30 degrees r/t SOB (shortness of breath) while laying flat. O2 in use 2-3 L (liter) via nasal cannula. Urinary CAA triggered r/t resident always incontinent of bowel and bladder during the look back period. Check and change Q (every) 2 and PRN (as needed). No skin breakdown noted from incontinence. Falls CAA triggered r/t decline, chronic respiratory symptoms, O2 in use, visual impairment, medications in use that can increase risk for falls- anti-psychotics, [MEDICATION NAME] and antidepressant. No falls documented at the facility since (MONTH) of (YEAR). Pressure CAA triggered r/t above findings - visual impairment, O2 in use, requires extensive staff assist with most ADL. medications in use daily listed above, incontinence. No pressure wounds documented. Staff will continue to assess for changes in skin. [MEDICAL CONDITION] CAA triggered r/t daily scheduled antipsychotic, [MEDICATION NAME] and antidepressant in use. Medication are in use to manage depression and anxiety. Resident is able to make needs known, no behaviors noted. Staff will continue to monitor for side affects r/t medications in use. The Braden assessment dated [DATE] has a score of 14 (13-14 moderate risk). The skin care plan with a problem s

Based on a complaint received at the Southeastern Regional office, interview and record review the Facility did not ensure Facility staff provided basic life support to 1 (R3) of 1 Residents who required Cardiopulmonary Resuscitation (CPR.) The facility currently has 49 residents who desire CPR (Full Code). R3 had a change of condition and was found unresponsive. Certified Nursing Assistant (CNA)-V announced the first code blue but staff did not respond. Two minutes later CNA-U then announced another code blue which staff then responded to. Central Supply Clerk-AA ran to the first floor nurses station where an AED (Automatic External Defibrillator) is located. Central Supply Clerk-AA brought the AED to R3's room but the AED was not in working order. Central Supply Clerk-AA had to then go up to the 2nd floor to retrieve another AED. The back board wasn't immediately placed under R3 who was on an air mattress. According to LPN-F who was the responding nurse on R3's unit there was no ambu bag in R3's room or on the crash cart. The failure of staff to immediately respond to a code blue for resuscitation, the failure of the facility to have working equipment necessary to immediately use an AED, and the failure of staff for not immediately using a backboard until after chest compressions was started, created a finding of immediate jeopardy beginning on [DATE]. The Nursing Home Administrator (Administrator-A) and Director of Nursing (DON-B) were notified of the immediate jeopardy on [DATE] at 2:27 p.m. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope/severity of [NAME] (potential for more than minimal harm/pattern) as the facility continues to implement its plan of correction. Findings include: The Emergency Procedure -Cardiopulmonary Resuscitation policy & procedure revised (MONTH) (YEAR) under Preparation for Cardiopulmonary Resuscitation documents; 1. Obtain and/or maintain American Red cross or American Heart Association certifications in Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR) for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel. 2. The facility's procedure for administering CPR shall incorporate the steps covered in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or facility BLS training materials. 3. Provide periodic Mock codes (simulations of an actual [MEDICAL CONDITION]) for training purposes. 4. Select and identify a CPR Team for each shift in the case of an actual [MEDICAL CONDITION]. To the extent possible, designate a team leader on each shift who is responsible for coordinating the rescue effort and directing other team members during the rescue effort. 5. The CPR Team in this facility shall include at least one nurse, one LPN/LVN and two CNAs all of whom have received training and certification in CPR/BLS. 6. Maintain equipment and supplies necessary for CPR/BLS in the facility at all times. 7. Provide information on CPR/BLS polices and advance directives to each resident/representative upon admission. Surveyor noted the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Cardiovascular Care. Berg RA, Hemphill R, Abella BS, et al. Part 5: adult basic life support: Circulation. 2010; 122(18)(suppl 3):S685-S705. states the following: Because hospital beds are typically not firm and some of the force intended to compress the chest results in mattress displacement rather than chest compression, we have traditionally recommended the use of a backboard despite insufficient evidence for or against the use of backboards during CPR. R3's [DIAGNOSES REDACTED]. R3 was on a ventilator at night and [MEDICAL CONDITION] with a speaking valve during the day. R3 was 6 feet 3 inches tall and had a documented weight of 227 pounds. R3's power of attorney was activated on [DATE]. The CPR (cardiopulmonary resuscitation)/DNR (do not resuscitate) documentation form with a telephone consent dated [DATE] indicates CPR- full code for R3. The nurses note dated [DATE] at 9:42 a.m. documents, Call placed to POA (power of attorney)-O to update on patient change of condition. No answer at (telephone number). Will attempt call back. Received note from HUC (Health Unit Coordinator) to contact Social Worker-P at Froedtert hospital. Contacted Hospital Social Worker-P needs updated POA information. Will fax. The nurses note dated [DATE] at 11:54 a.m. documents, Writer alerted by floor aide that patient appeared unalert. Arrived to patients room, patient unresponsive to verbal or tactile stimuli. Skin ashen, dry and warm. Crash cart retrieved while aide called for code. CPR initiated. 911 alerted by first floor center nurse. 5 rounds CPR performed prior to EMS (emergency medical services) prior to transport. POA called with no answer. NP (nurse practitioner) and MD (medical doctor) updated on transfer to Froedtert. The nurses note dated [DATE] at 13:23 (1:23 p.m.) documents, Call placed to Froedtert. Floor nurse unavailable. Given information by receptionist that patient has been admitted to MICU (medical intensive care unit). The nurses note dated [DATE] at 7:50 a.m. recorded as late entry on [DATE] at 4:57 p.m. documents, At approx (approximately) 0750 (7:50 a.m.) am medications administered to patient at which time patient was alert per normal baseline. Skin non ashen, dry and warm. Mucus membranes appeared moist and pink. No apparent distress noted by writer. The nurses note dated [DATE] at 8:05 a.m. recorded as a late entry on [DATE] at 4:59 p.m. documents, At approx (approximately) 0805 (8:05 a.m.) writer alerted by floor aide that patient appeared unalert. Arrived to patients room, patient unresponsive to verbal or tactile stimuli. Skin ashen, dry and warm. Crash cart retrieved while aide called for code. The nurses note dated [DATE] at 8:07 a.m. recorded as a late entry on [DATE] at 5:03 p.m. documents, At approx 0807 (8:07 a.m.) patients code status verified and CPR initiated by writer. The nurses note dated [DATE] at 8:10 a.m. recorded as a late entry on [DATE] at 5:07 p.m. documents, At approx 0810 (8:10 a.m.) EMS activated by first floor center nurse. Respiratory therapist arrived and began providing patient rescue breaths via ambu bag. Central supply staff provided AED with no pads or batteries. 3 rounds of compressions completed by writer. The nurses note dated [DATE] at 8:15 a.m. recorded as a late entry on [DATE] at 5:09 p.m. documents, At approx. 0815 (8:15 a.m.) AED provided by central supply staff. Leads applied to patient. 5 Rounds of CPR completed with no shock advised per round. The nurses note dated [DATE] at 8:20 a.m. recorded as a late entry on [DATE] at 5:10 p.m. documents, At approx 0820 (8:20 a.m.) EMS arrived. The nurses note dated [DATE] at 9:00 a.m. recorded as a late entry on [DATE] at 5:12 p.m. documents, At approx 0900 (9:00 a.m.) EMS left facility to transport patient to Froedtert hospital. Patient active pulses per EMS prior to transport. POA called with no answer. NP (Nurse Practitioner) and MD updated on patient change of condition and transport to Froedtert. On [DATE] at 8:15 a.m., Surveyor asked CNA-U to explain to Surveyor what had occurred on [DATE] with R3. CNA-U explained she came in and did her rounds. R3 was smacking his lips and stating pain. CNA-U informed Surveyor she told LPN-F R3 was in pain, LPN-F said ok and she would give R3 pain medication. CNA-U informed Surveyor she and CNA-V were walking by R3's room and CNA-V said R3 didn't look right, he was pale. CNA-U indicated she went into R3's room, R3 didn't look right, she touched R3 and he looked like he wasn't alive. CNA-U informed Surveyor she rushed out of R3's room to the nurse and told her. CNA-V paged for help. Surveyor asked what CNA-V said. CNA-U informed Surveyor R3 room vent stat. CNA-U informed Surveyor no one came so she paged again and then ran down the hall to LPN-X. CNA-U informed Surveyor LPN-E came and CSC-AA was there. CNA-U indicated after CNA-V paged no one came and after she paged everyone started to come. Surveyor asked how long was it between when CNA-V paged and when she paged. CNA-V informed Surveyor about 2 minutes. CNA-U informed Surveyor after everyone came she went to take care of other Residents. On [DATE] at 8:17 a.m. Surveyor asked LPN (Licensed Practical Nurse)-F if she was working the day R3 went to the hospital. LPN-F informed Surveyor she was. Surveyor asked LPN-F what occurred with R3. LPN-F replied, He coded obviously. LPN-F informed Surveyor R3 was alert and in a ten minute time frame CNA (Certified Nursing Assistant)-U called her. LPN-F informed Surveyor she had been in R3's room earlier giving him his medication. LPN-F indicated R3 wasn't talking, just mumbling. LPN-F indicated she asked R3 if he was in pain as he usually said pain, pain. LPN-F explained R3 wasn't a yes/no person but would say pain. LPN-F explained to Surveyor she was putting out supplies in Residents' rooms and the CNA called over stating R3 doesn't look right. LPN-F indicated she dropped the supplies and ran into R3's room. LPN-F stated R3 went from being a normal color to gray and rolling his eyes. LPN-F stated she yelled to CNA-U to call the code and grab the crash cart. LPN-F stated she ran to the computer to validate he was a full code- CPR. LPN-F informed she started doing chest compressions. LPN-F informed CNA-V called the first code but no one came. CNA-U called the second code. After the second code some agency staff and then DON (Director of Nursing)-B came. LPN-F informed Surveyor an agency nurse who was working 1 Center called 911. Surveyor asked if she knew who the nurse was. LPN-F informed Surveyor she has only seen her two times before. CSC (Central Supply Clerk)-AA handed her an AED but there was nothing on the back, no battery & no pads, just the machine itself. LPN-F informed Surveyor CSC-AA said she was going to run upstairs and get the AED from upstairs. LPN-F informed Surveyor a respiratory therapist started bagging R3. LPN-F informed Surveyor the issue was the crash cart didn't have an ambu bag and there was no ambu bag in the room, the respiratory therapist brought one in. LPN-F indicated then another nurse started doing chest compressions but she didn't know the name of the nurse. Surveyor asked if CSC-AA brought a second AED. LPN-F replied, Yes, that was ok. LPN-F informed Surveyor after the second code when everyone responded R3 had a pulse and his oxygen was up. Surveyor asked LPN-F if she stopped giving compressions. LPN-F replied no and thinks she gave three rounds before someone came in and started bagging him. Surveyor asked LPN-F if there was anything else she would like Surveyor to know. LPN-F stated just the response at first and not having the correct equipment. On [DATE] at 8:30 a.m., Surveyor asked LPN-F why she documented the late entries. LPN-F explained she had put an original note in R3's record but DON-B wanted exact times on what happened. LPN-F informed Surveyor [DATE] was the next time she worked at the Facility. On [DATE] at 1:41 p.m., Surveyor spoke with RT (respiratory therapist)-Y on the telephone. RT-Y informed Surveyor one of the nurses aides came screaming R3 was dead, R3's dead. RT-Y informed Surveyor he went to R3's room and there was a nurse doing chest compressions. RT-Y indicated the nurse looked pretty fatigued and she wanted him to do chest compressions and she bagged. Surveyor asked RT-Y if he heard code blue being paged. RT-Y replied no and explained its very difficult to hear pages in the hallway and if you're in a room with the vents you can't hear. Surveyor asked if LPN-F was in the room. RT-Y informed Surveyor he's guessing she was. Surveyor asked if there was a back board. RT-Y replied yes and explained the nurse with the short hair and he believes some aides put it under R3. Surveyor asked RT-Y if he was in the room when they placed the board under R3. RT-Y replied yes. Surveyor asked RT-Y if he was in the room when the AED was brought in. RT-Y replied yes and explained it was saying low batteries and to attach cable. RT-Y informed Surveyor the AED indicated no shock, continue CPR. Surveyor asked RT-Y if he was in the room when EMS arrived. RT-Y informed Surveyor he was. RT-Y informed Surveyor EMS put on R3 an automatic chest compressor and R3 did have a pulse in the 80's when they took him out. On [DATE] at 7:42 a.m., Surveyor asked CNA-V to explain to Surveyor what happened on [DATE] with R3. CNA-V informed Surveyor they were going to another Resident's room and looked into R3's room and R3 looked jaundiced. CNA-V indicated he immediately got the nurse. CNA-V informed Surveyor he called over head code blue stat vent and CNA-U went to look for the respiratory therapist. CNA-V indicated he went into the room with the nurse and lowered the bed flat. CNA-V informed Surveyor CNA-U called the second code blue. CNA-V informed Surveyor central supply brought in an AED. CNA-V informed Surveyor DON-B came after the second code blue was called. CNA-V informed Surveyor LPN-F started to do compressions then LPN-X took over the compressions and then the respiratory therapist came in. After the respiratory therapist everyone else started to come in. Surveyor asked if there was anyone bagging R3. CNA-V replied not immediately. On [DATE] at 9:37 a.m. Surveyor asked CNA-U if she called 911. CNA-U replied, No, I did not. Surveyor asked CNA-U if she helped place a board under R3. CNA-U replied, No, I wasn't involved. On [DATE] at 9:39 a.m., Surveyor asked CNA-V if he called 911. CNA-V replied, No. Surveyor asked CNA-V if he helped place a board under R3. CNA-V replied no and explained LPN-X and LPN-E did that. On [DATE] at 12:21 p.m., Surveyor asked LPN-X if she called 911 on [DATE]. LPN-X replied no and informed Surveyor she was working down here and one of the aides from the vent unit was calling in the hallway (LPN-X) can you help with R3 we need help we need help. LPN-X informed Surveyor as she was going down the hall she heard code blue for R3's room. LPN-X informed Surveyor she went to R3's room and LPN-F was doing CPR. LPN-X indicated she told LPN-F her CPR won't be sufficient without a board. LPN-X informed Surveyor LPN-F was really distraught stating she was calling the code, no one would come, and she couldn't find any equipment. LPN-X informed Surveyor she took over CPR. Surveyor asked LPN-X when she went to R3's room was the crash cart in the room. LPN-X replied no. Surveyor asked if there was only LPN-F in the room. LPN-X replied yes. Surveyor asked LPN-X if the mattress was deflated. LPN-X replied, No, inflated. LPN-X informed Surveyor she felt bad because no one would help LPN-F. LPN-X informed Surveyor after she started doing compressions the RT came in and bagged R3. LPN-X informed Surveyor the male RT asked her if she was tired and he took over doing compressions while a female RT bagged R3. Surveyor asked LPN-X when did EMS arrive. LPN-X informed Surveyor 10 to 15 minutes after. LPN-X indicated at first R3 was aystole (without ventricular contractions) but they worked on R3 for a good 25 minutes and when they took him out he had sinus tach (increase in the rate of electrical impulses from cells located in the wall of the right atrium). LPN-X informed Surveyor she thought it was very scary for a code as it was chaotic and no one knew what to do. On [DATE] at 10:27 a.m., DON-B informed Surveyor she came down with LPN-X and LPN-F was doing compressions. On [DATE] at 10:55 a.m., Surveyor spoke to RT-Y to clarify who was doing compressions after DON-B spoke to Surveyor. Surveyor asked RT-Y when he went in R3's room who was doing chest compressions. RT-Y informed Surveyor he didn't know the nurses name but she had short hair. His description described LPN-X. Surveyor asked if DON-B was in the room. RT-Y informed Surveyor she came in after he was there. On [DATE] at 9:34 a.m., Surveyor asked LPN-E if R3 was on her assignment. LPN-E replied, He was not. Surveyor asked LPN-E how many times the code was announced over head. LPN-E informed Surveyor as far as she knew twice. LPN-E indicated she did not hear the first code because she was in a room and the code was called again. LPN-E informed Surveyor after she heard the code she and a pool nurse ran down and assisted with putting the board under R3. LPN-E informed Surveyor when she went into the room a RT (respiratory therapist) was doing compressions and another RT was using the ambu bag. On [DATE] at 10:31 a.m., Surveyor asked LPN-E when she entered R3's room was the back board under R3 or on the crash cart. LPN-E informed Surveyor it was still on the crash cart. On [DATE] at 9:51 a.m., Surveyor spoke with CSC (Central Supply Clerk)-AA regarding R3. CSC-AA informed Surveyor she happened to be on the vent unit stocking in the backroom and heard a commotion. CSC-AA informed Surveyor she went to R3's room and then ran to the first floor nurses station to grab the AED and brought it back. CSC-AA informed Surveyor the AED didn't have a pad. The nurse said there wasn't any pads so she ran up to the 2nd floor to get that AED. CSC-AA informed Surveyor all she knows is that she was running like a fool trying to get one from the second floor. CSC-AA informed Surveyor the second AED was saying something about the battery and plug. CSC-AA informed Surveyor they changed the batteries but the machine kept saying change batteries. CSC-AA indicated one of the nurses Googled it and said the AED has to be reset. CSC-AA informed Surveyor that the AED machine worked. CSC-AA informed Surveyor after R3's incident she called her representative and he sent her a booklet on the AED. CSC-AA indicated she printed off the booklet and gave it to Administrator-A and RN's (Registered Nurses). Surveyor asked CSC-AA if she was responsible for checking the AED machines. CSC-AA replied, absolutely not and explained the only thing she does is call for pads and calls the rep (representative) for [MEDICATION NAME] batteries. Surveyor asked CSC-AA if she knew why there wasn't a pad on the first floor AED. CSC-AA replied no and stated she would guess it was used and the pads were not replaced. Surveyor asked who would be responsible for checking the AED. CSC-AA informed Surveyor she wasn't sure. Surveyor asked where the pads are kept. CSC-AA informed Surveyor they were in central supply and now they are on each of the crash carts Surveyor asked when this changed. CSC-AA after R3, they told her that week they were changing the policy. On [DATE] at 10:54 a.m., Surveyor asked LPN-BB if she responded to R3's room on [DATE]. LPN-BB informed Surveyor she ran down the stairs and when she got there, there were several people in the room. Surveyor asked if LPN-BB heard the code paged one or two times. LPN-BB informed Surveyor it may have been twice. LPN-BB informed Surveyor she already had turned her clip board over and locked her medication cart when she heard the second code. On [DATE] at 11:01 a.m., Surveyor asked CNA (Certified Nursing Assistant)-Z if she recalled hearing any code blue pages on [DATE]. CNA-Z informed Surveyor she thinks she remembers hearing code blue vent unit stat. Surveyor asked how many times she heard the code. CNA-Z informed Surveyor she thinks twice. Surveyor asked if she responded or who would respond. CNA-Z informed Surveyor the nurses would. CNA-Z informed Surveyor she had asked one of the other CNAs if they are suppose to go and she said the nurses. CNA-Z informed Surveyor she was wondering what code blue meant and if she should go down. On [DATE] at 1:04 p.m., Surveyor spoke with West Allis Fire Department-CC who informed Surveyor he was unable to provide Surveyor with any details regarding R3's call but informed Surveyor their dispatch received a call at 8:12:14 a.m., EMS was dispatched at 8:13:16 a.m., they arrived on scene at 8:17:04 a.m. and left the Facility at 8:47:49 a.m. EMS transferred care at 8:54:49 a.m. On [DATE] at 3:05 p.m., Administrator-A informed Surveyor the respiratory therapists are checking the crash carts which is a change after R3's code. Prior to the code the night nurse was checking the crash carts. On [DATE] at 3:08 p.m., Surveyor showed Administrator-A the check list for the AED on a clip board for the first floor AED which is blank, behind the blank sheet for (MONTH) and May. The check list was completed on [DATE], [DATE], [DATE] & [DATE]. Administrator-A informed Surveyor this is one of the things they were inservicing on as no one knew about the check list. On [DATE] at 9:00 a.m. Surveyor spoke with the Complainant on the telephone. The Complainant informed Surveyor the hospital called and stated R3 was unresponsive to Froedert. The paramedics had administered CPR two times, R3's heart started up but he was declared brain dead. R3 passed away on [DATE]. The failure of staff to immediately respond to a code blue, the failure of the facility to have working equipment necessary to immediately use an AED, and the failure of not immediately using a backboard until after chest compressions were started, created a finding of Immediate Jeopardy. The facility removed the immediate jeopardy on [DATE], when it had completed the following: * The resident affected is no longer at the facility. * Care staff was educated beginning [DATE] related to CPR policy to include immediate response to a code blue and CPR technique. * On [DATE] the facility ensured that employees were given education prior to or during their shift. * All crash carts were inspected to ensure all necessary equipment was present on [DATE]. Moving forward, a daily verification of crash cart equipment and supplies to include Ambu bag and suction machine will be completed by nursing staff or designee. In addition, an RN supervisor or Respiratory therapist will validate the contents of the crash cart daily. The AED will be checked daily to ensure pads are in place and available and the AED is functioning. * Care staff were educated prior to and or during their shift and have participated in a mock drill highlighting the immediate use of the backboard to ensure adequate compression and how to properly initiate a code blue. * The Facility reviewed the agency orientation packet to ensure all information regarding crash cart location and Policies and Procedures related to CPR are present. This information is now be part of the agency orientation and education packet ongoing. * All nursing staff was re-educated to respond to all codes. The 1st nurse that arrives is the team lead in charge of the code. This nurse will assign duties to other responders who will assist with the code. The facility continues to complete mock code blue drills on every shift to ensure staff knowledge and competency. * A Performance Improvement continuous quality improvement (CQI) tool is being completed by a supervisor daily to monitor for compliance and to self-identify any ongoing areas that have an opportunity for improvement. The code will be paged overhead using a clear and concise voice to mitigate risk of staff not understanding message. * RN supervisors are responsible to ensure that crash carts and AED checklist are completed daily. In addition the Director of Nursing/Administrator will monitor the log and sign as a Quality Assurance (QA) process to monitor compliance related to crash cart and AED checks. * Code blue drills are being completed every shift until all nursing staff has attended and posttest completed. Facility will have ongoing continuous quality improvement (CQI) checks and complete code blue drills monthly across all shifts ongoing. On [DATE] at 8:12 a.m., Surveyor observed RD-W checking the crash cart on the vent unit. Surveyor asked RD-W when they started checking the crash carts. RD-W informed Surveyor they approached her yesterday and said their respiratory therapists were checking the other crash carts and asked her if they would check the vent unit crash cart. On [DATE] at 9:47 a.m., Administrator-A informed Surveyor maintenance checked the AED machines yesterday and she signed them off today. Administrator-A also provided Surveyor with monthly AED checks provided by maintenance.

Based on interviews and record reviews, the facility did not ensure 1 of 3 residents reviewed (R26) was free of significant medication errors. R26 had a physician's orders [REDACTED]. On 8/19/19 at 11:00 a.m. and 5:30 PM as well as 8/20/19 at 3:00AM, R26 was administered 50 mg of [MEDICATION NAME] when the facility intended to administer 10 mg. This was 5 times the ordered dose, and 2.5 times the maximum dose that could have been administered. The order had been transcribed incorrectly in the computer twice as well as not being properly reconciled by the nurses administering the medication. The facility did not recognize issues with nursing staff not knowing how to input orders into the electronic medical record and that nursing staff were selecting the closest option when entering orders. Facility failure to ensure nursing staff transcribed physician orders [REDACTED]. Surveyor notified NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B of the immediate jeopardy on 9/17/19 at 9:00 AM. The immediate jeopardy was removed on 9/17/19. However, the deficient practice continues at a scope/severity level of [NAME] (potential for more than minimal harm/pattern) as the facility continues to implement its action plan and is able to show sustained compliance. Findings include: Starting on 9/3/19 and continuing during the survey, multiple complaints were received by The Division of Quality Assurance indicating a resident received an overdose of [MEDICATION NAME] after the facility had already had an incident of a [MEDICATION NAME] overdose prior to this incident. R26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R26 was admitted to hospice on 8/11/19 and at that time the family decided to end [MEDICAL TREATMENT] services. No records indicate R26 received any other opiate medication while in the facility prior to 8/19/19. R26's Admission Minimum (MDS) data set [DATE] indicated R26 had long and short term memory impairment and severely impaired decision making skills. R26's Admission Minimum Data Set also indicated he was totally dependent for all activities of daily living. R26 also received all food, fluids and medication through a gastrostomy tube. R26's physician orders [REDACTED]. The concentrate of [MEDICATION NAME] in the physician's orders [REDACTED]. Registered Nurse (RN) - FF entered this order into the electronic medical record on 8/11/19 as: [MEDICATION NAME] 20 mg/5 ml. Amount to administer 5 mg for mild pain. [MEDICATION NAME] 20 mg/5 ml. Amount to administer 10 mg for moderate pain. [MEDICATION NAME] 20 mg/5 ml. Amount to administer 20 mg for severe pain. The orders are also written as every hour in the narrative but on the Medication Administration Record [REDACTED]. On 9/17/19 at 3:40 PM RN-FF was interviewed and indicated she knew the order from Hospice for R26 was what was in the contingency supply, at the right concentration but she couldn't find the correct concentration in the computer so she just used what was there. RN-FF said she has recently been trained but is still not totally comfortable putting in custom orders into the electronic medical record. RN-FF indicated she put in R26's order as every 2 hours instead of every hour because that option wasn't in the computer and she was told to just put in the closest thing. Note: The facility had discontinued the practice of having nurses double check all medication entries that it had put in place following its previous IJ citation for administering too much [MEDICATION NAME]. On 9/16/19 at 3:10 PM ADON-CC was interviewed and indicated she was instructed to write R26's [MEDICATION NAME] order again in mls on 8/15/19 because it was easier to read. RN-CC indicated she didn't know why she didn't include the dosage in mgs also. Assistant Director of Nurses (ADON) - CC rewrote R26's orders on 8/15/19 as: [MEDICATION NAME] 20 mg/5 ml. Amount to administer 1.25 ml for mild pain. [MEDICATION NAME] 20 mg/5 ml. Amount to administer 2.5 ml for moderate pain. [MEDICATION NAME] 20 mg/5 ml. Amount to administer 5 ml for severe pain. The concentrate of [MEDICATION NAME] in the physician's orders [REDACTED]. The orders are also written as every hour in the narrative but on the Medication Administration Record [REDACTED]. This set of orders does not include how many milligrams of medication R26 is to receive only how many mls. On 9/12/19 at 2:32PM Medical Doctor (MD) -V indicated when she saw R26 on 8/19/19 he was grimacing (nonverbal sign of pain) and [MEDICAL CONDITION] (elevated heart rate). MD - V's progress note from 8/19/19 read: Nursing staff reports R26's blood pressure and heart rate have been elevated. R26 may benefit from increased pain medication. (MONTH) need to schedule [MEDICATION NAME] with [MEDICATION NAME]. MD-V also indicated she instructed the staff to administer 10 mg of [MEDICATION NAME] on 8/19/19 after she saw R26. On 9/16/19 R26's controlled drug record for [MEDICATION NAME] sulfate 100 mg/ml was reviewed and indicated: on 8/19/19 R26 received 2.5 mls (which equals 50 mg) at 11:00AM and 5:30 PM. On 8/20/19 at 3:00AM R26 received an additional 2.5 mls. On 9/12/19 at 2:35PM Vice President of Clinical Services (VPCS) - T was interviewed and indicated R26 should have gotten 10 mg of [MEDICATION NAME] on 8/19/19 (twice) and 8/20/19 and instead received 50 mg. On 9/16/19 R26's progress note from a visit from MD-V on 8/22/19 was reviewed and read: R26 received 10 times the dose ([MEDICATION NAME]) prescribed on 8/19/19 and 8/20/19. R26's vital signs remained stable with no decrease or change in respiratory rate. R26's vital signs from 8/19/19-8/26/19 remained stable aside from an elevated heart rate at times. MD-V indicated on 9/12/19 at 2:32PM that she saw R26 on 8/22/19 and 8/23/19 after the error was found and R26's heart rate was still elevated and his breathing rate remained constant on the ventilator. MD-V indicated the 3 incorrect doses of [MEDICATION NAME] did not contribute to R26's death (which occurred on 8/27/19) and she suspected he passed away related to [MEDICAL CONDITION]. On 9/16/19 R26's consultation report written by Medical Doctor (MD) - V dated 8/23/19 was reviewed and indicates: Called (R26's) wife to inform her of the medication error that occurred on 8/19/19 and 8/20/19. (R26's) wife stated she visited (R26) on 8/19/19 in the afternoon and questioned why he appeared more sedated. Wife was notified that the medication error was noticed on 8/22/19 and an investigation began immediately. Licensed Practical Nurse (LPN)-RR's statement regarding the medication error was reviewed. (LPN-RR administered R26 50 mg of [MEDICATION NAME] liquid on 8/19/19 at 11:00AM and 5:30PM). The statement read: On 8/19/19 I was updated by the MD to give (R26) [MEDICATION NAME] for his increased heart rate and uncomfortable signs she noticed. I told the MD the dosages that were in matrix (computer records) to be administered and was advised to give the 2.5 ml dosage in the system. (The bottle of [MEDICATION NAME] that had been pulled on 8/16/19 by RN-PP was not the order that was in the computer as the concentrate was 5 times stronger than the order in the computer and that was what was in the medication cart when LPN-RR administered the first dose to R26 on 8/19/19). On 9/16/19 Licensed Practical Nurse (LPN)-QQ's statement regarding the medication error was reviewed. (LPN-QQ administered R26 50 mg of [MEDICATION NAME] liquid on 8/20/19 at 3:00AM). The statement read: On 8/20/19 I gave (R26) 2.5 mls of [MEDICATION NAME] based on him being [MEDICAL CONDITION]. (R26) had a pulse of 127 and appeared to be uncomfortable. I thought I gave the right dose but I didn't do the proper conversion. On 9/12/19 at 2:32PM MD-V was interviewed and indicated that 5 different people came up with 5 different doses that R26's [MEDICATION NAME] should have been converted to after the error was found and it was hard to do the math. Although there is no evidence that R26 was harmed as a result of the medication error (except for possibly being more sedated), there was a reasonable expectation that serious harm could occur. An overdose of [MEDICATION NAME] can cause profound [MEDICAL CONDITION] and death. According to the Canadian Virtual Hospice, The amount of [MEDICATION NAME] that can cause an overdose or death depends on what a person's body is used to. It takes more [MEDICATION NAME] to cause an overdose in someone who is already taking [MEDICATION NAME] than in someone who has never had it before .It's when too much is given too quickly that the side effects of an overdose appear. These are ways to recognize whether someone has had an overdose: * The patient becomes very tired, stops talking and eventually becomes unresponsive. * Breathing remains regular but becomes very slow. It may drop to less than six breaths per minute and even stop if there's a great deal of [MEDICATION NAME] in the body. The significant medication error that resulted in R26 receiving 5 times the ordered amount of [MEDICATION NAME] on 3 occasions created a finding of immediate jeopardy. The facility removed the jeopardy on 9/17/19 when: Education for all Licensed Nurses will begin immediately. No licensed nurse will be allowed to work until education has been completed on the following with return demonstration & Post-test. Accurately transcribing a Physicians order The 5 rights of medication administration Two nurses will verify transcription of all handwritten physician orders Processing a Physicians order to include timely pharmacy notification Facility will adopt new Policy going forward when removing multi dose vials of liquid medications from facility Stat Safe 1) When multi-dose medication is removed Pharmacy will be notified 2) Licensed Nurse will let Pharmacy know that multi dose medication will need to still be sent to the facility with pharmacy label and directions 3) When multi-dose medication arrives from licensed nurse will destroy medication that had been removed from Stat Safe per facility policy Nursing Administration team (DON/ADON/UM) will review and validate transcription of all admission/readmission orders [REDACTED]. DON/ADON/UM will then check medication carts to ensure timeliness delivery of admission/readmission medications A daily review will be conducted for any multi dose vial medications that were removed from Stat Safe to ensure pharmacy notification and delivery of medication with label The facility will conduct a weekly QAPI meeting for one month to monitor compliance with the above plan for any further recommendations and/or resolution. On 9/12/19 at 2:35PM Vice President of Clinical Services (VPCS) - T indicated no liquid [MEDICATION NAME] has been given in the facility starting 8/23/19 continuing into the survey and all residents have been changed to pill form. VPCS-T also indicated that all nurses have been educated on medication administration and conversion of doses. On 9/16/19 R26's consultation report written by Medical Doctor (MD) - V dated 8/23/19 was reviewed and indicates: All concentrated liquid [MEDICATION NAME] was removed from contingency; Registered Nurses were educated on medication conversion, 5 rights and double verification for liquid [MEDICATION NAME].

Based on interviews and record reviews, the facility did not ensure 1 of 16 residents reviewed (R3) was free of significant medication errors. R3 had a physician's orders [REDACTED]. On 5/29/19 at 12:00 a.m., RN-Q (Registered Nurse) administered 100 mg (5.0 milliliters) of [MEDICATION NAME] to R3. This was 50 times the ordered dose. There is no evidence anyone checked R3 from midnight until 4:30 AM when RN-Q documented the administration and realized her error. RN-Q went to assess R3 and was unable to arouse her. The physician was contacted and an order was obtained to administer [MEDICATION NAME]. Facility failure to ensure nursing staff followed the 5 rights of medication administration (right person, right medication, right dose, right time, right route), created a finding of immediate jeopardy that began on 5/29/19. Surveyor notified the NHA (Nursing Home Administrator) and DON (Director of Nursing) of the immediate jeopardy on 7/25/19 at 9:00 AM. The immediate jeopardy was removed on 7/25/19. 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 is able to show sustained compliance. This is evidenced by: R3 was admitted to the facility 5/2/19 following hospitalization for Acute [MEDICAL CONDITION] and exacerbation of [MEDICAL CONDITION]. Other medical [DIAGNOSES REDACTED]. On admission, R3's Physician ordered [MEDICATION NAME] solution, 20 mg/5 ML, give 2 mg every 8 hours as needed for pain. This order was clarified on 5/5/19 to read [MEDICATION NAME] Liquid, 20 mg/ML, give 2 mg (0.125ML) every 8 hours for pain. This was a concentration change in the medication supplied by the Pharmacy (The original order was 20 mg per 5 ML and this new order was 20 mg per ML). Pharmacies supply medications as concentrations based on availability, including [MEDICATION NAME]. Oftentimes, these concentrations are different than previously supplied. All bottles look the same but the concentration of its contents may be very different. Manufacturers change the concentration often without notification. It is the responsibility of the professional administering the medication to review the concentrations on the bottle and complete the calculations in order to administer the correct dosage to the patient. According to the Medication Error investigation, on 5/29/19, RN-Q (Registered Nurse) administered 100 mg (5 ML) to R3 at midnight. She identified her error when she completed her charting and signing out of the medication in the count book of narcotics. She went to assess R3 and found the resident was lethargic and difficult to arouse. The nurse did notify the physician and an order was given to administer [MEDICATION NAME]. The nurse continued to assess R3 and no negative effects occurred. At 5:56 AM, R3 became easily arousable. There is no evidence that anyone checked on R3 between midnight and 4:30 AM or assessed the effectiveness of the pain medication, a time period during which the side effects of an overdose could have intensified. Side effects of a [MEDICATION NAME] overdose include: 1) Comatose-like behavior: people may slip into a state of unconsciousness. 2) Pinpoint pupils: one or both eyes may exhibit erratic behavior or have tiny pupils that do not react to light. 3) Slower respiration rate: [MEDICATION NAME] overdoses can lead to [MEDICAL CONDITIONS], the filling of the lungs with fluid, which is a leading cause of death for such an overdose. For this reason, monitoring breathing is essential. More overdose warning signs that should never be ignored include limpness, the inability to speak, itching, pale skin, a bluish complexion on lips and fingernails, nausea and confusion. https://www.therecoveryvillage.com/[MEDICATION NAME]-addiction/[MEDICATION NAME]-overdose/#gref On 7/25/19 at 7:20 AM, Surveyor interviewed RN-Q regarding this error. RN-Q stated she has been a nurse for over [AGE] years and has worked in Hospice and with drug addicts and has never made a mistake of this nature. She stated she is the house supervisor on the evening and night shifts. That particular night (5/29/19) she had many issues to deal with regarding staffing and was frequently interrupted during her medication administration pass. RN-Q stated she normally gives a medication and signs it out immediately after giving, but on this particular date, because she was busy and things were hectic, she did not do that. She stated around 4:30 AM or so, she finally was able to chart on her medications given and realized her error. She stated she immediately went in to R3's room to assess her and realized the resident was difficult to arouse. She then called the physician and he had ordered her to give [MEDICATION NAME] 0.4 mg at 4:45 AM. She administered the [MEDICATION NAME] and about an hour or so later, the resident became more arousable. She stated she stayed with R3 into the day shift to continue to assess her. RN-Q stated the error occurred because she read the concentration on the bottle instead of the normal practice of reading the resident's label supplied by the Pharmacy and making a comparison with the Medication Administration Record [REDACTED] The investigation supplied to Surveyor indicates the facility educated RN-Q on the 5 rights of medication administration. There were no further systematic changes or education of all other staff nurses to prevent an error of this magnitude to be repeated in the future. On 7/23/19 at 12:35 PM, Surveyor interviewed the Director of Nursing (DON) regarding the medication error and the interventions implemented. The DON stated that she met with RN-Q regarding the error and presented her with a final written warning, the first warning that RN-Q was given in the history of her working in the facility. She stated the reason the warning was so severe was because of the severity of the error. The DON also stated that she met with RN-Q and also educated her on the 5 Rights of medication administration; to read the bottle concentrations and compare to the Pharmacy label and the Medication Administration Record [REDACTED] The DON stated that she did not educate all other nursing staff as this was an isolated event. The failure to ensure licensed nurses followed the 5 Rights of medication administration, created a finding of immediate jeopardy. The facility removed the jeopardy on 7/25/19 when it: 1. Provided education to licensed nursing staff on the 5 Rights and medication incidents prior to the start of their next scheduled shift; 2. Administered a post-test on medication incidents to those licensed nurses after completion of the training; 3. Daily audits of medication administration to ensure accuracy of delivery; and 4. Began medication administration competency audits on all licensed nurses.

Based on observation, record review and interview the facility did not ensure 1 of 3 residents (R11) at risk for falls, received the necessary care and services to prevent falls. R11 was identified as being at risk for falls and had 4 falls since her admission on 3/27/19. Following the fall on 4/3/19, the facility added an approach to offer toileting before meals. R11 fell on [DATE] again responding to a toileting need, and required sutures to a laceration on her head. R11 fell on [DATE] while responding to toileting needs and was hospitalized until 7/12/19 for a mild [MEDICAL CONDITION]. This is evidenced by: R11 was admitted [DATE] with [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) dated 4/03/19 indicated R11: ~Is able to understand others; ~Is able to make self-understood; ~Cognition is intact; ~Requires assist of 1 for bed mobility, transfer, ambulation, dressing, toilet use and personal hygiene; ~Is occasionally incontinent of bladder and not on a toileting plan; ~Had 2 falls since admission with major injuries. ~Balance: not steady, only able to stabilize with staff assist. Review of the Fall Risk Assessment identifies R11 as being at risk for falls since admission to the facility. Falls: ~4/01/19: 8:00 a.m. No injury. Resident up to closet unassisted. When CNA (Certified Nursing Assistant) entered room, resident lost balance and CNA assist to floor. Resident did not have call light on. Educated on the importance of use of call light. On 4/02/19 the IDT (Interdisciplinary Team) reviewed R11's fall and noted: Interventions in place to have non-skid socks at HS (hour of sleep) Resident is currently on PT/OT (physical therapy and occupational therapy). R11's care plan included a focus area of at risk for falls related to generalize weakness developed on 3/27/19. Interventions included Educate/remind on use of call light for staff assistance dated 4/01/19. The care plan does not include the IDT's recommendation for non-skid socks at HS. R11's CNA care card includes educate/remind on use of call light for staff assistance dated 4/01/19. The care card does not include the intervention of non-skid socks at HS. ~4/03/19, 11:59 a.m. No injury. Resident is with decreased safety awareness, was ambulating independently without assistance to the bathroom. Resident stated she pushed on the door, lost her balance and fell to her buttocks. Denies hitting head. Denies pain. No apparent injury. On 4/4/19, the IDT review stated, IDT met today regarding resident's recent fall. Added intervention is to offer toileting assistance before meals. Resident still on PT/OT. R11's care plan was updated on 4/4/19 to include an approach of, Provide toileting assistance before every meal. ~On 5/23/19 at 8:25 a.m. Laceration R (right) side of head, skin tear mid back. Resident was self-ambulating to the bathroom and lost balance, fell to floor, bumped head on (R) right side. 5/23/19 at 8:50 a.m. note indicates [NAME] ambulance here for transport to ER (emergency room ). 5/23/19 at 12:50 p.m. note indicates returned via ambulance CT (scan) done and stitches applied to (R) [MEDICAL CONDITION]. Denies headache/dizziness. Denies pain/discomfort. No signs of distress. 5/24/19: F/U (follow up) fall/laceration to R/S (right side) of head/abrasion to upper/mid back .Resident alert and oriented. Can make needs known. No c/o (complaint of) pain or discomfort. Will continue to monitor. R11's care plan was updated on 5/23/19 to include an approach of: Therapy eval. for strengthening. R11's CNA care card shows no revision on 5/23/19. Physical Therapy Evaluation and Plan of Treatment dated 5/29/19 start of care was reviewed by the surveyor. Notes show R11 is receiving services to date, with goals of improving her functional activity tolerance, strength, balance, coordination and independence with transfer and ambulation. Although the facility addressed R11's loss of balance with her fall, there is no evidence the facility addressed the root cause of R11's need to use the bathroom. ~On 6/27/19 at 6:35 a.m. Abrasion, bruising, other: 2 bumps on back of head. Resident found on the floor. Incontinent of stool, juice was spilled on resident and floor. Candy on floor with resident .resident to ER for evaluation and treat. Resident notes, care plan or CNA care card shows no change in resident plan of care from 6/27/19 fall. Hospital discharge notes dated 6/27/19 admission with 7/12/19 discharge notes resident discharge Diagnosis: [REDACTED]. Resident care plan for falls shows no change in plan after R11's fall on 6/27/19. On 7/24/19 at 7:30 a.m. Surveyor observed CNA-C assist R11 with her morning cares. R11 was assisted to sit at the edge of her bed for cares. R11 was noted to have bare feet upon rising from bed. On 7/24/19 at 9:00 a.m. Surveyor spoke with R11 about her falls and fall precautions. R11 indicated she has fallen since her admission to the facility and has hit her head when she has fallen. R11 stated she gets up on her own to go to the bathroom and has fallen. Surveyor asked R11 about the need for gripper socks when she goes to bed. R11 indicated she knows she needs the gripper socks because the floor is slick. Surveyor asked R11 why she was bare foot when she got up this morning. R11 responded there were no gripper socks available when she went to bed, but will wear them when they are available. R11 stated staff often tell her there the gripper socks are in laundry and none are available. On 7/24/19 at 9:15 a.m. Surveyor spoke with CNA-C regarding R11's falls and fall precautions. CNA-C indicated she only works 2 times a month and is not familiar with R11. CNA-C stated she had to go to laundry to obtain gripper socks after R11 got up this morning. CNA-C indicated there were no gripper socks on the unit and R11 should have them on due to being at risk for falls. On 7/24/19 at 9:25 a.m. Surveyor spoke with CNA-D about R11's falls and fall precautions. CNA-D indicated she is familiar with R11. CNA-D expressed R11 needs to be monitored more closely for the need to go to the bathroom. Surveyor asked CNA-D about the use of gripper socks. CNA-D indicated R11 should have gripper socks on at all times as she will get up on her own and slip. On 7/24/19 at 10:30 a.m. Surveyor spoke with the DON (Director of Nursing) regarding the facility's fall investigation process and R11's falls. The DON explained the floor nurse would assess residents for injuries at the time of the fall. The floor nurse or nurse manager will begin the fall investigation using the fall event form in the computer. The form includes where the incident occurred, what happened and assessment of the root cause of the fall. The nurse talks with staff and resident. The IDT will meet and go through the investigation, based on the information that was gathered. Root cause analysis is reviewed and the resident care plan is updated. Surveyor and the DON reviewed and discussed R11's falls. The DON indicated the following: ~4/01/19 fall: IDT recommended gripper socks at hour of sleep as change to the care plan; however the gripper socks approach did not get added to the care plan or CNA care card. It should have been added, staff have no way of knowing the gripper sock are part of R11's care plan. ~4/03/19: IDT recommended toileting before meals with care plan and care card updated. ~5/24/19: Therapy evaluated R11 for balance. Toileting was not addressed. ~6/27/19: Root cause not addressed and resident care plan was not updated. Staff should have looked at resident routine, was incontinent, may need to be first resident up in a.m. failed to identify a root cause and place an intervention to prevent a future fall.

Based on observations, record review, staff and resident interviews, the facility did not keep the residents ' environment as free from accident hazards as possible. The facility failed to maintain the base board heaters in residents ' room as evidenced by exposed heating coils and sharp edges. Environmental tours were conducted on all 5 units, noting that 31 out of the facility's 96 resident rooms contain baseboard heaters that were in disrepair- either deflector plates were missing or the faceplates were loose and bent, leaving areas of heating coils exposed. During the survey, it was identified that 3 residents (#9, #15, and #3) were at the greatest risk of suffering injuries due to their living environments not being free from potential accident hazards. The heaters in Resident #3, #9, & #15 were observed to have sharp edges. The deflectors were missing and there were gaps between the face plate and the heating elements, which were noted to be very hot. While checking the heating units the Surveyors touched the heating elements and were unable to keep their hand on the element due to the high temperature. Resident #9 is non verbal, dependent upon staff for her activities of daily living and is identified at being high risk for falls. Resident #9 does not have a bed alarm and if Resident #9 were to have fallen onto the heater the Facility staff may not have known until they conducted their room checks. Resident #3 and Resident #15 are are both identified to be at risk for falls and have fallen a number of times from their bed. According to http://list.uvm.edu/cgi-bin/wa?A2=ind0308C&L=SAFETY&P=3519, "Liquids or solids at 72 degrees C./162 degrees F. will cause third degree burns almost instantly. The material being contacted is also significant; hot metals burn the worst because they conduct a continued supply of heat to the burn point ...." The failure to maintain the heaters in good repair left residents at risk for serious injury occurring in the immediate future. This deficient practice resulted in a finding of immediate jeopardy beginning on 2/3/11. The facility was notified of the immediate jeopardy on 2/3/11 and removed the jeopardy that day. The deficient practice continues at a scope/severity level E (potential for harm that is not immediate jeopardy/pattern) because the facility needs to repair the heaters in the other 28 rooms and because of issues related to supervision to prevent falls and unlocked hazardous chemicals. Specifically: * 2 out of 12 residents (#3, #15) were assessed to be at high risk for falls and were not always provided with the appropriate supervision and interventions per interview with the Assistant Director of Nursing (ADON) and/or as indicated in the Resident's plan of care to prevent further falls. - Resident #3 was at high risk for falls, and had a history of [REDACTED]. The Certified Nursing Assistant (CNA) left the room and Resident #3 attempted to stand and fell , receiving abrasions to his forehead. ADON- I stated that the CNA should not have left Resident #3 unattended, as he was at high risk for falls. - Resident # 15 is assessed to be at risk for falls and has a history of fall. The plan of care dated 11/20/10 and 1/15/11 states that his wheelchair should be kept out of the room when not in use and should have gripper socks on while in bed. Observations were made during the survey of these interventions not being put in to place. Additionally on 2/8/11, the facility did not ensure the environment on the Special Care Unit was free from accident hazards by locking up all hazards chemicals. This is evidenced by: 1. Resident #9 is a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #9 is non verbal, receives her nutrition via a tube, does not ambulate, is transferred with a mechanical lift, and is dependent upon staff for all her ADL's (activities of daily living). The Resident Care Card, which directs the CNA (Certified Nursing Assistant) how to care for the Resident, located on the back of Resident #9's room door and updated 9/27/10, documents that Resident #9 "Is unable to speak. Follow gestures," has a "low bed, body pillow, floor mat" and "requires 2 for all cares at all times." The thought process care plan dated 9/28/2010 documents, "This resident suffered a debilitating CVA (cerebral vascular accident) leaving her unable to speak, interact or care for herself. Resident is unable to communicate needs or thoughts at this time. Resident is capable of holding eye contact and squeezing hand when asked but that is all for now. Resident appears unresponsive at times." The mobility care plan not dated documents, "Resident has decreased mobility related to CVA in 3/10. Is (L) (left) hemiparesis and will need a full body mechanical lift to transfer. She has no trunk control and is unable to follow directions consistently." The quarterly MDS (minimum data set) with an assessment reference date of 12/17/10 documents that Resident #9 has short and long term memory problems, is dependent upon staff for her activities of daily living and has not had any falls. The safety/fall risk assessment dated [DATE] scores Resident #9 for cognitive status as "severe impairment" and has a total score of "11" which is high risk. The summary of information documents, "High risk for falls secondary to CVA, confusion." The plan documents, "Low bed, body pillow in place on exit side of bed, landing strip in place at bedside." Surveyor # noted the Facility does not have an intervention of bed alarm which would alert Facility staff that Resident #9 had fallen out of bed. On 2/3/11 from 8:17 a.m. to 8:55 a.m., Surveyor # observed morning cares for Resident #9 with CNA (Certified Nursing Assistant)-II and CNA-HH. Surveyor # observed Resident #9 was positioned on her right side with the head of the bed elevated at forty five degrees. The left side of the bed was against the wall and there was a mat on the floor on the right side of the bed. Before CNA-II started to wash Resident #9's upper body, CNA-II and CNA-HH pulled Resident #9's bed away from the wall. After CNA-II and CNA-HH moved the bed away from the wall, Surveyor # observed that a heater ran along the wall the entire length of the bed on the left side and across the length of the head board. Surveyor # observed the heater to be in disrepair. The deflector piece was missing. The face plate that runs along the front of the heater was pulled away and was apart in two pieces. There was a sharp pointed edge on top of the face plate that came out and another sharp piece that came out approximately one inch. There were two screws pointing out. There was a gap from the heating element inside to the face plate that ranged from approximately one inch to five inches and was three to four feet in length. Surveyor # touched the heating element and had to immediately remove her hand. Surveyor # observed the heater behind the head of Resident's #9 bed that the face plate bowed out. 2. On 2/3/11 at 9:16 a.m., Surveyor # conducted an environmental tour of Resident #15's room. At this time, it was noted that the baseboard heater in the room was in disrepair. The entire faceplate of the heater was severely bent away from the heater and was missing the entire deflector piece. Due to the faceplate being severely bent, this left a very large section of the heating coils exposed. The coils were very sharp and Surveyor # placed her hand onto the heating coils, and needed to immediately move her hand away as the temperature was very hot. Upon further observation, it was noted that Resident #15 had his head of the bed parallel to the baseboard heater, right next the the area which the faceplate was the most severely bent, leaving the heating coils exposed. Resident #15 was lying in a low bed at the time of the observation. Surveyor # conducted a medical record review of Resident #15 who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility conducted a " Safety/ Fall Risk Assessment" on 1/27/11. The assessment states that Resident #15 is at high risk for falls due to mobility impairments secondary to Parkinson's Disease. Uses wheelchair for general mobility. Requires assist with transfers but often attempts to self transfer. The plan is to use bed sensor alarm, tab alarm when up in wheelchair. A review of the individual plan of care for mobility, updated 11/30/10 and the Certified Nursing Assistant Care Card last updated 1/15/11 states that Resident #15 is at risk for falls related to falls history and Cervical Disk Disease. The listed interventions included to keep wheelchair out of room until ready to transfer, bed sensor and tab alarm in wheelchair, encourage rest periods daily to avoid overtiring, do not allow in room or dining room alone, bed at sitting height. A review of Resident #15's recent falls, per the post fall assessments noted that Resident #15 fell on [DATE] (from bed), 10/25/10, 11/30/10 (from bed), 12/6/10 (from bed), 12/25/10 (from bed), 1/9/11, and 1/21/11. The summary of the fall on 1/21/11 noted that Resident #15 has a history of frequent falls, impulsive with transfers and stiff extremities secondary to Parkinson's Disease. Resident #15 was sent out for evaluation, facility staff suspecting possible seizure activity. 3. On 2/3/11 at 9:24 a.m., Surveyor # conducted a general environmental tour of the Special Care Unit. At this time, observations were made of Resident#3's room #24. At this time it was noted that Resident #3 was the only resident residing in this room. The bed was in a very low position and ran parallel to the baseboard heater. The wheels on the bed were not locked and the bed was easily moved away from the wall, and the baseboard heater. The baseboard heater was in very bad disrepair. The entire faceplate of the heater was separated from the baseboard itself, leaving a very large section of the heating coil exposed. Surveyor # touched the heating coils, noting that she had to immediately remove her hand due to the very hot temperature of the heating coils. The heating coils were very sharp and there were 2 large metal brackets that were sticking upward towards the bed. These brackets were to hold the faceplate together to the baseboard heater. It was also noted that the actual baseboard heating device was loosely attached to the wall. Surveyor # conducted a medical record review of Resident #3 who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Initial Minimum Data Set ( MDS), dated [DATE], Resident #3 has long and short term memory impairments and is moderately impaired in decision making skills for daily living. The facility conducted a Safety/ Falls Risk Assessment on 1/24/10 that states that Resident #3 is at high risk for falls and has had 2 falls recently and remains at high risk due to Dementia and lack of safety awareness. The listed interventions state to use a bed and chair alarm, bolsters on the bed and mat on the floor. The individual plan of care, updated 1/13/2010, states that resident #3 is at risk for falls related to a history of multiple falls, Alzheimer's (impulsive, unaware of safety needs) Delirium. The listed interventions included bed in low position, mat on floor, assist with repositioning to provide comfort and maintain body alignment, bilateral bolsters on bed, body pillow in bed, sensor alarm in bed and chair. A review of the "Post Fall Assessment" forms located in the medical chart show that Resident #3 has had the following recent falls: 9/8/10 at 12:10 a.m. Resident #3 was attempting to get out of low bed, sitting on mattress pad, Resident #3 appeared to be crawling because his legs are too weak, no injuries noted. 10/5/10 at 6:20 a.m., Resident #3 was found on the floor, had fallen from low bed next to mattress, no injuries noted. 11/3/10 at 8:30 a.m., Resident #3 had tried to self- transfer from the bed fallen from his low bed to the floor, no injuries noted. 11/29/10 at 9:15 p.m., Resident #3 managed to crawl over the bolster and body pillow and slid to the floor, no injuries noted. 12/27/10 at 5:00 a.m., Resident # 3 was found half sitting /lying on his mat with his mattress half on the bed along with the blankets, sheets and pillows. The findings also stated that Resident #3 becomes easily agitated and impulsive and is at times defensive with caregivers and kicking his legs at caregivers. Upon learning that Resident #3 was at very high risk for falls, and had several recent falls from the bed to the floor, and given the position of his bed to the baseboard heater that was in bad disrepair, Surveyor # immediately alerted the Administration staff on 2/3/11 at approximately 10:00 a.m. that Resident #3 would be at a significant risk of injury either by burning himself or cutting himself if he fell from the bed, landing near the baseboard heater. Resident #3's bed did not lock and was easily moved away from the wall, and Resident # 3 has been observed to be able to move about the bed, sometimes noting to be half on the bed and half on the floor. Resident #3 is impulsive and has poor safety awareness. On 2/3/11 at 10:15 a.m., Surveyor # interviewed the Director of Nursing (DON) who was able to verify that Resident #3's locking mechanism on the bed was not working, easily moved away from the wall. The DON stated that the facility would immediately fix this. On 2/7/11 at 10:10 a.m., Surveyor # interviewed Licensed Practical Nurse (LPN)- X who stated that Resident #3 can move about his bed very much and is very mobile. LPN- X stated she has witnessed Resident #3 in bed sitting up right with his back against the wall (noting this is the wall where the baseboard heater is located). Surveyor # conducted a review of the " Maintenance Request Log" that was located in the Special Care Unit nursing office. At this time it was noted that their was an entry in the log dated 11/16/10 that stated Resident room #24 the bed will not go up or down and the vent is also broken. The date completed and who completed the task was left blank. ADDITIONAL OBSERVATIONS OF HEATERS: 4. Surveyor # noted the following rooms with concerns with the baseboard heater during the environmental tour that was initiated on 2/3/11 at 9:05 a.m. on the 1 north unit; Room #104, the middle of the baseboard was bent, leaving the heating coil exposed. There was no bed near the baseboard heater, only a dresser and a chair. Room #106, baseboard heater slightly bent, headboard resting parallel to heater, area too small to fit a limb in to possible get injured. Room #110, middle of baseboard heater is bulging, leaving the heating coils exposed, dresser in front of the heater. Room #112, dresser is in front of the baseboard heater, in the middle, its noted that the faceplate is bent, leaving the heating coils exposed. Room #116, heater noted to have a bulge in the middle of the faceplate, residents bed positioned away from heater. Cozy Corner dining room, to the right of the window it was noted that there was 2 very large gaps in the baseboard heater where the faceplate had separated, leaving the heating coil exposed in 2 large spots. Room #121, large separation between the faceplate of the baseboard heater, leaving heating coils exposed. There was a dresser in front of the heater and the resident bed was not postponing closely to the heater. Room #119, large separation between the faceplate and the baseboard heater. It was noted that the dresser was placed in front of this area. On 2/3/11 at 9:22 a.m., Surveyor # conducted and environmental tour of the Special Care Unit, which is a 10 bed Dementia Care unit. At this time the following concerns were noted: Room #28, slight bulge in the faceplate of the baseboard heater, leaving heating coils exposed. The bed was positioned away from the heater. 5. On 2/3/11 from 9:03 a.m. to 9:26 a.m. Surveyor # checked the heaters on the 2 South unit and observed the following: The heater in room 230 by the B bed head board has two metal hooks sticking up. There is approximately three feet in length where there is a gap between the face plate and the heating element. The heater in room 234 by bed B, there is approximately six feet across where the face plate is coming off and there is a gap between the face plate and the heating element. The left side of the heater is coming off the wall. The heater in room 238 by the B bed, there is a wire sticking up on the left side. Behind the head board and approximately one foot to the right of the bed the face plate is bowed out and there is a gap between the face plate and the heating element of approximately four inches. The deflector piece was missing and there were two metal hooks sticking out. An accumulation of dust and pieces of paper were in the heater. The heater in room 240 by bed B, the face plate is bowed out for a length of approximately five feet leaving a gap between the face plate and the heating element. Pieces of wood, paper, and dust were observed in the heater. The heater in room 242 by bed B, the deflector piece was missing. The face plate bowed out in length approximately two feet leaving a gap between the face plate and the heating element. The heater in room 239, the face plate bowed out in length approximately six feet leaving a gap between the face plate and the heating element. The heater in room 237 to the left of the bed at the end of the heater there was a sharp edge on the face plate. 6. On 2/3/11 at 11:13 a.m., Surveyor # observed the heater in room 239 the face plate bowed out leaving a gap between the face plate and the heating element. 7. On 2/3/11, Surveyor # observed the following on the 2 North Unit: In room 202 the heating vent face plate was bent in two areas, the area of the heating vent under the window was touching the floor. One hook that the reflector is to be connected onto was sticking out beyond the face plate. In room 207, the heating vent face plate was bent in several areas along the face plate. In room 208 the heating vent face plate was bent in several areas along the face plate. In room 210 the heating vent face plate was bent in several areas along the face plate. At the far right side of the heating vent face plate (towards the bathroom door) a metal wire was sticking out beyond the heating vent face plate. In room 214 the heating vent face plate was bent in several areas along the heating vent face plate. Areas of the heating vent face plate where touching the floor. In room 221 the heating vent face plate was bent in several areas along the heating vent face plate. In room 222 the heating vent face plate was not attached to the heating component properly. The far left side of the face plate and the middle of the face plate was not attached to the heating component and was touching the floor. 8. On 2/3/11 at 9:03 a.m. Surveyor # observed room 134. The heat register cover was completed disengaged from the base of the heater. 9. On 2/3/11 at 9:04 a.m., Surveyor # observed room 136. The heat register cover was completed disengaged from the base of the heater. 10. On 2/3/11 at 9:06 a.m., Surveyor # observed room 141. The heat register cover was completed disengaged from the base of the heater. On 2/3/11 at 10:30 a.m., the Survey team shared the concerns with the facility heat registers with the Administrator and Director of Nurses. INTERVIEWS On 2/3/11 at 9:27 a.m., Surveyor # spoke with Maintenance Director-D and asked if they check the heaters. Maintenance Director-D informed Surveyor # they are checked every so often. Surveyor # inquired what does " every so often" mean. Maintenance Director-D replied that they could be checked once a week, twice a week, or if they are in a room for another issue they may look at the heater. On 2/3/11 at 10:12 a.m., Surveyors # and # accompanied the Administrator, Director of Nursing, Maintenance Director-D and RN (Registered Nurse)-I to Room #24 and showed the Facility staff the heater. Maintenance Director-D informed the survey team that he didn't realize the heater was in this condition. Surveyor # inquired how his department is notified when a heater needs to be repaired. Maintenance Director-D replied that if they are in a room fixing something they will look at the heater or nursing will let them know if there is a problem. Surveyor # inquired if Maintenance Director-D or his staff take temperatures of the heaters. Maintenance Director-D replied that he has taken room temperatures but not necessarily the heater in the room itself. Surveyor # inquired if there is a maintenance log book on the floors. Maintenance Director-D informed Surveyor # that they have a log book on the first and second floors. Surveyor # asked if there was a log book for the special care unit. Maintenance Director-D replied that he found out a few weeks ago there was also a log book on this unit. Maintenance Director-D informed Surveyors # & # that staff can also leave them a voice message or page them. On 2/3/11 at 10:23 a.m., Surveyors # & # showed the Administrator, Director of Nursing, Maintenance Director-D and RN-I the heater in room 118. Surveyor # informed that Resident #9's heater is in disrepair but that Maintenance-JJ was working on the heater. On 2/3/11 at 10:30 a.m., the Survey team met with the Administrator, Director of Nursing, Maintenance Director-D and RN-I. Surveyor # asked if maintenance has ever taken the surface temperature of the heaters. Maintenance Director-D replied that he has taken room temperatures during the time when the Facility was having a problem with their boilers to make sure the rooms weren't too cold but the problem with the boilers has been fixed. The Administrator informed the survey team that they added another full time person in the maintenance department so there is three full time employees. The Administrator indicated that they had identified there were environmental issues that needed to be repaired and informed the survey team that he wasn't saying they weren't aware of this. Surveyor # then asked if the facility was aware there were problems what did you do. Maintenance Director-D replied they have repaired some of the heaters. Surveyor # inquired how many were fixed. Maintenance Director-D replied that they repaired three of them. Surveyor # inquired after they were aware of the three heaters that needed to be fixed, did maintenance do a house wide sweep to check the heaters. Maintenance Director-D replied, "No, I did not." The survey team inquired if any Residents sustained any injuries from the heaters. The Director of Nursing replied, "No." The survey team informed the Facility staff that the heaters in rooms #226, #24, & #118 were in such bad condition that the survey team strongly suggested that the Residents not be placed back in bed until after the heaters were fixed. The survey team had also identified numerous rooms were the heaters needed to be repaired and suggested that the Facility should check all the heaters. On 2/3/11 at 2:03 p.m. the Administrator informed the survey team that they have identified twelve rooms on the first floor that the heaters needed to be fixed. The Administrator informed the survey team that he personally checked the first floor and SCU (special care unit) and would be checking the second floor also. The Administrator informed the Survey team that they called in additional staff from another nursing home and they expected the repairs to be completed today. Admissions Coordinator-C informed the survey team that they contacted State Wide Heating and Cooling Company to see if there was something better that could be done. Admissions Coordinator-C also informed the survey team that a second company will be coming in tomorrow to look at the heaters. On 2/3/11 at 2:12 p.m., Corporate Consultant-KK informed the survey team that are starting to inservice staff on the heaters and that a separate log for the heaters has been developed and will be implemented today. On 2/3/11 at 3:46 p.m., Surveyor # informed the Administrator, Director of Nursing, Admissions-C, RN-I, and Corporate Consultant-KK that the Survey team identified the issue involving the heaters at immediate jeopardy. The facility removed the immediate jeopardy at F323 was removed on 2/3/11 when the facility completed the following: * Resident #9 was moved to another room, while the heating unit was being repaired. * The facility repaired the heaters in the rooms for Resident #9, #3 & #15. * Baseboard heaters in resident rooms have been checked and any needed repairs completed. * State Wide Heating and Cooling was called to the facility to assess and recommend any further need for repair. * Maintenance will check baseboard heaters in residents ' rooms and common areas weekly to assure they are in good repair and functioning properly. These checks will be recorded by maintenance and reviewed by the administrator/designee. * Staff have been inserviced to report any baseboard heaters noted to need repair. This inservice included the need for repair recorded in a log, with maintenance reviewing the log daily. Nursing Management staff have been inserviced related to providing safety for residents who are highly susceptible to environmental hazards when a need for repair is reported. The deficient practice continues at a scope/severity of E (potential for harm that is not immediate jeopardy/pattern) because of the following: FALLS CONCERNS: 11. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Initial Minimum Data Set ( MDS), dated [DATE], Resident #3 has long and short term memory impairments and is moderately impaired in decision making skills for daily living. On 8/14/10, the facility conducted the "Safety Fall Risk Assessment." The assessment stated that Resident #3 is at high risk due to having previous falls. The recommended plan is to use a bed alarm. A review of the medical record showed that on 10/16/10, Resident #3 slid from his Broda chair, no injuries noted. The facility stated that it would continue with 15 minute safety checks and add a clip alarm to the chair. According to the post fall assessment, dated 11/17/10 at 6:45 a.m., Resident #3 was in the bathroom of room #24 when he self- transferred himself from the toilet. Resident #3 sustained a 0.5 centimeter by 0.5 centimeter abrasion to the forehead, a 0.4 cm by 0.5 cm abrasion below the right knee and 2.5 cm by 0.5 cm abrasion to the side of the right leg. At the time of the fall, the Certified Nursing Assistant was not in the restroom with Resident #3. On 2/8/11 at 11:50 a.m., Surveyor # interviewed Assistant Director of Nursing (ADON)- I in regards to Resident #3 being left unattended in the restroom. ADON- I stated that at the time Resident #3 was seated on the toilet on 11/7/10, the Certified Nursing Assistant (CNA) had left the bathroom only for a minute to get clothing out of the closet. ADON- I stated that the CNA should not have left Resident #3 unattended, as he was at high risk for falls. ADON- I stated that the CNA was re-educated. It was noted that Resident #3 only needed minimal first -aid from the nursing staff for the abrasions received after the fall on 11/17/10. 12. Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most recent quarterly Minimum Data Set ( MDS), dated [DATE], Resident #15 had a fall in the last month prior to admission, had a a fall in the last 2- 6 months of admission and has a fracture related to a fall in the last 6 months prior to admission. The facility conducted a "Safety/ Fall Risk Assessment" on 1/27/11. The assessment states that Resident #15 is at high risk for falls due to mobility impairments secondary to Parkinson's Disease. Uses wheelchair for general mobility. Requires assist with transfers but often attempts to self transfer. The plan is to use bed sensor alarm, tab alarm when up in wheelchair. A review of the individual plan of care for mobility, updated 11/30/10, states that Resident #15 is at risk for falls related to falls history and Cervical Disk Disease. The listed interventions included to keep wheelchair out of room until ready to transfer, bed sensor and tab alarm in wheelchair. The Certified Nursing Care Card, most recently updated on 1/15/11, states that Resident # 15 is to have gripper socks while in bed and the bed should be at sitting height. On 2/7/11 at 2:17 p.m., Surveyor # made observations of Resident #15 lying in bed awake. At this time, it was noted that Resident #15's wheelchair was in the room directly off to the side of the bed. It was also noted that Resident #15 had regular socks on. On 2/8/11 at 10:30 a.m., Surveyor # made observations of Resident #15 lying in bed. It was noted that his wheelchair was directly next to the bed. Staff then entered the room and lowered the bed from sitting height to lowest level to the floor. On 2/8/11 at 2:00 p.m., Surveyor # made observations of Resident #15 lying in bed with the wheelchair directly next to the side of the bed. On 2/8/11 at the daily exit, Surveyor # shared the above observations of Resident #15 lying in bed without gripper socks on and with the wheelchair directly next to the bed where he may attempt to self transfer into. No further information was provided as to why the facility staff had not followed the plan of care by removing the wheelchair from the room until ready to transfer or to have gripper socks on while in bed. On 2/9/10 at 8:05 a.m., Surveyor # made observations of Resident # 15 lying awake in a low bed with the wheelchair just off to the side of the foot of the bed. CHEMICALS 13. On 2/8/11 at 7:55 a.m., Surveyor # conducted an environmental tour of the Special care Unit (SCU). This unit consists of 16 residents with Dementia diagnosis. Upon the tour, Surveyor # noted that the closet located near room #24 was unlocked. The following chemicals were found underneath the sink: * U-1 germicidal cleaner with the warning may cause skin or eye irritation * Clorox cleaner spray * 2 bottles of "Zero-in-sok" flying, crawling insect killer with the warning that it is very hazardous if inhaled, on skin, in eyes or swallowed, call poison control immediately. * Probowl cleaner- corrosive- severe skin and eye irritation. On 2/8/11 at 8:30 a.m., Surveyor # brought these items to the attention of Assistant Director of Nursing- I who then locked the door and stated that normally this closet is locked.

Based on observation, interview, and record review the Facility did not comprehensively assess 4 of 12 Residents (#1, #4, #21, and #22) who are incontinent of bladder to restore as much normal bladder function as possible. * Resident #1 had a decline in her bladder continence from being continent to incontinent following hospitalization for a fracture to the left humeral bone after a fall. The Facility did not assess Resident #1's decline in bladder status in order to restore or maintain as much bladder function as possible. * Resident #21 was enrolled into hospice services on 9/24/10. Resident #21 had a decline bladder her continence from occasionally incontinent to frequently incontinent. The Facility did not assess the cause of this decline, did not monitor the Resident's usual voiding patterns, did not identify the type of incontinence and did not explore reversible causes of incontinency in order to assist Resident #21 with restoring or maintaining as much bladder function as possible. After Surveyor brought this to the attention of the Facility a urinary incontinence assessment was completed on 2/8/11. The Facility did not complete bladder assessments for Resident #21, #1, #4, and #22. Resident #1 & #21 experienced declines in their bladder continence status while Resident #4 & #22 did not have a decline in their bladder continence status. Findings include: 1. Resident #1 was admitted tot he facility on 6/23/10 and then readmitted to the facility on [DATE] following a fall in which she fracture her left humeral bone. The facility conducted a 3-day baseline elimination patterning from 7/19/10 to 7/21/10. The baseline elimination pattern summary, which was dated 6/23/10 states that Resident #1 is continent of bladder and the interventions are to maintain independence with toileting. According to the Quarterly Minimum Data Set ( (MDS) dated [DATE] and 12/9/10, Resident #1 is continent of bladder. On 1/18/11, Resident #1 was readmitted to the facility after she suffered a fracture to the left humeral bone after a fall. Resident #1 was noted to have some increased confusion with the use of the prescribed pain medications. Nursing note dated 1/23/11 at 10:20 a.m., states that Resident #1 is incontinent of bowel and bladder at times and is dependent on staff for mobility. The facility conducted a " baseline elimination patten" which is to be completed for 3 days to evaluate both bowel and bladder continence. The facility staff documented for only 2 days, 1/19/11 and 1/20/11, noting that the patterning was incomplete with many time entries left blank. The " Baseline Elimination Pattern Summary," dated 1/24/11, states that Resident #1 is continent of bladder. The plan/ interventions states to re-do due to not complete and decreased recognition secondary to pain pills. Nursing note dated 1/24/11 at 10:40 p.m. states that Resident #1 alert and orientated with some occasional confusion and is continent of bladder with some dribbling. Nursing Note dated 1/27/11 at 10:20 p.m. states that Resident # 1 is incontinent of bladder and bowel. Nursing Note 2/1/11 at 3:35 p.m. states that Resident #1 is incontinent of bowel and bladder at times, alert and orientated with confusion and anxiousness at times. The individual plan of care was updated 1/31/11 and states that Resident #1 is frequently incontinent of bladder. The listed approaches include to assess elimination pattern and contributing factors with a 3-day bowel/ bladder record, provide assist with toileting upon rising, before/ after meals, at night and late night during rounds and as needed. It was noted that this plan of care for elimination was not based on a comprehensive bladder assessment or was it individualized to address Resident #1's needs to maintain or increase bladder functioning. The facility had not conducted a complete 3- day patterning prior to developing the plan of care, not identified what type of incontinence Resident #1 was experiencing. Nursing Note 2/2/11 at 7:25 a.m. states that Resident # 1 has the potential for alteration in skin integrity due to frequent incontinence of bladder. Resident #1 has short term memory deficits, able to make needs known. The Certified Nursing Assistant Care Card, updated 2/2/11 states that Resident #1 is incontinent of bladder and uses pull- up briefs and needs the assist of 1 staff to use the bathroom. The frequency is left blank on the care card. The facility conducted another 3- day elimination patterning from 2/1/11 to 2/3/11. Review of the patterning shows that it was not completed appropriately as there was noted to be many time frames with blank documentation. The Baseline Elimination Summary states that Resident #1 is incontinent of bowel and bladder post re-admit from the hospital. The plans/ intervention states to re-do due to continued confusion but with some improvement of mental condition. The plan also states that in 2 weeks the patterning will be re-done again and to complete the urinary incontinence assessment at that time. Nursing note 2/4/11 at 10:30 p.m. states that Resident #1 is incontinent of bladder at times and will use the bedpan and commode. Nursing Note 2/7/11 at 11:25 p.m. states that Resident #1 is mostly continent of bowel and bladder except when going through confusion. On 2/7/11 at 1: 55 p.m., Surveyor # interviewed Certified Nursing Assistant- W who often cares for Resident #1. CNA- W stated that Resident # 1 has become more incontinent, and will sometime let staff know when she needs to use the bathroom. On 2/7/11 at 3:00 p.m., Surveyor # interviewed the Director of Nursing (DON) and asked if a comprehensive assessment had been completed for Resident #1 as she was experiencing a significant change in her bladder incontinence. The DON stated that due Resident #1's confusion, they were going to wait to complete the assessment. It was then discussed that Resident #1 was noted to be having incontinent episodes upon re-admission on 1/18/11 and that it was now 2/7/11 and she had not been comprehensively assessed so a plan of care could be written to help maintain or increase her bladder functioning. It was noted that this had not been done as of 2/7/11. 2. Resident #4 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/12/10, the facility completed the Resident Admission Assessment, indicating that Resident #4 is incontinent of bladder. On 9/24/10 to 9/26/10, the facility conducted a 3 -day baseline elimination patterning for Resident #4. It was noted that the patterning was incomplete as there was time periods that did not have documentation noted. The Baseline Elimination Pattern Summary, dated 9/27/10, states that Resident #4 is continent of bowel and bladder with occasional accidents. The plan/ interventions state to assist Resident #4 to maintain independence. It was noted that the facility did not conduct a comprehensive evaluation of Resident #4's occasional bladder incontinence and develop a individualized plan of care based on that assessment. The annual Minimum Data Set ( MDS), dated [DATE], states that Resident #4 is frequently incontinent of bladder. The Resident Assessment Protocol, dated 9/28/10, states that Resident #4 is incontinent of bowel and bladder due to the [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE] states that Resident #4 is occasionally incontinent of bladder. Nursing note dated 12/27/10 at 1:00 a.m. states that Resident #4 is continent of bladder and requires the assist of 2 staff members for toileting needs. The plan of care, last updated 1/4/2011, states that Resident #4 is continent of bowel and bladder. Assist of 2 with toileting. The listed interventions included to provide assist with toileting upon rising, before/ after meals (dinner especially), at night and late night rounds between 3 a.m. and 4 a.m. and as needed. Nursing note dated 1/27/11 states that Resident #4 is usually continent of bowel and bladder and is able to make needs known. On 2/7/11 at 10:10 a.m., Surveyor # interviewed Licensed Practical Nurse ( LPN)- X in regards to Resident #4's continence status. Surveyor # reviewed Resident #4's record with LPN- X showing that there was various indications that Resident #4 was frequently incontinent, occasionally incontinent and continent of bladder. LPN- X stated that although she works with Resident #4 often, she would need to check with the Certified Nursing Assistant (CNA) staff to see if Resident #4 is continent of bladder or not. LPN- X stated that sometimes Resident #4 will alert staff when she has to use the toilet. LPN- X then spoke with the CNA staff that was on duty, who verified that Resident #4 is incontinent at least 2 times a week, and that is only on the day shift. LPN- X stated that the incontinence assessment is to be done annually or unless a resident experiences a change in condition. On 2/8/11 at 11:05 a.m., Surveyor # interviewed the Director of Nursing (DON) in regards to Resident #4 not having a comprehensive urinary assessment. The DON stated she verified with the direct care staff and Resident #4 is frequently incontinent of urine and that the staff would need to complete a comprehensive urinary assessment and a new 3-day patterning. After this is complete, the facility staff would then update the individual plan of care. On 2/8/11 at 1:25 p.m., The DON was able to verify that Resident #4 did not have a previous comprehensive urinary assessment in place. 3. Resident #21 was originally admitted to the facility on [DATE] and has a readmission date of [DATE]. Resident #21 was enrolled into hospice services on 9/24/10. Resident #21's [DIAGNOSES REDACTED]. On 2/8/11 Surveyor # reviewed Resident #21's medical record and noted the following: The significant change MDS (minimum data set) with an assessment reference date of 8/22/10 documents that Resident #21 has short and long term memory problems, is occasionally incontinent of bladder, is dependent on staff for toilet use, and there is no change in her urinary continence. The incontinence RAP (Resident Assessment Protocol) summary dated 8/22/10 documents "See ADL (activities of daily living) Rap summary for details/plan in place. This summary documents, "Staff has to anticipate her needs and not that she does not request toileting but when staff take her to the toilet she will use the toilet if she has not already had an incontinent episode. She does wear incontinent products to prevent soiling of her clothing and/or bed linens." The Facility completed a two day patterning on 8/11/10 and 8/12/10 which showed Resident #21 was occasionally incontinent of bladder. The quarterly MDS with an assessment reference date of 11/21/10 documents that Resident #21 is always incontinent of bladder. Surveyor # was unable to locate a voiding diary or a comprehensive assessment after the Facility had identified there was a decline in Resident #21's bladder status. On 2/8/11 at 8:00 a.m., Surveyor # observed morning cares for Resident #21 with Hospice CNA (Certified Nursing Assistant)-EE and CNA-F. After Hospice CNA-EE washed Resident #21's upper body, Hospice CNA-EE informed Resident #21 that she was going to wash her bottom. Hospice CNA-EE unfastened the incontinence product and washed Resident #21's inner thighs and perineal area. Resident #21 was positioned on her right side and Surveyor # observed the incontinence product contained urine. On 2/8/11 at 1:44 p.m., Surveyor # informed RN (Registered Nurse)-J that Surveyor # was unable to locate a voiding diary or a comprehensive bladder assessment after the quarterly MDS with an assessment reference date of 11/21/10 which showed that Resident #21 had a decline in her bladder status. RN-J informed Surveyor # that she would look into this and get back to Surveyor # . On 2/8/11 at approximately 4:00 p.m., during the daily exit conference the Administrator and Director of Nursing were informed of the above. On 2/9/11 at 7:34 a.m., the Director of Nursing provided Surveyor # with a urinary incontinence assessment dated [DATE] completed by RN-J after speaking with Surveyor # . On 2/9/11 at 11:24 a.m., Surveyor # asked the Director of Nursing if there was a patterning that was completed in November 2010. The Director of Nursing informed Surveyor # that she didn't think there was a patterning completed in November but would double check. At the time of the exit on 2/9/11, Surveyor # was not provided with any patterning or assessment when Resident #21 was identified as having a decline in her bladder continence in November 2010. 4. On 2/8/11, Surveyor # reviewed Resident #22's closed medical record. Resident #22 was admitted into the facility on [DATE] and discharged back to the assisted living living facility on 12/20/10. The initial Minimum Data Set ((MDS) dated [DATE] with a reference date of 11/18/10 indicated Resident #22 was frequently incontinent of bladder. The Care Area Assessment (CAA) dated 11/24/10 indicated Resident #22 was frequently incontinent of bladder and occasionally incontinent of bowel at night, requires total assistance with toileting. Resident #22's care plan dated 11/15/10 addressed Resident #22 as being incontinent of bowel and bladder with interventions which included but was not limited to: assess elimination pattern and continent factors with a 3 day bowel and bladder record, provide assistance with toileting upon rising, before and after meals, at HS, during NOC (night time), observe changes in bladder, monitor bowel habits, if no bowel movement in 2 days, follow facility bowel program. Upon review of Resident #22's closed medical record, Surveyor # did not see a comprehensive bladder assessment. On 2/8/11 at 3:15 p.m., Surveyor # informed Administrative staff there Surveyor # did not locate a comprehensive bladder incontinent assessment for Resident #22. As of 2/9/11, no further information was received in regards to whether Resident #22's urinary incontinence was thoroughly assessed. Resident #22's incontinence care plan was not developed based off of a comprehensive assessment in order to develop an individualize toileting care plan in order to restore as much normal bladder function as possible.