Every finding on record at Rivers Edge Nursing and Rehab

Based on observation, interview, and record review, the facility failed to ensure each resident receives care, consistent with professional standards of practice (SOP), to prevent pressure injuries (PI) and to ensure each resident with PIs receives necessary treatment and services, consistent with professional SOP (standards of practice), to promote healing, prevent infection, and prevent new injuries from developing for 2 of 3 Residents reviewed for pressure injuries out of a sample of 7 residents (R2 and R1). R2 was admitted to the facility with a stage 2 PI to the left gluteus and was at risk for the development of additional pressure injuries. R2 developed a total of 6 avoidable PIs while at the facility. The facility failed to ensure interventions were implemented correctly and timely to prevent PI development. The facility did not determine the root cause for R2's PIs. R1 was admitted to the facility with a PI. and determined to be at risk for PI development. The facility failed to complete daily diabetic foot checks, failed to measure and assess the PI upon discovery, failed to notify the physician upon discovery in order to put a treatment in place, failed to provide risks and benefits regarding refusing skin interventions, and wearing tennis shoes that put pressure on R1's Stage IV PI and wound vac. R1 developed an avoidable facility acquired Unstageable PI which deteriorated to a Stage IV PI that developed osteomyelitis to the left heel requiring surgical debridement and IV (intravenous) antibiotics. The facility's failure to ensure R1 and R2 received care consistent with professional standards of practice (SOP) to prevent avoidable pressure injuries (PI) from developing and/or worsening and failure to promote healing and prevent infection due to failing to provide necessary treatment and services consistent with SOP, created a finding of immediate Jeopardy that began on 4/20/26. Surveyor notified NHA A (Nursing Home Administrator) of the immediate jeopardy on 8/13/26 at 3:45 PM. The immediate jeopardy was removed on 8/15/26, however, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. This is evidenced by: The facility policy titled Pressure Injury Prevention and Management, dated 1/2026, states, in part: . Policy: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Policy Explanation and Compliance Guidelines: . 2. The facility shall establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. 4. Interventions for Prevention and to Promote Healing a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. b. Interventions will be based on specific factors identified in the risk management, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. f. Interventions will be documented in the care plan and communicated to all relevant staff. g. Compliance with interventions will be documented in the weekly summary charting. 6. Modifications of Interventions. b. Interventions on a resident's plan of care will be modified as needed. Considerations for needed modifications include: i. Change in resident's degree of risk for developing a pressure injury. ii. New onset or recurrent pressure injury development. iii. Lack of progression towards healing. iv. Resident non-compliance. v. Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights. The NPIAP (National Pressure Injury Advisory Panel) classifies a PI as follows: Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also be present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4: Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts may be associated with Stage 4 pressure ulcers. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often preceding skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may be resolved without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI (deep tissue injury)to describe vascular, traumatic, neuropathic, or dermatologic conditions. Additional pressure injury definitions: Medical Device Related Pressure Injury: This describes an etiology. Medical device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury conforms to the pattern or shape of the device. The injury should be staged using the staging system. Advancing Excellence notes that, Pressure ulcers can be dangerous and painful for a resident, in part because broken skin can allow infection into the body. If untreated, pressure ulcers can deepen and even expose the bone. Deeper ulcers may be hard to heal or may not heal at all. Sometimes, pressure ulcers can lead to death. The presence of pressure ulcers limits the quality of life for a resident as evidenced by: o Decrease in bowel and bladder function o More incontinence o Decrease in ability to move without help o Decrease in mental capacity o Increase in pain o Increased risk for infection o Less participation in activities http://www.nhqualitycampaign.org/files/factsheets/Staff%20Fact%20Sheet%20-%20Reducing%20Pressure%20Ulcers.pdf 1) R2 was admitted to the facility on [DATE] and has diagnoses that include periprosthetic fracture around unspecified internal prosthetic joint, vascular dementia, and parkinsonism. R2's admission Minimum Data Set (MDS) Assessment, dated 4/6/26, identifies R2 as being at risk for pressure injuries (PI) and shows that R2 had one stage 2 PI on the left gluteus that was present on admission. The assessment identifies the following in place for R2: pressure reducing device for bed and chair-yes, turning and repositioning-no, nutrition or hydration interventions to manage skin problems-yes, and PI care-yes. The MDS indicates R2 is dependent on staff for bed mobility, requiring 2 person assist. R2 has a Brief Interview for Mental Status (BIMS) score of 9 out of 15 indicating moderate cognitive impairment. R2's Braden Scale assessment dated [DATE] shows a score of 13 indicating R2 is at moderate risk for pressure injuries. R2's Clinical Skin admission Assessment and Progress admission Note, both dated 3/31/26, show on admission, R2 presented with a Stage 2 PI to the left gluteus measuring 1.5 centimeters (cm) in length (L) x 1.2 cm in width (W) x 0.1 cm in depth (D) and a dry scab to right dorsum first digit (great toe) measuring 0.2 cm (W) x 0.2 cm (L). R2's Physician Orders for March 2026, state in part: . Betadine two times a day for wound care right hallux. Date Initiated: 3/31/26. Zinc buttock three times a day for wound care. Date Initiated: 3/31/26. The following interventions were put into place on admission: -Complete Braden Scale per Living Center Policy. Date Initiated: 3/31/26 -Conduct weekly skin inspection. Date Initiated: 3/31/26 -Notify practitioner if symptoms worsen or do not resolve. Date Initiated: 3/31/26. -Nutritional and Hydration support. Date Initiated: 3/31/26. -Podiatry consult. Date Initiated: 3/31/26. -Provide thorough skin care after incontinent episodes and apply barrier cream. Date Initiated: 3/31/26. -Referral to Therapy. Date Initiated: 3/31/26. -Skin assessment to be completed per Living Center Policy. Date Initiated: 3/31/26. R2's Care Plan, dated 3/31/26, states in part: . Focus: Skin Integrity Impairment due to decreased mobility, bowel incontinence, multiple pressure injuries: 3/31/26 Kennedy terminal ulcer *Note: There is no documentation indicating R2 had a Terminal Kennedy ulcer in R2's medical records. Surveyor asked the facility management to provide this. No documentation was supplied to Surveyor. Date Initiated: 3/31/26. Interventions: -Complete Braden Scale per Living Center Policy. Date Initiated: 3/31/26 -Conduct weekly skin inspection. Date Initiated: 3/31/26 -Notify practitioner if symptoms worsen or do not resolve. Date Initiated: 3/31/26. -Nutritional and Hydration support. Date Initiated: 3/31/26. -Podiatry consult. Date Initiated: 3/31/26. -Provide thorough skin care after incontinent episodes and apply barrier cream. Date Initiated: 3/31/26. -Referral to Therapy. Date Initiated: 3/31/26. -Skin assessment to be completed per Living Center Policy. Date Initiated: 3/31/26. R2's care plan was updated to include CAM Boot on left foot for foot drop. Date Initiated: 4/01/26. *Note: The care plan does not reflect when to apply the CAM Boot or take it off. There are no specific instructions regarding the CAM Boot. On 8/12/26 at 3:56 PM, Surveyor interviewed NHA A (Nursing Home Administrator), DON B (Director of Nursing), LPN C (Licensed Practical Nurse), DONT J (Director of Nursing in Training,) and RC E (Regional Consultant). Surveyor asked if the CAM Boot that R2 used was available for Surveyor to see. DON B indicated R2 admitted with the CAM Boot. Surveyor asked what the instructions were for the CAM Boot. LPN C indicated she would have to look and get back to Surveyor. Focus: I have a physical functioning deficit related to: weakness, poor activity tolerance, balance deficits, fatigue, impaired cognition, Parkinson's disease. Date Initiated: 3/31/26. Interventions: -CAM Boot on left foot for foot drop. Date Initiated: 4/01/26. -I am dependent on staff for bed mobility and require assist of 2. Date Initiated: 3/31/26. *Important to Note: R2's MDS dated [DATE] indicates a pressure relieving cushion for chair is in place; it is not implemented on the care plan or the CNA Kardex. CNA (Certified Nursing Assistant) Kardex, dated 6/18/26, shows the following: -Skin Integrity: -Heel riser when in bed. -Reposition every two hours and prn. -CAM boot on left foot for foot drop. -Bed Mobility: -I am dependent on staff for bed mobility and require assist of 2. On 4/06/26, R2 began to see a Wound Specialist for wound care. On 4/06/26, Wound Specialist Service Date note states in part: .Chief Complaint: Patient presents with wounds on his left heel; right buttock.Review of Systems: . Support Surface: Bed- Group 2, Chair- Pressure Reduction Cushion, Feet- Pillow, Non-skid sock, wears foot drop boot device. Site 1: Unstageable Deep Tissue Injury (DTI) of the Left Heel undetermined thickness. Etiology: Pressure.Unstageable DTI with intact skin. Wound Size: (L x W x D): 3 cm x 1.5 cm x Not Measurable. Skin: Intact with purple/maroon discoloration. Expanded Evaluation Performed: . Reviewed off-loading surfaces and discussed surfaces care plan. Dressing Treatment Plan: Foam with silicone border apply three times per week and as needed: if saturated, soiled, or dislodged. Site 2: Stage 2 Pressure Wound of the Right Buttock Partial Thickness. Etiology: Pressure Stage: 2. Objective: Healing/Maintain Healing. Wound Size (L x W x D): 0.5 cm x 0.5 cm x 0.1 cm. Exudate: light sero-sanguinous. Dermis: Open areas with exposed dermis. Dressing Treatment Plan: Zinc ointment 20% apply every shift (3x day) and as needed: if saturated, soiled, or dislodged. Recommendations:. Off-load wounds. *Important to note: R2 admitted to the facility with a stage 2 PI to the gluteus on 3/31/26. On 4/06/26, R2 now has a DTI to the left heel and a stage 2 PI to the right buttock. The facility did not implement new interventions for R2's facility acquired PI to the right buttock. Per Wound Specialist note, pressure reduction cushion for chair is indicated but not implemented on R2's Care Plan or CNA Kardex. R2's Physician Order, dated 4/06/26, states, in part: . Staged the Left Heel DTI (3.0 cm x 1.5 cm) and entered orders for active offloading support devices, explicitly ordering a CAM/Ankle-Foot Drop Orthotic Boot alongside pillow elevation to keep the heel floating. *Important to Note: Pillow elevation to keep the heel floating, was not implemented on R2's Care Plan or the CNA Kardex. On 4/01/26, the facility implemented on R2's Care Plan: CAM Boot on left foot for foot drop. The Care Plan or the documentation does not specify when the boot goes on or comes off. R2's documentation for April 2026 shows: CAM Boot on the left foot for foot drop every shift. The following dates are left blank: 4/01/26, (6:00AM-2:00PM) 4/02/26 (2:00PM-10:00PM), (10:00PM-6:00AM) 4/04/26 (10:00PM-6:00AM) 4/06/26 (6:00AM-2:00PM) 4/07/26 (6:00AM-2:00PM) 4/08/26 (2:00PM-10:00PM), 4/09/26 (6:00AM-2:00PM) (2:00PM-10:00PM) 4/10/26 (2:00PM-10:00PM) On 4/13/26, Wound Specialist Service Date note states, in part: . Chief Complaint: Patient has wounds on his left heel; right buttock; left thigh .Review of Systems: . Support Surface: Bed- Group 2, Chair- Pressure Reduction Cushion, Feet- Pillow, Non-skid sock, wears foot drop boot device. Site 1: Unstageable DTI of the Left Heel undetermined thickness. Etiology: Pressure.Unstageable DTI with intact skin. Objective: Healing/Maintain Healing. Wound Size (L x W x D): 3 cm x 1.5 cm x Not Measurable. Surface Area: 4.50 cm to the second power.Skin: Intact with purple/maroon discoloration. Dressing Treatment Plan: . Foam with silicone border apply three times per week and as needed: if saturated, soiled, or dislodged. Site 2: Unstageable DTI of the Right Buttock. Etiology: Pressure. Unstageable DTI within and around wound. Objective: Healing/Maintain Healing. Wound Size (L x W x D): 3.5 cm x 4.5 cm x 0.1 cm. Exudate: Moderate sero-sanguinous. Wound Progress: Not at goal due to need more time. Dressing Treatment Plan: Primary Dressing: Leptospermum honey apply three times per week and as needed: if saturated, soiled, or dislodged. Secondary Dressing: Foam with border apply three times per week and as needed: if saturated, soiled, or dislodged. Sharp Selective Debridement Procedure: . Removed dried exudate or debris. Site 3: Non-Pressure Wound of the Left Thigh. Etiology: Pressure. Further Etiology Detail: abrasion from catheter adhesive. Wound Size (L x W x D): 1 cm x 1 cm x Not Measurable. Dressing Treatment Plan: . Skin prep apply once daily and as needed. *Important to Note: In addition to the DTI to Left heel, R2's stage 2 PI to the right buttock is now an unstageable DTI and R2 has a wound to left thigh from the urinary catheter. No new interventions were implemented in R2's plan of care. R2's documentation for April 2026 shows: CAM Boot on the left foot for foot drop every shift. The following dates are left blank: 4/15/26 (2:00PM-10:00PM) and 4/16/26 (2:00PM-10:00PM) (10:00PM-6:00AM) On 8/12/26 at 3:56 PM, Surveyor interviewed NHA A, DON B, LPN C, and DONT J and asked what was the root cause for R2's PI to right buttock that worsened from a stage 2 on 4/6 to unstageable on 4/13. RC E indicated it was ultimately a Kennedy ulcer. RC E indicated once a Kennedy ulcer starts, it just continues. Surveyor asked what interventions were implemented at this time. RC E indicated R2 had a pressure-relieving mattress in place, R2 was seen by wound specialist weekly, and R2 had nutrition in place upon admission. Surveyor asked what new interventions were implemented after the PIs worsened. DON B, RC E, and LPN C were looking in computer and indicated they would get back to Surveyor. On 4/20/26, Wound Specialist Service Date note states, in part: . Chief Complaint: Patient has wounds on his left heel; right buttock; left thigh; left lateral foot; right thigh; left buttock.Review of Systems: . Support Surface: Bed- Group 1, Chair- Pressure Reduction Cushion, Feet- Pillow, Non-skid sock, wears foot drop boot device. Site 1: Unstageable DTI of the Left Heel Etiology: Pressure.Unstageable DTI within and around wound. Objective: Healing/Maintain Healing. Approach: Close monitoring, Off-Loading. Wound Size (L x W x D): 3 cm x 1.5 cm x 0.1 cm. Exudate: Moderate sero-sanguinous. Dressing Treatment Plan: . Foam with silicone border apply three times per week and as needed: if saturated, soiled, or dislodged. Sharp Selective Debridement Procedure: . Removed dried exudate or debris. Site 2: Stage 3 Pressure Wound of the Right Buttock Full Thickness. Etiology: Pressure. Stage: 3. Objective: Healing/Maintain Healing. Wound Size (L x W x D): 3.5 cm x 4.5 cm x 0.1 cm. Exudate: Moderate sero-sanguinous. Thick adherent devitalized necrotic tissue: 20%. Granulation tissue: 80% . Dressing Treatment Plan: . Leptospermum honey apply three times a week and as needed. Foam with border apply three times per week and as needed. Surgical Excisional Debridement Procedure: . Remove necrotic tissue and establish the margins of Viable Tissue. Site 3: Non-Pressure Wound of the Left Thigh Partial Thickness. Etiology: undetermined/unknown. Further Etiology Detail: abrasion/irritation from catheter adhesive.Objective: Healing/Maintain Healing. Wound Size (L x W x D): 2cm x 2 cm x 0.1 cm.Exudate: Moderate sero-sanguinous. Dressing Treatment Plan: . Skin prep apply once daily and as needed.Note: Wound has increased in size from last weekly measurement. The following wounds were new since last weekly skin assessment on 4/13/26. Site 4: Unstageable DTI of the Left Lateral Foot. Etiology: Pressure. Stage: Unstageable DTI within and around wound. Objective: Healing/Maintain Healing. Approach: Close Monitoring, Off Loading. Wound Size (L x W x D): 3 cm x 3 cm x 0.1 cm) . Exudate: Moderate sero-sanguinous. Dressing Treatment Plan: . Foam with silicone border apply three times per week and as needed. Site 5: Non- Pressure Wound of the Right Thigh. Etiology: Undetermined/unknown. Further Etiology Detail: Abrasion/irritation from catheter adhesive. Objective: Healing/Maintain Healing. Wound Size (L x W x D): 2 cm x 4 cm x Not Measurable. Exudate: none. Blister: fluid filled. Dressing Treatment Plan: . Skin prep once daily and as needed. Site 6: Unstageable DTI of the Left Buttock. Etiology: Pressure. Stage: Unstageable DTI within and around wound. Objective: Healing/Maintain Healing. Approach: Close Monitoring, Off-Loading. Wound Size (L x W x D): 3.5 cm x 4.5 cm x 0.1 cm. Exudate: Moderate sero-sanguinous. Dressing Treatment Plan: . Leptospermum honey apply three times per week and as needed. Foam with silicone border apply three times per week and as needed. General Recommendations: Off-Load Wounds. Group 2 Mattress, Pressure Off-Loading Boot. *Important to Note: R2 admitted to the facility with a stage 2 PI to left gluteus. R2 now has a DTI to the left heel, stage 3 PI to the right buttock, an unstageable DTI to the left lateral foot, an unstageable DTI of the left buttock, and non-pressure wounds to the left and right thighs from his urinary catheter. R2 now has 4 additional pressure injuries. R2's Care Plan shows the following intervention was put into place: -Low, loss air mattress. Date Initiated: 4/21/26. R2's documentation for April 2026 shows: CAM Boot on the left foot for foot drop every shift. The following dates are left blank: 4/22/26 (2:00PM-10:00PM) and 4/24/26(6:00AM-2:00PM) On 8/12/26 at 3:56 PM, Surveyor interviewed NHA A, DON B, LPN C, RC E (Regional Consultant) and DONT J and asked from 4/13/26 to 4/20/26 where R2 went from having 2 PIs to 6 PIs, what was in place and what was the root cause for R2's new PIs. DONT J indicated WS H (Wound Specialist) ordered a new treatment consisting of Medi honey and foam border and debrided the PI to right buttock. DONT J indicated the root cause for new wounds was the catheter tubing. One PI started to heal and then became dark. Root Cause was a Kennedy ulcer. Surveyor asked for documentation indicating that R2 had a Kennedy ulcer. RC E indicated they would find what Surveyor was requesting and get it to Surveyor. Surveyor asked if a wound from a medical device is considered a PI. RC E indicated it could be from edema to the skin. Surveyor asked if a blister is a type of PI. RC E indicated he is not a doctor; WS H did not call it a PI. LPN C indicated the PIs would not have progressed so quickly if it was not a Kennedy ulcer. DON B indicated R2 was changed to an air mattress. Surveyor asked what intervention was implemented on 4/13/26 when a non-pressure wound to left thigh and an unstageable DTI of right buttock developed. LPN C indicated the facility requested a trial of removing the catheter but WS H wanted R2 to see urology to decide on a trial. LPN C indicated R2's POA (Power of Attorney) did not want R2 to see a urologist. Surveyor asked LPN C if a trial of the catheter was implemented. LPN C indicated no. Surveyor asked what was implemented on 4/20/26 when an unstageable DTI to the left lateral foot, a non-pressure wound to the right thigh, and a DTI to the left buttock developed. Management stated they were looking into resident's care plan with no answer to Surveyor. Surveyor reviewed WS H's notes from 4/20/26 visit with LPN C and asked if WS H recommended a pressure off-loading boot. LPN C indicated WS H removed the CAM Boot due to thinking it may be rubbing on foot. He recommended soft boots. LPN C indicated the soft boots should have been added to the care plan. LPN C did not find it on R2's Care Plan and indicated it may be under the CNA (Certified Nursing Assistant) Tasks in the computer. LPN C indicated she will locate it and print the documentation for Surveyor. *Important to note: No documentation for soft boot was provided to Surveyor. No documentation was provided to Surveyor regarding Kennedy ulcer. No documentation was provided for interventions. On 4/27/26, Wound Specialist Service Date note states in part: .Chief Complaint: Patient has wounds on his left heel; right buttock; left thigh; left lateral foot; right thigh; left buttock; right distal thigh.Review of Systems: . Support Surface: Bed- Group 1, Chair- Pressure Reduction Cushion, Feet- Pillow, Non-skid sock, wears foot drop boot device. Site 1: Unstageable (Due to Necrosis) of the Left Heel Full Thickness. Etiology: Pressure. Stage: Unstageable Necrosis. Objective: Healing/Maintain Healing. Approach: Close Monitoring, Off-Loading. Wound Size (L x W x D): 1.5 cm x 1.2 cm x Not Measurable. Exudate: light sero-sanguinous. Thick adherent black necrotic tissue (eschar): 100% . Dressing Treatment Plan: . Leptospermum honey apply three times per week and as needed. Foam with silicone border apply three times per week and as needed. Site 2: Sage 3 Pressure Wound of the Right Buttock Full Thickness. Etiology: Pressure. Stage: 3. Objective: Healing/Maintain Healing. Approach: Close Monitoring, Off-Loading. Wound Size (L x W x D): 2 cm x 4 cm x 0.1 cm Exudate: Moderate sero-sanguinous. Thick adherent devitalized necrotic tissue: 20% . Dressing Treatment Plan: . Leptospermum honey apply three times per week and as needed. Foam with border apply three times per week and as needed. Surgical Excisional Debridement Procedure: . Remove Necrotic Tissue and Establish the Margins of Viable Tissue. Site 3: Non-Pressure Wound of the Left Thigh Partial Thickness. Etiology: Undetermined/unknown. Further Etiology Detail: abrasion/irritation from catheter adhesive. Objective: Healing/Maintain Healing. Wound Size (L x W x D): 2 cm x 1 cm x 0.1 cm). Exudate: Moderate sero-sanguinous. Dressing Treatment Plan: . Skin prep apply once daily and as needed. Site 4: Stage 3 Pressure Wound of the Left Lateral Foot Full Thickness. Etiology: Pressure. Stage: 3. Objective: Healing/Maintain Healing. Wound Size (L x W x D): 1 cm x 0.5 cm x 0.1 cm. Exudate: Light sero-sanguinous. Dressing Treatment Plan: . Leptospermum honey apply three times per week and as needed. Foam with silicone border apply three times per week and as needed. Sharp Selective Debridement Procedure: . Remove dried exudate or debris. Site 5: Non-Pressure Wound of the Right Thigh Full Thickness. Etiology: Undetermined/unknown. Further Etiology Detail: abrasion/irritation from catheter adhesive. Objective: Healing/Maintain Healing. Approach: Close monitoring. Wound Size (L x W x D): 1 cm x 1 cm x 0.1 cm. Exudate: Moderate sero-sanguinous.Dressing Treatment Plan: . Skin prep apply once daily and as needed. Site 6: Stage 3 Pressure Wound of the Left Buttock Full Thickness. Etiology: Pressure. Stage: 3. Wound Size (L x W x D): 3 cm x 3 cm x 0.1 cm. Exudate: Moderate sero-sanguinous. Dressing Treatment Plan: . Leptospermum honey apply three times per week and as needed. Foam with silicone border apply three times per week and as needed. Note: All wounds were smaller than the previous week, however, there was now a seventh wound. Site 7: Stage 2 Pressure Wound of the Right Distal Thigh Partial Thickness. Etiology: Pressure. Further Etiology Detail: abrasion/irritation from catheter adhesive. Stage: 2. Wound Size (L x W x D): 2 cm x 2 cm x 0.1 cm. Exudate: Moderate sero-sanguinous. Dressing Treatment Plan: Skin prep apply once daily and as needed. General Recommendations: Off- Load Wounds. Group 2 Mattress, Pressure Off-Loading Boot. *Important to Note: R2 admitted to the facility with a stage 2 PI to left gluteus. R2 now has an unstageable pressure wound to left heel with 100% eschar, stage 3 PI to the right buttock with 20% necrotic tissue, a stage 3 (from an unstageable) DTI to the left lateral foot, a stage 3 PI (went from an unstageable DTI to stage 3) of the left buttock, a non-pressure wound to the left thigh, and a stage 2 PI to the right distal thigh. The facility failed to implement new and timely interventions into R2's plan of care to prevent new PIs from developing and prevent current PIs from deteriorating. R2's Care Plan shows the following intervention was put into place: -Heel riser when in bed. Date Initiated: 4/27/26. R2's documentation for April 2026 shows: CAM Boot on the left foot for foot drop every shift. The following dates are left blank: 4/29/26 (6:00AM-2:00PM) and 4/30/26 (6:00AM-2:00PM) (2:00PM-10:00PM) (10:00PM-6:00AM) On 8/12/26 at 3:56 PM, Surveyor interviewed NHA A, DON B, LPN C, RC E and DONT J and asked on 4/27/26 when R2 developed a stage 2 PI to right distal thigh, what was implemented to R2's Care Plan. RC E indicated they would look and write everything up and give it to Surveyor. DONT J indicated no interventions were put into place R2 was on hospice and family did not want treatments. On 5/04/26, Wound Specialist Service Date note states in part: . Signing off on patient who remains in facility. Family requests to end all wound treatments and assessments. Care plan was updated to include: Frequent repositioning if he allows. Date Initiated: 5/05/26. -Reposition every 2 hours and PRN (as needed). Date Initiated: 5/14/26. -Per family request along with hospice directive, no further weights, active wound treatments, or formal skin assessments. Strict comfort care to be maintained. Date Initiated: 5/22/26. On 8/12/26 at 1:51 PM, Surveyor interviewed LPN F (Licensed Practical Nurse) and

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, including injuries of unknown source, are reported immediately for 1 of 16 sampled residents (R) reviewed for abuse (R14).R14 made an allegation she was emotionally and sexually abused at the facility. The facility was aware on 6/9/26 of R14's allegations and did not report to the state agency timely. This is evidenced by: The facility's policy Abuse/Neglect/Exploitation, undated, includes: VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies. within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse.R14 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (mental health condition marked by hallucinations and delusions), and bipolar disorder (severe shifts in mood).R14's BIMS (Brief Interview for Mental Status), dated 3/6/26, has a score of 14, indicating R14 is cognitively intact. On 6/2/26, R14 was admitted to the hospital. On 6/9/26, R14's hospital progress notes include; Patient reports that she refuses to go to SNF (Skilled Nursing Facility), accusing SNF of emotional, psychical, and sexual abuse. On 6/15/26 at 3:33 PM, Surveyor interviewed NHA A (Nursing Home Administrator) regarding R14's allegations of abuse. NHA A indicated that the social worker at the hospital had called the facility on 6/9/26 and informed the facility of R14's allegations of abuse. NHA A indicated all allegations of abuse should be reported to the state agency within 2 hours. NHA A indicated they had not reported R14's allegation of abuse to the state agency.

Based on interview and record review the facility did not have evidence all allegations of abuse were thoroughly investigated for 1 of 16 sampled residents (R14).R14's allegation of emotional, psychical, and sexual abuse was not thoroughly investigated. This is evidenced by:The facility's policy Abuse/Neglect/Exploitation, undated, includes: V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. R14 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (mental health condition marked by hallucinations and delusions), bipolar disorder (severe unusual shifts in mood).R14's BIMS (Brief Interview for Mental Status), dated 3/6/26, has a score of 14, indicating R14 is cognitively intact. On 6/2/26, R14 was admitted to the hospital. On 6/9/26, R14's hospital progress notes include; Patient reports that she refuses to go to SNF (Skilled Nursing Facility), accusing SNF of emotional, psychical, and sexual abuse. On 6/16/26, NHA A (Nursing Home Administrator) provided a typed document, dated 6/9/26, that states: R14 told the social worker at [Hospital Name] that she was harmed at [Facility Name]. Social worker, [Name] called to discuss patients status and to let me know that she had made some accusations and that they had reported it to [Name] County APS (Adult Protective Services). Social worker stated that APS would be investigating.On 6/15/26 at 3:33 PM, Surveyor interviewed NHA A (Nursing Home Administrator) regarding R14's allegation of abuse. NHA A indicated that the social worker at the hospital had called the facility on 6/9/26 and informed the facility of R14's allegations of abuse. NHA A stated she did not reach out to or speak to R14 about the allegations of abuse. NHA A indicated the facility was unaware of the type of abuse allegation R14 made and therefore, they were unable to investigate the allegations of abuse. NHA A indicated adult protective services was going to investigate R14's allegation of abuse. Surveyor requested the investigation documentation for R14's allegations of abuse from NHA A. NHA A was unable to provide a completed and thorough investigation into R14's allegations of abuse.

Based on interview and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 (R3) of 3 residents reviewed for falls out of a sample of 16.R3 had four falls within a month's time. R3 has frequent falls. The facility has not completed root cause analysis for three of the falls to implement appropriate fall interventions.Evidenced by:The facility policy entitled Accidents and Supervision- [NAME] Edge Nursing and Rehab, dated 1/2026, states, in part: . Policy: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1) Identifying hazard(s) and risk(s). 2) Evaluating and analyzing hazard(s) and risk(s). 3) Implementing interventions to reduce hazard(s) and risk(s). 4) Monitoring for effectiveness and modifying interventions when necessary.Policy Explanation and Compliance Guidelines: The facility shall establish and utilize a systemic approach to address resident risk and environmental hazards to minimize the likelihood of accidents.1. Identification of Hazards and Risks- the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident.b. The facility should make a reasonable effort to identify the hazards and risk factors for each resident.3. Implementation of Interventions- using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: .f. Interventions are based on the results of the evaluation and analysis of information about hazards and risks and are consistent with relevant standards, including evidence-based practice. R3 was admitted to the facility on [DATE] and has diagnoses that include dementia, anxiety, unsteadiness on feet, and unspecified fall.R3's Quarterly Minimum Data Set (MDS) Assessment, dated 3/5/26, shows that R3 has a Brief Interview of Mental Status Score (BIMS) of 6 indicating R3 has severe cognitive impairment.R3's Care Plan, dated 9/13/25, states, in part: . Focus: I am at risk for falls related to dizziness. Fell in the past 31-180 days, use of medication. Repeated fall risk- 7 falls since 3/2026 r/t (related to): cognitive impairment/unaware of safety. Date Initiated: 9/17/25.Goal: I will not have a serious injury requiring hospitalization as a result of a fall. Date Initiated: 9/17/2025. Revision on: 6/16/2026. Target Date: 9/08/2026.Focus: I have a physical functioning deficit related to: Self-care impairment, decrease cognition, weakness. Date Initiated: 9/17.2025.I transfer independently- I sometimes use my walker when I remember. Date initiated: 9/17/2025 Revision on: 6/16/2026.Locomotion: Independent ambulation using walker. Sometimes I need reminders to use my walker. Date Initiated: 9/17/2025. R3's Fall Report 3/26/25: Date: 3/26/26 7:30AM.Incident Description: . Resident was found on floor with head and back resting on 2 pillows. Resident says they slowly lowered herself to the ground because she was tired.Immediate Action Taken: Resident had vital signs taken immediately and then a ROM (Range of Motion) assessment, skin assessment and pain assessment were done. Resident stated no pain, had ROM [SIC] and skin assessment was [SIC]. Vitals were [SIC] except the BP (Blood Pressure) being slightly elevated. Noted that her bed was not locked. Dr notified. Updated POAHC (Power of Attorney for Health Care) and DON (Director of Nursing). Staff educated to make sure beds are locked.IDT (interdisciplinary team) Weekly Fall, dated 3/26/26: Date: 3/26/26 Time: 7:30AM Location of fall: Her Room.Root/cause Analysis/cause of fall: Resident found on floor with head and back resting on two pillows. Noted bed was not locked. She stated she lowered herself to the floor.Note: The report does not indicate what R3 was trying to do when she lowered herself to floor. Therefore, the intervention that would be implemented would not be specific to fall. R3's Fall Report 4/7/26: Date: 4/7/26 2:00PM Incident Location: Resident's Room.Incident Description: R3 was found lying on the floor of her room. She said she was walking and fell. She was supported off the floor by staff. No obvious injuries. Staff continues to monitor.Immediate Action Taken: R3 was supported off the floor by staff. No obvious injuries. Staff continue to observe for delayed injuries. Supervisor informed. NP (Nurse Practitioner) informed and requested monitoring as per protocol and to update with any changes in mental or physical status. Vital signs and neuro observations WNL (within normal limits). Phone call to son and message left. Must wear grippy socks at all times. IDT Weekly Fall, dated 4/7/26. Time: 1:00PM. Location of fall: Her room. Root/Cause Analysis/Cause of Fall: Found lying on the floor. Ambulating by herself, dementia- unaware of safety.Note: The root/cause has not been identified. The facility did not identify what R3 was trying to do when she fell. R3's Fall Report 4/28/2026: Date: 4/28/2026 10:50AM. Incident Location: Resident's Room.Incident Description: Patient found sitting on the floor in her room. Unable to tell nurse what happened. Questioning if she had self-transferred from bed and lost balance. Noted to have her grippy socks on. Patient doesn't remember how she ended up on the floor. I didn't get hurt.Immediate Action Taken: RN (Registered Nurse) assessed. VSS (Vital Signs Stable). Neuro checks WNL. Full ROM to upper and lower extremities. No injuries noted. No non-verbal s/sx (signs and symptoms) of pain. Dr. notified. Updated son. Risks and Benefits completed. Medication review per pharmacy consult.IDT Weekly Fall dated 4/28/26: .Time :10:50AM. Location of Fall: Her room.Root Cause Analysis/Cause of Fall: Resident found sitting on floor in her room. Self-transferring and lost balance. On 6/16/26 at 11:00 AM, Surveyor interviewed DON B (Director of Nursing) regarding R3's falls. Surveyor asked DON B what the root/cause was for R3's fall on 3/26/26. DON B indicated she was unsure. DON B indicated maybe R3 was getting up to go to the bathroom or breakfast. DON B indicated R3 was unable to give an answer due to dementia. Surveyor asked DON B if the root/cause should be identified with each fall regardless of if the resident is cognitively impaired or not to be able to implement an appropriate intervention. DON B indicated yes, the facility tries to but R3 is a frequent faller. Surveyor asked DON B what the root/cause was for R3's fall on 4/7/26. DON B indicated unknown. DON B indicated R3 was unable to answer what she was doing at the time of the fall. Surveyor asked DON B what the root/cause was for R3's fall on4/28/26. DON B indicated R3 was unable to tell staff what she was doing. She was self-transferring. Surveyor asked DON B how R3 ambulates and transfers. DON B indicated independently. Surveyor asked DON B how the facility would know what intervention to implement without knowing the root/cause of falls. DON B indicated she sees what Surveyor is saying and understands.

Based on interview and record review, the facility did not ensure that each resident who was a trauma survivor received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for experiences and preferences in order to eliminate or mitigate triggers that may care re-traumatization for 1 of 1 residents reviewed (R9) for PTSD (Post-Traumatic Stress Disorder).R9's Psychosocial Assessment and Trauma Informed Care Assessment indicated R9 has a history of childhood physical abuse by father while growing up. The facility did not implement a Trauma Informed Care Plan for R9. Evidenced by:The facility policy entitled Trauma Informed Care- [NAME] Edge Nursing and Rehab, dated 1/2026, states, in part: . Policy: It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization.Policy Explanation and Compliance Guidelines: .4. The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals (such as psychologists and mental health professionals) to develop and implement individualized care plan interventions.6. The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident, and will be added to the resident's care plan.7. Trauma-specific care plan interventions will recognize the interrelation between trauma and symptoms of trauma. R9 was admitted to the facility on [DATE] and has diagnoses that include schizophrenia (a complex, chronic brain disorder that impairs a person's ability to interpret reality).R9's Quarterly Minimum Data Set (MDS) Assessment, dated 6/4/26 shows that R9 has a Brief Interview of Mental Status (BIMS) score of 12 indicating R9 has moderate cognitive impairment. R9's Psychosocial Assessment, dated 3/23/26, states, in part: . Abuse Assessment:In the past year has the patient been hit, kicked, or physically hurt by another person? Was hit 4 times, shoulder and head by his roommate. Argued over who to listen to on tv for music.Has the patient ever been abused? Yes. [name] his father, physically abused him while growing up.Developmental History: .Describe any traumatic experiences in the childhood: Father cursed him. R9's Trauma Informed Care Assessment, dated 6/15/26, states, in part: . Score: 1.Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic.1. Have you ever experienced this kind of event? Yes. R9's Care Plan does not include a trauma informed care plan. On 6/16/26 at 12:40PM, Surveyor interviewed SW E (Social Worker) and asked the process for care planning for a resident with a traumatic event in their past. SW E indicated on admission a Trauma Informed Care Assessment is completed. If answer yes to the question a care plan for trauma informed care is implemented. Surveyor showed SW E R9's Psychosocial assessment dated [DATE] regarding abuse assessment and R9's Trauma Informed Care Assessment, dated 6/15/26. Surveyor asked SW E if she would expect a Trauma Informed Care Plan to be in place for R9. SW E indicated yes. Surveyor asked SW E if there is a Trauma Informed Care Plan in place for R9. SW E reviewed R9's Care Plan and indicated no, she does not see one. SW E indicated there should be and she must have missed it for R9. On 6/16/26 at 3:00PM, Surveyor asked NHA A (Nursing Home Administrator) if she would expect a trauma informed care plan to be in place for R9 if a psychosocial assessment showed R9 had a childhood history of physical abuse. NHA A indicated yes. Surveyor informed NHA A of R9's Psychosocial Assessment and Trauma Informed Care Assessment indicating R9 had a history of childhood physical abuse by father growing up and R9 does not have a Trauma Informed Care Plan in place. NHA A indicated she would expect R9 to be care planned for trauma.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 2 of 8 residents (R3 & R4) reviewed for abuse involved in1 of 4 self-reports. The facility did not contact law enforcement on a resident-to-resident altercation regarding R3 and R4 on 12/23/25. Evidenced by:The facility policy entitled Abuse/Neglect/Exploitation, dated 11/2017, states, in part: . Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. VII. Reporting/ResponseThe facility will have written procedures that include: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: . R4 admitted to the facility 11/21/25 and has diagnoses that include dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbances. R4's MDS (Minimum Data Set) admission Assessment, dated 11/25/25 shows R4 has a Brief Interview of Mental Status score of 00, indicating R4 has severe cognitive impairment. R3 admitted to the facility 2/20/25 and has diagnoses that include dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. R3's MDS (Minimum Data Set) Quarterly Assessment, dated11/26/25 shows R3 has a Brief Interview of Mental Status score of 10 indicating R3 has moderate cognitive impairment. The facility's Misconduct Incident Report, submitted 12/30/25 3:11 PM, states, in part: .Briefly Describe the Incident. R4 was walking to the dining room. R3 was sitting in the lobby and R4 came up and slapped her in the face. Staff witnessed from around the corner and came immediately and removed R4 from the lobby. Nursing came immediately and assessed R3. No injuries. R4 was taken to her room and regular checks were implemented. Both residents have dementia. We are not sure if R3 said anything to R4 prior to the incident. Other residents interviewed regarding their [sic] feeling safe. No residents witnessed the incident.Affected Person Information: R3.Accused Person: R4.Law Enforcement Involvement:Was law enforcement contacted or involved? NoPerson Preparing This Report: NHA A (Nursing Home Administrator) .Report Submitted Date: 12/30/25 3:11:33PM On 1/21/26, at 09:30AM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked when law enforcement should be notified. NHA A indicated with every facility self-report. Surveyor asked NHA A if law enforcement was notified regarding R4 and R3's incident in December. NHA A indicated no, and it should have been. NHA A indicated it must have been forgotten.

Based on interview, and record review, the facility did not ensure residents are free of significant medication errors for 1 of 8 sampled residents (R5). R5 has an order for Metoprolol Succinate (medication that slows the heart rate and force of contraction of the heart which decreases blood pressure) 150 MG (milligrams) to be administered one time a day by mouth and to hold this medication for a systolic blood pressure (blood pressure when the heart contracts) below 110 and a heart rate less than 55 beats per minute. This medication was administered 14 times in December 2025 and 6 times from 1/1/26 through the survey date with a systolic blood pressure less than 110. As evidenced by The facility policy entitled, Medication Errors, undated, states, in part: . Definitions: Medication error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professionals providing services. Significant medication error means one which causes the resident discomfort or jeopardizes his/her health and safety. Policy Explanation and Compliance Guidelines: 1. The facility shall ensure medications will be administered as follows: a. according to physician's orders. 3. Medication errors, once identified, will be evaluated to determine if considered significant or not by utilizing the following three general guidelines. c. Frequency of Error: If an error is occurring repeatedly such as an omission of a resident's medication several times. 8. If a medication error occurs, the following procedure will be initiated: a. The nurse assesses and examines the resident's condition and notifies the physician or health care practitioner as soon as possible. b. Monitor and document the resident's condition, including response to medical treatment or nursing interventions. c. Document actions taken in the medical record. d. Once the resident is stable, the nurse reports the incident to the appropriate supervisor and completes the incident or occurrence report. R5 was admitted to the facility on [DATE] with diagnoses including: secondary parkinsonism (movement disorder that mimics Parkinson's disease such as tremors, stiffness, and slowed movements, but has different underlying causes such as medications or brain injuries), chronic obstructive pulmonary disease (progressive lung disease resulting in damage to the lung tissue that leads to difficulty breathing), type 2 diabetes mellitus without complications, acute on chronic systolic (congestive) heart failure (chronic condition where the heart is unable to pump enough blood to meet the body's needs for blood and oxygen), essential (primary) hypertension (high blood pressure), atrial fibrillation (irregular heart rhythm), and presence of coronary angioplasty implant and graph (stent placed in arteries that provide the heart muscle with oxygenated blood). R5's most recent Brief Interview for Mental Status (BIMS), conducted by an outside Psychiatric Nurse Practitioner, indicates R5 has a BIMS score of 15 out of 15, indicating he is cognitively intact. R5's Physician Orders indicate, in part:Metoprolol Succinate ER (Extended Release) Oral Tablet Extended Release 24 Hour. Give 150 MG by mouth one time a day related to Essential (Primary) Hypertension. Hold for SBP (Systolic Blood Pressure) below 110 and HR (Heart Rate) below 55. This medication is scheduled to be administered at 8:00 AM daily and has a start date of 9/9/25. R5's Medication Administration Record (MAR) indicates that staff administered Metoprolol Succinate with a systolic blood pressure under 110 on the following dates: 12/8/25: Administered with a blood pressure of 91/4512/9/25: Administered with a blood pressure of 103/5812/10/25: Administered with a blood pressure of 105/6112/16/25: Administered with a blood pressure of 109/7212/17/25: Administered with a blood pressure of 107/6812/18/25: Administered with a blood pressure of 101/7612/19/25: Administered with a blood pressure of 102/6812/20/25: Administered with a blood pressure of 98/6212/21/25: Administered with a blood pressure of 102/5412/22/25: Administered with a blood pressure of 99/5912/23/25: Administered with a blood pressure of 104/6212/26/25: Administered with a blood pressure of 98/5612/28/25: Administered with a blood pressure of 100/4712/30/25: Administered with a blood pressure of 98/62 1/3/26: Administered with a blood pressure of 108/551/4/26: Administered with a blood pressure of 108/521/5/26: Administered with a blood pressure of 108/661/9/26: Administered with a blood pressure of 88/581/16/26: Administered with a blood pressure of 102/641/20/26: Administered with a blood pressure of 106/67 This resulted in 20 significant medication errors from 12/1/25 through 1/20/26. On 1/21/26 at 10:07 AM, Surveyor interviewed MT (Medication Tech) D. Surveyor asked MT D how long she has been working at the facility. MT D indicates, 3 months. Surveyor asked MT D which halls she normally works. MT D indicates she usually does not work on R5's hall. Surveyor asked MT D how she knows which orders have vital sign parameters. MT D indicates the MAR (Medication Administration Record) has the vital sign parameters in the order. Surveyor asked MT D if the MAR will give a warning if the entered vital signs are outside the orders parameters. MT D states, yes. Surveyor asked MT D if a medication should be held if the entered vital signs are outside of the orders parameters. MT D states, yes. Surveyor asked MT D what happens when a medication is held. MT D indicates she notifies the charge nurse and puts in a progress note. Surveyor asked MT D what happens if the medication is administered despite the blood pressure being outside of the ordered parameters. MT D indicates staff need to report it right away to the charge nurse and a physician needs to be notified. Surveyor asked MT D what monitoring should be conducted in this scenario. MT D indicates the blood pressure needs to be monitored every half hour or per facility protocol. On 1/21/26 at 10:18 AM, Surveyor interviewed RN (Registered Nurse) E. Surveyor asked RN E how long she has been working at the facility. RN E indicates a few months. RN E also indicates she is now full-time with the facility but used to be agency staff. Surveyor asked RN E which halls she normally works. RN E indicates she usually works on R5's hall. Surveyor asked RN E how she knows which orders have vital sign parameters. RN E indicates since she works with the same residents frequently, she does have quite a few memorized but also showed Surveyor a document she keeps with resident vital signs. RN E also indicates the vital sign parameters are also listed in the medication orders in the MAR. The document presented to Surveyor appears to have multiple vital signs for many residents. RN E indicates she was previously employed in acute care and prefers to monitor residents more frequently than ordered, especially if she has any concerns. Surveyor asked RN E if the MAR will give a warning if the entered vital signs are outside the orders parameters. RN E indicates, she believes so, however she puts the medication on hold and will make separate notes regarding the vital sign readings and why the medication was held so she is not positive. RN E demonstrated on her computer how the system requires vital signs to be entered for R5 prior to signing off the medication in the MAR. Surveyor asked RN E if a medication should be held if the blood pressure is outside of the listed parameters. RN E states yes. Surveyor asked RN E what happens when a medication is held. RN E indicates the medication is not given, and my process is to reapproach, especially if the resident has just woken up, and recheck the blood pressure to ensure it is within parameters. Surveyor asked RN E what happens if the medication is administered despite the blood pressure being outside of the ordered parameters. RN E indicates a doctor needs to be called and the resident needs to be monitored. Surveyor asked RN E what monitoring should be conducted in this scenario. RN E indicates the resident's blood pressure should be monitored at least every 15 minutes along with a full assessment. Blood pressure monitoring should continue every hour, to monitor for peak effective of the medication. Additionally, if the resident needs to be sent to the emergency room a follow up needs to be completed upon the resident's return. Surveyor asked RN E how a physician should be notified. RN E indicates she calls and sends a fax to ensure multiple forms of communication are being sent. RN E also indicates in an emergency situation she would also call emergency services to ensure the resident receives the appropriate level of care in a timely manner. On 1/21/26 at 12:03 PM, Surveyor interviewed NHA (Nursing Home Administrator) A and DON (Director of Nursing) B. Surveyor asked NHA A and DON B how staff know which orders have vital sign parameters. DON B indicates it is written on the MAR and the order will say if less than or over than notify the physician. Surveyor asked NHA A and DON B how vital signs are put into the electronic medical record. NHA A and DON B indicate the vital signs get charted directly into the MAR. When staff sign-off that the medication was given, a pop-up will appear the requires staff to put in the required vital signs before completing the sign-off. Surveyor asked NHA A and DON B if the MAR alerts staff if the vital signs are outside the order's parameters. NHA A and DON B indicate they don't believe the MAR provides a warning. Surveyor asked NHA A and DON B if a medication should be held if the resident's blood pressure is outside the ordered vital sign parameters. NHA A and DON B state yes, and that the doctor should be notified. Surveyor asked NHA A and DON B if staff are expected to write a progress note when a medication is held. DON B states yes. Surveyor asked NHA A and DON B what happens if the medication is administered despite the blood pressure being outside the ordered vital sign parameters. DON B indicates staff need to notify a physician for orders and monitoring the resident. Surveyor asked NHA A and DON B what monitoring should be conducted in this scenario. DON B indicates the blood pressure should be monitored. Surveyor notes R5 has been administered his ordered Metoprolol Succinate with a blood pressure below the ordered parameter 14 times in December and 6 times from 1/1/26 through the survey date. Surveyor asked if R5's Metoprolol Succinate should have been held. NHA A and DON B state, yes. Surveyor asked NHA A and DON B if they would consider these instances medication errors. NHA A and DON B state, yes. DON B also indicates staff should also be reporting these instances to her when they occur. Surveyor asked NHA A and DON B if a physician have been notified when these instances have occurred. NHA and DON B state, yes. Surveyor asked NHA A and DON B if R5's blood pressure should have been monitored following these instances. NHA A and DON B state, yes.

Based on interview and record review the facility did not provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 1 resident (R3).Facility did not follow up on psycho-social needs with R3 after a resident-to-resident altercation involving R3 being slapped by another resident (R4).Evidenced by:The facility's policy Abuse/Neglect/Exploitation, dated 11/2017, states, in part: . Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Protection of Resident:The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: .F. Providing emotional support and counseling to the resident during and after the investigation. The facility's policy Social Services Director, dated 2023, states, in part: . Required Qualifications: All facilities must provide medically related social services to residents.Major Duties and Responsibilities: The Social Services Director is responsible for overseeing the development, implementation, supervision and ongoing evaluation of the Social Services Department designed to meet and assist residents in attaining or maintaining their highest practicable well-being. This includes identifying the need for medically related social services and ensuring that these services are provided in accordance with State and Federal regulations.The Social Services Director will coordinate implementation and oversight of procedures to ensure social services actions and interactions are adequately documented in each resident's medical record, and that legal, ethical, and professional standards of social work practice and being upheld in written recordings The Social Services Director will participate in facility policy development in order to positively impact the quality care delivered to residents. The facility's Misconduct Incident Report, submitted 12/30/25 3:11 PM, states, in part: . Briefly Describe the Incident. R4 was walking to the dining room. R3 was sitting in the lobby and R4 came up and slapped her in the face. Staff witnessed from around the corner and came immediately and removed R4 from the lobby. Nursing came immediately and assessed R3. No injuries. R4 was taken to her room and regular checks were implemented. Both residents have dementia. We are not sure if R3 said anything to R4 prior to the incident. Other residents interviewed regarding their feeling safe. No residents witnessed the incident.Describe the Effect that the incident had on the affected person.R3 was concerned that she had done something wrong. Staff reassured her that she had not, and she was safe. She brought the incident up for a few hours after the incident but has forgotten about it. No other residents witnessed the incident. Affected Person Information: R3.Accused Person: R4. Law Enforcement Involvement:Was law enforcement contacted or involved? NoPerson Preparing This Report: NHA A (Nursing Home Administrator) .Report Submitted Date: 12/30/25 3:11:33PM R3 admitted to the facility 2/20/25 and has diagnoses that include dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. R3's MDS (Minimum Data Set) Quarterly Assessment, dated11/26/25 shows R3 has a Brief Interview of Mental Status score of 10 indicating R3 has moderate cognitive impairment. R3's Progress Note dated 12/23/25 at 12:11PM, states, in part: . R3 involved in an altercation with another resident.she got slapped by another resident. I did an assessment and R3 ok physically but is shaken up. Of note: there is no follow up documentation with R3's psycho-social needs related to the resident-to-resident altercation. On 1/21/26 at 9:10 AM, Surveyor interviewed SW C (Social Worker) and asked if she was aware of the resident-to-resident altercation involving R3 and R4 on 12/23/25. SW C indicated she had heard about it but was not directly involved with the incident. Surveyor asked SW C what her role is regarding resident-to resident altercations as far as psychosocial follow up. SW C indicated she had not been informed. SW C indicated she is not sure what her role would be. Surveyor went over briefly the incident with SW C involving R3 and R4 and the documentation indicating R3 was concerned she had done something to cause the altercation and the progress note stating R3 was shaken up regarding the altercation. Surveyor asked SW C if she would expect follow up with R3 regarding psycho-social needs. SW C indicated yes, she would check in on her if she had known that. Surveyor asked SW C if she had checked in with R3. SW C indicated she talked with R3 every day after hearing about the incident. Surveyor asked what SW C spoke with R3 about and SW C indicated she had told R3 she heard about the incident. SW C indicated R3 had indicated she was shocked when it happened. Surveyor asked if she addressed psycho-social needs with R3. SW C indicated it was just general conversation. Surveyor asked if SW C had any documentation showing any follow up conversations with R3 and SW C indicated no. SW C indicated she normally would have documentation; SW C indicated she must have forgotten to document. On 1/21/26 at 09:15 AM, Surveyor interviewed DON B (Director of Nursing) and asked if she is familiar with the resident-to-resident altercation involving R3 and R4 on 12/23/25. DON B indicated yes. Surveyor went over briefly the incident with DON B involving R3 and R4 and the documentation indicating R3 was concerned she had done something to cause the altercation and the progress note stating R3 was shaking up regarding the altercation. Surveyor asked DON B if she would expect a psychosocial follow up with R3. DON B indicated yes. DON B indicated she remembers talking with R3 the next day, but DON B does not remember documenting the conversation. DON B indicated the facility should have followed up with R3 on her psychosocial needs following the incident and have it documented. On 1/21/26 at 9:30 AM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor went over briefly with NHA A the resident-to-resident altercation involving R3 and R4 on 12/23/25 and the documentation indicating R3 was concerned she had done something to cause the altercation and the progress note stating R3 was shaking up regarding the altercation. Surveyor asked NHA A if she would expect a psychosocial follow up with R3. NHA A indicated yes. Surveyor asked NHA A what the social workers role would be in this incident. NHA A indicated SW C would need to follow up on the psychosocial needs on a regular basis with R3 and changes in R3 and R4's behaviors following the incident. NHA A indicated she would expect SW C to document the follow up in R3's medical record.

Based on interview and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 (R2) of 8 sampled residents. R2 was at risk for falls and had three falls while residing at the facility. R2 had a care planned intervention to remain in line of sight while up in her broda chair (wheelchair that tilt and reclines). R2 experienced a fall from her broda chair while not in line of sight of staff. Neurological checks following the fall were not completed. This is evidenced by: The facility policy entitled, Fall Management Process, dated 2011, states, in part: 1. In the event a resident has fallen and/or is found on the ground, a complete head-to-toe assessment must be performed prior to moving the resident unless life-threatening safety concerns are present. 8. Obtain neurological check (neuro-checks) per policy for any unwitnessed fall or any fall with evidence of injury to head. 12. Contact physician and family and document in the medical record, including time and person spoken with. R2 was admitted to the facility on [DATE] with diagnoses including inflammatory spondylopathy, lumbar region (inflammation of the spine and associated structures in the lower back commonly causing pain and stiffness), chronic obstructive pulmonary disease (progressive lung disease resulting in damage to the lung tissue that leads to difficulty breathing), acute on chronic systolic (congestive) heart failure (chronic condition where the heart is unable to pump enough blood to meet the body's needs for blood and oxygen), type 2 diabetes mellitus with diabetic polyneuropathy (nerve damage caused by diabetes), unspecified symptoms and signs involving cognitive functions following cerebral infarction (stroke), muscle wasting and atrophy (reduction in size of muscle), unsteadiness on feet, and combined forms of age-related cataract (lens of eye becomes cloudy due to advanced age commonly causing blurred vision and difficulty seeing) right eye and left eye. R2's Minimum Data Set (MDS) with an Assessment Reference Date of 10/6/25, indicates R2 has a Brief Interview of Mental Status (BIMS) score of 99 indicating severe cognitive impairment. On 9/19/25, R2's Fall Risk Evaluation was conducted with a score of 10, indicating R2 is at risk for falls. On 9/19/25, R2's Comprehensive Care Plan was updated to include the focus: I am at risk for falls related to: use of medication, episodes of dizziness, cognitive impairment and unaware of safety with interventions including: assess me for pain, assess that I have a broda chair that is of appropriate size, clear and monitor environmental obstacles (tubing, cords, etc.), do not leave unattended in bathroom, elevate HOB (head of bed) before getting OOB (out of bed), encourage fluids, encourage me to participate in activities to improve strength or balance, encourage rest periods if feeling fatigued, I need to wear appropriate footwear to prevent slipping, involve me in activity programming - exercise, TV programs, make sure my bed is in a low position when I'm in it, make sure my call light and personal items are available in easy reach or provide reacher, monitor me for restlessness and implement interventions, monitor use of over bed table and discourage its use as a mobilty aide, observe me for side effects of medications, and use a gait belt with transfers. On 9/23/25, R2's Comprehensive Care Plan was updated to include the intervention: Falling Star-check q (every) 60 minutes. On 9/25/25, R2 experienced an unwitnessed fall in which she was found sitting on the floor in the doorway to her room. R2 was unable to state what happened. No injury was reported. On 9/26/25, R2's Comprehensive Care Plan was updated to include the intervention: I need to be with in eyesight when I'm up in my broda chair. On 9/28/25, R2's Fall Risk Evaluation was conducted with a score of 19, indicating R2 is at risk for falls. On 9/28/25, R2's Comprehensive Care Plan was updated to include the focus: Risk for Falls with interventions including: assist resident with ambulant and transfers utilizing therapy recommendations, determine resident's ability to transfer, evaluate fall risk on admission and PRN (as needed), If a fall occurs, alert provider, If a fall occurs, initiate frequent neuro (neurological) and bleeding evaluation per facility protocol, If resident is a fall risk, initiate fall risk precautions. On 11/1/25, R2's Fall Risk Evaluation was conducted with a score of 15, indicating R2 is at risk for falls. On 11/2/25, a Hospice Note is written by a registered nurse that indicates the time of the visit to be from 5:20 PM to 7:20 PM. This note indicates an assessment was conducted with findings including an irregular respiratory pattern with intermittent episodes of apnea followed by quick, labored, deep breathing and small period of shallow breathing at a regular rate. The assessment also notes the presence of abdominal pain. Neurologic findings include: R2 is alert, did not speak for the first half of the visit but would nod head to some questions and provide simple answers such as yes or no. The section titled, Encounter Notes includes recommendations of pain and anxiety management along with the monitoring of continued decline. On 11/1/25 at 9:15 PM, R2 experienced an unwitnessed fall. A Progress Note, written 11/1/25 at 22:17 (10:17 PM), indicates R2 was walking unsupervised in her room at the time of the fall. A document titled IDT Weekly Fall indicates R2 fell in her room while attempting to self-transfer from bed. On 11/2/25 at 11:01 PM, R2 experienced an unwitnessed fall from her wheelchair in the hallway. A statement written by a CNA indicates R2 was on the other side of the nurses' station while CNA and another staff member were gathering their paperwork for the night. It also states, in part: . I looked to see where she was less than 5 minutes from the last time I saw her. I saw that she wasn't by the med cart. I stood up from my chair at the nurses station and her w/c (wheelchair) was down 100 hall and she wasn't in her w/c (wheelchair). I saw her laying on her right side in front of room [number] on the floor . (Of note: R2's care plan included the intervention that R2 must remain in eyesight while in her Broda chair at the time of the fall) On 11/2/25 at 23:00 (11:00 PM), R2's Neurological Assessment indicates she is fully conscious, has movement in all four extremities, has equal and strong hand grasp in both hands, pupil size is 2 mm in both eyes, has brisk pupil reaction in both eyes, and has clear speech. On 11/2/25 at 23:15 (11:15 PM), R2's Neurological Assessment indicates she is fully conscious, has movement in all four extremities, has equal and strong hand grasp in both hands, pupil size is 2 mm in both eyes, has brisk pupil reaction in both eyes, and has clear speech. On 11/2/25 at 23:30 (11:30 PM), R2's Neurological Assessment indicates she is fully conscious, has movement in all four extremities, has equal and strong hand grasp in both hands, pupil size is 2 mm in both eyes, has brisk pupil reaction in both eyes, and has clear speech. On 11/2/25 at 23:45 (11:45 PM), R2's Neurological Assessment indicates she is fully conscious, has movement in all four extremities, has equal and strong hand grasp in both hands, pupil size is 2 mm in both eyes, has brisk pupil reaction in both eyes, and has clear speech. On 11/2/25 at 23:55 (11:55 PM) a Progress Note is written that indicates R2 sustained a fall with a subsequent physical assessment that notes the presence of pain. Under the section titled, Recommendations it states, Hospice was here and no new orders. Awaiting response from [Physician Name]. Under the section titled, New Intervention Orders, it indicates increase oral fluids and provide oxygen (if available). On 11/2/25 at 23:58 (11:58 PM) a Progress Note is written that indicates R2 was found on the floor and was assessed by a registered nurse. R2 initially denied pain. A hematoma (bruise) was identified on R2's forehead measuring 6.5 x 5 with no indication of unit of measurement. R2's family and hospice provider were notified. The note indicates DON (Director of Nursing) B and the physician were notified . On 11/3/25 at 00:15 (12:15 AM), R2's Neurological Assessment indicates she is asleep for all categories of assessment. On 11/3/25 at 00:25 (12:25 AM), a Progress Note is written that indicates a registered nurse from R2's hospice agency will arrive at the facility in 1.5 to 2 hours to assess R2. On 11/3/25 at 00:34 (12:34 AM), a Progress Note is written that indicates a cold pack (ice pack) was applied to R2's forehead to relieve the swelling. On 11/3/25 at 00:45 (12:45 AM), a Progress Note is written that indicates the hospice agency registered nurse arrived to assess R2.(Of note: Surveyor requested the note from this assessment, however the facility was unable to provide one). On 11/3/25 at 00:45 (12:45 AM), R2's Neurological Assessment indicates she is asleep for all categories of assessment. On 11/3/25 at 01:36 (1:36 AM), a Progress Note is written indicating R2 was given 15 MG (milligrams) of Morphine Sulfate (opioid pain medication) for pain which was effective. A second Progress Note written at the same time and date indicates R2 also received 0.5 MG of lorazepam (anti-anxiety medication).(of note: R2 was noted to receive medication at 1:36 AM, no neurological assessment was completOn 11/3/25 at 01:45, R2's Neurological Assessment indicates she is asleep for all categories of assessment.On 11/3/25 at 02:34 (2:35 AM), a Progress Note is written indicating R2 self-transferred and walked to the bathroom and R2's roommate reported to facility staff that R2 was in the bathroom. Hospice registered nurse to room to further assess R2. On 11/3/25 at 02:45 (2:45 AM), R2's Neurological Assessment indicates she is asleep for all categories of assessment.(of note: R2 was indicated as being awake at 2:35 AM and no neurological assessment was completed)On 11/3/25 at 03:00 (3:00 AM), a Fall Risk Evaluation is completed indicating a score of 11, indicating R2 is at risk for falls. On 11/3/25 at 03:45 (3:45 AM), R2's Neurological Assessment indicates she is asleep for all categories of assessment. On 11/3/25 at 04:45 (4:45 AM), R2's Neurological Assessment indicates she is asleep for all categories of assessment. On 11/3/25 at 04:56 (4:56 AM), a Progress Note is written that states, in part: . Fall was not witnessed. Fall occurred in the hallway. A statement dated both 11/2/25 and 11/5/25, was written by CNA (Certified Nursing Assistant) I, and states, in part: I was at the nurses station with my co-worker for the night shift gathering our proper paperwork I would need for the night. The resident [Resident Initials] was directly on the other side of the nurses station near the med (medication) cart within my line of view. I looked to see where she was less than 5 minutes from the last time I saw her. I saw that she wasn't by the med cart. I stood up from my chair at the nurses station and her wheelchair was down the hall and she wasn't in her wheelchair. I saw her laying on her right side in front of room (number) on the floor. On 1/21/26 at 10:07 AM, Surveyor interviewed MT (Medication Tech) D. Surveyor asked MT D how long she has worked at the facility. MT D indicates 3 months. Surveyor asked MT D how she knows which residents have fall precautions. MT D indicates they have the falling star picture on their door, the interventions are in the chart on the care plan and on the closet door. Surveyor asked MT D what in line of sight means in terms of fall interventions. MT D indicates staff need to be able to physically see the resident. On 1/21/26 at 10:18 AM, Surveyor interviewed RN (Registered Nurse) E. Surveyor asked RN E how long she has been working at the facility. RN E indicates a few months and that she used to be agency staff but now works full-time for the facility. Surveyor asked RN E how staff know which residents have fall interventions or precautions. RN E indicates these residents have star pictures on their doors, the interventions are listed inside the closet doors, and on the care plan. Surveyor asked RN E what in line of sight means in terms of fall interventions. RN E indicates the resident must be able to be physically seen by staff. Surveyor asked RN E if it is acceptable to mark asleep or sleeping for neurological assessments. RN E indicates, you can't do a neurological exam if the resident is asleep because you must assess pupils, pain, etc. On 1/21/26 at 12:03 PM, Surveyor interviewed NHA (Nursing Home Administrator) A and DON (Director of Nursing) B. Surveyor asked NHA A and DON B how staff know which residents have fall precautions. NHA A and DON B indicate there are star pictures on the residents door and the interventions are on the care plan and the Kardex on the residents' closet doors. Surveyor asked NHA A and DON B what in line of sight means on the care plans. NHA A and DON B indicate it means staff must be able to physically see the resident. Surveyor asked NHA A and DON B if it is acceptable to mark asleep or sleeping on a neurological assessment. DON B indicates she would wake the resident up because she wouldn't know if the resident has had a change in mental status. Surveyor asked NHA A and DON B what are some causes for concern or changes you would find pertinent on a neurological assessment. DON B indicates pupil size, vital signs . Surveyor notes R2's fall from her broda chair on 11/2/25 and asked NHA A and DON B if R2 should have been within line of sight of staff if she was in her broda chair. NHA A and DON B indicate they believe she was, but if she was not then R2 should have been kept within line of sight.(Of note: Surveyor allowed NHA A and DON B additional time to review documentation for alternative evidence regarding R2 being in line of sight of staff on 11/2/25 when she fell, however none was provided)

Based on observation, interview and record review, the facility failed to ensure each resident (R) received adequate supervision to prevent accidents for 1 of 4 sampled residents (R3) reviewed for falls. Surveyor observed R3's fall intervention not in place. R3 had a fall on 9/30/25 and facility failed to complete a falls investigation and update the physician on the fall. Evidenced by: The facility policy entitled Falls Management Process, undated, states, in part: . 1. In the event a resident has fallen and /or is found on the ground.11. The nurse will complete an event documentation report, fall risk assessment, pain assessment, and obtain witness statements.12. The nurse will determine the most appropriate intervention, implement, and update care plan.[12] Contact physician and family and document in the medical record, including time and person spoken with.13. Resident fall will be noted on 24-hour report for three days for post fall monitoring, assessing for injury, full vital signs every 8 hours, and pain assessment. R3 admitted to the facility on [DATE] and has diagnoses that include age related osteoporosis without current pathological fracture (a condition that weakens bones, making them more prone to fractures), acquired absence of right leg below knee and unilateral primary osteoarthritis (a type of joint disease that affects only one side of the body, typically in a single joint). R3's Quarterly MDS (Minimum Data Set) Assessment, dated 9/13/25, shows R3 has a BIMS (Brief Interview of Mental Status) score of 15 indicating R3 is cognitively intact. R3's Care Plan, dated 3/05/2024, states, in part: . Focus: At risk for falls related to bilateral amputee, impaired mobility.Interventions: .*Floor mat x 1 Date Initiated: 9/30/25*I need dycem in the seat of my wheelchair. Date Initiated: 9/30/25 R3's Progress Note dated 9/30/25, at 7:59 AM, states: Late Entry: Note Text: Resident went outside after breakfast and later in the day, a nurse from across the street brought him into the facility and stated he had been out there all day, and she was going to notify the state. HSKG D (housekeeping) environmental director, stated it was his right to be outside if he wanted to be. HSKG D informed this writer that he smelled like alcohol. When this nurse assessed him, his words were slurred. Eyes glazed. VSS (vital signs stable). Skin warm and dry. Denied having any pain or discomfort. I asked him if he wanted help for his drinking and he stated no. Will have social worker follow up with him. Dr updated per LPN C (licensed practical nurse).Of note: There is no mention of a fall. R3's Progress Note, dated 9/30/25, at 1:20 PM, states, in part: . Situation: The Change in Condition/s reported on this CIC (change in condition) Evaluation are/were: Altered mental status.Nursing observations, evaluation, and recommendations are: Resident is own person. Resident left facility in w/c (wheelchair). Does go out to smoke and to the local gas station. Resident was on sidewalk in w/c and writer was speaking to him earlier, offered to bring him inside and declined, noted 2 small bottles of alcohol in shorts. Resident was brought inside about 1 hour later and has squinty eyes, laughs at questions and has alcohol breath. Alcohol in shorts is gone. Resident stated he was fishing. Speech is slurred.Of note: There is no mention of a fall. On 10/13/25, at 09:25 AM, Surveyor observed R3 in bed with no fall mat on floor next to bed. On 10/13/25, at 09:40AM, Surveyor interviewed CNA E (certified nursing assistant) and asked if R3 is supposed to have floor mat in place next to bed while R3 is in bed. CNA E indicated yes. CNA E indicated maybe housekeeping had moved it while cleaning. CNA E indicated he would go in R3's room and place the mat down. On 10/13/25, at 10:40AM, Surveyor interviewed LPN C and asked her to tell Surveyor about the incident with R3 on 9/30/25. LPN C indicated R3 was sitting outside that morning for quite awhile and she approached him because he was getting red and asked him if he wanted to come inside and R3 told her no. LPN C reported later that day someone had brought R3 back into the facility from outside. LPN C indicated she did not know who it was as she did not see the person. LPN C was called to R3's room and assessed R3. It had been reported to LPN C R3 had been drinking. LPN C indicated after she had assessed R3 she had left the room and got called back to R3's room right away. R3 was on the floor and reported to LPN C he put himself on the floor. LPN C indicated DON B (Director of Nursing) came to room to assess R3. No injuries were noted. R3 reported to LPN C and DON B he was going fishing. R3 smelled to alcohol. LPN C indicated R3 was gotten up off the floor with the Hoyer lift and transferred into R3's bed. LPN C indicated bed was lowered to floor and floor mat was placed. LPN C indicated she had messaged the doctor. Fax to physician, dated 9/30/25, at 2:25PM, states: Resident Name: R3 Date: 9/30/25Note: Resident is own person. Left facility in w/c and came back intoxicated. No complaints of pain, no injuries noted. Stated he went fishing. Does have slurred speech and laughs at questions. Vital signs WNL (Within Normal Limits).Of note: Physician was not updated on fall. On 10/13/25, at 11:41 AM, Surveyor interviewed DON B and asked if she would expect if a resident was care planned to have a fall mat placed as a fall intervention, should it be in place. DON B indicated yes. Surveyor informed DON B of observation of R3 in bed with no floor mat placed. DON B indicated yes, it should have been, and she will start educating staff. On 10/13/25 at 11:59 AM, Surveyor interviewed DON B and asked if there was a fall investigation for R3 for 9/30/25. DON B indicated no. Surveyor asked if there should be one and DON B indicated yes, and she had educated that nurse that day on not completing a fall investigation for R3. Surveyor asked if a physician should have been updated on the fall and DON B indicated yes. DON B indicated she would expect staff to follow the facility's policy on fall management. R3 had a fall on 9/30/25 and facility failed to complete a falls investigation and update the physician on R3's fall. R3's fall mat was observed to be not in place.

Based on interview and record review the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, this has the potential to affect the census (39). The facility has no documentation of Infection Control Surveillance prior to August of 2025. The facility does not have documentation that Infection Control Policies and Procedures were reviewed annually. The facility does not have Infection Control rates documented. The facility has not been completing Legionella testing per their Water Management Plan. The facility has not completed their monthly NHSN (National Healthcare Safety Network) reporting since July. This is evidenced by: Example 1The only infection control documentation the facility could locate was from August of 2025 forward.On 9/29/25 at 10:37 AM, Surveyor interviewed DON/IP B (Director of Nursing/Infection Preventionist). Surveyor asked DON/IP B regarding the infection control documentation prior to August 2025, DON/IP B stated, I started August 1st, I don't know about prior, it's not in our computer system under the infection control tab, we are unable to find an infection control binder from the previous DON. Example 2The facility does not have documentation that infection control policies and procedures were reviewed annually.The following policies and procedures were undated; Infection Control Program, Infection Surveillance, Antibiotic Stewardship, Influenza vaccine, Pneumococcal vaccine, and COVID vaccine. Norovirus policy and procedure dated 3/1/19. Hand hygiene policy and procedure dated 1/8/20. Legionnaire's disease policy and procedure dated 6/1/24.On 9/29/25 at 10:37 AM, Surveyor interviewed DON/IP B (Director of Nursing/Infection Preventionist). Surveyor asked DON/IP B how often the infection control policies and procedures should be reviewed, DON/IP B stated policies should be reviewed annually, if they are not updated they should have been. Example 3The facility has no documentation that they are calculating monthly infection control rates by type.On 9/29/25 at 10:37 AM, Surveyor interviewed DON/IP B (Director of Nursing/Infection Preventionist). Surveyor asked DON/IP B about the infection control rates, DON/IP B stated I have not been tracking monthly rates based on infections because I don't have access to the infection control part of our computer system. Example 4The facility does not have documentation of any Legionella testing.Per the facility's Water Management Plan, review date of 8/21/25: .performing at a minimum 2 (biannual) tests per year .On 9/25/25 at 10:15 AM, Surveyor interviewed MD S (Maintenance Director). Surveyor asked MD S if he could locate Legionella testing documentation, MD S stated no Legionella testing has been done since I started. Surveyor asked MD S when he started, MD S replied February 2025. MD S went on to state that tests have been ordered and will start once they arrive.On 9/29/25 at 1:32 PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A if Legionella testing should have been done, NHA A stated yes we should be testing, we ordered the tests, we are waiting on them to arrive and we will test then. I am aware we were not, and we need to be. Example 5The facility currently does not have access to NHSN (National Healthcare Safety Network) to complete their monthly reporting and confer rights.On 9/25/25 at 2:42 PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A how long the facility has been without access to NHSN for reporting and conferred rights, NHA A stated, since July-ish when the receivership took place.On 9/29/25 at 10:37 AM, Surveyor interviewed DON/IP B (Director of Nursing/Infection Preventionist). DON/IP B explained they are unable to complete NHSN reporting because no one has access, we are working on getting that, but we do not have anyone yet.

Based on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 39 residents who reside in the facility. Surveyor observed hairlike dust built up in the frame of the drop ceiling, along the electrical covers, and on top of the outlets in the main kitchen, in the freezer unit, and in the refrigerator unit. Surveyor observed Mighty Shakes to be in the refrigerator thawed with no thaw dates. Surveyor observed a cup left in the sugar bin that had been used as a scoop. Surveyor observed cereal in large plastic containers with a use by date that had passed. Surveyor observed frozen drips in and on boxes of food that is no longer sealed by the manufacturer and ice built up inside of the facility's walk-in freezer over opened boxes of food.Surveyor observed cookie dough to be opened and resealed without an open date inside of the facility's freezer.Surveyor observed a stored stand mixer to have been stored unclean. Surveyor observed staff remove a pan from the clean dishware storage rack that was stored unclean. Surveyor observed the microwave to have different colored food particles on the inside top and a large orange spill. Staff continued to use the microwave to heat resident food without covering and without cleaning the spills/splashes. Surveyor observed broken tiles on the floor around the sink, near the refrigerator, and under the coffee pot. Staff indicated there was no way to sanitize the cracked tiles. Surveyor observed missed hand hygiene opportunities while dishwashing. DA F used a dirty rag from her pocket to dry clean trays before putting clean dishes on it. Evidenced by:Example: Food datingOn 9/24/2025 at 9:45 AM, during initial tour of the kitchen, Surveyor observed cereal in large round bins (Bran Flakes exp 9/10/25) (Rice Krispies exp 9/14/25). Surveyor observed a bag of frozen cookie dough opened and then resealed but not labeled or dated. Surveyor observed two plastic containers of soup covered with plastic wrap with no label or expiration date. DC D (Dietary Cook) indicated all items in dry storage/refrigerator/freezer should have labels and be dated.Surveyor observed a tray of Mighty Shakes in the facility refrigerator. The shakes were completely thawed and did not have any thaw dates noted. The shakes state on the container that they should be discarded within 14 days. DC D indicated that the mighty shakes had been thawed yesterday for today, but no one had dated them. Surveyor observed a sugar bag in a garbage can. A plastic cup was in the bottom of the garbage can. DC D indicated that she used this cup as a scoop. She was unaware that the scoop needed to have a handle on this. DC D discarded the scoop in the trash. Example: Uncleanliness On 9/24/25 at 10:00 AM during initial tour of the kitchen, Surveyor observed fans/pipe/light in refrigerator had dirt and grime on them. Surveyor observed the freezer fan had dirt and grime on them. The Condenser was iced up (approximate size of 2-liter bottle), and ice was building up on the back, right side of the ceiling. There were open boxes below both iced areas. DC D stated that the maintenance man comes and de-ices the freezer every couple of days. Surveyor observed a pipe alongside the oven going up to the ceiling was full of dirt and grime with webs hooked to the ceiling, Surveyor observed numerous ceiling tiles with dirt in corners of the tiles throughout the kitchen ceiling and the tiles touching the wall. Surveyor observed the mixer was put away dirty, removed cover, under carriage and stand itself had debris, and pieces of food on it. DC D indicated that the mixer should be cleaned before being stored. Surveyor observed DC D pulling out a baking pan to use and stated it was dirty. DC D indicated it needed to be rewashed.Surveyor observed the inside of the microwave had red/pink dried liquid on turntable and walls. DC D indicated staff heated up soup last night and didn't clean the inside. Surveyor observed broken tiles on the floor around the sink, near the refrigerator, and under the coffee pot. Staff indicated there was no way to sanitize the cracked tiles. On 9/30/28 at 3:15 PM NHA A (Nursing Home Administrator) indicated that maintenance is currently getting quotes for tiles to order and replace the current tiles. NHA A indicated that there would be no way to sanitize the tiles. Example: DishwashingOn 9/29/25 at 11:30 AM Surveyor observed DA F (Dietary Aide) rinsing dirty dishes and go to clean dishes and put them away without washing her hands between dirty and clean. Surveyor observed DA F wearing an apron with a pocket in the front to wash dirty dishes. DA F then pulled out a dirty rag from her pocket of the apron and wiped a tray off and put clean cups on the tray. DA F stated that she thought she washed her hands both times, but she may have forgot. DA F stated that no one ever told her about changing aprons when going from dirty side to clean side. DA F stated she understood why and would do that from now on.

Based on observation, interview and record review, the facility did not ensure that each resident receives food that is palatable and at a safe and appetizing temperature. This has the potential to affect all 37 residents who reside in the facility. Food being held in the steam table, did not meet the required hot holding temperature. Four residents (R26, R 31, R36, R46) voiced concerns about food being cold. Evidenced by: Facility policy, entitled Food Preparation and Service, last revised January 2025, includes in part: . Food Preparation, Cooking and Holding Temperatures and Times. 1. The danger zone for food temperatures is between 41 degrees F and 135 degrees F. The temperature range promotes the rapid growth of pathogenic microorganisms that cause food borne illness. The following internal temperatures/times for specific foods must be reached to kill or sufficiently inactivate pathogenic microorganisms: c. Fish and other meats - 145 degrees F for 15 seconds. c. Fresh, frozen or canned fruits/vegetables - 135 degrees F. 6. Previously cooked food must be reheated to an internal temperature of 165 degrees F for at least 15 seconds. Food Service/Distribution, 3. The temperature of foods held in steam tables will be monitored by food and nutrition services staff. Facility policy, entitled Metal Stem Food Thermometers: Calibration includes in part: . Policy: It is the policy of the Dietary department to ensure that handheld thermometers for ascertaining that food thermometers for food temperatures – at time of preparing, cooking, storing, or holding foods – are in satisfactory functioning condition to register accurate temperatures. Procedure: 1. Each numbered thermometer will be tested for accuracy at least one time per week, by the Food Service Department/designee. 5. The new, number engraved thermometer is to be entered on the tracking sheet for subsequent weekly quality assurance monitoring of handheld, metal stemmed thermometers. 6. The Director of Food Service is responsible for ensuring that the handheld, metal stemmed thermometers are engraved with an assigned numbers are tested weekly and that the findings/actions taken are recorded on the tracking sheet, accordingly. 7. Recorded tracking of the accuracy of handheld, metal stemmed food thermometers will be retained in a logbook. At least six month's records are to be retained at any given time. Example 1 On 9/26/25 at 11:15 AM Surveyor observed DC D (Dietary Cook) near the steam table. DC D indicated the food was taken out of the oven at 10:45 AM. Surveyor asked DC D to take a temperature reading of the food in the steam table. DC D used a food grade thermometer to temp the food and got the following results: Hamburgers- 100 degrees F (Fahrenheit), French Fries- 70 degrees F. DC D indicated these temperatures are too low and she does not think she has enough water in the steam table or in the pan with the hamburgers. Surveyor asked DC D when she routinely takes a temperature reading of the food in hot holding. DC C indicated she only temps the food coming out of the ovens and does not take the temperature again before serving the food.Of note, all residents who receive meals are served from the steam table being used. On 9/25/25 at 1:05 PM DC D indicated that food can be in hot holding at 10:30 AM and start plating at noon. DC D stated she does not re temp the food in hot holding prior to plating. DC D indicated that today she would have used the original temperatures out of the oven and not re temped prior to serving. Surveyor asked DC D how often calibration is done on the thermometers. DC D answered monthly. On 9/29/25 at 3:15PM Surveyor interviewed DM C. How often should thermometers be calibrated. DM C responded weekly. DM C indicated that she did not have logs for the calibration. Surveyor asked DM C how often you should be temping the food. DM C indicated she would be temping when it comes out of the oven, then before she serves from the steam table. On 9/29/25 at 3:30 PM NHA A indicated that thermometers should be calibrated weekly, and that food should be temped both coming out of the oven and before serving. Example 2 R36 was admitted to the facility on [DATE]. R36's most recent MDS (Minimum Data Set), with a target date of 8/11/25, indicates a BIMS (Brief Interview for Mental Status) score of 15 out of 15, indicating R36 is cognitively intact. 0n 9/25/2025 9:45 AM R36 indicated that food was hot only 50% of the time. Eggs and toast are always ice cold. Example 3 R26 admitted to the facility on [DATE]. His most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 8/27/25 indicates R26's cognition is moderately impaired with a BIMS (Brief Interview for Mental Status) score of 10 out of 15. On 9/24/25 at 11:20 AM R26 indicated he receives his hot food cold at times. R26 indicated this happens a few times a week. Example 4 R46 admitted to the facility on [DATE]. His most recent MDS with ARD of 9/21/25 indicates R46'a cognition is intact with a BIMS score of 14 out of 15. On 9/24/25 at 11:35 AM R46 indicated his hot food comes cold and at a undesirable temperature. Example 5: R31 admitted to the facility on [DATE]. Her most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/27/25 indicates R31's cognition is intact with a Brief Interview of Mental Status (BIMS) score of 15 out of 15. On 9/24/25 at 11:24 AM, Surveyor interviewed R31 and asked her how the food was at the facility. R31 replied that the food was lousy, really bad and that is one thing that still needs a lot of improvement. R31 stated there is no way I could eat a reasonable diet living here and most of the food is not what I would call edible. Surveyor asked R31 if she ate in the dining room or in her room. R31 stated that she ate in her room and that sometimes the food was hot but most of the time it was not hot. R31 stated I never order French fries. I like French fries but they never come hot and they are always undercooked so I can't eat them here. The facility did not ensure that each resident receives food that is palatable and at a safe and appetizing temperature

Based on observation, interview, and record review, the facility did not ensure they maintained medical records on each resident in accordance with professional standards of practice. This has the potential to affect 1 of 16 sampled residents (R3) and 3 of 3 supplemental Residents ((R27, R28, & R44) reviewed for medical records.R27's medical information was observed accessible in an unsecured area on 9/24/25.R28's medical information was observed accessible in an unsecured area on 9/24/25.R44's medical information was observed accessible in an unsecured area on 9/24/25.R3's medical information was observed accessible in an unsecured area on 9/24/25.Findings include:Facility policy, entitled HIPAA Security Measures, dated 3/1/19, includes, in part: Policy: It is the facility's policy to implement reasonable and appropriate measures to protect and maintain the confidentiality. of the resident's identifiable information. R27 was admitted to the facility on [DATE].R28 was admitted to the facility on [DATE].R44 was admitted to the facility on [DATE].R3 was admitted to the facility on [DATE].On 9/24/25 at 11:14 AM, Surveyor observed the medication cart on the 100 hallway with a form lying face up on the cart, halfway covered by another piece of paper. Surveyor observed the following names were left uncovered: R27, R28, R44, and R3. Surveyor observed this form included these residents' names, room numbers, medications, and other protected health information. Surveyor interviewed MT M (Med Tech) who was passing medications on the 100 hall. Surveyor asked MT M if the information that was uncovered was protected health information. MT M stated yes, and that usually the form was flipped over or covered while left out on top of the med cart.On 9/24/25 at 11:17 AM, Surveyor interviewed RN K (Registered Nurse) about resident's protected health information. RN K indicated that identifiable information related to residents should not be left unattended and visible on the medication carts. On 9/24/25 at 12:17 PM, Surveyor interviewed DON B (Director of Nursing) and shared with her the observation of resident information being visible on top of the medication cart. DON B indicated that the information that was visible was resident protected health information, and that staff should protect residents' private information, and should not leave paperwork with private information out and accessible to other residents or visitors.

Based on record review and interview the facility did not complete the PASRR Level II (Preadmission Screening and Resident Review) for residents having a major mentalDisorder and are receiving psychotropic medications to treat behaviors or symptoms of a major mental disorder affecting 1 of 3 residents (R8) reviewed for PASRR. R8 admitted to the facility with a major mental disorder and is receiving psychotropic medications. The facility did not ensure that a PASRR level 2 screen was performed by the PASRR contractor. Evidenced by: The Preadmission Screen and Resident Review Level 1 Screen directions include, in part, the following: 42 CFR 4830128(a) requires that the resident or his/her legal representative receive a written notice (copy of this front page) if the resident is suspected of having a serious mental illness or a developmental delay, and therefore, will require a Level II Screen. You may tell the resident or his/her legal representative that the Level II Screen will determine if the resident does have a serious mental illness or developmental disability, as defined in the federal regulations, and if so, if the resident is appropriate for nursing facility placement and if the resident needs specialized services or specialized psychiatric rehabilitative services to address his/her disability needs. Section D- Referring a person for a level 2 screen. If you have answered yes to any questions in section A and no to all of the exemptions listed in section B, follow these instructions: Contact the PASRR Contractor to notify them that the person is being considered for admission. Forward a copy of the Level 1 Screen to the PASRR Contractor (a copy must also be maintained by the nursing facility). The PASRR Contractor will perform a Level 2 Screen to determine if the person has a developmental disability and/or a serious mental illness as defined by the federal PASRR regulations and if so then whether or not the person needs nursing facility placement and if the person needs specialized services. The screening agency will notify the nursing facility, the county of responsibility and the resident or his representative, in writing of the determinations. Facility policy, titled PASRR, undated, includes: It is the policy of this facility to Complete and maintain a PASRR Level 1 screening for all new admissions, regardless of payer source. Ensure that individuals who screen positive receive a level 2 evaluation before admission unless an emergency categorical determination applies. R8 initially admitted to the facility on [DATE] and her most recent re-admission was on 2/19/25. Her diagnoses include Major Depressive Disorder and Schizoaffective disorder. R8's PASRR, dated 4/7/23, includes: Section A: Does the person have a major mental disorder: Yes. Has the person received psychotropic medications to treat symptoms or behaviors of a major mental disorder: Yes. Medication List: Aripiprazole and Escitalopram. Section B: hospital discharge exemption, 30 day maximum: No. Emergency placement- 7 day maximum: No. Respite Care- 7 days maximum: No R8's Physician Orders, for 9/1/25-9/30/25, include: Escitalopram Oxalate Tablet 5 MG (milligrams). Give 5 mg by mouth in the morning related to Major Depressive Disorder. Aripiprazole Tablet 5 MG. Give 5 mg by mouth in the morning related to Schizoaffective disorder. On 9/30/25 at 8:27 AM SW Q (Social Worker) indicated R8 should have had a level 2 screen completed. SW Q indicated she has not had training on PASRR policy and procedure yet. SW Q indicated she has been filling out PASRR 1 forms for residents after admission and she thought they should be done prior to admission. On 9/30/25 at 12:30 PM NHA A (Nursing Home Administrator) indicated R8 should have a PASRR 2 and she would make sure this was corrected today.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported to the State Survey Agency for 1 (R12) of 5 investigations reviewed. R12 indicated the nurse threw him on R12's bed. Facility did not report incident to state agency and did not contact law enforcement.The facility policy, Abuse/Neglect/Exploitation, with no date, states, in part;.1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.B. The Administrator will follow up with the government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.R12 was admitted to the facility on [DATE], with a diagnoses including Bipolar disorder (chronic mental health condition), antisocial personality disorder (mental health condition persistent pattern of disregard for and violation of the rights of others), kidney disease, and diabetes. R12's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 8/4/25, indicates R12 has a BIMS (Brief Interview for Mental Status) score of 12 indicating R12 is moderately cognitively impaired. R12 has an activated power of attorney.Nursing Home Administrator A (NHA) timeline states, in part;.9/19/25 Registered Nurse Care Coordinator from hospital called to voice a concern over a recent concern that was voiced. R12 was taken to the ER and told a nurse there that our nurse had threw him on the bed. NHA A told RN Care Coordinator that she would follow up and report back to her what was found.On 9/29/25 at 10:44AM, Nursing Home Administrator A (NHA) indicated the hospital care coordinator called NHA A on 9/19/25 to report a concern that R12 had voiced when R12 was at ER on [DATE]. NHA A indicated R12 told hospital staff that the night nurse threw R12 on the bed. NHA A indicated she talked to the nurse and Certified Nursing Assistant (CNA) that was working with R12 that night. The statements matched so NHA A did not investigate further. NHA A indicated she talked with R12 as well and R12 did not have any concerns, feels safe at the facility, and could not remember any incident that had occurred.On 9/30/25 at 11:03AM, Hospital Manager G indicated she did call and report R12's allegation of abuse to Nursing Home Administrator A (NHA) on 9/19/25. Hospital Manager G indicated it was reported that R12 told staff that the nurse at the facility threw him on the bed. Hospital Nurse G indicated NHA A followed back up and reported that she talked to the nurse and Certified Nursing Assistant that worked with R12 that night.On 9/30/25 at 12:21PM, Nursing Home Administrator A indicated she did not report R12's allegation to law enforcement and state agency. NHA A indicated R12 stating he was thrown on the bed could be an allegation of abuse and should be investigated and reported.The facility did not report an allegation of abuse to the state agency and law enforcement for 1 of 5 investigations reviewed.

Based on interview, observation, and record review, the facility did not provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals, to meet the needs for 1 of 16 sampled Residents (R31).R31 was observed with a cup of pills sitting on her bedside table. R31 did not have an order to self-administer medications, nor did she have an assessment completed to determine her competency for self-administering medications.This is evidenced by:The facility policy titled, Self-Administration of Medications, dated 10/25/14, states, in part: Policy: . residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. Procedures: A. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive. physical, and visual ability to carry out this responsibility. B. If the resident indicates no desire to self-administer medications, this is documented in the appropriate place in the resident's medical record, and resident is deemed to have deferred this right to the facility.The facility policy titled, Medication Administration, undated, states, in part: Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. Policy Explanation and Compliance Guidelines:. 15. Observe resident consumption of medication.R31 was admitted to the facility on [DATE] and has diagnoses that include Type 2 Diabetes Mellitus, Muscle Wasting and Atrophy, Muscle Weakness, Other Reduced Mobility, Unsteadiness on Feet, Unspecified Dementia, Major Depressive Disorder, and Mild Cognitive Impairment of Unknown Etiology.R31's most recent Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 9/27/25, indicated that R31 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R31 is cognitively intact. R31's Care Plan, dated 4/19/22, states in part: Focus: .Resident has history of refusals such as showers, Accu-checks, wound care, repositioning, and medications. Interventions: Administer medications as ordered.R31's Clinical Health Status Assessment, dated 3/31/23, indicates that resident does not wish to self-administer medications.Of note: R31 does not have a physician's order to self-administer medications, nor was there a competency assessment anywhere in R31's medical record for self-administering of medications.On 9/24/25 at 11:29 AM, Surveyor observed R31 in bed with a cup of medications in front of her on the bedside table. Surveyor asked R31 if those were her morning medications. R31 indicated that yes, those were all of her AM medications but that she wasn't ready to take them yet.On 9/29/25 at 11:17 AM, Surveyor interviewed MT M (Med Tech) and asked her if R31 was safe to self-administer her own medications. MT M stated that she didn't believe so but that she would double check. Surveyor observed MT M look up the information in R31's EHR (Electronic Health Record). MT M indicated that no, R31 did not have a physician's order to self-administer her own medications. Surveyor asked MT M if she normally would leave R31's medication on her table or if she would watch to ensure that she took them. MT M stated that she would stay there and make sure that R31 swallowed all of her medications before leaving the room. On 9/29/25 at 11:35 AM, Surveyor interviewed DON B (Director of Nursing) and asked her how she would determine if someone was safe to administer their own medications. DON B indicated that they would need to do a self-administration assessment. DON B stated that these are done upon admission or later if a resident decides that they want to take their own medications. Surveyor asked DON B who was responsible for completing the self-administer assessments. DON B indicated that the nurses do those. Surveyor asked DON B if there were any self-administer assessments or physician orders for R31. DON B stated no because her medications are administered by the staff. Surveyor asked DON B if R31 was safe to self-administer her medications. DON B indicated that no, R31 was not safe to self-administer medications. Surveyor shared with DON B her observation of R31 having a cup of pills left in her room in front of her on the bedside table. Surveyor asked DON B if MT M should have remained with R31 while she took her medications, given that she was not safe to self-administer them. DON B stated absolutely that meds should not be left at R31's bedside and that MT M should have remained to watch R31 take them. On 9/29/25 at 11:42 AM, Surveyor interviewed R31 about the medications that had been left on her bedside table. R31 stated that the staff always leave the medications in a cup on the table until she is ready to take them. R31 stated that she has a colostomy and that she has to wait until her stomach feels good before she can take any medications. The facility's failure to adequately assess and supervise medication administration enabled the resident to keep medications at the bedside and self-administer without demonstrating competency to do so.

Based on record review and interview the facility did not provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) and did not provide the accurate potential financial liability to residents whose Medicare coverage was ending for 3 of 3 residents reviewed (R2, R8, and R50).R2 was receiving Medicare A benefits. R2 was not provided the SNFABN form thus not provided with the accurate financial liability. R8 was receiving Medicare A benefits. R8 was not provided the SNFABN form thus not provided with the accurate financial liability. R50 was receiving Medicare A benefits. R50 was not provided the SNFABN form thus not provided with the accurate financial liability. Evidenced by:The facility's policy titled Advance Beneficiary Notice dated 10/01/22 states in part .5. The current CMS (Center for Medicare and Medicaid Services)- approved version of the forms shall be used at the time of issuance to the beneficiary (resident or resident representative). Contents of the form shall comply with related instructions and regulations regarding the use of the form. a. For part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), Form CMS-10055.Example 1R2's Medicare coverage ended on 7/3/25. R2 was not provided with a SNF ABN form. R2 was not informed of his entire potential liability and reason for ending of benefits. Example 2R8's Medicare coverage ended on 5/7/25. R8 was not provided with a SNF ABN form. R8 was not informed of her entire potential liability and reason for ending of benefits.Example 3R50's Medicare coverage ended on 8/20/25. R50 was not provided with a SNF ABN form. R50 was not informed of her entire potential liability and reason for ending of benefits.It is important to note that Surveyor requested SNF ABN/ NOMNC (Notice of Medicare Non-coverage) information for R2, R8, and R50, BOM R (Business Office Manager) wrote on the SNF Beneficiary Protection Notification Review form I didn't know I needed ABN- just did training on NOMNC/ ABNs. Additionally, BOM R printed out a copy of CMS-R-131 form for each resident, unsigned, which is not the correct form.On 9/29/25 at 10:05 AM Surveyor interviewed BOM R. Surveyor asked BOM R how long she had been completing the SNF ABNs, BOM R stated she started doing them in June 2025. BOM R stated that she had just completed the training for SNF ABNs last week. Surveyor asked BOM R if residents that are being discharged from Medicare A services should receive a SNF ABN, BOM R stated that if they are staying in the facility, they should.On 9/29/25 at 10:15 AM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A if she would expect that residents receive a SNF ABN form, NHA A stated yes.

Based on interview and record review the facility failed to ensure that all alleged violations are thoroughly investigated and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken this affected 1 (R12) of 5 investigations reviewed. R12 reported an allegation of abuse. The facility did not complete a thorough investigation.Evidenced by:The facility policy, Abuse/Neglect/Exploitation, no date, states, in part;.A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. R12 was admitted to the facility on [DATE], with a diagnoses including Bipolar disorder (chronic mental health condition), antisocial personality disorder (mental health condition persistent pattern of disregard for and violation of the rights of others), kidney disease, and diabetes. R12's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 8/4/25, indicates R12 has a BIMS (Brief Interview for Mental Status) score of 12 indicating R12 is moderately cognitively impaired. R12 has an activated power of attorney. Nursing Home Administrator A (NHA) timeline states, in part;.9/19/25 Registered Nurse Care Coordinator from hospital called to voice a concern over a recent concern that was voiced. R12 was taken to the ER and told a nurse there that our nurse had threw him on the bed. NHA A told RN Care Coordinator that she would follow up and report back to her what was found. On 9/29/25 at 10:44AM, Nursing Home Administrator A (NHA) indicated the hospital care coordinator called NHA A on 9/19/25 to report a concern that R12 had voiced when R12 was at ER on [DATE]. NHA A indicated R12 told hospital staff that the night nurse threw R12 on the bed. NHA A indicated she talked to the nurse and Certified Nursing Assistant (CNA) that was working with R12 that night. The statements matched so NHA A did not investigate further. NHA A indicated she talked with R12 as well and R12 did not have any concerns, feels safe at the facility, and could not remember any incident that had occurred. On 9/30/25 at 11:03AM, Hospital Manager G indicated she did call and report R12's allegation of abuse to Nursing Home Administrator A (NHA) on 9/19/25. Hospital Manager G indicated it was reported that R12 told staff that the nurse at the facility threw him on the bed. Hospital Manager G indicated NHA A followed back up and reported that she talked to the nurse and Certified Nursing Assistant that worked with R12 that night. On 9/30/25 at 12:21PM, Nursing Home Administrator A indicated she did not interview other residents and staff. NHA A indicated R12 stating he was thrown on the bed could be an allegation of abuse and should be thoroughly investigated. The facility did not complete a thorough investigation for 1 of 5 investigations reviewed.

Based on interview and record review, the facility failed to develop a person-centered comprehensive care plan to meet personal preferences and goals, or address the resident's medical, physical, mental and psychosocial needs for 1 or 16 sampled residents (R1).R1 displayed behaviors of making sexual remarks to a staff member and the facility failed to develop a behavior care plan with goals and interventions related to R1's behavior.Evidenced by:Facility policy, titled Comprehensive Care Plan, dated 3/1/23, includes: . it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessments.R1 admitted to the facility on [DATE]. His most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 7/18/25, indicates R1 is severely cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 8 out of 15.On 09/25/25 at 9:59 AM LPN O (Licensed Practical Nurse) indicated there was an incident on 9/1/25 at 8:00 PM in which R1 and another resident were making sexual remarks to her and threatening to sexually assault her. The police came and arrested the other resident and he has not been back to the facility.R1's Comprehensive Care Plan, reviewed 9/25/25, initiated 3/28/24, does not include goals or interventions related to inappropriate sexual behaviors.On 9/25/25 at 3:09 PM NHA A (Nursing Home Administrator) indicated R1 was involved in an incident that occurred on 9/1/25 around 8:00 PM in the shared gathering room. NHA A indicated staff reported to NHA A that R1 was making sexual remarks to LPN O and verbalizing a desire of sexual misconduct with LPN O. NHA A indicated other residents and staff were in the room while this was happening. NHA A indicated the facility did not add interventions or goals in R1's care plan related to this behavior. NHA A indicated the facility is not monitoring R1 for inappropriate sexual comments to staff or other residents, but they should be.

Based on interview and record review, the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 2 of 7 sampled residents (R4 and R5) reviewed for change of condition. R4 experienced a change in condition as evidenced by a change in mental status, decrease in intake, and change in urine color and output. Certified Nursing Assistants (CNAs) reported these changes to nursing staff. R4’s nurse did not complete an assessment, monitor resident, or report change in condition to the provider. R4 continued to deteriorate over the weekend and was found to be unarousable and then sent to ER. R4 was admitted to the hospital on [DATE] with bacteremia UTI (bacteremia presence of bacteria in the blood stream; if left untreated it can progress to sepsis), Urinary tract infection (UTI), severe sepsis (life threatening condition that occurs when the body responds to an infection leading to organ dysfunction/failure and can progress to shock if not treated), catheter-associated urinary tract infection, acute respiratory distress, and chronic indwelling foley catheter. R4 passed away at the hospital on 8/1/25 due to severe sepsis, bacteremia, acute respiratory distress, and UTI. The facility failed to provide care consistent with professional standards of practice for R4 when the facility failed to recognize a change of condition, failed to complete an RN assessment, failed to monitor R4's condition, failed to consult with the physician timely, and failed to monitor/document R4's intake and output. These failures created a finding of immediate jeopardy that began on 7/26/25. The Nursing Home Administrator (NHA) was notified of the immediate jeopardy on 8/14/25 at 2:45 PM. The immediate jeopardy was removed on 8/18/25; however, the deficient practice continues at a scope and severity of D (Potential for more than minimal harm/Isolated) as evidenced by the following example: R5 had a change of condition on 7/23/25. LPN K (Licensed Practical Nurse) utilized a straight catheterization (an invasive medical device used to drain urine from the bladder) without a Physician’s Order to obtain a urine sample. R5 has wounds to her left hip, left shoulder, right great toe, and right second toe that have not been consistently measured or assessed by staff since admission. The facility did not complete an admission skin assessment, did not complete treatments per physician orders, and no documentation was located indicating the classification or cause of R5’s wounds (e.g. pressure, diabetic, etc.). Evidenced by: The facility policy, “Notification of Changes Policy,” dated 3/19, states in part:…It is the policy of this facility that changes in a resident’s condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate….Requirements for notification of resident, the resident representative and their physician:…A significant change includes deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications… According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s (Licensed Practical Nurse) or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. According to N6.04(1), In the performance of acts in basic patient situations, the L.P.N. shall, under the general supervision of an R.N. or the direction of a provider . (b) Provide basic nursing care. (c) Record nursing care given and report to the appropriate person changes in the condition of a patient . (e) Perform the following other acts when applicable: 1. Assist with the collection of data . 1.R4 was admitted to the facility on [DATE] with diagnoses including Alzheimer’s disease, kidney disease, dysphagia (difficulty swallowing), unsteadiness on feet, dementia, weakness, obstructive and reflux uropathy (blockage in the urinary tract), and neurocognitive disorder. R4’s most recent Minimum Data Set (MDS) dated [DATE] indicates R4 had a Brief Interview for Mental Status (BIMS) of 00 indicating R4 was severely cognitively impaired. R4 had an activated power of attorney. R4’s Comprehensive Care Plan, stated, in part: “…5/6/22…Focus: Alteration in elimination of bowel and bladder Indwelling Urinary Catheter DX (diagnosis) obstructive uropathy, pyelitis cystica (multiple small cysts in the renal pelvis area). Bowel incontinence…Goal: I will be free of UTI. I will have no complications from use of my indwelling catheter such as pain, infection, obstruction…Interventions: Anchor catheter, avoid excessive tugging on the catheter during transfer and delivery care…Change catheter bag…change foley catheter monthly and PRN (as needed) per MD (Medical Doctor) order. 20Fr (French) coude (type of catheter)10ml (milliliter) balloon…Check catheter tubing for proper drainage and positioning…Encourage fluids…Indwelling catheter care every shift and as needed…Irrigate catheter as ordered…Keep drainage bag of catheter below the level of the bladder at all times and off floor…Labs as ordered…Monitor and report S&S (signs and symptoms) of UTI: changes in color, odor, or consistency of urine, dysuria, frequency, fever, pain… … Urinary Tract Infection (UTI), potential due to: recurrent urinary tract infections, indwelling foley catheter 7/7/22…Goal: will remain free of urinary tract infections…Interventions: Encourage fluids unless contradicted…Encourage fluids until urine is light yellow in color…Enhance barrier precautions…monitor and record foley output every shift…Notify practitioner if symptoms worsen or do not resolve…Observe and report signs and symptoms of UTI: changes in color, odor or consistency of urine, dysuria, frequency, fever, pain…Provide indwelling catheter care every shift and as needed. Secure catheter and tubing appropriately…” R4’s Kardex states, in part:…Monitor foley output, if reduced, change PRN (as needed) to decrease feelings of urgency…Monitor and report S & S (signs and symptoms) of UTI: changes in color, odor, or consistency of urine, dysuria, frequency, fever, pain… R4’s July 2025 output on Treatment Administration Record (TAR) states in part:…21st DAY: plus sign, EVENING: plus sign, NIGHT: plus sign. 22nd DAY: plus sign, EVENING: Blank, NIGHT: 50. 23rd DAY: 350, EVENING: 900, NIGHT: 420. 24th DAY: 550, EVENING: plus sign, NIGHT: plus sign. 25th DAY: 700, EVENING: Blank, NIGHT: Blank. 26th DAY: plus sign, EVENING: 450, NIGHT: 120. 27th DAY: Blank, EVENING: 300, NIGHT: 200. 28th DAY: 250, EVENING: plus sign, NIGHT: 400…R4’s documentation on task charting states in part:…23rd, 24th, 25th, 26th, and 28th are double documented showing an incorrect total. R4’s documentation for the 27th is Blank. Of note, staff were charting plus signs instead of an output amount, therefore it is unknown how much urine R4 had out each day. There is no documented nursing assessment of R4’s urine output. On 8/13/25 at 8:52 AM, NHA A (Nursing Home Administrator) indicated the plus signs on R4’s output documentation indicates positive output. NHA A indicated the documentation should have an actual amount for output. NHA A indicated they have started education with staff on correctly documenting on the output forms. R4’s July 2025 intake documentation states in part:…23rd Total 750cc, 24th Total 640cc, 25th 900cc, 26th 240cc, 27th 360cc, and 28th 600cc… R4’s July 2025 meal intake indicates in part:…26th Breakfast NPO (which indicates nothing by mouth.) Breakfast and Lunch documentation shows that R4 needed full staff assistance for meals. It is important to note this is a change from the rest of the month. Supper: blank. July 27th Breakfast 50%, Lunch and Supper Blank. July 28th Breakfast 75%, Lunch 25% with full assistance needed, Supper Blank…. R4’s Progress notes, state, in part:…7/26/25, Author LPN L (Licensed Practical Nurse) …Foley catheter patent with 600 cc (cubic centimeters) dark yellow urine, staff report concern “he’s been more sleepy lately.” He has remained in bed with the exception of ADLs (activities of daily living) and bed sheets being changed. Arouses easily. At meals in bed with HOB (head of bed) elevated. Fluids encouraged. Staff report concern of his left elbow, PROM (passive range of motion) with c/o (complaints of) discomfort and facial grimacing when left arm extended away from his body. Elbow appears swollen. Resident has advanced dementia and unable to indicate any cause of injury, harm, or recent fall/incident. Does not appear fearful of staff during assessment. Call placed to [Physician name] with an order for an x-ray to r/o (rule out) injury… On 8/12/25 at 11:20 AM, in interview with Surveyor, LPN L (Licensed Practical Nurse) indicated a Certified Nursing Assistant (CNA) had reported R4 was lethargic and staying in bed more. LPN L indicated that the noc (night) nurse on 7/25/25 would have been the nurse to report the concerns if they were reported to the doctor. LPN L indicated she requested an x-ray on R4’s elbow and that was what her message was to the doctor on the 26th. LPN L indicated the Registered Nurse (RN) on 7/29/25 sent R4 out by ambulance. LPN L indicated notifications and assessments should be completed if there is a change in condition with a resident. There was no documented RN assessment of R4’s condition on 7/26, 7/27, or 7/28/25. Facility documentation states in part:…On 7/29/25 vitals were taken on resident on 7/29/25, showing a slight temperature of 99.6F (Fahrenheit), blood pressure 141/81. Resident was lethargic (lack of energy/decreased alertness) and appeared unwell. POA (Power of Attorney) was contacted, and it was determined that resident should go to the emergency room. Resident was transported via ambulance and was seen in emergency room and admitted to the hospital. Resident passed on 8/1/25 due to sepsis. Hospital notes state: R4 presented to the hospital on 7/29 with bacteremia UTI, severe sepsis, catheter associated urinary tract infection, acute respiratory distress, chronic indwelling foley catheter. Can not talk and history is very limited…. R4 hospital course included antibiotics for bacteremia and urinary tract infection. Patient initially presented with confusion and lethargy from [Name of facility]. Patient remained relatively unresponsive despite treatment of severe sepsis. Decision made to withdraw care on 7/31. Patient expired on 8/1. Comfort measures including morphine and Ativan. MD notes state: in my opinion, R4’s cause of death was severe sepsis, bacteremia, acute respiratory distress, UTI… On 8/14/25 at 8:20 AM, in interview with Surveyor, RN R indicated she was the nurse working on 7/29/25 and she sent out R4 by ambulance. RN R indicated staff told her that R4 “didn’t look right.” RN R indicated she took R4’s vitals. R4 had a slight temperature, but everything else looked fine. RN R indicated it also concerned her because R4 had a catheter, and it was always dragging on the ground or wrapped around a wheel because R4 had advanced dementia. RN R indicated she also decided to send R4 out because of the wound on his toe. RN R indicated she was not familiar with R4 because she had only worked with him a couple times. On 8/12/25 at 11:45 AM, in interview with Surveyor, CNA M indicated she noticed changes in R4 prior to 7/29/25. CNA M indicated she noticed that R4 was sleeping more, lethargic, urine was not as clear, and that he was just staying in bed more. CNA M indicated she did report these changes. CNA M indicated on 7/29/25, R4 was not responding, was having difficulty breathing, and he just didn’t seem to be himself. CNA M indicated she reported on the 29th as well. CNA M indicated she also reported the concern with the band aid on R4’s toe and that the toe was red. CNA M indicated prior to the changes with R4 he was up and down a lot, self-transferring and he would be out in the common area. On 8/12/25 at 2:00 PM, in interview with Surveyor, CNA N indicated she was told by her coworker that R4 was more lethargic and just not himself around 5 days before being sent out on the 29th. CNA N indicated a coworker that had worked the weekend prior told her R4 was lethargic all weekend. CNA N indicated she saw R4 on 7/29/25 because she was helping down his hallway. CNA N indicated R4 had labored breathing and was not responding to staff on the 29th. On 8/12/25 at 3:20 PM, in interview with Surveyor, CNA O indicated she was probably the first person to notice a change in R4. CNA O indicated she believed it was around the middle or end of July. CNA O indicated she has worked with R4 for a few years now. CNA O indicated R4’s norm was he would wander all over the building, he would be in and out of bed, sit at the nurses’ station, and was very happy. CNA O indicated R4 was very tough on his catheter and tubing. CNA O indicated R4 would forget about it and end up tugging it hard. CNA O indicated she noticed R4 wouldn’t get out of bed, had loose stools, not responding when staff would say his name, not eating as well, and face was flushed. CNA O indicated she saw his elbow and foot as well. CNA O indicated both had been reported to nursing timely. CNA O indicated she reported R4’s changes to the previous DON (Director of Nursing), LPN L, and LPN E. On 8/13/25 at 10:00 AM, in interview with Surveyor, LPN E indicated he had multiple days off prior to R4 being sent out on the 29th. LPN E remembers CNA O reporting that R4 had been tugging at his catheter tubing. LPN E indicated R4 would self-transfer, was very pleasant, was on 15-minute checks, would eat well, hang out at the nurses’ station, and was easy to care for. On 8/13/25 at 10:15 AM, in interview with Surveyor, CNA P indicated when she first started working at the facility R4 was in and out of his room and self-transferring. CNA P indicated she noticed a change in him around 7/23/25 and over the weekend (which would be 7/25 and 7/26/25) prior to R4 being sent out on the 29th. CNA P indicated R4 had loose bowel movements for 3 days prior to being sent out, declined, appetite changed, needed more assistance, urine was a red/brown tint color, and a decline in output. CNA P indicated she did report the change in condition to LPN L. CNA P indicated she felt like staff were making R4 get up in his wheelchair and go to activities. CNA P indicated, “I felt like it was not appropriate to keep getting him up.” On 8/13/25 at 10:47 AM, in interview with Surveyor, PA Q (Physician Assistant) indicated she saw R4 on 7/28/25 for his toe. PA Q indicated staff did not report any other changes in condition to her. PA Q indicated she had only seen R4 once or twice before the visit on 7/28/25. PA Q indicated she would expect staff to report all changes in condition. On 8/14/25 at 12:16 PM, in interview with Surveyor, NP S (Nurse Practitioner) indicated she does not remember being notified of any changes of condition with R4. NP S indicated she would expect to be notified of a change of condition with a resident. On 8/13/25 at 11:53 AM, in interview with Surveyor, NHA A (Nursing Home Administrator) indicated she had known about the concern with R4’s elbow. NHA A indicated she was on vacation from 7/19/25-7/27/25. NHA A indicated RN R sent R4 out on 7/29/25, NHA A indicated Power of Attorney stopped at the facility after R4 went out and indicated R4 was not doing well. NHA A indicated she called the hospital Friday, and hospital returned her call on Saturday. NHA A indicated the hospital told her R4 had passed away due to sepsis. NHA A indicated she started a self-report investigation because R4 was diagnosed with sepsis and passed away. NHA A indicated she did not interview any staff and did not complete any audits. NHA A indicated she would look for any more documentation regarding MD notifications during R4’s change in condition and prior to being sent out on 7/29/25. NHA A indicated she would expect nursing to report changes in condition to primary physician and complete assessments. On 8/13/25 at 3:00 PM, in interview with Surveyor, DON B (Director of Nursing) indicated they will be doing education on documenting input and output. DON B indicated moving forward DON B will be the one responsible to review totals and documentation. DON B and NHA A indicated they do not know who is responsible right now for reviewing daily output totals and input documentation. DON B indicated output documentation should be an actual amount and not a plus sign or blank. DON B indicated if there is a change in a resident’s appetite and how much they are eating/drinking it should be documented, and proper notifications should be made to primary physician. DON B indicated nursing assessments should be completed timely as well. DON B indicated she would look for any documentation for physician notification prior to 7/29/25. DON B indicated an appropriate daily fluid intake would be 2,000ml unless the resident is on a fluid restriction. DON B indicated this could be found in the resident dietary assessment. It is important to note, DON B provided Surveyor with R4’s dietary assessment. The document does not include R4’s recommended daily fluid intake. On 8/13/25 at 5:00 PM, in interview with Surveyor, NHA A (Nursing Home Administrator) indicated understanding of the above concerns. NHA A indicated they would start change of condition education with staff immediately. The facility’s failure to ensure each resident received the necessary care and services in accordance with professional standards of practice when R4 experienced a change in condition created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy that began on 7/26/25. The facility removed the immediate jeopardy on 8/18/25 when the facility implemented the following action plan: -All nursing staff to be educated prior to next working shift, including agency on the following: 1) On 8/14/25 and 8/15/25 DON completed education on recognition of change of condition. If a resident is found to have a COC (Change of Condition), the staff will immediately report the COC to the nurse. The nurse will immediately perform a head to toe assessment and immediately notify the PCP of the findings. 2) On 8/14/25 and 8/15/25 DON completed education to staff on how to recognize a change of condition including changes in mental status, decreased intake or output, changes in urine color or output, talks or communicates less, pain, which is new or worsening, swollen legs/feet, tired, weak, changes in skin color. Use the stop and watch warning tool. 3) On 8/14/25 and 8/15/25 DON provided education when staff have recognized a possible COC they will report it to the nurse immediately. The nurse will do a full assessment including vitals, pain, GI (Gastrointestinal), respiratory symptoms, cardiac symptoms, GU (Genital Urinary) symptoms, call the MD immediately, follow directions of MD, document the change of condition, notify the POA/MCO (Power of attorney/Manage Care Organization), continue to monitor until resident returns to baseline or is sent for further evaluation. Complete documentation needs to be in resident’s charting, as well as in the 24-hour board binder and reported off to next shift. 4) On 8/14/25 and 8/15/25 DON provided education to the nurses on how to complete an assessment, including a head to toe review that includes vitals, pain, GI, respiratory, cardiac, GU symptoms, and immediately notify the MD regarding assessment. Continue to monitor until resident returns to baseline or is sent for further evaluation. Complete documentation needs to be in resident’s charting, as well in the 24-hour board binder and given in report to next shift. 5) On 8/14/25 and 8/15/25 DON provided training on properly recording the fluid cc’s of each resident on each shift including the intake of food %. CNA that is assigned to the dining room will record all the intakes on the clipboard and will then record any residents who have chosen to eat in their rooms or ask designee to record. CNA is responsible for charting this information into the resident’s chart on each shift. 6) On 8/14/25 and 8/15/25 DON provided education on recording the intakes by using the spreadsheet for each meal. Properly documenting in the residents chart and noting through out the day if the amount is off baseline and immediately report that to the nurse. 7) On 8/14/25 and 8/15/25 DON provided education to report immediately to the nurse if the resident’s intake or output has decreased. 8) On 8/14/25 and 8/15/25 DON provided education on the 24-hour board binder and the proper recording of COC of resident to be reviewed during report off. -8/14/25 completed a sweep of the building for any changes in condition. -8/14/25 reviewed policy related to changes of condition, notification of changes policy. -8/14/25 24-hour board binder implemented for monitoring. This binder will be collected and brought into stand up and reviewed. -8/14/25 implement process for monitoring fluid intake and output and when to notify MD/NP. -8/14/25 head to toe and system specific system reviewed for I and O. -8/14/25 implemented system to report off resident COC to next shift. -Audits: 1) The DON or designee will conduct 4 audits weekly for 4 weeks, then review at QAPI (Quality Assurance Performance Improvement) for ongoing monitoring of charting for COC, documentation. 2) The DON or designee will conduct 4 audits weekly for 4 weeks of the 24 hour report for properly completed and documented assessments and MD notification immediately. 3) The DON or designee will conduct 4 audits weekly for 4 weeks on the audit charting to ensure COC are recognized, assessments completed, and MD notification. 4) The DON or designee will conduct 4 audits weekly for 4 weeks on the intake sheets and proper documentation in charts. 5) The DON or designee will conduct 4 audits weekly for 4 weeks of output documentation and proper reporting of inadequate output. 6) The DON or designee will conduct 4 audits weekly for 4 weeks of the intake sheet and proper documentation and proper reporting of decreased intake. 7) The DON or designee will conduct 4 audits weekly for 4 weeks on proper reporting the COC to the next shift. -All facility actions, education and audits will be reviewed at QAPI. 2. R5 was admitted to the facility on [DATE] with diagnoses including, but not limited to, cystitis (inflammation of the bladder often caused by a urinary tract infection), muscle wasting and atrophy (decrease in size and wasting of muscle tissue). On 7/22/25, the physician ordered a urinalysis culture and sensitivity (UAC&S) for dysuria f/u (follow up) recent UTI (urinary tract infection). On 7/23/25 the physician examined R5. Reason for visit: Anemia, Multiple wounds, self-neglect, failure to thrive. No complaints apart from patient concerned that she has another UTI. On 7/23/25 LPN K (Licensed Practical Nurse) obtained R5’s urine sample via straight catheterization and sent the sample to the hospital laboratory for testing. The physician did not order a straight catheter urine sample. Of note, RN’s (Registered Nurses) and LPN’s (Licensed Practical Nurses) may not perform a straight catheterization without a physician’s order. On 7/24/25, the physician ordered the following medication: Macrobid oral capsule 100 mg (milligrams) – Give 1 capsule by mouth two times a day for UTI for 7 days. On 7/24/24 at 4:00 PM, R5 received the first dose of Macrobid. On 7/25/25, R5’s UAC&S results documented the following: Colony count > (greater than) 100,000 CFU/ml (colony forming units per milliliter) gram negative rods isolated. See ID (Infectious Disease) and sensitivity. On 8/12/25 at 10:05 AM, Surveyor spoke with R5. During the conversation R5 stated, LPN K (Licensed Practical Nurse) straight catheterized her to obtain a urine sample. R5 stated, “It was so painful and caused a fierce burning.” R5 stated, LPN K attempted to obtain a urine sample twice. R5 stated, the first time there was a very small amount of urine. R5 stated, the second sample contained bowel movement and was contaminated. R5 stated, after the second attempt, LPN K straight catheterized her to obtain the urine sample. On 8/13/25 at 12:00 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, is it your expectation that staff obtain a physician order before performing a straight catheterization on a resident. DON B stated, yes. Surveyor stated, LPN K obtained R5’s urine sample via straight catheter. Surveyor asked DON B, would you expect LPN K to have a physician’s order to straight catheterize a resident. DON B stated, yes. DON B stated, LPN K should not be utilizing straight catheterization to obtain a urine sample without a physician’s order. Facility policy entitled 'Wound Management,' undated, states in part: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Wound treatments will be provided in accordance with the physician orders…, Treatment decisions will be based on etiology of the wound. i. pressure injuries will be differentiated from non-pressure ulcers, such as arterial, venous, diabetic, moisture or incontinence related skin damage. ii. Surgical iii. Incidents (i.e. skin tear, medical adhesive related skin injury) iv. Atypical (i.e. dermatological or cancerous lesion, pyoderma (skin disease caused by bacteria) Characteristics of the wound: i. Pressure injury stage (or level of tissue destruction if not a pressure injury) ii. Size – including shape, depth, and presence of tunneling and/or undermining iii. Volume and characteristics of exudate iv. Presence of pain v. Presence of infection or need to address bacterial bioburden vi. Condition of the tissue in the wound bed vii. Condition of peri-wound skin. The facility will follow specific physician orders for providing wound care. Treatments will be documented on the Treatment Administration Record. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: Lack of progression towards healing. Changes in the characteristics of the wound. On 7/2/25, R5’s hospital discharge paperwork documents she has chronic wounds. There is no further detail. The facility did not complete an admission skin assessment. R5’s Certified Nursing Assistant (CNA) Kardex indicates, in part, as follows: Mobility: I am unable to walk; I need limited assistance of 1 and help lifting legs in and out of bed and rolling. I use a wheelchair for locomotion, and I am independent to get around the facility. ADL’S (Activities of Daily Living) I need limited assist of 1 for lower and upper dressing. I need set-up to perform my personal hygiene. The facility has no documentation of an initial care plan prior to 7/21/25. R5’s comprehensive care plan indicates, in part, as follows: (Date Initiated: 7/21/25) Pressure ulcer at risk due to: Assistance required in bed mobility, bowel incontinence, Braden Score 18. Goal: Will remain free from further breakdown. Interventions: Complete Braden Scale; Provide pressure reducing wheelchair cushion; Provide pressure reduction/relieving mattress; Provide thorough skin care after incontinent episodes and apply barrier cream; Referral to Therapy; Skin assessment to be completed per Living Center policy; Treatments as ordered. Note, all interventions were added 7/21/25. R5’s Braden scores are as follows: On 7/27/25, R5’s Braden score: 18 (Mild risk for pressure injury development) It is important to note, an agency nurse, that is no longer employed at the facility, was previously completing weekly wound measurements and assessments. It is important to note, weekly measurements and assessments were not being completed. There is no assessment of R5’s wounds, only periodic hand-written measurements that do not clarify tunneling from depth. R5's weekly wound measurements and assessments are as follows: Left Thigh Hip 7/7/25: 5.5 x 1.7 x 2.6 tunneling 7/14/25: 2.4 x 0.5 x 0.3 7/21/25: 3.0 x 1.5 x tunnel (no measurement) Left Thigh 7/7/25: 3.2 x 0.7 x 0.5 tunnel 7/14/25: 3.2 x 1.0 x 2.0 7/21/25: 0.5 x 0.5 x 0.1 Left Shoulder 7/14/25: 2.5 X 1.5 Right Second Toe 7/14/25: 0.2 x 0.2 7/21/25: 0.5 x 0.3 Right Great Toe 7/14/25: 0.5 x 0.3 R5’s physician orders for wounds are as follows: 7/5/25 Wound Care Left Posterior Shoulder – Cleanse wound, and peri wound area with wound cleanser, pat dry; Paint wound with betadine; Leave OTA (open to air) – every day shift 7/5/25 Wound Care Right Foot – First/Second Toe – Cleanse wound with wound cleaner. Pat dry; Paint with Betadine; Leave OTA (open to air) – every day shift 7/7/25 Wound Care Left Lateral Hip – Cleanse wound, and peri wound with wound cleanser. Pat dry: Pack wound with iodoform gauze packing strips or sterile gauze FLUFFED; Cover with gauzed border dressing – island dressing - every day shift 7/31/25 Referral to wound care clinic. *Left hip wound with tunneling 8/8/25 Change wound dressing to 3x (times) week. Cleanse wound and apply dressing such as Mepilex – every day shift Monday, Wednesday, Friday for wound care On 7/31/25 R5 was seen by a PA (Physician Assistant). The PA documented Reason for visit: Advanced Directives Plans: Anemia, Multiple wounds,

Based on interview and record review, the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 3 out of 18 sampled residents (R2, R16, and R18.) R2 reported to staff that she swallowed a toy stress ball. Staff did not call poison control to gain information on the toxicity of the contents within the ball. Staff did not complete a Registered Nurse assessment that included respiratory assessment, abdominal assessment, or pain assessment. Without having the ball back in possession, staff reported to R2's Nurse Practitioner (NP) that the ball was retrieved. R2 reported she asked to go to the hospital and laid in bed worrying about the ball overnight while staff did not make arrangements for R2 to go to the hospital until the next morning. Staff did not follow orders given by R2's NP to monitor R2 closely. The facility failed to update R2's Comprehensive Care Plan to prevent further occurrences. R2 was found to have a high-grade small bowel obstruction that required surgical intervention, necessitating a 6 day hospitalization . R16 went to the emergency room for abdominal pain and was noted to have cellulitis to R16's right third toe. R16 was ordered an antibiotic. The facility did not start the antibiotic timely. The facility did not monitor, assess, or document on R16's cellulitis on his right third toe. R16 was then seen by podiatry who noted R16 had wet and dry gangrenous changes with malodor to his right third toe. Podiatry ordered an x-ray which revealed possible acute osteomyelitis involving the right third toe, correlating with site of wound. Podiatry had ordered wound care for the right third toe. The facility did not complete wound care, did not measure, and did not assess R16's right third toe wound. R16 had all 5 toes from his right foot amputated. R16's care plan was not updated and did not reflect the infection, wound, or amputations. R18 developed a vascular ulcer on the right lateral leg. Staff failed to transcribe wound orders to the February TAR (Treatment Administration Record), failed to complete multiple treatments in February, March, and April, did not complete weekly wound assessments and measurements, failed to transcribe new antibiotic orders to the TAR, which delayed antibiotic administration for four days, and failed to develop a person-centered care plan for R18's vascular leg ulcer. R18's VLU (vascular leg ulcer) deteriorated and became infected. R18 was hospitalized for cellulitis requiring intravenous antibiotics. The facility's failure to provide care consistent with standards of practice for R2, R16, and R18 by not completing an RN assessment with a change of condition, not following orders, not completing diabetic foot checks, wound assessments, transcribing wound treatments and medication orders into the TAR (Treatment Administration Record) and MAR (Medication Administration Record), not completing weekly comprehensive wound assessments, not completing wound treatments or initiating antibiotics timely, and failing to send residents to the hospital timely created a finding of immediate jeopardy that began on [DATE]. Surveyor notified Nursing Home Administrator (NHA A) and Director of Nursing (DON B) of the immediate jeopardy on [DATE] at 4:52 PM. The immediate jeopardy was removed on [DATE], however, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Evidenced by: Facility policy titled Notification of Changes, implemented [DATE], includes: It is the policy of this facility that changes in condition are immediately shared with the resident and the resident representative, according to their authority, and reported to attending physician or delegate . The resident and/or their representative will be educated about treatment options and supported to make an informed choice about care preferences when there are multiple care options available. All pertinent information will be made available to the provider by the facility staff . requirements for notification of resident the resident representative and their physician: an accident involving the resident, which results in injury and has potential for requiring physician intervention . According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s (Licensed Practical Nurse) or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. According to N6.04(1), In the performance of acts in basic patient situations, the L.P.N. shall, under the general supervision of an R.N. or the direction of a provider . (b) Provide basic nursing care. (c) Record nursing care given and report to the appropriate person changes in the condition of a patient . (e) Perform the following other acts when applicable: 1. Assist with the collection of data . Example 1 R2 admitted to the facility on [DATE] with diagnoses including, but not limited to, dysphagia (difficulty swallowing), respiratory failure, and disorder of psychological development. R2's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of [DATE] indicates R2's cognition is intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15. On [DATE] at 8:37 AM, Surveyor observed R2 coughing while eating her breakfast meal. R2 indicated she has trouble swallowing and in [DATE] she choked on and swallowed a stress ball that was given to her by staff. On [DATE] at 12:35 PM during an interview, R2 indicated she begged the facility to send her to the hospital and she laid awake all night worrying about the ball exploding in her stomach. R2 stated, I could have died . I almost had it stuck in my throat, but then it went down to my stomach. I kept telling them they should get me to the hospital. R2 indicated this event scared her and has caused her a lot of grief, including the need for surgical intervention and six days in the hospital. R2 indicated she was unsure why she put the stress ball in her mouth, but she supposed it was soothing on her gums. R14 was eating at the table with R2 during this interaction and she joined the interview. R14 stated, She is telling the truth. I am an eyewitness. They told her no in front of me. She wanted to go to the hospital. R2 then stated, I wanted to go. They wouldn't let me. I was begging. (Of note: R14 admitted to the facility on [DATE]. Her most recent MDS with ARD of [DATE] indicates R14's cognition is intact with a BIMS score of 15 out of 15.) (Of note, per R2 and R14, R2 was not sent to the hospital on [DATE] per her request.) R2's Medical Record contained the following: Face sheet: indicates R2 is her own responsible party/own decision maker. Nurse Practitioner Note, created on [DATE], effective date [DATE] at 5:24 PM, includes: late entry . Reason for call - paged by nursing to discuss an incident of the resident reportedly swallowing a stress ball. The patient accidentally swallowed a stress ball while playing with it in her mouth. The stress ball was retrieved without apparent damage. The patient denies swallowing any other objects. She admits to swallowing one stress ball in clear encasing with white and blue beads in it. The patient denies any signs or symptoms of distress. Vitals remain stable. Plan: Continue to monitor the patient closely for any changes in signs or symptoms. Nursing given orders to page immediately with changes in patient vital signs or condition . (Of note, this note indicates the stress ball was retrieved without apparent damage, when the stress ball was not retrieved by staff. There is no indication if R2 was offered to go to the hospital or if R2 requested to go to the hospital.) On [DATE] at 1:08 PM, NP J (Nurse Practitioner) indicated on [DATE] she was paged by the facility regarding R2 swallowing a stress ball. NP J indicated staff reported to her that they retrieved the ball after R2 swallowed it. NP J indicated she was under the assumption that R2 no longer had the ball inside of her and gave orders for monitoring R2. NP J indicated her expectations for monitoring are the staff complete respiratory and abdominal assessments as well as check resident vitals every 30 minutes to one hour. Then once these are normal 2 times, staff will complete respiratory and abdominal assessments and check vitals every 2 hours. Once these are normal 2 times, staff can do abdominal assessments, respiratory assessments, and check vitals every 4 hours. NP J indicated on [DATE] around 10:00 AM she was paged again regarding R2 having pain in her stomach and at this time she still believed staff retrieved the ball but gave orders to send R2 to the emergency room due to her high pain rating. NP J stated, I thought she did not swallow the ball. I was surprised she had to go out and then surprised she needed surgery. Change In Condition form, dated [DATE] at 2:41 AM, includes: . Blood pressure: ,d+[DATE] recorded on [DATE] at 8:30 PM in lying position . Pulse: 66 recorded on [DATE] at 8:49PM . Respirations: 20 recorded at 8:49 PM . Temperature: 97 degrees Fahrenheit . route forehead recorded [DATE] at 8:50 PM . Weight: 169.7 pounds recorded on [DATE] at 12:59 PM . Pulse oximetry: 98% recorded on [DATE] at 8:51 PM . Code Status: Full code . Behavioral Status Evaluation (blank) . Respiratory Status Evaluation: (blank) . Abdominal Status Evaluation: (blank) . Pain Status Evaluation/Does the resident have pain: (blank) . Nursing observations, evaluation, and recommendations are: Resident informed myself and another resident of swallowing an object. No respiratory distress noted at this time and during the shift. Resident also stated that she is well aware of the object and states, I was just playing around and put it in my mouth, chewed it, and it was stuck in my throat. I drank pop and it went down into my stomach. Resident asleep and provider, DON B, and family notified. Recommendations: (blank) . New Testing Orders: (blank) . New Intervention Orders: (blank) . (It is important to note this assessment is incomplete as it does not contain orders given by R2's Nurse Practitioner, and is signed by a Licensed Practical Nurse (LPN), not a Registered Nurse (RN). There is no indication an RN assessed R2. There is no indication if R2 was offered to go to the hospital. There is no evidence poison control was contacted.) Nurses Note, dated [DATE] at 3:56 AM, includes: Resident no apparent respiratory distress at this time and no signs of discomfort. Resident asleep and vitals to monitor signs and symptoms after incident are taken every 2 hours as directed (It is important to note the facility failed to provide evidence of R2's vitals being monitored. R2's medical record did not contain documentation of vitals being taken every 2 hours.) Nurse Practitioner Note, created [DATE], effective date [DATE] at 10:00 AM, includes: Late entry . I was paged by nursing regarding R2 who is experiencing stomach pain. Stomach pain rated 9 out of 10. Patient consumed a stress ball yesterday. Patient believes the entirety of the stress ball was retrieved and denies swallowing anything other than the stress ball. No further complications reported initially. Vitals have been stable. Next steps or changes to the plan: Send R2 directly to emergency room due to consumption of a foreign object and current stomach pain. Nurses Note, dated [DATE] at 10:45 AM, includes: resident swallowed a stress ball on [DATE] during supper time. Resident denied emergency room visit. Nurse Practitioner ordered to monitor. [DATE] at approximately 10:00 AM resident complained of severe abdominal pain verbally rating 9 on pain scale zero to ten. Placed resident on toilet. Defecated without object present. Notified Nurse Practitioner. Ordered to send out. Telephoned emergency medical services. Called report to emergency department's registered nurse . Resident is own person. DON B notified . At time of departure resident was alert and oriented times 3. Respirations were even and nonlabored. Continues to rate abdominal pain 9 out of 10. Vitals: ,d+[DATE], 82, 97%, 18 . Change In Condition form, dated [DATE] at 10:45 AM, includes: . Blood pressure-,d+[DATE] . position lying . recorded on [DATE] at 10:51 AM, Pulse- 82 recorded on [DATE] at 10:52 AM, oxygen saturation- 98% recorded on [DATE] at 8:51 PM, respirations- 20 recorded on [DATE] at 8:49 PM . Temperature- 97.0 recorded on [DATE] at 8:50 PM . Route- forehead . Code Status: Full code . Respiratory Status Evaluation: (blanks) . Abdominal Status Evaluation: (blank) . Pain Status Evaluation/ Does the resident have pain: Abdominal pain . Recommendations: Send to emergency room . (It is important to note this assessment is incomplete and does not contain an abdominal assessment with bowel sounds or a description of any distention. The assessment also does not contain a respiratory assessment. The vitals on this assessment were recorded approximately 14 hours prior to this evaluation and the assessment is signed by an LPN and not an RN.) Emergency Department Note, dated [DATE], includes: date of service [DATE] . Stated complaint: Abdominal pain status post eating a stress ball on [DATE] . History of diabetes, hypertension, hyperthyroidism presenting for evaluation of foreign body ingestion. Patient reports earlier this morning she swallowed a . stress ball. Patient reports she is having abdominal pain and feeling nauseous. Patient denies episodes of emesis. Patient is not forthcoming on why she ate the stress ball. Active problems: foreign body in small intestine, complete small bowel obstruction . A complete review of 10 systems was performed including: . respiratory . GI . Physical exam: . Abdomen- Soft periumbilical tenderness with slight distension . Radiology: X-ray abdominal series impression: . single segment of dilated small bowel of concern for developing obstruction given the clinical context provided . Emergency Department Course and Medical Decision Making: . patient is with periumbilical abdominal pain as well as slight distension. Abdominal series X-ray revealed evidence of possible developing bowel obstruction. CT abdomen pelvis was obtained which revealed evidence of a high grade small bowel obstruction. General surgery evaluated patient. Emergency Department recommended NG tube placement as well as emergent operative management. Impression: high grade small bowel obstruction secondary to foreign object . Medical Imaging Note, dated [DATE] includes: Provided indication: foreign body ingestion of a stress ball . Findings: . a single segment of small bowel distension is seen within the leftward abdomen crossing to the right of midline measuring up to 4.6 centimeters in caliber. No radio opaque foreign body detected. The bowel gas pattern is non obstructive. Stool burden is normal . Comparison Abdominal X-ray from earlier same day. Indication: patient ingested a whole stress ball and abdominal X-ray with concern for developing small bowel obstruction. Technique: CT was obtained through the abdomen and pelvis without contrast in the axial plane, reconstructed using bone and soft tissue algorithms and reformatted in coronal and sagittal planes. Findings: Bowel and Peritoneal Cavity: there is an acute high grade small bowel obstruction due to a 3.5 x 4.8 x 5.0 centimeter ball shaped foreign body, which contains air and multiple small radiopaque beads . located in the jejunum in the left abdomen. The distal small bowel is decompressed. No bowel perforation. Impression: acute high grade small bowel obstruction due to a 5 centimeter ball shaped foreign body in the jejunum in the left abdomen, consistent with the clinical history of swallowed stress ball. No bowel perforation. Hospital Note, dated [DATE], includes: . Female presents for evaluation who presents for evaluation of abdominal pain. Patient ate a stress ball today. She is unable to explain to me why she ate the stress ball. CT shows acute high grade small bowel obstruction. Surgery found the patient to have a laparostomy with lysis of adhesions and enterotomy with removal obstruction foreign body consistent with a stress ball. Patient admitted to Intensive Care Unit for further recovery . Patient presents . is admitted for small bowel obstruction after ingesting a stress ball that had to be surgically removed. Currently NPO (nothing by mouth) with NG (nasal gastric) tube. General Surgeon is on consult monitoring for possible resection if bowel health does not improve . Hospital Note, dated [DATE], includes: Assessment: Small bowel obstruction due to foreign body- status post laparostomy with lysis of adhesions and enterotomy with removal of obstructing foreign body. Blood loss anemia- hemoglobin down trending today to 7.8 from 8.7. Has now received a total of 2 units of packed red blood cells . Patient is feeling much better . Hospital Note, dated [DATE], includes: discharge date [DATE] . R2's Comprehensive Care Plan, reviewed [DATE] and initiated on [DATE], does not include a focus, goals, or interventions related to placing objects in her mouth or swallowing a foreign object. (It is important to note the facility did not update R2's care plan to include interventions related to monitoring for R2 putting other things in her mouth after this event or a goal related to preventing future occurrences.) On [DATE] at 9:00 AM R2 stated, I got the stress ball from the activity department. It was at least 2 inches in diameter. Maybe bigger. I couldn't believe it went down my throat. On [DATE] at 10:15 AM, CNA H (Certified Nursing Assistant) indicated she worked the morning shift after R2 swallowed the stress ball. CNA H indicated she was made aware of R2 swallowing the stress ball at the start of her shift in morning report. CNA H indicated after breakfast R2 complained of having a lot of pain in her stomach. CNA H indicated she assisted R2 on the toilet where R2 had a large bowel movement that did not contain any fragments of the stress ball. CNA H indicated after having the bowel movement R2 was still reporting a lot of pain. CNA H indicated other residents also won stress balls at an activity group and she was unsure if staff collected them after the incident. On [DATE] at 10:30 AM, DON B (Director of Nursing) indicated she was not present in the building on [DATE] when R2 swallowed the stress ball. DON B indicated it is her expectation that staff would follow R2's Medical Doctor's or Nurse Practitioner's recommendations/orders. DON B indicated it was about 8:30 PM when she was made aware of the incident. DON B indicated there was an LPN (Licensed Practical Nurse) working and she completed an assessment on R2. DON B and Surveyor reviewed R2's Change in Condition Assessment form dated [DATE] at 2:41 AM. DON B indicated the form does not contain a respiratory assessment, a pain rating, an abdominal assessment, or Nurse Practitioner recommendations. DON B indicated the form is incomplete. DON B also indicated LPNs can collect data, but they cannot assess residents. DON B and Surveyor reviewed NP J's (Nurse Practitioner) note. DON B indicated staff should not have reported the ball was retrieved without having some or all of its contents in hand. DON B indicated this was inaccurate information. DON B indicated Activity Director K did call the company where the product was purchased to obtain toxicity information on the contents of the stress ball, but not the night R2 swallowed it. On [DATE] at 10:45 AM, Activity Director K indicated she had a few days off and when she came back to work she was told about R2 swallowing the stress ball and needing surgical intervention to remove the ball. Activity Director K indicated this is when she called the company she purchased the balls from to inquire more about the contents of the ball and toxicity information. Activity Director K indicated staff should have called poison control the night R2 ingested the ball to find out if the liquid or the tiny balls inside the encasing of the stress ball were toxic, but no one did this. On [DATE] at 10:55 AM, DON B indicated staff should have inquired about the toxicity of the stress ball the night they became aware R2 ingested the stress ball. DON B and Surveyor reviewed R2's medical record, noting only 2 sets of vitals are recorded for R2 on [DATE] and [DATE]. DON B indicated staff should have followed NP J's recommendations for close monitoring for R2. DON B indicated this means staff should have been checking vitals every 2 hours and they should have completed abdominal and respiratory assessments. Surveyor and DON B reviewed R2's Comprehensive Care Plan. DON B stated, I should have updated R2's care plan after the incident. I will do it right now in front of you. On [DATE] at 12:35 PM, LPN I (Licensed Practical Nurse) indicated if a resident reported they swallowed a foreign object she would check the resident's airway, listen to lung sounds, palpate the resident's abdomen for pain and for distention/swelling, listen for bowel sounds, and ask the resident to rate their pain. LPN I indicated she would check the resident's vital signs and report the findings to an RN. LPN I indicated LPNs are not able to assess, but they can collect data. LPN I indicated if an NP gave her orders or recommendations over the phone she would type the order/recommendations into the resident's medical record and she would follow them. The facility failed to ensure staff followed standards of practice resulting in staff assuming R2 did not swallow a stress ball without having the ball or pieces of the ball in hand. Staff reported inaccurate information to NP J. R2 indicated she wanted to go to the emergency room and staff did not send her upon her request. Assessments were incomplete and assessments were signed off by an LPN and not an RN, staff did not call poison control to inquire about the stress ball's contents and its toxicity. Staff did not follow NP J's orders for close monitoring. R2's care plan was not updated with new interventions to prevent future occurrences, and staff were not provided education regarding these deficient practices. 49436 Example 2 The facility's policy titled Wound Management, undated, states in part: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidenced-based treatments in accordance with current standards of practice and physician orders. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. Dressing changes may be provided outside the frequency parameters in certain situations: feces has seeped underneath the dressing, the dressing has dislodged, the dressing is soiled otherwise or is wet. Treatment decisions will be based on: a. etiology of the wound: i. Pressure injuries will be differentiated from non-pressure ulcers, such as arterial, venous, diabetic, moisture or incontinence related skin damage. ii. Surgical. iii. Incidental (i.e. Skin tear, medical adhesive related skin injury). iv. Atypical (i.e. dermatological or cancerous lesion, pyoderma, calciphylaxis). b. Characteristics of the wound: i. Pressure injury stage. ii. Size - including shape, depth, and presence of tunneling and/or undermining. iii. Volume and characteristics of exudate. iv. Presence of pain. v. Presence of infection or need to address bacterial bioburden. vi. Condition of the tissue in the wound bed. vii. Condition of peri-wound skin. c. Location of the wound. d. Goals and preferences of the resident/representative. Treatments will be documented on the Treatment Administration Record. The effectiveness of treatments will be monitored through ongoing assessment of the wound. R16 admitted to the facility on [DATE] with diagnoses including diabetes type 2, closed fracture of the right tibia, fibula, and medial malleolus, (a serious ankle fracture,) and dementia. R16's comprehensive care plan printed on [DATE] does not contain a focus, goals, or interventions related to actual skin infection, wounds, or amputation. R16's Physician orders include diabetic foot check nightly at bedtime for diabetes. Start date [DATE]. R16's Treatment Administration Record (TAR) indicates diabetic foot check nightly at bedtime for diabetes. Diabetic foot checks were not completed on the following days based on R16's TARs: R16's [DATE] TAR indicated on [DATE], and 18, R16's diabetic foot checks were not completed. R16's February 2025 TAR indicated on February 7, 8, 9, 10, 24, and 27, R16's diabetic foot checks were not completed. R16's [DATE] TAR indicated on [DATE], 12, and 13, R16's diabetic foot checks were not completed. On [DATE] at 3:15 PM, Surveyor interviewed LPN W (Licensed Practical Nurse) regarding diabetic foot checks. LPN W indicated if the order was on the TAR she would have completed a diabetic foot check. Surveyor asked LPN W if she had completed a diabetic foot check for R16, and LPN W indicated she had completed diabetic foot checks for R16. LPN W indicated she could not recall anything in particular with R16's foot checks. When asked if LPN W could recall wounds or open areas to R16's feet, LPN W could not recall. LPN W indicated R16 would become agitated if staff approached him when he was in bed, so many times the diabetic foot check would be rushed and not as thorough as it should be. On [DATE] at 10:19 AM, Surveyor interviewed IDON X (Interim Director of Nursing) regarding diabetic foot checks. IDON X indicated she would expect diabetic foot checks to be completed as ordered and to be signed out in the TAR. IDON X indicated if there was an abnormality found or something unusual, there would be a progress note indicating what was found/observed. On [DATE] at 12:04 PM, Surveyor interviewed MD V (Physician). MD V indicated he would expect physician orders to be completed and followed and if not, the facility should notify the physician. On [DATE], R16 went to the ER (emergency room ). R16's ER report states in part: R16 came in via ambulance from local nursing home with a complaint of right sided .abdominal pain .Right third toe redness and swelling for the last 1 week patient denies any trauma. Currently not on any treatment for the toe. Right third toe redness and swelling with bruising seems early cellulitis to the dorsum (back) of the right foot .Impression: right foot third toe cellulitis. Disposition: Follow-up with podiatrist in 1 week, return if problem worsening or change symptoms, follow-up with primary care doctor in 3 to 5 days for recheck of abdominal pain and right foot. New prescription Keflex (antibiotic) 500 mg capsule 4 times a day for 7 days, quantity 28. R16's Physician orders include Cephalexin (antibiotic) 500 mg four times a day for infection for 7 days. Order was entered on [DATE] with a start date of [DATE]. R16's March Medication Administration Record (MAR) indicates Cephalexin (antibiotic) 500 mg by mouth for times a day for infection for 7 days. Order date on [DATE] at 9:50 AM. First dose of R16's antibiotic was given on [DATE]. Of note, R16 was seen in theER on [DATE] and was prescribed an antibiotic for cellulitis of his right third toe. The antibiotic was not started until [DATE]. On [DATE] at 10:19 AM, Surveyor interviewed IDON X regarding medication orders and implementing physician orders. IDON X stated any physician order should be processed within 24 hours even though that is not considered very expedient. IDON X indicated new orders are not always seen right away by facility staff. On [DATE] at 12:04 PM, Surveyor interviewed MD V regarding antibiotic orders and processing times for new orders. MD V indicated any order placed in the system by 5:00 pm, the pharmacy will have the new order delivered that night, any time after 5:00 pm, the pharmacy would deliver the medication the next day. Of note, the facility does not have documented assessments of R16's right third toe or the effectiveness of the antibiotic. On [DATE], R16 was seen by podiatry. Podiatrist progress note for services on [DATE] includes the following: Follow-up concern of wound infection right third toe. Unclear duration .initial wound was seen in the emergency room approximately a week ago of concern of cellulitis .no erythema (redness) along the dorsal plantar forefoot there are wet and dry gangrenous (dead tissue) changes with malodor (unpleasant odor) and slight serous drainage (thin watery fluid) to the right third toe. I discussed nature of dry and wet gangrene of how this is a combination I discussed how this may cause problems in the near future. I do not think the toe is salvageable and I do think given the wet gangrene nature of this he would likely benefit from toe amputation however due to his unclear vascular status and stable nature of the condition we will order urgent ABIs (Arterial Brachial Index) and urgent vascular referral .Gangrene associated with type 2 diabetes mellitus .I assessed the site it is currently stable I counseled them and instructed nursing staff what to look for .additional instructions: To the wound base apply (a gauze soaked in betadine wring out any extra betadine and apply especially around the bottom of the toe and secure with roll gauze and tape), change the dressing every day or as needed if it becomes soaked wet or falls off, monitor for infection. If you notice spreading redness, redness that is getting a dark angry red, the site is getting more painful or more swollen, starts to drain more or drain cloudy or bad smelling liquid then call us right away . R16's medical imaging report dated [DATE] includes the following: X-ray of frontal, lateral and oblique views of the right third digit (middle toe) .There appears to be an erosion of the cortex of the tuft of the third digit distal phalanx .possible acute osteomyelitis involving the tuft of the third digit. Correlate clinically for site of wound. R16's [DATE] TAR includes the following: Monitor for s/s (signs and symptoms) of infection. Report it to the provider. Start [DATE] discontinued on [DATE]. Facility staff signed out as being completed on [DATE] night shift, [DATE] night shift, [DATE] evening shift, [DATE] day, evening and night shifts. Of note, monitoring for signs and symptoms of infection was signed out as completed only 6 times out of 14 opportunities between when the order was written on [DATE] and when the resident was admitted to the hospital on [DATE]. R16's [DATE] TAR includes the following: Wound Care Right foot: Soaked a gauze in Betadine wring out any extras. Apply it especially around the base of the toe. Secure with roll gauze and tape. Every day shift. Start date [DATE]. Of note: Facility staff did not sign out the [TRUNCATED]

Based on observation, interview, and record review, the facility did not ensure each resident received adequate supervision to ensure each residents' environment remains free of accidents and hazards for 2 of 5 sampled residents (R17 and R1.) R17 is being cited at a scope and severity level 3 (actual harm.) R17 requires staff assistance to, in part, stand, transfer, and toilet. On 2/5/25, PT Y (Physical Therapist) recommended R17 be provided with: 1:1 supervision required due to falls and history of seizures. The facility did not implement 1:1 supervision. On 3/2/25, R17 fell and fractured his hip while self transferring from his wheelchair to bed. Surveyor observed R1's motorized wheelchair charging in his room and not behind a fire safe door. As evidenced by: The facility's policy, Falls Management Process, undated, indicates in part as follows: .The nurse will complete an event documentation report, fall risk assessment, pain assessment, and obtain witness statements. The nursing supervisor will determine the most appropriate intervention, implement and update care plan.American Medical Directors Association (AMDA.) Falls and Fall Risk Clinical Practice Guideline [NAME], MD: AMDA 2011 Example 1: R17 was admitted to the facility with diagnoses including, but not limited to, Parkinson's disease (a disorder of the central nervous system that affects movement), traumatic brain injury with loss of consciousness (a complex injury to the brain), epilepsy (seizure disorder), difficulty walking, generalized anxiety disorder (severe ongoing anxiety that can interfere with daily life), and major depressive disorder (persistently depressed mood). R17's Significant Change Minimum Data Set (MDS) dated [DATE] indicates R17 scored 9 out of 15 on his Brief Interview for Mental Status (BIMS) indicating he is moderately cognitively impaired. R17 has a guardian. R17's comprehensive care plan documents, in part: (Date Initiated: 11/16/22) (R17) has a physical functioning deficit related to: Mobility impairment, self care impairment, need for assistance with personal care. Goal: I will improve my current level of physical functioning; receiving PT (Physical Therapy) OT (Occupational Therapy) ST (Speech Therapy). (Date Initiated: 6/16/23, Revised on 3/8/25) Toileting assistance of 2 with hoyer. R17's comprehensive care plan documents, in part: Focus: At risk for falls related to: history of falls, fall 3/2/25 with right femur fx (fracture). DX (diagnoses) including parkinson's (a disorder of the central nervous system that affects movement), a-fib (an irregular rapid heart rate that causes poor blood flow), epilepsy (seizure disorder), difficulty walking, weakness, TBI (Traumatic Brain Injury) (a complex injury to the brain) .Date Initiated: 11/16/22 Goal: No Falls No serious fall related injuries Interventions: (8/19/24) Anti roll backs applied to wheelchair; (Date initiated: 11/16/22) Assess for pain; (Date Initiated: 11/16/22) Call light and personal items available an in easy reach or provide reacher; (Date Initiated: 4/20/24) Clear and monitor environmental obstacles (tubing, cords, etc.); (Date Initiated : 11/6/24) Dycem placed in wheelchair .(Date Initiated: 11/16/22) Encourage to wear footwear to prevent slipping including grippy socks to bed. (Date Initiated: 4/20/24) Keep bed locked; (Date Initiated: 4/20/24) Keep personal items in reach; (Date Initiated: 1/10/25) Placed new non-skid strips on floor at bedside; (Date Initiated: 11/8/24) Placed signage in room to remind resident to call for assist for help don't fall; (Date Initiated: 9/27/24) Scoop mattress; (Date Initiated: 10/23/24) Therapy to work with resident with reinforcing safe self transfer techniques. On 9/11/24, PT Y (Physical Therapist) documented the following for R17: Functional Skills Assessment: Sit to stand = Supervision or touching assistance; Chair/bed-to-chair transfer=Supervision or touching assistance; Toilet Transfer = Supervision or touching assistance; Justification for Continued Skilled Services: Remaining impairment. Subject (R17) sudden outbursts of frustration and struggles to transfer in a consistent manner. Prior to falling and fracturing his hip, R17 would transfer independently without having the staff assistance that he needed. R17's most recent falls are documented as follows: R17's three (3) most recent falls are as follows: R17 fell on [DATE] at 8:50 PM. The fall investigation includes the following: Incident Location: Resident's Bathroom Person Preparing the Report: A nurse (title unknown) that no longer works at the facility Incident Description: Resident found on bathroom floor after attempting to ambulate self from wheelchair to toilet. Resident is not compliant with calling for assistance when he needs help. Resident did hit head on bathroom floor, so he was immediately sent out to ED (emergency department) further evaluation being that is his second fall this week with him hitting his head. Resident had minor contusion on r (right) side of forehead when assessed skin. Resident state that there was pain all over his body when asked about where his pain was coming from. Resident Description: Resident unable to give description Was the incident witnessed: No Immediate Action Taken: Blank Resident Taken to Hospital: Yes Injuries Observed at Time of Incident: Bruise/Contusion Face Level of Pain: 10 Mental Status: Blank Injuries Report Post Incident: No injuries observed post incident Predisposing Environmental Factors: Blank Predisposing Physiological Factors: Gait Imbalance Predisposing Situation Factors: Blank Statements: No statements found Notes: Resident found down in bathroom. Nurse completed assessment and vitals. Resident was sent to ER (emergency room ) due to he hit his head during fall. Resident attempted to self transfer and fell in bathroom (root cause). Signage placed in room to remind resident to call for assist don't fall. Care plan reviewed and updated. R17 fell on [DATE] at 1:53 PM. The fall investigation includes the following: Incident Location: Resident's room Person Preparing the Report: (A nurse (title unknown) that no longer works at the facility) Incident Description: Paged to room, resident on floor sitting upright bedside bed, no apparent injuries noted, bed lowered and locked, floor free of spills and clutter, room well lit. When asked pt what happened he stated, he was trying to get up out of bed to transfer and lost his balance, pt denies pain or any discomfort, assisted off floor by CNA and DON and placed back in bed, pt was given verbal education of importance of call light usage and risks of attempting to transfer without assistance, pt verbalized understanding, will continue to observe for remainder of shift. Was the incident witnessed: No Immediate Action Taken: Resident assisted off of floor by staff and placed back in bed Resident Taken to Hospital: No Injuries Observed at Time of Incident: No injuries observed at time of incident Level of Pain: Blank Level of Consciousness: Alert Mobility: Wheelchair Mental Status: Oriented to person Injuries Report Post Incident: No injuries observed post incident Predisposing Physiological Factors: Confused, mental illness Predisposing Situation Factors: Ambulating without assist Statements: No statements found Notes: Found resident on the floor. Pain indicators noticed such as grimacing, moaning and guarding of Rt (right) hip. His Rt leg was stabilized while vital signs was taken. He was alert and oriented x2 which is his baseline. Skin was intact. Resident said he was transferring from wheelchair to bed. Provider was notified and an order was given to send resident to hospital. During questioning of CNA (Certified Nursing Assistant) on that hall resident was noted to be sitting in his wheelchair with feet elevated on his bed around 2:10 PM. Nurse helping with assessment and CNA noted wheelchair was locked and resident was not incontinent of bowel of bladder [sic]. Resident was assisted off floor with hoyer lift and more than 2 nursing staff. MD (Medical Doctor) notified and new orders received to send to ER (emergency room ) for further evaluation. 911 was called. Care plan reviewed and current interventions remain appropriate. On 2/5/25, PT Y (Physical Therapist) documented in part the following in R17's Physical Therapy note: Summary of Daily Skilled Services - Precautions: 1:1 Supervision required (falls) and history of seizures The facility did not implement 1:1 supervision for R17 or add new interventions to ensure R17's safety. R17 fell on [DATE] at 2:45 PM. The fall investigation includes the following: Incident Location: Resident's room Person Preparing the Report: (An RN (Registered Nurse) that no longer works at the facility) Incident Description: Found resident on the floor. Pain indicators noticed such as grimacing, moaning and guarding of Rt (right) hip. His Rt leg was stabilized while vital signs was taken. He was alert and oriented x2 which is his baseline. Skin was intact. Resident said he was transferring from wheelchair to bed. Was the incident witnessed: No Immediate Action Taken: Provider was notified and an order was given to send resident to hospital. Level of Pain: Negative Vocalization: Repeated Troubled Calling Out. Loud Moaning or Groaning, Crying Facial Expression: Facial Grimacing Body Language: Tensed, Distressed Pacing Consolability: Unable to Console, Distract or Reassure Mental Status: Oriented to person and place Injury: Abrasion and other Predisposing Situation Factors: Ambulating without assist Statements: No statements found Notes: Found resident on the floor. Pain indicators noticed such as grimacing, moaning and guarding of Rt (right) hip. His Rt leg was stabilized while vital signs was [sic] taken. He was alert and oriented x2 which is his baseline. Skin was intact. Resident said he was transferring from wheelchair to bed. Provider was notified and an order was given to send resident to hospital. During questioning of CNA (Certified Nursing Assistant) on that hall resident was noted to be sitting in his wheelchair with feet elevated on his bed around 2:10 PM. Nurse helping with assessment and CNA noted wheelchair was locked and resident was not incontinent of bowel of bladder [sic]. Resident was assisted off floor with hoyer lift and more than 2 nursing staff. MD (Medical Doctor) notified and new orders received to send to ER (emergency room ) for further evaluation. 911 was called. Care plan reviewed and current interventions remain appropriate. On 3/2/25, R17's hospital report documents, in part: Principal diagnosis: Hip fracture; Major Procedures: 3/3/25 R (Right) IM (Intramedullary nailing is a surgical procedure used to treat femoral fractures) nail fixation femur. R17 was hospitalized from 3/2 - 3/6/25. Of note, staff present at the time of these falls are no longer employed at the facility. Of note, PT Y recommended R17 be on 1:1 supervision. The facility did not implement 1:1 supervision or any increased supervision despite R17 self-ambulating repeatedly. On 4/17/25 at 3:10 PM, Surveyor spoke with NHA A (Nursing Home Administrator). NHA A started working as the NHA on 3/3/25 (the day after R17's fall with fracture). Surveyor asked NHA A if the facility provided education to staff following R17's fall with fracture on 3/2/25. NHA A stated he does not know what was done. NHA A stated he does not see that education was done from the documentation. Surveyor asked NHA A, would you expect education to be done with all staff. NHA A stated, With any injury, yes. Surveyor asked NHA A if therapy is recommending 1:1 supervision for R17 do you expect the facility to provide 1:1. NHA A stated yes. Surveyor asked NHA A, why would 1:1 be important. NHA A stated, if R17 gets up independently staff could redirect him to sit back down or fall softer to the ground. NHA A added, staff would redirect him to sit down before he would hurt himself. On 4/17/25 at 3:30 PM, Surveyor spoke with CNA AA (Certified Nursing Assistant). Surveyor asked CNA AA how long she has worked at the facility. CNA AA stated 3.5 years. Surveyor asked CNA AA, has R17 ever been on 1:1 supervision. CNA AA stated no. Surveyor asked CNA AA does R17 self transfer. CNA AA stated, not so much now since breaking his hip but before his fall with fracture yes he would self transfer and self ambulate. CNA AA stated, since the hip fracture R17 now transfers with a hoyer (full body lift). CNA AA stated, R17 transferred with a stand lift prior to the fall with fracture. Surveyor asked CNA AA, do you recall if the facility provided education regarding falls to you as well as other staff after R17's fall with fracture. CNA AA stated no. On 4/17/25 at approximately 4:00 PM, Surveyor spoke with CNO Z (Chief Nursing Officer). CNO Z stated, We're not accustomed to providing 1:1. CNO Z stated, we'll do it if we have to for the safety of the resident. CNO Z stated there needs to be a discussion with IDT (Interdisciplinary Team) before 1:1 is implemented. There is no further documentation as to why 1:1 was not implemented as recommended by PT Y (Physical Therapist). On 4/22/25 at 2:00 PM, Surveyor called PT Y (Physical Therapist). PT Y was not available to speak with Surveyor on 4/17/25. Surveyor has not received a return phone call. PT Y recommended R17 be provided with 1:1 supervision due to falls and history of seizures. The facility did not implement 1:1 supervision or any additional interventions to increase supervision for R17, resulting in R17 having a fall with fracture while self transferring from his wheelchair to bed. 38882 Example 2: The facility did not provide a policy and procedure for power wheelchair charging. R1 was admitted to the facility on [DATE] with diagnoses that include Type 2 diabetes mellitus with foot ulcer, muscle weakness, morbid obesity, dysphagia, pressure ulcer stage 3, nicotine dependence, mild cognitive impairment, and polyneuropathy. R1's most recent MDS (Minimum Data Set) dated 2/16/25 states R1 has a BIMS (Brief Interview for Mental Status) score of 15 out of 15, indicating R1 is cognitively intact. On 4/3/25 at 10:43, AM Surveyor observed R1's power wheelchair to be charging in R1's room. R1 disconnected his powerchair and indicated he charges his chair over there as he pointed to the outlet with the charging cord hanging from it. On 4/3/25 at 11:41 AM, NHA A and Surveyor observed R1's room where his wheelchair had been charging and where now only the charging cord was attached to the outlet. NHA A stated, The chair should not be charging in here. It should be in the charging room. NHA A disconnected the cord from the outlet and removed it from R1's room. NHA A indicated the facility does not have a policy related to power wheelchair charging.

Based on observation, record review, and interviews, the facility did not ensure each resident received adequate supervision to prevent accidents from elopements for 1 of 3 residents (R8) reviewed for accidents. R8 has a guardian and is protectively placed at the facility. R8 has a history of dementia and made comments about his desire to leave the facility. R8 left the faciity on [DATE] and hitch hiked from the facility to Prairie [NAME] and then to La [NAME]. La [NAME] is approximately 70 miles away from the facility. Facility staff were not aware R8 left the building until R8's guardian notified the facility. R8 left the building around 2:00 PM and was not located until around 7:30 PM by law enforcement. The facility's failure to provide adequate supervision created a reasonable likelihood for serious injury or harm leading to a finding of immediate jeopardy that began on 10/30/24. NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were notified of the immediate jeopardy on 12/4/24 at 12:20 PM. The immediate jeopardy was removed on 10/31/24 and corrected on 11/4/24. This is being cited as past noncompliance. Findings: The facility policy, Elopement, no date, states, in part; .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .6. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team . R8 was protectively placed at the facility on 8/8/24 with diagnoses including dementia with mood disturbance, respiratory failure, pulmonary disease, alcohol use, tobacco use, pneumonia, depression, and anxiety. Guardianship paperwork indicates incompetent because (of) degenerative brain disorder, unable to make medical and personal decisions on his own behalf. R8's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/14/24 indicates R8 has a Brief Interview for Mental Status (BIMS) score of 8, indicating R8 is moderately impaired. R8's most recent MDS with ARD of 11/12/24, indicates R8 has a (BIMS score of 11 indicating R8 is moderately impaired. R8 has an Activated Power of Attorney and is protectively placed. On 12/4/24 at 8:30 AM, SSD Q indicated a few weeks after R8 was admitted to the facility R8 kept saying he wanted to leave and that he was going to leave. SSD Q indicated R8 was put on 30-minute checks at that time. SSD Q indicated it was 9/6/24 and through the weekend. SSD Q indicated they wanted to put the extra support in place because it was a weekend and there were staff that were not as familiar with R8. SSD Q indicated on that Monday, 9/9/24, SSD Q called the guardian and guardian gave the OK to take R8 off 30-minute checks and that he could go outside alone. Surveyor asked SSD Q if any sort of assessment was completed or if the care plan was updated. SSD Q indicated these would be questions for DON B (Director of Nursing). SSD Q indicated the 30-minute checks were discontinued because they thought R8 was doing very good and not attempting to leave. SSD Q indicated R8 just wants to leave and not be at the facility anymore and the entire team is trying to find an appropriate placement. R8's progress notes, state, in part; .9/9/24 .Called Guardian to see if she would be comfortable discharging the 30 min checks we had for elopement she has agreed. She also has agreed to let him go outside by himself to smoke and to be out. It is important to note, despite the facility putting R8 on 30-minute checks for elopement, the facility did not complete a smoking or elopement assessment for R8 until after the elopement incident on 10/30/24. Facility's report to the State agency, states, in part; .date occurred 10/30/24 .Briefly describe the incident .The resident was authorized to and often sat outside in the designated smoking areas or enjoyed the resident gazebo. On October 30, 2024, at approximately 4:30pm, the facility received a call from resident guardian. Guardian stated that a bank contacted her claiming the resident was attempting to withdraw funds. The facility's corporate regional team and administrator were notified. Both the [Town name] and [City Name] police were immediately notified to assist in locating the resident. Additionally, the facility's Interdisciplinary team (IDT), [managed care organization], the medical director, and Ombudsman were informed. All contacts listed in the resident's record were contacted to determine if they knew of the resident's location. The police located the resident near his{sic} single-family residence at a friend's house about 2 hours later. The friend is caring for the resident's dog. The police transported the resident to local hospital for examination .Describe the effect .The resident was not harmed during his trip. The resident claims he was happy to see his dog and his friends. The resident claims he hitch hiked to [City name] and used a bus to get to his area where his home and friend's home located in [name of town] or [Name area], which is on the border of [City name]. The resident's purpose for going to the bank was to get funds so he can get minutes for his cell phone. The guardian had refused to allow the resident to purchase minutes for his phone. However, after this incident, guardian put funds into the resident's trust account to purchase phone minutes .explain what steps entity took .An emergency elopement drill was performed to ensure the location of all current residents who were all located. The administrator, DON, and MDS were gathering information for the police and communicating with a sergeant at [City name]. The DON and MDS nurse left the facility at approximately 5:30pm to head to [City name] to assist in the search. The team picked up the resident from the hospital and transported him back to the facility. The resident's vital signs were taken, and skin assessed. An elopement assessment was completed, the care plan was updated, a change of condition was noted. 15-minute checks were initiated, a new smoking assessment, and a wander guard was placed on the resident. Elopement drills were initiated, staff received education, and other residents were asked to use resident logbook when exiting the building. The weather on 10/30/24 was a high of 79 degrees and a low of 61 degrees. R8's current care plan, states, in part; .Initiated 10/30/24 . Focus: At risk for elopement related to anger at placement in living center, attempts to leave living center, Resident states I am leaving, going home .Goal: Will remain safe during placement at living center. Interventions: Assess for risk of elopement per living center policy. Check function and battery percentage of wander guard on NOC shift daily. Front door function is checked daily. Check placement of wander guard every shift. Redirect patients from doors. Resident will smoke with staff supervision only at this time at designated smoking time, as he is unsafe to go outside alone. Take picture of patient upon admission for identification for updating elopement book. Wander guard placement on right ankle. Surveyor reviewed R8's 15-minute check documentation, smoking and elopement assessments, Medication Administration Record/Treatment Administration Record (MAR/TAR), hospital discharge paperwork from 10/30/24, and facility's check in/check out binder. Surveyor observed R8 multiple times on 12/3/24 and 12/4/24. R8 was assisted by staff on cigarette breaks, participating in activities, and discussing medications and plan of care with nursing staff. Surveyor interviewed CNA's, activities, housekeeping, LPN/RN staff and all staff indicated receiving education after elopement incident, knew R8 was at risk for elopement, has wander guard, is on 15-minute checks, and knows what R8 enjoys doing and behavior support that R8 may need. All documentation and observations corroborated facility self-report investigation and plan moving forward after incident. On 12/3/24 at 12:00 PM, R8 stated to Surveyor he will leave again. R8 indicated he does not want to stay here and that he might as well be in prison. R8 indicated to Surveyor that he will break his window and get out the next time he tries to leave. R8 indicated staff now sit with him when he smokes. R8 indicated he has a wander guard bracelet on his ankle. R8 indicated he remembers the incident from 10/30/24. Surveyor observed R8 raising his voice, talking fast, and rubbing his head. R8 indicated he was frustrated and anxious. On 12/3/24 at 1:00 PM, NHA A (Nursing Home Administrator) indicated understanding when Surveyor shared with NHA A that R8 voiced R8's plan is to break window and leave. NHA A indicated R8 will say things about wanting to leave but does not act on them. Surveyor asked if R8 is at risk for elopement. NHA A indicated yes, R8 is at risk for elopement. NHA A indicated facility, [managed care organization], and guardian are working for R8 to discharge to a less restrictive setting such as a group home. On 12/3/24 at 2:20 PM, R8 indicated R8 is sick of this shit and R8 indicated he will just go play bingo. R8 voiced frustration and not wanting to be at facility. On 12/3/24 at 3:20 PM, SSD Q (Social Service Director) indicated facility is working with R8 for discharge. R8 is ready for discharge. SSD Q indicated there have been several group homes that have denied R8 due to history of alcohol abuse and elopement. SSD Q indicated there is a referral for a group home and they are setting up a meeting. Surveyor reviewed SSD Q documentation regarding possible placements and follow up. SSD Q followed back up with Surveyor and indicated the meeting with possible group home is set for 12/4/24. On 12/4/24 at 8:49 AM, DON B (Director of Nursing) indicated on 10/30/24 the facility was notified of R8's elopement at 4:30 PM by guardian. DON B indicated it did not seem out of the norm that the staff wouldn't have known R8 was not there because R8 sat outside for hours at a time. DON B indicated guardian had approved of R8 being outside alone. DON B indicated elopement drills were completed and continue weekly. Surveyor reviewed documentation of elopement drills. DON B indicated R8 is on 15-minute checks and provided the documentation. DON B indicated the last time someone saw R8 at facility was another resident around 2:05 PM. DON B indicated there were no staff that observed R8 leaving or had any additional information. R8 left facility right at shift change, so elopement did not occur on first shift and second shift never saw R8 because he was gone. DON B indicated all notifications were made immediately once facility knew R8 was gone. DON and MDS nurse left at 5:30 PM to La [NAME] to assist in looking for R8. DON B indicated they were talking with the police multiple times while they were driving there. Police went to the bank, Kwik Trip, and then finally found R8 at R8's friend's house. The police brought R8 to the emergency room . DON and MDS nurse went directly to the hospital. R8 was discharged around 9:00 PM from the hospital. DON B indicated R8 was not harmed, and they talked about the incident on the way back to facility. DON B indicated education was provided and R8 expressed understanding. DON B indicated R8 was wearing a coat, pants, shoes and was appropriately dressed. DON B indicated once they returned to facility vitals and a skin check was completed. DON B indicated education was started immediately with staff, elopement drills conducted, wander guard was ordered, assessments completed, 15-minute checks completed, supervised smoking, and R8's care plan updated. DON B indicated the facility now has a check in/check out binder for residents and agreement documentation completed and signed for residents who can leave facility on their own. DON B indicated the facility previously had R8 on 30-minute checks in September because he was saying he was going to leave the facility. DON B indicated an assessment was not completed at that time to determine 30-minute checks were not needed. DON B indicated the care plan was not updated at that time. DON B indicated SSD Q called and talked to the guardian on 9/9/24, and the guardian felt the 30-minute checks and supervision with smoking could be discontinued. Surveyor asked DON B to provide any further elopement and smoking assessments. No further documentation was provided for assessments. The facility's failure to provide adequate supervision for R8 who voiced repeatedly wanting to leave this created a reasonable likelihood for serious harm, thus leading to a finding of Immediate Jeopardy. The facility removed the immediate jeopardy on 10/31/24 and corrected the deficient practice on 11/4/24 when it completed the following: An initial Elopement Drill was conducted to ensure all residents were accounted for at the facility on 10/30/24. Elopement drills immediately conducted on all three shifts. Elopement drills now completed weekly and documented. R8 vitals and skin check was completed. R8's wander guard placement. R8 Elopement and Smoking assessments were completed. R8 now has supervised designated smoking times. R8 is on 15-minute checks and checks are documented. R8's care plan has been updated to reflect plan of care. All staff educated: R8's risk for elopement, elopement policy, elopement drills, and behaviors to watch for in residents. Facility now has a check in/check out binder for residents. Residents who are able to safely go out on their own have signed and reviewed agreement form.

Based on interview and record review, the facility did not establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, the following elements: An Antibiotic Stewardship Program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 resident (R37) of 9 sampled residents reviewed. The facility did not thoroughly review R37's culture and sensitivities, and therefore, did not recognize R37 had resistance to antibiotics ordered for Urinary Tract Infections (UTIs). The facility did not follow Standards of Practice (SOP) for Antibiotic Stewardship. R37 was treated for a urinary tract infection three times within 6 weeks according to the Culture and Sensitivity (C&S; a lab test that distinguishes the bacteria in the urine and the appropriate antibiotic to use.) R37's C&S indicated R37 had resistance to two different antibiotics. R37 was prescribed an antibiotic which was resistant to the organism in the urine, meaning this antibiotic would not work to treat the infection. The facility did not recognize R37 was being treated with a resistant antibiotic. R37 began to grow resistance organisms towards Ciprofloxacin a broad-spectrum antibiotic. Evidenced by: The facility policy entitled Antibiotic Stewardship Program, dated 10/22, states, in part: . POLICY: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Policy Explanation and Compliance Guidelines: . 1a. Infection Preventionist- coordinates all antibiotic stewardship activities, maintains documentation, and serves as a resource for all clinical staff . 2c. Attending Physicians- prescribe appropriate antibiotics in accordance with standards of practice and facility protocols . 4. The program includes antibiotic use protocols and a system to monitor antibiotic use. a. Antibiotic use protocols: . i. Nursing staff shall assess residents who are suspected to have an infection and complete an SBAR (Situation, Background, Assessment, and Recommendation) form prior to notifying the physician. ii. Laboratory testing shall be in accordance with current standards of practice. iii. The facility uses the (CDC'S (Centers for Disease Control) NHSN (National Healthcare Safety Network) Surveillance Definitions) to define infections. iv. Criteria specific to each state are used to determine whether or not to treat an infection with antibiotics . vi. Reassessment of empiric antibiotics is conducted after 2-3 days for appropriateness and necessity, factoring in results of diagnostic tests, laboratory reports, and/or changes in the clinical status of the resident. vii. Whenever possible, narrow-spectrum antibiotics that are appropriate for the condition being treated shall be utilized. b. Monitoring antibiotic use: i. Antibiotic orders obtained upon admission, whether new admission or readmission, to the facility shall be reviewed for appropriateness. ii. Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness. iii. Random audits of antibiotic prescriptions shall be performed to verify completeness and appropriateness (process measure) 8. Documentation related to the program is maintained by the Infection Preventionist, including, but not limited to: . b. Assessment forms. c. Antibiotic use protocols/algorithms. d. Data collection forms for antibiotic use, process, and outcome measures . g. Records related to education of physicians, staff, residents, and families . The facility policy entitled Infection Surveillance, dated 10/22, states, in part: POLICY: A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections . Definitions: Infection surveillance refers to an ongoing systemic collection, analysis, interpretation, and dissemination of infection-related data. Outcome measure is a mechanism for evaluating outcomes or results, such as tracking specific infection events. Process measure is a mechanism for evaluating specific steps in a process that lead, either positively or negatively, to a particular outcome metric. Also known as performance monitoring, a process measure is used to evaluate whether infection prevention and control practices are being followed. Policy Explanation and Compliance Guidelines: 1. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility . 2. The RNS (Registered Nurses) and LPNS (Licensed Practical Nurses) participate in surveillance through assessment of residents and reporting changes in condition to the resident's physicians and management staff, per protocol for notification of changes and in-house reporting of communicable diseases and infections. Examples of notification triggers include, but are not limited to: . e. Microbiology test results show drug resistance . 4. The CDC's NHSN (National Healthcare Safety Network) Long Term Care Criteria, updated McGeer criteria or other nationally recognized surveillance criteria will be used to define infections. 5. Surveillance activities will be monitored facility wide, and may be broken down by department or unit, depending on the measure being observed. A combination of process and outcome measures will be utilized . R37 was admitted to the facility on [DATE] and has diagnoses that include Rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood) and Urinary Tract Infection (UTI; often starts when bacteria that gets into the tube through which urine leaves the body, the urethra). R37's Quarterly Minimum Data Set (MDS) assessment dated [DATE] shows that R37 has a Brief Interview of Mental Status (BIMS) score of 9 indicating R37 has moderate cognitive impairment. Section GG shows for toileting R37 is dependent on staff. Helper does all the effort to complete the activity and R37 does none of the effort to complete the activity. R37's Care Plan states, in part: Focus: Infection actual or at risk for related to history of UTI . (1/9/24). UTI with ABT (antibiotic therapy) 6/19/24. Chronic UTI ABT 7/1/24. Date initiated: 1/12/24. GOAL: Infection will resolve without complication. Date Initiated: 1/12/24 Revision on: 7/16/24 Target Date: 10/11/24. Interventions: -Administer antibiotics and treatments as ordered. Date Initiated: 1/12/24 . -Labs as ordered. Date Initiated: 1/12/24 . -Notify practitioner if symptoms worsen or do not resolve. Date Initiated: 7/3/24 . R37's Physician Orders for May 2024, states, in part: . Laboratory: urinalysis with culture ordered by NP G (Nurse Practitioner) Order Date: 4/24/24 . 4/29/24 Urine Culture and Sensitivity Report shows: Proteus Mirabilis greater than 100,000 colonies. Resistant Trimethoprim/Sulfamethoxazole (Bactrim DS) and Nitrofurantoin/Macrobid. R37's Medication Administration Record (MAR) dated 4/30/24, states, in part: . Macrobid Oral Capsule 100 mg (milligrams) (Nitrofurantoin Monohyd Macro). Give 100 mg by mouth two times a day for UTI until 5/6/24 . R37's MAR shows that R37 was administered Macrobid 100 mg twice a day from 5/1/24 through 5/6/24. Of note, R37 was started on an antibiotic: Macrobid which Proteus Mirabilis is resistant to. The use of Macrobid would not be effective in treating the UTI due to antibiotic resistance. The facility did not recognize this antibiotic was resistant to the organism in R37's urine. R37's Physician Orders for June 2024, states, in part: . Laboratory: urinalysis with C&S (culture and sensitivity) (ordered by NP G) for continued hematuria Order date: 5/9/24 . 5/13/24 Urine Culture and Sensitivity Report shows: Proteus Mirabilis greater than 100,000 colonies. Resistant to Nitrofurantoin/Macrobid and Trimethoprim/Sulfamethoxazole (Bactrim DS). Escherichia Coli greater than 100,000 colonies. Resistant to ampicillin, ampicillin/sulbactam (Unasyn), and Ciprofloxacin (cipro), which was ordered to treat UTI. R37's MAR dated 5/11/24, states, in part: . Cipro Oral Tablet 500 mg (Ciprofloxacin HCL (hydrochloride)). Give 1 tablet by mouth two times a day for UTI until 5/18/24 . R37's MAR shows that R37 was administered Cipro 500 mg on 5/11/24 and Cipro 500 mg twice a day from 5/12/24 through 5/18/24. Of note, R37 has now grown out two organisms. R37 was started on a broad-spectrum antibiotic: Cipro, which one of the organisms, E. Coli was resistant to. The use of Cipro would not be effective in treating the UTI due to antibiotic resistance. The facility did not recognize this antibiotic was resistant to the organism in R37's urine. 6/13/24 Urine Culture and Sensitivity Report shows: Proteus Mirabilis greater than 100,000 colonies. Resistant to Nitrofurantoin/Macrobid and Trimethoprim/Sulfamethoxazole (Bactrim DS). It now shows R37's sensitivity to cefazolin (Ancef), cipro, and levofloxacin is now intermediate (implies that the organisms are inhibited only by the maximum recommended dosage). Escherichia Coli greater than 100,000 colonies. Resistant to ampicillin, ampicillin/sulbactam (Unasyn), cefazolin (Ancef), cefoxitin (Mefoxin), cefuroxime axetil (ceftin), ciprofloxacin, and levofloxacin. It now shows R37's sensitivity to cefuroxime (ceftin), and piperacillin/tazobactam (zosyn) is now intermediate. R37's MAR dated 6/17/24, states, in part: . ceftriaxone sodium Injection Solution Reconstituted 1 GM (gram) (ceftriaxone sodium) Inject 1 dose intramuscularly one time only for UTI for 1 day . Cephalexin Oral Capsule 500 mg (Cephalexin) Give 1 dose by mouth two times a day for UTI for 7 days . R37's MAR shows R37 was administered the ceftriaxone injection 1 gm one time on 6/18/24 and cephalexin 500 mg twice a day from 6/19/24 through 6/25/24. Of note, R37 is now being treated for the third time for the same organism within six weeks. it should also be noted R37's organisms are leaning toward resistance to a broad-spectrum antibiotic Cipro. This can be caused when an antibiotic is used unnecessarily and frequently. 7/5/24 Urine Culture and Sensitivity Report shows: Enterococcus Faecalis greater than 100,000 colonies. Resistant to ciprofloxacin, gentamicin, Levofloxacin, and tetracycline. Of Note, R37 is now resistant to ciprofloxacin to another organism. On 7/25/24 at 9:17 AM, Surveyor interviewed DON B (Director of Nursing). DON B indicated she was not aware of the UA (urinalysis) and C&S dated 4/27/24 with R37 being treated with Macrobid, which the organism, Proteus Mirabilis was resistant to. DON B indicated R37 should not have been on Macrobid since Proteus Mirabilis was resistant to Macrobid. DON B indicated the NP (Nurse Practitioner) should have been phoned back with the C&S results and the C&S results reviewed for appropriate changes. DON B indicated she was not aware of the UA and C&S dated 5/13/24 with R37 being treated with Cipro, which one of the organisms, E. Coli was resistant to. DON B indicated R37 should not have been administered Cipro since it was resistant to the organism E Coli. DON B indicated the NP should have been phoned back with the C&S results and the C&S results reviewed for appropriate changes. DON B indicated the concern of R37 now growing out two organisms and being treated with inappropriate antibiotics. DON B indicated she was not aware of the UA and C&S dated 6/13/24 with R37 being treated with Rocephin. Surveyor asked DON B if there is concern R37 is now being treated a third time for Proteus Mirabilis plus another organism, E Coli and DON B indicated yes. DON B indicated the C&S results should have been reviewed with the NP for appropriate antibiotics. On 7/25/24 at 10:05 AM, Surveyor interviewed NP G. NP G indicated with C&S showing resistance to the antibiotics ordered she would have expected the antibiotics to be adjusted accordingly. Surveyor asked if NP G was aware of the lab results from 4/29/24 and 5/13/24. NP G indicated no as the MD would follow up on these issues. Surveyor asked NP G if C&S indicates 2 organisms grew out would you expect an antibiotic to be ordered to cover both organisms and NP G indicated yes. On 7/25/24 at 10:36 AM, Surveyor interviewed IP R (Infection Preventionist). Surveyor asked IP R if R37 should have been on the Macrobid for the UA and C&S dated 4/29/24 when the organism, Proteus Mirabilis showed resistance to the Macrobid. IP R indicated no; the C&S should have been followed up on with the physician. Surveyor asked if R37 should have been on Cipro for the UA and C&S dated 5/13/24 with Cipro being resistant to the E Coli and IP R indicated no, she should have followed up with the physician on the results of the C&S. Surveyor asked if IP R there is a concern with R37 being treated three times for the same organism and now growing out another organism, Enterococcus Faecalis IP R indicated yes. The facility did not ensure Antibiotic Stewardship was implemented for R37. R37 was treated unnecessarily with antibiotics that were resistant to organisms in R37's urine. R37 received full courses of antibiotics despite resistance and R37's C&S reports indicate resistance to broad spectrum antibiotics.

Based on interview and record review, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice for 2 (R46 and R32) of 16 residents reviewed for change of condition. R46 is being cited at severity level 3 (actual harm). R32 is being cited at severity level 2 (potential for more than minimal harm). R46 experienced a change of condition on 4/27/24 and received STAT (urgent or rush) orders for ultrasound (diagnostic testing which shows the structures inside the body). The facility failed to notify the physician when the STAT testing was not completed timely. Two days later, while still waiting for testing, the resident was taken to the hospital by family. R46 was admitted to the hospital from 4/29/24 through 5/2/24 with treatment of IV (intravenous) antibiotics for diagnosis of cellulitis of the left arm. R32 has an order for weekly weights. The facility was not weighing R32 weekly. Evidenced by: Facility policy titled, Notification of Changes Policy dated 3/1/19, states in part; It is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate (hereafter designated as the physician). The resident and/or their representative will be educated about treatment options and supported to make an informed choice about care preferences when there are multiple care options available. All pertinent information will be made available to the provider by the facility staff. Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative, and the resident's physician, to ensure best outcomes of care for the resident. Example 1 R46 was admitted to the facility on [DATE] with diagnoses that include in part, cellulitis of right upper limb. R46's Minimum Data Set (MDS), dated [DATE], states that R46 has a Brief Interview for Mental Status (BIMS) of 14, indicating the resident is cognitively intact. R46's Progress Note, dated 4/27/24 3:10 PM, states: Pt (patient) had complaints of pain in left elbow, and stated it hurts to touch and it is swollen. Writer had looked at Pt's left elbow, and upon visual inspection, it was larger than contralateral (opposite side) elbow. Upon palpation, calor (heat) present, along with swelling and touch produced tenderness. Pt describes the pain as throbbing and sharp. STAT ultrasound ordered . R46's Progress Note, dated 4/29/24 4:34 AM, states: resident continues to complain of pain to her left hand. Ultrasound was ordered 4/27/24 STAT from (Mobile x-ray company name). They were contacted again today by pm nurse and no answer, test has not been completed. R46's Progress Note, dated 4/29/24 8:49 AM, states: . (Mobile x-ray company name) does not provide STAT services on the weekend for ultrasound .R46 wanted it canceled as her sister was going to take her to (Clinic Name) . R46's Progress Note, dated 4/29/24 11:29 PM, states: Resident admitted to hospital (Clinic Name), diagnosis cellulitis. R46's Hospital Inpatient Discharge Summary, dated 5/2/24 states, in part; admitted [DATE] discharge date [DATE] Principle Diagnosis: Cellulitis of the left arm .patient presented with left elbow swelling, erythema (abnormal redness of skin) and warmth x5 (for 5) days .Did have elevated CRP (C-Reactive Protein; blood test indicative of inflammation from injury, infection, or other disease) .Patient hospitalized with IV Ancef (intravenous antibiotic) . On 7/25/24 at 4:27 PM, Surveyor interviewed MD C (Medical Director) and asked when a STAT ultrasound is expected to be complete. MD C stated within 4 hours. Surveyor asked MD C if the STAT order is not completed within 4-6 hours, would MD C expect to be updated? MD C stated, yes, it would be better to send resident out to emergency room . On 7/25/24 at 4:37 PM, Surveyor interviewed DON B (Director of Nursing) and asked if a resident is experiencing a COC (change of condition), and a STAT ultrasound is ordered when you would expect it to be completed. DON B stated same day. Surveyor asked DON B if the resident is presenting with a change from baseline and the STAT order is not completed within same day, would DON B expect that the physician be updated? DON B stated yes and ask the physician if they want the resident to be transferred to emergency room for further evaluation. R46 presented with a change of condition on 4/27/24 and the facility received orders to perform a STAT ultrasound. The facility failed to complete the STAT order and failed to notify the physician the order could not be obtained which delayed treatment for R46. On 4/29/24, family transported R46 to the clinic and R46 was hospitalized with cellulitis requiring IV antibiotics. 44552 Example 2 The facility policy, Weight Monitoring, dated 9/21/20, states, in part; .5. A weight monitoring schedule will be developed upon admission for all residents .7. Documentation: a. The physician should be informed of a significant change in weight and may order nutritional interventions . R32 was admitted to the facility on [DATE] with diagnoses including encounter for other orthopedic aftercare, muscle weakness, abnormalities of gait and mobility, weakness, difficulty in walking, insomnia, chronic pain syndrome, depression, and kidney disease. R32's current order, states, in part: .Weekly weight 2/15/24 .in the morning every Mon for significant weight changes weigh weekly BEFORE BREAKFAST . R32's care plan, states, in part; .Weights per orders .date initiated 1/11/23 . Surveyor reviewed R32's weight documentation .6/10/24 285.8 lbs., 7/11/24 292 lbs.Of note, there were no documented weekly weights for 3 weeks. On 7/25/24 at 9:39 AM, RD Z (Registered Dietician) indicated if a resident has an order for a weekly weight, staff should weigh resident weekly. RD Z indicated if a resident refuses, staff should document refusal in progress notes. RD Z indicated if she notices weights are not being completed, she will send out an email. RD Z indicated R32 should have weekly weights completed per order. Surveyor asked RD Z if weekly weights have been completed for R32? RD Z stated, So, yeah he missed a couple of weeks there . At 10:05 AM, RD Z indicated she reviewed R32's documentation and could not find any other weights taken during time frame. RD Z indicated she will follow up on concern. On 7/25/24 at 4:10 PM, DON B (Director of Nursing) indicated if a resident has an order for weekly weights staff should weigh resident weekly. DON B indicated R32 should have had weights completed weekly. The facility failed to ensure weekly weights were completed as per order.

Based on interview and record review, the facility did not ensure residents receive treatment and care in accordance with professional standards of practice for 1 of 4 residents reviewed (R1). R1 experienced a fall with fracture and the facility did not send the resident to the hospital for 2 days. Findings include: R1 was admitted to the facility on [DATE] and has diagnoses that include adult failure to thrive. R1 has been taking 81 mg of aspirin daily since his admission for heart failure. The facility's policy titled Notification of Changes states the following: * It is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident's representative, according to their authority, and reported to the attending physician or delegate. The resident and/or their representative will be educated about treatment options and supported to make an informed choice about care preferences when there are multiple care options available. All pertinent information will be made available to the provider by the facility staff. * The facility shall promptly notify the resident and/or the resident representative and his or her physician or delegate of changes in the resident's condition or status in order to obtain orders for appropriate treatment and monitoring and promote the resident's right to make choices about treatment and care preferences. * The nurse will immediately notify the resident, resident's physician and the resident representatives for the following: 1) An accident involving the resident which results in injury and has the potential for requiring physician intervention. 2) A need to alter treatment significantly (a need to discontinue or change an existing form of treatment due to adverse consequences or to commence a new form of treatment). 3) A decision to transfer or discharge the resident from the facility. The facility's Fall Management Process states the following: * Upon arrival of the nurse a quick head to toe scan will be performed without unnecessary movement, palpating and examining all areas for breaks in the skin and or other abnormal findings. * Resident fall will be noted on 24 hour report for 3 days for post fall monitoring, assessing for injury, full vital signs every 8 hours, and pain assessment. The Board of Nursing's N6 states: N 6.04 Standards of practice for licensed practical nurses (LPN). (1) PERFORMANCE OF ACTS IN BASIC PATIENT SITUATIONS. In the performance of acts in basic patient situations, the L.P.N. shall, under the general supervision of an R.N. or the direction of a provider: (a) Accept only patient care assignments which the L.P.N. is competent to perform. (b) Provide basic nursing care. (c) Record nursing care given and report to the appropriate per[1]son changes in the condition of a patient. (d) Consult with a provider in cases where an L.P.N. knows or should know a delegated act may harm a patient. (e) Perform the following other acts when applicable: 1. Assist with the collection of data. 2. Assist with the development and revision of a nursing care plan. 3. Reinforce the teaching provided by an R.N. provider and provide basic health care instruction. A fall report, documented by LPN C (Licensed Practical Nurse), dated 4/29/23 at 10:35 AM states: *Nursing description: Found resident sitting on side of bed with cheek bleeding, stated he fell trying to walk around the foot of his bed. There was a small amount of [NAME] blood on the floor at the bottom of the bed. Resident description: I fell , I didn't think I hit my face, but my hip (left hip) is achy, doesn't think he hit that side of his body though. *Immediate action taken: skin check for other areas of injury, nothing noted. No redness, scrapes or abrasions found. Cheek laceration, very little bleeding. Cleansed with soap and water. Vital signs taken within normal limits, neurochecks started. Gripper socks placed on resident, with verbal reminder to call for help and to not ambulate without assistance. A facility progress note, documented by LPN C and dated 4/29/23 states, Resident sitting in bed stating he fell , right cheek bleeding. Stated he was walking around the end of his bed and fell over, didn't think he hit his face, no pain to his face, complained of some right hip discomfort, able to move all extremities well. Alert. Vital signs and neuro checks started. Facial laceration cleansed with water, resident adamant about not going to the hospital. LPN C then placed an order for an x-ray of R1's left hip. A mobile x-ray company conducted an x-ray in the facility on R1 on 4/29/23, with results of a left femoral neck fracture (acute left hip fracture). The final report was documented as having been completed on 4/30/23 at 5:38 AM. This was also documented in the facility's electronic health records (EHR) system. (Of note, the mobile x-ray company can directly submit the x-ray into the facility's EHR, however, staff at the facility had not reviewed the x-ray results. R1 had a hip fracture and remained at the facility until 5/2/23 when staff following up on R1's complaints of pain reviewed the x-ray and noted R1 had a hip fracture). A physician's assistant conducted a telehealth visit with R1 on 5/1/23, which was documented in R1's record on 5/1/23 at 8:30 AM. The note states that DON B (Director of Nursing) was present during the visit and that R1 had an x-ray conducted on 4/29/23 after a fall and the results were negative for acute abnormalities. Additional progress notes for R1: 5/1/23 at 10:07 AM: Pain rating 3-4 out of 10. Location: resident states pain is in L (left) knee from fall over the weekend. Non-pharmalogical interventions: ice pack 5/1/23 at 1:57 PM: Therapy is requesting an x-ray of the affected limb. 5/1/23 at 2:53 PM: Pain issue, needs review .Left hip .Pain score 6 (note by LPN D) 5/2/23 at 11:35 AM: During skilled nursing assessment at 8:35 AM, resident denied any pain or discomfort. It was later reported that he had an unwitnessed fall on 4/29/23 and report from x-ray of left femoral fracture of neck with no displacement on 4/30/23. 5/2/23 at 11:40 AM: Client left the facility via ambulance enroute to the hospital On 5/2/23 at 11:54 AM, the physician's assistant added an addendum to her original note from her telehealth visit with R1 on 5/1/23. The addendum reads, Correction: x-ray did show nondisplaced left femur fracture on reevaluation. Orthopedic surgery consulted since pain is well controlled. If unable to be seen in the next day or 2, will need to send to ER for follow-up. On 5/2/23, the hospital performed 3 screw fixation surgery on R1 to repair his fractured left hip. It should be noted that between 4/29/23 when an x-ray was ordered for R1's hip and when R1 was sent to the hospital on 5/2/23, the facility was not conducting any additional assessments on R1 outside of the Advanced Skilled Nursing Assessments that the facility does on all Medicare residents daily. On 5/16/23 at 10:18 AM, Surveyor interviewed LPN D, who stated that she did not see the need to notify anyone on 5/1/23 when she documented R1's left hip pain as 6. LPN D also stated that on the morning of 5/2/23 at approximately 7:30 AM, she assisted therapy with providing needed cares on R1 in order to get him up and ready for therapy. At that time, as she and the therapist moved R1 around his bed, he said ouch and said his left knee hurt. LPN D stated that the therapist told her at that time that therapy had requested an order for an x-ray of R1's left knee the previous day (5/1/23) as R1 had been complaining of pain since yesterday. LPN D stated they finished cares and got R1 up out of bed and into his wheelchair, using stand-pivot assistance with R1 to be mindful of his sore knee. LPN D stated that after getting R1 into his wheelchair, she approached LPN C and asked her what was going on with R1's left knee x-ray request. LPN D stated that LPN C then told her that they were still waiting on x-ray results from 4/29/23 when she (LPN C) had received an order for R1's left hip. LPN D stated that her and LPN C then began searching to see if there was a fax received from the mobile x-ray company, as they typically fax a report once the results are found. They could not find a fax, but were able find results in a section of the facility's EHR system. According to LPN D, the mobile x-ray company has access to the facility's EHR system in order to quickly provide results. LPN D stated that once she had found the hip x-ray results, she immediately notified DON B. LPN D also stated that had she known that there were pending results for R1's left hip, she would never have moved him around in bed, nor gotten him up into his chair. On 5/16/23 at 11:10 AM, Surveyor interviewed LPN C, who stated that when she found R1 in his bed on 4/29/23, his legs were just hanging off the foot of the bed and he had blood on his face. LPN C stated she did not do an assessment on R1 as that was outside of her scope of practice, but did collect data and called R1's physician. Additionally, LPN C stated that she checked R1's range of motion and conducted neuro checks. Additionally, LPN C stated that she contacted DON B to notify her of the fall and also that she had gotten an order for an x-ray of R1's hip. LPN C stated DON B did not have any further comments or direction for her. On 5/16/23 at 12:01 PM, Surveyor interviewed DON B, who stated that she did not assess R1 and that somebody should have at some point. DON B stated that the facility was having a hard time ensuring that faxes sent over from different providers get saved and directed immediately. Additionally, DON B stated that pain assessments should have been done on R1 each shift knowing that there was a concern that warranted an x-ray. The facility identified that there was an issue with collecting faxes and put a plan into place to educate staff. The facility was aware that R1 had fallen and was complaining of pain first in his left hip, then his left knee. No complete assessment was conducted on R1 post-fall, nor were frequent pain assessments or monitoring of R1's hip conducted while the facility waited for x-ray results. Facility staff were aware on 5/1/23 that R1 was having more pain in his knee and hip, the latter being rated as a 6, and no additional assessing or reporting was done to alter R1's treatment in a timely manner.

Based on interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 4 residents reviewed for falls. R2 fell multiple times and the facility staff did not investigate the root cause of R2's falls, did not evaluate current fall interventions, or implement robust care plan interventions to prevent falls. R2 continued to fall and fractured her hip. Findings include: The facility's policy titled Notification of Changes states the following: * It is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident's representative, according to their authority, and reported to the attending physician or delegate. The resident and/or their representative will be educated about treatment options and supported to make an informed choice about care preferences when there are multiple care options available. All pertinent information will be made available to the provider by the facility staff. * The facility shall promptly notify the resident and/or the resident representative and his or her physician or delegate of changes in the resident's condition or status in order to obtain orders for appropriate treatment and monitoring and promote the resident's right to make choices about treatment and care preferences. * The nurse will immediately notify the resident, resident's physician and the resident representatives for the following: 1) An accident involving the resident which results in injury and has the potential for requiring physician intervention. 2) A need to alter treatment significantly (a need to discontinue or change an existing form of treatment due to adverse consequences or to commence a new form of treatment). 3) A decision to transfer or discharge the resident from the facility. The facility's Fall Management Process states the following: *Upon arrival of the nurse a quick head to toe scan will be performed without unnecessary movement, palpating and examining all areas for breaks in the skin and or other abnormal findings. *The nurse will complete an event documentation report comma fall risk assessment comma pain assessment comma and obtain witness statements. *The nurse will determine the most appropriate intervention, implement, and update care plan. *Resident fall will be noted on 24 hour report for 3 days for post fall monitoring, assessing for injury, full vital signs every 8 hours, and pain assessment. *Obtain finger-stick blood sugar if known diabetic. The facility's Falls Review Process states: *Director of nursing/designee will assess the resident and review fall documentation, including witness statements, resident interview, environment review of area where fall occurred, and equipment inspection. *The event will be discussed and event documentation reviewed for completion and IDT meeting. Compare data from previous assessments. Discuss identified trends. *Therapy referral and medication review initiated. *Other referrals if applicable. Neurological, vision, hearing, psyche, etcetera. Bye *Review fall risk assessment for any potential new risk factors. *Review plan of care/interventions to ensure all prior interventions are in place and still appropriate. *Adjust add interventions on the plan of care. Update and communicate interventions. Provide appropriate training for caregivers if appropriate. Educate residents/family if appropriate period *Discuss findings and interventions with the resident/patient/family for inclusion in the interdisciplinary plan of care (IPOC). R2 was admitted to the facility on [DATE] and has diagnoses that include: Alzheimer's Disease, Type II Diabetes, and atrial fibrillation. She currently takes Apixaban 2.5 mg twice daily and receives insulin daily. R2's most recent Minimum Data Set (MDS), dated [DATE], shows a Brief Interview for Mental Status (BIMS) score of 8, indicating R2 is moderately cognitively impaired. The facility documented the following falls for R2: *2/7/23 at 3:00 AM: Resident found on floor by staff. Resident was sitting on buttocks next to bed. Backwards against bed. No injuries noted. Resident stated, I was trying to get up. I couldn't find my call light. I'm not hurt and I don't want to go to the hospital. Resident was assisted to bed, skin assessed, vitals, neuro checks completed, pain assessed. *4/4/23: Approximately 4:45 PM, resident was observed on floor requesting someone to help her. She was found lying on her left side near her wheelchair. Resident originally denied hitting her head and reported when asked regarding if she had any areas of pain or discomfort that she was having a little pain in her left hip, but was unable to rate her pain. She was able to turn from her left side off of her left arm and was assessed up into wheelchair with assistance of this writer and CNA (Certified Nursing Assistant). Resident was able to move with both lower extremities once in wheelchair. Vital signs were obtained lying and sitting. Director of Nursing completed assessment of both lower extremities noting resident complained of pain during extension and flexion of left hip. Physician was called at 5:05 PM and provided information concerning resident. Orders to transfer to emergency department for post fall evaluation, CT scan (Computed Tomography) of head to rule out intracranial bleed as resident is on Eliquis blood thinner, rule out left hip fracture. Note: no remarkable findings were revealed through these tests. *5/1/23 at 12:29 AM: CNA notified writer that resident was found sleeping on the floor. Resident stated she didn't know how she ended up on the floor and was cold. Writer and 2 CNAs got resident off the floor with a Hoyer lift. Vitals assessed and neuro checks started for unwitnessed fall. Skin assessed for bruising. *5/2/23 at 6:01 AM: this nurse made aware that resident was on floor in her room, entered room to find resident sitting on the floor on her buttocks feet straight out in front of her facing the wall. No complaints of pain with no visible injuries at this time. Resident stated that she just slid out of bed. Vital signs completed at time of the fall, head to toe assessment performed with no immediate injuries found, aide assist with total lift to get resident up off from the floor back into her bed. Once in bed again aide assisted resident with ADLs to get ready for the day. R2's physician and DON B (Director of Nursing) were notified after each fall. A fall risk evaluation conducted on 5/1/23 at 1:36 AM states that R2 has had no falls in the past 3 months and gives R2 a fall risk of 3.0, indicating she is at low risk for falls. Additionally, LPN E (Licensed Practical Nurse), who wrote the fall report, did not mark anticoagulant in the 5/1/23 fall report. No interventions, clinical suggestions, or plan of action is mentioned or documented in any of R2's falls from 2/7/23 to 5/2/23. R2's care plan indicates that she has a history of falls and forgets to use her call light. On 5/4/23, the facility added a contour mattress and floor mat next to the bed as fall interventions. The most recent intervention before 5/4/23 was on 1/18/23 when the facility added to ensure that the bathroom floor is free of clutter to prevent resident from leaning to pick up items while sitting on the toilet. Additional nursing notes for R2: *5/10/23 at 1:18 PM: client complaints of right leg pain when moving. Client denies pain with range of motion completed by writer. No limitation with range of motion. Gave client PRN Tylenol and ice applied to leg. *5/11/23 at 10:58 AM: phoned hospital for an order for X-ray for right hip and ice therapy. Left message with triage nurse to return call. Will follow by end of shift. *5/11/23 at 4:02 PM: Received call from doctor's nurse, order received for right hip X-ray 2 view and pelvic X-ray one view, ice to right hip every 4 hours PRN for pain. *5/12/23 at 4:46 AM: Received results for X-ray of hip. Conclusion of right hip femoral neck fracture. Updated doctor suggestion to send resident to ER (emergency room ) for pain management and for ortho review on scans to determine whether fracture is surgical or non. R2 was taken to theER on [DATE] and later transferred to another hospital for surgical intervention (right hip closed reduction with percutaneous pinning). On 5/16/23 at 2:53 PM, Surveyor interviewed LPN D who stated that CNAs had come to her on 5/11/23 and stated R2 did not want to get out of bed, so she (LPN D) went to R2's room and did range of motion with her. LPN D stated R2 made a small grimace but did not complain of much pain, but she (LPN D) had a bad feeling as there had been so many falls in the facility lately that she requested an x-ray. LPN D stated that generally R2 does not have much pain and had not been complaining of pain recently and that it was like she couldn't feel pain or was unaware of her pain. LPN D stated that she does not put interventions on the care plan or recommend them as that is a task for the RNs (Registered Nurses). LPN D also stated that R2 is mostly confused and it is hard to get information from her. On 5/16/23 at 11:10 AM, Surveyor interviewed LPN C, who stated that she does not put interventions on the care plan or make suggests for care plans, as that is a job for the RNs. On 5/16/23 at 3:30 PM, Surveyor interviewed LPN E who stated that she did the best she could to assess R2 on the night/morning of 5/1/23 as she was the only nurse available. LPN E stated that she knows she is not to assess, but stated she had no choice. LPN E also stated that she called DON B after the fall and left a message and since DON B never replied to her or followed up with her, she thought that she had done everything right. Additionally, LPN E stated that she did not know R2 was on a blood thinner at the time of the fall. On 5/16/23 at 3:45 PM, Surveyor interviewed CNA F who stated that she has worked recently when R2 falls. CNA F states she will walk by R2's room and she will be sleeping and then a few minutes later she will walk by and her legs are hanging off the bed, but the resident is still sleeping. CNA F stated it always looks like she is out but somehow her legs get off the bed. CNA stated she has no idea how R2 does it. On 5/16/23 at 3:20 PM, Surveyor interviewed RN G, along with NHA A (Nursing Home Administrator) and DON B. RN G stated that the facility doesn't have an IDT team but meets about falls every morning for standup. When asked what the facility has done to try and prevent additional falls for R2 RN G stated, The DON would be notified of all falls and would give further direction. NHA A then stated the facility has a risk management team that meets about falls. Surveyor asked DON B what she has done for interventions when staff called her/notified her regarding R2's falls? DON B could not recall, but referred to the risk management team. Surveyor requested all of the facility's risk management documentation that includes what the facility has done and what they are currently doing to help prevent falls for R2. Surveyor was provided with a single piece of paper, titled Daily Management, and highlights a number of staffing concerns and changes of condition with certain residents. The information regarding R2 states, .fall 5/2 - review of times of falls. No other information was provided. The facility was aware that R2 was falling frequently, but did not investigate, seek a root cause analysis of why she was falling, create and/or discontinue interventions, or describe why the facility's current plan was appropriate. On 5/1/23 when R2 fell , nursing staff was unaware she was on a blood thinner, nor did the subsequent post fall evaluation show that R2 had multiple falls in the previous months. No interventions or plan of action was created after 4 falls and R2 was found to have a fractured hip on 5/12/23, which required surgical intervention.

Based on observation, interview, and record review, the facility did not implement professional standards of practice to prevent pressure injuries (PI) from worsening for 1 of 1 resident reviewed for PIs, out of a sample of 10 residents (R10). The facility did not ensure interventions were in place to prevent the PI from developing or worsening. R10 developed an Unstageable PI on 7/18/22. The facility failed to complete weekly skin assessments and did not follow care plan interventions. This is evidenced by: The facility's policy, Skin Assessment, undated, states, in part . Policy: It is out policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body assessment. Policy Explanation and Compliance Guidelines: 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. The facility's policy, Pressure Injury Prevention Guidelines, undated, states, in part . To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of the facility to implement evidence-based interventions for all residents who are assess at risk or who have a pressure injury present. Explanation and Compliance Guidelines: 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. In the absence of prevention orders, the licensed nurse will utilize nursing judgement in accordance with pressure injury prevention guidelines to provide care and will notify physician to obtain orders. 5. Prevention devices will be utilized in accordance with manufacturer recommendations (e.g., heel floatation devices, cushions, mattresses). 7. Interventions will be documented in the care plan and communicated to all relevant staff. 9. The effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound. Considerations for needed modifications include b. Lack of progression towards healing or changes in wound characteristics. According to the National Pressure Injury Advisory Panel an Unstageable Pressure Injury is defined as, Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed. According to the National Pressure Injury Advisory Panel a Deep Tissue Pressure Injury is defined as, Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or [MEDICATION(S)] separation revealing a dark wound bed or blood filled [NAME]. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). R10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R10's admission Braden Score, completed on 4/7/22, shows a score of 17, indicating R10 is at risk for PI development. R10's Comprehensive Care Plan, dated 4/8/22, states in part . Focus: I have a physical functional deficit related to: Mobility Impairment, Self-Care Impairment. Interventions/Tasks: Bed mobility assistance of 1, Inspect skin with care. Report reddened areas, rashes, bruising, or open areas to charge nurse. Resident transfers with the assist of an EZ (sit to stand lift) stand. May use Hoyer (full body lift) if resident is tired. R10's Comprehensive are Plan, dated 4/20/22, states in part . Focus: Pressure ulcer actual or at risk due to: Assistance required in bed mobility, occasional bowel incontinence. Interventions/Tasks: Provide pressure reducing wheelchair cushion and provide pressure reduction/relieving mattress. R10's Comprehensive are Plan, dated 7/15/22, states in part . Focus: Pressure ulcer actual or at risk due to Unstageable pressure ulcer to left heel. Interventions/Tasks: Heel boots, weekly wound assessment, treatment as ordered. R10's most recent Minimum Data Set (MDS), dated [DATE], indicates a Brief Interview of Mental Status (BIMS) of 3, indicating R10 has severe cognitive deficits. In R10's most recent MDS, section G0110 indicates extensive assist of two staff is needed with bed mobility, transfers, toileting, and dressing. R10 requires limited assistance of two staff members for hygiene. R10 is frequently incontinent of urine and always incontinent of bowel. M0150 - At Risk for Pressure Injury. Yes. M0210 - Unhealed Pressure Injury. Yes. M0300 - Unstageable 1. R10's Certified Nursing Assistant (CNA) Care Plan states in part . Skin Integrity: Geri sleeves to arms and legs as tolerated, provide pressure reducing wheelchair cushion, and provide pressure reduction/relieving mattress. ADL's: Footwear to prevent slipping and Inspect skin with care. Report reddened areas, rashes, bruising, or open areas to charge nurse. (Note: Interventions used to prevent and heal pressure injuries (heel boots) are not listed on the CNA care plan.) (Note: The facility did not have pressure relieving boots in place prior to 7/15/22 and R10 was at risk for PI's.) R10's discharge paperwork from the hospital from 7/15/22 states in part . Skin Intact: No. Pressure wound(s). Stage II Pressure Ulcer. Location/description: L (left) heel. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] (Note: R10 was hospitalized from 7/12/22 to 7/15/22 due to changes in mentation.) R10's Weekly Skin Impairment and Wound Evaluation -V 5, dated 7/18/22 at 17:37 (5:37 PM), states in part . 1a. Wound: Left heel. 1b. Description of skin issue: DTI (deep tissue injury). 2a. Indicate whether this site was acquired during the resident's stay or present on admission: admitted . 2b. Date Wound Identified: 7/15/22. Skin Impairment Type: 13. Pressure Ulcer. Original Pressure Ulcer Stage: 4a. Pressure Ulcer Stage. 1. Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. Current Stage: 4b. Pressure Ulcer Stage. 1. Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. 2. Wound Eval. Visible Tissue. 5j. Dry. 5k. Comments: purple/maroon filled blister, approx. 4 cm x 5 cm. Drainage. 6a. Drainage Type. None. Odor Present? No. Wound Measurements: 9a. Length (cm) 4. 9b. Width (cm) 5. 3. Treatment: 1a. Describe any changes to treatment plan in the last week. Skin prep BID (twice a day). Date Treatment Ordered: 7/18/22. 4. Evaluation. 2. Wound/Skin Impairment. 1. Initial observation/no prior reference. R10's Weekly Skin Impairment and Wound Evaluation -V 5, dated 7/18/22 at 17:39 (5:39 PM), states in part . 1a. Wound: Right heel. 1b. Description of skin issue: boggy heel. 2a. Indicate whether this site was acquired during the resident's stay or present on admission: admitted . 2b. Date Wound Identified: 7/15/22. Skin Impairment Type: 13. Other Closed. 3b. Other. Boggy Heel. 2. Wound Eval. 5k. Comments: Boggy heel. 12. Is there a short-term care plan in place? Yes. 3. Treatment: 1a. Describe any changes to treatment plan in the last week. Skin prep BID (twice a day). Date Treatment Ordered: 7/18/22. 4. Evaluation. 2. Wound/Skin Impairment. 1. Initial observation/no prior reference. R10's Weekly Skin Impairment and Wound Evaluation -V 5, dated 7/20/22 at 10:14 (10:14 AM), states in part . 1a. Wound: Left heel. 1b. Description of skin issue: DTI. 2a. Indicate whether this site was acquired during the resident's stay or present on admission: admitted . 2b. Date Wound Identified: 7/15/22. Skin Impairment Type: 1. Pressure Ulcer. Original Pressure Ulcer Stage: 4a. Pressure Ulcer Stage. 1. Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. Current Stage: 4b. Pressure Ulcer Stage. 1. Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. 2. Wound Eval. Visible Tissue. 5j. Dry. 5k. purple/maroon filled blister, approx. 4cmx5cm. Drainage. Drainage Type. None. Odor Present? No. Wound Measurements: 9a. Length (cm) 4. 9b. Width (cm) 5. Peri-Wound Tissue. 10a. Wound Margins. 1. Defined. 3. Treatment: 1a. Describe any changes to treatment plan in the last week. Skin prep BID (twice a day). Date Treatment Ordered: 7/18/22. 4. Evaluation. 2. Wound/Skin Impairment. 1. Unchanged. R10's Weekly Skin Impairment and Wound Evaluation -V 5, dated 7/20/22 at 10:18 (10:18 AM), states in part . 1a. Wound: Right heel. 1b. Description of skin issue: boggy heel. 2a. Indicate whether this site was acquired during the resident's stay or present on admission: admitted . 2b. Date Wound Identified: 7/15/22. Skin Impairment Type: 13. Other Closed. 3b. Other. Boggy Heel. 2. Wound Eval. 5k. Comments: Boggy heel. 12. Is there a short-term care plan in place? Yes. 3. Treatment: 1a. Describe any changes to treatment plan in the last week. None. 1b. Current treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Evaluation. 2. Wound/Skin Impairment. 1. Unchanged. (Note: Weekly Skin Assessments were not completed from 7/20/22 until 8/17/22.) R10's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Wound Care Orders Bilateral Heels. Skin prep every day and evening shift for wound tx. Ordered 7/18/22. - Prevalon [NAME] on while in bed every shift for wound tx. Ordered 7/18/22. - Multivitamin-Minerals Tablet. Give 1 tablet by mouth one time a day for, at risk for poor wound healing. Start date,7/21/22. - Zinc-220 Capsule. Give 1 tablet by mouth one time a day for, at risk for poor wound healing. Start date, 7/22/22. - Prostat two times a day for, at risk for poor wound healing. Start date, 7/22/22. R10's Treatment Administration Record (TAR) for the months of July and August, state in part . Wound Care Orders Bilateral Heels - skin prep every day and evening shift for wound tx (treatment). Ordered Date: 7/18/22. Treatment not signed out as ordered on the following dates and times. 7/28/22 - Day shift 7/30/22 - Day shift 8/2/22 - Day shift 8/3/22 - Day shift 8/6/22 - Evening shift R10's TAR for the months of July and August, state in part . Prevalon boots on while in bed every shift for wound tx. Ordered Date: 7/18/22. Treatment not signed out as ordered on the following dates and times. 7/30/22 - Day shift 8/6/22 - Day shift 7/16/22 - Evening shift Nurses Note from 7/18/22 at 17:37 (5:37 PM), states in part . Wounds assessed today by writer - see weekly skin impairment assessment. Nurses Note from 7/20/22 at 9:11 AM, states in part . Wounds assessed today by writer - see weekly skin impairment assessment. (It is important to note that PI was initially discovered on 7/15/22 but the facility did not complete an assessment of the areas until 7/18/22. The facility completed another assessment of R10's wounds on 7/20/22 but have not completed another assessment until today, 8/17/22. Interventions to prevent and/or heal pressure injuries were never placed on the CNA care plan. R10 did not have an intervention to offload the feet/heels prior to PI development, nor was this intervention added to the CNA care card after development.) Dietary Note from 7/21/22 at 12:01 PM, states in part . Note text: Re-admit/ Significant change/ Wound note: [AGE] year-old woman who returned after 3 nights in the hospital due to altered mental status and low blood sugars. She has a boggy right heal and a DTI to the left heel. Recommend starting proheal/prostat 30ml (milliliters) BID (twice a day), MVI w/ (multi vitamin with) minerals, and 14 days of 220mg (milligrams) zinc for wound healing. Facility document titled, CNA Bathing and Skin Inspection Report, states in part . 7/17/22 - Bath given: Yes. Skin Inspection: (place x on compromised area on the body). Nothing marked to indicate skin problems/issues. 7/20/22 - Bath given: Yes. Skin Inspection: (place x on compromised area on the body). Nothing marked to indicate skin problems/issues. 7/25/22 - Bath given: Yes. Skin Inspection: (place x on compromised area on the body). Nothing marked to indicate skin problems/issues. 8/01/22 - Bath given: Yes. Skin Inspection: (place x on compromised area on the body). Nothing marked to indicate skin problems/issues. 8/08/22 - Bath given: Yes. Skin Inspection: (place x on compromised area on the body). Red bottom/buttocks. 8/15/22 - Bath given: Yes. Skin Inspection: (place x on compromised area on the body). Bottom circled on diagram. Signs of inflammation: Redness. Description: Excoriation. Odor: No. On 8/17/22 at 9:38 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B who in the facility is responsible for wound treatments and weekly assessments. DON B stated, RN E (Registered Nurse) had been doing wounds with the help of the RN/WCC F (Wound Care Certified). RN E has been doing wounds since the previous WCC Nurse left approximately a month ago. RN E's documentation is lacking and often is late. On 8/17/22 at 9:56 AM, Surveyor interviewed RN E. Surveyor asked RN E if she is wound care certified. RN E stated, I am not wound care certified and I got blessed with this job after the previous wound nurse left. I know nothing about wounds. The RN/WCC F is coming today to show me what she can. Surveyor asked RN E if she had been doing the weekly wound assessments. RN E stated, I haven't done anything but mark off the skin prep was applied. On 8/17/22 at 10:21 AM, Surveyor interviewed RN/WCC F. Surveyor asked RN/WCC F how often skin and wound assessments should be completed. RN/WCC F stated, Skin and wound assessments should be completed on admit, weekly with showers and if there were any wounds there would need to be a weekly assessment. Surveyor asked RN/WCC F if she is completing wound care with RN E. RN/WCC F stated, This is my first week doing wounds with RN E. I will be doing education with her as well. Surveyor asked RN/WCC F how soon a skin assessment should be completed on admission or readmission. RN/WCC F stated, On admission, within 24 hours. If area is not identified on admit would be considered in house acquired. On 8/17/22 at 10:52 AM, Surveyor interviewed LPN J (Licensed Practical Nurse). Surveyor asked LPN J where CNAs would look to find interventions in place for a resident. LPN J stated, CNAs would look at the Kardex (CNA Care Plan). Surveyor asked LPN J who updates the care plan. LPN J stated, Care plans are updated by the MDS Nurse and in monthly care plan meetings. On 8/17/22 at 10:54 AM, Surveyor interviewed Med Tech/CNA K. Surveyor asked Med Tech/CNA K where staff would look for interventions in place for a resident and who updates the care plan. Med Tech/CNA K stated, Would look on the care plan for CNAs they would find interventions on the Kardex. The MDS Nurse or the Nurse updates the care plan. On 8/17/22 at 11:03 AM, Surveyor observed RN/WCC F and RN E complete wound assessment and treatment on R10. On entry into R10's room it was noted that R10 was in bed and did not have boots on feet. R10's heels were directly in contact with the mattress. RN/WCC F completed measurements on R10's left heel. Heel measured 4 cm x 5 cm (centimeters). Surveyor asked RN/WCC F to describe R10's wound. RN/WCC F stated, Area is 100 percent eschar, hard and leathery. The 50 percent superior portion of the wound is darker in color. Wound is unstageable. Surveyor asked RN/WCC F if R10 should have boots on while in bed. RN/WCC F stated, Yes. R10's son was in the room at the time of the assessment and asked RN/WCC F what R10's wounds were from. RN/WCC F stated, The wound is from pressure and not having the heels up off the bed. On 8/17/22 at 1:32 PM, Surveyor interviewed CNA L. Surveyor asked CNA L where she would find interventions in place for a resident. CNA L stated, On their care plan. The CNAs would find it on the Kardex. R10 was at risk for PI's R10 did not have wound care assessments completed weekly per standard of practice, treatments were not completed as ordered and observations were made of R10's heels not being offloaded. R10's heel worsened from a DTI to an unstageable PI.

Based on observation, interview and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 4 of 4 residents (R1, R2, R3 and R10) reviewed for supervision and accidents out of a total sample of 12. R1 is requires extensive assist of two staff with transfers. R1 has had 7 falls since admission in which the root cause was not identified, and the facility did not ensure that the Certified Nurse Assistant (CNA) care plan was updated with interventions. R1's last fall resulted in hospitalization and death. R2 was at risk for falls and the facility failed to ensure that the CNA care plan was updated with interventions appropriately. This is evidenced by: The facility's Fall Policy and Prevention Program, implemented [DATE], states in part, as follows: 6. Upon arrival of the nurse, a quick head-to-toe scan will be performed without unnecessary movement, palpating and examining all areas for breaks in the skin and/or other abnormal findings. 7. Obtain vital signs: blood pressure, pulse, pulse oximetry, and respirations. 8. Obtain neurological checks (neuro-checks) per policy for any unwitnessed fall or any fall with evidence of injury to head. 11. The nurse will complete an event documentation report, fall risk assessment, pain assessment, and obtain witness statements. 12. The nurse will determine the most appropriate intervention, implement, and update care plan. The facility's Falls Review Process, implemented [DATE], states in part, as follows: 1. The Director of Nursing/Designee will assess the resident and review fall documentation, including witness statements, resident interview, environment review of area where fall occurred, and equipment inspection. 2. The event will be discussed, and event documentation reviewed for completion in IDT (Interdisciplinary Team) meeting. Compare date from previous assessments. Discuss identified trends. 5. Review fall Risk Assessment for any potential new risk factors. 6. Review plan of care/interventions to ensure all prior interventions are in place and still appropriate. 7. Adjust/add interventions on the Plan of Care. Update and communicate interventions. Provide appropriate training for caregivers if appropriate. Educate resident/family if appropriate. The facility's Fall Risk Assessment, implemented [DATE], states in part, as follows: Process: Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls. The risk assessment will be completed by the MDS (Minimum Data Set) Coordinator or designee upon admission, quarterly, or when a significant change is identified. Policy Explanation and Compliance Guidelines: 1. The facility utilized a standardized risk assessment for determining fall risk. The risk assessment categorizes residents as a high risk with a score of 10 or greater. The risk assessment will be completed upon admission, quarterly, or when a significant change is identified. 3. The nurse will initiate interventions on the resident's baseline care plan, if the assessment indicates high risk. 4. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed. 5. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete an event documentation report. c. Complete a fall risk assessment. d. Notify physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. If fall is witnessed, obtain witness statements. Example 1 R1 was admitted to the facility on [DATE] with diagnoses that include in part . History of falling, muscle weakness, history of TIA ([CONDITION(S)]), hypertensive [CONDITION(S)] with heart failure, and dementia without behavioral disturbance. R1's Admission MDS (Minimum Data Set) dated [DATE], indicates R1's BIMS (Brief Interview of Mental Status) is 14 is cognitively intact. R1 has a guardian and AHCPOA (activated healthcare power of attorney) and is not his own decision maker. Section G0110, Functional Status Transfers: Extensive assistance of two staff, Toileting: Extensive assistance of two staff. Section G0300 Balance During Transitions and Walking, Moving from seated to stand position: Not steady, only able to stabilize with human assistance; Surface to Surface transfers (transfer between bed and chair or wheelchair): Not steady, only able to stabilize with human assistance. R1's Comprehensive Care Plan, initiated [DATE], states in part . Problem: I have a physical function deficit related to: Mobility impairment. Self care impairment. Interventions: Assistive devices (wheelchair); Bed mobility assistance of (limited assist of 1); Call bell in reach; Dressing assistance (Extensive assist of 1); Encourage choices with care; Locomotion assistance of (Dependent of 1); Toileting assistance of (Dependent assistance of (Dependent of 1 or 2); Transfer assistance of (Extensive with 1 or 2). R1's Comprehensive Care Plan, initiated [DATE], revised on [DATE], states in part . Problem: At risk for falls related to: fell in the past 30 days. New environment. Interventions: Bed in low position, initiated [DATE]; Call light and personal items available and in easy reach or provide reacher, initiated [DATE]; clean and monitor environmental obstacles (tubing, cords, etc.), initiated [DATE]; Encourage participation in activities to improve strength or balance, initiated [DATE]; footwear to prevent slipping, initiated [DATE]; keep bed locked, initiated [DATE]; keep environment well lit and free of clutter, initiated [DATE]; keep personal items within reach, initiated [DATE]; mat on floor at bedside, initiated [DATE]; monitor for restlessness and implement interventions, initiated [DATE]; resident to be toileted every 2 hours at NOC (night), (10pm (10:00 PM), 12am (12:00 AM), 2am (2:00 AM), 4am (4:00 AM), 6am (6:00 AM), initiated [DATE]; Callbell [sic] within and reminders to use callbell [sic] as needed, initiated [DATE]; check and change, initiated [DATE]; encourage exercise, initiated [DATE]; encourage fluids, initiated [DATE]; monitor and report changes in ability to toilet or continence status, initiated [DATE]; monitor and report S&S (signs and symptoms) of [CONDITION(S)] (urinary tract infection): changes in color, odor, or consistency of urine, dysuria, frequency, fever, pain, initiated [DATE]. R1's CNA Kardex (Care Plan) indicates the following in part . ADL's (Activities of Daily Living): Assistive devices (w/c (wheelchair)); bed mobility assistance of (Limited of 1); Call bell in reach; Dressing assistance of (Extensive assist of 1); Locomotion assistance of (Dependent of 1); Monitor and report changes in physical functioning ability; Personal hygiene assistance of (Extensive of 1); Resident to be toileted every 2 hrs (hours) at NOC (10pm, 12am, 2am, 4am, 6am); Toileting assistance of (Dependent with 1 or 2); Transfer assistance of (Dependent of 1 or 2). Bladder/Bowel: Monitor and report S/S of [CONDITION(S)]: changes in color, odor, or consistency of urine, dysuria, frequency, fever, pain. (Note: The CNA Kardex does not include a list of Safety interventions.) (Note: All Fall interventions on the care plan on not listed on the CNA Kardex.) On [DATE] at 14:15 (2:15 PM), Fall Incident Report, states in part . Nursing Description: Writer called to resident's room by aide upon entering room writer observed resident laying on the floor on his L (left) side parallel to the bed with head at foot of bed. Resident Description: When asked what happened resident states, I fell trying to get into bed then stated there was too much food. When asked resident had any pain he stated, Yeah my forehead. I hit it on the ground. Immediate Action Taken: No red marks on forehead. Room was clutter free. Res was wearing gripper socks. Writer x2 aides assisted resident to w/c. No injury; No pain Mental Status: Oriented to Person Predisposing Physiological Factors: Impaired memory, confused Predisposing Situation Factors: Ambulating without assist, admitted within last 72 hours. Physician (MD), Director of Nursing (DON), Activated Healthcare Power of Attorney (AHCPOA)/Guardian updated. COMS-Post Fall Evaluation, states in part . Date/Time of fall: [DATE] at 14:15 (2:15 PM) Was fall witnessed? No Location of Fall: Resident's room Activity at time of fall: Unknown Was the reason for the fall evident: No Pre-Fall: Fall Risk Score: 16 Post-Fall: Fall Risk Score: 16 Was a safety evaluation completed/documented prior to the fall? No Was safety teaching documented before the fall? No Contributing Factors: Recent change in environment Physical Findings Note: Resident abx (admission) today VS (vital signs) [DATE] at 16:20 (4:20 PM): Temp (temperature) 98.3, BP (blood pressure) ,d+[DATE], P (pulse) 91 with regular rhythm, R (respirations) 18, O2 (oxygen saturation) 98% RA (room air). Skin WNL (within normal limits), Mucous Membranes-Moist. Skin-Warm/dry. Did the resident's current medical condition(s) contribute to the fall? Yes (none noted) Does resident have a history of fall(s)? Yes - home and hospital Any similarities between current and post falls? Yes Prior fall note: Confusion/lack of safety awareness Conclusion Note: Scoop mattress, bedside mat in place. Performing frequent checks on resident. (Note: The scoop mattress and bedside mat are not listed on the CNA Kardex and there is no root cause of the fall indicated.) On [DATE] at 13:13 (1:13PM), Fall Risk Evaluation Score 16 (Note: Fall Risk Score of 16, indicates high risk for falls.) On [DATE] Care Plan Interventions included: call light and personal items available and in easy reach or provide reacher; clear and monitor environmental obstacles; encourage participation in activities to improve strength or balance, keep bed locked; keep environment well lit and free of clutter; keep personal items in reach. (Note: Care plan items listed as interventions are not listed on the CNA Kardex.) On [DATE] at 14:15 (2:15PM), Nurses Note states, Writer called to resident's room by aide. Upon entering room writer observed resident laying on floor on his left side parallel to the bed with head at foot of bed. When asked what happened, resident states, 'I fell trying to get into bed' then stated, 'there is too much food.' if resident had any pain he stated, 'yeah, my forehead, I hit it on the ground.' No red marks observed to forehead. Room was free of clutter. Resident was wearing gripper socks. Writer x2 aides assisted resident to w/c that was retrieved from storage. Scoop mattress placed. Vital signs and neuros are stable. Resident able to move all extremities without difficulty. Will continue to monitor. On [DATE] at 03:39 (3:39 AM), Fall Incident Report states in part . Nursing Description: During CNA rounds this nurse was called to the patients room where he was found on laying on his left side on the floor. Resident Description: Patient states 'I was trying to get out of bed, and I slipped. Patient states, I don't know where I was going. Immediate Action Taken: Patient was assessed for injuries noted, and full set of VS was obtained. VS WNL. Patient was then transferred into his wheelchair and placed at the nurses station where he was placed on neuro checks for further monitoring. No injury; No pain Mental Status: Oriented to Person Predisposing Physiological Factors: Gait Imbalance Predisposing Situation Factors: Ambulating without assist, Improper footwear. MD updated COMS-Post Fall Evaluation, states in part . Date/Time of fall: [DATE] at 02:55 (2:55 AM) Was fall witnessed? No Location of Fall: Resident's room Activity at time of fall: Attempting to self-transfer Was the reason for the fall evident: Yes Fall details Note: Refer to nurse description note in Risk Management Contributing factors: incontinent at time of fall, bedside call light on at time of fall Vital Signs [DATE] at 03:51 (3:51 AM): Temp 97.3, BP ,d+[DATE], P 65 with regular rhythm, R 16, O2 98% RA. Skin WNL, Mucous Membranes-Moist. Skin-Warm/dry Vitals Note: VS WNL, Neuro checks have been put in place and they have been WNL. They will continue to be monitored. Did the resident's current medical condition(s) contribute to the fall? Yes (none noted) Does resident have a history of fall(s)? Yes - home and facility Any similarities between current and post falls? Yes Prior fall note: baseline confused neglectful to use call light attempting to self-transfer (Note: The fall assessment states call light was on at time of fall. No interventions listed on the CNA Kardex and no root cause identified for this fall. R1 was also incontinent at the time of the fall.) On [DATE] at 15:59 (3:59 PM), Fall Risk Evaluation Score 20 (Note: Fall Risk Score of 20 indicates R1 is at high risk for falls.) On [DATE] at 03:56 (3:56 AM), Nurses Notes state, Patient had a recent fall during this shift. (Refer to risk management). He was attempting to self-transfer and ambulate to the bathroom. He was neglectful to use the call light and ask for assistance. At the time of the fall he was wearing regular socks instead of non-skid socks. VS WNL. Patient was placed on neuro checks which continue to be WNL. Patient denies any pain and no injuries noted at this time. On-call doc (doctor) for another physician has been notified. Attempted to notify DON via phone call. No answer. At this time patient is up in his wheelchair at the nurses station for further monitoring. On [DATE] at 03:10 (3:10 AM), Fall Incident Report states in part . Nursing Description: Writer summoned to room. Resident next to bed kneeling with his weight on his heels, left hand holding onto side rail. Resident Description: When asked by resident what he was attempting to do, resident stated, that machine didn't work! I need to get my keys out of my car. Immediate Action Taken: Resident assessed for acute pain, then assisted to nurses station for monitoring. First aid provided to left knee injury. No injury observed at time of incident Mental Status: Oriented to Person Injuries report post incident: Abrasion front of left knee and other type of injury front of left knee. Pain: None Mental Status: Oriented to Person. Notes: injury left knee skin tear with avulsion within wound, wound size 1.6 x 2.4 x 0.1, site cleansed with NS, 25% if wound approximated and x1 (times 1) steri strip applied, wound covered with nonstick dressing and window taped, resident denied any pain. Predisposing Physiological Factors: Impaired memory, Dementia MD/DON/AHCPOA updated (Note: This is the second fall on night shift.) COMS-Post Fall Evaluation, states in part . Date/Time of fall: [DATE] at 03:10 (3:10 AM) Was fall witnessed? No Location of Fall: Bedside Activity at time of fall: Other (specify below). Other activity: unable to determine Was the reason for the fall evident: No Did injury occur as a result of the fall? Yes. Injury Details: Skin tear with avulsion inside the wound. Fall details Note: Resident found on floor next to his bed kneeling and with weight on his heels, left hand holding onto his bedside rail, reason for fall unable to determine, vital signs elevated immediately after fall and improved later in shift, resident denied any pain, did not appear in pain or discomfort, abrasion with avulsion center of wound, site cleaned with normal saline, 25% of wound edge approximated and steri strip applied, dry non stick dressing applied, unwitnessed fall protocol stated, new orders. Contributing factors: using incontinence supplies at time of the fall Medication Review Note: medication review sent previous week, no changes. Physical Findings: Sensory Impairment VS [DATE] at 0724: Temp 98.1, BP ,d+[DATE], P 58, O2 99% RA. VAB abnormalities: [CONDITION(S)]: Pulse less than 60. Skin pale, Mucous Membranes-Dry and decreased. Skin-Warm/dry. Turgor-Decreased Vitals Note: VS WNL, Neuro checks have been put in place and they have been WNL. They will continue to be monitored. Did the resident's current medical condition(s) contribute to the fall? Yes. Multiple noted. Does resident have a history of fall(s)? Yes -facility On [DATE] at 03:10 (3:10 AM), Fall Risk Evaluation Score 17 On [DATE], Care Plan Intervention: Mat on floor at bedside (Note: Mat on floor at bedside is not listed on the CNA Kardex and there is no root cause indicated for the fall listed.) On [DATE] at 00:45, Fall Incident Report, states in part . Nursing Description: Writer found resident on bedside mat on the floor, resident laying on left side with left arm under his head, resident was in his bed prior to finding on the floor. Resident Description: I was trying to get back into bed. Immediate Action Taken: assessed for acute pain and injury, then assisted to nurses station No injury observed at time of incident Pain: None Predisposing Physiological Factors: Impaired memory, Cardiovascular, psychotropics, antihypertensives, confused, incontinent, dementia, CHF/cardiac disease Predisposing Situation Factors: Responding to toileting needs. Other Info: Resident's brief was wet with urine. MD/DON/AHCPOA updated (Note: This is the third fall on night shift.) COMS-Post Fall Evaluation, states in part . Date/Time of fall: [DATE] at 00:45 (12:45 AM) Was fall witnessed? No Location of Fall: Resident's room Activity at time of fall: Other (specify below). Other activity: resident did not report, was incontinent of urine. Fall details Note: resident denied pain, pupils equal and reactive, moves all extremities without pain, vital signs stable, no apparent injury noted, no elevation noted head with palpation, skin intact Contributing factors: Floor mat on floor, poor lighting, resident using incontinent supplies at time of fall, resident was incontinent at time of fall Medication Review Note: medication review sent previous week, no changes. Physical Findings: Sensory Impairment Vital Signs on [DATE] at 03:04 (3:04 AM): Temp 97.4, BP ,d+[DATE], P 51, R 18, O2 99% RA. Abnormalities: [CONDITION(S)]: Pulse less than 60. Skin color WNL, Mucous Membranes-Dry. Turgor-Decreased Vitals Note: Vitals are stable. Clinical Suggestions: Examine for signs of decreased cardiac output: [CONDITION(S)], dizziness, palpitations, [CONDITION(S)], JVD, crackles, decreased peripheral pulses, cool skin. Skin is cool to touch. Does resident have a history of fall(s)? Yes -facility Additional needs identified? Yes. Need Identified: Floor Mat (Note: Fall mat was the intervention put into place for the fall on [DATE], no root cause of the fall was identified. This is the second fall in which R1 was incontinent.) On [DATE] at 00:45 (12:45 AM), Fall Risk Evaluation Score 19 On [DATE], Care Plan Intervention: Resident to be toileted every 2 hours at NOC (10pm, 12am, 2am, 4am, 6am) On [DATE] at 20:56 (8:56 PM), Fall Incident Report states in part . No fall incident report was completed for this fall. COMS-Post Fall Evaluation states in part . Date/Time of fall: [DATE] at 16:25 (4:25 PM) Was fall witnessed? No Location of Fall: Resident's room Activity at time of fall: Other Specify below: Other activity - getting up Was the reason for the fall evident: No Pre-Fall: Fall Risk Score: 16 Post-Fall: Fall Risk Score: 16 Was a safety evaluation completed/documented prior to the fall? Yes Was safety teaching documented before the fall? Yes. Date of safety teaching documentation: [DATE] Fall Details Note: Resident was on his knees with his hands on the floor-denied hitting his head-denied any pain-upset with staff for thinking he hurt himself. Neurochecks started. Was assisted to chair. Fall teaching done. Contributing Factors: Footwear at time of fall-non-skid shoes/socks VS [DATE] at 1630: Temp 98.2, BP ,d+[DATE], P 73 with regular rhythm, R 20, O2 97% RA. Skin color WNL, Mucous Membranes-Moist. Skin-Warm/dry. Decreased Turgor Did the resident's current medical condition(s) contribute to the fall? Yes (cognitive issues) Does resident have a history of fall(s)? Yes -facility Any similarities between current and post falls? Yes, baseline confused neglectful to use call light attempting to self-transfer (Note: Interventions not in place on the CNA Kardex and the facility failed to identify the root cause of the fall.) On [DATE] at 20:40 (8:40 PM), Fall Risk Evaluation Score 24 On [DATE] at 21:35 (9:35 PM), Nurses Note states, at 1625 resident was found in the floor on his knees with his hands on the floor alert and oriented to his normal. Denied hitting his head and denied any pain. No obvious skin tears or trauma noted. Resident was upset with staff since we were making a big deal out of him falling. He stated, I did not get hurt and I caught myself with my hands! At first refused to let us do vital signs but then cooperated. MD notified and POA-daughter notified. On [DATE] at 04:10 (4:10 AM), states in part . Nursing Description: Resident found on his knees next to his bed. Resident was on top of his floor mat and the bed was in the low position. Resident appeared to be attempting to self-transfer out of bed. Resident denies any pain or discomfort. No injury observed. Neuro checks intact and VS WNL. Resident had been toileted 20 minutes prior to the fall occurring and denies any need to use the restroom at the time of the fall. Resident Description: Resident stated, I was trying to get up. Immediate Action Taken: Resident assessed for injuries. Resident assisted up off the floor with a gait belt and two staff members. Neuro checks initiated and VS obtained. Resident then brought out to the nursing station for further monitoring. DON, POA, and MD updated. No injury; No pain Mental Status: Oriented to Person, oriented to situation Predisposing Physiological Factors: Impaired memory, confused, gait imbalance Predisposing Situation Factors: Ambulating without assist, improper footwear. MD/DON/Guardian updated. (Note: This is the fourth fall on the night shift and the third fall between 3:10 AM and 4:10 AM.) COMS-Post Fall Evaluation states in part . Date/Time of fall: [DATE] at 04:10 (4:10 AM) Was fall witnessed? No Location of Fall: Resident's room Activity at time of fall: Other. Specify: Attempting to get out of bed. Was the reason for the fall evident: No Fall Details Note: Resident found on his knees next to his bed. Resident was on top of his floor mat and the bed was in the low position. Resident reported, I was trying to get up. Resident had been toileted 20 minutes prior to the fall occurring and denied any need to use the restroom at the time of the fall. No injuries observed. Neuro checks intact and VS WNL. Contributing Factors: Floor mat on floor, resident was wearing glasses at the time of the fall, bare feet at time of the fall. VS [DATE] at 1620: Temp 98.2, BP ,d+[DATE], P 69 with regular rhythm, R 17, O2 95% RA. Skin WNL, Mucous Membranes-Moist. Skin-Warm/dry. Normal Turgor. Did the resident's current medical condition(s) contribute to the fall? No Does resident have a history of fall(s)? Yes - Facility Any similarities between current and post falls? Yes Prior fall note: attempting to self transfer baseline confusion [DATE] Care Plan Intervention: Monitor for restlessness and implement interventions. (Note: Intervention is not listed on the CNA Kardex and no root cause of this fall identified. The resident was also barefoot at the time of the fall and the care plan indicates footwear to prevent slipping.) On [DATE] vat 15:01 (3:01 PM), Fall Risk Evaluation Score 24 [DATE] at 04:30 (4:30 AM), Nurses Note states, Resident found on floor next to his bed at 0410 (4:10 AM). Resident found on his hand and knees on top of his floor mat. Resident's bed was I the low position with call light in reach. Resident was barefoot at the time of the fall. Resident states, I was trying to get up. Resident had been toileted 20 minutes prior to the fall and denies any need to use the restroom at the time of the fall. Neuro checks intact and VS WNL. No injury noted and resident denies any pain or discomfort. On [DATE] at 15:05 (3:05 PM), Fall Incident Report states in part . Nursing Description: Resident was visualized by the CNA on the floor next to his wheelchair laying on his right side. He had a large goose egg like lump to the right side of his forehead. All nurses were notified and responded to the room. Neuro checks were completed immediately, and it was decided at that point that the resident needed to be sent out to the hospital for further evaluation due to abnormal neuro exam. The Nurse (DS) completed neuro exam and requested that we call for an ambulance. Nurse (RD) called the provider numerous times for orders, while (DB) called the guardian to get consent for sending the resident out and selection of hospital. Resident was sent out emergent ambulance with the permission of POA, daughter and guardian of the resident. Resident Description: Resident unable to describe incident, but stated, nurse help, help nurse. Immediate Action Taken: At approximately 15:00 (3:00 PM) the social worker and CNA were in the hallway and had visualized Res in his w/c (wheelchair). They were performing care down the hall and came back through when SB stated that Res had fallen out of his w/c. Staff called nursing staff to assist. The neuro exam was competed, and abnormal eye movement was noted immediately. The guardian was notified of the fall and gave permission for the resident to be sent out to the hospital. The staff called 911 and requested an ambulance as well as calling the provider for orders. The resident remained on the floor with his c-spine protected until the emergency medical professionals arrived on scene. EMS arrived within fifteen minutes of the call and he was stabilized and transported to hospital. At approximately 21:00 (9:00 PM) that evening, a nurse for the hospital called to let LPN RD know that resident had passed aware as a result of his injuries. Family aware and declined postmortem testing. Injury observed at time of incident: Bruise/contusion to top of scalp Level of Pain: Lethargic Mental Status: Oriented to Person Injuries report post incident: No injuries observed post incident. MD/DON/AHCPOA updated COMS-Post Fall Evaluation, states in part . Date/Time of fall: [DATE] at 16:16 (4:16 PM) Was fall witnessed? No Location of Fall: Resident's room Activity at time of fall: Other (specify below). Other activity: May have attempted to stand up from w/c Was the reason for the fall evident: Yes. Reason for fall: fell out of chair. Pre-fall: Fall risk score: 16 Post-fall: Fall risk score: 16 Did injury occur as a result of the fall? Yes. Injury Details: Raised area R (right) forehead. Did ER visit/hospitalization occur as a result of the fall? Yes. Details: Left 15:40 (3:40 PM), sent to Hospital Contributing factors: w/c involved, w/c unlocked, wearing glasses at time of fall, shoes on at time of fall, using incontinence products at time of fall. Contributing factors note: Confused, does not ask for help Vital Signs [DATE] at 15:15 (3:15 PM): Temp 97.6, BP ,d+[DATE], P 94, R 22. Skin color-WNL, Mucous Membranes-warm/dry. Skin-Warm/dry. Turgor-Decreased Vitals Note: VS WNL, Neuro checks have been put in place and they have been WNL. They will continue to be monitored. Did the resident's current medical condition(s) contribute to the fall? Yes. Dementia Does resident have a history of fall(s)? Yes -facility Any similarities between current and post falls? Yes. None listed. On [DATE] at 16:16 (4:16 PM), Neuro Focused Evaluation completed by LPN D, states in part . No vitals listed Obeys commands? Yes PERRLA? No Pupils-other? Sluggish response Detailed Neuro Eval: Right hand, left hand, right leg, left leg, right foot, left foot all normal. Neurological Note: Able to speak, Get me up. Abnormalities: Pupils: sluggish. On [DATE] at 15:48 (3:48 PM), SW I (Social Worker) Note states, Resident had an unwitnessed fall in his room. Nurses completed their assessment immediately. DON updated. Guardian was called and updated, agreeable to send resident out the Hospital. CNA stayed with resident in his room until EMS arrived. Nurse obtained order to send resident out to the ER from on call provider. On [DATE] at 21:00 (9:00 PM), Nurses Note states, At approximately 2100 (9:00 PM), LPN D was notified by an ER (emergency room ) Nurse from the Hospital that R1 had died due to his injuries that he sustained in the fall. Family was aware and declined postmortem testing. On [DATE] at 12:57 PM, Surveyor interviewed DON B (Director of Nursing), Surveyor asked DON B what her expectations were of staff following a fall. DON B stated, Staff here would be expected to complete the fall incident report and fall post evaluation but that does not always happen. They we are doing it and back dating, putting in late entries. This fall was startling for them. With fall will update the care plan and talk about it in IDT. Fall interventions are to be put into place immediately. The fall interventions are either put in the care plan or in a nurses note and the MDS Coordinator or I will update the care plan. Nurses let staff know immediately what the intervention is. Surveyor asked DON B where staff are to find the fall interventions. DON B stated, They are to look at the care plan or the CNA Kardex. The CNAs just know. The CNAs don't have access to the resident's actual care plan. CNA's have access to the CNA Kardex. Surveyor asked DON B if she could review R1's care plan and the CNA Kardex and identify the interventions for falls. DON B stated, I don't see all the interventions. I will audit the care plans and CNA Kardex this week to make sure they are on the CNA Kardex. On [DATE] at 3:21 PM, Surveyor interviewed CNA H. Surveyor asked CNA H if she was aware of what fall interventions were in place for R1. CNA H stated, R1 had a fall mat on the floor by his bed, a touch call light, and his bed was to be to the floor. We did supervision with him as much as we could. Surveyor asked CNA H how she is made aware of interventions put into place for residents. CNA H stated, Therapy or someone sometimes will tell us what the interventions are. I would look at the CNA Kardex if unsure. Surveyor asked CNA H if the Nurse ever reviews the care plan interventions with them. CNA H stated, No, the nurses don't go over the care plan with us. Surveyor asked CNA H what the procedure is if there is a fall. CNA H stated, I would y [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure it maintained an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infections such as COVID-19. This had the potential to affect all residents residing within the facility at the time of the outbreak on [DATE]. At the time of survey, this outbreak involved 35 residents, 5 whom expired, and 9 staff. The facility did not: * recognize or ensure to routinely screen all residents for signs and symptoms of COVID-19 daily and increase screening to every shift once the outbreak was identified * screen all individuals who come into the facility prior to entry * ensure staff do not enter the facility with symptoms without reporting to facility leadership/DON (Director of Nursing)/IP (Infection Preventionist) or document symptoms on the screening tool * ensure staff who were positive for COVID-19 did not work * use PPE (personal protective equipment) properly * treat a resident who refused testing as positive and place them on droplet precautions * begin to fit-test all staff for N95s after being trained to complete fit tests * provide training or skill competency checks for staff who perform their own COVID-19 tests via nasal swab. The above failures created a finding of immediate jeopardy that began on [DATE]. The Interim Nursing Home Administrator was notified of the immediate jeopardy on [DATE] at 12:17 PM. The immediate jeopardy was removed on [DATE], however the deficient practice continues at a scope/severity of F - potential for harm, widespread - as the facility continues to implement its removal plan. This is evidenced by: The facility policy titled, Coronavirus Surveillance, implemented [DATE] states, This facility will implement heightened surveillance activities for coronavirus illness during periods of transmission in the community and/or during a declared public health emergency for the illness. Policy Explanation and Compliance Guidelines read as follows: 1. The Infection Preventionist will monitor the status of COVID-19 outbreak through the CDC website, and will monitor for changes in prevention, treatment, isolation, or other recommendations. 2. Heightened surveillance activities will be implemented to limit the transmission of COVID-19. These include, but are not limited to, screening visitors, staff, and residents. 3. Screening for visitors and staff: a. Signs or symptoms of a respiratory infection such as fever, cough, shortness of breath, or sore throat. b. In the last 14 days, as had contact with someone with a confirmed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . c. International travel within the last 14 days to countries with sustained community transmission (i.e. China, [NAME], South Korea, Italy, and Japan). Others will be added as identified from the CDC's website. d. Residing in a community where community-based spread of COVID-19 is occurring. 4. Visitors will be denied entry into the facility if they exhibit any of the criteria listed above. They may be directed to the Infection Preventionist, Director of Nursing, or nurse manager on duty if they have any questions. 5. Staff who have signs and symptoms of a respiratory infection shall not report to work. Any staff that develop signs and symptoms while on the job shall: a. Immediately stop work, put on a facemask, and self-isolate at home. b. Inform the Infection Preventionist, and include information on individuals, equipment, and locations the person came in contact with, and c. Contact and follow the local health department recommendations for next steps such as testing and locations for treatment. 6. Residents will be monitored for signs and symptoms of coronavirus illness including but not limited to: fever, cough, shortness of breath. The physician will be notified immediately, if evident. Staff shall follow established procedures with COVID-19 is suspected. Considerations for managing residents with suspected or confirmed COVID-19 infection: a. Us clinical features and epidemiologic risk for making a determination that COVID-19 infection is suspected. Test for COVID-19 in accordance with current CDC guidelines. b. Collaborate with the local health department regarding a coordinated transfer, unless it is determined that transfer is not required. For example, the resident does not require a higher level of care and the facility can adhere to recommended infection prevention and control practices (with modifications if no airborne infection isolation room is available). c. Increase monitoring of resident for development of more severe symptoms or other changes in condition. d. Increase monitoring of all other residents win COVID-19 is suspected or confirmed. 7. The facility will refer to current CDC guidance for exposures that might warrant restricting asymptomatic staff from reporting to work. The facility policy, Novel Coronavirus Prevention and Response, effective [DATE] states, This facility will respond promptly upon suspicion of illness associated with a novel coronavirus in efforts to identify, treat, and prevent the spread of the virus. The policy explanation and compliance guidelines states, in part, 1. The Infection Preventionist will assess facility risk associated with COVID-19 through surveillance activities of emerging diseases in the community and illnesses present in the facility. a. No current risk - the facility will implement interventions for prevention and prepare for a potential outbreak. b. Threat detected - the facility will respond promptly and implement emergency and/or outbreak procedures. 2. Staff shall be alert to signs of COVID-19 and notify the resident's physician if evident: a. Fever b. Cough c. Shortness of breath . 1. Interventions to prevent the spread of respiratory germs within the facility: a. Keep residents and employees informed by answering questions and explaining what they can do to protect themselves and their fell ow residents (i.e. handwashing, spatial separation, respiratory hygiene/cough etiquette). b. Monitor residents and employees for fever or respiratory symptoms . ii. In general, for care of residents with undiagnosed respiratory infection use Standard, Contact, and Droplet Precautions with eye protection unless suspected diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] ., [CONDITION(S)]). iii. Implement heightened surveillance activities or consult public health authorities for additional guidance if there is transmission of COVID-19 in the community . d. Educate staff on proper use of personal protective equipment and application of standard, contact, droplet, and airborne precautions, including eye protection . The facility policy titled, COVID Testing Refusal, implemented on [DATE], states, It is the Policy of [the corporation] that residents and staff have the right to refuse testing of COVID-19. The policy does indicate, in part, that those who refuse testing will be educated on the reason for testing and review the policy and procedure for refusal, . and if outbreak testing has been triggered and an asymptomatic resident refuses testing, he or she should be placed on or remain on TBP until he or she meets the symptom-based criteria for discontinuation. Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes per the CDC, updated [DATE] documents, in part: Evaluate Residents at least Daily- Ask residents to report if they feel feverish or have symptoms consistent with COVID-19 or an acute respiratory infection. Actively monitor all residents upon admission and at least daily for fever (temperature greater than or equal to 100.0°F) and symptoms consistent with COVID-19. Ideally, include an assessment of oxygen saturation via pulse oximetry. If residents have fever or symptoms consistent with COVID-19, implement precautions described in Section: Manage Residents with Suspected or Confirmed [CONDITION(S)]-CoV-2 Infection. Older adults with [CONDITION(S)]-CoV-2 infection may not show common symptoms such as fever or respiratory symptoms. Less common symptoms can include new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell. Additionally, more than two temperatures >99.0°F might also be a sign of fever in this population. Identification of these symptoms should prompt isolation and further evaluation for [CONDITION(S)]-CoV-2 infection. Manage Residents with Suspected or Confirmed [CONDITION(S)]-CoV-2 Infection- HCP caring for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator) .In general, it is recommended that the door to the room remain closed to reduce transmission of [CONDITION(S)]-CoV-2. This is especially important for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection being cared for outside of the COVID-19 care unit. However, in some circumstances (e.g., memory care units), keeping the door closed may pose resident safety risks and the door might need to remain open. If doors must remain open, work with facility engineers to implement strategies to minimize airflow into the hallway. If limited single rooms are available, or if numerous residents are simultaneously identified to have known [CONDITION(S)]-CoV-2 exposures or symptoms concerning for COVID-19, residents should remain in their current location pending return of test results .Roommates of residents with [CONDITION(S)]-CoV-2 infection should be managed as described in Section: Manage Residents who have had Close Contact with Someone with [CONDITION(S)]-CoV-2 Infection. Increase monitoring of residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to identify and quickly manage serious infection. Facility indicated that their Screening for their residents is a document called Respiratory Assessment COVID 2, when referring to a Screen or a residents Screening, this is what is being referred to. Example 1 - not getting test results promptly, thus allowing a COVID-positive staff person to work. On the morning of [DATE], the facility learned that CNA D (Certified Nursing Assistant) tested positive for COVID-19 from a nasal swab done in the facility on [DATE] as part of the twice a week testing in place related to the current county positivity rate at the time. CNA D had worked on [DATE], [DATE], [DATE], and [DATE]. The facility informed Surveyor all of CNA D's shift assignments were on the 200 wing of the facility, but indicated CNA D may have helped on other units, also. CNA D's lab result from information sheet from the contracted lab indicated the specimen was collected on [DATE] at 3:20 PM and the positive results were available on [DATE] at 4:40 PM. On [DATE], at 12:21 PM, Surveyor spoke with CNA D regarding the days leading up to her positive test result. CNA D said looking back, she could have been having symptoms and not realized they could have been indicative of COVID-19 infection. CNA D said she had felt tired and fatigued, which she had attributed to the many hours and long days she had been working, as well as some sweating and possible chills, which she felt at the time was from wearing gowns in isolation rooms which is very hot and then cooling down when outside of those rooms. CNA D indicated to Surveyors she may have been starting to get a sore throat just prior to finding out she was positive, but did not report it. CNA D was informed of her positive test while at work on [DATE], at which time she left the facility at 11:40 AM. On [DATE], at 9:15 AM, Surveyor spoke with DCO/IP C (Director of Clinical Operations/Infection Preventionist). Surveyor asked when DCO/IP C realized CNA D was positive, and she informed Surveyor she requested access to results from the contracted lab on [DATE], after the facility's previous Nursing Home Administrator left without warning on [DATE]. DCO/IP C said it took 48 hours to get information on access to lab results from the contracted lab. DCO/IP C said her access was granted on [DATE] to lab results from [DATE] forward. DCO/IP C indicated there were no results flagged for review (indicating a positive) on [DATE], and when she logged in on [DATE] there was a notification of three positive results, one of those being CNA D. DCO/IP C did not recall what time she received these results. Surveyor asked how CNA D was notified, and DCO/IP C stated IDON B (Interim Director of Nursing) took care of updating CNA D. Surveyor asked DCO/IP C if it was typical to have a four to five day wait between obtaining a nasal swab test and getting the results. DCO/IP C indicated she was told the facility's previous administrator who quit abruptly had arranged for the [DATE]-[DATE] labs to be picked up, but it did not occur, so the labs were dropped off at the contracted lab by IDON B on [DATE]. On [DATE], at 10:27 AM, Surveyor spoke with DON/IP C who indicated the facility believed the source of COVID-19 coming into the building was CNA D and indicated, She (CNA D) was one who has to be reminded to wear her mask up over her nose. Surveyors did not observe CNA D wearing Personal Protective Equipment (PPE) incorrectly while on site. On [DATE], at 2:50 PM, Surveyor asked DCO/IP C when the facility last provided education to staff regarding COVID-19 symptoms. DCO/IP C said, It has probably been a couple of months since they were educated about symptoms. DCO/IP C indicated there had been other topics related to COVID-19 covered. On [DATE], at 9:34 AM, Surveyor spoke with IDON B who indicated she did not recall the exact time she was made aware of CNA D's positive result, but it was sometime between 10:00 AM and Noon on [DATE]. Surveyor asked what instructions were given or if any questions were asked to CNA D, and IDON B indicated CNA D was told she would need to go home and quarantine and she was asked if she was having any symptoms. IDON B said, She said that she was tired, but she had been working a lot of shifts, which was understandable. According to CNA D's timecard punches on [DATE], she began work at 5:55 AM and left work at 11:40 AM. On [DATE], at 3:50 PM, IDON B provided Surveyor with outlines and slides from recent staff trainings provided, but not sign in sheets to indicate who received the education. These trainings were dated [DATE], [DATE], and [DATE] and did not include COVID-19 symptoms. Subsequent tests following the outbreak that began on [DATE] revealed the following: Test on [DATE]= 14 residents and 3 staff positive; 6 on 200 unit, 6 on 100 unit and 2 on 400 unit Test on ,d+[DATE]-,d+[DATE]= 16 residents and 4 staff positive; 5 on 200 unit, 10 on 100 unit, 1 on 400 unit Test on [DATE]= 4 residents positive, no staff; 1 on 200 unit, 3 on 100 unit (3 others tested who were positive before this date (2 staff and 1 resident) R7 tested positive on [DATE] and passed away on [DATE] R4 tested positive on ,d+[DATE] and passed away on [DATE] R5 tested positive on [DATE] and passed away on [DATE] R6 tested positive on [DATE] and passed away on [DATE] R15 tested positive on [DATE] and passed away on [DATE] Example 2 - incorrect self-testing technique The facility was completing mandatory COVID-19 testing twice a week for all staff. Results of the [DATE] tests were not known on [DATE], when the facility was doing its second test of the week, therefore CNA D tested as scheduled. On [DATE], CNA D performed a COVID-19 test which eventually returned as a negative result, despite her [DATE] test results being positive. On [DATE], at 12:21 PM, Surveyor spoke with CNA D about her test result from the swab performed on [DATE] and the process of testing. CNA D stated, I think I did the test wrong. I put the stick (swab) in the tube first before I swabbed my nose that day. On [DATE], at 3:20 PM, Surveyor asked IDON B about the process of self-testing for COVID-19. IDON B stated, Staff is testing themselves out at the desk. IDON B showed Surveyor the testing kits at the nurse's station and stated, They take out the swab, swirl it in both nostrils, then swirl the swab into the solution and remove it, close the tube, label it, and put it in the refrigerator. Surveyor asked if the facility had done education for staff self-testing to show competency and she indicated she was not aware of any, and the facility had been doing this since she began as the IDON. On [DATE], at 8:51 AM, Surveyor spoke with Med Tech E (Medication Technician) and asked about COVID-19 testing at the facility and how she was trained and by whom to do the test. Med Tech E stated one of the Certified Nursing Assistants showed her and it was CNA D. (Of note, CNA D had performed one of her own tests incorrectly which then came back as a negative result, despite her previous swab indicating a positive result.) On [DATE], at 9:15 AM, Surveyor spoke with DCO/IP C to inquire about staff training for self-testing and if the facility was performing any audits. DCO/IP said she had not been doing audits on self-testing since she began working on-site at the facility and said, I'm guessing they haven't done them. On [DATE], at 3:50 PM, Surveyor spoke with IDON B who stated each Nasal Swab Collection kit has instructions inside the package, staff are expected to follow the instructions provided when obtaining a sample, and staff are expected to ask questions if they do not understand. Example 3 - not reviewing screen-in forms, thus allowing staff to work who self-screened with symptoms Surveyor reviewed the Coronavirus Screening Forms at the employee entrance and observed two employees, PTA G (Physical Therapy Assistant) and DA H (Dietary Aide), had screened in to work on that day, [DATE], with symptoms which could indicate COVID-19 infection. Part I of PTA G's Coronavirus Screening Form noted the following: - Have you been exposed to anyone with COVID-19 in the last 14 days? Yes - Do you have a cough? Yes - Do you have a sore throat? Yes - Do you have congestion or a runny nose? Yes Part II of PTA G's Coronavirus Screening Form is for comments and reads, Provide additional information, if you answered yes to any of the above. Onset and duration of any symptoms: Duration & proximity of contact with anyone with or under investigation for COVID-19: This section was left completely blank. Part III of PTA G's Coronavirus Screening Form is for Action/Signature reads as follows: - Visitation denied/work restricted: _____ No ______ Yes (exhibits criteria) - This was left completely blank. - Wishes to speak with Infection Preventionist: This marked as No with an X. - Signed by PTA G and dated [DATE] Part IV of PTA G's Coronavirus Screening Form is for Follow Up. This area includes a space for notes, Infection Preventionist Signature, and the date, and all areas were left blank. On [DATE], at 10:23 AM, Surveyor spoke with PTA G regarding his Coronavirus Screening Form. PTA G informed Surveyor he has had these symptoms for a couple of weeks and has noted them previously on his Coronavirus Screening Forms at this facility, as well. PTA G stated he does rapid tests for COVID-19 regularly because he doesn't want to take the virus home to an unvaccinated family member. Surveyor asked PTA G if he had spoken to anyone at the facility about his symptoms, and he stated his supervisor, a Physical Therapist, was aware. Surveyor asked PTA G if anyone from the facility had followed up with him regarding any of his previous Coronavirus Screening Forms about his symptoms, and he stated, No. No one here from the facility has followed up with me. Part I of DA H's Coronavirus Screening Form noted the following: - Do you have a fever or chills? (No) Time 88.6 Temp IN _____ (Note an abnormally low temperature written in next to Time.) - Do you have a headache? Yes - Are you having any nausea, vomiting or diarrhea? Yes Part II of DA H's Coronavirus Screening Form is for comments and reads, Provide additional information, if you answered yes to any of the above. Onset and duration of any symptoms: Duration & proximity of contact with anyone with or under investigation for COVID-19: This section was left completely blank. Part III of DA H's Coronavirus Screening Form is for Action/Signature reads as follows: - Visitation denied/work restricted: __X__ No ______ Yes (exhibits criteria) - Wishes to speak with Infection Preventionist: This marked as No with an X. - Signed by DA H and dated [DATE] Part IV of DA H's Coronavirus Screening Form is for Follow Up. This area includes a space for notes, Infection Preventionist Signature, and the date, and all were blank. On [DATE], at 10:15 AM, Surveyor spoke with DA H regarding the self-screening process and her screening form completed for that day. DA H said the process is to fill out the sheet, take your temp, and clock in. Surveyor asked DA H if she reported her symptoms which were marked on the sheet to anyone in the facility, and she indicated she had spoken to her manager, DM I (Dietary Manager). DA H reported to Surveyor she had a headache today because she was on her menstrual cycle, and she had diarrhea because she had eaten Taco Bell the night before and said, It usually hits me the next day. On [DATE], at 10:20 AM, Surveyor spoke with DM I and asked if DA H had reported any symptoms to her when she started work that morning. DM I indicated she was aware DA H had some symptoms, but said DA H had reported to her she thought the cause of them was due to some recent medication changes. On [DATE], at 10:27 AM, Surveyor spoke with DCO/IP C and asked what the expectation was of staff members if they came to work and were experiencing symptoms which could be related to COVID-19. DCO/IP replied, Don't come in. They should be calling in symptoms to their department heads and not coming to work. At 10:40 AM, Surveyor spoke with DCO/IP C and asked if employees screened themselves into work with symptoms, should they come to you to report their symptoms or would you expect to be informed? DCO/IP C stated, Oh, absolutely. They should be cleared by me. DCO/IP C was unaware two staff members had entered the building and marked symptoms on their Coronavirus Screening Forms that morning. On [DATE], at 4:35 PM, Surveyor spoke with DCO/IP C to ask if she had completed any follow up with PTA G or DA H on [DATE] and if they had worked their full shifts. DCO/IP C indicated she believed both PTA G and DA H worked their full shifts, and she did follow up with DA H's supervisor, but she didn't run into him (PTA G). Example 4 - not screening visitors On [DATE], Surveyors entered the facility at the front of the building at 9:15 AM. There was another man/visitor waiting in the vestibule for staff to return something to him. He was wearing a mask and did not enter the building. In the corner of the facility entrance/vestibule, there was a table set up with a binder, hand sanitizer, and temporal thermometer. Surveyors handed business cards to the staff member who returned to speak to visitor who was waiting and he then left. The Surveyors were led into the building and Surveyors' business cards were then handed to MR/CS J (Medical Records/Central Supply). MR/CS J then directed Surveyors through the building to the end of the 400 wing hall to the conference room. No one at the facility asked Surveyors to screen in, check temperatures, or complete a visitor screen in. Surveyors did leave for lunch, returned to the facility, and were not asked to screen in or if a screen had been completed on initial entry to the facility that morning. On [DATE], the first Surveyor to arrive at the facility was not screened by staff or asked to screen when entering the facility. The second Surveyor to arrive at the facility was greeted by DCO/IP C who was sitting in the office with a window looking into the entryway/vestibule. DCO/IP C opened the door for Surveyor and asked Surveyor, Did you fill out a sheet? Surveyor had not been instructed on the process and said, I haven't. What do you need me to do? DCO/IP C pointed towards the table in the corner of the vestibule and indicated there was a thermometer there and a form to fill out. There were no blank forms in the binder, so DCO/IP C retrieved one from a stack of papers on the wall and handed it to Surveyor. Surveyor took temperature, filled out paperwork, and asked DCO/IP C what to do with the completed form. DCO/IP C had Surveyor leave the form in the binder, and Surveyor entered the facility. Example 5 - PPE On [DATE], at 9:18 AM, upon being let into the facility and directed to the conference room, Surveyors observed MR/CS J wearing a surgical mask under her N-95 mask. On [DATE], at 8:51 AM, Surveyor observed Med Tech E working on the 200 wing of the facility. Med Tech E was wearing prescription eyeglasses and had her PPE goggles/eyewear sitting on the medication cart. Surveyor observed Med Tech E walking through the hallway, leaving the 200 wing unit, and passing medication (to a non-positive resident) without wearing eye protection. On [DATE], at 9:15 AM, Surveyor asked DCO/IP C about her expectations on PPE use in the facility. DCO/IP C stated, N-95 and eye protection at all times. Surveyor asked if eyeglasses were considered eye protection. DCO/IP C stated, No. I've addressed that but will address it again. DCO/IP C indicated Med Tech E was aware eye protection was to be worn at all times. On [DATE], at 4:35 PM, Surveyor discussed surgical mask under the N95 mask observation and DCO/IP C stated, It would be OK to do it reversed with the N95 on first and the surgical mask on top, but not necessary. The seal would be compromised that way. Staff were interviewed and indicated they were not wearing eye protection prior to the current outbreak. 2021 County positivity rates for COVID-19 were provided to Surveyors by DCO/IP C as the following: Week of ,d+[DATE] = 11.28%, week of ,d+[DATE] = 13.1%, week of ,d+[DATE] = 10.84%, week of ,d+[DATE] = 9.91%, and week of ,d+[DATE] = 9.10%. On [DATE] at 2:21 PM, Surveyor observed IDON B had on N95 mask with yellow straps crisscrossed (top strap toward neck and bottom strap toward top of head) thus causing a gap at her cheek, therefore no seal in place. Example 6 - not regularly screening residents for symptoms R1 is a recent admission to the facility. R1 is responsible for herself, normally alert and oriented to person, place and time, and able to call and converse with family. R1 has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 does not normally use O2. R1's screenings prior to [DATE] were only completed on [DATE] and [DATE]. This results in 2 of 21 screenings in September after admission [DATE]. It is important to note that prior to an outbreak, since pandemic has begun, residents should be screened every day. R1's screenings after [DATE] were on: [DATE], [DATE], and [DATE]. R1 did not have any documented screening on [DATE], [DATE], [DATE] or [DATE]. It is important to note once an outbreak has begun, residents should be screened more frequently than every day, typically every shift in order to stay on top of changes and be able to act quickly. R1 was hospitalized with COVID-19 on [DATE]. Example 7 - not regularly screening residents for symptoms R2 is a long term resident of the facility. R2 has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's screenings prior to [DATE] were on: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. This results in 8 of 31 screenings in August and 8 of 30 screenings in September. It is important to note that prior to an outbreak, since pandemic has begun, residents should be screened every day. R2's screenings after [DATE] were on: [DATE], [DATE], [DATE], [DATE] on 2 shifts, [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] on 2 shifts and [DATE]. R2 did not have any documented screening on [DATE], [DATE], [DATE], and [DATE]. It is important to note that once an outbreak has begun, residents should be screened more frequently than every day, typically every shift in order to stay on top of changes and be able to act quickly. R2's screening dated [DATE] documents, in part: .Temperature 99.0 .non-productive cough . There is no evidence that R2 was tested for COVID when he had symptoms documented on his screening. R2 was not tested with rest of residents during routine testing on [DATE]. R2 tested positive for COVID on [DATE], next round of routine testing. On [DATE] at 2:08 PM, Surveyor interviewed DCO/IP C (Director of Clinical Operations/Infection Preventionist). Surveyor asked DCO/IP C if R2 should have been tested on [DATE] with the rest of the routine testing, DCO/IP C stated yes, there should be another test for R2 between [DATE] and [DATE]. On [DATE] at 2:41 PM, Surveyor interviewed IDON B (Interim Director of Nursing). Surveyor asked IDON B if all residents should be tested when routine testing is completed, IDON B said yes, unless they've tested positive then they wouldn't need to test for 90 days. Surveyor asked IDON B if she knew how R2 was missed during testing on [DATE], IDON B stated I personally swabbed his unit and I know I swabbed him. IDON B went on to explain that they have had issues with the testing company with things like this in the past. Surveyor asked IDON B if that was documented somewhere, IDON B said no. Example 8 - not regularly screening residents for symptoms R3 is a long term resident of the facility. R3 has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R3 does not normally use O2. R3's screenings prior to [DATE] were only completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. This results in 7of 31 screenings in August and 8 of 30 screenings in September. It is important to note that prior to an outbreak, since pandemic has begun, residents should be screened every day. R3's screenings after [DATE] were on: [DATE], [DATE], [DATE], [DATE] on 2 shifts, [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] on 2 shifts, and [DATE]. R3 did not have any documented screening on [DATE], [DATE] or [DATE]. It is important to note once an outbreak has begun, residents should be screened more frequently than every day, typically every shift in order to stay on top of changes and be able to act quickly. R3 was sent to the emergency room for evaluation on [DATE]. Example 9 - not regularly screening residents for symptoms R4 was a long term resident of the facility. R4 had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's screenings prior to [DATE] were not completed daily. It is important to note that prior to an outbreak, since pandemic has begun, residents should be screened every day. R4's screenings after [DATE] were on: [DATE], [DATE], [DATE], and [DATE]. There were no screenings after [DATE]. It is important to note that once an outbreak has begun, residents should be screened more frequently than every day, typically every shift in order to stay on top of changes and be able to act quickly. Example 10 - not regularly screening residents for symptoms R5 was a new admiss [TRUNCATED]

Based on interview and record review, the Facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 5 of 14 sampled residents (R1, R3, R5, R6 and R7). The facility did not perform a thorough assessment when a resident was identified with a change of condition such as COVID-19, did not increase screening once an outbreak occurred, did not notify the resident's physician when a change of condition occurred, did not increase assessments and monitoring of residents once COVID-19 was identified as the cause for the change of condition, and did not provide medication and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was not screened per the guidance prior to the facility's outbreak nor once the outbreak occurred. R1 became symptomatic on 10/7/21 and did not have a thorough assessment again until 10/11/21 when she had a drastic change of condition and was sent to the ER (emergency room ). R3 was not screened per the guidance prior to the facility's outbreak nor once the outbreak occurred. R3 did not receive basic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Tylenol) while in the facility prior to being sent to the ER [DATE]. R5 was not screened per the guidance prior to the facility's outbreak nor once the outbreak occurred. R5 became symptomatic on 10/9/21, did not have a thorough assessment again until 10/12/21 when R5 required oxygen, R5's oxygen levels dropped significantly again on 10/14/21 and was sent to the ER. R6 was not screened per the guidance prior to the facility's outbreak nor once the outbreak occurred. R6 tested positive for COVID on 10/11/21, and did not have a thorough assessment until 10/15/21 when he had a drastic change of condition and was sent to the ER. R7 was not screened per the guidance prior to the facility's outbreak nor once the outbreak occurred. R7's daughter reported him not feeling well on 10/4/21, R7 tested positive for COVID on 10/7/21. R7 did not receive basic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Tylenol) while in the facility prior to being sent to the ER [DATE]. These failures created a finding of immediate jeopardy that began on 10/4/21. Surveyor notified INHA A (Nursing Home Administrator) of the immediate jeopardy on 10/20/21 at 12:17 PM. The immediate jeopardy was removed on 10/20/21, however the deficient practice continues at a scope/severity of E - potential for harm, pattern - as the facility continues to implement its removal plan. This is evidenced by: Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 (COVID-19) Spread in Nursing Homes per the CDC (Centers for Disease Control), updated 9/10/21 documents, in part: Evaluate residents at least daily: Ask residents to report if they feel feverish or have symptoms consistent with COVID-19 or an acute respiratory infection. Actively monitor all residents upon admission and at least daily for fever (temperature greater than or equal to 100.0°F) and symptoms consistent with COVID-19. Ideally, include an assessment of oxygen saturation via pulse oximetry. If residents have fever or symptoms consistent with COVID-19, implement precautions .Older adults with [CONDITION(S)]-CoV-2 infection may not show common symptoms such as fever or respiratory symptoms. Less common symptoms can include new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell. Additionally, more than two temperatures >99.0°F might also be a sign of fever in this population. Identification of these symptoms should prompt isolation and further evaluation for [CONDITION(S)]-CoV-2 infection .Manage residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection .increase monitoring of residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to identify and quickly manage serious infection. The Facility Policy and Procedure entitled, Coronavirus Surveillance, implemented 3/11/20 documents, in part: .This facility will implement heightened surveillance activities for coronavirus illness during periods of transmission in the community and/or during a declared public health emergency for the illness. Policy Explanation and Compliance Guidelines read as follows: 1. The Infection Preventionist will monitor the status of COVID-19 outbreak through the CDC website, and will monitor for changes in prevention, treatment, isolation, or other recommendations. 2. Heightened surveillance activities will be implemented to limit the transmission of COVID-19 .6. Residents will be monitored for signs and symptoms of coronavirus illness including but not limited to: fever, cough, shortness of breath. The physician will be notified immediately, if evident. Staff shall follow established procedures with COVID-19 is suspected. Considerations for managing residents with suspected or confirmed COVID-19 infection . c. Increase monitoring of resident for development of more severe symptoms or other changes in condition. d. Increase monitoring of all other residents when COVID-19 is suspected or confirmed . The Facility Policy and Procedure entitled Change of Condition, implemented 7/29/20 documents, in part: .Acute change of condition: A sudden, clinically important deviation from a patient's baseline in physical cognitive, behavioral, or functional domains .2. The facility will identify residents who are at risk for changes of condition. All residents are at risk for changes of condition, but especially those with pre-existing conditions, previous complications, or recent hospitalization .5. At a minimum, Change of Condition assessment (RN- Registered Nurse) or observation (LPN- Licensed Practical Nurse) will include, a. resident statement or signs and symptoms observed. No resident response should also be documented, b. Vital Signs, c. Overall condition, level of consciousness, and function, d. Describe symptoms in detail, e. Assess affected body system, f. Accurate description of the situation will allow practitioners to make informed decisions about care needed .8. Follow up documentation in EHR (Electronic Health Record) will occur every shift for 72 hours post resolution of symptoms. Include conversation with primary care provider, orders received and resident's response, notification of responsible party and their response . Facility indicated that their Screening for their residents is a document called Respiratory Assessment COVID 2, when referring to a Screen or a residents Screening, this is what is being referred to. Facility's Standing Orders for residents include the following: .Acetaminophen 650 mg (milligrams) po (oral) every 4 hours prn (as needed) for pain or temperature > (greater than) 101 F (Fahrenheit) orally, Acetaminophen 650 mg suppository pr (per rectum) every 4 hours for pain or temperature >101 F .). It is important to note this document does not include any type of oxygen orders. The Facility's COVID Outbreak began on 10/4/21. Example 1 R1 is a recent admission to the facility. R1 is responsible for herself, normally alert and oriented to person, place and time, and able to call and converse with family. R1 has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 does not normally use O2. R1's screenings prior to 10/4/21 were only completed on 9/20/21 and 9/21/21. This results in 2 of 21 screenings in September after admission 9/10/21. It is important to note prior to an outbreak, since pandemic has begun, residents should be screened every day. R1's screenings after 10/4/21 were on: 10/6/21, 10/10/21, and 10/11/21. R1 did not have any documented screening on 10/5/21, 10/7/21 or 10/9/21. It is important to note that once an outbreak has begun, residents should be screened more frequently than every day, typically every shift in order to stay abreast of changes and be able to act quickly. R1's Nurses' Note dated 10/7/21 documents: Resident wheezing, weak, refused breakfast. States not hungry, doesn't feel well. O2 sat (oxygen saturation= oxygen level on RA (room air) 86%. O2 (Oxygen) 2L (Liters) BNC (by nasal cannula) initiated. Rapid COVID test positive. R1 was swabbed 10/7/21, results returned on 10/9/21 were positive. It is important to note R1's physician was not updated with this change of condition and R1 did not have orders for O2. R1's screen dated 10/8/21 documents, in part: .temperature 100.2 and O2 sat 94% oxygen via nasal . It is important to note the rest of the vital signs (pulse, blood pressure and respirations) documented were from a previous date. There is no documented assessment of R1 on 10/9/21. R1's screen dated 10/10/21 has no new vital signs documented (all vital signs documented were from previous dates) and no abnormal respiratory symptoms documented. R1's next Nurses' Note dated 10/11/21 documents: Resident lethargic opens eyes with minimal response. O2 sat 83-85%. BP 149/84 (blood pressure) P 82 (pulse) RR 20 (respiratory rate) T 97.6 (temperature). Applied NRB (non-rebreather) mask with O2 5L/min (minute), sating (oxygen in blood) in 90%. Poor PO (by mouth) intake for breakfast and lunch. Updated md (Medical Doctor) rec'd (received) orders for D5 0.45 IV (intravenous fluids [MEDICATION(S)] 5% water 0.45 [MEDICATION(S)]) bolus (ran in via gravity) x1 (1 bag) bag then 100 cc (cubic centimeter) hour thereafter. 20 gauge (IV needle) started in L (left) wrist. Family updated and at bedside requesting to be sent to .ER for evaluation and treatment. VO (verbal order) from Dr .to transfer. EMS (Emergency Medical Services) called for transport. It is important to note that R1 has no documentation of thorough assessments following her COVID positive test on 10/7/21 with symptoms and then R1 is sent toER on [DATE] with acute exacerbation of symptoms. R1's documentation fromER on [DATE] includes, in part: .COVID positive, SOB (Shortness of Breath) moderate distress, hypoxemia (low oxygen in blood) .oral mucosa dry .rales heard in lung fields (abnormal lung sounds), O2 at 5L/min to keep sats at 90% .Chest x-ray showed peripheral hazy opacities (sign of pneumonia) .admit for supportive care .Plan: IV solumedrol (corticosteroid medication, given to decrease inflammation), NPO (nothing by mouth), IVF (IV fluids), empirically started IV [MEDICATION(S)] and [MEDICATION(S)] (both antibiotics) . R1's documentation from Med Surg (Medical Surgical Unit) includes, in part: .10/12/21 .R1 desatting on NC (nasal cannula) .CT scan of chest (imaging test to look at lungs) to rule out PE (pulmonary Embolism) .RT (Respiratory Therapy) put on high flow overnight .10/15/21 R1 began having SVT's (supraventricular [CONDITION(S)]- condition where your heart suddenly beats much faster than normal) . 10/17/21 .R1 more responsive today, high flow O2 with FiO2 at 80% (fraction of inspired oxygen- concentration of oxygen in the gas mixture; The gas mixture at room air has FiO2 of 21%) . orders for IV push [MEDICATION(S)] (a calcium channel blocker which works by relaxing blood vessels and lowers heart rate) 15 mg for SVT's. On 10/18/21 at 10:56 AM, Surveyor interviewed HSW K (Hospital Social Worker). Surveyor asked HSW K what condition R1 was in upon arrival, HSW K said she was positive for COVID and hypoxic. Surveyor asked HSW K what the plan is for R1, HSW K stated she will likely be put on palliative care. On 10/18/21 at 12:46 PM, Surveyor interviewed CNA D (Certified Nursing Assistant). Surveyor asked CNA D what level of function R1 was prior to the COVID outbreak, CNA D said she transferred with 1 assist. Surveyor asked CNA D what level of function R1 was after the COVID outbreak, CNA D explained R1 had a decline, had difficulty with transfers, she tested positive for COVID 10/7/21, she had heavy breathing, required oxygen and had a decrease in her responsiveness. Surveyor asked CNA D if there was anything else about R1's change of condition she could think of, CNA D said R1 kept taking the oxygen out of her nose and then she ended up going to the ER for low O2 sats. R1 was not being assessed daily or more frequently once outbreak in facility began (10/4/21) which could have caught symptoms earlier allowing for different treatment options. R1's physician was not consulted when her O2 sat dropped and she required oxygen on 10/7/21. R1 does not have documentation of thorough assessments from date R1 tested positive for COVID on 10/7/21 through when she had another change of condition on 10/11/21 when she went to ER and was subsequently hospitalized . Example 2 R3 is a long term resident of the facility. R3 has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R3 does not normally use O2. R3's screenings prior to 10/4/21 were only completed on 8/1/21, 8/3/21, 8/5/21, 8/10/21, 8/21/21, 8/24/21, 8/29/21, 9/8/21, 9/13/21, 9/16/21, 9/18/21, 9/19/21, 9/20/21, 9/21/21 and 9/25/21. This results in 7 of 31 screenings in August and 8 of 30 screenings in September. It is important to note to an outbreak, since pandemic has begun, residents should be screened every day. R3's screenings after 10/4/21 were on: 10/5/21, 10/6/21, 10/7/21, 10/8/21 on 2 shifts, 10/9/21, 10/10/21, 10/13/21, 10/15/21, 10/16/21, 10/17/21 on 2 shifts, and 10/18/21. R3 did not have documented screening on 10/11/21, 10/12/21 or 10/14/21. It is important to note once an outbreak has begun, residents should be screened more frequently than every day, typically every shift in order to stay abreast of changes and be able to act quickly. R3's SBAR (Situation, Background, Assessment, Response -communication tool between providers) Communication Form dated 10/14/21 documents, in part: .Pulse: 101, RR: 18, Temp: 101.7 .Pulse oximetry (oxygen sat) 79% (no indication if this level is with or without oxygen) .SOB (short of breath) .pain 8 to left flank/iliac crest . It is important to note there is no evidence R3 was rapid tested for COVID or R3 received Acetaminophen/Tylenol for his fever prior to going to ER. R3's documentation fromER on [DATE] includes, in part: .Fever with SOB .emesis earlier .temp 100.3 .CT pulmonary angiogram showed scattered bilateral airspace opacities in the lower lobes, R>L (greater than) could reflect pneumonia .Plan- IV LR (intravenous [MEDICATION(S)] (which is used for replacing fluids and electrolytes), oral Tylenol, requiring O2 2-3 L/min/nc to maintain O2 sat of 93% .diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R3's screen dated 10/15/21 documents, in part: .temperature 100.2, respirations 16 and O2 sat 91% oxygen via nasal .pressure in chest .short of breathe while lying flat .oxygen continuous . It is important to note the rest of the vital signs (pulse, blood pressure and respirations) documented were from previous dates. R3's screen dated 10/16/21 documents, in part: .non-productive cough . R3 tested positive for COVID 10/16/21. R3's screen dated 10/17/21 at 1:30 PM documents, in part: .non-productive cough . R3's screen dated 10/17/21 at 8:18 PM documents, in part: .no cough . R3's screen dated 10/18/21 documents, in part: .no cough . It is important to note there is no other documentation of a thorough assessment following R3's return fromER on [DATE]. R3 was not being assessed daily or more frequently once outbreak in facility began (10/4/21) which could have caught symptoms earlier allowing for different treatment options. R3 had symptoms on 10/14/21 and there is no evidence he was rapid tested for COVID. On 10/14/21 R3 has a fever of 101.7 and there was no evidence he received Acetaminophen/Tylenol prior to going to ER. R3 does not have documentation of thorough assessments from date R3 was inER on [DATE] through at least 72 hours post ER visit (10/17/21). Example 3 R5 was a new admission to the facility. R5 had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's screenings prior to 10/4/21 were not completed daily. It is important to note prior to an outbreak, since pandemic has begun, residents should be screened every day. R5's screenings after 10/4/21 were on: 10/5/21, 10/6/21, 10/9/21, 10/11/21, and 10/13/21. R5 did not have any documented screening on 10/7/21, 10/8/21, 10/10/21, 10/12/21 or 10/14/21. It is important to note once an outbreak has begun, residents should be screened more frequently than every day, typically every shift in order to stay on top of changes and be able to act quickly. R5's Nurses' Note on 10/9/21 documents, in part: Resident symptomatic with COVID-19, fatigue and poor PO intake. RAPID COVID ran on resident which yielded positive results . R5's Nurse's Note on 10/10/21 documents: Resident presents with anxious episodes. Unable to sleep. Reports she needs to go home to go to bed. Resident family requests Lorazepam (anti-anxiety medication) order. Updated Dr .who ordered Lorazepam 2 mg/ml- take 0.25-0.5 ml PO Q8H (every 8 hours) PRN for anxiety . There is no documented assessment of R5 on 10/11/12. R5's Nurses' Note on 10/12/21 documents, in part: resident repeatedly hollering out after all needs were met, unable to console, resident hyperventilating and confused, oxygen placed on resident and [MEDICATION(S)] (Lorazepam) was administered by staff nurse, effective, resident is afebrile .continues on contact and droplet precautions . R5's vital signs record dated 10/12/21 documents, in part: O2 sat 88% RA (room air), 96% with O2 on-unsure of liters (not documented). It is important to note R5's physician was not updated with R5's O2 sat dropping and need for use of oxygen. R5 does not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no documented assessment of R5 on 10/13/21. R5's Nurses' Note on 10/14/21 documents: Resident sating at 75% on 4L/min, turned up to 5L/min sating at 80-82%. Family aware. Order to transfer to ER for evaluation and treatment. R5's vital signs record dated 10/14/21 documents, in part: O2 sat 82% with O2 on- unsure of liters (not documented). It is important to note that R5 has no documentation of thorough assessments following her COVID positive test on 10/9/21 with symptoms and then R5 is sent toER on [DATE] with another change of condition. R5's documentation fromER on [DATE] includes, in part: Patient on 15 L of non-rebreather mask with oxygen sats around mid-80s .Spoke to R5's POA (Power of Attorney) .who stated .has been COVID positive for the last 6 days. Over the last 2 to 3 days her mentation and ability to talk has declined significantly .COVID-19 pneumonia- hypoxic(low oxygen in blood), currently requiring high flow NC(nasal cannula) to maintain saturations .significantly hypoxic .COVID 19 pneumonia- hypoxic on admission. Likely with bacterial component as well given elevated procalcitonin 1.06 ng/mL (normal range of procalcitonin- less than 0.1 ng/mL (nanogram per milliliter; indicates serious bacterial infection) .temp 99.9, pulse 143/147, respirations 32-40, BP 189/112-146/95 .placed on [CONDITION(S)] pressure 12/5 with FiO2 60%, O2 sat 91-93% later changed to vapotherm 75% with 15L/min .Plan to admit to Medical floor and enroll in Hospice Services . R5 passed away at the Hospital on 10/17/21. On 10/18/21 at 10:56 AM, Surveyor interviewed HSW K. Surveyor asked HSW K what condition R5 was in upon arriving to the ER, HSW K stated her oxygen sats were around 60% and she was rocking trying to get air, she's just one of the many that have passed away already. On 10/18/21 at 9:12 AM Surveyor was contacted by HSW K, HSW K stated we have received multiple patients from (Facility Name) the patients are presenting to us in various stages of disarray, unkempt, extremely ill with low oxygen saturations our physicians are extremely upset with the patients presentation to the ER. The level of illness we are seeing in our ER does not just happen overnight. The patients are not being cared for it's like their coming to us from a warzone. R5 was not being assessed daily or more frequently once outbreak in facility began (10/4/21) which could have caught symptoms earlier allowing for different treatment options. There is no evidence that R5's physician was updated with R5's O2 sat dropping and need for use of oxygen on 10/12/21. R3 does not have documentation of thorough assessments from date R3 tested positive for COVID on 10/9/21 through when she had another change of condition on 10/12/21, then another change of condition on 10/14/21 when she went to ER and was subsequently hospitalized and passed away at the hospital 10/17/21. Example 4 R6 was a long term resident of the facility. R6 had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's screenings prior to 10/4/21 were not completed daily. It is important to note prior to an outbreak, since pandemic has begun, residents should be screened every day. R6's screenings after 10/4/21 were on: 10/5/21, 10/6/21, 10/7/21, 10/8/21 on 2 shifts, 10/9/21. 10/10/21, and 10/13/21. R6 did not have any documented screening on 10/11/21, 10/12/21, 10/14/21, or 10/15/21. It is important to note once an outbreak has begun, residents should be screened more frequently than every day, typically every shift in order to stay abreast of changes and be able to act quickly. R6's Nurses' Note on 10/4/21 documents: refused rapid test R6 tested positive for COVID on 10/11/21 during routine testing. There is no documented assessment of R6 on 10/12, 10/13, or 10/14/21. R6's next Nurses' Note on 10/15/21 at 7:38 AM documents: Writer was called to resident room by staff stated resident didn't look well, upon assessing resident he was having SOB, and very lethargic. Vitals taken B/P 150/79 Resp 14, Pulse 63 Temp 102.0. Called placed to on call talked to Dr .gave her report stated to send resident put 911, called placed to 911. Called .Hospital ER .gave her nurse to nurse report. There is no documentation the facility administered Acetaminophen/Tylenol for fever prior to R6 going to ER. R6's Nurses' Note on 10/15/21 at 7:53 AM documents: Writer received a call .at .Sheriff Department stated EMS is in route and to turn resident oxygen level to 4. Writer did what was asked. Awaiting EMS R6's Nurses' Note on 10/15/21 at 9:00 AM documents, in part: Wife returned call. Updated her on COVID status, inability to keep O2 sats up and transfer to hospital . It is important to note R6 has no documentation of thorough assessments following his COVID positive test on 10/11/21 then R6 is sent toER on [DATE] with a drastic change of condition. R6's documentation fromER on [DATE] includes, in part: COVID positive, [CONDITION(S)] .today was hypoxic into the 70s to 80s on room air. 2 L of nasal cannula started at the nursing home .only increased the patient's oxygen saturations to the low 80s. EMS .started .non-rebreather at 15% and got oxygen saturations of 93-95% .active rigors(cold, shaking) .RESP- the patient is tachypneic without retractions (sinking in of chest), course breath sounds bilaterally (abnormal breath sounds) .8:52 AM: EKG (electrocardiogram-test shows heart rhythm) shows [CONDITION(S)] with rapid ventricular response at 133 bpm (beats per minute) .chest x-ray within normal limits .10:35 AM: patient's respiratory status continues to deteriorate despite being on non-rebreather his saturations have fallen into the low 80s .placed on [CONDITION(S)], patient's work-up demonstrates multi-organ failure with troponin of 0.83 (normal range 0-0.04), a creatinine of 3.9 up from baseline of 1.3 (normal range 0.74-1.35), with obvious respiratory failure and [CONDITION(S)] (alteration in brain function) .12:00 PM: doing better on [CONDITION(S)] with small amounts of [MEDICATION(S)] to control his breathing .2:30 PM POA(power of attorney) arrives .3:00 PM POA does not want any aggressive measures .just wants the patient to be comfortable .admit the patient for comfort measures .[CONDITION(S)] 2/2 (secondary to) COVID pneumonia with likely underlying bacterial infection- elevated procalcitonin 2.21 (less than 0.1 ng/mL), NSTEMI (non-ST segment elevation [CONDITION(S)] infarction) .AKI (acute kidney injury)- creatinine 2.6 (0.74-1.35), lactic acidosis (lactic acid build up in blood stream, lactic acid is produced when oxygen levels become low in cells within the areas of the body where metabolism takes place) .admit patient for comfort care . R6 passed away at the hospital on 10/16/21. R6 was not being assessed daily or more frequently once outbreak in facility began (10/4/21) which could have caught symptoms earlier allowing for different treatment options. There is no documentation that the facility administered Acetaminophen/Tylenol for fever prior to R6 going toER on [DATE]. R6 does not have documentation of thorough assessments from date R6 tested positive for COVID on 10/11/21 through when he had another change of condition on 10/15/21 when he went to ER and was subsequently hospitalized and passed away at the hospital 10/16/21. Example 5 R7 was a fairly new admission to the facility. R7 had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's screenings prior to 10/4/21 were only completed on 8/29/21, 9/6/21, 9/8/21, 9/20/21, and 9/21/21. This results in 1/31 screenings in August and 4/30 screenings in September. It is important to note that prior to an outbreak, since pandemic has begun, residents should be screened every day. R7's screenings after 10/4/21 were on: 10/5/21 and 10/6/21. R1 did not have any documented screening on 10/7/21 or 10/8/21. It is important to note that once an outbreak has begun, residents should be screened more frequently than every day, typically every shift in order to stay on top of changes and be able to act quickly. R7's Nurses' Note on 10/4/21 documents: daughter reported to writer resident was not feeling well, seemed weak, vital signs obtained, resident febrile with low oxygen level, 28 respirations, lungs clear to auscultation, no congestion noted upon auscultation, non-purulent nasal drainage noted with dry cough, resident denied any [MEDICATION(S)] pain, denied any body aches, temp 101.5 88% RA, oxygen placed 2 L NC, oxygen saturation increased to 96%, fluids provided to resident and he drank 25%, rapid COVID test performed, results were positive, POA (power of attorney) .at bedside for entire assessment, requested that father stay here at the home and not to the ER and notify her if his condition worsens, resident placed on contact and droplet precautions, Dr .updated this evening, will monitor vital signs and respiratory symptoms q (every) shift for 3 days It is important to note there is no documentation R7 was given Acetaminophen/Tylenol as R7 does not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's screen dated 10/5/21 documents, in part: .temp 100.0 .O2 sat 94% on RA . It is important to note the rest of the vital signs (pulse, blood pressure and respirations) documented were from a previous date, there is no documentation R7 was administered Acetaminophen/Tylenol, and R7 should have had two more screens on 10/5/21. R7's screen dated 10/6/21 documents, in part: .temp 99.3, BP 124/80, pulse 79 regular .O2 sat 97% on RA . It is important to note that R7's respirations documented were from a previous date, there is no documentation that R7 was administered Acetaminophen/Tylenol, and R7 should have had two more screens on 10/6/21. R7 did not have any screens completed on 10/7/21 despite following above change of condition from 10/4/21 where it is documented Will monitor vital signs and respiratory symptoms q shift for 3 days 10/5/21-10/7/21. R7's Vital Sign record following above change of condition from 10/4/21 where it is documented Will monitor vital signs and respiratory symptoms q shift for 3 days 10/5/21-10/7/21: Blood pressure was taken 10/6/21 twice; O2 sat was taken 10/5/21 once, 10/6/21 twice and 10/7/21 once; Pulse was taken 10/6/21 twice and 10/7/21 once; Respirations were taken 10/6/21 once and 10/7/21 once; and Temperature was taken 10/5/21 once, 10/6/21 twice and 10/7/21 once. The Facility has no documentation regarding R7 going to theER on [DATE]. R7's documentation fromER on [DATE] includes, in part: COVID + .presents with respiratory distress .per POA, patient started having shaking chills and fever 4 days ago. Associated with lethargy and poor appetite .Daughter would like patient to get steroid, IV fluid as he has not been eating/drinking well and possible antibody infusion .malaise .cough, SOB .pulse 112, respirations 40 .[CONDITION(S)], respiratory distress, tachypnea .Patient still hypoxic 86% despite high flow oxygen .Spoke to daughter about adding comfort care .Patient does not qualify for monoclonal antibody infusion. Patient's prognosis is poor and grave condition was discussed with daughter .Patient was sent back to SNF (Skilled Nursing Facility) with [MEDICATION(S)] concentrate and lorazepam liquid for respiratory distress, agitation or pain and [MEDICATION(S)] (a corticosteroid medication). Oxygen as needed for comfort . R7 passed away at the facility on 10/8/21. R7 was not being assessed daily or more frequently once outbreak in facility began (10/4/21) which could have caught symptoms earlier allowing for different treatment options. There is no documentation R7 was given Acetaminophen/Tylenol on 10/4/21 when he had a change of condition and tested positive for COVID. R7 does not even have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/18/21 at 10:56 AM, Surveyor interviewed HSW K. Surveyor asked HSW K what her concern was regarding the residents from this facility they were seeing at the hospital, HSW K stated They are unkempt, some have wounds, they have odors as if they haven't had showers; we get them in the ER, admit them and they pass away; the condition these residents are in did not just happen overnight. On 10/19/21 at 1:51 PM, Surveyor interviewed RN N (Registered Nurse). Surveyor asked RN N when a physician should be updated regarding an O2 sat, RN N said when it is below 90%. Surveyor asked RN N if an O2 sat was below 90%, O2 was applied and the O2 sat then rose above 90%, would that require a call to a physician; RN N replied yes, you'd still call even if it increased because it was low prior to that. Surveyor asked RN N when a physician should be updated regarding a temperature, RN N said if above 100.1. Surveyor asked RN N if the facility had standing order for oxygen, RN N replied she was not sure, but knew as a nurse should could apply and then obtain order from physician. Surveyor asked RN N if the facility had standing order for Acetaminophen/Tylenol, RN N replied yes, oral and suppository forms. Surveyor asked RN N how often residents should be screened for COVID symptoms while in an outbreak, RN N stated every shift and that is in the EHR (electronic health record) under the assessment tab. Surveyor asked RN N how often residents should be screened for COVID symptoms when not in an outbreak, RN N said daily. Surveyor asked RN N once a resident [NAME] [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure it maintained an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infections such as COVID-19. This had the potential to affect all residents residing within the facility at the time of the outbreak on [DATE]. At the time of survey, this outbreak involved 35 residents, 5 whom expired, and 13 staff. The facility did not: * recognize or ensure to routinely screen all residents for signs and symptoms of COVID-19 daily and increase screening to every shift once the outbreak was identified * screen all individuals who come into the facility prior to entry * ensure staff do not enter the facility with symptoms without reporting to facility leadership/DON (Director of Nursing)/IP (Infection Preventionist) or document symptoms on the screening tool * ensure staff who were positive for COVID-19 did not work * use PPE (personal protective equipment) properly * treat a resident who refused testing as positive and place them on droplet precautions * begin to fit-test all staff for N95s after being trained to complete fit tests * use proper disinfectant to clean eye protection * seat vaccinated and unvaccinated residents six feet apart from each other in the dining room with source control in use when not eating * provide training or skill competency checks for staff who perform their own COVID-19 tests via nasal swab. The above failures created a finding of immediate jeopardy that began on [DATE]. The Interim Nursing Home Administrator was notified of the immediate jeopardy on [DATE] at 12:17 PM. The immediate jeopardy was removed on [DATE], however the deficient practice continues at a scope/severity of F - potential for harm, widespread - as the facility continues to implement its removal plan. This is evidenced by: The facility policy titled, Coronavirus Surveillance, implemented [DATE] states, This facility will implement heightened surveillance activities for coronavirus illness during periods of transmission in the community and/or during a declared public health emergency for the illness. Policy Explanation and Compliance Guidelines read as follows: 1. The Infection Preventionist will monitor the status of COVID-19 outbreak through the CDC website, and will monitor for changes in prevention, treatment, isolation, or other recommendations. 2. Heightened surveillance activities will be implemented to limit the transmission of COVID-19. These include, but are not limited to, screening visitors, staff, and residents. 3. Screening for visitors and staff: a. Signs or symptoms of a respiratory infection such as fever, cough, shortness of breath, or sore throat. b. In the last 14 days, as had contact with someone with a confirmed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . c. International travel within the last 14 days to countries with sustained community transmission (i.e. China, [NAME], South Korea, Italy, and Japan). Others will be added as identified from the CDC's website. d. Residing in a community where community-based spread of COVID-19 is occurring. 4. Visitors will be denied entry into the facility if they exhibit any of the criteria listed above. They may be directed to the Infection Preventionist, Director of Nursing, or nurse manager on duty if they have any questions. 5. Staff who have signs and symptoms of a respiratory infection shall not report to work. Any staff that develop signs and symptoms while on the job shall: a. Immediately stop work, put on a facemask, and self-isolate at home. b. Inform the Infection Preventionist, and include information on individuals, equipment, and locations the person came in contact with, and c. Contact and follow the local health department recommendations for next steps such as testing and locations for treatment. 6. Residents will be monitored for signs and symptoms of coronavirus illness including but not limited to: fever, cough, shortness of breath. The physician will be notified immediately, if evident. Staff shall follow established procedures with COVID-19 is suspected. Considerations for managing residents with suspected or confirmed COVID-19 infection: a. Us clinical features and epidemiologic risk for making a determination that COVID-19 infection is suspected. Test for COVID-19 in accordance with current CDC guidelines. b. Collaborate with the local health department regarding a coordinated transfer, unless it is determined that transfer is not required. For example, the resident does not require a higher level of care and the facility can adhere to recommended infection prevention and control practices (with modifications if no airborne infection isolation room is available). c. Increase monitoring of resident for development of more severe symptoms or other changes in condition. d. Increase monitoring of all other residents win COVID-19 is suspected or confirmed. 7. The facility will refer to current CDC guidance for exposures that might warrant restricting asymptomatic staff from reporting to work. The facility policy, Novel Coronavirus Prevention and Response, effective [DATE] states, This facility will respond promptly upon suspicion of illness associated with a novel coronavirus in efforts to identify, treat, and prevent the spread of the virus. The policy explanation and compliance guidelines states, in part, 1. The Infection Preventionist will assess facility risk associated with COVID-19 through surveillance activities of emerging diseases in the community and illnesses present in the facility. a. No current risk - the facility will implement interventions for prevention and prepare for a potential outbreak. b. Threat detected - the facility will respond promptly and implement emergency and/or outbreak procedures. 2. Staff shall be alert to signs of COVID-19 and notify the resident's physician if evident: a. Fever b. Cough c. Shortness of breath . 1. Interventions to prevent the spread of respiratory germs within the facility: a. Keep residents and employees informed by answering questions and explaining what they can do to protect themselves and their fell ow residents (i.e. handwashing, spatial separation, respiratory hygiene/cough etiquette). b. Monitor residents and employees for fever or respiratory symptoms . ii. In general, for care of residents with undiagnosed respiratory infection use Standard, Contact, and Droplet Precautions with eye protection unless suspected diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] ., [CONDITION(S)]). iii. Implement heightened surveillance activities or consult public health authorities for additional guidance if there is transmission of COVID-19 in the community . d. Educate staff on proper use of personal protective equipment and application of standard, contact, droplet, and airborne precautions, including eye protection . The facility policy titled, COVID Testing Refusal, implemented on [DATE], states, It is the Policy of [the corporation] that residents and staff have the right to refuse testing of COVID-19. The policy does indicate, in part, that those who refuse testing will be educated on the reason for testing and review the policy and procedure for refusal, . and if outbreak testing has been triggered and an asymptomatic resident refuses testing, he or she should be placed on or remain on TBP until he or she meets the symptom-based criteria for discontinuation. Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes per the CDC, updated [DATE] documents, in part: Evaluate Residents at least Daily- Ask residents to report if they feel feverish or have symptoms consistent with COVID-19 or an acute respiratory infection. Actively monitor all residents upon admission and at least daily for fever (temperature greater than or equal to 100.0°F) and symptoms consistent with COVID-19. Ideally, include an assessment of oxygen saturation via pulse oximetry. If residents have fever or symptoms consistent with COVID-19, implement precautions described in Section: Manage Residents with Suspected or Confirmed [CONDITION(S)]-CoV-2 Infection. Older adults with [CONDITION(S)]-CoV-2 infection may not show common symptoms such as fever or respiratory symptoms. Less common symptoms can include new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell. Additionally, more than two temperatures >99.0°F might also be a sign of fever in this population. Identification of these symptoms should prompt isolation and further evaluation for [CONDITION(S)]-CoV-2 infection. Manage Residents with Suspected or Confirmed [CONDITION(S)]-CoV-2 Infection- HCP caring for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator) .In general, it is recommended that the door to the room remain closed to reduce transmission of [CONDITION(S)]-CoV-2. This is especially important for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection being cared for outside of the COVID-19 care unit. However, in some circumstances (e.g., memory care units), keeping the door closed may pose resident safety risks and the door might need to remain open. If doors must remain open, work with facility engineers to implement strategies to minimize airflow into the hallway. If limited single rooms are available, or if numerous residents are simultaneously identified to have known [CONDITION(S)]-CoV-2 exposures or symptoms concerning for COVID-19, residents should remain in their current location pending return of test results .Roommates of residents with [CONDITION(S)]-CoV-2 infection should be managed as described in Section: Manage Residents who have had Close Contact with Someone with [CONDITION(S)]-CoV-2 Infection. Increase monitoring of residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to identify and quickly manage serious infection. Facility indicated that their Screening for their residents is a document called Respiratory Assessment COVID 2, when referring to a Screen or a residents Screening, this is what is being referred to. Example 1 - not getting test results promptly, thus allowing a COVID-positive staff person to work. On the morning of [DATE], the facility learned that CNA D (Certified Nursing Assistant) tested positive for COVID-19 from a nasal swab done in the facility on [DATE] as part of the twice a week testing in place related to the current county positivity rate at the time. CNA D had worked on [DATE], [DATE], [DATE], and [DATE]. The facility informed Surveyor all of CNA D's shift assignments were on the 200 wing of the facility, but indicated CNA D may have helped on other units, also. CNA D's lab result from information sheet from the contracted lab indicated the specimen was collected on [DATE] at 3:20 PM and the positive results were available on [DATE] at 4:40 PM. On [DATE], at 12:21 PM, Surveyor spoke with CNA D regarding the days leading up to her positive test result. CNA D said looking back, she could have been having symptoms and not realized they could have been indicative of COVID-19 infection. CNA D said she had felt tired and fatigued, which she had attributed to the many hours and long days she had been working, as well as some sweating and possible chills, which she felt at the time was from wearing gowns in isolation rooms which is very hot and then cooling down when outside of those rooms. CNA D indicated to Surveyors she may have been starting to get a sore throat just prior to finding out she was positive, but did not report it. CNA D was informed of her positive test while at work on [DATE], at which time she left the facility at 11:40 AM. On [DATE], at 9:15 AM, Surveyor spoke with DCO/IP C (Director of Clinical Operations/Infection Preventionist). Surveyor asked when DCO/IP C realized CNA D was positive, and she informed Surveyor she requested access to results from the contracted lab on [DATE], after the facility's previous Nursing Home Administrator left without warning on [DATE]. DCO/IP C said it took 48 hours to get information on access to lab results from the contracted lab. DCO/IP C said her access was granted on [DATE] to lab results from [DATE] forward. DCO/IP C indicated there were no results flagged for review (indicating a positive) on [DATE], and when she logged in on [DATE] there was a notification of three positive results, one of those being CNA D. DCO/IP C did not recall what time she received these results. Surveyor asked how CNA D was notified, and DCO/IP C stated IDON B (Interim Director of Nursing) took care of updating CNA D. Surveyor asked DCO/IP C if it was typical to have a four to five day wait between obtaining a nasal swab test and getting the results. DCO/IP C indicated she was told the facility's previous administrator who quit abruptly had arranged for the [DATE]-[DATE] labs to be picked up, but it did not occur, so the labs were dropped off at the contracted lab by IDON B on [DATE]. On [DATE], at 10:27 AM, Surveyor spoke with DON/IP C who indicated the facility believed the source of COVID-19 coming into the building was CNA D and indicated, She (CNA D) was one who has to be reminded to wear her mask up over her nose. Surveyors did not observe CNA D wearing Personal Protective Equipment (PPE) incorrectly while on site. On [DATE], at 2:50 PM, Surveyor asked DCO/IP C when the facility last provided education to staff regarding COVID-19 symptoms. DCO/IP C said, It has probably been a couple of months since they were educated about symptoms. DCO/IP C indicated there had been other topics related to COVID-19 covered. On [DATE], at 9:34 AM, Surveyor spoke with IDON B who indicated she did not recall the exact time she was made aware of CNA D's positive result, but it was sometime between 10:00 AM and Noon on [DATE]. Surveyor asked what instructions were given or if any questions were asked to CNA D, and IDON B indicated CNA D was told she would need to go home and quarantine and she was asked if she was having any symptoms. IDON B said, She said that she was tired, but she had been working a lot of shifts, which was understandable. According to CNA D's timecard punches on [DATE], she began work at 5:55 AM and left work at 11:40 AM. On [DATE], at 3:50 PM, IDON B provided Surveyor with outlines and slides from recent staff trainings provided, but not sign in sheets to indicate who received the education. These trainings were dated [DATE], [DATE], and [DATE] and did not include COVID-19 symptoms. Subsequent tests following the outbreak that began on [DATE] revealed the following: Test on [DATE]= 14 residents and 3 staff positive; 6 on 200 unit, 6 on 100 unit and 2 on 400 unit Test on ,d+[DATE]-,d+[DATE]= 16 residents and 4 staff positive; 5 on 200 unit, 10 on 100 unit, 1 on 400 unit Test on [DATE]= 4 residents positive, no staff; 1 on 200 unit, 3 on 100 unit (3 others tested who were positive before this date (2 staff and 1 resident) Example 2 - incorrect self-testing technique The facility was completing mandatory COVID-19 testing twice a week for all staff. Results of the [DATE] tests were not known on [DATE], when the facility was doing its second test of the week, therefore CNA D tested as scheduled. On [DATE], CNA D performed a COVID-19 test which eventually returned as a negative result, despite her [DATE] test results being positive. On [DATE], at 12:21 PM, Surveyor spoke with CNA D about her test result from the swab performed on [DATE] and the process of testing. CNA D stated, I think I did the test wrong. I put the stick (swab) in the tube first before I swabbed my nose that day. On [DATE], at 3:20 PM, Surveyor asked IDON B about the process of self-testing for COVID-19. IDON B stated, Staff is testing themselves out at the desk. IDON B showed Surveyor the testing kits at the nurse's station and stated, They take out the swab, swirl it in both nostrils, then swirl the swab into the solution and remove it, close the tube, label it, and put it in the refrigerator. Surveyor asked if the facility had done education for staff self-testing to show competency and she indicated she was not aware of any, and the facility had been doing this since she began as the IDON. On [DATE], at 8:51 AM, Surveyor spoke with Med Tech E (Medication Technician) and asked about COVID-19 testing at the facility and how she was trained and by whom to do the test. Med Tech E stated one of the Certified Nursing Assistants showed her and it was CNA D. (Of note, CNA D had performed one of her own tests incorrectly which then came back as a negative result, despite her previous swab indicating a positive result.) On [DATE], at 9:15 AM, Surveyor spoke with DCO/IP C to inquire about staff training for self-testing and if the facility was performing any audits. DCO/IP said she had not been doing audits on self-testing since she began working on-site at the facility and said, I'm guessing they haven't done them. On [DATE], at 3:50 PM, Surveyor spoke with IDON B who stated each Nasal Swab Collection kit has instructions inside the package, staff are expected to follow the instructions provided when obtaining a sample, and staff are expected to ask questions if they do not understand. Example 3 - not reviewing screen-in forms, thus allowing staff to work who self-screened with symptoms Surveyor reviewed the Coronavirus Screening Forms at the employee entrance and observed two employees, PTA G (Physical Therapy Assistant) and DA H (Dietary Aide), had screened in to work on that day, [DATE], with symptoms which could indicate COVID-19 infection. Part I of PTA G's Coronavirus Screening Form noted the following: - Have you been exposed to anyone with COVID-19 in the last 14 days? Yes - Do you have a cough? Yes - Do you have a sore throat? Yes - Do you have congestion or a runny nose? Yes Part II of PTA G's Coronavirus Screening Form is for comments and reads, Provide additional information, if you answered yes to any of the above. Onset and duration of any symptoms: Duration & proximity of contact with anyone with or under investigation for COVID-19: This section was left completely blank. Part III of PTA G's Coronavirus Screening Form is for Action/Signature reads as follows: - Visitation denied/work restricted: _____ No ______ Yes (exhibits criteria) - This was left completely blank. - Wishes to speak with Infection Preventionist: This marked as No with an X. - Signed by PTA G and dated [DATE] Part IV of PTA G's Coronavirus Screening Form is for Follow Up. This area includes a space for notes, Infection Preventionist Signature, and the date, and all areas were left blank. On [DATE], at 10:23 AM, Surveyor spoke with PTA G regarding his Coronavirus Screening Form. PTA G informed Surveyor he has had these symptoms for a couple of weeks and has noted them previously on his Coronavirus Screening Forms at this facility, as well. PTA G stated he does rapid tests for COVID-19 regularly because he doesn't want to take the virus home to an unvaccinated family member. Surveyor asked PTA G if he had spoken to anyone at the facility about his symptoms, and he stated his supervisor, a Physical Therapist, was aware. Surveyor asked PTA G if anyone from the facility had followed up with him regarding any of his previous Coronavirus Screening Forms about his symptoms, and he stated, No. No one here from the facility has followed up with me. Part I of DA H's Coronavirus Screening Form noted the following: - Do you have a fever or chills? (No) Time 88.6 Temp IN _____ (Note an abnormally low temperature written in next to Time.) - Do you have a headache? Yes - Are you having any nausea, vomiting or diarrhea? Yes Part II of DA H's Coronavirus Screening Form is for comments and reads, Provide additional information, if you answered yes to any of the above. Onset and duration of any symptoms: Duration & proximity of contact with anyone with or under investigation for COVID-19: This section was left completely blank. Part III of DA H's Coronavirus Screening Form is for Action/Signature reads as follows: - Visitation denied/work restricted: __X__ No ______ Yes (exhibits criteria) - Wishes to speak with Infection Preventionist: This marked as No with an X. - Signed by DA H and dated [DATE] Part IV of DA H's Coronavirus Screening Form is for Follow Up. This area includes a space for notes, Infection Preventionist Signature, and the date, and all were blank. On [DATE], at 10:15 AM, Surveyor spoke with DA H regarding the self-screening process and her screening form completed for that day. DA H said the process is to fill out the sheet, take your temp, and clock in. Surveyor asked DA H if she reported her symptoms which were marked on the sheet to anyone in the facility, and she indicated she had spoken to her manager, DM I (Dietary Manager). DA H reported to Surveyor she had a headache today because she was on her menstrual cycle, and she had diarrhea because she had eaten Taco Bell the night before and said, It usually hits me the next day. On [DATE], at 10:20 AM, Surveyor spoke with DM I and asked if DA H had reported any symptoms to her when she started work that morning. DM I indicated she was aware DA H had some symptoms, but said DA H had reported to her she thought the cause of them was due to some recent medication changes. On [DATE], at 10:27 AM, Surveyor spoke with DCO/IP C and asked what the expectation was of staff members if they came to work and were experiencing symptoms which could be related to COVID-19. DCO/IP replied, Don't come in. They should be calling in symptoms to their department heads and not coming to work. At 10:40 AM, Surveyor spoke with DCO/IP C and asked if employees screened themselves into work with symptoms, should they come to you to report their symptoms or would you expect to be informed? DCO/IP C stated, Oh, absolutely. They should be cleared by me. DCO/IP C was unaware two staff members had entered the building and marked symptoms on their Coronavirus Screening Forms that morning. On [DATE], at 4:35 PM, Surveyor spoke with DCO/IP C to ask if she had completed any follow up with PTA G or DA H on [DATE] and if they had worked their full shifts. DCO/IP C indicated she believed both PTA G and DA H worked their full shifts, and she did follow up with DA H's supervisor, but she didn't run into him (PTA G). Example 4 - not screening visitors On [DATE], Surveyors entered the facility at the front of the building at 9:15 AM. There was another man/visitor waiting in the vestibule for staff to return something to him. He was wearing a mask and did not enter the building. In the corner of the facility entrance/vestibule, there was a table set up with a binder, hand sanitizer, and temporal thermometer. Surveyors handed business cards to the staff member who returned to speak to visitor who was waiting and he then left. The Surveyors were led into the building and Surveyors' business cards were then handed to MR/CS J (Medical Records/Central Supply). MR/CS J then directed Surveyors through the building to the end of the 400 wing hall to the conference room. No one at the facility asked Surveyors to screen in, check temperatures, or complete a visitor screen in. Surveyors did leave for lunch, returned to the facility, and were not asked to screen in or if a screen had been completed on initial entry to the facility that morning. On [DATE], the first Surveyor to arrive at the facility was not screened by staff or asked to screen when entering the facility. The second Surveyor to arrive at the facility was greeted by DCO/IP C who was sitting in the office with a window looking into the entryway/vestibule. DCO/IP C opened the door for Surveyor and asked Surveyor, Did you fill out a sheet? Surveyor had not been instructed on the process and said, I haven't. What do you need me to do? DCO/IP C pointed towards the table in the corner of the vestibule and indicated there was a thermometer there and a form to fill out. There were no blank forms in the binder, so DCO/IP C retrieved one from a stack of papers on the wall and handed it to Surveyor. Surveyor took temperature, filled out paperwork, and asked DCO/IP C what to do with the completed form. DCO/IP C had Surveyor leave the form in the binder, and Surveyor entered the facility. Example 5 - improper use and improper sanitizing of personal protective equipment On [DATE], at 9:18 AM, upon being let into the facility and directed to the conference room, Surveyors observed MR/CS J wearing a surgical mask under her N-95 mask. On [DATE], at 8:51 AM, Surveyor observed Med Tech E working on the 200 wing of the facility. Med Tech E was wearing prescription eyeglasses and had her PPE goggles/eyewear sitting on the medication cart. Surveyor observed Med Tech E walking through the hallway, leaving the 200 wing unit, and passing medication (to a non-positive resident) without wearing eye protection. On [DATE], at 9:15 AM, Surveyor asked DCO/IP C about her expectations on PPE use in the facility. DCO/IP C stated, N-95 and eye protection at all times. Surveyor asked if eyeglasses were considered eye protection. DCO/IP C stated, No. I've addressed that but will address it again. DCO/IP C indicated Med Tech E was aware eye protection was to be worn at all times. On [DATE], at 4:35 PM, Surveyor discussed surgical mask under the N95 mask observation and DCO/IP C stated, It would be OK to do it reversed with the N95 on first and the surgical mask on top, but not necessary. The seal would be compromised that way. Staff were interviewed and indicated they were not wearing eye protection prior to the current outbreak. 2021 County positivity rates for COVID-19 were provided to Surveyors by DCO/IP C as the following: Week of ,d+[DATE] = 11.28%, week of ,d+[DATE] = 13.1%, week of ,d+[DATE] = 10.84%, week of ,d+[DATE] = 9.91%, and week of ,d+[DATE] = 9.10%. On [DATE] at 2:21 PM, Surveyor observed IDON B had on N95 mask with yellow straps crisscrossed (top strap toward neck and bottom strap toward top of head) thus causing a gap at her cheek, therefore no seal in place. On [DATE] at 2:34 PM, Surveyor interviewed RN L (Registered Nurse). Surveyor asked RN L what she cleans her eye protection with, RN L stated antiseptic (hand sanitizer) and paper towel. On [DATE] at 3:54 PM, Surveyor interviewed CNA M (Certified Nursing Assistant). Surveyor asked CNA M what she cleans her eye protection with, CNA M stated glass cleaner, don't know what else to use. Surveyor asked CNA M how often she cleans her eye protection, CNA M stated when they get fogged up or at the end of the night. Example 6 - not regularly screening residents for symptoms R1 is a recent admission to the facility. R1 is responsible for herself, normally alert and oriented to person, place and time, and able to call and converse with family. R1 has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 does not normally use O2. R1's screenings prior to [DATE] were only completed on [DATE] and [DATE]. This results in 2 of 21 screenings in September after admission [DATE]. It is important to note that prior to an outbreak, since pandemic has begun, residents should be screened every day. R1's screenings after [DATE] were on: [DATE], [DATE], and [DATE]. R1 did not have any documented screening on [DATE], [DATE], [DATE] or [DATE]. It is important to note once an outbreak has begun, residents should be screened more frequently than every day, typically every shift in order to stay on top of changes and be able to act quickly. R1 was hospitalized with COVID-19 on [DATE]. Example 7 - not regularly screening residents for symptoms R2 is a long term resident of the facility. R2 has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's screenings prior to [DATE] were on: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. This results in 8 of 31 screenings in August and 8 of 30 screenings in September. It is important to note that prior to an outbreak, since pandemic has begun, residents should be screened every day. R2's screenings after [DATE] were on: [DATE], [DATE], [DATE], [DATE] on 2 shifts, [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] on 2 shifts and [DATE]. R2 did not have any documented screening on [DATE], [DATE], [DATE], and [DATE]. It is important to note that once an outbreak has begun, residents should be screened more frequently than every day, typically every shift in order to stay on top of changes and be able to act quickly. R2's screening dated [DATE] documents, in part: .Temperature 99.0 .non-productive cough . There is no evidence that R2 was tested for COVID when he had symptoms documented on his screening. R2 was not tested with rest of residents during routine testing on [DATE]. R2 tested positive for COVID on [DATE], next round of routine testing. On [DATE] at 2:08 PM, Surveyor interviewed DCO/IP C (Director of Clinical Operations/Infection Preventionist). Surveyor asked DCO/IP C if R2 should have been tested on [DATE] with the rest of the routine testing, DCO/IP C stated yes, there should be another test for R2 between [DATE] and [DATE]. On [DATE] at 2:41 PM, Surveyor interviewed IDON B (Interim Director of Nursing). Surveyor asked IDON B if all residents should be tested when routine testing is completed, IDON B said yes, unless they've tested positive then they wouldn't need to test for 90 days. Surveyor asked IDON B if she knew how R2 was missed during testing on [DATE], IDON B stated I personally swabbed his unit and I know I swabbed him. IDON B went on to explain that they have had issues with the testing company with things like this in the past. Surveyor asked IDON B if that was documented somewhere, IDON B said no. Example 8 - not regularly screening residents for symptoms R3 is a long term resident of the facility. R3 has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R3 does not normally use O2. R3's screenings prior to [DATE] were only completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. This results in 7of 31 screenings in August and 8 of 30 screenings in September. It is important to note that prior to an outbreak, since pandemic has begun, residents should be screened every day. R3's screenings after [DATE] were on: [DATE], [DATE], [DATE], [DATE] on 2 shifts, [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] on 2 shifts, and [DATE]. R3 did not have any documented screening on [DATE], [DATE] or [DATE]. It is important to note once an outbreak has begun, residents should be screened more frequently than every day, typically every shift in order to stay on top of changes and be able to act quickly. R3 was sent to the emergency room for evaluation on [DATE]. Example 9 - not regularly screening residents for symptoms R4 was a long term resident of the facility. R4 had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's screenings prior to [DATE] were not completed daily. It is important to note that prior to an [TRUNCATED]

Based on interview and record review, the Facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 5 of 14 sampled residents (R1, R3, R5, R6 and R7). The facility did not perform a thorough assessment when a resident was identified with a change of condition such as COVID-19, did not increase screening once an outbreak occurred, did not notify the resident's physician when a change of condition occurred, did not increase assessments and monitoring of residents once COVID-19 was identified as the cause for the change of condition, and did not provide medication and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was not screened per the guidance prior to the facility's outbreak nor once the outbreak occurred. R1 became symptomatic on 10/7/21 and did not have a thorough assessment again until 10/11/21 when she had a drastic change of condition and was sent to the ER (emergency room ). R3 was not screened per the guidance prior to the facility's outbreak nor once the outbreak occurred. R3 did not receive basic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Tylenol) while in the facility prior to being sent to the ER [DATE]. R5 was not screened per the guidance prior to the facility's outbreak nor once the outbreak occurred. R5 became symptomatic on 10/9/21, did not have a thorough assessment again until 10/12/21 when R5 required oxygen, R5's oxygen levels dropped significantly again on 10/14/21 and was sent to the ER. R6 was not screened per the guidance prior to the facility's outbreak nor once the outbreak occurred. R6 tested positive for COVID on 10/11/21, and did not have a thorough assessment until 10/15/21 when he had a drastic change of condition and was sent to the ER. R7 was not screened per the guidance prior to the facility's outbreak nor once the outbreak occurred. R7's daughter reported him not feeling well on 10/4/21, R7 tested positive for COVID on 107/21. R7 did not receive basic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Tylenol) while in the facility prior to being sent to the ER [DATE]. These failures created a finding of immediate jeopardy that began on 10/4/21. Surveyor notified INHA A (Nursing Home Administrator) of the immediate jeopardy on 10/20/21 at 12:17 PM. The immediate jeopardy was removed on 10/20/21, however the deficient practice continues at a scope/severity of E - potential for harm, pattern - as the facility continues to implement its removal plan. This is evidenced by: Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 (COVID-19) Spread in Nursing Homes per the CDC (Centers for Disease Control), updated 9/10/21 documents, in part: Evaluate residents at least daily: Ask residents to report if they feel feverish or have symptoms consistent with COVID-19 or an acute respiratory infection. Actively monitor all residents upon admission and at least daily for fever (temperature greater than or equal to 100.0°F) and symptoms consistent with COVID-19. Ideally, include an assessment of oxygen saturation via pulse oximetry. If residents have fever or symptoms consistent with COVID-19, implement precautions .Older adults with [CONDITION(S)]-CoV-2 infection may not show common symptoms such as fever or respiratory symptoms. Less common symptoms can include new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell. Additionally, more than two temperatures >99.0°F might also be a sign of fever in this population. Identification of these symptoms should prompt isolation and further evaluation for [CONDITION(S)]-CoV-2 infection .Manage residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection .increase monitoring of residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to identify and quickly manage serious infection. The Facility Policy and Procedure entitled, Coronavirus Surveillance, implemented 3/11/20 documents, in part: .This facility will implement heightened surveillance activities for coronavirus illness during periods of transmission in the community and/or during a declared public health emergency for the illness. Policy Explanation and Compliance Guidelines read as follows: 1. The Infection Preventionist will monitor the status of COVID-19 outbreak through the CDC website, and will monitor for changes in prevention, treatment, isolation, or other recommendations. 2. Heightened surveillance activities will be implemented to limit the transmission of COVID-19 .6. Residents will be monitored for signs and symptoms of coronavirus illness including but not limited to: fever, cough, shortness of breath. The physician will be notified immediately, if evident. Staff shall follow established procedures with COVID-19 is suspected. Considerations for managing residents with suspected or confirmed COVID-19 infection . c. Increase monitoring of resident for development of more severe symptoms or other changes in condition. d. Increase monitoring of all other residents when COVID-19 is suspected or confirmed . The Facility Policy and Procedure entitled Change of Condition, implemented 7/29/20 documents, in part: .Acute change of condition: A sudden, clinically important deviation from a patient's baseline in physical cognitive, behavioral, or functional domains .2. The facility will identify residents who are at risk for changes of condition. All residents are at risk for changes of condition, but especially those with pre-existing conditions, previous complications, or recent hospitalization .5. At a minimum, Change of Condition assessment (RN- Registered Nurse) or observation (LPN- Licensed Practical Nurse) will include, a. resident statement or signs and symptoms observed. No resident response should also be documented, b. Vital Signs, c. Overall condition, level of consciousness, and function, d. Describe symptoms in detail, e. Assess affected body system, f. Accurate description of the situation will allow practitioners to make informed decisions about care needed .8. Follow up documentation in EHR (Electronic Health Record) will occur every shift for 72 hours post resolution of symptoms. Include conversation with primary care provider, orders received and resident's response, notification of responsible party and their response . Facility indicated that their Screening for their residents is a document called Respiratory Assessment COVID 2, when referring to a Screen or a residents Screening, this is what is being referred to. Facility's Standing Orders for residents include the following: .Acetaminophen 650 mg (milligrams) po (oral) every 4 hours prn (as needed) for pain or temperature > (greater than) 101 F (Fahrenheit) orally, Acetaminophen 650 mg suppository pr (per rectum) every 4 hours for pain or temperature >101 F .). It is important to note this document does not include any type of oxygen orders. The Facility's COVID Outbreak began on 10/4/21. Example 1 R1 is a recent admission to the facility. R1 is responsible for herself, normally alert and oriented to person, place and time, and able to call and converse with family. R1 has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 does not normally use O2. R1's screenings prior to 10/4/21 were only completed on 9/20/21 and 9/21/21. This results in 2 of 21 screenings in September after admission 9/10/21. It is important to note prior to an outbreak, since pandemic has begun, residents should be screened every day. R1's screenings after 10/4/21 were on: 10/6/21, 10/10/21, and 10/11/21. R1 did not have any documented screening on 10/5/21, 10/7/21 or 10/9/21. It is important to note that once an outbreak has begun, residents should be screened more frequently than every day, typically every shift in order to stay abreast of changes and be able to act quickly. R1's Nurses' Note dated 10/7/21 documents: Resident wheezing, weak, refused breakfast. States not hungry, doesn't feel well. O2 sat (oxygen saturation= oxygen level on RA (room air) 86%. O2 (Oxygen) 2L (Liters) BNC (by nasal cannula) initiated. Rapid COVID test positive. R1 was swabbed 10/7/21, results returned on 10/9/21 were positive. It is important to note R1's physician was not updated with this change of condition and R1 did not have orders for O2. R1's screen dated 10/8/21 documents, in part: .temperature 100.2 and O2 sat 94% oxygen via nasal . It is important to note the rest of the vital signs (pulse, blood pressure and respirations) documented were from a previous date. There is no documented assessment of R1 on 10/9/21. R1's screen dated 10/10/21 has no new vital signs documented (all vital signs documented were from previous dates) and no abnormal respiratory symptoms documented. R1's next Nurses' Note dated 10/11/21 documents: Resident lethargic opens eyes with minimal response. O2 sat 83-85%. BP 149/84 (blood pressure) P 82 (pulse) RR 20 (respiratory rate) T 97.6 (temperature). Applied NRB (non-rebreather) mask with O2 5L/min (minute), sating (oxygen in blood) in 90%. Poor PO (by mouth) intake for breakfast and lunch. Updated md (Medical Doctor) rec'd (received) orders for D5 0.45 IV (intravenous fluids [MEDICATION(S)] 5% water 0.45 [MEDICATION(S)]) bolus (ran in via gravity) x1 (1 bag) bag then 100 cc (cubic centimeter) hour thereafter. 20 gauge (IV needle) started in L (left) wrist. Family updated and at bedside requesting to be sent to .ER for evaluation and treatment. VO (verbal order) from Dr .to transfer. EMS (Emergency Medical Services) called for transport. It is important to note that R1 has no documentation of thorough assessments following her COVID positive test on 10/7/21 with symptoms and then R1 is sent toER on [DATE] with acute exacerbation of symptoms. R1's documentation fromER on [DATE] includes, in part: .COVID positive, SOB (Shortness of Breath) moderate distress, hypoxemia (low oxygen in blood) .oral mucosa dry .rales heard in lung fields (abnormal lung sounds), O2 at 5L/min to keep sats at 90% .Chest x-ray showed peripheral hazy opacities (sign of pneumonia) .admit for supportive care .Plan: IV solumedrol (corticosteroid medication, given to decrease inflammation), NPO (nothing by mouth), IVF (IV fluids), empirically started IV [MEDICATION(S)] and [MEDICATION(S)] (both antibiotics) . R1's documentation from Med Surg (Medical Surgical Unit) includes, in part: .10/12/21 .R1 desatting on NC (nasal cannula) .CT scan of chest (imaging test to look at lungs) to rule out PE (pulmonary Embolism) .RT (Respiratory Therapy) put on high flow overnight .10/15/21 R1 began having SVT's (supraventricular [CONDITION(S)]- condition where your heart suddenly beats much faster than normal) . 10/17/21 .R1 more responsive today, high flow O2 with FiO2 at 80% (fraction of inspired oxygen- concentration of oxygen in the gas mixture; The gas mixture at room air has FiO2 of 21%) . orders for IV push [MEDICATION(S)] (a calcium channel blocker which works by relaxing blood vessels and lowers heart rate) 15 mg for SVT's. On 10/18/21 at 10:56 AM, Surveyor interviewed HSW K (Hospital Social Worker). Surveyor asked HSW K what condition R1 was in upon arrival, HSW K said she was positive for COVID and hypoxic. Surveyor asked HSW K what the plan is for R1, HSW K stated she will likely be put on palliative care. On 10/18/21 at 12:46 PM, Surveyor interviewed CNA D (Certified Nursing Assistant). Surveyor asked CNA D what level of function R1 was prior to the COVID outbreak, CNA D said she transferred with 1 assist. Surveyor asked CNA D what level of function R1 was after the COVID outbreak, CNA D explained R1 had a decline, had difficulty with transfers, she tested positive for COVID 10/7/21, she had heavy breathing, required oxygen and had a decrease in her responsiveness. Surveyor asked CNA D if there was anything else about R1's change of condition she could think of, CNA D said R1 kept taking the oxygen out of her nose and then she ended up going to the ER for low O2 sats. R1 was not being assessed daily or more frequently once outbreak in facility began (10/4/21) which could have caught symptoms earlier allowing for different treatment options. R1's physician was not consulted when her O2 sat dropped and she required oxygen on 10/7/21. R1 does not have documentation of thorough assessments from date R1 tested positive for COVID on 10/7/21 through when she had another change of condition on 10/11/21 when she went to ER and was subsequently hospitalized . Example 2 R3 is a long term resident of the facility. R3 has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R3 does not normally use O2. R3's screenings prior to 10/4/21 were only completed on 8/1/21, 8/3/21, 8/5/21, 8/10/21, 8/21/21, 8/24/21, 8/29/21, 9/8/21, 9/13/21, 9/16/21, 9/18/21, 9/19/21, 9/20/21, 9/21/21 and 9/25/21. This results in 7 of 31 screenings in August and 8 of 30 screenings in September. It is important to note to an outbreak, since pandemic has begun, residents should be screened every day. R3's screenings after 10/4/21 were on: 10/5/21, 10/6/21, 10/7/21, 10/8/21 on 2 shifts, 10/9/21, 10/10/21, 10/13/21, 10/15/21, 10/16/21, 10/17/21 on 2 shifts, and 10/18/21. R3 did not have documented screening on 10/11/21, 10/12/21 or 10/14/21. It is important to note once an outbreak has begun, residents should be screened more frequently than every day, typically every shift in order to stay abreast of changes and be able to act quickly. R3's SBAR (Situation, Background, Assessment, Response -communication tool between providers) Communication Form dated 10/14/21 documents, in part: .Pulse: 101, RR: 18, Temp: 101.7 .Pulse oximetry (oxygen sat) 79% (no indication if this level is with or without oxygen) .SOB (short of breath) .pain 8 to left flank/iliac crest . It is important to note there is no evidence R3 was rapid tested for COVID or R3 received Acetaminophen/Tylenol for his fever prior to going to ER. R3's documentation fromER on [DATE] includes, in part: .Fever with SOB .emesis earlier .temp 100.3 .CT pulmonary angiogram showed scattered bilateral airspace opacities in the lower lobes, R>L (greater than) could reflect pneumonia .Plan- IV LR (intravenous [MEDICATION(S)] (which is used for replacing fluids and electrolytes), oral Tylenol, requiring O2 2-3 L/min/nc to maintain O2 sat of 93% .diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R3's screen dated 10/15/21 documents, in part: .temperature 100.2, respirations 16 and O2 sat 91% oxygen via nasal .pressure in chest .short of breathe while lying flat .oxygen continuous . It is important to note the rest of the vital signs (pulse, blood pressure and respirations) documented were from previous dates. R3's screen dated 10/16/21 documents, in part: .non-productive cough . R3 tested positive for COVID 10/16/21. R3's screen dated 10/17/21 at 1:30 PM documents, in part: .non-productive cough . R3's screen dated 10/17/21 at 8:18 PM documents, in part: .no cough . R3's screen dated 10/18/21 documents, in part: .no cough . It is important to note there is no other documentation of a thorough assessment following R3's return fromER on [DATE]. R3 was not being assessed daily or more frequently once outbreak in facility began (10/4/21) which could have caught symptoms earlier allowing for different treatment options. R3 had symptoms on 10/14/21 and there is no evidence he was rapid tested for COVID. On 10/14/21 R3 has a fever of 101.7 and there was no evidence he received Acetaminophen/Tylenol prior to going to ER. R3 does not have documentation of thorough assessments from date R3 was inER on [DATE] through at least 72 hours post ER visit (10/17/21). Example 3 R5 was a new admission to the facility. R5 had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's screenings prior to 10/4/21 were not completed daily. It is important to note prior to an outbreak, since pandemic has begun, residents should be screened every day. R5's screenings after 10/4/21 were on: 10/5/21, 10/6/21, 10/9/21, 10/11/21, and 10/13/21. R5 did not have any documented screening on 10/7/21, 10/8/21, 10/10/21, 10/12/21 or 10/14/21. It is important to note once an outbreak has begun, residents should be screened more frequently than every day, typically every shift in order to stay on top of changes and be able to act quickly. R5's Nurses' Note on 10/9/21 documents, in part: Resident symptomatic with COVID-19, fatigue and poor PO intake. RAPID COVID ran on resident which yielded positive results . R5's Nurse's Note on 10/10/21 documents: Resident presents with anxious episodes. Unable to sleep. Reports she needs to go home to go to bed. Resident family requests Lorazepam (anti-anxiety medication) order. Updated Dr .who ordered Lorazepam 2 mg/ml- take 0.25-0.5 ml PO Q8H (every 8 hours) PRN for anxiety . There is no documented assessment of R5 on 10/11/12. R5's Nurses' Note on 10/12/21 documents, in part: resident repeatedly hollering out after all needs were met, unable to console, resident hyperventilating and confused, oxygen placed on resident and [MEDICATION(S)] (Lorazepam) was administered by staff nurse, effective, resident is afebrile .continues on contact and droplet precautions . R5's vital signs record dated 10/12/21 documents, in part: O2 sat 88% RA (room air), 96% with O2 on-unsure of liters (not documented). It is important to note R5's physician was not updated with R5's O2 sat dropping and need for use of oxygen. R5 does not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no documented assessment of R5 on 10/13/21. R5's Nurses' Note on 10/14/21 documents: Resident sating at 75% on 4L/min, turned up to 5L/min sating at 80-82%. Family aware. Order to transfer to ER for evaluation and treatment. R5's vital signs record dated 10/14/21 documents, in part: O2 sat 82% with O2 on- unsure of liters (not documented). It is important to note that R5 has no documentation of thorough assessments following her COVID positive test on 10/9/21 with symptoms and then R5 is sent toER on [DATE] with another change of condition. R5's documentation fromER on [DATE] includes, in part: Patient on 15 L of non-rebreather mask with oxygen sats around mid-80s .Spoke to R5's POA (Power of Attorney) .who stated .has been COVID positive for the last 6 days. Over the last 2 to 3 days her mentation and ability to talk has declined significantly .COVID-19 pneumonia- hypoxic(low oxygen in blood), currently requiring high flow NC(nasal cannula) to maintain saturations .significantly hypoxic .COVID 19 pneumonia- hypoxic on admission. Likely with bacterial component as well given elevated procalcitonin 1.06 ng/mL (normal range of procalcitonin- less than 0.1 ng/mL (nanogram per milliliter; indicates serious bacterial infection) .temp 99.9, pulse 143/147, respirations 32-40, BP 189/112-146/95 .placed on [CONDITION(S)] pressure 12/5 with FiO2 60%, O2 sat 91-93% later changed to vapotherm 75% with 15L/min .Plan to admit to Medical floor and enroll in Hospice Services . R5 passed away at the Hospital on 10/17/21. On 10/18/21 at 10:56 AM, Surveyor interviewed HSW K. Surveyor asked HSW K what condition R5 was in upon arriving to the ER, HSW K stated her oxygen sats were around 60% and she was rocking trying to get air, she's just one of the many that have passed away already. On 10/18/21 at 9:12 AM Surveyor was contacted by HSW K, HSW K stated we have received multiple patients from (Facility Name) the patients are presenting to us in various stages of disarray, unkempt, extremely ill with low oxygen saturations our physicians are extremely upset with the patients presentation to the ER. The level of illness we are seeing in our ER does not just happen overnight. The patients are not being cared for it's like their coming to us from a warzone. R5 was not being assessed daily or more frequently once outbreak in facility began (10/4/21) which could have caught symptoms earlier allowing for different treatment options. There is no evidence that R5's physician was updated with R5's O2 sat dropping and need for use of oxygen on 10/12/21. R3 does not have documentation of thorough assessments from date R3 tested positive for COVID on 10/9/21 through when she had another change of condition on 10/12/21, then another change of condition on 10/14/21 when she went to ER and was subsequently hospitalized and passed away at the hospital 10/17/21. Example 4 R6 was a long term resident of the facility. R6 had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's screenings prior to 10/4/21 were not completed daily. It is important to note prior to an outbreak, since pandemic has begun, residents should be screened every day. R6's screenings after 10/4/21 were on: 10/5/21, 10/6/21, 10/7/21, 10/8/21 on 2 shifts, 10/9/21. 10/10/21, and 10/13/21. R6 did not have any documented screening on 10/11/21, 10/12/21, 10/14/21, or 10/15/21. It is important to note once an outbreak has begun, residents should be screened more frequently than every day, typically every shift in order to stay abreast of changes and be able to act quickly. R6's Nurses' Note on 10/4/21 documents: refused rapid test R6 tested positive for COVID on 10/11/21 during routine testing. There is no documented assessment of R6 on 10/12, 10/13, or 10/14/21. R6's next Nurses' Note on 10/15/21 at 7:38 AM documents: Writer was called to resident room by staff stated resident didn't look well, upon assessing resident he was having SOB, and very lethargic. Vitals taken B/P 150/79 Resp 14, Pulse 63 Temp 102.0. Called placed to on call talked to Dr .gave her report stated to send resident put 911, called placed to 911. Called .Hospital ER .gave her nurse to nurse report. There is no documentation the facility administered Acetaminophen/Tylenol for fever prior to R6 going to ER. R6's Nurses' Note on 10/15/21 at 7:53 AM documents: Writer received a call .at .Sheriff Department stated EMS is in route and to turn resident oxygen level to 4. Writer did what was asked. Awaiting EMS R6's Nurses' Note on 10/15/21 at 9:00 AM documents, in part: Wife returned call. Updated her on COVID status, inability to keep O2 sats up and transfer to hospital . It is important to note R6 has no documentation of thorough assessments following his COVID positive test on 10/11/21 then R6 is sent toER on [DATE] with a drastic change of condition. R6's documentation fromER on [DATE] includes, in part: COVID positive, [CONDITION(S)] .today was hypoxic into the 70s to 80s on room air. 2 L of nasal cannula started at the nursing home .only increased the patient's oxygen saturations to the low 80s. EMS .started .non-rebreather at 15% and got oxygen saturations of 93-95% .active rigors(cold, shaking) .RESP- the patient is tachypneic without retractions (sinking in of chest), course breath sounds bilaterally (abnormal breath sounds) .8:52 AM: EKG (electrocardiogram-test shows heart rhythm) shows [CONDITION(S)] with rapid ventricular response at 133 bpm (beats per minute) .chest x-ray within normal limits .10:35 AM: patient's respiratory status continues to deteriorate despite being on non-rebreather his saturations have fallen into the low 80s .placed on [CONDITION(S)], patient's work-up demonstrates multi-organ failure with troponin of 0.83 (normal range 0-0.04), a creatinine of 3.9 up from baseline of 1.3 (normal range 0.74-1.35), with obvious respiratory failure and [CONDITION(S)] (alteration in brain function) .12:00 PM: doing better on [CONDITION(S)] with small amounts of [MEDICATION(S)] to control his breathing .2:30 PM POA(power of attorney) arrives .3:00 PM POA does not want any aggressive measures .just wants the patient to be comfortable .admit the patient for comfort measures .[CONDITION(S)] 2/2 (secondary to) COVID pneumonia with likely underlying bacterial infection- elevated procalcitonin 2.21 (less than 0.1 ng/mL), NSTEMI (non-ST segment elevation [CONDITION(S)] infarction) .AKI (acute kidney injury)- creatinine 2.6 (0.74-1.35), lactic acidosis (lactic acid build up in blood stream, lactic acid is produced when oxygen levels become low in cells within the areas of the body where metabolism takes place) .admit patient for comfort care . R6 passed away at the hospital on 10/16/21. R6 was not being assessed daily or more frequently once outbreak in facility began (10/4/21) which could have caught symptoms earlier allowing for different treatment options. There is no documentation that the facility administered Acetaminophen/Tylenol for fever prior to R6 going toER on [DATE]. R6 does not have documentation of thorough assessments from date R6 tested positive for COVID on 10/11/21 through when he had another change of condition on 10/15/21 when he went to ER and was subsequently hospitalized and passed away at the hospital 10/16/21. Example 5 R7 was a fairly new admission to the facility. R7 had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's screenings prior to 10/4/21 were only completed on 8/29/21, 9/6/21, 9/8/21, 9/20/21, and 9/21/21. This results in 1/31 screenings in August and 4/30 screenings in September. It is important to note that prior to an outbreak, since pandemic has begun, residents should be screened every day. R7's screenings after 10/4/21 were on: 10/5/21 and 10/6/21. R1 did not have any documented screening on 10/7/21 or 10/8/21. It is important to note that once an outbreak has begun, residents should be screened more frequently than every day, typically every shift in order to stay on top of changes and be able to act quickly. R7's Nurses' Note on 10/4/21 documents: daughter reported to writer resident was not feeling well, seemed weak, vital signs obtained, resident febrile with low oxygen level, 28 respirations, lungs clear to auscultation, no congestion noted upon auscultation, non-purulent nasal drainage noted with dry cough, resident denied any [MEDICATION(S)] pain, denied any body aches, temp 101.5 88% RA, oxygen placed 2 L NC, oxygen saturation increased to 96%, fluids provided to resident and he drank 25%, rapid COVID test performed, results were positive, POA (power of attorney) .at bedside for entire assessment, requested that father stay here at the home and not to the ER and notify her if his condition worsens, resident placed on contact and droplet precautions, Dr .updated this evening, will monitor vital signs and respiratory symptoms q (every) shift for 3 days It is important to note there is no documentation R7 was given Acetaminophen/Tylenol as R7 does not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's screen dated 10/5/21 documents, in part: .temp 100.0 .O2 sat 94% on RA . It is important to note the rest of the vital signs (pulse, blood pressure and respirations) documented were from a previous date, there is no documentation R7 was administered Acetaminophen/Tylenol, and R7 should have had two more screens on 10/5/21. R7's screen dated 10/6/21 documents, in part: .temp 99.3, BP 124/80, pulse 79 regular .O2 sat 97% on RA . It is important to note that R7's respirations documented were from a previous date, there is no documentation that R7 was administered Acetaminophen/Tylenol, and R7 should have had two more screens on 10/6/21. R7 did not have any screens completed on 10/7/21 despite following above change of condition from 10/4/21 where it is documented Will monitor vital signs and respiratory symptoms q shift for 3 days 10/5/21-10/7/21. R7's Vital Sign record following above change of condition from 10/4/21 where it is documented Will monitor vital signs and respiratory symptoms q shift for 3 days 10/5/21-10/7/21: Blood pressure was taken 10/6/21 twice; O2 sat was taken 10/5/21 once, 10/6/21 twice and 10/7/21 once; Pulse was taken 10/6/21 twice and 10/7/21 once; Respirations were taken 10/6/21 once and 10/7/21 once; and Temperature was taken 10/5/21 once, 10/6/21 twice and 10/7/21 once. The Facility has no documentation regarding R7 going to theER on [DATE]. R7's documentation fromER on [DATE] includes, in part: COVID + .presents with respiratory distress .per POA, patient started having shaking chills and fever 4 days ago. Associated with lethargy and poor appetite .Daughter would like patient to get steroid, IV fluid as he has not been eating/drinking well and possible antibody infusion .malaise .cough, SOB .pulse 112, respirations 40 .[CONDITION(S)], respiratory distress, tachypnea .Patient still hypoxic 86% despite high flow oxygen .Spoke to daughter about adding comfort care .Patient does not qualify for monoclonal antibody infusion. Patient's prognosis is poor and grave condition was discussed with daughter .Patient was sent back to SNF (Skilled Nursing Facility) with [MEDICATION(S)] concentrate and lorazepam liquid for respiratory distress, agitation or pain and [MEDICATION(S)] (a corticosteroid medication). Oxygen as needed for comfort . R7 passed away at the facility on 10/8/21. R7 was not being assessed daily or more frequently once outbreak in facility began (10/4/21) which could have caught symptoms earlier allowing for different treatment options. There is no documentation R7 was given Acetaminophen/Tylenol on 10/4/21 when he had a change of condition and tested positive for COVID. R7 does not even have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/18/21 at 10:56 AM, Surveyor interviewed HSW K. Surveyor asked HSW K what her concern was regarding the residents from this facility they were seeing at the hospital, HSW K stated They are unkempt, some have wounds, they have odors as if they haven't had showers; we get them in the ER, admit them and they pass away; the condition these residents are in did not just happen overnight. On 10/19/21 at 1:51 PM, Surveyor interviewed RN N (Registered Nurse). Surveyor asked RN N when a physician should be updated regarding an O2 sat, RN N said when it is below 90%. Surveyor asked RN N if an O2 sat was below 90%, O2 was applied and the O2 sat then rose above 90%, would that require a call to a physician; RN N replied yes, you'd still call even if it increased because it was low prior to that. Surveyor asked RN N when a physician should be updated regarding a temperature, RN N said if above 100.1. Surveyor asked RN N if the facility had standing order for oxygen, RN N replied she was not sure, but knew as a nurse should could apply and then obtain order from physician. Surveyor asked RN N if the facility had standing order for Acetaminophen/Tylenol, RN N replied yes, oral and suppository forms. Surveyor asked RN N how often residents should be screened for COVID symptoms while in an outbreak, RN N stated every shift and that is in the EHR (electronic health record) under the assessment tab. Surveyor asked RN N how often residents should be screened for COVID symptoms when not in an outbreak, RN N said daily. Surveyor asked RN N once a resident test [TRUNCATED]

Based on interview and record review the facility did not consult with the resident's physician when a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); a need to alter treatment significantly for 2 out of 6 residents reviewed (Residents 1 and 2). Resident 1had an incident where her right lower extremity dropped to the floor and her right foot/leg bent under the wheelchair during transportation on 8/24/14. Resident 1 squealed in pain and requested as needed pain medication. The facility did not report the incident to the MD (Medical Doctor) F until 8/25/14 after Resident 1 brought the incident to the attention of UM (Unit Manager) H. X-Rays ordered and obtained 8/25/14 were not reported to the physician until 8/26/14, new bruising/swelling to Resident 1's right lower extremity noted on 8/26/14 was not reported to MD F until late in the afternoon on 8/27, and blood work ordered and drawn 8/27/14 was not reported to the MD until 8/28/14 at which time MD came to the facility, examined Resident 1 and had Resident 1 directly admitted to the hospital. Resident 1 was transfused with 2 Units of Packed Red Blood Cells and diagnosed with [REDACTED]. The facility did not consult with Resident 1's MD timely on Resident 1's multiple changes of condition. Resident 2 had a change in condition where he was noted to be sleepy, difficult to feed and was making slow movements. The facility did not consult with a physician regarding Resident 2's change in condition. Resident 2 was hospitalized and diagnosed with [REDACTED]. This is evidenced by: Example 1 Resident 1 was re-admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident 1's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/31/2014 indicates that Resident 1 makes self-understood, understands others, speech is clear, and Resident 1's cognition is intact. The MDS indicates that Resident 1 is an extensive assist of two persons for transfers, is non ambulatory, requires extensive assist of one for mobility off the unit. Resident 1's functional limitation in range of motion is impaired on both sides of her lower extremities, and Resident 1 uses the mobility device of a wheelchair. Resident 1's care plan titled "I have a physical function deficit related to Self-care impairment, Mobility impairment, Dx (diagnosis) of RLS (Restless Leg Syndrome), recent trimalleolar fracture left ankle" with a reviewed date of 8/14/14 under interventions states, "Locomotion Assistance of (1) is able to propel w/c (wheelchair) short distances, needs assist when fatigued or distance is long, and Transfer assistance of (2) with Hoyer lift. Review of Resident 1's nurses titled LATE ENTRY 8/24/14 13:00 Type SBAR- Change of Condition Created Date 8/25/2014 at 16:21(4:21 PM) "Situation: Resident was on her way back to room from lunch when approaching the carpet from the wood floor when resident got stuck on the threshold. CNA (Certified Nursing Assistant offered assistance and begun to push resident to room. Resident ' s right foot caught on carpet from not lifting feet up high enough. Resident does not routinely use foot pedals due to propelling self around facility. Resident yelled in pain. Taken to room and CNA reported to self that Resident wanted some pain medication. Assessment: Resident found sitting in chair complaining of pain in her right posterior knee. On inspection there is no redness or swelling noted. Resident complained when I touched all aspects of her knee even lightly. She focused my attention to the posterior aspect mainly. Area felt very taunt feeling like a muscle spasm. I gave resident [MEDICATION NAME] 500 mg and rubbed bio freeze liberally on the total knee area front and back. Resident requested a foot pedal be put on her wheelchair and we did such and also added a pillow folded under the right foot since resident requested it to be up higher. No complaints of pain in right ankle but did complain of discomfort in lower leg. Response: Pain medication and bio freeze to right knee." *Pease note review of the 24 hour report sheets does not include that Resident 1 experienced the incident to the right lower extremity, and no changes were made to Resident 1's care plan* Nurse's notes state the following: 8/25/14 03:01, "C/O (complaint of) right knee pain @ (at) 12 AM, Tylenol 500 mg (milligrams) given. Slept at intervals. Bio-Freeze to right knee and under right shoulder." 8/25/14 13:06, "Resident has been c/o right knee pain. Mobile X-ray here at this time." 8/25/14 13:50, "Does c/o pain right lower leg. X-Ray completed awaiting results." 8/26/14 00:16, "[MEDICATION NAME] 500 mg, Right knee pain. Rated at 6." 8/26/14 04:18, "C/o right knee pain @ 12 AM, Tylenol 500 mg given. Slept intervals. Large bruise on right leg below knee. Right leg swollen. Leg elevated on pillow." 8/26/14 13:28, "Resident c/o right knee pain. Gave resident PRN Tylenol 500 mg. R knee/leg continues have bruise which is dark purple. Continues to be swollen and tender to touch. R leg elevated on pillow. Resident has been resting in bed throughout the day." Late Entry 8/26/14 15:27, "Daughter her to visit and has concerns with her mother's RLE (right lower extremity). Resident has been in bed for 2 days d/t(due to ) complaint of pain with transfer and any kind of movement. Attempted to get up for lunch but refused after staff lifted her in the hoyer d/t being in too much pain. Transfers with assist x 2 using the Hoyer. Has a large hematoma located just below the right side of her knee. Area around the hematoma is swollen and her skin is tight. Daughter wondering about putting ice on the area that is swollen. Ice was applied and message left for MD F to get PRN order for ice and possibly something stronger for pain." 8/26/14 21:08, "MD F returned call and said to use ice to right leg at this time and assess tomorrow to see how ice pack went. Resident has been resting quietly." *Please note MD F has yet to be notified of the bruising/hematoma of Resident 1's right lower extremity, and there is no documentation regarding the physician notification of the right lower extremity X-ray that was done on 8/25/14. 8/27/14 13:03, "Resident continues to have dark purple/black bruise to RLE. C/O pain with movement. Warm and tender to touch. Blanchable, 2+ [MEDICAL CONDITION] noted to RLE. Resident making nonsensical comments to the nurse. Talking to people who aren't there, seeing things that weren't there. Productive cough noted with yellow sputum. Audible crackles noted with breathing. LS (lung sounds) with rhonchi and crackles noted. Will continue to monitor." 8/27/14: 14:10, "Confronted by daughter, regarding Mother's condition. Asked if I had spoken to MD F yet today to give MD F update on Residents condition. Assured daughter that I would call MD F right away. Updated MD F on residents breathing, and coughing up thick yellow phlegm as well as redness and warmth to lower right extremity. The hematoma remains dark blue/ purple in color. She continues to complain of pain to the area with any kind of movement. She is assisted x 3 using the Hoyer lift into her wheelchair for lunch. She has been delusional all morning and seeing things that weren't there. MD F also updated on this. New orders for Levequin 500 mg x 10 days, and draw CBC, BMP and CRP today. Labs were obtained." 8/27/14, 15:38, "CBC, BMP, CRP drawn from left arm." 8/27/14 21:00, "Leg remains discolored and swollen. No complaint of pain or discomfort. Right leg warm to touch." *Please note there is no mention of labs that were drawn earlier on 8/27/14 8/28/2014, 02:51, "RLE circumference measured 16 cm (centimeters) down from right patella = 47.5 cm. Area on right upper shin is reddened, purple coloration, warm to touch, skin is taunt. Left lower extremity skin is PWD (Pink, Warm, and Dry). Circumference 16 cm down from center of left patella = 35 cm." 8/28/14 11:54, "Call placed to MD F this morning at 08:30 to update on lab results. CRP is 19.0. Spoke with nurse. She stated she would update MD F and call back with any new orders. MD F's nurse called back at 10:45. MD F would like to see resident in office across street and then have her sent by Squad to ER (emergency room ) at (hospital name) to be evaluated and treated. Assured MD F's nurse that resident was in too much pain and in no condition to be wheeled across the street. Asked if MD F would come here to see resident. MD F's nurse stated, that would be fine and MD F would be here a little after 1200. Daughter updated and to be at (Facility) soon." 8/28/14 13:15, " MD F here to assess resident. Daughter at bedside at this time. MD F gave dx (diagnosis) of hematoma, [MEDICAL CONDITION] to RLE, and [MEDICAL CONDITION]. MD requested to have resident sent over to (Hospital Name) as a direct admit for further evaluation. Squad called for transport." 8/28/2014 13:40, "Resident transported to hospital via squad. Daughter here at time of transport will follow in her car." Review of the facility document titled 24 Hour Report for Resident 1 state the following: 8/24/14: 7-3, "Tylenol 500 mg 1330 Bio freeze" 3-11 "Drsg CDI (Clean/Dry/Intact)" 11-7 "Left buttocks [MEDICATION NAME] DSG (Dressing) CDI *Please Note 8/24/14 is the date that Resident 1's right lower extremity was rolled under the wheelchair, there is no mention of the incident in the 24 Hour Shift-Shift Report.* 8/25/14: 7-3,"[MEDICATION NAME] Changed" 3-11, "[MEDICATION NAME] buttocks" 11-7, "[MEDICATION NAME] Left Butt" *Please note, MD F ordered a mobile X-RAY of Resident 1's Right Lower Extremity there is mention of this on the 24 Hour Shift-Shift Report for follow-up or MD notification of X-ray Results.* 8/26/14: 7-3 "[MEDICATION NAME] Left butt, Right Lower leg bruise/swollen" 3-11 "[MEDICATION NAME] Left Butt, Right lower bruise/swollen" 11-7 "[MEDICATION NAME] left butt, lg (large) bruise right lower leg." *Please note on 8/26/14 the physician was called regarding ice and a stronger pain medication for Resident 1, there is no mention of this in the 24 Hour Shift-Shift Report for follow-up or MD notification for the bruise.* 8/27/14: 7-3, "RLE Bruise/Swollen" 3-11, "RLE Bruise, Swollen ATB" 11-7, "Lg bruise right lower leg" *Please note on 8/27/14 labs/blood work was drawn and taken to the hospital, there is mention of this on the 24 Hour Shift-Shift Report for followup.* Review of Resident 1's physician telephone orders indicate that on 8/25/15 MD F ordered complete X-rays of Resident 1's right foot, ankle, knee, tibia and fibula with results not communitcated to the physician, and on 8/27/14 MD F ordered for the facility to check the following labs for Resident 1: CBC (Complete Blood Count), BMP (Basic Metabolic Panel) and CRP (C-Reactive Protein) Review of nurses notes state that the CBC, BMP, and CRP were drawn from Resident 1's left anticubital and taken to lab on 8/27/14. Lab results were not obtained from the lab until 0830 am on 8/28/14, at which time were called to the physician. The X-ray results were faxed to the facility on [DATE] at 14:18, the results were as follows: Right Foot: Limited, lateral view only. Modest [MEDICAL CONDITION] joint disease; otherwise, no fracture or dislocation seen, Right Ankle: Ankle swelling but no fracture, Right Knee: Intact right knee Arthroplasty. *Please note that there is no documentation in the medical record or on the radiology reports that MD F was notified of the results* Review of Resident 1's history and physical report dated 8/28/14 prepared by MD F states, "This [AGE] year old female, who had a date of injury, 8/24/14, was being wheeled down the hallway, by 'I think' a nurses aid when the nurses aid did not notice right leg hyper-flexed underneath the wheelchair. The patient did not fall but had external flexion of that knee and was in quite a bit of pain. Within hours a large hematoma on the medical shin developed and continued to grow over the next few days, such that by the time I was alerted to it on 8/27/14, the patient had some mild altered mental status. On 8/27/14, I ordered lab work which included CBC, CRP, and basic metabolic panel. Those labs are reported to be collected at 4:44 PM on 8/27/14. They were not reported to me until 10 AM, on 8/28/14. The patient's hemoglobin was 7/3. On 8/27/14, when I was informed for her condition and the redness and tenderness to this large hematoma on the right medical calf, we started Levequin based on the patient ' s allergy history. Bases on the new information I examined her myself. Plan: we are going to get a CT (Cat Scan) of that right lower extremity to further analyze this and see if there is any evidence of active bleeding. Her aspirin will be held. She will be transfused with two units of packed red blood cells." Review of CT scan performed at hospital on [DATE] states the following: "1. Periprosthetic fracture involving the medial tibial plateau, with extension to involve the anterior cortex of the proximal tibia as detailed above. 2. There is a large associated soft tissue hematoma anteromedially up to 9 cm (centimeters) in size. 3. Peroisteal in the distal tibia, which could be related to chronic venous stasis." First call out to the physician: On 9/12/14 at 9:45 AM, Surveyor interviewed Unit Manager (UM) H, who is also a Licensed Practical Nurse (LPN). UM H stated that on 8/25/14, she was summoned to (Resident 1's) room (by Resident 1) as they talk frequently and (Resident 1) told her what had happened on 8/24/14. UM H stated that (Resident 1) stated that it (the incident) had happened when (CNA J) was pushing her. UM H stated that she looked and (Resident 1's) leg from the knee down and there was no bruising or anything there. UM H stated that she complained of pain with movement and she stopped moving her leg. UM H stated that she told the nurse, on the floor, and then called the physician. UM H stated she spoke with the physician's MA (Medical Assistant), told what had happened and asked for an x-ray. UM H stated that she did not know at that time if this was the first time the physician had been notified. UM H stated that the MA called back and gave the order for the x-ray. UH H stated that she did not speak to the doctor. Surveyor 2797 asked UM H about the facility's process for when an incident occurs. UM H stated that a SBAR would be completed, which would trigger a DQI (incident report). UM H stated that she was not sure if one was required in this case. UM H stated that monitoring would be completed and communicated via the 24 hour board or a nursing measure placed on the TAR (treatment administration record). UM H stated that she would call the doctor for an incident such as this, as you just never know. UM H stated that she had not received any recent education related notification of changes. Nurse on duty when hematoma first observed: Surveyor interviewed LPN I on 9/12/14 at 11:09 AM. Surveyor asked LPN I about Resident 1's complaint of knee pain on 8/26/14. LPN I stated that (Resident 1) had complained of knee pain and was given Tylenol. LPN I stated that she noted a large bruise below the right knee as well. LPN I stated that it was size of a closed fist. LPN I stated she did not call the doctor, but passed this information onto the next shift. LPN I stated that she was aware of the incident with (Resident 1's) right leg and the wheelchair. LPN I stated that she does not normally call the doctor at night if it is not a real emergency. Nurse on duty during incident: Surveyor spoke with RN G on 9/12/14 at 11:12 AM. Surveyor asked RN G about her late entry documented in Resident 1's "Progress Notes" on 8/24/14. RN G stated that she was passing meds, next to the med room at about 1:00 PM. RN G stated that (Resident 1) was coming out from lunch and she was near the threshold where the carpet begins. RN G stated that (Resident 1) was having trouble with this so (CNA J) assisted went to help her. RN G stated that she heard (Resident 1) let out a yelp and stated that she got her toe caught on the lump. RN G stated that later, (CNA J) informed her that (Resident 1) really complained of her knee hurting. RN G stated that she took her some Tylenol and that she touched (Resident 1's) knee and she said "oh, oh, oh." RN G stated that she assessed the knee and there was nothing there but that behind the knee was a tight feeling so she applied Bio freeze to the area. RN G stated that she thought it was a muscle spasm; she put the foot pedal on and a pillow under (Resident 1's) leg. RN G stated that there was not a bruise at this time. Surveyor asked RN G if she called the doctor at this time. RN G stated that at this time she thought it was a muscle spasm, so she didn't. Surveyor asked RN G why she did not document this incident and her assessment until the next day. RN G stated that she probably should have. RN G stated that she passed this information onto the next shift, verbally. RN G state that she did not do an SBAR (change of condition report) because she thought (Resident 1) had just stubbed her toe. RN G stated that the facility called her the next day to do the SBAR. Surveyor asked RN G if she had thought an injury occurred from the incident versus a muscle spasm, given what had happened earlier. RN G stated that the resident told her she had stubbed her toe on the carpet. RN G stated that (Resident 1) has a low pain tolerance. Surveyor asked RN G what the facility's process was for when an incident occurs. RN G stated that the nurse would fill out a SBAR and DQI report, let the doctor know, report the incident to the oncoming shift, and also place this information on the 24 hour report. Nurse on duty second time hematoma observed: Surveyor spoke with RN K on 9/12/14 at 11:50 AM. Surveyor asked RN K about her documentation ("Progress Notes" 8/26/14, 1:28 PM). RN K stated that this was the first time she had seen the bruising, swelling and tenderness. Surveyor asked RN K if this would warrant a call to the physician. RN K stated that this would probably warrant a call. RN K stated that she notified RN C (Director of Nursing at the time). RN K stated that she and RN C talked about calling the physician but never did and that she would be the one who would call, but she could not recall for certain. RN K stated that (Resident 1's) leg was warm to touch and black and blue. RN K stated that she looked at the x-ray and noted that it was negative. Surveyor asked RN K about Resident 1 during her shift. RN K stated that she (Resident 1) did not get up, even when they tried to get her. RN K stated that this was not the norm. RN K stated that they tried the Hoyer lift as well, but this caused increased pain. Surveyor asked RN K about her administration of Tylenol (per "Progress Notes" dated 8/26/14 at 1:55 PM. RN K stated that Resident 1 was moaning and that she could assume that this was due to her leg. RN K stated that (Resident 1) does request pain meds frequently. Surveyor asked RN K about communication and continued monitoring, and the facility's process. RN K stated that they use the 24 hour board but that she prefers just a verbal report. RN K stated that this (Resident 1's incident) would be something that should be written on the board. Surveyor asked RN K about the facility's use of pain scales. RN K stated that it depends on the resident. RN K stated that some residents can verbalize numbers and some can only say if the pain is better or worse. Staff involved in incident: Surveyor spoke with Certified Nursing Assistant (CNA) J on 9/12/14 at 12:20 PM. CNA J stated that (Resident 1) was in the hallway and she asked if she wanted help. CNA J stated that she pushed (Resident 1) and her right foot and toe got caught and went down and under the chair. CNA J stated that (Resident 1) let out a squeal so she stopped, (Resident 1) picked her feet up and they went to the dining room. CNA J stated that (Resident 1) reported that it hurt but she took her to the table and then reported the incident to (Registered Nurse (RN) G). Surveyor asked CNA J what exactly she told the nurse. CNA J stated that she told (RN G) that (Resident 1's) foot got under the chair and it must have twisted under the chair. CNA J stated that (RN G) could have seen this as well as she was in her path. CNA J stated that she told (RN G) about the pain as well. CNA J stated that (RN G) stated she would take care of it. On 9/12/14 at 2:45 PM, Surveyor interviewed RN D regarding the labs for Resident 1. RN D stated, "I drew the labs before I left the facility for the day. I charted before I drew the labs. I told whoever was on that that I drew the labs and told them to watch for the results." Surveyor then asked RN D who the lab information was reported to, RN D stated, "I don't remember, but when I came in the next morning I called the lab to get the results because it wasn ' t done." Surveyor then asked RN D if the information about the lab draws should have been written on the 24 Hour Report sheet for communication regarding the follow-up, RN D stated, "Yes". Surveyor then asked RN D if the labs should have been called to MD F on 8/27/14, RN D stated, "Yes". On 9/12/14 at 3:00 PM, Surveyor spoke with RN C regarding notification of Resident 1's physician with the multiple changes in Resident 1's condition, RN C stated, "I was first made aware of the bruise on Resident 1's right leg on 8/26/14. I did not look at Resident 1's leg; RN D saw Resident 1's leg on 8/25/14 and said there was no redness or swelling. On 8/26/14 Resident 1's daughter came to me and asked if we could put ice on Resident 1's knee. I called MD F on 8/26/14 and spoke with MD F's nurse and asked for something stronger than Tylenol and ice for the swelling. I did not report the bruising. Resident 1's daughter was in the room when I called MD F. On 8/27/14 Resident 1's daughter confronted me, and asked if I would call MD F, that is when I looked at Resident 1's right leg and noticed the hematoma, and Resident 1's leg was red and swollen. I called MD F and again spoke with the nurse, I did not tell MD F that Resident 1's hematoma was black/purple. RN K and myself (RN C) should have called MD F sooner in the day, and I (RN C) should have followed up on the request for additional pain medication." On 9/12/14 at 3:15 PM, Surveyor spoke with LPN E regarding the labs drawn for Resident 1 on 8/27/14. LPN E stated, "I did not know about the labs." Surveyor then asked LPN E if pain was reported to MD F on 8/26/14, LPN E stated, "I do not believe that pain was discussed." On 9/12/14 at 3:35 PM, Surveyor asked RN C when the foot/knee/ankle X-ray obtained for Resident 1 on 8/25/14 was reported to MD F. RN C stated, "I don't know, there is no documentation in the computer saying when, and it is not written on the X-ray report. The physician should be notified as soon we get the test results or x-ray." Physician Interview: On 9/12/14 at 3:30 PM Surveyor interviewed MD F regarding Resident 1 and her change of condition. MD F stated that he had 2 concerns why it happened in the first place as she should have had the wheel chair pedals on and why he was not made aware of all of her issues timely. MD F stated the facility did not call with x-ray results obtained on 8/25 until 8/26. MD F stated that they (the facility) did not call until the 27 late afternoon to inform him of the new hematoma nor the new swelling of her leg that had been there at least the day before. MD F stated that he ordered labs on the 27 th and was very surprised that they were not called to him on that day as they were trying to figure out what her condition change was about. MD F also stated that he was not aware or does not remember the facility calling about increasing her (Resident 1) pain medications. The facility did not consult with a physician regarding Resident 1's multiple changes of condition, starting with the right leg being pushed under the wheelchair during transport on 8/24/14, results from X-ray taken 8/25/14, initial bruising of the right lower extremity, and increased pain on 8/26/14, and lab work ordered on [DATE]. Example 2: Resident 2 has [DIAGNOSES REDACTED]. "Progress Notes" dated 9/8/14 state, "Note text: 120/60 80 18 95% 97.1. Early am resident was quiet and sat Resident by med cart. After breakfast Resident was restless. Hitting and kicking at staff. Laid down for about an hour and then wanted up. Appeared more restless. Resident eats lunch at this time with some assist. Resident remains confused." "Progress Notes" dated 9/9/14 at 1:08 PM state, "Resident has been sleeping most of the day. Difficult to feed at dinner. Continues to try self-transfer. Movement appears very slow today. Will monitor and report." "Progress Notes" dated 9/9/14 at 9:18 PM state, "Resident was sleepy this shift, no yelling, hitting or calling out." "Progress Notes" dated 9/10/14 at 9:31 PM state, "Resident remains sleepy. Writer held [MEDICATION NAME] at 1700 (5:00 PM) was fed in bed. Daughter called and requested resident be up for all meals. Took small bites for supper. Responds to verbal stimuli." "Progress Notes" dated 9/11/14 at 4:00 AM state, "SBAR-Change in Condition; Situation: Resident found at his bedside, right-side lying on floor mat. Resident leaning on right arm, head up. Resident's head towards the east. Background: Resident with Hx (history) of falls, behaviors including exit seeking behaviors. Most recent episode of resident found on the floor was 9/6/14. Pertinent medical dx (diagnoses): dementia, paranoid state, anxiety state. Resident in low bed, floor mat at bedside, tab alarm on, sensor alarm, 1 pillow on resident's right side. Assessment: Initial VS (vital signs) 143/78, AP (apical pulse) 72 irreg (irregular), 22 97.1 (ax) (axillary), 72% (oxygen saturation) RA (room air). O2 nc (nasal cannula) at 2lpm (liters per minute) re-applied (was on during last rounds). Resident stated "get me up" when asked if he hit his head. Message written on paper for resident to read asking if he hit his head, resident replied "get me up." No noted deformities, contusions, abrasions, lacerations, tenderness nor swelling on head to toe primary assessment of resident. Facial symmetry present. Pelvis intact ...Dr. (name) updated at 0435 (4:35 AM), new orders for CBC (complete blood count), BMP (basic metabolic panel) mobile chest x-ray, and to monitor and update with any changes. 0535 call to Dr. (name) to update that resident's color ashen, delayed capillary refill > (greater than) 5 sec, O2 increased, resident not satting. New order to send to ER ..." The facility did not consult with a physician regarding Resident 2's change of condition, to include sleepiness, inability to assist with feeding and slowed movements. It is important to note that Resident 2 had an increase in [MEDICATION NAME] on 9/8/14. Resident 2's order dated 9/8/14 states, "[MEDICATION NAME] (Klonopin) 1 mg (milligram) tablet, take 1 tab by mouth 3 times daily." Resident 2 was admitted to a hospital on [DATE]. "Admission History and Physical" dated 9/11/14 notes that Resident 2 was diagnosed with [REDACTED]. Surveyor spoke with Director of Nursing (DON) B on 9/12/14 at 3:18 PM. Surveyor asked DON B about Resident 2's symptoms of sleepiness an increased dependence with feeding and if this would warrant consultation with a physician. DON B stated that if this was a change in condition, a call should be made within 24 hours. Surveyor went through Resident 2's changes starting on 9/9/14, continuing 9/10/14 and the fall on 9/11/14 after which Resident 2 was sent to the hospital.

Based on observation, interviews, and record review the facility did not ensure that 1 (Resident 1) out of 6 residents reviewed for pain received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Resident 1's right leg rolled under her wheelchair during transport and she "squealed in pain." The facility did not notify the physician of increased pain, update the care plan or complete a comprehensive assessment of Resident 1's pain following the incident when Resident 1 had an increase in pain. The facility did not consistently utilize the 24 hour board to monitor Resident 1's condition from shift to shift. This is evidenced by: Resident 1 was re-admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident 1's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/31/2014 indicates that Resident 1 makes self-understood, understands others, speech is clear, and Resident 1's cognition is intact. The MDS indicates that Resident 1 is an extensive assist of two persons for transfers, is non ambulatory, and requires extensive assist of one for mobility off the unit. Resident 1's functional limitation in range of motion is impaired on both sides of her lower extremities, and Resident 1 uses the mobility device of a wheelchair. Section J Pain Management indicates that Resident 1 receives scheduled and PRN (As needed) pain medication, experiences pain that limits day to day activities, rates pain at a 4 on a scale of 0-10 (10 being the highest). Resident 1's care plan titled "Needs Pain management and monitoring related to [MEDICAL CONDITION], Chronic Back Pain, trimalleolar fracture left ankle" with a reviewed date of 8/14/14, Goals* Will maintain adequate level of comfort as evidenced by no s/sx (signs or symptoms) of unrelieved pain or distress, or verbalizing satisfaction with level of comfort, and Interventions states, "Administer Pain Medications ordered, Acceptable Pain Level - 2" Revision date 1/29/13, Evaluate and Establish level of pain on numeric scale/evaluation tool, Evaluate Characteristics and frequency/pattern of pain, Utilize pain monitoring tool to evaluate effectiveness, Implement the patients preferred non-pharmacological pain relief strategies." Resident 1's document titled, "Quarterly Interdisciplinary Resident Review" dated 8/5/14, Section O Pain states, Resident 1 rating pain level at a 5 on a scale of 0-10, pain is moderate, location of pain is in left lower extremity hip/leg, radiating, and throbbing. The assessment indicates that Resident 1's acceptable level of pain is 0 on a scale of 0-10. Resident 1's current pain treatment plan is documented as [MEDICATION NAME]. The goal for Resident 1's treatment plan states, "Maintain Resident comfort level of "0" tolerable level." Review of Resident 1's physician's orders [REDACTED]. 12/2/2013: [MEDICATION NAME] Give 500 mg by mouth four times a day for Pain. 12/2/2013: [MEDICATION NAME] Tablet 500 mg. Give 500 mg by mouth as needed for Pain 12/2/2013: Give Additional Dose as needed throughout the Day. 5/27/2011: [MEDICATION NAME] 25 MCG/HR Patch [MEDICATION NAME] in the evening Chronic Pain, Apply Q 3 days, 8/17/2012: [MEDICATION NAME] 600 mg, Give 600 mg by mouth three times a day for pain. Review of Resident 1's MAR (Medication Administration Record) for the month of August 2014 indicated that from August 1st through August 23, 2014 Resident 1 was not administered PRN Tylenol 500 mg. The August MAR indicated [REDACTED] August 24 th 1 additional dose of Tylenol 500 mg administered at 13:29 (1:29 PM) E (Effective) August 25th, 1 additional dose of Tylenol 500 mg administered at 0008 E (Effective), August 26th, 1 additional dose of Tylenol 500 mg at 0016 E (Effective), and 1300 (Effective), August 27th, 1 additional dose of Tylenol 500 mg at 0415 E (Effective). Review of Resident 1's TAR (Treatment Administration Record) for the month of August 2014 shows that Resident 1 has a treatment order for Bio-Freeze TO AFFECTED AREAS, (SHOULDERS, UPPER ARMS AND KNEES) which was increased to Two Times Daily on 8/14/14, 8/26/14- Ice Applied to RLE (Right Lower Extremity) Every 4 hours as needed related to SWELLING OF LIMB. *Please Note the order for the application of ice was never signed out as being administered on the TAR.* Review of Resident 1's nurses titled LATE ENTRY 8/24/14 13:00 Type SBAR- Change of Condition Created Date 8/25/2014 at 16:21(4:21 PM) "Situation: Resident was on her way back to room from lunch when approaching the carpet from the wood floor when resident got stuck on the threshold. CNA (Certified Nursing Assistant offered assistance and begun to push resident to room. Resident's right foot caught on carpet from not lifting feet up high enough. Resident does not routinely use foot pedals due to propelling self around facility. Resident yelled in pain. Taken to room and CNA reported to self that Resident wanted some pain medication. Assessment: Resident found sitting in chair complaining of pain in her right posterior knee. On inspection there is no redness or swelling noted. Resident complained when I touched all aspects of her knee even lightly. She focused my attention to the posterior aspect mainly. Area felt very taunt feeling like a muscle spasm. I gave resident [MEDICATION NAME] 500 mg and rubbed bio freeze liberally on the total knee area front and back. Resident requested a foot pedal be put on her wheelchair and we did such and also added a pillow folded under the right foot since resident requested it to be up higher. No complaints of pain in right ankle but did complain of discomfort in lower leg. Response: Pain medication and bio freeze to right knee." *Pease note review of the 24 hour report sheets does not include that Resident 1 experienced the incident to the right lower extremity, received the PRN Tylenol, and no changes were made to Resident 1's care plan* Nurse's notes state the following: 8/25/14 03:01, "C/O (complaint of right knee pain @ (at) 12 AM, Tylenol 500 mg (milligrams) given. Slept at intervals. Bio-Freeze to right knee and under right shoulder." 8/25/14 13:06, "Resident has been c/o right knee pain. Mobile X-ray here at this time." 8/25/14 13:50, "Does c/o pain right lower leg. X-Ray completed awaiting results." 8/26/14 00:16, "[MEDICATION NAME] 500 mg, Right knee pain. Rated at 6." 8/26/14 04:18, "C/O right knee pain @ 12 AM, Tylenol 500 mg given. Slept intervals. Large bruise on right leg below knee. Right leg swollen. Leg elevated on pillow." 8/26/14 05:13, "PRN Administration was: Effective." 8/26/14 13:00, "[MEDICATION NAME] 500 mg c/o right knee/leg pain." 8/26/14 13:28, "Resident c/o right knee pain. Gave resident PRN Tylenol 500 mg. R knee/leg continues have bruise which is dark purple. Continues to be swollen and tender to touch. R leg elevated on pillow. Resident has been resting in bed throughout the day." 8/26/14 13:55, "PRN Administration was: Effective" Late Entry 8/26/14 15:27, "Daughter here to visit and has concerns with her Mother's RLE (right lower extremity). Resident has been in bed for 2 days d/t (due to ) complaint of pain with transfer and any kind of movement. Attempted to get up for lunch but refused after staff lifted her in the Hoyer d/t being in too much pain. Transfers with assist x 2 using the Hoyer. Has a large hematoma located just below the right side of her knee. Area around the hematoma is swollen and her skin is tight. Daughter wondering about putting ice on the area that is swollen. Ice was applied and message left for MD F to get prn order for ice and possibly something stronger for pain." 8/26/14 21:08, "MD F returned call and said to use ice to right leg at this time and assess tomorrow to see how ice pack went. Resident has been resting quietly." 8/27/14 04:15, "[MEDICATION NAME] 500 mg given for moaning and calling out." 8/27/14 05:53 "PRN administered was Effective" 8/27/14 13:03, "Resident continues to have dark purple/black bruise to RLE. C/O pain with movement. Warm and tender to touch. Blanchable, 2+ [MEDICAL CONDITION] noted to RLE. Resident making nonsensical comments to the nurse. Talking to people who aren't there, seeing things that weren't there. Productive cough noted with yellow sputum. Audible crackles noted with breathing. LS (lung sounds with rhonchi and crackles noted. Will continue to monitor." 8/27/14: 14:10, "Confronted by daughter, regarding Mother's condition. Asked if I had spoken to MD F yet today to give MD F update on residents condition. Assured daughter that I would call MD F right away. Updated MD F on residents breathing, and coughing up thick yellow phlegm as well as redness and warmth to lower right extremity. The hematoma remains dark blue/ purple in color. She continues to complain of pain to the area with any kind of movement. She is assisted x 3 using the Hoyer lift into her wheelchair for lunch. She has been delusional all morning and seeing things that weren't there. MD F also updated on this. New orders for Levequin 500mg x 10 days, and draw CBC, BMP and CRP today. Labs were obtained." 8/27/14, 15:38, "CBC, BMP, CRP drawn from left arm." 8/27/14 21:00, "Leg remains discolored and swollen. No complaint of pain or discomfort. Right leg warm to touch." 8/28/2014 02:51, "RLE circumference measured 16 cm (centimeters) down from right patella = 47.5 cm. Area on right upper shin is reddened, purple coloration, warm to touch, skin is taunt. Left lower extremity skin is PWD (Pink, Warm, and Dry). Circumference 16 cm down from center of left patella = 35 cm." On 9/12/14 at 11:00 PM, Surveyor asked DON (Director of Nursing) B what "Effective" means as a follow up to PRN medication administration, DON B stated, "It was effective, it worked." Review of the facility document titled 24 Hour Report for Resident 1 state the following: 8/24/14: 7-3, "Tylenol 500 mg 1330 Bio freeze" 3-11 "Drsg CDI (Clean/Dry/Intact)" 11-7 "Left buttocks [MEDICATION NAME] DSG (Dressing) CDI *Please Note 8/24/14 is the date that Resident 1's right lower extremity was rolled under the wheelchair, there is no mention of the incident in the 24 Hour Shift-Shift Report.* 8/25/14: 7-3,"[MEDICATION NAME] Changed" 3-11, "[MEDICATION NAME] buttocks" 11-7, "[MEDICATION NAME] Left Butt" *Please note, MD F ordered a mobile X-RAY of Resident 1's Right Lower Extremity there is mention of this on the 24 Hour Shift-Shift Report for followup.* 8/26/14: 7-3 "[MEDICATION NAME] Left butt, Right Lower leg bruise/swollen" 3-11 "[MEDICATION NAME] Left Butt, Right lower bruise/swollen" 11-7 "[MEDICATION NAME] left butt, lg (large) bruise right lower leg." *Please note on 8/26/14 the physician was called regarding ice and a stronger pain medication for Resident 1, there is no mention of this in the 24 Hour Shift-Shift Report for follow-up.* 8/27/14: 7-3, "RLE Bruise/Swollen" 3-11, "RLE Bruise, Swollen ATB" 11-7, "Lg bruise right lower leg' *Please note on 8/27/14 labs/bloodwork was drawn and taken to the hospital, there is mention of this on the 24 Hour Shift-Shift Report for followup.* Surveyor interviewed Unit Manager (UM) H, who is also a Licensed Practical Nurse (LPN) on 9/12/14 at 9:45 AM. UM H stated that she was summoned to (Resident 1's) room (by Resident 1) as they talk frequently and (Resident 1) told her what had happened on 8/24/14. UM H stated that (Resident 1) stated that it (the incident) had happened when (CNA J) was pushing her. UM H stated that she looked and (Resident 1's) leg from the knee down and there was no bruising or anything there. UM H stated that she complained of pain with movement she stopped. UM H stated that she told the nurse and then called the physician. UM H stated she spoke with the physician's MA (Medical Assistant), told what had happened and asked for an x-ray. UM H stated that she did not know at that time if this was the first time the physician had been notified. UM H stated that the MA called back and gave the order for the x-ray. UH H stated that she did not speak to the doctor. Surveyor 2797 asked UM H about the facility's process for when an incident occurs. UM H stated that a SBAR would be completed, which would trigger a DQI. UM H stated that she was not sure if one was required in this case. UM H stated that monitoring would be completed and communicated via the 24 hour board or a nursing measure placed on the TAR (treatment administration record). UM H stated that she would call the doctor for an incident such as this, as you just never know. UM H stated that she had not received any recent education related notification of changes. Surveyor interviewed LPN I on 9/12/14 at 11:09 AM. Surveyor asked LPN I about Resident 1's complaint of knee pain on 8/26/14. LPN I stated that (Resident 1) had complained of knee pain and was given Tylenol. LPN I stated that she noted a large bruise below the right knee as well. LPN I stated that it was size of a closed fist. LPN I stated she did not call the doctor, but passed this information onto the next shift. LPN I stated that she was aware of the incident with (Resident 1's) right leg and the wheelchair. LPN I stated that she does not normally call the doctor at night if it is not a real emergency. Surveyor spoke with RN K on 9/12/14 at 11:50 AM. Surveyor asked RN K about her documentation ("Progress Notes" 8/26/14, 1:28 PM). RN K stated that this was the first time she had seen the bruising, swelling and tenderness. Surveyor asked RN K if this would warrant a call to the physician. RN K stated that this would probably warrant a call. RN K stated that she notified RN C (Director of Nursing at the time). RN K stated that she and RN C talked about calling the physician but never did and that she would be the one who would call, but she could not recall for certain. RN K stated that (Resident 1's) leg was warm to touch and black and blue. RN K stated that she looked at the x-ray and noted that it was negative. Surveyor asked RN K about Resident 1 during her shift. RN K stated that she (Resident 1) did not get up, even when they tried to get her up. RN K stated that this was not the norm. RN K stated that they tried the Hoyer lift as well, but there was increased pain. Surveyor asked RN K about her administration of Tylenol (per "Progress Notes" dated 8/26/14 at 1:55 PM. RN K stated that Resident 1 was moaning and that she could assume that this was due to her leg. RN K stated that (Resident 1) does request pain meds frequently. Surveyor asked RN K about communication and continued monitoring, and the facility's process. RN K stated that they use the 24 hour board but that she prefers just a verbal report. RN K stated that this (Resident 1's incident) would be something that should be written on the board. Surveyor asked RN K about the facility's use of pain scales. RN K stated that it depends on the resident. RN K stated that some residents can verbalize numbers and some can only say if the pain is better or worse. Surveyor spoke with Certified Nursing Assistant (CNA) J on 9/12/14 at 12:20 PM. CNA J stated that (Resident 1) was in the hallway and she asked if she wanted help. CNA J stated that she pushed (Resident 1) and her right foot and toe got caught and went down and under the chair. CNA J stated that (Resident 1) let out a squeal so she stopped, (Resident 1) picked her feet up and they went to the dining room. CNA J stated that (Resident 1) reported that it hurt but she took her to the table and then reported the incident to (Registered Nurse (RN) G). Surveyor asked CNA J what exactly she told the nurse. CNA J stated that she told (RN G) that (Resident 1's) foot got under the chair and it must have twisted under the chair. CNA J stated that (RN G) could have seen this as well as she was in her path. CNA J stated that she told (RN G) about the pain as well. CNA J stated that (RN G) stated she would take care of it. On 9/12/14 at 3:00 PM, Surveyor interviewed RN (Registered Nurse) C regarding Resident 1's increased pain. RN C stated, "I phoned MD F and left a message with MD F's nurse on 8/26/14 requesting ice and something stronger than Tylenol for pain. RN C stated that by reviewing Resident 1's documentation RN C noted that Resident 1 was experiencing an increase in pain since 8/24/14." Surveyor asked RN C if why the MD did not order additional pain medication, RN C stated, "The PM Nurse spoke with the MD, not sure why." Surveyor then asked RN C if any other follow up was done regarding pain management for Resident 1, RN C stated, "No." Surveyor then asked RN C if Resident 1 should have had a updated pain assessment completed. RN C stated, "Yes." Surveyor then asked RN C if Resident 1's plan of care for pain should have been updated, and RN C again stated, "Yes." On 9/12/14 at 2:45 PM, Surveyor interviewed RN D regarding the labs that were drawn on 8/27/14. RN D stated, "I drew the labs before I left for the day and dropped the labs at the hospital." Surveyor then asked RN D if the lab draw was reported to the oncoming shift, RN D stated, "I told whoever was on that night when I left, can't remember who I told but I told them to watch for the labs. When I came back the next morning I called the lab to get the results, I had to call to get the results." Surveyor asked RN D if the lab orders/draw were written on the 24 hour shift-to shift report board for follow up, RN D stated, "No, but they should have been so the physician could have been called with the results that night." On 9/12/14 at 3:20 PM, Surveyor spoke with LPN (License Practical Nurse) E regarding the return call from MD F for Resident 1 and if pain was addressed. LPN E stated, "I did speak with MD F personally, I received the order for the application of ice, but do not believe that additional pain medication was discussed." Surveyor then asked LPN E if LPN E was made aware of the labs that were ordered and drawn on 8/27/14, LPN E stated, "No I did not know labs were drawn or that I was to follow up on them." On 9/12/14 at 3:30 PM Surveyor interviewed MD F regarding Resident 1 and her change of condition. MD F stated that he had 2 concerns why it happened in the first place as she should have had the wheel chair pedals on and why he was not made aware of all of her issues timely. MD F stated the facility did not call with x-ray results obtained on 8/25 until 8/26. MD F stated that they (the facility) did not call until the 27th late afternoon to inform him of the new hematoma nor the new swelling of her leg that had been there at least the day before. MD F stated that he ordered labs on the 27th and was very surprised that they were not called to him on that day as they were trying to figure out what her condition change was about. MD F also stated that he was not aware or does not remember the facility calling about increasing her (Resident 1) pain medications. The facility did not reassess, update the care plan or evaluate Resident 1's pain. The facility did not communicate from shift to shift to address the needs of Resident 1 to allow Resident 1 to receive the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.

Based on observation, interview, and record review, the facility did not ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 4 of 11 residents reviewed (Residents 3, 7, 1 and 8). Resident 3 was noted to wander into other resident's rooms and become aggressive. Resident 3 knocked a TV off of a stand and the facility did not provide additional supervision to prevent future aggressive episodes. The same evening, Resident 3 was suspected to have pulled Resident 5 from her bed and subsequently slapped Resident 4 across the face. The facility did not update Resident 3's plan of care with safety interventions. Resident 7 was noted to be lowered to the floor. The facility did not complete a thorough investigation into the fall. The facility did not provide therapy in a prompt manner. Resident 7 sustained a subdural hematoma which was evacuated. After Resident 7's hospitalization , the facility did not complete a thorough assessment of Resident 7's fall risk. Resident 7 fell from her chair and sustained a clavicle fracture. Resident 7's care plan was not updated with fall interventions. Resident 1's medical record contains entries of Resident 1 wandering about the facility, exit seeking, being intrusive into other resident's room, and making a threatening statement to Resident 2's family member. The facility did not ensure the resident's environment remains safe. Resident 8 was sustained a fall on 3/8/14, the facility did not investigate the fall to determine the root cause analysis. Examples 1 and 2 involving Resident's 3 and 7 are determined to be examples at the s/s (scope and severity) of "G" actual harm/isolated. The remaining examples are determined to be severity level of potential for harm. This is evidenced by: The facility's policy titled "Falls Management Clinical Guidelines" revised in 2013 states, "The center implements the falls prevention and intervention program including: During preadmission intake, determine if the potential resident has a history of falling or unsteady gait. Assure that the appropriate fall interventions are in place prior to the resident's admission. Newly admitted /readmitted residents are assessed for fall risk by means of the Clinical Health Status tool. The immediate Plan of Care At Risk-Falls Risk (see attachment) is initiated. At risk residents are identified through a "fall alert" communication system to care givers. During orientation new employees are educated to the fall management system ...Following a resident's fall: (See fall decision tree). The licensed nurse assesses the resident for injuries (including neuro checks if indicated) and provides necessary treatment and initiates the Change in Condition report-Post Fall/Trauma. The physician and resident's representative is notified. Appropriate interventions are implemented. (See tool: Resource for Resident Interventions to Prevent Falls attached.) Care plan is updated. Continue ongoing assessment and documentation by licensed nurses per center practice. (See QA Falls Intervention Tracking) The licensed nurse initiates the DQI Quality Control Report. Licensed nurse reflects fall on 24 Hour Report. The interdisciplinary Team reviews the Change of Condition Report-Post Fall/Trauma and makes additional recommendations within 72 hours of the fall ..." An attached document titled "Post Fall Investigation Summary" revised in 2013 states, "Purpose: To assess individual condition after a fall occurs and to identify the reason and/or risk factors for the fall in order to prepare a plan of care to reduce the potential for future falls. Policy: It is the policy of the facility to complete the Post Fall Investigation Summary after every known resident fall. Fall Definition: A fall is a sudden change in position usually involving the floor. Finding a resident on the floor or lowering/assisting a resident to the floor is considered a fall. Procedure if a resident falls: 1. The licensed nurse will assess the resident for injuries and provide the necessary emergency treatment. Initiate the facility 911 policy and procedure if appropriate. 2. The licensed nurse shall initiate the Post Fall Investigation Summary. This shall be kept in the resident's medical record. Indicate the date, time and location of the fall. Subjective-record what the resident states including their response to range of motion, subjective complaints of paint and if they are able to state reason they fell . Objective-record the residents current vital signs, response to neurological assessment, food and fluid intake last 24 hours, current labs if applicable, identify any pertinent disease or diagnosis, any medications that could contribute to falling, history of previous falls, and evidence of impaired safety judgment. Evaluate for causative factors including changes in environment, presence of restraints or assistive devices, psychological issues including change in mood or roommates ...Nurses Note/Interventions: Summarize the significant assessment findings, actions taken to treat injuries, the resident's response to the treatment ....Care plan developed revised as indicated ..." Example 1 Resident 3 has [DIAGNOSES REDACTED]. The facility completed an admission Minimum Data Set (MDS) assessment dated [DATE] for Resident 3. This assessment notes that Resident 3 scored three points on the Brief Interview for Mental Status, indicating severe cognitive impairment. Section E of this assessment, Behavior, notes that Resident 3 displayed physical and verbal behavioral symptoms directed toward others and that behaviors put others at risk for injury. Section E also indicates that Resident 3 wanders. Section G, Functional Status, notes that Resident 3 needs limited assist/one person physical assist for ambulation and locomotion throughout the facility. Resident 3's care plan dated 2/28/14 states, "At risk for elopement related to: wandering ...Interventions: assess for risk of elopement per living center policy. Educate family/responsible party on talking positively about living center placement. Encourage family to bring in personal possessions ...redirect from doors. Take picture of patient upon admission for identification for updating elopement book ...Impaired neurological status related to: Alzheimer's dementia disease, mixed vascular dementia ...Interventions: Assist in ADLs (activities of daily living) and mobility as needed. Assure patient is monitored during mealtime if needed. Diet as ordered, monitor intake. Encourage family to visit and bring in photos and mementos ..." Resident 3's Certified Nursing Assistant (CNA) care plan states, "Transfers: up ad lib (up freely); Mobility/Rehab: up ad lib PT (physical therapy), OT (occupational therapy) ST (speech therapy). Toileting: Inc (incontinent), wears depends. At risk for: falls. Special Needs: Wanderguard, very brittle diabetic, motion sensor at night. Bed and chair alarms ..." Progress Notes state the following: "3/1/14 ...Entering other resident's room, redirected by staff ...wanders in and out of others rooms. Staff could redirect at times by would get combative and wanted to be left alone ...Incont (incontinent) episodes of B&B (bowel and bladder) in others rooms ... 3/2/14:..out wandering 100 hall at 3AM, redirected back to bed ... 3/3/14:..restless in and out of residents rooms. Found in other room sleeping in chair. Redirected each time ...Res (resident) continues with agitated behaviors 1:1 (one on one) given t/o (throughout) the day. Res refuses to be touched ...Much 1:1 provided today with SSC (Social Services Coordinator). SSC sat with resident before, during and after lunch. Resident was agitated and threw cups filled with water X2 (two times). Resident making statements of wanted to be taken home ...reassurance provide, resident very difficult to redirect. Resident weepy at times. Writer brought resident down to her room and continued to provided 1:1 while resident rested in bed ... 3/4/14 ...continues to wander halls and enter other rooms ...20:00 (8:00 PM) Staff informed this writer that resident was in another residents room and pushed TV off stand onto floor. Resident redirected with activities. Ineffective. Continues to wander into resident rooms throughout shift. Staff redirection continues to be ineffective. Exit seeking behaviors multiple times this shift. Resident becomes angry when staff redirects and was seen kicking doors in facility." It is important to note that the facility identified that Resident 3's behaviors increased to a physical nature and redirection was not effective. No interventions or increase in supervision was provided after Resident 3 knocked the TV from the TV stand. Progress notes continue as follows: "3/5/14 03:46 (3:46 AM); Note text: Heard a voice in room (number) @ 10:45 PM. Found (Resident 3) standing by another resident who was part ways out of bed onto the floor. (Resident 3) kept asking if she was ok. Tried to redirect (Resident 3) away from resident on the floor. While writer was assessing resident on the floor while waiting for other staff to come and assist, (Resident 3) walked to the other bed in the room and slapped the male in bed, 3 times on the right side of the face with her open hand. She was yelling at him. (Resident 3) was physically removed from the room and back to her room and back into bed. Found O2 (oxygen) tubing from the male resident in the hallway, appeared to have been taken off the resident by (Resident 3). Right cheek of male monitored, no signs of redness, no c/o (complaints of) pain. (Doctor on call) notified of incident, no new orders. (Nursing Home Administrator (NHA) A) notified of incident. (Resident 3) did stay in bed and go to sleep shortly after the incident. Motion detector in place. (Resident 3) was monitored closely the rest of the night." "3/5/14: Note Text: Res had 15 min checks when she is in her room. Res. has 1:1 when ambulating outside of her rm. Res does become very agitated easily when she asks where her husband is ..." It is important to note that these interventions were not added to Resident 3's Plan of Care or CNA Care Plan. Resident 3's Medication Administration Record (MAR) for March, 2014 indicates that Resident 3 was ordered a motion sensor alarm on March 1, 2014 and this had been in place from March 2nd to the day of survey (March 10, 2014). The "15 Minute Checks (NOC)" form dated 3/5/14 is not documented as completed from 1:15 AM to 5:45 AM. There are no documented 15 Minute checks for 3/6/14. PM shift (2:00 PM to 9:45 PM) 15 minute checks are not documented as complete for 3/7/14. 15 minute checks are not documented as completed on 3/9/24 from 2:15 PM to 9:45 PM. On 3/10/14 at 9:05 AM, Surveyor observed Resident 3 in her room. Surveyor noted that Resident 3 had bed and chair alarms as well as a motion alarm attached to the wall, near the door to the room. Surveyor spoke with Licensed Practical Nurse (LPN) E on 3/10/14 at 1:40 PM. Surveyor asked LPN E about the incident where (Resident 3) pushed the TV from a stand on 3/4/14. LPN E stated that Maintenance told her what happened and that the DON (Director of Nursing) told her to document what happened. Surveyor asked LPN E what she did to prevent a future physical behavior for (Resident 3). LPN E stated that she removed (Resident 3) from the area and talked to her. LPN E stated that (Resident 3) continued wandering. LPN E stated that she gave as much as she could with the staff available. LPN E stated that 1 on 1 was not given, but staff was working together as a team. LPN E stated that she reported this off to the night shift. Surveyor asked LPN E if anyone or she heard Resident 3's sensor alarm going off (when Resident 3 was found in the room of Residents 4 and 5). LPN E stated that she did not. At 2:40 PM, LPN E stated that she did not know that (Resident 3) had a sensor alarm and that she was not working (Resident 3's) hallway and found (Resident 3) on her (the 400) hallway. Surveyor spoke with LPN F on 3/10/14 at 1:45 PM. LPN F stated that (Resident 3) did have the motion sensor alarm on at the time of the incident involving (Resident 3) entering (Resident 4 and 5's) room and that she did not hear in alarm before the incident. Surveyor asked if 1 on 1 was provided at the time before the incident. LPN F stated that 1 on 1 was not provided but that she was trying to keep track of her. LPN F stated that she was at the nurse's station and that she heard loud voices in room (number). LPN F stated that (Resident 5's) upper body was in bed but the rest of her was off of the bed. LPN F stated that (Resident 5) was in an unsafe position. LPN F stated that (Resident 3) was standing over (Resident 5) and it looked as if (Resident 3) pulled (Resident 5) from her bed. LPN F stated that she yelled down the hallway for help and was trying to make sure (Resident 5) was still breathing. LPN F stated that (Resident 3) then went and slapped (Resident 4) not too hard but she could hear the slap. LPN F stated that she did not feel that (Resident 3) was intently doing this and that (Resident 3) does not know what she is doing. LPN F sated that she informed (NHA A) and was told to call the doctor. Surveyor asked LPN F why she thinks the incident occurred. LPN F stated that there is only three staff on at night, herself and two CNAs. LPN F sated that there are a lot of alarms, so when one is alarming there is not always someone to answer the alarm. LPN F stated that she believes this is what happened this night. LPN F stated that the only thing that would help is to have staff stand at (Resident 3's) door and that the facility does not have the staff to do this at night or to do 1 on 1. LPN F stated that she was not informed about the TV incident that occurred earlier that evening. Surveyor spoke with CNA H on 3/10/14 at 1:57 PM. CNA H stated that it is very hard to decide which alarm to answer on night shift. CNA H stated that she did not hear the sensor alarm go off before the incident with (Resident 3). CNA H sated that she and the other CNA were clear down the 200 hallway, not close to the hallway where the incident occurred. The facility did not complete an investigation or incident report related to the incidents with Resident 3 allowing her to pull Resident 4 from her bed and slap Resident 5 in the face. Surveyor spoke with Director of Nursing (DON) B on 3/10/14 at 1:25 PM. DON B stated that she was in charge of conducting investigations. At 2:25 PM, DON B stated that (Resident 3's) incident with the TV on 3/4/14 was a separate incident and she was redirected and the physician was called. DON B stated that she would expect staff to do something different if their interventions were ineffective. DON B stated that this should have been reported to the night shift as well. DON B stated that the incidents should be looked into and that she would have put 15 minute checks into place right away. DON B stated that she should have looked into why the sensor alarm was not alarming and that she did not know why each situation was not investigated. Surveyor spoke with NHA A on 3/10/14 at 3:25 PM. NHA A stated that she would expect that staff respond to the alarm. NHA A stated that this incident was discussed in morning meeting. NHA A stated that she would expect to be informed of the TV incident and that she did not know about it. Example 2 Resident 7's "[DIAGNOSES REDACTED]. Resident 7's care plan dated 4/6/11 state, "Impaired neurological status related: dementia ...Assist in ADLs (activities of daily living) and mobility as needed ...I have a physical functioning deficit related to: self care impairment, dementia ...Interventions: bed mobility assistance of (as requested per resident), call bell within reach ...wears glasses ...independent with transfers. Grip strips to floor ...Monitor and report changes in physical functioning ability ...At risk for falls related to: Use of medication ...Interventions: activity programming-exercises, TV programs. Assess for pain. Assess that wheelchair is of appropriate size, assesses need for footrests, assesses need to have wheelchair locked/unlocked for safety. Anti-tippers. Bed in low position. Call light and personal items available and in easy reach or provide reacher. Footwear to prevent slipping. Grab bar. Keep environment well lit and free of clutter. Observe for side effects of medications ..." The facility completed a "Risk for Falls" assessment on 12/13/13. This assessment notes that Resident 7 scored 10 points, indicating risk for falls to occur. Progress Notes state the following: "1/28/14 ...Res (resident) was lowered to the floor this morning. No apparent injury. Res denies pain or discomfort. VS (vital signs): BP (blood pressure) 165/73, O2 (oxygen saturation) 94%, HR (heart rate) 64 T (temperature) 96.4. PCP (primary care physician) notified of fall ...no new orders or noted concerns." "2/3/14: Situation: Unable to use left hand/fingers. Dragging left foot with ambulation. Background: Lowered to the floor on 1/28/14 while ambulating. Ambulates short distances with assist X 1, FWW (front wheeled walker), w/c (wheelchair) to trail as tolerated ...MD updated ..." "2/12/14: Dr. (name) called to give update on Resident's MRI. Stated subdural hematoma was noted and he was going to make arrangements to send to UW hospital in Madison. Called to update daughter ..." A physical therapy (PT) note, "PT Daily Treatment Note" indicates that Resident 7 was first seen by the PT department on 1/30/14, two days after she was lowered to the floor. Resident 7 was out of the facility from 2/12/14 to 2/20/14. "Discharge Summary" dated 2/20/14 from the hospital states, "Primary Discharge Diagnosis: [REDACTED]. She lives at a nursing facility with some mild baseline dementia (son notes she is oriented X2 usually and recognizes family), where they reportedly noticed diminished strength of the left side. Her son agrees that her left hand which she had difficulty opening from a fist used to be functional. She has not had any falls, headaches, other changes in her neuro exam ...Hospital Course: ...She has currently not returned to that prior baseline. She does not wish to eat, stating the food tastes bad and fearful, not wanting to be alone. Palliative care was consulted ..." The facility completed a "Risk for Falls" assessment on 2/20/14 upon Resident 7's return to the facility. Resident 7 scored 8 points on this assessment, deeming Resident 7 not at risk for falls. It is important to note that a section of the fall assessment called "Ambulation/Elimination Status" is not completed. Section F of the "Clinical Health Status" assessment, in which the "Risk for Falls" assessment is contained, notes that Resident 7 is frequently incontinent. The Braden Scale for Predicting Pressure Sore Risk, within the "Clinical Health Status" assessment notes that Resident 7 is very limited in mobility. The facility did not accurately assess Resident 7's risk for falls after her return. Resident 7's care plans dated 2/20/14 state, "Impaired neurological status related to: subdural hematoma ...Interventions: Assist in ADLs and mobility as needed ...2/26/14 Fracture L (left) clavicle-sling to be worn X 1 month ...I have physical functioning deficit related to: self care impairment, dementia ...Interventions: bed mobility assistance of (as requested by resident), call bell within reach ...independent with transfers. Grip strips to floor ...toileting assist of 1 as needed. Also toilets independently. At risk for falls related to: subdural hematoma ...Interventions: Assess that wheelchair is of appropriate size, assess need for footrests, assesses for need to have wheelchair locked/unlocked for safety, anti-tippers ...Tab monitor at all times in w/c to alert staff of unassisted transfer attempts, 2/23/14 ..." "Progress Notes" state the following: "2/21/14: ...Resident is unable to make her needs known, staff anticipates needs. Sutures to right side of head are clean and intact ...Assist of 2 with Hoyer. Uses w/c for locomotion, staff propels. Resident is very confused as to where she was this morning. She is unable to answer questions ..." "2/23/14: 13:30 (1:30 PM); Situation: Resident found lying face down on the floor in the activity room with her wheelchair behind her. Background: Status: DNR (do not resuscitate). Resident has been a resident in this facility since (2006). Resident was recently admitted to the hospital on [DATE] d/t (due to) subdural hematoma where resident underwent [REDACTED]. Wheelchair behind her ...resident alert stating that her head on the left side hurts. Resident unable to recall what happened. Sutures to right scalp intact with no bleeding noted. All extremities palpated with no facial grimacing noted or complaints of pain. ROM (range of motion) WNL (within normal limits). No c/o blurred vision. Skin check reveals a small red area above the left eye ...MD updated. No new orders received ...20:31 (8:31 PM) ...c/o LUE (left upper extremity) pain. PRM (SIC) (as needed) pain medications given. Effective." "2/26/14: Situation: Resident has c/o left shoulder pain ...Resident has general discomfort, but today she started grasping her left shoulder and facial grimacing. Her left arm is flaccid d/t subdural hematoma. She does have periods of confusion, as able to answer questions and recognize pain. MD updated ...13:55 (1:55 PM) MobiX here and took xray of left shoulder. Waiting results ...14:00 (2:00 PM) resident had x-ray for L (left) shoulder r/t c/o pain to L arm. Results of mobilx found gleunohumeral joint is in alignment, but there is a narrowing of joint space due to mild degenerative changes. Fracture to the distal clavicle with minimal displacement is noted ..." The facility failed to accurately assess Resident 7's fall risk and review and revise Resident 7's plan of care after her return from the hospital. Resident 7 fell and sustained a clavicle fracture. Surveyor spoke with Licensed Practical Nurse (LPN) I on 3/13/14 at 1:08 PM. Surveyor asked LPN I about her assessment of Resident 7 on 1/28/14. LPN I stated that she did not see (Resident 7) get lowered to the floor as a CNA was ambulating the resident. LPN I stated that this CNA did not work at the facility any longer. LPN I stated that (Resident 7) was seated on the floor, comfortably and that she checked her range of motion, vital signs and made sure there was not fracture. Surveyor asked LPN I if she ever asked if Resident 7 hit her head. LPN I stated that she did ask this, she always does and that she probably did not document it. LPN I stated that (Resident 7) did not hit her head. Surveyor spoke with Director of Nursing (DON) B on 3/13/14 at 12:10 PM. DON B stated that when (Resident 7) was lowered to the ground on 1/28/14, she would expect that the assessing nurse ask either the resident or CNA (Certified Nursing Assistant) if the resident hit their head. Surveyor asked what was done after Resident 7 was lowered to the floor on 1/28/14. DON B stated that she thought a PT screen was done. DON B stated that PT should have been into see (Resident 7) on that day, on 1/28/14 to assess her. Surveyor asked DON B about Resident 7's subdural hematoma and its origin. DON B stated that she tried to figure this out and that (Resident 7) had not had any injuries or changes leading up to the symptoms of the foot drag and weakness. DON B stated that she did not document this work. Surveyor asked DON B about Resident 7's fall after her return from the hospital. DON B stated that (Resident 7) was seeing PT and OT (occupational therapy) after her hospitalization and (Resident 7) was not moving well and required a Hoyer for transfers. Surveyor asked if the Hoyer should be listed on Resident 7's care plan. DON B stated that it should be on the care plan. DON B stated that (Resident 7) fell in the activity room on 2/23/14 while doing a word puzzle. DON B stated that she was alone and a nurse walked by and saw (Resident 7) on the floor. DON B stated that (Resident 7's) fall risk assessment should be completed and each section should be coded. Example 3 Resident 1's was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident 1 has an Activated Health Care Power of Attorney. Review of Resident 1's hospital discharge summary dated 1/30/14 notes that Resident 1 has wandering behaviors and was aggressive at home. Resident 1's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/7/14 includes the following: Section C Cognitive Patterns, C0500 Summary Score: 5, indicating Resident 1 is cognitively impaired. Section E Behavior, indicates Resident 1 is rejective to cares, and wandering occurs daily which includes Resident 1 being intrusive on the privacy of others. Resident 1's Care Plan titled "At Risk for Elopement related to History of Wandering" dated 1/31/14, includes the following interventions: Assess for risk of elopement, encourage family to bring personal possessions, introduce patient to other patients in the living center, involve patient in preferred activities, redirect patient from doors, on 2/3/14 the following intervention was added: Sensor alarm to alert staff if up at noc (Night). In addition, on an unknown date the following was added, Name on sign of door to assist with orientation. The following entries were found in Resident 2's Nurse's Notes: 1/31/14, 14:55 ... "Resident alert and oriented to self. Resident's cognitive skills needs assist with decision making. Resident is able to understand what is being said to him but is unable to repeat a statement that was requested. No s/s(signs/symptoms) of depressed behavior at this time. Res (Resident) does have a history of wandering and verbally abusive per wife of behavior at home." 2/17/14, 14:57... "Res found in another male res room. Res had no clothes on and had BM (bowel movement) in Res bathroom. When I approached res he began to kick and state, "I'll kill you, just leave me alone." Much encouragement to get res in his own room. When cleaning up res began to swing his fist at the staff. Much 1:1 (one on one) given and res re-approached with effectiveness. Res urinated in another res rm (room) trash can. Res assisted q1hr (every hour) to promote bathroom assistance." Please note this q hour bathroom assistance was never put on Resident 1's care plan. 2/18/14, 02:32..... "Was in a residents room. When staff attempted to redirect him he began to push and state, "I'll kill you." Staff was able to get him out of room, and have him go down hallway. Presently wandering around unit." 2/18/18, 10:48..."Resident pacing the halls freq (frequently) t/o (throughout) the building. Much 1:1 given. Res encouraged to use the bathroom every hr (hour). Res refuses freg to have assist. Res attempted to go outside x2(2 times) so far today. Wanderguard in place. Alarms on doors functioning properly. CNA(Certified nursing assistant) reported res urinated in the wt (weight) Room on the floor at 10:30 am. When staff approached res, Res would become resistant and become agitated and swing his fists. PCP (Primary Care Physician) is here at this time and is aware of Res' behaviors." 2/19/14, 12:09..... "Resident attempting to go out the door. Door alarming. This writer attempted to escort resident back into the facility. Resident resistive. 1:1 and re-direction ineffective. Resident held balled up hand up to this writer. This writer assisted by a second staff member to assist resident into facility. Effective." 2/20/14, 04:56......"Up and in hall x2 (two times). Redirected back into room. Cooperative with staff. Was trying to take the motion alarm off of the wall, redirected away from alarm." 2/20/14, 14:04..... "At 0830 CNA went into Residents room to assist him with dressing and toileting. Resident refused. Staff nurse assisted for 30 minutes to try to help wash resident up, he had bowel on him and was resisting help. He would clench his fist and shake it making inappropriate statements. Resident had exit seeking behaviors 8 times this shift. Continued to wander the halls. At times would stop and talk to residents. He voiced concern as if he knew them. He is very confused." 2/20/14, 21:16... "Continues with exit seeking behaviors. Continues to wander in and out of other residents rooms. Remained very difficult to redirect." 2/21/14, 13:52...."Res restless, agitated, striking out and noncompliant. Much 1:1 given today." 2/22/14, 02:55......"Earlier in the shift went into the activity room and urinated twice on the floor and leg of the table. Attempted to exit front of building was redirected by CNA(Certified Nursing Assistant). 2/22/14, 13:21....."Res (resident) after assisted to bathroom urinated on floor in his rm (room). Upon cleaning up res, res becomes agitated and strikes out at staff. Res continues to go in other Res's rooms with much assistance and 1:1 to redirect." 2/22/14, 16:00...... "Family member of another resident (Resident 2) phoned this writer in regards to behaviors exhibited by Resident 1. Resident has history of wandering throughout facility and into other residents rooms. Also has been noted to take things from rooms and becomes aggressive with staff members. Family member of (Resident 2) called this writer and reported that (Resident 1) had entered (Resident 2's) room multiple times during visit. This caused (Resident 2) to become upset. The family member then reported that the family member redirected (Resident 1) out of (Resident 2's) room and (Resident 1) stated to another resident, "She's gonna get it one of these days." RN (Registered Nurse) ED (Executive Director) updated. On call MD (Medical Doctor) updated, new orders received, family updated." 2/22/14, 22:50..... "Res had threatening and aggressive behavior. Writer called SWBC (South West Behavioral Center) for availability of male bed. Bed available, MD updated and request for eval and labs approved. RCH ER (Richland Center Hospital emergency room ) notified. Res sent to RCH for labs and eval." 2/22/14, 23:00...... "writer updated by RCH. Res has UTI, Low Sodium and Hyperglycemic. Res started on ATB (Antibiotic) and will be admitted to SWBC. GLC (Golden Living Center) staff social worker going to RHC to be with transport to SWBC." On 3/10/14 at 9:55 AM, Surveyor interviewed Resident 2 regarding the situation with Resident 1. Surveyor asked Resident 2 if Resident 2 ever felt fearful or threatened by any other residents, Resident 2 stated, "Oh heavens no, no-one has ever done that. There was a man a few weeks ago that would come and stand there and look at me but that never bothered me, never made me feel afraid. They put the stop signs on the doors so folks wouldn't wander in, but we don't put it up anymore, no reason to no one bothers us." On 3/10/14 at 1:30 PM, Surveyor interviewed DON (Director of Nursing) B and SW (Social Worker) C regarding Resident 1's wandering behaviors and incident that transpired on 2/22/14. DON B stated, "Resident 1 was a wanderer and most of the time easily redirected. Towards the end before sending him out he was harder to redirect and was having some abdominal pain which the doctor was treating." SW C stated, "When the incident was called we called DON B who called NHA A, and we updated the doctor and got the order to transfer Resident 1 to Richland Hospital for the completion of the labs needed f