Every finding on record at Rock Haven

Based on observation and interview, the facility did not prepare and distribute food in accordance with professional standards for food service safety. This has the potential to affect all 91 residents. Surveyor observed a cook take the temperatures of food without properly cleaning the food thermometer probe. Evidenced by: Facility policy, entitled Food Temping, dated 10/8/25, states, in part: Purpose: To provide every resident adequate nutrition in a safe environment. Store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Policy: Rock Haven will provide residents with meals that are safe. following infection prevention measures. Procedure: Service: . 9. [NAME] food to proper temperature. 10. Use a clean thermometer. On 1/26/26 at 12:16 PM, Surveyor observed [NAME] D taking the temperatures of the food in the steam table prior to lunch being served in the dining room. Surveyor observed [NAME] D cleaning the food thermometer probe off with a napkin prior to inserting the thermometer probe into the various foods. Surveyor interviewed [NAME] D about her food temping process. [NAME] D stated that she cleans the food thermometer probe after she is done temping all the food and in between foods if the food could be an allergen like seafood. On 1/28/26 at 10:50 AM, Surveyor interviewed FSM E (Food Service Manager). Surveyor shared with FSM E the observations of food temping in the dining room before meal service. FSM E indicated that she would expect that the cooks would clean the food thermometer probe properly between each food by using a cleaning wipe and allowing it to dry for 10 seconds before inserting the food thermometer probe into the next food item.

Based on interview and record review the facility did not establish an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 4 of 4 supplemental residents (R79, R43, R17, and R27). R79, R43, R17, and R27 were treated with antibiotics without meeting Loeb Criteria. R79, R43, R17, and R27 did not have an antibiotic stewardship conversation with the Provider. This is evidenced by: The Facilities Antibiotic Stewardship Policy and Procedure dated 10/20/25 documents in part: .Antibiotic stewardship will include an assessment process, use of evidence-based criteria, efforts to identify the microbe responsible for disease, selecting the appropriate antibiotic along with documentation indicating the rationale for use, appropriate dosing, route, and duration of antibiotic therapy; and to ensure discontinuation of antibiotics when they are no longer needed. Example 1 R79 is on the line list for UTI (urinary tract infection), listed symptoms are cloudy urine with sediment and mucus, and foul odor. Per Loeb criteria for UTI with indwelling catheter: .One of the following: acute dysuria OR fever (temp >37.9 C/100 F or 1.5 C/2.4 F above baseline); PLUS one or more of the following: fever (temp >37.9 C/100 F or 1.5 C/2.4 F above baseline), rigors, new onset delirium OR new costovertebral angle tenderness . On 1/29/26 at 1:00 PM, Surveyor interviewed ADON/IP K (Assistant Director of Nursing/Infection Preventionist). Surveyor asked ADON/IP K if this met Loeb criteria for R79, ADON/IP K stated no. Surveyor asked ADON/IP K if R79's Provider was contacted regarding this to discontinue the antibiotic or give rationale for why to continue, ADON/IP K said no. Example 2 R43 is on the line list for UTI (urinary tract infection), there are no symptoms listed. Per Loeb criteria for UTI without indwelling urinary catheter: .One of the following: acute dysuria OR fever (temp >37.9 C/100 F or 1.5 C/2.4 F above baseline); PLUS one or more of the following: urinary urgency, suprapubic pain, urinary incontinence, urinary frequency, gross hematuria, and costovertebral angle tenderness. On 1/29/26 at 1:00 PM, Surveyor interviewed ADON/IP K (Assistant Director of Nursing/Infection Preventionist). Surveyor asked ADON/IP K if this met Loeb criteria for R43, ADON/IP K stated no. Surveyor asked ADON/IP K if R43's Provider was contacted regarding this to discontinue the antibiotic or give rationale for why to continue, ADON/IP K said no. Example 3 R17 is on the line list for respiratory, listed symptom worsening cough. Per Loeb criteria for LRTI (lower respiratory tract infection): With temp >38.9 C (>102 F) and one or more of the following: productive cough or Respiratory rate >25 breaths per minute; With temp >37.9 C (>100 F) or 1.5 C ( 2.4 F) above baseline and both of the following: cough AND One or more of the following: pulse rate >100 beats per minute, respiratory rate >25 breaths per minute, rigors, or new onset delirium; Afebrile with COPD (chronic obstructive pulmonary disease- progressive, treatable, yet incurable lung disease characterized by chronic inflammation, leading to limited airflow and breathing difficulties) and >[AGE] years old, Both of the following: new or increased cough AND purulent sputum production; Afebrile without COPD, All of the following: new onset cough AND purulent sputum production AND one or more of the following: respiratory rate >25 breaths per minute or new onset delirium. On 1/29/26 at 1:00 PM, Surveyor interviewed ADON/IP K (Assistant Director of Nursing/Infection Preventionist). Surveyor asked ADON/IP K if this met Loeb criteria for R17, ADON/IP K stated no. Surveyor asked ADON/IP K if R17's Provider was contacted regarding this to discontinue the antibiotic or give rationale for why to continue, ADON/IP K said not at the time but now I'm told these (R17 was prescribed two antibiotics) were ordered for inflammation. Example 4 R27 is on the line list for UTI (urinary tract infection), listed symptoms are urine odor and nausea. Per Loeb criteria for UTI without indwelling urinary catheter: .One of the following: acute dysuria OR fever (temp >37.9 C/100 F or 1.5 C/2.4 F above baseline); PLUS one or more of the following: urinary urgency, suprapubic pain, urinary incontinence, urinary frequency, gross hematuria, and costovertebral angle tenderness. On 1/29/26 at 1:00 PM, Surveyor interviewed ADON/IP K (Assistant Director of Nursing/Infection Preventionist). Surveyor asked ADON/IP K if this met Loeb criteria for R27, ADON/IP K stated no. Surveyor asked ADON/IP K if R27's Provider was contacted regarding this to discontinue the antibiotic or give rationale for why to continue, ADON/IP K said no. On 1/29/26 at 3:39 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B would you expect residents that are treated with an antibiotic that they have signs and symptoms to support the antibiotic use, DON B stated yes. Surveyor asked DON B if they do not have the signs and symptoms to support the antibiotic, is it your expectation that the staff have a conversation with the Provider for rationale to continue the antibiotic, DON B explained they would review documentation first and then if there isn't any to support the continuation, then a discussion with the Provider would be the next step.

Based on observation, interview, and record review, the facility did not ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 4 Sampled residents (R47) reviewed for trauma informed care. R47 did not have a Trauma Informed Care Assessment completed upon admission. Psychiatric notes written while admitted to the facility indicate R47 has a history of nightmares related to combat he experienced in Vietnam. R47's trauma was not identified, and no care plan approaches to mitigate triggers to prevent re-traumatization were put into place. This is evidenced by: The facility policy entitled, Trauma Informed Care, dated [DATE], states in part: . A Trauma Informed Care Information sheet will be provided in each new admission booklet. Social [NAME] will briefly review during admission and invite questions and conversation. Any information received from the resident/HCPOA (Healthcare Power of Attorney)/Guardian will be entered in the Social History/Trauma Informed Care folder by the Social Worker. The Social Worker will add any identified approaches to the care plan under the Trauma Informed Alert heading which is found in the Mental Wellbeing care plan. The approaches listed under the Trauma Informed Alert will also pull to the CNA Kardex (Care Summary). The Social Worker will email the Trauma Informed Care team and approaches. If specialized psychiatric rehabilitative services (SPRS) are required per the PASRR screen recommendations, this is to be included in the resident's comprehensive plan of care. The facility policy entitled, Comprehensive Person-Centered Care Planning, dated [DATE], states, in part: . A comprehensive care plan will be developed and implemented based on a comprehensive person-centered care plan for each resident, consistent with resident's rights that includes. Trauma informed-care interventions. The comprehensive care plan must describe the following. b) Interventions to ensure culturally competent care and trauma-informed care interventions as applicable. R47 was admitted to the facility on [DATE] with diagnose including Parkinson's disease (neurological disorder causing slow movement, tremors, balance problems, and cognitive impairment) with dyskinesia (uncontrollable and involuntary movements), secondary parkinsonism due to other external agents, contact with and (suspected) exposure to other hazardous substances - agent orange, dementia without behavioral disturbance, generalized anxiety disorder, and chronic post-traumatic stress disorder. R47's most recent Minimum Data Set with Assessment Reference Date of [DATE], indicates R47 has a Brief Interview for Mental Status score of 13 out of 15, indicating he is cognitively intact. Section I indicates R47 is diagnosed with anxiety disorder and post-traumatic stress disorder. R47's Physician Orders indicate:Mirtazapine (antidepressant) 15 MG (milligram) tablet by mouth at bedtime for Mood Changes. An initial evaluation conducted by a mental health provider on [DATE] indicates R47 has a military history of being a Vietnam veteran with agent orange exposure. A mental health provider visit note from [DATE] indicates R47 has historically experienced nightmares related to his military service. A mental health provider visit note from [DATE] indicates previously staff have reported R47 having increased nightmares related to his time in the military. On [DATE] at 3:39 PM, Surveyor observed the Plan of Care Summary posted on R47's bathroom door. This document did not include information related to R47's history of trauma, identified triggers, and interventions to prevent possible triggers. R47's Comprehensive Care Plan has a Need/Preference, dated [DATE], that states, I EXPERIENCED: Minor car accidents over the years. I had a couple surgeries. I had my esophagus operated on twice as well. I also was shot at while serving in the military in the Vietnam War. The Approach section for this Need/Preference, also dated [DATE], states I need the SW to --- Talk to me and let me know what is going on.(Of note: No further history of trauma, triggers, or interventions were added to R47's care plan related to his military service.) A document titled, Life Events Checklist (LEC) was provided to Surveyor as the tool that is used to assess for trauma in newly admitted residents. This checklist lists several stressful events that may happen to people. Choices to respond to the assessment are: things that happened to you personally, you witnessed it happen to someone else, you learned about it happening to someone close to you, you're not sure if it fits, or it doesn't apply to you. The instructions note to consider your entire life as you go through the list of events. On [DATE] at 2:21 PM, a note was written by SW (Social Worker) O. This note indicates a trauma assessment was conducted on [DATE] with findings of fire or explosion, combat or exposure to a war-zone, life-threatening illness or injury, severe human suffering, sudden, unexpected death of someone close to you, and other stressful event or experience are all indicated to have happened to R47. The finding of a sudden, violent death is indicated that R47 learned about an overdose.(Of note: R47's severe human suffering finding is in relation to the recent loss of his wife. This is the only part of the assessment included on R47's comprehensive care plan). On [DATE] at 3:34 PM, Surveyor interviewed CNA (Certified Nursing Assistant) P. Surveyor asked CNA P how long she has worked at the facility. CNA P indicates, 3 years and she works all over the facility. Surveyor asked CNA P how she knows which residents have a history of trauma. CNA P indicates staff can always ask a nurse, it should be in the care plan, and that she usually checks the resident's chart. Surveyor asked CNA P how she knows which residents have triggers or interventions in place to prevent any triggers related to trauma. CNA P indicates, it is more on the nurses stuff for interventions, but they should be listed on the CNA Kardex (Plan of Care Summary) in the bathroom. On [DATE] at 3:47 PM, Surveyor interviewed CNA Q. Surveyor asked CNA Q how long she has worked at the facility. CNA Q indicated 13 years, and she mostly works on R47's section. Surveyor asked CNA Q how she knows which residents have a history of trauma. CNA Q indicates it is on the residents' charts. Surveyor asked CNA Q how she knows which residents have interventions in place to avoid any triggers related to trauma. CNA Q indicates the interventions and triggers are listed on the residents' Kardex (Plan of Care Summary). Surveyor asked CNA Q if she was aware if R47 has a history of trauma. CNA Q indicates he has a lot of history of trauma, especially with his wife passing. Surveyor asked CNA Q if she was aware if R47 had any triggers or interventions for his trauma. CNA Q indicates R47 likes his door shut and he gets up early for church. On [DATE] at 3:54 PM, Surveyor interviewed RN (Registered Nurse) R. Surveyor asked RN R how she knows which residents have a history of trauma. RN R indicates the Social Worker will evaluate the resident and then develop a care plan around it. RN R also indicates if changes are made to the care plan, the changes are highlighted in a book at the nurses station. Surveyor asked RN R how she knows which residents have interventions for triggers related to their trauma RN R indicates, the resident's care plan. Surveyor asked RN R if R47 has a history of trauma. RN R indicates she knows R47 recently lost his wife, and they were together for a long time. Surveyor asked RN R if R47 has any triggers or interventions related to his trauma. RN R indicates she gets along good with R47, and he would tell RN R if something was bothering him. Surveyor asked RN R if she was aware R47 was a veteran who experienced combat. RN R indicates she is aware he was in the service, but he talks very proudly about his service. On [DATE] at 9:44 AM, Surveyor interviewed SW (Social Worker) N. Surveyor asked SW N what the process is for performing trauma assessments. SW N indicates she meets with and interviews the resident, interviews family, reviews the resident's History and Physical, meets with the nurses, and uses the assessment tool if needed. Surveyor asked SW N if she uses the assessment tool for all admitted residents. SW N indicates, no, it is on a per resident basis. Surveyor asked SW N if the trauma assessments indicate possible triggers for the residents. SW N indicates she uses the tool to identify possible triggers along with the comprehensive admission assessment. Surveyor asked SW N how this information is disseminated to staff. SW N indicates she communicates with staff verbally, by email, and speaks with the charge nurse and the Director of Nursing. Surveyor asked SW N how she arranges for needed mental and psychological counseling services. SW N indicates she asks every resident if they want to see a mental health provider. SW N acknowledges that a resident asking for counseling can be traumatic in and of itself, so she makes sure to offer the service to all residents. Surveyor asked SW N what triggered the need for R47's psychological assessment in [DATE]. SW N indicates she was not employed at the facility at that time, and that she started around [DATE]. Surveyor asked SW N if R47 has a PTSD care plan. SW N reviewed R47's care plan and indicated she does not see one. Surveyor asked if R47 should have a PTSD care plan, especially related to his military services. SW N indicated yes. Surveyor asked SW N if she was employed at the facility at the time of R47's admission, how would she assess R47 related to his trauma. SW N indicates R47 should have a full trauma assessment related to his military service and it should be on his care plan. On [DATE] at 1:05 PM, Surveyor interviewed SW (Social Worker) O. Surveyor asked SW O if she knew R47. SW O indicates she knows him, but he is assigned to a different social worker. Surveyor asked SW O if she was aware if he had any history of trauma. SW O indicates she thinks he does from when his father died, SW O is also aware he was in the army and that his wife passing was very hard on him. Surveyor asked SW O if R47 should have had a trauma assessment completed on admission. SW O indicates, yes. Surveyor asked SW O who is responsible for reviewing psychiatric notes. SW O indicates social work and nursing reviews psychiatric notes, but she does not believe R47 is seeing a psychiatric provider. Surveyor asked SW O to review R47's electronic health record to see if R47 ever had a trauma assessment completed. On [DATE] at 1:30 PM, SW O returned to Surveyor and reported R47 did not have a previous trauma assessment on file. SW O also indicated she just went to complete a trauma assessment using the Life Events Checklist (LEC) tool which indicated the findings listed previously. On [DATE] at 3:54 PM, Surveyor interviewed DON (Director of Nursing) B. Surveyor asked DON B what assessments are included in the admission process for social services. DON B indicates BIMS, PHQ-9 (depression screening), social determinants, trauma assessment, mini mental exam, SLUMS (cognitive assessment), and discharge planning disposition. DON B also notes that social services are responsible for the trauma-informed care plan. Surveyor asked DON B if all residents who are admitted to the facility receive depression and trauma assessment. DON B indicates, yes. Surveyor asked DON B how the results of these assessments are disseminated to staff. DON B indicates positive findings on assessments are communicated to staff through the care plan, everyday communication with social services and nursing, and through IDT (Interdisciplinary Team) meetings. Surveyor asked DON B if these positive findings should be added to the care plan. DON B indicates, yes. Surveyor asked DON B if she was aware R47 has a history of PTSD along with nightmares associated with his military service. DON B indicates it is social services responsibility to review psychiatric notes and behaviors. Surveyor asked DON B if R47 has a care plan related to his PTSD and military service-related nightmares. DON B indicates, yes.

Based on observation, interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 22 sampled residents (R53). R53 has a diagnosis of Congestive Heart Failure and the facility failed to recognize R53's severe weight gain as a significant change in condition, and the PCP was not notified. Staff failed to re-weigh, conduct assessments, and put appropriate interventions into place regarding R53's weight gain and increased edema. This is evidenced by: Facility policy titled, Weight Management, dated 6/10/15, states, in part, Procedure: . Residents will be weighed monthly unless otherwise ordered by the Physician or deemed necessary by the Interdisciplinary Team. Re-Weights will be obtained as soon as possible for any resident with a +/- five (5) lb. change from the previous weight. This weight should be documented in the residents record as a re-weight. Nursing staff will notify the physician and responsible parties of any significant unexpected and/or unplanned weight changes. The notification will be documented in the resident's chart. Each resident's weight will be monitored regularly by the Interdisciplinary Team. All resident with patterned or significant weight changes will be assessed by the team as indicated. Interventions to address medical or nutritional issues that might contribute to weight change will be initiated and incorporated into the plan of care and re-evaluated on a timely and periodic basis. R53 was admitted to the facility on [DATE] with diagnoses that include, in part: Atherosclerotic heart disease of native coronary artery without angina pectoris, Hypertensive heart disease with heart failure, Lymphedema, and Heart failure, unspecified. R53's most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 1/21/26 indicates that R53 has a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating that R53 is cognitively intact. Section GG of R53's MDS states R53 needs partial/moderate assist with lower body dressing and putting on footwear. R53s Comprehensive Care Plan, states, in part:Need/Preference: I have unintended weight gain. Because I have a history of CAD (Coronary Artery Disease)/ASHD (Atherosclerotic Heart Disease), CHF (Congestive Heart Failure), DVT (Deep Vein Thrombosis). I take Lasix as diuretic. My Mini Nutritional Assessment score is 11, indicating that I am at risk for malnutrition.Approach: I need my nurses to keep an eye on how much I drink and eat, monitor my serum protein level, check me for signs of dehydration, such as dry gums and poor skin turgor. I need my aides to record how much I drink and eat, weigh me every week, setup my meal so I can eat, remind me and encourage me, offer something else if I don't like the meal, offer me a snack.Start Date: 1/22/26. No revision date. R53's Physician Orders state, in part: --Furosemide 40 mg tablet. Dose: (1 tablet/40 mg) by mouth daily AM for edema. Start Date: 10/17/25. No end date.--Treatment: Weights/Heights/Vitals: Measure weight one time per month 1st Thursday PM. Start Date: 10/17/25. No end date. Of note, R53's care plan indicates R53 is to be weighed weekly, however R53's physician orders indicate monthly weights, despite R53's complex cardiac history. R53's recent weights were documented as follows:10/23/25: 268 lbs. (pounds)10/30/25: 268.3 lbs.11/6/25: 266.2 lbs.12/2/25: 265.6 lbs. 1/1/26: 290 lbs. (Note: this is almost a 25-pound weight gain in one month, which is a 9.1% severe unintended weight gain). Of note: Despite R53 having a nearly 25-pound weight gain in one month, there is no indication that R53's weight was rechecked for accuracy, no nurse assessment was completed, the physician was not notified, nor was R53's care plan updated with any new interventions. R53's unintentional weight gain could be a symptom of worsening edema due to his history of congestive heart failure. On 1/28/26 at 9:25 AM, Surveyor interviewed R53 in his room and observed R53 sitting in his wheelchair with his legs dependent and appearing edematous (swollen). Surveyor observed R53 wearing Velcro tennis shoes without socks, and the Velcro straps were not all the way closed on the tennis shoes. Surveyor asked R53 about his swollen legs. R53 stated that more recently his legs have been hurting upon standing, and that he is unable to wear socks due to his shoes being too tight. On 1/28/26 at 9:30 AM, Surveyor interviewed LPN H (Licensed Practical Nurse) about the facility's weight management process. LPN H indicated the MAR (Medication Administration Record) lets them know who needs to be weighed each day, and that the CNAs are the ones who get the weights and then let the nurses know so they can be entered into the computer. LPN H indicated that if there was a discrepancy in the weight, such as 2 pounds or more, the resident should be re-weighed. LPN H stated that if a resident has a physician's order to notify the doctor if there is a 3-pound weight change, then the nurses let NM G (Nurse Manager) know, and she will notify the doctor to see if they have any new orders or recommendations. LPN H indicated that she will call the doctor personally right away if there is a 5-pound or greater weight loss or weight gain. LPN H stated that residents with CHF (Congestive Heart Failure) should have doctor's orders for daily weights and for notification if there is a daily or weekly weight change within certain parameters. LPN H stated that NM G asked her to re-weight R53 this morning before breakfast, because his monthly weight was 290 pounds and it had been 266 pounds the month prior. Surveyor asked LPN H if R53 should have been re-weighed three weeks ago at the time of his severe unintended weight gain. LPN H replied that is typically how it is done. LPN H stated that she was not sure what happened with R53, but that he should have been re-weighed and the doctor notified of the weight change. On 1/28/26 at 9:39 AM, Surveyor interviewed CNA I (Certified Nursing Assistant), who stated that when they get a resident's weight, the wheelchair weight is already pre-weighed and then they subtract the wheelchair weight from the total scale weight and give it to the nurse as the resident's weight. CNA I stated that typically it is the nurses who will compare that weight to the previous month's weight. On 1/28/26 at 9:52 AM, Surveyor interviewed CNA J about R53's weight gain. CNA J stated that she doesn't always work on R53's unit, but that she did notice that R53's legs and feet were significantly more swollen than they normally were the last time I worked over here a month ago. CNA J indicated that she noticed that the Velcro straps on R53's tennis shoes couldn't be all the way fastened this morning, and that she had let the nurse know so that they could find out what was going on. On 1/28/26 at 11:04 AM, Surveyor interviewed NM G (Nurse Manager) about R53's severe unintentional weight gain and the facility's weight management process. NM G stated that normally significant weight changes are caught by RD F (Registered Dietician) and she would add the resident to the NAR (Nutrition at Risk) list and they would be discussed at the NAR meetings and do a follow-up. NM G indicated that if a resident had an off weight, NM G would ask the staff to do a re-weigh. NM G stated that the EHR (Electronic Health Record) system that the facility uses will flag if there is a significant weight decrease or gain. NM G stated that the PCP (Primary Care Provider is called as soon as there is a significant weight loss or gain of 5% or more, and it is usually the floor nurses' responsibility to notify the PCP. Surveyor asked NM G if they had a CHF protocol. NM G stated that they don't have a standing order for re-weights or notifying the PCP because usually the residents who need that would have a notification order or weight parameters on their discharge paperwork when they are admitted to the facility. Surveyor asked NM G about R53's recent unintentional weight gain. NM G stated that she had staff re-weigh him today and his weight was back to normal. Surveyor asked NM G if R53 should have been re-weighed immediately after an almost 25-pound weight gain was indicated. NM G stated that generally if a resident had a weight that is off like that significantly then they do a re-weigh right away. NM G indicated that significant weight changes are usually caught by RD F, who keeps track of the monthly weights. NM G stated that yes, R53 should have been re-weighed sooner than today. Surveyor asked if any interventions had been put into place to monitor or mitigate R53's edema in his feet and legs. NM G stated that she would have to look on R53's care plan to see what the interventions were. Of note: R53 was re-weighed on 1/28/26 with a weight of 266 pounds. However, R53 was not re-weighed until Surveyor started asking questions and asking for documentation regarding his severe unintended weight gain. On 1/28/26 at 11:17 AM, Surveyor interviewed RD F (Registered Dietician) about R53's severe unintended weight gain. RD F stated that she keeps a list of all the residents' weights by the week and reviews them on a weekly basis. RD F stated that if she notices there is a weight change, she will ask for a re-weigh and also look to see if the resident had any other changes like medication or meal intake changes. RD F stated that she will then notify the nursing supervisors and put the resident on the NAR list for 4 weeks of monitoring. RD F indicated that if the resident was not already on weekly weights, they would be put on weekly weights for the time they were on the NAR list. Surveyor asked RD F if R53 should have been re-weighed after his severe unintended weight gain of nearly 25 pounds. RD F stated that she did send out a notice to get a re-weigh on him and she never got a re-weigh from nursing. RD F stated that she sent an email to the nursing staff on the 14th initially and then reminded them again on the 20th asking for a re-weigh. Surveyor asked RD F if she would expect that the staff would re-weigh a resident with a 25-pound weight change in one month. RD F stated yes, she would have expected the staff to get a re-weigh on R53. RD F stated she thought that R53's weight gain was discussed at the NAR meeting but he wasn't added to the NAR list because she was waiting for a re-weight to see what was going on with him. RD F provided Surveyor with a copy of the email she sent to the nursing staff. On 1/14/26 at 1:53 PM, RD F (Registered Dietician) sent an email to the nurse managers asking that R53 be re-weighed. On 1/20/26, RD F sent another email to the nurse managers reminding them that R53 still needed to be re-weighed. On 1/28/26 at 11:24 AM, Surveyor interviewed NM G who verified that R53 did not have any weight parameters and no new nursing interventions were added to his care plan to monitor R53's weight or edema. On 1/28/26 at 1:36 PM, Surveyor interviewed DON B (Director of Nursing) about R53's severe unintentional weight gain. DON B stated that she would have expected staff to re-weigh R53 right away when there was a nearly 25-pound weight gain in one month. DON B indicated that R53 did not have a special physician's order for weights, so they just used the facility policy and procedure of monthly weights for him. DON B stated that she would follow-up with the clinical team right away to see about getting R53 on a program to reduce his edema. On 1/29/26 at 8:32, Surveyor again observed R53 in his room with his legs dependent, no socks on and tennis shoes without the Velcro straps completely closed On 1/29/26 at 3:38 PM, Surveyor interviewed DON B and asked if the facility had a CHF protocol. DON B stated that the facility did not have a CHF protocol. Surveyor asked DON B who was responsible for following up on significant weight changes. DON B stated that it was the nurse manager's responsibility to make sure that the nurses are following through on the re-weights that the dietician requests. Surveyor asked DON B what interventions had been put in place to manage R53's edema in his legs and feet. DON B indicated that R53 was not out of his baseline or showing increased symptoms so no new interventions had been put into place. Despite R53's severe unintentional weight gain, the facility failed to obtain reweights to ensure accuracy, failed to assess his edema, failed to evaluate his care plan and implement interventions to prevent further weight gain and edema. The facility failed to recognize R53's severe weight gain as a significant change in condition, and the PCP was not notified.

Based on interview and record review, the facility did not ensure to develop and implement written policies and procedures that: S483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 8 staff reviewed for background checks.MT C (Maintenance Tech) did not have a background check completed every 4 years.This is evidenced by:The facilities Policy and Procedure for Background Checks states in part. Wisconsin law requires caregiver background checks using a Background Disclosure Form mandating completion at hire and every four years. MT C (Maintenance Tech) hire date was 12/14/20. His last completed background check was completed on 1/28/26. MT C should have had a background check completed by 12/14/24.On 1/28/26 at 4:45 PM surveyor interviewed NHA A (Nursing Home Administrator) and asked if background checks are supposed to be completed every 4 years. NHA A replied yes.On 1/29/27 at 8:26 AM surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A if background check information be accessible? NHA A replied yes, the regulation states that all the information should be in the nursing home because we are responsible. NHA A reported that she has been trying to get access to background checks for 5 years, but since this is a county building, they keep records in HR (Human Resources) which is in a totally different building downtown.

Based on interview, record review, facility document and policy review, the facility failed to reassess the risk of elopement and identify interventions to prevent a resident from exiting the facility through the bedroom window for 1 (Resident #1) of 5 residents reviewed for accidents. Resident #1 was observed by staff packing their belongings in a bag and saying they were leaving the facility but was not reassessed for the risk of elopement. Resident #1 exited the facility on 07/03/2025 at 12:05 AM, unnoticed and unsupervised by staff, and was found after approximately ten minutes in the bushes outside the resident's bedroom window. Findings included: The facility policy titled, Elopements, revised 07/09/2025, indicated, III. Definitions: Elopement behavior: Making verbalizations about wanting to leave, talking about going home, packing belongings, opening windows, and opening doors. IV. Elopement: When a resident who is cognitively, physically, mentally, emotionally, and/or chemically impaired wanders away, walks away, runs away, escapes, or otherwise leaves a caregiving facility unsupervised, unnoticed, and/before to [sic] their scheduled discharge. The section of the policy titled, Procedure: specified, 2. Staff should promptly assess elopement behavior for initiation of Code Alert [departure alert system], window alarms, or other care planning interventions to prevent elopement. A Face Sheet, printed on 07/10/2025, revealed the facility admitted the Resident #1 on 01/17/2025. According to the Face Sheet, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease (COPD). The Face Sheet indicated the resident was receiving hospice services and was not at risk of elopement. An Elopement Risk Assessment, dated 02/14/2025, indicated Resident #1 ambulated with an assistive device, was alert, had no cognitive impairment, and no history of elopement. The Elopement Risk Assessment revealed the resident scored a 4, which indicated the resident was not at risk of elopement. The medical record revealed no documented evidence of subsequent Elopement Risk Assessments until 07/03/2025. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/25/2025, indicated Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #1 was independent with sit to stand transfers, chair/bed-to-chair transfers, and walking 10 feet and did not exhibit wandering behavior during the seven-day assessment look-back period. A Behavior note, dated 06/24/2025 at 12:34 AM, indicated Resident #1 was pacing, rummaging, and packing all [their] belongings in bag, saying [they were] leaving. The note indicated the resident demonstrated very anxious and agitated, noncompliant behavior after the supper meal until midnight, when staff tried to redirect the wandering behaviors. There was no documented evidence that staff completed a new elopement risk assessment. A Behavior note, dated 06/25/2025 at 11:24 PM, indicated Resident #1 demonstrated chronic behavior: Continues to sort out alot [sic] of items in room and ‘packing some up.' There was no documented evidence that staff completed a new elopement risk assessment. A Behavior note, dated 06/29/2025 at 7:39 AM, documented as a late entry for 06/28/2025 at 7:49 PM, indicated Resident #1 had wandering behaviors, was rummaging through their belongings, and was more confused than normal. There was no documented evidence that staff completed a new elopement risk assessment. A Behavior note, dated 07/03/2025 at 1:43 AM, documented as a late entry for 07/02/2025 at 10:31 PM, indicated Resident #1 demonstrated chronic behavior: to include pacing/rummaging and was difficult to redirect. The note indicated the resident got upset when staff attempted to redirect. Per the note, a hospice nurse was notified. There was no documented evidence that staff completed a new elopement risk assessment.A Behavior note, dated 07/03/2025 at 5:32 AM, revealed a nurse attempted to administer Resident #1's medications, but the resident refused and told the nurse to get out. According to the note, when the nurse left the resident's room, the resident was pacing back and forth. The note indicated that at 12:05 AM, shortly after Resident #1 refused their medications, the resident opened their window, punched the screen out, and was found lying outside on top of the bushes. According to the note, Resident #1 sustained a 3-centimeter (cm) by 2-cm bruise to the left upper buttocks, a 2-cm scratch to the left shin, and scattered abrasions to their bilateral knees. The note indicated hospice was notified, and the resident was placed on one-to-one (1:1) supervision until further evaluation. An Alleged Nursing Home Resident Mistreatment, Neglect, And Abuse Report, completed by Administrator (ADM) F on 07/03/2025 at 10:33 AM, indicated Resident #1 opened their bedroom window, pushed the screen out, and was found in the bushes right outside the resident's bedroom window. The report indicated Resident #1 was last observed by a nurse within ten minutes prior to the incident. A Misconduct Incident Report, completed by Interim Director of Nursing (IDON) E on 07/10/2025 at 4:34 PM, revealed Resident #1 was transferred to the emergency room following the incident and no further injuries were identified. During a phone interview on 08/01/2025 at 6:50 AM, Certified Nursing Assistant (CNA) G stated she worked the 10:00 PM to 6:30 AM shift. She stated that on the night of the incident, Resident #1 did not allow her to enter their room, and she notified the nurse. CNA G stated she saw the resident standing in their room about ten minutes before she left for a 30-minute break around 11:45 PM, and when she returned from break, she was told Resident #1 pushed the screen out of their window and exited the building. CNA G stated that CNA I told her they found a chair turned over in front of the resident's window. During a phone interview on 08/01/2025 at 7:24 AM, CNA H stated she currently worked the night shift and recalled working the night Resident #1 exited the facility through their window. CNA H stated that within the last month, Resident #1's behaviors changed. CNA H stated the resident experienced sundowners on night shift, tried to stand on their wheelchair, and saw people who were not there. Per CNA H, these behaviors were reported to a nurse. CNA H said the resident also made comments all the time to staff that the resident wanted to go home; however, the comments about wanting to go home were not reported to a nurse because CNA H thought the resident said the same thing to the nurses. CNA H stated that on the night the resident went out their window, the resident was agitated and staff took turns keeping an eye on them. CNA H stated she recalled seeing Resident #1 and then within ten minutes, she was informed the resident was outside. CNA H said she immediately ran outside and saw the resident in the bushes outside their room, still with their supplemental oxygen on. CNA H said the resident was wearing long pants, a t-shirt, and socks, saying, This isn't my house; I broke that window because I am going home, this is not my home. During a phone interview on 08/01/2025 at 7:26 AM, CNA I stated that in the prior few weeks, Resident #1 was more confused, agitated, and restless. CNA I stated she worked 2:00 PM to 2:00 AM on the night Resident #1 went out their window. CNA I said that while the resident's assigned CNA was on break, she (CNA I) completed rounds around 12:00 AM or 12:15 AM and did not see Resident #1 in their bed or bathroom. CNA I said she noticed the screen was missing from the resident's window, the resident's oxygen tubing was leading out the window, and a chair was tipped over next to the window. CNA I stated she looked out the window and saw Resident #1 on the ground. During an interview on 08/01/2025 at 12:08 PM, Nurse Manager (NM) N stated she worked from 10:00 PM on 07/02/2025 until 6:00 AM on 07/03/2025. NM N said Resident #1 had intermittent confusion and often made comments about wanting to live at home again. NM N stated that when she started her shift on 07/02/2025, she was told Resident #1 was experiencing increased agitation. NM N stated that CNA I notified her that Resident #1 had exited the facility through their window. NM N said that when she entered the resident's room, she saw the screen was missing from the resident's window, the resident's oxygen tubing was leading out the window, and a chair was tipped over next to the window; Resident #1 was seen in the bushes outside. NM N said staff brought the resident back inside the facility and assessed the resident. During a phone interview on 08/01/2025 at 8:59 AM, Hospice Registered Nurse (RN) L said she arrived at the facility around 10:00 PM on 07/02/2025 in response to a call from the facility for complaints that Resident #1 was experiencing severe agitation and left around midnight on 07/03/2025. RN L said that when she arrived at the facility, Resident #1 was in their room alone, and the resident would not allow her to complete an assessment. Hospice RN L said the resident was agitated and screaming. RN L said she waited and re-entered the resident's room when they were calmer. According to Hospice RN L, the resident was conversive but then asked the RN to leave. RN L said she left the resident's room right before 12:00 AM, and the resident was standing near the window with their oxygen in place. RN L stated she did not observe the resident make any attempts to push on the window, and she advised staff to make frequent checks from the hallway because going into the room made the resident more agitated. During a phone interview on 08/01/2025 at 1:50 PM, Hospice RN K stated she arrived at the facility around 1:35 AM on 07/03/2025 to complete a focus visit after the facility notified hospice that Resident #1 had an unwitnessed elopement/fall from the window of their room. RN K stated that when she arrived at the facility, Resident #1 was calm and seated in a recliner in a common area with their feet elevated. RN K said she asked the resident if they remembered climbing out the window in their room, and Resident #1 said they climbed out the window to go home to help a dog, and then stated, And they hauled me back in here. During an interview on 07/31/2025 at 3:37 PM, IDON E stated residents were assessed for risk of elopement upon admission, weekly for four weeks, quarterly, and as needed. IDON E stated she expected all residents to have an elopement risk assessment completed per the facility policy, and if a resident was identified as at risk of elopement, the facility should update the resident's care plan with interventions for the resident's safety. IDON E stated that staff did not complete a new elopement risk assessment for Resident #1 in June 2025 after the resident expressed a desire to leave the facility and return home. During an interview on 08/01/2025 at 9:46 AM, ADM F stated that if a resident was exit seeking, verbalized a desire to leave the facility, attempted to leave through exit doors, or packed their belongings, she expected the resident to be evaluated for their risk of elopement.

Based on interview, record review, and facility policy review, the facility failed to prevent significant medication errors for 2 out of 7 residents (R1 and R4) reviewed for medication administration out of a total sample of 15 residents. R1 was administered medications prescribed for R2 on 04/16/25. This medication error caused R1 to be transferred to the hospital due to an accidental medication overdose. The facility's failure to prevent significant medication errors, continually assess the resident after the medication error, and immediately notify the physician of the medication errors created a finding of immediate jeopardy that began on 4/16/25. Surveyor notified the Administrator and Assistant Director of Nursing (ADON) of the immediate jeopardy on 6/5/25 at 10:20 AM. The immediate jeopardy was removed on 6/4/25, however, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as evidenced by the following example. R4 was administered R3's nebulizer medication. Findings include: Review of the facility's policy titled, Medication Administration revised 4/21/25, indicated, . The person who prepares the dose for administration is the person who administers the dose . Review of the facility's policy titled, Medication Error, revised 04/21/25 indicated, . In addition, the facility will follow the procedure listed below: Contact Poison Control if applicable. Contact PCP for notification. Contact POA if applicable. A Medication Error Report Form will be initiated (see attached form) A Post Medication Error monitoring flow sheet or monitoring via [by] EHR [electronic health record] Nurses' To Do List will be initiated and will continue for a full 3-day [sic] post error unless continued monitoring is directed by the MD [Medical Doctor] (see attached form) Education will be provided to staff on an as needed basis to prevent future errors Medication errors will be reviewed by the ID [Interdisciplinary] team and brought to Quality Assurance no less than quarterly . 1. Review of R1's Face Sheet, located under the Face Sheet tab in the electronic medical record (EMR), indicated R1 was admitted to the facility on [DATE] with diagnoses that included stroke, diabetes mellitus, bipolar disorder, hypertensive chronic kidney disease, and seizures. Review of R1's quarterly Minimum Data Set (MDS), located under the MDS tab in the EMR and with an Assessment Reference Date (ARD) of 1/21/25, indicated R1 had short- and long-term memory loss with modified independence in making daily decisions. Review of R1's Medication Administration Record (MAR), provided by the facility and dated 4/2025, indicated that on 4/16/25 at 7:00 AM, R1 had been administered amlodipine 10 mg (milligrams) (a blood pressure medication), lamotrigine 225 mg (a bipolar medication), Keppra 500 mg (a seizure medication), metoprolol 25 mg (a blood pressure medication), and losartan 50 mg (a blood pressure medication) while in the dining room. Review of R2's Face Sheet, located under the Face Sheet tab in the EMR, indicated R2 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, hypertension, anemia, atrial fibrillation, and depression. Review of R2's annual MDS, located under the MDS tab in the EMR and with an ARD of 4/5/25, indicated R2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R2's MAR, provided by the facility and dated 4/2025 indicated that on 4/16/25, R2 had been administered Lasix 20 mg (a fluid pill), amlodipine 10 mg, carvedilol 12.5 mg (a blood pressure and heart failure medication), venlafaxine 150 mg (a depression medication), magnesium 500 mg (a supplement), and iron (a medication to treat anemia) while in the dining room for breakfast. Review of the Executive Summary, provided by the facility, indicated on 4/16/25 at 8:44 AM, Certified Nursing Assistant 1 (CNA) observed several pills mixed in with R1's food in the divided plate that belonged to R1. CNA1 notified Unit Manager 1 (UM) of this finding. UM1 came to the unit, took the plate, and separated the pills out of the food and then administered these medications to R1. UM1 then walked through the dining room and noted two pills lying on the floor where R1 sits at the dining room table. UM1 took these two medications to the medication cart and reviewed R1's medication profile in the computer. UM1 noted that these medications were not R1's. UM1 then looked in the computer at R2's medication profile, knowing that R2 sat beside R1 at the dining table, and compared these medications when UM1 noted the two medications that were found on the floor belonged to R2. As UM1 continued to review the medication profile of R2, she noted the medications that she had administered to R1 were actually R2's medications. UM1 recognized she had made a medication error. Continued review of the Executive Summary revealed, . -At 8:55 AM, UM1 went to the morning IDT [Interdisciplinary Team] meeting and told [name of the ADON] that [UM1] need to talk to her after the meeting. Throughout the meeting [UM1] told [ADON] that she needed to talk to [ADON] about a med [medication] error that she had made. -9:15 AM, [UM1] sent a text message to the . nurses' cell requesting [LPN1] to please assess [R1] vitals [vital signs] immediately. -9:17 AM, [UM1] sent a text message to . nurses' cell requesting [LPN1] call the PCP (Primary Care Provider) to notify [sic]. -9:34 AM, [UM1] stepped out of the morning meeting and [UM1] called [LPN1] who was the nurse . and working with R1. [UM1] explained what had happened and requested she assess [R1's] vitals immediately and then also assess her [R1's] vitals at 1130 [sic ]. [UM1] then came back into the room and spoke with [DON], [ADON], and . Supervisor about the med error [sic ]. [LPN1] stated she immediately assessed vitals after getting off the phone with [UM1] which were: T [temperature] 98.2, P [pulse] 72, BP [blood pressure] 122/76, O2 [oxygen saturation] 100% RA [room air]. -10:30 AM, Vitals assessed: T 97.4, P 76, BP 122/74, O2 100% RA. -10:43 AM, . [LPN1] stated that she had watched the resident [R2] put the meds in her mouth and take a drink of her water. [LPN1] had thought that the resident [R2] had swallowed her pills. -10:45 AM, [DON] and [UM1] attempted to call [name of medical doctor] to notify him of the med error, he did not answer. A message was sent asking him to call back to discuss a med error. -12:00 PM, [LPN1] states she returned from her lunch to find [R1] with her arms hooked over the arms of the wheelchair, slid down out of the wheelchair in the dining room. [LPN1] states that [R1's] eyes were rolling back and [R1] was yelling 'help me I am dying.' [LPN1] immediately came over and called for help . were able to unhook [R1's] arms and lower her to the floor. [LPN1] ran to get assistance . The resident's [R1] BP was 92/50 HR [heart rate] 58. -12:03 PM, A code blue [sic] called, resident [R1] was reporting dizziness and was disoriented. [UM1] heard the code blue called and ran onto the unit from the main building. -12:05 PM, BP was 100/65, HR 58, R [respirations] 20, 97% [oxygen saturation] RA. -12:06 PM, Call placed to [name of MD] again, code blue called on resident [R1], we had attempted to call earlier and sent a text message to update him [MD] at 10:45a [sic] . on the med error made earlier this morning. Resident [R1] received another residents [sic] [R2] AM [morning] medications by mistake . [UM1] reported to [MD] that [R1's] BP was 92/60 and that the resident [R1] was disoriented and had been lowered to the floor . [MD] instructed for us to send [R1] to the ER via 911. Informed [MD] that [UM1] had instructed the nurse [LPN1] on the unit to monitor BPs once at 9:35 and again at 11:30 [sic]. -12:08 PM, 911 was called, information given to them on the resident [R1] receiving the wrong medications this morning . resident's [R1] BP of 92/60, resident disoriented [sic]. -12:15 PM, EMS [Emergency Medical Services] arrived, transfer packet including a list of resident's medications that were administered and the incorrect medications that were administered. 12:25 PM, Resident [R1] exited the building with EMS . Review of R1's Nursing Progress Notes, provided by the facility and dated 4/16/25 at 1:59 PM, revealed, . family/guardian [name], POA (Power of Attorney) updated that there was a medication error, explained the situation, Resident became symptomatic around noon, was sent to ED [emergency department] [sic] . During an interview on 6/2/25 at 1:25 PM, LPN1 stated she had given R1's medications around 7:00 AM while R1 and R2 were eating at the dining room table together on 4/16/25. LPN1 stated R2 was given her medications and drank a full glass of water, so she assumed that R2 had swallowed her medications. LPN1 stated that R2 will sometimes refuse to take her medications but to the best of her knowledge, R2 did not have any behaviors in pocketing her medications in her cheek or spitting out her medications. LPN1 stated she then went on her morning break, and when she returned to the unit, she was informed that [UM1] had been given R1's divided plate, and it had her pills in the food. LPN1 stated she and UM1 had figured out together that R1 had received R2's medications in error, and UM1 stated she was going to her office to make some phone calls which included the doctor. LPN1 was asked if Poison Control was called and notified of the medication error to seek advice from them. LPN1 stated, I am not sure, but the DON said it was done in the ED. LPN1 continued to state, Her [R1's] vital signs were checked at 9:20 and again at 10:30, then I didn't take them at 11:30 because I went to lunch. She [R1] was drinking lots of fluids, going to the bathroom, and told me she felt fine. LPN1 stated, When I came back from lunch, I saw her [R1] slumped over in her chair, took her vital signs, and called for help. She wasn't responding to us but when we laid her down and put her legs up, she started to respond to us better. We called 911 and the ambulance came and transferred the resident to the hospital. During an interview on 6/3/25 at 8:45 AM, CNA1 stated, I was cleaning up after breakfast and saw [R1's] divided plate had pills in the food that was left on the plate. I knew [LPN1] was on break, so I called [UM1] and told her of what I had found. [R1] and [R2] always sit beside each other in the dining room for their meals and [R1] is the only resident at that table that has a divided plate. During an interview on 6/2/25 at 2:08 PM, UM1 stated, [CNA1] called me and told me that they had found pills in [R1's] food that was left in her divided plate. I do not know for sure it was [R1's] food or not or if it was a plate that [R1] was eating out of. I went onto the unit and [CNA1] verified that this was [R1's] divided plate that she was eating out of. I then for some reason separated the meds [medications] from the food and [CNA2] went into [R1's] room, and I administered those pills to [R1]. I came back through the dining room and saw two more pills on the floor under the table, and the CNAs confirmed that [R1] was sitting there in that place. I went to the medication cart and reviewed [R1's] medication profile that has the picture of the medications and did not see the two pills that I found under the table on her profile. I know who was sitting beside [R1] at the table, so I looked at [R2's] medication profile. That was when I discovered that the medications that I had administered to [R1] belonged to [R2]. I went to our meeting at that time, and I was sitting next to [ADON] and told her I needed to talk to her about a medication error. I told her as the meeting went on that I accidentally gave the wrong meds to the wrong resident. I sent a text message to the medication nurse [LPN1] and told her to get her [R1's] vital signs now and check them again at 11:30. She [LPN1] did check it [vital signs] more frequently than that. But as far as I know, [R1] had received everything [medications] that she was supposed to receive that morning. UM1 was asked if she should administer medications to a resident that she did not prepare and UM1 stated, No you shouldn't give them [medications] to residents especially if you are not the nurse preparing the medications. I should have locked the medications up until the nurse that prepared the medications originally could have looked at them to see if they had belonged to [R1] or to [R2]. Then the medications should have been destroyed, and the PCP would have been notified of [R2] spitting out her medications and not have taken them. UM1 stated R1 was found slumped over in her wheelchair and then LPN1 called out for help to assist with R1. UM1 stated a Code Blue was called to get extra people on hand on the unit, then the doctor was notified, and 911 was called. UM1 stated R1 was transferred out to the ED. UM1 was asked if Poison Control was called while R1 was in the facility, and UM1 replied, No, they were not called. UM1 was asked why the physician was not notified earlier than he was when the medication error was discovered. UM1 stated, I had texted [LPN1] asking that she notify the doctor about the error, but we didn't find out until after this incident that the nurses' cell phone that they have does not accept text messaging. Then when he [doctor] was called and texted after that, we did not call any further because [R1] was doing ok and we just waited until he would call us back. UM1 was asked when the family/guardian was notified. She stated, I believe it was after the resident went to the ED. During an interview on 6/2/25 at 2:43 PM, CNA2 stated, [UM1] came up to me and asked if I would go with her to [R1's] room while she gave [R1] her medications. So that is what I did. During an interview on 6/3/25 at 11:14 AM, the PCP for R1 stated, A lot of the time the staff will text me and I will call them right back but on this incident, I do not know why the text did not come through. I have worked with the DON to tell staff if they cannot get me on the phone and I do not answer a text message, then they are to call the 24-7 answering service at the hospital, and the on-call doctor could have been notified and probably have the resident sent to the ER. I would have expected to have been notified as soon as this error was discovered. That way we could have worked as a team and collaborate for what needed to be done for [R1]. For example, I could have given orders to administer IV [intravenous] fluids and to monitor her vital signs more frequently than once an hour and asked for updates in her condition to be called after the fluids started. Then maybe we wouldn't have had the issues of [R1's] blood pressure going low. Then if the fluids didn't help her blood pressure, then I would have decided to have the resident go to the ER. Since this incident, the DON and I have started planning on myself or a resident doctor to have staff education on what to do in certain instances such as changes in condition or falls to help prevent this from happening and give the staff more insight on what to assess and when. During an interview on 6/5/25 at 5:54 PM, the Administrator stated, I expect the RNs [Registered Nurses] to perform assessments when they see the resident has a change in condition for whatever reason and notify the physician immediately of these changes. If the physician does not respond or cannot be reached, the staff will send the residents out to the ER in good faith that they are doing the right thing for the residents at that time. That they [staff] don't leave the residents alone during these changes in condition assessments. We need to make sure we are practicing safely and if there is harm to a resident, then we will report that to the state agency. Education will begin immediately for all licensed personnel to ensure this does not happen again to any other residents. During an interview on 6/2/25 at 2:55 PM, the Director of Nursing (DON) stated, There were several things that we have learned from this medication error. One is that the doctor should have been called immediately after we discovered the medications error. Then we should have called Poison Control to seek their advice on what to do. The family should have been notified earlier than they were and of what the plans were for [R1] at that time. We started the education for the nurses on 4/16/25 of the five rights of medication administration, and that a medication error was a change in condition, and the physician was to be notified of this immediately. I called the physician for [R1] which is also the Medical Director and asked what to do if we were unable to get him on the phone and he said to call the answering service at the hospital, so we educated the nurses on this. Both nurses involved were put on leave, then when they returned to work, both nurses had to take a medication test and have the education of the five rights of medication administration. [LPN1] was observed by the nurses and the pharmacy consultant for medication administration and with those there had not been any identified concerns with those observations. The failure to prevent significant medication errors, continually assess a resident after discovery of a medication error, and immediately notify the physician of a medication error created a reasonable likelihood for serious harm which led to a finding of immediate jeopardy. The facility removed the immediate jeopardy on 6/4/25 when it had completed the following (the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) based on example 2): Upon identification of the serious concern on June 4, 2025, the facility took the following immediate corrective measures to protect all residents involved and those who could potentially suffer serious adverse outcomes: Once the error is identified, determine if the resident received a high-risk medication. In the event of any high-risk medication being given in error, the nurse will follow these steps: An assessment by RN should be completed immediately. Evaluate for harm and provide first aid if indicated. Continue close monitoring until instructed otherwise by PCP. Seek medical advice. Place call out to PCP. If not immediately available, call the pharmacy and ask for a pharmacist. If unable to speak with a physician or pharmacist, send to the ER by calling 911. Document the event, including medication, dose, route, and any other relevant information. Describe the circumstances surrounding the event and all actions taken. Notify POA/family contact. Inform of events and planned interventions. The nursing supervisor or management should be called to the unit and remain on the scene until the resident is transported to the ER or the PCP deems the resident stable. Continue to monitor for 12 hours or another interval specified by PCP/ER MD. LPNI has been observed for 4 shifts 4/12/2025,4/12/2025,4/13/2025,5/11/2025. UM1 was provided with training and passed her competency test. She will be observed by the ADON. On 4/12/2025, PharMerica Consultant observed medication pass with LPN1 with no concerns regarding the medication pass and five rights of medication administration ensuring all residents were administered with the right medication. During the March 2025, QAPI, Medication Errors were a topic of discussion, and the facility will continue to address this concern through this quarter. Review any revised or developed policies and procedures related to the IJ situation. The Assistant Director of Nursing (ADON), updated the Medication Error Policy and implemented immediate training on the evening of June 4,2025, for licensed nursing staff. The training updates will continue for the clinical team, and those who are not present will review the training prior to assuming duties on the floor. The measure will be validated with our scheduling officer, ensuring that all nursing personnel on the floor have demonstrated compliance with reading and understanding this medication error policy update. Staff education and/or retraining should include return demonstration, if applicable. All clinical staff will be educated on the revised policies and procedures. Education included medication administration and policies regarding medication errors. This training will be conducted by clinical leadership titled Medication Error Policy, managed by the Director of Nursing or designees. Completion Date: 4 June 2025. A make-up training plan is in place for PRN (as needed), agency, or vacationing staff. Staff will not be scheduled to work until they have completed and documented their education. Ongoing monitoring will be conducted to ensure the effectiveness of corrective actions. Monitoring is conducted by the Unit Manager or designated by the Director of Nursing. Frequency-Daily for 2 weeks then weekly for 4 weeks. Results will be reviewed during monthly QAPI (Quality Assurance Performance Improvement) meetings for a minimum of 3 months. Random medication administration observations will continue all shifts including weekends. The Nursing Home Administrator, Medical Director, and Assistant Director of Nursing conducted an ad hoc meeting regarding the serious concern. The Medical Director will provide oversight to the residency physicians and offer additional training to licensed nursing staff. 2. Review of R3's undated Face Sheet, located under the Face Sheet tab in the EMR, indicated R3 was admitted to the facility on [DATE] with the diagnosis of asthma. Review of R3's significant change MDS, located under the MDS tab in the EMR and with an ARD of 2/6/25, revealed R3 had a BIMS score of 13 out of 15, which indicated R3 was cognitively intact. Review of R3's Physician Orders, dated 2/14/25 and located under the Orders tab in the EMR, revealed an order for Ipratropium-Albuterol 0.5 MG/3ML [milligram per milliliter]-2.5 (3) MG/3ML inhalation as needed for shortness of breath. Review of R4's undated Face Sheet, located under the Face Sheet tab in the EMR, revealed R4 was admitted to the facility on [DATE] with the diagnosis of chronic obstructive pulmonary disease. Review of R4's Physician Orders, dated 5/5/25 and located under the Orders tab in the EMR, revealed an order for Ipratropium-Albuterol 0.5 MG/3ML [milligram per milliliter]-2.5 (3) MG/3ML inhalation four times a day for chronic obstructive pulmonary disease. On 5/6/25 at 2:30 PM, R4 reported to the Unit Manager that he had not received his nebulizer treatments all day. Review of the facility reported incident, which was reported to the state survey agency, revealed it was discovered LPN1 had used R3's nebulizer medication for R4 at 8:00 AM on 5/6/25 and had not given R4's nebulizer medication at 12:00 PM. During an interview on 6/3/25 at 12:51 PM, LPN1 stated, I was told in report that morning [05/06/25] that we did not have any nebulizer medication from the pharmacy, nor did we have any in the contingency box on the unit for [R4]. I knew another resident [R3] had an order for the same medication, so I borrowed one from that resident [R3] to administer to [R4]. LPN1 was asked what she should have done instead of borrowing the medication from another resident. LPN1 stated, I should have checked the contingency box myself and if there really wasn't any to administer, then I should have called the pharmacy and let my supervisor know. LPN1 was asked if she had administered the nebulizer medication to R4 at 8:00 AM. She replied, [R4] was in the bathroom with a CNA. I set it up adding the medication [liquid] to the nebulizer chamber, and he [R4] stated he would do it in a minute. But he [R4] must have forgotten to and when I was questioned about it from [UM1], I realized I didn't go back into his room to make sure he had taken the nebulizer treatment. LPN1 was asked if the nebulizer medication was to be left at the bedside for the resident to take. She stated, No, you are not to leave the medication at the bedside. LPN1 was asked if she gave R4 the 12:00 PM dose of the nebulizer medication. She stated, No, I didn't realize he [R4] had a treatment at noon so when [UM1] was asking me about it, I told her [UM1] that I haven't given it, but I could if she wanted me too. [UM1] told me not to give it now because it was 2:30 PM. During an interview on 6/3/25 at 2:00 PM, UM1 stated, I believe that either he [R4] or his family notified me of [R4] not getting his nebulizer treatments at all on 5/6/25. I went to investigate this and interviewed the nurse [LPN1] that was assigned to him that day. When interviewing [LPN1], I asked if she had given him his nebulizer treatments today and [LPN1] stated she had given it to him at 8:00 AM but she did not know that he [R4] was ordered to have any more treatments on her shift. I told her that he was to have one at 12:00 PM. She stated to me that she had not given it to him, but she could go in and give it to him [R4] now if she needed to. It was already 2:30 PM so I told her that we would have the evening shift nurse do a respiratory assessment and give the 4:00 PM dose, and I called the PCP to notify of the missed doses and the monitoring. She [LPN1] also stated to me that because we had not received the DuoNeb [nebulizer medication] solution from pharmacy that she had used another resident's [R3] medication. It was shift change and the evening nurse went with me into [R4's] room to look for the nebulizer equipment and there was a large amount of solution in the nebulizer was 3 ml [milliliters], the dose of the DuoNeb is 3 ml. I took a syringe in the room with me when we went and was able to draw up 3 mls. (milliliters) of a solution. During an interview on 6/3/25 at 3:30 PM, DON stated, The nurse is not to leave medication at the bedside for the resident to self-administer unless they have orders to perform this themselves. I expect the nurses to stay with the resident while the resident is receiving a nebulizer treatment to make sure the resident is administered the whole dose of medication the physician had ordered. DON was asked if R4 had been assessed and if the physician had ordered for R4 to self-administer the nebulizer medication, and the DON stated, No, he had not. Review of the facility's education to the licensed nurses, provided by the facility revealed, . Medication administration is an important part of delivering healthcare. It refers to the process of giving or receiving a medication . A simple checklist covering the basics - referred to as the '5 Rights' - is a standard for safe medication administration [sic]/ These rights include: 1. The right patient, 2. The right drug, 3. The right time, 4. The right dose, 5. The right route . Medications CANNOT [sic] be prepared and left . with the resident to take later. Resident must be watched .

Based on interview, record review, and document review, the facility failed to follow professional standards for 1 of 3 residents (R8) reviewed for Power of Attorney (POA) status out of a total sample of 15. Findings include: Review of R8's undated Face Sheet, located under the Face Sheet tab in the electronic medical record (EMR), indicated R8 was admitted to the facility on [DATE] with diagnoses that included fracture of the left pubis, cancer, and Alzheimer's disease. Review of R8's admission Minimum Data Set (MDS), located under the MDS tab of the EMR and with an Assessment Reference Date (ARD) of [DATE], indicated R8 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated R8 was moderately cognitively impaired. Review of R8's Advance Directive including Power of Attorney for Health Care, which was provided by the facility and signed by R8 on [DATE], revealed R8's spouse had been selected as the resident's health care agent. The form recorded, . If the health care agent is unable or unwilling to make choices for me, then my next choice for a health care agent is . and Daughter1 was named. The form continued to record, . If the alternate health care agent is unable or unwilling to make these choices for me, then my next choice for a health care agent is . and Daughter2 was named. This was presented to the facility at the time of admission. Review of R8's Social Service Progress Note, provided by the facility and dated [DATE] at 3:33 PM, revealed, . Family came in today to inform resident her husband passed away last evening. Review of R8's EMR revealed a second Power of Attorney for Health Care, which was provided by the facility and signed by R8 on [DATE]. In this POA document, under the section of Designation of Health Care Agent the form recorded, If I am no longer able to make health care decision for myself, due to my incapacity, I hereby designate . and [Daughter 1's Name] was named. The form continued to record, . If he or she is ever unable or unwilling to do so, I hereby designate . and [Daughter 2's Name] was named. Review of R8's Social Service Progress Note, provided by the facility and dated [DATE] at 4:59 PM, revealed, This writer heard from [R8's] daughter [name of Daughter1]. She [Daughter1] stated she doesn't know what to do because she relinquished as POA some months back because she had a health concern and wasn't able to make the trip each week. She [Daughter1] had been driving 300 miles about every week and a half to take her father to doctor's appointments and care for her mother [R8]. One day after she [R8] was admitted here the family came in to let her know her husband died. At this time [sic] she [R8] still thinks she is going home to him, In the meantime, [Daughter2] the other daughter went to the bank had everything transferred so she [Daughter2] could be POA over finances and went to an attorney to get the health POA changed so she [Daughter2] is in control. This writer had [R8] sign a new POA for health on 04.10.2025 since [R8's] husband passed away. [R8] said it was fine once this writer told her nothing would change. This writer kept it the same way, [Daughter1] was first, then [Daughter2] . During an interview on [DATE] at 1:16 PM, the Social Worker (SW) stated, The day she [R8] was admitted her whole family was here with her to tell her that her husband had passed away the night before. The family was attentive and did what they could. Her husband had passed away and he was her original POA along with the two daughters as alternates. Wherever I have worked before and while I have been here, I have just drawn up a new one [POA] if this happened. I didn't see anything wrong with doing it that way. Everything stayed exactly the same except the husband was removed. The SW was asked when she had conversations with R8 and/or R8's daughters regarding preparing a new POA document. The SW replied, I talked to her [name of Daughter1] a lot. The SW was asked if she had documentation of these conversations with R8 and/or R8's daughters and the SW stated, Let me go and I will bring it back to you. The SW returned with a copy of the progress notes dated from [DATE] through [DATE]. The SW confirmed she documented the progress notes. Review of the progress notes presented reflected only one conversation, dated [DATE] at 4:59 PM. The SW was asked if she had any further documentation to reflect conversations with R8 and/or R8's daughters prior to the new POA document being prepared and signed by R8 on [DATE] and the SW replied, No, I guess I didn't document the ones that I had. The SW was asked if there should have been documentation to reflect R8's wishes to form a new POA document prior to R8 signing this document and she stated, I guess there should have been. During an interview on [DATE] at 4:00 PM, the Administrator stated, Once I learned of this incident occurring, I went and emailed our legal department to get guidance on what our practice should be in this situation. It was my understanding that the POA document did not need to be redone in this instance. Since the husband had passed away, the next in line that was listed as the alternate health care agent would been her daughter that was listed, then if that daughter was unwilling or was unable then it went to the next daughter listed on the document. Review of the email between the legal department of the facility and the Administrator, provided by the facility and dated [DATE] at 9:35 AM, revealed, . Staff should never be assisting with the creation of a new POA if the original POA has been activated . Most POA forms designate a POA to act in case the first person can't/won't act. In a situation where the first person designated passes away or declines to act, the alternate person would then be the POA. There is no need to create a new document foin order for this to take effect . Review of the Position Description for the Classification Title of Position for Master Social Worker revealed, The incumbent of this position works with the interdisciplinary team and administration of [name of facility] to promote and protect residents' rights and the psychosocial well being [sic] of each resident. By coordinating medically related social services at [name of facility], the incumbent assists each resident to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being . Review of the Authorized Social Worker Practice, published under s.35.93, Wis. Stats., by the Legislative Reference Bureau, Chapter 6, Page 827, [DATE], revealed, . A certified social worker may evaluate and assess difficulties in psychosocial functioning, develop a plan to alleviate those difficulties, and either carry out the plan or refer clients to other qualified resources for assistance. Intervention plans may include counseling of individuals, families, and groups; advocacy; referral to community resources; and facilitation of organizational change to meet social needs based on psychosocial evaluation .

Based on review of facility policy, record review, and interview, the facility failed to ensure two residents (R) (R16 and R43) out of 22 residents reviewed for abuse/neglect were protected from potential physical abuse. The facility failed to ensure R16 was protected from potential physical abuse by Certified Nurse Aide (CNA) 2 by continuing to schedule CNA2 on the same unit that R16 resides. As a resident, R16 continued to be fearful. The facility failed to prevent physical and verbal abuse of R43 in which CNA3 prevented R43 from rising from a chair and was potentially verbally abusive during this same interaction by CNA3. (Cross Reference F610 and F730) Findings include: Review of a facility polity titled Abuse, Neglect, Mistreatment dated 01/26/24 indicated .The facility will strive to educate staff and other applicable individuals in techniques to protect all parties. 1. Review of a facility document for R16 titled Face Sheet provided by the facility indicated the resident was admitted to the facility on [DATE]. Review of R16's admission Minimum Data Set (MDS) provided by the facility with an Admission Reference Date (ARD) of 04/05/24 with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 revealed the resident was cognitively intact. The assessment indicated the resident had no behaviors directed towards others. The assessment indicated the resident required moderate assistance from staff for toileting. Review of a facility document titled Interview with [R16] provided by the facility dated 05/14/24 indicated R16 voiced she was still scared of CNA2. The document indicated the resident voiced that CNA2 did not assist her with cares such as: will leave her walker away from her and then CNA2 will just stand, wait, and not offer the resident assistance. The document revealed the resident asked that CNA2 not provide her care since she was scared of CNA2. This note was written by (Interim) Director of Nursing (DON). Review of a facility document untitled and dated 05/14/24 provided by the facility indicated the Social Worker (SW) was told R16 wanted to speak with her. The SW stated the resident voiced she no longer wanted CNA2 to provide her care. The note went on to state the resident stated CNA2 did not want to provide her assistance and would [sic] too rough when CNA2 would wipe her. SW wrote that the resident voiced she was terrified of CNA2. Review of a facility document untitled and dated 05/14/24 provided by the facility indicated the Infection Preventionist (IP) wrote the note which indicated R16 wanted to speak with her. The IP wrote R16 voiced to her she was afraid of CNA2 and alleged the staff member was rude and did not understand the level of care she needs. The IP wrote R16 claimed she would tremble when CNA2 was present. Review of facility document titled Daily Schedule provided by the facility revealed CNA2 worked on the following dates on the Limestone [NAME] Unit: 05/14/24, 05/21/24, 05/24/24, 05/27/24, 05/28/24, 06/01/24, 06/02/24, 06/06/24, 06/10/24, 06/11/24, 06/13/24, 06/14/24, 06/15/24, 06/16/24, 06/17/24, 06/19/24, 06/23/24, 06/24/25, 06/25/24, 06/27/24, 07/01/24, 07/02/24, 07/05/24, 07/07/24, 07/08/24,07/09/24, 09/11/24, 07/12/24, 07/13/24, 07/14/24, 07/16/24, 07/18/24, 07/20/2407/22/24, 07/23/24, 07/26/24, 07/27/24, 07/28/24, 07/29/24, 07/30/24, 08/01/24, 08/05/24, 08/06/24, 08/09/24, 08/10/24, 08/11/24, 08/15/24, 08/19/24, 08/20/24, 08/21/24, 08/22/24, 08/23/24, 08/24/24, 08/27/24, 08/28/24, 09/01/24, 09/02/24, 09/03/24, 09/06/24, 09/08/24, 09/09/24, and 09/10/24. Review of a facility document titled Administrative Leave provided by the facility dated 05/15/24, indicated CNA2 was placed on administrative leave. Review of a facility document titled Regarding Reportable Incident dated 05/17/24 provided by the facility indicated the letter was directed to CNA2 and specifically stated .Communication between residents and CNAs needs to be person-centered. It's important for you to work on improving your communication skills as a professional. This is not the first time concerns have been raised about your gestures and tone. CNA2 refused to sign this document. During an interview with the Administrator and Interim DON on 09/17/24 at 1:35 PM, the Administrator stated CNA2 no longer provides care to R16. The Administrator and Interim DON were asked if they had any additional monitoring/auditing of CNA2 and her performance since the initial allegation was made on 05/14/24. The Administrator stated they provide a weekly customer service tool and would be able to determine if there were problems. The Administrator stated R16 continues to make allegations against CNA2 and stated there have been grievances made. The Administrator and the Interim DON were asked why CNA2 continued to work on the same unit as R16. The Administrator stated they did not look at this from the perspective of the resident continuing to be triggered. The Interim DON confirmed there was no documentation to show that the facility continued to monitor CNA2. The Interim DON stated CNA2 continues to work 24 hours a week and typically on the Limestone [NAME] Unit. During an interview with R16 on 09/17/24 at 1:50 PM, the resident stated she was aware that CNA2 was working today, even though the resident remains in her room to keep her legs elevated. R16 stated CNA2 was quite abusive to her. The resident stated she asked the CNA to be more careful and she continued to be rough. She said that CNA2 did not enter her room but again was aware she was still working on the unit. The resident stated that the CNA2 continues to make her nervous on the off chance that the staff member might provide her care. During an interview on 09/17/24 at 1:58 PM, CNA2 confirmed she continued to work on Limestone [NAME] Unit and confirmed that R16 lived on the unit. CNA2 confirmed she was placed on administrative leave and returned to the Limestone [NAME] unit. CNA2 stated she did not enter R16's room and denied the abuse allegations made by R16. During an interview on 09/17/24 at 2:52 PM, the Administrator and the Interim DON were asked if CNA2 was still on the Limestone [NAME] Unit. The Administrator stated CNA2 needed to be removed from the unit immediately. The Administrator stated CNA2 did not go into R16's room. During an observation on 09/17/24 at 3:00 PM, CNA2 was in a resident room providing care while on the Limestone [NAME] Unit. During an interview on 09/17/24 at 4:19 PM, the Interim DON stated she could not locate any additional grievances made by R16 against CNA2. The Interim DON stated even though there were continued complaints made by R16 regarding CNA2 there were no additional investigations. During an interview on 09/17/24 at 4:42 PM, Assistant Director of Nursing (ADON) confirmed she was the Nurse Manager for the Limestone [NAME] Unit. The ADON stated she was not directed by the facility to monitor CNA2 after the 05/14/24 abuse allegation. During an interview on 09/18/24 at 8:05 AM, R16 stated she was aware CNA2 was on the same unit as her since she could see CNA2 in the hallway next to her room on a regular basis. 37590 2. Review of R43's quarterly MDS, with an ARD of 8/20/24 and located in the Electronic Medical record (EMR) under the MDS tab, revealed R43 was admitted to the facility on [DATE], had diagnoses that included Alzheimer's disease, and had a BIMS score of one out of 15, which indicated the resident was severely cognitively impaired. Review of R43's Care Plan, located under the Care Plan tab of the EMR, revealed that the resident had a diagnosis of Alzheimer's dementia, resulting in increased disorientation and need for reminders. Review of a facility reported incident, dated 07/17/24, revealed that at approximately 12:00 PM, Activities Therapy Assistant (ATA) 1 expressed to Registered Nurse (RN) 2 that during meal service in the lower 300-unit dining room, Certified Nursing Assistance (CNA) 3 was verbally aggressive and physically prevented R43 from standing by placing her knee in the back of R43's chair to prevent the resident from sliding her chair and standing. Per the facility provided abuse investigation documentation, a written statement by ATA1 advised that she told RN2 that R43 would not stay seated during the meal service. The written statement continued, advising that CNA3 could be heard saying [R43] stop that right now in a way that made ATA1 uncomfortable, and she felt she needed to report it. ATA1 added that she also witnessed CNA3 put her knee on the back of [R43]'s chair so she couldn't move. During an interview on 09/17/24 at 12:00 PM, the Administrator was asked about the facility's investigation into R43's facility-initiated abuse allegation, and she initially stated their investigation found the allegation was a misunderstanding between staff members and reported hearsay. In a subsequent interview on 09/17/24 at 3:00 PM, the Administrator was asked about the witness statements and how they were written as if they were eyewitness testimony. The Administrator stated that after discussing the incident with the team, she confirmed that the statements alleging abuse were not hearsay. She was asked if there was any additional investigation conducted. The Administrator stated that her goal for their investigation was to safeguard the resident, educate the staff, and report it if necessary. She stated that the incident involving R43 was reported on 07/17/24 at 3:16 PM, and CNA3 was immediately put on administrative leave.

Based on interview, record review, and policy review, the facility failed to ensure a Certified Nurse Aide (CNA) 1 reported allegations of physical abuse by Licensed Practical Nurse (LPN) 3 against Resident (R) 93 immediately to the Administrator for 1 out of a sample of 22 residents reviewed for abuse. This failure increased the risk of other vulnerable residents for further physical abuse. Findings include: Review of a facility polity titled Abuse, Neglect, Mistreatment dated 01/26/24 indicated .It is the policy of this facility that all allegations of abuse, neglect, exploitation, mistreatment .are reported per Federal and State Law.The facility will ensure that all alleged violations as noted will be reported immediately, but no later than two hours after the allegation is made. Review of a facility document for R93 titled Face Sheet provided by the facility indicated the resident was admitted to the facility on [DATE] with a diagnosis of dementia. Review of a facility document for R93 titled quarterly Minimum Data Set (MDS) provided by the facility with an Assessment Reference Date (ARD) of 06/11/24 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which revealed the resident was moderately cognitively impaired. The assessment indicated the resident had no behaviors directed to self or to others. Review of facility document titled Misconduct Incident Report dated 06/25/24 provided by the facility indicated at 3:30 AM, CNA1 alleged she observed LPN3 enter R93's room and grabbed the back of the resident's neck and forcibly gave her medication in which the resident then spit out. The report indicated CNA1 delayed in reporting her observation to the night shift supervisor Registered Nurse (RN)3. The report revealed CNA1 then reported the observation to RN2 who was the day shift nurse supervisor. The report indicated CNA1 was provided additional training on reporting timely concerns on alleged abuse. The investigation indicated LPN3 was an agency nurse, and the facility requested that LPN3 not return back to the facility due to other professionalism concerns. The report revealed RN3 interviewed R93, and the resident denied any allegations of abuse. The facility concluded the allegation of abuse was unsubstantiated. In addition, the facility interviewed staff and other residents as part of their investigation. On 09/17/24 at 11:15 AM, an attempt was made to contact CNA1, and it was not successful. During an interview on 09/17/24 at 11:16 AM, RN3 confirmed she was the night nursing supervisor who worked on 06/25/24. RN3 stated that CNA1 never shared any concerns of potential abuse with her which involved RN1 and R93. RN3 stated if CNA1 had reported any potential abuse allegations, she would have immediately removed RN1, gathered a statement from RN1, and then sent her home. RN3 stated this process was to be done to protect the resident(s). RN1 stated staff were to report all allegations of potential abuse immediately. During an interview on 09/17/24 at 11:33 AM, LPN3 stated she was not suspended on 06/25/24. LPN3 denied the allegations of potential abuse against R93. During an interview on 09/17/24 at 12:20 PM, RN2 confirmed she was the staff member CNA1 reported the potential abuse allegations to on 06/25/24 sometime between 6:30 AM and 7:00 AM. RN2 stated she remembered asking CNA1 why the delay in reporting and was told by CNA1 that she believed RN3 and LPN1 were friends. RN2 stated as part of her investigation she gathered a statement from CNA1 and R93. RN2 stated the resident has advanced dementia and could not remember anything about the incident. RN2 stated the reason allegations of potential abuse need to be reported immediately was to be able to protect the resident. During an interview on 09/17/25 at 12:54 PM, the Administrator stated staff were to report all allegations of potential abuse immediately.

Based on interviews and record reviews, the facility failed to ensure that allegations of abuse were thoroughly investigated for two residents (Resident (R)16 and R43) out of a sample of 22 residents reviewed for abuse. This lack of investigation had the potential to lead to continued episodes of physical and verbal abuse. Findings include: Review of a facility polity titled Abuse, Neglect, Mistreatment dated 01/26/24 indicated . To comply with the eight-step approach to abuse and neglect detection and prevention. The abuse policy will be reviewed on an annual basis and will be integrated into the Facility Assurance and Performance Improvement program. The eight components are composed of screening, training, prevention, identification, investigation, protection, reporting and response . designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed . 1. Review of a facility document for R16 titled Face Sheet provided by the facility indicated the resident was admitted to the facility on [DATE]. Review of a facility document titled Interview with [R16] provided by the facility dated 05/14/24 indicated R16 voiced she was still scared of CNA2. The document indicated the resident voiced that CNA2 did not assist her with cares such as will leave her walker away from her and then CNA2 will just stand, wait, and not offer the resident assistance. The document revealed the resident asked that CNA2 not provide her care since she was scared of CNA2. This note was written by (Interim) Director of Nursing (DON). Review of a facility file referred to as an investigative file for R16 provided by the facility contained documents titled Customer Service Questions, all dated 05/14/24 all collected on the date of the potential abuse allegation made by R16. There were no specific questions directed to each resident interviewed which asked if they had been abused by any staff member during their stay at the facility. During an interview on 09/18/24 at 10:01 AM, the Administrator stated the issue with R16 was a customer service issue and not potential abuse. The Interim Director of Nursing (DON) was present during the interview. 37590 2. Review of R43's quarterly MDS, with an ARD of 8/20/24 and located in the EMR under the MDS tab, revealed R43 was admitted to the facility on [DATE], had diagnoses that included Alzheimer's disease, and had a BIMS score of one out of 15, which indicated the resident was severely cognitively impaired. Review of R43's Care Plan, located under the Care Plan tab of the EMR, revealed that the resident had a diagnosis of Alzheimer's dementia, resulting in increased disorientation and need for reminders. Review of a facility reported incident, dated 07/17/24, revealed that at approximately 12:00 PM, Activities Therapy Assistant (ATA)1 expressed to Registered Nurse (RN) 2 that during meal service in the lower 300-unit dining room, Certified Nursing Assistance (CNA) 3 was verbally aggressive and physically prevented R43 from standing by placing her knee on the back of R43's chair to prevent the resident from sliding her chair away from the table. Per the facility provided abuse investigation documentation, a written statement by ATA1 advised that she told RN2 that R43 would not stay seated during the meal service. The written statement continued, advising that CNA3 could be heard saying [R43] stop that right now in a way that made ATA1 uncomfortable, and she felt she needed to report it. ATA added that she also witnessed CNA3 put her knee on the back of [R43]'s chair so she couldn't move. There was no documentation the incident had been investigated as an allegation of abuse. During an interview on 09/17/24 at 12:00 PM, the Administrator was asked about the facility's investigation into R43's facility-initiated abuse allegation, and she initially stated their investigation found the allegation was a misunderstanding between staff members and reported hearsay. In a subsequent interview on 09/17/24 at 3:00 PM, the Administrator was asked about the witness statements and how they were written as if they were eyewitness testimony's. The Administrator stated that after discussing the incident with the team, she confirmed that the statements alleging abuse were not hearsay. She was asked if there was any additional investigation conducted. The Administrator stated that her goal for their investigation was to safeguard the resident, educate the staff, and report it if necessary. She stated that the incident involving R43 was reported on 07/17/24 at 3:16 PM, and CNA3 was immediately put on administrative leave.

Based on record review and interview, the facility failed to ensure one of one Resident (R) (R34's) clinical records out of a sample of 22 residents contained evidence the resident and/or her representative participated in the development or revision of her care plan. Findings include: Review of a facility document for R34 titled Face Sheet provided by the facility indicated the resident was admitted to the facility on [DATE]. Review of a facility document referred to as a Nursing Progress Notes provided by the facility dated 03/19/24 revealed the clinical record contained evidence R34 participated in the development/revision of her Care Plan. Review of a facility document untitled referred to a care plan invite, provided by the facility dated 05/23/24 indicated R34 was invited to participate in her care conference which was scheduled on 06/21/24. Review of R34's record failed to contain evidence the resident and/or her representative participated in her care conference scheduled on 06/21/24. Review of a facility document for R34 titled annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/12/24 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which revealed the resident was cognitively intact. The assessment indicated the resident had no behaviors. During an interview on 09/16/24 at 10:16 AM, R34 stated she did not get invited to participate in her care conference. During an interview on 09/18/24 at 1:50 PM, the Social Worker (SW) stated each resident receives an invitation to participate in their care conferences. SW stated the electronic medical record (EMR) would have documentation to support the resident and/or their representative participated in the care plan meeting. During this interview, SW reviewed the EMR and confirmed the last entry was dated 03/19/24 which showed the resident had participated in her care plan meeting. During an interview on 09/19/24 at 10:17 AM, the Administrator stated the facility had no care plan policy. During an interview on 09/19/24 at 10:33 AM, the Interim Director of Nursing (DON) stated her expectation was for the care plan meetings to be documented in the clinical record and to identify the resident and/or representative and the disciplines who participated in these quarterly meetings.

Based on observation, interview, and record review the facility did not ensure that residents with an indwelling catheter received the appropriate care and services to prevent a urinary tract infection (UTI) for 3 of 5 Residents (R90, R243, R89) reviewed for catheters as catheter bags were observed to be uncovered and resting/touching on the floor. Findings include: Review of the facility's Infection Prevention and Control Program, dated 01/26/24, revealed that the . primary mission is to establish and maintain an Infection Prevention and Control Program (IPCP) designed to provide a safe, sanitary and comfortable environment and to help prevent, treat, and control the development and transmission of communicable diseases and infection . 1. Review of R90's Face Sheet, undated and located in the resident hard chart, revealed R90 was admitted to the facility on [DATE] with diagnoses that included UTI, chronic kidney disease, and hypertension. According to the admission Minimum Data Set Assessment (MDS), with an Assessment Reference date of 08/05/24 and located in the electronic medical record (EMR) under the MDS tab, R90 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated the resident was moderately cognitively impaired. During an observation on 09/16/24 at 12:45 PM, R90 was observed lying in bed with the bed in the lowest position. R90's urinary catheter bag was observed lying directly on the carpeted floor, folded in half, with the tubing resting on the floor, and positioned above the level of the bladder. R90's bedspread was observed covering half of the catheter bag. Urine was observed in the tubing. During an observation on 09/16/24 at 2:00 PM, R90 was observed lying in bed with the bed in the lowest position. R90's urinary catheter bag was observed lying directly on the carpeted floor, folded in half, with the tubing resting on the floor, and positioned above the level of the bladder. R90's bedspread was observed covering half of the catheter bag. During an observation on 09/16/24 at 4:00 PM, R90 was observed lying in bed with the bed in the lowest position. R90's urinary catheter bag was observed lying directly on the carpeted floor, folded in half, with the tubing resting on the floor and wrapped around the wheels of the overbed table, and was positioned above the level of the bladder. During an observation on 09/17/24 at 10:15 AM, R90 was observed lying in bed, with the bed in the lowest position. R90's urinary catheter bag was observed lying directly on the carpeted floor, folded in half, with the tubing resting on the floor, and positioned above the level of the bladder. During an observation on 09/18/24 at 12:40 PM, R90 was observed lying in bed with the bed in the lowest position. R90's urinary catheter bag was observed hooked to the bedframe, and the bottom half of the bag was folded in and touching the carpeted floor and positioned at the level of the bladder. Urine color was observed to be an amber color, no sediment but some mucous and no odor noted. During an observation and interview on 09/18/24 at 3:15 PM, the Interim Director of Nursing (IDON) and surveyor observed R90 in bed, with her catheter bag hooked to the bedframe. The bottom half of the bag was folded in on itself and touching the carpeted floor, and it was positioned at the level of the bladder. Urine color was observed to be amber colored. There was some mucous noted. The catheter bag was not covered with a dignity bag. The IDON acknowledged the urinary catheter bag should not be touching the floor or folded in on itself. The IDON was unable to confirm if urinary catheter bags should be contained in a dignity bag or protective bag, regardless of whether the resident was in or out of their room. 2. Review of R243's undated Face Sheet, located in the residents' hard chart, revealed R243 was admitted to the facility on [DATE] with diagnoses that included heart failure, urinary retention (lack of ability to urinate and empty the bladder), and hypertension. According to the admission MDS, with an ARD of 09/18/24 and located in the EMR under the MDS tab, R243 had a BIMS score of 11 out of 15, which indicated the resident was moderately cognitively impaired. During an observation on 09/16/24 at 1:00 PM, R243 was observed lying in bed, with his urinary catheter bag hanging from the bed frame, uncovered, and positioned above the level of the bladder. Urine color was observed to be deep golden yellow, and in the tubing. During an observation on 09/16/24 at 1:45 PM, R243 was observed lying in bed, and his catheter bag was observed hanging from the bed frame, uncovered, and positioned above the level of the bladder. Urine color was observed to be deep golden yellow, with no sediment noted. There was urine in the tubing. During an observation on 09/16/24 at 4:15 PM, R243 was observed lying in bed, and his catheter bag was observed hanging from the over bed table which placed the catheter bag above the level of his bladder. The catheter bag was uncovered. Urine color was observed to be deep golden yellow, with no sediment noted. There was urine in the tubing. During an observation on 09/17/24 at 10:10 AM, R243 was observed lying in bed, and his catheter bag was observed hanging from the bed frame even with the level of his bladder. The bag was uncovered, and the tubing was touching the floor. Urine color was observed to be deep golden yellow, with no sediment or odor noted. During an interview and observation of R90 and R243 on 09/18/24 at 2:05 PM, Certified Nursing Assistant (CNA) 5 stated Our policy is to have catheter bags covered when the resident was out of their room, but not when they are in their room He also stated catheter bags should not be resting on or touching the floor, should be below the level of the bladder, and not attached to items like the residents' over bed table. During an observation and interview on 09/18/24 3:20 PM with the Interim Director of Nursing (IDON), R243 was observed in his bed, his urinary catheter bag was hooked to the bedframe, at the level of his bladder, and urine observed in the tubing, however the knees of the bed were approximately at a 30-degree angle, which placed the catheter tubing at risk for backflow of urine into his bladder. The catheter bag was not touching the floor. The IDON acknowledged the catheter bag should have been placed lower than the bladder level. During an interview on 09/19/24 at 10:54 AM, the Infection Preventionist (IP) stated she would conduct random walk throughs in the facility to observe residents with catheters. She stated she would be looking for proper placement or any potential infection control practices with care/maintenance. The IP further stated she was not aware of the observations made during the survey period of R90 and R243, and had she observed the catheters on the floor, or touching the floor, she would have spoken with the staff and corrected the situations. She further stated it was not appropriate for urinary catheter bags to be placed/lying directly on the floor, shoved under the bed, tubing wrapped around the over bed tables, catheter bags hooked to the over bed table, or placed above the level of the resident's bladder. The IP stated those practices increased the potential risk of infection of UTIs for residents. Multiple requests were made during the survey period for policies regarding infection control practices with care/maintenance of urinary catheters, and the IDON, IP and Administrator were unable to provide any. 37590 3. Review of R89's EMR revealed that she was readmitted to the facility on [DATE] with diagnoses that included urinary retention. Review of R89's Care Plan, dated 09/12/24 and provided by the facility, revealed a problem related to R89's urinary catheter, with interventions that included taking care of the catheter equipment and covering for privacy while outside the resident's room. R89 was observed on 9/16/24 at 12:11 PM, in the lower 300-unit dining room, seated in a wheelchair. R89's urinary catheter bag and tubing were touching the floor. During an observation on 09/16/24 at 2:35 PM, R89 was in her room, reclined in a chair, and with her legs and feet elevated. R89's catheter tubing was hanging from the elevated leg rest and came in contact with the floor. The catheter bag and the dignity cover, which was not covering the catheter bag, were both in contact with the floor. The catheter bag and dignity cover were attached to the lower bar on the resident's walker. During an observation on 9/17/24 at 5:28 PM, R89 was seated in her wheelchair in the lower 300 dining room. R89's catheter bag and tubing were touching the floor. During an interview on 09/17/24 at 5:30 PM, Registered Nurse (RN) 5 confirmed the observation and stated that the catheter bag and tubing should not be in contact with the floor, as this could lead to possible contamination and infection. During an interview with the Infection Preventionist (IP) on 09/19/24 at 10:40 AM, the IP confirmed that it was not best practice for a catheter and/or accessories to come in contact with the floor. She added that she completed annual training and as needed training regarding infection control with all clinical staff, as well as conducting random walkthroughs to confirm that staff were following infection control best practices and facility protocols.

Based on interview, personnel file review, and policy review, the facility failed to ensure 1 of 2 Certified Nurse Assistant (CNA) (CNA2) reviewed was provided an annual performance review. This failure had the potential for decreased quality of life or quality of care for the residents. Findings include: Review of the personnel file of CNA2 revealed a copy of a document titled Performance Review and was date stamped 01/10/23. There was no current performance reviews contained in CNA2's employee record. During an interview on 09/18/24 at 3:28 PM, the Human Resource Director (HRD) stated the last performance review in CNA2's employee record was completed on 01/10/23. The HRD stated there were no current policies available for annual performance reviews of the nursing home staff. During an interview on 09/19/24 at 10:33 AM, the Interim Director of Nursing (DON) stated the county currently requires bi-annual employee performance reviews and prior to this current change it was the expectation for the facility to conduct performance reviews on an annual basis.

Based on interview and record review, the facility failed to ensure the medication regimen was free from unnecessary medications for one (Resident (R) 43) of five residents reviewed for unnecessary medications out of a total sample of 24. The facility failed to ensure staff did not administer as needed (PRN) lorazepam (Ativan, a psychotropic anxiolytic medication) to R43 without indication for use and failed to ensure the PRN lorazepam was not prescribed beyond 14 days without documented rationale. Findings include: Review of the facility's policy titled, Psychotropic Medication Policy and Procedure, last updated 01/26/24, revealed, . Psychotropics medication may be prescribed on a PRN basis in certain situations . When a PRN psychotropics medication is ordered, the medical record will include: indication/clinical need for medication, dose and frequency for use, non-pharmacological interventions to be identified, tried, documented before administering the medication. Review of R43's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/20/24 and located in the electronic medical record (EMR), revealed R43 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and had a Brief Interview for Mental Status (BIMS) score of 1 out of 15, which indicated the resident was severely cognitively impaired. Review of R43's Physician Orders, located in the EMR under the Physician Orders tab, revealed an order, dated 03/14/24, for Lorazepam 0.5mg [milligrams] . twice a day as needed For: Agitation associated with Dementia . There was no stop date for the order. Review of R43's Note to Attending Physician/Prescriber, dated 06/17/24, signed by the pharmacist, and provided by the facility, revealed, . PRN psychotropic orders to be written for more than 14 days. If PRN psychotropic orders are deemed necessary beyond this time, clinical rationale and a specific duration need to be provided by the prescriber . R43's physician returned a response on 06/23/24 that stated that discontinuing the medication is contraindicated. There was no rationale documented. Review of R43's Medication Administration Record (MAR), dated 07/19/24 through 09/19/24 and provided by the facility, revealed R43 received PRN lorazepam on 08/24/24, 09/03/24, 09/06/24, 09/08/24, and 09/11/24. Review of the corresponding nursing notes in the EMR did not reveal any associated behaviors for the use of the lorazepam or if any types of non-pharmacological interventions were attempted. During an interview on 09/19/24 at 11:39 AM, the Interim Director of Nursing (IDON) stated she had assumed the physician's response that discontinuing R43's lorazepam was contraindicated was sufficient to continue the PRN medication. She confirmed the nursing documentation related to the times R43 received PRN lorazepam was not adequate to show why the resident received the doses. The IDON stated she would educate the nursing staff on documenting behaviors in relation to administering PRN psychotropic medications.

Based on observation, interview and record review, the facility failed to ensure medical records were complete and accurate for 1 resident (R), R89, of 22 residents sampled. The facility failed to ensure R89 had orders for an indwelling urinary catheter. This had the potential to cause R89's care needs to go unmet. Findings include: Review of R89's electronic medical record (EMR) revealed R89 was readmitted to the facility on [DATE] following a hospitalization with diagnoses that included urinary retention. Review of R89's hospital records, provided by the facility, revealed R89 had a failed voiding trial, and an indwelling urinary catheter was inserted while the resident was in the hospital. Review of R89's Physician Orders, located under the Physician Orders tab of the EMR, revealed an order to measure R89's urinary output three times daily. There was no order for a urinary catheter. Review of R89's Care Plan, dated 09/12/24 and provided by the facility, revealed a problem related to R89's need for a urinary catheter. The goals included reporting concerns and having no signs or symptoms of urinary tract infections. Interventions included documenting urinary output and notifying the physician of any changes. During observations on 09/16/24 at 12:11 PM and 2:35 PM and 09/17/24 at 5:28 PM, R89 was observed to have an indwelling urinary catheter. During an interview on 09/19/24 at 10:33 AM, the Interim Director of Nursing (IDON) confirmed that hospital transfer orders should be reconciled and confirmed upon admission and readmission with the resident's physician. The IDON stated she was not aware of the missing orders for the urinary catheter for R89 but stated that she expected staff to confirm orders and for physicians to reconcile resident orders every 30 days. The Medical Director was interviewed on 09/19/24 at 12:52 PM. He confirmed that all transfer orders must be verified and confirmed with the resident's physician. He stated that he was not aware of the missing order for R89, but that staff could contact him if they were having an issue contacting any of the residents' primary care physicians. The facility was asked to provide a policy related to physician orders, and the IDON advised on 9/19/24 at 12:00 PM that they did not have a policy related to physician orders.

Based on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer one of five residents reviewed for flu/pneumonia vaccinations (Resident (R) 71) and/or their representatives, the opportunity for the residents to be vaccinated with Pneumococcal 20-valent Conjugate Vaccine PCV 20 or Pneumococcal polysaccharide vaccine 23 (PPSV23), in accordance with nationally recognized standards out of a total sample of 22 residents. Findings include: Review of the CDC website titled Pneumococcal Vaccination: Summary of Who and When to Vaccinate, effective 01/28/22, indicated . CDC recommends pneumococcal vaccination for all adults [AGE] years or older . For adults [AGE] years or older who have not previously received any pneumococcal vaccine, CDC recommends you . Give 1 dose of PCV [Pneumococcal Conjugate Vaccine] 15 or PCV20 . If PCV15 is used, this should be followed by a dose of PPSV 23 [Pneumococcal polysaccharide vaccine] at least one year later. The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak . If PCV20 is used, a dose of PPSV23 is NOT indicated . For adults [AGE] years or older who have only received a PPSV23, CDC recommends you . May give 1 dose of PCV15 or PCV20 . The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For adults [AGE] years or older who have only received PCV13, CDC recommends you . Give PPSV23 as previously recommended . For adults who have received PCV13 but have not completed their recommended pneumococcal vaccine series with PPSV23, one dose of PCV20 may be used if PPSV23 is not available. If PCV20 is used, their pneumococcal vaccinations are complete . For adults who received PCV13 at any age and PPSV23 after age [AGE] years . use shared clinical decision-making to decide whether to administer PCV20 . Review of a facility policy titled Pneumococcal Vaccines dated 01/26/24 indicated .To reduce morbidity and mortality from pneumococcal disease by vaccinating all adults who meet the criteria established by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices.Rock Haven will follow CDC recommendations for the administration of pneumococcal vaccine as directed by signed standing order from our Medical Director and in collaboration with contracted pharmacy and/or community physicians of our residents. Review of a facility document for R71 titled Wisconsin Immunization Registry printed 9/16/24 provided by the facility indicated the resident received the Prevnar 13 (PCV13) vaccine on 8/31/22 prior to her admission to the facility. Review of a facility document for R71 titled Face Sheet provided by the facility indicated the resident was admitted to the facility on [DATE]. The resident was over the age of 65 when she was admitted to the facility. During an interview on 09/19/24 at 10:27 AM, the Infection Preventionist (IP) stated R71 received the PCV13 prior to her admission to the facility. During this interview, she confirmed R71 should have been offered PCV20 one year after she was administered the PCV13.

Based on record review, interview, and facility policy review, the facility failed to notify the resident and resident's representative (RR) of a transfer or discharge in writing for one of one resident (Resident (R) 6) reviewed for hospitalization . This created a potential for the resident or their resident representative to have incomplete information, misunderstand the reason, and process for transfer or discharge, and the discharge appeal process. Findings include: Review of a facility policy titled Involuntary Transfer/Discharges 01/26/24, indicated .When discharging to another facility or continuum of care documentation in the resident's medical record must include.The facility will notify the residents and the resident's representative(s) of the transfer or discharge in writing and in a language and manner they understand. The Facility will also send a notice to the Office of the State Long Term Care Ombudsman.The state's department of protection and advocacy for the mentally ill or those with developmental disabilities will also be notified if applicable. The resident has 7 days from the notice to appeal the discharge or transfer.The facility policy failed to address the following aspects: 1. The transfer notice must be in writing and in a language that the resident and/or the representative understands. 2. The transfer notice must identify the location and the reasons for the transfer. 3. If the facility has a resident with an intellectual disability or related disability, the transfer notice must include the name, mailing address, email address, and telephone number for the agency for the protection and advocacy of people with developmental disabilities. 4. If the facility has a resident with a mental disorder or a related disability, the transfer notice must include the name, mailing address, email address, and the telephone number for the protection and advocacy of people with mental illness. Review of a facility document for R6 titled Face Sheet provided by the facility indicated the resident was admitted to the facility on [DATE]. Review of a facility document for R6 referred to as the Nursing Progress Notes dated 08/21/24 provided by the facility revealed the resident sustained a change in her condition and sent to the local hospital for evaluation and treatment. There was no evidence the facility provided the resident and/or her representative with a written transfer notice. On 09/16/24 the Progress Note indicated the resident sustained a change in her condition and was sent to the local hospital for evaluation and treatment. There was no evidence the facility provided the resident and/or the representative with a written transfer notice. During an interview on 09/18/24 at 11:21 AM, Licensed Practical Nurse (LPN) 1 stated when a resident was sent to the hospital a written bed hold notice was sent with the resident and a transfer notice was given to the hospital. LPN 1 stated the family was always notified, by phone, when a resident was sent to the local hospital when there was a change in their condition. During an interview on 09/18/24 at 1:41 PM, the Administrator was asked when a resident was transferred to the local hospital for a medical emergency, was a written transfer notice sent with them. The Administrator confirmed there was no written transfer notice given to the resident and/or the RR.

Based on observation, interview, and record review, the facility did not ensure it maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections. The facility does not have a water management plan that identifies all areas where Legionella and other opportunistic waterborne pathogens can grow and spread. This had the potential to affect all 89 residents (R) in the facility. The facility's water management plan did not identify/assess through text and flow diagrams areas where Legionella and other opportunistic waterborne pathogens can grow and spread. This is evidenced by: The facility policy titled, Legionella Plan, undated, indicates, in part: . The following references are incorporated in the Disaster Preparedness Plan and indicate actions that will be taken in the event of Legionella Disease detection . The chlorine dioxide generator mitigates the development of Legionella disease in the water system. A sample of water is taken and tested daily in different areas of the facility and is also tested monthly by our water treatment company to ensure the chlorine stays within the specified range. Our water treatment company collect and tests samples annually for Legionella . The CDC Legionella Toolkit-Version 1.1 - June 24, 2021, Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings. A Practical Guide to Implementing Industry Standards, indicates, in part: Page 4 - Where can Legionella grow and/or spread? . *Water heaters . *Electronic and manual faucets . *Showerheads and hoses . *Ice Machines . Page 8 - Describe Your Building Water Systems Using Text .You will need to write a simple description of your building water system and devices .This description should include details like where the building connects to the municipal water supply, how water is distributed, and where pools, hot tubs, cooling towers, and water heaters or boilers are located . Page 10 - Describe Your Building Water Systems Using a Flow Diagram .In addition to developing a written description of your building water system, you should develop a process flow diagram . Page 11 - Identify Areas Where Legionella Could Grow & Spread .Once you have developed your process flow diagram, identify where potentially hazardous conditions could occur in your building water system . Record Review indicated: On 3/10/22 Legionella water test was negative from the water contractor. On 5/11/23 Legionella water test meaured 0.4 indicating Legionella feeleii from the water contractor. ( Of note, this is at an exceptable range.) On 5/31/23 Legionella water test indicated NLI (No Legionella Isolated) from the water contractor. On 7/12/23 at 8:43 AM, Surveyor interviewed MS E (Maintenance Supervisor). Surveyor asked MS E to identify areas where Legionella could grow or spread, he indicated there is a wing that is currently shut down and every week they run all the sink, showers, and flush toilets. Surveyor asked MS E to identify an outside source that could affect the facility for Legionella, he indicated construction, remodeling, or a water main break. MS E further indicated of a water main break on 4/21/23 he observed while coming to work that was located on the same road as the facility and the city reported to him that it was the responsibility of the facility. MS E indicated he then called their normal plumbing contractor that took care of the water main break. Surveyor asked MS E if he had any text or flow diagrams, he indicated he did not and that their contracted company come in to do the testing annually for Legionella. MS E further indicated they did find a trace of Legionella in the bakers sink in the kitchen that was found on a routine test, the system was flushed, and another test was taken and was negative. On 7/12/23 at 10:24 AM, Surveyor interviewed FSM D (Food Service Manager). Surveyor observed the bakers sink located in the kitchen with FSM D. FSM D identified the sink as the bakers sink. Surveyor asked FSM D how the sink is used, she indicated to wash fruits and vegetables and was the bakers prep area. Surveyor asked FSM D how often the sink water was tested , she indicated every month. Surveyor asked FSM D if she has been notified of any positive Legionella test and if she would expect to be notified, she indicated there has not been any positive Legionella test and would expect the maintenance department to inform her. Surveyor asked FSM D if the bakers sink has stopped being used at anytime, she indicated only when the maintenance department takes a water sample to let the water run. On 7/13/23 at 8:34 AM, Surveyor interviewed RN, IP C (Registered Nurse, Infection Preventionist). Surveyor asked RN, IP C if she has been notified of any positive lab legionella water tests in the facility, she indicated that she has not since she has been here at the facility. Surveyor asked RN, IP C how she would be informed of a positive lab result, she indicated the maintenance department. On 7/13/23 at 11:06 AM, Surveyor interviewed MS E again. Surveyor asked MS E to describe the steps taken from the water main break on 4/21/23. MS E indicated he did not see the water main break as a concern, the water main break was by the other building, and it was isolated. Surveyor asked MS E if there was any additional water testing performed, he indicated the water contractor monitors remotely and the Legionella test is done annually. Surveyor asked MS E the steps taken when the Legionella water tested positive at 0.4 on 5/11/23 the steps taken to mitigate, he indicated the system was flushed and the test was repeated on 5/31/23. Surveyor asked MS E of the water test done on 5/11/23 was a routine test, he indicated yes, and their water contractor should have tested sooner as the Legionella test done prior was on 3/10/22. Surveyor asked MS E the reasoning for a delayed annual test from the water contractor, he indicated he was informed it was due to their staffing. Surveyor asked MS E if anyone was informed of the positive Legionella test on 5/11/23, he indicated he informed NHA A. Surveyor asked MS E again if he had any text or water flow diagram, he indicated he did not and will work with the water contractor to have them by the next survey. On 7/13/23 at 12:54 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked if a water main break is a concern for legionella and what would you do if Legionella was present in the facility. NHA indicated that Legionella is a concern and would automatically not use anything from the faucets, to use bottled water, the residents would receive a bath by using wipes, making sure the water is boiled when using with food, having a rapid response and may have to investigate evacuation procedures. Surveyor asked NHA A if she has been notified of a positive Legionella test, she indicated she was notified and was tested again that resulted in a negative test result. Surveyor asked NHA A if the outbreak team included the RN, IP C, she indicated yes. Surveyor asked NHA A for a text or water flow diagram, she indicated she did not after checking the emergency disaster book.

Based on interview and record review, the facility did not ensure that a Discharge Summary, with a recapitulation of the resident's stay includes, but is not limited to: diagnosis, course of illness/treatment or therapy, pertinent lab, radiology, and consultant results was developed for 1 of 1 sampled residents (R94) reviewed for discharge summary/recapitulation. R94 did not have recapitulation of stay or a discharge care plan prior to being discharged from the facility. Findings include The facility's policy, titled Discharge Planning states the following *The interdisciplinary team shall prepare a comprehensive discharge plan with the resident and resident representative to assist the resident to reach their discharge goal. *A discharge summary will be completed upon discharge to include: a) A recapitulation of the residents stay in the facility (diagnosis, course of illness, treatment, therapy, lab, radiology, and consultation reports.) b) A final summary of the resident status. R94 was admitted to the facility on [DATE] and was discharged from the facility to his home with services on 6/13/23. The facility completed a post-discharge plan of care, dated 6/13/23, that stated R94 would be returning home with his daughter and receiving physical and occupational therapy at an outpatient facility. The facility did not have or provide Surveyors a recapitulation of R94's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. On 7/13/23 at 10:52 AM, Surveyor interviewed DON B (Director of Nursing) who stated that the facility usually has a face to face with the resident and a physician upon discharge; however, R94 was abruptly discharged from therapy services on 6/8/23 and the facility was unable to conduct their typical face to face with him before he left on 6/13/23. Additionally, DON B stated that the facility did not care plan R94's discharge but it is expected that one would have been completed with a day or two of being admitted to the facility.

Based on observation, interview, and record review the facility did not ensure each resident received the necessary care and services in accordance with professional standards of practice to meet each resident's physical needs for 2 of 5 sampled residents (R3 and R1). R3 was seen in the emergency roiagnom on [DATE] and diagnosed with a urinary tract infection (UTI) and bleeding from her bladder. On 3/5/23 R3's active bleeding from R3's bladder continued throughout the day. R3's physician was not updated on R3's continued bleeding. On 3/6/23 R3 was hospitalized , diagnosed with acute blood loss anemia, and administered two units of blood. R1 had a change of condition, including low oxygen saturations, and the facility failed to notify the physician timely with this condition change. Evidenced by: The facility Notification of Change of Condition policy, updated 11/2021, includes, in part, the following: I: Purpose: An acute change of condition (ACOC) as defined by AMDA (American Medical Directors Association) is a sudden, clinically important change from a patient's well established and documented baseline in physical, cognitive, behavioral, or functional domains. ACOCs may occur abruptly or over several hours to several days, presenting as physical changes or as changes in Function, Pain, Mood, Cognition, or Behavior. An acute change of condition, without intervention, may result in complications or death. II: Policy: A physician must be notified of any ACOC, including, but not limited to physical, cognitive, behavioral, or functional changes. Notification will occur within the timeframe of the nurse's (Discovering the change of condition) scheduled shift unless in the case of 911 emergent calls, which would dictate an immediate response. II: Procedure: Physician notification will occur, when there is any change of condition in a resident. AMDA (American Medical Directors Association) Acute Change of Condition in the Long-Term Care Setting, includes, in part, the following: Condition: Bleeding. Report Immediately: Uncontrolled or repeat episode within 24 hours. Grossly bloody urine. Per AMDA (American Medical Directors Association) guidelines, it states, in part: .an ACOC (acute change of condition) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death .When reporting information to a practitioner about a patient's condition, a nurse should not assume that the practitioner knows the patient well or can remember relevant details such as previous lab abnormalities or the patient's current medication regimen .Examples of Staff Roles and Responsibilities in Monitoring Patients With ACOCs .Staff nurse *Recognize condition change early, *Assess the patient's symptoms and physical function and document detailed descriptions of observations and symptoms, *Update the charge nurse or supervisor if patient's condition deteriorates or patient fails to improve within expected time frame, *Report patient status to practitioner as appropriate . AMDA guidelines provided to Surveyor by the facility state in part . Dyspnea: Immediate notification: Acute onset of change from usual pattern, OR with chest pain, labored respirations, or unstable vital signs. Example 1 R3 was readmitted to the facility on [DATE] after a hospitalization . R3's diagnoses include right renal stone, acute blood loss anemia, diabetes, dementia, and history of stroke. R3's most recent Minimum Data Set (MDS), dated [DATE], indicates R3 has moderate cognitive impairment, needs extensive assist of two persons for transfers and toileting, and is frequently incontinent of urine. R3's Emergency Department (ED) Provider Notes, dated 3/4/23, includes, in part, the following: Patient presents with bright red blood per rectum from the nursing home. Limited history from the patient as she seems to have dementia .Medical Decision Making: Patient appears to have hematuria rather than rectal bleeding. Rectal exam had no blood on it at the tip of the gloved finger, but blood appears to be dripping down from the urethral meatus. We will do a straight cath (catheterization) for urinalysis and culture .Details: Urinalysis consistent with UTI (urinary tract infection). Culture sent. Discussion of management or test interpretation with external provider(s): Patient with hematuria that is controlled and not causing urinary retention. Patient with UTI and will treat with cefdinir (an antibiotic) here and then for 5 days at the nursing home .Risk Details: Patient is safe for discharge as she lives in a nursing home and can get the antibiotics easily. Clinical impression as of 3/4/23 2010 (8:10 PM): Gross hematuria, Acute hemorrhagic cystitis. R3's Nurse's Notes include, in part, the following: 3/5/23, 5:13 AM, Urine Clarity: hematuria, with clots. Temp (temperature) - 97.6. 3/5/23, 12:41 PM, Urine Clarity: hematuria. 3/5/23, 1:08 PM, Urine Clarity: hematuria, antibiotics given. 3/5/23, 7:12 PM, Action: continue to observe, had bright red blood in 1st incontinent episode then passed 1 clot formed 3 cm (centimeters). 3/5/23, 9:51 PM, Urinary findings: gross hematuria. Urine clarity: red bloody. Urinary/renal infection remains on antibiotic for urinary tract infection. Action: continue to observe, fluids encouraged. [Of note, despite being on an antibiotic, R3 continues with gross hematuria yet the facility failed to update the physician of now gross hematuria.] 3/5/23, 10:39 PM, Urinary findings: passed 2 clots this shift with urination. Urinary/renal pain denies pain with urination, incontinent x (times) 3. Urine clarity: hematuria. Action: continue to observe, fluids encouraged, PM supv (supervisor) (RN C (Registered Nurse)) updated with condition. Of note the resident continues to pass clots despite antibiotic however the facility did not update the physician. 3/6/23, 12:15 AM, Urinary findings: continues to have bleeding from vag (vaginal)/rectal area. Of note resident continues to present with bleeding despite antibiotic however facility did not update the physician. 3/6/23, 7:08 AM, Transferred to acute care hospital ED (Emergency Department). Transportation: by ambulance. Time: 7:00 AM. Date: 3/6/23. Reason for transfer: Gastrointestinal/Genitourinary symptoms: Rectal bleeding with 4 large golf ball size clots. R3's Physician Discharge Summary, dated 3/9/23, includes, in part, the following: Principal/Final Diagnoses: Acute blood loss anemia .Patient Course & Care: .UA (urinalysis) was positive for large hematuria despite being treated for a UTI (urinary tract infection), FOBT (fecal occult blood test) was also noted to be positive therefore a CT (computed tomography) abdomen pelvis was ordered that showed a large 18 mm (millimeter) urethral stone causing some hydronephrosis there was also a large bladder hematoma concerning for a malignancy. Urology was consulted who performed a cystoscopy and urethral stent, given the size of the stone it could not be removed at this time. Therefore, they recommend following up with patient in one to two weeks for reassessment; they may need transfer to UW (University of Wisconsin) Urological service for percutaneous nephrostolithotomy (procedure to remove kidney stone). Gastroenterology was consulted for her hematochezia (rectal bleeding), during admission patient did not have any bloody bowel movements and hemoglobin remained stable after receiving two units (of blood) in the emergency department. Patient was noted to have elevated potassium levels likely secondary to decreased renal function given the urethral stone. Her K-Dur was held during admission. One day she was requiring extra oxygen so therefore repeat chest x-ray was done and showed worsening of a pleural effusion seen in 2020, she received 1 dose of IV (intravenous) Lasix and was back on room air after that. On 3/28/23 at 11:10 AM Surveyor interviewed RN F (Registered Nurse). Surveyor asked RN F what she would do if a resident continued to have gross hematuria. RN F stated the resident should be monitored, including vital signs, and amount of blood and color of blood in the urine. RN F stated if the bleeding continued or worsened a physician should be called. On 3/28/23 at 11:20 Surveyor interviewed LPN G (Licensed Practical Nurse). Surveyor asked LPN G what she would do if a resident continued to have gross hematuria. LPN G stated the resident should be monitored and if the resident continued with signs and symptoms or if the signs or symptoms worsened the resident's physician should be called. On 3/28/23 at 11:43 AM Surveyor interviewed MD H (Medical Doctor). Surveyor asked MD H about R3's continued genitourinary bleeding and when he would have expected staff to update MD H. MD H stated if passing bright red blood clots would have expected to update immediately and if signs and symptoms of hematuria continued. On 3/28/23 at 12:10 PM Surveyor interviewed IDON/RN B (Interim Director of Nursing). Surveyor asked RN B when she would have expected staff to update R3's physician when R3's genitourinary bleeding continued. IDON/RN B stated she would expect staff to update the physician immediately when R1's signs and symptoms continued. 39713 Example 2 R1 admitted to facility, on 8/18/22, following hospitalization for hypertensive heart and chronic kidney disease with heart failure and stage 1-4/unspecified kidney disease-Cardiorenal Syndrome. R1 is a DNR (do not resuscitate - if no pulse or breathing). R1 had the following diagnoses, in part: Pain, shortness of breath, chronic obstructive pulmonary disease (COPD), acute systolic heart failure, typical atrial flutter, Type 2 diabetes mellitus, and anxiety disorder. Per R1's care plan, notes the following in part . Initiated 10/13/22 . I: have been tested /treated for COVID19. BECAUSE I: tested positive for COVID-19 on 10/8/22. I SHOW THIS BY: Having a positive test and having mild symptoms, isolation during my 10-day infectious period. I need my nurse to --- Continue to monitor VS (vital signs), resp. (respiratory) status and cog. (cognitive) status q (every) shift for signs of infection. Communicate with family regarding health status and any changes. Resume routine testing per RT-PCR 90 days after positive test (do not test again until 1/06/23). I need my aides to --- Monitor for changes in condition and report to my nurse. Encourage use of face covering when out of room. Assist with frequent hand hygiene. Initiated 12/31/22 . I: can't complete my cares on my own. BECAUSE I: have chronic illness, CHF (congestive heart failure) and COPD. Have a hard time moving getting tired quickly being incontinent. I need my nurse to --- assess my functional level monitor my med use secure adaptive equipment for me assure my safety. I need my aides to --- check my skin during cares explain procedures to me. I repositioned in bed: with the help of 2 people doing 100% of the effort I use an assist bar. I transfer: With the help of 2 people extensive assistance. Repositioning: reposition me at least every 2 hours use pillows to position me comfortably. R1's Significant Change Minimum Data Set (MDS) dated [DATE] states in part .R1 requires extensive assistance of two staff members for bed mobility, toileting, and hygiene. R1 also requires extensive assistance of one staff member for dressing. Brief Interview of Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. R1's signed Physician Orders from 10/12/22, do not include any orders for Oxygen or parameters for physician notification if oxygen saturations are low. R1's admission standing orders dated 8/24/22, do not include any orders for Oxygen or parameters for physician notification if oxygen saturations are low. Review of R1's immunizations shows that R1 did not receive COVID-19 immunization. On 11/10/22 at 11:40 AM, nurse's notes state, offered and declined on: 11/10/2022, this RN (Registered Nurse) explained and left fact sheet from CDC (Centers for Disease Control) on COVID vaccine. Declination form scanned into chart. Note: R1 was not offered COVID-19 vaccination during her stay in the facility until after she was diagnosed and hospitalized with COVID-19. Nurses Note dated 10/14/22 at 11:33 AM, documents in part . Respiratory Findings: O2 (oxygen) Saturation: 91; Nasal/Sinus Discharge: none noted; Cough: none noted; Sputum: none noted; Lung Sounds: lungs are clear. Nurses Note dated 10/14/22 at 7:20 PM, documents in part . Respiratory Findings: O2 Saturation: 90% on room air; Cough: congested; Sputum: none noted; Lung Sounds: diminished, bases bilaterally. Mucus: none noted. Action: 7:20 PM continue to observe, encourage to rest, repositioned, head of bed elevated, encouraged cough and deep breathing. Nurses Note dated 10/15/22 at 1:41 AM, documents in part . No problems noted. Nurses Note dated 10/15/22 at 9:24 AM, documents in part . Respiratory Findings: O2 Saturation: 89. Nasal/Sinus Discharge: none noted. Cough: none noted. Sputum: none noted. Lung Sounds: Lungs are clear. Nurses Note dated 10/15/22 at 5:04 PM documents in part . Respiratory Findings: O2 Saturation: 93. Nasal/Sinus Discharge: none noted. Cough: nonproductive. Sputum: none noted. Lung Sounds: Lungs are clear. Mucus: none noted. Nurses Note dated 10/15/22 at 5:10 PM documents in part . Respiratory Findings: O2 Saturation: 93. Nasal/Sinus Discharge: none noted. Cough: none noted. Sputum: none noted. Lung Sounds: Lungs are clear. Mucus: none noted. Note: There is Respiratory Findings charted for R1 from night shift. Nurses Note dated 10/16/22 at 11:45 AM documents in part . Respiratory Findings: O2 Saturation: 89. Nasal/Sinus Discharge: none noted. Cough: none noted. Sputum: none noted. Lung Sounds: lungs are clear. Mucus: none noted. Nurses Note dated 10/16/22 at 4:42 PM documents in part . no problems noted. Note: There is Respiratory Findings charted for R1 from night shift. Nurses Note dated 10/17/22 at 10:07 AM documents in part . Respiratory Findings: O2 Saturation: 90. Cough: dry. Nurses Note dated 10/17/22 at 2:46 PM documents in part . Temperature: 99.5. O2 Saturation: 88% on room air. Note: Physician was not updated on residents Temperature and low oxygen saturation. Nurses Note dated 10/17/22 at 2:57 PM documents in part . Respiratory Findings: Cough. Cough: nonproductive. Lungs sounds: lungs are clear. Signs/Symptoms of Respiratory Distress: none present. Nurses Note dated 10/17/22 at 3:59 PM documents in part . O2 Saturation: 84% on room air. Nurses Note dated 10/17/22 at 4:52 PM documents . Procedure Done: 4:30 PM per cannula 4L (4 liters). Procedure Results: 4:51 PM tolerating well, Resident pulse ox (oximetry) increased from 84% to 87%. Action: 4:51 PM continue to observe, encourage to rest. Nursing supervisor notified of oxygen administration. Note: The facility did not have orders for oxygen at this time and the facility did not contact the physician for oxygen orders and/or to updated on change in condition. Nurses Note dated 10/17/22 at 5:08 PM documents in part . Family/Guardian Contact: Daughter - Resident gave nurse verbal permission to speak with daughter regarding her current health status. Regarding: Change in condition, daughter expressing concern that her mom is not doing well. She is failing health wise and was upset that 'no one had noticed her vitals were out of sort.' She feels that her mom is alone in the room and not feeling well. Upset that nursing told her that she presented fine but daughter sees a different side of her. Daughter wished her mom would sign up for hospice. This RN practiced active listening and made a plan with daughter to try and get R1 to increase her food/drink intake (she reports R1 is not eating/drinking unless assisted). RN assured daughter we would continue to provide quality care and safe care for R1. Nurses Note dated 10/17/22 at 8:32 PM documents in part . Temperature: 99.9. Temperature 98.6. O2 Saturation: 88% on O2: Resident on 4 L of O2 per NC (nasal cannula), O2 running from 82 to 92, but mostly staying at the 88% range. Action: Continue to observe. Note: The facility did not have orders for oxygen at this time and the facility did not contact the physician for oxygen orders and/or to updated on change in condition. Nurses Note dated 10/18/22 at 1:12 AM documents in part . O2 Saturation: 81-82% on room air. Procedure Done: Oxygen applied 2L via NC with no increase in saturation. O2 sats did not increase. Oxygen increased to 4L with sats at 84-87%. Resident was also repositioned to increase O2 sat. Supervisor notified and call placed to on call doctor. Physician gave this writer orders for oxygen and to send to ER (emergency room ) for evaluation for hypoxia related to complications due to COVID. 911 called and responded at 0005 (12:05 AM). Report was given to EMS (emergency medical services) and to ER. POA (power of attorney) was called by staff to updated him on resident's condition. POA stated he would be by his phone all night and to call him again with any new updates on condition or an admission to the hospital. Note: The facility initially put oxygen on R1 due to low oxygen saturation at 4:52 PM. The physician was not contacted or orders and/or to update on R1's condition for approximately 7 hours. Nurses Note dated 10/18/22 at 1:26 AM documents in part . oxygen Saturation: 81-82% on room air. Comments: see notes about sending to ER for low oxygen sats. Nurses Note dated 10/18/22 at 4:50 AM documents . Time: 4:41 AM. Note: Called ER and talked with resident's nurse, [name]. She stated that resident has double lung pneumonia and will be getting admitted for IV antibiotics. She states that resident is doing fine and is stable at this time. Nurse supervisor updated and POA will be contacted and informed. Hospital Admission History and Physical dated 10/18/22 states in part . HPI (History of Present Illness): Patient was sent from [facility name] due to being positive for COVID one week ago and recently started dropping in oxygen to 86% on room air. Her baseline is no oxygen requirements. EMS (emergency medical services) was called, and she was put on NRB (nonrebreather) mask at 94% at 12 liters. Patient denies any CP (chest pain), abdominal pain, fevers, and chills. Patient is agitated at baseline and only responds to questions with yes or no. She is frustrated with situation. TX (treatment) provided: Zosyn and Zithromax once, NS (normal saline) bolus. Assessment/Plan: Acute Hypoxic Respiratory Failure secondary to Hospital Acquired Pneumonia -- Acute. Patient requiring O2 (oxygen) as her saturation dropped to 86% and she was put on NRB mask at 94%. Echo on 7/11/22 showed worsening LV (left ventricular) systolic function, EF (ejection fraction) of 20-25%, global hypokinesis (range of motion of the heart) and moderate pulmonary HTN (hypertension). Lactic acid wnl (within normal limits). CT chest revealed 1) diffused emphysema 2) multifocal airspace disease in both lings, worst in the dependent lower lobes, consistent with pneumonia. 3) cholelithiasis w/o (without) acute cholecystitis. 4) fatty liver. Patient continued on Zithromax and Zosyn. AKI (acute kidney injury): acute, ongoing. Cr (Creatinine) 1.7. Either secondary to dehydration due to infection or cardiorenal. Will provide IV hydration. Will continue to treat symptomatically. Hospital Physician Discharge Summary dated 10/17/22, states in part . Principal/Final Diagnoses: Pneumonia of both lungs due to infectious organism, unspecified part of lung. Secondary Diagnoses and/or Complications: Pneumonia of both lungs due to infectious organism, unspecified part of lung. Hospital acquired pneumonia. Reason for hospitalization : Aspiration PNA (pneumonia), COVID-19 + (positive). Patient Course and Care: Patient was sent from [facility name] due to being positive for COVID one week ago and recently started dropping in oxygen to 86% on room air. Her baseline is no oxygen requirements. EMS (emergency medical services) was called, and she was put on NRB (nonrebreather) mask at 94% at 12 liters. Patient denies any CP (chest pain), abdominal pain, fevers, and chills. Patient is agitated at baseline and only responds to questions with yes or no. She is frustrated with situation. Patient was initi (initially) admitted for acute hypoxic respiratory failure secondary to hospital acquired pneumonia. Acute hypoxic respiratory failure secondary to aspiration pneumonia and COVID-19 +: Treated with Zithromax 500 mg (milligrams) (10/18-10/21) and Zosyn 3.375 mg (10/18-10/25) for aspiration. Vit C (Vitamin C), Vit D, Zinc daily for COVID +, pt (patient) was COVID + at home prior to admission. Steroid therapy was not initiated. AKI: resolved with IVF (IV Fluids). XR (X-Ray) Chest Portable 1V (1 view), dated 10/18/22, states in part . Relatively peripheral airspace disease. Pattern suggesting acute infectious or inflammatory disease. Mild cardiomegaly (enlarged heart) without features of active congestive heart failure. CT Chest Without IV Contrast, dated 10/18/22, states in part . 1. Bilateral dependent airspace consolidation is suggestive of aspiration pneumonitis, aspiration pneumonia, or conventional multi lobar bronchopneumonia. Very small bilateral parapneumonic effusions. 2. Mild mediastinal lymphadenopathy is likely reactive. On 3/28/23 at 9:39 AM, Surveyor interviewed IDON/RN B (Interim Director of Nursing/Registered Nurse). Surveyor asked IDON/RN B what the facility protocol was for monitoring patients who are positive for COVID-19. IDON/RN B stated, A respiratory assessment should be completed every shift and more often if needed. This would include Temperature, Respiratory Rate, and O2 Saturation. Surveyor asked IDON/RN B what oxygen saturation level would require physician notification. IDON/RN B stated, below 90% would be a change of condition requiring physician notification. Surveyor asked IDON/RN B if a resident requires supplemental oxygen should you obtain orders for that oxygen. IDON/RN B stated, Absolutely, the physician would need to give orders for oxygen and be updated on the change of condition. On 3/28/23 at 10:52 AM, Surveyor interviewed LPN K (Licensed Practical Nurse). Surveyor asked LPN K the facility protocol for change of condition. LPN K stated, For a change of condition would need to update the physician and family. Complete an assessment of the resident. Surveyor asked LPN K when notification to the physician for low O2 saturation would be appropriate. LPN K stated, If a resident has no orders for oxygen and their saturation is at 88% or below would need to contact the physician, update on the change of condition and get orders for oxygen administration. Surveyor asked LPN K for the facility protocol for assessments for COVID positive residents. LPN K stated, For COVID positive residents would complete an assessment every shift that included vital signs and lung sounds. On 3/28/23 at 11:04 AM, Surveyor interviewed RN L. Surveyor asked RN L when it would be appropriate to contact the physician for low O2 saturation. RN L stated, The physician would need to be notified of any oxygen saturation below 90%. If there are no orders for oxygen, we would apply oxygen and update the physician immediately. We would need to complete a respiratory assessment and vital signs and going to send the patient out if needed. Surveyor asked RN L the facility protocol for monitoring a COVID positive resident. RN L stated, If a patient is COVID positive would notify the physician, IP (infection preventionist), Nurse Supervisor, DON, and NHA (Nursing Home Administrator). We would chart in electronic charting system that the physician was notified and update on any change from baseline. Charting for COVID patients should be completed every shift. On 3/28/23 at 11:30 AM, Surveyor interviewed MD H (Medical Doctor). Surveyor asked MD H if he would expect to be contacted for a resident who does not require oxygen normally now requiring the use of oxygen. MD H stated, It would depend on the parameters the facility has. Surveyor asked MD H if there were no parameters or orders for oxygen what his expectation would be. MD H stated, Anything below 92% I would expect to be notified about if there are no orders for oxygen, no parameters to follow, and/or the patient does not have a diagnosis of COPD. On 3/28/23 at 12:15 PM, Surveyor was notified by IDON/RN B that she had contacted the IP regarding R1 not receiving anti-viral with diagnosis of COVID with no vaccination. IP stated to IDON/RN B that she did not push the subject of antiviral medications for R1, and the physician did not order the antivirals when he was updated with the diagnosis. The physicians do not generally order the antivirals for residents. R1 had a change of condition this was documented by nursing staff requiring oxygen therapy. The facility did not update the physician nor obtain oxygen orders. R1 had a change of condition and the facility failed to immediately notify the physician with the concerns.

Based on observation, interview and record review, the facility did not ensure each resident received staff assistance to prevent accidents for 1 of 3 residents (R1) reviewed for incidents/accidents out of a total sample of 3. R1 has severe cognitive impairment, and requires extensive assist of two staff with mechanical lift for transfers. Staff did not follow R1's care plan and attempted to transfer R1 with 1 staff member into a chair rather than with the assistance of 2 staff members. R1 fell resulting in a [CONDITION(S)] that required staples. This is evidenced by: The facility Policy, titled, Transfer Manual and/or Mechanical lift, Updated 12/13/21, states in part: . Policy: To protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Procedure: 5. Two (2) trained staff will be required when using mechanical lifting devices. 6. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding manual transfer and mechanical lifting device transfer. The Manufacturers Guidelines for the EZ Way Smart Lift, state in part: .Transferring patient from chair, wheelchair or toilet, Step 2: 3. Do not lock the wheels of the EZ Way Smart Lift when lifting or transferring patients. The Manufacturers Guidelines for the EZ Way Smart Stand Lift, state in part: .The only time you should lock the wheels of the EZ Way Smart Stand is when you are raising or lowering the patient during ambulation . The facility checklist for new employees titled, All Nursing staff: Expectations of C.N.A.'s (Certified Nursing Assistance), undated, states in part: .General equipment operation: Transfer EZ-lift-2 person and Transfer EZ-Stand-2 person. R1 was admitted to the facility on [DATE] with diagnoses that include in part . Dementia in other diseases classified elsewhere with behavioral disturbance, injury of right shoulder and upper arm, [CONDITION(S)], R1's Quarterly Minimum Data Set (MDS) dated [DATE], indicates R1's Brief Interview of Mental Status (BIMS) is 00 indicating severe cognitive impairment. R1 has an activated Activated Health Care Power of Attorney (HCPOA). Section G0110, Functional Status, Transfers: Dependent of two staff, Toileting: Dependent of two staff, Dressing: Dependent of two staff, Hygiene: Extensive assistance of one staff member. R1's Comprehensive Care Plan, initiated 9/26/21, states in part . Problem: I have had a decline in my ability to properly dress myself. Because I: have dementia. I need my aides to --- give me time to do tasks encourage my independence encourage me to do for myself, as able, for ADL's (activities of daily living) offer me simple instructions praise my progress/effort speak slowly & (and) clearly distract me with activities and socialization give me cues give me rest periods during tasks check my skin during care. I Transfer with the help of 2 people for all transfers using EZ-Lift. R1's Certified Nursing Assistant (CNA) Kardex states the following in part . Transfer: 1 assist mechanical lift (total) with the help of 2 people doing 100% (percent) of the effort. Transfer me with full body lift. Dressing: I dress with the help of 2 people doing 100% of the effort. Interventions: Keep slit R eye are (sic), abrasion R (right) forehead, stapled post occipital area clean & dry. Remove staple posterior occipital 1 week. Use medium sling when using EZ-Lift (not small). Nurses Note dated 12/7/21 at 7:20 PM states in part . Late Entry for: 12/07/21. Time: 5:00 PM. F/U (follow up incident): Observed on floor next to bed (window side) after resident fell to floor while in a sling using a total mechanical lift machine after lift tipped during use by staff; resident alert and orientated to name only; no signs of pain or grimace while lying on her back on the floor; vital signs wnl's (within normal limits); resident had a small slit on crease of right outer eye approximately 1.5 cm (centimeters) in length x (by) 0.1 cm width without any bleeding; resident had a small amount of blood from right lateral abrasion of forehead above her right eye & approximately 1.5 cm in length x 0.1 cm width-cleansed area with NS (normal saline) & gauze & applied one steri-strip; head exam reflects an open laceration approximately 3 cm in length x 0.3 cm in width right occipital lobe of skull & cleansed hair with normal saline & pressure applied with gauze/dry wipes & ice pack applied; resident on [MEDICATION(S)] 5 mg (milligrams) BID (twice a day); no signs of [CONDITION(S)]/pelvis since no external rotation of legs but resident has lower extremity/foot contractures; Resident only replied, 'ouch' when cleansing right occipital lobe laceration; 4 assist to bed with mechanical lift into bed without signs of pain; CMS (circulation, motion and sensation) wnl's to LE's (lower extremities) & UE's (upper extremities); neuro (neurological) check wnl's; resident sent out 911 to ER (emergency room ) for evaluation since had head injury & on anticoagulant therapy. Physician notified; Administrator and Director of Nursing notified timely. Nurses Note dated 12/7/21 at 8:03 PM states in part . Hospice nurse called unit nurse at 1945 (7:45 PM) with update; CT scan head negative and few staples in right occipital lobe & will return to facility in about an hour. DON (Director of Nursing) called at 1950 (7:50 PM) with update on resident condition. Nurses Note dated 12/7/21 at 8:08 PM states in part . Late Entry for: 12/7/21. Time: 4:45 PM. Incident Type: Fall. Location: resident's room. Activity at the time: transferring. Equipment Involved: Mechanical lift (total). Injury: laceration 3 cm x 0.3 cm R occipital lobe of [NAME]. Other: slit on crease of R outer eye 1.5 cm x 0.1 cm; abrasion R lateral forehead above R eye 1.5 cm x 0.1 cm. Did Resident Hit Head? Yes, neuro assessment initiated. Is resident Anticoagulated? Yes, with (type): [MEDICATION(S)] 5 mg BID for DVT ([CONDITION(S)]). First Aid: immediately applied, Supervisor cleansed laceration & abrasion with NS & gauze. Applied one steri-strip upper R forehead abrasion. Hand held pressure & ice pack applied to R occipital lobe. Root Cause: Total mechanical lift tipped during transfer by staff. Actions: 911 called & sent to hospital for evaluation. Interventions: other: 2 assist with transfer of mechanical lift (total). Teaching done: safe transfer, 2 assist with mechanical lift transfer. Nurses Note dated 12/7/21 at 11:36 PM states in part: . Late entry for: 12/07/21. Time: 6:30 PM transferred to hospital. Transportation: by ambulance. Time 6:30 PM. Date: 12/07/21. Reason for Transfer: Fall Related Injury; major injury, fall, laceration R occipital head, on [MEDICATION(S)] 5 mg po (by mouth) BID. Treatment Prior to Transfer: CT scan of head. ED/HOSP Comments: Negative CT scan cervical spine complex, CT head w/o (without) contrast negative, CT thoracic spine WO con (without contrast) negative. Nurses Note dated 12/8/21 at 10:13 AM states in part . Hospice Communication: Hospice provider. Result: update on resident given, Nurse will remove staples from [CONDITION(S)] next week at visit (floor nurse updated), please call hospice with any changes in condition or questions. Hospital ED (Emergency Department) notes from 12/7/21 state in part: . HPI (History of Present Illness): [AGE] year-old female history of Alzheimer's disease presents after fall. History obtained from EMS (Emergency Medical Service) and from facility staff over the phone. Patient was being transferred with a Hoyer lift. She fell approximately 2 feet onto the ground during transfer. She struck her head and sustained a laceration to the occiput. HENT (Head, ears, nose, throat): Head: Comments: Skin tear over the right forehead. 1 cm laceration over right posterior occiput. Location: Scalp. Scalp location: R parietal. Laceration Repair: Preparation: Patient was prepped and draped in usual sterile fashion. Skin repair: Repair Method: Staples. Number of Staples: 2. On 1/3/22 at 12:29 PM, Surveyor interviewed CNA E. Surveyor asked CNA E about the events of 12/7/21. CNA E stated, I was getting ready to transfer. Changed sling on her. The transfer over to the chair was okay but I started to readjust her and lower the mechanical lift, it started to tip. I tried to guide but she fell to the floor. It didn't work as well as I thought it would. Surveyor asked CNA E if she had ever transferred residents independently prior to this incident. CNA E stated, 'No. Surveyor asked CNA E if she locked the brakes on the mechanical lift. CNA E stated, Yes. Surveyor asked CNA E if she had ever received training on mechanical lifts. CNA E stated, Not really. I did not get good training. I asked questions when I needed too. I really only trained for 1 shift out of three weeks. This was my first CNA job and I had never used an EZ-stand or full body lift before. Surveyor asked CNA E if care plans indicate a resident's transfer status. CNA E stated, Yes, I had to figure it out on my own. On 1/3/22 at 11:27 AM, Surveyor interviewed RN H (Registered Nurse). Surveyor asked RN H if she has had any recent education on mechanical lift transfers. RN H stated, No, but there has been other education. Surveyor asked RN H if there was any concerns with staff getting assistance with mechanical lift transfers. RN H stated, I have no concerns with the staff. They will ask nurses to be the second if unable to find another CNA. On 1/3/22 at 11:35 AM, Surveyor interviewed RN C. Surveyor asked RN C if she had received any education within the last month regarding transfers/lifts. RN C stated, It is in my mailbox to complete but I have not done it yet. I was off for a 3 days. Surveyor asked RN C if she had done any skills testing. RN C stated, Not sure. On 1/3/22 at 11:45 AM, Surveyor interviewed CNA D. Surveyor asked CNA D if she had any recent training on mechanical lifts. CNA D stated, Yes, we had a packet, discussed transfers, reading the care plan, and safety precautions. Surveyor asked CNA D if she had been observed completing a mechanical lift transfer. CNA D stated, I heard they were but no one has watched me. On 1/3/22 at 12:24 PM, Surveyor interviewed CNA G. Surveyor asked CNA G if she had received any recent training on the use of mechanical lifts. CNA G stated, We had education on transfers about a month ago. There was a fall and we were brushing up on how to do transfers. Surveyor asked CNA G if she ever had any staff observe her doing a transfer with a mechanical lift. CNA G stated, I have never had anyone watch me do a transfer with a lift. On 1/03/22 at 12:47 PM, Surveyor interviewed ADON F (Assistant Director of Nursing). Surveyor asked ADON F about CNA E's new hire education. ADON F stated, There is a check off list that has to be completed by new hires. CNA E was signed off on the check off list on 9/10/21, indicating she was able to demonstrate use of the full body lift and stand lift. Surveyor asked ADON F how often staff are educated on the use of lifts. ADON F stated, Mechanical lift training is completed on Relias yearly. Surveyor asked ADON F if the facility completes audits on staff use of mechanical lifts. ADON F stated, We do audits when we feel there is a need. We do audits on knowing what the care plan says and where to find a resident's transfer status on the Kardex (CNA care plan). Surveyor asked ADON F if all staff were re-educated after the incident on 12/7/21. ADON F stated, We focused on the unit that the incident occurred and tried to get as many as we could throughout the building. We had education that came out after the incident on mechanical lift use. We tried to watch transfers and if unable we had them verbalize the steps. On 1/3/22 at 1:23 PM, Surveyor observed CNA I and CNA J transfer a resident with stand lift from the wheelchair into the bathroom. Staff locked the brakes of the wheelchair, opened the legs of the stand lift, placed resident's feet on the platform, and applied a leg strap. Staff then locked the stand lift brakes and raised the resident out of the wheelchair. Once the resident was standing the staff unlocked the stand lift brakes and moved the resident into the bathroom. Staff lowered resident onto the toilet and when done lifted resident back up. Staff then were observed to lock the brakes of the stand lift prior to lowering the resident back into the wheelchair. Of note, the staff were observed using the EZ Lift Smart Stand and were observed to lock the brakes of the stand. Staff was not following manufacturer's recommendations for the use of this lift. On 1/3/22 at 1:40 PM, Surveyor interviewed CNA I. Surveyor asked CNA I if she had received education recently on transfers with mechanical lifts. CNA I stated, We had an in-service 1 week ago with the supervisor. They went over step by step safety and transfers using mechanical lifts. Last month we also had some education on Relias. Surveyor asked CNA I if during that training she recalls being trained on using the brakes while doing a transfer. CNA I stated, I don't remember. I always lock the brakes during the transfer to stabilize the resident from jerking back and forth while lifting the resident up. I think I was trained to lock them way back in CNA training. Surveyor asked CNA I if she primarily works a certain area in the building. CNA I stated, I am all over the building, not stationed to just one area. On 1/3/22 at 1:40 PM, Surveyor interviewed CNA J. Surveyor asked CNA J if she had received any recent training on mechanical lifts. CNA J stated, I thought just the other unit received the recent training. I did not. The last training I had on mechanical lifts was last summer or fall. I always lock the brakes putting resident onto toilet. Surveyor reviewed the facility self-report and training. It was noted that 76 out of approximately 125 staff members have worked several shifts without having beein retrained. The facility failed to ensure R1 received adequate staff assistance and that staff followed the care plan to prevent accidents. The facility failed to ensure that all staff were educated prior to their next working shift on the proper use of the mechanical lifts.

Based on observation, interviews and record review, facility staff did not adequately assess and treat pain and provide necessary care and services to attain or maintain the highest practicable physical wellbeing for 1 of 27 residents (R168) reviewed for pain out of total of 30 residents sampled. R168 sustained a fall at the facility on 3/26/19. Starting on 3/28/19, R168 was reporting new onset of severe right rib pain rating her pain from an 8-10 out of 10. R168 requested to go to the hospital due to the significant increase in pain. The facility failed to notify the physician of R168's increase in pain, failed to complete an assessment when R168 complained of increased pain. R168 was later found to have rib fractures leading to inadequate pain management. Evidenced by: The facility's Pain Management policy, dated 10/5/16, includes, in part, the following: I: Purpose: The purpose of this protocol is to assess the resident's pain level and provide optimal comfort through a pain control plan which is mutually established with the resident, family, and members of the health care team. All patients will receive the best level of pain control that can safely be provided in order to prevent unrelieved pain. II: Policy: Pain is recognized as a sixth vital sign, with a goal to try and maintain any pain the resident may have, below the established acceptable level of pain for that individual. This policy provides guidelines to caregivers in how to assess, treat, and assist in managing a patient's pain. III. Procedure: Pain is whatever the experiencing person says it is, existing whenever s/he says it does. Self-report is the preferred indicator of pain, and behavioral/physiological indicators are used only when the patient is unable to self-report. The facility uses a self-rating scale 0-10 to evaluate pain. 0 indicates no pain, 10 indicates worst pain imaginable. treatment of [REDACTED]. A comprehensive pain assessment will be completed as part of the initial nursing assessment with the development of a pain management as indicated. The comprehensive pain assessment will be reviewed quarterly and as needed. Continuing assessment of the pain management program will occur and will focus on the effectiveness of the program and comfort level of the resident. Evaluation of effectiveness of non-pharmacological interventions (e.g. repositioning, warm or cold compresses, etc.) in pain reduction and interventions will be added to the resident care plan. Pain will be assessed and documented at regular intervals, and as necessary. Evaluation of effectiveness of, as needed, [MEDICATION NAME] medication in relieving pain to a level that is acceptable to the resident will occur within 2 hours of administration. If the resident has had a significant change in pain control, the MD (Medical Doctor) shall be notified when pain is not managed with current regimen. If a PRN (as needed) [MEDICATION NAME] medication is utilized on regular basis (e.g., every night, on bath days, multiple times a day for three consecutive days, etc.) the nursing staff will refer to the MD to evaluate appropriateness of scheduling the pain medication. Example 1 R168 was admitted to the facility, 3/8/19, with [DIAGNOSES REDACTED]. R168's pain is usually either all over due to [MEDICAL CONDITION], or on left side due to a history of shingles. R168's Admission MDS indicates a BIMS (Brief Interview for Mental Status) of 14, indicating cognitively intact. R1 is own person. R168's CAA (Care Area Assessment) for Pain Section J0500A: R168's pain is frequent. Pain has made it hard for resident to sleep at night over the past 5 nights. Diseases and Conditions: history of shingles, [MEDICAL CONDITION] that may cause pain. Description: R168 has dx (diagnosis) of [MEDICAL CONDITION] and has pain from shingles. Has had various areas of pain and uses [MEDICATION NAME] to treat this. R168 Physician order [REDACTED]. [MEDICATION NAME] 5 mg: 1 tab by mouth every 6 hours as needed for pain. [MEDICATION NAME] 600 mg (1 tablet/600 mg) three times per day. AM, Midday, PM for neuropathic pain. R168's Pain Assessment, dated 3/15/19 at 12:43 PM, includes, the following: Current Pain Level: Moderate. Location of Pain: All over R168's Pain Assessment, dated 3/15/19 at 4:30 PM, includes, the following: Current Pain Level: no pain Been on a scheduled pain medication regimen? Yes Received PRN Pain medications: [REDACTED] Offered a PRN Pain Med and Declined: No Received Non-Medication intervention for pain? No Makes Self Understood: Understood Have you had hurting at any time in the last 5 days: Yes How much of the time have you been experiencing pain or hurting over the last 5 days: Frequently Over the past 5 days has pain made it hard for you to sleep at night: Yes Over the past 5 days have you limited your day-to-day activities because of pain: No Please rate the intensity of your worst pain over the last 5 days: Moderate Manner of expressing pain: Verbal Location of pain: all over various areas, usually left side of body, dx (diagnosis) of [MEDICAL CONDITION] Description of pain: Ache, stinging Alleviating Factors: Rest, [MEDICATION NAME] Should the staff assessment for pain be conducted: No R168's Pain Assessment, dated 3/22/19 at 12:29 PM, includes the following: Been on a scheduled pain medication regimen? Yes Received PRN Pain medications: [REDACTED] Offered a PRN Pain Med and Declined: No Received Non-Medication intervention for pain? No Makes Self Understood: Understood Have you had hurting at any time in the last 5 days: Yes How much of the time have you been experiencing pain or hurting over the last 5 days: Almost constant Over the past 5 days has pain made it hard for you to sleep at night: Yes Over the past 5 days have you limited your day-to-day activities because of pain: Yes Please rate the intensity of your worst pain over the last 5 days: 10/10 Manner of expressing pain: Verbal Location of pain: left leg(s) all over Description of pain: Varies Comments: R168 has [MEDICAL CONDITION] and has had shingles approximately 2 years ago. States worst pain is from the shingles and in left leg. Also has pain in various areas due to the [MEDICAL CONDITION]. [MEDICATION NAME] is scheduled, [MEDICATION NAME] is used PRN (as needed) at least daily, and [MEDICATION NAME] has been used less than daily. R168's care plan, dated 3/27/19, states: I need some assistance to maintain pain control and self-care because I have pain and/or discomfort and have chronic illness. I show this by having a hard time moving, being forgetful, participating less. I need my nurses to assess my functional level explain procedures to me help me understand my conditions help control my pain by encouraging me to space out my pain medication. I need my aides to give me time to do tasks. I reposition in bed with the help of 1 person, I transfer with the help of 1 person. I eat without help. I use the bathroom with gait belt, 4 ww (wheeled walker), limited assist x (times) 1 for clothing management, hygiene. I walk to and from dining room for all 3 meals with limited assist x1, gait belt, and 4 wheeled walker (It is important to note the facility does not document a pain goal for R168.) R168's CNA (Certified Nursing Assistant) Care Plan states: I have episodes of depression I may feel anxious. I need my aides to ask me if I'm having pain. On 3/26/19 at 4:30 AM, R168 was ambulating in R168's room without staff assistance and fell . The fall investigation documents that R168 had complaints of pain right rib and shoulder The facility sent R168 to the hospital to be evaluated. On 3/26/19, the hospital H&P (Hospital admission medical documentation template) states as follows: [AGE] year-old woman from nursing home with multiple medical problems as reviewed presents after a fall. Patient reports mechanical fall where (R168) banged head, but denies loss of consciousness. No significant headache. No neck pain. Reports some mild discomfort to the right lateral chest wall. No fevers or chills. No cough. No nausea or vomiting. No dizziness. No other complaints. Patient denies pain in hips, pelvis or legs. Poor historian overall. The patient denies any other aggravating or alleviating factors. The patient denies any other associated symptoms. The Physician's Physical Exam at the hospital states Mild right lateral chest wall tenderness without bruising, rash or ecchymosis. The physician documents: Did order a chest x-ray for some mild right lateral chest wall tenderness that is very reproducible. Also evaluated brain with CT (Computed Tomography) head as resident is on [MEDICATION NAME] and order baseline CBC (Complete Blood Count) and INR (International Normalized Ratio - clotting ability of blood). (Note: a diagram is included in the assessment and the area R168 is indicating there is mild pain is in the location of rib fractures identified 6 days later.) The hospital portable chest x-ray findings: No acute osseous abnormality is identified (no fracture). On 3/26/19 at 2:57 PM, a Nurses Note (NN) states as follows: Spoke with hospital ER (emergency room ); they stated they are sending resident back and has no injuries or new orders. ER Doctor stated they gave resident tyl (Tylenol) for pain and labs were good. The ambulance brought resident back and resident is comfortable at this time. Resident did request an ice pack for comfort on right side of back. Will continue to monitor. The NN's indicate the following medication administration, pain level for right rib area, and effectiveness. On 3/26/19 at 11:35 PM: Agency Nurse administered Tylenol Extra Strength 500 mg (milligrams) for pain level 3/10. Location: Right rib; Result: 10:56 PM sleeping On 3/27/19 at 5:58 PM: Charted by RN H (Registered Nurse) [MEDICATION NAME] HCL 5 mg for pain level 8/10. Location: Right beneath the breast; Result: 7:39 PM med effective On 3/28/19 at 7:59 AM: Charted by RN F Tylenol Extra Strength 500 mg for pain level 5/10. Location: Right rib cage; Result: 9:15 AM no further complaints On 3/28/19 at 1:01 PM, R168's NN states: F/U (Follow Up) Incident: Resident has had no change in L[NAME] (Level of Consciousness) or bx (behaviors) during today's shift., able to perform ROM (Range of Motion) and participate in therapy without complaints, resident has complained of pain in right rib and was relieved with APAP (Tylenol) per patient, will continue to monitor, no signs of any delayed injuries at this time. On 3/28/19 at 1:42 PM: Charted by RN F [MEDICATION NAME] 5 mg for pain level 10/10. Location: Right rib cage grimacing with deep breaths; Result: 4:27 PM no further complaints On 3/28/19 at 7:59 PM: Charted by RN H [MEDICATION NAME] 5 mg for pain level 9/10. Location: Right ribs/side; Result: 9:04 PM med effective On 3/29/19 at 12:26 AM, R168 NN states: F/U Fall Muscle/Skeletal Pain: Resident description of pain: deep and aching tender on palpation Actions: Blank On 3/29/19 at 4:58 AM: Charted by RN G [MEDICATION NAME] 5 mg for pain level 9/10. Location: In right chest area rib pain from (sic) fallen down. Result: 5:58 AM med effective resting sleeping continue to observe. On 3/29/19 at 6:11 PM: Charted by RN H [MEDICATION NAME] 5 mg for pain level 10/10. Location: Right side. Result: 7:30 PM med effective. On 3/30/19 at 4:54 PM: Agency Nurse [MEDICATION NAME] 5 mg for pain level 9/10. Location: Both sides. Result: Not noted. On 3/31/19 at 5:23 AM: Charted by RN G [MEDICATION NAME] 5 mg for pain level 8/10. Location: Right rib cage. Result: Not noted. On 3/28/19 at 7:59 PM: Charted by RN H [MEDICATION NAME] 5 mg for pain level 9/10. Location: Right ribs/side. Result: 9:04 PM med effective. On 4/1/19 at 9:03 AM, Surveyor spoke with R168. R168 stated to Surveyor that R168 was having pain in right rib area. Surveyor observed R168 grimacing. Surveyor asked R168 to show me where the pain is located. Surveyor observed R168 point to their lower right rib cage and start rubbing the area. Surveyor asked R168 to rate the pain on a scale of 0 to 10, with 10 being severe. R168 stated rib pain is 10/10. Surveyor asked if R168 had any falls recently. R168 fell last week and has had pain in right ribs ever since. R168 stated to Surveyor that they wanted to go to the hospital to get checked out. R168 has been telling staff they want to go to the hospital for the rib pain but nobody is listening. R168 stated I don't know why RN D gives me my medications so late, and indicated R168 really needs them earlier in the morning, before pain reaches this high level. On 4/1/19 at 9:07 AM, Surveyor immediately notified RN D regarding R168's pain level of 10/10 in right rib area. Surveyor asked if R168 would like Surveyor to wait with R168 until RN D arrived with the medications. R168 stated yes. Surveyor waited with R168. On 4/1/19 at 9:11 AM, RN D approached R168 to give morning medications. Surveyor stated to RN D that R168 is requesting to go to the hospital to be evaluated due to right rib pain. RN D stated that R168 had a fall last week and was previously sent out to the hospital to be evaluated and x-ray was negative. RN D administered morning medications, including pain medication (R168 received [MEDICATION NAME] 600 mg and [MEDICATION NAME] PRN (as needed) 5 mg for pain) and continued passing medication. Surveyor reviewed R168's chart and noted on R168's hospital report on 3/26/19 that R168 complained of right rib pain while in the emergency room and the pain was then described as mild. The pain R168 described to Surveyor is a 10/10, severe pain. On 4/1/19 at 10:15 AM, Surveyor spoke with ADON C (Assistant Director of Nursing). Surveyor asked if ADON C is familiar with R168's pain. ADON C stated that R168 has been sent out to the hospital once or twice. ADON C stated that R168 fell last week and was complaining of right rib and right shoulder pain and the hospital sent R168 back to the facility stating R168 had no injuries. Surveyor stated to ADON C that R168 stated to Surveyor that R168 is having 10/10 pain in right rib area and is requesting to go to the hospital to be evaluated. Surveyor stated that R168 has been telling staff that that R168 wants to go to the hospital to be evaluated, but nobody is listening. Surveyor stated that Surveyor shared this information with RN D. ADON C stated they will take care of it. On 4/1/19 at 11:17 AM, the facility wrote a Physician's Telephone Order that states: PA lateral chest x-ray for c/o (complaint) of right rib pain. On 4/1/19 at 2:56 PM, R168 had two chest x-rays taken. On 4/1/19 at 3:23 PM, the physician electronically signed the chest x-ray results stating: Chronic appearing increased interstitial markings are noted. Mild left basilar airspace opacity versus atelectasis is noted, with small left pleural effusion. The cardiac silhouette and the [MEDICAL CONDITION] vasculature are within normal limits. There is a mildly displaced [MEDICAL CONDITION] 8th rib and possible nondisplaced 9th rib fracture. Impressions 1. Left basilar pleuroparenchymal changes, which may reflect pneumonia 2. Right rib fractures On 4/2/19 at 10:15 AM and 4/3/19 at 8:50 AM, Surveyor spoke with R168. R168 stated that moving makes the pain worse. R168 moves more slowly and I can't do the things like I used to. R168 added, I can't move as good as what I was (moving prior to the fracture). Surveyor asked if R168 participates in activities at the facility. R168 has never been much for activities. R168 stated with [MEDICAL CONDITION] and [MEDICAL CONDITION] they are not a very active person. Surveyor asked R168 if the pain in right rib area is worse than one's usual pain. R168 stated, Oh yes. Surveyor asked R168 if the pain in right rib area was new. R168 stated, yes. R168 stated the pain is sometimes overwhelming. Surveyor asked R168 how it makes one feel when in that much pain. R168 stated, It made me mad, because it hurts so bad and I can't move that well - it hurts. Surveyor described the term breakthrough pain to R168. Surveyor asked R168 how often one experiences breakthrough pain. R168 stated, Quite often. Surveyor asked R168 can you tell me how many times a day you experience breakthrough pain. R168 stated 4 or 5 times a day my pain level is at a 7 or 8. R168 stated that 7 or 8 times, since sustaining a fall with fracture, on 3/26/19, pain has been a 10/10. When R168 tells the nurses, they will give R168 either Tylenol or [MEDICATION NAME]. R168 told the facility on Friday, 3/29/19, that they wanted to go to the hospital to be checked out due to right rib pain and nobody would listen. R168 stated, Nobody would believe me. R168 added it made me feel like they thought I was just making it up and I was lying to them. On 4/2/19 at 3:00 PM, Surveyor spoke with RN D. RN D stated I heard in report that R168 had a fall and was sent to the hospital to get checked out. Surveyor asked RN D if R168 normally has pain. RN D stated yes, and if asked, R168 will normally say they have 10/10 pain in left leg and left foot because R168 has had shingles or will say pain is all over. Surveyor asked if RN D heard before yesterday that R168 was having pain in right rib area. RN D stated, no, RN D was off this past weekend and worked on a different Wing last week. (Note: RN D was aware that pain in this location was new to R168 and RN D did not address R168's pain or request to be evaluated, nor did RN D address R168's pain when Surveyor expressed concern and brought it directly to their attention.) On 4/3/19 at 10:40 AM, Surveyor spoke with CNA E. CNA E has been a long term employee at the facility. Surveyor asked CNA E if R168 has pain. CNA E stated yes. Surveyor asked CNA E to tell me about R168's pain. CNA E stated, R168 is always saying 168's in pain all over. CNA E stated for the last week or so, R168 has been complaining of pain right here (pointing to rib area) in right rib area and kept holding onto it. (It is important to note that CNA E is describing guarding which is an involuntary reaction to protect an area of pain.) CNA E reported to RN on duty when they observed R168 guarding right rib cage area. CNA E stated that the nurses are aware of this and they (Nurses) talk about pain during the rounds. Surveyor asked CNA E what did the nurses do about it. CNA E does not know if anything was done to address R168's pain. There is no evidence that further steps were taken to address R168's pain or that Physician I was contacted. On 4/3/19 at 12:25 PM, Surveyor spoke with RN F. On 3/28/19 at 1:42 PM, RN F documented the first report of 10/10 right rib cage grimacing with deep breaths. RN F asked ADON C about it and ADON C told RN F to read R168's Hospital Report. RN F stated R168's son had been worried that R168 had been taking too much pain medication. RN F stated that R168 will always say 10/10 pain when I ask. RN F stated I know I need to keep my bias to myself. Surveyor asked RN F what that means. RN F sometimes will observe R168 stating having 10/10 pain and then observe R168 moving around and laughing. RN F is unsure if this (frequent rating of 10/10) is a habit of R168 or not. RN F spoke to Physician I when he was in the building on either 3/26 or 3/29 about R168's pain. RN F did not call Physician I regarding R168's new onset of right rib pain with difficulty breathing. RN F stated R168 wanted pain medication. I had R168 do range of motion (ROM) and paid attention to facial expressions. RN F stated I asked if the medication helped at all because I don't know if R168's honest with rating because R168 always says 10/10. RN F had noticed that R168 was grimacing with ROM assessments when assessing ribs. RN F believes this was documented on 3/28/19. Surveyor noted a ROM evaluation documented on 3/28/19. RN F did not contact Physician I as he was scheduled to be at the facility the following day. No further steps were taken to address R168's new onset of severe pain in right rib area at this time. On 4/3/19 at 2:15 PM, Surveyor spoke with RN G. RN G was working the N[NAME] (Night) shift last week when R168 fell while self-transferring. RN G stated immediately following the fall that R168 was complaining of pain in right rib area and lower back. RN G contacted the Nurse Practitioner who was on call for Physician I and sent R168 to the hospital. RN G passes morning medications around 5:00 AM - 5:30 AM. RN G stated R168 always states 10/10 pain. RN G stated R168's [MEDICATION NAME] is not scheduled. RN G assessed R168 following the fall; R168 complained of pain in the right side of rib cage. Surveyor asked RN G if R168 continued to complain of right rib pain after returning from the hospital following the fall. RN G stated, Yes, maybe twice in the past week. On 3/29/19 at 4:58 AM, RN G documented that R168's pain as 9/10 in right chest area rib pain from (sic) fallen down. Surveyor asked RN G what do you do when R168 complains of pain. RN G stated if the pain is a 5 or below, gives Tylenol, and if it's 6 or above, gives [MEDICATION NAME], or whatever the physician has ordered. RN G stated sometimes R168 will state they are having 10/10 pain and RN G goes to the cart to get medication and when RN G comes back, R168 is sleeping. No further steps were taken to address R168's new onset of severe pain in right rib area. On 4/3/19 at 2:45 PM, Surveyor spoke with RN H. On 3/28/19 at 7:59 PM, RN H documented R168's pain as 9/10 right ribs/side. RN H stated that normally R168 will not give a level when asked for current level of pain. RN H stated that R168 says it hurts really bad or something. RN H stated that R168 will give a numeric rating if alert. RN H stated I've only got R168 to say a number once for me and RN H judges R168's pain based on how uncomfortable R168 looks. RN H stated when I wake R168 to do something, pain starts. When R168 was in the dining room for dinner that night (3/28/19), R168 stated pain was a 10 and RN H gave [MEDICATION NAME]. Surveyor asked RN H if R168 had complained of right rib pain prior to fall on 3/26/19. RN H stated, no, R168 would usually say they had pain all over. RN H stated that night, R168 was more alert than normal. RN H stated when R168 describes pain as it's bad, RN H takes that as pain level is over 6 and administers [MEDICATION NAME]. Surveyor asked if RN H contacted the physician. RN H is not sure if RN H contacted the Physician. No further steps were taken to address R168's new onset of severe pain in right rib area. On 4/3/19 at 3:30 PM, Surveyors spoke with DON B (Director of Nursing). Surveyor asked DON B what is your expectation if a resident is having increased pain. DON B stated that staff should administer medications per Physician Orders. DON B stated if a resident is having increased pain, her expectation is that staff notify the physician and the family/POA (Power of Attorney). Surveyor asked if a resident has a fall and the initial x-ray is normal (no fractures indicated), but then the resident starts complaining of severe localized pain of 8/10, 9/10, and 10/10 in a location the resident does not normally have pain, what should staff do. DON B stated she would expect staff to contact the physician immediately. If a resident has a BIMS of 14, is their own person, and is requesting to go to the hospital for new onset of 10/10 localized rib pain following a fall what should staff do. DON B stated staff should act on the resident's request, honor the resident's wishes, and contact the physician to be evaluated. Surveyor asked DON B what RN D should have done when R168 was stating severe 10/10 pain in right rib area this morning. DON B stated she should have listened to the resident and contacted the physician. On 4/4/19 at 11:13 PM, Surveyor spoke with Physician I. Physician I stated that when R168 came to them from the hospital (where R168 was sent from the previous facility), R168 was overmedicated, in [MEDICAL CONDITION], and they gave [MEDICATION NAME] in the hospital (the hospital reports it was a small dose of [MEDICATION NAME] with little effect). Physician I stated that R168 always rates pain at a 10/10. Physician I stated, If R168 can exaggerate pain, R168 will. Physician I added, R168 manipulates their pain rating to get narcotics. Physician I stated that R168 is terribly demented and chemically dependent. Surveyor asked Physician I if the facility contacted him regarding R168 between Tuesday, 3/26/19 and Sunday 3/31/19. Physician I stated he was contacted by the facility when R168 fell (3/26/19) and was sent to the ED (Emergency Department), Physician I stated he signed a note for the transfer. Physician I stated he is at the facility on Tuesdays and Fridays. Physician I could not recall if he saw R168 on 3/29/19. Physician I stated he recalls staff talking to him about R168's pain when he was at the facility on either 3/26/19 or 3/29/19. Physician I stated if he had seen R168 he would have left a note on the right side of the physician's orders [REDACTED]. Physician I does not recall the exam. There is no indication that R168's ribs were examined during this visit. R168's pain was unmanaged and uncontrolled following fall. Per the facility policy, which is consistent with the standard of practice, pain is whatever the experiencing person says it is, existing whenever s/he says it does. The facility failed to identify R168's rib fractures leading to inadequate pain management, and failed to provide person centered care with the resident's goals in mind.

Based on interview and record review, the facility did not ensure updates were provided to the physician, resident representative or the resident for 1 of 27 sampled residents (R168) out of a total of 30 residents sampled. R168 sustained a fall at the facility on 3/26/19. R168 was sent to the hospital for evaluation and returned to the facility with no identified injuries. On 3/28/19, R168 reported new onset of severe right rib pain rated as an 8/10 (pain scale representing 8 out of 10, with 10 being severe), 9/10 and 10/10. The facility failed to immediately contact R168's physician. Evidenced by: The facility's Change of Condition Notification policy, revised 7/11/18, includes, in part, the following: I: Purpose: An acute change of condition (AC[NAME]) is defined by AMDA (American Medical Directors Association) is a sudden , clinically important change from a patient's well established and documented baseline in physical cognitive, behavioral, or functional domains. AC[NAME]'s may occur abruptly or over several hours to several days, presenting as physical changes or as changes in Function, Pain, Mood, Cognition, or Behavior. II: Policy: A physician must be notified of any AC[NAME], including but not limited to physical, cognitive, behavioral, or functional changes. III: Procedure: Physician notification will occur, when there is any change of condition in a resident. R168 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R168's pain is usually either all over due to [MEDICAL CONDITION], or on left side, due to a history of shingles. R168's Admission MDS (Minimum Data Set) indicates a BIMS (Brief Interview for Mental Status) of 14, indicating R168 is cognitively intact. R168 is her own person. R168's Pain Assessment, dated 3/15/19 at 12:43 PM, includes, the following: Current Pain Level: Moderate Location of Pain: All over. Comments: R168 has [MEDICAL CONDITION] and has had shingles approximately 2 years ago. States worst pain is from the shingles and in left leg. Also has pain in various areas due to the [MEDICAL CONDITION]. R168's care plan, dated 3/27/19, states: I need some assistance to maintain pain control and self-care because I have pain and/or discomfort and have chronic illness. R168's CNA (Certified Nursing Assistant) Care Plan states: I need my aides to ask me if I'm having pain. On 3/26/19 at 4:30 AM, R168 was ambulating in room without staff assistance and fell . The fall investigation documents that R168 had complaints of pain, right rib and shoulder. The facility sent R168 to the hospital to be evaluated. On 3/26/19 at 2:57 PM, a Nurses Note (NN) states as follows: Spoke with hospital ER (emergency room ); they stated they are sending resident back and R168 has no injuries or new orders. ER Doctor stated they gave resident tyl (Tylenol) for pain. Resident did request an ice pack for comfort. Will continue to monitor. On 3/27/19 at 5:58 PM: by RN H (Registered Nurse) administered [MEDICATION NAME] HCL ([MEDICATION NAME]) 5 mg. Pain Level Before Med: 8/10. Location: Right beneath the breast. Of note R168 had a significant increase in pain from baseline with no MD (Medical Doctor) update. On 3/28/19 at 7:59 AM: RN F administered PRN Tylenol Extra Strength 500 mg Pain Level Before Med: 5/10. Location: Right rib cage. On 3/28/19 at 1:42 PM: RN F administered [MEDICATION NAME] 5 mg for pain level 10/10. Location: Right rib cage grimacing with deep breaths Of note R168 had a significant increase in pain from baseline with no MD update. On 3/28/19 at 7:59 PM: RN H administered [MEDICATION NAME] 5 mg for pain level 9/10. Location: Right ribs/side On 3/29/19 at 12:26 AM, R168 NN states: F/U Fall Muscle/Skeletal Pain: Resident description of pain: deep and aching tender on palpation. Of note R168 had a significant increase from baseline with no MD update. On 3/29/19 at 4:58 AM, RN G administered [MEDICATION NAME] 5 mg for pain level 9/10. Location: right chest area rib pain from (sic) fallen down Of note R168 had a significant increase in pain from baseline with no MD update. On 3/29/19 at 2:05 PM, Physician I documented the following Note: lethargic SLR (Straight Leg Raising - is a physical exam technique to determine abnormality of the sciatic nerve or tightness or the hamstring) 90 degrees left and right without pain the straight leg, smiling, generally better. , Note there is no indication that R168's right rib pain was assessed during this visit. On 3/29/19 at 6:11 PM, RN H administered PRN [MEDICATION NAME] 5 mg for pain level 10/10. Location: Right side Of note R168 had a significant increase in pain from baseline with no MD update. On 3/30/19 at 4:54 PM, Agency Nurse administered [MEDICATION NAME] 5 mg for pain level 9/10. Location: Both sides Of note R168 had a significant increase in pain from baseline with no MD update. On 3/31/19 at 5:23 AM, RN G administered [MEDICATION NAME] 5 mg for pain level 8/10. Location: Right rib cage Of note R168 had a significant increase in pain from baseline with no MD update. On 4/1/19 at 9:03 AM, Surveyor spoke with R168. R168 stated to Surveyor that R168 was having pain in right rib area. Surveyor observed R168 grimacing. Surveyor asked R168 to show me where the pain is located. Surveyor observed R168 point to lower right rib cage and start rubbing the area. Surveyor asked R168 to rate the pain on a scale of 0 to 10, with 10 being severe. R168 stated rib pain is 10/10. Surveyor asked if R168 had any falls recently. R168 fell last week and has had pain in right ribs ever since. R168 stated to Surveyor that R168 wanted to go to the hospital to get checked out. R168 has been telling staff R168 wants to go to the hospital for rib pain but nobody is listening. On 4/1/19 at 9:07 AM, Surveyor immediately notified RN D regarding R168's pain level of 10/10 in right rib area. Surveyor asked if R168 would like Surveyor to wait with R168 until RN D arrived with the medications. R168 stated yes. Surveyor waited with R168. On 4/1/19 at 9:11 AM, RN D approached R168 to give morning medications. Surveyor stated to RN D that R168 is requesting to go to the hospital to be evaluated due to right rib pain. RN D stated that R168 had a fall last week and was previously sent out to the hospital to be evaluated and x-ray was negative. RN D administered morning medications, including pain medication (R168 received [MEDICATION NAME] 600 mg and [MEDICATION NAME] PRN (as needed) 5 mg for pain) and continued passing medication. Surveyor let R168 know that I would review R168's chart. Surveyor reviewed R168's chart and noted on R168's Hospital Report, on 3/26/19, that R168 complained of right rib pain while in the emergency room and the pain was then described as mild. The pain R168 described to Surveyor is a 10/10, severe pain. On 4/1/19 at 10:15 AM, Surveyor spoke with ADON C. Surveyor asked if ADON C is familiar with R168's pain. ADON C stated that R168 fell last week and was complaining of right rib and right shoulder pain and the hospital sent R168 back to the facility stating there were no injuries. Surveyor stated to ADON C that R168 stated to Surveyor that R168 is having 10/10 pain in right rib area and is requesting to go to the hospital to be evaluated. Surveyor stated that R168 has been telling staff that that R168 wants to go to the hospital to be evaluated but nobody is listening. Surveyor stated that Surveyor shared this information with RN D. ADON C stated she will take care of it. On 4/1/19 at 11:17 AM, the facility wrote a Physician's Telephone Order that states: PA lateral chest x-ray for c/o (complaint) of right rib pain. On 4/1/19 at 2:56 PM, R168 had two chest x-rays taken. On 4/1/19 at 3:23 PM, the Physician electronically signed the chest x-ray results stating: There is a mildly displaced [MEDICAL CONDITION] 8th rib and possible nondisplaced 9th rib fracture. Impressions: 1. Left basilar pleuroparenchymal changes, which may reflect pneumonia, 2. Right rib fractures. On 4/2/19 at 10:15 AM and 4/3/19 at 8:50 AM, Surveyor spoke with R168. R168 stated that moving makes the pain worse. R168 moves more slowly and I can't do the things like I used to. R168 added, I can't move as good as what I was (moving prior to the fracture). Surveyor asked if R168 if participates in activities at the facility. R168 stated has never been much for activities. R168 stated with [MEDICAL CONDITION] and [MEDICAL CONDITION] one is not a very active person. Surveyor asked R168 if the pain in right rib area is worse than one's usual pain. R168 stated, Oh yes. Surveyor asked R168 if the pain in right rib area was new. R168 stated, yes. R168 stated the pain is sometimes overwhelming. Surveyor asked R168 how it makes one feel when in that much pain. R168 stated, It made me mad because it hurts so bad and I can't move that well - it hurts. Surveyor described the term breakthrough pain to R168. Surveyor asked R168 how often one experiences breakthrough pain. R168 stated, Quite often. Surveyor asked R168 can you tell me how many times a day you experience breakthrough pain. R168 stated 4 or 5 times a day my pain level is at a 7 or 8. R168 stated that 7 or 8 times since sustaining a fall with fracture, on 3/26/19, pain has been a 10/10. R168 stated when R168 tells the nurses they will give either Tylenol or [MEDICATION NAME]. R168 told the facility on Friday, 3/29/19, that R168 wanted to go to the hospital to be checked out due to right rib pain and nobody would listen. R168 stated, Nobody would believe me. R168 added it made me feel like they thought I was just making it up and I was lying to them. On 4/2/19 at 3:00 PM, Surveyor spoke with RN D. RN D stated I heard in report that R168 had a fall and was sent to the hospital to get checked out. Surveyor asked RN D if R168 normally has pain. RN D stated yes, and if RN D asks, R168 will normally say pain is 10/10 pain in left leg and left foot because R168 has had shingles or will say pain is all over. Surveyor asked RN D heard before yesterday that R168 was having pain in right rib area. RN D stated, no, RN D was off this past weekend and worked on a different Wing last week. (Note: RN D was aware that pain in this location was new to R168 and RN D did not contact Physician I per R168's request and Surveyor concern.) On 4/3/19 at 10:40 AM, Surveyor spoke with CNA E (Certified Nursing Assistant). CNA E has been a long term employee at the facility. Surveyor asked CNA E if R168 has pain. CNA E stated yes. Surveyor asked CNA E to tell me about R168's pain. CNA E stated, R168 is always saying one is in pain all over. CNA E stated for the last week or so, R168 has been complaining of pain right here (pointing to the rib area) in right rib area and kept holding onto it. (It is important to note that CNA E is describing guarding which is an involuntary reaction to protect an area of pain.) CNA E reported to the RN on duty when they observed R168 guarding right rib cage area. CNA E stated that the nurses are aware of this and they (Nurses) talk about pain during the rounds. Surveyor asked CNA E what did the nurses do about it. CNA E does not know if anything was done to address R168's pain. There is no evidence that further steps were taken to address R168's pain or that Physician I was contacted. On 4/3/19 at 12:25 PM, Surveyor spoke with RN F. On 3/28/19 at 1:42 PM, RN F documented the first report of 10/10 right rib cage, grimacing with deep breaths. RN F spoke with Physician I when he was in the building on either 3/26 or 3/29 about R168's pain. RN F did not call Physician I regarding R168's new onset of right rib pain with difficulty breathing. RN F stated R168 wanted pain medication. RN F had R168 do range of motion (ROM) and paid attention to facial expressions. RN F noticed that R168 was grimacing with ROM assessments when assessing R168's ribs. RN F believes this was documented on 3/28/19. Surveyor noted a ROM evaluation documented on 3/28/19. RN F did not contact Physician I as he was scheduled to be at the facility the following day. No further steps were taken to address R168's new onset of severe pain in right rib area at this time. On 4/3/19 at 2:15 PM, Surveyor spoke with RN G. ; R168 complained of pain in the right side of rib cage. Surveyor asked RN G if R168 continued to complain of right rib pain after returning from the hospital following the fall. RN G stated, Yes, maybe twice in the past week. On 3/29/19 at 4:58 AM, RN G documented that R168's pain as 9/10 in right chest area rib pain from (sic) fallen down. Surveyor asked RN G what do you do when R168 complains of pain. RN G stated if the pain is a 5 or below, gives Tylenol, and if it's 6 or above, gives [MEDICATION NAME] or whatever the physician has ordered. RN G stated sometimes R168 will state having 10/10 pain and RN G goes to the cart to get medication and when RN G comes back, R168 is sleeping. RN G did not contact Physician I regarding R168's new onset of severe pain in right rib area. On 4/3/19 at 2:45 PM, Surveyor spoke with RN H. On 3/28/19 at 7:59 PM, RN H documented R168's pain as 9/10 right ribs/side. RN H stated that normally R168 will not give a level when one asks for current level of pain. RN H stated, when R168 describes pain as it's bad, RN H takes that as pain level is over 6 and administers [MEDICATION NAME]. Surveyor asked if RN H if contacted the Physician. RN H is not sure if they contacted the physician. No further steps were taken to address R168's new onset of severe pain in right rib area. On 4/3/19 at 3:30 PM, Surveyors spoke with DON B (Director of Nursing). Surveyor asked DON B what ones expectation is if a resident is having increased pain. DON B stated that staff should administer medications per Physician Orders. DON B stated if a resident is having increased pain, her expectation is that staff notifies the physician and the family/POA (Power of Attorney). Surveyor asked if a resident has a fall and the initial x-ray is normal (no fractures indicated), but then the resident starts complaining of severe localized pain of 8/10, 9/10, and 10/10 in a location the resident does not normally have pain, what should staff do. DON B stated she would expect staff to contact the physician immediately. If a resident has a BIMS of 14, is their own person, and is requesting to go to the hospital for new onset of 10/10 localized rib pain, following a fall, what should staff do. DON B stated staff should act on the resident's request, honor the resident's wishes, and contact the physician to have resident evaluated. Surveyor asked DON B what RN D should have done when R168 was stating severe 10/10 pain in right rib area this morning. DON B stated she should have listened to the resident and contacted the physician. On 4/4/19 at 11:13 PM, Surveyor spoke with Physician I. Physician I stated that when R168 came to them from the hospital (where R168 was sent from the previous facility), R168 was overmedicated, in [MEDICAL CONDITION], and they gave [MEDICATION NAME] in the hospital (the Hospital Reports it was a small dose of [MEDICATION NAME] with little effect). Physician I stated that R168 always rates pain at a 10/10. Physician I stated, If R168 can exaggerate pain, R168 will. Physician I added, R168 manipulates pain rating to get narcotics. Physician I stated that R168 is terribly demented and chemically dependent. Surveyor asked Physician I if the facility contacted him regarding R168 between Tuesday, 3/26/19, and Sunday, 3/31/19. Physician I stated he was contacted by the facility when R168 fell (3/26/19) and was sent to the ED (Emergency Department), Physician I stated he signed a note for the transfer. Physician I stated he is at the facility on Tuesdays and Fridays. Physician I could not recall if he saw R168 on 3/29/19. Physician I stated he recalls staff talking to him about R168's pain when he was at the facility on either 3/26/19 or 3/29/19. Physician I stated, if he had seen R168, he would have left a note on the right side of the physician's orders [REDACTED]. Physician I does not recall the exam. There is no indication that R168's ribs were examined during this visit. Staff failed to contact Physician I when R168 began complaining of severe 10/10 localized pain in right rib area one day after sustaining a fall. As a result, R168's rib fractures went undiagnosed and was in severe pain for over 5 days.

Based on interview and record review, the facility failed to develop and implement a Comprehensive Care Plan for 1 of 4 sampled Residents (R2). R2, prior to admission, was found wandering outside her home on 6/24/18. An Elopement Risk Assessment on admission indicated she was not an elopement risk; however, the MDS (Minimum Data Set) assessment on 7/10/18 indicated she had wandered in the previous 1-3 days and was at significant risk of getting into a potentially dangerous place/situation. The Care Area Assessment (CAA) under Behavioral Symptoms noted she was an immediate threat to self and had wandered out of the Unit. Due to long-standing mental health problems, depression, recent loss of her husband, and moderate cognitive loss (BIMS (Brief Interview for Mental Status) score of 9 of 15) they would develop a care plan. The care plan was not completed. Consequently, there was no plan in place for preventing elopement, and the resident did have a WanderGuard bracelet. The facility failed to comprehensively assess and implement care plan interventions to monitor a resident with a known history of elopement attempts, which resulted in the resident leaving the building unsupervised, and putting the resident at risk for serious injury or death, creating a finding of IJ (Immediate Jeopardy) that began on 7/10/18. The NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were notified of the IJ on 8/23/18 at 4:20 PM. The IJ was removed on 8/23/18; however, the deficient practice continues at a scope/severity of D (potential for more than minimal harm that is not IJ/isolated) as the facility continues to implement its action plan. This is evidenced by: Facility policy entitled 'Wandering/Elopement assessment,' dated 7/10/17, indicates: I. Purpose: to provide a safe environment for the residents who reside at (facility) .III. All residents of (facility) will be assessed for wandering/elopement risk within two hours of admission by a member of their health care team, using the following definitions, as outlined in the Wisconsin State Operations Manual for Long-Term Care Facilities. Wanderer is a person who aimlessly moves with intentional destination within facility and consistently returns to familiar areas .Wanderer, Elopement Risk is a person who moves aimlessly or with intention, exhibiting or verbalizing exit-seeking behaviors, such as opening exit doors, asking for directions to home, bus, etc.The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) .Staff will institute a monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. Based on these assessments or the occurrence of a wandering and/or elopement event, the necessary interventions are to be initiated which include but are not limited to: placement of a WanderGuard or other appliance on resident extremity. Initiation of wandering and/or elopement care plan Example 1 R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2's Admission MDS assessment, with target date of 7/10/18, indicates the following: R2 has a BIMS of 9 out of 15, indicating there is some cognitive function loss. Section E indicates wandering presence and frequency occurring 1 to 3 days, during the look back period. E 1000 indicates that wandering has an impact on R2 and is marked as yes, indicating the wandering places R2 at significant risk of getting to a potentially dangerous place (e.g., stairs, outside of the facility). Section G indicated that R2 needs physical assist of 1 with bed mobility, transfers and that she uses a walker and wheelchair as devices. R2 does not have any impairment to her extremities. R2's CAA indicates: CAA 09- Behavioral symptoms Condition(s): 2. Wandering has a value of 1 through 3 as indicated by: E 0900>= 1 and E 0900 <=3 . Seriousness of behavioral symptoms: Resident is immediate threat to self. Resident wandered out of her Unit. Staff afraid she may get lost or go outdoors. Illness or conditions: Long-standing mental health problem associated with the behavioral disturbances: Depression, recently lost husband and son. Factors that can cause or exacerbate the behavior: Didn't know she couldn't move about. Behavior cognitive status problems: Recent cognitive loss (from record, interviews with family etc.) due to recent hospitalization . Resident scored a 9/15 on BIM's on 7/10/2018. Care plan: Will develop care plan. Seriousness of behavioral symptoms: Not serious. Behavioral disturbance: There was no disturbance. Illness or conditions: Long-standing mental health problem associated with the behavioral disturbances: Depression. Resident recently lost her husband and her son. She states she does not want to take anything for this. Problems: Scored 9/15. Family believes this is recent and due to recent hospitalization . Care plan: Will develop care plan.CAA 11 - Falls .She is working with OT (Occupational Therapy) and PT (Physical Therapy). She (SIC) goal is to return home at an independent level. She is walking short distances with assist in the facility. R2's care plan, dated 7/10/18, indicates: (MONTH) experience forgetfulness, was recently hospitalized and I was fine until then. I believe it has something to do with my sodium. Not been able to remember things that happened a short time ago. 7/23/18 - Have the potential to fall down and hurt myself because I sometimes get confused, take some medications that can make me dizzy, tired, confused or weak .because I forgetting where I am. I need aides to use the following assistive devices, to be able to better help me; 2 WW (wheeled walker), frequently check on me make sure my important items are within my reach, give me non-skid footwear, so I don't slip make sure I can reach my glasses, remind me to wear my glasses, remind me to get up and move slowly. R2's care plan does not address being a wandering/elopement risk or any of the information identified in R2's CAA. On 8/23/18 at 12:30 PM, Surveyor interviewed SW H (Social Worker) regarding R2's Section E of her Admission MDS. SW H indicated she marked Section E that way because her son found her outside of her home. SW H stated, Yes, that a previous situation of being found outside prior to admit puts a resident at risk for elopement. SW H indicated that R2 did not require a Wandering/Elopement Care Plan, because she came from the hospital on medications, her BIMS was fine and when SW H talked with her son, he stated she doesn't need a WanderGuard. SW H indicated that R2 did not have a care plan at the time of her Comprehensive Assessment, but since Section E is marked, in a way, that indicates R2 should have a care plan. SW H indicated that a history of being found outside/wandering would put a resident at higher risk for wandering/elopement. SW H indicated that MDS Nurse G stated she would put information in the nursing notes after SW H mentioned it to her and stated she would develop a care plan. On 8/23/18 at 2:35 PM, Surveyor interviewed MDS Nurse G regarding R2's care plan. MDS Nurse G indicated that each department does the CAA associated with their sections and then they would make the decision to care plan or not to care plan. MDS Nurse G indicated SW H is responsible for Sections C, D, and E, and if triggered, SW H should care plan. MDS Nurse G indicated that if SW H does a CAA, saying it needs to be addressed, then SW H needs to complete the care plan. MDS Nurse G indicated that care plans are not monitored, as they do not go back and read each CAA and that Section V is the only section looked at to see if CAA is addressed. MDS Nurse G indicated they do not look at care plans to see if problems are addressed in the care plan, she just looks to see the work is completed by looking at Section V. MDS Nurse G indicated she expects each person doing the CAA to do a Comprehensive Care Plan and follow up if needed. MDS Nurse G again indicated no one ensures care plans are completed as they do not compare the CAA to the care plan. MDS Nurse G indicated that a resident with a history of wandering out of their home indicates they are a wandering risk and that R2 should have had a care plan for wandering/elopement. The facility's MDS Assessment had assessed R2 as being at significant risk for getting into a potentially dangerous place or situation, yet failed to provide the safety devices (e.g., WanderGuard bracelet) or direction to staff for keeping her safe. Consequently, the resident was able to elope out the facility, unknown by staff, on 8/20/18. It was only fortuitous that a Certified Nursing Assistant (CNA) on break and a CNA looking out the window happened to see R2, as she fell to her knees outside. (Cross reference F689.) The facility's failure to develop a Comprehensive Care Plan for a resident with known wandering created a finding of IJ. The IJ was removed on 8/23/18 when it had completed the following: ~Resident that was directly involved in this deficient practice was re-evaluated for elopement risk. A WanderGuard was subsequently placed. During the investigation period, it was noted that the resident had several identifying moments to which the facility had opportunity to ensure safety of this resident. R2's 8/20/18 care plan indicates: I transfer with the help of 1 person not bearing my weight with a 2 WW. I walk with the help of 1 person, not bearing my weight. I use a standard walker gait belt and wheelchair (w/c) to follow, ambulate to/from dining each meal. Special precautions: Elopement Risk *** has WanderGuard #6 on left wrist. Do not leave resident alone in room while in w/c . ~To ensure that other residents are not at risk for this deficient practice, all residents that could be potentially at risk for elopement were re-evaluated using the elopement risk tool. The facility has taken measures to ensure that this deficient practice does not occur again by the following: 1. Reviewed pre-admission screen, placed a question Hx (History) of wandering/elopement with 3 answers: No History, 1 or 2 episodes, 3 or more episode. 2. Updated Elopement Assessment to guide nursing staff to review any documentation that could potentially identify at risk individuals. 3. MDS Coordinator to review all section E and associated CAA for all residents. If resident is identified as at risk, an Elopement Assessment will be completed and care plan will reflect any new interventions needed for the risk. If the individual is identified as at risk in Section E and the CAA and the individual does not meet the criteria for elopement risk, the MDS Coordinator will bring this information to the IDT (Interdisciplinary Team) to collaborate potential plan of care. 4. Educate individual staff associated with the system breakdown, as well as continued education of all staff on ensuring safety of all residents at facility. Nursing Supervisor or designee will ensure that staff in house will be educated prior to leaving shift today 8/23/18, with the remainder of all staff, with exception of seasonal staff or individuals on any type of leave, receiving education by 8/28/18. The facility will ensure that the deficient practice is corrected and does not recur by the DON or designee auditing all new admissions for elopement risk and ensuring that appropriate interventions are in place. The DON or designee will also audit completed MDSs to ensure that the care plan reflects identified concerns on the CAA's. All audits will be reviewed monthly at QAPI (Quality Assurance and Performance Improvement) for no less than three months or until the QAPI Team feels it is no longer a concern.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices to prevent accidents from elopement for 1 of 3 sampled residents (R2) who wander. R2, prior to admission, was found wandering outside her home on 6/24/18. An Elopement Risk Assessment on admission indicated she was not an elopement risk; however, the MDS (Minimum Data Set) Assessment on 7/10/18 indicated she had wandered in the previous 1-3 days and was at significant risk of getting into a potentially dangerous place/situation. The Care Area Assessment (CAA), under Behavioral Symptoms, noted she was an immediate threat to self and had wandered out of the Unit. Due to long-standing mental health problems, depression, recent loss of her husband, and moderate cognitive loss (BIMS (Brief Interview for Mental Status) score of 9 of 15) the facility would develop a care plan for R2. The care plan was not completed. Consequently, there was no plan in place for preventing elopement and the resident did have a wanderguard bracelet. R2 eloped from the facility on 8/20/18. Staff was not aware the resident was outside. Two Certified Nursing Assistants (CNAs), who were on break, happened to see the resident as she fell to her knees. The facility's failure to provide adequate supervision for a resident, with known wandering, created a finding of Immediate Jeopardy (IJ) that began on 8/20/18. NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were notified of the IJ on 8/23/18 at 4:20 PM. The IJ was removed on 8/23/18; however, the deficient practice continues at a scope/severity of D (potential for harm that is not IJ/isolated) as the facility continues to implement its action plan. This is evidenced by: Facility policy entitled 'Wandering/Elopement assessment,' dated 7/10/17, indicates: I. Purpose: To provide a safe environment for the residents who reside at facility .III. All residents of (facility) will be assessed for wandering/elopement risk within two hours of admission by a member of their health care team, using the following definitions, as outlined in the Wisconsin State Operations Manual for Long-Term Care Facilities. Wanderer is a person who aimlessly moves with intentional destination within facility and consistently returns to familiar areas .Wanderer, Elopement Risk is a person who moves aimlessly or with intention, exhibiting or verbalizing exit-seeking behaviors, such as opening exit doors, asking for directions to home, bus, etc.The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) .Staff will institute a monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. Based on these assessments or the occurrence of a wandering and/or elopement event, the necessary interventions are to be initiated, which include, but are not limited to: placement of a WanderGuard or other appliance on resident extremity. Initiation of Wandering and/or Elopement Care Plan Facility Policy entitled 'Elopements,' dated 8/21/2017, indicates: . III: Definitions: Elopement: When a resident who is cognitively, physically, mentally, emotionally, and/or chemically impaired; wanders away, walks away, runs away, escapes, or otherwise leaves a care giving facility unsupervised, unnoticed, and/or prior to their scheduled discharge. Attempted elopement: When a resident is actively seeking to exit a building/unit, however, does not cross the threshold of the door unnoticed Example 1 R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2's Elopement Risk Assessment, dated 7/3/18, indicates the following: Ambulation as being ambulatory or wheelchair, mental status alert, cognitive processes as being responsible to redirection/cueing. History of elopement episodes during past 6 months, indicated as no history. Total score is 5, resident is not at risk for elopement. R2's Admission MDS AssessmentMDS Assessment, with target date of 7/10/18, indicates the following: R2 has a BIMS of 9 out of 15, indicating there is some cognitive function loss. Section E indicates wandering presence and frequency occurring 1 to 3 days during the look back period. E 1000 indicates that wandering has an impact on R2 and is marked as Yes, indicating the wandering places R2 at significant risk of getting to a potentially dangerous place (e.g., stairs, outside of the facility). Section G indicated that R2 needs physical assist of 1 with bed mobility, transfers and that she uses a walker and wheelchair (w/c) as devices. R2 does not have any impairment to her extremities. R2's CAA indicates: CAA 09 - Behavioral Symptoms Condition(s): 2. Wandering has a value of 1 through 3 as indicated by: E 0900>= 1 and E 0900 <=3 . Seriousness of behavioral symptoms: Resident is immediate threat to self. Resident wandered out of her Unit. Staff afraid she may get lost or go outdoors. Illness or conditions: Long-standing mental health problem associated with the behavioral disturbances: Depression, recently lost husband and son . Factors that can cause or exacerbate the behavior: Didn't know she couldn't move about. Behavior cognitive status problems: Recent cognitive loss (from record, interviews with family etc.) due to recent hospitalization . Resident scored a 9/15 on BIM's on 7/10/2018. Care plan: Will develop care plan. Seriousness of behavioral symptoms: Not serious. Behavioral disturbance: There was no disturbance. Illness or conditions: Long-standing mental health problem associated with the behavioral disturbances: Depression. Resident recently lost her husband and her son. She states she does not want to take anything for this. Problems: Scored 9/15. Family believes this is recent and due to recent hospitalization . Care plan: Will develop care plan.CAA 11 - Falls .She is working with OT (Occupational Therapy) and PT (Physical Therapy). She (SIC) goal is to return home at an independent level. She is walking short distances with assist in the facility. R2's Care plan, dated 7/10/18, indicates: (MONTH) experience forgetfulness was recently hospitalized and I was fine until then. I believe it has something to do with my sodium. Not been able to remember things that happened a short time ago. 7/23/18 - have the potential to fall down and hurt myself, because I sometimes get confused, take some medications that can make me dizzy, tired, confused or weak .because I (SIC) forgetting where I am. I need aides to use the following assistive devices, to be able to better help me. 2 WW (wheeled walker), frequently check on me, make sure my important items are within my reach, give me non-skid footwear, so I don't slip make sure I can reach my glasses, remind me to wear my glasses, remind me to get up and move slowly. The care plan did not address R2's elopement risk. On 8/23/18 at 12:30 PM, Surveyor interviewed SW H (Social Worker) regarding) regarding R2's Section E of her Admission MDS. SW H indicated she marked Section E that way because her son found her outside of her home. SW H stated, Yes, that a previous situation of being found outside prior to admit puts a resident at risk for elopement. SW H indicated that R2 did not require a Wandering/Elopement Care Plan, because she came from the hospital on medications, her BIMS was fine and when SW H talked with her son he stated she doesn't need a WanderGuard. SW H indicated that R2 did not have a care plan at the time of her Comprehensive Assessment, but since Section E is marked in a way that indicates R2 should have a care plan. SW H indicated that a history of being found outside/wandering would put a resident at higher risk for wandering/elopement. SW H indicated that MDS Nurse G stated she would put information in the nursing notes after SW H mentioned it to her and stated she would develop a care plan. On 8/23/18 at 2:35 PM, Surveyor interviewed MDS Nurse G regarding R2's care plan. MDS Nurse G indicated that each department does the CAA associated with their sections and then they would make the decision to care plan or not to care plan. MDS Nurse G indicated SW H is responsible for Sections C, D, and E and if triggered should create a care plan. MDS Nurse G indicated that a resident with a history of wandering out of their home would indicate the resident is a wandering risk and that R2 should have had a care plan for wandering/elopement. R2's Physician/NP (Nurse Practitioner) Assessment, signed 7/16/18, indicates the following: History of present illness: Resident was found outside wandering in a confused state by her neighbor on 6/24/18. She was admitted to (Hospital name) for [MEDICAL CONDITION], [DIAGNOSES REDACTED], and [DIAGNOSES REDACTED] due to diuretic .Electrolytes improved and mental status returned to baseline .Resident remained weak so short-term rehab was recommended. She was admitted to (Facility) on 7/3/18, and her goal is to return home . 7/30/18 1:55 PM Behavior Charting indicates: Change from baseline: Delusions: (R2) believes that the reminder sign placed in her room, to remind her to use her call light, that sign placed in my room because they think I won all that money, and I did not kill that kid. I want to call my son, or I'm going to call the cops. Assisted (R2) to phone son, (name), on his work phone and cell phone without an answer and (R2) left (sons name) a message to come see me or call the cops. Initiated behavior monitoring and was not confused earlier, but is now accusing staff of (SIC) unplugged my call light. Reassured that the call light is not unplugged and checked call light and it is functioning. 7/30/18 7:14 PM Progress Note indicates: Son (name) approached this Writer with MDS Nurse, (MDS nurses name) and asked if a call could be placed to Primary Care Provider (PCP) (physician name) in regards to residents increased confusion and increased falls. Stated that labs and urinalysis (UA's) have been done and everything is coming back with-in normal limits (WNL). The son noticed that the changes aligns with when resident began taking [MEDICATION NAME] (antidepressant) 10 mg (milligrams) (every day) while in the hospital. The medication has been carried over to resident's stay at (facility). A request for a decrease in dosing or a discontinuation, and also an update of a fall with no injury was left with (name), to be forwarded to the MD (Medical Doctor). 7/30/18 8:59 PM Progress Note indicates: Fall, resident's room, crawling on floor, mental state confused. Was not able to specify what she was doing, in one account stated she was getting out of bed, another she was going to check on her son (had just left her room). 7/30/18 10:18 PM Progress Note indicates: Increased confusion. 7/31/18 5:49 AM Behavior Note indicates: New behavior: Confusion. Resident thought it was daytime at 1:00 AM. Resident also trying to self-transfer. 7/31/18 1:37 PM Behavior Note indicates: Continues to be confused, has wandered around to (SIC) has tried to self-transfer, easily redirected. 7:36 PM Behavior Note indicates: Increased confusion, 1:1, assessed for pain, changed position, conversation, given food, reoriented, redirected, reassured, toileted, outcome: unchanged. 7/31/18 9:17 PM Behavior Note indicates: Confusion persists, disoriented and occasionally upset with staff for not doing what or taking her where she wants to go i.e.: home, park etc. 7/31/18 11:27 PM Mood Note indicates: resident is in the recliner in living room. Resident asked Writer if the firemen were okay. Having some hallucinations. Seems calm. Has not been sleeping as of yet. 8/1/18 12:38 PM Behavior Note indicates: Resident appears to be less confused today. Able to hold conversation with visitors. However, is very sleepy from being up all night d/t (due to) confusion as reported by N[NAME] (evening/overnight) Shift Nurse, will continue to monitor. 8/1/18 at 9:12 PM Progress Note indicates: Agitation, anxious, resident behaviors began around 7:30 PM tonight. Resident kept trying to stand up unattended, refusing assist, pushing at staff. Denied pain when asked. Offered snack/fluid, threw water across room, refused several attempts to complete shower tonight. Attempted position change from w/c to recliner and proceeded to get up from recliner. Difficult to redirect. Self-propelled her own w/c into several peers rooms tonight, was able to redirect from peers rooms without any problems .Resident was making statements of having to get home to cook for her children, having a car out here to drive, and that she does not need any assistance. (Please note resident is making statements about having to go home on 8/1/18 and previously made indications of wanting to go home on 7/31/18.) 8/2/18 12:19 AM Behavior Note Indicates: Resident is in living room, not trusting anyone tonight. Resident is talking about getting the people out of the room. Refusing cares so far this shift. 8/2/18 at 7:10 PM Behavior Note indicates: No behavior issues, resident has been redirectable and pleasant thus far. Did ask to go outside to wait for her visitors, but agreed to wait in recliner in living room by the door, so if she he has visitors she would see them come in. (Please note that charting on 7/30/18 indicated a change in baseline as the resident was delusional (accusing staff of unplugging her call light, going to call cops). Charting on 7/31/18 indicates the resident was wandering and had increased confusion. On 8/2/18, the resident began indicating she wanted to go home and was looking for visitors. Despite this change in behavior, no one questioned if the resident should be wearing a wanderguard bracelet.) 8/6/18 at 1:48 PM Daily Decision Making Note states: Resident's decisions are poor, cues/supervision required. 8/6/18 at 1:48 PM Nursing Progress Note states: Wandering: behavior occurred 4-6 days in the last 7 days, but not daily. 8/9/18 at 7:42 AM Physician/NP Contact Note states, in part: .noted (R2's) cognitive improvements since [MEDICATION NAME] was decreased to 5 mg QAM (every morning) and asked (physician name) to clarify . (R2)'s mental status remains variable with both long & short term memory. A few notations indicate difficulties during the evening hours, .asked (physician name) if R2 would benefit from a cognitive enhancer medication or not and if would consider it or not. 8/10/18 1:35 AM Progress Notes indicate: Requires one aide assist for transfers, requires one aide assist to walk in room and in corridor. R2 requires one aide assist to move about the unit. 8/12/18 6:40 PM Nervous System Findings Note states: Oriented to first name. Cannot recall last name. 8/12/18 6:42 PM Recall Note states: Doesn't recall things. 8/13/18 at 2:44 AM Daily Decision Making Note states: Resident's decisions are made with difficulty in new situations, and and Wandering: behavior not exhibited in past 7 days. 8/13/18 at 11:10 AM Physician/NP Contact Note indicates: Fax received regarding lab results. New orders received and noted, 8/13/18 recheck a basic metabolic panel 9/11/18 - [MEDICAL CONDITION] (low sodium) (Please note that R2 had low sodium prior to being hospitalized , when she was found outside her home wandering by her neighbor.) 8/19/18 at 11:30 AM, Short Term Memory Note states: Poor short term memory. 8/19/18 at 11:30 AM Long Term Memory Note states: Poor long term memory. 8/19/18 at 9:04 PM Mood Note states: Needs are met, appeared to be restless. Found up and walking on numerous occasions, was reminded to call for assistance and led back to a chair, or assisted with a walk. Intervention: 1:1 interaction, accompanied outside for walk, assessed for pain, offered conversation, given food, offered distracting activity, offered snack, reassured. (Please note there is no indication if these interventions were successful, or if R2's behaviors stopped or continued.) 8/20/18 at 5:43 PM Incident Note indicates: Fall out of facility; Resident went out door 8 unattended. R2 was found outside kneeling on her right knee while hanging onto a tree in the parking lot out door 6. Mental status: oriented, confused per her usual. R2 was walking unattended without any assistive device, while carrying a blanket. Unwitnessed. R2 states she did not hit her head and has no evidence of any head injury. Neuro checks initiated per protocol for an unwitnessed fall and within normal limits. Possible Cause: Without assistive device, without staff left out door 8 walking outside. Ambulated unattended outside. Resident states she did not fall, she was going to fall and went down on her knee so she would not fall. Interventions: WanderGuard applied at 5:10 PM to R2's right wrist. Son agreed for placement of the WanderGuard. R2 agreed for placement of the WanderGuard to alert staff when she is close to the exit door so staff can assist her. 5:57 PM Behavior Note states: Monitor for exit seeking behavior. Found in team parking lot 8/20/18. WanderGuard applied. 8/20/18 Investigation, regarding the incident with R2, indicates: . (R2) was observed outside of the building, without staff knowledge, at which time she fell . Fall Scene Investigation Report: I'm better, so I was going home. Indicates eloped out door 8 and ambulated around to parking lot by door 6, found kneeling on right knee hanging onto a tree in grass. Mood or mental status heading home. Re-creation of last 3 hours before fall: at 4:05 PM, I came back from my break and toileted her; at the beginning of the shift 2:00 PM she was sleeping in the recliner in living area. Previous Aide said last time toileted was at 1:00 PM. At 4:15 PM, after being toileted, I helped her (R2) walk back to recliner in living area. I took (another residents name) to the bathroom. When we came out, R2 was not in the recliner I put her in. I went into her room and she was not there; a call light came on and then another. I answered both and then approached the Nurse on Unit and mentioned speech therapy taking her. At 4:30 PM we were notified she was outside of the team building door 6. CNA I's (Certified Nursing Assistant) written statement states: I was in the break room at approximately 4:30 PM when I observed a woman at and around door number 6. She was holding a blanket and walking around. First I thought it was a visitor, then she started walking towards the parking lot and I noticed that she was staggering unsteady. I saw all this through the window. I decided to go outside to investigate. I saw her stumble and fall next to a tree, by the disabled parking area. CNA E might have been on the sight (SIC) she was talking to the resident. I identified her as the above mentioned resident (R2). I quickly notified the nurse in charge of that unit who promptly attended to the resident . CNA E's written statement states: As I was exiting my car 4:30PM, I seen her (R2) walking near door #6. That was the direction I was going. I seen (SIC) her stumble and she was gone. Knowing she must have fallen, I rushed to her. Not knowing if she was a resident or a visitor. I asked if she was okay, she said yes. She was kneeling on her right knee, her hand on the tree, attempting to stand. I quickly realized she was a resident when she was telling me everyone left. I'm looking for them. I ran to door #6 as CNA I was heading to door #6. I asked CNA I to call for help and I stayed with the resident. CNA I returned knowing who she was and encouraged her to sit down while help was coming. She was looking for people or son's truck. On 8/23/18 at 2:07 PM, Surveyor interviewed CNA E regarding 8/20/18 incident with R2. CNA E indicated she was on break and her break was over. She was at the end of the parking lot, to the right, leaving her car to walk towards the building. CNA E indicated she saw a woman on the side walk between the building and the first handicap spot. CNA E indicated what caught her eye was she (R2) was holding a blanket by her waist area with two hands. CNA E indicated R2 was walking and did a shuffle, then she disappeared. CNA E knew she fell and ran, at that point she didn't know if she was a resident or a visitor. To CNA E's knowledge, no one knew R2 was out of the building. CNA E asked are you okay. R2 was trying to get up and said she was looking for her people. CNA E indicated R2 was on her right knee by a tree holding onto the tree. Once she realized she was a resident, CNA E was focused on R2's well-being. CNA E indicated she was flailing her arms towards the office, but no one seen her, so she ran to the closest door and there was a CNA in the hall and she asked for help. CNA I went to get help. A gentleman in a black truck wanted to get her up, and I told him we couldn't. CNA E indicated this occurred around 4:30 PM. CNA E indicated she had never worked with her (R2) before and no one else was with R2. On 8/23/18 at 2:30 PM, Surveyor interviewed CNA I regarding R2's incident on 8/20/18. CNA I indicated that 2-3 days ago she was in the break room at approximately 4:30 PM and she could see outside. CNA I saw a woman with a blanket by door #6 of Limestone Unit. CNA I indicated she was thinking maybe it was a visitor. CNA I saw her start moving and walking to parking lot. CNA I was able to see she was unsteady and having difficulty walking. CNA I saw her stumble and fall by a tree. CNA I indicated she fell on the lawn and there was no CNA with her. CNA I went to assist and meet up with CNA E. CNA I indicated the other CNA said she was not sure if she's a resident or a visitor. CNA I went out and identified her as R2, went to Limestone and told the nurse, who went out and did what she needed to do. CNA I indicated she is unaware if anyone knew R2 was out there. CNA I indicated she had worked with R2 before and that is how she was able to identify R2. CNA I indicated she remembers that R2 was able to walk, but not by herself. On 8/23/18 at 11:15 AM, Surveyor observed the area where R2 exited the building with NHA A. NHA A indicated the facility was able to validate via cameras that R2 went out this door, after coming through double doors, between both Limestone units and out both sets of exit doors into the staff/visitor parking lot facing the county jail. (Please note: In order to get to the location where R2 was found, you would have to go through the dining room on R2's Unit, through a doorway into the second half of the unit. Past the 2nd half of the units own dining room, through a hallway of resident rooms, then through a set of 2 heavy metal doors, into a corridor/hallway, where there are offices set back between the West and East Units to the right. Then R2 had to go through one set of exit doors into a little entry way and through another set of exit doors to get outside to the parking lot. 8/21/18 12:41 PM Short Term Memory Note indicates: Poor short term memory, memory is variable and R2 is at times forgetful and will transfer herself and staff attempt to anticipate needs. Long term memory: Long term memory OK. R2 remembers leaving the building on 8/20/18 without assist and informed this Writer she was going to check out the cars, but does not recall why she went over by the tree, where she was found. On 8/23/18 at 11:10 AM, Surveyor interviewed CNA D regarding R2. CNA D indicated that R2 has gotten more confused since she came to the facility. CNA D indicated R2 attempts to get up out of her bed or wheelchair, and has never seen her attempt to get outside prior to incident. On 8/23/18 at 11:25 AM, Surveyor interviewed RN F (Registered Nurse) regarding R2. RN F indicated that R2 will try and self-transfer and that R2 normally gets directions wrong and tries to wheel self down the wrong hall. RN F indicated that R2 is very unsteady and ambulates with 1 assist with a gait belt and her walker. RN F indicated that R2 has gotten more and more confused, thought her sodium was off again, but levels was fine. On 8/23/18 at 11:50 AM, Surveyor interviewed DON B regarding R2's elopement risk. DON B indicated depending on the assessment, redirectablity and attempts to exit determines if someone is at risk. DON B indicated potentially, when asked if a resident who has had a previous incident of elopement/wandering prior to admission would that place them at risk. The facility's failure to provide adequate supervision for a resident with known wandering created a finding of IJ. (Please note: Because the resident did not have her WW, it is questionable how far she could have gotten, once she got outside. Had she gotten farther, there are environmental risks in the immediate area. The facility is on County Road F, which is sandwiched between Highway 51 and Business Highway 14. There is construction traffic from a county building that is being torn down to the left of the building and area where R2 was found. A potential for serious harm, however, existed given that this resident's vulnerabilities (particularly her diminished ambulatory skills - as indicated by her need for assistance and the use of a walker - and the fact that she would get directionally lost) placed her at risk. The IJ was removed on 8/23/18, when the facility had completed the following: ~Resident that was directly involved in this deficient practice was re-evaluated for elopement risk. A WanderGuard was subsequently placed. During the investigation period, it was noted that the resident had several identifying moments to which the facility had opportunity to ensure safety of this resident. ~To ensure that other residents are not at risk for this deficient practice, all residents that could be potentially at risk for elopement were re-evaluated using the Elopement Risk Tool. The facility has taken measures to ensure that this deficient practice does not occur again by the following: 1. Reviewed pre-admission screen, placed a question Hx (history) of wandering/elopement with 3 answers: No History, 1 or 2 episodes, 3 or more episode. 2. Updated Elopement Assessment to guide nursing staff to review any documentation that could potentially identify at risk individuals. 3. MDS Coordinator to review all section E and associated CAA for all residents. If resident is identified as at risk, an Elopement Assessment will be completed and care plan will reflect any new interventions needed for the risk. If the individual is identified as at risk in Section E and the CAA and the individual does not meet the criteria for elopement risk, the MDS Coordinator will bring this information to the IDT (Interdisciplinary Team) to collaborate potential plan of care. 4. Educate individual staff associated with the system breakdown, as well as continued education of all staff on ensuring safety of all residents at facility. Nursing Supervisor or designee will ensure that staff in house will be educated prior to leaving shift today 8/23/18, with the remainder of all staff, with exception of seasonal staff or individuals on any type of leave, receiving education by 8/28/18. The facility will ensure that the deficient practice is corrected and does not recur by the DON or designee auditing all new admissions for elopement risk and ensuring that appropriate interventions are in place. The DON or designee will also audit completed MDSs, to ensure that the care plan reflects identified concerns on the CAAs. All audits will be reviewed monthly at QAPI (Quality Assurance and Performance Improvement) for no less than three months or until the QAPI team feels it is no longer a concern.

Based on observation, interview and record review the facility did not ensure each resident 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 for 3 of 24 residents (Residents 9, 8 and 15). Resident 9 developed a wound on his foot. Once the area developed the physician was not notified for a change in care or treatment. Resident 9's wound developed osteo[DIAGNOSES REDACTED] and his toe had to be amputated. Resident 8 sustained a fall from a mechanical lift; the facility did not identify fractures in Resident 8's leg for 5 days. The facility did not ensure that Resident 15's constipation was assessed and interventions were in place to ensure she had regular bowel movements (BMs). The facility did not re-evaluate interventions when documentation showed they were ineffective. This is evidenced by the following: Example 1 The American Diabetics Association guidelines for foot care includes: Daily foot checks and to seek care early if you get a foot injury. Resident 9's [DIAGNOSES REDACTED]. Resident 9's care plan, dated [DATE], includes: Problem: Impaired skin related to impaired mobility and contractures. Approaches: Diabetic nail care by nurse, wheelchair with pillow under lower extremities to relieve pressure on feet. Assess any skin concerns reported immediately. If pressure ulcer is noted inform physician as indicated (Stage I- remove pressure and prevent further breakdown notify physician within 24 hours, Stage II or greater-call physician and obtain orders for follow up initiate wound rounds). Wears socks when up in wheelchair. Shoes donned when pressure areas are not present. Resident 9's nursing notes: -[DATE], 10:00 PM, DTI (deep tissue injury) left foot non-blanchable. Initiated wound rounds and three scratches to left ankle. Toe nails clipped. (There is no signature to indicate who make the note/discovery.) The Wound Scale Assessment Guide was started on [DATE]. It indicates a questionable DTI that is unstageable on the underside of Resident 9's left foot. Measurements are 0.7 cm by 0.5 cm. It is dry, intact black color. Wound Status: New. Current treatment: skin prep twice a day, soft heel suspension boots. On [DATE] Resident 9's Physician Notification Form indicates a DTI was noted to the left foot underside and wound rounds were started. This was initialed by Medical Director (MD) R (Resident 9's physician) but there is no date indicating when this was noted by him. -The facility uses the PNF as the primary notification of the physician for non-immediate notifications. The physician is in the building Monday-Friday. MD R did not order any treatment for [REDACTED]. Resident 9's care plan was updated on [DATE]: Skin prep twice a day, soft heel suspension boots when up and wound nurse weekly and as needed. Resident 9's wound was assessed weekly via the Wound Scale Assessment Guide by Wound Nurse S: -[DATE], Unstageable, Left foot underside, tan soft eschar, left lateral periwound firm, inferior and right lateral periwound soft. Resident 9 was seen by Podiatrist P on [DATE] at the facility for routine foot care. Podiatrist P's report does not indicate any concerns related to wounds on Resident 9's feet. On [DATE], at 4:20 PM, Surveyor interviewed Podiatrist P. Podiatrist P confirmed he saw Resident 9 for a routine visit on [DATE]. Podiatrist P stated he did not see any wound on Resident 9's foot but there may have been a discoloration. Podiatrist P also stated he did not recall the facility informing him of any new concerns for Resident 9. Resident 9 does have a history of an unstageable pressure ulcer on his left foot from [DATE] that has healed. Podiatrist P stated if he would have been aware of a wound on Resident 9's foot that was not open he likely would have instructed the facility to off load the area with a boot or pad the area. Resident 9's Wound Scale Assessment Guide: -[DATE], no change continue skin prep. -[DATE], Unstageable DTI, 0.7 cm by 0.5 cm, 100% soft brown necrosis/eschar, no change continue skin prep. -[DATE], DTI underside left foot 1.2 cm by 0.7 cm, deteriorated, increase in size physician updated. On [DATE], MD R ordered skin prep twice a day to the left foot open area. Resident 9's Wound Scale Assessment Guide: -[DATE], 0.3 cm by 0.3 cm, 1.5 cm air space, wound edges dry and calloused, deteriorated. Eschar now not present. 0.3 cm by 0.3 cm granulation. 1.5 cm air space under calloused skin to left of wound bed. Physician viewed and ordered Santyl and referral for debridement. On [DATE] Resident 9 was seen in the wound clinic. The clinic notes: The wound is located on the plantar aspect of the left foot over the 5th metatarsal beginning approximately 2 months ago, cause in unknown-patient and CNA unsure what is causing pressure or friction in the area as the original injuring event. Vascular status: wound bed slough, pink firmly adherent. Barriers to wound healing include contractures limiting position changes, decreased sensation and diabetes. Wound location: Left foot, plantar surface over 5th toe. Etiology: Diabetic Ulceration with potential for pressure as an additional etiology. Thickness: full Measurements: 1.2 cm x 1 cm x 0.3 cm depth prior to debridement. Undermining/tracts/tunneling: Circumferential undermining of entire wound with largest measurement of 1.1 cm at 0300. Sinus tract noted in center of wound tracking to tendon and likely bone. Drainage: Serous, scant to small amount, moist. Wound condition: wound bed slough 50% granulation 50%. Wound margins: defined but undermined, calloused. Assessment: Neuropathic/diabetes ulcer with pressure features. Full thickness. No progress in 2 weeks, 6 weeks without improvement, suspect osteo[DIAGNOSES REDACTED]. Procedure: Debridement of debris/necrosis. Debrided area of 2 cm x 2 cm x 1 cm. Plan: MRI to rule out osteo[DIAGNOSES REDACTED], Bactrim DS for 10 days for empiric antibiotic coverage until osteo[DIAGNOSES REDACTED] can be ruled out. Wound Clinic notes: -[DATE]-Neuropathic ulcer located on the plantar aspect of the left foot 5th metatarsal. Wound has sinus tract that appears to reach bone/tendon. No appreciable change in size. Wound bed 100% granulation tissue. Ordered foot X-ray as Resident 9 is unable to have a MRI. -[DATE]-Wound has sinus tract that appears to reach almost to bone/tendon. This has filled in some from last visit where I was able to clearly tap bone. Wound measurement after debridement 0.7 cm x 0.9 cm x 0.4 cm. X-ray without suspicion for osteo[DIAGNOSES REDACTED]. Stopped Santyl. Packed wound with ,[DATE] inch packing strip, covered with foam dressing change ,[DATE] times a week. -[DATE]- Wound has tunnel that appears to reach almost to tendon, bone not visible or palpable. No appreciable change in size. Measurements after debridement 0.8 cm x 0.9 cm x 0.5 cm. Wound bed 50% granulation 40 % smooth nongranular tissue and 10% slough. -[DATE]-No appreciable change in size except a newer tunnel in the center of the wound bed. Wound measures 0.8 cm x 0.9 cm x 0.5 cm depth over most of the wound with a small area in the center of the wound bed that tracks in 1.8 cm. Plan: Need to rule out [MEDICAL CONDITION] vs osteo[DIAGNOSES REDACTED] of left foot due to swelling and [DIAGNOSES REDACTED]. 3 phase bone scan to rule out osteo[DIAGNOSES REDACTED] in swollen foot. Start Bactrim DS. -[DATE]- Wound measures 0.8 cm x 0.9 cm x 0.9 cm depth over most of the wound with a small area in the center of the wound bed that tracks in 1.8 cm. Bone is palpable in terminal end of tunnel. Wound assessment: Nonhealing wound with osteo[DIAGNOSES REDACTED] present. Ulcer appears healthy and mostly clean. Presence of exposed bone and results of bone scan indicate that there is osteo[DIAGNOSES REDACTED] of the left 5th metatarsal. Examined for appropriateness of surgical excision of the bone affected by osteo[DIAGNOSES REDACTED]. On [DATE] Resident 9 went to the hospital to have is left fifth digit amputated due to osteo[DIAGNOSES REDACTED]. On [DATE], at 2:22 PM, Surveyor interviewed DON B who stated the facility does not have standing orders. DON B stated staff would need an order for [REDACTED]. On [DATE], at 10:28 AM, Surveyor interviewed MD R. MD R reviewed his notes and stated he was made aware of the concern with Resident 9's foot on [DATE] but the first time he made a note was on [DATE] where he noted a 2 cm defect on the bottom of the left foot. MD R stated he could not determine what type of wound it was and would have to look at the wound clinic documentation. MD R stated when a wound is noted the wound nurse will do an evaluation then have him see it. If it is a deep tissue injury or pressure ulcer the wound nurse will do the weekly evaluation and if needed he will see it and order treatment. MD R stated yes the staff has him sign orders for skin prep as there are no standing orders for wounds. MD R was asked what he would do for a resident who was diabetic with a DTI. MD R stated I would go and check any trauma on the foot of a diabetic. I would need to see it, check pulses and deal with it right away if it was on a diabetic. MD R was not aware of Resident 9 needing his toe amputated. On [DATE], at 1:40 PM, Surveyor interviewed Registered Nurse (RN) S. RN S stated she is not wound certified but she takes care of the wounds and is the facility wound nurse Monday-Wednesday. RN S stated Resident 9's wound was first noted on [DATE] when the paperwork was completed and sent to her. RN S first saw the wound on [DATE]. The wound was maroon in color and was not open and the area was soft. RN S stated the nurse who first noted it called it a DTI so she continued to call it that. RN S stated they applied skin prep to the wound which they would need an order for [REDACTED]. That is when she noted the callous and talked with MD R about it. RN S stated when she was initially made aware of the DTI she looked at Resident 9's wheelchair and asked therapy to lower the foot rest and added bilateral blue suspension boots to relieve pressure to the bottom of his feet. When Resident 9 developed a wound on the foot the facility did not ensure he was assessed by the physician timely and Resident 9 ultimately had to have his toe amputated. Example 2 Resident 8's care plan, dated [DATE], indicates he is legally blind and he requires 2 staff assistance with the EZ lift (mechanical full body lift) for transfers. Per the facility Fall/Incident report, on [DATE], at 5:00 AM, Certified Nursing Assistant (CNA) L and N were transferring Resident 8 from his bed to his wheelchair with the EZ lift when the lift tipped over and Resident 8 was lowered to the floor. Licensed Practical Nurse (LPN) T was immediately notified and completed the fall incident report. The report indicates Resident 8's range of motion was per baseline and there was no apparent injury. The physician was notified via the Physician Notification Form (PNF) book. There was no Registered Nurse (RN) assessment immediately following the fall. The last page of the incident report are 3 hand written notes: Follow-up with CNA to get better statements of how EZ lift was used to transfer. EZ lift to be checked by maintenance. Lift is working properly. After speaking with staff it sounds like they didn't have the legs of the lift open all the way causing it to tip. None of the notes are signed or dated. The facility shift report sheets for Resident 8: -[DATE], No delayed injury other than bruising found on night. -[DATE], as needed Tylenol at 4:00 PM -[DATE], slept well. -[DATE], Do not get him up (underlined) Resident 8's Medication Administration Record [REDACTED] -Beginning [DATE], Monitor bruise on left lower extremity until healed 4 cm X 1.5 cm left shin AM and PM shift. Monitor bruise on top of hand until healed AM and PM shift. Monitor for delayed injury for 72 hours AM, PM and Night shift. -Tylenol for fever or pain 650 mg received on ,[DATE] at 3:00 PM, ,[DATE] at 4:00 AM, ,[DATE] at 2:30 PM. -Resident 8 receives Tylenol 650 mg twice a day scheduled at 8:00 AM and 7:00 PM. Resident 8's nursing notes include: -[DATE], at 10:30 AM, No delayed injury. Denies pain. Continue to monitor and document changes.-Documented by an RN. -[DATE], at 5:00 AM, Resident 8 has bruise to top of right hand and bruise to left lower extremity. Delayed injury from being lowered to floor on [DATE]. Denies pain, no swelling. Physician notified via PNF book. RN Supervisor notified. Resident 8's PNF on [DATE] indicates a bruise on left lower extremity 4 cm by 1.5 cm. -[DATE], No delayed injury other than bruising. (No additional notes until [DATE]) -[DATE], at 3:00 AM, Bruise on resident left lower extremity has increased in size. Bruise measures 11 cm by 16 cm. Lower leg red in color and warm to the touch. Left lower extremity swollen and painful with movement and touch. Tylenol 650 mg given for pain and was effective. Pedal pulse positive. RN Supervisor aware. Physician and family to be updated in morning. -[DATE], at 8:30 AM, Left lower extremity appears warm, red with large purple/blue bruise that extends anterior to posterior ankle. Increased pain since yesterday. Appears to have changed over last 24 hours. Physician notified via phone. Orders written. Bed rest at this time. Resident 8 complains of pain when repositioning. On [DATE], Medical Director (MD) R (Resident 8's physician) ordered an X-ray of the left tibia/fibula, ankle and foot, a doppler of left leg and laboratory tests for possible [MEDICAL CONDITION] and possible [MEDICAL CONDITION] with trauma. Resident 8's hospital notes indicate he was admitted on [DATE] for a closed [MEDICAL CONDITION] tibia and fibula on the left. A closed reduction and casting of the left tibia/fibula fracture was recommended. Resident 8 was discharged back to the facility on [DATE]. On [DATE], at 8:00 AM, Surveyor interviewed DON B. DON B stated after a fall staff check for injury and complete an accident incident report. If it is an LPN who is working the hall the Charge RN is to come behind them and do the assessment. DON B stated she spoke with staff and RN Z did an assessment on Resident 8 after the fall but she did not document it. (RN Z was on vacation and not available for interview). DON B stated Resident 8 was placed on the 24 hour Shift Report to monitor for any injuries after the fall and then the bruises were being monitored in the Medication Administration Record. DON B stated if there was a change in the bruise she would expect staff to document the changes and notify the physician either via the PNF book or with a phone call based on the significance of the change and the AMDA Guidelines. The facility did not recognize Resident 8 had multiple fractures following a fall for 5 days. Example 3 The facility policy Titled Bowel (Lower Gastrointestinal Tract) Disorders - Clinical Protocol revised ,[DATE] states: As part of the initial assessment the staff and physician will help identify individuals with previously identified lower gastrointestinal tract conditions and symptoms. Examples include: Alteration in bowel movements. The staff and physician will identify risk factors related to bowel dysfunction; characterize symptoms related to bowel function; and check for diffuse or localized tenderness and listen for bowel sounds in area of suspected of ileus or obstruction. The physician will identify and order pertinent cause-specific and symptomatic interventions; the staff and physician will monitor the individual's response to interventions and overall progress; for example frequency and consistency of bowel movements. The physician will adjust interventions based on identification of causes, resident responses to treatment, and other relevant factors. Before prescribing additional courses of medications, the physician should carefully evaluate - and may need to examine - an individual who has not responded as expected to an initial course of treatment . Resident 15 was admitted to the facility in [DATE]. Her [DIAGNOSES REDACTED]. Resident 15 expired on [DATE]. The facility Continence Assessment completed for Resident 15 [DATE] indicates she is continent of bowel however her history of constipation was not completed. It was reviewed on [DATE] and indicates she has a toileting plan but does not address any constipation. [DATE] Resident 15's Care Area Assessment under the title Nutritional Status/Dehydration and Fluid Maintenance it states, (Resident 15) has had some constipation. She had one bowel movement during the 7 day look back period. She has a PRN order for [MEDICATION NAME] suppository and this has been used with good results. Note that no other interventions were added to address her constipation. Resident 15's Resident Plan Report dated [DATE] states for Bladder and Bowel: Monitor for BM's on your shift. Document, none, small, medium, large, extra large. Report if it's been longer than 3 days if no BM. Resident 15's hospice care plan initiated [DATE] states for constipation: Sodium [MEDICATION NAME]/Fleets enema PRN (as needed), [MEDICATION NAME] 10 mg suppository PRN, Milk of Magnesia ,[DATE] ml PRN, [MEDICATION NAME] Sodium 50 mg/Senna 8.6 mg 1 tablet - 4 tablets up to 3 times a day PRN. She started 17 gm of polyethylene [MEDICATION NAME] 3350 powder once a day and 100 mg of [MEDICATION NAME] sodium daily for constipation. Non-pharmacological interventions were not attempted. Resident 15's Progress Notes [DATE] at 10:30 AM states, Bowel sounds hyperactive in 4 quadrants - on BM list due to no BM for the 4th day. The documentation did not include that any additional PRN was given or other interventions were attempted. The facility Continence Assessment completed for Resident 15 [DATE] indicates has constipation and uses laxative/enema and states to describe type, frequency, and effectiveness; however there is no additional information added. It was reviewed [DATE] and states, No continence. End of life care. And still does not address her constipation. [DATE] Resident 15's Care Area Assessment under the title Nutritional Status/Dehydration and Fluid Maintenance it states, (Resident 15) has had some constipation. She has a PRN order for [MEDICATION NAME] suppository and this has been used with good results. The facility documentation of Resident 15's Bowel Movements (BM) from [DATE] to [DATE] are as follows: [DATE] to [DATE] - no BMs documented [DATE] - 2 small BMs [DATE] to [DATE] - no BMs documented [DATE] - medium BM [DATE] - small BM [DATE] - large BM [DATE]- no BMs [DATE] - large BM [DATE] to [DATE]- no BMs [DATE] - medium BM [DATE] to [DATE] no BMs [DATE] - small BM [DATE] - 2 small BMs [DATE] and [DATE] - no BMs The facility Medication Administration Records for Resident 15 state she received the following: [DATE] She received [MEDICATION NAME] Powder 17 gm and [MEDICATION NAME] Sodium 100 mg daily except she refused all of her medications on the 23rd and 30th. [MEDICATION NAME] EC 5 mg tablet PRN the following days 5,11, 16, 18, 19, 25, and 29. The space for result is blank for all of the dates. [MEDICATION NAME] 10 mg suppository was given the 30th and the results were not documented. [DATE] Resident 15 started refusing all her medication but did receive the following: [MEDICATION NAME] Powder on the 6th and 7th PRN [MEDICATION NAME] 5 mg tablet 3rd and 23rd with the results not documented. On [DATE] at 2:00 PM Surveyor interviewed Director of Nursing B who stated that the facility process for assessment and treatment of [REDACTED]. She agreed that non- pharmacological interventions should be considered prior to medication; that interventions should be evaluated if they are not working and documentation should be complete to include the results.

Based on observation, record review and interview the facility did not ensure 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 6 of 21 residents (Residents 8, 9, 19, 2, 13, 12). Resident 8 sustained a fall from a lift that resulted in a tibia and fibula fracture. Resident 8 is cited at the actual harm level, additional examples below are cited at the potential for harm level. Resident 9 was transferred with a mechanical lift and staff did not follow manufacture recommendations. Resident 19's safety tab alarm was not plugged in and functioning. Resident 2's care plan stated to use a gait belt when transferring her. CNA O was observed transferring Resident 2 without a gait belt. The facility did not follow manufacturer's recommendations when transferring Resident 13 with a mechanical lift. Resident 12 was observed being manually transferred with 2 staff, without the use of a gait belt. This is evidenced by the following: The facility uses the EZ Way full body lift. The manufactures operator's instruction manual includes: Transferring Patient from Bed to Chair: Position sling under patient: 5) Make sure sling is centered underneath the patient. 6) Lift patient's left thigh and pull the left wing of sling under patient's thigh. Then place excess wing over the top of the patient's left thigh. 7) Repeat above step for right thigh. Note: If the patient's legs are extremely rigid, it may work better to bring the left wing under the right thigh and the right wing under the left thigh instead of going between the patient's legs. Attach sling to lift: Attach the loops to the hanger bar hooks of the lift nearest each shoulder using the same length and color of loop strap on each side. Take the wing that is lying over the left leg and hook it on the right hook on the longest loop. Then take the wing lying over the right leg, cross it over and hook it on the left hook uing the same length and color of loop strap on each sling leg. Note: If you have gone under both legs with the wings for a rigid patient, bring the loops straight up along the outside of the legs and hook on the longest loop. Transferring Patient from Chair to Lift: Position Sling on Patient: 4) Lift the patient's left knee and with a tug, pull the right wing of the sling under the hip and thigh. 5) Place the excess sling over the right thigh. Repeat this procedure on the opposite side. Attach Sling to the Lift: 3) Attach the straps by the patient's shoulders to the lift using the shortest loop. 4) Take th wing that is lying over the patient's left thigh and attach it to the right hook on the hanger bar. 5) Take the sling leg lying over the right thigh and attach to the left hook on the hanger bar, again using the same length and color of loop strap on each side. -There is no indication for bringing the wings to the outside of a patient specified in the chair to lift section. Example 1 Resident 8's care plan, dated 9/20/15, indicates he is legally blind and he requires 2 staff assistance with the EZ lift (mechanical full body lift) for transfers. Per the facility Fall/Incident report, on 9/29/15, at 5:00 AM, Certified Nursing Assistant (CNA) L and N were transferring Resident 8 from his bed to his wheelchair with the EZ lift when the lift tipped over and Resident 8 was lowered to the floor. Licensed Practical Nurse (LPN) T was immediately notified and completed the fall incident report. The report indicates Resident 8's range of motion was per baseline and there was no apparent injury. The physician was notified via the Physician Notification Form (PNF) book. There was no Registered Nurse (RN) assessment immediately following the fall. The last page of the incident report are 3 hand written notes: Follow-up with CNA to get better statements of how EZ lift was used to transfer. EZ lift to be checked by maintenance. Lift is working properly. After speaking with staff it sounds like they didn't have the legs of the lift open all the way causing it to tip. None of the notes are signed or dated. The facility began in-servicing all CNA's on 10/4/15 by having them watch a video Your Total Patient Lift Solution. -This video addresses how to apply a sling and attach it to the lift. It does not specifically address the positioning, open or closed, of the lift legs during transfers. Resident 8's nursing notes include: -9/29/15, at 10:30 AM, No delayed injury. Denies pain. Continue to monitor and document changes.-Documented by an RN. -9/30/15, at 5:00 AM, Resident 8 has bruise to top of right hand and bruise to left lower extremity. Delayed injury from being lowered to floor on 9/29/15. Denies pain, no swelling. Physician notified via PNF book. RN Supervisor notified. Resident 8's PNF on 9/30/15 indicates a bruise on left lower extremity 4 cm by 1.5 cm. -10/1/15, No delayed injury other than bruising. (No additional notes until 10/4/15) -10/4/15, at 3:00 AM, Bruise on resident left lower extremity has increased in size. Bruise measures 11 cm by 16 cm. Lower leg red in color and warm to the touch. Left lower extremity swollen and painful with movement and touch. Tylenol 650 mg given for pain and was effective. Pedal pulse positive. RN Supervisor aware. Physician and family to be updated in morning. -10/4/15, at 8:30 AM, Left lower extremity appears warm, red with large purple/blue bruise that extends anterior to posterior ankle. Increased pain since yesterday. Appears to have changed over last 24 hours. Physician notified via phone. Orders written. Bed rest at this time. Resident 8 complains of pain when repositioning. On 10/4/15, Medical Director (MD) R (Resident 8's physician) ordered an X-ray of the left tibia/fibula, ankle and foot, a doppler of left leg and laboratory tests for possible deep vein thrombosis and possible cellulitis with trauma. Resident 8's hospital notes indicate he was admitted on [DATE] for a closed fracture of the distal tibia and fibula on the left. A closed reduction and casting of the left tibia/fibula fracture was recommended. Resident 8 was discharged back to the facility on [DATE]. On 10/15/15, at 9:45 AM, Surveyor interviewed Director of Nursing (DON) B about Resident 8's fall. DON B stated she was told Resident 8 was in the EZ lift and the lift legs were not spread out/open and the lift tipped over. DON B stated the nurse manager did provide immediate education to the CNAs involved. DON B stated there was no documentation of the in-service but she did verify that it occurred. On 10/19/15, at 9:47 AM, Surveyor observed CNA J and K transfer Resident 8 from his wheelchair to bed. CNA J and K used the EZ lift and crossed the sling wings under both legs and brought them up on the outside of Resident 8's legs. The CNAs attached the bottom end of the sling using the middle loops. CNA J was having trouble fitting the lift under the bed, CNA K stated to close the lift legs. CNA J replied no remember we can't close the legs all the way. CNA J then lifted the bed slightly and the lift fit under the bed. On 10/20/15, at 7:36 AM, Surveyor interviewed DON B. DON B stated all mechanical lifts are done with two staff. DON B stated she did not know who determines if staff should cross the sling wings between the resident's legs or go up on the outside. DON B stated staff should be crossing between the legs unless there is a hip fracture of something then they would go on the outside. DON B stated she trains staff to cross the wings of the sling and bring them up between the legs. On 10/20/15, at 8:30 AM, Surveyor interviewed CNA J. CNA J stated she was in-serviced on the lifts upon hire and watched a video after Resident 8 fell . CNA J stated she liked to cradle (wings on the outside) resident in the sling and does not like the crisscross between the legs. CNA J stated she uses the middle loops on the bottom of the sling so she can double it up if something were to happen, it's what she has always done. CNA J stated there was no training on what loop they should be using on the slings. Surveyor asked about the positioning of the lift legs. CNA J stated when you are lifting someone the legs have to be out then you can close it half way to move the resident but they cannot be closed all the way or it might tip. On 10/20/15, at 2:57 PM, Surveyor interviewed CNA L. CNA L stated when Resident 8 fell she and CNA N were transferring him from bed to his wheelchair. CNA L stated she was controlling the lift. CNA L stated the legs were open around the wheelchair. CNA N was guiding Resident 8 with the sling handles and CNA L was guiding Resident 8's feet as she was lowering him to the chair. CNA L stated then the lift went up on one leg and CNA L tried to keep the lift down but it tipped over and Resident 8 landed on the floor. CNA L stated the lift did not hit Resident 8 and the feet were in the 1/2 open position. CNA L stated they immediately got the nurse. CNA L stated following the incident the nurse manager spoke with both of them to find out what happened. CNA L stated she was educated to have the legs all the way open and she watched a video about the lift use. CNA L stated Resident 8 did not voice any pain immediately and he will moan if in pain but can't say my leg hurts. On 10/20/15, at 3:14 PM, Surveyor interviewed Nursing Home Administrator (NHA) A who stated she played the video for staff on how to use the lift. NHA A confirmed there was no return demonstration or observations on how to use the lift following the incident. See additional examples for transfers with lifts not per manufacturer's directions. Example 2 On 10/14/15, at 2:47 PM, Surveyor observed Certified Nursing Assistants (CNA) U and V transfer Resident 9 from a wheelchair to his specialized wheelchair. Resident 9 had a sling already under him in the wheelchair he was sitting in. CNAs U and V crossed the sling wings under both legs bringing them up on the outside of Resident 9's legs and attached them to the lift. CNA U began lifting Resident 9. Surveyor asked CNA U and V to stop the transfer as the sling was not centered under Resident 9's buttock and it appeared he would slide out the side. CNA U stated they always have the wings on the outside as it cradles Resident 9. CNA U and V both stated they were trained to bring the wings up on the inside between the legs but when they started at this facility staff told them to always cradle the residents and bring the wings up on the outside. CNAs U nor V was able to state who trained them at the facility. CNA U and CNA V adjusted the sling under Resident 9 and completed the transfer the sling wings on the outside of Resident 9. On 10/20/15, at 7:36 AM, Surveyor interviewed Director of Nursing (DON) B. DON B stated all mechanical lift transfers are done with two staff. DON B stated she did not know who determines if staff should cross the sling wings between the resident's legs or go up on the outside. DON B stated staff should be crossing between the legs unless there is a hip fracture of something then they would go on the outside. DON B stated she trains staff to cross the wings of the sling and bring them up between the legs. Example 3 Resident 19 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident 19's care plan identified the problem area of risk for falls with interventions that include a tab alarm when in his wheelchair. Per Resident 19's nursing notes Resident 19 was found on the floor on 8/19/15. The notes also indicate Resident 19 was attempting to transfer himself many times on 10/2/15. On 10/14/15, at 2:35 PM, Surveyor noted Resident 19 in the dining room. Resident 19 had a sensor pad alarm that was not plugged into the alarm box. There was no staff present in the area. At 2:39 PM, Surveyor interviewed Certified Nursing Assistant (CNA) I about the alarm. CNA I stated the CNA who just finished her shift had unplugged it because the box was not working. CNA I plugged the alarm pad it and the box sounded continuously. CNA I stated the previous shift tried new batteries and that did not help so they were going to get a new alarm box for Resident 19. CNA I confirmed Resident 19 is a high risk for falls and that is why he has the alarm. CNA I stated Resident 19 was left alone for a little bit but should not have been without the alarm functioning. On 10/21/15, at 1:08 PM, Surveyor interviewed Director of Nursing B who stated staff mad her aware of the incident on 10/14/15 with Resident 19's alarm. DON B stated she already did an education and audit regarding alarms and that if an alarm is not functioning properly a staff member must stay will the resident to ensure they are safe until the alarm is functioning. Example 4 Resident 2's Resident Plan Report includes her Transfer Program started 6/5/15 and states, The patient can be transferred bed to and from wheelchair with minimal assist of one person, gait belt and no assistive device. On 10/15/15 at 8:04 AM Surveyor observed CNA O transfer Resident 2 in the lounge area where Resident 2 resided. CNA O faced Resident 2 and with her right hand took Resident 2's right hand as if to shake hands. CNA O put her left hand on Resident 2's right arm near her elbow and assisted Resident 2 to stand up from her wheelchair. CNA O pivoted with Resident 2 and she sat down on the loveseat in the lounge. Surveyor observed a gait belt on the love seat next to Resident 2 that was on the loveseat during the transfer. On 10/21/15 at 8:45 AM Surveyor interviewed Director of Nursing (DON) B who stated that CNA O should have followed Resident 2's care plan and used the gait belt when transferring Resident 2. Example 5 Resident 13 has a [DIAGNOSES REDACTED]. Resident 13's Plan Report dated 10/19/15, which is part of the comprehensive care plan, states in part: EZ lift transfers. Use caution, has right sided weakness. Check and double check proper positioning/placement of straps on the EZ lift before attempting transfers. On 10/15/15 at 9:15 AM Surveyor observed CNA (Certified Nursing Assistant) D and CNA E transfer Resident 13 from his wheelchair to his bed using the EZ lift. CNA D and CNA E crossed the lower straps of the sling under both of Resident 13's legs as to cradle Resident 13's legs, and hooked both leg straps on the second of 3 loops (green loop) of the sling and proceeded to transfer Resident 13 into bed. Surveyor asked CNA E how she determined how to apply the sling for transferring Resident 13; she stated that she was taught to cradle both legs in the sling because it was more comfortable for the resident; she also stated that she had training on the lift use 2 weeks ago. Example 6 Resident 12 [DIAGNOSES REDACTED]. Resident 12's annual MDS (minimum Data Set) assessment dated [DATE] indicates that Resident 12 requires extensive assistance of 2 staff for transfers. Resident 12's Resident Plan Report dated 10/19/15, which is part of Resident 12's comprehensive care plan states: Transfers: Pivot with walker, gait belt and extensive assist of 2. On 10/15/15 at 9:30 AM, Surveyor observed CNA (Certified Nursing Assistant) F and CNA G transfer Resident 12 from her bed to her wheel chair. CNA F and CNA G each placed one of their arms under Resident 12's left and right arm pit and proceeded to transfer Resident 12 into her wheelchair. Surveyor interviewed CNA F about the correct method to transfer Resident 12 safely; CNA F stated that a gait belt should be used to transfer Resident 12 and it was not. CNA G stated that she would make sure a gait belt was placed in Resident 12's room. On 10/20/15 at 7:50 AM Surveyor interviewed DON (Director of Nursing) B about the facility's practice for the use of gait belts for manual transfers, DON B stated that staff should use a gait belt when manually transferring residents.

Based on observation, interview and record review, the facility did not ensure that the resident environment remained as free of accident hazards as is possible and that each resident received adequate supervision and assistance devices to prevent accidents for 3 of 4 Residents reviewed (Residents 4, 1, and 2). The facility identified 38 residents to be at risk for elopement from the facility. The facility has two main units, Limestone and Sandstone. Each unit is divided into East and West sections. Each section has two exits into other areas of the facility and is equipped with an alarm, which requires a key card for exit, to disable the alarm. In addition, each section has an entrance/exit to the outdoors that requires key cards to be swiped upon leaving the section. Residents' families have been given key cards so they can exit without seeking a staff person to let them out. This leaves open the possibility that a resident (unnoticed or unrecognized as a resident) could slip off the section with a visitor or group of visitors. Because there are no other lines of defense once a resident is off the section, a resident could then easily exit the facility. Resident 4, who was admitted on [DATE], was assessed by the facility to be at risk for elopement from the facility. The facility's process is to complete every 15 minute checks on residents upon admission to the facility. The facility did not have a process for evaluating this data in order to decide if 15 minute checks should be continued or stopped, or identify increased risk for elopement. The facility did not fully complete the 15 minute checks for 72 hours for Resident 4, per their unwritten protocol, and did not evaluate whether the checks should continue. On 12/20/14, Certified Nursing Assistant (CNA) H questioned Licensed Practical Nurse (LPN) J about Resident 4's checks. LPN J stated that she did not know if Resident 4 was to be on the checks. Follow up was not completed regarding the checks by either LPN J or CNA H and no checks were done. CNA H and LPN J were not aware of Resident 4's whereabouts on 12/20/14 until a Code Orange was called because Resident 4 had eloped from the facility and had been found by Dietary staff G, who was in her car. Dietary G called the facility and informed the facility that she had Resident 4, who "was on the highway" prior to his approaching her car and did not have a walker. Interviews collected by the facility revealed that Resident 4 was unsteady in his gait. The facility failed to ensure that the Resident 4's environment was free of hazards and that adequate supervision was provided in attempt to prevent accidents. This created a situation of immediate jeopardy on 12/20/14. The immediate jeopardy began on 12/20/14. Nursing Home Administrator (NHA) A was officially notified of the Immediate Jeopardy on 1/6/15. The facility removed the immediate jeopardy on 1/6/15, however, the deficient practice continues at a scope/severity level E (potential for harm that is not immediate jeopardy/pattern) as the facility continues to implement its removal plan and because of the following examples. Resident 1 was to be assisted with repositioning with two people. Resident 1 was repositioned with one assist. Resident 1 sustained an injury of unknown source, a fractured arm. The facility completed an investigation but did not identify that Resident 1 was repositioned with one assist and not the required two staff member assist. Resident 2 was being assisted with bath and then became very combative with staff. During this episode a bolt from the transitioning chair that he was being assisted with came off the device and Resident 2 had to be lowered to the floor. The facility did not fully investigate the root cause of the incident to prevent the incident from occurring again. The facility addressed it as equipment failure and did not address his combativeness during cares which can occur again. This is evidenced by: The facility's policy titled "Elopement" (revised 2007) states in part, "1. The resident shall be assessed by a nurse for elopement risk, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding wandering and elopement risk. 2. To try to prevent deaths/injuries from a possible elopement the facility shall promote the following approaches: a. An elopement risk assessment will be completed upon admission, change of condition, and quarterly thereafter. b. Ensure resident risk is noted and care planned when applicable." The facility's policy titled "Safety and Supervision of Residents" (revised 2007) states in part, "Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistant to prevent accidents are facility-wide priorities. Resident-Oriented Approach to Safety; 1. Our resident-oriented approach to safety addresses safety and accident hazards for individual residents. 2. Staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident and MDS (Minimum Data Set). 3. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. The care team shall target interventions to reduce the potential for accidents. 4. Implementing interventions to reduce accident risk and hazards shall include the following: a. communicating specific interventions to all relevant staff; b. assigning responsibility for carrying out interventions; c. providing training as necessary; d. ensuring that interventions are implemented; and e. documenting interventions." As noted earlier, the facility has two main units, Limestone and Sandstone and two sections (East and West sections) within each unit. Each section has two exits into other areas of the facility and is equipped with an alarm, which requires a key card for exit, to disable the alarm. In addition, each section has an entrance/exit to the outdoors that requires key cards to be swiped upon leaving the section. Residents ' families have been given key cards so they can exit without seeking a staff person to let them out. This leaves open the possibility that a resident (unnoticed or unrecognized as a resident) could slip off the section with a visitor or group of visitors. Because there are no other lines of defense once a resident is off the section, a resident could then easily exit the facility. The outside areas surrounding the facility include a retention pond and rough terrain. There are noted multiple parking lots surrounding the facility. A county highway and major highway in close proximity to the facility. The facility in located on a County Highway. Example 1 Resident 4 has [DIAGNOSES REDACTED]." This document further notes that Resident 4 has an activated Power of Attorney for Health Care as of 12/14/14 and is [AGE] years old. His gait is unsteady and he walks with a walker. The facility completed a Brief Interview for Mental Status (BIMS) on 12/23/14. Resident 4 scored 9 points on this assessment, indicating moderate cognitive impairment. The facility completed a Preadmission Screen for Resident 4 on 12/17/14. This screen notes that Resident 4 was hospitalized [DATE] for abdominal pain with diarrhea and confusion with disorganized thoughts. Resident 4's transfer status is up with a walker and one assist, and is "alert & oriented in AM. Mid afternoon-4 pm begins to sun down, delusions & hallucinations in evening. Redirects well. Very pleasant." The facility completed a "Wandering and/or Elopement Risk Assessment" for Resident 4, upon admission to the facility, 12/17/14. This assessment states in part, "Mobility and Physical Capacity. Does resident have the physical capacity to wander/elope? Yes. Cognitive Skill for Daily Decision Making. Is the resident independent in making decisions, aware of dangers, and responsible for self? No. History of Wandering and/or Elopement. Does the resident wander of have a history of wandering and/or elopement? Yes. Intent to leave. Has the resident verbalized strong desire to leave the facility or attempted to leave the unit and/or facility against the advice of treatment team? No. Decisions: At risk." The facility completed a CNA care plan titled "RH-Profile History Report" upon admission for Resident 4. This document, which is provided to CNA staff for delivery of care, states in part, "General Information; 12/17/14-12/18/14-Wears glasses. ADLs (Activities of Daily Living) 12/17/14-12/27/14-1 assist transfer and ambulation with walker. Bladder and Bowel-12/17/14 -present-continent of bowel and bladder. Moods and Behaviors; 12/17/14-present-alert and oriented in the AM. Baseline behavior is intermittent confusion with delusions, especially at NOC (night). Be aware that he may wander. Begins to sundown mid afternoon. Sometimes believes he sees his wife at a younger age. Redirects well. Pleasant." The facility completed "Resident Care Plan" with the following problems, goals and approaches: "12/18/14: Problem: Health Management Deficit Due To: illness or recent hospitalization leading to a nursing home admission; Approaches: Ensure resident checks at regular intervals during each shift. Goal: Resident will remain free from physical injury through the next three months. Approaches: Provide safety measures. Keep call light in reach. Provide safe environment free of harmful objects. Alert and Oriented in the AM. Baseline behavior is intermittent confusion with delusions, especially at NOC. Be aware that he may wander. Begins to sundown mid afternoon ...1 assist transfer and ambulation with walker." The facility assessed Resident 4 to be at risk for elopement and noted that he may wander, as described on his "Resident Care Plan" and "RH-Profile History Report." The facility initiated "Flow Sheet-15 Minute Checks" upon admission of Resident 4 to the facility on [DATE] at 1:45 PM. Checks were completed on 12/17/14 for 10 hours and 12/18/14 for 21.25 hours. It is important to note that checks were not documented as completed on 12/18/14 from 8:00 PM until 10:15 PM. Handwritten on the bottom of the 12/18/14 flow sheet is "(Resident 4) 15 " (minute) (checkmark) X (for) 72? (hours)." 12/19/14 "Flow Sheet-15 Minute (checkmark) for Safety 72? Hrs (hours)" indicates that checks were completed from 12:00 AM until 10:15 PM, a total of 22.25 hours. The facility completed checks for Resident 4 for a total of 53.5 hours. The facility did not complete checks on 12/20/14 until 4:00 PM, after Resident 4 had eloped from the facility. The facility did not complete their standard 72 hour checks on Resident 4 upon admission despite his assessed risk for elopement from the facility. The facility completed "Injury/Incident Investigation Report" for Resident 4. This document sates the following: "Date/Time of Injury/Incident Discovery: 12/20/14, 3:30 PM; Describe: Elopement from (facility) onto road and out of facility. Discoverer: (Dietary G). Type of Injury: Elopement. Location of Injury: None noted. Severity: Other, none needed on return to facility at skin check by RN (Registered Nurse) on PMs. Injury/incident Cause: Health condition: diagnosed confusion with disorganized thoughts. Actions Taken as a Result of this Incident: Review for relationship to event in past 24 hrs. Review for occurrence while in unsupervised care. Review for individual considerations specific to resident. Abuse, Neglect, Misappropriation: No. (Dietary G), an employee from Rock Haven kitchen called supervisor (RN K) at 3:30 PM and asked if we had (Resident 4) as a resident. She brought him back to (facility). A Code Orange was called for (RN K) to talk with nurse and tell of his elopement of (facility). (RN L) saw with family and talking and passed by walked out with them. (RN L) did not recognize him as a resident. Was brought back at 4 pm & VS (vital signs) & neuro (neurological) checks done by (LPN I). Lungs clear, dim (diminished) bases, VSS (vital signs stable). Immediate Intervention: Physical assessment; Neurological checks. 15 minute checks initiated. (Neuro-WNL (within normal limits)) T (temperature) 96.0, 155/86 (blood pressure), 72 (pulse), 18 (respirations), 100% RA (oxygen saturation on room air). Measures Implemented/Plan of Action: Plan of care revision, started 15 minute checks, 1:1 (one-on-one) CNA with resident started 24 hrs/day. Flow started X 24? to (checkmark) LOC (level of consciousness) & VS q (every) 4 hrs (hours)." According to www.usclimatedata.com, outside temperatures for Janesville, Wisconsin on 12/20/14 were 27 degrees Fahrenheit (high) and 25 Fahrenheit degrees (low). The facility initiated an investigation and collected statements as follows: RN K: "I (RN K) RN PM Supervisor received a phone call on Supervisor's phone at 3:30 PM, Sat (Saturday) 12/20/14 from (Dietary G), who stated works in the kitchen and asked if we have a resident (Resident 4) at (facility). I stated yes, and she stated she could get him back to the facility. I called a 'Code Orange' ...(LPN J) his PM shift nurse called stat, and I informed her of this occurrence and to be waiting for him when he arrives back. I, as supervisor, told (LPN J) to do VS, neuro checks and assess skin for injuries and have (RN L) do skin check during PM shift. Told (LPN J) to check temp. Enc (encourage) staff to get him to drink any warm fluids. VSS & temp 96.0 at 4 PM, return time. (VSS). He was alert, pleasantly confused. (Other Resident's daughter) stated to myself at around 4:05 PM 12/20 when I arrived on (unit) that she had seen this man (Resident 4) around the 'Old Rock Haven Building' at 3:30 PM and had talked to him and he stated he wanted a ride downtown. I'm not sure whether they (she) knew that he was a resident here when she spoke with him. (Other Resident's) daughter spoke to me in (facility) at 4:05 PM but she never did talk to any other staff prior his return, when noticed staff's concern and meeting here. I had talked to (CNA H) on PMs to have her make out her statement, 12/20/14, and she told me she asked (LPN J) @ 3 pm if (Resident 4) was on 15 minute checks. Noted that Resident came into (facility) on 12/17/14 and was charted in TPN (Treatment Progress Notes) notes by RN at 2:50 PM, so the 72 hour: 15 minute checks would be completed for the admit 15 min ones on 12/20/14 at 2:50 PM. I talked to (LPN J) on Sunday 12/21/14 in regards to if she had any staff or CNAs on Friday PM or night shift, especially ask her if (Resident 4) was on 15 minute checks. (LPN J) stated to me that she had no one (staff) approach her (especially 12/19/14 nights) and ask her about 15 checks. Summarizing & in conclusion of looking at this elopement investigation; 1. (Resident 4) was seen between 3-3:30 pm by (RN L), who was not aware he was a resident in building. 2. The kitchen employee (Dietary G) called (RN K) at 3:30 PM and reported him outside facility. 3. (Maintenance D), maintenance employee, after the fact of hearing about this incident, did see him at 3:45 pm outside. 4. The resident (Resident 4) was brought back and in facility by 4 pm by (Dietary G) kitchen employee. Administrator (Nursing Home Administrator (NHA) A) notified by 4:30 PM, (doctor) at 5 pm, and both sons (names) between 5pm and 515 pm. In conclusion: VS, neuro checks, skin assessment & 1:1 CNA supervision started with 15 minutes checks always." RN K wrote an additional notes in Resident 4's TPN which states in part, "(Dietary G) called (RN K) at 3:30 PM, and stated she asked if we had a (Resident 4's name) at (facility). He's out on the highway ...He stated he wanted to go downtown to uncertain address. Another resident's family was visiting in TV room and they told me they did see him at 3:30 pm by the old Rock Haven and they stopped and asked where he was going. His gait was unsteady. Had on pants, t-shirt & green velour shirt. No coat. He refused these visitors (of another resident) to take him back to (facility) ..." Dietary G: "(Resident 4) walked up to my car & asked for a ride home. Not sure if he was a resident asked his name, called desk, confirmed he was, brought him back. 3:30-3:45 PM we had a nice chat." CNA H (Resident 4's assigned CNA): "From 2:00-3:00 PM, I received report from the day nurse and while my partner (CNA M) passed linen, I began cares and rounds on other residents. (CNA M) assisted me with two 2-assist residents and then went to break because family was visiting our other 2-assist resident. When she left, I went to sign my 15 minute checks. Noticing that some were missing and some were not signed for the preceding shift, I asked the nurse (LPN J) if they were still active. She stated to continue checks on (other resident) and when I asked about (Resident 4), she said she didn't know because he was new and she doesn't work this side often. A short time later, the supervisor called a code orange for (Resident 4). I immediately went to the resident's room, along with the RN on (unit) (RN L). I pointed out that both his walker and wheelchair were still in his room. Shortly thereafter, (Resident 4) was returned to the unit. He became a one on one and I sat with him for a half hour while the other aide went on break. While I was with him, he stated that he intentionally walked out with visitors while talking to them to 'blend in' and that he was going to walk home so he could get him 'flying saucer so I can blow this city up.' He was very serious about this and then began talking about unrelated, but equally of the wall topics. I tried redirecting him, but he stated that he knew what I was doing, but he was too smart for that. That is when the other aide returned to 1:1 with him." LPN J (Resident 4's assigned nurse): "Describe all cares and interactions with client that you provided during your shift: No cares did not see resident." It is important to note that despite Resident 4's assessed risk for elopement, care planned interventions regarding wandering, and uncertainty of whether every 15 minute checks were to be completed, each assigned staff member (LPN J and CNA H) did not ensure Resident 4's safety and whereabouts for Resident 4 from the start of their shift at 2:00 PM until Resident 4's return to the facility at 4:00 PM. RN L: "At approximately 3:45 pm today I heard an overhead CODE ORANGE with instructions for the nurse caring for the resident located in room (Resident 4's room number) to call the supervisor. I was working on Limestone West Upper at the time. (LPN J) who was caring for the resident in that room responded to the supervisor and was told that the resident had been found outside and was being returned to the facility shortly. When he returned, I recognized him as the same man I had seen over on Limestone West Upper earlier in the shift (approximately between 3 & 3:30 pm). At that time, I witness him talking, laughing, and traveling with a group of people. I did not recognize him as one of our patients. I am not familiar with (Resident 4's) physical attributes as he is new to our facility and I was not working on the side of the building where his room is located at the time of his elopement. It is presumed that (Resident 4) left with one of the groups of people that had their own key card, as there were many people here this afternoon attending a Christmas function. Starting at 2:30 this afternoon (shift change), the residents started coming back from the functions and there were many visitors going in and out of the doors for at least an hour after that." Maintenance D: "I seen a man talking to someone in white car in Rock Haven (old) parking lot from by road (Co (County Road) F). I just thought he was someone walking or a family member going to bus stop and knew who each other, never thought anything about it. Til I heard someone eloped Saturday afternoon. The time I seen the man was approximately 3:45 pm at location stated. " NHA A: "After investigation it was discovered that the incident in which (Resident 4) left the building was a direct result of another client family member (wife) who opened the outside door for (Resident 4) when he requested. This resident appears alert and oriented although he is confused. This was verified by the camera on the exit doors and the number of the proximity card swiped. The family member has been cautioned to not use her card to allow anyone except herself to exit or enter the building. This is explained to every family member who requests a proximity card. The resident was placed on one on ones until he became acclimated to the building, at which time he was placed on 15 minute checks. There was no way the facility could have known that a client(s) family member would open the door for (Resident 4). " Resident 4 continued to show desire to exit the facility, as noted on the "Flow Sheet" as follows: 12/26/14 at 10:45 PM: "Found by break room doors, no walker. He was brought out to living room by her." 12/27/14 at 3:15 AM: "Pt (patient) not in room found walking ? (down) hallway looking for car." 1/1/15 at 1:00 AM: "Came out of bedroom, wanting to no (SIC) how to leave the facility. Therefore he was redirected and agreed to get more sleep ..." During the survey, on 1/6/15, Surveyor and Surveyor requested evidence of when Resident 4 exited the facility on 12/20/14. The facility provided "Events/History" which indicates when key cards are used for exiting the units. This log notes that a key card was used at 3:31 PM on 12/20/14 on the Limestone West Upper unit. Surveyor spoke with Dietary G on 1/6/15 at 2:12 PM. Dietary G stated that (Resident 4) approached her car when she was parked in the lot of the old building. Dietary G stated that she saw (Resident 4) off of the "property" about 15 feet, standing on County Road F. Dietary G stated that it was chilly outside and (Resident 4) did not have a walker or coat on. Surveyor spoke with CNA H on 1/6/15 at approximately 2:00 PM. CNA H stated that she worked on 12/20/14 with (Resident 4) and her shift started at 2:00 PM. CNA H stated that she had worked with (Resident 4) in the days prior as well. Surveyor asked CNA H about the facility's process for completing every 15 minute checks upon admission. CNA H stated that every 15 minute checks are completed for 72 hours upon admission for everyone. Surveyor asked CNA H about when she asked (LPN J) about whether (Resident 4) remained on checks. CNA H stated that (LPN J) never followed up with her when she asked if (Resident 4) should be on checks. CNA H stated that (LPN J) told her to continue checks on another resident but was not sure about (Resident 4). CNA H stated that she had worked with (Resident 4) prior to 12/20/14 and that he was not exit seeking during those shifts. CNA H stated that she should have gone to the nurse on the other unit and asked about the 15 minute checks for (Resident 4). CNA H stated that she did not get any information about (Resident 4) in report and that the day shift did not report anything to her about (Resident 4's) whereabouts prior to leaving. Surveyor asked CNA H if anyone from the facility has talked to her about this incident, besides her written statement. CNA H stated that no one has spoken to her about this and that she has not received education regarding this. Surveyor asked CNA H about Resident 4's safety awareness. CNA H stated that it was poor. CNA H stated that Resident 4 was a one assist with a gait belt and walker at the time of the elopement. Surveyor spoke with LPN J on 1/6/15 at 2:57 PM. LPN J stated that she started her shift on 12/20/14 at 2:00 PM. LPN J stated that she never saw (Resident 4) at the beginning of her shift. LPN J stated that (Resident 4) was a new resident at this time. LPN J stated (CNA H) asked her if (Resident 4) was still on 15 minute checks and she told her that she did not know. Surveyor asked LPN J how she would determine this. LPN J stated that she would look at the resident's medical record. LPN J stated that she did not look and that that was partially her fault. Surveyor asked LPN J if anyone from the facility has spoken to her or provided education to her regarding the incident. LPN J stated that no one has done this. LPN J stated that she did not see (Resident 4) at all at the beginning of her shift. On 1/6/15 at 5:30 PM Surveyor questioned DON B and ADON C regarding 72 hour 15 minute check procedure. ADON C and DON B stated that they had been doing this on all residents for years. DON B handed Surveyor a "Wandering, Unsafe Resident" policy. DON B stated that there was not a policy for the admission 72 hour 15 minute checks before. Surveyor spoke with NHA A on 1/6/15 at approximately 4:30 PM. NHA A stated that another Resident's family member let (Resident 4) out of the building with their key card. NHA A stated that she looked at the video of (Resident 4) leaving the unit exit on 12/20/14 at 3:31 PM. NHA A stated that she could not see the person swipe the card on video, but she could see (Resident 4) leaving. NHA A stated that it was her understanding that (Resident 4) had just come off of his 72 hour 15 minute checks and that these had been fully completed. NHA A and Surveyor reviewed Resident 4's documented 15 minute checks. NHA A stated that she did not catch that the checks had not been fully completed and that she read (RN K's) statement as if they were finished. Surveyor asked NHA A about the 15 minute check data analysis after completion of 72 hours. NHA A stated that it was her understanding that the residents just come off the 15 minute checks but the ADONs monitor the data. Surveyor asked NHA A if she spoke with family members about not letting others out of the building by way of their key card. NHA A stated that she spoke with this one family member who let (Resident 4) out of the building, but did not speak with all family members. NHA A stated that she does not write down or document what she tells family members upon giving them a key card. Surveyor asked NHA A how the facility identifies residents who are at risk for elopement. NHA A stated that the facility does not use a book or binder for staff to become aware of who is at high risk of elopement. NHA A stated that there is no way to identify this other than to go through each chart. NHA A stated that the facility would be making a binder with residents who are at risk. NHA A stated that they use the alarms at the exits to become aware of residents leaving the units. On 1/7/15, the facility identified that they have 38 residents at risk for elopement from the facility. The facility ' s failure to have a system with redundancies to prevent resident elopement, and its failure to prevent Resident 4 from eloping from the facility on 12/20/14 created an Immediate Jeopardy situation by placing residents at risk for injuries from falls, from traffic, or from weather conditions. The facility removed the Immediate Jeopardy on 1/6/15 by implementing the following interventions: -The facility began to immediately update all policy and procedures for residents who are at risk for elopement. This was to include how to assess the resident to institute the 72 hour 15 minute checks policy on all admissions. This 72 hour 15 minute check admission policy will be used to reassess the resident and to update the care plan using the post 72 hour assessments with information gathered from the checks. -The facility will develop a letter to all family members to sign when issue a proximity card that the understanding and agreement for the issue of said card will mean they do not use the card to open or allow anyone other than themselves or immediate family members to gain access to and from the building. The facility will immediately begin to call all family members who have been issued a card to re-educate them on the importance of using the care in the appropriate manner for themselves and immediate family members only. -A letter regarding appropriate use of the card will be placed in the admission packet for all new residents. -Immediate inservicing of all staff members on the importance of the safety and the importance of properly completing the every 15 minute checks to ensure safety and wellbeing of all of our residents as well as the new policies that were modified regarding elopement. -The facility will began immediately to review all care plans to ensure they are current and updated for the risk of elopement and proper intervention place on the care plan. -The facility will immediately begin to gather information of residents who are at risk for wandering an place copies of their photos in a binder that will have copies placed in all units on the building and in all department managers office as will as the front office for the use of all staff members for reference and review to help ensure the safety of residents at risk. The deficient practice continues at severity level 2 (potential for harm that is not immediate jeopardy) as evidenced by the following examples. Example 2 Resident 1 has [DIAGNOSES REDACTED]." The facility completed a quarterly Minimum Data Set (MDS) assessment dated [DATE]. This assessment indicates that Resident 1 is totally dependent with bed mobility and needs two or more person physical assist with this task. The assessment notes that Resident 1 does not ambulate and has limitations in range of motion to both lower extremities. Resident 1 has not sustained falls since the previous assessment. This assessment notes that Resident 1 weighs 197 pounds. "Nursing Weekly Summary" dated 12/3/14 states in part, "ADL (Activities of Daily Living) Area: Bed Mobility: ADL Self-Performance: 4, Number of Staff Needed: 2." A scoring code on the bottom of this documents notes ADL Self-Performance scoring as follows: 4=total assist=staff completes entire task." Resident 1's "RH-Profile History Report", used by Certified Nursing Assistant (CNA) staff for delivery of care states, "10/30/14-12/10/14. Bed rest. Reposition q (every) 2 hours with staff assist. Use draw sheet for lifter folded in 2." Resident 1's "Resident Care Plan" dated 11/9/14 states, "Assist to reposition q 2h (hours) when in bed." The facility completed a "Misconduct Incident Report" for an injury of unknown source of Resident 1's fractured right humerus. This report states in part, "Date occurred: Unknown. Date Discovered: 12/6/14. Resident was noted to have swollen arm and hands. Physician was notified and resident was sent to ER where he was found to have a mildly comminuted fracture of the proximal humeral shaft with approximately 1 cm of posterior displacement of the distal fracture fragment. " The facility obtained statements from caregivers in attempt to discover the source of Resident 1's injury. Director of Nursing (DON) B interviewed CNA I on 12/1014. "1) What time did you first have contact with (Resident 1) on Saturday, December 6, 2014? About 7 am or 7:30 am. 2) Describe the cares provided at that time. I gave him his am cares then. He still had that long gown on-(CNA N) told me she had done him but I didn't know that till later. I though since he had that gown on her hadn't been done. I don't think his mouth care was done either. So I did all his morning cares then at about 7 or 7:30 am ...4) What time did you last check on this resident. It was about noon-I took the pillow out from behind his back again to reposition him ...6) Did you assist each time to reposition this resident? I repositioned him twice be myself and once with (CNA N) that day ...8) How do you reposition this resident? With a lift sheet but I can do him by myself if all I have to do is pull a pillow out from behind his back." Surveyor spoke with CNA I on 1/6/15 at 10:35 AM. CNA I stated that she worked on 12/6/14 and that she repositioned (Resident 1) alone twice. CNA I stated that she used a draw sheet. CNA I stated that around 7:30 AM (Resident 1) had a pillow behind his back so she pulled it out. CNA I stated that the second time she repositioned was around 10:30 AM and (Resident 1) was on his back. CNA I stat

Based on observation, interview and record review the facility did not ensure that a resident who enters the facility without a pressure ulcer does not develop pressure ulcers and a resident who has a pressure ulcer receives necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for 7 of 14 residents (Residents 7, 5,26, 2, 28, 19, and 20). Resident 7 is identified at risk for the development of a pressure ulcer (PU). Resident 7 developed a stage 4 facility acquired pressure ulcer to the left great toe. Resident 7 did not receive the necessary assessments for treatment and care of the pressure ulcer based upon the current standard of practice. Interventions were not put into place to promote healing and prevent pressure to the left and right great toes. (Resident 7 was also identified during the survey process to have a stage 1 Pressure ulcer on the right great toe.) Changes were not made in the care plan or to care when weekly assessments showed deterioration in the wound. Observations were made that Resident 7 did not have current interventions in place to prevent pressure ulcers or to promote healing, to include observations of: * protective boots not in place * toes pressed against foot board of the bed * boot cloth and sheet pulled tight against Resident 7's bilateral great toe ulcers * alternating mattress in static position, not alternating. Resident 7 is receiving antibiotic treatment for [REDACTED]. On 10/20/14 Resident 7 received a new [DIAGNOSES REDACTED]. The facility failed to ensure that Resident 7 received proper treatment and care for preventing and treating pressure ulcers, which resulted in an infected stage 4 pressure ulcer. This created an Immediate Jeopardy situation that began 9/18/14. On 10/27/14 the Administrator was formally notified that an Immediate Jeopardy existed beginning 9/18/14. The Immediate Jeopardy situation was determined to be removed, but not corrected on 10/23/14. The deficient practice continues at a scope/severity level of H (actual harm/pattern) as evidenced by the following examples: Resident 5 is identified at risk for the development of a pressure ulcer (PU). Resident 5 developed facility acquired stage 3 PU. Interventions were not put into place to prevent Resident 5 from developing re-occurring PU's or to promote healing. These included a stage 3 pressure ulcer. Observations were made that Resident 5 did not have interventions in place to prevent pressure ulcers to include bilateral heels not floated, sitting in wheel chair with sheep skin on top of preventative cushion, lying flat on back in bed with head of bed up greater than 45 degrees. Resident 5 was also observed during the survey process to have 3 small open areas to her right buttock and a reddened area to her labia. Resident 26 is identified at risk for the development of a pressure ulcer (PU). Resident 26 developed a re-occurring facility acquired unstageable PU. Upon discovery of the initial PU pressure redistributing interventions were not initiated for 13 days after the PU was first identified. Observations were made that Resident 26 did not have current interventions in place to prevent pressure ulcers to include observations of shoes on both feet while up in the wheel chair. Resident 26 was not given risk benefits in the wearing of his shoes. The facility did not identify a root cause for the recurring unstageable pressure ulcers. Resident 2 was assessed to be at risk for pressure ulcers (PU). Resident 2 has a stage 3 PU to his coccyx area. Observations were made when Resident 2 did not have interventions in place to prevent or promote healing of Resident 2's PU. Resident 2 was observed to be placed on a non stage 3 bed, Resident 2 was sitting in a reclining chair with a pillow and sheep skin under his buttock. Resident 2's care plan did not identify when to offload Resident 2 and Resident 2 was observed in his chair for greater than 3 hours. Resident 2 was not given risk benefits when Resident 2 declined the pressure redistribution devices or to be placed in bed to offload the PU. Resident 28 was assessed to be at risk for pressure ulcers. Resident 28 was admitted with a brace to the left leg. The facility did not assess to ensure that the splint was of correct size, inspect the skin in contact with the device at least daily, and did not educate staff on placement of device and prevention of skin breakdown. Resident 28 developed an avoidable Stage III pressure ulcer to the left lateral foot. Upon discovery of the pressure ulcer, the facility did not immediately consult with a physician, despite signs of potential infection of the wound. Resident 19 has a pressure ulcer to the right buttock and the right inner heel. Resident 19 was noted to not have heels floated. Resident 19's alternating air mattress was noted to be on the "static" position, not alternating. Resident 20 was observed to be wearing a donut-shaped device under the legs and then around the heels. Resident 20 was observed to be wearing a "bunny boot." These devices were placed despite current standards of practice indicating their lack of pressure relieving properties. This is evidenced by: On 10/14/14, at 1:30 PM Surveyor DON B what standard of practice she uses for pressure redistribution and treatment when placing mattresses, cushion and staging of pressure ulcers DON B stated she uses the AMDA guidelines and the National pressure ulcer advisory committee for pressure ulcer care. The American Medical Directors Association's (AMDA) "Pressure Ulcers in the Long-term Care Setting" (2008) states, in part, "Stages of a Pressure Ulcer ...Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the ulcer bed. Further description: Until enough slough and/or eschar is removed to expose the base of the ulcer, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED]* or fluctuance*) eschar on the heels serves as 'the body's natural (biological) cover and should not be removed ...Table 5: Pressure Ulcer Prevention Measures ...Position the patient to minimize pressure over bony prominences and shearing forces over the heels and elbows, base of head and ears ...Table 6: Physical Factors that May Influence Pressure Ulcer Treatment Choices ...Heel ulcers present unique management considerations: Heel ulcers with dry, hard nondraining eschar should generally not be debrided unless there is evidence of infection ...Step 7; Provide general support for the patient ...Do not use donut-shaped devices for reduction or relief of pressure ...Patients who have or are at risk for developing heel ulcers (e.g. postoperative hip or knee surgery patients) will require offloading or pressure-redistribution device (e.g., heel boot, heel elevator, heel lift, suspension boot, or device that 'floats' the heel) to relieve pressure on the heels." The National Pressure Ulcer Advisory Panel: Prevention and treatment of [REDACTED]. Avoid positioning the individual on an area of [DIAGNOSES REDACTED] whenever possible. [DIAGNOSES REDACTED] indicates that the body has not recovered from the previous loading and requires further respite from repeated loading. . Nutrition in pressure ulcer prevention and treatment: Protein intake: 1. Provide adequate protein for positive nitrogen balance for adults assessed to be at risk of pressure ulcer. 2. Offer 1.24 to 1.5 grams of protein per kilogram of body weight daily for adults at risk of a pressure ulcer, who are assessed to be at risk of malnutrition when compatible with goals of care and reassess as condition changes. 3. Provide adequate protein for positive nitrogen balance for adults with a pressure ulcer. 4. Offer 1.24 to 1.5 grams of protein per kilogram of body weight daily for adults with an existing pressure ulcer, who are assessed to be at risk of malnutrition when compatible with goals of care and reassess as condition. 5. Offer high calorie, high protein nutritional supplement in addition to the usual diet with adults with nutritional risk and pressure ulcer risk. 7. Supplement with high protein, [MEDICATION NAME] and micro-nutrients for adults with a pressure ulcer Category/Stage III or IV or multiple pressure ulcers when nutritional requirement cannot be met with traditional high calorie and protein supplements. Repositioning and early mobilization: General repositioning for all individuals: 2. Consider the condition of the individual and the pressure redistribution support surface in use when deciding if repositioning should be implemented as a preventive strategy. Reposition frequency: 1. Consider the pressure redistribution support surface in use when determining the frequency of repositioning. 2. Determine repositioning frequency with the consideration to the individuals; 1. Tissue tolerance, level of activity, general medical condition, overall treatment objective, skin condition, comfort. Repositioning techniques: 1. Reposition the individual in such a way that the pressure is relieved or redistributed. 2. Avoid positioning the individual on bony prominences with existing non blanchable [DIAGNOSES REDACTED]. Non-blanchable [DIAGNOSES REDACTED] is an early sign of pressure ulcer damage. If an individual is positioned directly onto bony prominences with pre-existing non-blanchable [DIAGNOSES REDACTED], the pressure and/or shearing force sustained will further occlude blood supply to the skin, there by worsening the damage and resulting in more severe pressure ulceration. 3. Avoid subjecting the skin to pressure or shear force. Repositioning in bed, in part, 2. Limit head of bed elevation to 30 degrees. 2.1 If sitting in bed is necessary, avoid head of bed elevation or a slouched position that placed direct pressure and shear on the sacrum and coccyx. Additional recommendation for individuals with existing pressure ulcers: 1. Do not position an individual directly on a pressure ulcer. Repositioning for individual with existing pressure ulcers: 1. Minimize seating time. 3. If sitting in a chair is necessary for individual with pressure ulcer on the sacrum/coccyx or ischia, limit sitting to three times day in periods of 60 minutes or less. 4. Sitting an individual with an ischial ulcer in a fully erect position in chair or bed. 5. Modify sitting time schedules and re-evaluate the seating surface and the individuals posture if the ulcer worsens or fails to improve. Repositioning to prevent and treat heel pressure ulcers: 1. Ensure that the heels are free of the surface of the bed. Use heel suspensions devices that elevate and offload the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon. Apply heel devices according to the manufacturing instructions. Repositioning for treating existing heel pressure ulcers: Relieve pressure under the heels with Category Stage I or II ulcers by placing legs on a pillow to float the heels off the bed or by using a heel suspension device. For Category stage II or IV and unstageable, place the leg in a device that elevates the heel from the surface of the bed, completely off loading the pressure ulcer. Pressure category stage III, IV and unstageable should be completely offloaded as much as possible. Elevation of the heel on a pillow is usually inadequate. General recommendation for mattress and bed support surfaces: Select a support surface that meets the individual's needs. Consider the individual's needs for pressure for redistribution based on the following factors: Level of immobility, need for shear reduction, size and weight, risk for development of new pressure ulcer, and number and severity and location of existing pressure ulcers. Examine the appropriateness and functionality of the support surface on every encounter with the individual. Mattress and bed support surfaces for individuals with existing pressure ulcer: Whenever possible do not position an individual on an existing pressure ulcer. Select a support surface that provides enhanced pressure redistribution, shear reduction, and microclimate controls for individuals with Stage III, IV and unstageable pressure ulcers. Example 1 The National pressure Ulcer Advisory Panel: Prevention and treatment of [REDACTED]. Slough or Eschar may be present on some part of the wound bed. Exposed bone and tendon is visible or directly palpable. Resident 7 has the following Diagnoses: [REDACTED]. Resident 7's Pressure ulcer (PU) scale dated 10/9/14 indicates a total score of 8. A score of 14 or less indicates resident to be at high risk. Resident 7's care plan, dated 3/30/12, and review date 10/9/14, indicates in part: Problem: Impaired skin integrity "potential" due to impaired mobility and [MEDICAL CONDITION] DX (diagnosis) senile purpura.(It is important to note Resident 7 left great toe pressure ulcer is not identified as a problem.) Goal: Resident 7 will remain free from new skin impairment over the next 3 months. (It is important to note the goal does not indicate what the expectation for Resident 7's left great toe PU.) Interventions: 1. Monitor skin for evidence of irritation and redness. 2. Reposition every 2 hours. 3. Provide support cushion to bony prominences. 4. Avoid potential trauma to skin. 5. Encourage resident to elevate lower extremities when up. Assist with transfer to recliner between meals. 6. Monitor lower extremities for [MEDICAL CONDITION]. 7. "Is high risk for lesion/infection of feet due to numbness and lack of sensation." 8. Treatment to left great toe as ordered. Pillow boot to left foot. Elevate and offload pressure of both feet as able. 9. Gel cushion in wheel chair. Resident 7's Resident Plan Report (CNA computerized care plan), undated, Skin: Repo (reposition) side to side when in bed and float heels off bed. Apply pillow boot to left foot at all times. Check every shift that this is on. Gel Cushion in wheel chair. Resident 7's wound treatment order 8/1/14 to the left great toe. 1. Cleanse intact skin and wound with soap and water. 2. Pat dry. 3. Protect peri wound with skin prep. 4. Apply Iodosorb to wound base. 5. Cover with gauze and secure with kling. 6. Change daily. Do not soak foot in tub or basin. Wound scale assessment guide, dated 9/1/14, Wound stage 3. Size L 1.8 X (times) W 2.5 . Odor "No." Slough "Yes." Exudate of serous, Serosanguineous or purulent drainage "No." Pain "Yes." Surrounding skin with [DIAGNOSES REDACTED], maceration and induration "Yes." Notes: Slough and maceration noted. Resident states pain while taping wound. Will continue to monitor for any further changes. Resident 7's weekly wound pressure ulcer wound round form Pressure ulcer facility acquired with [MEDICAL CONDITION]. Week 1, dated 9/9/14. Interventions included: * dietary code 1(Vitamin therapy) * Intervention code 1 (positioning pillow) * Intervention code 2 (pressure relief mattress) * Intervention code 6 (seat cushion) * Intervention code 9 (Specialized equipment) * Intervention code 11 (reposition). Wound scale assessment guide, dated 9/9/14, Wound stage 3. Size L 1.8 X W 3.0 (increased in size). Odor "No." Necrotic and Slough "Yes." Exudate of Serosanguineous drainage "Yes." Surrounding skin with [DIAGNOSES REDACTED] and maceration "Yes." Notes: No pain. Larger wound bed, Slough and Necrotic tissue observed. Treatment done as ordered. Will continue to monitor. (It is important to note Resident 7 PU has increased in size, has serosanguineous drainage and necrotic tissue compared to 9/1/14. Physician was not notified and no changes to the plan of care were made.) Resident 7's weekly wound pressure ulcer wound round form Pressure ulcer facility acquired with [MEDICAL CONDITION]. Week 2, dated 9/15/14, (increased in size from week 1. Dietary and intervention codes remained the same as week 1 (9/9/14). No changes were made to the intervention codes from week 1. Wound scale assessment guide, dated 9/15/14, Wound stage 3. Size L 2.2 X W 3.0 (increased in size). Odor "Yes" (New from last assessment). Necrotic and Slough "Yes." Exudate of Serosanguineous and purulent drainage "Yes" (new from last assessment) Surrounding skin with [DIAGNOSES REDACTED], maceration and induration "Yes." Notes: Resident 7 slept through changing of dressing, no complaint of pain. Will continue to monitor this wound. Wound clinic note in part, dated 9/18/14, reason for referral: Follow up wound. Treatment: L great wound. Results of Treatment: Stable. Recommendation for follow up: Return to clinic in about 3 weeks (10/9/14). Left Great toe: Clean intact skin and wound with soap and water. 2. Pat dry. 3. Protect peri wound with skin prep. 4. Apply Santyl (Chemical debridement agent) to wound base. 5. Cover with gauze secure with kling. 6. Change daily. Note: Do not soak toe in tub or basin. Wound is down to tendon (stage 4 by definition). (It is important to note: A change in treatment to a chemical debridement agent was made 9 days after the initial PU changes were identified on 9/9/14. Also the wound clinic identifies Resident 7 PU as a stage 4.) Resident 7's weekly wound pressure ulcer wound round form: Pressure ulcer facility acquired with [MEDICAL CONDITION]. Week 3, dated 9/23/14, Intervention codes remained the same as week 1 (9/9/14), with the exception of noting 9/22/14 new MD (Medical Doctor) order. Wound scale assessment guide, dated 9/23/14, Wound stage 3. Size L 2.5 X W 2. Odor "Yes." Necrotic and Slough "Yes." Exudate of Serosanguineous and purulent drainage "Yes." Surrounding skin with [DIAGNOSES REDACTED] and maceration "Yes." Notes: No pain, exudate purulent and Serosanguineous present, will continue to monitor. (It is important to note the exudate is now purulent.) CNA care card was updated on 9/26/14 to include: Float heels in bed. Assist with repositioning every 2 hours. Resident 7's weekly wound pressure ulcer wound round form: Pressure ulcer facility acquired with [MEDICAL CONDITION]. Week 4, dated 9/30/14, Intervention codes remained the same as week 1 (9/9/14), but included: * Intervention code 10 (float heels). Wound scale assessment guide, dated 9/30/14, Wound stage 3. Size L 3.2 X W 1.6 (increased in size from last assessment on 9/23/14) Odor "Yes." Necrotic and Slough "Yes." Exudate of serous, Serosanguineous and purulent drainage "Yes." Surrounding skin with [DIAGNOSES REDACTED] and maceration "Yes." Notes: Left great toe moderate amount of drainage. No complaint of pain while treatment is being done. Will continue to monitor. (It is important to note PU increased from length of 2.5 to 3.2 cm. in 1 week. No notification to the Physician was done and no changes to the plan of care were made as Resident 7's Left great toe continue to decline.) Nursing note, dated 10/1/14, at 4:00 AM Temperature 96.6 degrees. Left great toe wound dressing change. Dressing was saturated with Serosanguineous purulent drainage. There is slough and necrotic tissue in the wound. Pus drainage from under slough unable to see wound bed. "Placed in MD book to assess wound and dressing orders." Physician notification form (a form in the chart where nurses write messages for MD to review on next visit) dated 10/1/14: Toe is draining large amount Serosanguineous and purulent fluid. Dressing is saturated by the time it should be done. Should it be done BID? MD review date 10/1/14. (No changes to the plan of care were made. Resident 7 was a wound clinic resident but no call to the wound clinic was made for further directions.) Resident 7's Minimum data set (MDS), dated [DATE], noted, in part: Resident 7 is at risk for pressure ulcers and has 1 stage 3 pressure ulcer. Tissue type for stage 3 pressure ulcer: Slough yellow or white tissue. Nutrition Assessment in part, dated 10/2/14, states: [MEDICAL CONDITION], Chronic Venous status, Acute [MEDICAL CONDITION], Chronic [MEDICAL CONDITIONS] Fibrillation. Diet 2 gram sodium, 1500 milliliters (ml) per day fluid restriction.. Estimated protein needs 83.6 grams (gm). Skin condition: open area (stage not documented) left great toes, skin tears, and bruises present. Plan of Care (POC) reviewed and updated. Impaired skin integrity. Food preferences: Portions are average. Noted in file, often request extra portions. Resident fluid intake in last 7 days 1894 ml per day. Resident 7's weight is 274 pounds (124.5 kg). Dietary note, dated 10/2/14, states in part...Current intake exceeds needs, fluid intake exceeds current restriction. No protein supplements at this time. He has open areas to his left great toe, multiple bruises and skin tears present. With continued good intake no further supplements should be needed. POC reviewed, diet addresses under skin impairment, goals and approached are appropriate at this time. (The standard of practice indicates Resident 7 would need 149 grams of protein for added healing, no dietary changes were added as Resident 7's PU declined.) Nursing note, dated 10/8/14, at noc (night), Wound rounds done on resident's left great toe. Resident stated not much pain now. "Foul odor & (and) moderate amt (amount) of drainage" will monitor. (There is no evidence Resident 7's physician was notified of the foul odor and the moderate drainage to Resident 7's left great toe wound.) Wound scale assessment guide, dated 10/8/14, Wound stage 3. Size L 3.8 cm X W 1.6 cm. (Increased in size from last assessment) Odor "Yes." Necrotic and Slough "Yes." Exudate of Serosanguineous and purulent drainage "Yes." Surrounding skin with [DIAGNOSES REDACTED] and maceration "Yes." Notes: Left great toe has been having increased pain and drainage. Blackened area, growing and foul odor. Will continue to monitor. (It is important to note the assessment shows increase in size, change to black area and odor. Physician was not notified and the care plan was not revised with the changes in the pressure ulcer.) Resident 7's foot assessment, dated 10/9/14, Medical history: History of foot sore/difficulty healing/amputation. "L" (left) is marked. Assessment of foot skin, structure and circulation. A "B" (both) is placed in the box corresponding to foot temperature appropriately warm and [MEDICAL CONDITION] present. Pedal pulses: a "P" (present) is placed in the box corresponding to Doralis pedis pulse present. Sensory exam: negative equals cannot feel. Determine risk status: High risk. Resident 7's care area assessment summary, dated 10/9/14: Resident 7 continues to have issues with skin integrity and infection. He is being treated with Santyl for a pressure ulcer on his left great toe. This wound had tested positive for [MEDICAL CONDITION] (MRSA). (Not a current positive test result.) He was treated with oral and topical antibiotics. Facility has had 3 negative cultures. At times the wound has excessive Serosanguineous drainage. He is followed by Nurse Practitioner for this wound. Resident scored a 12 on the Brief Interview Mental status (BIMs). This is a decrease from his prior score of 15. He has been noted to have episodes of confusion when infection is present and not yet treated. Pressure ulcer: Resident 7 is at risk for pressure ulcers. He requires extensive assist with bed mobility. He currently has a pressure ulcer on his left great toe. Pressure relief measures are taken. This is addressed in the plan of care under impaired skin integrity. Nursing notification form (Form in the chart to notify the physician of changes), dated 10/13/14: Night nurse reported worsening of left great toe wound with foul odor. Getting Santyl. Question to change treatment and culture. (It is important to note on 10/8/14 Resident 7's assessment indicated foul odor and moderate drainage, 5 days prior to the physician notification.) On 10/13/14, at 12:25 PM, Surveyor during the verification survey observed Resident 7 sitting in his wheel chair in the dining room. Resident 7 was sitting with both feet flat on the floor and wearing white socks covering all toes stretched over to the bottom portion of his ankle just above his heel. Resident 7 did not have a pillow boot on his left or his right foot as directed by his plan of care. On 10/13/14, at 1:45 PM, Surveyor during the verification survey observed Resident 7 sitting in his wheel chair in his room. Surveyor knocked on the door and was granted permission to enter his room. Resident 7 was sitting with both feet flat on the floor. Resident 7 had white socks on both feet stretched over his feet to cover the bottom portion of his ankle just above his heel. Surveyor asked Resident 7 if he wore pillow boots on his feet or does he usually just wear socks. Resident 7 stated he wears socks and attempted to look at his feet. On 10/13/14 at approximately 1:50 PM, Surveyor spoke with Assistant Director of Nursing (ADON) C regarding Resident 7's pillow boots. ADON C stated the care plan has to wear boots but does not identify when Resident 7 is to have boots applied. ADON C reviewed the certified nursing assistant plan which directs the CNAs to provide care. ADON C stated Resident 7 is to have a pillow boot on his left foot at all times. On 10/13/14, at 1:55 PM, Surveyor and ADON C observed Resident 7 sitting in his room with no boot to his left foot. ADON C stated Resident 7 is to have a boot on his left foot. ADON C stated according to the care report Resident 7 is to have a boot on both feet. ADON C asked Resident 7 if he had his boot for his left foot. Resident 7 was unable to indicate where is pillow boot was for his left foot. Facility staff updated the care plan on 10/13/14 to include: Culture and sensitivity (C&S) left great toe ulcer. Discontinue Santyl. [MEDICATION NAME] ointment 2% BID (twice a day) to left great toe. [MEDICATION NAME] 100 milligram BID times 14 days urinary tract infection. Wound scale assessment guide, dated 10/14/14, Wound stage 3. Size L 5 cm X W 2 cm. depth Slough. Odor "Yes." Necrotic and Slough "Yes." Exudate of Serosanguineous and purulent drainage "Yes." Notes: See nursing notes. On 10/14/14, at 9:15 AM Surveyor with DON B and Registered Nurse (RN) D during the verification survey observed Resident 7 in bed. Resident 7 was in a Bariatric bed with the head of the bed in the up position greater than 45 degrees. Resident 7's feet were pressing tight against the foot of the bed. Resident 7's feet were fully covered with a sheet and thin blanket. The blanket pulled across Resident 7 right and left toes forcing Resident 7's right and left great toe to bend forward toward Resident 7. The blanket was under Resident 7's feet pressed against the foot board and Resident 7 had the covers pulled taunt to his chest region. DON B removed the covers from Resident 7 feet. Resident 7 was wearing a green type boot on both feet. DON removed the boots from Resident 7's feet. The boot was covering Resident 7's entire foot to include his toes. The green boot had a 2 layer silk like material covering his toes. The back of the toes was covered with silk like material and the sole of the boot. (It is important to note there was not pressure relieving or redistributing material covering or supporting Resident 7's left or right great toe.) Resident 7 was lying on an alternating air mattress. The air mattress machine button called Static was illuminating to indicate the static mode was on; meaning the alternating of the mattress was stopped. Resident 7's right great toe was observed with a stage 1 pressure ulcer approximately 1 cm by 1 cm round red area. Surveyor spoke with DON B and RN D regarding the area to the right great toe. DON B observed the area and asked RN D what the plan was for Resident 7's right great toe. RN D stated Resident 7 has had the area on his right great toe we are just monitoring the area. DON B stated to RN D Resident 7 should have an order for [REDACTED]. On 10/14/14, at 9:15 AM, Surveyor with DON B and RN D observed Resident 7's left great toe wound care. RN D placed Resident 7's wound supplies on Resident 7's bed side dresser. Resident 7's bed side dresser had visible dust and other items on the dresser. RN D proceeded to remove Resident 7's dressing from his left great toe. Resident 7's wound appearance was a grey colored stringy slough covering the entire wound bed. Resident 7's wound had a very strong foul odor. Resident 7's wound measured 5 cm by 2 cm. RN D then cleansed the wound with soap and water and completed the treatment. She ended by removing the tape from the bed side dresser and placed a piece of tape on the kerlix. DON B and RN D replaced the boots to Resident 7's bilateral feet and placed the sheet and cover over the foot of the bed. Resident 7 remained positioned at the foot of the bed with his toes pressing against the foot board. Resident 7's head of the bed remained elevated. DON B and RN D exited the room. On 10/14/14 at approximately 9:40 AM Surveyor spoke with DON B regarding Resident 7's prevention devices for his left great toe. DON B stated she pulled the covers over the foot of the bed. Surveyor asked DON B what other devices she has looked at for Resident 7. DON B stated there are just so many item that we have available for use for the residents, she would have to see if there was a foot cradle to keep the covers from pulling on Resident 7's toes. DON B stated there are not enough to go around, but she would look and may have to order a foot cradle. Surveyor requested the manufacturer recommendation for Resident 7's pillow boots. DON B stated she would provide the information. On 10/14/14 at 1:30 PM Surveyor spoke with DON B regarding the choice of pillow boot provided to Resident 7. Surveyor asked DON B what assessment and standard of practice was used to decide to use the pillow to Resident 7's left great toe for pressure prevention intervention. DON B stated there are just so many boots that we have in the DME (supply room). DON B stated they picked a boot that was in the closet and would fit Resident 7 foot. DON B continued to state the facility only has so many boots so we use whatever we can find and put into place. DON B stated no she did not review the manufacturer's recommendation for the Pillow boot prior to applying the boot to Resident 7 left foot. On 10/14/14 at 4:00 PM DON B provided Surveyor Resident 7's Pillow boot information. The information provided was a 2 page document. Page 1 states Please read: The Heel Pleezr is a simple off-loading device to be worn preventatively or therapeutically. Page 2 shows a picture of the boot with the following information: Achilles wedge block: place the Achilles are on the wedge block. Toe Pocket: Toes in or on top of pocket. (It is important to note the Heel Pleezr does not indicate use for pressure redistribution to the great toe region.) Resident 7 X ray report, dated 10/14/14, states in part: Exam: foot and lateral 2 view left. Conclusion: "Findings are suspicious for Osetoe[DIAGNOSES REDACTED] at the proximal 1st phalanx." Physician order, dated 10/14/14, at 11:10 AM, in part 1. Clean left great toe with Allclenz, skin prep peri wound, and apply [MEDICATION NAME] 2% ointment to center of wound BID for wound healing. Wound with foul odor heavy slough and appears infected. 2. X-ray left great toe to rule out Osetoe[DIAGNOSES REDACTED]. 3. Skin prep Right great toe BID for skin protection. Facility staff added each of these three approaches to the care plan, along with: 4. Nutrashield to both legs and feet before ace wrap and after ace wrap removed at bedtime. On 10/20/14, office visit note: Diagnosis: [REDACTED]. Reason for consult: foot infection. History and Physical: Medical problems including [MEDICAL CONDITION] venous stasis, chronic toe ulceration followed by the wound clinic, here for worsening foot infection. On 10/16/14 his wound appeared acutely infected and significantly worse in the wound

Based on observation, interview and record review the facility did not ensure that a resident who enters the facility without a pressure ulcer does not develop pressure ulcers and a resident who has a pressure ulcer receives necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for 7 of 12 residents (Resident 11, 20, 12, 23, 16, 19, and 18). Resident 11 was identified as at risk for pressure ulcers. Interventions were not put into place and Resident 11 developed a pressure ulcer. Resident 11 was also observed with interventions not in place after the development of the pressure ulcer. Resident 20 was identified as at risk for pressure ulcers. Interventions were not put into place and Resident 20 developed a pressure ulcer. Resident 20 was observed with current interventions in place. Resident 12 was identified as at risk for pressure ulcers. Resident 12 did not have interventions in place and developed pressure ulcers on both heels. Resident 12 was observed with current interventions not in place. Resident 23 was assessed to be at risk for pressure ulcer development. Resident 23 developed a pressure ulcer to the right heel. The facility did not have evidence that Resident 23's heels were floated, in attempt to relieve pressure to the heels, until after the development of the pressure ulcer. Resident 23 developed an avoidable pressure ulcer to the heel. Resident 23's comprehensive plan of care did not include interventions that would instruct staff to float heels. Resident 16 developed SDTI's (Suspected Deep Tissue Injuries) to the bilateral heels. On 8/18/14 wound documentation indicated that the heels were covered with dry eschar and free of infection. The facility wound certified nurse was not observing the SDTI's, and did not notify the physician of the SDTI's until 8/19/14 at which time the attending ordered a [MEDICATION NAME] agent. Resident 19 is identified at risk for the development of a pressure ulcer (PU). Resident 19 developed re-occurring stage 2 PU's while in the facility with the most recent PU rated at a stage 3. Interventions were not put into place to prevent Resident 19 from developing re-occurring PU's. Observations were made that Resident 19 did not have current interventions in place to prevent pressure ulcers to include observations of heels not being offloaded off the surface of the bed. Resident 18 was admitted without a pressure ulcer (PU) and was identified as at risk for pressure ulcer development. Interventions were not put into place to prevent Resident 18 from developing a pressure ulcer (PU). Resident 18 developed a PU while in the facility and observations were made that Resident 18 did not have current interventions in place to prevent pressure ulcers to include observations of heels not being offloaded off the surface of the bed. This is evidenced by the following: The Quick Reference Guide entitled "Pressure Ulcer Prevention" published by the National Pressure Ulcer Advisory Panel (NPUAP) in 2009 indicated to prevent pressure ulcers in individuals considered to be at risk for the development of pressure ulcers, ensure the heels are free of the surface of the bed. Heel protection devices should elevate the heels completely (offload them) in such a way as to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon. Ensure the heels are free of the surface of the bed. Using a pillow under the calves so the heels are elevated (i.e., "floating") will accomplish reduction of pressure on heels. The NPUAP also indicated the use of transfer aids to reduce friction and shear. Lift--don't drag--the individual while repositioning. The facility's Procedure Manual for "Ulcer Care," undated includes the following: 1. Upon initial discovery of a wound the nurse will complete the Ulcer Care Initiation checklist including: entering resident name in wound care book, initiation of wound scale assessment guide and notification of the nurse manager, Director of Nursing and dietician of the wound. Procedure: 4. Wound dressing is performed according to physician's orders [REDACTED]. Pressure Ulcers/Skin Breakdown. Treatment/Management. 1. The physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings and application of topical agents. The facility indicated that they follow the American Medical Directors Association's (AMDA) "Pressure Ulcers in the Long-term Care Setting" (2008) as their standard of practice for prevention and treatment of [REDACTED]. Further description: Until enough slough and/or eschar is removed to expose the base of the ulcer, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED]* or fluctuance*) eschar on the heels serves as 'the body's natural (biological) cover and should not be removed ...Table 5: Pressure Ulcer Prevention Measures ...Position the patient to minimize pressure over bony prominences and shearing forces over the heels and elbows, base of head and ears ...Table 6: Physical Factors that May Influence Pressure Ulcer Treatment Choices ...Heel ulcers present unique management considerations: Heel ulcers with dry, hard nondraining eschar should generally not be debrided unless there is evidence of infection ...Step 7; Provide general support for the patient ...Do not use donut-shaped devices for reduction or relief of pressure ...Patients who have or are at risk for developing heel ulcers (e.g. postoperative hip or knee surgery patients) will require offloading or pressure-redistribution device (e.g., heel boot, heel elevator, heel lift, suspension boot, or device that 'floats' the heel) to relieve pressure on the heels ..." The facility uses a "Geo-Mattress, Atlas" as their standard mattress. The manufactures guidelines indicate "at the foot, the proven Heel Slope feature provides added protection from dangerous ulcers of the heel and ankle." It does not indicate that it relieves the pressure from the heels. On 8/20/14, at 2:10 PM, Surveyor interviewed Director of Nursing (DON) B regarding the skin care policy/program. DON B stated she is wound care certified along with another nurse manager. DON B stated a skin risk assessment is completed on admission then they look at individual needs and identify them on the care plan. DON B stated it is not expected to float resident heels unless there is a special need and it is identified on the care plan because the mattress they use has pressure redistributing properties. If a wound is identified DON B is notified and the floor nurse sets up the treatment and then the treatment and assessment is done weekly by the night nurse. DON B stated she reviews the charting on wounds and unless there is a problem she does not visualize all the wounds. Example 1 Resident 11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 11's admission Skin Assessment, dated 11/7/13, indicates a stage I pressure ulcer on the coccyx. Resident 11's Pressure Ulcer Scale (Norton), dated 4/25/14, scored a 6 indicating high risk. This assessment was again completed on 7/9/14 with a score of 9 still high risk. Resident 11's admission Minimum Data Set (MDS), reference date 11/14/13, identifies Resident 11 as at risk for developing pressure ulcers and the presence of a stage I pressure ulcer. Resident 11's MDS, reference date 7/10/14, again indicates Resident 11 is at risk for developing a pressure ulcer. The assessment also indicates a healed Stage 4 pressure ulcer. Treatments include: pressure reducing device for chair, pressure reducing device for bed and turning/repositioning program. Resident 11 is not indicated as having any current pressure ulcers. Resident 11's bed mobility is indicated as Extensive Assistance with two or more person physical assist. Resident 11's care plan includes the following interventions and updates related to skin: 5/1/14- Impaired Skin Integrity-Treatment to coccyx ulcer. Provide support and cushioning to bony prominences. Monitor skin for any new breakdown weekly and report to nurse. Pressure relief mattress and cushion in wheelchair. 7/26/14-extra-large concave mattress (due to falls) 7/27/14-Pressure relief boots to right and left foot blister. 7/28/14-Santyl all changes to open area at right gluteal site till healed. 8/19/14-Wound rounds initiated to left heel. No date-Wound rounds initiated to left heel, bottom and right foot. Resident 11's Cerner (care plan for certified nursing assistants) includes the following: -Skin: 3/11/14 Repositioning every 2 hours. 7/31/14 Pressure relief boot right and left heels to healed blister. -Bladder and Bowel: 3/2/14 Nutrashield (barrier cream) with each brief change. Resident 11's nursing notes include the following: -7/28/14- 4.0 cm by 2.5 cm intact blister discovered on left heel. Skin blanchable. Both heels placed on pillow to reduce further friction. In doctor book for further direction on how to treat. -7/29/14- 4.0 com by 2.5 cm blister continues to be intact, blanchable. -8/5/14- Skin intact. Staff reminded to use pressure relief boots in place of shoes. -8/6/14-Blue "donut" being used in place of blue booties previously being used on left foot. Blister to left heel is flat pink in color, is re-absorbing. Small red area on top of left foot appears to be from strap of bootie. -8/6/14-Blister left heel 3.5 cm by 3.5 cm blanchable. Not open. Fluid inside blister absorbed into tissue. -8/19/14-at 2:10 PM, Blister on left heel measures approximately 3 by 4 cm is not fluid filled. Fluid has reabsorbed, skin intact, no redness to area. Blanches with gentle pressure not tender. Is more callus like at this time. Skin prep effective. Right heel has no skin integrity concerns. Bottom of right foot has approximately 4 by 5 cm pink area, blanches with gentle pressure. Pressure relief boots on and lower extremities elevated at all times. The manufacture's information for the mattress Resident 11 began using on 7/26/14 indicates for Stage 1 and 2 and super soft layered heel section provides maximum pressure redistribution. The Certified Nursing Assistant (CNA) Skin Check Detail Report for 7/20/14-7/30/14 indicates no new skin problems. On 8/17/14, at 1:51 PM, Surveyor observed Resident 11 in bed with his feet directly on the mattress. On 8/18/14, at 8:13 AM, Surveyor observed Resident 11 in a lounge wheelchair with is feet hanging over the end and blue padded boots on. On 8/19/14, at 9:09 AM Surveyor observed CNA H and CNA I assist Resident 11 out of bed for the morning. Resident 11 was wearing socks on both feet. Resident 11 had a blue padded boot on the left foot. Surveyor observed Resident 11's left heel and noted a blister that was in the process of reabsorbing but was still present. Resident 11's right foot was directly on the bed and pressing against the foot board. CNA H and CNA I provided morning cares to Resident 11 however did not apply barrier cream to Resident 11's buttock. Resident 11 was then incontinent again and needed to be changed again. At this time Licensed Practical Nurse (LPN) J came in and prompted CNA H and CNA I to apply barrier cream. Surveyor then noted in Resident 11's wheelchair was a folded sheet and two folded up pieces of dycem on top of two gel cushions. Resident 11 was wearing socks with a blue padded boot on the left foot and a slipper on the right foot when transferred into the wheelchair. Surveyor then interviewed CNA I who confirmed barrier cream was not applied to Resident 11 with the first brief change. Surveyor then interviewed LPN J who stated they should be putting the barrier cream on with each brief change. On 8/19/14, at 12:42 PM, Surveyor observed Resident 11 in the lounge with socks on with a blue padded boot on the left foot and a slipper on the right foot. On 8/19/14, at 1:29 PM, Surveyor and Surveyor observed Resident 11 heels with LPN K. LPN K stated Resident 11's left heel was getting hard and calloused. Resident 11's right foot bottom was red but blanchable. LPN K stated when Resident 11 is in bed his feet are elevated with a pillow and they put a donut on the left foot and a blue boot on the right foot. On 8/20/14, at 8:18 AM, Surveyor observed Resident 11 in the lounge with blue padded boots on both feet. On 8/20/14, at 9:42 AM, Surveyor observed Resident 11 in the lounge with the blue padded boots off both feet one on the floor and one moved up his leg. Resident 11 was taken back to his room and assisted into bed. On 8/20/14, at 10:41 AM, Surveyor with Director of Nursing (DON) B observed Resident 11's feet. Resident 11 was lying in bed with a blue padded boot on is left foot and the right foot directly on the mattress, neither heel was floated. Resident 11 was also wearing socks. The ankle donut was sitting on Resident 11's dresser. DON B stated the position of Resident 11's feet was not okay. Surveyor asked about the use of the donut for Resident 11 and DON B stated she did not know they even had ankle donuts in the building as they are not the current standard of practice. On 8/20/14, at 2:10 PM, Surveyor interviewed DON B regarding Resident 11's pressure ulcer. DON B stated she was not notified that Resident 11 had a pressure ulcer until Surveyor brought it to her attention. DON B confirmed there were no weekly assessments noted for Resident 11's heel pressure ulcer; as the nursing notes were not a complete assessment. DON B also stated Resident 11's heels should have been floated and the boots Resident 11 was wearing are not pressure relieving boots. Example 2 Resident 20's [DIAGNOSES REDACTED]. Resident 20's Pressure Ulcer Scale, dated 8/12/14, identifies him as being at high risk for developing pressure ulcers. Resident 20's wound flow sheet notes reoccurring since 2011 a Stage 2 pressure ulcer on the left gluteal thigh/crease and right buttock/ischeal spine with the most recent healed date of 8/3/14. Resident 20 also developed a stage 2 pressure ulcer on his scrotum on 6/23/14 that healed on 7/11/14. There is no indication Resident 20 has/had a pressure ulcer on his right heel on the flow sheet. Resident 20's care plan, dated 5/9/14, includes the problem area of impaired skin integrity. Approaches include: Use periguard after brief changes and washing and as needed. Updated 6/24/14 to include up for meals only until opened areas on left gluteal are healed. Updated on 7/2/14 to include heel boot shoe on right foot when up in wheelchair until blister-like area resolved. Ankle pillows to bilateral feet on when in bed to elevate heels/feet until blister-like area resolved. Resident 20's "Physician Notification Form" indicates on 7/2/14 a blister like area to right lateral heel measuring 1.2 cm by 1.3 cm was noted. Ankle boots (donuts) bilateral while in bed and request skin prep twice a day. Resident 20's nursing notes, dated 7/2/14, indicate a blister like area to right lateral heel. Area intact measuring 1.2 cm by 1.3 cm triangular in shape with a red border and purple center. Denies pain. Heel boot to shoe placed on right foot when up in wheelchair this shift. Ankle pillows placed while not in bed. On 8/20/14, at 8:16 AM, Surveyor observed Resident 20 up in his wheelchair with a padded bootie on his right foot. On 8/20/14, at 9:21 AM, Surveyor requested Certified Nursing Assistant (CNA) I to see Resident 20's feet. Resident 20 was lying in bed and CNA I lifted the sheet. Surveyor noted a donut on Resident 20's right ankle with the lateral side of his foot resting on the mattress. Resident 20's left foot was resting directly on the mattress. Resident 20's right heel had an area where the blister was reabsorbing into the skin. Surveyor noted to CNA I that Resident 20's bed was soaked. CNA I then proceeded to change Resident 20's linen and brief. Registered Nurse (RN) Y came in to assist. Following the cares Surveyor interviewed CNA I about the cares. CNA I stated she did not apply any barrier cream. CNA I stated if Resident 20's buttock was red then she would use the Nutrashield cream. RN Y then looked at the treatment record and stated the Nutrashield cream should be used each brief change. There was no cream in Resident 20's room and RN Y had to get some. On 8/20/14, at 12:30 PM, Surveyor interviewed Assistant Director of Nursing (ADON) G. ADON G stated Resident 20 should have wound sheets and a push tool for the pressure ulcer on his heel. ADON G was not able to locate these documents. On 8/20/14, at 2:10 PM, Surveyor interviewed Director of Nursing (DON) B. DON B stated Resident 20's left gluteal pressure ulcer healed on 8/6/14 and he does not have any pressure ulcers. DON B stated she was unaware that Resident 20 had a pressure ulcer on his foot and she should have been notified of such. DON B also stated she would expect staff to use barrier cream each time if it is on the care plan. Note: The ankle boots are same booties that are not pressure reducing as noted in interview with DON B in previous example. Example 3 Resident 12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/17/14, Resident 12's Pressure Ulcer Scale indicated Resident 12 was at high risk for developing pressure ulcers. Resident 12 had a doppler assessment on 8/5/14 with no concerns noted. Resident 12's care plan does not address pressure ulcers until 8/8/14 when it was updated to include: Demi boots left and right heels while up in wheelchair. Float bilateral lower extremities on pillow while in bed. 8/18/14-pressure relief boots on in bed or in wheelchair or recliner, no ambulating. Resident 12's wound sheet indicates: 8/6/14 Right heel - 6 cm by 7 cm blister on the right heel that is unstageable. 8/7/14 heel protector boots ordered. 8/7/14 Left heel- unstageable pressure ulcer 6 cm by 5 cm. Circular area intact skin. 8/14/14 Right heel- unstageable 6 cm by 7 cm fluid filled intact heel blister. Wearing heel protector boots. 8/14/14 Left heel-unstageable 6 cm by 5 cm fluid filled heel blister. Using heel protector boots. Resident 12's fall reports indicate on 8/11/14 Resident 12 fell in his room and his feet were bare. Intervention to add non-skid foot wear. (Note Resident 12 had the bilateral heel blisters at the time.) On 8/18/14, Surveyor observed Resident 12 in bed at 8:04 AM. Surveyor noted the bootie on Resident 12's left foot had slid off and neither heel was elevated off the bed. At 8:07 AM, Certified Nursing Assistant (CNA) E entered Resident 12's room and lowered the bed a little then left. Surveyor interviewed CNA E. CNA E stated she was just checking on Resident 12 as he does not get up till later. CNA E did not attempt to reposition the bootie or Resident 12's feet. On 8/18/14, at 9:22 AM, CNA E was getting Resident 12 up. CNA E stated the blister on Resident 12's foot broke open. Resident 12 was wearing the Demi boots. On 8/18/14, at 2:27 PM, Surveyor observed Resident 12 in the recliner. Resident 12's bilateral lower extremities were wrapped with ace bandages due to [MEDICAL CONDITION]. Resident 12 did not have heel protector boots on. On 8/18/14, at 4:41 PM, Surveyor interviewed Director of Nursing (DON) B regarding Resident 12's boots. Surveyor showed DON B the booties Resident 12 had on in bed. DON B stated they were not pressure relieving just for protection. On 8/19/14, at 7:49 AM, Surveyor observed Resident 12 in the dining room. Resident 12 had a heel protector boot on the left foot. The right foot did not have a boot on and the heel was resting directly on the floor. Example 4 According to "Admissions Face Sheet", Resident 23 has [DIAGNOSES REDACTED]. The facility completed and annual Minimum Data Set (MDS) assessment dated [DATE]. This assessment notes that Resident 23 scored six points on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Section G of this assessment notes that Resident 23 needs extensive, two-person physical assist with bed mobility, and has functional impairment in range of motion to one side of the lower extremity. This assessment notes that Resident 23 is at risk for pressure ulcer development, but did not have current pressure ulcers during the assessment period. This assessment also notes that Resident 23 was not on a turning and repositioning program. The facility completed a "Pressure Ulcer Scale" assessment on 1/22/14. This assessment notes that Resident 23 scored 11 points based on factors of poor physical condition, confused mental condition, chairbond, slightly limited mobility and incontinence of urine and feces. A score of 11 points indicates that Resident 23 is at high risk for pressure ulcer development. The facility documents current and past wounds on "Wound Flow Sheet." This document notes that Resident 23 developed a pressure ulcer on 2/11/14 and this was healed on 5/5/14. Resident 23's "Resident Care Plan" in place immediately prior to the development of the right heel pressure ulcer, dated 1/22/14 states, "2/4/2012: Impaired Skin Integrity: Potential due to Impaired mobility related to decreased strength and endurance; Approaches: Provide skin treatment to skin impairment as prescribed and monitor effectiveness; record, report, and take action as indicated. Monitor skin integrity for evidence of irritation, redness, warmth; record report and take action as indicated. Monitor for [MEDICAL CONDITION] for possibility of reducing or eliminating as behavior or condition warrants. Provide perineal care after each toileting and prn (as needed). Provide cushioning and support to bony prominences. Provide nail care per schedule. Instruct resident to notify staff of any skin irritations or open areas. Encourage resident to elevate lower extremities when up. Monitor for lower extremity [MEDICAL CONDITION]; record report and take action. Increase fluid intake to 1500-2000 mL per day. Encourage clinical dietician consultation and education with resident and family as indicated ...assist to change positions q (every) 2 h (hours) and prn. Monitor skin for changes and report unusual findings to unit nurse asap (as soon as possible) for assessment ..." Resident 23's comprehensive plan of care does not instruct staff to float Resident 23's heels off of the bed. "Profile History Report" for Resident 23 contains an intervention date of 2/12/14 that states, "Skin, 2/12/14-Present ...Float heels off bed (use pillow under ankles). When up in chair make sure pressure is off heals and shoes/slippers are not to tight." It is important to note that this information was not included in Resident 23's closed medical record during the time of survey. This intervention was not placed on Resident 23's comprehensive plan of care. "Physician's Notification Form" dated 2/11/14 states, "Initiated wound rounds to R (right) heel. 0.5 cm (centimeter) blackened area, closed c (with) 5 cm reddened area surrounding. Pain c slight pressure ...Please determine treatment." The facility received an order for [REDACTED]." The facility assessed Resident 23's pressure ulcer on the right heel, as documented on "Wound Assessment Guide" as follows: 2/11/14: Stage II, 5 cm X 5 cm, necrotic tissue, [MEDICATION NAME], pain, [DIAGNOSES REDACTED], "5 cm round reddened area c (with) .5 round black area in the center. ? (no) drainage. Remains closed. Pain c slight pressure." 2/18/14: 0.5 cm X 0.5 cm, (no stage indicated), necrotic tissue, pain, [DIAGNOSES REDACTED], "0.5 cm tan hardened tissue. ? drainage. Pain when touched. Closed." 2/25/14: 1 cm X 1 cm. "Area is tan in color. Not open." 3/3/14: 1 cm X 1 cm. "Site ? open, area is 1 X 1 cm, yellow, hard, cracked looking, hard to touch, OTA (open to air)." 3/10/14: 1.5 cm X 1.4 cm. "Area calloused over except open on one end. White around edges." 3/17/14: Stage I, .4 cm X .2 cm. ".4 x .2 cm faint purple are underneath, yellowish callous area apprx 1 cm x 1.3 cm, then dried skin peeling off surrounding yellowish area. ? tx (treatment) @ this time." 3/24/14: (no stage indicated). 2.4 cm x 1.5 cm. "Has small pink area in the middle surrounded by white calloused skin. Area dry." It is important to note that Resident 23's pressure ulcer has increased in size since that last assessment on 3/17/14. 3/31/14: (no stage indicated). 2.4 x 1.5 cm. "0.5 cm diameter dark spot in center of white. Scaled dry skin. ? open area." 4/7/14: 2.4 x 1.5 cm, granulation. "0.5 cm diameter dark area-surrounding skin is dry and peeling." 4/14/14: .3 x .2 cm, scab " ...scab surrounded by peeling skin ..." 4/21/14: 1 x 1 cm, surrounding area is white and dry-peeling. Center is small scab. 4/27/14: "Yellowish skin is off. Tissue med pink c some flaking, monitor one more week & d/c (discontinue) if closed." 5/5/14: "Sm yellow scab remains-surrounding skin dry. Area healed." Surveyor spoke with Director of Nursing (DON) B on 8/20/14 at 2:30 PM. Surveyor requested evidence that Resident 23's heels were floated off of the mattress before she acquired the pressure ulcer to her right heel. DON B stated that (Resident 23's) heels should have been floated and this intervention should have been on the care plan. DON B stated that the facility uses the AMDA guidelines for their standard of practice. Resident 23 acquired an avoidable pressure ulcer to the right heal at the facility. The facility did not place preventative measures to ensure that Resident 23's heels were floated from while in bed until after the development of a pressure ulcer. Resident 23 had the pressure ulcer for approximately three months and experienced pain with the pressure ulcer. Example 5 The facility indicated that they follow the American Medical Directors Association's (AMDA) "Pressure Ulcers in the Long-term Care Setting" (2008) as their standard of practice for prevention and treatment of [REDACTED].* or fluctuance*) eschar on the heels serves as 'the body's natural (biological) cover and should not be removed ... Resident 16 was originally admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident 16's admission MDS(Minimum Data Set) with a ARD(Assessment Reference Date) of 7/22/14 indicated that Resident 16 is cognitively intact, is an extensive assist of two for bed mobility, transfers and toileting. The MDS also indicates that Resident 16's skin is intact and is a risk for Pressure Ulcer development, and has a pressure reducing device on the bed, in the wheelchair and is on a turning and repositioning program. Review of Resident 16's initial skin assessment dated [DATE] indicates that Resident 16 has 4 + [MEDICAL CONDITION] to both the upper and lower extremities. Resident 16's Pressure Ulcer Scale (Norton) dated 7/15/14 indicates a score of 10, meaning that Resident 16 is a high risk for pressure ulcer development. Review of Resident 16's care plan titled, Health Management Deficit, dated 7/16/14, directs staff to turn and reposition, notify DON (Director of Nursing) of need for wound rounds, and pressure relief mattress and cushion in wheelchair. 7/24/14: Keep Heels floated on pillows, blue booties for pressure relief. Review of Resident 16's nurses' notes dated 7/25/14 state,"2 cm x 2 cm probable deep tissue bruise to the right heel, heels are up and heel protectors on." Review of Resident 16's nurses' notes dated 7/26/14 state,"1 cm x 1 cm deep tissue injury to left heel. Wound assessment complete. Heels are up off mattress and heel protectors are on when in bed. Skin prep to both right and left heels." Review of Resident 16's TAR'S (Treatment Administration Record) for July 1024 indicate that the treatment of [REDACTED]. Review of Resident 16's physician orders, physician progress notes [REDACTED]. Review of Resident 16's weekly wound documentation for the month of August 2014; indicate the following for Resident 16's left heel: 8/11/14: 3 cm x 3.5 cm x surf, escar, "Brown Escar without surrounding redness," 8/18/14: 2 cm x 2.5 cm x scab, No redness noted, stable escar intact, no drainage." On 8/19/14 at 12:55 PM, Surveyor observed Resident 16 sitting in the recliner in his room. Resident 16's feet were bare, heels floated on a pillow. Surveyor observed a 2 cm x 2.5 cm brownish colored area on the left heel, and a 2.5 cm x 3.0 cm black/leathery escar area to the right heel. Resident 16's heels were dry, no odor or drainage. Resident 16 stated to Surveyor ,"I wear blue boots when I am in bed, and they keep my heels up on pillows. They have been doing that since I came in here." On 8/19/14 at 2:20 PM, Surveyor interviewed RN (Registered Nurse) O regarding the treatment for [REDACTED]. I put Resident 16 on MD (Medical Doctors) N to see if MD N wants Resident 16 to go to the wound clinic to have the heels debrided." Surveyor then asked RN O if RN O was wound certified, RN O stated, "No." Surveyor then asked RN O if the facility had a wound certified nurse, RN O stated, "Yes, the DON (Director of Nursing)." Surveyor then asked RN O if the DON ever comes to the units to assess residents' wounds. RN O stated, "I am sure she does, you can ask her." Surveyor requested to observe the treatment to Resident 16's heels on 8/2014. RN O stated the information would be passes on. On 8/20/14 at 9:37 AM, Surveyor asked MD N when MD N was notified of the SDTI's to Resident 16's right and left heels. MD N stated, "The first time I heard about his heels was a note on the 19th of August." Surveyor then asked MD N if MD N was part of ordering the skin prep to the left heel on 7/25/14 and the right heel on 7/26/14, MD N replied, "No." On 8/20/14 at 9:40 AM, Surveyor interviewed ADON (Assistant Director of Nursing) L regarding who wrote the orders for the heel treatments. ADON L stated, "RN P wrote the orders on the TARS on July 25th and 26th. I do not see where RN P wrote anything to the doctor." Surveyor then asked ADON L where RN P got the treatment order, ADON L stated, "Probably the skin protocol, but I do not see an order." On 8/20/14 at 10:00 AM, Surveyor reviewed Resident 16's physician progress notes [REDACTED]. Evaluate in 1 week. Surveyor asked ADON L about observing the treatment to Resident 16's heels, ADON L stated the treatments were already done. On 8/20/14 at 1:00 PM, Surveyor interviewed DON B regarding Resident 16's SDTI's to the bilateral heel areas, and what Standard of Practice the facility follows for Pressure Ulcer Treatment and Prevention. DON B stated, "I must have picked up in report that Resident 16's had the SDTI's, I was not sent the wound forms which is part of our protocol, and as of 7/31/14 Resident 16 is not on my wound list." Surveyor then asked DON B what the standard of practi

Based on observation, interview, and record review, the facility did not ensure that the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents and the Facility did not consistently implement new interventions to prevent falls when past interventions had proven ineffective for 1 (Resident 3) of 3 Residents reviewed for falls. Resident 3 fell 8 times since admission to the facility on [DATE]. Resident 3's falls were not thoroughly investigated to determine the root cause of the falls in order to develop appropriate interventions to prevent future falls. Resident 3 fell on [DATE] which resulted in a new oblique femur fracture. The facility did not ensure that interventions were put in place after her falls on 3/5/14, 3/6/14, 3/7/14, 3/9/14, 3/13/14 and 3/18/14. This is evidence by; Falls and Fall Risk Managing, revised December 2007, Policy statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. Policy Interpretations and implementation: 1. The staff with input of the attending physician will identify appropriate interventions to reduce the risk of falls...4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 5 if underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature of category of falling, until falling is reduced or stopped, or unit the reason of the continuation of falling is identified as unavoidable. 6. in conjunction with the Attending Physician, staff will identify and implement relevant interventions... Monitoring subsequent fall risk: 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risk of falling... 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the Attending Physician will help the staff reconsider possible causes that may not previously been identified. 4. The staff and/or Physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. Falls Clinical Protocol, revised October 2010,... Cause Identification: 1. For an individual who has fallen, staff will attempt to define possible cause within 24 hours of the fall. a. Causes refer to factors that are associated with or that are directly result in a fall...2. If the cause is unclear ... a physician will review the situation and help identify contributing causes... 3. The staff and Physician will continue to collect and evaluate information until either the cause of the falling is identified or it is determined that the cause cannot be found or that finding a cause would not change the outcome... 1. Resident 3 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident 3's History and Physical, dated 2/27/14,... Consult notes: Resident 3 currently has a sitter because she tries to get up by herself and she pulls tubes and clothing... Resident 3's preadmission screen, dated 3/4/14, states Current history: Fall in the garage at home on 2/23/14. Resident 3 had an open reduction and internal fixation of the right hip on 2/24/14. Cognition: Resident 3 is oriented to self, redirects well. The hospital uses a wipe board to write out reminders to Resident 3. Short term memory problem "yes." Long term memory problem "yes"... Special Equipment: Resident 3 had a sitter up until 3/3/14 (The day prior to admission to the nursing home.) ... Resident 3 had a chair and bed alarm... Resident 3's current medications include Donepazil 10 milligrams (mg) daily, Seroquel 25 mg every 6 hours and as needed (PRN) conduct dangerous to others, Seroquel 25 mg three times a day. Celexa 10 mg daily. Resident 3 also received the following medication since admission on 3/4/14 Seroquel 12.5 mg at bedtime. Seroquel 12.5 mg every 6 hour PRN given 2 doses on 3/5 and 3/6/14 and discontinued on 3/6/14. Xanax 0.25 mg PRN for agitation and anxiety given times 10 doses and discontinued on 3/13/14... Resident 3's care plan Problem: Health management deficit due to: Illness or recent hospitalization leading to a nursing home admission, dated 3/4/14. Goal: Resident 3 will remain free from physical injury through the next three months. Interventions: 1. Keep call light in reach. 2. Provide safe environment free of harmful objects. 3. Bed and chair alarm. 4. review fall risk assessment including predisposint diseases, history of falls, mobility, cognition... If the resident is high risk for falls initiate preventative measures... the following interventions are circled a. assistive devices. b. low bed. 5. Chair alarm when up. 6. Primus mattress (A mattress with an alarming device built into the mattress.) The following additional interventions were added to the care plan; On 3/5/14, 15 minute checks for safety. (It is important to note Resident 3 was on 15 minutes checks on admission, prior to this intervention.) On 3/10/14, Keep resident at arms length from other Resident. On 3/13/14, Dycem to wheel chair (W/C) or non skid pad to prevent sliding out of W/C, and Rubber sole shoes or gripper socks. Undated entries on the care plan are CNAs to check every shift that bed alarm is functioning and mat to floor at all times when resident is in bed. A nursing note on 3/4/14 at 2:20 PM states, Resident 3 has severe memory deficit. Able to redirect, but lasts only seconds before she needs redirection again. A nursing note on 3/4/14 at 8:00 PM states, Resident 3 was agitated at supper time, attempting to stand, wanting to leave. A nursing note on 3/4/14 at 9:05 PM states, Resident 3 found up walking unassisted. Primus mattress not working box replaced. A nursing note on 3/4/14 at 11:30 PM states, Resident 3 sitting at a table with another resident. Resident 3 became increasingly loud... Resident 3 continued to hollering at staff and trying to stand up in her W/C. Review of Resident 3's injury/Incident investigation reports indicates the following: On 3/5/14, at 8:10 PM, Resident 3 was found on the floor - tipped her wheel chair (W/C) in the television room. Measures implemented Plan of care revision Continue 15 minutes checks after first 72 hours admission checks. Resident 3 already has bed alarm and chair alarm. Other added: Requested daughter bring in hearing aide. Resident 3's attached Nursing note indicates, Resident 3 is very restless and concerned about going home... Resident 3 unable to redirect. Called Medical Doctor and received order for Seroquel (antipsychotic medication). Seroquel given at 3:30 PM and at 8:10 PM Resident 3 was found on the floor. It is important to note Resident 3 was found on the floor and no evidence Resident 3's chair alarm was sounding while Resident 3 was on the floor. Resident 3's chair also tipped. The facility did not determine what may have caused or contributed to the fall. The facility did not revise the Resident's plan of care and/or the facility practices, as needed, to reduce the likelihood of another fall. The investigation form is signed as reviewed by the Interdisciplinary team on 3/6/14. A nursing note on 3/5/14 at 8:00 PM states, Resident 3 found on the floor in Television room. Resident 3 attempted to get out of W/C to "Go home". Interdisciplinary team (IDT) referral made. A nursing note on 3/6/14 at 4:05 AM states, Resident 3 attempted to self transfer to use bathroom. Found on floor on buttocks. States she hit her head...Reoriented to call light. Resident 3 able to return demonstration use of call light and verbalized "I will press this when I need help. Ok." A nursing note on 3/6/14 at 11:40 AM states, Resident 3 very confused to the point of agitation various times this am. Kept in line of sight at all times. An Interdisciplinary team (I-team) record, dated 3/6/14 states, Rationale: Resident 3 very restless, get agitated. Wants to leave and go home... Very Very short memory, denies breaking hip. During PM and Night unable to redirect. Resident 3 had a fall 3/5/14 PM's....Initiated 15 minute checks for safety "(already on 15 min (checks) for 3 days - admission)" PRN as needed Seroquel 12.5 mg only slightly effective. Summary of I-team Discussion: Review of falls 3/5 @ (at)19:10 (7:10 PM) & (and) @ 04:05 AM. review of current medications. has PRN Tylenol. Seen by (Psychiatrist name) today. Decision/Follow-up... MD (Medical Doctor) to review for pain to schedule. [DIAGNOSES REDACTED]. Xanax 0.25 mg every 6 hours PRN and Discontinue Seroquel. A nursing note on 3/6/14 PM (no time given) states, Resident 3 very restless, unable to re-orient. had staff with resident majority of the night...Family brought in hearing aide. Resident 3's fall risk assessment, dated 3/4/14, states Resident's total score is 17. Scores reported as 13 or higher are at high risk for falls. On 3/6/14, at 4:05 AM, Resident 3 was found sitting on the floor in her room. Resident 3 stated she was trying to go to the bathroom. Immediate interventions: bed alarm in place. Measures implemented after the fall: Requested the daughter bring in hearing aids. Resident 3's investigation statement indicates Resident 3's bed alarm was sounding (The bed alarm was placed on 3/4/14.). Resident 3 stated she was trying to go to the bathroom and she fell backwards and hit her head on the dresser. The statement also indicates the staff tried to explain the call light to Resident 3 earlier and she did not seem to understand. (Resident 3 has a [DIAGNOSES REDACTED].) The facility did not revise the Resident's plan of care and/or the facility practices, as needed, to reduce the likelihood of another fall. The investigation form is signed as reviewed by the Interdisciplinary team on 3/6/14. A nursing note on 3/7/14 at 5:30 AM states, Resident 3 up in W/C, anxious and keeps calling out... and call out help me help me... Resident 3 is "found sitting up at side of bed - This has gone on thru the whole NOC (night) shift." A nursing note on 3/7/14 at 4:50 PM states, Witnessed Resident attempting to get out of W/C, she scooted herself forward and the W/C tipped forward and the resident slid to the floor...Informed Power of attorney (POA) that staff may consider a different chair for resident to sit in... On 3/7/14 at 4:50 PM, Resident 3 was witnessed sliding out of her W/C. Immediate interventions Resident 3 has a chair alarm (The chair alarm placed on 3/4/14). Measures implemented and plan of action; Resident was placed on 1:1 rotating staff to watch her until 8:00 PM when the nurse took her along on med pass. Resident 3's nursing notes attached to the investigation indicates Resident 3 was attempting to get out of her W/C and she scooted forward and the W/C tipped forward and Resident 3 slid to the floor. (It is important to note this is the second episode of Resident 3's W/C tipping forward.) The investigation form is signed as reviewed by the Interdisciplinary team on 3/10/14, 4 days after Resident 3's fall. A nursing note on 3/7/14 at 6:30 PM states, Resident 3 anxious trying to get out of W/C. A nursing note on 3/7/14 at 8:00 PM states, Resident 3 was found on the floor lying on her left side in the common area while Registered Nurse (RN) F was resident room doing a treatment. On 3/7/14 Resident 3 had a second fall at 8:00 PM; Resident 3 was found on the floor lying on her left side in the common area. Additional comments: Resident 3 was left alone in the common room while the Registered Nurse and the Certified Nursing Assistant were doing a treatment on another resident. Resident 3 was yelling out loudly... and unable to reorient. Immediate interventions: Continue with current safety measures. There is no evidence Resident 3's W/C alarm was sounding when Resident 3 was found yelling on the floor. Measures implemented and Plan of action. The box "other" has a check mark and the following statement is written "asked for a sitter", attempting to do 1:1 as much as possible. There is no direction or plan of care when to provide Resident 3 with 1:1 personnel. The facility did not revise the Resident's plan of care and/or the facility practices, as needed, to reduce the likelihood of another fall. The investigation form is signed as reviewed by the Interdisciplinary team on 3/10/14. (4 days after Resident 3 had fallen.) A nursing note on 3/8/14 at 1:30 AM states, Resident 3 has been restless in bed...Not bearing weight well at all... Does rub right thigh "oh oh oh it hurts. A nursing note on 3/9/14 at 5:30 AM states, awake yelling confused 1:1 continued 1:1 to calm her...Confusion 1:1 not very effective finally did calm down and nap... bed alarm effective to alert staff when Resident 3 trying to exit the bed. A nursing note on 3/9/14 at 12:00 PM states, Resident 3 in a reclining chair in the day room... Witnessed fall Resident 3 slid out of the chair. Chair alarm intact. On 3/9/14 at 12:00 PM, Resident 3 slid out of a chair in the day room. Immediate interventions: Chair and bed alarm in place. The investigation form is signed reviewed by the Interdisciplinary team on 3/10/14. The facility did not revise the Resident's plan of care and/or the facility practices, as needed, to reduce the likelihood of another fall on 3/9/14 or 3/10/14. An Addendum for Measures implemented was dated 3/13/14. Dycem or non skid surface to the W/C seat. Add rubber sole shoes or gripper socks. (It is important to note this is Resident 3's fourth fall from a chair.) Resident 3's nursing notes attached to the investigation form indicate Resident 3 was sitting in a reclining chair in the day room and seen by a CNA sliding out the chair. (It is important to note Resident 3's plan of care does not indicate to place Resident 3 in a recliner alone in the day room. Resident 3 was not on 1:1 during this fall event.) A nursing note on 3/10/14 at 6:30 AM states, Resident 3 was found half in and half out of the bed at 10:15 PM and again at 2:30 AM... At 2:30 AM Resident 3 was given Xanax 0.25 mg. At 4:00 AM Resident 3 attempted to get out of bed. A nursing note on 3/10/14 at 10:30 AM states, Resident 3 was up in recliner chair. A nursing note on 3/10/14 PM (no time given) states, Resident 3 yelling out most of shift. "mother help me"... "I want to go home." Attempting to get out of chair. A nursing note on 3/11/14 at 6:10 AM states, Resident 3 needed intervention times 3 to keep her from getting out of the bed by herself. Assisted to the bathroom trickle when she voids. A nursing note on 3/12/14 PM Shift, Nursing weekly summary states, Review of resident adaptive equipment... Resident 3 placed in Geri Chair. (A reclining chair with wheels to be pushed by the staff.) (It is important to note Geri chair is not on the comprehensive care plan for instruction of the staff when to use.) On 3/13/14 at 5:45 AM, Resident 3 was found on the floor at bedside on her buttocks. Action taken as a result of the incident: "Bed alarm noted not functioning." Measures implemented CNA's to check every shift that bed alarm is functioning. No further interventions were implemented for Resident 3. A root cause to the fall was not completed as to why Resident 3 was exiting the bed. Resident 3's nursing notes attached to the investigation indicates Resident 3 was sitting on the floor on the window side of the bed, scooting on her buttocks. "Note bed alarm did not go off - needs charging."... Resident 3 is too confused to say what happened. Resident 3 was checked 10 minutes prior to being found on the floor. (It is important to note Resident 3 was not on 1:1 during this fall event.) A nursing note on 3/13/14 at 6:00 AM states, Resident 3 found sitting on the floor... "Note bed alarm did not go off- needs charging." A physician progress notes [REDACTED]. Has fallen 6 times since admission 10 days ago.... Falls not likely induced by Seroquel. A nursing note on 3/14/14 at 1:40 PM states, Very active this shift.... "Does not like to be left alone." A nursing note on 3/14/14 PM (no time given) states, 1:1 majority of shift, kept attempting to get out of W/C. A nursing note on 3/16/14 at 12:00 PM states, Resident became restless, while wheeling self around and attempting to enter another resident room... Redirection ineffective. Several attempts to stand unassisted. A nursing note on 3/16/14 from 2:00 PM through 7:00 PM states, has been 1:1 yells if left alone....Don't leave me. "I am afraid!... If staff leave her side she gets upset and states "don't leave me" "take me with you" Has attempted to get out of chair several times. A nursing note on 3/16/14 from 7:45 PM until 9:30 PM states, When Resident 3 had to sit unattended more then (SIC) five minutes she became anxious and complained of feeling "afraid" to be alone. Resident 3 was taken to the bathroom every hour this shift. A nursing note on 3/17/14 at 6:30 AM states, Staff took turns 1:1 Resident 3... Unable to be left alone would start hollering. A physician progress notes [REDACTED]. A nursing note on 3/18/14 at 12:00 AM states, Resident 3 has not slept in 24 hours, she is now up in a W/C, has not gone to bed. On 3/18/14 at 8:50 PM, Resident 3 was "found in the hallway (got out of bed) scooting butt towards dining room." (It is important to note Resident 3's bed is approximately 20 feet from the bed to the doorway of her room.) Resident 3's nursing notes attached to her investigation indicates Resident 3 was found in the hallway scooting down the hallway on her buttocks. (Resident 3 scooted over 20 feet before she was seen by the staff.) Resident 3's investigation does not show evidence Resident 3's bed or chair alarm was sounding, while Resident 3 was scooting down the hallway. Plan of care changed to have floor mats beside her bed. (It is important to note Resident 3 was not on 1:1 during this fall event.) A nursing note on 3/18/14, at 9:30 PM states, Skin tear found on right calf... from leg rests due to frequent attempts to get out of W/C and stand... At 8:50 AM Resident 3 found in the hallway (was in bed) scooting down hallway on buttock...Resident 3's Nurses notes does not show evidence Resident 3's bed alarm was sounding. (It is important to note Resident 3 was not on 1:1 during this fall event.) A nursing note on 3/19/14 at 5:00 AM states, Resident 3 found on the floor sitting on buttock on matt beside bed. Bed in lowest position. Resident 3 stated "My leg hurts"... Continued to have escalating pain... At 5:30 AM Resident 3 was willing to go to the emergency room ... Resident 3 sent out to emergency room ... Resident 3's nursing notes does not show evidence Resident 3's bed alarm was sounding. (It is important to note Resident 3 was not on 1:1 during this fall event.) On 3/19/14 at 5:05 AM, Resident 3 was found on the floor sitting on matt at bedside. Resident 3's nursing notes attached to Resident 3's investigation indicates Resident 3 was found on the floor on buttock on matt beside her bed. Bed in lowest position... There is no evidence Resident 3's bed alarm was sounding when Resident 3 was found on the floor. Resident 3's attached Statement by CNA E indicates "went to do 15 minute checks on her" and when CNA E was outside Resident 3's door she was yelling. When CNA E entered the room Resident 3 was sitting on the floor... There is no evidence that Resident 3's alarm was sounding. The investigation was reviewed and signed by the IDT team on 3/19/14 as completed. (It is important to note Resident 3 was not on 1:1 during this fall event.) Resident's 3 hospital history and physical, dated 3/19/14 in part, Resident 3 admitted to the hospital with [REDACTED]. Assessment and Plan: Oblique right femur fracture, Surgical plan and activity per orthopedic surgery... Case and xrays discussed with radiology. Radiology agrees femur fracture is new... On 3/20/14 at 10:30 AM, Surveyor and DON B observed Resident 3's mattress. DON B stated Resident 3's mattress is an alarming mattress. DON B stated the facility is having trouble with the mattresses due to they (the mattresses) after not working well and had to remove some from the floors due to not working. DON B removed the sheets to Resident 3's bed and exposed the area to where the battery would be applied. The Mattress did not have a battery in the Mattress at the time of the observation. DON B stated she was not sure when the battery was removed, but would get the information to Surveyor . No further information was provided from DON B to Surveyor . On 3/20/14 at 10:30 AM Surveyor spoke with DON B regarding Resident 3's W/C sitting in Resident 3's room. DON B stated yes that is Resident 3's W/C. Resident 3's W/C was observed to have foot rest sitting in Resident 3's chair. Resident 3's W/C did not have anti-tip device to prevent Resident 3's W/C from tipped forward when Resident 3 scooted to the edge of her chair. On 3/20/14, at 10:58 AM Surveyor requested follow-up investigation regarding alarm sounding during fall o 3/18/14 and 3/19/14. DON reviewed the incident investigation signed by the DON and ADON as reviewed. DON B stated the form does not indicate the alarm was sounding. Surveyor asked DON B how she knew the alarm would be sounding when Resident 3 had 2 previous occasions (3/4/14 and 3/13/14) when Resident 3 got out of bed and the bed alarm did not function. DON B stated she would get the information for Surveyor . Surveyor asked DON B would the alarm sounding be identified as part of the investigation and review process? DON B stated yes the information of the alarm sounding should be identified by the review person doing the investigation. No further information was provided to Surveyor regarding the alarm sounding on Resident 3's bed during her last 2 falls. On 3/20/14 at 10:58 AM Surveyor spoke with Director of Nursing (DON) B and Assistant Director of Nursing (ADON) D regarding the written request on 3/7/14 for a sitter for Resident 3. DON B stated Resident 3 did have a sitter while she was at the hospital. DON B stated the facility does not provide sitter for any residents. Resident who are in need of a sitter are not admitted to the facility. DON B stated she was not aware the request for a sitter for Resident 3 and no investigation was completed as to why the staff believed a sitter was necessary. DON B stated she did review the incident investigation report on 3/10/14 and did not see the words sitter on the form. DON B stated we do not provide a sitter for any residents in the facility. Surveyor requested a timeline of events for Resident 3's falls from DON B. On 3/20/14 at 10:58 AM, Surveyor spoke with ADON D also regarding the written request for a sitter. ADON B stated she did not see the request on the form for a sitter. ADON B also stated she signed the form as reviewed on 3/10/13. On 3/20/14 at 10:58 AM, Surveyor spoke with DON B regarding Resident 3 tipping her W/C forward and preventing the chair from tipping forward. DON B stated the facility does not have or use anti tipping devices on the W/C. DON B stated the facility was going to place the brakes on the back of Resident 3's chair, which would lock when she stands. Surveyor asked DON B what plan was in place to prevent Resident 3 from tipping her W/C forward again in the future. DON B stated again we do not have anti tip devices. No further information was given how the facility was going to prevent the W/C from tipping forward Timeline per the Director of Nursing completed 3/20/14 at 1:30 PM. 3/4/14 - "Low bed / call light in reach / Bed Chair Alarm." 3/5/14 - "15 minute checks". (It important to note Resident 3 was already on 15 minute checks prior to this intervention as part of the facility admission process.) 3/7/14 - "1:1" 3/9/14 - "Orthostatic blood pressures" (It is important to note this was medication monitoring for the use of Seroquel.) 3/13/14 - "Choice of footwear evaluated / Med (medication) reviews Dycem or anti skid surface to the w/c". (Resident 3 fell out of bed on 3/13/14.) 3/18/14 - "Recent - Mats on floor / per incident report" 3/19/14 - "Hospital - not reviewed in" On 3/20/14 at 1:30 PM, Surveyor spoke with DON B regarding the time line of events. DON B stated this is the full timeline there is not any more information that needs to be added. Surveyor spoke with DON B regarding the 1:1 placed on the time line and when the staff was to use the 1:1. DON B stated they do not give a person to do 1:1 that was on the investigation form. No further information was provided on how or when the staff was to perform the 1:1 for Resident 3. Surveyor spoke with DON B regarding the use of a Geri Chair for Resident 3, and the use of the Geri chair not on the plan if care to indicate when the staff would use the Geri chair for Resident 3. DON B stated the Geri chair was trial use only. The Geri chair did not work and the Geri Chair was removed. On 3/20/14, Resident 3's Plan of Care did not have clear instructions on when to do the 1:1 or the level of supervision required for Resident 3 fall prevention. Resident 3's timeline received by DON B indicates Resident 3 has been on 1:1 since 3/7/14. Resident 3 had 4 falls since 3/7/14 when 1:1 was not provided prior to or during the fall. Resident 3's nursing notes and Physician documentation indicates Resident 3 becomes agitated when left alone. Resident 3 voiced to the staff she was afraid when left alone. Resident 3's plan of care does give clear direction when Resident 3 needs 1:1. The need for increased supervision was never addressed in the care plan after multiple falls and after a fall with a major injury.

Based on observation, interview and record review the facility did not ensure that the residents' environment remained as free of accident hazards as is possible and that each resident received adequate supervision and assistive devices to prevent accidents in 3 of 8 (Resident 3, 1 and 8) residents reviewed. Resident 3 was assessed to be at high risk for falls and had a written plan of care to be a 2 person pivot transfer. On 8/30/12 Resident 3 sustained a fall that resulted in fracture of the right ankle. Staff did not use a 2 person assist during a pivot transfer as directed by the resident ' s plan of care. Resident 3 has swallow precautions on her plan of care. Observations were made when this intervention was not followed. Resident 8's physician orders [REDACTED]. away from other resident during meals observations were made when these care plan intervention were not followed. Resident 1 experienced a choking episode that required the Heimlich maneuver. During this incident, Resident also experienced a fracture of his femur. The facility did not investigate the incident to determine the cause of the incident and did not implement preventative measures. The facility did not update Resident 1's plan of care with physician orders [REDACTED]. The facility did not follow up on a physician's orders [REDACTED]. This is evidence by: Example 1 Occurrence 1 Resident 3 was admitted to the facility on [DATE] and readmitted after a hospitalization on [DATE] with the following diagnoses; End stage Renal Disease, Multiple Sclerosis, Cerebrovascular Accident (CVA) with left sided hemiparesis... Resident 3's readmission orders [REDACTED]. Resident 3's care plan titled Trauma, original date 8/4/10, top right hand corner of the care plan states "report date states 7/22/12." Problem: Potential risk for Falls due to the presence of following identified risk factors: Decreased strength, Uncompensated cognitive impairment, Weakness... history of falls. Goal: Resident 3 will be free from physical injury due to falls over the next 3 months. Approaches:... Toilet with 2 assist of 2 pivot using wall bar and/or EZ stand (mechanical stand lift)... Praise Resident 3 for progress towards goal. Assess and monitor Resident 3 for fatigue... Transfer with 2 assist. Resident 3's fall risk assessment, dated 8/27/12, states Resident 3's total fall risk score is a 14. The fall risk assessment sheet guidelines state a score of 13 and higher is high risk for falls. Resident 3 was assessed to be at high risk for falls. Resident 3's Balance during transitions and walking quarterly assessment, date of testing 8/20/12 and 8/27/12, states A. Balance while moving from sitting to standing; code entered is 8 (8- Activity did not occur.) B. Balance while walking: Code entered is 8 (8- Activity did not occur.) C. Balance while turning around: Code entered is 8 (8- Activity did not occur.) D. Balance while transferring on and off the toilet: Code entered is 2 (2- Not steady, only but to stabilize with staff assistance.) E. Balance during surface-to-surface transfers is 2 (2- Not steady, only but to stabilize with staff assistance.) Resident 3's Physical Therapy treatment note, dated 8/27/12, states... Maximum assist of 1 for balance and to block left knee from buckling. Resident 3's Physical Therapy treatment note, dated 8/28/12, states Resident 3 static stand with facilitation of weight bearing onto to left lower extremity. Therapist blocked knee and insured that left ankle remained in neutral position. Facilitate forward shift of hips to maintain stand balance with right upper extremity support... Stand pivot transfer training with moderate assist. Maximum assist was needed to elevate to stand and cue given to pivot with right foot. Resident 3 initiated foot moment but was unable to complete motion with turn, was 1/6 consistent with complete turn with pivot... Resident 3's Physical Therapy treatment note, dated 8/29/12, states Pivot transfer training working with resident placing hand on mat and lifting hips high enough to clear armrest. Resident 3 was unable to maintain balance to complete turn with hand on mat. Change hand position to push from armrest and then place on mat., requires maximum assist to complete transfer. Attempted mat to wheelchair with assist in front. Resident 3 was able to come to stand and reach for armrest and pivot with right lower extremity with moderate assist. Coming to a stand remains maximum assist.. Resident 3's nursing note, dated 8/30/12, at 7:45 AM, states During pivot transfer from the toilet left ankle gave way causing Resident 3 to "fall / sit quickly" to the toilet... Resident 3 complained of left ankle pain... Resident 3's nursing note, date 8/30/12, at 9:30 AM, Resident 3 refused ice pack after 1-2 minutes of application. Resident 3 has some swelling noted to left ankle... Resident 3 agreed to "pivot transfer" to bed. "She (Resident 3) is sobbing and wailing. Offered a PRN offered Baclofen which Resident 3 accepted. Resident 3's left foot is elevated and ice to outer ankle. Resident 3 stated her right knee gave out and Resident 3 fell to the floor. Resident 3's area on left knee approximately 1.5 centimeter superficial abrasion... Resident 3's nursing note, date 8/30/12, at 9:45 AM,... Resident 3's swelling is unchanged. Resident 3 resumed wailing when staff present. Resident 3 is able to speak calm and clear, then sobbing, begging for help... Resident 3's Physician aware and will order X-ray upon Resident 3's return from Dialysis. Vicodin (pain medication) given at 10:15 AM.... Resident 3's nursing note, date 8/30/12, at 10:50 AM, Resident 3 crying out in lobby while waiting for pick up to Dialysis. Reminded Resident 3 how important Dialysis was, that pain medication and ice pack will help and that X-ray was ordered. Ace wrapped left ankle. Resident 3 ultimately refused to go to Dialysis. Resident 3's Physician assessed Resident 3 ankle and told Resident 3 X-ray was ordered. "2 assist back to bed."... Resident 3's nursing note, date 8/30/12, at 8:30 PM,... Resident 3's ankle X-ray occurred at approximately 3:00 PM. Results were faxed and showed "Acute Ankle Fracture- non- displaced good alignment." Paged Resident 3's Physician decision made to call Orthopedic office in the morning. Resident 3 is to be "no wt (weight) bearing".... Resident 3's Injury/Incident Investigation Report, dated 8/30/12, at 7:45 AM, States Injury/incident description: Resident 3 fell on to toilet during pivot transfer when leg gave out. 1. Type of injury: Abrasion and Potential for injury; Left ankle pain and swelling. 2. Location of injury: "knee" 3. Location: Resident bathroom. 4. Severity: Minor. 5. Injury/Incident cause: Accident, bumped during ADLs (Activities of Daily Living). Measures implemented / Plan of action: "2 staff for all cares." (It is important to note Resident 3's current plan of care states Resident 3 is to have 2 assist for pivot transfers.) Resident 3's follow-up review of fall, dated 9/7/12, states... Resident 3 has no functional use of her left upper extremity and minimal use of her left lower extremity. Resident 3 is alert and able to verbalize both any concerns she might have and verbalize pain. The following is a description of the incident... prior to breakfast on the morning of 8/30/12, Certified Nursing Assistant (CNA) J was assisting Resident 3 off the toilet. Resident 3 was holding the grab bar in the bathroom with her right hand, as CNA J was assisting Resident 3 off the toilet and pulling up Resident 3's clothing. CNA J believes is was Resident 3's "left" leg that gave out, but (Resident 3) is sure it was her right leg that gave out... The follow-up review of the fall also states; The X-ray read, at 5:48 PM, on 8/30/12 that there was an acute ankle fracture involving the distal tibula and fibula with no displacement. Resident 3's physician was updated and ordered that Resident 3 see Orthopedic Physician the following day... Resident 3 was hospitalized from [DATE] to 8/13/12 for altered mental status. On return from the hospital Resident 3 had been working with therapy for strengthening. At the time of the incident Therapy were transferring Resident 3 with moderate assist of one. Therapy notes indicate that Therapy was blocking Resident 3's left knee which would support CNA J's belief that it was the left knee that gave out. Physical Therapy had not sent an updated FMP (Change of care plan) to indicate change in transfer status for Resident 3. PNA/POC (plans of care) indicated Resident 3 should be a 2 assist transfer... Spoke with CNA J regarding importance of waiting for POC (Plan of care) changes before changing how cares are provided.. Certified Nursing Assistant (CNA) J's witness statement, written 8/30/12, at 7:45 AM states: CNA J stood Resident 3 from the toilet and her left leg gave out. Resident 3's ankle twisted and CNA J lowered Resident 3 to the toilet. Resident 3 did have small skin tear on both knees as Resident 3's knees may have rubbed the wall. Resident 3 did complain of pain several times. On 9/19/12, 1:40 PM Surveyor spoke with Administrator (Admin) A regarding Resident 3's incident resulting in a fracture of her left ankle during a transfer when Resident 3's care plan was not followed. Admin A stated the incident with Resident 3 was not self-reported and staff education was not completed after the incident occurred. No further information was provided to Surveyor . On 9/19/12, at 2:00 PM Surveyor spoke with Physical Therapy Director (PTA) K regarding informing CNAs and Nurses and change in Resident 3's plan of care. PTA K stated after a resident has completed a training therapy writes a FMP (change in plan of care) and provides a copy to the Nurses and CNAs. PTA stated a FMP is only given if a change in the plan of care is going to take place. PTA K also stated therapy also does on the floor training with the resident and the CNAs to be assured the proper restorative plan is being completed. Surveyor asked PTA K if Resident 3 had completed her therapy and if a FMP was provided to nursing prior to Resident 3's fall on 8/30/12. PTA K stated no Resident 3 had not completed transfer training and the FMP was not provided to the CNAs prior to CNA J transferring Resident 3 with 1 assist. Surveyor continued speaking with PTA K regarding Resident 3. Surveyor asked PTA K her if she intended to educate the CNAs regarding Resident 3's transferring with 1 assist. PTA K stated yes she intended to train the CNAs due to Resident 3 needed guideline and blocking of her knee during the transfers. PTA K stated she had not trained any CNAs on how to 1 person transfer Resident 3 prior to her fall on 8/30/12. On 9/19/12, at 2:20 PM Surveyor spoke with CNA J regarding transferring Resident 3. CNA J stated she used 1 assist to stand Resident 3 from the toilet on the day of 8/30/12. CNA J also stated Therapy had verbally stated they had been transferring Resident 3 with 1 assist. Surveyor asked CNA J how Therapy communicates to CNA J that a change is made in a plan of care. CNA J stated therapy will send a FMP (Restorative program change) and Therapy also will educate the CNAs if there is a specific way a resident should be transferred or walked. CNA J stated Therapy did not send a FMP or do training on Resident 3 prior to CNA J transferring Resident 3 with 1 assist. On 9/19/12, at 4:10 PM Surveyor spoke with Director of Nursing (DON) B regarding Resident 3's plan of care. DON B stated she would expect all staff to follow the care plan as written. DON B stated Resident 3 should have been transferred with 2 assist from the bathroom on 8/30/12 according to Resident 3's care plan. On 9/19/12, at 4:10 PM, Surveyor spoke with director of Nursing (DON) B regarding staff education for following the care plan after Resident 3's incident on 8/30/12. DON B stated the staff has not been provided education on or since 8/30/12 on following the resident's plan of care. No further information was provided to Surveyor . Resident 3 was not transferred according to her plan of care, which resulted in fall creating a fracture in Resident 3's left ankle. Example 1 Occurrence 2 Resident 3's Hospital discharge summary, dated 8/13/12, states Resident 3 was admitted to the hospital for recurrent Altered mental status, Anemia, Pneumonia, and End Stage renal Disease with abnormalities. Resident 3's care plan titled Health management, original date 8/4/10, Report date 9/7/12, states Problem: Health management deficit due to: Decreased activity tolerance... Goal: Resident 3 will alert staff of any health concerns over the next 3 months. Approaches:... Diet: 1800 calorie, General diet, low sodium renal diet with restriction of 1500 ml per day. Thin liquids to be given by teaspoon... Safe-Swallow recommendations per Speech therapy 1. May have thin liquids (via spoon with chin tuck) for all meals "NO STRAWS" 2. needs to perform chin tuck with each swallow for safe transition. 3. Resident 3 to alternate food and liquid. 4. encourage to clear mouth before taking drink of liquid. 5. monitor for signs and symptoms of aspiration... Document time spent with supervision of this plan/cueing... Resident 3's care plan titled "Aspiration", original date 8/4/10, report date 9/7/12, states Problem: Aspiration potential due to presence of the following identified factors: Resident 3 has history of CVA with swallowing problems. Goal: Resident 3 will have normal breath sounds with absence of crackles, Rhonchi, and wheezes... Approaches:.. Head turn left with a chin tuck every swallow of liquids and solids. if Resident 3 does not turn head to the left with every swallow, Resident 3 is at risk for silent aspiration... Resident 3's Nursing Assistant flow sheet, dated 9/7/12 through 9/19/12, states safe-swallow recommendations per Speech Therapy (ST) 1. may have thin liquids. (via spoon with chin tuck) for all meals. "No Straws" 2. needs to perform chin tuck with each swallow for safe transition. 3. Resident 3 to alternate food and liquids. 4. Encourage to clear mouth of food before taking a drink of liquid. 5. Monitor for signs and symptoms of aspiration. Resident 3's nursing weekly Summary, dated 8/21/12, shift 2- 10 PM,... Restorative: head turn to left with chin tuck every swallow of liquids and solids. "Silent Aspiration Risk."... Encourage clear mouth every food before drinking every fluid... On 9/19/12, at 12:30, Surveyor observed Resident 3 sitting in her wheelchair in the dining room at a dining table. Resident 3 was severed her lunch meal of Lasagna, mixed vegetables, coffee, and water. Resident 3 independently took her first bite of Lasagna. Resident 3 did not have a staff member supervising or cueing her during her meal. Resident 3 took 12 bites of Lasagna without drinking fluids. Resident 3 did not chin tuck during her eating of the Lasagna. Resident 3 sat at the table with Resident 8. Resident 8 was assisted with her meal by Certified Nursing Assistant (CNA) M. Resident 3 talked to CNA M assisting Resident 8. Resident 3's mouth was full of food as she conversed with CNA M assisting Resident 8. Resident 3 was not directed to tuck her chin or drink fluids between bites of food. Resident 3 ate 50% of her Lasagna with CNA M present assisting Resident 8. Resident 3 did not chin tuck or alternate fluids while eating during the staff presence. Resident 3 finished another 25 % of her Lasagna without a staff member present at Resident 3's table. Resident 3 did not drink fluid while eating the 75 % of her Lasagna. Resident 3 pushed her plate away from in front of her. Resident 3 picked up a dark brown cup and drank coffee from the cup. Resident 3 did not use a spoon to drink the fluids and Resident 3 did not do a chin tuck maneuver while swallowing the coffee. Resident 3 had an approximately 16 ounce Styrofoam glass of water. Resident 3 asked CNA M for a straw for her glass. CNA M gave Resident 3 a cover for her glass and unwrapped a straw and handed the straw to Resident 3. Resident 3 placed the straw into her glass. Resident 3 took a sip of the water from the glass by use of the straw. Resident 3 placed the Styrofoam glass with the straw in a cup holder on her wheelchair and exited the dining room. On 9/19/12, at 4:10 PM Surveyor spoke with Director of Nursing (DON) B regarding Resident 3's swallow precaution guidelines. DON B stated Resident 3's swallow precautions of chin tuck and no straw are current and should be followed during every meal. DON B stated she would have expected the CNAs to follow the CNA flow sheet with Resident 3 at all meals. Example 2 Resident 8's was admitted to the facility on [DATE], with the following diagnoses; Alzheimer's Disease, Depression, Diabetes Mellitus... Resident 8's care plan titled Health management, original date 9/23/11, Report date 8/26/12, states Problem: Health management deficit due to: Decreased activity tolerance... Approaches:... diet: Soft, Lactose free, no added salt, serve in separate bowls at meals. monitor meal intake. "To sit an arm's length from peers at meals using table tray up to table to prevent grabbing food items from others residents." Alternate between solids and liquids; small bites-cut up into small pieces if needed... Resident 8's care plan Restorative nursing needs related to: decreased ability to eat independently..., original date 10/7/11, Report date 8/26/12, states 2. Alternate solids and liquids. 30 small bites... Sit arm's length away from peers at meals using table tray up to table... Resident 8's care plan also includes a hand written entry on 8/27/12 Upgrade to soft diet and thin liquids... Resident 8's revised swallow Restorative plan, dated 8/27/12, states upgrade to soft diet on 8/27/12. Resident 8 to remain on thin liquids: 1. Periodic supervision. 2. Alternate between solids and liquids. 3. Small bites. 4. Cut up food into small pieces if needed. On 9/19/12, at 12:50 PM Surveyor observed Resident 8 sitting beside the standard table with a tray table sitting diagonal to the standard table. Resident 8 was sitting behind the tray table and sideway to the dining table. Resident 8 remained within reach of the standard dining table. Resident 8 reached over and remove a bowl from Resident 9. No facility staff was sitting or standing near Resident 8 when she removed the bowl from Resident 9. Resident 8 began to remove the food from the bowl with her fingers and place the food in her mouth. Resident 8 was observed to be eat 3 bites of Resident 9's salad. Resident 8 did not drink between bites of food and staff was not present while Resident 8 ate the salad. Resident 3 yelled out Resident 8 took Resident 9's salad. CNA L walked over to Resident 8's bedside table and talked to Resident 8. CNA L asked Resident 8 if she could have the salad. Resident 8 remained eating the salad with CNA L standing next to Resident 8. CNA L did not direct Resident 8 to alternate liquids with solids or remove the salad from Resident. CNA L turned her back to Resident 8 and walked across the room to the food cart. Resident 8 was left alone at the table eating the salad, not currently a food on Resident 8's diet restriction. Surveyor observed Resident 8 eat two more fingers full of salad while CNA L had her back to Resident 8. CNA L removed a fork from the food cart and returned to Resident 8. Resident 8 took 1 more finger full of salad as CNA L walked back to Resident 8. CNA L offered Resident 8 a drink of fluid. CNA L removed the salad bowl from Resident 8. CNA L gave Resident 8 the cup of fluid. CNA L asked Resident 8 is she was still hungry. Resident 8 stated yes. CNA L removed the salad from Resident 8's reach. Resident 8 remained sitting sideways to the dining table within reach of Resident 9. On 9/19/12, at 4:10 PM Surveyor spoke with Director of Nursing (DON) B regarding Resident 8's supervision during meals. DON B stated she would expect CNA L to remove the salad from Resident 8 by offering Resident 8 another food alternative. DON B also stated CNA L should have remained next to Resident 8 while Resident 8 ate the salad and not turned her back on Resident 8 while eating a food which was not on her diet. DON B stated she would expect the CNA assisting Resident 8 to remain with Resident 8 as long as there if food on the table within Resident 8's reach. DON B also stated she would expect Resident 8 to be removed from the table when staff is not present after Resident 8 was finished with her meal. Resident 8's physician order [REDACTED]. Resident 8 was not directed to alternate liquids and solids while eating the salad. Resident 8's diet was not followed. Example 3 Resident 1 has [DIAGNOSES REDACTED]. Resident 1's physician orders [REDACTED]." A Physician order [REDACTED]." Physician's Therapy Order note dated 8/9/12 indicates that Resident 1 was discharged from speech therapy and was to have nectar thick liquids but could have thin liquid milk with his cereal at breakfast. The facility completed "Injury/Incident Investigation Report" dated 8/19/12. This report indicates the Resident 1 was choking at supper (6:10 PM) and was put on the floor to perform the Heimlich maneuver. This investigation states the following: "Discoverer: (Certified Nursing Assistant (CNA) C)...Type of Injury; Broken Bone ? Explain: possible fx (fracture) sent to ER for eval; Location of injury: leg; Location: unit dayroom...Injury/Incident Cause: choking; Actions taken as a Result of this incident: Review for individual considerations specific to resident; Abuse, neglect or misappropriation: no; Immediate Intervention: physical assessment; other: Resp (respiratory) flow started p (after) event of Heimlich. Measures Implemented/Plan of Action: Sent to Mercy ER for eval Rt (right) leg." This investigation does not indicate the cause of Resident 1's choking episode. The facility did not investigate to determine if Resident 1 was served the correct diet. Progress Notes, dated 8/19/12 state, "This writer was called to respond to east dining room situation. When arrived, resident was sitting on floor c (with) back facing me. LPN (Licensed Practical Nurse E) stated resident is choking & she was unable to get arms around resident for Heimlich maneuver. Stated she recognized sx (symptoms) of airway obstruction so she and CNAs put resident on the floor for better positioning for Heimlich. After 2nd Heimlich thrust small amt (amount) ground beef coughed out. Is able now to breath/air clear ..." CNA C wrote a statement as follows: "8/19/12, It was supper time, pt (patient) was bite cheese hamburger then he was coughing and choking. I told the next table LPN, 'He is choking." LPN E wrote the following statement in "Progress Notes": Res was @ DR (dining room) table eating being fed by CNA. CNA called to this writer d/t (due to) Res choking. Two CNAs et this writer lowered Res to the floor using the EZ lift sling. Once Res was on floor Res was helped into sitting position et the Heimlich maneuver started. Asked CNA to call RN-RN took over doing Heimlich maneuver which resulted in dislodging of sm amt of food/ Res breathing on his own. Res EZ lifted into his w/c (wheelchair). A 'pop' sound was noted during Heimlich. Res c/o (complained of) leg pain et was assessed by RN when back in room." 8/20/12 Progress Notes state, "Writer called Mercy ER & res was admitted c a Rt hip fracture." Surveyor reviewed Resident 1's supper meal card for 8/19/12. This meal card states, "Cheeseburger...Fr Fries, Juice-Cran-Nectar." Hospital Notes from this incident state the following:"...Pre-op Diagnosis: [REDACTED]. Rock Haven Readmission orders Check all that apply: PT (physical therapy) eval and treat (checked), OT (occupational therapy) eval and treat (checked), ST (speech therapy) eval and treat (checked)-per (hospital staff) suggest ST 2-3x (times)/week for 30-45 minutes X 4 weeks to improve swallow function..." These orders are signed by a physician. The facility did not have evidence that follow up was done with Speech Therapy, as directed in the signed physician orders. Physician order [REDACTED]. Nectar thickened only." Physician order [REDACTED]. Only nectar thickened." Resident 1's CNA care plan, reviewed on 9/19/12 states: "...Diet: NAS, NCS, ADA, Nectar Thick Liquids. Can have thin liquid milk with his cereal..." The facility did not update Resident 1's plan of care to in response to Physician orders [REDACTED]. Surveyor spoke with CNA C on 9/19/12 at 2:15 PM. Surveyor asked CNA C about the night when Resident 1 choked. CNA C stated that she was feeding Resident 1, it was the start of the meal and that Resident 1 was eating a cheeseburger. CNA C stated that she gave Resident 1 a drink first. CNA C stated that Resident 1 took a first bite of the burger and it was okay, but the second bite he took, he started to cough. CNA C stated that at this time she alerted the LPN who was at the next table. CNA C stated that the LPN tried to do the Heimlich behind the wheelchair and she said that they were going to have to place the resident on the floor. CNA C stated that there were four people at each corner of the hoyer sling, including CNA C, CNA G, CNA H and LPN E. CNA C stated that the four of them did not drop Resident 1 at all. CNA C stated that RN F an RN D were there as well and that RN D was the one who got the food out. CNA C stated that she had no clue at the moment that there was a fracture and that she has no idea how the fracture happened. Surveyor asked CNA C if the milk that she was feeding to Resident 1 was thickened. CNA C stated that the milk was thickened and that this was the only drink on the tray. Surveyor spoke with Director of Nursing (DON) B on 9/19/12 at 3:00 PM. Surveyor asked DON B if she investigated whether the care plan was followed for Resident 1 and if the correct diet was served to Resident 1. DON B stated that the week he fell , the following week she was on vacation and that the nurse had stated that everything was followed correctly and all looked good. Surveyor asked DON B if anyone looked into if Resident 1 was served the correct meal and if statements were obtained from the other staff involved in the incident. DON B stated that she did not write anything down and she thought it was all taken care of. Surveyor asked if interventions such as the physician order [REDACTED]. DON B stated that interventions should be added to the care plan. Surveyor asked for follow up related to the speech therapy orders that were ordered on [DATE] as there was no documentation in Resident 1's record that would indicate that this was followed up upon. DON B stated that she would try to find more information. During the facility exit on 9/19/12 at 5:15 PM, DON B stated that the facility had found some speech therapy documentation. Surveyor requested that this information be provided to Surveyor . On 9/20/12, via fax, the facility provided a therapy screen report for Resident 1 dated 8/27/12. This report indicates that Resident 1 was screened for occupational therapy and physical therapy, but not speech therapy. Resident 1 was not provided the speech therapy as ordered by his physician. No additional information was provided.

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 1 out of 8 residents reviewed (Resident 3). Resident 3 had [MEDICAL CONDITION] activity on 7/13/11 and Resident 3 began to have acute pain in her lower abdomen and right hip noted on 7/14/11. The facility placed Resident 3's acute change of condition on the MD board on 7/15/11 in the evening. Resident 3 continued to complain of a significant amount of pain with movement from 7/14/11 to 7/18/11. Resident 3's MD was not consulted over the weekend and Resident 3 was seen on 7/18/11 and received x-rays with the results being bilateral pelvic fractures and L1 and L3 fractures. Resident 3's was placed on bed rest at that time and scheduled pain medications were increased. The facility did not consult with Resident 3's physician from 7/14 to 7/18/11 after she had an acute change of condition on 7/14/11, which caused ongoing pain and prevented earlier detection and treatment. Findings as follows: The facility's policy and procedure for "Physician and Family Notification Guidelines" last revised on 3/31/10 includes the following: Nurse Action: Call MD immediately (if immediately unavailable by phone page to your number with the digits "911" afterward to indicate immediate response is required. Situations: Incident with injury requiring sutures, suspected fractures...Sudden severe and unremitting pain (never slacking, persistent). Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 3's MDS (minimum data set) dated 5/12/11 indicates that she scored a "1" on her brief interview for mental status assessment. Resident 3 is not her own legal decision maker. The MDS also indicates that Resident 3 rarely has pain and when she does it is mild in intensity. Resident 3's physician's orders [REDACTED]. Resident 3's nursing notes dated 7/13/11 indicate at 7:30 AM Resident 3 was sitting in her wheelchair and she had what appeared to be a full body [MEDICAL CONDITION]. Arm was shaking, she stiffened and then had snore/snort respirations [MEDICATION NAME] approximately 4-5 minutes. Resident 3 was taken to her bed and the MD was coming on rounds and seen patient. On 7/13/11 a nursing note, no specific time noted other than "PM", Resident 3 was very irritable and refused medications, face was flushed and warm refused vital signs, refused Tylenol for fever or discomfort, and slapped at nurses. The nurse documented that Resident 3 was placed in MD (medical doctor) book for eval, orders, and follow up. The entry written on 7/13/11 is initialed as MD responded but there is no documentation as to what was done or any follow up. A nursing note on 7/14/11 at 4:00 AM states, "Pt. C/O (complaints of) pain in bilateral legs during repositioning by CNA's (Certified Nursing Assistant) at about 3:50 AM pt took about 1/2 dose of Tylenol and refused to take any more..." A nursing note on 7/14/11 at 9:30 AM states, "C/O lower extremity pain at this time. Supervisor staff checked for Fentynal Patch not found..." Patch was replaced. Nursing did not consult with the physician on 7/14/11 concerning the resident's increased pain in the lower extremities. A nursing note on 7/15/11 at 1:30 PM states that CNA's report increased c/o of lower abdominal pain during transfer with EZ stand since episode of [MEDICAL CONDITION] to monitor and document changes. A Nursing note on 7/15/11 at 5:40 PM states, "...denies pain until legs are moved then has sudden acute pain over lower abdomen. Discussed with day nurse. Question if pain is caused by sore muscles from [MEDICAL CONDITION] activity 2 days ago or if related to episode of vaginal bleeding that she had in the past. Over the past 6 months has had many complaints of back pain. Tylenol #3 was ordered but frequently refused the med. [MEDICATION NAME] was ordered to help provide consistent pain control...On MD book to eval for need to increase of [MEDICATION NAME] (continues to have Tyl #3 for breakthrough pain by is often resistive to meds..." A physician notification form (an orange form that is used to communicate with the MD) dated 7/15/11 states, "Resident (1) is showing acute lower abdominal pain with movement of lower extremities, (2) ? increase [MEDICATION NAME] (has one already) med for breakthrough pain...(4) Also acute pain to left hip with gentle palpation ? Pathological fracture..." This information was placed on the book and there is no evidence that a phone call was made to Resident 3's MD to report the acute change of condition of increased pain in her hip and lower abdomen. A nursing note on 7/15/11 at 9:15 PM states, "Resident was helped to get up for supper and staff reported resident was in a lot of pain and crying. Resident was given Tylenol #3 at 4:40 PM for breakthrough pain. Resident states after 1 hour that she is more comfortable...Staff also reported to writer that resident stated to her 'I'm dying.' Statement made when staff was putting resident to bed." A nursing note on 7/16/11 at 4:30 AM states, "S-'Oh don't do that', O-moaning, swinging and hitting CNA's during brief change and repositioning, A-appears to be in a lot of pain, P-RN notified." This entry was written by a CNA. There is no evidence that an RN assessed Resident 3 at the time of the concern of increased pain or called Resident 3's physician for continued acute pain. A nursing note dated 7/16/11 at 6:00 PM states, "Refused vital so far this shift. Would only allow minimal assessment. Reported abdominal pain and when asked to point to area of pain this writer was unable to observe as she would not allow her blanket to be pulled back for observation. When trying to palpate the abdomen, she did not show any signs of acute pain, but as soon as this writer touched her left hip, she reacted as though in acute pain. She would not allow any further assess after that. She has not had any recent falls, so question if perhaps she has suffered a pathological [MEDICAL CONDITION]. Will use EZ lift for transfers instead of EZ stand and have MD eval." There is no evidence that Resident 3's physician was notified of her continued new onset of acute pain or that facility staff were questioning a fracture. A nursing note written 7/17/11 at 4:30 AM states, "S-Oh, Oh, O-Moaning and crying out in pain when right foot was lifted up slightly to put sock on, A-Appeared to be in pain, P-RN Notified." (This entry was written by a CNA.) There is no evidence of any RN assessment or physician notification for Resident 3's continued new onset of acute pain. A nursing note dated 7/17/11 at 12:30 PM indicates that Resident 3 has a bruise on her right elbow, top of forearm, and right outer wrist and RN reported that staff really had to hold on to her during and after her [MEDICAL CONDITION] on the 13th of July. The information was reported to RN. A note at 1:30 PM states that the above information was reported to an RN supervisor. There is no evidence that this information was reported to Resident 3's MD or placed on the MD book to update MD of the bruises or increased pain. A nursing note on 7/17/11 at 6:10 PM states, "...Resident continues to experience a significant amount of pain in her left hip with gently palpation, but does appear to be fairly comfortable when lying still and not being touched. [MEDICATION NAME] remains in place and has Tyl #3 for breakthrough pain. Will continue to monitor." There is no evidence that a physician was called to report Resident 3's continued onset of acute pain. A nursing note dated 7/18/11 at 4:05 AM states, "...Pt c/o of right hip pain when repositioned this shift. Facial grimacing and guarding noted. Pt appeared comfortable after positioning..." A nursing note on 7/18/11 at 1:30 PM states, "Increased c\o pain to pelvis and legs. Evaluated By MD. Pelvic and lumbar x-rays completed. Pelvic fractures bilaterally and fractures to L1 and L3 (lumbar vertebrae). Bed rest has been ordered and increased in pain medications. Fractures may be d/t recent [MEDICAL CONDITION] activity on 7/13/11". Resident 3's [MEDICATION NAME] was increased to 50 mcg and Tylenol #3 was discontinued with [MEDICATION NAME] 5-500 mg 1 every 4 hours as needed for pain was added. A physician's note on the orange MD book states that Resident 3 has dementia with no complicated behaviors, does not tell severity, exam-no findings. Chronic pain management. Increased pain-? etiology, increased pain with right lower extremity movement. The facility identified an acute change of condition related to Resident 3's pain on 7/14/11, and placed Resident 3's condition change on the MD board. Facility nurses even questioned if a fracture could have occurred from [MEDICAL CONDITION] activity on 7/13/11 but did not update Resident 3's MD until the 18th when she was diagnosed with [REDACTED]. On 10/25/11 at 1:30 PM Surveyor interviewed ADON C regarding pain assessments. ADON C stated that they were done quarterly and when a resident has an acute episode of pain, and also looking at prn medications used and how the resident is currently doing. Resident 3 did not have a pain goal listed. ADON C stated that the nursing staff was monitoring Resident 3 for pain and when the MD came on rounds he looked at Resident 3. ADON C did state that if the staff felt that there was a fracture they should have called the MD right away and not left it on the MD board.

Based on interview and record review the facility did not ensure that each resident received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 resident out of 8 reviewed (Resident 3). Resident 3 had an acute onset of significant pain after what appeared to be [MEDICAL CONDITION] activity on 7/13/11. Resident 3 complained of significant pain on 7/14, 7/15, 7/16, 7/17, and 7/18/11. A facility staff suspected a pathological fracture due to her complaints of lower abdomen and right hip when moved. The facility placed the acute change form of Resident 3's increased pain on the MD book on 7/15/11 (Friday evening). No physician was called to consult with or report the change in pain status until 7/18/11 (Monday) when Resident 3's MD made rounds even though Resident 3 continued to complain of pain. X-rays were done and Resident 3 was found to have bilateral pelvic fractures along with L1 and L3 vertebrae fractures. Resident 3 did not have a comprehensive pain assessment completed when she presented with a significant change of condition. The facilty did not consistantly monitor for effectiveness of PRN pain medications. Findings as follows: The facility's policy and procedure for "Pain Assessment and Management" last revised 1/31/11 includes the following information: ...2. Pain management is defined as the process of alleviating the resident pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals...5. Conduct a comprehensive pain assessment upon admission to the facility at the quarterly review and whenever there is a significant change in condition and when there is onset of new pain or worsening of existing pain. Recognizing pain: observe the resident during rest and movement for physiologic and non verbal signs of pain. ex (groaning crying screaming grimacing frowning irritability guarding rubbing part of body). Assessing Pain: Character of pain, intensity descriptors pattern location and [MEDICAL CONDITION] of pain frequency timing and duration of pain. Discuss pain goals and management and satisfaction with current level of pain. Monitoring and Modifying approaches: Re-assess the resident pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. If pain is not adequately controlled the multidisciplinary team and physician shall reconsider approaches and make adjustments as indicated. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 3's MDS (minimum data set) dated 5/12/11 indicates that she scored a "1" on her brief interview for mental status assessment (BIMS). Resident 3 is not her own legal decision maker. The MDS also indicates that Resident 3 rarely has pain and when she does it is mild in intensity. Resident 3's MDS dated [DATE] indicates that resident still scored a "1" on her BIMS assessment. Resident 3 had pain almost constantly, but was unable to answer intensity. Resident 3's "Pain Assessment Report" dated 8/3/11 indicates Resident 3's pain as moderate and is caused or increases with movement; the pain is described as a sharp ache in her back, bone, hip, and joint. The section for stating pain goal is blank. Resident 3's care plan dated 5/16/11 does not indicate a problem for pain. Under the altered thought process problem on Resident 3's care plan is an approach that states 'when questioned about pain, (Resident 3's name) has denied on several occasions that she never has any pain except for a rare headache or toothache. Staff should be alert for nonverbal s/sx (signs and symptoms) of pain and consider pain as a possible cause if any behavioral changes are noted. Administer PRN [MEDICATION NAME] as indicated, and monitor for effectiveness. Resident 3's physician's orders [REDACTED].) Resident 3's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident 3's medication administrator record from July 1 - July 13 reveals that she has had no PRN pain medication. Resident 3's nursing notes dated 7/13/11 indicate at 7:30 AM Resident 3 was sitting in her wheelchair and she had what appeared to be a full body [MEDICAL CONDITION]. Arm was shaking, she stiffened and then had a snoring/snorting respirations [MEDICATION NAME] approximately 4-5 minutes. Resident 3 was taken to her bed and the MD was coming on rounds and seen patient. MD saw Resident 3 and ordered antiemetic medications for her nausea. On 7/13/11 a nursing note, no specific time noted other than "PM", indicates Resident 3 was very irritable and refused medications, face was flushed and warm refused vital signs, refused Tylenol for fever or discomfort, and slapped at nurses. The nurse documented that Resident 3 was placed in MD (medical doctor) book for eval, orders, and follow up. The entry written on 7/13/11 is initialed as MD responded but there is no documentation as to what was done or any follow up if any. A nursing note on 7/14/11 at 4:00 AM states, "Pt. C/O (complaints of) pain in bilateral legs during repositioning by CNA's (Certified Nursing Assistant)at about 3:50 AM pt took about 1/2 dose of Tylenol and refused to take any more..." A nursing note on 7/14/11 at 9:30 AM states, "C/O lower extremity pain at this time. Supervisor staff checked for Fentynal Patch not found..." Patch was replaced. Resident 3's MAR (medication administration record) indicates that Resident 3 was given Tylenol 650 mg 3 times on the 14th at 3:50 AM, 8:30 AM and 3:50 PM and no documentation if the medication was effective. A nursing note on 7/15/11 at 1:30 PM states that CNA's report increased c/o of lower abdominal pain during transfer with EZ stand since episode of [MEDICAL CONDITION] to monitor and document changes. A Nursing note on 7/15/11 at 5:40 PM states, "...denies pain until legs are moved then has sudden acute pain over lower abdomen. Discussed with day nurse. Question if pain is caused by sore muscles from [MEDICAL CONDITION] activity 2 days ago or if related to episode of vaginal bleeding that she had in the past. Over the past 6 months has had many complaints of back pain. Tylenol #3 was ordered but frequently refused the med. [MEDICATION NAME] was ordered to help provide consistent pain control (was on medication previously)...On MD book to eval for need to increase of [MEDICATION NAME] (continues to have Tyl #3 for breakthrough pain but is often resistive to meds)..." A physician notification form (an orange form in a book that is used to communicate with the MD) dated 7/15/11 states, "Resident (1) is showing acute lower abdominal pain with movement of lower extremities, (2) ? increase [MEDICATION NAME] (has one already) med for breakthrough pain...(4) Also acute pain to left hip with gentle palpation ? Pathological fracture..." This information was placed on the book and there is no evidence that a phone call was made to Resident 3's MD to report the acute change of condition of increased pain in her hip and lower abdomen. A nursing note on 7/15/11 at 9:15 PM states, "Resident was helped to get up for supper and staff reported resident was in a lot of pain and crying. Resident was given Tylenol #3 at 4:40 PM for breakthrough pain. Resident states after 1 hour that she is more comfortable...Staff also reported to writer that resident stated to her 'I'm dying.' Statement made when staff was putting resident to bed." Resident 3's MAR for July indicates that she received 650 mg Tylenol at 5:45 AM (no effectiveness noted), and 12 midnight, states effective. Resident 3 also received Tylenol # 3 at 4:40 PM which does not state effectiveness of medication. A nursing note on 7/16/11 at 4:30 AM states, "S-'Oh don't do that', O-moaning, swinging and hitting CNA's during brief change and repositioning, A-appears to be in a lot of pain, P-RN notified." This entry was written by a CNA. There is no evidence that an RN assessed Resident 3 at the time of the concern of increased pain or called Resident 3's physician for continued acute pain. A nursing note dated 7/16/11 at 6:00 PM states, "Refused vital so far this shift. Would only allow minimal assessment. Reported abdominal pain and when asked to point to are of pain this writer was unable to observe as she would not allow her blanket to be pulled back for observation. When trying to palpate the abdomen, she did not show any signs of acute pain, but as soon as this writer touched her left hip, she reacted as though in acute pain. She would not allow any further assess after that. She has not had any recent falls, so question if perhaps she has suffered a pathological [MEDICAL CONDITION]. Will use EZ lift for transfers instead of EZ stand and have MD eval." There is no evidence that Resident 3 physician was notified of her continued new onset of acute pain or that facility staff was questioning a fracture. A nursing note written 7/17/11 at 4:30 AM states, "S-Oh, Oh, O-Moaning and crying out in pain when right foot was lifted up slightly to put sock on, A-Appeared to be in pain, P-RN Notified." (This entry was written by a CNA) There is no evidence of any RN assessment or physician notification for Resident 3's continued new onset of acute pain. A nursing note dated 7/17/11 at 12:30 PM indicates that Resident 3 has a bruise on her right elbow, top of forearm, and right outer wrist and RN reported that staff really had to hold on to her during and after her [MEDICAL CONDITION] on the 13th of July. The information was reported to RN. A note at 1:30 PM states that the above information was reported to an RN supervisor. There is no evidence that this information was reported to Resident 3's MD or placed on the MD book to update MD of the bruises or increased pain. A nursing note on 7/17/11 at 6:10 PM states, "...Resident continues to experience a significant amount of pain in her left hip with gently palpation, but does appear to be fairly comfortable when lying still and not being touched. [MEDICATION NAME] remains in place and has Tyl #3 for breakthrough pain. Will continue to monitor." There is no evidence that a Physician was called to report Resident 3's continued onset of acute pain. Resident 3's MAR indicated [REDACTED] A nursing note dated 7/18/11 at 4:05 AM states, "...Pt c/o of right hip pain when repositioned this shift. Facial grimacing and guarding noted. Pt appeared comfortable after positioning..." Resident 3's MAR indicated [REDACTED]. A nursing note on 7/18/11 at 1:30 PM states, "Increased c\o pain to pelvis and legs. Evaluated By MD. Pelvic and lumbar x-rays completed. Pelvic fractures bilaterally and fractures to L1 and L3 (lumbar vertebrae). Bed rest has been ordered and increased in pain medications. Fractures may be d/t recent [MEDICAL CONDITION] activity on 7/13/11". Resident 3's [MEDICATION NAME] was increased to 50 mcg and Tylenol #3 was discontinued with [MEDICATION NAME] 5-500 mg 1 every 4 hours as needed for pain was added. The following are nursing notes regarding Resident 3's pain following consult with Resident 3's MD and change in pain medications: On 7/19/11 from 3-11 PM indicates that Resident 3 is not in pain and is comfortable. On 7/20/11 at 10:00 AM states that Resident 3 had facial grimacing and slight groaning when moved. At 10:30 AM the facility talked to MD regarding quality of life and bed rest, orders changed to get up for meals and evaluate pain before transfers and give PRN [MEDICATION NAME]. At 6:00 PM states Resident 3 admits to pain with movement and states, 'I'm not doing well.' On 7/21/11, NOC, S-"Oh, mamma, mamma, yes" , O-moans and cries out when foot was lifted sl. (slightly) up to put sock on said "yes" when asked if she was in pain but could not tell writer where, A-Appears in pain, P-RN notified, observe and chart. On 7/21/11, at 6:30 AM Resident 3 was crying in pain asked her if she wanted a pain pill and she stated "whatever you think" (unsure how much medication was received as she wiped it out of her mouth with a tissue). 7-3 PM facial grimacing and groaning during transfers. Appears comfortable at rest but uncomfortable when moved. Received [MEDICATION NAME] at 6:30 AM and slightly effective. No documentation from 7/21 PM shift to 7/26 NOC shift. 7/26/11, NOC shift note at 2:00 AM states, "S-Oh, Oh all over", O-Moaning and grabbing at her groin area when brief was being changed, A- Appeared to be in pain and when asked she said "yes" and asked were she said "all over", P- RN notified. At 9:15 PM seems comfortable when lying still but has major increase in pain with any movement. Continue to monitor. On 7/26/11 a note on the MD doctor book states, "Increased pain when repositioning can we increase Fentynal patch? No response to the request to increase Fentynal patch until 7/28/11 when the MD increased the patch to 75 mcg. Resident 3 received 1 [MEDICATION NAME] 5-500 mg tablet 2 times on 7/19, 3 times on 7/20, 2 times on 7/21, 4 times on 7/22, 3 times on 7/23, 3 times on the 24th one time on the 25th, none on the 26th, 2 times on the 27th and 4 times on the 28th. Resident 3 received 27 doses of [MEDICATION NAME] from 7/19/11 to 7/28/11 (9 days). Surveyor asked the facility for a current comprehensive pain assessment for Resident 3. The facility gave Surveyor Section J pain interview for MDS and Pain Assessment report for 2/14/11, 5/11/11, 8/3/11 which coordinated with the quarterly MDS. There was no comprehensive pain assessments completed when Resident 3 had experienced a new onset of pain due to her pelvic fractures and L1, L3 fractures. Resident 3's PRN [MEDICATION NAME] Record/Pain Flow Sheet indicates that Resident 3 had 34 doses of "as needed" pain medications. Out of the 34 PRN pain medications 20 doses do not have any effectiveness, or state slightly effective documented on the pain flow sheet from 4/1/11 to 10/14/11. On 10/25/11 at 1:30 PM Surveyor interviewed ADON C regarding pain assessments. ADON C stated that they were done quarterly and when a resident has an acute episode of pain, and also looking at prn medications used and how the resident is currently doing. Resident 3 did not have a pain goal listed. ADON C stated that the nursing staff was monitoring Resident 3 for pain and when the MD came on rounds he looked at Resident 3. ADON C did state that if the staff felt that there was a fracture they should have called the MD right away and not left it on the MD board. Resident 3 expressed and showed signs of symptoms of increased pain after an apparent [MEDICAL CONDITION]. The facility acknowledged the increased pain calling it significant pain. No physician was called to report this pain and to receive medications/interventions to treat or diagnose the pain. The facility gave pain medications although Resident 3 continued to complain of acute pain.