Every finding on record at Rock River Nursing & Rehab

Based on observations, interviews, and record review, the facility did not ensure that residents at risk for pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 2 (R3 and R13) of 3 residents reviewed for pressure injuries. *R3 was admitted to the facility with a pressure injury to the sacrum. The pressure injury healed on 2/9/26. On 3/2/26, R3's sacrum pressure injury reopened. The facility Wound MD recommended a treatment and the order was not entered into R3's medical record. From 3/3/26 through 3/8/26, R3 did not have a treatment completed to R3's pressure injury. R3's pressure injury healed on 4/2/26. *R13 is at risk for pressure injuries. R13 was observed multiple times without R13's heels being offloaded per R13's care plan intervention. Findings include: The facility's policy titled pressure injury prevention and management, dated 12/31/25, documents the following: Definitions: Pressure ulcer/injury refers to localized damage to the skin and/or underlying soft tissue usually over in bony prominence or related to a medical or other device. Avoidable means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. Unavoidable means that the resident developed a pressure ulcer/injury even though the facility had evaluated the resident's clinical condition and risk factors; defined and implemented interventions that are consistent with resident needs, goals, and professional standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate. Interventions for prevention and to promote healing: After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. Interventions will be based on specific factors identified in the risk assessment, skin assessments, and any pressure injury assessment. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. The sick or routine care and survey actions can include, but are not limited to: Redistribute pressure (such as repositioning, protecting and/or off floating heels, etc.); Minimize exposure to moisture and keep skin clean, especially of fecal contamination; Provide appropriate, pressure-redistributing, support surfaces; Provide non-irritating surfaces; and Maintain or improve nutrition and hydration status, where feasible. Compliance with interventions will be documented in the weekly summary charting. Interventions on a resident's care plan will be modified as needed. Considerations for needed modifications include: Changes in resident's degree of risk for developing a pressure injury. New onset or recurrent pressure injury development. Lack of progression towards healing. Resident noncompliance. Changes in the resident's goals and preferences, such as at end of life or in accordance with his/her rights. 1.) R3 was admitted to the facility on [DATE] with diagnosis that include stage 4 pressure ulcer to sacrum, Left above knee amputation, Right below knee amputation, Quadriplegia incomplete (A cervical spinal cord injury where the spinal cord is not completely severed, allowing some signals to pass below the injury site), and Neuromuscular dysfunction of bladder (occurs when nerve damage from injury interrupts signals between the brain, spinal cord and bladder muscles, causing loss of control, retention or overactive bladder symptoms). R3's Modification to the Quarterly Minimum Data Set assessment dated [DATE], documents R3 is cognitively intact. R3 is dependent on staff for toileting hygiene, bathing and transfers. R3 requires partial/moderate assistance for bed mobility. R3 has an indwelling catheter and is occasionally incontinent of stool. R3 is at risk for pressure injuries and has an unhealed stage 4 pressure injury that was present on admission. R3's Braden Scale for predicting pressure ulcer risk evaluation, dated 12/15/25, documents a score of 14, indicating R3 is at moderate risk for developing pressure injuries. R3's Pressure Ulcer care plan initiated 3/28/21 documents the following pertinent interventions: Air mattress: setting at 4. Often sets mattress higher or on static mode for comfort. Encourage to keep on alternating. At times, resident refuses wound care appointments, wound care treatments and recommendations, pressure relief interventions. Continue to encourage resident to follow plan of care for prevention and treatment of skin breakdown. Conduct weekly skin inspection. Encourage to allow treatments. Encourage turning and repositioning every 2-3 hours. Provide supplements (medication and dietary) as ordered. Weekly wound assessments. Treatments as ordered. R3's MD order with a start date of 1/12/26 documents: Wound Care Sacrum: Apply Zinc cream with cares every shift for Impaired skin. R3's Interdisciplinary Team (IDT) note dated 2/10/26 at 1:14 PM, documents, in part: Stage 4 pressure injury to sacrum has healed. R3's wound MD note dated 3/2/26 documents, in part: Sacrum pressure ulcer stage 4. Measurement 1.41 centimeters (cm) x 0.42 cm x 0.8 cm. Fully granulated attached edges. Orders: Protect periwound with Skin Prep. Cleanse wound with saline. Apply Alginate to wound bed. Cover wound with superabsorbent dressing. Change daily and [as needed]. Surveyor noted R3's sacrum pressure re-opened. Surveyor reviewed R3's MD orders. Surveyor noted that the previous order of Zinc every shift was discontinued on 3/2/26. Surveyor noted facility staff did not enter the Wound MD's order for R3's sacral wound treatment. R3's Stage 4 pressure injury to sacrum care plan initiated 3/2/26 documents, in part: area healed, re-opened on 3/2/26. On 3/2/26 Wound MD discussed risk vs benefits with resident regarding turning and repositioning, air mattress settings, and not staying up in w/c for long periods of time. Pertinent Intervention included treatments as ordered. Surveyor noted from 3/3 through 3/8/26, R3 did not have a documented treatment on R3's sacrum pressure injury. R3's Wound MD note dated 3/9/26, documents, in part: Sacrum pressure ulcer stage 4. Measurement 0.84 x 0.27 x 0.2cm. Fully granulated attached edges. Orders: cleanse wound with saline. Zinc barrier cream [Three times a day and as needed]. R3's MD order with a start date of 3/9/26 documents: Wound care: Cleanse sacrum withwound cleanser, pat dry and apply zinc barrier cream every shift [and as needed] for wound care. Surveyor noted R3's wound measurements decreased and recommended wound treatment order was placed. R3's wound was treated as ordered. On 4/2/26, R3's sacrum wound healed and treatment to the area remain the same as of 5/6/26. On 5/4/26 at 10:42 AM, Surveyor observed R3 in bed on left side with the air mattress on and functioning. R3 informed Surveyor that sacrum wound had healed last month. R3 stated that R3 decides when R3's wounds get treated and when R3 will reposition. On 5/5/26 at 9:03 AM, Surveyor observed R3 in bed on R3's back with the air mattress on and functioning. On 5/6/26 at 9:54 AM, Surveyor observed R3 in bed on R3's right side with the air mattress on and functioning. Surveyor asked if Surveyor could observe wound care being completed. R3's voice was raised. R3 asked Surveyor to leave. On 5/6/26 at 1:14 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C. Surveyor asked how wound rounds work. ADON- C stated that wound rounds are completed every Monday. The facility wound MD, Director of Nursing (DON)-B and ADON-C will go to each resident with a wound and complete the assessment and treatment. When the wound MD makes new treatment recommendations, either DON-B or ADON-C will put the new orders into the medical record. Surveyor asked ADON-C about R3's sacrum wound. ADON-C stated that it healed and did reopen in March, but it is healed again. ADON-C indicated that the sacrum wound has opened and closed in the past. ADON-C stated that it depends on how compliant R3 is with all of R3's pressure relieving interventions. ADON-C stated that the wound MD talks with R3 on a weekly basis about R3's compliance. ADON-C stated in the end, R3 decides what R3 is going to let us do. Surveyor informed ADON-C of the concern that when R3's sacral wound reopened on 3/2/26 the Wound MD's recommended treatment was not implemented by the facility and R3 went from 3/3/26 to 3/8/26 without a treatment being completed. ADON-C acknowledged the concern. On 5/6/26 at 1:31 PM, Surveyor interviewed DON-B. Surveyor asked if R3 had a treatment in place for R3's sacral wound from 3/3/26 through 3/8/26. DON-B looked in R3's Electronic Medical Record (EMR). DON-B indicated that DON-B did not see a treatment order for that period in R3's EMR. On 5/6/26 at 3:08 PM, Surveyor informed Nursing Home Administrator (NHA)-A and DON-B of the concern that when R3's sacral pressure injury reopened on 3/2/26, the wound MD treatment orders were not placed in R3's EMR and R3 went 6 days without a treatment. No further information was provided. 2.) R13's diagnoses include diabetes mellitus (high blood sugar), atrial fibrillation (irregular and rapid heartbeat), congestive heart failure (heart doesn't pump enough blood to meet the body's needs), and vascular dementia (type of cognitive decline caused by damage to the blood vessels in the brain). R13's physician order dated 5/17/24 documents Heel boots to Bilateral foot at all times while in bed. If refuses, float heels with pillows. R13's at risk for skin impairment care plan initiated 12/19/24 documents the following interventions: *Complete Braden Scale per Living Center Policy. Initiated 12/19/24. *Conduct weekly skin inspection. Initiated 12/19/24. *Encourage use of heel boots, if declines use pillows if declines both, reapproach at a later time. Don't over ask resident becomes behavioral (yelling, etc.). Initiated 12/19/24 & revised 6/2/25. *Nutritional and hydration support. Initiated 12/19/24. *Provide pressure reducing wheelchair cushion. Initiated 12/19/24. *Provide thorough skin care after incontinent episodes and apply barrier cream. Initiated 12/19/24. *Treatments as ordered. Initiated 12/19/24. *Encourage repositioning every 2-3 hours. Initiated 6/16/25. *Different brands may run smaller. Ensure brief fits correctly. Initiated 7/15/25 & revised 10/27/25. R13's pressure injury CAA (care area assessment) dated 1/23/26 under analysis of findings for nature of problem documents no areas. Under care plan decision for describe impact of this problem/need on the resident and your rationale for care plan decision documents pressure reducing devices in place. R13's Braden assessment dated [DATE] has a score of 13 which indicates moderate risk for pressure injury development. R13's quarterly MDS (minimum data set) with an assessment reference date of 4/24/26 has a BIMS (brief interview mental status) score of 3 which indicates severe cognitive impairment. R13 is assessed as having only verbal behavior. R13 requires set up for eating and is assessed as being dependent on toileting hygiene, roll left and right, and chair/bed to chair transfer. R13 is always incontinent of urine and frequently incontinent of bowel. R13 is at risk for pressure injuries and is assessed as not having any pressure injuries. On 5/4/26, at 9:34 a.m., Surveyor observed R13 sitting in a wheelchair in R13's room. Surveyor observed there is a pressure-relieving boot on R13's left foot and a pillow under R13's lower right leg with R13's right heel resting directly on the pillow. R13's right heel is not being offloaded. On 5/4/26, at 1:33 p.m., Surveyor observed R13 sitting in a wheelchair alongside R13's bed talking to herself. Surveyor observed that R13 has a pressure-relieving boot on the left foot and the right heel is resting directly on a pillow. On 5/5/26, at 7:45 a.m., Surveyor observed R13 in bed on her back, with the head of the bed elevated and her eyes closed. Surveyor observed R13's heels are resting directly on the mattress and are not being offloaded. On 5/5/26, at 9:08 a.m., Surveyor observed R13 continues to be in bed on her back. Surveyor observed R13's heels continue not to be offloaded. Surveyor observed that the pressure relieving boot is on the seat of R13's wheelchair. On 5/5/26, at 10:05 a.m., Surveyor observed R13 continues to be in bed on her back with her eyes closed and the head of the bed up. R13's heels continue to be resting directly on the mattress and R13's heels are not being offloaded. On 5/5/26, at 10:55 a.m., Surveyor observed R13 continues to be in bed on the right side. R13's heels are not being offloaded and are resting directly on the mattress. Surveyor observed R13's pressure relieving boot continues to be in the wheelchair. On 5/5/26, at 1:06 p.m., Surveyor observed R13 continues to be in bed on the right side with her eyes closed. Surveyor observed that R13's heels continue to be resting on the mattress and are not being offloaded. On 5/5/26, at 3:54 p.m., Surveyor observed R13 in bed on her back with the head of the bed elevated. Surveyor observed that R13's heels continue to be resting directly on the mattress and are not being offloaded. On 5/6/26, at 7:12 a.m., Surveyor observed R13 sitting in a personal type of recliner with her legs extended. On 5/6/26, at 8:51 a.m., Surveyor interviewed Certified Nursing Assistant (CNA)-N regarding R13. Surveyor asked CNA-N what she has to do for R13. CNA-N explained they have to do everything for R13, she is totally dependent and is very behavioral. CNA-N explained sometimes she thinks someone is in her room or her husband is outside and starts hollering. Surveyor asked CNA-N if R13 wears pressure relieving boots. CNA-N replied yes for her heels explaining sometimes she will slide them off and won't put them back on. Surveyor asked CNA-N what they do if R13 refuses the boots. CNA-N informed Surveyor they should float R13's heels. Surveyor asked CNA-N if R13 refuses to wear pressure-relieving boots or have her heels offloaded, do they document this. CNA-N informed Surveyor they document refusals in her chart. Surveyor reviewed R13's medical record and did not note any evidence that R13 refused to wear the pressure relieving boots or have her heels being offloaded on 5/5/26. On 5/6/26, at 12:21 p.m., Surveyor asked Assistant Director of Nursing (ADON)-C if R13's heels should be offloaded. ADON-C replied yes. Surveyor informed ADON-C of the observations on 5/5/26 of R13 being in bed all day while Surveyor was in the building and the observations of R13 not wearing the pressure relieving boots or having R13's offloaded. On 5/6/26, at 3:08 p.m., Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the observations of R13's heels not being offloaded. No additional information was provided to Surveyor as to why R13's heels were not being offloaded.

Based on observation, interview, and record review the facility did not ensure 1 (R21) of 4 residents with limited range of motion receive appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.R21 is assessed as having functional limitations in range of motion for bilateral lower extremities. The facility has not implemented any interventions to prevent decline in R21's range of motion.Findings include: The facility's policy titled, Prevention in Range of Motion and dated 12/31/25 under Policy Explanation and Compliance Guidelines documents 1. The facility in collaboration with the medical director, director of nursing and as appropriate physical/occupational consultant shall establish and utilize a systematic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventative care.3. Appropriate Care Planning a. Based on the comprehensive assessment, the facility will provide interventions, exercises and/or therapy to maintain or improve range of motion. B. The facility will provide treatment and care in accordance with professional standards of practice. This includes but is not limited to: i. Appropriate services (specialized rehabilitation, restorative, maintenance). ii. Appropriate equipment (braces or splints). Iii. Assistance as needed (active assisted, passive, supervision). c. Care plan interventions will be developed and delivered through the facility's restorative program, or through specialized rehabilitative services as ordered by the attending practitioner. d. Interventions will be documented on the resident's person-centered care plan. Documentation should include but not limited to: i. Type of treatments; ii. Frequency and duration of treatments; iii. Measurable objectives; iv. Resident goals. e. A nurse with responsibility for the resident will monitor for consistent implementation of the care plan interventions. Refusals of care or problems associated with range of motion exercises will be documented in the medical record. f. Modifications to the plan of care will be made as needed. g. The resident/resident's representative will be included in the development of the restorative/rehabilitation care plan and provided the risks and benefits of the treatment.R21's diagnoses include hypertension (high blood pressure), diabetes mellitus (high blood sugar), and muscle weakness.Surveyor reviewed R21's care plans and noted the following care plans:*Physical functioning deficit. Initiated 7/10/22.*At risk of altered skin integrity and pressure injuries. Initiated 7/10/22.*Needs pain management and monitoring. Initiated 7/10/22.*Alteration in blood glucose. Initiated 7/10/22.*At risk for malnutrition. Initiated 7/12/22.*At risk for sleep pattern disturbance. Initiated 8/12/22.*Sometimes have difficulty starting and staying involved in recreational activities. Initiated 10/18/22.*My plan is to reside at [facility's initials] long term. Initiated 12/6/22.*Resident requires a Level II (2) screening. Initiated 1/26/23.*Resident presents with the potential for drug related complications associated with use of psychotropic medications. Initiated 1/26/23.*Resident is anticipated to reside at this facility for LTC (long term care) to achieve & maintain his safest & highest level of functioning. Initiated 2/3/23.*I sometimes have behaviors which include refusing cares. Initiated 2/3/23.*Resident presents with impairments in his cognitive functioning. Initiated 2/3/23.*Resident was referred to Adult Protective Services (APS). Initiated 9/22/23.*Impaired cardiovascular status. Initiated 4/17/24.*Patient has an advanced directive. Initiated 4/24/24.*At risk for infection. Initiated 5/29/25.*Alteration in Hydration. Initiated 1/17/26.*Altered skin integrity non pressure. Initiated 3/13/26.*At risk for dental problems. Initiated 4/2/26.*Personalized care. Initiated 4/23/23.*At risk for elopement. Initiated 8/6/24.*At risk for falls. Initiated 7/10/22.Surveyor noted the facility did not implement a care plan or develop any interventions to prevent a decline in R21's range of motion for R21's bilateral lower extremities.R21's Functional Abilities and Goals assessment dated [DATE] under functional limitations range of motion for B. Lower extremity (hip, knee, ankle, foot) is checked for impairments on both sides.R21's significant change MDS (minimum data set) with an assessment reference date of 3/10/26 for functional limitation in range of motion assesses R21 as having lower extremities (hip, knee, ankle, foot) impairment on both sides for lower extremities.On 5/4/26, at 1:30 p.m., Surveyor observed R21 propelling himself by moving his feet in a high back wheelchair down the hallway.On 5/5/26, at 10:02 a.m., Surveyor observed R21 sitting in a high back wheelchair in the hall.On 5/5/26, at 12:34 p.m., Surveyor spoke with Registered Nurse/Minimum Data Set (RN/MDS) Coordinator-O on the telephone. Surveyor asked the process to complete a resident's MDS. RN/MDS-O explained section A is completed by the business office, she completes section B, sections C, D, & E are completed by Social Services, section F is completed by Activities, and she completes section GG. Surveyor asked RN/MDS Coordinator-O how she determined R21 has functional limitations range of motion for lower extremities impairments on both sides. RN/MDS Coordinator-O informed Surveyor she looked at the functional assessment dated [DATE] which documented R21 has range of motion limitation on lower extremities both sides and was completed by the Assistant Director of Nursing. Surveyor inquired who is responsible for implementing a care plan to address R21's bilateral limitations for his lower extremities. RN/MDS Coordinator-O replied for us it's always been the therapist; explaining this is her understanding.On 5/6/26, at 7:59 a.m., Surveyor asked Physical Therapy Assistant (PTA)-Q if therapy is involved when a resident is identified as having limitations in range of motion in their lower extremities. PTA-Q informed Surveyor if they receive a screen from the MD (medical doctor) they will do an evaluation and they complete quarterly screens for falls and general mobility if their transfer status has changed. Surveyor asked PTA-Q how Surveyor would know what interventions have been implemented to prevent a resident's range of motion from declining. PTA-Q explained he doesn't know as the director of rehab is not here but believes this is discussed in the morning meeting.On 5/6/26, at 8:58 a.m., Surveyor interviewed Certified Nursing Assistant (CNA)-N regarding R21. CNA-N informed Surveyor R21 can be difficult, and you have to tiptoe around R21 as he gets mad, it's often his way or no way. Surveyor asked CNA-N if she does any range of motion with R21. CNA-N informed Surveyor when they get R21 dressed they lift his legs. Surveyor asked if there are any specific exercises they do with R21. CNA-N replied no.On 5/6/26, at 12:15 p.m., Surveyor asked Assistant Director of Nursing (ADON)-C how interventions are determined for a resident who has limitations in their range of motion. ADON-C explained they meet as an IDT (interdisciplinary team) with nursing, therapy, social worker, and if they need an order from the MD (medical doctor) they would update the resident or their guardian. Surveyor informed ADON-C R21 is assessed as having limitations in his range of motion for bilateral lower extremities. Surveyor informed ADON-C Surveyor was unable to locate any interventions or a care plan to prevent a further decline in R21's range of motion.

Based on observation, interview, and record review the facility did not ensure 2 (R21 & R7) of 2 residents environment remained free of potential accident hazards.R21 and R7 were observed with an elopement device attached to the metal portion of their wheelchair. The facility was purchasing the incorrect device to be attached to the wheelchair and the device was not two inches away from the metal portion.Findings include:The facility's policy titled, Resident alarms, dated 12/31/25, under policy documents It is the policy of this facility to utilize resident alarms in limited circumstances, in accordance with the resident's needs, goals, and preferences so the resident will be able to attain or maintain his or her highest practicable level of physical, mental, and psychosocial well-being. Under Policy Explanation and Compliance Guidelines documents 1. Wander/elopement alarms - includes devices such as bracelets, pins/buttons worn on the resident's clothing, sensors in shoes, or building/unit exit sensors worn/attached to the resident that alert the staff when the resident nears or exits an area or building. This includes devices that are attached to the resident's assistive device (e.g., walker, wheelchair, cane) or other belongings. 1.) R21's diagnoses include hypertension (high blood pressure), diabetes mellitus (high blood sugar), and muscle weakness.R21's elopement assessment dated [DATE] has a score of 4. A score value of 1 or higher indicates risk of elopement. Surveyor was unable to locate an elopement assessment after 8/6/24.R21's at risk for elopement care plan initiated 8/6/24 documents the following interventions:*Assess for risk of elopement per living center policy. Initiated 8/6/24.*Educate family/responsible party on talking positively about Living Center Placement. Initiated 8/6/24.*Encourage family to bring in personal possessions. Initiated 8/6/24.*Involve patient in preferred activities. Initiated 8/6/24.*Involve the patient in decision making regarding daily choices. Initiated 8/6/24.*Redirect patients from doors. Initiated 8/6/24.*Take picture of patient upon admission for identification for updating elopement book. Initiated 8/6/24.R21's physician orders dated 9/10/24 document Check wander guard function at a door, Check wander guard function, and wander guard applied d/t (due to) exit seeking. Check placement.On 5/5/26, at 7:43 a.m., Surveyor observed R21 propelling himself in a high back wheelchair down the hall by moving his feet. Surveyor observed on the back of R21's wheelchair on R21's right side there is an elopement device attached to the metal portion by the wheelchair handle.On 5/5/26, at 9:12 a.m., Surveyor observed R21 propelling himself in a high back wheelchair down the hall by moving his feet. Surveyor observed that the elopement device is still attached to the metal portion by the wheelchair handle.On 5/5/26, at 10:59 a.m., Surveyor observed R21 propelling himself in a high back wheelchair in the hallway by moving his feet propelling towards the north nurses station. Surveyor observed that the elopement device is still attached to the metal portion by the wheelchair handle.On 5/5/26, at 1:16 p.m., Surveyor observed R21 sitting in a high back wheelchair in the doorway of R21's room. Surveyor observed that the elopement device is still attached to the metal portion by the wheelchair handle.On 5/5/26, at 3:55 p.m., Surveyor observed R21 sitting in a high back wheelchair in the hallway propelling himself down the hall. Surveyor observed that the elopement device is still attached to the metal portion by the wheelchair handle.On 5/6/26, at 7:16 a.m., Surveyor observed R21 sitting in a high back wheelchair in the doorway of the room. Surveyor observed that the elopement device is still attached to the metal portion by the wheelchair handle.On 5/6/26, at approximately 10:30 a.m., Surveyor reviewed the Accutech LC 1200 manual provided to Surveyor by Nursing Home Administrator (NHA)-A. Surveyor noted under Attaching LT (long term)/SB (slotted back) Tags includes documentation of Note: LT (Long Term) Tags are used for resident care. SB (Slotted Back) Tags are used on small infants and assets. 2. Adjust the band length to the nearest accommodating hole for a comfort fit around the patient's extremity. Note: Once the band is secured it cannot be adjusted. Surveyor noted this manual did not address attaching the elopement device to the metal portion of a wheelchair.On 5/6/26, at 10:57 a.m., Surveyor called Accutech and spoke with their representative. Surveyor inquired if their elopement device (tag) can be attached to the metal portion of a wheelchair. Surveyor was informed there is a specific tag model number 77L016 that can be connected to the wheelchair, and it then needs to be a couple inches away from the metal on the wheelchair. Surveyor was informed that the regular tag 1200 has a gray band and is attached to a person.On 5/6/26, at 11:30 a.m., Surveyor asked Medical Records (MR)-P, who is also responsible for central supplies, what model elopement tag she orders. MR-P informed Surveyor she has not had to order them in a while, but she orders Accutech model LC1200.On 5/6/26, at 11:34 a.m., Surveyor asked Assistant Director of Nursing (ADON)-C how they decide where an elopement device is placed. ADON-C informed Surveyor they place it where it's best for the resident. ADON-C explained they will put it on the wrist if it won't bother the resident or it may be placed on the lower leg or the wheelchair. Surveyor asked ADON-C how they determine where to put the elopement device on the wheelchair. ADON-C informed Surveyor they are placed on, so it doesn't fall off. Surveyor informed ADON-C that the facility has not been ordering the correct elopement device from Accutech to attach to the wheelchair and R21's elopement device is not attached two inches away from the metal portion of the wheelchair.On 5/6/26, at 3:08 p.m., Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the facility does not have the correct elopement device tag to be attached to a resident's wheelchair and R21's elopement device was observed not two inches away from the metal portion of the wheelchair according to manufacturer's recommendations.2.) R7's diagnoses includes schizophrenia (chronic mental disorder that affects how a person thinks, feels and behaves), hypertension (high blood pressure), diabetes mellitus (high blood sugar), paranoid personality disorder (a mental health condition characterized by a pervasive long term pattern of distrust and suspicion of others), and depression (serous mood disorder that causes a persistent feeling of sadness and a loss of interest in activities, interfering with daily life).R7's at risk for elopement care plan initiated 5/23/24 documents interventions of:*Assess for risk of elopement per living center policy. Initiated 5/23/24.*Educate family/responsible party on talking positively about Living Center Placement. Initiated 5/23/24.*Involve the patient in decision making regarding daily choices. Initiated 5/23/24.*Redirect patients from doors. Initiated & revised 5/23/24.*Take picture of patient upon admission for identification for updating elopement book. Initiated 5/23/24.*Check wander guard placement and function. Initiated 10/8/25.*Wander guard on W/c (wheelchair). Initiated 10/8/25 and revised 4/1/26.R7's physician orders dated 11/21/25 documents Check wander guard placement every shift.R7's elopement evaluation dated 1/7/26 has a score of 2. A score of 1 or higher indicates risk for elopement.R7's physician orders dated 1/19/26 documents Check wander guard function every night shift and Check wander guard function at door every evening shift.Surveyor reviewed R7's April 206 & May 2026 TAR (treatment administration record) and noted that facility staff are checking R7's elopement device according to physician orders.R7's elopement assessment dated [DATE] has a score of 0. A score of 1 or higher indicates risk of elopement.R7's nurses note dated 4/16/26 at 0304 (3:04 a.m.) written by Registered Nurse (RN)-G documents Res. (resident) up as usual in w/c propelling self about facility without difficulty skin warm and dry color good. Offering no c/o (complaints of). No s/s (signs/symptoms) hypoglycemia observed or reported.On 5/5/26 at 7:50 a.m., Surveyor observed R7 in bed on the right side covered with bedding. Surveyor observed R7's wheelchair is next to the foot portion of R7's bed. There is an elopement device attached on the bottom metal bar on the left side of R7's wheelchair.On 5/5/26, at 10:06 a.m., Surveyor observed R7 in bed on the left side covered with bedding. R7's wheelchair continues to be near the footboard of R7's bed. The elopement device is still attached on the bottom metal bar on the left side of R7's wheelchair.On 5/5/26, at 1:09 p.m, Surveyor observed R7 ambulating by herself in her room and then sat on the edge of the bed. Surveyor observed the elopement device is still attached on the bottom metal bar on the left side of R7's wheelchair.On 5/5/26, at 1:10 p.m., Surveyor asked RN-G how it is decided where an elopement device is placed. RN-G explained it depends on the person whether to place it on the person or wheelchair. Surveyor asked RN-G why they would place the device on the wheelchair instead of the resident. RN-G explained if the resident takes it off or if they have swelling.On 5/5/26, at 3:56 p.m., Surveyor observed R7 in bed on her right side. Surveyor observed R7's wheelchair is next to the dresser across from R7's bed. The elopement device is still attached on the bottom metal bar on the left side of R7's wheelchair.On 5/6/26, at 7:14 a.m., Surveyor observed R7 in bed on her left side. The elopement device is still attached on the bottom metal bar on the left side of R7's wheelchair.On 5/6/26, at approximately 10:30 a.m., Surveyor reviewed the Accutech LC 1200 manual provided to Surveyor by Nursing Home Administrator (NHA)-A. Surveyor noted under Attaching LT (long term)/SB (slotted back) Tags includes documentation of Note: LT (Long Term) Tags are used for resident care. SB (Slotted Back) Tags are used on small infants and assets. 2. Adjust the band length to the nearest accommodating hole for a comfort fit around the patient's extremity. Note: Once the band is secured it cannot be adjusted. Surveyor noted this manual did not address attaching the elopement device to the metal portion of a wheelchair.On 5/6/26, at 10:57 a.m., Surveyor called Accutech and spoke with their representative. Surveyor inquired if their elopement device (tag) can be attached to the metal portion of a wheelchair. Surveyor was informed there is a specific tag model number 77L016 that can be connected to the wheelchair, and it then needs to be a couple inches away from the metal on the wheelchair. Surveyor was informed that the regular tag 1200 has a gray band and is attached to a person.On 5/6/26, at 11:30 a.m., Surveyor asked Medical Records (MR)-P, who is also responsible for central supplies what model elopement tag she orders. MR-P informed Surveyor she has not had to order them in a while, but she orders Accutech model LC1200.On 5/6/26, at 11:34 a.m., Surveyor asked Assistant Director of Nursing (ADON)-C how they decide where an elopement device is placed. ADON-C informed Surveyor they place it where it's best for the resident. ADON-C explained they will put it on the wrist if it won't bother the resident or it may be placed on the lower leg or the wheelchair. Surveyor asked ADON-C how they determine where to put the elopement device on the wheelchair. ADON-C informed Surveyor they are placed on, so it doesn't fall off. Surveyor informed ADON-C that the facility has not been ordering the correct elopement device from Accutech to attach to the wheelchair and R21's elopement device is not attached two inches away from the metal portion of the wheelchair.On 5/6/26, at 3:08 p.m., Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the facility does not have the correct elopement device tag to be attached to a resident's wheelchair and R21's elopement device was observed not two inches away from the metal portion of the wheelchair according to manufacturer's recommendations.

Based on interview and record review the facility did not ensure 3 (R13, R7, & R17) of 6 residents were free from unnecessary medications. *R13 and R7 were administered an antibiotic when they did not meet the criteria for treating an urinary tract infection. *R17 is taking an anticoagulant medication and did not have a care plan. Findings include: The facility was unable to provide Surveyor with a policy for treating urinary tract infections. 1.) R13's diagnoses include diabetes mellitus (high blood sugar), atrial fibrillation (irregular and rapid heartbeat), congestive heart failure (heart doesn't pump enough blood to meet the body's needs), and vascular dementia (type of cognitive decline caused by damage to the blood vessels in the brain). R13's quarterly MDS (minimum data set) with an assessment reference date of 4/24/26 has a BIMS (brief interview mental status) score of 3 which indicates severe cognitive impairment. R13 is assessed as being dependent for toileting hygiene. R13 is assessed as always being incontinent of urine. R13's change in condition note dated 4/30/26 documents Under Outcomes of Physical for GU (genitourinary)/urine Status Evaluation have not been completed. Nursing observations, evaluation, and recommendations are: Called to resident's room by CNA (Certified Nursing Assistant) stating that the resident was on the floor. Upon entering resident's room, resident was lying on her stomach with her hips on top of her overhead table bar next to her bed. Mattress on her bed was cocked eyed. Resident stated her head, legs, hip hurt. Resident stated she hit her head on the floor. Bruising noted to her right ear. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Send to ER (emergency room) for evaluation. R13's nurses note dated 4/30/26 at 1606 (4:06 p.m.) written by Registered Nurse (RN)-R documents Resident returned from [hospital name] ER (emergency room) at 1430 (2:30 p.m.). Hospital paperwork reviewed by writer. A UA/C&S (urinalysis/culture and sensitivity) was done at the hospital, but the urine specimen was contaminated, so the C&S was unable to be done. Resident's NP (nurse practitioner) for [Physician name] was informed of the situation by writer and order received for a straight cath for a UA/C&S. Urine obtained by writer and sent to the lab at [Name] Hospital. Surveyor reviewed R13's medical record prior to being sent to the hospital on 4/30/26 and did not see any evidence of R13 having any urinary symptoms which would indicate R13 had a UTI (urinary tract infection). R13's nursing note dated 5/1/26 documents Consulted with NP on UA results, continue with ABX (antibiotic) and wait for sensitivity results. DPOA (durable power of attorney) and resident aware. R13's nurses note dated 5/2/26 documents Resident continues on post fall observation with neuros. Resident alert to person. Staff to anticipate needs. Neuro check at baseline. Resident is with UTI pending delivery of cefpodoxime 250 mg (milligrams) BID (twice daily) x (times) 7 days. Pending sensitivity results. Resident denies pain with urination and urine-soaked brief noted x 2 this noc (night) shift, amber yellow with no foul odor. Afebrile. Fluids encouraged and tolerated well. R13's physician order dated 5/2/26 documents Cefpodoxime Proxetil Oral Tablet 200 MG (Cefpodoxime Proxetil) Give 1 tablet by mouth two times a day for UTI for 7 Days. On 5/6/26, at 12:23 p.m., Surveyor met with Assistant Director of Nursing (ADON)-C who is the facility's infection preventionist to inquire why R13 was placed on an antibiotic for a urinary tract infection when there was no evidence R13 was experiencing any signs or symptoms. Surveyor asked ADON-C if the facility uses McGeer Criteria as their definition of infections. ADON-C replied yes. Surveyor asked ADON-C how R13 met the McGeer criteria. ADON-C showed Surveyor an infection surveillance data collection form for R13 dated 4/30/26 which she completed. ADON-C informed Surveyor they were waiting for a culture and sensitivity, they updated the doctor that the sample was contaminated & the hospital wasn't going to do a culture and sensitivity. ADON-C informed Surveyor the doctor said to do their own sample and continue with the antibiotic. Surveyor informed ADON-C there isn't any evidence the facility informed the doctor R13 didn't meet their definition of infection. ADON-C informed Surveyor she checked in absence of fever or leukocytosis then 2 or more of the following suprapubic pain, gross hematuria, new or marked increase in incontinence, new or marked increase in urgency, new or marked increase in frequency. ADON-C informed Surveyor that when the nurse sent R13 out she had pain. Surveyor asked ADON-C if R13's pain could be from the fall. ADON-C informed Surveyor she couldn't get generalized pain but R13 is incontinent. Surveyor informed ADON-C R13 had been incontinent and there is no evidence prior to R13 being sent to the ER she had any urinary symptoms which would indicate an UTI. Surveyor asked ADON-C if she could show Surveyor how R13 met the McGeer criteria. No additional information was provided to Surveyor on how R13 met the facility's definition of infection in order to be treated with an antibiotic. 2.) R7's diagnoses includes schizophrenia (chronic mental disorder that affects how a person thinks, feels and behaves), hypertension (high blood pressure), diabetes mellitus (high blood sugar), paranoid personality disorder (a mental health condition characterized by a pervasive long term pattern of distrust and suspicion of others), and depression (serious mood disorder that causes a persistent feeling of sadness and a loss of interest in activities, interfering with daily life). R7's change in condition note dated 4/7/26 documents Under Outcomes of Physical for GU (genitourinary)/urine Status Evaluation have not been completed. Nursing observations, evaluation, and recommendations are: Resident hypoglycemic with BS (blood sugar) of 49. Initially unresponsive but started to respond following administration of Glucagon. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Send resident to [Name] hospital ER (emergency room) for evaluation and treatment. Surveyor reviewed R7's medical record prior to being sent to the hospital on 4/7/26 and did not see any evidence of R7 having any urinary symptoms which would indicate R7 had a UTI (urinary tract infection). R7's nurses note dated 4/8/2026 at 02:51 (2:51 a.m.) documents This writer received a call from [hospital name] ER stating that patient will be returning from hospital with a diagnosis of Hypoglycemia, Altered Mental status, and UTI (urinary tract infection). Patient was placed on antibiotic and was given her first dose of Ceftriaxone 1gm (gram) IV (intravenous) at the hospital. Hospital fax script to [Name] Pharmacy. Patient arrived at 0150 (1:50 a.m) by paramedics. Patient is resting comfortable in her bed vital signs are within normal range and patient has no concerns at this time. R7's physician orders dated 4/8/26 documents Cephalexin Oral Capsule 500 MG (Cephalexin) Give 1 capsule by mouth two times a day related to urinary tract infection for 7 Days. Surveyor reviewed R7's April 2026 MAR (medication administration record) and noted R7 receive Cephalexin 500 mg twice daily from 4/8/26 to 4/15/26. R7's nurses note dated 4/10/26 at 0126 (1:26 a.m.) documents Tolerated antibiotics well no adverse reaction. R7's quarterly MDS (minimum data set) with an assessment reference date of 4/13/26 has a BIMS (brief interview mental status) score of 8 which indicates moderate cognitive impairment. R7 is assessed as requiring partial/moderate assistance for toileting hygiene and toilet transfer. R7 is frequently incontinent of urine. On 5/6/26, at 12:41 p.m., Surveyor met with Assistant Director of Nursing (ADON)-C who is the facility's infection preventionist to inquire why R7 was placed on an antibiotic for a urinary tract infection when there was no evidence R7was experiencing any signs or symptoms. Surveyor asked ADON-C how R7 met the McGeer criteria. ADON-C informed Surveyor it would be the same thing (referring to R13). ADON-C informed Surveyor there are days when R7 is up and moving and there are other days when R7 is down & out and sleeping. ADON-C informed Surveyor R7 would be with incontinence. Surveyor asked ADON-C if R7 incontinent before. ADON-C replied not always. Surveyor informed ADON-C Surveyor couldn't locate any evidence R7 met the McGeer criteria which is the facility's definition of infection. ADON-C replied I see where you are coming. No additional information was provided to Surveyor as to how R7 met the facility's definition of infection in order to be treated with an antibiotic for an UTI. 3.) The facility policy dated 12/31/25 and titled, High risk medications-Anticoagulant, documents, in part: The facility recognized that some medications, including anticoagulants, are associated with greater risks of adverse consequences than other medications. This policy addresses the facility's collaborative, systematic approach to managing anticoagulant therapy for efficacy and safety. Anticoagulants shall be prescribed by a physician or other authorized practitioner with clear indications for use. The resident's plan of care shall alert staff to monitor for adverse consequences. The residents' plan of care shall include interventions to minimize risk of adverse consequences. Examples include (depending on the medication): Limit venipunctures and injections, as possible. Be aware of the need to apply pressure following these procedures. Use soft toothbrush and electric razors. Caution resident/family about alcohol use while taking anticoagulants. Educate resident/family on risks of bleeding, dietary modifications, and symptoms to report to nurse/physician. Avoid (strenuous) activities that may lead to injury. R17 was admitted to the facility on [DATE] with diagnosis that include Hypertension (high blood pressure), Congestive Heart Failure (chronic, progressive condition where the heart cannot pump blood efficiently, causing fluid to back up into the lungs and body), Atrial fibrillation (Afib- often rapid, irregular heart rhythm affecting the heart's upper chamber) and Chronic kidney disease (long-term, irreversible loss of kidney function). R17's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documents R17 is cognitively intact. R17 takes an anticoagulant. R17's MD order dated 10/16/25 documents: Anticoagulant use: monitor for: Nosebleeds, bruising, bleeding that is severe or cannot be controlled, Pink, red or brown urine, vomiting blood or coffee-ground emesis, red stools or black tarry stools, and coughing up blood or blood clots. Document Y if present and N if no symptoms. Every shift. R17's MD order with a start date of 1/19/26 documents: Eliquis oral tablet 5 milligrams (mg). Give 5 mg by mouth two times a day for Afib. Surveyor reviewed R17's Comprehensive Care Plan. Surveyor noted that R17 did not have an anticoagulant care plan per facility policy. On 5/6/26 at 10:00 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-F, Surveyor asked what documentation is entered into a resident's medical record if the resident is taking an anticoagulant medication. LPN-F stated that there is an order for the medication and an order to monitor for bleeding and bruising. LPN-F stated that a care plan should be in place as well. On 5/6/26 at 1:31 PM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked what documentation is entered into a resident's medical record if the resident is taking an anticoagulant medication. DON-B stated that an order to monitor signs and symptoms of bleeding is placed and a care plan is put in place. Surveyor asked if R17 had a care plan for R17's anticoagulant medication use. DON-B looked in R17's medical record. DON-B stated that DON-B did not see an anticoagulant care plan. On 5/6/26 at 3:08 PM, Surveyor informed DON-B and Nursing Home Administrator (NHA)-A of the concern that R17 is taking an anticoagulant medication and does not have a care plan for the medication per facility policy. No further information was provided.

Based on interview, observation, and record review, the facility did not assist 1 (R2) of 1 resident reviewed for obtaining routine dental care. *The dentist recommended R2 be evaluated by an oral surgeon as soon as possible for two teeth to be extracted due to a cavity and broken tooth. The facility did not ensure a physician order to follow up and schedule an appointment was documented until 16 days after the recommendation. Findings include:The facility's Dental Services policy and procedure dated 12/31/25 documents:Policy:It is the policy of this facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care.Definitions: Emergency dental services includes services needed to treat an episode of acute pain in teeth, gums, or palate; broken, or otherwise damaged teeth, or any other problem of the oral cavity that required immediate attention by a dentist.Policy Explanation and Compliance Guidelines:.4. The facility will, if necessary or requested, assist the resident with making dental appointments and arranging transportation to and from the dental services' location.8. All actions and information regarding dental services, including any delays related to obtaining dental services, will be documented in the resident's medical record.R2 was admitted to the facility on [DATE]. R2's Quarterly Minimum Data Set (MDS) completed 3/29/26, documents R2's Brief Interview for Mental Status (BIMS) score to be 14, indicating R2 is cognitively intact for daily decision making. R2's MDS also documents that R2 requires set-up for eating. R2's MDS documents R2 has no difficulty chewing.R2's comprehensive care plan includes:At risk for dental problems related to: broken, loose or carious teeth 12/28/25 Assistance with oral care twice a day- 12/28/25 Educate resident on risk/benefits of refusal of oral care- 4/2/26 Inspect oral cavity for bleeding of gums or other issues- 4/26/26 Refer for Dental services as needed- 12/28/25 Visit resident to obtain information on any food/beverage intolerances- 12/28/25On 4/1/26, R2 was evaluated and treated by the dental group that treats residents in the facility. The following is documented: .(R2) only has 2 teeth remaining on the lower arch. The 2 teeth are in poor condition. #21 is fractured to the gumline and #22 will likely fracture soon. Extraction of #21 and #22 is recommended. Fabrication of lower complete denture is recommended following extractions. Referral to oral surgeon is the recommended treatment.On 5/04/2026, at 1:37 PM, Surveyor reviewed R2's progress notes that document on 4/20/26 to set up appointment with a dentist as soon as possible (ASAP) for left lower lateral incisor tooth removal. (R2) has a cavity and top of the tooth broke off.Surveyor reviewed R2's current physician orders:-(R2) receives a regular texture, regular (thin) consistency. 2/12/24-Please set up appointment with a dentist as soon as possible for left lower lateral incisor tooth removal. (R2) has a cavity and top of the tooth broke off. 4/20/26Surveyor notes that the dental consult is dated 4/1/26, an order was not obtained until 4/20/26 which documents that R2 needs to see an oral surgeon ASAP to have 2 teeth extractions. On 5/05/2026, at 9:14 AM, Surveyor interviewed Receptionist (REC)-M. REC-M confirmed that REC-M is responsible for making appointments for the residents of the facility. Surveyor asked REC-M how REC-M is notified about appointments needing scheduling/follow up for residents. REC-M stated that REC-M is given a form with the date or time of the appointment needed and then calls to make the appointment. Surveyor asked REC-M when REC-M was informed of the need for R2 to see an oral surgeon. REC-M informed Surveyor that REC-M was notified about 4/15/26 of R2 needing to see the oral surgeon. REC-M informed Surveyor that REC-M tries to make appointments within the week of being notified and then set up transportation. Surveyor asked why there was a delay in making R2's appointment with the oral surgeon. REC-M is not sure why there has been a delay in making R2's oral surgeon appointment.On 5/05/2026, at 9:16 AM, REC-M informed Surveyor that REC-M checked their notes and was waiting on clarification on who the oral surgeon is for R2; further stating I guess I need to talk with (R2).On 5/05/2026, at 3:13 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that on 4/1/26 a recommendation was documented that R2 required 2 teeth to be extracted as soon as possible, and the appointment has not been set up with an oral surgeon to have R2's teeth extracted.

Based on observation, interview, and record review the facility did not ensure each resident receives, and the facility provides food prepared by methods that conserve nutritional value, flavor, and appearance. This deficient practice had the potential to affect 2 of 2 residents receiving a pureed diet. *The recipe for preparing pureed diet was not followed to ensure puree food is prepared by methods that conserve nutritional value, flavor and appearance. Findings include:The facility's undated Pureed Food Preparation policy and procedure documents:Policy:.Facility will prepare pureed foods in a manner that sustains nutritional value and taste. The foods will be pureed to assure the desired consistency.Procedure:Pureed foods will be made from regular menu items to assure similar taste and nutritional quality. Recipes for regular menu items will be followed during production. Puree procedures are as follows:1. Portion out the number of pureed items needed to prepare pureed meals for all residents (i.e. 15 (3 oz) portions of meat or 15 (4 oz portions of vegetables).2. Place foods in the processor to be blended to the proper consistency.7. Please follow manufacturer's directions when adding thickeners to foods to assure proper consistency.Puree and Mechanical Soft GuidelinesPureed.Texture is smooth, lump free; no bits or fibers; not firm or sticky; does not require chewing or bolus formation.Falls off spoon as intact spoonful and holds shape.No mixed consistency.Cannot be poured or drunk from a cup; nor sucked through a straw.No chewing or biting required nor ability to form bolus.On 5/05/2026, at 9:59 AM, Surveyor observed [NAME] (Cook)-H prepare pureed chicken for lunch. Surveyor observed Cook-H take a ladle size of chicken pieces times two. Surveyor asked Cook-H how much chicken Cook-H was placing inside the food processor. Cook-H stated, since we have 2 pureed, will put 2 portions of chicken in. Surveyor then observed Cook-H pour milk without measuring it into the food processor. Surveyor asked how does Cook-H know how much milk to place into the food processor. Cook-H stated, I just eyeball it, maybe 2-3 tablespoons. Cook-H stated Cook-H turned the food processor on low, so it gets creamy. Cook-H then poured more milk in without measuring. Dietary Director (DD)-E then walked over to Cook-H and Surveyor. DD-E stated 'eyeball' is not a good term and explained to Cook-H that you don't want it too thin or too thick. DD-E looked at the consistency in the food processor and instructed Cook-H to add more chicken and informed Cook-H that it should be a pudding mixture. DD-E also then informed Cook-H, you don't want lumps. Cook-H took the lid off the food processor. Surveyor asked Cook-H if that is the consistency Cook-H was going to go with. Cook-H stated, I think so. Surveyor noted the consistency appeared to be a pudding consistency after DD-E intervened with the process. Surveyor asked Cook-H if Cook-H follows a recipe for pureed meals. Cook-H replied, sometimes I do, not sure where the recipe book is.Surveyor asked DD-E for the pureed chicken recipe. DD-E went through 3 recipe books and was unable to locate the pureed chicken recipe. DD-E stated that DD-E will need to find the pulled chicken pureed recipe and make it accessible to the cooks. Surveyor shared with DD-E at this time that the pureed chicken was not pureed following a recipe. DD-E acknowledged the concern. On 5/05/2026, at 3:13 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern that a recipe was not followed by Cook-H for preparing pureed chicken for today's lunch, that a recipe could not be provided for the pureed consistency.

Number of residents sampled:1Number of residents cited:1Craig- his certification of terminal illness and care plan not available until yesterday. No process in building.Based on interview and record review the Facility did not ensure hospice services were coordinated for 1 (R6) of 1 residents reviewed for hospice care.*R6's certification of terminal illness was not updated and there was not an updated plan of care from hospice.Findings include:The Hospice Services Facility Agreement implemented 3/1/25 documents:Policy.It is the policy of this facility to provide and/or arrange for hospice services in order to protect a resident's right to a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility.Policy Explanation and Compliance Guidelines:.4. The written agreement(s) will set out at least the following:a. The services the hospice will provide.b. The hospice's responsibilities for determining the appropriate hospice plan of care.c. The services the facility will continue to provide based on each resident's plan of care.d. A communication process, including how the communication will be documented between the facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day.5. The facility has a designated member to be responsible for working with hospice representatives to coordinate care to the resident provided by facility and hospice staff.6. The designated member of the facility working with hospice representative is responsible for:a. Collaborating with hospice representatives and coordinating LTC (long term care) facility staff participation in the hospice care planning process for those residents receiving these services.b. Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the resident and family.d. Obtaining the following information from the hospice:i. The most recent hospice plan of care specific to each residentii. Hospice election formiii. Physician certification and recertification of the terminal illness specific to each resident.The Hospice-Nursing Facility Services Agreement effective 1/8/26 documents:Agreements1. Definitions.Hospice Plan of Care means a written care plan established, maintained, reviewed, and modified, if necessary, at intervals identified by the Hospice Interdisciplinary (IDT) in coordination with Facility and each Hospice Patient's attending physician, if any.(ii) Design of Hospice Plan of Care. In accordance with applicable federal and state laws and regulations, facility shall coordinate with hospice in developing a hospice plan of care for each hospice patient that is consistent with the hospice philosophy and is responsible to the unique needs of each hospice patient and his or her expressed desire for hospice care. Hospice retains primary responsibility for determining each hospice patient's appropriate hospice plan of care in accordance with its applicable regulations. The hospice plan of care will identify which provider is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Facility shall ensure that facility's care plan for each hospice patient reflects both the most recent hospice plan of care and a description of the facility services furnished by facility in accordance with its applicable regulations.(v) Designated Facility Member. Facility shall designate a member of facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to each hospice patient provided by facility and hospice. The designated team member shall have a clinical background, function within their state scope of practice act, and have the ability to assess a hospice patient or have access to someone that has the skills and capabilities to a hospice patient.3. Responsibilities of Hospice.(i) Hospice Plan of Care, Medications and Orders. The most recent hospice plan of care, medication information, and physician orders specific to each hospice patient residing at facility.(ii) Election Form. The hospice election form and any advance directives(iii) Certifications. Physician certifications and recertifications of terminal illness.6. Records.(a) Creation and Maintenance of Records. Each party shall prepare and maintain complete and detailed records concerning each hospice patient receiving services under this agreement in accordance with prudent recordkeeping procedures and as required by applicable federal and state laws and regulations and Medicare and Medicaid program guidelines.R6 was admitted to the facility on [DATE] with diagnoses of Intracerebral Hemorrhage (life threatening type of stroke caused by ruptured blood vessel bleeding into the brain tissue) in brain stem, Aphasia (a language disorder caused by brain damage, typically from a stroke or injury, affecting speech production, comprehension, reading, and writing), Dysphagia (difficulty swallowing foods), Hyperlipidemia (high levels of fat particles in the blood), Insomnia (sleep disorder characterized by difficulty falling asleep), Essential Hypertension (chronic condition of persistently high blood pressure), Major Depressive Disorder (persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities), and Anxiety Disorder (mental health disorder characterized by feelings of worry, fear that interfere with daily activities).R6's Annual Minimum Data Set (MDS) completed 4/9/26 documents R6's Brief Interview for Mental Status score to be 12 indicating R6 demonstrates moderately impaired skills for daily decision making. R6's MDS documents no depressive or behavioral symptoms. R6's MDS also documents R6 has range of motion impairment on both sides both upper and lower extremity impairment. R6 is dependent for eating, mobility, transfers, and showers. R6's MDS documents R6 is receiving hospice services. R6's physician orders document R6 enrolled in hospice services effective 4/19/25.R6's facility comprehensive care plan with interventions effective 4/21/25 documents:Patient is on Hospice care related to: End of life care Allow patient to verbalize fears and concerns about dying process Check in with resident to see if there is any special request to keep him comfortable Coordinate Care Plan with Hospice Evaluate effectiveness of medications/interventions to address comfort Keep family informed of change in condition Notify hospice of any change in condition or medication changes Obtain Physician order and appropriate Referral Provide emotional support to patient and family during decline in the dying process Provide religious/spiritual support as needed Respect patient and family wishesOn 5/5/26, at 12:57 PM, Surveyor reviewed R6's hospice binder located at the facility's nurse's station. Surveyor noted the binder did not contain the certification of terminal illness, and no hospice care plans. Surveyor reviewed R6's electronic medical record and noted R6's EMR has the original hospice plan of care last edited on 4/19/25. R6's certification of terminal illness in the EMR has a start date of 4/19/25 and end date of 7/17/25.On 5/5/2026, at at 3:13 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern that there is no current certification of terminal illness and no updated hospice plan of care accessible in R6's EMR. DON-B realized that R6's EMR was missing both items and requested them from hospice on 5/4/26. DON-B informed Surveyor that the facility cannot explain why both certification of terminal illness and hospice plan of care have not been part of R6's EMR. Surveyor asked who is the facility liaison to coordinate the hospice services and was informed that Director of Social Services (DSS)-I is the facility liaison. On 5/6/2026, at 10:19 AM, DSS-I informed Surveyor that DSS-I was not aware that DSS-I was the facility liaison to communicate with hospice. DSS-I stated the facility has not had a process for anyone to keep track of all the required components to coordinate hospice services for a resident. DSS-I shared they know about the hospice binder for R6 but does not know what medical records are located in the hospice binder. On 5/6/2026, at 11:03 AM, the facility provided an updated plan of care effective 4/21/26 and a certification of terminal illness with a start date of 4/14/26 and end date of 6/12/26.

Based on facility policy review, record review, facility document review, and interview, the facility failed to ensure that an allegation of abuse was reported immediately, but not later than two hours after the allegation was made, to the state survey agency for 1 (R1) of 3 residents reviewed for abuse.Findings included:A facility policy titled, Abuse, Neglect, and Exploitation, dated 10/01/2022, indicated, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy revealed, VII. Reporting/Response included, A. The facility will have written procedures that include, which included, 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. [exempli gratia; for example], law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.An admission Record indicated the facility admitted R1 on 11/05/2025. According to the admission Record, the resident had a medical history that included diagnoses of Parkinson's disease, depression, anxiety disorder, somatization disorder, personality disorder, and Alzheimer's disease.An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/09/2025, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment.R1's Care Plan Report included a Diagnosis area initiated 11/06/2025, that indicated that the resident sometimes had behaviors that included verbal aggression, combativeness, throwing objects at staff, refusing participation in care, swinging the call light when staff were assisting, refusing therapy and not remembering refusals, calling 911 for nonemergent needs, was accusatory towards staff, and had delusions that included saying there was a cult in the basement. Interventions initiated 11/06/2025 directed staff to give the resident their personal space; make sure the resident was not in pain or uncomfortable; minimize the potential for behavior by offering diversional tasks; and when the resident became agitated, intervene before escalation, engage calmly in conversation, and if the response was aggressive, walk away and reapproach later.A document titled, Misconduct Incident Report, dated 01/09/2026, indicated that the facility reported to the state survey agency that at approximately 3:30 PM, R1 reported that they had been hit by staff and indicated that the resident had a bloody nose. Further review of the report revealed that it was submitted to the state survey agency on 01/09/2026 at 9:16 PM by the previous Executive Director (ED), over five hours after the resident made the allegation.During an interview on 02/06/2026 at 3:41 PM, the previous ED stated that he did not report R1's allegation of abuse within the two hours and stated he was following the direction from the Corporate Lead.A call was placed and a message left on 02/06/2026 at 4:11 PM for the Corporate Lead, with no response by the end of the survey.During an interview on 02/06/2026 at 3:47 PM, the Director of Nursing (DON) stated that any abuse allegation should be reported to the ED immediately, and she had two hours to report it to the state survey agency. The DON reviewed the initial report submitted to the state survey agency related to R1's allegation and confirmed that it was not submitted timely, and she stated she did not know why.During an interview on 02/06/2026 at 4:03 PM, the facility's current ED stated all abuse allegations needed to be reported to her immediately and then reported to the state survey agency within two hours.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated to resolve the allegation and staff education provided to prevent further incidences for 1 (R11) of 1 facility reported incidents reviewed.R11 made an allegation of misappropriation of property that was not followed up on to resolve the missing computers allegation and no staff education was provided to prevent further misappropriation.Findings include:The Facility Policy titled Abuse, Neglect, and Exploitation dated 10/1/25 documents (in part): Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.4. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following: a. Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; b. Defining how care provision will be changed and/or improved to protect residents receiving services; c. Training of staff on changes made and demonstration of staff competency after training is implemented; d. Identification of staff responsible for implementation of corrective actions; e. The expected date for implementation; and f. Identification of staff responsible for monitoring the implementation of the plan.R11 admitted to the facility on [DATE]. R11's quarterly Medicare Minimum Data Set (MDS) with an assessment reference date of 11/3/25 indicated R11 had a Brief Interview for Mental Status score of 14, indicating R11 is cognitively intact. R11 is coded to have adequate hearing and clear speech. R11 is assessed to understand others and make self understood. R11 exhibited no behaviors during the look back period.Surveyor reviewed the Misconduct Incident Report dated 10/9/2025 regarding R11 reporting missing two broken laptops. On 10/9/25, R11 reported to the Nursing Home Administrator (NHA)-A that R11 was missing two Apple laptops. R11 stated the computers were in a box in the corner. With permission, NHA-A searched the box and did not find any laptops. Other storage boxes in R11's room were also searched. Two staff were interviewed, the first moved R11 to a new room and stated the boxes were already packed so did not see the laptops. The second staff member stated they saw the two laptops in a box back in October/November of 2024. Seventeen Resident's were interviewed and asked have you taken anything from another resident? Have you seen anyone take anything from a resident? Have you seen anyone take anything from you? All interviewed residents answered no to all 3 questions.On 12/02/2025, at 9:05 AM, Surveyor interviewed R11 regarding the missing computers. Per R11, the issue was not taken care of. There was never an offer to replace the computers, they were Apple laptops, that were stored in a box of other stuff. R11 was waiting for funds to repair them. The other items that were in the same box are still there. Per R11, NHA-A came into R11's room and went through R11's possessions, with permission, looking for the laptops after R11 reported them missing. R11 was upset because NHA-A moved stuff around and left a mess in the room, NHA-A even moved the bed and didn't put it back. R11 filed a grievance on 10-10-25 regarding the mess the room was left in. This was resolved.On 12/04/2025, at 9:47 AM, Surveyor interviewed NHA-A to find out what was being done regarding the missing Apple laptops. NHA-A stated they were going to offer R11 a lock on R11's nightstand drawer to lock up valuables. Surveyor asked if this had been done and was told not yet, Surveyor asked why the delay, as this was reported in October. NHA-A did not know why there was a delay. Surveyor asked if there had been any education or staff follow up regarding misappropriation and was told no, they followed procedure and reported to NHA-A as soon as they heard. Surveyor confirmed there was nothing in the works to replace the value of R11's computers and was told no.On 12/04/2025, at 10:14 AM, Surveyor interviewed Certified Nursing Assistant-C who stated CNA-C does not remember R11's computers, but if they were in a box they wouldn't regularly see them, does know R11 has other Apple devices though. When asked what to do if a resident reports missing property, the Surveyor was told would tell the nurse or a manager.On 12/04/2025, at 10:17 AM, Surveyor returned to R11's room and Regional Clinical-E was in the room talking with R11 regarding the missing computers. Regional Clinical-E determined that the two computers were over 6 years old and a resolution was agreed upon with R11 to replace with one working computer. Regional Clinical-E was giving R11 until Wednesday to determine what R11 wants ordered. After Regional Clinical-E left the room Surveyor asked R11 if this was an acceptable resolution and R11 was disappointed to only get one computer but understood the missing two were older and not working.On 12/04/2025, at 12:47 PM, Surveyor informed NHA-A of the concern that there was no follow up with R11 to resolve the missing computer issue and there was no training provided to staff regarding misappropriation.No additional information was provided regarding the lack of follow up or resolution of the missing laptop computers and no training provided to staff regarding misappropriation.

Based on interview and record review, the facility did not develop and implement a comprehensive person-centered care plan for 1 (R2) of 12 residents reviewed to meet a resident's medical, nursing and psychosocial needs that are identified in the comprehensive assessment.R2 receives Spironolactone for diuresis. R2 does not have a comprehensive care plan that addresses diuretic therapy.Findings include:The Facility Policy titled Comprehensive Care Plans dated 10/1/22 documents (in part): Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . Policy Explanation and Compliance Guidelines:2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS (Minimum Data Set) assessment but no more than 21 days from admission. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record.3. The comprehensive care plan will describe, at a minimum, the following:a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.R2 was admitted to the facility on [DATE] with diagnoses that include hemiplegia and hemiparesis following cerebral infarction (Hemiplegia refers to paralysis on one side, while hemiparesis refers to weakness on one side, both occurring after a stroke), and heart failure (occurs when the heart muscle doesn't pump blood as well as it should.R2's Quarterly Minimum Data Set (MDS) with an assessment reference date of 11/17/2025 indicated R2 had a Brief Interview for Mental Status score of 15 (cognitively intact). R2's MDS indicted adequate hearing and clear speech and that R2 is understood and understands others. R2's physician order for Spironolactone Oral Tablet 25 MG indicates to give 1 tablet by mouth one time a day for Heart failureSurveyor reviewed R2's electronic medical record (EMR) and was unable to locate any care plan or order related to monitoring of R2's heart failure or diuretic use.On 12/03/2025, at 1:31 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-D regarding a care plan or monitoring for R2's diuretic use or heart failure diagnosis and was told ADON-D would look into it. On 12/04/2025, at 12:48 PM, Surveyor interviewed Director of Nursing (DON)-B and ADON-D and asked if a care plan or monitoring was available for R2's diuretic use or included in a heart failure care plan and was told they did not find any.No additional information was provided regarding the lack of a comprehensive care plan that addresses diuretic therapy.

Based on interview and record review, the facility did not ensure that pharmacy recommendations reported to the physician were not acted upon for 2 (R6 and R17) of 5 residents reviewed for pharmacy recommendations.R6 and R17's monthly pharmacy medication regimen reviews included recommendations that were not acted upon.Findings include:The facility policy titled Pharmacy Recommendations and Review Policy dated 12/2025 documents (in part) . Purpose: To ensure all pharmacy recommendations and medication regimen reviews are evaluated, documented, communicated to the provider and implemented.1. The consultant pharmacist will complete monthly medication regimen reviews (MRR) for all residents.2. All pharmacy recommendations will be reviewed by nursing leadership and the attending provider.3. Provider response (accept or decline) must be documented in the electronic record with rationale if the recommendation is declined.4. Nursing leadership is responsible to ensure approved recommendations are implemented as ordered.5. All pharmacy recommendations, responses, and actions taken must be documented in resident medical record, pharmacy recommendation log.Procedure:1. Pharmacy submits recommendations to the DON (Director of Nursing)/designee after the MRR.2. The DON/designee routes recommendations to the provider for review.3. Provider documents acceptance or declination of each recommendation.4. Nursing updates orders in the EHR (electronic health record) and notifies staff.5. Consultant pharmacist verifies completion during the next review.1.) On 12/3/25 at 11:45 PM, Surveyor asked DON-B for R6's pharmacy recommendations. The pharmacy note to attending physician/prescriber documented: Resident has the following therapy change Continues on Synthroid 100 mg recommend the following TSH (Thyroid Stimulating Hormone) on next convenient lab day. Rational (Guideline monitoring) TSH 4 to 8 weeks after initiating treatment or dose change at 6 months after dose stabilization, then at 12-month intervals or more frequently as clinically indicated. Surveyor noted an X next to Agree and was signed by the physician on 6/6/25.Surveyor noted lab work for TSH was not done until 9/2/25. Surveyor asked for all R6's lab work for the past year. Surveyor noted lab results dated 11/26/24 did not include a TSH and there was no evidence a TSH was completed the previous year. The pharmacy note to attending physician/prescriber documented: A1C monitoring resident receives treatment for diabetes and does not have a recent A1C, The ADA Recommends routine A1C testing approximately q (every) 3 to 6 months. Please consider clinical monitoring. Surveyor noted an X next to Agree and was signed by the physician on 6/6/25.Surveyor noted lab work for A1C was not done until 9/2/25. Results indicated: High 8.8 (reference range 4.3-6.3).2.) On 12/3/25 at 11:45 PM, Surveyor asked DON-B for R17's pharmacy recommendations.The pharmacy note to attending physician/prescriber documented: The resident appears to continue the following: Metoprolol Tartrate 12.5 mg (milligrams) BID (twice daily). Recommend the following: Change to Metoprolol Succinate XL (extended release) 25 mg QD (every day) hold for SBP (systolic blood pressure) below 110 and HR (heart rate) below 60. Surveyor noted an X next to Agree and was signed by the physician on 6/6/25.Surveyor noted the same pharmacy note/recommendations to attending physician prescriber with an X next to Agree signed by the physician on 8/18/25.Surveyor note the pharmacy recommendations signed Agree by the physician on 6/6/25 were not followed until after the same recommendations were made and signed by the physician on 8/18/25. R17's June and July MAR (Medication Administration Record) documented R17 received Metoprolol Tartrate 12.5 mg by mouth two times a day (ordered 1/10/25). The order was not changed and implemented on the MAR per June 2025 pharmacy recommendations until 8/20/25.On 12/4/25 at 1:40 PM, Surveyor advised Nursing Home Administrator (NHA) of the above concerns R6 and R17's pharmacy recommendations and physician orders were not acted upon. No additional information was provided.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 4 of 4 residents (R2, R3, R8 and R11) reviewed for smoking. The failure to prevent and assess a residents risk for injury related to smoking and not ensuring smoking materials are contained to prevent injury created a finding of Immediate Jeopardy beginning on 7/10/25.Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 4 of 4 residents (R3, R8, R11 and R2) reviewed for supervision with smoking. R3 was observed with cigarette ashes on his person, going through smoking receptacle taking out cigarette butts to smoke and asking other residents for cigarettes. R8 was observed with a sweatshirt on his lap with several burn holes, using a wooden clothespin to hold his cigarettes, and having a car receptacle in his wheelchair to place cigarette butts in. R11 was observed with a burn hole in her shirt. R11’s care plan indicates R11 should be using a smoking apron, which was not available during the first day of survey. R2 was observed going through the smoking receptacle taking out cigarette butts to smoke. The failure to assess a resident’s risk for injury related to smoking and its failure to put care plan interventions in place to ensure safety while smoking and its failure to ensure smoking materials are contained to prevent injury created a finding of Immediate Jeopardy beginning on 7/10/25. On 7/11/25 at 11:06 AM, NHA and CNO (Chief Nursing Officer) were notified of IJ, with a start date of 7/10/25. The facility removed the immediate jeopardy on 7/16/25; the deficient practice continues at a scope and severity of an E (potential for harm/pattern) as the facility continues to implement their action plan. Findings include: The facility policy titled, Resident Smoking, dated 1/01/25, states in part… Policy: It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents. Policy Explanation and Compliance Guidelines: 6. Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all. 8. Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas (weather permitting), at designated times, and in accordance with his/her care plan. 12. If a resident or family does not abide by the smoking policy or care plan (e.g. smoking materials are provided directly to the resident, smoking in non-smoking areas, does not wear protective gear), the plan of care may be revised to include additional safety measures. 15. Documentation to support decision making will be included in the medical record, including but not limited to: b. Assessment of relevant functional and cognitive factors affecting ability to smoke safely. d. Compliance with smoking policy. The Facility assessment dated [DATE] reviewed and does not address smoking by residents in the facility. The Facility admission Agreement, Attachment D, Tobacco-Free Environment Policy, states in part… 1. Policy. Facility prohibits the use of tobacco and tobacco products by employees, contractors, volunteers, residents, visitors and others entering out healthcare facility premises such as any agencies contracting with the Facility. 2. Rationale. Facility recognizes tobacco and tobacco smoke pose a significant health threat to anyone exposed to them. Definitions: Tobacco and Tobacco Products. Any tobacco-containing or smoking product, including cigarettes, cigars, pipes, chewing tobacco, smokeless tobacco and e-cigarettes. 3. Facility Premises: Property leased or owned by the facility including all buildings, sheds, and other structures on Facility owned or leased property parking lots, including vehicles parked on Facility owned or leased parking lots or property. There will be no designated smoking areas on Facility premises unless specifically identified for the use of Resident admitted to the facility before the implementation of the Tobacco-Free Environment Policy. Example 1 R3 is a [AGE] year-old male admitted to the facility on [DATE]. R3 has a BIMS (brief interview of mental status) of 10, indicating R3 has moderate cognitive impairment. R3’s diagnoses include in part… paranoid schizophrenia, borderline personality disorder, encephalopathy, seizures, pulmonary embolism with acute cor pulmonale (where a blood clot acutely obstructs blood flow in the lungs, leading to a sudden strain on the right ventricle of the heart, causing it to fail). R3’s care plan states in part… Diagnosis: Tobacco Use. Interventions/Tasks: Conduct Smoking Safety Evaluation on admission and PRN (as needed). Educate Resident/Responsible Party on the facility’s tobacco/smoking policy(s). If a smoking facility, orient Resident to smoking times and procedures. Diagnosis: I sometimes have behaviors which include refusing personal cares and bathing. Asking residents for cigarettes and money. I sometimes have behaviors due to decrease in the amount of money that I am given from my guardian. Interventions: Continue to encourage and educate resident on the importance of cleanliness and maintaining good personal hygiene. Help me to avoid situations or people that are upsetting to me. Please tell me what you are going to do before you begin. Redirect me and remind me that it’s not appropriate to ask residents for money and cigarettes. Diagnosis: At risk for smoking related injury related to independent smoking. Able to maintain smoking materials. At times I look for cigarettes in the garbage and cigarette canister outside. When I am out of cigarettes, I will ask other residents and visitors for cigarettes. I will try to take cigarettes out of other residents (sic) hands. I am easily redirected and do not pose a threat to others. Interventions: Complete smoking safety assessment per Living Center policy. Keep my lighter in the nurses cart while I’m not outside smoking to keep myself safe. Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources. Immediately inform facility management. Redirect me if I am searching for cigarettes in the garbage or cigarette canister. Review smoking policy with patient and or family. R3’s smoking assessments dated 11/8/24 states in part… Smoking Safety Interaction: 2. Which of the following products does resident use? Tobacco. 3. Does the resident display any of the following? Follows the facility’s policy on location and times of smoking. Care planning: Tobacco Use. Interventions/Tasks: Conduct Smoking Safety Evaluation on admission and PRN. Educate Resident/Responsible Party on the facility’s tobacco/smoking policy(s). If a smoking facility, orient Resident to smoking times and procedures. Clinical Suggestions: Nothing marked. R3’s smoking assessments dated 3/17/25 states in part… Smoking Safety Interaction: 2. Which of the following products does resident use? Tobacco. 3. Does the resident display any of the following? Nothing marked. Smoking Safety Notes: Resident needs to be occasionally reminded of where the smoking area is. Care planning: Nothing marked. Clinical Suggestions: Nothing marked. On 7/10/25 at 9:10 AM, Surveyor went out to interview R3 regarding an incident that was being investigated. R3 was in the courtyard of the facility returning from the smoking area. While speaking with R3 it was noted that he had cigarette ashes all down the front of his shirt and on his pants. On 7/10/25 at 1:00 PM, R3 was observed by Surveyors taking the lid off the smoking receptacles and removing cigarette butts. R3 was then observed attempting to light the butts that he had removed from the receptacle. On 7/10/25 at 1:16 PM, R3 was observed by Surveyor throwing cigarette butts that he had removed from smoking receptacle on the ground in the courtyard. R3 then was heard asking R11 to share a portion of her cigarette with him. R11 replied, “Can’t I just enjoy what I have.” On 7/10/25 at 2:50 PM, R2 observed outside with R3 in the gazebo where they are observed taking cigarette butts out of the smoking receptacles. R3 and R2 are lighting the butts and passing them between themselves. On 7/11/25 at 8:35 AM, R3 was observed outside in smoking area removing the lid of the smoking receptacles and taking out discarded cigarette butts. On 7/10/25 at 9:43 AM, Surveyor interviewed Receptionist D. Surveyor asked Receptionist D about residents that require supervision while smoking. Receptionist D stated, R3 does try to go out front to smoke but just needs redirection. Surveyor asked Receptionist D if he knew of any other concerns with residents who smoke. Receptionist D stated, I have heard that R3 has been trying to bum cigarettes from other residents. On 7/10/25 at 2:40 PM, Surveyor interviewed LPN F. Surveyor asked the LPN F if she has ever noticed burn holes in any of the residents’ clothing. LPN F states, R3 does in his sweater. Seeing all those burn holes makes me question their safety. On 7/11/25 at 7:48 AM, Surveyor interviewed CNA H. Surveyor asked CNA H if she had ever witnessed R3 going through the smoking receptacle. CNA H stated, R3 does pick up butts but I don’t know what he does with them. On 7/11/25 at 8;05 AM, Surveyor interviewed MT/CNA I. Surveyor asked MT/CNA I if she knew where R3 gets his smoking material or if she has ever witnessed R3 going through the smoking receptacles. MT/CNA I states, I don’t know where he gets his cigarettes. I have never seen R3 pick up butts. On 7/11/25 at 9:37 AM, NHA A and LPN/UM B returned to answer questions regarding smoking that NHA A was unable to previously answer. Surveyor reported observations of R3 and R2 and asked who monitors residents for opening the smoking receptacles and taking out cigarette butts. LPN/UM B states, we just look out and watch. I know we should monitor. Example 2: R8 is an [AGE] year-old male admitted to the facility on [DATE]. R8 has a BIMS of 13, indicating R8 is cognitively intact. R8’s diagnoses include in part… COPD (chronic obstructive pulmonary disease), confusional arousals, A-fib (atrial fibrillation), hypotension, GERD (gastroesophageal reflux disease), and arthritis. R8’s care plan states in part… Diagnosis: At risk for smoking related injury related to: Smokes independently. Interventions/Tasks: Able to maintain smoking materials. Complete smoking safety assessment per facility policy. Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources. Immediately inform facility management. Review smoking policy with patient and/or family. R8’s Smoking assessment dated [DATE] states in part… Smoking Safety Interaction: 2. Which of the following products does resident use? Tobacco. 3. Does the resident display any of the following? Follows the facility’s policy on location and times of smoking. Care planning: Nothing marked. Clinical Suggestions: Nothing marked. R8’s Smoking assessment dated [DATE] states in part… Smoking Safety Interaction: 2. Which of the following products does resident use? Tobacco. 3. Does the resident display any of the following? Nothing marked. Care planning: Nothing marked. Clinical Suggestions: Nothing marked. On 7/10/25 at 9:55 AM, R8 observed sitting in the gazebo area smoking. Surveyor approached R8 and noted he had a sweatshirt on his lap with several cigarette burns. R8 was smoking a cigarette that was being held by a wooden clothespin. R8 had on his lap a plastic container containing 2-3 wooden clothespins, a plastic spoon, and lighter. Note: Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. On 7/10/25 at 1:08 PM, Surveyor inquired with R8 about his sweatshirt with the noted burn holes. R8 stated his sweatshirt has been like that. Surveyor asked R8 what he uses the plastic spoon for. R8 stated, I use the plastic spoon to put out cigarettes when I am done smoking. R8 indicates he has a hard time using the smoking container. R8 was then observed pulling out a cigarette receptacle, noted to be a car ashtray “butt bucket” from next to him in his wheelchair and indicated that he will be trying to use this now and then when it gets full will empty it in the receptacle in the gazebo. Note: Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. Note: A car ashtray sometimes known as a “butt bucket” is not fire rated and is made of a plastic material. On 7/11/25 at 8:50 AM, Surveyor observed R8 and R11 outside smoking, alone/independent. R8 continues to use wooden clothespin but now has metal spoon. On 7/11/25 at 8:55 AM, LPN/Unit Manager entered smoking area and stayed with residents who were out in the smoking area. On 7/10/25 at 2:40 PM, Surveyor interviewed LPN F. Surveyor asked the LPN F if she has ever noticed burn holes in any of the residents’ clothing. I am not sure if R8 does but seeing all those burn holes makes me question their safety. On 7/11/25 at 9:37 AM, NHA A and LPN/UM B returned to answer questions regarding smoking that NHA A was unable to previously answer. Surveyor then explained observations of R8. LPN/UM B states that she completed an observation of R8 smoking and had no concerns. LPN/UM B states that R8 had the wooden clothespin high on filter area and that R8 does not use the spoon. Surveyor asked LPN/UM B about the car cup receptacle that R8 has in his wheelchair. LPN/UM B states that she did not observe this cup in R8’s wheelchair and when she observed him, he did not use it. Example 3: R11 is a [AGE] year-old female, admitted to the facility on [DATE]. R11 has a BIMS of 14, indicating R11 is cognitively intact. R11’s diagnoses include in part… hemiplegia and hemiparesis (neurological conditions that can occur after a stroke, resulting in weakness or paralysis on one side of the body) following cerebral infarct, dementia, cognitive communication deficit, and heart failure. R11’s care plan states in part… Diagnosis: At risk for smoking related injury related to smokes independently. Able to maintain smoking materials. Known to smoke Delta 8. Educated on risk provider and POA (Power of Attorney) aware with no concerns. History of giving and receiving cigarettes and was educated on to not give or take cigarettes from other residents. Resident chooses to smoke off the property at times POA aware and no concerns. Interventions: Complete smoking safety assessment per living center policy. Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources. Immediately inform facility management. Review smoking policy with patient and/or family. Smoking apron to be available for resident to use. R11’s smoking assessment dated [DATE] states in part… Smoking Safety Interaction: 2. Which of the following products does resident use? Tobacco. 3. Does the resident display any of the following? Nothing marked. Care planning: Interventions: Resident with adhere to the tobacco/smoking policies of the facility. Educate resident/responsible party on the facilities tobacco/smoking policies. Provide education adverse effects of smoking. Clinical Suggestions: Nothing marked. R11’s smoking assessment dated [DATE] states in part… Smoking Safety Interaction: 2. Which of the following products does resident use? Tobacco. 3. Does the resident display any of the following? Limited or no ROM (range of motion) in arms or hands. Care planning: Nothing marked. Clinical Suggestions: Nothing marked. R11’s smoking assessment dated [DATE] states in part… Smoking Safety Interaction: 2. Which of the following products does resident use? Tobacco. 3. Does the resident display any of the following? Nothing marked. Smoking Safety Notes: Resident has access to smoking apron when she goes out to smoke. Care planning: Nothing marked. Clinical Suggestions: Nothing marked. On 7/10/25 at 2:10 PM, Surveyor interviewed CNA C. Surveyor asked CNA C if she had aware of the facility having any smoking aprons. CNA C indicates that she has never seen any smoking aprons. Surveyor asked CNA C if any residents in the facility needed supervision while smoking. CNA C stated all the residents can smoke independently. Surveyor asked if there were any safety concerns that she knew of with the residents who do smoke. CNA C states, I have no safety concerns, but I have never been out to watch them smoke. On 7/11/25 at 8:15 AM, Surveyor observed two smoking aprons sitting next to the door behind the receptionist near the door going out to the smoking area. One was silver-gray in color. The smoking aprons tag indicates it is a NyOrtho, Model 9532. The other smoking aprons tag it is a NyOrtho Model 9530. On 7/11/25 at 8:37 AM, Surveyor observed that there are now three smoking aprons, NyOrtho, Model 9532, sitting next to the door behind the receptionist near the door going out to the smoking area. Surveyor reviewed warning label on the NyOrtho Model 9532 smoking apron which states in part… This product is not a substitute for proper supervision. Patients or residents in wheelchair who smoke must be supervised. Surveyor reviewed warning label on the NyOrtho model 9530 smoking apron which states in part… Certified flame-resistant fabric is not a substitute for proper supervision. Read all instructions and warnings before use. On 7/10/25 at 12:35 PM, Surveyor observed R11 smoking in courtyard/gazebo area. R11 noted to have burn hole over the left breast area. Surveyor asked R11 if there are smoking times or if she can come out to the smoking area anytime. R11 states that she can come out and smoke whenever she wants. R11 was observed having difficulty getting lighter to work to light her cigarette. Surveyor asked R11 if she has ever observed any residents with safety concerns while smoking. R11 states that she has observed R3 going through the smoking receptacles looking for butts to smoke. R11 indicates R3 does not have anyone to bring him cigarettes. R3 bums cigarettes from other residents when able and gets them from friends at times. On 7/10/25 at 1:20 PM, Surveyor observed R11 in courtyard area. Surveyor asked R11 about the burn on her shirt. R11 states “that’s what happens when you can only use one arm. I am also blind in the left eye.” On 7/11/25 at 8:50 AM, Surveyor observed R8 and R11 outside smoking, alone/independent. R11 has no apron on. R11 reports that yesterday it was suggested she wear a smoking apron, but she chooses not to. On 7/11/25 at 8:55 AM, LPN/Unit Manager entered smoking area and stayed with residents who were out in the smoking area. On 7/10/25 at 2:15 PM, Surveyor interviewed CNA E. Surveyor asked CNA E if there were concerns with residents’ safety while smoking. CNA E stated. I believe that someone should be out there monitoring residents are safe. R11 clothes have a lot of burn holes in them. On 7/10/25 at 2:40 PM, Surveyor interviewed LPN F. Surveyor asked LPN F if she has ever noticed burn holes in any of the residents clothing. LPN F states that she has noticed burn holes in R11’s clothes. Seeing all those burn holes makes me question their safety. On 7/11/25 at 8:30 AM, Surveyor interviewed CNA J. Surveyor asked CNA J if R11 uses a smoking apron. CNA J states that residents can refuse to wear aprons that is their right. On 7/11/25 at 9:37 AM, Surveyor reported observations of R11 to NHA A and LPN/UM B. LPN/UM B stated that now that they have the knowledge, they will have to watch for this. I did a smoking assessment, and everything was done appropriately. Surveyor asked LPN/UM B if the smoking aprons were available for R11 prior to this morning. LPN/UM B states that the facility had them but did not have them out. Example 4: R2 is a [AGE] year-old male, admitted to the facility on [DATE]. R2 has a BIMS of 13, indicating that he is cognitively intact. R2’s diagnoses include in part… Diabetes Mellitus Type 2, dementia, bipolar disorder, developmental disorder of scholastic skills, PVD (peripheral vascular disease), Klinefelter Syndrome (extra X chromosome). R2’s care plan states in part… Diagnosis: At risk for smoking related injury related to: Smokes independently. Able to maintain smoking materials. Resident has a history of trying to sell and ask other residents for cigarettes. Provider and POA updated. Resident is aware that POA is limiting how many cigarettes POA is bringing in. Interventions: Able to maintain smoking materials. Complete smoking safety assessment per facility policy. Encourage resident to not sell or ask other residents for cigarettes. Observe patient for unsafe smoking behaviors or attempts to obtain smoking [NAME] from outside sources. Immediately inform facility management. Review smoking policy with patient and or family. R2’s smoking assessment dated [DATE] states in part… Smoking Safety Interaction: 2. Which of the following products does resident use? Tobacco. 3. Does the resident display any of the following? Nothing marked. Care planning: Nothing marked. Clinical Suggestions: Nothing marked. 7/10/25 at 2:20 PM, R2 reported to Surveyor that he no longer smokes due to not having any cigarettes. On 7/10/25 at 2:50 PM, Surveyor observed R2 outside with R3 in the gazebo where they were taking cigarette butts out of the smoking receptacle. R3 and R2 are lighting the butts and passing them between themselves. On 7/11/25 at 9:37 AM, Surveyor reported observations of R3 and R2 and asked who monitors them for opening the smoking receptacles and taking out cigarette butts. LPN/UM B states, we just look out and watch. I know we should monitor. On 7/10/25 at 9:43 AM, Surveyor interviewed Receptionist D. Surveyor asked Receptionist D if he had or had heard of any concerns with residents who smoke. Receptionist D states, I have no real concerns but have had issues with cigarette butts being cleaned up. There was a receptacle, but it began overflowing so the residents began throwing their cigarette butts on the ground. When we were emptying the smoking receptacle this morning it was kicking up ash and smoke, so I was asked to get a bucket of water. Surveyor asked Receptionist D if there are any residents who require supervision with smoking. Receptionist D states, we don’t have any residents that require supervision. On 7/10/25 at 2:15 PM, Surveyor interviewed CNA E. Surveyor asked CNA E if she had any concerns with resident safety in the smoking area. CNA E stated I don’t have any concerns for resident safety, but the area is disgusting. On 7/10/25 at 2:40 PM, Surveyor interviewed LPN F. Surveyor asked LPN F if any residents require supervision while smoking. LPN F states that no residents require supervision. Surveyor asked LPN F what the facility process is to ensure residents are safe while smoking. LPN F states that residents are screened to see if they are able to smoke independently. Surveyor asked LPN F if the facility has any smoking aprons. LPN F states we have no smoking aprons but do have smoking blankets and fire extinguisher hanging on the gazebo/smoking area. Surveyor asked LPN F what the facility does if a resident is noted to not be safe smoking independently. The LPN F indicates that if a resident deemed unsafe a care plan should be created, and interventions put in place. Surveyor asked the LPN F what is done with residents smoking materials. LPN F states that residents keep their own smoking materials in their room or on their person. On 7/11/25 at 7:48 AM, Surveyor interviewed CNA H. Surveyor asked CNA H if she had ever observed any residents who smoked being unsafe. CNA H stated I have never observed any unsafe smoking, but I do not observe smoking. If I did see any unsafe smoking, I would report to management. Surveyor asked CNA H if the facility did supervised smoking. CNA H states that there are no supervised smokers that she knows of. Surveyor asked the CNA H if the facility had any smoking aprons for residents to use. The CNA H stated that there are smoking aprons in back area behind receptionist, by the door leading outside to smoking area. On 7/11/25 at 8;05 AM, Surveyor interviewed MT/CNA I. Surveyor asked MT/CNA I if she had supervised residents smoking. MT/CNA I states that she has never observed residents smoking and there are no smoking times, open ended. Residents can go at any time they wish to smoke. A few months ago, the smoking area was changed from the front of building to the courtyard/gazebo area. Surveyor asked MT/CNA I if she had ever witnessed any unsafe smoking behavior. MT/CNA I states that she has never witnessed any unsafe smoking practices or seen any resident with burn holes. On 7/11/25 at 8:30 AM, Surveyor interviewed CNA J. Surveyor asked CNA J if she knew who the residents who smoke are and if they require supervision. CNA J states, I know who the smokers are, but no supervision is needed that I know of for any residents, they can smoke anytime they want. Surveyor asked CNA J if she had ever seen any burn holes in residents clothing. CNA J states she has never seen any burn holes in anyone’s clothing and if she did, she would report to nurse right away. Surveyor asked CNA J if the facility has smoking aprons for residents to use. CNA J indicates that there are smoking aprons next to the door going outside to the smoking area. On 7/11/25 at 8:52 AM, Surveyor interviewed RN/MDS Coordinator G. Surveyor asked RN/MDS Coordinator the facility procedure for completing smoking assessments. RN/MDS Coordinator states that he would go out and observe patients while smoking. Document anything unsafe that could cause harm. Surveyor asked RN/MDS Coordinator G who is able to complete residents smoking assessments. RN/MDS Coordinator G states that smoking assessments can be completed by anyone. Surveyor asked RN/MDS Coordinator G if he has completed any of the smoking assessments on the residents who smoke. RN/MDS Coordinator G stated he was last in the facility sometime in March. Surveyor asked RN/MDS Coordinator G what the expectations would be for completing the smoking assessments. RN/MDS Coordinator G stated he would expect whoever is completing the assessments to physically watch the residents smoke and if seeing anything unsafe this would be put on the assessment when it is gone through and completed. Surveyor asked RN/MDS Coordinator G about the boxes not marked on the smoking assessment. RN/MDS Coordinator G states that if boxes are not marked on the assessment, it indicates that there was nothing seen. I don’t normally complete the smoking assessments but think I was there helping the facility out at the time the assessments were completed in March. On 7/11/25 at 9:30 AM, Surveyor interviewed NHA A. Surveyor asked NHA A what the procedure was for a resident who admits to the facility and smokes. NHA A stated, I am not sure, but I can get that information for you. Surveyor asked NHA A who assesses the resident who smoke. NHA A stated, I am not sure, but I can get that information for you. Surveyor asked NHA A who determines what interventions are put in place. NHA A stated, I am not sure, but I can get that information for you. Surveyor asked NHA A who creates the care plans for residents who smoke and puts interventions in place. NHA A stated, I am not sure, but I can get that information for you. Surveyor asked NHA A who monitors smokers with known concerns when out smoking. NHA A stated, I am not sure, but I can get that information for you. On 7/11/25 at 9:37 AM, NHA A and LPN/UM B returned to answer questions regarding smoking that NHA A was unable to previously answer. NHA A states that on admission a smoking assessment is completed and if determined to be unsafe they would be unable to smoke. LPN/UM B states, if a resident is unsafe, we would assess and make decisions of what would be safe. If unsafe would offer patch, or supervised smoking. NHA A states that the IDT (interdisciplinary team) completes the assessments by watching residents’ smoke. Safety assessments can be completed by the social worker, LPN or RN. The RN should follow up and sign the assessment. LPN/UM B states that depending on what the smoking assessment states we would sit down as a team and come up with interventions. The care plans and any changes are made by the social worker and nursing staff. Surveyor asked how often residents are monitored when out in the smoking area. LPN/UM B states, staff will peek out occasionally. We have no one that needs monitoring. We would reassess though if a resident had a change of condition that would warrant it. Surveyor asked NHA A and LPN/UM B if they had ever witnessed burn holes in R11’s clothing. LPN/UM B states that she has never seen burn holes but would expect that staff would report burn holes in clothing if observed and a new assessment would be done. The facility's failure to ensure residents are safe while smoking led to a finding of immediate jeopardy. The immediate jeopardy was removed on 7/16/25 when the facility implemented the following action plan: Assessed all residents who smoke to evaluate their physical and cognitive capabilities. Identified residents who require supervision or adaptive equipment during smoking. Updated each resident's care plan to reflect safe smoking inte

Based on interview and record review the facility did not ensure 2 of 2 non nursing staff chosen at random receive behavior health training.Cook-L and Housekeeping-M did not receive annual behavioral health training.Findings include:1.) Cook-L was hired on 10/2/23.On 7/23/25, at 11:38 a.m., Surveyor requested in-service training for 6 randomly selected nursing staff and 2 non nursing staff including Cook-L.On 7/23/25, at 1:38 p.m., Surveyor reviewed Cook-L's in-service training provided. Surveyor was unable to locate when Cook-L received behavioral health training.On 7/23/25, at 2:30 p.m., Surveyor asked Corporate-N who Surveyor should speak to regarding training for non-nursing staff. Corporate-N informed Surveyor the Administrator is responsible for non-nursing training.On 7/23/25, at 2:46 p.m., Surveyor informed Nursing Home Administrator (NHA)-A Surveyor was not able to locate when Cook-L received behavioral health training. NHA-A informed Surveyor he will look into this and get back to Surveyor.On 7/23/25, at 3:22 p.m., NHA-A informed Surveyor he does not have any training for Surveyor. Surveyor asked NHA-A who is responsible to ensure non nursing staff receive their required training. NHA-A replied that would be the Administrator.2.) Housekeeping-M was hired on 4/12/24.On 7/23/25, at 11:38 a.m., Surveyor requested in-service training for 6 randomly selected nursing staff and 2 non nursing staff including Housekeeping-M.On 7/23/25, at 1:38 p.m., Surveyor reviewed Housekeeping-M's in-service training provided. Surveyor was unable to locate when Housekeeping-M received behavioral health training.On 7/23/25, at 2:30 p.m., Surveyor asked Corporate-N who Surveyor should speak to regarding training for non-nursing staff. Corporate-N informed Surveyor the Administrator is responsible for non-nursing training.On 7/23/25, at 2:46 p.m., Surveyor informed Nursing Home Administrator (NHA)-A Surveyor was not able to locate when Housekeeping-M received behavioral health training. NHA-A informed Surveyor he will look into this and get back to Surveyor.On 7/23/25, at 3:22 p.m., NHA-A informed Surveyor he does not have any training for Surveyor. Surveyor asked NHA-A who is responsible to ensure non nursing staff receive their required training. NHA-A replied that would be the Administrator.

Based on observation, interview, and record review, the facility did not provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 2 of 2 residents (R2 and R3) reviewed out of a total sample of 13 residents. R2 reported that he no longer smoked then was observed by Surveyors going through the smoking receptacle removing cigarette butts to smoke. The facility did not offer R2 any alternatives for smoking such as smoking cessation options. R3 is noted to have documented behaviors of going to smoking receptacles to pull out cigarette butts to smoke, asking other residents and staff or cigarettes and taking cigarettes out of other residents hands. The facility failed to offer R3 smoking alternatives such as smoking cessation options.This is evidenced by:The facility policy titled Social Services last reviewed January 2025, states in part, .Policy: The facility, regardless of size, will provide medically related social services to each resident, to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Policy Explanation and Compliance Guidelines: 2. The facility, regardless of size, will provide medically related social services to each resident, to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 4. The social worker, or social service designee, will pursue the provision of any identified need for medically related social services of the resident. Attempts to meet the needs of the resident will be handled by the appropriate discipline(s). Services to meet the resident's needs may include: a. Advocating for residents and assisting them in assertion of their rights within the facility. b. Assisting residents in voicing and obtaining resolution to grievances about treatment, living conditions, visitation rights and accommodation of needs. d. Making arrangement for obtaining items, such as adaptive equipment, clothing, and personal items. e. Maintaining contact with the facility (with the resident's permission) to report on changes in health, current goals, discharge planning, and encouragement to participate in care planning. f. Assisting with informing and educating residents, their family, and/or representative(s) about health care options and their ramifications. j. Providing or arranging for needed mental and psychosocial counseling services. k. Identifying and seeking ways to support residents' individual needs through the assessment and care planning process. n. Identifying and promoting individualized, non-pharmacological approaches to care that meet the mental and psychosocial needs of each resident. 6. The resident's plan of care will reflect any ongoing medically related social service needs, and how these needs are being addressed. 7. The social worker, or social service designee, will monitor the resident's progress in improving physical, mental, and psychosocial functioning.Example 1R3 is a [AGE] year-old male admitted to the facility on [DATE]. R3 has a BIMS (brief interview of mental status) of 10, indicating R3 has moderate cognitive impairment. R3's diagnoses include in part. paranoid schizophrenia, borderline personality disorder, encephalopathy, seizures, pulmonary embolism with acute cor pulmonale (where a blood clot acutely obstructs blood flow in the lungs, leading to a sudden strain on the right ventricle of the heart, causing it to fail). R3's care plan states in part.Diagnosis: Tobacco Use. Interventions/Tasks: Conduct Smoking Safety Evaluation on admission and PRN (as needed). Educate Resident/Responsible Party on the facility's tobacco/smoking policy(s). If a smoking facility, orient Resident to smoking times and procedures. Diagnosis: I sometimes have behaviors which include refusing personal cares and bathing. Asking residents for cigarettes and money. I sometimes have behaviors due to decrease in the amount of money that I am given from my guardian. Interventions: Continue to encourage and educate resident on the importance of cleanliness and maintaining good personal hygiene. Help me to avoid situations or people that are upsetting to me. Please tell me what you are going to do before you begin. Redirect me and remind me that its not appropriate to ask residents for money and cigarettes. Diagnosis: At risk for smoking related injury related to independent smoking. Able to maintain smoking materials. At times I look for cigarettes in the garbage and cigarette canister outside. When I am out of cigarettes, I will ask other residents and visitors for cigarettes. I will try to take cigarettes out of other residents hands. I am easily redirected and do not pose a threat to others. Interventions: Complete smoking safety assessment per Living Center policy. Keep my lighter in the nurses cart while I'm not outside smoking to keep myself safe. Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources. Immediately inform facility management. Redirect me if I am searching for cigarettes in the garbage or cigarette canister. Review smoking policy with patient and or family.Note: R3's care plan address behaviors and provides interventions, it does not provide R3 with alternatives to smoking when cigarettes are unavailable to him or for the option of quitting smoking. Example 2R2 is a [AGE] year-old male, admitted to the facility on [DATE]. R2 has a BIMS of 13, indicating that she is cognitively intact. R2's diagnoses include in part. Diabetes Mellitus Type 2, dementia, bipolar disorder, developmental disorder of scholastic skills, PVD (peripheral vascular disease), Klinefelter Syndrome (extra X chromosome).R2's care plan states in part.Diagnosis: At risk for smoking related injury related to: Smokes independently. Able to maintain smoking materials. Resident has a history of trying to sell and ask other residents for cigarettes. Provider and POA updated. Resident is aware that POA is limiting how many cigarettes POA is bringing in. Interventions: Able to maintain smoking materials. Complete smoking safety assessment per facility policy. Encourage resident to not sell or ask other residents for cigarettes. Observe patient for unsafe smoking behaviors or attempts to obtain smoking [NAME] from outside sources. Immediately inform facility management. Review smoking policy with patient and or family. On 7/11/25 at 11:35 AM, Surveyor interviewed LPN/UM. Surveyor asked LPN/UM if the facility has tried any alternatives to smoking, such as smoking cessation, for R2 and R3. LPN/UM states, no we have not. Surveyor was unable to interview Social Worker as she was out of the building.

Based on interview and record review the facility did not ensure 1 of 2 non nursing staff chosen at random received resident rights and facility responsibilities training.Cook-L did not receive resident rights and facility responsibilities training annually.Findings include:Cook-L was hired on 10/2/23.On 7/23/25, at 11:38 a.m., Surveyor requested in-service training for 6 randomly selected nursing staff and 2 non nursing staff including Cook-L.On 7/23/25, at 1:38 p.m., Surveyor reviewed Cook-L in-service training provided. Surveyor noted Cook-L received resident rights and facility responsibilities on 10/2/23. Cook-L did not receive these trainings after 10/2/23.On 7/23/25, at 2:30 p.m., Surveyor asked Corporate-N who Surveyor should speak to regarding training for non-nursing staff. Corporate-N informed Surveyor the Administrator is responsible for non-nursing training.On 7/23/25, at 2:46 p.m., Surveyor informed Nursing Home Administrator (NHA)-A Surveyor was not able to locate when Cook-L received annual training for resident rights and facility responsibilities. NHA-A informed Surveyor he will look into this and get back to Surveyor.On 7/23/25, at 3:22 p.m., NHA-A informed Surveyor he does not have any training for Surveyor. Surveyor asked NHA-A who is responsible to ensure non nursing staff receive their required training. NHA-A replied that would be the Administrator.

Based on interview and record review the facility did not ensure 1 of 2 non nursing staff chosen at random received abuse, neglect, exploitation, and dementia training.Cook-L did not receive annual abuse, neglect, exploitation, and dementia training.Findings include:Cook-L was hired on 10/2/23.On 7/23/25, at 11:38 a.m., Surveyor requested in-service training for 6 randomly selected nursing staff and 2 non nursing staff including Cook-L.On 7/23/25, at 1:38 p.m., Surveyor reviewed Cook-L in-service training provided. Surveyor noted Cook-L received abuse, neglect, exploitation on 10/2/23. Cook-L received dementia management & abuse prevention on 10/2/23. Cook-L did not receive these trainings after 10/2/23.On 7/23/25, at 2:30 p.m., Surveyor asked Corporate-N who Surveyor should speak to regarding training for non-nursing staff. Corporate-N informed Surveyor the Administrator is responsible for non-nursing training.On 7/23/25, at 2:46 p.m., Surveyor informed Nursing Home Administrator (NHA)-A Surveyor was not able to locate when Cook-L received annual training for abuse, neglect, exploitation, and dementia training. NHA-A informed Surveyor he will look into this and get back to Surveyor.On 7/23/25, at 3:22 p.m., NHA-A informed Surveyor he does not have any training for Surveyor. Surveyor asked NHA-A who is responsible to ensure non nursing staff receive their required training. NHA-A replied that would be the Administrator.

Based on interview and record review the facility did not ensure 1 of 2 non nursing staff chosen at random received QAPI (quality assurance performance improvement) training.Cook-L did not receive annual QAPI training.Findings include:Cook-L was hired on 10/2/23.On 7/23/25, at 11:38 a.m., Surveyor requested in-service training for 6 randomly selected nursing staff and 2 non nursing staff including Cook-L.On 7/23/25, at 1:38 p.m., Surveyor reviewed Cook-L's in-service training provided. Surveyor noted Cook-L received elements and goals of QAPI (quality assurance performance improvement) program on 10/2/23. Cook-L did not receive these trainings after 10/2/23.On 7/23/25, at 2:30 p.m., Surveyor asked Corporate-N who Surveyor should speak to regarding training for non-nursing staff. Corporate-N informed Surveyor the Administrator is responsible for non-nursing training.On 7/23/25, at 2:46 p.m., Surveyor informed Nursing Home Administrator (NHA)-A Surveyor was not able to locate when Cook-L received annual QAPI training. NHA-A informed Surveyor he will look into this and get back to Surveyor.On 7/23/25, at 3:22 p.m., NHA-A informed Surveyor he does not have any training for Surveyor. Surveyor asked NHA-A who is responsible to ensure non nursing staff receive their required training. NHA-A replied that would be the Administrator.

Based on interview and record review, the facility did not ensure staff postings were accurate which has the potential to affect 24 out of 24 residents residing at the facility.Review of staffing schedules and required staff postings revealed discrepancies between the documents. This resulted in inaccuracies with the total number and the actual hours worked for licensed and non-licensed staff directly responsible for resident care each shift.Evidenced by:Facility policy entitled ‘Nurse Staffing Posting Information,' dated 01/2025, states in part: It is the policy of this facility to make nurse staffing information readily available in a readable format to residents and visitors at any given time.1. The Nurse staffing sheet will be posted on a daily basis and will contain the following information: a. Facility name. b. The current date c. Facility's current resident census. D. the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. i. Registered Nurse ii. Licensed Practical Nurses/Licensed Vocational Nurses. Iii. Certified Nurse Aides. 2. The facility will post the Nurse Staffing Sheet at the beginning of each shift. 3. The information posted will be: a. present in a clear and readable format.The schedules and Census posting were in accurate on the following dates:On 6/21/25 the Census posting indicates for the AM shift that 2 CNA's (Certified Nursing Assistants) worked the entire shift with a total of 21.5 hours. The scheduled for AM shift indicates 2 CNA's worked a full shift and 1 CNA worked a half shift. The Census posting shows on PM shift that there were 3 CNA's in the building when the schedule shows 3 CNA's and a Medication Tech, which would make 4 CNA's on PM shift.On 6/23/25 The Census posting is not presented in a clear format. The Census form indicates 4 CNAs worked the AM shift, when the schedule shows Two CNA's, a medication tech and then one CNA in training.(Of note: the CNA in training is being counted in the census posting numbers.)On 6/25/25, the Census posting for NOC (night shift) shows 3 CNA's were working and the schedule shows 2 CNA's were working with 1 CNA training. On 6/27/25, the Census posting for PM shows 4 CNA's were working and the schedule shows 3 CNA's were working with 1 CNA training.On 6/28/25, the Census posting is not in a clear format to be read. The census posting shows there was 1 LPN (licensed Practical Nurse) and no RN working. The scheduled shows there was an LPN and 1 RN working.On 6/30/25, the census posting is not in a clear format to read. On PM shift the census posting indicates there are 4 CNA's and the schedule indicates 3 CNAs with 1 trainee. The Census posting for NOC shift indicates 3 CNAs worked when the schedule reflects 1 CNA worked the entire shift with 1 Trainee and they had 1 call in.On 7/2/25, the Census posting for NOC shows three CNA's were working and the schedule shows 2 CNA's were working with 1 CNA training.On 7/4/25, the Census posting is not in a clear format to read. Census posting indicates for PM shows 3 CNAs were worked a full shift (2pm-10pm) and the schedule shows Two CNA worked 2pm to 7pm and two other CNA's came in at 7pm.On 7/7/25, the Census posting indicates for NOC shift, 3 CNA's worked and the schedule shows 2 CNA worked with 1 trainee.On 7/8/25, the Census posting indicates for AM shift, 5 CNA's worked and the schedule shows 3 CNA's, 1 Medication tech and 1 trainee. Census posting indicated for PM shift 3 CNA's worked the entire 2p-10pm shift, when the schedule shows 2 CNA's worked a full shift and 1 left at 3:30pm.On 7/11/25 at 11:30AM, Surveyor interviewed Scheduler K while reviewing the census posting and schedules from the last 3 weeks with Scheduler K. Scheduler K indicated the hours marked should equal up to the correct CNA hours. Scheduler K indicated the census posting should be updated to reflect staff leaving early or calling off. Surveyor asked if trainees should be counted in CNA's hours, Scheduler K indicated some nurses do and some nurses don't, but they should not be counted. Surveyor asked Scheduler K if the census posting for 7/4/25, 6/30/25, 6/28/25 and 6/23/25 were legible, Scheduler K stated, not really. Surveyor asked who is responsible for updating the posting, Scheduler K indicated the nurses are if she's not here otherwise Scheduler K. Scheduler K indicated it should be accurate and posting should be readable. On 7/11/25 at 11:45 AM, Surveyor spoke with NHA A (Nursing Home Administrator) regarding concerns with Census posting not matching the schedule and vice versa. NHA A indicated they should match and be accurate.

Based on interview and record review, the facility did not ensure 2 of 12 residents (R25 and R19) reviewed received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. *R25 has a history of depression and receives medication to treat depression. The facility did not have a care plan, with resident specific interventions in place, upon R25's admission to the facility. R25 displayed multiple behaviors of depression including social isolation, refusals of care, refusal of multiple meals, and meal intake was low since R25's admission. R25's primary Nurse Practitioner (NP)-H, was not notified of R25's low meal intake. Fifteen days after admission, facility staff documented R25 had a 30.4-pound weight loss which is 15.7% of R25's body weight. NP-H was not notified of R25's significant weight loss. On 3/20/25, Dietician-C documented that facility staff would offer a trial of Prostat for supplemental calories and protein to support weight stability and recommended a possible psychological evaluation of R25. A physician order for Prostat was not placed at that time and Surveyor did not locate documentation that the Interdisciplinary Team (IDT) was consulted about R25's nutrition. R25 continued to display symptoms of depression and refusals of meals. From 3/27/25 through 3/31/25, R25's documented fluid intake (total amount of fluid drank by R25) was less than 500 milliliters (mls) per day and output (urine output) was minimal Dietician-C was not notified of R25's low fluid intake. NP-H was not notified of R25's low fluid intake and output. On 4/1/25, NP-H assessed R25 between 8 AM and 9 AM. NP-H documented that R25 appeared to be in distress and ordered STAT (immediate) labs to be drawn. These labs were not ordered as STAT. Results of the labs were not completed until after 6 PM on 4/1/25. The labs reported that R25 had a critical low potassium level of 2.2 and NP-H ordered that R25 should be sent to the hospital. R25 was hospitalized with severe sepsis (a life-threatening condition), C-diff infection, pulmonary embolism, and hypokalemia (low potassium). R25 required a stay in the intensive care unit and returned to the facility on 4/4/25. R25's meal and fluid intake continued to be low. R25 was sent to the emergency room again on 4/9/25 with dehydration and a low potassium level of 2.5. The facility's failure to recognize and treat R25's depressive symptoms and failure to recognize R25's significant weight loss created a finding of immediate jeopardy that began on 3/20/25 when Dietician-C noted a 15.7% weight loss in 15 days. Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were notified of the immediate jeopardy on 4/10/25 at 3:34 PM. The immediate jeopardy was removed on 4/11/25, however the deficient practice continues at a scope/severity level of D based on the following example: * R19 had a fall from the bed on 7/21/24. R19 was sent to the emergency room after the fall and diagnosed with a closed head injury. The facility policy states that neurological (neuro) checks should be completed after a fall with head injury. The facility did not provide evidence that neuro checks were completed after R19's fall. Findings include: The facility's policy, dated 10/1/2022 and titled, Behavioral Health Services documents in part: It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning . The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goals for care, while maximizing the residents dignity, autonomy, privacy, socialization, independence, choice, and safety . the facility utilizes the comprehensive assessment process for identifying and assessing a residence mental and psychosocial status and providing person centered care period this process includes, but is not limited to: . Ongoing monitoring of mood and behavior. Care plan development and implementation. Evaluation .The resident, and as appropriate the resident's family, are included in the comprehensive assessment process along with the interdisciplinary team and outside sources, as indicated. The care plan shall: Have interventions that are person-centered, evidence based, culturally competent, trauma-informed, and in accordance with professional standards of practice. Provide for meaningful activities which promote engagement and positive, meaningful relationships Reflect the resident's goals for care. Account for the resident's experiences and preferences . Use pharmacological interventions only when non-pharmacological interventions are ineffective or when clinically indicated . Be reviewed and revised as needed, such as when interventions are not effective or when the resident experiences a change in condition . examples of individualized, non-pharmacological interventions to help meet behavioral health needs of all ages may include, but are not limited to: ensuring adequate hydration and nutrition (e.g., enhance taste and presentation of food, addressing food preferences to improve appetite and reduce the need for medications intended to stimulate appetite); . Pain relief . Assisting residents with access to therapies such as psychotherapy, behavior modification, cognitive behavioral therapy, and problem solving therapy . The Social Services Director shall serve as the facility's contact person for questions regarding behavioral services provided by the facility and outside sources such as physician, psychiatrists, or neurologist. The facility's policy dated 3/1/2019 and titled, Notification of Changes Policy documents, in part: It is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident's representative, according to their authority, and reported to the attending physician or delegate (hereafter designated as the physician). The resident and/or their representative will be educated about treatment options and supported to make an informed choice about care preferences when there are multiple care options available. All pertinent information will be made available to the provider by the facility staff. Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative, and the resident's physician, to ensure best outcomes of care for the resident . The objective of the notification policy is to ensure that the facility staff makes appropriate notification to the physician and delegated Non-Physician Practitioner and immediate notification to the resident and/or the resident representative when there is a change in the resident's condition . The intent of the policy is to provide appropriate and timely information about changes relevant to a resident's condition or change in room or roommate to the parties who will make decisions about care, treatment and preferences to address the changes . Requirements for notification of resident, the resident representative and their physician: . A significant change in the resident's physical, mental, or psychosocial status. A significant change includes deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications . Notification is provided to the physician to facilitate continuity of care and obtain input from the physician about changes, additions to or discontinuation of treatments . 1.) R25 was admitted to the facility on [DATE] with diagnoses that include fracture of right tibia status post open reduction and internal fixation surgery, major depressive disorder, Gastro-esophageal reflux (GERD), Osteoarthritis, and Cellulitis of Right leg. R25's admission Minimum Data Set (MDS) assessment dated [DATE] documents that R25 is cognitively intact. R25 displays verbal behavioral symptoms directed toward others 4-6 days in a 7-day period. R25 has rejections of care 1 to 3 days in a 7-day period. R25 requires set up or clean-up assistance for eating. R25 is dependent for toileting, bed mobility, and transfers. R25 is frequently incontinent of bladder and always incontinent of bowel. R25's at risk for malnutrition care plan initiated on 3/4/25 documents that R25 is at risk related to potential inadequate food/beverage intake with history of depression, GERD and recent surgical intervention for [leg fracture]. Increased nutrition needs for wound healing. Patterns of unfavorable weight change. Interventions include: Diet as ordered. Monitor for [signs and symptoms] of depression. Monitor meal consumption daily, encourage meal and snacks intake as able. Offer food preferences. Encourage family/friends to bring in favorite food items. R25's Gastrointestinal distress due to GERD care plan initiated on 2/28/25 documents the following pertinent interventions: . Encourage patient to follow nutritional and hydration program . Labs per Physician order and [as needed] for change in condition/manifestation of clinical signs or symptoms . Monitor weights and appetite. Report any significant findings to Physician. R25's Refusal care plan initiated on 2/28/25 documents: [R25] sometimes have (sic) behaviors which include refusing cares, therapy, getting up into wheelchair for appointments, and medications. Interventions include: Give me my medications as my doctor has ordered. Let my physician know if my behaviors are interfering with my daily living. Make sure I am not in pain or uncomfortable and offer pain medications prior to therapy or getting up. Offer me something I like as a diversion. Please tell me what you are going to do before you begin. Speak to me unhurriedly and in a calm voice. R25's MD orders dated 3/3/25 include: -Cephalexin oral capsule 500 milligrams (mg). Give one capsule by mouth four times a day related to cellulitis of right lower limb until 3/13/25. -Oxycodone 5mg by mouth every 8 hours as needed for pain control related to pain in right leg. -Daily weight for 3 days upon admission. Every day shift for monitoring for 3 days. -Monitor-behavior symptoms (frequent crying, repeats verbalization, repeats movement, yelling/screaming, kicking/hitting, pinching/scratching/spitting, biting, wandering, abusive language, threatening behavior, sexually inappropriate, rejection of care) every shift for monitoring. -Resident receives an antidepressant. Document number of times per shift that any of these behaviors occurred: states feel [sic] sad or depressed, crying, tearfulness, social isolation. -Fluoxetine HCL oral tablet 10mg. Give 1 tablet by mouth one time day for depression related to Major depressive disorder. Surveyor noted that R25 has a diagnosis of Major Depressive disorder and is currently taking Fluoxetine (an antipsychotic/antidepressant medication). Surveyor could not locate a care plan with person-centered interventions for R25's Depression. On 4/10/25 at 9:30 AM, Surveyor interviewed Social Worker (SW)-D. Surveyor asked who is supposed to put a care plan in place for residents who are on an antipsychotic for depression. SW-D stated the previous MDS coordinator would typically place the care plan, but they no longer work for the facility. SW-D stated the nurse would enter the care plan. Surveyor asked if SW-D should be entering a depression care plan. SW-D stated SW-D has not played a part in that since being in the Social Work role. Surveyor asked if R25 should have a depression care plan. SW-D stated yes. On 4/10/25 at 10:14 AM, Surveyor interviewed DON-B. Surveyor asked who is supposed to put a care plan in place for residents who are on an antipsychotic for depression. DON-B stated Social Services. Surveyor asked if R25 should have a care plan for R25's diagnosed depression. DON-B stated yes. Surveyor asked if DON-B could locate a depression care plan for R25. DON-B stated DON-B thought R25 had one but did not locate one within the medical record. Surveyor noted the discrepancy between SW-D and DON-B in who is supposed to place a care plan for an antipsychotic medication. R25's Dietary note dated 3/4/25 documents, in part: . Current Diet order: Regular diet, regular texture, thin liquids. PO intake: 25-50% of meals consumed. Feeding Ability: Independent. Chewing/swallowing: no concerns noted. Supplements: [not applicable] . Food Preferences: Honor preferences as able, [R25] shared with [Director of Nursing] that [R25] likes raisin bran. Labs: hospital labs (2/27/25) . [Potassium] 4.7 [within normal limits]. Weight: Hospital wt.: 193 [pounds]. [R25] reports poor appetite, [R25] refuses nutrition interview and states to writer that you try to talk to me about this every day, I have more important things that I need to worry about right now. [R25] also has refused height and weight measurements when staff attempted since admission . No skin concerns noted. Will continue to attempt to obtain nutrition and weight history, preferences as able, will monitor for height and weight data to assess nutritional needs and monitor intake patterns for improvement vs need to consider supplementation. Goals are for nutrition intake to be adequate in meeting nutritional needs as evidenced by weight stability [without] significant change, improved or stable hydration status, labs and skin integrity. R25's Treatment Administration Record (TAR) documents that R25 refused daily weights three times since admission. On 3/6/25 at 8:50 AM, R25's electronic Medication Administration (eMAR) note for behavior monitoring documents: repeat verbalization, kicking/hitting, sexually inappropriate, rejection of care, social isolation. On 3/7/25 at 12:42 AM, R25's eMAR note for behavior monitoring documents: frequent crying, yelling, screaming, rejection of care. On 3/11/25 at 2:07 PM, R25's eMAR note for weight documents: Refused. On 3/14/25 at 7 AM, R25's eMAR behavior note documents: Frequent crying, repeat verbalization, yelling, screaming, abusive language. Surveyor noted R25 had documented behaviors of depression including refusals and no new interventions were placed by facility staff to address these behaviors. On 3/14/25, R25's skin assessment documents a pressure injury. The facility documents a deep tissue injury (DTI) developed on R25's left heel. The facility implemented a DTI actual pressure ulcer care plan and implemented a treatment for R25's facility-acquired pressure injury. Surveyor reviewed R25's Meal Intake task. Surveyor noted that from admission [DATE]) until 3/21/25, R25 had 4 days where R25 had documentation of 3 meals consumed. All other days the resident refused at least one meal per day. Surveyor noted that with the meals eaten: 8 meals were documented as 0 to 25% consumed, 6 were documented as 26 to 50% consumed, 4 were documented as 51 to 75% consumed, and 7 were documented as 76 to 100% consumed. Surveyor noted that most of the meals consumed by R25 were less than 51% eaten. On 4/9/25 at 11:55 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-M. CNA-M stated R25 just doesn't eat. CNA-M indicated R25 almost always refuses R25's food. On 4/9/25 at 12:33 PM, Surveyor interviewed Medication Technician (MT)-L. MT-L indicated R25 would consistently refuse food. MT-L stated MT-L would offer alternatives but R25 was not always receptive. MT-L stated MT-L approached nursing staff about R25's appetite and lack of food taken in. MT-L stated MT-L told nursing staff that R25 needed supplements since R25 was not eating well enough. MT-L indicated MT-L does not think MT-L's concerns about R25's meal intake were taken seriously. Surveyor noted staff awareness and concerns about R25's meal intake. On 3/18/25 at 11:22 AM, facility staff documented a weight of 163 pounds. On 3/20/25 at 9:42 PM, Dietician-C completed a dietary note which documents in part: . [R25] is noted to have new pressure injury to [left] heel . Meal intake has been variable, [R25] has been refusing most meals over the past 2 days . Weight: (3/18/25): 163 [pounds] . Compared to documented dosing weight per hospital records, current weight reflects significant loss of 30.4 [pounds]/15.7% . Estimated Needs: . Calories: 1850-2220 kcal . Fluid: 2220 ml . [R25] continues to refuse conversation with writer regarding nutrition preferences and needs . [R25] has been refusing meals over the past couple of days and intake prior to that was variable ranging from 25% to 75% . Current weight reflects a significant loss of 15.7% compared to hospital measurements . Spoke with nursing staff this evening, nurse, [name of nurse] on duty will offer a trial of Prostat to [R25] when [nurse] does the next medication pass to see if [R25] would agree to taking this for supplemental [calories] and protein to support weight stability and skin healing. Will review with IDT, for additional considerations, including possible psych evaluation. Will continue to monitor and encourage meal intake, monitor weight pattern and hydration status, monitor for wound assessments. Goal for nutrition intake to remain adequate in preventing significant weight loss, improving skin status, improved or stable labs and hydration status. Surveyor reviewed R25's MD orders and did not locate evidence that a trial of Prostat was ordered to start on 3/21/25. Surveyor reviewed R25's medical record and did not locate documentation of an IDT note indicating that R25 nutrition status was discussed. Surveyor reviewed R25's medical record and did not locate documentation that R25's primary care provider was notified of R25's weight loss and refusals to eat. On 3/20/25, a new intervention was added to R25's care plan: Nutrition status adequate to promote stable or improved skin status. Surveyor noted R25's 15.7% weight loss and R25's multiple refusals of meals. Surveyor noted that an intervention or MD order for accurate Intake and Output with parameters was not added to R25's plan of care. On 3/21/25 at 7:01 AM, a dietary note documents: [R25] was given Ensure by PM nurse per dietitian recommendation . Nurse removed cup of ensure at [4 AM] from room since it had been in there too long. Cup still full, [R25] stated it was too sweet. Surveyor noted a trial of Ensure was given, not Prostat as was documented to be trialed in Dietician note on 3/20/25. On 4/14/25 at 9:34 AM, DON-B gave Surveyor a copy of an email sent by Dietician-C dated 3/20/25 which documents, in part: R25 continues to refuse to talk to [Dietician-C] . [Dietician-C] spoke to the nurse, [name of nurse], this evening, [name of nurse] is going to try Prostat with [R25] to see if [R25] will take it. [R25] is not eating well. [R25] has snacks in [R25's] room brought from family, not eating these either. [Dietician-C] put [R25] on our [Nutritionally at Risk] NAR list for tomorrow and [name of nurse] said that [nurse] would document if [R25] was accepting of the Prostat or anything else that [nurse] offered tonight. On 4/14/25, DON-B also provided a summary of the facility NAR meeting conducted on 3/21/25. The summary documents in part: R25's significant weight loss and refusal of meals and wound care were highlighted. They considered using yogurt and Prostat to improve [R25's] nutrition . Surveyor did not locate an MD order or documentation that Prostat or yogurt was trialed or implemented on 3/20/25 or 3/21/25. On 4/10/25 at 12:06 PM, Surveyor interviewed Dietician-C about R25's significant weight loss. Dietician-C stated Dietician-C used a weight that was documented in R25's hospital record before R25's admission to the facility to calculate the weight loss. Dietician-C indicated R25's weight is something that Dietician-C was going to keep an eye on and trend what was happening. Dietician-C stated at first, anesthesia from R25's leg surgery could influence R25's meal intake at admission. Dietician-C indicated Dietician-C was going to let things settle at first. Dietician-C stated staff stated it is difficult to convince R25 to eat. Dietician-C stated R25 would refuse interviews with Dietician-C. Dietician-C stated family members would bring in some of R25's favorite foods and R25 would still refuse. Dietician-C stated R25 likes juice and was drinking appropriately. Surveyor asked if Dietician-C notified R25's primary care provider about the weight loss. Dietician-C stated Dietician-C does not communicate with the provider. Dietician-C stated Dietician-C would assume the nurses would let the provider know. Surveyor asked why the Prostat or other supplements were not ordered when the weight loss and new wound was discovered. Dietician-C stated Dietician-C spoke to the evening nurse who was going to trial Prostat and let the team know how R25 did with the trial. Dietician-C stated Dietician-C currently has R25 on supplements. Dietician-C stated R25 was refusing psych services but stated that there are medications that could help both psych symptoms and appetite. On 3/21/25 at 6:03 PM, R25's eMAR behavior note documents: crying, repeats verbalization, yells when [R25] wants a pain pill, rejection of care noted even after reviewed step by step what we will do. On 3/24/25 at 12:30 AM, R25's eMAR behavior note documents: crying or moaning often during the shift, might even be in her sleep. Surveyor reviewed R25's Meal intake task and noted R25 continued to refuse at least one meal a day and documented 0-25% consumed on any other meal eaten from 3/22 through 3/25/25. R25 refused all meals on 3/26/25. Surveyor reviewed R25's Medication Administration Record (MAR) from admission through 3/26/25. R25 was consistently taking 2 to 3 doses of Oxycodone narcotic pain medication a day. Surveyor reviewed R25's urine elimination task and noted from admission through 3/26/25, R25 had between 2 and 5 urine output occurrences per day. On 3/27/25, R25 had 0-25% of breakfast and lunch, and there is no documentation of meal consumption at dinner. R25 had a documented 400 mls of fluid intake. R25 had one urine output occurrence. R25 received one dose of Oxycodone. Surveyor noted R25's meal intake continued to be poor, R25's fluid intake is well below the recommended 2220 mls per day which resulted in only one urine output, and R25's use of pain medication is decreased from R25's typical pattern. On 3/28/25, R25 refused all meals. R25 had a documented 480 mls of fluid intake. R25 had one urine output occurrence. R25 received one dose of Oxycodone. Surveyor noted R25's food and fluid intake are well below the recommendations per day which resulted in only one urine output. Surveyor reviewed R25's medical record and did not find documentation that R25's primary care provider was notified of R25's concerning low fluid intake and low urine output on 3/27 and 3/28/25. On 4/9/25 at 2:56 PM, Surveyor interviewed DON-B. Surveyor asked if a resident has less than 500 mls of fluid intake for 2 days in a row, would DON-B expect the nurse to notify the primary provider. DON-B stated yes. DON-B stated the nurse would only know if the CNA told the nurse though so it would depend on communication. Surveyor asked if a resident had only one urine output in a 24-hour period, would DON-B be concerned. DON-B stated absolutely. Surveyor asked if a nurse should notify the primary provider of the low urine output. DON-B indicated yes. On 3/28/25 at 11:18 AM, R25's eMAR behavior note documents: Frequent crying, repeats verbalization, yelling, rejection of cares such as repositioning and wash ups only allows staff to wash her peri area . Resident declined diversional activities such as group activity, TV, movie, magazine, book, etc. Resident likes to just lay in [R25's] bed, multiple attempts made to offer. On 3/28/25 at 2:27 PM, R25's eMAR behavior note documents: Crying, social isolation. Surveyor noted R25 had documented continued behaviors of depression including refusals and no new interventions were placed by facility staff to address these behaviors. On 3/29/25 at 2:52 PM, R25's progress note documents: Resident refused to eat breakfast and lunch today. Writer encouraged resident to eat x3; resident refused. Fluids encouraged. On 3/29/25, facility staff documented that R25 had 3 soft, formed stools. R25 had 1080 mls of fluid intake and 4 urine output occurrences. R25 had one dose of Oxycodone. On 3/30/25, R25 refused breakfast and dinner and had 0-25% of lunch. R25 had 3 soft, formed stools. R25 had 1700 mls of fluid intake and 6 urine output occurrences. R25 did not receive Oxycodone. On 3/31/25, R25 had 0-25% of breakfast and lunch, and there is no documentation of meal consumption at dinner. R25 had a documented 500 mls of fluid intake. R25 had one soft, formed stool and 2 urine output occurrences. R25 had one dose of Oxycodone. Surveyor noted R25's meal intake continued to be poor, and R25's fluid intake is well below the recommended 2220 mls per day. Surveyor reviewed R25's medical record and did not find documentation that R25's primary care provider was notified of R25's concerning low fluid intake on 3/31/25. On 3/31/25 at 2:48 PM, R25's eMAR behavior note documents: Social isolation noted does not want to get out of bed. R25's MD orders entered on 3/31/25 documents: -House Supplement two times a day for poor appetite and meal intake. Provide 206 juice with breakfast and lunch daily. -Prostat two times a day for wound healing. Surveyor noted Prostat was added to R25's orders 11 days after Dietician-C documented a trial of this in Dietician-C's note. On 4/1/25, R25 did not have any recorded fluid intake. R25 refused 2 meals. R25 had 2 urine output occurrences. R25 did not receive Oxycodone. R25's Change of condition note entered on 4/1/25 at 9:31 AM documents, in part: . Seems different than usual . [blood pressure] 135/98. Pulse 97. [Respiratory Rate] 18. [Temperature] 97.6. Pulse Oximetry 93% . Mental Status evaluation: other symptoms or signs of delirium . Functional Status Evaluation: General weakness . Resident has been noted to have decreased eating the last couple of days. [R25] has been drinking water and [R25's] 7 up without any problems. Today [R25] was very dry and coughing. [Nurse Practitioner] in house and assessed [R25], requested labs afterwards. Peri area was assessed as well as [R25's] vitals and lungs and abdomen. After lab results returned, [Nurse Practitioner] requested that [R25] be sent out to ER for IV [potassium] [due to] [R25's] [potassium] being 2.2 . NP-H's visit note dated 4/1/25 documents, in part: The patient appears to be in distress with increased respirations and is reporting discomfort, though unwilling to elaborate on the specifics. The patient has been refusing to eat and has declined Prostat supplements . Nutritional status: Patient has been refusing to eat and declining Prostat supplements, raising concerns about nutritional status and potential electrolyte imbalances. Ordered stat [Complete blood count (CBC) and Basic metabolic panel (BMP)] . R25's MD order dated 4/1/25 documents: BMP and CBC today. One time only for labs-screening. Surveyor noted R25's labs were not ordered as STAT as documented in NP-H's visit note. Surveyor reviewed R25's Laboratory result dated 4/1/25 which documents in part: Specimen collected: 4/1/2025 10:27. Specimen Received 4/1/2025 [2:56] PM. Final Reported: 4/1/2025 [6:14] PM. Potassium 2.2 [Critical low]. Reference [NORMAL] Range 3.5-5.1. Surveyor noted 4-hour and 29-minute difference between the collection time and the time the specimen was received by the laboratory. Surveyor noted it took an additional 3 hours and 18 minutes to run the labs and get results. Surveyor noted it took a total of 7 hours and 47 minutes to complete the lab tests. On 4/10/25 at 8:56 AM, Surveyor interviewed NP-H regarding R25's change of condition. NP-H stated R25 was the first resident that NP-H visited on 4/1/25. NP-H stated NP-H evaluated R25 between 8 and 9 am. NP-H stated R25 seemed off but R25 was not good at vocalizing what was wrong. R25 just kept repeating that R25 did not feel good. R25 was also pointing at R25's peri-area. NP-H and DON-B assessed R25's peri-area and noted there was no redness or concerns. NP-H stated R25 kept saying that R25 was thirsty, and staff were giving R25 water. NP-H indicated R25's vitals were fine. NP-H stated NP-H ordered STAT labs, and the lab results came back between 6 and 7 PM that night. NP-H stated R25's potassium was 2.2 and NP-H ordered R25 be sent to the hospital. Surveyor asked what a reasonable amount of time would be for STAT labs to be resulted. NP-H stated, for NP-H, a STAT lab would be completed within a couple hours. Surveyor asked if NP-H was aware R25 had refused eating and had low food intake since admission. NP-H stated NP-H was told on 4/1/25 that R25 was not eating or drinking that much. NP-H stated NP-H found out that morning and was not notified prior of any refusals to eat. Surveyor asked if NP-H was aware of a 30.4-pound weight loss that occurred 15 days after R25 was admitted to the facility. NP-H stated NP-H was not aware of R25's weight loss. Surveyor asked if knowing about R25's weight loss and meal refusals would have changed how NP-H assessed and cared for R25. NP-H stated NP-H would have inquired more and would have gotten labs sooner. Specifically, NP-H would order a Complete Metabolic Panel and look at R25's albumin level. Surveyor asked if NP-H was made aware of R25's less than 500 mls of fluid intake that occurred on 3/27/25, 3/28/25, and 3/31/25. NP-H stated from what NP-H can recall, NP-H was only told of low food and fluid intake on 4/1/25. On 4/10/25 at 10:14 AM, Surveyor interviewed DON-B who entered R25's change of condition note on 4/1/25. DON-B stated on that morning, R25 was acting really goofy. R25 was calling out and wanted R25's peri area washed. DON-B stated DON-B and NP-H assessed R25's peri area and had no concerns. DON-B stated NP-H was going to order a urinalysis but R25 did not have an ounce of pee all day. DON-B stated R25 was also bringing R25's bedding to R25's mouth and rubbing it on R25's tongue. DON-B stated because of that NP-H and DON-B thought maybe R25 had thrush and R25 was tested for that. Surveyor asked why the STAT labs were not ordered and completed as STAT. DON-B stated the facility utilizes a Laboratory that is in a different state. DON-B stated for any lab, it takes at least four hours to get results. DON-B stated there is a local hospital with a lab close to the facility and DON-B does not understand why the facility has to use a Laboratory that is so far away. Surveyor asked if DON-B was aware of R25's significant weight loss. DON-B stated DON-B was aware. DON-B stated DON-B spoke to R25's family member who stated they did not believe R25 was ever 193 pounds. The family member told DON-B they did not believe that R25 has ever weighed over 180 pounds. DON-B continued and stated DON-B was not sure how involved the family member was because the family member was incarcerated for years. Surveyor asked if IDT reviewed R25's weight loss and nutrition. DON-B stated yes. Surveyor asked for documentation completed by IDT regarding R25's weight loss and nutrition. DON-B indicated DON-B would get back to Surveyor. Surveyor asked what was being done for R25's depression and the results of R25's behavior monitoring. DON-B stated the facility conducts behavior meetings regularly. Surveyor asked when the last behavioral meeting was. DON-B stated it was on the 18th of March. Surveyor asked if R25's behaviors were discussed. DON-B stated no because R25 had refused psych services multiple times. Surveyor asked if behaviors are discussed in the behavioral meetings even to identify non-pharmacological interventions that could be used. DON-B stated R25 was not discussed at all for non-pharmacological interventions because R25 refused psych services multiple times. DON-B indicated R25 would [TRUNCATED]

Based on observation, interview, and record review, the facility did not ensure 2 of 3 residents (R10 and R25) reviewed with pressure injuries had the necessary care and treatment to prevent and heal the pressure injuries. *On 3/11/25, R10 developed a Deep Tissue Injury (DTI) to the right heel. R10 was assessed to be at risk for pressure injuries. R10's Treatment Administration Record (TAR) documents an order dated 2/19/25, to float R10's heels when in bed as needed (PRN) with no documentation noted in February or March 2025, indicating R10's heels were floated. R10's care plan was updated on 4/8/25, to include bed extenders which is 48 days from when R10 was noted to have an open wound on the right foot on 2/20/25 that developed into a DTI on 3/11/25. *R25 was admitted on [DATE] without any pressure injuries and was assessed by facility staff to be at moderate risk for developing pressure injuries. On 3/10/25, R25 was assessed by facility staff to be at a very high-risk for developing pressure injuries. Facility staff did not initiate any new care plan interventions to prevent pressure injuries. R25 had an active physician order since admission to float heels when in bed as needed. From 3/3/25 through 3/14/25, facility staff did not document that this was being completed. On 3/14/25, 11 days after admission, R25 developed a Stage 1 pressure injury to R25's left heel. When the facility wound nurse assessed R25 on 3/17/25, the pressure injury had developed into a Deep Tissue injury (DTI). On 3/20/25, the facility dietician documented that facility staff would trial Prostat (a liquid designed for individuals who require extra protein, especially those with conditions like pressure ulcers) for weight stability and wound healing. The facility did not provide documentation that Prostat was trialed, and an active physician order was not started until 4/1/25. Findings include: The facility's policy titled, Pressure Injury Prevention Guidelines, with no date, documents: To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present. Explanation and compliance guidelines: 1 Individualized interventions will address specific factors identified in the residence risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). 2 The goal and preferences of the resident and/or authorized representative will be included in the plan of care. 3 Interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used and, for tasks, the frequency for performing them. 4 In the absence of prevention orders, the licensed nurse will utilize nursing judgment in accordance with pressure injury prevention guidelines to provide care and will notify physician to obtain orders. 5 Prevention devices will be utilized in accordance with manufacturer's recommendations (e.g., heel flotation devices, cushions, mattresses). 6 Guidelines for prevention may be utilized in obtaining physician orders. a The guidelines are to be used to assist in treatment decision making. b Due to unique needs and situations of individuals, the guidelines may not be appropriate for use in all circumstances. c When physician orders are present, the facility will follow specific physician orders. 7 Interventions will be documented in the care plan and communicated to all relevant staff. 8 Compliance with interventions will be documented in the medical record. a For at-risk-residents: treatments or medication administration records. b For residents who have a pressure injury present: treatment or medication administration records; Weekly wound summary charting. 9 The effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound. Considerations for needed modifications include: a Development of a new pressure injury. b Lack of progression towards healing or changes in wound characteristics. c Changes in the resident's goals and preferences, such as at end of life or in accordance with his/her rights. Preventative skin care: 1 Inspect skin while providing care, paying close attention to bony prominences. 2 Inspect skin underneath medical devices at least twice weekly. Keep skin clean and dry underneath. Adjust devices as needed for proper fit. 3 Avoid positioning the resident on an area of redness whenever possible. 4 Keep the skin clean and dry. a Manage incontinence and absorptive products. Check every two hours and provide perineal care as needed after incontinent episodes. Diaper usage in bed is not recommended. b Protect skin from exposure to excessive moisture with barrier products. 5 Moisturize dry skin. 6 Use positioning devices or folded linens to keep body surfaces from rubbing against one another period 7 Consider use of prophylactic dressings for prevention of sacral and heel pressure injuries. 8 Avoid vigorous massage over bony prominences. Nutrition/Hydration: 1 Consult dietitian for nutritional screen for each resident who is at risk for a pressure injury or has a pressure injury present. 2 Develop an individualized nutrition care plan for each resident with or at risk for a pressure injury, considering the recommendations made by the dietician. 3 Monitor weight and intake according to facility policy. 4 Provide and encourage adequate daily fluid intake. Repositioning: 1 Reposition all residents at risk of, or with existing pressure injuries, unless contraindicated due to medical condition. Utilize small shifts in repositioning, if otherwise contraindicated. 2 Routine repositioning schedule every two hours, using both side-lying and back positions. Reposition when in bed, and out of bed. 3 Considerations for alternative repositioning schedule: a General Medical condition b Tissue tolerance c Overall treatment goal/resident's goals and preferences d Skin condition e Comfort 4 Teach residents to do pressure relief lifts or other pressure relieving maneuvers as appropriate. 5 Repositioning techniques: a Avoid positioning the resident on bony prominences/turning surfaces with existing pressure injuries, including stage one. b Utilize lift sheets or pads to reduce shear force. Avoid dragging the resident when repositioning. c Limit head of bed to 30 degrees, if not contraindicated. [NAME] the knees when head of bed is elevated to reduce shearing. d Avoid positioning the resident directly onto medical devices (i.e., tubes, drainage systems). e When turning to side lying position, do not tilt more than 30 degrees. f Ensure that heels are floated off the surface of the bed, using pillows or devices that elevate and offload the heel in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon. g When in chair, provide adequate seat tilt to prevent sliding forward. Ensure the feet are properly supported. h Position bariatric residents with a large abdominal [NAME] on his/her side and use a pillow or other device to lift the pannus away from the underlying skin surface. 6 Minimize seating time/out of bed time to promote ischial and sacral wound healing. Pressure relieving devices: 1 Support surfaces do not eliminate the need for turning and repositioning. 2 Pillows and wedges may be utilized to maintain proper positioning. 3 Apply heel suspension devices according to the manufacturer's instructions. 4 The standard mattress for all facility beds are pressure redistribution mattresses. 5 The standard seat cushion for wheelchairs are pressure redistribution seat cushions. 6 Provide alternative support services as needed. Considerations for utilizing specialized support services: a Medical condition and weight. b Cannot be positioned off existing pressure injury. c Has pressure injuries on two or more turning surfaces that limit turning options. d Failure to heal or deterioration in wound status despite appropriate comprehensive care. e Stage 3, 4, unstageable, or deep tissue injury on trunk. f Bottoms out on the existing support surface. g Need for microclimate (i.e. moisture) control. 7 Do not use ring or doughnut shaped devices, synthetic sheepskin pads or mattresses, or egg crate type mattresses for residents with or at risk for pressure injuries. 1.) R10 was admitted to the facility on [DATE]. R10 was hospitalized from [DATE] to 2/19/25 and readmitted to the facility on [DATE]. R10's diagnoses include Type 2 Diabetes Mellitus (DM) with Diabetic Peripheral Angiopathy without gangrene, osteomyelitis, chronic embolism and thrombosis of right femoral vein, history of pulmonary embolism, End Stage Renal Disease (ESRD), Congestive Heart Failure (CHF), and unsteadiness on feet. R10's Significant Change Minimum Data Set (MDS) completed on 2/26/25, documents that R10 has lower extremity impairment on once side, uses a walker and wheelchair, requires partial/moderate assistance with toileting hygiene and rolling left to right. R10 requires substantial/maximal assistance when transferring. R10's 2/26/25 MDS documents no unhealed pressure injuries, no venous and arterial ulcers, and is at risk for pressure injuries. R10 is documented as having a diabetic foot ulcer. R10 was documented as having a Brief Interview for Mental Status (BIMS) score of 14, indicating that R10 is cognitively intact. R10's Care Area Assessment (CAA) for Pressure Injury documents R10 is at risk for pressure injuries with Care Plan considerations documented, to minimize risks for R10. Surveyor noted there is no further documentation on R10's Pressure Injury CAA. R10's care plan, dated 2/20/25, documents: R10 has a physical functioning deficit related to mobility impairment (date initiated 2/24/25) Interventions include: Assistive devices - Walker, quad cane, wheelchair, power wheelchair (date initiated 2/24/25). Bed mobility with assistance of one (date initiated 2/24/25). Dressing with assistance of one (date initiated 2/24/25). Toileting with assistance of one. R10 is incontinent. (date initiated 2/24/25). Transfer assistance with two staff. Mechanical lift required (date initiated 2/24/25). R10 sometimes has behaviors which include refusing therapy and medications (date initiated 3/18/25). Interventions include: Notify R10's physician if behaviors are interfering with my daily living related to refusals (date initiated 3/18/25). R10 is at risk for pressure ulcer and altered skin integrity due to DM, osteomyelitis, ESRD, CHF, gout, contracted left hand, Hypertension, Peripheral Vascular Disease (PVD), needs assistance with bed mobility, and incontinent (date initiated 3/18/25). Interventions include: Air mattress (date initiated 3/21/25). Bed extender to keep feet from pushing up against footboard of bed (date initiated 4/8/25). Conduct weekly skin inspection (date initiated 3/18/25). Diabetic foot monitoring (date initiated 3/21/25). Encourage heel boots to left and right foot when in bed (date initiated 3/18/25). Encourage to float heels when in bed (date initiated 3/18/25). Encourage turning and repositioning (date initiated 3/21/25). Treatments as ordered (date initiated 3/18/25). Wound Management (date initiated 2/21/25). Interventions include: Encourage R10 to elevate legs (date initiated 2/21/25). Evaluate ulcer characteristics (date initiated 2/21/25). Measure ulcer at regular intervals (date initiated 2/21/25). Monitor ulcer for signs of infection (date initiated 2/21/25). Monitor ulcer for signs of progression or declination (date initiated 2/21/25). Notify provider if no signs of improvement on current wound regimen (date initiated 2/21/25). Provide wound care per treatment order (date initiated 2/21/25). R10's Skin Check dated 2/19/25, after returning from the hospitalization on 2/10/25 - 2/19/25, documents no skin issues on R10's right heel. R10's TAR (Treatment Administration Record) documents a physician order placed on 2/19/25 that indicated that R10 was to have R10's heels floated when in bed as needed (PRN) for precautionary measures. Surveyor noted there are no entries documented in February or March 2025 TAR documenting that R10's heels were floated. R10's shower sheet dated 2/20/25, documents no skin abnormalities to R10's right heel. R10's Advanced Wound Care noted dated 2/25/25, documents an open wound to R10's right foot with heavy amount of serosanguinous exudate with exposed subcutaneous tissue and macerated periwound. Surveyor noted there are no measurements and no wound descriptions that include where the open wound is on R10's right foot. Treatment orders include cleanse the area with Vashe Wound Solution and the periwound area followed by Hydrofera Blue Ready dressing, followed by Abdominal Pad (ABD), cotton roll, and ace wrap daily. Wound is to be offloaded using Prevalon boots. Surveyor noted, R10's TAR did not change to document that R10's heels were to be offloaded using Prevalon boots. R10's facility Skin Check dated 2/27/25, documents no skin abnormalities to R10's right heel. Surveyor noted there is no documentation of R10's right foot wound documented on 2/25/25. R10's Wound Care noted dated 3/5/25, documents R10 refused wound care visit due to nausea. Wound care recommendations were to continue previous wound care orders and follow up next week. R10 refused shower on 3/6/25. R10's weekly facility skin evaluation dated 3/11/25, documents a right heel DTI measuring 4 x 10 x <0.1 with no drainage and dry visible wound tissue. Current treatment noted to be area is off loaded with ABD pad and wrapped with kerlix every other day. R10's physician was notified. Surveyor noted there were no addditional wound descriptions. R10's wound care noted dated 3/12/25, document a right plantar foot blister intact with orders to paint with betadine, cover with foam or ABDs, kerlex, and tubigrips three times weekly. Surveyor noted a handwritten note indicating cancelled appointment and R10 to follow with wound care at the facility on 3/18/25. Surveyor also noted there are no measurements or wound descriptors for R10's right plantar foot blister. R10's Advanced Wound Care noted dated 3/18/25, documents a right heel/foot pressure ulcer first noted on 3/18/25 measuring 27 x 9 x 0 with no exudate and intact skin. Treatment orders include betadine to periwound followed by foam border dressing three times a week. Surveyor noted there are no further wound descriptors for the wound bed. R10's TAR documents an order placed on 3/18/25, for heel boots when R10 is in bed. Float heels if R10 refuses heel boots every shift. R10's wound care noted dated 4/1/25, documents right heel/foot DTI measuring 21.5 x 7.5 x 0 with no exudate and intact skin. Orders include betadine to periwound followed by ABD, followed by roll gauze three times a week and PRN. Recommendations to float heels when in bed and non-weight bearing. Surveyor noted there are no additional wound descriptions for R10's wounds. R10's wound care noted dated 4/8/25, documents right heel/foot DTI measuring 18.5 x 6.5 x 0 with no exudate and intact skin. Orders include betadine to periwound followed by Abdominal Pads (ABD) followed by roll gauze three times a week and PRN. Recommendations to float heels in bed and non-weight bearing. Surveyor noted there are no additional wound descriptions for R10's wounds. On 4/7/25, at 11:00 AM, Surveyor interviewed R10 who reported R10 has had multiple wounds for a long time and was recently hospitalized . Surveyor noted wound care dressings to R10's feet and a pillow under the left foot with the right foot directly on the bed. R10 stated the wounds are pretty good. R10's bed is pushed up against the wall on the right side. R10 is laying on the right side with a pillow by R10's head against the wall and another pillow behind R10's head. Surveyor noted R10 being tall and bed extenders level with the mattress to prevent R10's feet from hitting the end of the bed. On 4/8/25, at 3:20 PM, Surveyor interviewed R10 and noted R10 to be wearing Prevalon boots. R10 stated they use to put my boots on, then they took them off, and now they are back on. R10 stated the physician recommended amputation of R10's foot and R10 refused. Surveyor asked R10 why the wounds got so bad, and R10 stated it's probably because R10 was getting up and doing things when R10 was not supposed to. On 4/9/25, at 10:50 AM, Surveyor interviewed R10 who denied any additional concerns. Surveyor noted R10 having Prevalon boots on and bed extenders on the bed. On 4/9/25, at 12:44 PM, Surveyor interviewed Wound Care Registered Nurse (WC RN)- E who stated she has followed R10's wound care since 3/17/25. WC RN- E indicated she rounds with Wound Care Physician Assistant (WC PA)- G weekly during wound care rounds. WC RN- E stated R10 was previously being seen by an Advanced Wound Care facility outside the facility. WC RN-E stated that R10 was declining leaving the facility for Advanced Wound Care and was requesting to be seen by the wound care team within the facility. WC RN- E stated R10 was noted to have a large blister to the entire plantar foot on 3/12/25 by the Advanced Wound Care team. WC RN- E stated R10 was then seen by WC PA- G on 3/18/25. WC RN- E stated R10 did not have a right foot/heel blister on 3/18/25 and R10 had a pressure injury to the right foot/heel. Surveyor asked WC RN- E how she thought R10's right DTI formed. WC RN- E stated it was due to his foot being up against the foot board. WC RN- E stated the facility put foot bed extenders on R10's bed on 3/18/25. WC RN- E then stated she talked with WC PA- G who thinks R10's right heel/foot DTI was caused by calciphylaxis (a condition where calcium builds up in the blood vessels and skin that can result in skin ulcers and life-threatening infections). WC RN- E stated R10's right heel/foot DTI is smaller and improving. WC RN- E stated R10's right heel/foot DTI may be improving by applying Prevalon boots and elevating R10's legs. WC RN- E also noted orders were placed on 4/1/25 for R10 to be non-weight bearing. On 4/9/25, at 1:44 PM, Surveyor observed R10's wound care with WC RN- E performing R10's wound care to the right heel/foot DTI. WC RN- E gathered supplies outside R10's room and donned gown and gloves prior to entering R10's room. WC RN- E removed R10's right heel/foot dressing dated 4/8/25, that was noted to be around R10's right foot up to mid-calf with toes exposed. Surveyor noted eschar present throughout approximately 75% of R10's bottom of the foot. Boggy skin was noted throughout R10's mid foot and up to R10's mid-calf. Redness and stasis changes were noted throughout R10's foot up to mid-calf. Eschar was present but limited on R10's right heel with eschar mainly noted on R10's bottom of the foot. Hand hygiene was performed appropriately throughout wound care treatment and WC RN- E applied betadine, followed by ABD pad, and roll gauze appropriately per wound care orders. Surveyor interviewed WC RN- E immediately after wound care observation. WC RN- E stated R10's wound looks the same from yesterday on 4/8/25, but noted wound has improved since 4/1/25. WC RN- E stated eschar has improved on R10's heel indicating eschar is mainly on the bottom of R10's right foot with very limited eschar on R10's right heel. On 4/10/25, at 10:54 AM, Surveyor interviewed WC PA- G who stated she first saw R10 on 2/4/25, and R10 was off dialysis at that time. R10 was experiencing very painful DM neuropathy on 2/4/25, which WC PA- G stated is not normal. WC PA- G stated R10's wounds were very suspicious of calciphylaxis and advised R10 go to the emergency room (ER) for wound care management and further evaluation of ESRD with suspicion of R10 needing to go back on dialysis. R10 declined going to the ER at that time and later agreed to go to the ER on [DATE] and was hospitalized [DATE] - 2/19/25. WC PA- G stated R10 chose to see an outside wound clinic instead of following with vascular care. WC PA- G stated she was prepared to bring in the ultrasound machine on 3/4/25 for further vascular evaluation and R10 declined wound care at that time on 3/4/25. WC PA- G stated R10 went out of the facility on 3/5/25, for wound care treatment but was not seen due to R10 refusing the wound care visit. WC PA- G stated the outside wound care clinic noted a blood-filled blister on 3/12/25, on R10's right foot/heel and ordered wrapped compression for treatment orders. WC PA- G stated she was provided a photo from the outside wound clinic of R10's right foot/heel blister found on 3/12/25. WC PA- G stated R10's right heel/foot wound then changed to eschar on 3/18/25 due to the outside wound care clinic ordering compression treatment. WC PA- G stated R10 just restarted dialysis, and she would not recommend compression treatment due to R10's vascular status. WC PA- G stated compression over a blood-filled blister will cause a pressure injury and WC PA- G stated she would not have put compression on an ESRD resident but that is what the outside wound clinic chose to do for treatment. WC PA- G stated R10 barely got through the dressing changes on 3/12/25, due to pain and noted R10 was readmitted to the hospital on [DATE], due to ESRD and treatment. WC PA- G stated R10's blood-filled blister, is due to calciphylaxis which is due to kidney failure and the ESRD can cause wound concerns. WC PA- G stated R10 is not compliant with dialysis and did not want to go back on dialysis. WC PA- G stated it's hard to treat R10 because of R10 going to multiple clinics. WC PA- G stated she would have thought R10 would have both legs amputated by now due to ESRD and calciphylaxis. WC PA- G stated each time she sees R10, there is a new abrasion or wound which is expected due to R10's ESRD and calciphylaxis. On 4/14/25, at 10:45 AM, Surveyor interviewed Director of Nursing (DON)- B who stated R10 doesn't like to move a lot and was adamant about always wearing the surgical shoes even when in bed. DON- B stated R10's surgical shoes were only supposed to be used when walking and then stated it's not documented that R10 refused to take off the surgical shoes. Surveyor noted to DON- B that R10 had left leg and foot hanging over the side of the bed during the interview on 4/14/25, at 9:24 AM. DON- B stated R10 likes to hang left foot over the bed, indicating R10's left leg feels better when hanging low. DON- B indicated R19 use to spend most of the time in the wheelchair but now prefers to be in bed as of recently. DON- B then stated, R10 is R10's own worst enemy. On 4/9/25, at 3:20 PM, Surveyor notified Nursing Home Administrator (NHA)- A and Director of Nursing (DON)- B of concerns with R10 developing a right heel DTI while residing at the facility along with concerns listed above. NHA- A and DON- B acknowledged concerns. 2.) R25 was admitted to the facility on [DATE] with diagnoses that include fracture of right tibia status post open reduction and internal fixation surgery, major depressive disorder, osteoarthritis and cellulitis of right leg. R25's admission Minimum Data Set (MDS) assessment dated [DATE] documents that R25 is cognitively intact. R25 displays verbal behavioral symptoms directed toward others 4-6 days in a 7-day period. R25 rejections care 1 to 3 days in a 7-day period. R25 is dependent for toileting, bed mobility and transfers. R25 is frequently incontinent of bladder and always incontinent of bowel. R25's Pressure ulcer at risk care plan initiated on 2/28/25 documents the following interventions: Conduct weekly skin inspection. Do not massage over bony prominence. Encourage me to float heels while in bed. Encourage turning and repositioning 2-3. Monitor vitals signs as needed. Provide pressure reducing wheelchair cushion. Provide pressure reduction/relieving mattress. R25's Refusal care plan initiated on 2/28/25 documents: [R25] sometimes have behaviors which include refusing cares, therapy, getting up into wheelchair for appointments, and medications. Interventions include: Give me my medications as my doctor has ordered. Let my physician know if my behaviors are interfering with my daily living. Make sure I am not in pain or uncomfortable and offer pain medications prior to therapy or getting up. Offer me something I like as a diversion. Please tell me what you are going to do before you begin. Speak to me unhurriedly and in a calm voice. R25's at risk for malnutrition care plan initiated on 3/4/25, documents that R25 is at risk related to potential inadequate food/beverage intake with history of depression, GERD and recent surgical intervention for [leg fracture]. Increased nutrition needs for wound healing. Patterns of unfavorable weight change. Interventions include: Diet as ordered. Monitor for [signs and symptoms] of depression. Monitor meal consumption daily, encourage meal and snacks intake as able. Offer food preferences. Encourage family/friends to bring in favorite food items. R25's Braden scale assessment (a tool used to assess a resident's risk for developing pressure injuries) dated 3/3/25 documents a score of 13. According to facility documentation a score of 13 indicated R25 is at moderate risk for developing pressure injuries. R25's MD order with a start date of 3/3/25 documents: Float Heels when in bed as needed for precautionary measures. R25's Dietary note dated 3/4/25 documents, in part: . [By mouth] intake: 25-50% of meals consumed. Supplements: [not applicable] . Food Preferences: Honor preferences as able . Weight: Hospital wt.: 193 [pounds]. [R25] reports poor appetite, [R25] refuses nutrition interview . [R25] also has refused height and weight measurements when staff attempted since admission . No skin concerns noted. Will continue to attempt to obtain nutrition and weight history, preferences as able, will monitor for height and weight data to assess nutritional needs and monitor intake patterns for improvement vs need to consider supplementation. Goals are for nutrition intake to be adequate in meeting nutritional needs as evidenced by weight stability [without] significant change, improved or stable hydration status, labs and skin integrity. Surveyor noted that from the beginning of admission, R25's dietician documented low oral intake which does affect skin integrity. R25's Braden scale assessment dated [DATE] documents a score of 9. According to facility documentation a score of 9 indicated R25 is at very high risk for developing pressure injuries. Surveyor reviewed R25's At risk for pressure injury care plan and noted that no new interventions were placed after R25 was assessed at very high risk. R25's Skin Check Evaluation dated 3/12/25 documents, in part: No skin issues. Foot evaluation completed. Surveyor reviewed R25's Treatment Administration Record (TAR) and noted that facility staff did not document that R25's heels were being floated at any time from 3/3/25 through 3/14/25. R25's progress note dated 3/14/25 at 5:40 AM documents: Called to resident's room by [Certified Nursing Assistant (CNA)]. Resident has a pressures injury on the bottom of [R25's] left heel approximately 1.5 oval shape. Red and pink in color not open. Denies pain to the area. Placed [R25's] foot on a pillow and applied a boot. Notified [Nurse Practitioner], [Director of Nursing] and [Family member]. R25's Skin assessment dated [DATE] documents: Left heel pressure ulcer/injury measuring 4 x 1. Stage 1. Non-blanchable erythema of intact skin. R25's progress note dated 3/14/25 at 10:45 AM documents: 24 Hour [Interdisciplinary Team] Note: Resident was assessed this morning and added to wound team for next week for assessment of area. Resident has been difficult to convince to follow plan of care. All staff continue to attempt and encourage [R25] to partake in therapy and [activities of daily living]. [R25] has had [R25's] left leg on a pillow since admission per [R25's] choice. [R25] has a boot in place as of this am to bilateral feet. Surveyor noted that documentation reads that R25 has boot in place as of this am, the day that the pressure injury was found. R25's physician order with a start date of 3/14/25 documents: Betadine Swab sticks External Swab 10 % (Povidone-Iodine). Apply to Left Heel topically every day and evening shift for open area . Apply topically [two times a day] until evaluated by wound care team. R25's actual pressure injury care plan initiated on 3/14/25 documents: DTI pressure ulcer actual to left heel. Interventions include: Evaluate need for pain reliever prior to cleansing or dressing changes. Float heel on pillows when in bed. Heel boot on as resident will allow. Notify practitioner if symptoms worsen or do not resolve. Treatments as ordered. On 4/9/25 at 8:11 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-U. Surveyor asked what interventions are currently in place for R25's pressure injury. CNA-U stated that R25's heels are floated, R25 has heel boots on, R25 has an air mattress, and staff will try to reposition R25 but R25 refuses. Surveyor asked when the air mattress was put in place. CNA-U stated that CNA-U was not sure. Surveyor asked when R25's heel boots were in place. CNA-U stated they started at least 2 weeks ago. Surveyor noted that CNA-U did not say that heel boots were in place since admission. On 4/9/25 at 12:33 PM, Surveyor interviewed Medication Technician (MT)-L. Surveyor asked what interventions are in place for R25's pressure injury. MT-L stated that R25's heels are floated, and heel boots are on. MT-L stated that MT-L was the staff member who found R25's pressure injury on 3/14/25 and MT-L informed the nurse. MT-L stated MT-L noted the dark spot on R25's heel. R25 was not wearing heels boots at the time. Surveyor asked if heel boots were in place before the pressure area was found. MT-L stated prior to the development of the heel pressure injury R25 was not using heel boots. Surveyor noted MT-L stated that heel boots were not in place prior to the development of the left heel pressure injury. On 4/9/25 at 12:05 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-V. LPN-V stated that LPN-V was alerted by the CNA that R25 had developed a pressure injury. LPN-V stated that LPN-V let the provider know and a treatment was put in place. LPN-V did not indicate if heel boots were on prior to the development of the wound but did state that R25 had an air mattress on. R25's Weekly skin impairment and wound evaluation dated 3/17/25 documents, in part: DTI to left heel .In-house acquired. Date wound identified-3/14/25 . Skin impairment type-pressure ulcer . Comments-deep purple. Wound measurements: 3 [centimeters (cm)] x 3.4 cm . Current treatment plan- Betadine [two times a day] . [Nurse Practitioner (NP)-H] updated. R25's Wound NP note dated 3/18/25 documents: Attempted to see patient, but patient refused. Will attempt to see patient at next visit. Discussed with [Name of facility wound nurse], Facility RN and [Name of facility wound nurse] is managing wound appropriately. On 3/18/25 at 11:22 AM, facility staff documented a weight of 163 pounds. On 3/20/25 at 9:42 PM, Dietician-C completes a dietary note which documents, in part: . [R25] is noted to have new pressure injury to [left] heel . Meal intake has been variable, [R25] has been refusing most meals over the past 2 days . Weight: (3/18/25): 163 [pounds] . Compared to documented dosing weight per hospital records, current weight reflects significant loss of 30.4 [pounds]/15.7% . Estimated Needs: . Calories: 1850-2220 kcal . Fluid:2220 ml . [R25] continues to refuse conversation with writer regarding nutrition preferences and needs . [R25] has been refusing meals over the past couple of days and intake prior to that was variable ranging from 25% to 75% . Current weight refle

3.) R24 was originally admitted to the facility on [DATE] with diagnosis that included unspecified convulsions, Schizophrenia, Depressive Episodes, Anxiety Disorder, Cognitive Communication Deficit and Chronic Artial Fibrillation. A review of the most recent quarterly MDS ( Minimum Data Set), dated 3/21/25 documents that R24 has a BIMS ( brief interview for mental status) score of zero ( severe cognitive impairment). R24 has also had a fall at the facility without injury and is frequently incontinent of urine and always incontinent of bowel. R24's individual plan of care documents that he is at risk for falls related to history of falls, use of medication, diagnosis history that includes HTN, CVA, seizure, schizophrenia, a-fib and insomnia. Use of Psychotropic medications. Require staff assist with ADLS/mobility, incontinence cares. Impaired range of motion. This plan of care was initiated on 6/30/23. Interventions included pillows for positioning while in bed. R24 to wear helmet at all times. Off during cares and showers. Room rearranged for safety. Staff to ensure that when R24 gets up out of bed that his call light is attached to the edge of bed, easily accessible for him. Standard cushion to wheelchair. The Visual Bedside Kardex Report, dated 4/14/25 ( for use by Certified Nursing Assistants) documents under safety that R24 should be offered to lay down after meals, anti-tip bars added to wheelchair, bed in lowest position, footwear to prevent slipping, keep bed locked, check bed positioning on rounds at night to ensure not on edge of bed, mat beside bed, perimeter mattress to assist with identifying edge of bed, call light and personal items available and in easy reach. Nursing note dated 2/28/2025 at 01:30 AM ;General Note Text: (R24) Found on floor parallel to bed but feet were by the head. Gown on, had taken the brief off, no shoes or socks. Bed was in the lowest position. Mat on floor was partially on it. Floor was wet as were his blankets. When I walked into his room, he said I'm wet. Used the mechanical lift and sling to lift him back into bed. Vitals taken for neurological checks notified DON ( Director of Nursing), NP ( Nurse Practitioner) . Nursing note dated 2/28/2025 at 03:00 AM; R24 Sent to Fort Hospital ER. for evaluation and treatment from being found on floor and NP orders. Guardian aware and was in agreement to it. Nursing note dated 2/28/2025 at 06:23 AM; R24 returned to facility per stretcher transport. Transferred to his bed. Neurochecks WNL ( within normal limits) . Nursing note dated 2/28/2025 at 11:25 AM; Late Entry: Note Text: 24 Hour IDT Note: R24 without any c/o pain when asked. Up in w/c per his norm. No injuries noted. Continues with neurological checks. The electronic medical record contained the Post Fall Evaluation Fall Details : Date / Time of Fall: 02/28/2025 at 1:30 AM. Fall was not witnessed. Fall occurred in the Resident's(R24) room. Activity at the time of fall: brief was off and was soiled the reason for the fall was not evident. Did an injury occur because of the fall: No. Did fall result in an ER visit/hospitalization: Yes. ER Visit/Hospitalization Details: sent to ER per NP because we don't know if he hit his head, and he is on Coumadin. Provider: NP Time notified: 02/28/2025 Notified of fall no injuries. New orders received; See Provider order sheet. Fall Details Note: found ( R24) on floor parallel to bed but feet were by the head. Gown on, had taken the brief off, no shoes or socks. Bed was in the lowest position. Mat on floor was partially on it. floor was wet as were his blankets. When I walked into his room, he said I'm wet. Used the mechanical lift and sling to lift him back into bed. Vitals taken for neurological checks notified DON, NP. Guardian, Case worker. Contributing Factors: Recent change in environment: Yes. Was fluid spilled on floor: No. Clutter present on the floor: No. Floor mat was on floor: Yes. Poor lighting in the area: Yes. Bed was at an improper height: No. Other furniture involved: No. Wheelchair was not involved in fall. Wearing glasses at the time of the fall: No. Footwear at time of fall: Bare feet. Resident was not using cane/walker as instructed. Resident was not wearing oxygen as prescribed at time of fall. Resident was using incontinence supplies at the time of the fall. Incontinent at time of fall: Yes. Bedside call light on when Resident was found: No. Bathroom call light on when Resident was found: No. Personal alarm sounding when Resident found: No. Other Residents were not involved in fall. On 04/09/25 at 11:15 AM, Surveyor conducted a review of facility's falls investigation dated 2/28/25 at 1:30 a.m. The investigation stated that R24 was found on floor parallel to bed, but feet were by the head. Gown on had taken the brief off, no shoes or socks. Bed was in lowest position. Mat on floor was partially on it. Floor was wet as were his blankets. When I walked into his room, he said I'm wet. R24 was found on the floor during rounds with a wet depend/ brief that he took off and wet blankets. Intervention: Staff to reposition, check and change resident every 2-3 hours to ensure that he is clean and dry. Further review of R24's individual plan of care documented that R24 has an alteration in elimination of bowel and bladder. R24 is always incontinent of bowel and bladder, requires staff assist with incontinent cares. Date Initiated: 01/09/2024. Interventions included : Use of briefs/pads for incontinence protection. Date Initiated: 01/09/2024. The facility's investigation did not include statements from staff that would indicate the last time R24 was cared for on 2/28/25. R24 is incontinent of bowel and bladder and would need the assistance of staff for all toileting needs, including checking and changing the incontinence brief. The investigation also did not address if all of the fall's interventions were in place at the time of the fall. The facility added the intervention for staff to reposition, check and change R24 every 2-3 hours to ensure that he is clean and dry. Date Initiated: 02/28/2025. This intervention should have already been apart of R24's plan of care as he is dependent on staff for all activities of daily living. In addition, the facility did not determine a possible root cause of this unwitnessed fall. On 3/23/2025 at 06:29 AM, the facility staff completed the Post Fall Evaluation Fall Details for a fall that happened on 03/22/2025 at 10:29 AM. The fall was not witnessed. Fall occurred in the Resident's ( R24) room. R24 was reaching for item(s) at time of the fall. Reason for the fall was evident. Reason for fall: R24 stated he was reaching for his call light. Did an injury occur as a result of the fall: No. Did fall result in an ER visit/hospitalization: No. Provider: NP Time notified: 03/22/2025 Notified of: R24 on his bedroom floor . Contributing Factors: Recent change in environment: No. Was fluid spilled on floor: No. Clutter present on the floor: No. Floor mat was on floor: No. Poor lighting in the area: No. Bed was at an improper height: No. Other furniture involved: Yes. Wheelchair was involved in fall. Wheelchair was unlocked at time of fall. Wheelchair footrest(s) were in the way at the time of fall. Wearing glasses at the time of the fall: Yes. Footwear at time of fall: Shoes. Resident was not using cane/walker as instructed. Resident was not wearing oxygen as prescribed at time of fall. Resident was using incontinence supplies at the time of the fall. Incontinent at time of fall: Yes. Bedside call light on when R24 was found: No. Bathroom call light on when Resident was found: No. Personal alarm sounding when Resident found: No. Other Residents were not involved in fall. Contributing factors note: R24 stated he needed to use the restroom was trying to reach the wall button that turns it off his soft touch was on his bed as per usual there was a recliner in front of R24. R24 was sitting in an upright position on the floor leaning against the recliner. On 4/9/25 at 11:40 AM, Surveyor conducted a review of the facility's falls investigation for the fall that occurred on 3/22/25. The investigation stated that R24 had an unwitnessed fall and was found on floor next to recliner in his room sitting upright leaning on recliner. R24 stated he was trying to get to his call light. 2 assist with hoyer to assist R24 off the floor into his bed. R24 without any injuries noted. Denies pain when asked. VSS, Skin assessment completed without any findings. No injuries observed at time of incident. No statements found. 3/22/25 Notes: R24 was reaching for call light that was on his bed, but he went between the two beds, rather than from the edge of bed. Intervention: Staff to ensure that when resident gets up out of bed that his call light is attached to the edge of the bed, easily accessible for him. The falls investigation did not include statements from staff that would help determine the last time R24 was provided cares. In addition , it is not clear if all the falls' interventions were in place at the time of the fall and if a root cause for the fall was determined. On 04/14/25 at 10:49 AM, Surveyor conducted an interview with DON- B regarding R24's falls on 2/28/25 and 3/22/25. Surveyor asked if the falls investigation had information about when the last time R24 was provided cares on 2/28/25. At the time R24 was found he was soaked in urine, had taken his brief off. DON- B stated that staff did rounds, he would have been toileted then and I'm guessing that would have been around 10:30 PM. Surveyor asked DON- B how she was able to confirm this without any statements from the staff working that evening. DON- B stated that she was just guessing and as far as she knew it was done. Surveyor asked if all interventions were in place at the time of the fall on 2/28/25 and 3/22/25. DON- B stated that if she checked the boxed on the report, then they were in place. DON- B was not able to provide evidence that staff were interviewed to confirm this for the fall on 2/28/25 or 3/22/25. DON- B was not able to provide evidence that the facility had determined the root cause of the unwitnessed falls on 2/28/25 and 3/22/25. 2.) R10 is a [AGE] year-old-resident who was admitted to the facility on [DATE]. R10 was hospitalized from [DATE] to 2/19/25 and readmitted to the facility on [DATE] with diagnoses that include Type 2 Diabetes Mellitus (DM) with , osteomyelitis, chronic embolism and thrombosis of right femoral vein, history of pulmonary embolism, End Stage Renal Disease (ESRD) and unsteadiness on feet. R10's Significant Change Minimum Data Set (MDS) completed on 2/26/25, documents that R10 has lower extremity impairment on once side, uses a walker and wheelchair, requires partial/moderate assistance with toileting hygiene and rolling left to right. R10 requires substantial/maximal assistance with transfers. R10 is always continent of bowel and bladder and has no falls since admission. R10's Care Area Assessment (CAA) for Functional Abilities (Self-Care and Mobility) documents R10's Care Plan considerations, to improve and avoid complications. Surveyor notes there is no further documentation on R10's Functional Abilities CAA. Surveyor also notes there is no Falls CAA documented for R10. R10's care plan, dated 2/20/25, documents: R10 has a physical functioning deficit related to mobility impairment (date initiated 2/24/25) Interventions include: Assistive devices - Walker, quad cane, wheelchair, power wheelchair (date initiated 2/24/25). Bed mobility with assistance of one (date initiated 2/24/25). Dressing with assistance of one (date initiated 2/24/25). Toileting with assistance of one. R10 is incontinent. (date initiated 2/24/25). Transfer assistance with two staff. Mechanical lift required (date initiated 2/24/25). R10 is at risk for falls related to weakness, physical limitations, and need for staff assistance (date initiated 2/24/25). Interventions include: Assess that wheelchair is of appropriate size; assess need for footrests; assess for need to have wheelchair locked/unlocked for safety, anti-tippers (date initiated 2/24/25). Encourage fluids (date initiated 2/24/25). Encourage participation in activities to improve strength or balance (date initiated 2/24/25). Encourage rest periods if feeling fatigued (date initiated 2/24/25). Encourage use of a chair with armrests (date initiated 2/24/25). Ensure proper placement of R10's feet on foot pedals to reduce the risk of R10 sliding out of the wheelchair (date initiated 4/5/25). Footwear to prevent slipping (date initiated 2/24/25). Gait belt with transfers (date initiated 2/24/25). Keep bed locked (date initiated 2/24/25). Keep environment well lit and free of clutter (date initiated 2/24/25). Keep personal items within reach (date initiated 2/24/25). Nonskid socks/slippers (date initiated 2/24/25). Surveyor reviewed the facility fall investigation dated 4/5/25, which states on 4/5/25, at 11:00 AM, R10 was heard yelling for help. Staff noted R10 to be lying on back, on the floor, in front of the wheelchair with both legs extended in front. R10 was noted to have surgical shoes on. Assessment was completed and R10 denied hitting head. Neurological checks were completed. Surveyor notes the 4/6/25, AM documentation is blank with no entry. R10 was assisted off the floor using the Hoyer lift and assistance of 3 staff members. Skin check was completed with no new concerns noted. Provider, family, and Director of Nursing (DON)- B were updated on 4/5/25. R10's statement indicates R10 was taking feet of wheelchair pedals and just slipped out of the wheelchair. Care plan was updated on 4/5/25, to ensure proper placement of R10's feet on wheelchair foot pedals to reduce the risk of R10 sliding out of the wheelchair. Therapy Screen Form dated 4/7/25, documents R10 with a fall on 4/5/25, and R10 refusing to participate in therapy. Therapy recommends, facility staff ensure proper placement of feet on foot pedals. Surveyor notes the fall investigation form does not include the following documentation being filled out: Mental Status Predisposing factors (Environmental, Physiological, Situation) Statements from staff Risk for falls (including diagnosis of risk for falls, goals and interventions) Surveyor notes R10's gait/balance was documented as not able to perform function on the fall investigation form, however, the check box indicating requires use of assistive devices (i.e. cane, wheelchair, walker, furniture) was not marked. Surveyor notes R10 was noted to have a fall from the wheelchair. Surveyor reviewed R10's medical record which documents on 4/6/25, the Interdisciplinary Team (IDT) notes R10 without any pain or adverse effects and R10 is up per R10's normal with neurological checks being within normal limits. Surveyor reviewed R10's medical record which documents on 4/8/25, the IDT notes R10 continues therapy case load with little participation. R10 has been dependent on staff to provide cares and needs reminders to call for assistance with transfer needs. Surveyor notes R10's care plan does not include the need for increased monitoring or checks after R10 is noted as needing reminders to call for assistance with transferring. On 4/7/25, at 11:00 AM, Surveyor interviewed R10 who reports R10 has had multiple wounds for a long time and was recently hospitalized . Surveyor notes wound care dressings to R10's feet and a pillow under the left foot with the right foot directly on the bed. R10's bed is pushed up against the wall on the right side. R10 is laying on the right side with a pillow by R10's head against the wall and another pillow behind R10's head. Surveyor notes R10 being tall and bed extenders level with the mattress to prevent R10's feet from hitting the end of the bed. R10 states dialysis occurs 3 times weekly and is transported via wheelchair to dialysis. Surveyor notes a low bed and bed extenders level with the mattress. On 4/8/25, at 3:20 PM, Surveyor interviewed R10 and noted R10 to be wearing Prevalon boots. R10 states they use to put my boots on, then they took them off, and now they are back on. R10 states the physician recommended amputation of R10's foot and R10 refused. Surveyor asked R10 why the wounds got so bad, and R10 states it's probably because R10 was getting up and doing things when R10 was not supposed to. On 4/14/25, at 9:24 AM, Surveyor interviewed R10 who was noted to be laying supine in bed with head of bed approximately 60 degrees. R10 was noted to have Prevalon boots on both feet and R10's left foot and leg was hanging over the side of the bed. R10 states he was looking for a spoon to eat his cereal. Surveyor suggested he press his call light and staff entered R10's room within 1-2 minutes to assist R10. On 4/14/25, at 10:45 AM, Surveyor interviewed DON- B who states R10 had just got back from dialysis on 4/5/25 when R10 had a fall. DON- B states R10's care plan was updated to include an intervention to put R10 to bed upon return from dialysis per R10's request. Surveyor noted there is no documentation on R10's care plan to put R10 to bed upon return from dialysis. DON- B stated R10 hasn't been tolerating being up in the chair on dialysis days. DON- B indicated that R10 will take feet off the wheelchair foot pedals and R10 hasn't been using the electric wheelchair due to it not fitting in the van when being transported to dialysis. DON- B states she has asked therapy to get a chair that works better for R10 and therapy is working on this. DON- B states it depends on which vehicle comes to transport R10 to dialysis, because one wheelchair is not long enough and R10 will kick feet forward. Surveyor noted to DON- B there is no documentation on R10's 4/5/25 fall investigation, indicating when and where R10 was last seen prior to R10's fall on 4/5/25, at 11:00 AM. DON- B states R10 gets back from dialysis at 10:45 AM. DON- B then states she wouldn't doubt it, if R10 was trying to get back into bed but the facility is unable to determine this as R10 is not a good historian. Surveyor noted to DON- B that R10 had left leg and foot hanging over the side of the bed during the interview on 4/14/25, at 9:24 AM. DON- B states R10 likes to hang left foot over the bed, indicating R10's left leg feels better when hanging low. DON- B indicates R19 use to spend most of the time in the wheelchair but now prefers to be in bed as of recently. DON- B then stated, R10 is R10's own worst enemy. Surveyor notified DON- B on concerns with R10's 4/5/25 fall investigation, not identifying a thorough root cause, no staff statements, and no documentation to identify when and where R10 was last seen prior to the fall. Surveyor requested additional information if available. DON- B acknowledged concerns. On 4/14/25, at 12:30 PM, Wound Care Registered Nurse (WC RN)- E provided a copy of a progress note that was entered in R10's medical record, with a created date of 4/14/25, at 12:19 PM, and an effective date of 4/5/25, at 11:07 AM. Surveyor notes the progress note indicates WC RN- E heard R10 calling out for help. WC RN- E entered R10's room and noted R10 sitting on buttocks with legs in front. R10 stated R10 just slid out of the wheelchair. R10 had just returned from dialysis. Surveyor notes R10's fall investigation identifies the manager on duty responded to R10 on 4/5/25 after hearing R10 yelling for help. Surveyor notes Assistant Director of Nursing (ADON)- F completed the fall investigation and did not mention WC RN- E responding to R10's fall on 4/5/25. Based on interview and record review, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 (R19, R10, and R24) of 3 residents reviewed for falls. *On 7/21/24, R19 was receiving cares from two aides. During cares, R19 fell from R19's bed. R19 complained of immediate pain and was sent to the Emergency Room. R19 was diagnosed with a closed head injury. The facility did not thoroughly investigate the fall. *R10 fell on 4/5/25 and the fall was not thoroughly investigated. *R24 fell on 2/28/25 and 3/23/25. These falls were not thoroughly investigated. Findings include: The facility's undated policy titled, Fall Risk Assessment, documents, in part: Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls . Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk . Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. Interventions will be monitored for effectiveness. The plan of care will be revised as needed. When any resident experiences a fall, the facility will: Assess the resident. Complete an event documentation report. Complete a fall risk assessment. Notify physician and family. Review the resident's care plan and update as indicated. Document all assessments and actions. If a fall is witnessed, obtain witness statement. The undated facility policy titled, Falls Management Process documents, in part: In the event a resident has fallen and/or is found on the ground, a complete head-to-toe assessment must be performed prior to moving the resident unless life-threatening safety concerns are present . Resident is not to be moved until assessed for injury by a nurse . If able, ask the resident to explain what happened and what they were attempting to do at the time of the fall (helpful for root cause analysis later) . Obtain vital signs: blood pressure, pulse, pulse oximetry, and respirations. Obtain neurological checks per policy for any unwitnessed fall or any fall with evidence of injury to head . The nurse will complete an event documentation report, fall risk assessment, pain assessment, and obtain witness statements. The nursing supervisor will determine the most appropriate intervention, implement, and update care plan . Resident fall will be noted on 24 hour Report for three days for post fall monitoring, assessing for injury, full vital signs every 8 hours, and pain assessment . Post fall: Director of Nursing/Designee will assess the resident and review fall documentation, including witness statements, resident interview, environment review of area where fall occurred, and equipment inspection. The event will be discussed, and event documentation reviewed for completion in [Interdisciplinary Team] meeting. Compare data from previous assessments. Discuss identified trends. Therapy referral and Medication Review initiated . Review fall risk assessment for any potential new risk factors. Review plan of care/interventions to ensure all prior interventions are in place and still appropriate. Adjust/add interventions on the Plan of Care. Update and communicate interventions. Provide appropriate training for caregivers if appropriate . 1.) R19 was admitted to the facility on [DATE] with diagnoses that included stroke, Type 2 Diabetes, muscle weakness, and acquired absence of right and left leg above the knee. R19's Annual Minimum Data Set (MDS) assessment dated [DATE] documents R19 is severely cognitively impaired. R19 is independent for rolling left and right. R19 is dependent for toileting, bathing and transfers. R19's Falls Care Area assessment dated [DATE] documents, in part: Resident is at risk for falls. Resident has bilateral amputation to legs. Resident uses Hoyer for transfers. Resident receives antidepressant, antianxiety, anticoagulant, opioids and antiplatelet medications. Staff to monitor for side effects of medication. On 4/7/25 at 10:33 AM, Surveyor interviewed R19. Surveyor asked if R19 had experienced any recent falls. R19 stated that R19 did have a fall from R19's bed and R19 had to go to the hospital. R19 stated that R19 suffered a head and knee injury as a result of the fall. Surveyor asked for more details regarding the fall and R19 stated that R19 could not remember much more than rolling out of bed. R19's Fall risk care plan initiated on 12/21/2021, documents the following pertinent interventions: Bed in low position, fall mat next to bed, and health teaching regarding changing positions slowly. R19's Fall Risk Evaluation dated 12/28/23, documents R19 is at risk for falls. R19's Annual MDS assessment dated [DATE], documents that R19 is cognitively intact. R19 is dependent for toileting, bathing and transfers. R19 has not had any falls since admission/entry or reentry or the prior assessment. R19's Falls Care Area assessment dated [DATE] documents, in part: [R19] is at risk for falls related to medication use including opioid and psychotropics. [Diagnosis history] including [stroke], [both side lower extremity] amputation, obesity, [chronic obstructive pulmonary disease], [Osteoarthritis]. R19's progress note dated 7/21/24 at 9:42 PM documents: Writer called to room around [2:58 PM]. alerted by [Certified Nursing Assistant (CNA)] that patient had rolled out of bed. Writer called to room, upon walking in room, patient on floor with aide bed was in a high position, writer asked patient what happen, patient stated I was lying on side and rolled to floor, I am in a lot of pain. Writer assessed patient vitals T98.9, R22, B/P 144/80, P77. Writer called [Doctor]on call and was given ok to send patient to ER for evaluation and treatment. Writer called [Director of Nursing (DON)] and updated DON as well. Surveyor noted that facility staff documented that the bed was in a high position and not low according to R19's plan of care. Surveyor reviewed R19's Risk Management Fall investigation dated 7/21/24 which documents, in part: Writer called to resident's room. Patient on floor on side. Writer was told by CNA that cares was being performed and patient rolled to the floor. Resident description, I was lying on my side while they performed cares and just rolled to floor. I don't know what happened. Was this incident witnessed. Yes . Statements: [CNA-X, CNA-Y and R19] . Root cause: [R19] is bilateral amputee, [R19's] left stump was crossed over to give proper hygiene of peri cares. It is possible that crossing [R19's] stump may have made her roll toward the door. 5 Whys: Why 1-rolled out of bed. Why 2- did not want bolsters inflated. Why 3- didn't feel [R19] needed them. Why 4- feels safe in bed. Why 5- bilateral amputee and needs assist with rolling from staff and uses enabler bar. Intervention: [R19] has agreed to inflate bolsters to enhance bed boundaries when in bed . Surveyor noted that witness statements were not included in the fall investigation documentation. Surveyor noted that the investigation did not include that the bed was at a high height. Surveyor noted that there is no further documentation of where the aide/aides were located when R19 fell. Surveyor noted that the fall was not thoroughly investigated in order to come up with an accurate root cause. R19's Post Fall evaluation dated 7/30/24 documents, in part: Who witnessed fall? [CNA-X and CNA-Y]. Location of fall? Resident's room. Activity at the time of fall? On [R19] side to get cleaned up. Was the reason for the fall evident? No . Did ER visit/hospitalization occur as a result of the fall? Yes . Floor mat on floor? No. Surveyor noted that facility staff documented that a fall mat was not in place at the time of R19's fall according to R19's plan of care. On 4/14/25 at 11:14 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-W. LPN-W was the nurse who was called into R19's room after R19's fall. LPN-W stated that 2 aides were completing cares. LPN-W stated that an aide told LPN-W that the aides turned R19 on R19's side and R19 tried to grab one of the CNAs that R19 was leaning on. R19 slipped out of bed. LPN-W stated that LPN-W assessed R19 on the floor. LPN-W took vitals, did not move R19 because R19 was complaining of pain. LPN-W let the Director of Nursing know what happened and informed R19's provider who ordered that R19 be to the hospital. LPN-W stated that LPN-W put a pillow under R19's head and waited for paramedics to arrive. Surveyor asked if neurological-checks were completed. LPN-W did not remember doing neurological-checks. Surveyor asked where R19's pain was. LPN-W stated that R19 was complaining of pain everywhere. Surveyor asked if a fall mat was on the floor. LPN-W stated I don't think so. Surveyor asked what height the bed was at. LPN-W stated, It wasn't low, I know that. Surveyor asked if R19 had bolsters on R19's bed prior to this fall. LPN-W stated I don't think so. LPN-W continued and stated that R19's bed was weird, and LPN-W stated that LPN-W did not feel like it was safe. LPN-W told management about the concerns but R19 liked the bed how R19 had it, so nothing was changed. Surveyor asked if any education was completed with staff after this fall. LPN-W stated LPN-W can't remember and didn't know. Surveyor noted that both aides, CNA-X and CNA-Y, that witnessed R19's fall are no longer employed by the facility. Surveyor attempted to reach both CNA-X and CNA-Y by telephone but was unsuccessful. In addition, Surveyor attempted to reach any other staff member that was on the PM shift on the day the fall occurred. On 4/14/25 at 11:42, Surveyor spoke to CNA-O who did not have any information on R19's fall. CNA-O stated that CNA-O did not hear anything about R19 having a fall that occurred with CNAs as witnesses. R19's ED physician note dated 7/21/25 documents, in part: . [R19] presenting to the ED for evaluation after a fall. [R19] notes an aide was doing cares on [R19] and the other aide left the room to get more supplies. [R19] is unsure if the aide in the room touched [R19] wrong, but [R19] slid out of [R19's] bed, noting that this has happened before when laying on [R19's] right side. Since [R19's] fall, [R19] feels like where her knees and toes would be are in pain and burning. [R19] also notes the back of [R19's] head and hips are in pain. [R19] denies being in pain before falling . CT of head without evidence of bleed . There are no acute traumatic injuries found on secondary survey or imaging . Diagnosis: Closed head injury . Surveyor noted the ED note documented that R19 informed the ED physician that 2 aides were in the room, but one aide left to get supplies and that is when R19 fell. Surveyor noted that this was not included in the facility investigation. Surveyor noted that R19 complained of head pain. R19's Emergency Department (ED) Patient Summary dated 7/21/24 documents, in part: Diagnosis from today's visit: Closed head injury . Fall . You have a head injury. It doesn't appear serious at this time. But symptoms of a more serious problem, such as a mild brain injury (concussion) or bruising or bleeding pin the brain, may appear later . R19's progress note dated 7/22/25 at 9:50 AM documents: resident returned from ER with noted head injury but stated it doesn't appear serious at this time. writer will update [Doctor]. R19's Family Practice outpatient clinic note dated 7/24/24 documents, in part: ED follow up . Chief complaint- fall from bed at skilled nursing facility. Reporting phantom pain to bilateral knees and toes, posterior head and bilateral hips . Diagnosis- closed head injury . Surveyor noted multiple documents that indicate that R19 suffered a closed head injury as a result of R19's fall. Surveyor reviewed R19 electronic medical record for documentation of completed Neurological checks after R19's fall and diagnosis of a closed head injury. No neurological check documentation was found. Surveyor reviewed R19's vital signs tab within R19's medical record and noted that BP, pulse, and oxygen saturation are not documented as being completed from 7/18/24 through 7/30/24. These vital signs are typically completed with Neurological checks. Cross reference F684 citation. Surveyor reviewed R19's electronic medical record for IDT note documentation regarding R19's fall. No IDT [TRUNCATED]

Based on interview and record review, the facility did not ensure residents received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 4 (R5, R3, R10, and R13) of 21 sample Residents. On [DATE], R5 experienced a seizure, which was a change of condition for R5, as R5 had not a seizure previously. The facility did not ensure that R5 was assessed to determine the etiology of the seizure, did not develop a seizure care plan and did not monitor R5 closely for seizures. R5 experienced another seizure on [DATE]. Following a seizure on [DATE], Lorazepam 0.5 mg every two hours as needed for seizure activity was ordered. This order was not picked up until [DATE]. On [DATE], R5 received an order for Levetiracetam, an anti-convulsant medication. R5 did not start receiving this medication until [DATE], which was two days after it was ordered. R5 continued to have seizures on [DATE], [DATE], and [DATE]. R5 did not receive Lorazepam every two hours as needed for seizure activity as there was not a signature on the prescription from the provider and the pharmacy did not send this medication. On [DATE], R5 was transferred to the hospital due to seizure activity and medications not being available. R5 continued to have seizures in the ER (emergency room ) on [DATE] and on [DATE] in the hospital R5 was comatose & did not respond to verbal or tactile stimuli. R5 expired in the hospital on [DATE]. The facility did not provide treatment and care in accordance with professional standards for R5, who had a change in condition (seizures) with new medication orders, by failing to provide the following: - The facility did not ensure R5 was assessed to determine the etiology of the change of condition (seizure) - The facility did not process the new medication orders for R5 - The facility did not ensure that R5 received the medications as ordered - The facility did not monitor R5 for seizure activity as ordered - The facility did not implement a care plan with interventions to manage seizure activities - The facility did not monitor any interventions for R5 to prevent seizures and provide safety The facility's failure to implement the above created a finding of Immediate Jeopardy (IJ) which began on [DATE]. NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B were notified of the immediate jeopardy on [DATE] at 3:36 p.m. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope and severity of D (potential for harm/isolated) related to the examples of R3, R10, and R13 and as the facility continues to implement its action plan. * R3's Midodrine 10 mg physician order instructs staff to hold the medication if R3's systolic blood pressure is greater than 130. R3 received Midodrine 10 mg even though the systolic blood pressure was greater than 130 on [DATE] at 12:00 p.m., [DATE] at 7:00 a.m. and 12:00 p.m., [DATE] at 7:00 a.m., [DATE], [DATE], and [DATE] at 5:00 p.m., [DATE] at 7:00 a.m. and 5:00 p.m., [DATE] at 5:00 p.m., [DATE] at 7:00 a.m. and 12:00 p.m., and [DATE] at 7:00 a.m. * R10 had a Medical Doctor (MD) order to check R10's heart rate 3 times a day and notify the MD if R10's heart rate was lower than 45 beats per minute. The facility did not always document a heart rate 3 times a day per MD order. * R13 has an active physician order indicating that R13 had an area of Moisture Associated Skin Damage (MASD) on R13's left thigh that developed in February of 2024. Facility staff initially assessed the area as MASD and was actively treating the area with zinc two times a day. The facility did not complete weekly wound assessments of the area to determine if the area was improving or worsening. On [DATE], R13 informed Surveyor that R13's has had a skin issue off and on for months and that R13's skin had opened again. On [DATE], Director of Nursing (DON)-B informed surveyor that the open area looked more like a skin tear from R13's incontinence brief. On [DATE], the facility wound MD diagnosed a stage 2 pressure injury to R13's left thigh. * R13 had an MD order placed on [DATE] alerting staff to make an appointment for R13 to see a surgeon regarding R13's hernia. The facility did not follow through with making an appointment with a surgeon until Surveyor brought it to the facility's attention on [DATE]. Findings include: The facility policy titled, Notification of Changes Policy, and implemented [DATE] under policy documents: It is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate (hereafter designated as the physician). The resident and/or their representative will be educated about treatment options and supported to make an informed choice about care preferences when there are multiple care options available. All pertinent information will be made available to the provider by the facility staff. Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative, and the resident's physician, to ensure best outcomes of care for the resident. According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s (Licensed Practical Nurse) or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. According to N6.04(1), In the performance of acts in basic patient situations, the L.P.N. shall, under the general supervision of an R.N. or the direction of a provider . (b) Provide basic nursing care. (c) Record nursing care given and report to the appropriate person changes in the condition of a patient . (e) Perform the following other acts when applicable: 1. Assist with the collection of data. 2. Assist with the development and revision of a nursing care plan. 3. Reinforce the teaching provided by an R.N. provider and provide basic health care instruction. 4. Participate with other health team members in meeting basic patient needs. According to [NAME] Hopkin's Medicine, Evaluation of a First-Time Seizure, The goal of treatment is to control, stop, or reduce how often seizures occur. Treatment is most often done with medicine. There are many types of medicines used to treat epilepsy. Your healthcare provider will need to identify the type of seizure you are having. Medicines are selected based on the type of seizure, age of the person, side effects, cost, and ease of use . It is important to take your medicine on time and as prescribed by your doctor. 1.) R5 was originally admitted to the facility on [DATE] with diagnoses that included osteomyelitis, diabetes mellitus, MRSA (methicillin resistant staphylococcus aureus), PVD (peripheral vascular disease), chronic kidney disease, hypertension, Atrial Fibrillation, acute embolism and thrombosis of unspecified deep veins of lower extremities and necrotizing diabetic foot infection. On [DATE], R5 was transferred to the hospital and returned to the facility on [DATE] and begun hospice services. The significant change MDS (minimum data set) with an assessment reference date of [DATE], documents a BIMS (Brief Interview for Mental Status) score of 10, indicating moderate cognitive impairment for R5. R5 is assessed as being dependent for toileting hygiene & chair/bed to chair transfer, and partial/moderate assistance for rolling left and right. R5 is assessed as frequently incontinent of urine and bowel. The cognitive loss/dementia & functional abilities (self care and mobility) CAA (care area assessment) both dated [DATE] were triggered but all the sections are blank and have not been completed. The hospital discharge summary dated [DATE] documents under final diagnosis section: 1. Diabetic foot ulcer with osteomyelitis. 2. Necrotizing soft tissue infection. 3. Insulin requiring or dependent type II diabetes mellitus. 4. PVD (peripheral vascular disease). 5. Phalanges fracture foot. 6. Hypertension. 7. Hyperlipidemia. 8. Chronic kidney disease. 9. Gastro-esophageal reflux disease without esophagitis. 10. Depression The hospice note dated [DATE] at 11:30 a.m. documents: focused visit performed d/t (due to): unresponsive episode. Staff greeted writer and shoed writer to Pt (patient) room. Pt was in bed upon arrival and was responsive to voice. Pt collaborated with writer as well as facility RN who also came to Pt room. Pt declined breakfast this AM (morning) but did take medications and was able to drink water. Per caregiver who was with the Pt he had full body convulsions that resolved quickly. Pt was alert and talking prior to convulsions. Pt is alert and answers questions per baseline at time of writers assessment. Facility asking for comfort medications. Writer voiced that TC (telephone call) will be placed to Pt POA (power of attorney) who needs to be asked prior to getting comfort medications in place. DON (Director of Nursing) was accepting of Lorazepam, Hyoscyamine and current Oxycodone orders. She declines need/want for Haldol. TC placed to POA with no answer, detailed message left. Symptoms/needs addressed and recommendations: continue to monitor, comfort medications if needed There was no evidence that the physician was consulted that R5 had seizures for the first time. There was no evidence that the physician was consulted to evaluate R5's change in condition. The Centers for Disease Control (CDC) Epilepsy webpage documents, First Aid for Seizures: When to call for help - The seizure lasts for more than 5 minutes; It is also important to call 911 if the person having the seizure - Has never had a seizure before. The nurses note dated [DATE] at 9:04 a.m. by LPN (Licensed Practical Nurse)-X documents: 7:14 a.m. convulsing then became unresponsive, with labored breathing. 7:16 a.m. [Name of] hospice nurse called ([First name]) will be in to evaluate. 7:25 a.m. resident alert. 7:36 a.m. POA (power of attorney): [First name] called, left voicemail with detailed message regarding [R5's first name] episode of convulsing. BP (blood pressure): ,d+[DATE], p (pulse): 101, T (temperature): 96.4, O2 (oxygen): 98% /RA (room air) R (respirations) 24, labored. On [DATE] at 2:04 p.m., Surveyor spoke with LPN-X on the telephone. Surveyor read LPN-X her nurses note dated [DATE] and asked if she remembered R5. LPN-X replied that LPN-X did not honestly remember and stated that so much goes on at that place (the facility). LPN-X informed Surveyor she didn't think R5 was her resident. Surveyor asked LPN-X if prior to [DATE] did R5 have any seizures. LPN-X replied that LPN-X was not sure if R5 had history of seizures. There was no evidence that the physician was consulted that R5 had seizures for a second time. There was no evidence that the physician was consulted to evaluate R5's change in condition. The hospice note dated [DATE] at 9:50 a.m. documents: focused visit performed d/t: seizure like behavior. Symptoms/needs addressed and recommendations: Please see previous report of seizure like behavior. Requested nurse assessment. Arrived no staff available to check in with. Went to patient room and CNA (Certified Nursing Assistant) [first name] was giving [R5's first name] a bath. She was with him at the time of the seizure. She stated she was getting him ready for a shower when he started to seize. She described it as a whole body shaking that lasted for ,d+[DATE] seconds. He was unresponsive afterwards and incontinent of bowel and urine. Per [Name], the med tech had given him his morning medications but no insulin. This was confirmed by nurse [first name]. Assessed [R5's first name]. Pupil in left eye responsive to light, alert and oriented to al but day-- thought it was Tuesday. VSS (vital signs stable). He is sleepy. Blood glucose at 9 am was 263. There is no earlier blood glucose. He is currently sleeping and comfortable. Reassessment plan: resolved during visit. Discussed goals of care? Yes. Discussion included the following domains symptom management, medical interventions, and routine tasks .Training provided: Check blood glucose during seizure or unresponsive episodes, call [Hospice name] for any further questions or concerns. Surveyor noted that there was no evidence that the physician was consulted that R5 experienced a seizure, which was not R5's baseline. There was no evidence that the physician was consulted about a change in R5's condition. The medication order with an order date & start date of [DATE] documents Lorazepam (Ativan) 0.5 mg tab Dose: 0.5 mg/Route: Oral/Freq (frequency): EVERY 2 HOURS PRN (as needed)/Admin Inst (administration instruction): Every 2 hours as needed for seizure activity. The facility did not note this order until [DATE]. The facility did not develop a seizure care plan after R5 experienced a seizure on [DATE] and [DATE]. The facility did not have any evidence that R5's seizures were being monitored or that the physician was consulted about R5's seizure activity. The nurses note dated [DATE], at 7:00 a.m., by LPN-Y documents: Resident noted with ,d+[DATE] minutes of unresponsiveness and fixated stair [sic] (stare). Resident noted drooling. BP ,d+[DATE], HR 133, BS (blood sugar) 188 mg/dl, Spo2 99%. Per RN took resident about 12 minutes to come out of seizure. Hospice updated. Surveyor noted that there was no evidence that the facility called emergency services to manage R5's seizures, as R5 had a seizure lasting ,d+[DATE] minutes and took approximately 12 minutes to come out of the seizure. On [DATE] at 1:53 p.m., Surveyor interviewed LPN-Y on the telephone regarding the nurses note dated [DATE] which LPN-Y wrote. LPN-Y informed Surveyor she doesn't really remember too much about R5 and doesn't remember R5 on this date ([DATE]). Surveyor asked LPN-Y if she recalls R5 having seizures. LPN-Y replied yes, seizure like activity, can't diagnose seizures. Surveyor inquired if she knew how often R5 would have seizures. LPN-Y replied no. R5 did not receive Lorazepam 0.5 mg every two hours as needed for seizure activity as the facility had not processed this medication order. Lorazepam is a benzodiazepine, and its primary use in seizure management is to stop ongoing seizures. The use of Lorazepam is critical in the management of R5's change in condition due to seizures as it helps prevent or stop seizures. The facility had no evidence that a physician was consulted about R5's change in condition due to seizure activity. There was no evidence that the facility called emergency services to manage R5's seizures, despite R5 having a seizure lasting ,d+[DATE] minutes and taking approximately 12 minutes to come out of the seizure. The nurses note dated [DATE], at 9:26 a.m., documents: Writer spoke with [first name] RN (Registered Nurse) from [Name] team and updated her on the continuous seizure activity. Resident was to have an appt (appointment) today for wound care. When up in w/c (wheelchair) resident had 2 active seizures hospice updated and agreed to not send resident to appt. Writer tried to reach out to resident mom with no answer, when speaking to [first name] she stated that she is working on trying to get a new facility for resident closer to home. Hospice is updated on current medication for pain and that resident needs to have schedule pain meds (medication). Writer is waiting on hospice nurse to arrive. This note is written by LPN-Z who is no longer employed at the facility. Surveyor noted that the facility did not have any evidence that R5's seizures were being monitored or that the physician was notified of R5's seizure activity or lack of medication used to manage seizure activity for R5. The hospice note for date of service [DATE] 9:30 a.m. documents: Focused visit performed d/t seizures. Symptoms/needs addressed and recommendations: Writer arrived to facility and spoke with [Name] (facility LPN) and [Name] (facility RN). Staff reports pt had 2 seizures this morning. He had wound appt. scheduled offsite but facility canceled out of concern for seizure activity during transport. Staff stated pt had first seizure around 6:50 am that lasted ,d+[DATE] minutes and it took him ,d+[DATE] minutes to recover. Blood glucose checked and was 188. Staff gave him apple juice and around 7:30 am pt had 2nd seizure that also lasted about ,d+[DATE] minutes. Staff reports pt has been sleepy since. Writer arrived to pt room and found pt resting comfortably in bed. Pt was easily woken and answered questions sleepily but appropriately. Pt denies pain, SOB (shortness of breath), N/V (nausea/vomiting) or discomfort of any kind. BP ,d+[DATE], HR 96, RR 18. Wound dressing not saturated and [Name] RNCM (Registered Nurse Case Manager) has scheduled visit tomorrow for wound care and f/u so writer did not remove dressing to assess wound. Writer in communication with RNCM and discussed asking for orders to increase scheduled Oxycodone for pain and scheduling Lorazepam for seizures. The order date [DATE] documents: Levetiracetam oral tablet 500 mg (Levetiracetam) Give 1 tablet by mouth two times a day for seizures. R5 did not start receiving this medication until [DATE], which was two days after it was ordered. R5 received Levetiracetam 500 mg BID from [DATE] to [DATE]. According to MedlinePlus, Levetiracetam is used alone and along with other medications to control partial-onset seizures (seizures that involve only one part of the brain) in adults, children, and infants 1 month of age or older. Levetiracetam is also used in combination with other medications to treat seizure in adults and children [AGE] years of age or older with juvenile myoclonic epilepsy. Levetiracetam is also used in combination with other medications to treat primary generalized tonic-clonic seizures (formerly known as a grand mal seizure; seizure that involves the entire body) in adults and children 6 years of age or older with epilepsy. Levetiracetam is in a class of medications called anticonvulsants. It works by decreasing abnormal excitement in the brain. https://medlineplus.gov/druginfo/meds/a699059.html The APNP (Advanced Practice Nurse Prescriber) history and physical note dated [DATE] under subjective documents In the last few days, the patient has been experiencing seizures. Ativan 0.5 mg every six hours was initially prescribed, but it didn't seem to help as he still had a seizure. Keppra 500 mg twice a day has been scheduled for seizure activity, the patient will continue to be monitored for comfort. The patient is alert, oriented, and responsive. He complains of pain and has some extremity edema. Under Assessment & plan includes documentation of 2. Seizure activity: Discontinue Ativan 0.5 mg every 6 hours. Initiate Keppra 500 mg twice daily. Monitor seizure frequency and effectiveness of medication. Keppra (Levetiracetam) 500 mg twice daily was not started until [DATE] and there was not an order for Ativan 0.5 mg every 6 hours as documented in APNP note dated [DATE]. The nurses note dated [DATE] at 15:13 (3:13 p.m.) documents: RN received call from lab; critical C reactive level @ (at) 7.03. (Protein produced by the liver in response to inflammation). RN notified [APNP-BB], she received. Awaiting any new orders. This nurses note was written by RN-CC. Hospice note dated [DATE] under reason for call documents seizure. Under call documentation documents Telephone call time: 0854 (8:54 a.m.) Who called: [First name], Relationship to patient: RN at facility, Call back # [phone number], Reason for call Seizure Patient having seizures this morning. He is conscious and taking, all vitals WNL (within normal limits). Is at baseline. [First name] said they don't have any orders for seizure activity. Writer looked on the MAR and he has an order for Lorazepam PRN for seizure activity, and another PRN Lorazepam order for anxiety, nausea etc. She said they do not have those orders. Writer offered to fax those over to her today. She was very thankful. Writer faxed those over to her at [number] with success. She did not feel like pt needed an RN visit and will call with any further needs. Updated team on this today and they can f/u if needed. Surveyor noted there is no documentation of R5 having a seizure on [DATE] in R5's medical record. Surveyor received this information on [DATE] from [name] hospice. R5 did not receive Lorazepam 0.5 mg every two hours as needed for seizure activity and there was no monitoring for seizures. The facility did not have any evidence that R5's seizures were being monitored or that a physician was notified of R5's seizure activity. This note provided to Surveyor was provided by hospice services and was not part of R5's medical record. Depite R5 having a change in condition due to seizures, this was not documented accurately in R5's medical record. The nurses note dated [DATE] at 22:13 (10:13 p.m.) documents: 1600 (4:00 p.m.) [Name] Hospice arrived to assess pt after his transfer wasn't completed earlier today d/t (due to) seizure activity. Meds reviewed and oxy (Oxycodone) needs to be sched (scheduled) and Lorazepam for seizures. Res started continually seizing while nurse was here sent to ER (emergency room ) via 911. Pt sister came in around 2030 (8:30 p.m.) to pick up his belongings per family he was being directly admitted to the Hospice inpatient unit and would not be returning to us. This note was written by RN-L. On [DATE] at 11:11 a.m., Surveyor interviewed RN-L regarding the nurses note she wrote on [DATE] at 10:13 p.m. RN-L explained to Surveyor this was her first day back to work. RN-L informed Surveyor she thinks they came to her because she was the RN in the building. RN-L informed Surveyor she doesn't know anything about prior seizures and was putting a medication list together but by the time she came back with the eMAR EMS was taking R5 out the front door. The hospice note for date of service [DATE] documents: Focused visit performed d/t: Assess comfort after reported seizure activity before planned transfer to another facility. Symptoms/needs addressed and recommendations: TC (telephone call) to facility with ETA (estimated time arrival), no answer. TC collab with [hospice name] SW (social worker) [first name], update received on [hospice name] receiving update from [Name] case manager [first name] on pt having seizure before planned transport to [Name] SNF (skilled nursing facility) in [NAME]. Transport arranged was non-medical and unable to transport pt until stable. No update received today from [Hospice name] from facility. On arrive to facility spoke with [Name] Administrator on purpose of visit. [First name] states I heard pt had another seizure. Collab (collaboration) with [Name] RN and med tech [Name]. Writer asking if pt received PRN Lorazepam after reported seizure. [Name] RN reports that they have not yet received Lorazepam order from pharmacy confirms facility has orders, but no Lorazepam. Writer notes that pt has 2 orders for Lorazepam. The initial comfort pack order from ,d+[DATE], Lorazepam 0.5 mg Q4 PRN and an order placed by facility provider on ,d+[DATE] Lorazepam 0.5 q2 for seizure activity. [Name] looks at pts facility chart and reports that the medication is listed as arrived today, searched several med carts and other area of facility and could not find the medication. Writer asked about scheduled and PRN Oxycodone. Facility reports they only have an order for PRN Oxycodone, pt last received on ,d+[DATE]. [Name] RN and [Name] med tech confirm that patient has not been receiving scheduled Oxycodone 5 mg Q6 ordered on ,d+[DATE]. TC collab with [Name]Pharmacy staff [Name]. Reports order for Lorazepam 0.5 mg Q2 for seizures was not sent due to pending provider signature. Reports that pharmacy sent an update to provider and they have not received a signed order. Reports facility can't request Lorazepam from contingency until pharmacy receives a signed order. [Name] confirms that scheduled order Oxycodone 5 mg Q6 was sent on ,d+[DATE] and received by facility. Writer updated that scheduled Oxycodone is not at facility and pt has not been receiving it as prescribed. [Name] med tech confirms that pt has been receiving scheduled Keppra 500 mg BID .No wipes in pts room. Writer went to care to grab incontinence supplies. Once back in pts room, [Name] and CNA (Certified Nursing Assistant) present and starting to complete incontinence cares. Writer assisting, noted pt to not be responding to questions, staring off and eyes rolling back, stiffened movements and jerking began, followed by abnormal respiratory pattern, gagging and active seizure noted at 1755 (5:55 p.m.), pt turned to right side, seizure lasted ,d+[DATE] minutes, pt unresponsive after, P 116, RR 22 and uneven. TC update to guardian/[Name] with update, confirms she would like writer to call 911 and send pt out to ER The hospital ED (emergency department) Clinical Summary dated [DATE] at 20:00 (8:00 p.m.) documents arrival as [DATE] 18:32:44 (6:32 p.m. and 44 seconds). Under Chief Complaint documents pt BIBA (brought in by ambulance) for seizures. Reports has had 3 seizures today, one witnessed by EMS (emergency medical services) that lasted aprx. (approximately) 30 secs (seconds) and described as tonic clonic. Pt is actively on Keppra, facility had no medications to give patient. Pt. is on hospice. Under History of Present Illness documents [R5's last & first name] is a male patient age [AGE] years. 62 yom (year old male) on hospice for PAD (peripheral artery disease) and necrotizing left foot wound, inpatient hospice does not have meds, hx (history) of seizure off antiepileptics x (times) 2 weeks but hospice center did not have any meds (medication) for treatment so came to ED. Pt non verbal cannot provide history, here with hospice nurse and mother. The hospital history and physical dated [DATE] at 22:07 (10:07 p.m.) under chief complaint documents Intractable seizures in the hospice patient. Under history of present illness documents [AGE] year-old male wit history of mild cognitive impairment, hypertension, diabetes mellitus type 2, peripheral vascular disease and who has had gangrene and necrotizing infection of the left foot and who is currently and nursing home resident on hospice care is brought in to be evaluated for intractable seizures. Patient is obtunded and unable to give any history. History was provided by hospice nurse. The patient was being moved from the current nursing home to another facility to continue with inpatient hospice today. When the nurse visited, the patient was found to be having seizures and apparently the seizures had been going on for 2 weeks. Apparently the medications that had been prescribed for the treatment of the patient's seizures had not been made available since this prescription about 2 weeks ago a such the patient had not been receiving any treatments. Prior to coming, the patient had had 3 seizures already and so the patient was brought to the ER for treatment of that. The hospice nurse had made an arrangement for the patient to be transferred to a different nursing home but did not have beds available right now and therefore the patient will be admitted here as GIP hospice while keeping the patient comfortable and controlling the seizures. The hospice emergent care note dated [DATE] under additional comments documents Patient is being admitted GIP (general inpatient care) to [Name] hospital after uncontrolled seizure activity, EOL (end of life) status and unable to return to current facility due to ordered comfort medications not available and Guardian [Name] not agreeable to pt returning to facility. Collab with ER staff [Physician name] and [Name] RN during visit. Pt received IV (intravenous) fluids, Zofran and Keppra after several seizures/emesis in ER, MD declined administering PRN Lorazepam for seizures/comfort due to reported low BPs and prevention of possible cardiac arrest The hospice note dated [DATE] documents RN performed comprehensive assessment, medication reconciliation, and plan of care review. Symptoms addressed and recommendations: Joint visit with [Name] RN precepting. Collaborated with [Name] hospital SW (social worker). Confirmed pt admitted for GIP (general inpatient care) stay. Upon arrive to pt room, pt comatose, does not respond to verbal or tactile stimuli . R5 expired in the hospital on [DATE]. On [DATE] at 12:00 p.m., Surveyor interviewed CNA (Certified Nursing Assistant)-M regarding R5's seizures on [DATE]. CNA-M informed Surveyor R5 didn't like to take showers but he agreed to take a shower. CNA-M informed Surveyor she believes when back in the room, she was getting R5 dressed and back to bed R5 wasn't responding. R5 indicated she went to get the nurse, LPN-Z who is not at the facility anymore and another nurse who is not here anymore. CNA-M informed Surveyor the nurses took vital signs and asked her to get fresh water. Surveyor asked CNA-M if R5 seizures started in R5's room. CNA-M informed Surveyor they kind of started when going back to his room. CNA-M informed Surveyor the nurse said R5 was having a seizure. Surveyor asked CNA-M if R5 had seizures before. CNA-M informed Surveyor R5 had seizures several times. CNA-M explained she didn't have R5 too often but couple times CNA-J would ask her to help her as R5 was having mild seizures. CNA-M informed Surveyor she can't say how often R5 had seizures. On [DATE] at 12:08 p.m., Surveyor asked CNA-J if she remembers R5 having any seizures. CNA-J replied no. Surveyor asked CNA-J if she remembers asking CNA-M for help because R5 was having a seizure as this is what CNA-M had told Surveyor. CNA-J informed Surveyor she doesn't recall as it has been awhile. CNA-J informed Surveyor if [name of CNA-M] said that it was probably true but she doesn't recall. On [DATE] at 2:21 p.m., Surveyor informed NHA-A and DON-B of the above findings. Surveyor asked NHA-A and DON-B if there was any additional information as to why the facility had not obtained R5's seizure medication that was critical to managing R5's change in condition. DON-B stated that DON-B was not at the facility at the time and could not speak to the events regarding R5's seizure activity. Surveyor asked DON-B if the physician was consulted of R5's change in condition and DON-B stated she could not speak to the events regarding R5's seizure activity as DON-B was not at the facility at the time of R5's seizures. The facility's failure to ensure R5 received appropriate care and treatment when R5 experienced a change in condition created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The immediate jeopardy was removed on [DATE] when the facility implemented the following action plan: * Education has to be completed the next tour of duty for all licensed nursing staff on change of condition and responsibilities that include collaboration with the physician, identification of necessary interventions, and the effectiveness of those interventions and implementing new interve [TRUNCATED]

Based on interview and record review, the facility did not provide pharmaceutical services to meet the needs of each resident for 3 (R5, R4, and R3) of 6 residents. On [DATE], R5 experienced a seizure, which was a change of condition for R5. On [DATE], R5 received a physician order for Lorazepam 0.5 mg (milligrams) every 4 hours as needed for comfort medication. This order was not picked up by the facility until [DATE]. R5 experienced another seizure on [DATE]. Following the seizure on [DATE], Lorazepam 0.5 mg every two hours as needed for seizure activity was ordered. This order was not picked up until [DATE]. On [DATE], R5 received an order for Levetiracetam 500 mg (an anti-seizure medication): Give 1 tablet by mouth two times a day for seizures. R5 did not start receiving this medication until [DATE]. R5 continued to have seizures on [DATE], [DATE], and [DATE]. R5 did not receive Lorazepam every two hours as needed for seizure activity as there was not a signature on the prescription from the provider and the pharmacy did not send this medication. On [DATE], R5 was transferred to the hospital due to seizure activity and medications not being available. R5 continued to have seizures in the ER (emergency room ) on [DATE] and on [DATE] while in the hospital, R5 was comatose and did not respond to verbal or tactile stimuli. R5 expired in the hospital on [DATE]. The facility's failure to ensure medication orders were reconciled correctly, required medication orders contained the required signature, and to ensure there was collaboration and communication between the facility, pharmacy, and hospice created a finding of Immediate Jeopardy (IJ) which began on [DATE]. NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B were notified of the immediate jeopardy on [DATE] at 3:36 p.m. The immediate jeopardy was removed on [DATE] however, the deficient practice continues at a scope/severity level of D (potential for harm/isolated) related to the examples of R4 and R3 and as the facility continues to implement its action plan. * R4 did not receive scheduled medications one hour before or one hour after the scheduled time 88 times between [DATE] and [DATE]. * R3 did not receive scheduled medication one hour before or on hour after the scheduled time 11 times on [DATE] to [DATE] and 21 times [DATE] to [DATE]. Findings include: 1.) R5 was originally admitted to the facility on [DATE] with diagnoses that included osteomyelitis, diabetes mellitus, MRSA (methicillin resistant staphylococcus aureus), PVD (peripheral vascular disease), chronic kidney disease, hypertension, Atrial Fibrillation, acute embolism and thrombosis of unspecified deep veins of lower extremities, and necrotizing diabetic foot infection. On [DATE], R5 was transferred to the hospital and returned to the facility on [DATE] with hospice services. The hospital discharge summary dated [DATE] documents under final diagnosis: 1. Diabetic foot ulcer with osteomyelitis. 2. Necrotizing soft tissue infection. 3. Insulin requiring or dependent type II diabetes mellitus. 4. PVD (peripheral vascular disease). 5. Phalanges fracture foot. 6. Hypertension. 7. Hyperlipidemia. 8. Chronic kidney disease. 9. Gastro-esophageal reflux disease without esophagitis. 10. Depression. On [DATE], hospice ordered Lorazepam (Ativan) 0.5 mg. Route: Take 1 tab (tablet) by mouth every 4 hours as needed Comfort Med, call [hospice name] prior to first dose. May crush or dissolve. Purpose: Anxiety, Hospice Related, Nausea, Restlessness. The facility did not pick up this order until [DATE]. On [DATE], hospice ordered Hyoscyamine Sulfate 0.125 mg disintegrating tab. Route Take 1 tab by mouth every 2 hours as needed comfort med. Call [Hospice Name] prior to 1st dose. May crush or dissolve. Purpose: Bladder spasm, Hospice related respiratory congestion. The facility did not pick up this order. The nurses note dated [DATE] at 9:04 a.m. by LPN (Licensed Practical Nurse)-X documents: 7:14 a.m. convulsing then became unresponsive, with labored breathing. 7:16 a.m. [Name of] hospice nurse called ([First name]) will be in to evaluate. 7:25 a.m. resident alert. 7:36 a.m. POA (power of attorney): [First name] called, left voicemail with detailed message regarding [R5's first name] episode of convulsing. BP (blood pressure): ,d+[DATE], p (pulse): 101, T (temperature): 96.4, O2 (oxygen): 98% /RA (room air) R (respirations) 24, labored. The medication order with an order date and start date of [DATE] documents Lorazepam (Ativan) 0.5 mg tab Dose: 0.5 mg/Route: Oral/Freq (frequency): EVERY 2 HOURS PRN (as needed)/Admin Inst (administration instruction): Every 2 hours as needed for seizure activity. The facility did not note this order until [DATE]. The nurses note dated [DATE] at 7:00 a.m., by LPN-Y documents: Resident noted with ,d+[DATE] minutes of unresponsiveness and fixated stair [sic] (stare). Resident noted drooling. BP ,d+[DATE], HR 133, BS (blood sugar) 188 mg/dl, Spo2 99%. Per RN took resident about 12 minutes to come out of seizure. Hospice updated. R5 did not receive Lorazepam 0.5 mg every two hours as needed for seizure activity as the facility had not noted this order. The nurses note dated [DATE] at 9:26 a.m., documents: Writer spoke with [first name] RN (Registered Nurse) from [Name] team and updated her on the continuous seizure activity. Resident was to have an appt (appointment) today for wound care. When up in w/c (wheelchair) resident had 2 active seizures hospice updated and agreed to not send resident to appt. Writer tried to reach out to resident mom with no answer, when speaking to [first name] she stated that she is working on trying to get a new facility for resident closer to home. Hospice is updated on current medication for pain and that resident needs to have schedule pain meds (medication). Writer is waiting on hospice nurse to arrive. This note is written by LPN-Z who is no longer employed at the facility. The order dated [DATE] documents: Levetiracetam oral tablet 500 mg (Levetiracetam) Give 1 tablet by mouth two times a day for seizures. R5 did not start receiving this medication until [DATE]. R5 received Levetiracetam 500 mg BID from [DATE] to [DATE]. Levetiracetam (also known as Keppra) treats seizures by slowing electrical activity in the brain. The APNP (Advanced Practice Nurse Prescriber) history and physical note dated [DATE] under subjective documents: .In the last few days, the patient has been experiencing seizures. Ativan 0.5 mg every six hours was initially prescribed, but it didn't seem to help as he still had a seizure. Keppra 500 mg twice a day has been scheduled for seizure activity, the patient will continue to be monitored for comfort. The patient is alert, oriented, and responsive. He complains of pain and has some extremity edema. Under Assessment and plan includes documentation of 2. Seizure activity: Discontinue Ativan 0.5 mg every 6 hours. Initiate Keppra 500 mg twice daily. Monitor seizure frequency and effectiveness of medication. Keppra 500 mg twice daily was not started until [DATE] and there was not an order for Ativan 0.5 mg every 6 hours as documented in APNP note dated [DATE]. Hospice note dated [DATE] under reason for call documents: seizure. Under call documentation documents: Telephone call time: 0854 (8:54 a.m.) Who called: [First name], Relationship to patient: RN at facility, Call back # [phone number], Reason for call Seizure Patient having seizures this morning. He is conscious and taking, all vitals WNL (within normal limits). Is at baseline. [First name] said they don't have any orders for seizure activity. Writer looked on the MAR and he has an order for Lorazepam PRN for seizure activity, and another PRN Lorazepam order for anxiety, nausea etc. She said they do not have those orders. Writer offered to fax those over to her today. She was very thankful. Writer faxed those over to her at [number] with success. She did not feel like pt needed an RN visit and will call with any further needs. Updated team on this today and they can f/u if needed. Surveyor noted there is no documentation of R5 having a seizure on [DATE] in R5's medical record. Surveyor received this information on [DATE] from [name] hospice. R5 did not receive Lorazepam 0.5 mg every two hours as needed for seizure activity. The nurses note dated [DATE] at 22:13 (10:13 p.m.) documents: 1600 (4:00 p.m.) [Name] Hospice arrived to assess pt after his transfer wasn't completed earlier today d/t (due to) seizure activity. Meds reviewed and oxy (Oxycodone) needs to be sched (scheduled) and Lorazepam for seizures. Res started continually seizing while nurse was here sent to ER (emergency room ) via 911. Pt sister came in around 2030 (8:30 p.m.) to pick up his belongings per family he was being directly admitted to the Hospice inpatient unit and would not be returning to us. This note was written by RN-L. The hospice note for date of service [DATE] documents: Focused visit performed d/t: Assess comfort after reported seizure activity before planned transfer to another facility. Symptoms/needs addressed and recommendations: TC (telephone call) to facility with ETA (estimated time arrival), no answer. TC collab with [hospice name] SW (social worker) [first name], update received on [hospice name] receiving update from [Name] case manager [first name] on pt having seizure before planned transport to [Name] SNF (skilled nursing facility) in [NAME]. Transport arranged was non-medical and unable to transport pt until stable. No update received today from [Hospice name] from facility. On arrive to facility spoke with [Name] Administrator on purpose of visit. [First name] states I heard pt had another seizure. Collab (collaboration) with [Name] RN and med tech [Name]. Writer asking if pt received PRN Lorazepam after reported seizure. [Name] RN reports that they have not yet received Lorazepam order from pharmacy confirms facility has orders, but no Lorazepam. Writer notes that pt has 2 orders for Lorazepam. The initial comfort pack order from ,d+[DATE], Lorazepam 0.5 mg Q4 PRN and an order placed by facility provider on ,d+[DATE] Lorazepam 0.5 q2 for seizure activity. [Name] looks at pts facility chart and reports that the medication is listed as arrived today, searched several med carts and other areas of facility and could not find the medication. Writer asked about scheduled and PRN Oxycodone. Facility reports they only have an order for PRN Oxycodone, pt last received on ,d+[DATE]. [Name] RN and [Name] med tech confirm that patient has not been receiving scheduled Oxycodone 5 mg Q6 ordered on ,d+[DATE]. TC collab with [Name]Pharmacy staff [Name]. Reports order for Lorazepam 0.5 mg Q2 for seizures was not sent due to pending provider signature. Reports that pharmacy sent an update to provider and they have not received a signed order. Reports facility can't request Lorazepam from contingency until pharmacy receives a signed order. [Name] confirms that scheduled order Oxycodone 5 mg Q6 was sent on ,d+[DATE] and received by facility. Writer updated that scheduled Oxycodone is not at facility and pt has not been receiving it as prescribed. [Name] med tech confirms that pt has been receiving scheduled Keppra 500 mg BID. Writer asking if pt is receiving scheduled Tylenol prior to wound care as ordered. [Name] reports that the PRN Tylenol order and scheduled Tylenol order were entered incorrectly, so the Tylenol would not come up as scheduled and pt has not been receiving scheduled Tylenol prior to daily wound care or any pain regimen routinely .No wipes in pts room. Writer went to care to grab incontinence supplies. Once back in pts room, [Name] and CNA (Certified Nursing Assistant) present and starting to complete incontinence cares. Writer assisting, noted pt to not be responding to questions, staring off and eyes rolling back, stiffened movements and jerking began, followed by abnormal respiratory pattern, gagging and active seizure noted at 1755 (5:55 p.m.), pt turned to right side, seizure lasted ,d+[DATE] minutes, pt unresponsive after, P 116, RR 22 and uneven. TC update to guardian/[Name] with update, confirms she would like writer to call 911 and send pt out to ER The hospital ED (emergency department) Clinical Summary dated [DATE] at 20:00 (8:00 p.m.) documents: arrival as [DATE] 18:32:44 (6:32 p.m. and 44 seconds). Under Chief Complaint documents pt BIBA (brought in by ambulance) for seizures. Reports has had 3 seizures today, one witnessed by EMS (emergency medical services) that lasted aprx. (approximately) 30 secs (seconds) and described as tonic clonic. Pt is actively on Keppra, facility had no medications to give patient. Pt. is on hospice. Under History of Present Illness documents [R5's last and first name] is a male patient age [AGE] years. 62 yom (year old male) on hospice for PAD (peripheral artery disease) and necrotizing left foot wound, inpatient hospice does not have meds, hx (history) of seizure off antiepileptics x (times) 2 weeks but hospice center did not have any meds (medication) for treatment so came to ED. Pt nonverbal cannot provide history, here with hospice nurse and mother. The hospital history and physical dated [DATE] at 22:07 (10:07 p.m.) under chief complaint documents: Intractable seizures in the hospice patient. Under history of present illness documents [AGE] year-old male with history of mild cognitive impairment, hypertension, diabetes mellitus type 2, peripheral vascular disease and who has had gangrene and necrotizing infection of the left foot and who is currently and nursing home resident on hospice care is brought in to be evaluated for intractable seizures. Patient is obtunded and unable to give any history. History was provided by hospice nurse. The patient was being moved from the current nursing home to another facility to continue with inpatient hospice today. When the nurse visited, the patient was found to be having seizures and apparently the seizures had been going on for 2 weeks. Apparently the medications that had been prescribed for the treatment of the patient's seizures had not been made available since this prescription about 2 weeks ago as such the patient had not been receiving any treatments. Prior to coming, the patient had had 3 seizures already and so the patient was brought to the ER for treatment of that. The hospice nurse had made an arrangement for the patient to be transferred to a different nursing home but did not have beds available right now and therefore the patient will be admitted here as GIP hospice while keeping the patient comfortable and controlling the seizures. The hospice emergent care note dated [DATE] under additional comments documents: Patient is being admitted GIP (general inpatient care) to [Name] hospital after uncontrolled seizure activity, EOL (end of life) status and unable to return to current facility due to ordered comfort medications not available and Guardian [Name] not agreeable to pt returning to facility. Collab with ER staff [Physician name] and [Name] RN during visit. Pt received IV (intravenous) fluids, Zofran and Keppra after several seizures/emesis in ER, MD declined administering PRN Lorazepam for seizures/comfort due to reported low BPs and prevention of possible cardiac arrest. R5 expired at the hospital on [DATE]. On [DATE] at 3:28 p.m., Surveyor asked LPN-S who is responsible for picking up new medication orders. LPN-S informed Surveyor the nurse that's on. On [DATE] at 9:24 a.m., Surveyor asked RN-L who is responsible for picking up new medication orders. RN-L informed Surveyor the nurse on duty and she heard the ADON (Assistant Director of Nursing) when she starts is going to be. On [DATE] at 11:59 a.m., Surveyor spoke with Hospice RN/CM (Registered Nurse/Case Manager)-AA to inquire if there were any concerns regarding R5's medications. Hospice RN/CM-AA informed Surveyor there were scheduled comfort medications that were never processed and PRN Lorazepam for seizure activity was not received. Hospice RN/CM-AA stated on [DATE], R5 had a seizure during incontinence cares and R5 was sent to the hospital due to medication not being available on [DATE]. RN/CM-AA informed Surveyor R5 did not have a previous diagnosis of seizures. RN/CM-AA informed Surveyor it might be worthwhile to request R5's records from [hospice name]. On [DATE] at 1:29 p.m., Surveyor asked LPN/UM (Licensed Practical Nurse/Unit Manager)-F who is responsible for picking up hospice orders or when a resident is readmitted to the hospital. LPN/UM-F informed Surveyor the admitting nurse. Surveyor informed LPN/UM-F that on [DATE], Lorazepam 0.5 mg q 4 hours PRN was ordered for comfort and on [DATE], Lorazepam 0.5 mg q 2 hours PRN for seizure activity was not picked up until [DATE]. LPN/UM-F replied, Honestly I don't know what to say. On [DATE] at 11:45 p.m., Surveyor asked DON-B to review R5's Lorazepam (Ativan) narcotic sheets. DON-B informed Surveyor she would look for them. On [DATE] at 2:21 p.m., Surveyor interviewed DON-B regarding R5's Lorazepam (Ativan) narcotic sheet. DON-B stated there is no narcotic sheet for Ativan due to nurse practitioner sending order for medication to pharmacy directly without a signature. DON-B stated the form was sent back requesting a signature by pharmacy. States medication was never delivered. DON-B stated there is no narcotic sheet for a medication that was not delivered or given to resident. The facility's failure to ensure the accurate acquiring and administration of medications created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The immediate jeopardy was removed on [DATE] when the facility implemented the following action plan: * Education has to be completed the next tour of duty for all licensed nursing staff on steps to take when receiving new orders, education provided on ensuring medication is monitored for effectiveness by shift to shift report, use of the 24 hour board, effective documentation. * Licensed nursing staff education on using the SBAR when communicating with providers to ensure the information is the most up to date and factual based on current observations by the licensed nurse. * All licensed nurses will be educated on the use of PRN medications when appropriate. * Nurses will be educated on the process to follow when orders cannot be carried out as written by the provider. * All licensed nurses educated on steps to take when medications do not arrive timely that include provider, pharmacy, and Director of Nurses. * The facility has reviewed and education has to be completed the next tour of duty for all licensed nursing staff on the following policies: medication administration. * System implemented will review 24 hour charting, review all appointments and all incoming medical records in clinical stand up meeting to ensure all new orders are reviewed from all sources: new and readmissions, telephone orders, provider visits including hospice. * Nurse managers and DON will conduct random audits weekly x 4 to ensure all orders from all sources are checked for accuracy, timeliness, and availability. Root cause analysis will be conducted. * All audits will be reviewed at QAPI (quality assurance performance improvement) for further recommendations. Medical Director will be included in QAPI and reviewing the root cause analysis. The deficient practice continues at a scope/severity level of D (potential for no more than minimal harm/isolated) as evidenced by: 2.) The facility's policy titled, Medication Administration with an effective date of [DATE] under procedures section B Administration documents 12) Medications are administered within 60 minutes of scheduled time, except before, with or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the Prescriber, routine medications are administered according to the established medication administration schedule for the facility. R4 was admitted to the facility on [DATE] and discharged on [DATE]. R4 was reviewed as a closed record. R4's diagnoses includes non-traumatic intracerebral hemorrhage, hemiplegia, hypertension, anxiety disorder, depressive disorder, and polyneuropathy. On [DATE], Surveyor reviewed R4's medication administration audit report for the time period [DATE] to [DATE] provided to Surveyor by DON (Director of Nursing)-B. This audit report shows the scheduled time and administration time for R4's medication. This report revealed the following: * On [DATE], Carvedilol 25 mg (milligrams) two times a day, Losartan Potassium 100 mg once daily, Fluticasone Propionate Nasal suspension 50 mcg/act (micrograms/actuation) once daily, Multivitamin with minerals once daily, and Magnesium Oxide 500 mg twice daily were scheduled at 6:00 a.m. R4 received these medications at 7:37 a.m., 1 hour and 37 minutes after the scheduled time. On [DATE], Magnesium Oxide 500 mg two times a day and Carvedilol 25 mg two times a day were scheduled at 1400 (2:00 p.m.). R4 received these medications at 15:53 (3:53 p.m.). * On [DATE], R4 received Carvedilol 25 mg at 8:15 a.m., Losartan Potassium 100 mg at 8:16 a.m., Fluticasone Propionate Nasal suspension 50 mcg/act at 8:26 a.m., Multivitamin with minerals at 8:18 a.m., and Magnesium Oxide 500 mg at 8:18 a.m. R4's medication were administered over two hours after the scheduled time of 6:00 a.m. On [DATE], Magnesium Oxide 500 mg two times a day and Carvedilol 25 mg two times a day were scheduled at 1400 (2:00 p.m.). Magnesium Oxide 500 mg was administered at 17:02 (5:02 p.m.) and Carvedilol 25 mg was administered at 17:03 (5:03 p.m.). * On [DATE], Carvedilol 25 mg (milligrams) two times a day, Losartan Potassium 100 mg once daily, Fluticasone Propionate Nasal suspension 50 mcg/act (micrograms/actuation) once daily, Multivitamin with minerals once daily, and Magnesium Oxide 500 mg twice daily were scheduled at 6:00 a.m. R4 received these medications at 7:15 a.m., 1 hour and 15 minutes after the scheduled time. On [DATE], Magnesium Oxide 500 mg two times a day and Carvedilol 25 mg two times a day were scheduled at 1400 (2:00 p.m.). Magnesium Oxide 500 mg and Carvedilol 25 mg were administered at 18:25 (6:25 p.m.). On [DATE], Diclofenac Potassium 50 mg twice daily, Diazepam 2 mg three times daily, Clonazepam 1 mg three times daily, Propranolol 10 mg three times daily, and Pregabalin 100 mg three times daily were scheduled for 16:00 (4:00 p.m.). R4 received these medications at 18:24 (6:24 p.m.). * On [DATE], R4 received Carvedilol 25 mg at 9:35 a.m., Losartan Potassium 100 mg at 9:36 a.m., Fluticasone Propionate Nasal suspension 50 mcg/act at 10:40 a.m., Multivitamin with minerals at 9:36 a.m., and Magnesium Oxide 500 mg at 9:36 a.m., over three hours after the scheduled time of 6:00 a.m. On [DATE], Artificial Tears 1 drop in both eyes is scheduled four times daily. R4's schedule dose at 7:30 a.m. was administered at 10:40 a.m., 3 hours after the scheduled time. On [DATE], R4 received 8:00 a.m. medications as follows: Clonazepam 1 mg and Pregabalin 100 mg at 9:33 a.m., Diazepam 2 mg and Diclofenac Potassium 50 mg at 9:25 a.m., and Propranolol 10 mg at 10:40 a.m. * On [DATE], R4 received Multivitamin with minerals and Magnesium Oxide 500 mg at 10:13 a.m., Fluticasone Propionate Nasal suspension 50 mcg/act, Losartan Potassium 100 mg, and Carvedilol 25 mg at 10:14 a.m. This was four hours after the scheduled time of 6:00 a.m. On [DATE], Artificial Tears 1 drop in both eyes is scheduled four times daily. R4's schedule dose at 7:30 a.m. was administered at 10:13 a.m. On [DATE], Clonazepam 1 mg, Pregabalin 100 mg, Diazepam 2 mg, and Diclofenac Potassium 50 mg were administered at 10:13 am. Propranolol 10 mg was administered at 10:15 a.m. Scheduled time was 8:00 a.m. On [DATE], Magnesium Oxide 500 mg two times a day and Carvedilol 25 mg two times a day were scheduled at 1400 (2:00 p.m.). Magnesium Oxide 500 mg and Carvedilol 25 mg were administered at 18:10 (6:10 p.m.). On [DATE], Diclofenac Potassium 50 mg twice daily, Diazepam 2 mg three times daily, Clonazepam 1 mg three times daily, Propranolol 10 mg three times daily, and Pregabalin 100 mg three times daily were scheduled for 16:00 (4:00 p.m.). R4 received these medications at 18:10 (6:10 p.m.). * On [DATE], Carvedilol 25 mg (milligrams) two times a day, Losartan Potassium 100 mg once daily, Fluticasone Propionate Nasal suspension 50 mcg/act (micrograms/actuation) once daily, Multivitamin with minerals once daily, and Magnesium Oxide 500 mg twice daily were scheduled at 6:00 a.m. R4 received these medications at 9:50 a.m. On [DATE], Artificial Tears 1 drop in both eyes is scheduled four times daily. R4's schedule dose at 7:30 a.m. was administered at 9:40 a.m. On [DATE], Propranolol 10 mg was administered at 9:41 a.m., Diclofenac Potassium 50 mg was administered at 9:47 a.m., and Pregabalin 100 mg, Clonazepam 1 mg, and Diazepam 2 mg were administered at 9:48 a.m. These medications were scheduled at 8:00 a.m. On [DATE], Magnesium Oxide 500 mg two times a day and Carvedilol 25 mg two times a day were scheduled at 1400 (2:00 p.m.). Magnesium Oxide 500 mg and Carvedilol 25 mg were administered at 16:38 (4:38 p.m.). On [DATE], Surveyor reviewed R4's medication administration audit report for the time period [DATE] to [DATE], R4's date of discharge, provided to Surveyor by DON-B. * On [DATE], Carvedilol 25 mg (milligrams) two times a day, Losartan Potassium 100 mg once daily, Fluticasone Propionate Nasal suspension 50 mcg/act (micrograms/actuation) once daily, Multivitamin with minerals once daily, and Magnesium Oxide 500 mg twice daily were scheduled at 6:00 a.m. R4 received these medications at 8:58 a.m. On [DATE], Artificial Tears 1 drop in both eyes is scheduled four times daily. R4's schedule dose at 7:30 a.m. was administered at 8:59 a.m. * On [DATE], Carvedilol 25 mg (milligrams) two times a day, Losartan Potassium 100 mg once daily, Fluticasone Propionate Nasal suspension 50 mcg/act (micrograms/actuation) once daily, Multivitamin with minerals once daily, and Magnesium Oxide 500 mg twice daily were scheduled at 6:00 a.m. R4 received these medications at 7:56 a.m. On [DATE], Magnesium Oxide 500 mg twice daily and Carvedilol 25 mg twice daily were scheduled at 14:00 (2:00 p.m.). R4 received these medications at 16:10 (4:10 p.m.). * On [DATE], Carvedilol 25 mg (milligrams) two times a day, Losartan Potassium 100 mg once daily, Fluticasone Propionate Nasal suspension 50 mcg/act (micrograms/actuation) once daily, Multivitamin with minerals once daily, and Magnesium Oxide 500 mg twice daily were scheduled at 6:00 a.m. R4 received these medications at 7:28 a.m. On [DATE], Magnesium Oxide 500 mg twice daily and Carvedilol 25 mg twice daily were scheduled at 14:00 (2:00 p.m.). R4 received these medications at 18:34 (6:34 p.m.). * On [DATE], Diclofenac Potassium 50 mg two times a day, Diazepam 2 mg three times a day, Propranolol 10 mg three times a day, Clonazepam 1 mg three times a day, and Pregabalin 100 mg three times a day were scheduled at 16:00 (4:00 p.m.) R4 received these medications at 18:33 (6:33 p.m.) * On [DATE], R4 received Fluticasone Propionate Nasal suspension 50 mcg/act, Losartan Potassium 100 mg, Carvedilol 25 mg at 9:26 a.m., and Multivitamin with minerals and Magnesium Oxide 500 mg at 9:28 a.m. These medications were scheduled for 6:00 a.m. On [DATE], Artificial Tears 1 drop in both eyes is scheduled four times daily. R4's schedule dose at 7:30 a.m. was administered at 9:26 a.m. On [DATE], Clonazepam 1 mg three times daily, Pregabalin 100 mg three times daily, Diazepam 2 mg three times daily, Diclofenac Potassium 50 mg two times daily, and Propranolol 10 mg three times daily were scheduled at 8:00 a.m. R4 was administered these medications at 9:26 a.m. On [DATE], Magnesium Oxide 500 mg twice daily and Carvedilol 25 mg twice daily were scheduled at 14:00 (2:00 p.m.). R4 received these medications at 17:21 (5:21 p.m.). * On [DATE], Carvedilol 25 mg (milligrams) two times a day, Losartan Potassium 100 mg once daily, Fluticasone Propionate Nasal suspension 50 mcg/act (micrograms/actuation) once daily, Multivitamin with minerals once daily, and Magnesium Oxide 500 mg twice daily were scheduled at 6:00 a.m. R4 received these medications at 9:59 a.m. On [DATE], Artificial Tears 1 drop in both eyes is scheduled four times daily. R4's schedule dose at 7:30 a.m. was administered at 10:02 a.m. On [DATE], Pregabalin 100 mg and Clonazepam 1 mg were administered at 9:47 a.m., Propranolol 10 mg and Diclofenac Potassium 50 mg were administered at 9:59 a.m., and Diazepam 2 mg was administered at 10:02 a.m. These medications were scheduled for 8:00 a.m. * On [DATE], Carvedilol 25 mg was administered at 7:54 a.m. and Multivitamin with minerals, Fluticasone Propionate Nasal suspension 50 mcg/act, Losartan Potassium 100 mg, and Magnesium Oxide 500 mg were administered at 7:55 a.m. These medications were scheduled for 6:00 a.m. * On [DATE], Magnesium Oxide 500 mg twice daily and Carvedilol 25 mg twice daily were scheduled at 14:00 (2:00 p.m.). R4 received these medications at 17:46 (5:46 p.m.). On [DATE], R4 received Diclofenac Potassium 50 mg, Diazepam 2 mg, Clonazepam 1 mg, and Pregabalin 100 mg at 17:45 (5:45 p.m.) and Carvedilol 25 mg and Propranolol 10 mg were administered at 17:46 (5:46 p.m.) These medications were scheduled for 4:00 p.m. On [DATE], Artificial Tears four times a day was scheduled at 20:00 (8:00 p.m.). R4 received the eye drops at 17:46 (5:46 p.m.). * On [DATE], Carvedilol 25 mg, Losartan Potassium 100 mg, Multivitamin with minerals, and Magnesium Oxide 500 mg were administered at 7:36 a.m. and Fluticasone Propionate Nasal suspension 50 mcg/act was administered at 7:37 a.m. These were scheduled for 6:00 a.m. On [DATE], Magnesium Oxide 500 mg twice daily and Carvedilol 25 mg twice daily were scheduled at 14:00 (2:00 p.m.). R4 received these medications at 18:46 (6:46 p.m.). On [DATE], R4 received Propranolol 10 mg at 18:46 (6:46 p.m.), Diclofenac Potassium 50 mg at 18:47 (6:47 p.m.), and Diazepam 2 mg, Clonazepam 1 mg, and Pregabalin 100 mg at 18:48 (6:48 p.m.) These medications were scheduled for 4:00 p.m. On [DATE], Artificial Tears four times a day was scheduled at 20:00 (8:00 p.m.). R4 received the eye drops at 22:42 (10:42 p.m.). On [DATE], Propranolol 10 mg three times a day, Pregabalin 100 mg three times a day Clonazepam 1 mg three times a day, and Diazepam 2 mg three times were scheduled at 21:00 (9:00 p.m.). R4 received these medications at 22:42 (10:42 p.m.). * On [DATE], Magnesium Oxide 500 mg twice daily and Carvedilol 25 mg twice daily were scheduled at 14:00 (2:00 p.m.). R4 received these medications at 15:54 (3:54 p.m.). * On [DATE], Magnesium Oxide 500 mg twice daily and Carvedilol 25 mg twice daily were scheduled at 14:00 (2:00 p.m.). R4 received these medications at 19:17 (7:17 p.m.). * On [DATE], Losartan Potassium 100 mg, Carvedilol 25 mg, and Fluticasone Propionate Nasal suspension 50 mcg/act were administered at 8:02 a.m. and Multivitamin with minerals and Magnesium Oxide 500 mg were administered at 8:03 a.m. These medications were scheduled for 6:00 a.m. On [DATE], Magnesium Oxide 500 mg twice daily and Carvedilol 25 mg twice daily were scheduled at 14:00 (2:00 p.m.). R4 received these medications at 21:19 (9:19 p.m.). * On [DATE], Multivitamin with minerals, Fluticasone Propionate Nasal suspension 50 mcg/act, Carvedilol 25 mg, and Magnesium Oxide 500 mg were administered at 8:38 a.m. and Losartan Potassium 100 mg at 8:39 a.m. These medications were scheduled for 6:00 a.m. On [DATE], Magnesium Oxide 500 mg twice daily and Carvedilol 25 mg twice daily we [TRUNCATED]

UNCORRECTED ON REVISIT Based on interview, and record review the facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 2 (R6 and R51) of 3 residents reviewed for pressure injuries. *R6 did not have an ordered treatment in the Treatment Administration Record (TAR) for the sacral pressure injury from 4/10/2024 through 6/11/2024. *R51 had a pressure injury to the right metatarsal identified on 6/10/2024 and was not assessed until 6/12/2024 when Wound Nurse Practitioner (NP)-I determined the pressure injury was Unstageable. The air mattress was observed to be at an improper weight during the survey. Findings include: The facility policy and procedure entitled Wound Management undated documents: Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse or the assigned licensed nurse in the absence of the treatment nurse. 7. Treatments will be documented on the Treatment Administration Record. 1.) R6 was admitted to the facility on [DATE] with diagnoses of incomplete quadriplegia, chronic obstructive pulmonary disease, anxiety, right below the knee amputation, depression, insomnia, and tobacco use. R6's Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R6 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13. R6 did not have an activated Power of Attorney. The MDS documented R6 had three Stage 4 pressure injuries. R6's Physical Functioning Deficit Care Plan initiated on 3/28/2021 indicated R6 needed extensive assistance with bed mobility and used a Hoyer lift for transfers. On 4/24/2024, R6 was seen by Wound NP-I. Wound NP-I comprehensively assessed R6's three Stage 4 pressure injuries: the right midline ischium, the center midline sacrum, and the left medial heel. The treatment to the right midline ischium wound was to cleanse the wound with cleanser and pat dry with gauze; apply collagen to the wound bed followed by alginate; cover with foam with silicone bordered dressing three times weekly and as needed for soiled or loose dressing. The treatment to the center midline sacrum wound was the same as the right midline ischium. The treatment to the left medial heel wound was to cleanse the wound with cleanser and pat dry with gauze; apply medial grade honey to the wound bed followed by alginate; cover with foam with silicone bordered dressing three times weekly and as needed for soiled or loose dressing. R6 had a treatment to the center midline sacrum on the TAR that was discontinued on 4/10/2024. No treatment to the center midline sacrum was found after that date. R6 was seen weekly by Wound NP-I for comprehensive assessments of the three Stage 4 pressure injuries. On 5/1/2024, Wound NP-I changed the treatment to the right midline ischium wound to include medical grade honey followed by alginate. The treatments to the other two Stage 4 pressure injuries did not change. On 5/15/2024, Wound NP-I changed the treatment to the center midline sacrum wound to include collagen to the wound base followed by oil emulsion gauze and alginate; cover with foam with silicone dressing three times weekly and as needed for soiled or loose dressing; use absorbent pad dressing between scheduled dressing changes and as needed for soiled or loose dressing; secure with tape as needed. Surveyor noted no treatment was on the TAR for the center midline sacrum wound. On 5/22/2024, Wound NP-I initiated a procedure to the center midline sacrum wound that included a biologic product put on the wound bed and was applied weekly by Wound NP-I. The treatment continued to be the same for the facility staff. Surveyor noted R6 had two Stage 4 pressure injuries to the buttock area: the sacrum and the right ischium. The treatments to the two areas were not the same and the treatment to the sacrum was not on the TAR. On 5/23/2024 at 6:14 PM in the progress notes, Registered Nurse (RN)-G documented the dressings were changed to the sacrum and the right ischium due to both being soiled and coming off. Surveyor noted the sacrum did not have a treatment order in the TAR and the treatment order per Wound NP-I was not the same for each wound. Surveyor noted no treatment was entered into the computer charting system for R6's sacral pressure injury from 4/10/2024 until 5/22/2024. On 5/22/2024, the treatment order was entered incorrectly into the computer charting system under the therapy tab and therefore not visible to nursing staff. In an interview on 6/11/2024 at 8:58 AM, Surveyor asked Licensed Practical Nurse (LPN) Nursing Supervisor (NS)-E how orders are obtained for pressure injuries. LPN NS-E stated LPN NS-E does wound rounds with Wound NP-I on Wednesdays. LPN NS-E stated Wound NP-I puts the treatment orders on their documentation that is scanned into the computer and LPN NS-E puts the orders into the TAR. Surveyor asked LPN NS-E how many wounds R6 currently had. LPN NS-E stated R6 had 3 wounds and is getting biologicals to the heel and the sacrum which is a new wound technique. Surveyor asked LPN NS-E to pull up R6's TAR to see if LPN NS-E could see the treatment order for R6's sacrum wound. LPN NS-E could see the order on the order sheet but was not able to see it on the TAR. Surveyor shared the observation of the order being entered for therapy to complete the treatment. LPN NS-E stated LPN NS-E did not know why therapy was clicked and correctly put the order in to appear on the TAR. In an interview on 6/11/2024 at 9:34 AM, Surveyor asked LPN-L how many wounds R6 had. LPN-L stated R6 had 3 or 4 wounds but did not really know. LPN-L stated the sacrum wound was deep. Surveyor asked LPN-L what treatment was done to the sacrum wound. LPN-L sated whatever the treatment was that was in the chart. Surveyor noted no treatment was in the chart at the time LPN-L completed the treatment. On 6/11/2024 at 9:39 AM, Surveyor asked R6 about R6's pressure injuries. R6 stated R6 had three wounds and has had them for a while. R6 stated the facility was pretty good about doing dressing changes to all three areas and the wound NP comes in every Wednesday to do treatment, too. In an interview on 6/11/2024 at 2:48 PM, Surveyor asked RN-G if RN-G had done any treatments to R6's pressure injuries. RN-G stated RN-G had not done any treatments in a while. Surveyor shared with RN-G that the treatments to the sacrum and the right ischium were different. RN-G stated on PM shift, RN-G looked for as needed orders because the dressings were soiled and did not see any order, so RN-G went directly to the order sheet and saw the order there. In an interview on 6/12/2024 at 10:47 AM, Surveyor shared with Director of Nursing (DON)-B R6 did not have a treatment to the sacrum on the TAR from 4/10/2024 through 5/22/2024 and then on 5/22/2024, the treatment for the sacrum wound was put in under therapy so was not on the TAR. Surveyor shared with DON-B the concern R6 had two different treatment orders for the sacrum wound and the right ischium wound so the wrong treatment could have been done to the sacrum since 4/10/2024. DON-B agreed they could not be sure what treatment was done to the sacrum wound. On 6/12/2024 at 12:35 PM, Surveyor observed Wound NP-I, accompanied by LPN NS-E, complete an assessment and treatment to R6's left heel, right ischium, and sacrum. Surveyor asked Wound NP-I if Medihoney to the sacrum would affect the biologic being applied weekly by Wound NP-I. Wound NP-I stated Medihoney and the biologics do not mix so that is why it was not in the order for the sacrum wound. Wound NP-I stated Medihoney would be used if the wound had slough and the documentation for the biologic must show the wound is clean. Wound NP-I stated the Medihoney would not harm the wound itself and the biologic is absorbed in twelve hours. At 1:45 PM, Surveyor asked Wound NP-I if Wound NP-I was aware the treatment for the sacrum wound was not on the TAR since 4/10/2024. Wound NP-I was not aware of that. On 6/12/2024 at 2:01 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and DON-B the concern R6's sacral wound treatment was not transcribed into R6's medical record from 4/10/2024 until 5/25/2024 and then on 5/25/2024, the treatment was entered incorrectly into R6's computer charting system so it was not visible on the TAR. Surveyor shared the concern the treatments to the right ischium and the sacrum were not the same and staff were changing the dressing to the sacrum, but administration is unable to tell what kind of treatment was done. DON-B agreed the treatment was not on the TAR. No further information was provided at that time. 20483 2.) R51's diagnoses includes encephalopathy, hypertension, diabetes mellitus, chronic kidney disease, cognitive communication deficit, and depression. The pressure ulcer actual or at risk care plan initiated 3/10/24 documents the following interventions: * Completed Braden scale per living center policy. Initiated 3/10/24. * Conduct weekly skin inspections. Initiated 3/10/24. * Monitor vital signs as needed. Initiated 3/10/24. * Provide pressure reducing wheelchair cushion. Initiated 3/10/24. * Provide pressure reduction/relieving mattress. Initiated 3/10/24. * Skin assessment to be completed per living center policy. Initiated 3/10/24. * Treatments as ordered. Initiated 3/10/24. * Diabetic foot monitoring. Initiated 3/21/24. * Evaluate need for pain reliever prior to cleansing or dressing changes. Initiated 3/21/24. * Float heels. Initiated 3/21/24. * Heel elevating cushion when in bed. Initiated 3/21/24. * Notify practitioner if symptoms worsen or do not resolve. Initiated 3/21/24. * Nutritional and hydration support. Initiated 3/21/24. * Provide thorough skin care after incontinent episodes and apply barrier cream. Initiated 3/21/24. * Weekly wound assessment. Initiated 3/21/24. * Air mattress to bed. Initiated 4/12/24. * Diet/supplements per MD (medical doctor) order. Initiated 5/1/24. * Heel boots and pillow between knees for pressure prevention. Initiated 6/7/24. The quarterly MDS (minimum data set) with an assessment reference date of 5/9/24 has a BIMS (brief interview mental status) score of 10 which indicates moderate cognitive impairment. R51 is assessed as being dependent for rolling left & right and chair/bed to chair transfer. R51 is at risk for pressure injuries and has no pressure injuries. On 6/10/24, at 10:38 a.m., Surveyor observed R51 in bed on the left side with the call light on. Surveyor asked R51 about the call light being on. R51 informed Surveyor she wants the boots off. On 6/10/24, at 10:41 a.m., Surveyor observed TD (Therapy Director)-J enter R51's room. R51 told TD-J she wants the boots off as she can't move her legs. TD-J informed R51 she will take the boots off and will tell the nurse. TD-J then removed the blue cushioned boots and left R51's room. On 6/10/24, at 10:43 a.m., LPN (Licensed Practical Nurse)-F entered R51's room and asked R51 if she could put a pillow under her legs. R51 stated okay. After LPN-F placed a pillow under R51's lower legs, R51 then stated I don't want that pillow. On 6/10/24, at 10:49 a.m., Surveyor observed R51's air mattress is set at 620 pounds. On 6/10/24, at 10:53 a.m., Surveyor asked LPN-F if there are any treatments for R51 she has to do. LPN-F informed Surveyor she will have to check with the regular nurse as she hasn't been here in four months. Surveyor informed LPN-F Surveyor would like to observe any treatments for R51 with her. On 6/10/24 at, 11:44 a.m., LPN-F entered R51's room, cleansed her hands, placed gloves on, and informed R51 she was going to uncover her feet. LPN-F informed Surveyor R51 has areas on her right ankle & foot. LPN-F sprayed saline wound cleanser on four by four gauze which were in a cup. LPN-F cleansed the right ankle with the saline wound cleanser and then the left heel stating I noticed two areas. LPN-F informed R51 she was going to double check, removed her gloves and left R51's room. On 6/10/24 at 11:52 a.m. LPN-F entered R51's room along with LPN Nurse Supervisor/Wound Nurse-E. At 12:00 p.m. Surveyor asked LPN Nurse Supervisor/Wound Nurse-E if the area on R51's right metatarsal is new. LPN Nurse Supervisor/Wound Nurse-E informed Surveyor it was and her concern is R51 wears boots. At 12:05 p.m. LPN-F measured R51's right metatarsal wound indicating measurements of 1 cm (centimeters) x 1 cm. LPN Nurse Supervisor/Wound Nurse-E informed Surveyor as far as she knows they have not seen it and is going to get orders for these areas. LPN Nurse Supervisor/Wound Nurse-E informed Surveyor as soon as she (referring to the NP (Nurse Practitioner)) gets back to her she will let Surveyor know. The late entry note dated 6/10/24 at 09:49 (9:49 a.m.) documents Writer called into resident room to observe resident left heel with noted scabbed area 4 x (times) 4 cm (centimeter) no redness noted to peri wound. right foot metatarsal abrasion 1 cm x 1 cm no redness noted to wound layer of dry skin noted to top of wound. This nurses note was written by LPN Nurse Supervisor/Wound Nurse-E. The nurses note dated 6/10/24 at 14:20 (2:20 p.m.) documents Wounds - new skin issues found on R (right) metatarsal 1 cm x 1 cm abrasion and 4 cm x 4 cm scab on L (left heel). See TAR (treatment administration record) for tx (treatment). Will continue to monitor. This nurses note was written by LPN-F. The E-interact change in condition dated 6/10/24 by LPN-F for signs and symptoms identified is checked for skin wound or ulcer. For skin status evaluation is checked for abrasion & other. If other specify- R foot great toe abrasion 1 cm x 1 cm. L heel scab 4 cm x 1 cm. For document location and details for site documents 50) left heel under description documents scab 4 cm x 1 cm. Under site documents 51) right toe(s) and for description documents abrasion to side of great toe. Surveyor was unable to locate an RN (Registered Nurse) assessment of R51's right metatarsal wound. On 6/11/24, at 7:18 a.m., Surveyor observed R51 in bed on the left side. Surveyor observed one of R51's pressure relieving boots is on the floor. The air mattress weight is set at 660 to 750 pounds. On 6/11/24, at 8:43 a.m., Surveyor observed R51 asleep in bed on the left side. Surveyor observed the blue boot continues to be on the floor on the left side of the bed. The Proactive air mattress continues to be set at a weight of 660-750 pounds. On 6/11/24, at 8:57 a.m., Surveyor asked NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B regarding Resident's wounds. NHA-A informed Surveyor [Name of Company] comes in on Wednesday. Surveyor inquired if there are wound rounds on this day. NHA-A replied yes. Surveyor asked if [Name of Company] sees all Residents with open areas. NHA-A replied everyone with pressure injuries. DON-B informed Surveyor the first name of LPN Nurse Supervisor/Wound Nurse-E is the wound nurse. Surveyor inquired what happens when a Resident is identified with a new area. DON-B informed Surveyor the nurse on the floor would measure, gets treatment orders from the doctor, makes sure everyone is updated and depending on what it is notifies LPN Nurse Supervisor/Wound Nurse-E and she would notify [Name of wound company]. A skin eval is completed in PCC by the nurse on the floor and risk management is completed if it's a new area. On 6/12/24, at 7:17 a.m., Surveyor observed R51 in bed on the left side with the call light on. Surveyor asked R51 why her call light is on. R51 informed Surveyor she needs to be changed & dressed to get out of this bed. Surveyor observed one of R51's blue boots is on the floor on the left side and the Proactive air mattress is set at 660-750 pounds. On 6/12/24, at 9:39 a.m., Surveyor asked DON-B if air mattresses should be programmed to a Resident's weight. DON-B informed Surveyor depends on what the manual has to say. Surveyor informed DON-B R51's last weight on 6/4/24 was 209.6 pounds and Surveyor has observations of R51's air mattress being set at 660 to 750 pounds. Surveyor asked if this was appropriate. DON-B informed Surveyor she will look into this and get back to Surveyor. On 6/12/24, at 9:51 a.m., Surveyor informed DON-B R51 was identified with two new areas on 6/10/24 including the right metatarsal. Surveyor inquired if there is a RN assessment of this area as Surveyor was unable to locate one in R51's medical record. DON-B informed Surveyor she did not go in to assess R51. On 6/12/24, at 11:11 a.m., Surveyor observed R51 in bed on the left side. Surveyor observed the air mattress is now set at 220 pounds. Surveyor noted this is the first observation of R51's air mattress being set at 220 pounds. On 6/12/24, at 11:35 a.m., NHA (Nursing Home Administrator)-A informed Surveyor R51's air mattress was at 220 pounds. Surveyor informed NHA-A Surveyor has two days of observation with the air mattress at 660-750 pounds. NHA-A informed Surveyor she placed it at 220 pounds and as a therapist she goes around and checks the weights on the air mattresses. On 6/12/24, at 1:25 p.m., Surveyor spoke with Wound NP (Nurse Practitioner)-I regarding R51's right metatarsal identified on 6/10/24. Wound NP-I informed Surveyor the new area on the right foot near by the bunion, staff felt it was pressure and she staged it as unstageable. Surveyor inquired about measurements of the pressure injury. Wound NP-I informed Surveyor the picture didn't upload. Wound NP-I informed Surveyor she will go back, re-measure and let Surveyor know. On 6/12/24, at 1:45 p.m., Wound NP-I informed Surveyor the right metatarsal is 0.4 x 0.4, unstageable for slough. On 6/12/24, at 2:08 p.m., during the daily exit Surveyor informed NHA-A, DON-B, and Nurse Consultant-D R51 last weight was 206 and multiple observations of the air mattress being set at 660 to 750 pound. On 6/10/24 R51 was identified with an abrasion on right metatarsal by a LPN. This was not comprehensively assessed until Wound NP-I assessed this area on 6/12/24 and was assessed as an unstageable pressure injury.

Based on record review and interviews, the facility did not provide CPR (cardiopulmonary resuscitation) per a resident directive. This was observed with 1 (R55) of 2 residents reviewed who requested CPR in the facility. -R55 created Advanced Directives documenting the wish to have CPR performed. When staff found R55 pulseless and non-breathing, the facility did not Initiate CPR. R55 was pronounced dead without life-sustaining measures having been implemented. The facility's failure to implement CPR created a finding of immediate jeopardy that began on [DATE]. On [DATE] at 2:12 PM, this Surveyor shared the finding of immediate jeopardy with Nursing Home Administrator-A, (Director of Nurse) DON-B, (Regional Nurse Consultant) RNC-N and RNC-V. The facility had identified the noncompliance and removed and corrected the immediate jeopardy on [DATE]. This citation is being issued as past non-compliance. Findings include: The facility policy and procedures for CPR dated [DATE] was reviewed by Surveyor. The policy includes the following: -If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services; and in accordance with the resident's Advance Directives. The facility's policy and procedure for Communication of Code Status dated [DATE] was reviewed by Surveyor. The policy includes the following: -When an order is written pertaining to a resident's preference, the directions will be clearly documented in the designated sections of the medical record. -Additional means of communication of code status include banner in PointClickCare (Electronic Medical Record). -The resident's code status will be reviewed at least quarterly and documented in the medical record. Per staff interviews, as noted below, the facility does not use DNR (Do Not Resuscitate) bracelets to identify residents who do not want CPR performed. R55 was admitted on [DATE] for rehabilitation services due to an arthritic joint infection. R55 had a 5-day MDS (Minimum Data Set) assessment completed on [DATE]. This MDS assessment indicated R55 had no cognitive impairment. R55's physician orders indicated R55 is a Full Code status (CPR). R55 signed a facility form designating the desire to be a Full Code on [DATE]. This form also is signed by two witnesses and the Nurse Practitioner. R55's medical record banner in PointClickCare Care indicates a Full [NAME] status. R55 had a change in status on [DATE] and was transferred to the hospital and returned to the facility on [DATE]. R55 was also admitted to hospice care, provided at the facility, on [DATE]. The hospice assessment on [DATE] indicates R55 desired to be a Full Code status. R55's physician orders and medical record indicate R55's desire to be a Full Code status. On [DATE], at 11:11 AM, Surveyor spoke with LPN-DD (Licensed Practical Nurse) who worked on [DATE] with R55 and her readmission to the facility. LPN-DD stated she spoke with hospice staff who were completing R55's hospice admission assessment and paperwork. LPN-DD was informed by hospice R55 was their own person and desired to be a Full Code. LPN-DD stated the hospital indicted R55 was a DNR but R55 and her family met with hospital social workers and elected to be a Full Code. LPN-DD input the Full Code information into R55's medical record. LPN-DD was not aware of R55 wearing a DNR bracelet. LPN-DD confirmed the facility does not utilize a bracelet system to identify code status. On [DATE], at 1:49 PM, Surveyor spoke via phone to Hospice Manager-R and Hospice RN-W. Hospice RN-W conducted the Hospice Admission assessment of R55 at the facility on [DATE]. Hospice RN-W indicated R55 and their family desired to be a Full Code along with Hospice services. Hospice RN-W indicated they do not utilize code status wrist bands to identify code status. Hospice RN-W did speak with LPN-DD, and Nursing Home Administrator-A, when they left the faciity on [DATE] and shared R55's full code status desire. On [DATE], at 2:27 PM, Surveyor spoke via phone to Hospice Manager-R and Hospice SW-T (Social Worker). Hospice SW-T stated she discussed the Full Code process with R55 and her family. SW-T stated R55 wished to remain a Full Code at this time. SW-T noted there was a DNR bracelet on R55 from the hospital. Hospice SW-T shared with Nursing Home Administrator-A, and facility SW-G, who were in a meeting that R55 had a DNR bracelet on however elected a full code status. Nursing Home Administrator-A and facility SW-G indicated to Hospice SW-T that they would take care of the DNR bracelet. On [DATE], at 6:35 AM, R55's progress notes indicate the following: At 3:55 AM CNA-U (Certified Nursing Assistant) informed RN-Q (Registered Nurse) that R55 appeared to be expired. RN-Q immediately responded. Upon entering R55's room RN-Q observed R55 appeared yellow throughout with blue lips. When RN-Q was checking for pulses RN-Q noticed immediately R55's body temp was cold. RN-Q was unable to obtain any vital signs. RN-Q observed R55's bracelet that stated R55 is a DNR (Do Not Resuscitate). R55 is also a patient of Hospice. RN-Q immediately contacted Hospice RN-S (who is actually R55's assigned RN) and informed her of R55's death, reviewed R55's profile information, emergency contacts and who'd make them aware (hospice RN-S). Phone call ended as Hospice RN-S reported they were enroute to facility. Approximately 5 minutes afterwards [name of city] police officer arrived; RN-Q let the officer into building. RN-Q contacted DON (Director of Nursing)-B and informed them of R55's death. Approximately 15 minutes after police officer arrived Hospice RN-S arrived and informed RN-Q R55 was a full code. Hospice RN-S informed RN-Q that after our previous phone conversation she realized R55 was full-code and she attempted to call back but was unable to reach RN-Q. Therefore she called 911. Then 911 arrived and spoke to RN-Q briefly about addressing R55's situation. Surveyor notes R55 passed away in the facility and did not receive CPR per R55's wishes. Surveyor notes the facility CPR policy and procedure does not include the use of a DNR bracelet as a means to identify code status. Surveyor also notes RN-Q used the DNR bracelet to identify R55's code status and not documentation in R55's medical record per facility policy. Surveyor notes R55's medical record contained the appropriate documentation for R55's election of a Full Code status. CPR was not implemented by RN-Q as indicated. On [DATE], at 9:46 AM, Surveyor spoke to RN-Q via phone. RN-Q is a long-term contracted Agency RN who has worked at the facility since [DATE]. RN-Q indicated she was the only nurse in the building the night of the incident. RN-Q stated she didn't know all the residents at the facility. RN-Q stated around 4:00 AM, CNA-U told RN-Q R55 had died . RN-Q asked CNA-U if they knew anything about R55. RN-Q indicated she looked at the report sheet and it indicated R55 is on hospice. RN-Q also stated R55 also had a DNR bracelet on her wrist. RN-Q stated upon arriving to R55's room it appeared as if R55 had been deceased for a while. R55 was yellow colored, and purple around their mouth. R55's mouth was open and their hand was stiff when touched. RN-Q looked at R55's medical record and called hospice. RN-Q indicated they reviewed R55's medical record with hospice RN-S. During this review there was no indication or discussion that R55 elected a Full Code status. RN-Q had staff cleanup R55 and checked for valuables. RN-Q then went to perform other nurse duties with other residents. RN-Q stated hospice RN-S was coming to the facility to do all the necessary phone calls and paperwork. RN-Q stated the Police then arrived at the facility and wouldn't state why they were there. Hospice RN-S then arrived at the facility. The Police and Hospice RN-S went into R55's room. The police then asked RN-Q if she was aware R55 was a Full Code. The Police indicated they observed a bracelet on R55 for DNR. The Police and RN-Q were confused about the DNR bracelet on R55's wrist and R55 electing a Full Code status. RN-Q indicated she would have started CPR on R55 if she knew she elected a Full Code. R55 was a Hospice patient and had a DNR bracelet on them so RN-Q did not initiate CPR. RN-Q stated she did not review R55's medical record to locate R55's code status. On [DATE], at 2:55 PM, Surveyor spoke via phone to Hospice RN-S. Hospice RN-S stated she received a call from RN-Q indicating R55 passed away. Hospice RN-S indicated RN-Q just wanted to know if they (hospice staff) were taking care of the notifications and paperwork related to R55's passing. Hospice RN-S indicated she did not review R55's medical record with RN-Q. Hospice RN-S indicated R55 was admitted to hospice care the day before and she was not R55's Case Manager. Hospice RN-S looked through R55's hospice record and identified R55 was a Full Code. Hospice RN-S stated she attempted to call RN-Q back and could not get through to anyone at the facility. Hospice RN-S called 911 to have them go to the facility and told them there was a hospice patient at the facility that was a Full Code. Hospice RN-S informed her manager and R55's family of the events. Hospice RN-S went to the facility around 5:00 AM. The Police were waiting outside when hospice RN-S arrived. Hospice RN-S went into the facility with the Police. The Police indicated they would not call a code due to R55 being on Hospice. Hospice RN-S shared with the Police that R55 was still a Full Code even on hospice. Hospice RN-S stated the Police Officer did call for Emergency Medical Staff to come to the facility. Hospice RN-S stated at the point the emergency medical staff arrived to the facility R55 was dead and CPR was not appropriate. Hospice RN-S indicated all the paperwork was correct in the medical record to indicate R55 elected a Full Code status. On [DATE], at 2:00 PM, Surveyor spoke with Lieutenant Officer (LT)-O. LT Officer-O completed the Police Report however, was not the responding Officer. LT Officer-O indicated R55's hospice nurse (RN-S) called the police saying R55 was dead at the facility. LT Officer-O stated they sent Officer-P to the facility, who indicated R55 was clearly dead. LT Officer-O stated hospice RN-S said CPR should be initiated. LT Officer-O did request Emergency Medical Staff come to the facility. LT Officer-O stated at this point R55 was dead and CPR would not have been appropriate. On [DATE], at 2:07 PM, Surveyor spoke with Officer-P who indicated R55 appeared dead upon his arrival to the facility. Officer-P stated the facility had called R55's hospice nurse to inform them R55 had passed away and the hospice nurse tried to call the facility back to tell them to initiate CPR. The hospice nurse could not reach anyone at the facility so she contacted the police. Officer-P stated hospice RN-S wanted CPR performed on R55 however, when we (police) arrived R55 was clearly dead and had obvious signs of death and CPR was not initiated. On [DATE], at 10:19 AM, Surveyor called the hospital from which R55 had returned on [DATE]. The hospital staff stated they utilize the DNR bracelet that was discovered on R55's wrist. On [DATE], at 7:57 AM, Surveyor spoke with facility SW-G. SW-G indicated she was not aware of a DNR bracelet on R55's wrist. SW-G indicated she was aware R55 was a Full Code. On [DATE], at 8:03 AM, Surveyor spoke with Nursing Home Administrator-A. Nursing Home Administrator (NHA)-A stated she is the facility staff person identified as responsible for communication with hospice. Hospice staff did review R55's plan of care and code status with NHA-A. Contrary to what Hospice Social Worker (SW-T) had stated, NHA-A stated they were not made aware of a DNR bracelet on R55. The failure to provide CPR as requested by R55 denied R55 the only opportunity of living. This created a reasonable likelihood for serious harm, thus creating a finding of immediate jeopardy. The facility removed and corrected the immediate jeopardy on [DATE] by which time it had conducted an investigation and reported to the Office of Caregiver Quality. The facility did review all residents for bracelets and appropriate code status documentation on [DATE] and began implementing the following:. -All staff were educated on following code status procedures. -The facility conducted Code Drills. -The facility conducted audits of all resident records to ensure code status information was accurate. -All staff were educated on Hospice and code status.

Based on interview, and record review the facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 1 (R6) of 6 residents reviewed for pressure injuries. R6 was readmitted to the facility on [DATE] from the hospital. Hospital discharge paperwork identifies R6 as having a deep tissue injury (DTI) to the left heel. The facility did not comprehensively assess R6's DTI upon readmission. A treatment was ordered on 1/22/24, implemented on 1/23/24 and the DTI was comprehensively assessed by the wound care physician on 1/24/24. The area declined and progressed to a Stage IV pressure injury that required surgical debridment. Finding include: R6 was admitted to the facility on [DATE] with diagnoses which include quadriplegia, chronic obstructive pulmonary disease, generalized anxiety disorder, acquired absence of right leg below knee, major depressive disorder, insomnia, and tobacco use. R6's Annual Minimum Data Set (MDS) with an assessment reference date of 1/5/24 indicated R6 had a Brief Interview for Mental Status score of 14 indicating R6 is cognitively intact for daily decision making. R6's MDS also documents range of motion impairment to both lower extremities, no behavior concerns are identified including no documentation of a concern for rejection of care that is necessary to meet goals for health and wellbeing; has stage I or greater unhealed pressure injuries, has 2 stage 4 pressure injuries, application of nonsurgical dressings; R6 requires partial-moderate assistance from staff to roll left to right, partial-moderate, helper does more than 1/2 the effort, for moving from sit to stand, dependent on staff for bed to chair transfer and toilet transfers. R6 uses a wheelchair for mobility, has a urinary catheter and is continent of bowel. Surveyor notes R6 had a left heel pressure injury that healed while at the Facility prior to R6's hospitalization from [DATE]-[DATE]. Upon return to the facility on [DATE], R6's hospital discharge paperwork identifies a skin concern on R6's left heel. R6's care plan effective 3/28/2021, documents Pressure ulcer actual and at risk due to: assistance required in bed mobility, bowel incontinence, pressure ulcers present, paraplegia, non-adherence to pressure relieving recommendations, hx (history) osteomyelitis, use of tobacco, Braden scale 18 or less. Interventions implemented include (in part): -Assist resident to reposition every 1-2 hours while in bed; resident is independent with repositioning when in power wheelchair, date initiated: 4/29/21, revised on 10/5/2023. -At times, resident refuses wound care appointments, wound care treatments and recommendations, pressure relief interventions. Continue to encourage resident to follow plan of care for prevention and treatment of skin breakdown, date initiated: 11/29/22, revised on 10/5/2023. -Resident has prevelon boot for LLE (Left Lower Extremity). Resident refuses heel boots at times encouraged to keep heel elevated with pillow when refusing heel boots, date initiated: 3/28/21, revised on 10/5/2023. -Up to chair max (maximum) three times daily, max 1 hour at a time with reposition every 20 minutes while up. Must use roho cushion or waffle when up in chair. Must use pulsate mattress, initiated 2/7/2024. R6's care plan dated 10/20/2023 documents, Altered skin integrity (non-pressure) r/t (related/to) paraplegia; limited mobility, hx (history) of malnutrition, non-compliance with plan of care. Current wounds: left heel, coccyx and left ishium. Interventions include (in part): -Provide pressure reduction/relieving mattress; provide heel elevation cushion to elevate RLE (Right Lower Extremity) off of bed/surface, date initiated: 12/11/23, revised on 12/11/2023. -Treatments as ordered, date initiated: 10/20/23 -Turning and repositioning schedule per assessment, initiated 12/11/2023. -Up to chair max three times daily, max 1 hour at a time with reposition every 20 minutes while up. Must use roho cushion or waffle when up in chair. Must use pulsate mattress, date initiated: 2/7/2024, revised on 2/7/2024. R6's care plan dated 5/14/2021 documents, I sometimes have behaviors which include refusing supplements, non-adherent to pressure relief recommendations. I have diagnosis of major depressive disorder as evidenced by decreased social interaction, negative comments, and self-depreciating statements, slamming of his door, pacing, driving quickly in the hallway with power scooter, refusal of cares and wound care recommendations. Interventions include: -Attempt interventions before my behaviors begin, revised on 1/18/2022. -Give me my medications as my doctor has ordered, initiated 5/14/2021. -Help me to avoid situations or people that are upsetting to me, initiated 9/30/2021. -Let my physician know if I my behaviors are interfering with me daily living, initiated 5/14/2021. -Make sure I am not in pain or uncomfortable, initiated 9/30/2021. -Please refer me to my psychologist/psychiatrist as needed, initiated 5/14/2021. -Speak to me unhurriedly and in a calm voice, initiated 5/14/2021. -Verbally remind me to drive safely in the hallway, initiated 9/28/2022. Surveyor notes R6's care plan was not revised with new interventions to address R6's refusal of care and treatment of skin concerns since 9/2022 and/or new treatment interventions to promoted healing once R6 was readmitted to the facility on [DATE] with an identified skin concern to the left heel which had previously been healed. On 1/16/24 (prior to R6's transfer to the hospital), R6's medical record documents a skin only assessment. Surveyor notes the assessment does not document a concern for a pressure injury to R6's left heel. On 1/17/24, (prior to R6's transfer to the hospital), R6's medical record documents a skin assessment by Vohra, wound care physician. Surveyor notes the assessment does not identify a pressure injury to R6's left heel. R6's medical record documents R6 was hospitalized [DATE]-[DATE]. R6's a hospital discharge summary dated 1/20/24 documents a silicone dressing treatment to the left heel should be completed every Monday and Friday. Surveyor notes the left heel pressure injury is not identified or comprehensively assessed by the Facility upon R6's readmission and the treatment documented by the hospital is not documented in R6's physician orders upon readmission to the facility on [DATE]. R6's January 2024 Treatment Administration Record (TAR) documented, 1/22/2024 an order was initiated for Left heel: cleanse with NS (Normal Saline), wound cleanser or soap and water, paint with Betadine daily. Cover with silicone dressing, every day shift for skin care. This order was implemented on 1/23/2024. Surveyor notes there is another order dated 1/23/2024 for Offloading boot at all times on bil (bilateral) Lower ext (extremity) to relieve pressure every shift for pressure relief. Surveyor also noted, an order dated 12/11/2023, for Prevelon boot to LLE (Left Lower Extremity) at all times. May remove for bathing/cares and inspection of skin, every shift for prevention of skin breakdown. Document refusals in progress note. Surveyor notes on 1/22/24, the Facility obtains a treatment order for betadine daily to R6's left heel. Surveyor notes the treatment is obtained 2 days after R6's readmission to the Facility and is not implemented until 1/23/24. Surveyor also notes the Facility has not comprehensively assessed R6's heel pressure injury including measurements or description of the tissue type. On 1/24/2024, [NAME] wound care notes document, Unstageable DTI (Deep Tissue Injury) with intact skin, size 2.19 cm (centimeters) x 1.58 x depth not measurable, skin intact with purple/maroon discoloration, treatment plan skin prep apply once daily. Surveyor notes this this the first comprehensive assessment of R6's left heel DTI. On 1/24/24, the Facility completed a Skin and Wound Evaluation which documents an unstageable:obscured full-thickness skin and tissue loss, pressure ulcer to the left heel due to a non-removable device/dressing; in-house (Facility) acquired. It is identified as a new wound that measures 2.2 cm by 1.6 cm with no documentation as to the wound bed tissue type, primary dressing: skin prep, progress of wound: new. Surveyor notes the Facility does not identify the pressure injury as a DTI as documented by the wound physician and do not document the exact date the pressure injury was fisrst identified. On 1/31/2024, [NAME] wound care notes document, Unstageable DTI with intact skin, size 2.15 x 2.44 x depth not measurable, skin intact with purple/maroon discoloration, treatment plan skin prep apply once daily. On 1/31/24, the Facility completed a Skin and Wound Evaluation which documents an unstageable:obscured full-thickness skin and tissue loss, pressure ulcer to the left heel due to a non-removable device/dressing; in-house acquired. It is identified 2 weeks ago measuring 2.2 cm by 2.4 cm with no documentation as to the wound bed tissue type, primary dressing: skin prep, wound progress: deteriorating. On 2/7/2024, [NAME] wound care notes document, Unstageable DTI with intact skin, size 2.97 x 2.51 x depth not measurable, skin intact with purple/maroon discoloration, treatment plan xerofoam gauze with gauze island with boarder once daily. On 2/7/24, the Facility completed a Skin and Wound Evaluation which documents an unstageable:obscured full-thickness skin and tissue loss, pressure ulcer to the left heel due to a non-removable device/dressing; in-house acquired. It is identified 2 weeks ago measuring 3.0 cm by 2.5 cm, intact with purple/maroon discoloration, cleaning solution: soap and water, primary dressing: xeroform gauze with border gauze, wound progress: stalled. On 2/14/2024, [NAME] wound care notes document, Stage IV left heel pressure wound measuring 2.29 x 1.96 x depth not measurable, thick adherent devitalized necrotic tissue 100%, surgical excisional debridement procedure done to remove necrotic tissue and establish margins of viable tissue. Treatment plan: alginate calcium with silver with gauze island with boarder once daily. On 2/14/24, the Facility completed a Skin and Wound Evaluation which documents an unstageable:obscured full-thickness skin and tissue loss, pressure ulcer to the left heel due to a non-removable device/dressing; in-house acquired. It is identified 2 weeks ago measuring 2.3 cm by 2.0 cm, no documentation as to the wound bed tissue type, cleaning solution: soap and water, generic wound cleaner, surgical-outpatient debridment, primary dressing: calcium alginate, wound progress: stalled. Surveyor notes on 2/14/2024 R6's left heel DTI is documented by the wound physician to have declined from a purple/maroon DTI to necrotic tissue needing debridement and now assessed as a stage IV pressure injury. Surveyor notes the Facility does not comprehensively assess the area including the correct staging or note the decline in status due to necrotic tissue requiring surgical debridment. On 2/21/2024, [NAME] wound care notes document, Stage IV pressure wound of the left heel, size 2.5 x 3 x depth not measurable, thick adherent devitalized necrotic tissue 50% and granulation tissue 50%, surgical excisional debridement procedure done to remove necrotic tissue and establish margins of viable tissue. Treatment plan alginate calcium with silver with gauze island with boarder twice daily. On 2/21/24, the Facility completed a Skin and Wound Evaluation which documents a Stage IV pressure ulcer to the left heel-full thickness skin and tissue loss; in-house acquired. It is identified 1-3 months ago measuring 3.1 cm by 3.6 cm, wound bed: granulation-50% eschar-50%, surrounding tissue macerated, cleaning solution: soap and water, generic wound cleaner, sharp debridment, primary dressing: calcium alginate and bordered gauze, wound progress: stalled. On 2/28/2024, R6's wound visit was rescheduled, seen by local wound team this week. On 2/28/24, the Facility completed a Skin and Wound Evaluation which documents a Stage IV pressure ulcer to the left heel-full thickness skin and tissue loss; in-house acquired. It is identified 1-3 months ago measuring 1.8 cm by 2.1 cm, wound bed: granulation-50% eschar-50%, cleaning solution: soap and water, generic wound cleaner, sharp debridment, primary dressing: calcium alginate, wound progress: stalled. On 3/6/2024, [NAME] wound care notes document, Stage IV pressure wound of the left heel, size 2.37 x 2.28 x depth not measurable, thick adherent devitalized necrotic tissue 50% and granulation tissue 50%, surgical excisional debridement procedure done to remove necrotic tissue and establish margins of viable tissue. Treatment plan alginate calcium with silver with gauze island with boarder twice daily. On 3/6/24, the Facility completed a Skin and Wound Evaluation which documents a Stage IV pressure ulcer to the left heel-full thickness skin and tissue loss; in-house acquired. It is identified 1-3 months ago measuring 2.4 cm by 2.3 cm, wound bed: granulation-50% eschar-50%, cleaning solution: soap and water, generic wound cleaner, sharp debridment, primary dressing: calcium alginate, wound progress: stalled On 3/13/2024, [NAME] wound care notes document, Stage IV pressure wound of the left heel, size 2 x 2 x depth not measurable, thick adherent devitalized necrotic tissue 50% and granulation tissue 50%, surgical excisional debridement procedure done to remove necrotic tissue and establish margins of viable tissue. Treatment plan hydrofera blue foam with gauze island with boarder once daily. On 3/13/24, the Facility completed a Skin and Wound Evaluation which documents a Stage IV pressure ulcer to the left heel-full thickness skin and tissue loss; in-house acquired. It is identified 1-3 months ago measuring 2.0 cm by 1.9 cm, wound bed: granulation-50% eschar-50%, cleaning solution: soap and water, generic wound cleaner, primary dressing: calcium alginate, wound progress: stable. On 3/20/2024, [NAME] wound care notes document, Stage IV pressure wound of the left heel, size 2 x 1.5 x 0.5, granulation tissue 100%. Treatment plan hydrofera blue foam with gauze island with boarder once daily. On 3/21/24, the Facility completed a Skin and Wound Evaluation which documents a Stage IV pressure ulcer to the left heel-full thickness skin and tissue loss; in-house acquired. It is identified 3-6 months ago measuring 1.6 cm by 1.0 cm with no depth, wound bed: 100% granulation tissue, cleaning solution: normal saline, soap and water, sterile water, primary dressing: hydrofera blue foam with gauze island with boarder, wound progress: improving. Surveyor notes the Facility does not asses the Stage IV Left heel pressure injury to have any depth as assessed and documented by the wound physician. On 3/29/2024, [NAME] wound care notes document, Stage IV pressure wound of the left heel, size 1.7 x 1 .4 x 0.3, granulation tissue 100%. Treatment plan leptospermum honey with gauze island with boarder once daily. On 3/29/24, the Facility completed a Skin and Wound Evaluation which documents a Stage IV pressure ulcer to the left heel-full thickness skin and tissue loss; in-house acquired. It is identified 3-6 months ago measuring 1.7 cm by 1.4 cm with no depth, wound bed: 100% granulation tissue, cleaning solution: normal saline, soap and water, sterile water, primary dressing: medihoney with border gauze, wound progress: improving. Surveyor notes the Facility assessment does not identify any depth to the wound which was identified and documented by the wound physician. On 4/3/2024, [NAME] wound care notes document, Stage IV pressure wound of the left heel, size 1.54 x 1.4 8 x 0.3, slough 20% and granulation tissue 80%. Treatment plan leptospermum honey with gauze island with boarder once daily. Surveyor notes the Facility does not comprehensively assess R6's Stage IV pressure injury to the left heel. On 4/3/24, the Facility completed a Skin and Wound Evaluation which documents a Stage IV pressure ulcer to the left heel-full thickness skin and tissue loss; in-house acquired. It is identified 3-6 months ago measuring 1.5 cm by 1.5 cm with no depth, wound bed: 80% granulation tissue 20% slough, cleaning solution: normal saline, soap and water, sterile water, primary dressing: medihoney with border gauze, wound progress: improving. Surveyor notes the Facility assessment does not identify any depth to the wound which was identified by the wound physician. On 04/11/24 at 02:43 PM, Surveyor interviewed Unit Manager (UM)-L to ask where the Facility documents wound assessments. UM-L reported [NAME] (wound care) does a weekly progress note and assessment and the Facility has a skin assessment and skin and wound assessment, but [NAME] does the assessments and measurements. On 04/15/24 at 12:53 PM, Surveyor interviewed [NAME] Wound Medical Doctor-HH about his documentation on 2/14/24. Surveyor asked why the documentation indicated the wound changed from a DTI to a stage IV pressure injury if the wound was covered with necrotic tissue. Wound Medical Doctor-HH stated he debrided the wound on 2/14/24 and removed the necrotic tissue and some tissue underneath. A tendon was revealed during debridement which is why he then staged it as a Stage IV. Review of the procedure note on 2/14/2024 shows Post-debridement assessment of this previously unstageable necrotic wound has revealed the underlying deep tissue at the muscle/fascia level, which had been obscured by necrosis prior to this point. This wound has now revealed itself to be a Stage IV pressure injury. This is not a wound deterioration. On 4/15/2024 Surveyor was provided a copy of R6's 1/20/24 hospital discharge summary. In addition, a second copy of the page with wound information for the left heel was provided with a handwritten note: Present on admission Registered Nurse (RN)-Q stated it was there but did not chart. UM-L seen it on 1/22/24 Monday (when d/t (due to) be changed) new tx (treatment) orders and tx completed. On 04/15/24 at 10:04 AM, Surveyor spoke with Director of Nursing (DON)-B to confirm the handwritten note on R6's hospital discharge paperwork was written by the Facility staff. DON-B confirmed Facility staff did write on R6's hospital discharge summary. Surveyor asked DON-B if the Facility completed a comprehensive assessment of R6's left heel pressure injury. DON-B confirmed the Facility did not complete a comprehensive assessment of R6's left heel pressure injury. Surveyor explained the concern R6's was assessed to be at risk for pressure injuries, the left heel DTI was not identified or assessed upon readmission to the facility, a treatment was ordered 2 days after readmission and implemented 3 days after readmission, the first comprehensive assessment was completed by the wound care doctor 4 days after readmission, the pressure injury declined from a DTI to 100% necrotic tissue requiring surgical debridement and is assessed to be a Stage 4 pressure injury where a tendon was revealed during debridement.

Based on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 1 of 3 residents reviewed (R7) for falls and 2 of 18 residents reviewed (R17 and R33) for thickened liquids. R7 has a diagnosis of unspecified convulsions, a history of multiple falls, and is on anticoagulation therapy. R7 is at a high risk for falls and has had two falls with head injuries. The facility failed to find root causes for every fall for R7 and failed to have an RN assess R7 after several falls. R7's falls resulted in 2 head injuries one requiring staples and another requiring glue. With R7's risk of head injury and potential for brain bleeding with anticoagulant therapy the facility failed to implement robust interventions including offering interventions such as a helmet, to prevent further injury from falls. The facility failed to follow diet orders and provide nectar thick liquid R33. The facility failed to follow diet orders and provide nectar thick liquids for R17. Surveyors observed R17 receive thin liquids on two seperate observations. This is evidenced by: The facility policy, Falls Management Process, dated 2011, includes, in part: .11. The nurse will complete an event documentation report, fall risk assessment, pain assessment, and obtain witness statements. 12. The nurse will determine the most appropriate intervention, implement, and update care plan .Post Fall 1. Director of Nursing/Designee will assess the resident and review fall documentation, including witness statements, resident interview, environment review of area where fall occurred, and equipment inspection. 2. The event will be discussed, and event documentation reviewed for completion in IDT (Interdisciplinary Team) meeting. Compare data from previous assessments. Discuss identified trends. 3. Therapy referral and Medication Review initiated. 4. Other referrals if applicable .5. Review Fall Risk Assessment for any potential new risk factors. 6. Review plan of care/interventions to ensure all prior interventions are in place and still appropriate. 7. Adjust/add interventions on the Plan of Care. Update and communicate interventions . R7 was admitted to the facility on [DATE] with diagnoses that include, in part: Unspecified convulsions, traumatic brain injury, atrial fibrillation (irregular heartbeat), cognitive communication deficit, and schizophrenia. R7's most recent quarterly MDS (Minimum Data Set) dated 9/30/23 documents the following, in part: Section C: A BIMS (Brief Interview for Mental Status) of 2, indicating R7 has a severe cognitive impairment. Section G: .bed mobility extensive assistance of 2 staff, locomotion on and off unit supervision with one-person physical assist .mobility device: wheelchair. Section J: .Number of falls since prior admission or prior assessment: A. No Injury .2 (=Two or more); B. Injury (Except major) 2 (=Two or more); C. Major injury 0 (=None). R7's care plan includes, in part: Diagnosis: I have a physical functioning deficit related to: Mobility impairment r/t (related to) weakness from recent stent placement and seizures. Date initiated: 6/29/23. Goal: I will improve my current level of physical functioning. Date initiated: 6/29/23. I will maintain my current ROM (Range of Motion). Date Initiated: 6/29/23. Interventions/Tasks: Assistive devices w/c (wheelchair) with dumped seat and self-releasing belt to aid in proper positioning. Revision: 9/28/23). Call bell within reach. Revision date: 6/29/23. Locomotion assistance of one dependent in w/c. Revision on: 6/29/23. Diagnosis: Impaired neurological status related to: Traumatic brain injury, Development Delay, Seizures, History of CVA (Cerebral Vascular Accident). Date initiated: 6/30/23. Goal: Will maintain my current level of function: Date initiated: 6/30/23. Revision on 8/11/23. Diagnosis: At risk for complications related to anticoagulant or antiplatelet medication due to Atrial Fibrillation. Date initiated: 8/11/23. Goal: .I will remain without complications from bleeding or injury. Date initiated and revision on: 8/11/23. Interventions/Tasks: Observe for s/s (signs and symptoms) of bleeding tarry stools, blood in urine, bruising, petechiae (tiny red spots on the skin caused by bleeding). Date initiated: 8/11/23 . Diagnosis: Risk for Seizure Activity Seizure. Date Initiated: 6/20/23. Goal: If suspected Seizure Activity Remain with Resident and Maintain Airway. Date Initiated: 6/30/23 . Interventions/Tasks: .Implement seizure precautions per facility guidelines. Date initiated 6/30/23. Monitor for sign/symptom of seizure activity. Date Initiated: 6/30/23 . Diagnosis: At risk for falls related to: fell in the past 30 days, History of falls, new environment, Use of medication. Date Initiated: 6/30/23. Goal: I will have No fall related injuries. Date Initiated and Revision on: 6/30/23. I will have reduced number of falls. Date initiated and revision on: 6/30/23. Interventions/Tasks: 6/28: bed in lowest position. 6/29: Mat beside bed. I should have Footwear to prevent slipping. Date Initiated 6/30/23. Keep bed locked. Date Initiated: 6/30/23. My Call light and personal items available and in easy reach or provide reacher. Date Initiated: 6/30/23. Staff to use Gait belt with transfers. Date Initiated: 6/30/23. 7/2: Offer resident to get up in w/c (wheelchair) when awake. Room rearranged for safety. Date initiated: 7/2/23. Revision on: 8/17/23. 7/6/23: Pillows for positioning when in bed. 7/8/23: Resident provided a larger bed. 7/18: Resident to be in custom wheelchair when out of bed. 8/8: wheelchair assessed and repaired. Check bed positioning on rounds at night to ensure not on edge of bed. Date initiated: 8/25/23. Offer to get resident up on last rounds on nights. Date Initiated: 9/2/23. 9/5/23: Offer activities in room to help reduce anxiety and restlessness during period of illness (while on isolation precautions). 9/6/23: Offer to assist resident to bed after dinner. 9/9: Fall COVID-19 positive - no new interventions. 9/10/23: COVID positive - no new interventions. 9/12/23: Fall Wedge Cushion ordered. 9/19/23: Foot Pedal to be on when resident is up in w/c. R7's physician orders for 8/8/23 through 9/23/23 were requested from the facility and indicate, in part, the following: R7 was prescribed Coumadin, a blood thinner, and was to be monitored for bleeding. R7 was prescribed Phenytoin for Seizures. R7's Fall Investigations, Nurses Notes, and emergency room Visit Notes related to falls were requested by Surveyor. Information provided by the facility for R7, includes, in part, the following: A fall document dated, 8/8/23 at 9:30AM indicating #1879 Fall, documents in part: Incident Description: Nursing description: Writer called into resident's room. Upon entering room resident was laying on his right side fastened in his wheelchair. Therapist [Name] was in room and witness resident's fall. Resident's wheelchair wheel on the right side was broke. Resident description: Resident stated his head hurt; his right arm hurt. Immediate Action Taken: Description: Writer assessed resident. Call place to 911 to be sent to [Name] Hospital to be evaluated. Resident on Warfarin . 8/8/23 3:07PM Nurses Notes: Fall Risk Evaluation Fall Risk: History of falls (past 3 months): 3 or more falls in past 3 months. Level of consciousness/mental status: Intermittent confusion. Vision status: Adequate .Predisposing disease: 3 or more present. Resident did not have a change in condition in the last 14 days. Recent hospitalization history in last 30 days: No. Gait/balance: Requires use of assistive devices .Medication: Takes 3-4 these medications (or medication classes) currently and [sic]/or within last 7 days. Fall Risk Score: 17.0 . 8/8/23 Emergency Department Note includes, in part: Chief Complaint: fall out of wheelchair. Patient from [Name] Center, wheel apparently got turned on chair and patient fell out. Witnessed by staff, pt is on blood thinners, no loc (loss of consciousness) . CT (CAT Scan - imaging of head) of the head without contrast: Impression: 1. There is no discrete CT evidence for acute traumatic intracranial injury . CT Spine Cervical w/ Contrast: Impression: 1. No CT evidence for acute traumatic injury to the cervical spine . Impression and Plan: Fall 8/25/23 5:33AM Nurses Notes: At 5:18AM resident was seen sitting on the padded floor mat beside his bed, shortly after the aide walked out of the room. Unwitnessed fall, no signs of injury observed. Resident was guided towards the bed and crawled back in. VS (Vital Signs) taken, MD notified via fax, will continue to monitor, follow care plan . 8/26/23 6:14PM Nurses Notes: Late Entry: Writer alerted that resident was found on floor. CNA (Certified Nursing Assistant) [Name] was walking by his room and she heard a thud she went back to check, and he was on the floor. Writer entered room and writer instructed her to get a cold washcloth and apply pressure to obvious facial and forehead bleeding. Hemostasis was obtained and then dressed. No signs of seizure at that time. EMS (Emergency Medical Services) activated, and resident sent to ER (emergency room ) for eval and treat . 8/26/23 Emergency Department Note includes, in part: Chief Complaint: Unwitnessed fall - Pt found by staff lying on the floor. Pt has hx (history) of TBI (Traumatic Brain Injury). Pt incontinent of urine. Pt has laceration to face. Bleeding controlled. History of Present Illness: .Patient presents with head injury at his skilled nursing facility .noted hematoma over the frontal forehead with laceration associated. Patient is anticoagulated . -Procedure: Wound Repair .Local anesthesia was performed .The wound, located on the forehead measured 2 cm and was linear .The wound was closed using staples . -Procedure: Wound Repair .Local anesthesia was performed .The wound, located on the R eyebrow measured 1.5cm and was linear .The wound was closed using staples . -Procedure: Wound Repair .The wound, located on the nasal bridge measured 0.5cm and was linear .The wound was closed using adhesive . CT of the head without contrast .Impression: 1. No Acute intracranial abnormality . CT of the cervical spine without contrast .Impression: No acute osseous abnormality. Impression: .Closed head injury . 9/2/23 6:05AM Nurses Notes: Resident sent to [Name] ER for evaluation after found lying on his stomach next to his bed. Resident c/o (complained of) right shoulder pain along with redness/bruising to left forehead. Resident is on coumadin and is COVID + . 9/2/23 Emergency Department Note includes, in part: Chief Complaint: Pt comes by ems (Emergency Medical Services) from [Name] center for an unwitnessed event/fall last seen in bed around 5:30AM. Abrasion to L forehead, unk loc (unknown loss of consciousness), hx (History) seizures has sutures in head from a similar event this month. On warfarin . History of Present Illness: .The patient has been seen in the emergency department several times over the past month for falls .Per EMS, the patient is COVID positive, and they suspect he had a seizure . CT head or Brain w/o contrast: .Impression: No acute intracranial abnormality. Stable CT of the head . CT Spine Cervical w/o Contrast: .Impression: 1. No cervical spine fracture identified . XR Pelvis .: Impression: No acute osseous abnormality identified . Patient Discharge Summary: .Your diagnosis is: Recurrent fall out of bed. Your blood work and CT scans and x-rays were normal. 9/3/23 6:30PM Nurses Note: Post Fall Evaluation: Fall Details: Date/Time of Fall: 9/3/23 6:30PM Fall was not witnessed. Fall occurred in the Resident's room. Activity at the time of fall: resident was buckled in wheelchair with seat belt unbuckled himself as belt was not broken. The reason for the fall was not evident. Did an injury occur as a result of the fall: Yes. Injury details: laceration to left eye. Did fall result in an ER visit/hospitalization : Yes. ER Visit/hospitalization . Details: accidental fall from wheelchair facial laceration to left eye glued CT of head and neck neg . 9/3/23 6:30PM Nurses Notes: Fall Risk Evaluation: Fall Risk: History of falls (past 3 months): 3 or more falls in past 3 months. Level of consciousness/mental status: Disoriented x 3 at all times. Resident is chairbound/incontinent. Systolic blood pressure: No noted drop between lying and standing. Predisposing disease: 3 or more present. Resident had a change in condition in the last 14 days. Recent hospitalization history in last 30 days: Yes. Notes: falls seizures Gait/balance: N/A (not applicable) - not able to perform function. Medication: Takes 3-4 these medications (or medication classes) currently and / or within last 7 days. Fall Risk Score: 21.0 . 9/3/23 Emergency Department Note includes, in part: Chief Complaint: Unwitnessed fall from wheelchair, pt had undone his lap belt, possible seizure. Unknown if LOC (loss of consciousness). Lac to L eyebrow .COVID + . History of Present Illness: .The patient has a history of frequent falls and was last seen here yesterday with a similar fall. He is anticoagulated Physical exam .Head: Laceration over the lateral aspect of the left periorbital area with no bony deformity., [sic] . Procedure: Laceration repair .Description/repair: Laceration 2.5cm in length. Shape: Curving laceration .Skin closure: Dermabond (topical skin adhesive) . CT head or Brain w/o contrast: .Impression: 1. No acute intracranial abnormality . CT Spine Cervical w/o Contrast: .Impression: No acute disease of the cervical spine . 9/5/23 4:30PM Nurse Note: Post Fall Evaluation: Fall Details: Date/Time of Fall: 9/5/23 2:31PM Fall was not witnessed. Fall occurred in the Resident's room. Reason for the fall was evident. Reason for fall: Resident restless and rolled out of bed. Did an injury occur as a result of the fall: No. Did fall result in an ER visit/hospitalization : No .Fall Details Note: Resident has been restless d/t (due to) isolation precautions and COVID infection. Rolled out of bed onto floor . 9/5/23 22:00 Nurse Note: Resident appeared to have rolled out of bed at 2:45PM, No injury noted . 9/6/23 4:34PM Nurses Notes: Fall Risk Evaluation: History of falls (past 3 months): 3 or more falls in past 3 months. Level of consciousness/mental status: Intermittent confusion. Resident is chairbound/incontinent. Systolic blood pressure: No noted drop between lying and standing. Vision status: Adequate (with or without glasses). Predisposing disease: 3 or more present. Resident had a change in condition in the last 14 days. Recent hospitalization history in last 30 days: No. Gait/balance: N/A - not able to perform function. Medication: Takes 3-4 these medications (or medication classes) currently and / or within last 7 days. Fall Risk Score: 21.0 . 9/6/23 8:56PM Nurses Notes: Fall Risk Evaluation: History of falls (past 3 months): 3 or more falls in past 3 months. Level of consciousness/mental status: Intermittent confusion. Resident is chairbound/incontinent. Systolic blood pressure: No noted drop between lying and standing. Predisposing disease: 1-2 present. Resident had a change in condition in the last 14 days. Recent hospitalization history in last 30 days: No. Gait/balance: Requires use of assistive devices (i.e., cane, wheelchair, walker, furniture). Medication: Takes 3-4 these medications (or medication classes) currently and /or within last 7 days. Fall Risk Score: 19.0 . 9/6/23 10:00PM Nurses Notes: Late Entry: Unwitnessed Fall: Resident was found on top of mat on floor next to bed. Writer noted that resident had his hand trying to pull top cover back. Resident asked resident [sic] how did he fall and to use call bell. Resident said, I'm sorry. [sic] Abrasion noted to top of head measuring approx. 6.0 x 8.0 x <0.1. ROM (Range of Motion) per usual. neuro check neg. skin assessed. T 97.9 P 79 R20 B/P 131/74 SpO2 99% R/A (oxygen saturation on room air). Blood glucose 117 .Sent to [Name] Hospital. 9/6/23 Emergency Department Note includes, in part: Chief Complaint: Pt comes from [Name] for a fall while transferring with staff, may have hit his head. Has had repeated falls and seen here several times, COVID +. Alert per baseline. On warfarin . CT of the head without contrast .Impression: No acute intracranial abnormality . CT of the Cervical Spine without contrast .Impression: No acute disease of the cervical spine . 9/7/23 7:44AM Nurses Notes: Post Fall Evaluation: Fall Details: Fall was not witnessed. Fall occurred in the Resident's room. Activity at the time of fall: appeared to self self [sic] transfer to be Reason [sic] for the fall was evident. Reason for fall: attempting to put self in bed. Did an injury occur as a result of the fall: Yes. Injury details: Abrasion to top of head .Sent to ER for eval . 9/9/23 10:30AM Nurses Notes: Late Entry: Writer observed resident roll out of bed; attempted to get into room and prevent fall, however it happened quickly and writer unable to get into room in time. Bed was in low position and fall mat in place; resident did not hit his head. Assessment completed and unremarkable . no new injuries noted .Will use pillows for positioning while in bed as immediate intervention; will request larger bed/mattress and/or bolsters. 9/10/23 8:17PM Nurses Notes: Post Fall Evaluation: Fall Details: Date/Time of Fall: 9/10/23 8:17PM fall was not witnessed. Fall occurred bedside. Activity at the time of fall was in seizure activity when staff got in there. Reason for the fall was evident. Reason for fall: seizure .Did an injury occur as a result of the fall: Yes. Injury details: bumped top of head causing an abrasion where he had a previous abrasion. Did fall result in an ER visit/hospitalization : Yes. ER Visit/hospitalization Details: sent out did lab work and CT scan and returned .Fall Details Note: a resident found him on the floor and called out to us. He was in bed then on the floor by foot of bed laying perpendicular to the bed. He had a couple 30 sec seizures also hit is [sic] head and has a small skin tear on the top by his previous cut. Had gown and grippy socks on . 9/10/23 10:45PM Nurses Notes: Fall Risk Evaluation: Late Entry: History of falls (past 3 months): 3 or more falls in past 3 months. Level of consciousness/mental status: Intermittent confusion. Resident is chairbound/continent. Systolic blood pressure: No noted drop between lying and standing. Vision status: Adequate (with or without glasses) Predisposing disease: 1-2 present. Resident did not have a change in condition in the last 14 days. Recent hospitalization history in last 30 days: No. Gait/balance: Balance problem while standing. Medication: Takes 3-4 these medications (or medication classes) currently and / or within last 7 days. Fall Risk Score 17.0 9/10/23 Emergency Department Note includes, in part: Chief Complaint: Pt presents from his home facility who report that pt fell from bed to floor while having a seizure immediately PTA (prior to arrival). No thinners reported. Skin tear to head and bruising to left upper arm . CT Head or Brain w/o contrast: Impression: 1. No acute intracranial abnormality . Diagnosis and Disposition: Presentation most consistent with multifactorial ground level fall . 9/11/23 2:02PM Nurses Notes: Late Entry: Resident fell out of w/c has hematoma over Rt eye [Name] in building with order to send to ER for eval .911 called . 9/12/23 5:54AM Nurses Notes: Resident had unwitnessed fall. At 5:34am staff observed resident sitting on the floor mat beside his bed. No new injury observed. Resident assisted back into bed by staff. MD notified via fax. Will continue to monitor, follow care plan. 9/12/23 5:55AM Nurses Notes: Post Fall Evaluation: Late Entry: Fall Details: Date/Time of Fall: 9/12/23 5:34AM Fall was not witnessed. Fall occurred in the Resident's room. Activity at the time of fall: Unknown. Resident was resting/sleeping in bed prior to fall. The reason for the fall was not evident. Did an injury occur as a result of the fall: No. Did fall result in ER visit/hospitalization : No .Fall Details Note: Resident was observed to be sitting on the floor mat at the side of his bed. No new injury observed . 9/19/23 10:30AM Nurses Notes: Resident found in room on floor v/s 120/88-82-16-97.8-spo2-96% above writer assessed resident able to flex and extend upper and lower ext (extremities) no visible injuries no c/o (Complaints of) pain helped into his recliner educated on importance of not taking his seat belt off unsupervised states he understands . 9/19/23 10:30AM Nurses Notes: Post Fall Evaluation: Fall Details: Date/Time of Fall: 9/19/23 10:15AM Fall was not witnessed. Fall occurred in the Resident's room. Resident was in a hurry/rush at the time of the fall. Reason for the fall was evident. Reason for fall: Resident took seat belt off and shoe got stuck under his wheelchair. Did an injury occur as a result of the fall: No. Did fall result in ER visit/hospitalization : No . 9/20/23 2:43PM Nurses Notes: Resident with 13 falls in 3 months. Multiple interventions tried. Resident with developmental delay and is still adjusting to his new environment. There is no pattern to time of falls. Most recent falls were when resident had COVID. Resident has a seat belt, which he can release, and does-and then falls forward. Unable to drop seat in wheelchair. Broda chair would be a restraint. Wedge cushion ordered and awaiting arrival to assist with positioning. Will review for increased involvement with activities. 9/23/23 8:12PM Nurses Notes: Resident up in w/c by the Nurses station Rt (right) wheel broke on w/c resident was placed in his bed for safety he got very upset started cursing yelling swinging his hand attempting to hit and kick me above writer left the room to go get another w/c (wheelchair) resident was placed in chair still angry stating I want my chair rolled down the hall halfway down the hall resident jumped out of chair face first his his [sic] face, nose and lip bleeding looks like he bit his lip Ice pack applied to nose and lip bleeding stopped v/s (vital signs) obtained 130/70-76-16-97.6-SPO2-94 R/A resident helped back in chair able to move all extremities placed at the Nursing station resident started having Seizure 3 of them lasting from 30 seconds to 1 minute 911 called .ES (Emergency Services) in to transport resident to Hospital resident c/o Rt Neck Pain. 9/23/23 Emergency Department Note includes, in part: Chief Complaint: Pt reported to have fallen forward from wheelchair just prior to arrival .Abrasion to scapl [sic] and laceration to lip. +Coumadin Bleeding is controlled . Medical Decision Making: .To abrasion over the lower lip, no lacerations for repair . CT head or Brain w/o contrast .Impression: No Acute Intracranial abnormality . Impression and Plan: Fall .Lip Abrasion .Disposition: discharged : to home. On 10/12/23 at 2:05PM Surveyor interviewed LPN L (Licensed Practical Nurse) who documented the nurses note for the 9/23/23 fall for R7. Surveyor and asked if a RN performed an assessment on R7 prior to her moving him after the fall on 9/23/23. LPN L indicated, no, we did not have a RN in the building. Surveyor asked LPN L if she tried to call a RN prior to moving R7. LPN L indicated, no, I assessed him and sent him to the ER. Surveyor asked LPN L if there is a facility policy or process for contacting a RN prior to moving a resident after a fall if there is not one in the building. LPN L indicated, no. On the afternoon of 10/11/23 Surveyor interviewed IDON B (Interim Director of Nursing) and asked who the best staff member would be to review R7's falls with. IDON B informed Surveyor to speak with MDS (Minimum Data Set) Coordinator R. On 10/12/23 at 9:41AM Surveyor asked MDS Coordinator R how the root cause for falls is determined. MDS Coordinator R indicated, normally in morning meeting DON and the NHA (Nursing Home Administrator) would come up with a root cause with everyone, but they would make the final decision. Surveyor asked MDS Coordinator R where the root cause would be documented. MDS Coordinator R referenced the risk management notes. Surveyor reviewed R7's falls from 8/8/23 to 9/23/23 with MDS Coordinator R for root cause and interventions. MDS Coordinator R indicated she could not locate a root cause for falls on 8/25/23, 8/26/23, 9/2/23, 9/3/23, 9/5/23, 9/9/23, and 9/10/23. Surveyor asked MDS Coordinator R how one would know what current interventions were physically in place at the time of R7's falls. MDS Coordinator R indicated there isn't a place to document that, only the new intervention. Surveyor asked MDS Coordinator R how a true root cause could be found if there isn't a way to see what current interventions were physically in place at the time of the fall. MDS Coordinator R indicated, that is a good question. Surveyor asked MDS Coordinator R if they are able to provide safe and appropriate fall interventions with root causes. MDS Coordinator R indicated, no. Of note, after review of fall reports obtained, root causes were found for the following falls on 9/5/23, and 9/10/23. On 10/12/23 at 3:23PM Surveyor interviewed IDON B (Interim Director of Nursing) and asked if she knew any information on whether R7's falls were related to behaviors. IDON B indicated when he came from the group home, they said he had several falls related to behavior. Surveyor asked IDON B if she would have expected that to be care planned and if she could locate this information on his care plan. IDON B indicated yes and that she could not locate it on the care plan. Surveyor asked IDON B if they were monitoring for behaviors. IDON B indicated, they did not start monitoring behaviors until the most recent care conference and the group home told us about his behaviors with falls. Of note, behaviors are noted on the TAR (Treatment Administration Record) starting 9/20/23. On the afternoon of 10/12/23, A Fall Action Plan for R7 was left in the conference room for Surveyor to review. The document has a title of Fall Action Plan and has R7's name is written on it with a date of 9/13/23. The document has four columns and ten lines. The document mentions a drop seat, fidget board/box and education. Per the care plan, the drop seat was implemented, on 9/28/23, 15 days later. No education was received from the facility or further information on the fidget board/box. There is no information in the third or fourth columns labeled Responsible Team Member and Date of Completion. On 10/12/23 at 3:38PM Surveyor interviewed Unit Manager S (UM) regarding a Fall Action Plan that was left in the conference room and asked if she could explain what the document was showing. Unit Manager S indicated, on 9/13/23 they had a rapid response and worked with an outside consulting team to find out what to do with bigger issues. They discussed R7's behaviors and having more activities. Surveyor asked Unit Manager S if she could help me understand what the information on the document means or what was put in place based on the document. Unit Manager S indicated she could not add any information, just knows what is on it. On 10/12/23 at 12:08PM Surveyor interviewed Unit Manager S and asked what process should be followed post fall. Unit Manager S indicated that there is a post fall UDA (user defined assessment), fall risk UDA, and skin assessment. Surveyor asked Unit Manager S if a RN assessment should be completed after a fall prior to moving resident. Nurse Manager indicated, yes. Surveyor asked what staff should do if a RN is not in the building. Unit Manager S indicated they should call the Unit Manager or DON. Surveyor asked when a resident falls, should current physical interventions that were in place at the time of the fall be documented in the record. Unit Manager S indicated, yes. Unit Manager S indicated when she teaches staff how to document what was correct, they should document this under other info on the fall incident report. Unit Manager S showed Surveyor on a random Fall report of R7's, received from the facility, where this section is located. Fall reports reviewed and the following dates did not contain what was correct under other info for falls on 8/25/23, 8/26/23, 9/2/23, 9/3/23, 9/5/23, 9/6/23, 9/9/23, 9/10/23, 9/12/23, and 9/19/23. Unit Manager S indicated that she didn't feel the reports had the UDA's with them. Surveyor asked Unit Manager S if she wanted to provide them for Surveyor to review. Unit Manager S indicated she did not feel they would be helpful for further information. Surveyor asked Unit Manager S where the root cause should be documented. Unit Manager S indicated it would depend on the quality of the nurses note. It should be in the progress notes or on the notes page in risk management. Unit Manager S added, in talking with his care team his falls are behavioral for attention and this is not new. We have been trying to get him more involved in activities. Surveyor asked Unit Manager S if they can provide safe and effective fall interventions without a root cause. Unit Manager S indicated, absolutely not. On 10 12/23 at 12:04PM Surveyor interviewed IDON B and asked for the title of the nurse, LPN, or RN, for R7's falls from 8/8/23 through 9/23/23 as some notes did not list this. On 10/12/23 at 1:03PM Surveyor interviewed IDON B and asked if a RN should assess a resident before moving them after a fall. IDON B indicated, yes. Surveyor asked IDON B if there is not a RN in the building what should the LPN do related to assessment of a resident that has fallen. IDON B indicated she was not sure. IDON B also indicated they could not locate a RN assessment for falls on 8/25/23, 9/3/23, and 9/19/23. On 10/12/23 at 5:11pm Surveyor interviewed Unit Manager S and asked with knowing R7's history with falls, anticoagulation therapy, and risk for a brain bleed were any other options, for example, a helmet or hipsters or anything discussed for further interventions for R7 to protect him when he falls. Unit Manager S indicated nothing discussed other than what is on the care plan. It is important to note that R7 has a seizure disorder which puts him at risk for falls. R7 is on anticoagulation therapy which puts him at risk for bleeding. R7 has had multiple falls including multiple falls where R7 has struck his head, a fall requiring staples and multiple ER visits. R7 is a significant risk for poor outcome such as a brain bleed due to anticoagulant therapy and falls with head injury. The facility did not offer robust interventions such as a helmet or other devices that could subsequently prevent major injury. the examples below are cited at a minimum potential for harm/isolated 30992 Example 2: The facility policy and procedure, Pre-Thickened Liquids, undated, indicates the following: Facility will provide pre-thickened liquids as follows: 1. Pre-thickened liquids will be poured from 1 qt. (quart) bulk containers into glasses and served at each meal per physician's orders R33 was admitted to the facility 2/7/22 with diagnoses including, but not limited to, Dysphagia (difficulty swallowing), Alzheimer's Disease, and Dementia. R33's Quarterly MDS (Minimum Data Set), dated 9/23/23, indicates R33 is severely cognitively impaired. Section G indicates that R33 is independent with eating and requires set up help only. Section K indicates R33 does not have a swallowing disorder and weighs 223 pounds. On 8/28/23 Speech Therapy evaluated R33. Pt (Patient) will maintain adequate hydration/nutrition with optimum safety and efficiency of swallowing function on P.O. intake w/o (without) overt s/s (signs/symptoms) of aspiration for highest appropriate diet level (Target 10/17/23). Basel [TRUNCATED]

Based on interviews and record review, the facility did not ensure residents were free of significant medication errors for 1 of 3 (R412) residents reviewed. R412 did not receive Diltiazem as ordered which resulted in hospitalization for atrial fibrillation/flutter. Findings include: R412 admitted to the facility on [DATE] and has diagnoses that include atrial fibrillation with rapid ventricular response, coronary artery disease, and chronic heart failure. The facility policy titled, Medication Unavailable, which was not dated, documents (in part) . 1. The facility maintains a contract with a pharmacy provider to supply the facility with routine, prn (as needed) and emergency medications. 2. A STAT (immediate) supply of commonly used medications is maintained in house for timely initiation of medications. 3. The facility shall follow established procedures for ensuring residents have a sufficient supply of medications. 4. Medications may be unavailable for a number of reasons. Staff shall take immediate action when it is known that the medication is unavailable. a. Determine reason for unavailability, length of time medication is unavailable, and what efforts have been attempted by the facility or pharmacy provider to obtain the medication. b. Notify the Physician of inability to obtain medication upon notification or awareness that medication is not available. Obtain alternative treatment orders and/or specific orders for monitoring resident while medication is on hold. c. If facility allows: Determine whether resident has home supply. Obtain orders to use home supply. Administer first dose after pharmacist has verified that the medication is correct with respect to name, dose, and form of medication. 5. If a resident misses a scheduled dose of the medication, staff shall follow procedures for medication errors, including physician/family notification, completion of a medication error report, and monitoring the resident for adverse reactions to omission of the medication. On 1/13/23, R412 was admitted to the hospital. Chief complaint: Altered mental status, patient diagnosed with UTI (Urinary Tract Infection) but refusing antibiotic at facility. Emergency Department (ED) findings: Afebrile with tachycardia but stable vital signs otherwise. EKG (electrocardiogram) showed atrial flutter with rapid ventricular response. Hospital records further document (in part) . .Assessment/plan: Atrial flutter with rapid ventricular response. The patient is already on Metoprolol and Diltiazem at the nursing home but may not have been taking all her medications. The patient has been started on Diltiazem drip in the ED and this will be continued and titrated for rate control. The hospital discharge summary dated 1/22/23 documented (in part) . Family has requested enteral access. I am dubious about its benefits. Case was discussed with granddaughter who wished to have a feeding tube placed. We explained at this point that she should decide between hospice care over aggressive care with a G-tube (Gastrostomy) and she decided on the G-tube for the time being. Condition at discharge: Improved. Medications to continue included Diltiazem XR (extended release) 240 mg (milligrams) every day. R412 readmitted to the facility on [DATE] with the gastrostomy tube. Review of facility documentation revealed prior to hospitalization on [DATE], R412 frequently refused her medications, including Diltiazem. R412's primary physician and Cardiologist were aware of R412's refusal of medications. Facility progress notes dated 1/25/23 at 7:28 PM documented: Resident had elevated HR (heart rate) low SPO2 (oxygen level) and labored breathing. MD (Medical Doctor) and family notified. Sent to ER for eval and treat. The hospital discharge summary dated 1/27/23 documented (in part) . Final diagnosis: Atrial Flutter with rapid ventricular response. Altered mental status. She was recently hospitalized as above and a PEG tube was placed at that time presumably to make sure the patient is compliant with taking her medications. Emergency Department course: The patient was given IV (intravenous) fluids as well as multiple doses of IV Metoprolol without significant improvement in heart rate and therefore was admitted for observation and further treatment of her atrial fibrillation/flutter with rapid ventricular response. Spoke with (nurse at facility). (Resident) has been taking all her medications except not her Cardizem XL (Diltiazem) since hospitalization , so last dose was 1/22. It was not available to give. Rapid ventricular response appears to be from med non-adherence. No Diltiazem XL since discharge from hospital on 1/22 because it was not available at the healthcare center. While reviewing R412's Medication Administration Record (MAR) from 1/23/23 to 1/25/23, Surveyor noted 13 ordered medications were signed out as having been administered between 1/23/23 and 1/25/23. However, Diltiazem HCL ER 240 mg documented 7 on 1/23/23 with staff initials, a check mark on 1/24/23 with staff initials, and 7 on 1/25/23 with staff initials. Surveyor review of the MAR entry codes documented: 7 = other/see NN (nursing notes). Surveyor review of facility progress notes revealed no documentation from 1/23/23 to 1/25/23 regarding Diltiazem not having been administered. There was no documentation of refusal or why the medication was not administered, and no documentation the physician was notified per the facility policy and procedure. Surveyor verified and identified the staff initials on the MAR/Diltiazem order from 1/23/23 to 1/25/23 as Medication Technician (Med Tech)-C and Registered Nurse (RN)-D. On 2/14/23, at 9:30 AM, Surveyor spoke with Med Tech-C who reported she knows the resident well. Med Tech-C reported R412 would refuse all of her medications except for Tylenol. When she came back from the hospital, she had a G-tube, so we were able to give her medications through the tube. Surveyor asked what the 7 entered on the MAR on 1/23/23 meant. Med Tech-C reported 7 means the medication was not available and showed Surveyor the medication cards. Med Tech-C reported medications in the cards are not available in contingency, adding if it's not re-ordered, we don't have it in contingency. Med Tech-C reported she entered 7 because the Diltiazem was not available. When asked what she does when a medication is not available, Med-Tech-C reported she tells the nurse. Surveyor advised there was no charting in the progress notes regarding the Diltiazem not available or that the physician was notified. Med Tech-C reported she does not chart in the progress notes; if a medication is not available, she tells the nurse and it is her responsibility to call the doctor and pharmacy. Surveyor advised R412 was previously on Diltiazem prior to hospitalization and asked why the medication wasn't available upon readmission to the facility. Med Tech-C reported she did not know. She reported sometimes the cards are sent back when the resident is discharged . Med Tech-C stated: All I know is it wasn't available to give. On 2/14/23, at 11:07 AM, Surveyor spoke with Registered Nurse (RN)-D who reported R412 refused her medications all the time. RN-D stated: When she came back from the hospital, she had a G-tube, so we gave them that way. Surveyor asked what 7 entered on the MAR meant. RN-D reported 7 means the medication wasn't available. Surveyor asked if it would be in contingency. RN-D stated: Probably not. If I put 7 means it wasn't available to give. Surveyor advised RN-D of the check mark on 1/24/23 and 7 on 1/25/23. RN-D stated: I don't think it was available at all, I probably put the check mark by mistake instead of 7. Since it wasn't available, I'm sure I called the pharmacy to send it. Surveyor advised RN-D there was no documentation regarding the Diltiazem and asked if she called the Physician to notify the medication was not available. RN-D reported she did not remember. Surveyor asked if she spoke to someone at the hospital about R412 not receiving Diltiazem because it was not available. RN-D stated: I don't remember specifically, but if the medication wasn't available, I probably did tell them that. Surveyor reviewed the facility contingency medication list and verified Diltiazem XR 240 mg is not available in contingency. R412 was hospitalized [DATE] for atrial flutter with rapid ventricular response. She received Diltiazem drip in the hospital for rate control. She was discharged back to the facility on [DATE] with a G-tube and in improved condition per the hospital discharge summary. R412 had physician orders to continue Diltiazem XR 240 mg every day. Staff interviewed reported medications were administered through the G-tube. From 1/23/23 to 1/25/23, Diltiazem was not administered as ordered because, according to staff interviews, it was not available. There was no evidence the physician was notified Diltiazem was not available. R412 was sent to theER on [DATE] due to an elevated heart rate, low oxygen levels and labored breathing. She was subsequently admitted to the hospital with atrial flutter with rapid ventricular response. Hospital records documented R412's rapid ventricular response appears to be from med non-adherence. Resident did not receive Diltiazem XL since discharge from hospital on 1/22 because it was not available at the healthcare center. On 2/14/23, Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were notified of the above concern. No additional information was provided.

Based on interviews, record review, facility document review, and a review of the facility's policy, the facility failed to protect the residents' right to be free from sexual abuse by a resident. This failure affected 2 (R37 and R10) of 6 residents reviewed for abuse. R33 touched R37 inappropriately on the breast on 02/19/2022, the facility failed to implement interventions to address R33's behavior, and then on 07/08/2022 R33 touched R10's private area outside the resident's clothing. This failure resulted in R10 experiencing psychosocial harm due to being inappropriately touched by R33, which brought back the trauma of being molested as a child. Findings included: The facility policy titled, Abuse/Neglect/Exploitation, dated 03/01/2019, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. According to the policy, Sexual abuse is non-consensual sexual contact of any type with a resident. The policy indicated, The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. A review of R33's medical diagnosis list from the resident's electronic medical record (EMR) revealed the resident had diagnoses that included major depressive disorder, diabetes, chronic diastolic heart failure, generalized edema, reduced mobility, chronic kidney disease, and chronic embolism of the deep veins of an unspecified lower extremity. A review of R33's annual Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS also revealed R33 needed supervision (oversight, encouragement, or cueing) for locomotion on and off the unit. The MDS indicated R33 had no behaviors. A review of R33's care plan, dated 09/29/2021, revealed R33 liked to keep busy with independent activities and visiting with family and friends. Further review revealed the facility developed a care plan, dated 09/25/2021, related to R33's risk for depression. According to R33's care plan, dated 02/16/2022, the resident ambulated independently and was independent with locomotion on and off the unit. A review of a facility Investigation Report revealed on 02/14/2022, R37 reported that R33 touched R37's breast inappropriately on 02/14/2022. R37 stated she consented for R33 to provide a massage; however, R33 reached over and touched R37's breast. R37 asked R33 to stop, and R33 stopped. A review of Administrator A's statement, dated 02/17/2022, revealed R37 came to the Administrator A's office and stated she wanted to tell Administrator A something. R37 reported that on 02/14/2022, another resident (R33) touched her inappropriately. The statement indicated R37 stated she told R33 her shoulder's hurt and R33 stated he would massage them. R37 agreed to the massage and R33 reached over and attempted to grab R37's breast. R37 told R33 to stop, and R33 immediately stopped. A review of R37's quarterly MDS, dated [DATE], revealed the resident had diagnoses that included depression and anxiety disorder. The resident had a BIMS score of 15, which indicated intact cognition. Further review of R37's MDS revealed R37 exhibited no behaviors. During an interview on 01/14/2023 at 5:18 PM, R37 stated there was a time last year when R33 gave R37 a shoulder massage. R37 stated R33 often gave R37 hand, arm, and shoulder massages. R37 stated R33 was massaging her shoulders and moved too far down the front and touched R37's breasts. R37 asked R33 to stop and he immediately stopped. R37 stated she informed Administrator (A) because R37 thought Administrator (A) would help reinforce to R33 not to behave in that way. R37 stated it never happened again. R37 further stated it was not abuse in her opinion. R37 stated, Oh no, no, no, not at all. We were good friends, and we still are good friends. R37 stated she thought R33 was confused at the time. According to R37, R33 apologized and nothing like that had happened since. According to the facility's investigation, the facility reviewed the residents' care plans and educated residents during a Resident Council meeting about resident rights and abuse reporting. The facility concluded that R37's care plan indicated the resident made false allegations. Further, the facility's conclusion revealed R37 chose to continue to have contact with R33, had no other issues with R33, and would like to continue friendship with the resident. Further review of R33's care plan revealed no documented evidence that the facility implemented any interventions as a result of the incident on 02/14/2022 to prevent further incidents from occurring. A review of a Misconduct Incident Report revealed on 07/08/2022 at 4:20 PM, (R10) reported that (R33) touched (R10) inappropriately. (R10) reported that (R33) entered her room while (R10) was sleeping and started touching the resident's foot. (R10) woke up and (R33) was moving up (R10's) thigh to the private area, touching (R10) outside the resident's pants. (R10) asked (R33) to stop, but (R33) did not stop. (R10) then yelled for (R33) to stop, but (R33) did not stop. (R10) reported the incident to a certified nursing assistant (CNA). Surveyor noted the CNA is not identified in the Misconduct Incident Report. A review a witness statement, dated 07/13/2022, revealed she found (R33) in (R10's) room beside (R10's) bed on 07/08/2022. (R10) was screaming for help as (R33) was sitting in a wheelchair looking at (R10). The statement indicated that (R33) was taken out of the room and told that (R33) was not allowed to go into other residents' rooms. Further review revealed staff assured (R10) that everything was being done to protect the resident. According to the witness statement, (R33) was transferred to the hospital thirty minutes after the incident. A review of R10's medical diagnoses list revealed the resident had diagnoses that included major depressive disorder, chronic post-traumatic stress disorder, and anxiety disorder. A review of R10's quarterly Minimum Data Set (MDS), dated [DATE], revealed R10 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. No behaviors were indicated on the MDS. A review of a Trauma Informed Care Assessment, dated 07/08/2022, revealed R10 indicated she had something happen that was unusually or especially frightening, horrible, or traumatic. Further review revealed in the last month, R10 had nightmares about the event or thought about the event when R10 did not want to; had been constantly on guard, watchful, or easily startled; had felt numb or detached from people, activities, or surroundings; and felt guilty or unable to stop blaming herself or others for the event or any problems the event may have caused. A review of a Psych [Psychiatric] Initial Evaluation, dated 07/13/2022, documented R10 was seen that day for an incident of inappropriate touching. The evaluation indicated R10 was, Feeling down and depressed regarding the situation that occurred and R10 and felt she was dealing with it. Further review revealed R10 reported being molested as a child and this incident brought up memories for R10. During an interview on 01/09/2023 at 2:13 PM, R10 stated she was in bed sleeping, and another resident (R33) entered her room and began touching R10's body, starting at the legs and feet, and moving to the perineal area and breasts. R10 stated when R33 touched her perineal area, R10 woke up and told R33 to get the hell out of here. R10 stated R33 would not stop and touched the resident's breasts twice and would not leave. R10 stated she pushed R33 away, yelled loudly for help a few times, and a CNA came in removed R33. R10 stated that the next day she observed R33 in a wheelchair at R10's doorway, staring. R10 stated she called the CNA, and the CNA moved R33. R10 stated she did not see R33 after that day. R10 stated she was sexually abused when R10 was a small child, and even though R10 thought she had put the past incident behind them, the incident brought the trauma back. Continued review of R33's Progress Notes revealed on 07/08/2022 at 2:35 PM, the facility notified a nurse practitioner that the resident continued to have confusion and an order was obtained to send the resident to the emergency room (ER). Further review revealed on 07/08/2022 at 3:28 PM, R33 had increased confusion. On 07/08/2022 at 4:30 PM, the progress notes revealed R33 was transferred to the ER. According to the note dated 07/08/2022 at 7:49 PM, the resident returned from the ER with a diagnosis of cellulitis of the left lower leg. The note indicated R33 had confusion and required staff redirection during the shift. During an interview on 01/12/2023 at 10:13 AM, R33 stated they did not remember going into anyone's room. R33 stated July was a long time ago, but the resident (R33) would never go into a room and touch anyone. R33 stated he had friends but talked to them from the doorway and did not enter their rooms. R33 appeared to be hesitant and somewhat confused when speaking about July 2022. Continued review of the facility's Misconduct Incident Report for the incident on 07/08/2022 revealed the facility educated staff on abuse and reporting, educated R33 not to enter other resident rooms, and moved R10 to the other side of the building. Continued review of R33's care plan revealed the facility developed a care plan on 07/09/2022 that indicated the resident sometimes had sexually inappropriate behaviors exhibited by inappropriate touching. The facility developed interventions that included offering the resident something else that the resident liked, attempting to redirect the resident, reminding the resident that the behavior was not appropriate, keeping the resident in line of sight when the resident was not in his room, and treating the resident with dignity and respect regardless of behavior. During an interview on 01/11/2023 at 6:02 PM, Licensed Practical Nurse (LPN) I stated R33 did not have wandering behavior and did not go into other residents' rooms. She stated R33 had an infection last year and touched another resident, but since then staff monitored the resident's behavior. During an interview on 01/11/2023 at 6:10 PM, LPN C stated R33 stayed in his room or the dining room. She also stated R10 was quiet, stayed in her room and was anxious occasionally. During an interview on 01/11/2023 at 6:13 PM, CNA E stated R33 did not have any behaviors. She stated R33 spoke to other residents, but she had not seen the resident go into anyone's room. She stated R33 was never inappropriate with staff or other residents and was a kind person. CNA E stated R10 kept to herself, rarely came out of her room, and was cooperative. During an interview on 01/11/2023 at 6:31 PM, LPN M stated the nurses monitored R33 for inappropriate behavior toward other residents. LPN M stated R33 kept to himself and traveled to the dining room and back to his room. She stated R10 did not have any behaviors and was pleasant, cooperative, and somewhat anxious. During an interview on 01/11/2023 at 6:46 PM, Registered Nurse (RN) L stated R33 did leave his room to speak to other residents. He stated R33 stayed in the doorway and did not go into residents' rooms. He stated staff monitored the resident every shift, and if there was a problem with behaviors, they documented the behavior in the progress notes. RN L stated staff monitored R10 for behaviors, but the resident did not have any. He stated R10 stayed in her room and did not seem depressed or anxious. During an interview on 01/11/2023 at 7:17 PM, LPN K stated Resident #33 did not have any behaviors and spent time in his/her room or the dining room. She stated the resident was noted to be in the doorway of other resident rooms visiting but did not enter the rooms. LPN #9 stated Resident #10 did not have any behaviors, and kept the door open to his/her room. During an interview on 01/12/2023 at 12:03 PM, LPN I stated R10 did have behaviors of repeating the same concerns, was anxious most of the time, but did not express fear. She stated R10's depression appeared to be mild. She stated the resident had somewhat disorganized thinking and kept her room door open at all times. R10 did not use the call light and called out when the resident saw staff walk by her room. LPN I stated the resident did not talk about being worried that somebody might come into her room. R10 stayed by themself, usually stayed in her room, and seemed overall content and happy. LPN I stated R33 was on monitoring due to inappropriate contact with another resident. According to LPN I, R33 had an infection when the incident occurred with R10 and R33 had not displayed that behavior again. LPN I stated R33 used to visit with other residents but did not go into anyone's room now. During an interview on 01/12/2023 at 1:07 PM, LPN F stated staff monitored R33 every shift for behaviors and stated the resident did not display any behaviors. She stated R33 was often talking to other residents, but the residents did not complain. LPN F stated R33 would go to other residents' doorways and visit but did not enter their rooms. During an interview on 01/13/2023 at 3:03 PM, RN Y stated she had never seen R33 act inappropriately with another resident, make contact with another resident, or heard the resident say anything to another resident that was inappropriate. During an interview on 01/13/2023 at 3:31 PM, LPN MM stated she never had a problem with R33, who was very sweet. She stated R33 talked with other residents and sat at their doorways to visit. She stated she was not aware of R33 entering another resident's room. During an interview on 01/13/2023 at 2:21 PM, CNA P stated R33 was very quiet, and did not bother anyone. She stated R33 went back and forth to the dining room and would spend long periods of time in the bathroom. CNA P stated the resident did not try to touch any of the staff that she was aware of, and she had not heard of the resident ever having been inappropriate with anyone. CNA P stated R10 was cheerful and did not have any behaviors. During an interview on 01/14/2023 at 2:26 PM, Director of Nursing (DON) B stated staff took precautions and monitored R10 after the incident with R33. She stated after the incident, R10 saw R33 in the hallway and was uncomfortable, so on 07/09/2022, they moved R10 to a room on the end of a hall where R33 rarely went. DON B stated R33 had an active infection and was very confused when the incident occurred, and no incidents had happened since then. She stated staff monitored R33 every shift. DON B stated they also continued to monitor R10. DON B further stated that abuse should not happen in the facility. During an interview on 01/14/2023 at 2:20 PM, Administrator A stated R33 had an incident of inappropriate touching of another resident in May 2022 and acknowledged R33 had two instances of inappropriate touching. Administrator A stated she did not ever expect abuse to occur at the facility.

Based on interviews, record review, and review of the facility policy, the facility failed to ensure assistive devices to prevent accidents were provided for 1 (R410) of 4 residents reviewed for accidents. This failure resulted in R410 falling from a wheelchair that did not have footrests while being assisted by staff and sustaining a subdural hematoma (a pool of blood between the brain and its outermost covering) and an acute osteophyte fracture of second and third cervical spine (C2/C3) vertebrae (fracture of a bone spur on the cervical spine bones in the neck). Findings included: The facility's undated policy titled, Accidents and Supervision Policy, indicated, The resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. A review of R410's Admission Record revealed the facility admitted the resident with diagnoses that included type 2 diabetes with polyneuropathy, chronic kidney disease, displaced fracture of the sixth cervical vertebra, and osteoarthritis. A review of the admission Minimum Data Set (MDS), dated [DATE], revealed R410 had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS indicated R410 required limited assistance from 2 or more staff for transfers and the resident required the physical assistance of one person for locomotion off the unit. The MDS indicated R410 had a history of falls and had sustained a fall in the previous month but had not sustained any falls since admission to the facility. A review of R410's care plan, initiated 11/04/2022, indicated R410 was at risk for falls related to physical limitations, leg fracture, and need for staff assistance. The interventions included to assess that a wheelchair was of appropriate size, assess need for footrests, and assess for need to have the wheelchair locked/unlocked for safety (initiated on 11/04/2022). A review of Progress Notes revealed on 11/14/2022 at 7:05 AM R410 was being transported in a wheelchair on the roadway and began to pitch self out of the wheelchair onto the ground. The progress note indicated a body check was completed and the resident had an abrasion to the left upper forehead and had light bleeding from the abrasion. The note further indicated R410 was alert and speaking without difficulty after the fall. Further review of progress notes revealed a post fall evaluation was completed at 11:35 AM on 11/14/2022 which indicated wheelchair footrests were not in use at the time of the incident. A review of an Investigation Report, dated 11/15/2022, revealed R410 missed their ride to dialysis and a registered nurse (RN) and staff from medical records decided to walk the resident to dialysis, which was approximately one block from the facility. The investigation report indicated the wheelchair hit a pothole and R410 fell out of the wheelchair and hit his head. The investigation report further indicated the RN assessed R410 and called emergency medical services and R410 was transported to the local emergency room (ER). The investigation report further indicated the ER notified the facility that R410 had a subdural hematoma and an acute osteophyte fracture of C2/C3. The conclusion of the investigation report indicated other residents were interviewed and no other residents reported issues with wheelchair transportation and all staff would be educated on safe transfers. A review of the Discharge Summary from the hospital, dated 11/17/2022, revealed R410's diagnoses during the hospital admission were subdural hematoma and C2/C3 fracture of the osteophyte. The radiology information on the discharge summary indicated the subdural hemorrhage was small and stable and R410 did not require surgery. An interview with Medical Records (MR) NN on 01/12/2023 at 9:13 AM revealed she and RN X were transporting R410 when the resident was injured. She stated the resident was not ready for the dialysis appointment and the transit driver could not wait, so they were going to take the resident next door to the dialysis center in a wheelchair. MR NN stated RN X left with R410, and she waited on the paperwork and caught up to them. She stated that as soon as she caught up to R410 and RN X, the accident happened. She stated she thought the wheelchair caught on a hole on the road and R410 put down their feet, causing R410 to fall out of the wheelchair. She stated the accident happened fast, but R410 fell out of the chair slowly. She stated the wheelchair did not have foot pedals on it. She stated the facility had an in-service about making sure foot pedals were on all wheelchairs during transport, but she was not sure of the date. An interview with Licensed Practical Nurse (LPN) I on 01/12/2023 at 2:05 PM revealed she was working the day of the incident with R410, and she received a phone call from MR NN asking for assistance. She stated she ran out to the resident, and there were two other nurses there from the dialysis center that were assessing and taking care of the resident. She stated she took the resident's vital signs, an ambulance arrived, and R410 was taken to the hospital. She stated she did not remember if the wheelchair had foot pedals on it, but she knew that if a resident was to be transported by wheelchair, there must be footrests on the wheelchair. An interview with Physical Therapy Assistant (PTA) OO on 01/13/2023 at 11:35 AM revealed that when a resident was pushed in a wheelchair, they had to have foot pedals on the wheelchair; this was a safety measure. She stated by having foot pedals, it may keep the resident's foot from dropping down and causing them to fall out of the wheelchair. An interview with PTA #29 on 01/13/2023 at 11:41 AM revealed she heard R410 had an accident while being transported in a wheelchair to the dialysis center. She stated for safety reasons, the foot pedals should be on the wheelchairs during any transport. She stated she thought the foot pedals could have prevented the incident with R410. She stated if a resident was being transported, the wheelchairs must have foot pedals as a safety measure. PTA PP stated the foot pedals may keep the resident's foot from dropping down and prevent them from falling out of the wheelchair. An interview with Therapy Director QQ on 01/13/2023 at 11:51 AM revealed during transport in a wheelchair, all residents should have foot pedals on the wheelchair. She stated this could prevent the residents' feet from dropping low enough to get caught on anything or fall out of the chair. She stated R410 fit well in the wheelchair, and she had no concern that R410 was leaning forward and fell out of the wheelchair, but she said the foot pedals would keep the resident safe during transport. A phone interview with Registered Nurse (RN) X on 01/13/2023 at 12:20 PM revealed she and Medical Records NN were transporting R410 next door to a dialysis appointment when there was an accident when R410 pitched themselves forward out of the wheelchair onto the ground. She stated she did not remember if the wheelchair had foot pedals on it, but she knew the resident did not tell her that she needed to put them on the wheelchair. RN X stated she was not sure if the foot pedals would have prevented the accident but may have kept R410 from being able to lean forward. She stated that during the resident's assessment, the resident did not complain of any pain, but she saw an abrasion above the resident's left eyebrow. She stated she did not receive any in-services related to foot pedals on wheelchairs during transport until after the incident. A review of in-service records revealed an in-service was conducted on 11/23/2022 and the topic was safe transport and included ensuring foot pedals were attached to wheelchairs, ensuring wheelchairs were in appropriate working order, ensuring residents were properly sitting in the wheelchair, and ensuring residents were dressed appropriately for the weather. A review of the Inservice Education Summary revealed RN X had not received the in-service. An interview with Administrator A and Director of Nursing (DON) B on 01/14/2023 at 5:22 PM revealed after the incident with R410, the resident was not in the facility and an in-service was not conducted until 11/23/2022 after the resident returned to the facility. They stated they did not have an in-service after each fall/incident, but they did talk about them in their morning meetings. DON B stated she thought everyone had been in-serviced regarding placing foot pedals on wheelchairs when staff were transporting the resident. They stated residents should have foot pedals on the wheelchair if they were being transferred by a staff member.

Based on observation, interview, and record review, the facility did not follow proper sanitation in accordance with professional standards for food service safety to ensure dishes and utensils were properly sanitized by the facility's dishwashing machine. This had the potential to affect 51 of 53 Residents who receive nutrition orally from food prepared in the kitchen. The wash and rinse temperatures did not meet manufacturer's minimum recommendations for proper washing and rinsing. The facility did not consistently check temperatures and did not [MEDICATION(S)] when temperatures were below minimum wash and rinse temperatures for proper sanitization of dishes and utensils. Kitchen staff are not aware of the recommended temperature for proper sanitation of dishes and utensils for their dishwashing machine. When the facility added a chemical solution to change the sanitization method from temperature to chemical, test strips were not being used to ensure there is sufficient chemical solution to sanitize the dishes and flatware. Facility failure to have systems in place to ensure wash and rinse temperatures and chemical sanitization was being carried out to ensure proper sanitization of dishes and utensils for a population vulnerable to food-borne illness created a finding of Immediate Jeopardy that began on 8/14/22 and has not yet been removed. On 8/31/22 at 3:55 PM, Administrator (NHA-A), Director of Nursing (DON-B), Regional Director of Clinical Operations (RDCO-I), and Assistant Administrator (AA-H) were informed of the Immediate Jeopardy. Findings Include: Surveyor reviewed the facility's undated dishwasher temperature policy and procedure. .Policy: It is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperatures. Policy Explanation and Compliance Guidelines: 1. All items cleaned in the dishwasher will be washed in water that is sufficient to sanitize any and all items. 2. Manufacturer's instructions shall be followed for machine washing and sanitizing. 3. For high temperature dishwashers (heat sanitization): a. The wash temperature shall be 150-165 F i. For a single tank, conveyor, dual temperature machine: 160 F b. The final rinse temperature shall be 180 F or above but not to exceed 194 F. Corrective actions shall be taken for final temperatures below the required final rinse temperatures. 4. For low temperature dishwashers (chemical sanitization): a. The wash temperature shall be 120 F b. The sanitizing solution shall be 50 parts per million(ppm) hypochlorite (chlorine on dish surface in final rinse. 5. Chemical solutions shall be maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines. Results of concentration checks shall be recorded. 6. Water temperatures shall be measured and recorded prior to each meal and/or after the dishwasher has been emptied or re-filled for cleaning purposes. Surveyor also reviewed the materials that are used in training with all kitchen staff and noted the following: Safety in the Dietary Department Policy This facility will provide a safe environment for performing dietary duties. Staff members will be trained in following proper procedures. Procedure The dietary manager is responsible for maintaining safety standards, and for reviewing these with new staff members. The safety procedures and standards are reviewed periodically with all personnel in the Dietary Manager. The Dietary Manager enforces Dietary Department safety procedures and limits the operation of dietary equipment to authorized, trained personnel. A check list may be used in establishing and checking safety procedures. The Dietary manager is responsible for instructing the staff members in the proper use and maintenance of equipment. The Dietary Manger notifies the Maintenance Department of any safety hazards or equipment breakdowns. A preventive maintenance program is developed to avoid unnecessary breakdowns and hazards. Dish Handling Use special caution when preparing dish washing solutions. Carefully follow the instructions as to quantities, temperatures, etc On 8/31/22 at 8:37 AM, Surveyor spoke to dietary staff (DS-C) who informed Surveyor that the dishwashing machine has been working fine. DS-C stated that the facility switched to Styrofoam products when there was a hot water issue but are back to using regular dishes and utensils. Surveyor then observed DS-C run a rack of dishes in the dishwashing machine. Surveyor observed the wash cycle temperature reach 144 degrees F (Fahrenheit) and the rinse cycle temperature reach 75 degrees F. Surveyor asked DS-C what the temperatures should be at. DS-C stated, I don't know what the temperatures should be at. I don't know what to do with the temperature information. Surveyor notes that DS-C has been employed at the facility since 4/1/22. On 8/31/22, at 8:50 AM, Surveyor requested a copy of the June, July, and August dishwashing machine temperature logs from Administrator (NHA-A). NHA-A informed Surveyor that a chemical sanitation was placed on the dishwashing machine because it had not been holding temperatures. NHA-A stated that the dishwashing machine is in the process of getting fixed. On 8/31/22 at 9:07 AM, Surveyor interviewed Dietary Director (DD-E). Surveyor asked DD-E what should the dishwashing machine temperature be at for the wash cycle? DD-E replied 180. Surveyor asked DD-E what should the dish machine temperature be at for the rinse cycle? DD-E stated they did not know what the temperature should be at. Surveyor reviewed the August dish machine temperature log with DD-E and pointed out there are multiple days where the wash and rinse cycle did not reach the minimum required temperature. DD-E appeared confused with the temperature documentation. DD-E informed Surveyor that the chemical sanitation was added to the dish machine on Monday night (8/29/22). On 8/31/22 at 9:20 AM, Surveyor spoke again to DD-E. DD-E stated DD-E has been employed at the facility since 6/27/22 and is unable to locate June's dish machine temperature log. DD-E stated they called a Dietary Manager at another facility who informed DD-E that the minimum required temperature should be between 130 and 140 F. DD-E stated, I didn't know what it should be. Surveyor asked DD-E what the expectation for the use of the temperature log is. DD-E stated the expectation would be for the staff to inform DD-E if the temperatures are low with the dish machine. DD-E stated that they have not been checking the temperature logs on a daily basis to make sure the dish machine was operating at the required level for wash and rinse cycles. DD-E stated, I will do better to check the temperatures when I come in everyday. DD-E stated the facility used Styrofoam over the weekend because of the hot water issue and are back to using regular dishes and utensils. DD-E confirmed that they are not using test strips to test the ppm (parts per million) of the chemical solution that is being used in place of the high temperature sanitization and do not have a log for monitoring the chemical ppm levels with wash cycles. On 8/31/22 at 9:41 AM, Surveyor interviewed Maintenance Director (MD-F) in regard to the dish machine. MD-F stated that they went into the kitchen on 8/29/22 to work on the hot water issue in the facility and ran a load of dishes through the dishwasher to verify the temperature, and the temperature was low. MD-F discovered that the booster heater on the dish machine was not working. MD-F stated the chemical company was contacted and they came out to put the chemical sanitation on. MD-F confirmed that the ideal temperature should be at 180 degrees F. MD-F stated they had not been notified prior to Monday (8/29/22) that there was an issue with the dish machine temperatures. MD-F stated, I found the temperature issue when looking for the water leak. MD-F confirmed the facility's dish machine is a high temperature dishwasher and putting the chemical solution on is like treating the dish machine as a low temperature dish machine. During the survey, Surveyor was provided a 'hot water timeline' which states that on 8/29/22 at 3:30 PM, MD-F discovered the low temperatures for the dish machine and the heat booster having malfunctioned. MD-F found the breaker flipped and reset. Heard a loud bang, reset the machine and again heard the same sound. The kitchen began using paper products for meals. The dish machine company was called to repair the heat booster and the chemical company was called to place the cold-water sanitizer on the dish machine. At 6:00 PM, the chemical company arrived at the facility and placed the cold-water sanitizer on the dish machine. Surveyor reviewed the chemical company's Extra Service Request. It is documented the company found the booster heater that provides hot water for machine rinse had failed. Installed machine sanitizer on unit and tested at 75 ppm. It is suggested the dish machine should not be used until booster heater is fixed as incoming water is only around 70-80 degrees Fahrenheit. Minimum water temperature is 120 degrees Fahrenheit. Recommending calling dish machine company for booster repair. Surveyor reviewed the manufacturer's recommendations for model #C44A revised 12/96. On page 17 of the manual the following is documented: The tank water temperature is regulated by the solid state thermostat. The thermostat is preset at the factory and no adjustment should be required. If an adjustment is necessary, contact your local authorized service office. Use thermometers for verification of proper water temperatures. Minimum temperatures for model single tank C44A are: Wash-160 F (minimum) Rinse-180 F (minimum) Minimum temperatures for optional low-temperature operation are: Wash-140 F Rinse-140 F Surveyor reviewed the facility's dishwasher temperature/chemical record for July and August. Surveyor notes where the chemical column is, instead of ppm filled in, for both July and August, the initials of the staff are written in. There is a column for Dietary Manager initials for each day, however for both July and August, the entire column is blank, indicating that DD-E never reviewed the temperature logs. July 2022 Breakfast-wash cycle never reached 160 degrees F for all 31 days; 7 days the rinse cycle did not reach 180 degrees F. Lunch-16 days wash cycle did not reach 160 degrees F; 2 days the rinse cycle did not reach 180 degrees F. Dinner-20 days the wash cycle did not reach 160 degrees F. On 7/20/22 and 7/21/22, the temperature recorded was 115 degrees F; 7 days the rinse cycle did not reach 180 degrees F; on 7/20/22 the temperature was recorded as 102 degrees F;and on 7/21/22 it was recorded at 105 degrees F. Surveyor notes there are missing recorded temperatures for dinner on 7/7/22, 7/8/22, 7/9/22, 7/12/22, 7/22/22, and 7/23/22. August 2022 Breakfast-wash cycle never reached 160 degrees F for all 31 days; 17 days the rinse cycle did not reach 180 degrees F. Lunch-19 days the wash cycle did not reach 160 degrees F; 15 days the rinse cycle did not reach 180 degrees F. Dinner-19 days the wash cycle did not reach 160 degrees F; 19 days the rinse cycle did not reach 180 degrees F. Surveyor notes there are missing recorded temperatures for dinner on 8/2/22, 8/3/22, 8/4/22, 8/17/22, 8/20/22, 8/27/22 (both lunch and dinner), and 8/28/22. Surveyor notes that the rinse cycle temperatures for all 3 meals drops from a 3 digit temperature to a 2 digit temperature, ranging from 75 degrees F to 98 degrees F starting on 8/14/22. On 8/31/22 at 10:54 AM, Surveyor spoke to the dish machine technician (HT-G) who was present in the facility. HT-G stated the booster heater on the dish machine is blown. HT-G stated by code, the rinse cycle must be between 180-190 F for the high temperature dish machine which the facility has. HT-G stated the facility's dish machine is now being treated as a low temperature machine due to the chemical solution being placed on temporarily until the booster heater can be replaced. HT-G stated that this is not the ideal situation but works to safely sanitize the dishes and utensils. On 8/31/22 at 11:24 AM, Surveyor interviewed HT-G again who stated that the temperature of the wash and rinse cycle with the chemical solution should be at 120 F for both. On 8/31/22 at 12:12 PM, Surveyor observed regular dishes and utensils being utilized for room trays and the dining room lunch meal. DD-E confirmed the facility stopped using Styrofoam on 8/29/22. On 8/31/22 at 1:16 PM, Surveyor observed Dietary Staff D (DS-D) washing dishes from lunch utilizing the dish machine. DS-D stated they just started working at the facility as of 8/17/22. DS-D stated they have not been trained on how to write down the temperatures or know what to do with the temperatures. DS-D stated they do not know what the required minimum temperatures should be for the dish machine. Surveyor noted at time of survey, the facility documented seven Residents to be COVID-19 positive. Surveyor reviewed the facility's infection line list and notes there has not been a gastrointestinal illness outbreak, or any other infection outbreaks. Surveyor noted that although there were no outbreaks, facility practices of not properly sanitizing the dishes and utensils created a likelihood that at some point an infection could be spread. Wisconsin State Food Code defines a highly susceptible population as: persons who are more likely than other people in the general population to experience food borne disease because they are: (1) Immunocompromised; preschool age children, or older adults; and (2) Obtaining food at a facility that provides services such as custodial care as .hospital or nursing home. According to the 2013 Food and Drug Administration (FDA) Food Code, Most foodborne illnesses occur in persons who are not part of recognized outbreaks. For many victims, foodborne illness results only in discomfort or lost time from the job. For some, especially preschool age children, older adults in health care facilities, and those with impaired immune systems, foodborne illness is more serious and may be life threatening. Complications typically occur because of the effects of dehydration. According to Why a Dish Needs to Hit 160 Degrees to Really be Clean, Because most bacteria are killed at temperatures between 140 -150 , 160 is considered a safe industry standard to assure a dish or utensil has been properly sanitized. Common bacteria that may be spread include: Norovirus is a common bacteria which is easy to contract and quite contagious . Salmonella is perhaps the best known of bacterial infections and is present on many raw foods. Although cooking removes the bacteria assuming the inner portion of the food reaches a temperature of 150 , any utensils or surfaces used to prep the food remains infected. Listeria can be a particularly dangerous bacteria as it is able to grow even in refrigeration. Poisoning via Listeria typically resembles a mild flu condition but can be lethal for small children or the elderly. Staphylococcus aureus (S. aureus) is the typical bacterial variant in foods which are prepared after cooking, such as salads, especially the mayonnaise varieties such as potato or chicken salad. Preventing an outbreak requires diligent hand washing before and after handling each component of the recipe along with proper refrigeration of the food and of course, cleaning the dishes used during storage and serving. [CONDITION(S)] botulinim, commonly known as [CONDITION(S)], is one of the rarer bacteria but is more likely to be a fatal infection rather than causing simple stomach problems for a few days. It's important to properly sanitize everything used for [NAME] foods and boil the food well before serving after the seal is broken. https://paperthermometer.com/blogs/posts/why-a-dish-needs-to-hit-160-degrees-to-really-be-clean On 8/31/22 at 2:38 PM, Surveyor met with NHA-A and RDOC-I and shared the concern of the potential of serious harm related to the dish machine not sanitizing at the required minimum manufacturer temperatures for both wash and rinse cycle. Surveyor explained that Surveyor had an observation of the dish machine not reaching the required temperatures, staff is unaware of what the temperatures should be including DD-E, and kitchen staff and DD-E not knowing what to do if the temperatures drop below the required range of temperatures. Surveyor also shared the concern that when the facility switched to the chemical solution to sanitize, test strips were not utilized to ensure proper chemical quantities. Surveyor explained that DD-E did not [MEDICATION(S)] when the recorded temperatures of the rinse cycle dropped significantly as of 8/14/22. NHA-A informed Surveyor that DD-E is new to the dietary manager position and was hired knowing that DD-E still needed more qualifications, and the facility was working on getting DD-E trained. Surveyor noted that of the 11 kitchen staff, 5 were trained on the facility's policy and procedure on 8/31/22 which covered dishwasher temperatures. Surveyor noted the training was provided by DD-E. The facility's failure to ensure they had proper working dishwashing equipment and systems in place to monitor for proper sanitization led to a situation of Immediate Jeopardy that started on 8/14/22 and was not removed at the time of exit from the survey.

Based on interview, observation and record review, the facility failed to ensure that 5 (R9, R4, R14, R1, and R8) of 14 residents reviewed for quality of care received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, that will meet each resident's physical, mental, and psychosocial needs. * R9 was admitted [DATE] from the hospital following a below-the-knee amputation and was at high risk for skin breakdown. The facility did not develop an individualized care plan to prevent pressure injuries or prevent skin breakdown. The resident developed what the facility determined was a furuncle (boil) on her left hip. The facility did not oversee and coordinate the resident's care including assessments of the site. The resident was seen by two different nurse practitioners, a doctor at the wound clinic, and two plastic surgeons. They would give orders that would be changed, and the facility was unclear who was ultimately overseeing the wound. On 11/22/22 the Plastic Surgeon assessed the wound as a Stage 4 Pressure Injury. The facility did not routinely monitor and assess the resident's wound, but instead, relied on the nurse practitioner. The facility did not obtain labs as ordered and on one occasion lost the lab results. The facility did not follow bolded and highlighted orders to keep a dressing in place after a hospitalization for severe bleeding from the wound. The facility did not always consult with a physician when a significant change occurred. The facility did not address R9's refusal of care until addressing this on an updated care plan on 3/17/22. R9's furuncle increased in size from 1 x 1 x 0.1 cm to 16.8 x 8 x 3 cm. R9 had repeated infections requiring treatment with antibiotics and was hospitalized four times. When hospitalized in March 2022, R9 was in hemorrhagic shock (BP of 80/40) from profuse bleeding. Eighteen days after returning to the facility, R9 was hospitalized again, this time for 28 days. The facility's failure to properly care for R9's left hip wound including assessment, following MD orders, updating the correct MD or NP overseeing the wound and delay in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing Home Administrator (NHA)-A, Regional Consultant (RC)-H and Director of Nursing (DON)-B were informed of the Immediate Jeopardy on 5/19/22 at 12:13 P.M. At the conclusion of the partial extended survey exit on 6/1/22, the immediate jeopardy had not yet been removed. Noncompliance that created a potential for more than minimal harm that is not immediate jeopardy was identified with R4, R14, R1, and R8. *R4 was admitted to the facility on [DATE] with an abscess to the left lower extremity that had been debrided in the hospital prior to admission. The facility did not comprehensively assess the wound on admission or weekly and no treatment was provided to the wound as ordered from the time of admission until R4 was discharged from the facility on 12/28/2021. R4 received antibiotics through a central line for the infection to the left lower leg wound; the dressing to the central line was not changed and the central line was not flushed when the line was not being utilized per facility protocol. R4 did not go to a physician appointment on 11/10/2021 for follow up on the left lower leg wound as ordered due to transportation issues. *R14 had multiple areas that were being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . * R1 had hospital discharge orders that indicated to wear TEDS (thrombi-embolic deterrent)most of the day and off at night for 2 weeks. This was not transcribed to the facility medication orders. * R8 had a non-pressure wound on the left lower leg and right hip that were not comprehensively assessed weekly. Both areas were not assessed from 12/23/21 until 1/23/22. Findings include: Surveyor reviewed facility's Wound Management policy with no implementation date. Documented was: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidenced-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse . 5. Treatment decisions will be based on: a. Etiology of the wound: i. Pressure injuries will be differentiated from non-pressure ulcers, such as arterial, venous, diabetic, moisture or incontinence related skin damage. ii. Surgical. iii. Incidental (i.e. skin tear, medical adhesive related skin injury). iv. Atypical (i.e. dermatological or cancerous lesion, pyoderma, [CONDITION(S)]). b. Characteristics of the wound: i. Pressure injury stage (or level of tissue destruction if not a pressure injury). ii. Size - including shape, depth, and presence of tunneling and/or undermining. iii. Volume and characteristics of exudate. iv. Presence of pain. v. Presence of infection or need to address bacterial bioburden. vi. Condition of the tissue in the wound bed. vii. Condition of peri-wound skin. c. Location of the wound. d. Goals and preferences of the resident/representative. 6. Guidelines for dressing selection may be utilized in obtaining physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. The guidelines are to be used to assist in treatment decision making. b. Due to unique needs and situations of individuals, the guidelines may not be appropriate for use in all circumstances. c. The facility will follow specific physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 7. Treatments will be documented on the Treatment Administration Record. 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. Lack of progression towards healing. b. Changes in the characteristics of the wound (see above). c. Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights. Surveyor reviewed facility's Change of Condition policy with an implementation date of 7/29/20. Documented was: This facility will identify and manage acute changes of condition to evaluate and manage a patient in the facility and attempt to avoid transfer to a higher level of care. Definitions: Acute change of condition: 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. Policy Explanation and Compliance Guidelines: 1. Timely identification and intervention are essential to manage acute changes of condition in long term care. 2. The facility will identify residents who are at risk for changes of condition. All residents are at risk for changes of condition, but especially those with pre-existing conditions, previous complications, or recent hospitalization . 3. All staff are responsible for identifying changes of condition and reporting to the appropriate nurse. 4. Baseline assessment completed on admission in Point Click Care. Ongoing assessments will be at a minimum quarterly and as needed with changes in condition. S. At a minimum, Change of Condition assessment [Registered Nurse (RN)] or observation [Licensed Practical Nurse (LPN)] will include: a. Resident statement or signs and symptoms observed. No resident response should also be documented b. Vital Signs c. Overall condition, level of consciousness, and function d. Describe symptoms in detail e. Assess affected body system f. Accurate description of the situation will allow practitioners to make informed decisions about care needed 6. Practitioner, Responsible Party and RN notification per notification policy 7. When contacting Primary Care Provider, ensure that information is present and organized and documented timely in the medical record. Examples include, but not all inclusive . b. Labs . d. Medication changes e. Recent hospitalization s or appointments f. How long this has been going on 8. Follow up documentation in Point Click Care will occur every shift for 72 hours post resolution of symptoms. Include conversation with primary care provider, orders received and resident's response, notification of responsible party and their response. Surveyor reviewed facility's Physician, Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Lab Notification policy with an implementation date of 3/1/19. Documented was: It is the policy of this facility to timely notify the physician, physician assistant, nurse practitioner or clinical nurse specialist of lab results. Definitions: Promptly means that results shall be relayed with little or no delay to the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist. Policy Explanation and Compliance Guidelines: 1. The facility must promptly notify the attending physician, physician assistant, nurse practitioner or clinical nurse specialist of lab results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per ordering physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Guidelines: 1. Upon receipt of the lab result, document as received in the lab log. 2. Determine if the lab result requires immediate or non-immediate notification, according to the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 3. Immediate notifications - a. Call physician, physician assistant, nurse practitioner or clinical nurse specialist office with lab result and resident current condition. b. Fax result. c. Staple fax confirmation to original fax and place in lab log binder under 'notifications. d. Place original lab result in medical record and flag for signature. e. Document notification of result and condition (date, time, name of individual reported to, new orders if applicable). f. Notify and document notifications to resident representative, if applicable. g. Implement new orders . 1. R9 was admitted to the facility 7/29/21 from the hospital following a below-the-knee amputation. She has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor reviewed R9's Braden Scale for Predicting Pressure Sore Risk with a date of 7/29/21. Documented was Braden Risk Scale Score: 17 which indicated at risk for pressure injuries. Surveyor reviewed R9's Comprehensive Care Plan with an initiation date of 7/30/21. There was no care plan or interventions to prevent skin breakdown. Surveyor reviewed R9's MDS (Minimum Data Set) Admission Assessment with an assessment reference date of 8/3/21. Documented under Cognition was a BIMS (brief interview mental status) score of 15 which indicated cognitively intact. Documented under Functional Status for Bed Mobility was 3/3 which indicated Extensive Assistance - resident involved in activity, staff provide weight-bearing support; Two plus persons physical assist. Documented under Functional Status for Transfer was 4/3 which indicated Total dependence - full staff performance every time during entire 7-day period; Two plus persons physical assist. Documented under Skin Conditions was Is this resident at risk of developing pressure ulcers/injuries? 0. No and Does this resident have one or more unhealed pressure ulcers/injuries? 0. No. Surveyor reviewed R9's Care Area Assessment (CAA) related to Pressure Ulcer/Injury with an assessment date of 8/3/21. Documented under Describe impact of this problem/need on the resident and your rationale for care plan decision was Res has interventions in place to help prevent skin breakdown. She has a pressure redistribution mattress and cushion for the [wheelchair (w/c)]. She is assisted with repositioning. She is in therapies to help improve mobility. Her skin is monitored with cares. She has a weekly skin inspection. The CAA and Braden assessment contradicted the MDS that the resident is not at risk for skin breakdown. It also states there are interventions in place but there was no care plan created for skin breakdown prevention. On 9/13/21 a Stage 3 PI was identified to R9's left buttocks and a care plan was then put in place. The care plan documented: Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] Pressure ulcer at risk due to: Assistance required in bed mobility, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Stage III PI - Left Buttock Goal: - Skin will remain free of pressure ulcers. Interventions: - Complete Braden Scale per Policy - Diabetic foot monitoring - Heel boots - Monitor vital signs as needed - Provide pressure reducing wheelchair cushion - Provide pressure reduction/relieving mattress - Provide thorough skin care after incontinent episodes and apply barrier cream - Referral to Therapy - Turning and repositioning - assist as needed. The resident was a bilateral [CONDITION(S)] and would not require foot checks or heel boots. Surveyor reviewed Treatment Administration Record (TAR) and diabetic foot checks were marked as completed in the month of September twice daily. Surveyor reviewed R9's Progress Notes. Documented on 10/1/21 at 1:31 PM by DON-B was Writer called to resident's room. Resident noted to have area to left hip that has purulent blood tinged drainage. Area has dime sized eschar. Surrounding area noted to be red, swollen and warm to touch. Writer updated [Nurse Practitioner (NP)-F] obtained orders for penicillin [500mg 4 times a day for 7 days] and topical [MEDICATION(S)] [twice daily (bid)]. There was no facility assessment of the area including measurements of the wound or identified etiology. Surveyor reviewed MD Orders for R9 with a start date of 10/2/21. Documented was Penicillin V Potassium Tablet 500 MG, Give 1 tablet by mouth four times a day for [CONDITION(S)] of left hip for 7 Days. Left hip open area: Cleanse with wound cleanser, apply [MEDICATION(S)] to open area, apply bordered gauze dressing, every day and evening shift for open area to Left hip. Surveyor reviewed R9's Braden Scale for Predicting Pressure Sore Risk with a date of 10/5/21. Documented was Braden Risk Scale Score: 13 which indicated moderate risk for pressure injuries. Surveyor reviewed Assessments for R9. There were no facility skin assessments for R1 from 10/1/21 through 10/8/21. On 10/8/21 MD-G saw R9. Surveyor reviewed visit note and there is no mention of the open area on left hip. On 10/8/21 NP-E assessed R9's left hip. Documented was Interventions in Place: Orders for a bariatric alternating pressure air mattress or low air loss mattress. Pressure reducing cushion for when patient is up in the chair. Turn every 2 hours side to side frequently reposition. Triad cream ordered twice a day to the buttock and thigh areas. Wound dressings ordered for the remainder of the open sores. Physical Examination: Left hip furuncle The area measures 1.0 cm x 1.0 cm x 0.1 cm with 90% slough at the base with 10 granular tissue percent. No drainage is present at this time. No periwound [CONDITION(S)] but appears that the area did slightly peel. No overt signs or symptoms of infection at this time . The wound had now declined to include slough in the wound bed. R9 did not have a bariatric alternating pressure air mattress or low air loss mattress. An MD order was entered with a start date of 10/9/22 and documented L Hip .Wash with wound cleanser, pat dry [followed by (f/b)] [MEDICATION(S)] Blue Ready to wound f/b border foam dressing. Change daily and [as needed (PRN)]. Every day shift for wound care. There was no facility skin assessment of the left hip wound from 10/8/21 through 10/22/21. Assessment of the wound was not completed but additional information was added to R9's Care Plan on 10/12/21 to address the furuncle wound. Documented was: Goal: - Folliculitis wounds will heal without complication. Interventions: - Antibiotics as ordered. - Remind res to not pick at sores. - Wound treatment as ordered. On 10/22/21 NP-E assessed R9's left hip. Documented was: Interventions in Place: Orders for a bariatric alternating pressure air mattress or low air loss mattress. Pressure reducing cushion for when patient is up in the chair. Turn every 2 hours side to side frequently reposition. Triad cream ordered twice a day to the buttock and thigh areas. Wound dressings ordered for the remainder of the open sores. Physical Examination: Left hip furuncle The area measures 1.0 cm x 1.5 cm x 0.1 cm with 100% slough at the base. Area that measures 3.6 cm x 3.7 cm x 0.1 cm with 90 percent eschar and 10 percent granular tissue. Moderate serosanguineous drainage. Slight periwound [CONDITION(S)] with induration around the wound. But appears that the area did slightly peel. [subcutaneous (Sub Q)] tissue is with slight [CONDITION(S)] and more painful to palpation. Status-Declined . The wound had now declined further to include an infection in the wound bed and tripled in size. R9 did not have a bariatric alternating pressure air mattress or low air loss mattress. MD orders were entered with a start date of 10/22/22 and documented [MEDICATION(S)] Tablet 100 MG, Give 1 tablet by mouth two times a day for L. HIP INFECTION for 14 Days and Cleanse area with cleanser, Prep Periwound, Apply silver alginate . L. hip cover with a bordered foam dressing, change daily and PRN every evening shift . According to Silver and Alginates: Role in Wound Healing and Biofilm Control, Antimicrobials, in particular silver, are incorporated into wound dressings, including alginates, for use in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . https://www.ncbi.nlm.nih.gov > articles > PMC 46 There was no facility skin assessment of the left hip wound from 10/22/21 through 11/2/21. On 11/2/21 NP-D assessed R9. Documented in the visit note was: Chief Complaint: Asked to see due to concerns over drainage from left lateral hip ulcer. History of Present Illness: .reports patient had blister/cystic like lesion on left lateral hip which was thought to be HS lesion. About a month ago, it was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Currently, house wound care team has been seeing patient and treating with calcium alginate. [DON-B] notes that there is purulent drainage today that can be expressed from the wound. Thick eschar area appears enlarged from when she saw last. Patient denies having any pain over the area. Denies any fevers or chills. She does not tend to lie on her left side to cause it pressure . Left lateral hip ulcer: Nursing reports started as a blister/ cyst and then turned into eschar. Etiology is unknown. If I did not know this; would have thought it to be an [unstageable US] Pl, as it is over a bony prominence. [approximately] 3x5 [cm] area of thick eschar that is attached and stable except at about 10:00 there is a small opening that small amt of purulence can be expressed through when central wound is pressed. It does not feel boggy; but I suspect tunneling under the eschar. Mild tenderness in this area. 4-5 cm surrounding light [CONDITION(S)] with induration. No heat or tenderness over this area. Assessment/Plan: 1. Ulcer of trochanteric region of left hip suspect tunneling under eschar. Needs surgical debridement - [computerized tomography (CT) scan] pelvis with contrast (hold IV contrast if [creatinine] > 1.2) - [basic metabolic panel (BMP)] day prior to CT and call radiology with creatinine results - General Surgery Consult appointment. - I will call to coordinate holding [MEDICATION(S)] once I know CT results and surgical plan. - Cleanse with wound cleanser or water, cover with ABD. Change daily and PRN . An MD order was entered with a start date of 11/3/22 and documented L lateral hip wound: Keep covered with ABD, change daily. Every day shift for L hip wound. This discontinued the silver alginate that was being used as an antimicrobial that NP-E ordered. On 11/5/21 the facility completed its first assessment of the left hip wound. Surveyor reviewed R9's Weekly Skin Impairment and Wound Evaluation with a date of 11/5/21. Documented was .1b. Description of the skin issue: Left hip furuncle . 5k. Comments: Full thickness with large area of eschar and induration - eschar area measures 5.3 x 8.0 depth of smaller ulcer 0.8cm Indurated area 25cm x 15cm firm and red . On 11/5/21 NP-E assessed R9's left hip. Documented was: Subjective: Patient is seen lying in the bed today. Today she has increased redness warmth swelling and pain to the left hip rating it an eight on a scale of 0-10 which is new over the last 48 hours. Patient overall does not feel as well. No fever or chills and she is eating and drinking however more fatigued in general. Patient was evaluated by primary and a CT of the left hip was set up for Monday however there is unstable eschar and there is the potential for infection under the area. Interventions in Place: Orders for a bariatric alternating pressure air mattress or low air loss mattress. Pressure reducing cushion for when patient is up in the chair. Turn every 2 hours side to side frequently reposition. Triad cream ordered twice a day to the buttock and thigh areas. Wound dressings ordered for the remainder of the open sores. Physical Exam: Left hip furuncle-now with large eschar area. Infectious wound. Full-thickness with large area of eschar and induration now. The eschar area measures 5.3 cm x 8.0 cm with a depth of the smaller open ulcer of 0.8%. Eschar is 95% dry however there is unstable eschar 5% of the total area. There is a large area of induration around the unstable eschar measuring 25 cm x 15 cm that is firm and red. The area is also red and swollen. Periwound [CONDITION(S)] is present. Status-Declined Plan: Given the large area of induration that is red warm and swollen, the increase in eschar with the unstable portion of the 5% of the wound that is soft and slough, transfer patient to the hospital emergency room for further diagnostics and evaluation and the need for the possibility of more urgent diagnostics, treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Discussed with patient is noted agreement . R9 was sent to the ER and returned to the facility the same day with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor reviewed Discharge Summary which documented: .Follow-up instructions: Follow up with Wound Clinic . NEW medications: [MEDICAL RECORD OR PHYSICIAN ORDER] Acetaminophen-[MEDICATION(S)] ([MEDICATION(S)] 5 mg - 325 mg oral tablet) 1 tabs Oral every 6 hours as needed for pain. [MEDICATION(S)] ([MEDICATION(S)] 500 mg oral capsule) 1 Capsule Oral Three Times Per Day for 10 Days . R9 returned to the facility and no wound care orders were received. The facility continued the ABD pad and not the Silver Alginate as directed by the Wound NP from 11/6/21 through 11/19/21. There was no facility skin assessment of the left hip wound on readmission and no assessments from 11/6/21 through 11/19/21. Surveyor reviewed R9's Progress Notes with a date of 11/9/21. At 1:42 PM it was documented Writer spoke with wound clinic, appointment for debridement of left hip scheduled for Monday, 11/22 at 9:45am. There was no updated wound care orders received. The facility continued the ABD pad and not the Silver Alginate as directed by the Wound NP. On 11/19/21 NP-E assessed R9's left hip. Documented was: Subjective: Patient is seen lying in the bed today. The wound clinic will debride the left hip on Monday given the amount of eschar present . Interventions in Place: Orders for a bariatric alternating pressure air mattress or low air loss mattress. Pressure reducing cushion for when patient is up in the chair. Turn every 2 hours side to side frequently reposition. Triad cream ordered twice a day to the buttock and thigh areas. Wound dressings ordered for the remainder of the open sores. Physical Exam: Left hip furuncle-now with large eschar area. Infectious wound. Full-thickness with large area of eschar and induration now. The eschar area measures 10.7 cm x 6.4 cm x 0.9 cm. Depth of the open 5% of the wet slough wound is 0.9 cm. Dry eschar is 95 percent black and hard. Periwound [CONDITION(S)] is present. Area is with slight odor. Status-Declined Plan: Patient will be evaluated at the wound clinic on Monday for debridement. CT was done in theER on [DATE]. Unable to review today. Done at the hospital. Per wound nurse, no deep infection, set up for debridement out-patient. Wound care, silver alginate to the open area of the wound, f/b large piece over the entire area, opsite and a 6x6 border foam and change everyday: . The wound had now declined further and was larger in size. R9 did not have a bariatric alternating pressure air mattress or low air loss mattress. The wound NP-E changed orders back to silver alginate with a border foam dressing to be changed daily. The facility completed a skin assessment of the left hip wound on 11/19/21 with the same measurements and assessment as NP-E. R9 went to the Wound Clinic on 11/22/21 where they stated the left hip was stage 4 pressure injury. Documented under Instructions was: Return in 2 weeks Culture obtained. Results in 48 to 96 Hr. Left Hip Dressing: Santyl, [MEDICATION(S)], Large foam border. Change every other day. Area was debrided monitor for bleeding next 24 hr . Monitor for signs infection. Report as necessary. The facility, on the Treatment Administration Record, incorrectly recorded the order as change the dressing every Monday, Wednesday, and Friday. On 11/26/21 the wound culture came back and was positive for Heavy Amount Proteus mirabilis; Heavy Amount Gram Positive Cocci Presumptive Enterococcus species; unable to isolate due to proteus swarming . Surveyor reviewed R9's Progress Notes. Documented on 11/26/21 at 10:33 AM was received call from [NP-D] regarding midline placement and new orders for treatment to wound. Resident to have IV [MEDICATION(S)] for 7 days and [oral (PO)] [MEDICATION(S)] for 7 days. Resident to be transported to Fort Hospital for midline placement today and first administration of IV [antibiotics (Abx)]. Resident aware, no concerns at this time. The resident was transferred to the hospital and a central IV line was placed. The resident returned to the facility the same day. On 12/3/21 NP-E assessed R9's left hip. Documented was: Interventions in Place: Orders for a bariatric alternating pressure air mattress or low air loss mattress. Pressure reducing cushion for when patient is up in the chair. Turn every 2 hours side to side frequently reposition. Triad cream ordered twice a day to the buttock and thigh areas. Wound dressings ordered for the remainder of the open sores. Physical Exam: Left hip furuncle-now with large eschar debrided wound per wound clinic. Infectious wound. Full-thickness with large area of eschar and induration now. The eschar area measures 11.5 cm x 7.2 cm x 0.6 cm [status post [MEDICAL RECORD OR PHYSICIAN ORDER] . 100 percent slough necrotic tissue. Slight Periwound [CONDITION(S)] is present. Area is with slight odor. Status- s/p debridement-new wound baseline measurement. Plan: Dermal wound cleanse f/b santyl, calcium alginate and Border foam. Change daily and PRN. Last day of [MEDICATION(S)] today IV, f/b with the wound clinic next week, and on oral [MEDICATION(S)] . NP-E changed the wound treatment to daily but the facility did not follow those orders and it remained Monday, Wednesday and Friday until 12/7/21 when R9 returned to the Wound Clinic. The facility completed a skin assessment of the left hip wound on 12/3/21 with the same measurements and assessment as NP-E. R9 returned to the Wound Clinic on 12/7/21. The wound was measured at 8 x 12 x 1.2 cm. Documented under Assessment/Plan was: .2. Pressure ulcer of left hip, stage 3 The debridement of hip wound limited by bleeding today. Hemostasis finally obtained with silver [MEDICATION(S)] and surgifoam and pressure. Also there was quite a large amount of devitalized tissue in wound that I could not remove either with scalpel or dermal curette. It is very possible that the fatty tissue of her lateral hip has a hematoma or infarcted tissue. I am not able to do any further debridement herein Wound clinic. I am referring to UW plastic surgery as she will need a flap to close this defect. Ordered: External Transition Consult . Discussed with patient. I am no able to do any additional debridement at this time so until she can be seen by plastic surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . She will return here as instructed by UW plastic surgery team. Documented under Instructions was: Wound care for: L hip every other day . Cleanser: soap and water or wound cleanser Dressings . santyl, apply nickel thickness to wound bed, [MEDICATION(S)] ag, foam border Offloading; continue all offloading measures, pressure relieving measures . R9 did not have a pressure relieving mattress. Surveyor reviewed R9's Comprehensive Care Plan with a revision date of 12/8/21. The facility added a care plan for the left hip wound 2 months after it was originally found. Documented was: Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] Altered skin integrity related to: - L hip Furuncle Goal: - Affected area will heal without complications Interventions: - Complete Braden Scale per Living Center policy - Evaluate need for pain reliever prior to cleansing or dressing changes - Monitor for signs and symptoms of infection such as swelling, redness, warm, discharge, odor notify physician of significant findings - Nutritional and Hydration support- refuses supplements. - Provide pressure reducing wheelchair cushion - Provide pressure reduction/relieving mattress - Provide thorough skin care after incontinent episodes and apply barrier cream - Turning and repositioning schedule per assessment Resident typically refuses turning and prefers to lay on right side. - Weekly Wound evaluation R9 continued to not have a pressure reducing/relieving mattress. Surveyor reviewed R9's 12/10/21 wound assessment completed by the facility. Documented was Full thickness with large area of eschar and induration - eschar area measures 11 x 7.5 depth of smaller ulcer 0.5cm Moderate amount serosanguineous drainage noted. Surveyor reviewed R9's Progress Notes. Documented on 12/16/21 at 10:45 AM was Resident referred appointment has been schedule to see [Plastic Surgeon] at UW specialty clinic on 12/22/2021 at 10:30am. Resident is aware of the appointment and okay with. The facility completed a skin assessment of the left hip wound on 12/17/21 with the same measurements and assessment as NP-E. On 12/17/21 NP-E assessed R9's left hip. Documented was: Interventions in Place: Bariatric alternating pressure air mattress or low air loss mattress. Pressure reducing cushion for

Based on interview and record review the Facility did not ensure 3 (R19, R17, & R14) of 6 Residents reviewed for accidents received adequate supervision and assistance to prevent accidents. * R19's Broda chair was not reclined according to manufacturer's recommendations when R19 fell out of the Broda. R19 sustained a laceration to his head requiring 11 sutures. * R17 has a history of falls from the bed and was observed without the body pillow while R17 was in bed according to the plan of care. * The Facility did not ensure the safety of R14 who is transported for outside appointments following a fall from the van ramp. Findings include: 1.) R19 has [DIAGNOSES REDACTED]. R19 has been receiving hospice services since (YEAR). The physical functioning deficit care plan initiated 1/9/15 includes an intervention initiated 5/30/17 of Broda chair for safety and positioning due to poor trunk support. On 7/12/18 at 12:48 p.m. Administrator 2-I provided Surveyor with the Broda Operating Manual for Model 30VT Semi-Recliner. Surveyor noted on Page 5 of this manual under 2.5 Hazards documents 2.5.1 Position of Chair - 'Danger of Falling' After a resident is transferred into a chair, assess the amount of tilt required. We recommend that the chair's set be tilted sufficiently to prevent the resident from sliding or falling forward off the chair. The amount of seat tilt used should be determined by the resident's caregiver who is responsible for seating. We recommend that the resident's feet be correctly positioned on the footrests and slightly to fully elevated to prevent the resident from sliding or falling forward off the chair. The amount of elevation used should be determined by the resident's caregiver who is responsible for seating. The resident's care plan prior to 4/4/18 did not address tilting the Broda chair. The fall report dated 4/4/18 and revised on 5/2/18 under incident description documents Resident found lying on the floor on his R (right) side perpendicular to geri-chair (Broda). Geri-chair (Broda) was completely upright. Large amount of blood draining from laceration on top of head. R side. C/o (complained of) head pain. Neuros WNL (within normal limits). Under immediate action taken documents Transferred to bed with hoyer, laceration cleaned with NS (normal saline), covered with gauze. Hospice updated, hospice RN (Registered Nurse) in to assess. Son called, came in to see resident, spoke with Hospice RN. Resident sent to ER (emergency room ) via Ryan Bros (Brothers) ambulance at 1830 (6:30 p.m.). The nurses note dated 4/4/18 documents Returned from Fort ER with head wrapped in gauze. Per Hospice RN, 11 sutures placed. Keep dressing clean and dry. Follow up for suture removal in one week, 4/11/18. The nurses note dated 4/5/18 documents 98.0 tym-89-18-100%RA-BP (blood pressure) :131/89. Res. alert and quiet this shift. Neuros wnl (within normal limits). Remains to have laceration and bump to right side of head. Attempted to pull the dressing off. Did state he was having discomfort to area when asked. Tyl. (Tylenol) given at 0744 (7:44 a.m.), good effects noted after. Minimal amount of blood noted to old dressing. Sutures to site intact. New dressing applied. 3 Steristrips to right elbow intact. No signs of infection or active bleeding present. Hospice nurse-O here this afternoon to see res. (resident) Stated hospice needs to be consulted before removing sutures. The nurses note dated 4/6/18 documents No new injuries noted from post fall. Sutures to [MEDICAL CONDITION] intact. Minimal dry blood noted to site. Purple bruising and swelling present to right side of head. Two Steristrips to right elbow skin tear intact. No signs of infection noted. Res. alert and quiet. No signs of discomfort noted. Neuros wnl. On 7/12/18 at approximately 10:25 a.m. Surveyor asked DON (Director of Nursing)-B why R19's Broda chair wasn't reclined back prior to his fall. DON-B informed Surveyor they didn't initiate the intervention of reclining the back of the Broda until 4/4/18. The post fall analysis/plan dated 4/4/18 under IDT (interdisciplinary team) review and recommendations for additional recommendations documents Res (Resident) to be in semi reclined when up in Broda chair. Res. tends to lean towards R (right) side. 2.) R17 has a history of falls from her bed. The fall risk assessment dated [DATE] has a score of 10 which indicates at risk. The quarterly MDS (minimum data set) with an assessment reference date of 5/6/18 and signed as complete on 5/10/18 has a BIMS (brief interview mental status) score of 4 which indicates severe impairment. R17 requires extensive assistance with two plus person physical assist for bed mobility, is dependent with two plus person physical assist for transfers, does not ambulate, and is always incontinent of bowel & bladder. R17 is coded as not having any falls since prior assessment period. The CNA (Certified Nursing Assistant) care card updated 7/3/18 under special notes documents Use body pillows and ensure in middle of bed. Depending on alertness level likes to stay up past 8; res (resident) to have shoes on when up in w/c (wheelchair) to prevent injury to feet when propelling self in hallways. On 7/9/18 at 2:20 p.m. Surveyor observed R17 in bed on her back with the head of the bed up slightly. The bed was in the low position and there is a mat on the floor. Surveyor did not observe a body pillow. On 7/10/18 at 7:21 a.m. Surveyor observed R17 in bed on her right side. Surveyor did not observe a body pillow. On 7/10/18 at 1:49 p.m. Surveyor observed R17 in bed on her right side. The bed is in the low position and there is a mat on the floor on the left side. Surveyor did not observe a body pillow on R17's bed. On 7/10/18 at 2:43 p.m. Surveyor observed R17 continues to be in bed on her right side. Surveyor observed there is still not a body pillow on R17's bed. On 7/11/18 at 2:12 p.m. Surveyor observed R17 in bed on her right side. Surveyor observed R17's bed is in the low position and there is a mat on the floor. Surveyor did not observe a body pillow. On 7/12/18 at 7:51 a.m. Surveyor showed CNA-J R17's CNA care card and asked if the body pillow is a long pillow. CNA-J replied yes and informed Surveyor the body pillow may be soiled and she didn't know the process of cleaning the pillow. CNA-J informed Surveyor when R17 is in bed they also put a pillow behind her back and between her knees. Surveyor informed CNA-J Surveyor has not seen the body pillow on R17's bed. CNA-J informed Surveyor the pillow maybe in the laundry. On 7/12/18 at 10:43 a.m. Surveyor informed DON (Director of Nursing)-B of Surveyor not observing a body pillow on R17's bed when she was in bed and CNA-J had informed Surveyor it may be in the laundry. DON-B informed Surveyor she would speak with laundry and the pillow may not be able to be dried. 3.) R14 is transported to [MEDICAL TREATMENT] three times a week. The fall risk assessment dated [DATE] has a score of 11 which indicates at risk. The fall report dated 2/2/18 under incident description documents Paged to front lobby. Resident was wheeling himself in through front door. Was reported that resident had fallen off the side of the ramp while in his wheelchair of the van and hit his head. The fall was unwitnessed. Bump noted to back of head, skin is intact. Some redness to R (right) elbow, skin intact. C/o (complained of) mild headache initially, later denied any pain. Alert and oriented x (times) 3. Speech is clear. Moves all extremities. Equal strength. Pupils equal, R side is non reactive. States he was Tying to beat the driver, Had his brakes unlocked and began going backward down the wheelchair ramp, hit the side of the ramp and fell on to the ground hitting his head. Denies losing consciousness. The nurses note dated 2/2/18 documents MD (medical doctor) office called back at 1330 (1:30 p.m.), orders to send to ER for head CT scan. The nurses note dated 2/2/18 documents Transferred to ER via Ryan Bros. (Brothers). DON (Director of Nursing) updated. POA (power of attorney) updated. Report given to ER nurse, notified nurse that MD was requesting CT scan of the head, d/t (due to) anticoagulation therapy Informed of last INR (international normalized ratio) and most recent BP (blood pressure) of 78/36, post [MEDICAL TREATMENT]. The hospital ER notes dated 2/2/18 documents patient presents via ambulance due to 2 feet fall in wheelchair. The nurses note dated 2/2/2018 documents Res returned to facility after CT scan apprx. (approximately) 1815 (6:15 p.m.). No injury or head trauma detected by scan, no additional orders recd. VSS (vital signs stable), neuro checks WNL (within normal limits), res denies pain. No noted swelling or lump to back of head. Will cont. (continue) to monitor. The post fall analysis dated 2/2/28 under residents explanation documents Unlocked brakes on wc (wheelchair) and went backward down ramp without assistance from Lavigne driver. Under possible cause documents Poor safety awareness. Unlocked wc brakes and started going down wc ramp independently. Under additional recommendations documents Res (resident) sent out to ER (emergency room ) to have CT scan-negative for any side effects from fall. POA (power of attorney) made aware of situation. Education provided to res about waiting for help when trying to get out of w/c van. On 7/11/18 at 2:00 p.m. Surveyor spoke with LPN (Licensed Practical Nurse)-N regarding R14's fall on 2/2/18. LPN-N informed Surveyor she had been paged for the fall and by the time she arrived at the front lobby R14 was wheeling himself into the building. Surveyor asked LPN-N if she knew how R17 got up off the ground. LPN-N informed Surveyor she didn't know. On 7/11/18 at 2:02 p.m. Surveyor spoke with R14 regarding his fall on 2/2/18. Surveyor inquired how he got off the ground and back into his wheelchair. R14 informed Surveyor a couple of staff helped him but he can't remember who came out and got him up. Surveyor asked R14 how he fell . R14 explained he wanted to help the driver out while he was unloading another resident. R14 indicated he unlocked his wheelchair brakes and didn't make it down the ramp. R14 stated the driver got smart because he hooks him up now and explained there is a strap from back to front that wasn't on before. R14 informed Surveyor he wouldn't be able to release the strap. R14 informed Surveyor the driver told the insurance company it was strapped but it wasn't. R14 stated staff was worried because he is on a blood thinner and he had a CT scan done. R14 stated the only damage was his pride. On 7/11/18 at 3:05 p.m. during the daily exit conference Surveyor asked Administrator-A and DON-B how R14 got up from the ground when he fell off the van ramp, was there any investigation done with the transportation company as to whether R14 was strapped in properly, and what the Facility did to ensure R14 was strapped in properly in the future. On 7/12/18 at 10:32 a.m. DON-B informed Surveyor she has not received any information regarding R14's fall and is waiting for the bus company to fax their portion. Surveyor asked DON-B if the fall occurred in (MONTH) (YEAR) why didn't they get this information prior and inquired if they spoke with the driver of the van. DON-B informed Surveyor the driver wouldn't speak to them. Surveyor asked DON-B if she knew what staff helped R14 get up off the ground. DON-B informed Surveyor R14 got up himself. DON-B informed Surveyor she was at the Facility when R14 fell but found out after the fact. Surveyor informed DON-B R14 had told Surveyor staff helped him up and asked DON-B if she spoke with staff. DON-B replied yes. Surveyor asked where this would be documented. DON-B informed Surveyor maybe in a progress note. Surveyor was unable to determine who helped R14 off the ground. Surveyor asked if the driver and other staff of the bus company were inserviced to make sure R14 is strapped in properly after the fall. DON-B informed Surveyor she was hoping that will be in the report from Lavigne (the transportation company) and is not sure what they did. On 7/12/18 at 11:55 a.m. Surveyor informed DON-B Surveyor still has not received any investigation from the transportation company. DON-B informed Surveyor unfortunately they aren't able to get it from the transportation company.

Based on observation, interview and record review, facility staff did not provide appropriate care and treatment to promote healing for 2 of 2 Residents with pressure ulcers (#5 and #6). Resident #5's pressure ulcer began as an abrasion that is now a Stage IV pressure ulcer. Resident #5 did not have a dressing on the pressure ulcer for 4 hours on 1/4/16. Resident #5 did not receive her dietary supplement multiple times. The wound clinic communicated concerns with staff performance using the [DEVICE] treatment. Staff did not monitor or obtain measurements from the wound clinic of Resident #5's pressure ulcer from October until 1/7/15 after Surveyor # requested them. This example is cited at the scope and severity level G, actual harm. Resident #6 presented at the wound clinic multiple times without a dressing covering her Stage III wound. Staff did not provide services to prevent pressure ulcers for 3 of 6 residents at risk for developing pressure ulcers (Residents #3, #4, and #7) as they were observed without their heels floated or other prevention measures in place such as heel lift boots. Findings include: 1.) Resident #5 has resided at the facility for more than a year. Resident #5 had a pressure ulcer on admission on her left ischium, which healed in July, 2015. In September, 2015, Resident #5 was noted to have an abrasion on her left ischium. As of 1/6/16, the abrasion has deteriorated to a Stage IV pressure ulcer. On 1/4/16 at 11:32 a.m., Surveyor # observed CNAs (Certified Nursing Assistants)-P and CNA-V leaving Resident #5's room with bagged dirty linens. The CNAs and Resident #5 stated the CNAs had just repositioned Resident #5 and cleaned up a BM (bowel movement), and they removed the dressing on Resident #5's bottom because it was soiled with BM. On 1/4/16 at 1:52 p.m., Surveyor # observed CNA-V and CNA-H reposition Resident #5 from her left side to her right side. Resident #5 momentarily requested to be repositioned on her back, then stated she should be repositioned on her right side because (day shift) LPN (Licensed Practical Nurse)-W would be in shortly to replace the dressing on her pressure ulcer before she goes home for the day. Resident #5 stated she previously had a wound vac ([DEVICE]) on her pressure ulcer, but the wound clinic staff thought she should take a break from the wound vac for a week to let her red, irritated skin surrounding the ulcer heal. Surveyor # remained near Resident #5's room and observed that no staff re-entered her room until 3:30 p.m. On 1/4/16 at 2:55 p.m. Surveyor # interviewed LPN-W, asking her if she was going to perform the treatment and replace Resident #5's dressing on her left ischium. LPN-W stated the treatment is done every other day and she did not think it needed to be done that day, but she would check. Second shift RN (Registered Nurse)-X was nearby and stated she performed the treatment yesterday and it does not need to be done today. Surveyor # asked LPN-W if the CNAs informed her that they had to remove the dressing around 11:30 a.m. because it was soiled with stool. LPN-W stated her shift ended an hour ago, it has been a typical, very busy, hectic Monday and she does not remember if the CNAs told her the dressing was off and needed to be replaced or not. LPN-W left the building shortly after that. RN-X stated she would perform Resident #5's treatment but she had to attend to a few other things first. On 1/4/16 at 3:20 p.m. RN-X stated she was going to do Resident #5's treatment soon. At 3:30 p.m. RN-X entered Resident #5's room but had to leave a few moments later to answer a phone call. RN-X returned to Resident #5's room at 3:33 p.m. and performed the treatment of [REDACTED]. When RN-X assisted Resident #5 to turn further on her side at the start of the treatment, Surveyor # observed a large area of red excoriation on Resident #5's left buttocks. Inside this red area, Surveyor # observed a Stage IV pressure ulcer, approximately 1.0 x 2.0 x 1.0 cm. (centimeter). The base of the wound is clean, red/pink. Zinc oxide was applied around the ulcer. Resident #5's pressure ulcer had been uncovered for 4 hours. The National Pressure Ulcer Advisory Panel (NPUAP) 2009 Quick Reference Guide states the wound bed should be kept moist for optimum wound healing. In addition, when a pressure ulcer is left uncovered, it results in the loss of body heat which also slows healing. Starting on 1/5/16, Surveyor # reviewed Resident #5's medical record. Resident #5 has been a resident at the facility for more than a year, with primary [DIAGNOSES REDACTED]. HISTORY OF PRESSURE ULCER Older facility Wound Evaluation Flow Sheets show Resident #5 had a Stage IV pressure ulcer on her coccyx 9/4/14 that healed 1/16/15. Facility staff documented on the Wound Evaluation Flow Sheets weekly, including measurements, with some measurements noted to be from the wound clinic and some measurements obtained by facility staff. Some of the Nurses' Notes included measurements and descriptions of the pressure ulcer, too. Additional Wound Evaluation Flow Sheets indicate Resident #5 had a pressure ulcer on her left ischium starting 3/12/14 that healed on 4/24/14. There is documentation most weeks including measurements though staff never indicate what stage the ulcer is. A pressure ulcer is again noted to Resident #5's left ischium on 7/17/14 with weekly measurements on the Wound Evaluation Flow Sheets, but no staging of the pressure ulcer is noted. By 8/19/14, the pressure ulcer is documented as 2.4 x 1.3 x 1.8 cm., reddish, tender to touch, 60% granulation tissue, 40% adherent yellow slough with irregular wound margins. The ulcer was surgically debrided on 9/8/14. Weekly documentation is noted including measurements, but staff did not stage the pressure ulcer except a few Stage II which would indicate staff were back staging. This pressure ulcer is noted to be healed 3/3/15. A Consultation/Clinic Referral Form dated 12/17/14, used for communication between the clinic and facility staff includes a request by nursing home staff: Please include wound measurements. WE (Wound and [MEDICAL CONDITION]) Clinic staff did include measurements of: Left ischium: 1.5 x 1.8 x 1.8 cm.; coccyx: 0.1 x 0.1 x 0; proximal coccyx: 0.3 x 0.3 x 0.1 cm. At some point Resident #5's left ischial pressure ulcer re-opened. Again on 4/15/15, nursing home staff wrote on the communication sheet .Please include wound assessment measurements with return progress/physician orders. WE Clinic staff did write: left ischial 1.4 x 1.1 x 0.6; (tunneling) @ 9:00 o'clock- 0.5; @ 11:00 o'clock 1.7; @12-1:00 o'clock- 0.5 cm. It appears often the wound clinic did not provide measurements (or a description of the pressure ulcer) unless nursing home staff specifically requested the measurements, but this was known to nursing home staff in December, 2014 and April, 2015. Surveyor # did not observe Wound Evaluation Flow Sheets completed for Resident #5 starting again when Resident #5's pressure ulcer re-opened. Documentation from the wound clinic dated 4/22/15 states the ulcer to left ischial was cleansed with normal saline, [MEDICATION NAME] AG rope and foam border applied (no measurements given); starting SNAP (wound) vac next week. Nursing home staff obtained Physician order [REDACTED]. A Preliminary Report dated 5/7/15 from the Wound and [MEDICAL CONDITION] (WE) Clinic states Resident #5 was seen at the clinic for follow up of a recurrent Stage IV pressure ulcer to the left ischial area which measured 1.1 x 1.5 cm. (centimeters) with a depth of 0.8 cm. This pressure ulcer healed in July, 2015 as indicated by WE Clinic documentation discontinuing the wound vac June 26, 2015 and starting a foam border dressing to be changed 3 times a week. The foam dressing was discontinued 7/31/15. On 7/23/15 the wound clinic only documented Left ischial area: Zinc oxide type skin protectant/ barrier, 2 times a day and prn (as needed). ASSESSMENTS/CARE PLAN Surveyor # reviewed a Clinical Health Status form completed 7/7/15 which includes a Braden Scale for Predicting Pressure Sore Risk. Resident #5 scored 13-moderate risk; a score of 10-12 indicates high risk, a score of 9 or < indicates severe risk. Resident #5 was noted to be at risk due to slightly limited sensory perception, skin rarely moist, bedfast, completely immobile, adequate nutrition, and problem with friction and shearing. Resident #5's Quarterly MDSs (Minimum Data Sets) dated 7/8/15 and 9/10/15 indicate Resident #5 had no unhealed pressure ulcers at Stage 1 or higher. Resident #5's Annual MDS, with an Assessment Reference Date of 12/10/15 (Assessment Reference Date is the last day in the look back period to be included in the MDS-nothing after 12/10/15 should be included), indicates Resident #5 had 1 Stage IV pressure ulcer measuring 1.7 x 1.0 x 1.5 cm.; the most sever tissue type is granulation tissue. Surveyor Note: As described below, facility staff did not have any measurements or documentation for Resident #5's pressure ulcer that re-opened after 9/10/15 until Surveyor # requested measurements on 1/6/16 and nursing home staff obtained them from W&E Clinic staff on 1/7/16. Surveyor # interviewed MDS RN (Registered Nurse)-J on 1/7/16, asking where she obtained the measurements to complete Resident #5's Annual MDS on 12/10/15. MDS RN-J looked in her computer and found a note stating Wound measurements, tissue description and Stage obtained from W&E Clinic from 12/16/15 visit. Surveyor # asked how and why RN-J would include a measurement and description from 12/16/15 if the Assessment Reference Date is 12/10/15. RN-J stated The clinic doesn't send the measurements, they said that is the only measurement they had. Surveyor # noted the requests on the communication forms between the facility and W&E Clinic in December, 2014 and April 2015 ask clinic staff to include the measurements and they do but only for that one day/request. Surveyor # asked if more formal efforts were made to obtain the measurements timely, and/or why facility nurses do not measure and assess Resident #5's pressure ulcer once a week when they are doing the treatment. RN-J stated she did not know. RN-J stated she coded no pressure ulcer on Resident #5's Quarterly MDS dated [DATE] because at the time, Resident #5 only had an abrasion on her left ischium, not a pressure ulcer. Surveyor # then interviewed Interim DON (Director of Nursing)-B, asking if efforts were made to get the measurements from the clinic timely and/or why the facility nurses do not measure and assess Resident #5's pressure ulcer weekly since they are doing the treatment three times a week anyway. DON-B was not aware of the lack of documentation of Resident #5's pressure ulcer in Resident #5's medical record. DON-B was aware Resident #5 went to the wound clinic routinely for wound care. Resident #5 is the only Resident who goes to the wound clinic now, the rest of the Residents are seen in-house by a physician who specializes in wound care. The CAA (Care Area Assessment) completed for Resident #5 on 12/23/15 states Resident #5: has chronic pressure ulcers related to medical issues. Currently has Stage IV non-healing ulcer. Is seen by the wound clinic. Has a wound vac in place currently. Is incontinent of bowel, has a urinary catheter in place. Is checked and changed with incontinence cares. Barrier cream applied as needed. Is turned and repositioned every 2-3 hours and prn as she allows. Goal is improvement with no further skin breakdown. Risk is further skin breakdown. Will proceed with present POC (plan of care). Resident #5's Quarterly MDS dated [DATE] and Annual MDS dated [DATE] indicate Resident #5 is cognitively intact; requires extensive assistance of two staff for bed mobility and transfers; has functional impairments on both sides of upper and lower extremities; has a urinary catheter and is frequently incontinent of bowel. Resident #5's Care Plan regarding pressure ulcers is dated 2/3/15 and most recently revised 12/23/15 stating: Pressure Ulcer actual or at risk due to: Pressure ulcer present, bed fast, Braden Score 18 or <, bowel incontinence, skin desensitized, bed mobility issues. admitted with Stage IV pressure ulcer- coccyx. Goal: Pressure ulcers will heal without complication; target date 3/10/16. Will remain free from further breakdown; target date 3/10/16. Interventions: Assist with pericare; grab bars on bed to promote bed mobility and repositioning related to MS ([MEDICAL CONDITION]); check and change every 2 hours, provide thorough skin care after incontinent episodes and apply barrier cream; complete Braden scale and skin assessments per policy; conduct daily skin inspection for signs/symptoms of skin breakdown, if observed report immediately; lotion with skin cares daily; may be up in wheel chair daily with time determined by nursing based on wound healing progress or MD; nutritional and hydration support (tube feedings); pad sides of wheel chair during transfers; provide specialty air mattress; position changes every 2-3 hours, float heels; treatments as ordered to existing pressure ulcers; use larger size shower chair; weekly wound assessment; wound clinic referral and follow-up as ordered. Resident #5's Nutrition care plan dated 12/23/15 states: Resident is at nutrition risk secondary to resident receiving full nutrition from feeding tube. Resident with increased nutritional needs for open areas. Resident with history of [MEDICAL CONDITION] embolism, urinary [MEDICATION NAME], constipation, hypertension, depression, MS, contracture of lower leg joint, contracture of pelvic joint. Resident/responsible party refused to have increased tube feeding for wound healing as resident does not want to have weight gain. Aware of risks/ benefits of this refusal. Resident with history of low pre-[MEDICATION NAME]. Goal: Resident will heal open areas, target date (for all goals) 3/10/16; Maintain weight between 155-165 pounds. Resident will tolerate tube feeding. Resident will show no s/s (signs/ symptoms) of dehydration or fluid overload. Interventions: Meds and labs per MD order; monitor for s/s dehydration or fluid imbalance; [MEDICATION NAME] per MD order; therapy as ordered; tube feeding and water flushes per MD order; update MD with significant weight changes; monthly weights. CURRENT PRESSURE ULCER On 1/5/16 and 1/6/15, Surveyor # reviewed Resident #5's medical record in regards to her current Stage IV pressure ulcer on her left ischium. Surveyor # did not observe any Wound Evaluation Flow Sheets in Resident #5's record for the current pressure ulcer, that, according to MDS RN-J, began as an abrasion in September, 2015. Surveyor # observed a Nurses' Note dated 9/26/15 stating Left ischial abraised area 3.7 x 1.7 cm., no depth, just raw. No new treatment orders were obtained until Resident #5 was seen at the Wound and [MEDICAL CONDITION] Clinic on 10/8/15. The previous treatment order dated 7/23/15 was in place: Apply zinc oxide to left ischial area and to skin around [DEVICE] site two times a day and as needed for skin protectant. While there were no Wound Evaluation Flow Sheets in Resident #5's record, there was documentation from the Wound and [MEDICAL CONDITION] (W&E) Clinic starting 10/8/15. Only one of the communication forms from the clinic included a measurement of Resident #5's left ischial pressure ulcer: on 11/4/15 it was noted to be 1.1 x 2.0 x 2.5 cm. (The next measurement was received 1/6/16 when Resident #5 returned from the wound clinic. Nursing home staff had asked for the measurements after Surveyor # requested measurements for Resident #5's pressure ulcer. Resident #5 returned with the 1/6/16 measurements- 1.5 x 2.1 x 1.3 cm., and partial documentation from the 12/30/15 visit.) Wound and [MEDICAL CONDITION] Clinic documentation in Resident #5's record pertaining to the left ischial pressure ulcer includes: -10/8/15 Wound location-Left ischial; cleansed with saline; dressing applied- foam border, every other day; zinc oxide to peri-area daily. Return to clinic in 2 weeks. (No measurements. Nursing home staff obtained new orders from Resident #5's doctor for this treatment on 10/8/15.) -10/21/15 Dressing/ treatment changed to [MEDICATION NAME] AG applied followed by a foam border; change every other day. (No measurements, new treatment orders received.) -11/4/15 Wound size 1.1 x 2.0 x 2.5. Dressing applied: skin prep, [MEDICATION NAME] silver, border dressing. Continue until wound vac is present, every other day and as needed. Please order KCI positive pressure wound vac with small black foam ad simplex dressing- change 3 times a week. Initiate at facility and send dressings and canister next visit Juven one packet daily via [DEVICE]. Wound vac care during waking hours during AM shift. -11/11/15 Dressing applied: Wound vac, black foam, skin prep, 3 times a week. Wound veil over area of irritation below wound. canister not changed today. Return in 1 week. (No measurements). -11/19/15 NPWT (Negative pressure wound therapy- wound vac), change 3 times a week. Turn and reposition Q (every) two hours, do no place on wound. [MEDICATION NAME] to skin not covered by drape. Continue supplement protein as soon as possible. (No measurements.) -12/2/15 Wound vac black foam. DuoDerm open area x 2. Change 3 times a week. Use [MEDICATION NAME] Plus on red, dry skin. DuoDerm -2 areas of skin breakdown. Please rotate site of vac drape to give skin a chance to heal. Use [MEDICATION NAME] on dry reddened areas. DuoDerm to two open areas inferior to wound. (No measurements) -12/9/15 NPWT, skin prep periwound. [MEDICATION NAME] to red areas not covered by dressing. Do not put lotion/cream on skin that will have dressing placed over it. Vac foam can only be left in wound for 2 hours without being attached to suction. If this suction is not obtained, remove foam. (underlined several times by wound clinic staff). Leaving it in without suction increases bacterial infection. Then dress wound or replace vac. -12/16/15 Try DuoDerm peri-wound, black foam, vac, 3 times a week and prn. [MEDICATION NAME] to red areas where drape was not applied. Return in 2 weeks. -12/30/15 Hold off vac for this week. Silver alginate rope. Zinc oxide to red, irritated skin periwound, cover with large foam border. Every other day and prn. Continue all off-loading measures. On the morning of Wednesday, 1/6/16 at 7:00 a.m., Surveyor # observed PT (physical therapist)-AA perform another Resident (#6)'s pressure ulcer treatment and measure the ulcer. A short time after that was completed, at approximately 8:30 a.m., PT-AA went to the nursing office at the same time as Surveyor # . PT-AA requested the Wound Care Binder to add her documentation for Resident #6's wound measurement and assessment. PT-AA asked if Surveyor # needed the binder first. Surveyor # said no, and asked Interim DON-B that after PT-AA is done documenting her information from her Wednesday measurements, Surveyor # would like copies of Resident #5 and #6 pressure ulcer documentation. PT-AA stated she did not measure Resident #5's wound because Resident #5 had an appointment at the wound clinic that day and she would not want to remove a dressing to measure, apply a new dressing, then have the wound clinic remove the new dressing- that can be hard on the skin to keep pulling off an adhesive dressing. Interim DON-B stated she would copy Resident #5 and #6's pressure ulcer documentation for Surveyor. On the morning of 1/7/16, Surveyor noted a communication form -Physician Orders/ Patient Instruction form from the Wound and [MEDICAL CONDITION] Clinic- in Resident #5's chart. It states: NPWT (negative pressure wound therapy), skin prep periwound. 3 times a week. It seems battery is dead (on wound vac.). Charge and apply within 2 hours. Left ischial 1.5 x 2.1 x 1.3. Also now in Resident #5's medical record was a packet of notes from the Wound and [MEDICAL CONDITION] Clinic from 12/30/15 that was not present in Resident #5's record on 1/6/16. The pages indicate they were printed 1/6/16. No measurements from 12/30 were previously in Resident #5's facility record. The 12/30/15 Progress Note states: Objective: Resident #5's left ischial is a Stage IV pressure ulcer- not healed. Measurements are 1.0 x 1.0 x 1.2 cm. with undermining noted at 9:00 o'clock and ends at 11:00 o'clock with a maximum distance of 1.7 cm. There is small amount of serosanguinous drainage noted which has no odor. The wound margin is well defined. Wound bed has no slough present. The wound is improving. The periwound exhibited: friable, denuded, moist maceration, [DIAGNOSES REDACTED] Periwound skin is raw, red and weeping .The periwound skin is quite [DIAGNOSES REDACTED]tous and irritated appearing. This does not appear to be [MEDICAL CONDITION]. Wound base itself is relatively clean with small amount of pale slough. Assessment: 1. Stage IV left ischial pressure ulcer with extension into the muscle layer. 2. Periwound [MEDICAL CONDITION]. 3. Advanced [MEDICAL CONDITION]. Procedures: Resident #5 had the wound selectively debrided. MD used an ultrasound probe tip to remove devitalized tissue: biofilm and exudate . Post debridement measurements: 1.0 x 1.0 x 1.2 depth. Post-debridement stage noted as stage IV. This documentation states the wound was acquired on 9/21/15. On 1/7/16 at approximately 8:00 a.m. Surveyor # asked Interim DON-B for Resident #5's wound measurements and was informed they were working on them. As of 10:00 a.m. on 1/7/16, Surveyor # still had not seen any other wound measurements or documentation of Resident #5's pressure ulcer. On 1/7/16 at 10:13 a.m., Surveyor # called the Wound and [MEDICAL CONDITION] Clinic to speak with one of the nurses who treat Resident #5 at the clinic to discuss some of the comments made on the communication sheet for Resident #5 (and #6). After Surveyor # introduced self and explained who I would like to speak with, the receptionist stated someone from the facility already called requesting Resident #5's measurements since October and she is working on it, but they have been busy and she will fax the information as soon as possible. Surveyor # then spoke with one of the nurses at the clinic who frequently sees Resident #5, RN-BB. Surveyor # asked about the 12/9/15 note stating the foam can only be left in the wound for 2 hours without suction, if suction not obtained remove foam (underlined several times). Leaving it in without suction increases bacterial infection . RN-BB stated that was written because Resident #5 arrived at the clinic with the foam and dressing left on, but the wound vac had been off all night. Resident #5 stated the wound vac had been leaking so nursing home staff turned the vac off until she was seen at the clinic. RN-BB stated staff did not seem to be aware this was not appropriate. The clinic staff had concerns with the way the nursing home staff were carrying out orders for the wound vac. A KCI representative was scheduled to provide an inservice to nursing home staff at the end of December, but she was involved in an auto accident and has to reschedule. The representative called Monday 1/4/16 to reschedule but was told they would like to wait until their State survey was completed. RN-BB stated more than once Resident #5 arrived at the clinic with the bridge (foam from the ulcer to the side of the resident to make it more comfortable for the resident to sit and lay) on without the required [MEDICATION NAME] drape underneath to protect her skin- that is what caused Resident #5's peri-wound skin to be so irritated and raw, that led to the wound vac being left off this past week so that skin can heal. RN-BB stated it was cumulative issues noted with the way Resident #5 would present at the clinic, with the missing [MEDICATION NAME] (12/9 and 12/16) causing the raw skin as the last issue before clinic staff determined nursing home staff needed additional education regarding use of the wound vac. so they called the KCI representative to provide an inservice to nursing home staff. Surveyor # asked about communication stating nursing home staff have to send dressings and canister, that canister was not changed, etc. RN-BB stated even though the nursing home and clinic both use KCI [DEVICE], they have different models and if the nursing home staff do not send the canister along with Resident #5, they cannot change it- theirs do not fit the nursing home model. On 1/7/16 at approximately 10:25 a.m. Surveyor # interviewed Interim DON-B, asking again for wound measurements and assessments of Resident #5's left ischial pressure ulcer. DON-B stated Therapy has the Wound Binder, and measurements from the clinic should be on the communication forms returned with Resident #5. Surveyor # stated there were only one or two measurements from the clinic in Resident #5's record since October. Surveyor # also noted Resident #5's Care Plan states staff should conduct Weekly wound assessments; Resident #5 frequently was seen at the clinic at two week intervals, so relying solely on the wound clinic for measurements and assessment would not provide weekly assessments. DON-B was not aware the measurements were not on the communication sheets. Surveyor # asked how the nurses knew how to properly use the wound vac. DON-B stated she personally showed the nurses and would do the treatment with them at times. Surveyor # then went to therapy department and spoke with the Manager of Therapy-CC, who stated they have no documentation for Resident #5 except for a one-page Therapy Screen form dated 12/21/15 stating there have been no changes in condition regarding Occupational, Physical or Speech Functional Deficits. Comments: continues on Vac for ischial wound, side-to-side positioning, up in chair for desired activities and appointments, signed by PT-AA. Manager-CC stated Resident #5 is seen at the wound clinic so they do not have her on their caseload in the facility. Therefor, they do not perform the treatments or measure or assess the pressure ulcer. Surveyor # then spoke with DON-B and ADON (Assistant Director of Nursing)-N, stating therapy has no documentation regarding Resident #5's pressure ulcer, the communication forms between the clinic and facility do not have any measurements or descriptions of the pressure ulcer, asking how staff are conducting Weekly wound assessments per Resident #5's plan of care. ADON-N stated she just called again for the measurements. Surveyor # asked when she previously called. ADON-N stated she called a few weeks ago but they never sent the documentation. Surveyor # asked if the knew they were not receiving the documentation from the wound clinic, who often saw Resident #5 at two week intervals, why they did not instruct facility nurses to assess, measure and document regarding Resident #5's pressure ulcer at least weekly during one of the 3-times-a-week treatments. No information was provided. On 1/7/16 at 12:20 p.m. RN-D provided Surveyor # with documentation from the Wound and [MEDICAL CONDITION] Clinic from 10/8/15 through 12/16/15, received via fax that morning. The documentation includes notes showing Resident #5's pressure ulcer was: -Stage II on 10/21/15, 1.0 x 1.0 x 0.1; -Stage III on 11/4/15, 1.1 x 2.0 x 2.5 cm., deteriorating; -Stage IV on 11/11/15, 2.0 x 0.8 x 2.2 cm., deteriorating; -Stage IV on 11/19/15, 2.5 x 1.5 x 1.5 cm. deteriorating; -Stage IV on 12/2/15, 2.3 x 1.2 x 2.3 cm., deteriorating; Stage IV on 12/9/15, 2.2 x 1.1 x 1.0 cm., improving; Stage IV on 12/16/15, 1.7 x 1.0 x 1.5 cm., improving; Stage IV on 12/30/15, 1.0 x 1.0 x 1.2, debrided, improving; Stage IV on 1/6/16, 1.5 x 2.1 x 1.3 (larger, but documentation page stating improving or deteriorating was not provided. The wound vac was left off between 12/30/15 and 1/6/16 to let Resident #5's peri-wound skin start healing from the irritation caused by leaving the [MEDICATION NAME] drape off under the bridge. In addition to staff not measuring and assessing Resident #5's pressure ulcer weekly per the facility's plan of care, and concerns with the use of the wound vac, and the dressing being left off of Resident #5's pressure ulcer for 4 hours, Surveyor # skimmed some of Resident #5's Nurses' Notes which indicated on 9/14, 9/15, 9/16, nurses' documented eMar- supplies unavailable or waiting for supplies. Similar notes were observed on 10/5/, 10/6, 10/11, 10/12, 10/14, 11/5, stating eMar- med not available, or out of supplies. On 11/19/15 the notes state [MEDICATION NAME] powder not available. At the daily exit meeting on 1/7/16, Surveyor # asked what supplies were unavailable. On 1/11/16, RN-D informed Surveyor # that on those dates, Resident #5's Juven was not available as ordered (one packet via [DEVICE] BID (twice a day), except for the 11/19 note where the protein supplement [MEDICATION NAME] was not available. RN-D stated they have added Juven and protein powder to the routine monthly orders so they will not run out in the future. Surveyor # checked the manufacturers web page which states JUVEN is a targeted therapeutic nutrition drink mix that has been clinically shown to support tissue building in 2 weeks, and to help build and maintain lean body mass (LBM) in 4 weeks. http://abbottnutrition.com/brands/products/juven No further information was provided regarding Resident #5's pressure ulcer care and treatment. 2.) Surveyor # reviewed Resident #6's medical record beginning 1/5/16. Resident #6 has major [DIAGNOSES REDACTED]. Resident #6 was admitted in January 2014 with a Stage III pressure ulcer which healed. Resident #6's Annual MDS (Minimum Data Set) dated 1/6/15 and Quarterly MDS dated [DATE] show Resident #6 had no pressure ulcers at those times. (Surveyor Note: Surveyor # observed a Nurses' note dated 3/13/15 stating Resident #6's MD gave permission for her to be seen at the wound clinic. On 1/19/15 via phone NHA (Nursing Home Administrator)-A informed Surveyor # that the first documentation he observed regarding Resident #6's pressure ulcer reopening is a Nurses' note dated 3/24/15. It is unclear when staff first observed the pressure ucler.) Resident #6's 6/25/15 Quarterly MDS indicates she had a Stage II pressure ulcer. Resident #6's Quarterly MDS dated [DATE] indicates she has a Stage III pressure ulcer and the Annual MDS dated [DATE] indicates she has a Stage IV pressure ulcer. On 1/6/16 at 7:00 a.m., Surveyor # observed PT (Physical Therapist)-AA perform a treatment to Resident #6's Stage IV coccyx pressure ulcer. PT-AA measured the pressure ulcer as 0.9 x 0.9 x 0.3 cm. (centimeters) and noted it to be improving with defined wound margins and no undermining or tunneling; surrounding tissue noted to be pink, intact. Scar tissue at 7:00 o'clock vs. maceration. PT-AA stated a few weeks prior, Resident #6's wound had a build up of scar tissue and the physician performed a sharp debridement of the wound. (Nurses' Notes dated 10/29/15 state Sacral wound 0.6 x 0.4 cm. debrided by MD, post debridedment 1.0 x 0.9 cm.). Resident #6's previous wound measurements on 12/29/15 were 1.2 x 1.2 x 0.5. Therapy staff have documentation of weekly wound measurements for Resident #6's pressure ulcer from 11/4/15 to present. Manger of Therapy-CC informed Surveyor # their documentation starts 11/4/15. Previously Resident #6 was seen at the wound clinic and not on their case load, so they did not do the treatment or measure the pressure ulcer. According to the Wound Evaluation Flow Sheet documentation, Resident #6's sacral pressure ulcer on 11/4/15 measured 0.4 x 0.2 x 0.2 cm., no sta

Based on observation, record review and staff interview, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 3 (Resident #'s 1, 3, and 13) of 7 sampled residents and 1(Resident #14) supplemental resident and 1 (Resident #7) of 4 residents with siderails. Resident #14 did not have safety interventions put in place when she came into the facility due to a fall and fracture of the left ankle. During a very short stay at facility Resident #14 had a fall, sent to the hospital with [DIAGNOSES REDACTED]. This example is cited at the scope and severity level G, actual harm. Resident #1 was observed to be transferred without a gait belt. Resident #1 was observed in bed and the bed was not in it's lowest position. The facility did not have a root cause after a second fall for Resident #1. Resident #3 had falls and the facility did not have a root cause for these falls. Care plan not updated or changes of interventions implemented. Resident was observed to have a pillow behind her back while sitting in lounge chair, the pillow is care planned to be a support for her arms. Resident #7 had grab rails on the side of the bed but, did not have an assessment for the grab rails. Resident #13 had fallen on 11-21-15 and 11-22-15, the nurse documented under only under a General Nurses Note regarding these falls, with no investigations. Findings: 1.) Resident #14 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The right leg was wrapped with an ACE wrap and a splint. On 1-11-16 at 10:25a.m. Surveyor # completed a closed record review of Resident #14. Resident was admitted to the facility for rehab, due to a fracture of the left ankle/heel on 12-24-15 at approximately 4:24p.m. and was sent out to the hospital on 12-25-15 at approximately at 8:30p.m. Therefore no Minimum Data Set was completed. Review of the nurses notes: Nurses notes dated 12-24-16 at 16:24 (4:24p.m.) state: Admission note , resident admitted for m mercy hospital, arrived via ambulance in gown. Her pants and shirt were sent from hospital, but they were cut off of her and resident did say to throw them away. Pleasant, alert and orientated x(times) 4. Two person assist to pivot/transfer no ambulation at this time. Facility TV placed in room for her use. Nurses notes dated 12-24-15 at 22:44 (10:44p.m.) as general note state: 99.2 (temperature), 146/78 (blood pressure), 97 (heart rate), 18 (pulse), 91% (oxygen) RA (room air). Alert. Oriented x2 at times, intermittent confusion. Resident becomes agitated during periods of confusion, calling out for her daughter. Unable to reorient or redirect. Resident attempts to self transfer, states I don't care if I fall, it will be your fault! 2 assist pivot transfer. One assist with cares. One assist with bed mobility. Ate in room this evening. Feeds self. Lungs clear, diminished bilaterally throughout. No SOB (shortness of breath). Dry cough. Bowel sounds present x4. Abdomen soft, non distended. Cast to LLE (left lower extremity), CMTS (circulation, movement, temperature, sensory) WNL (within normal limits). Denies any pain at this time. Nurses notes dated 12-25-15 at 00:23 (12:23a.m.) state: 97.8, 66, 18, 165/75, 95% RA. L (left) ankle fx (fracture) is wrapped and protected, she has no noted pain this shift. She wakes and then tries to get out of bed by herself. Her roommate will put on the call light when this happens. Staff do not want the roommate to feel that she has to watch and listen for Resident so staff has been looking in on Resident very often for her safety. When she wakes she is disorientated and confused. She can be angry at first. She will relax with calm words from staff. LCTA (lungs clear to auscultation). Active bowel sounds x4 quads. Abd (abdomen) is rounded and nontender with palpation. Skin warm and dry. A&O x2 (alert and oriented times 2). Nurses notes dated 12-25-15 at 03:43 (3:43a.m.) state: Resident found trying to get out of bed by herself at 0300 (3:00a.m.). Writer assisted her back in bed and did incontinence cares. She became combative with writer and yelling that writer was keeping her hostage. Writer explained to her where she was and why she was here and she relaxed and allowed writer to finish cares. She is now reading with her light on in her room. Staff continue to check on her for her safety. Nurses notes dated 12-25-15 at 05:16 (5:16a.m.) state: She was again found trying to get out of bed at 0500 by RN and writer. She was yelling at writer and calling her names. After a minute of yelling she stopped and was nice. She was helped to the bathroom and cleaned up after having an incontinent BM (bowel movement). Clothes were found for her from donated clothes in laundry because she has none with her. She is now sitting down by writer at south nurses station. Nurses notes dated 12-25-15 at 13:58 (12:58p.m.) state: 97.7, 95, 18, 167/75, 95% RA. A&) x2, pleasant with staff. Resident is a diabetic and has scheduled insulin. She has been up and down the halls this shift. She is an extensive assist of 2 for transfers. She has been incontinent of bladder this shift. She has a cast on her left foot. Nurses notes dated 12-25-15 at 21:47 (9:47p.m.) SBAR - Change of Condition state: 2030 (8:30p.m.) writer was called by social worker to resident's room. Social worker stated she heard a loud bang in resident's room, responded immediately and found res. on the floor. LPN (Licensed Practical Nurse) stated res. had been confused, oriented to self and wandering looking for her cat most of the shift. Cast and ACE wrap to left leg d/t (due to) left ankle fracture. Has a [DIAGNOSES REDACTED]. Type 2 diabetes and hypertension. Found res. sitting on the floor by the bathroom door, back against the wall, right leg bent inwards with left leg on top of it. Supper tray next to her. Wheel chair to her right side and a few feet away. When questioned, res. stated, I was trying to put something on the table and slid out of the w/chair (wheelchair)., when I fell I heard a loud pop in my right knee. Complained of severe pain to right knee. Able to perform ROM (range of motion) of only upper extremities. Denied hitting head. No further injuries noted at that time. Res. had gripper socks and pants saturated with urine. Confusion noted as well. TPR (temperature, pulse, and respirations) 97.9, 79, 20, 94% RA B/P (blood pressure) 193/69, BS (blood sugar) 522. Res assessed by writer in the presence of LPN and social worker. Writer by resident's side as the LPN was making the phone call to the MD. 2035 (8:35p.m.) Doctor called and updated by LPN, gave order to send res to ER for evaluation. 2045 (8:45p.m.), res. transported to Fort hospital by Ryan brothers ambulance. RN on call notified by writer at 2140 (9:40p.m.). Nurses note dated 12-25-15 at 23:12 (11:23p.m.) state: Resident continues to be confused, wandering. Looking for her cat, believes that the cat had gotten out. Believes she is still in her apartment and is wondering why there is a woman in her room. Resident continues to go through the curtain over to roommates side of the room. Irritable, yelling out. Unable to redirect. Resident states that she pinched her R leg during a transfer this am on wheelchair. No injury noted to R leg at time complaint was made. Will continue to monitor. Had an unwitnessed fall at 2030, limited ROM to RLE (right lower extremity), c/o severe pain. Sent to ER for eval via Ryan Bros ambulance. Daughter updated. Daughter able to give limited history on resident, lives in California. Was unaware of residents admission to facility. Per daughter there is some family issues. Call received from MD at Fort Hospital at 2230, resident has R knee fx. On call RN updated. Resident will be moved to rm (room) 27 upon her return to facility. Wanderguard will also be placed on resident for safety. Nurses notes dated 12-26-15 state: Writer received a call from the RN at Fort Memorial Hospital regarding resident. She will be having surgery in the next day or 2 and should be returning to the facility early next week. Note: Resident #14 was admitted to St. Mary's in Madison for surgery on her right knee and did not return to the facility she was being admitted to a different facility. Reviewed the Immediate Plan of Care for, At Risk For Falls, dated 12-24-15. Under At risk for falls related to: It is checked for fell in the past 30 days and dizziness. Under Interventions: It is checked for ensure balance in wheelchair. Specify positioning devices, none noted. Assist in transfer, 2 person pivot. It is checked for Call light available. It is checked for Assist with mobility. Specify type of assistance needed: Wheelchair is noted. It is checked for, encourage rest periods daily to avoid overtiring. It is checked for, Gather and document information if resident does fall: (examples) Use change of condition form for post-fall evaluation. Time of day, what activity was resident involved in, was resident reaching, was there glare on the floor, furniture in path, foreign objects in walkway, low lighting, what medications were taken prior to fall. It is checked for, Gait belt. Specify Pivot transfer. It is checked for, Wheelchairs. It is checked for, Evaluate, with physician, the potential impact of medications, i.e. diuretics, cardiovascular meds, psychotropic med's. Look for alternatives. It is checked for, Notify rehab for possible assessment. This Immediate Plan of Care for At risk for falls under interventions is not checked for the following: Institute fall prevention program such as Falling Star. Evaluate need for bed alarm or chair alarm. Wheelchair/walker safety check performed or If the resident uses an appliance or prosthesis observe for possible problems. Reviewed the Clinical Health Status form for Resident #14 dated 12-24-15. Under Risk For Falls, this area was not completed and given a score. Reviewed the Verification of Investigation form dated 12-25-15. This form states under Causal/Contributing Factors and Observations: Impaired judgement. Confusion. Incontinent at time of fall. Under Specify Recommendations/Interventions Taken to prevent reoccurrence, it states: Toileting schedule. Toilet every 2 hours while awake. Under Care Plan Revised, it is checked NO. Reviewed the Post Fall Analysis/Plan which states: Fall Details; lost balance, slid out of wheelchair, lost strength, history of falls, impaired safety awareness/judgment, recent changes in environment, recent changes in roommates. Subjective or patient states: Discomfort with ROM, Residents explanation of what they were doing right before fall. Which was trying to put something on the table. Prior to Fall Resident Was: Reaching for something, was in wheelchair/chair. Underlying Illness/Dx: Cardiovascular and Ortho. Physical Assessment After Fall: Blood Glucose 522. Anxious/Irritable, Change in Range of Motion. Footwear at time of fall: Gripper socks. Adaptive Equipment at time of fall: Has device and was in use (Note: this device is not identified). Time last toileted/voided: 12-25-15 at 05:00 (5:00p.m.) (Note: Fall happened at 8:30p.m.and Resident #14 incontinent brief was saturated). Under Possible Causal/Contributing Factors and Observations it states: Impaired judgement, confusion, restlessness. Was incontinent of bowel and bladder at time of fall. Interventions taken to prevent reoccurrence is to toilet every 2 hours. On 1-11-16 at approximately 10:50a.m. Surveyor # interviewed Interim DON-B regarding Resident #14. Interim DON-B stated Resident came in with a fracture to her left ankle. Stated Resident was not at facility very long. Stated Resident had a fall and was sent out to the hospital for evaluation. Stated Resident did sustain a fracture to her right knee. Stated Resident didn't return to facility. NOTE: During Resident #14's short stay at the facility she attempted to get out of bed several times. Nurses note that Resident had intermittent confusion and that Resident would become agitated during periods of confusion, yelling at staff and calling out for her daughter. Nurses note that Resident #14 would be disorientated and confused when she would wake and that Resident #14 was unable to be reoriented or redirected. The facility did not put any safety interventions in place such as 15 minute checks or 1 to 1 observations for Resident #14 even knowing of Resident #14's periods of confusion. Resident #14 ended up with a fracture of the right knee and needed surgery. The above information was shared with the facility. 2.) Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1-4-16 at 9:00a.m. during the initial tour Surveyor # observed Resident #3 to have a blackened right eye. Surveyor # asked Director Alzheimer Care-G what happened to cause the blackened eye. The Director Alzheimer Care-G stated that Resident #3 leans forward when sitting up in wheelchair or lounge chairs. Stated that Resident #3 was leaning while in her chair and fell . Stated there were no other injuries except for the blackened eye. Stated they are still working with her leaning forward. On 1-4-16 at 2:10p.m. Surveyor # observed Resident #3 sitting up right in a lounge chair in the Porch area (Lounge area on unit). Resident #3 had a full pillow behind her back and Resident #3 could not sit totally back in the chair. On 1-4-16 at 3:00p.m. Surveyor # reviewed the medical record of Resident #3. Reviewed the nurses notes and noted Resident #3 had several falls. Surveyor # requested all fall investigations since the last survey. Review of the nurses care plan revision date 12-18-15, which states under At Risk for Falls: Intervention to provide pillows and/wedge pillow for when resident is sitting in chair in lounge area for resident to rest her arms on for upper body support. Therapy screen for seated positioning, if she allows use gripper pad in chair in lobby. Call light or personal items available and in easy reach or provide reacher (resident has a soft touch call light). Bed in lowest position, Footwear to prevent slipping when out of bed. Remove walker from bedside when resident is in the bed to discourage self transferring. Scoop mattress. Toilet schedule every 2-3 hours and upon request. Place soft touch call light close to resident's body where it can easily be triggered when resident sits up in bed. Gait belt with transfers. No where in this nurses care plan does it address Resident #3 leaning forward when sitting in lounge chair/wheelchair and what interventions the facility has put in place to help prevent this leaning forward. Resident #3 will attempt to transfer and ambulate by herself at times according to nurses care plan. Reviewed the Verification of Investigation for the following falls: On 6-26-16 at 0030 (12:30a.m.) Resident #3 was ambulating with out assist in her room and was found 3 feet away from her bed. Under Adaptive Equipment at time of fall it notes: Had device and was not in use. It doesn't state what type of device was to be in use. No interviews with staff regarding what resident was doing before incident or when resident was toileted last. On 8-28-15 3:00p.m. Resident #3 was observed to be lying to the right side close to toilet and the door frame of the bathroom with head sticking out of the bathroom and the rest of the body parts in the bathroom. Intervention was to place soft touch call light close to resident's body where it can easily be triggered when resident sits up in bed. Under Adaptive Equipment at time of fall it states, had device and was not in use. It doesn't identify what the device was. No interviews with staff regarding what resident was doing before incident or when resident was toileted last. On 10-7-15 at 10:05a.m. Resident #3 was sitting in porch area (lounge area on unit) after breakfast noted resident had fallen out of chair face first, hitting her forehead on floor in front of the chair. Resident noted to have red abrasion to forehead. Redness to bridge of nose and right inner corner of eye. C/O (complained of) slight headache. Resident prefers to lean forward bending at waist when in recliner. Under Adaptive Equipment at time of fall it states had device and was not in use. It doesn't identify what the device was. On 12-14-15 at 0050 (12:50a.m.) the call light noted to be on in nurses station. Writer went to answer light and found resident sitting on her buttocks on the floor next to her bed. Resident has Dx of dementia so does not remember safety issues. Will attempt to stand up from bed on her own. Has soft touch call light but system not sounding hallway. Maintenance was left message regarding call system. Resident was brought out to the porch area. On 1-1-16 at 9:05a.m. Witnessed Fall: Resident was noted to have fallen out of recliner hitting forehead on floor, Was found sitting on floor in front of recliner in ACU (Alzheimer Care Unit) porch. Immediate hematoma to right forehead above right eye. Under Contributing Factors and Observations it states: When resident is sitting up in chair always leans forward, leaning forward is her usual body language and stature. When asked to please sit back she responds blah, blah, blah, or shut up, does have grippy matt on seat of chair. Motion sensor call light when in bed (soft touch call light). Intervention was to have PT evaluate next morning, recommending cushion or mat to be placed in front of chair while resident sitting up in porch. Surveyor could not locate at PT evaluation nor did the facility provide one. The above information was shared with the facility. 3.) Surveyor # reviewed Resident #1's medical record on 1/4/16 to 1/7/16. Resident #1 has a [DIAGNOSES REDACTED]. The at risk for falls care plan initiated on 4/28/14 includes interventions of bed in low position when he is in it dated 8/22/15, and the following interventions dated 5/23/14 of call light or personal items available and in easy reach or provide reacher, Encourage rest periods to avoid overtiring., Footwear to prevent slipping when out of bed., If resident should have a fall gather info (information) and document on change of condition post fall form., Keep environment well lit and free of clutter., Orientation to new room and roommate on admission to room., and Therapy as ordered. The physical functioning deficit care plan with a date initiated of 4/28/15 includes an intervention dated 7/28/15 of Transfer and ambulate with assist x (times) 1 and gait belt. The annual MDS (minimum data set) signed as complete on 5/13/15 has a BIMS (brief interview mental status) total score of 0 which indicates severely impaired. Resident #1 requires limited assistance with one person physical assist for transfers & ambulation and has not had any falls since prior assessment. The Fall CAA (care area assessment) dated 5/12/15 documents under care plan considerations Resident #1 is a fall risk d/t (due to) cognitive/safety issues. Walks with staff to minimize risk of falls. Goal is no falls, Risk is fall with/without injury. Will proceed to CP (care plan). The SBAR (situation background assessment response) note dated 9/13/15 documents under situation 0558 (5:58 a.m.) this writer informed by CNA (Certified Nursing Assistant) on duty that resident was sitting on the floor in his room. Res (Resident) sitting on top of his blankets on the floor with back leaning against the bed. Under assessment documents VS (vital signs) 96.8tymp (tympanic) 92% RA (room air) 161/99, 80, 16. A & O (alert and oriented) to self, more than usual confused at the tie of the fall. PERRL (pupils equal round reactive light) 3 mm (millimeters) bil (bilateral). Small superficial scrape noted on the R (right) knee. No other injury noted upon inspection. ROM (range of motion) WNL (within normal limits). Res. assisted off the floor by this writer and CNA on duty with no issues. C/o (complaint of) generalized pain per usual. The detailed wing assignment dated 12/15/15 and provided to Surveyor # on 1/4/16 documents for Resident #1 under the section mobility/transfers 1 assist for ambulation and transfers, no assistive device and under section miscellaneous pressure sensitive call light, wanderguard, low bed risk, benefit waiver signed. The quarterly MDS signed as complete on 12/29/15 has a BIMS (brief interview mental status) total score of 0 which indicates severely impaired. Resident #1 requires limited assistance with one person physical assist for transfers & ambulation and has not had any falls since prior assessment. On 1/4/16 at 11:42 a.m. Surveyor # observed CNA-F assist Resident #1 to stand up from the dining room chair and then ambulate with Resident #1 out of the dining room, down the hallway and into his room by holding onto Resident #1's hand. CNA-F did not place a gait belt around Resident #1 according to his plan of care. On 1/4/16 at 11:48 a.m. Surveyor # observed CNA-F ambulate with Resident #1 out of the bathroom and over to his bed. CNA-F did not use a gait belt while ambulating with Resident #1. Resident #1 sat on the bed, CNA-F removed Resident #1's sneakers, placed gripper socks on, and assisted Resident #1 with laying in bed. CNA-F asked Resident #1 if he was comfortable and washed her hands. Surveyor # observed that Resident #1's bed was not at the lowest position. On 1/5/16 at 8:22 a.m. Surveyor # observed CNA-E ambulating with Resident #1 out of the dining room, down the hall and into the bathroom in Resident #1's room. Surveyor # observed that CNA-E was holding onto Resident #1 's hand and did not have a gait belt around Resident #1. On 1/5/16 at 8:24 a.m. Surveyor # asked CNA-E what she does for Resident #1. CNA-E informed Surveyor # that she walks with him, he's a limited assist because of his gait and they don't want him to fall. On 1/5/16 at 1:59 p.m. Surveyor # asked CNA-E when she walks with Resident #1 is Resident #1 suppose to have a gait belt on. CNA-E replied yes I do. On 1/5/16 at 3:17 p.m. Surveyor # observed Resident #1 in bed asleep. Surveyor # observed the bed is not at the lowest position. On 1/6/16 at 3:23 p.m. Surveyor # informed Administrator-A, Interim DON (Director of Nursing)-B and Interim DON-C of the observations of a gait belt not being used while transferring and ambulating with Resident #1. Surveyor # also asked for any fall information regarding Resident #1's fall on 9/13/15. On 1/7/16 at 11:10 a.m. Surveyor # informed Corporate RN (Registered Nurse)-D and Assistant DON (Director of Nursing)-N that Surveyor # reviewed the verification of investigation for the 9/13/15 fall and did not see where the facility tried to determine the root cause and implement interventions to help prevent further falls. On 1/7/16 at 11:34 a.m. Interim DON-C provided Surveyor # with the SBAR note dated 9/13/15 which Surveyor # had already reviewed in Resident #1's medical record and informed Surveyor # that's all that the Facility has. 4.) Surveyor # reviewed Resident #13's closed medical record on 1/7/16 & 1/11/16. The admission clinical health status dated 11/19/15 section M risk for falls has a total score of 11. A total score of 10 or above deems resident at risk. The at risk for falls care plan dated 11/19/15 includes interventions not dated of Assist in transfer. Specify type of assistance: 1-2 assist w/ (with) walker., Call light available. There is a handwritten notation dated 11/20/15 of make sure within reach. Assist with mobility. specify type of assistance needed: 1-2 assist. Encourage rest a periods daily to avoid overtiring. Gather and document information if resident does fall: (Examples) Use change of condition form for post fall evaluation. Time of day. What activity was resident involved in. Was resident reaching. Was there glare of the floor. Furniture in path. Foreign objects in walkway. Low lighting. What medications were taken prior to fall. Gait belt. Wheelchairs (circle correct response) Transport: Other therapy activities. If the resident uses an appliance or prosthesis, observe for possible problems. Evaluate, with physician, the potential impact of medications, i.e. diuretics, cardiovascular meds, psychotropic meds. Look for alternatives. Notify rehab for possible assessment. PT (physical therapy). and Other: touch pad call lite gripper socks if she'll wear. The nurses note dated 11/21/15 documents Resident was tearful and agitated on am (day) shift in the beginning, gave prn (as needed) Lorazepam and scheduled Lorazepam as ordered, husband did come in and spend time with her. her mood did go up after breakfast she did go to therapy, Vs (vital signs) were WNL (within normal limits), BP (blood pressure) 138/78, 88, 20, 97.0 Tymp. (tympanic), denies pain, assist of 1-2 for transfers extensively at times. PM (evening) shift at approx. (approximately) 515pm resident was found on floor of bathroom, she stated she slipped, denies hitting her head, had no griper socks on nor pants nor depends, able to move all extremities, weak, no bruising or other injury noted, she denied to have her husband called still is her own person, VS (vital signs) are WNL (within normal limits), and neuros are WNL, educated and interventions were to use call light for assistance and re-applied gripper socks, placed call light with in reach, low bed in place already. During the remainder of the shift she continued to use call light and didn't self transfer. Continue to monitor. The nurses note dated 11/22/15 documents Res. (Resident) slept til 03:10 (3:10 a.m.) and then writer heard a noise as she was trying to get OOB (out of bed) and her feet knocked the w/c (wheelchair) foot pedals lying on the floor. Bed in low posn (position) and res wouldn't wait til writer could put the bed up higher to facilitate standing and her butt started to slide off the mattress as too difficult to stand with the bed so low, so writer helped her the last few inches to sit on the floor til CNA (Certified Nursing Assistant) could come and help with res. standing. Res. helpful to stand up with 2 assist. She insisted on going to bed and refused to be assisted to the BR (bathroom) 3 mins (minutes) later she set off the call lite and found again trying to get OOB to go to the BR and this time she was cooperative with amb (ambulation) with 2 assist to the toile. Then she wanted to sit in her w/c (wheelchair) in the hall and was supervised. Would only take some water. Remains confused to time, place and situation. She offered $ (money) to staff to get her some alcohol. The admission MDS (minimum data set) with an assessment reference date of 11/26/15 has a BIMS (brief interview mental status) total score of 13 which indicates is cognitively intact. Resident #13 requires extensive assistance with two plus persons physical assist for bed mobility, toilet use, transfer, & walk in room and is frequently incontinent of bowel & bladder. Resident #13 has had one fall since admission with no injury. The fall CAA (care area assessment) dated 12/2/15 documents under care plan considerations [AGE] year old female admitted post hospitalization for detox from ETOH (alcohol). History includes but is not limited to alcoholism, anemia, depression, hepatic failure, cirrhosis of liver, portal HTN (hypertension). Triggers d/t (due to) use of meds, recent fall, balance issues, behavior issues. Goal is no falls. Risk is fall with/without injury. Will proceed to CP (care plan). On 1/11/16 at 9:38 a.m. Surveyor # asked Interim DON (Director of Nursing)-B for Resident #13's fall investigations. On 1/11/16 at 10:00 a.m. Surveyor # reviewed the verification of investigation for date of occurrence 11/23/15. This is the only fall investigation Surveyor # was provided with. Surveyor # did not have any concerns regarding Resident #13's fall on 11/23/15. On 1/11/16 at 10:17 a.m. Surveyor # spoke with Interim DON-B to inquire if there was any further information regarding Resident #13's fall on 11/21/15 & 11/22/15. Interim DON-B informed Surveyor # that the nurse documented Resident #13's falls in a general note so the notes did not flag for the fall. Interim DON-B informed Surveyor # that she wasn't aware of these falls so there was no investigation as to the root cause of the falls or interventions implemented to prevent further falls. On 1/11/16 at 2:33 p.m. Administrator-A, Interim DON-B, and Interim DON-C were informed of the above. 5.) Resident #7 was re-admitted to the facility on [DATE] with a discharge [DIAGNOSES REDACTED]. Resident #7 also had [DIAGNOSES REDACTED]. Resident #7's admission Minimum Data Set (MDS) assessment, dated 9/19/15, documents that Resident #7 had a Brief Interview for Mental Status (BIMS) score of 0 indicating that Resident #7 is severely cognitively impaired. Resident #7's Care Card dated 1/5/16 under the Mobility/Transfers column states bilateral grab rails. Resident #7's care plan with a focus of being at risk for falls includes the intervention for the use of Grab Bar so resident may help reposition. This intervention has an initiation date of 9/16/15. On 1/5/16 at 7:57 a.m. during an observation of morning cares Surveyor # noted bilateral grab bars on Resident #7's bed. Surveyor # noted that Resident #7 had an alternating pressure air mattress in place. A progress note dated 1/5/16 at 2:46 p.m. documents Abrasion to L (left) hand, 2nd finger. Redness to knuckles on 1st and 2nd finger, L (left) hand. Resident is scraping hand on wall when using R (right) siderail. Response: Bed pulled out to allow adequate room between side rail and wall to avoid resident scraping hand on the wall when using the siderail. Education provided to CNA(certified nursing assistant)'s. On 1/6/16 at 8:41 a.m. Surveyor # noted Resident #7 positioned in bed with bilateral grab bars in place on Resident #7's bed and the alternating pressure air mattress in place and functioning. Surveyor # reviewed Resident #7's medical record and noted that there was no documentation regarding an assessment or evaluation regarding the safe use of grab rails on the bed as an assistive device. On 1/6/16 during the daily exit meeting with the facility, Surveyor # asked if the facility performed assessments regarding residents use of grab rails. Interim Director of Nursing (DON)-B informed Surveyor # the facility did. Surveyor # asked where that information would be located. Interim DON-B and was informed that it would be in the chart. Surveyor # informed the facility that they had been unable to locate an assessment and requested to be provided with any additional information. On 1/7/16 Surveyor # received a copy of a siderail consent/grab bar consent form for Resident #7 dated 1/6/16 stating that The facility has explained the potential risks and benefits regarding the utilization of side rails. The consent form documents that verbal consent was given over the phone for the use of grab bars by Resident #7's Power of Attorney for Health Care. Surveyor # also received a copy of a Grab Bar Assessment Review dated 1/6/16 with a check mark stating that Resident Grab Bar Utilization remains unchanged. On 1/7/16 at 8:35 a.m. Corporate Registered Nurse-D informed Surveyor # that they had been unable to locate a safety assessment/evaluation performed regarding the safety of Resident #7's use of grab bars on his bed with an alternating pressure air mattress. No further information was provided to Surveyor # .

Based on observations, interviews and record reviews, facility staff did not thoroughly analyze repeated falls to attempt to identify the root cause of the falls from which interventions could be developed to try to prevent future falls for 2 of 4 residents who had falls. Resident #7 had 10 falls before falling and fracturing her pelvis. For most of the falls, information was not obtained regarding what Resident #7 and staff were doing prior to the falls. This information is needed to identify potential interventions to prevent future falls. Resident #15 had 7 falls in three months. Staff did not always obtain the specific information of events leading up to his falls. Staff did not implement a contour mattress as noted on Resident #15's care plan and he sustained a second fall from his bed. Staff repeated interventions as "new interventions" that were already supposed to be in use (floor mat, soft touch call light). Findings include: 1.) Surveyor # reviewed Resident #7's medical record 10/6/14- 10/13/14. Resident #7 was admitted to the facility September 11, 2013 with [DIAGNOSES REDACTED]. On the Initial Tour of the facility, Activity Director-C stated Resident #7 used to ambulate with a walker, but since she sustained a fracture over the summer, she uses a wheel chair for mobility. ASSESSMENTS/MDS (MINIMUM DATA SET) On 9/11/13 staff completed Section M "Risk for Falls" of their Clinical Health Status form. This indicates Resident #7 scored "12"; a "total score of 10 or above deems resident is at risk." Resident #7 was noted to be at risk due to intermittent confusion, 1-2 falls within the past 3 months,poor vision, medications and 1-2 predisposing diseases present. Resident #7's Initial MDS (Minimum Data Set) dated 9/18/13 indicates Resident #7 had falls within one month prior to admission and within 2-6 months prior to admission. "Risk for Falls" assessments completed quarterly for Resident #7 (12/14/13, 3/16/14, 6/15/14, and 9/13/14) all indicate Resident #7 continues to be at risk for falls. Starting with the 3/16/14 assessment and subsequent assessments, staff also note Resident #7 now has balance problem while standing and walking, change in gait pattern while walking through doorway, and requires use of assistive devices (i.e. cane, walker, furniture). Resident #7's Power of Attorney for Healthcare was activated in the hospital a few weeks prior to admission to the facility, but upon admission to the facility, Resident #7 was rated cognitively intact on the Initial MDS. Resident #7's Falls CAA (Care Area Assessment) completed with the Initial MDS on 9/18/13 states Resident #7 is at risk for falls "due to balance issues, falls at home. Goal is no falls. Risk is fall with/without injury." Resident #7 had a "Discharge-Return Anticipated" tracking form completed 7/12/14 indicating Resident #7 had 1 fall with no injury and 1 fall with a major injury since the previous MDS. (Resident #7 suffered a left inferior pubic ramus (pelvis) fracture from a fall on 7/12/14- see details below.) A Significant Change in Status Assessment MDS was completed for Resident #7 on 9/15/14 which indicates Resident #7 had one fall with no injury (should reflect 2 falls with no injury-8/7/14 and 8/8/14) after her return. The Falls CAA completed with Resident #7's Significant Change in Status Assessment on 9/15/14 states Resident #7 is "At risk (for falls) due to balance issues and forgetting to call for help prior to trying to get up. Goal is no falls. Risk if fall with/without injury." On 10/1/13, staff developed a Care Plan for Resident #7: At risk for falls related to: fell in past 30 days, use of antidepressants, confusion and physical limitations. The "Goal" is "No falls while a resident at this facility." The most recent target date is 10/7/14. Interventions initiated 10/1/13 include: -Call light or personal items available and in easy reach or provide reacher; -Footwear to prevent slipping when out of bed; -Gait belt with transfers. Ambulate using walker with gait belt and CNA (certified nursing assistant); -Keep environment free of clutter. FALLS On 10/7/14 at 9:50 a.m., Surveyor # interviewed ADON (Assistant Director of Nursing)-F regarding the facility's response to resident falls. ADON-F stated when a resident falls, the nurse on duty provides any needed first aid or medical care, calls the physician and family if needed, and starts an investigation. When ADON-F returns to work (if the fall happened while ADON-F was off duty), she reviews the fall documentation, summarizes the fall and adds the information to her tracking binder. ADON-F then adds in red ink what interventions were needed/implemented. ADON-F stated she keeps the binder with the Fall summary and interventions, and NHA (Nursing Home Administrator)-A keeps the actual Post Fall Investigations. ADON-F then provided Surveyor # with both the tracking binder and Resident #7's Fall investigations from NHA-A. Surveyor # reviewed the documentation regarding Resident #7's falls in the facility and noted Resident #7 fell 10 times between 11/3/13 and 5/22/14. On Resident #7's 11th fall, on 7/12/14, she fractured her pelvis (left inferior pubic ramus). Resident #7 fell two more times after returning from the hospital on [DATE]- Resident #7 fell on [DATE] and 8/8/14, for a total of 13 falls in just over 9 months. Few of the fall investigations contain statements from people who may have knowledge of the circumstances surrounding the falls except for statements from Resident #7 and the staff who found her, but no statements from other staff who may have seen or assisted Resident #7 prior to the falls. On 10/9/14 at approximately 1:30 p.m., Surveyor # again interviewed ADON-F regarding specific questions pertaining to Resident #7's falls. The questions and ADON-F's replies from this interview are noted below. Resident #7 had the following falls: -11/3/13 at 8:40 p.m. The Post Fall Investigation/Plan dated 11/3/13 states Resident #7: slid out of her recliner, was attempting a self-transfer, has impaired safety awareness/judgement, had bare feet, has an adaptive device that was not used (walker), last toileted at 7:30 p.m., and was sitting in her recliner watching TV since returning from supper. Resident #7 stated she was attempting to go to bed. The IDT (Interdisciplinary Team) recommendations are "Reminder posted in room to help her remember to request assistance." A SBAR (Situation/Background/Assessment/Response) Nurses' Note dated 11/3/13 at 11:04 p.m. states at 8:40 p.m. "Staff reported to writer that she found Resident sitting on the floor when she walked into Resident's room to answer the call light. Resident attempts to self-transfer with in room and sometimes forgets to use a walker. Has [DIAGNOSES REDACTED]. Observed Resident sitting on floor between bed and recliner. Both legs were stretched out and back was against her bed. When questioned, she stated 'I slide (sic) off the chair when I was getting up to go to my bed.' Also had no shoes and socks on. Informed writer that she took her shoes and socks off because she was having difficulty getting up from the floor with them on. Call light and walker were within reach. Room light was also on. Able to perform ROM (range of motion) of the extremities without difficulty. Denied discomfort. No injuries noted...Assisted Resident off the floor using Hoyer lift with two assist..." There is no documentation regarding what Resident #7's mood/behavior was when toileted at 7:30 p.m., when staff last saw Resident #7, what was she doing, how long was the call light on prior to the CNA entering the room, how many staff were on duty and what were they doing at the time of the fall- all important information which is usually gathered through staff interviews. At times, other residents may have knowledge of what led up to the fall- for example a roommate or another resident in a common area if the fall happened outside the resident's room. No statements were included with the fall investigation/follow-up documentation. Surveyor # mentioned to ADON-F that other than posting a reminder for Resident #7 to request help, staff did not address facts they were aware of, such as Resident #7 sliding out of recliner, and it appears they did not interview staff to get other information regarding the circumstances regarding the fall needed to develop interventions to try to prevent future falls. ADON-F stated some nurses use a worksheet "Suggested Resident Interventions to Prevent Falls", but it is not required. ADON-F later provided Surveyor # with worksheets for falls on 5/17/14, 5/22/14 and 8/7/14, but no other worksheets could be found. Surveyor # noted the SBAR note says staff were responding to Resident #7's call light, and also that Resident #7 took off her shoes and socks while trying to get up off the floor- and asked ADON-F if they interview staff to try to determine how long the call light had been on before the staff member answered it. ADON-F stated it appears there are no interviews regarding this fall, and she would be hesitant to document that the call light was on for 15 minutes, for example, because that would prompt others to ask why it took so long for the call light to be answered. Surveyor # stated that is exactly the kind of information they do need to obtain to get at the root cause and contributing factors of Resident #7's fall. If they interviewed staff and found Resident #7's call light had been on for a prolonged period of time but all staff were busy assisting other residents and couldn't get to it, that may necessitate an evaluation of staffing levels, or look at where staff were at the time (anyone on break, could certain tasks be reorganized to be done at a different time, etc. Whereas if the light was only on for a few minutes, that presents other questions- do staff know Resident #7's preferences for going to bed, etc. The call light was on long enough for Resident #7 to request help via the call light, wait an undetermined amount of time, attempt self-transfer, fall, try to get up, decide to remove socks and shoes in an attempt to help her get up, remove socks and shoes... Surveyor # also asked since Resident #7 said she slid out of the recliner, did they consider adding Dycem or other gripper-type fabric to the recliner to address the slipping concern. ADON-F stated they did add a gripper pad to the recliner but not until after Resident #7 slipped out of the recliner again on 12/9/13. -11/7/13 1:45 a.m. SBAR note: Resident put on call light and informed nurse that she had fallen and bumped her head. Had a recent fall. Does not always wait for assistance from staff. [DIAGNOSES REDACTED]. Resident sitting on bed when this nurse entered room. "I stood up and my feet slipped. I fell and bumped my head. then I got back up." Has lump to right side of head behind ear. Refused offer of ice pack. No other injuries noted... (later noted bruise to right buttock). The Post Fall Investigation dated 11/7/13 indicates Resident #7 slipped, attempting to self-transfer, has history of falls, impaired safety awareness/judgement, had been sleeping, stood up and feet slipped, got herself up and put on call light, lump to right side of head behind ear, was wearing regular socks. Where the form asks "Time last toileted/voided", staff wrote "PM shift- had not yet called back as of now." "Possible Causal/Contributing Factors and Observations- Does not always call for assistance. Was wearing socks on her feet." The new Intervention was for Resident #7 to wear gripper socks at night. Surveyor # asked ADON-F how that is different than the Care Plan intervention dated 10/1/13 "Footwear to prevent slipping when out of bed." ADON-F stated that is the same thing, so Resident #7 should have already had gripper socks on her feet, not regular socks. There is no evidence of staff re-education regarding not following Resident #7's care plan. Since there are no staff interviews, it is unknown if the staff assisting Resident #7 to bed was aware of the need for gripper socks, or if none were available, or what the circumstances were. Surveyor # asked if staff ever followed up regarding when Resident #7 was last assisted to the bathroom, or when staff last checked on Resident #7, since the night shift nurse only indicated PM staff had not called back yet. ADON-F stated there was no further information regarding this fall. -11/8/13 3:15 p.m. Post Fall Investigation/Plan dated 11/8/13 indicates Resident #7 lost balance, slipped while ambulating with a CNA (Certified Nursing Assistant) using a walker and gait belt to an activity. Resident #7 sustained a bruised right knee. The new intervention is staff are to ensure Resident #7 has sufficient time to fully wake up before ambulating, and while ambulating, cue Resident #7 to keep the walker closer to her, walk slowly and pick her feet up. -12/9/13 8:45 p.m. Post Fall Investigation/Plan states Resident #7 slipped from her recliner while trying to pick up candy from the floor. Resident #7 was wearing gripper socks and was last toileted at 8:00 p.m. "Possible Causal/Contributing Factors and Observations: Slippery fabric on recliner cushion. Specify Recommendations /Interventions taken to prevent reoccurrence: Non-slip pad to be placed on seat of recliner." The SBAR note dated 12/9/13 at 10:55 p.m. states "At 8:45 p.m., writer walked into the room to administer HS (hour of sleep) medications to resident. Found Resident sitting on the floor facing her recliner. Resident sometimes attempts to self transfer unassisted... Surveyor # noted again there are no staff or resident (Resident #7 and/or roommate) interviews and asked ADON-F if they knew how long Resident #7 had been on the floor, when did staff last see or assist Resident #7, and why they would not have put the gripper pad on the reclines after the first time Resident #7 slid out of her recliner on 11/3/13. ADON-F had no additional information. -12/18/13 8:40 p.m. Post Fall Investigation/Plan: Resident #7 was assisted to the bathroom and to be at 8:30 p.m. but left Resident #7's dentures in her mouth. Resident #7 got up to put her dentures in the denture cup in the bathroom and lost her balance while trying to turn on the bathroom light. Resident #7 landed on the floor in a sitting position. Staff were reminded to put Resident #7's dentures away while assisting with HS cares. The SBAR note dated 12/18/13 at 9:55 p.m. states "At 8:40 p.m., Resident's roommate came out of the room and informed staff that Resident had fallen. When interviewed, roommate stated "I heard a loud noise and asked my roommate if she was OK and she responded 'No, I am not'. So when I turned I saw her hand under my bed." Background: Sometimes resident attempts to transfer self forgetting to use a walker or call for assistance...Assessment: Found sitting by bathroom door. Had back against the wall and both legs extended. in night dress with gripper socks on. Call light was off but within reach. 2 x 2 bump noted at back of head... When questioned, Resident responded "I was trying to turn the bathroom light on so I could put my dentures away then I fell ." -2/3/14 6:30 p.m. Post Fall Investigation/ Plan: Resident #7 slid out of her wheel chair; she stated she was trying to reach for stuffed animals, was over-reaching and first fell to hands and knees, then turned and sat on her buttocks. Resident #7 had last been assisted to the bathroom at 4:30 p.m., was wearing socks and shoes on her feet. Staff are now to help Resident #7 arrange her stuffed animals they way she likes them. (Resident #7 has a large collection of stuffed animals and likes to change them around.) The SBAR note dated 2/3/14 at 11:22 p.m. states "Called to room by NA (nursing assistant) who stated that Resident was on all 4's next to wheel chair...When writer entered room, Resident was sitting on butt next to closed door, had been reaching for stuffed animals when she fell from wheel chair,... no injuries noted. (On next shift, dark blue bruises appeared on Resident #7's right wrist and elbow). There is no documentation indicating if any staff saw/had interactions with Resident #7 after the 4:30 p.m. toileting assistance, such as when did she return from supper if she ate in the dining room, was the call light on, had Resident #7 asked anyone to help her with rearranging her animals... Nor is there any indication of how the nursing assistant came upon Resident #7 on the floor- was the Resident or roommate calling out? Did they roommate inform staff? Was the CNA just passing by and saw Resident #7? Here again, valuable information is missing due to lack of staff interviews. Surveyor # asked ADON-F if they had thought to be proactive and place a gripper pad in Resident #7's wheel chair when they placed a gripper pad in the recliner instead of waiting until after she slides out of the wheel chair and falls. ADON-F stated they had not discussed adding it to the wheel chair at that time. -3/9/14 9:18 p.m. Nurses Notes: 3/9/14 at 12:57 p.m.: Resident "seems to have less patience for staff to help to the bathroom and continues to transfer herself on own still." SBAR Nurses Note 3/9/14 at 9:00 p.m.: At 7:45 p.m., was called to the room as Resident had a fall to the floor, was sitting on butt. Has history of falls, syncope, hypertension, osteoporosis, restless leg syndrome, and diabetes without complications. Upon entering room resident was sitting on floor; floor was dry, had slipper socks on. Resident's so had just left the room. Has bump on back of head, no other injuries noted... Nurses Note 3/10/14 4:36 p.m. "...No apparent further injury as related to fall yesterday. Resident noted to be up ambulating in her room X2 (twice) this shift without assistance. Staff intervened and assisted her with the task and then escorted her back to her chair. This writer reviewed the signs in her room as related to her safety. (Resident) read them out loud to this writer and stated "I've fallen a few times and haven't got hurt yet!" Again reviewed safety measures with her. She states "I will try harder to follow the rules" with a smile on her face." The Post Fall Investigation /Plan dated 3/9/14 indicates Resident #7 slipped while attempting to self-transfer and sustained a bump on the back of her head. Last toileted at 7:00 p.m., was wearing gripper socks. Possible Causal/Contributing Factors and Observations: Dementia, poor safety awareness, had been sitting in her recliner since after supper watching TV with son who came to visit....Soon after he left (Resident #7) got up to get ready for bed. She was wearing gripper socks. Door to room had been closed at her request. Educate son that door to be left open; he is in agreement to leave door open when he is not in room. Intervention taken: Door to be kept open when she does not have visitors and if cares are not being provided. There are no other staff statements other than what is noted above. Interviewing all staff may provide additional information to help get to the root cause of the fall. For example, did staff see Resident #7's son leave her room- that may clue them in to realizing Resident #7 may now try to use the bathroom or get ready for bed unassisted. Interviewing all staff may reveal root causes not specific to this resident-such as staffing levels-perhaps the son told staff Resident #7 is ready to go to bed but they were busy with other residents, or that he could not find staff to tell them, or staff were on break. It is noted the son is in agreement to keep the door open when he leaves-did staff talk with him about alerting them when he leaves due to multiple falls after supper? The Investigation does not indicate if the gripper pad was in Resident #7's recliner or if the call light was activated or within reach. The Investigation does not indicate how staff were alerted that Resident #7 was on the floor- was call light on, did Resident #7 call out, did the roommate tell staff, did they just happen to pass by? Do staff know if Resident #7 is sliding out of her recliner versus standing up and then falling? Knowing this information as much as possible will help determine the root cause of the fall which will help in developing appropriate interventions to prevent future falls. Surveyor # asked ADON-F the above questions, and asked if staff were instructed to monitor or check on Resident #7 more closely after supper due to multiple falls at that time, or if other interventions -besides keeping door open-were tried or considered. ADON-F stated that is all the information regarding this fall-there are no additional interviews or statements or notes. -5/16/14 7:15 a.m. CNA called writer to Resident's bathroom-Resident sitting on floor leaning against the toilet with legs fully extended, states "I leaned forward to tie my shoelaces and slid onto the floor...I hit my head on the wall." Contusion with swelling left occipital area (back of head), small bruise right hand 3rd finger approximately 3 centimeters (cm.) diameter. Causal Factors-...Anxiety, Resident often non-compliant with safety measures in place as related to transfers and ambulation. Intervention- Staff are to ensure shoelaces are tied while providing cares. CNA-R informed RN-E of the fall, but the investigation does not indicate where CNA-R was when Resident #7 tried to tie her shoes- was she in the Resident's room just outside the door, was she in another resident's room, did she take another resident to the dining room for breakfast, was there sufficient staff on the unit... Knowing what was happening on the unit, what staff were working, where staff were and what they were doing is needed to get to the root cause of the fall. Again, it does not indicate how staff became aware of the fall. ADON-F did not have any additional information regarding this fall. -5/17/14 12:45 a.m. Post Fall Investigation/ Plan- CNA was ambulating Resident to the bathroom when Resident began to lean to the left. CNA unable to straighten Resident up so she got behind Resident and lowered her to the floor. When nurse entered room, Resident was sitting on buttocks with legs extended out near recliner. No new injuries. Was wearing gripper socks and gait belt in use. Resident and staff were only half way to the bathroom when Resident began to lean to the left. New Intervention: Use a bedside commode at night so Resident does not have to ambulate all the way to the bathroom. It is noted Resident #7 recently began taking melatonin at HS (discontinued 9/30/14). Surveyor # made numerous observations on multiple days (10/6 through 10/9) from 7:00 a.m. to 7:00 p.m. and did not see a commode in Resident #7's room. Surveyor # interviewed multiple CNA's on first and second shift (first shift starts at 6:00 a.m., second shift assists Resident #7 to bed), and they all stated Resident #7 had used a bedside commode for a little while after she fractured her pelvis during the summer, but hasn't used it in quite a while. Resident #7's Care Plan and CNA Care Card both include "uses bedside commode at night." Surveyor # asked ADON-F about Resident #7's bedside commode-noting staff state she no longer uses it. ADON-F was not aware the commode was no longer in use and would talk with staff to see if it should be used or if that intervention should be removed from the care plan. Surveyor # asked if they routinely have the pharmacist review medications for Residents having falls. ADON-F stated that is something they could do, but it is not done routinely now. -5/22/14 4:00 p.m. Verification of Investigation form and SBAR Nurses' Note states staff witnessed Resident #7 slide out of wheel chair in her room, trying to pick something up from the floor. Resident #7 suffered a 2 x 2 cm. scrape to her back. "Background-Resident has a history of falls. Usually attempts to self-transfer without calling for assistance... The Intervention is to place a gripper pad in Resident #7's wheel chair. Surveyor # asked ADON-F why they did not take proactive measures when they placed a gripper pad in Resident #7's recliner and place a gripper pad in Resident #7's wheel chair, but rather react after Resident #7 slid out of her recliner and then place the gripper pad in the wheel chair. ADON-F stated they did not think of that at the time. -7/12/14 9:00 p.m. Verification of Investigation and Post Fall Investigation/ Plan: Resident #7's roommate alerted staff that Resident #7 had fallen in their room after disposing a Kleenex in the garbage can by her recliner that Resident #7 had used to clean the soda roommate had spilled on the floor. Resident #7 was found lying on her left side with left knee bent and head by bedside table. Resident reported hitting head on bedside table. Complained of lateral left thigh discomfort upon range of motion of left leg. No shortness of left leg noted. Two purple bruises, 2x1 cm. to left arm and 1x1 cm. to right elbow noted...Resident responded she was trying to get back to my seat. Last time toileted-8:30 p.m., wearing shoes. "Recommendations/Interventions taken to prevent re-occurrence: *Keep walker within reach at all times*." The Investigation does not indicate where Resident #7's walker was, or if the call light was within reach, or any interviews with staff or further information from the roommate- such as when was the soda spilled- did it just happen or was it left there for a while, did staff know about it, did Resident #7 or roommate put call light on, if so, was there any response, nor does the investigation contain documentation regarding who was working, when did they last see Resident #7, etc. to get at the root cause of the fall. Resident #7 was sent to the Emergency Department and returned at 12:30 a.m. on 7/13/14 with a [DIAGNOSES REDACTED]. Nurses Notes dated 7/15/14 at 11:29 p.m. state Resident #7 "was seen self-transferring x4 (four times) without putting call light on. At last transfer, roommate yelled for help due to Resident standing, stuck, holding bathroom door, unable to move due to pain in her hip. Resident keeps claiming "I won't get up by myself." ADON-F stated there were no additional statements or background information regarding this fall. -8/7/14 8:52 p.m. Verification of Investigation: Found lying on the floor next to bathroom door. Stated she had been trying to get to the bathroom. Has poor short term memory and poor safety awareness. She forgets that she is no longer able to safely ambulate on her own and needs to call for help. Has a Foley catheter in place due to urinary retention and may have tripped on the tubing or drainage bag. Intervention: Foley drainage bag will be changed to a leg bag with morning cares and back to a drainage bag with HS cares. The SBAR Nurses' Note also adds "POA (Power of Attorney) aware, he stated he would call (Resident #7) tomorrow and talk to her about asking for help." (Note: This is Resident #7's 12th fall and she has been reminded to call for help repeatedly). Surveyor # asked ADON-F why staff felt Resident #7 may have tripped on the tubing- Resident #7 was able to say she was on her way to the bathroom- did she say she tripped on the bag or tubing, or was the catheter dislodged. ADON-F stated there is no information documented that indicates why the nurse came to that conclusion. Surveyor # also noted neither the Nurses' Notes nor Investigation indicates when Resident was last seen or assisted by staff- was she in her recliner prior to the fall or in bed; what was she wearing on her feet; did the family member visit that evening, if so, when did he leave, was the door open per plan of care; how was staff alerted to the fall- it just states Resident #7 was "found on the floor..."- did Resident #7 or roommate call out or put call light on, did Resident #7 put call light on prior to getting up to go to the bathroom and had to wait too long for staff or was the call light not activated, did staff just happen to see Resident #7 on the floor. Again- without knowing the circumstances, staff do not have a clear understanding of what happen and what interventions may be most helpful. ADON-F stated they had no additional information. -8/8/14 4:40 p.m. Verification of Investigation: Nurse informed by CNA that Resident #7 was on the floor in her room with her back leaning against the recliner. Resident #7 stated "I was gonna get up and go eat dinner. One minute I was standing, then I don't know what happened. I was sitting on the floor and couldn't get up..." Causal/Contributing Factors: Resident has had frequent falls lately due to non-compliance with asking for help. Room was observed for clutter, nothing noted. Has a history of fractured pelvis which does cause resident pain from time to time, especially during transfers. "Recommendations/Interventions taken to prevent re-occurrence: Knowledge re-inforced about importance of asking for help and using a call light to prevent further falls and possible injury. (Resident) Stated "I will be OK." Resident agreed to use the call light appropriately when needed. Was seen transferring without assist several hours after the fall. Frequent visual checks performed through the shift." The Post Fall Investigation/Plan states Resident #7 had been watching TV in her room sitting in her recliner when she tried to get up on her own. The "Recommendation/ Intervention taken to prevent reoccurrence" is "Visual reminder posted in room to make Resident aware of mealtime." None of the documentation indicates if there was a gripper pad in the recliner, if Resident #7's call light was within reach, if it was activated, when staff last saw or assisted Resident #7 ("Time last toileted" is blank). The investigation does not indicate how staff were alerted to the fall- was the call light on, did Resident #7 or roommate call out, did staff just happen to see Resident #7 on the floor. The investigation does not indicate what staff were on duty and what they were doing. The investigation does not note where Resident #7's wheel chair or walker were positioned. Surveyor # noted this was Resident #7's 13th fall in 9 months, and observed staff continue to remind Resident #7 to ask for help or post more reminders, but Resident #7 continued to have falls. Surveyor # noted even after 13 falls, they have not increased supervision or more frequent checks with Resident #7 except the "frequent visual checks performed throughout the shift" on 8/8/14. ADON-F stated nurses can use a worksheet to help them gather information regarding falls, but it is not required. Surveyor # observed a sign taped to Resident #7's over-the-bed table stating "Supper is at 5:30 p.m. Use your call light at 5:00 p.m. for help into your wheel chair. DO NOT get up by yourself." Surveyor # asked ADON-F if they had considered having staff check with Resident #7 to see when she would like to go to supper instead of telling her to request help at 5:00 pm. Numerous residents have been observed in the dining room socializing well before the meal time, or perhaps she does not want to go to the dinging room until just before the meal is served. ADON-F stated it would be up to Resident #7. ADON-F later provided Surveyor # with worksheets for three of Resident #7's falls and stated those are the only ones completed for Resident #7. The worksheets are for: 5/17/14 -lowered to floor while ambulating with staff, 5/22/14-staff witnessed slide out of wheel chair, and 8/7/14-may have tripped over Foley bag/tubing. The Worksheet does add that Resident #7's call light was within reach and it was not on/activated; Resident #7 was last assisted to the toilet at "HS" but it does not say what time that was; Time last seen is left blank." If Reside

Based on observation, interview and record review, the facility did not ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident 1) reviewed for accidents. Resident 1 sustained a fall at the facility while seated in a transport wheelchair (Everest and Jennings bariatric transport chair model EJ,[DATE]). Resident 1's plan of care indicates that the facility would assess any wheelchair that may be used by Resident 1. The facility did not complete an assessment to determine if the wheelchair used was safe. Manufacturer's instructions for use of the wheelchair direct to have an attendant behind the wheelchair at all times and recommend the use of anti-tippers on the wheelchair. Neither was in place when Resident 1 fell . Resident 1 sustained fractures from the fall and later expired at an acute care hospital. This is evidenced by the following: The facility's policy titled, "Fall Management Clinical Guidelines" (Revised January, 2011), states: "The center implements the falls prevention and intervention program including:...The interdisciplinary team evaluates the fall prevention plan of care for residents 'at risk' for falls...This evaluation may include a screening by rehabilitation services representative and pharmacy consult for medications that could affect balance or gait...continue ongoing assessment and documentation by licensed nurses per center practice..." The website www.grahamfield.com contains EJ-,[DATE] Bariatric Transport Chair Operations Manual. This manual states, "EJ,[DATE] Transport Chair user and attendant: Read this manual before operating the Transport Chair...The EJ,[DATE] Transport Chair is intended to be propelled by an attendant at all times, who should remain behind the Transport Chair when the user is being positioned or the Transport Chair is in use...WARNING: Do not lean over the top of the Transport Chair back. This could cause the Transport Chair to tip over...WARNING: We recommend the use of anti-tippers at all times to prevent the Transport Chair from tipping backward and causing injury...The Everest & Jennings EJ,[DATE] Transport Chair has been designed and engineered to perform as a stable and well balanced unit when used for its intended purpose. However, it is possible to tip the Transport Chair over if it is used improperly. We urge both user and attendant to learn the characteristics of your Transport Chair. It is most important to learn safe methods to perform the daily activities basic to your lifestyle...TO ATTENDANT: WARNING: To avoid possible tilt hazard, do not leave user unattended. Attendant must always be behind and in control of Transport Chair when user is being positioned or Transport Chair is in use...Proper balance is the key to maintaining the stability of your EJ,[DATE] Transport Chair. Reaching, bending, and transferring to or from a Transport Chair will change your weight distribution and center of gravity. Have an attendant with you at all times, especially when reaching, bending, or transferring...The person performing adjustments on the Transport Chair has the responsibility of making certain that the user and attendant can safely operate the Transport Chair with the adjustments selected. This person must evaluate the user's ability, weight, physical condition, the environment in which the Transport Chair will be used, and the terrain over which the Transport Chair will travel..." According to "Admission Record", Resident 1 has the following Diagnoses: [REDACTED]. Resident 1's plan of care for falls (Print date [DATE]) states the following interventions: "Ambulate with one assist, assess for pain prn (as needed) with behaviors, calling out etc.; assist resident to recliner after supper to watch TV and visit with roommate; Bed in low position when (Resident 1) is in it; Call light or personal items available and in easy reach or provide reacher; (Resident 1) to have his walker placed in front of him with the wheels locked when in recliner...(Resident 1) will participate in Activity Programming-exercises, TV programs; Footwear to prevent slipping when out of bed; If (Resident 1) has need for w/c (wheelchair) assess that wheel chair is of appropriate size; assess need for footrests; assess for need to have wheelchair locked/unlocked for safety, anti-tippers; keep environment well lit and free of clutter; monitor closely after returning to facility after appointment as (Resident 1) becomes quite confused; must wear glasses when ambulating; observe for side effects of medications; one staff assist with transfers...therapy referral if decline noted; toilet schedule...when agitated remain with resident until he is calm and feels secure; [DATE] watch for proper placement of feet during transfers to avoid foot injury..XXX[DATE] anti-tippers to back of w/c." The facility completed an annual Minimum Data Set (MDS) assessment, dated [DATE]. This assessment states that Resident 1 scored 3 points on the Brief Interview for Mental Status (BIMS). This indicates that Resident 1 has severe cognitive impairment. Section G, Functional Status, of this assessments notes that Resident 1 used a walker as a mobility device. It is important to note that 'wheelchair' is not marked as a device that is normally used by Resident 1. The facility completed Care Area Assessments (CAAs) for Falls states the following: "2. Balance problems during transition indicated by a value of 1 or 2 for any items as follows: Moving from seated to standing position=Not steady, only able to stabilize with staff assistance. 5. Resident has fallen at least one time since admission or the prior assessment as indicated by: Has the resident had any falls since admission or the prior assessment, whichever is more recent? Yes. 7. Resident received antidepressant medication...antidepressant...Resident is at risk for falls due to being unsteady and needing assistance form staff, had one fall and is taking antidepressant medications. Goal is no falls. Risk is fall with injury/no injury. Will proceed to care plan..." The facility completed a quarterly MDS assessment, dated [DATE]. This assessment indicates that Resident 1 normally uses a walker. It is important to note that this assessment does not indicate that Resident 1 used a wheelchair. "Clinical Health Status" dated [DATE] indicates that Resident 1 scored 11 points on "Risk for Falls" assessment. This score implies that Resident 1 was at risk for falls. Resident 1's Progress Notes state the following, in part (please note that Resident 1 has been utilizing this wheelchair since [DATE]): [DATE]: Uses wheelchair for long distances [DATE]: Offered wheelchair X 2 (twice) and he refused [DATE]: Ambulates with wheeled walker and stand by assist when not complaining of hip pain, otherwise he has been using a w/c [DATE]: uses w/c for distance [DATE]: sat in w/c and visited with staff [DATE]: uses w/c for longer distances [DATE]: Staff transferred res. to dining room for breakfast using w/chair [DATE]: Using w/c this shift due to weakness [DATE]: At 1 am resident was calmer-dozing in wheelchair [DATE]: uses walker for short distances in facility, wheelchair for longer [DATE]: Tends to try getting up from wheelchair by himself [DATE]: When he awoke he went to the dining room to sit for activities. He had tried to stand several times. It is important to note that Resident 1 used his wheelchair, without an assessment completed to ensure proper fit and safeness of the chair. "Change in Condition Report-Post Fall/Trauma" states the following: "Date: [DATE]; Time: 13:00 (1:00 PM)...Resident had been anxious and restless. He has new orders for ([DATE]) for Lorazepam 0.5 mg scheduled q (every) 0800 (8:00 AM) and had also received a prn dose at 1100 (11:00 AM) because of anxiety/restlessness. Prior to fall, resident was: doing usual activities-yes (checked); standing still-no; walking-no; reaching up-no; reaching down-yes (checked); reaching out-no; in a crowd of people-no; responding to bladder of bowel urgency-no. Physical assessment: localized pain-severe back pain; skin tear, describe: abrasion to left elbow...Nurses note intervention: On [DATE] at 13:00, the following occurred: Falls: wheelchair in corridor (ACU (Alzheimer's Care Unit) porch), injuries: abrasion: arm (left), other (Res c/o (complains of) severe pain to his back): Back. He did not fall out of the wheelchair, was still in it after chair tipped over. First aid administered in facility, physician notified, family notified, resident seen by physician, resident taken to hospital, care plan updated. Interventions used prior to fall: toilet schedule, assistive device in reach, pain assessment, bed in low position, call light w/in (within) reach, other (blank). Post Fall Investigation Summary: Recommendations and interventions post fall: w/c positioning, other: anti-tippers. Summary: Res tipped his wheelchair over backwards. He did not fall out of the w/c, but remained with it after chair tipped over. He had been in the ACU porch area @ (at) the time. He had been restless/anxious and needed frequent reassurance. He calms when he is with others-does not like to be alone. He began to lean down and forward-reaching down. Staff asked him to sit up straight. He straightened up quickly & hit the back of his wheelchair rest hard with feet planted on floor causing the wheelchair to tip over backward. There is no evidence of hitting his head. He had received a prn Lorazepam @ 1100 d/t (due to) ? (increased) anxiety. BS (blood sugar) 119. He ate 100% of breakfast and lunch. His wife was in to visit in the morning and he was restless c (with) her also (not usual). [DATE]: ER report-Fx (fracture) T (thoracic spine) 9. He was dx'd (diagnosed ) with small bilat (bilateral) plural effusions-Atelectasis vs. infiltrates. IDT (interdisciplinary team) Team Review and Recommendations: Anti-tippers to back of w/c." The facility completed "Verification of Investigation" which states: "Resident had been leaning forward in his wheelchair. A staff member asked him to sit back. Resident pushed back with his legs and wheelchair tipped backward. Resident remained in the wheelchair landing on his back. No loss of consciousness or indication that he hit his head. Resident was at baseline neuro (neurological) status. No loss of consciousness or indication of having hit head. Resident's facial features symmetrical with equal pupils. Eyes moist with no sunken appearance. Oral mucous membranes pink and moist. Speech clear. Able to answer questions, although confused answers, which is at baseline. Heart rate regular, lungs clear. Resident independently moved all extremities and had equal hand grasps. Resident grimaced and verbalized pain in middle back. He was assisted to stay on the floor as still as possible while 911 was called for emergent transport to ER for evaluation. Resident unable to vocalize how fall occurred. Immediate assessment completed...Resident has advanced Alzheimer's disease with poor safety awareness. Resident experiences anxiety with agitation at times. He has scheduled Lorazepam ordered at 0800 and prn Lorazepam if other interventions are not successful. Resident was tired and weak, yet anxious and moving around quite a bit. Resident has history of vitamin D deficiency which could contribute to weakness, brittleness, or degeneration of bones increasing risk for fractures. Intervention prior to incident: Resident was given scheduled Lorazepam at 0800. The unit RN (registered nurse) assessed him again at 11:00 and administered a PRN dose of Lorazepam due to anxiety and agitation. Resident reassessed at 12:00 for continued anxiety and pan and RN administered 500 mg (milligrams) of Tylenol for discomfort. Resident was assisted with lunch and ate 100% of the meal. After lunch he was assisted to the toilet. Two staff members assisted him to stand up out of the wheelchair and one staff member completed assisting him. (Resident 1) was cooperative and transferred to/from toilet with one assist. Resident is followed by the Behavior Committee. Staff was conducting a quiet activity called 'The Den' and were playing classic music for the residents to relax to in the resident lounge. Residents were being monitored by a staff member. Resident was in his wheelchair, self propelling in lounge area. Resident leaned forward in his wheelchair and was asked by the staff member to sit back for safety. Recommendations and Interventions Post Incident: Resident will be assessed upon return to the facility by therapy for a properly sized wheelchair with anti-tippers to prevent tipping self backward. Therapy to evaluate upon return to the facility. Continued follow up by behavior committee to monitor behaviors and develop interventions/strategies or medication recommendations. Pain assessments to be completed with changes in behavior or increased restlessness...Staff felt that if he transferred from wheelchair or his recliner that he would have been at risk for a fall due to constant activity and possibility of trying to stand up unassisted. Staff felt that assisting him to bed would have also been a fall risk. Staff felt that attempting ambulate resident would have been a risk due to his fatigue. Staff felt that resident's wheelchair was the most appropriate fall prevention as he was able to independently propel the w/c using his feet. Resident had been doing so in the hall and staff felt this physical activity helped to prevent resident from developing increased anxiety. A staff member present during the activity in the resident lounge had been trying to maintain the resident's safety by asking him to sit back in his wheelchair. The fall was an unfortunate accident that resulted in an injury. Staff followed his plan of care and consistently made attempts to keep him safe." The facility felt that Resident 1 was safe in a wheelchair that had not been assessed to determine if this assistive device was safe for Resident 1's use. The facility did not follow Resident 1's plan of care, which directs staff to assess a wheelchair, if Resident 1 is in need of wheelchair use. The facility did not follow the manufacturer's recommendations for use of the chair. Emergency Department notes for Resident 1, dated [DATE] state: "Diagnosis: [REDACTED]. The onset was just prior to arrival. The occurrence was a single episode. Tipped over backwards in his wheelchair...Calls-Consults-...orthopedic surgeon, phone call, consult, recommends transfer to UW due to need for spine surgeon to evaluate..." On [DATE], Surveyor observed Resident 1's chair that he fell from on [DATE], which was still at the facility. Surveyor noted that Resident 1's chair was a transport style chair, with four small wheels and was lightweight. Certified Nursing Assistant (CNA) D stated that Resident 1 was placed into this chair when he was agitated and wanting to be mobile. CNA D stated that Resident 1 could self-propel in the chair using his feet. Surveyor asked CNA D to show the model number of the chair. CNA D stated that the model number was EJ,[DATE]. The chair was labeled with the brand "Everest and Jennings." Surveyor noted that the chair had brakes on the back handles. Surveyor requested information regarding the manufacturer's instructions for use for the chair from the facility. The facility was not able to locate information regarding the chair. It is important to note that Resident 1 used Everest and Jennings bariatric transport chair model EJ,[DATE]. The operations manual described above refers to model EJ,[DATE]. Surveyor spoke with Wheelchair Manufacturer Representative (WMR) H on [DATE] at 11:12 AM. WMR H stated that the version 1 model had been discontinued. WMR H stated that the version 2 model has a deeper seat (18 inches compared to 17 inches on the previous model). WMR H stated that the frame of the version 2 model is now made of aluminum instead of steel. WMR H stated that the operation manual for use of the 1 model would be the same as the 2 model. Surveyor spoke to Director of Nursing (DON) B on [DATE] at 1:43 PM. DON B stated that the process for placing a resident in a wheelchair usually goes through therapy. DON B stated that most residents come from the hospital and have a wheelchair. DON B stated that Resident 1 had his own wheelchair and it was only used when his wife was at the facility to visit. Surveyor asked how often Resident 1's wife would come to the facility and visit. DON B stated that she would visit every day. DON B stated that the chair was appropriate for Resident 1's weight, height and width. Surveyor requested this information from Resident 1's medical record. DON B stated that Resident 1 could self propel in the chair. DON B stated that a formal assessment for the wheelchair was not completed. Surveyor asked DON B about the facility's process for ensuring that wheelchairs are appropriate. DON B stated that usually the restorative aides will find if someone is in need of this. DON B stated that Resident 1 had Alzheimer's and had a decline and this resulted in greater wheelchair use. DON B stated that it was the wife's request to place Resident 1 in the wheelchair earlier in the day, on the day of the fall and that Resident 1 wanted to walk down the hall. Surveyor asked if the facility assessed the wheelchair for possible use of the anti-tippers. DON B stated that there was no indication the Resident 1 needed the anti-tippers placed. Surveyor requested this assessment. Surveyor asked DON B what happened to Resident 1 after his discharge from the facility. DON B stated that Resident 1 was transferred to a palliative care unit at UW (University of Wisconsin Hospital). DON B stated that she would look for more information regarding the incident. Surveyor spoke with Rehab Manager (RM) F on [DATE] at approximately 2:15 PM. RM F stated that she asks staff to let her know if someone may need a wheelchair assessment and that the facility screens each resident at least quarterly for wheelchair positioning. RM F stated that these residents would be picked up for therapy caseload and assessed. Surveyor asked about Resident 1's wheelchair use and if an assessment was completed. RM F stated that she would expect an assessment because this would be a change in condition. RM F stated that nursing should send the resident to therapy and that this would also be a change in transferring. RM F stated that if the wheelchair use was a one-time thing, then this would be different. RM F stated that Resident 1 was on her caseload two or three times and rehabbed to walk with a four-wheeled walker. Surveyor asked about Resident 1's wheelchair use. RM F stated that she thinks it was just a transport wheelchair that the family brought in and she believes the brakes are usually on the back handles. Surveyor asked RM F if Resident 1 was assessed to use the wheelchair. RM F stated that there was never a screen done for wheelchair positioning because he had walked to and from meals. RM F stated that Resident 1's wife used the wheelchair to take Resident 1 out of the facility. Surveyor asked RM F what type of chair would be used for Resident 1 after he ambulated to his destination. RM F stated that he would use a standard chair. Surveyor again asked for information regarding an assessment for the use of a wheelchair, in particular the transport wheelchair that was in use. RM F stated that she knew they did not do one. RM F stated that the restorative aides have been trained to wheelchair assessments. Surveyor spoke with Restorative Aide (RA) G on [DATE] at 2:31 PM. RA G stated that she had been trained to identify potential residents who may be in need of wheelchair assessments. RA G stated that she had worked with Resident 1 regarding ambulation. RA G stated that Resident 1 was walking at the time prior to his discharge. RA G stated that Resident 1 did not use a wheelchair but he did use a transport chair when going out of the facility with his wife. Surveyor asked RA G to describe that wheelchair. RA G stated that it had four little wheels and was not sure if there were brakes on it. RA G stated that these were not safe because there was no balance to the wheelchair and they could tip backwards. Surveyor spoke with RA E on [DATE] at 2:52 PM. RA E stated that she did not work with Resident 1 regarding his wheelchair but did work with him for ambulation. RA E stated that before he fell , he was ambulating to the dining room about 25 to 50 feet but was getting unsteady. RA E stated that he was placed in the wheelchair for transport and then should be placed in the recliner or chair. Surveyor spoke with RM F at 3:25 PM. RM F stated that the transport wheelchair was intended to be used for transport as it is lightweight and used for shopping or appointments. RM F stated that the transport wheelchair used by Resident 1 probably would not be safe and that residents should not be unsupervised in the chairs. RM F stated that this chair is not intended for everyday use. RM F stated that she rehabbed him and discontinued him from rehab on [DATE] as ambulating using 1 assist and a four-wheeled walker. Surveyor spoke with Nursing Home Administrator (NHA) A at approximately 4:00 PM on [DATE]. NHA A stated that he was not able to find information regarding the operation instructions for the wheelchair. NHA A stated that this wheelchair was Resident 1's personal chair. Surveyor asked NHA A about the facility's process for assessing equipment used by residents if brought into the facility. NHA A stated that he could not say that they have one. Surveyor spoke with DON B on [DATE]. Surveyor asked DON B if Resident 1 fell from the transport wheelchair. DON B stated that Resident 1 fell from the transport wheelchair. DON B stated that, according to the Jefferson County Coroner, Resident 1 died from a cardiac arrest with contributing factors from the fall and hypertension. DON B stated that the death was ruled as accidental. The facility did not address the fact that Resident 1 was in a wheelchair that was not intended to be used without an attendant and did not assess Resident 1's need for an appropriate wheelchair. The facility did not follow Resident 1's plan of care and did not provide Resident 1 with an appropriate assistive device and supervision in order to prevent accidents. The facility did not use Resident 1's wheelchair in accordance with manufacturer's instructions. No additional information was provided.