Every finding on record at Rolling Hills Rehab Ctr

Based on interview and record review, the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 of 19 sampled Residents (R2) and 1 of 1 supplemental Residents (R58) reviewed for change of condition. R58 was diagnosed with Covid 19 on [DATE] and then pneumonia on [DATE]. On [DATE], R58 had noted oxygen saturation levels in the low 80s, complained of shortness of breath (SOB), labored breathing and was also noted to be more fatigued than the day prior and disoriented at times. There is no evidence comprehensive assessment or R58's physician being updated of R58s condition changes and R58 expired [DATE]. The facility's failure to recognize a resident change in condition, perform comprehensive nursing assessments, and failure to update the physician timely created a finding of immediate jeopardy that began on [DATE]. NHA (Nursing Home Administrator) was notified of the immediate jeopardy on [DATE] at 11:06 AM. The immediate jeopardy was removed on [DATE]. However, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as evidenced by the following examples: R2 had a 6-pound weight gain in one week. R2 was not assessed, and her medical provider was not updated. Evidenced by: 1.) The facility's Significant Change—Reporting policy, dated 5/2000, states, in part: Procedure: 1.Consult with provider will occur immediately (within 1 hour) when there is: .b. a significant change in the resident's physical, mental or psychosocial status. (For example: A deterioration in health, mental or psychosocial status resulting in life-threatening conditions. 2. Consult with provider will occur within 4 hours for: .b. A need to alter treatment significantly. 4. Nursing assessments will continue on the resident until the immediate threat to the health or safety of the resident is resolved. 5. Further changes in the resident's status will be reported to the doctor and family in a timely manner until the resident's problem is resolved. Significant Change Indicators/Guidelines The following is a list of signs and symptoms which, when observed in an otherwise stable resident, may indicate illness, exacerbation of previous disease conditions, injury, or decline in functional ability. The circumstances surrounding the suspected problem should be thoroughly assessed using the nursing process (problem solving technique – assess, plan, implement, evaluate) and with the consideration of the special problems of the individual resident. The pertinent historical (subjective) data and physical findings, laboratory / Xray (objective) data should be recorded on the appropriate form and the doctor notified promptly. Presenting Signs and Symptoms . 5. Respiratory Cough 2 day duration Worsening of cough in resident with COPD (Chronic obstructive pulmonary disease—a lung condition that makes breathing difficult by damaging airways), CHF (congestive heart failure—a chronic, progressive condition where the heart cannot pump efficiently, causing fluid back up in the lungs and body) . Lower respiratory tract Sustained symptoms lasting > (greater than) 24 hours without improvement. Risk factor for decompensation of a cardiac, COPD, or debilitated patient. Upper respiratory tract Sustained symptoms lasting 24 hours without improvement Possible Associated Signs and Symptoms .Acute onset or worsening of SOB (shortness of breath), dyspnea (difficult or uncomfortable breathing) on exertion, orthopnea (shortness of breath when lying down), cough, fever, or chills: Increase in sputum production. Presence of rales, rhonchi, or wheezes in lungs (abnormal lung sounds heard through a stethoscope that indicate underlying respiratory issues) R58 admitted to the facility on [DATE] and had diagnoses that include: pneumonia due to SARS-associated coronavirus (a severe respiratory infection characterized by inflammation and fluid filling the lungs which may prevent oxygen from entering the bloodstream); chronic diastolic congestive heart failure (a condition in which the heart doesn't fill properly, leading to fluid back up); paroxysmal atrial fibrillation (irregular, rapid heart rhythm that can have symptoms of chest pain, dizziness, fatigue, and shortness of breath) R58's MDS (Minimum Data Set), dated [DATE], indicates a BIMS (Brief Interview for Mental Status) score of 11, indicating the resident has moderate cognitive impairment. R58's Provider Orders for Scope of Treatment (POST) form, signed and dated by Physician's Assistant on [DATE], unsigned by R58 or activated Power of Attorney (POA), indicates: Cardiopulmonary Resuscitation (CPR).Do Not Attempt Resuscitation/DNR (Do not resuscitate) Medical Interventions: If Patient has pulse and is breathing.Selective Treatment—primary goal of treating medical conditions while avoiding burdensome measures. In addition to treatment described in Comfort-Focused Treatment, use medical treatment, IV antibiotics, and IV fluids as indicated. Do not intubate. May use non-invasive positive airway pressure. Transfer to hospital when indicated, generally avoid intensive care. R58's Nurses Notes include, in part: On [DATE] at 6:46 AM, Late Entry for: [DATE] Time: 6:00 AM Resident tested positive [DATE]. Resident has had some diarrhea throughout the night. Had cough on and off this shift. Assist of one to restroom every 1.5-2 hours. Stated she had a sore throat. No wheezing or difficult with breathing noted. Will continue to monitor. On [DATE] at 6:50 AM Respiratory Findings: Resident tested positive [DATE] with covid. No shortness of breathing noted. Continues to have sore throat and is achy all over. VS (vital signs) WNL (within normal limits). Does have a cough at times. No wheezing noted. No mucus noted. Assist of one with transfers. Will continue to monitor. On [DATE] at 6:10 AM Date/Time: [DATE] at 3:00 AM.Resident was overhead calling out from her room at approximately 3:00 AM, repeatedly shouting for help. Upon entering, resident returned from using restroom with aide assistance and seated at the edge of her bed, noticeably out of breath and exhibiting signs of respiratory distress. This behavior is inconsistent with her baseline and considered an acute change in condition. Resident is currently under COVID-19 quarantine precautions following a recent positive test. Upon approach, resident was disoriented and had difficulty following simple instructions. The resident's lung assessment revealed audible wheezing and rhonchi; breath sounds diminished in upper, mid, and lower lobes bilaterally (on both sides). The resident is using accessory muscles (muscles that assist in breathing when demand increases or during respiratory distress) to breathe and appear to struggle with both inspiration and expiration. O2 (oxygen) saturation (amount of oxygen in the blood) on room air was 88%, and oxygen therapy at 2 L/min (liters per minute) via nasal cannula (tubing to deliver supplemental oxygen) was initiated per nursing protocol, with noted improvement. Respiratory rate was elevated and effortful.Blood pressure: 114/46 Pulse: 59 bpm (beats per minute), bounding and palpable at wrist Temperature: 100.3 degrees Fahrenheit O2 (oxygen) saturation: 88% (percent) on room air ? (sic) improved with 2L(liters) O2 NC (nasal cannula).Resident is documented as DNR (Do Not Resuscitate) with a Provider Orders for Scope of Treatment (POST) indicating Selective Treatment as the goal of care, and care is focused on treating medical conditions while avoiding burdensome interventions. Healthcare Power of Attorney (POA).will be notified of the resident's status and changes. (Of note: there is no indication that a provider was updated at the time of R58's acute change in condition as noted above.) On [DATE] at 1:40 PM Surveyor interviewed DON B (Director of Nursing) and NHA A (Nursing Home Administrator) related to R58's change in condition. NHA A and DON B indicated they are going through everything. Surveyor asked if starting oxygen would require an MD (Medical Doctor) order? NHA A indicated they started oxygen before going to the ER per the standing orders, family was contacted and sent non emergent to the hospital. NHA A indicated R58's oxygen was up and down between 1-2L (liters) during that entire time, R58's oxygen saturation was on room air. DON B indicated they check their oxygen saturation on room air and on oxygen. Surveyor asked if the facility was monitoring the oxygen use, DON B indicated they have documentation in the nurses notes showing oxygen use. Surveyor asked NHA A and DON B about R58's nurses note on [DATE] at 0300(3:00am). Surveyor asked NHA A to read the progress note, and surveyor asked if an MD was contacted related to R58's change in condition. NHA A indicated the provider was updated in the morning but not during the night. Surveyor asked NHA A and DON B, would the symptoms in that note warrant a call? NHA A indicated they upped her oxygen and then R58 rebounded and improved. By 7:30 she has improved and is 97% on oxygen and more alert and responsive. Surveyor asked if on [DATE] if the MD was updated regarding the use of accessory muscles to breathe and appearing to struggle with both inspiration and expiratory breathing. NHA A indicated she did not know if the MD was contacted as it's not documented. Surveyor asked if they would expect this to be documented. NHA A stated Yes. DON B indicated that at 8:21 AM, the POA was updated, and a voicemail was left. Surveyor asked DON B if the Physician was updated, DON B indicated it does not say that. On [DATE] at 8:21 AM .BP: 112/56 Pulse: 60 bpm O2 Saturation: 97% on 2L O2 Temperature: 96.7 Resident is more alert, speech now clear and intelligible. No further respiratory distress observed at this time. POA/family was called regarding earlier change in condition. Voicemail was left when initially contacted. Family returned call to the AM nurse and communicated their preference for the resident to be sent out via ambulance for further evaluation. On [DATE] at 9:30 AM .Call placed to on call physician and order received to transfer to ER (Emergency Room) for further eval and TX (treatment) by non-emergent ambulance. On [DATE] at 1:43 PM, note indicates: Result: Returned from ER with new ATB (antibiotic) orders.alert without increased confusion or s/sx (signs and symptoms) of increased SOB or cough on return. Tolerated manual transfers without difficulty. R58's Physician Orders include: [DATE] Doxycycline Monohydrate (an antibiotic used for respiratory infections) 100 mg (milligrams)capsule Dose: (1 capsule / 100mg) by mouth twice per day AM Supper through [DATE] for: pneumonia. *[DATE] Cefdinir (an antibiotic used to treat pneumonia) 300 mg capsule Dose: (1 capsule / 300mg) by mouth twice per day AM Supper through: [DATE] for: pneumonia. R58's Occupational Therapy note, dated [DATE], includes: .Patient completes appropriate hand placement and sit to stand pivot with contact guard assist and 1 cue for turning proper direction. Patient choses not to participate in CM (clothing management) down or up at this time reporting she is too tired and unsteady. Patient is dependent for post BM (bowel movement) hygiene.Requires max A (assist) to cut up provided brat. COTA (Certified Occupational Therapy Assistant) cuts even smaller after report of difficulty to swallow. R58's Nurses Notes include, in part: On [DATE] at 3:53 AM, Respiratory Findings: .Stated is feeling a little better tonight. Sleeping well tonight. Assist of one with transfers.Lungs note some Rhonchi but was able to clear. Denies shortness of breath with O2 noted to 82% room air. With O2 came up to 95. All other VS WNL. On [DATE] at 10:18 AM, Medicare Charting: .Due to weakness her endurance is below her normal baseline today. Staff assisted with toileting.ate approximately 50% of breakfast seated in wheelchair in room. On [DATE] at 1:46 PM, Respiratory Infection: .appeared to have more strength with transfers today. Assist of 1 today. Ate approx. 50-75% of breakfast meal. Denied SOB. Cough present.O2 saturations ranging 88-90% on 1 liter oxygen. On [DATE] at 10:19 PM .has not been eating or drinking well.I fed him/her almost all of his/her cake, drank all juice, ate part of beets, one spoonful of chicken. head of bed left up 30% to help with breathing. On [DATE] at 4:43 AM .Respiratory Rate: 20 On [DATE] at 4:44 AM Respiratory Findings: .Checked after going to the restroom, was in low 80's. Bumped O2 up to 2L. Complain [sic] of SOB. Respirations: labored Cough: nonproductive. Important to note: R58 is experiencing SOB and labored respirations there is no comprehensive assessment including a lung assessment or a recheck of R58s oxygen saturation following increasing the supplemental oxygen level to 2L. There is no evidence a provider was updated regarding R58 having SOB or labored breathing. On [DATE] at 11:31 AM .more fatigued today than yesterday. Cough present, short of breath, disoriented at times. Currently on 1 liter of O2. Important to note: there is no lung assessment or respiratory rate assessed at this time although R58 continues to experience SOB. R58's Occupational Therapy Treatment Encounter Note, dated [DATE] 11:35 AM, includes: increased loose stools, supplemental oxygen, decreased energy and appetite On [DATE] at 12:24 PM .SOB and nonproductive cough present. Respirations are labored.SaO2 ranging from 85-90%; currently on 2 liters oxygen. Important to note: there is no comprehensive assessment including a lung assessment or respiratory rate assessed at this time or indication a provider was updated with sustained SOB and labored breathing. R58's Physical Therapy Treatment Encounter Note, dated [DATE] 3:53 PM, includes, in part: .Patient Remarks/Goals: Patient wheelchair in his/her room when approached for treatment for this PM and was agreeable to participate with treatment but continued to cry out help me throughout treatment and stating that he/she is so sick and having pain at his/her buttock crease wound and global achiness and pain from illness. Instructed patient in toilet transfer with grab bar wheel chair-toilet with moderate assist and cues for turning and backing to toilet but patient continued to have cognitive deficits and difficulty following cues and performing tasks with fatigue and weakness. On [DATE] at 3:30 PM, Surveyor interviewed DON B (Director of Nursing) and asked about standard of practice used for change of condition. DON B stated loosely based on Interact. Surveyor asked about updates to the physician with change of condition. DON B stated the POST form would be reviewed, if the resident is comfort care, the physician may not be updated right away. Surveyor asked if there is more timely notification of the physician if the POST indicates 'Selective'. DON B stated it depends on what is happening. Surveyor asked what is in place for monitoring when a resident goes out to the ER. DON B states, I won't say we are doing lung assessment, but we do oxygen saturation levels; if they are just comfort care, providers will often say we won't need to do all the assessments, we will just keep them comfortable. They would document daily. Surveyor asked what R58 selected per the POST. DON B stated Selective. Surveyor asked if based on Selective level of care, resident having SOB and labored breathing, what would be done. DON B stated it should've been an update, and I believe there was. Surveyor asked if an update would be documented. DON B stated yes in the nurse's notes. Surveyor reviewed the documentation of [DATE] at 4:44 AM with oxygen level in low 80s, complaint of SOB and labored breathing. DON B states would expect a respiratory assessment including lung sounds, respiratory rate, and oxygen saturation level, to see if there was a change from the day prior. DON B indicated we typically update frequently. It should be documented if we did. Depending on who was working. It may not have been documented. Our NPs are so easily reached, we update quite often. On [DATE] at 2:15 AM Respiratory Findings: c/o (complained of) SOB Respirations: labored, Cough: Hacking.Respiratory Rate: 20 On [DATE] at 5:54 AM PRN (as needed) medication result: 5:54 AM Still hollering help me help me On [DATE] at 7:33 AM Respiratory Findings: shortness of breath or trouble breathing with exertion (walking, bathing, transferring) Important to note: there is no lung assessment or respiratory rate indicated, and no evidence a provider was updated and R58 has been noted to have SOB and trouble breathing for over 24 hours. On [DATE] at 9:58 AM Comments: Called to resident's room by CNA (Certified Nursing Assistant) at approximately 9:15 AM, resident was without heart rate, cessation (stop / termination) of breaths. On [DATE] at 9:12 AM, Surveyor interviewed RN X (Registered Nurse) and asked about protocol for residents with respiratory symptoms. RN X stated do an assessment including heart and lung sounds, O2 sat, vital signs. RN X stated you need to check the resident's diagnoses and notify the provider as well as the supervisor. Surveyor asked about residents on an antibiotic for pneumonia. RN X stated the resident is checked daily to ensure improvement and there is daily charting. There is a 7 day follow up with the provider; if the resident is not improving in between, reach out to the supervisor for assist and update the provider. Surveyor asked if RN X was familiar with R58. RN X stated yes, I was here when R58 passed away. RN X stated R58 was on precautions for covid; assessments were done constantly to see if she was getting better. Surveyor asked what was included with R58's assessment. RN X stated there should have been blood pressure, pulse, respirations, heart and lung sounds, and oxygen saturations. Surveyor asked about parameters for oxygen saturation. RN X stated under 90% would be a concern unless they have COPD, then may be 88% or above. Surveyor asked what would happen if a resident was in the low 80s. RN X stated notify the provider. Surveyor asked is a reassessment is needed after applying oxygen. RN X stated yes, you need to stay with the resident after applying oxygen to make sure they are going up (their oxygen level) at least for the first 15 minutes. If going up, monitor every 30-60 minutes to ensure they are stabilized. If stable check regularly. There is to be an update to provider and DON (Director of Nursing). Surveyor asked if an update to provider is documented. RN X stated yes, we put a note in the chart anytime we reach out to the provider and include the information presented and the providers response. RN X stated I was here on R58's last day. I went to give R58 morning medications and R58 needed to use the bathroom. I didn't feel safe doing a transfer due to R58s weakness and R58 verbalized feeling 'off'. I got another nurse and we got R58 up with the EZ stand (mechanical transferring device); after using the bathroom, we got R58 into the wheelchair. R58 said, I can't do this anymore. R58 was concerned about weakness. I sent the other nurse to get the vitals monitor and by the time the nurse returned, R58 had passed; it happened quickly. On [DATE] at 8:43 AM, Surveyor interviewed RN E (Registered Nurse) and asked about protocol when a resident has a change in condition. RN E stated do an assessment and update the provider and POA. If a new antibiotic is started you need to make sure the antibiotic is working, watch for side effects; we are doing checks. Surveyor asked what the checks are. RN E stated vital signs, including Temperature, pulse, respirations and oxygen saturation, and listen to lung sounds. Surveyor asked how often assessments are completed. RN E stated at least daily; are symptoms improving or worsening; if symptoms are changing/worsening, update the provider. Surveyor asked about parameters for oxygen saturation. RN E stated 88% is okay, we like to keep above 90%, but some providers are okay with 88%. Surveyor asked if the physician is updated with oxygen saturations levels in the 80s. RN E stated not necessarily; if the provider is already aware and the resident's level goes back up with our interventions. If it is a resident who isn't usually on oxygen or having respiratory issues, we'd need to do an assessment and update the provider. Surveyor asked if there are additional checks if a resident's level is in the low 80s and oxygen is applied. RN1 states yes, we might need to stay with the resident to ensure they are getting more comfortable, or we may return to check in 15-30 minutes depending on how they are / their diagnosis. On [DATE] at 11:41 AM, Surveyor interviewed RN Y from the physician's office. RN Y stated there is an update in the chart from the ER physician about R58 being seen in the ER on [DATE] and then a note about a call from the facility when R58 passed away 5 days later. I don't see any other updates in between. On [DATE] at 11:49 AM, Surveyor interviewed PCP Z (Primary Care Provider) and asked about expectations for a resident on antibiotic for pneumonia. PCP Z stated continue to give the antibiotic as ordered and update with significant change in status. Surveyor asked about assessment. PCP Z stated at least twice daily eyes on the resident, more in between if needed. Monitor respiratory status daily to every other day with respiratory rate or listening to the chest; unless end of life cares, then would not expect this. I had conversation with R58 and family about end of life care / focus on comfort. R58 was in that category. I'd still expect eyes on her twice daily. R58 was clear that R58 did not want to go into the hospital. Surveyor asked if an update is expected if a resident's oxygen saturation is in the 80s, they have SOB, and labored breathing. PCP Z stated yes. Surveyor asked if PCP Z had been updated on R58. PCP Z stated I can't say that I was, but I was out of office. Surveyor asked if an update to the on-call provider would be documented. PCP Z stated maybe, but it is assumed that the nursing home would document this. On [DATE] at 2:17 PM, Surveyor interviewed NP AA (Nurse Practitioner). NP AA stated I cannot recall any updates on R58; normally there would be a note in the chart stating that there was a notification. On [DATE] at 2:58 PM, Surveyor interviewed POA I (Power of Attorney). POA I stated R58 had a focus on comfort care but had been agreeable to care if provider thought R58 could get better. R58 refused hospice care as R58 stated that he/she wasn't going to die. Surveyor asked if R58 would've wanted to go back to the hospital for further evaluation. POA I stated, I don't know for sure. R58 did agree to go to the ER ([DATE]). On [DATE] at 3:13 PM, surveyor interviewed MD J (medical director) regarding R58. MD J indicates she remembered talking about the situation and reviewing the death and re-admissions. Surveyor asked MD J about R58's progress Note from [DATE] written at 0300 (3:00AM) regarding R58's change in condition. MD J indicated she always asks the nurses to give a baseline or a trend, I would ask them to review the notes and ask if symptoms or exam changes were being noted prior to now. MD J indicated you can see a lot of ups and downs with Covid. Surveyor asked MD J if she would expect a physician to be updated? MD J indicated she would lean on the nurses as an extension, most definitely the next morning she would expect a call. Surveyor read R58's notes from [DATE] and [DATE] to MD J. Surveyor asked MD J if she would expect a nurse to call the provider on the [DATE]th with labored breathing and SOB. MD J indicated it would require notification if it's a change in the way the resident had been as well as for changes in the overall plan of care. The failure to recognize a change in condition and complete comprehensive nursing assessment created a reasonable likelihood for serious harm, which created a finding of immediate jeopardy. The facility removed the jeopardy on [DATE] when it completed the following: *The resident identified (R58) in the F-tag cited at the IJ level has expired. All current residents were reviewed to identify if any were having a significant change in condition and if appropriate steps were taken for assessment, notification and documentation. One resident was identified as currently having a change in condition and all aspects of assessment, notification and documentation were completed appropriately. He is pinked to continue assessments until he returns to a well state. *The licensed nurses are receiving education on responses required for significant changes in resident condition. This includes the following items: Identification of significant change as listed in the Significant change policy, notification/consultation with the medical provider and notification of the resident / resident legal representative; documentation of the notification including the name and time of the contact, orders received and comments; completing assessments appropriate to the resident condition daily on each shift until the resident returns to a well state or is transferred; procedure to flag residents for significant change for on coming shifts. *Training is being provided by the DON, nursing management and designated nurses who have completed the training. Nurses are being trained before working their shift. All Full time and Part time nurses have completed education as of 05/11 and casual call nurses will be trained prior to their next scheduled shift. Training on significant change identification, assessment, notifications and documentation will be provided to all nurses at hire, annually and if additional training needs are identified with our QAPI process. Staff will be educated on all future revisions to the significant change policy. *The facility significant change policy was reviewed with the Medical Director on [DATE]. Future updates to the policy will be discussed and approved by the medical director. * The RN supervisor will do daily review of each unit to identify residents with a change in condition and ensure appropriate assessment, notification and documentation are in the record, and if not, required steps will be taken appropriate to the specific resident situation. Nurses assigned to care for those residents will be reminded to report significant changes to the RN supervisor and notify the medical provider as appropriate. The facility will conduct daily audits x two weeks. If compliance is noted the frequency of audits will be reduced to 3x per week. The results of the audits will be reviewed weekly during the IDT meeting as part of a QAPI project. The reports will be provided for review to the QA committee quarterly. If elements are found that are incomplete or missing, corrective action will be taken which may include additional training, and systems / procedure revisions. Cross reference F678 2.) The facility's policy Weighing Residents and Recording Weights, dated 5/25, includes: The unit charge nurse is to ensure that weights are completed per the care plan/physician order. Unit charge nurse or designee is responsible to assess reported weight differences of three (3) or more pounds as needed. R2 admitted to the facility on [DATE] with diagnoses that include CHF (congestive heart failure; a chronic, progressive condition where the heart muscle is too weak or stiff to pump blood efficiently, causing blood to back up and fluid to accumulate in the lungs, legs, and other tissues) and edema (swelling caused by excess fluid trapped in the body's tissues). R2's quarterly Minimum Data Set (MDS) assessment, dated [DATE], has a BIMS (Brief Interview for Mental Status) score of 15, indicating R2 is cognitively intact. R2's comprehensive care plan, printed [DATE], includes: Problem (CHF/Circulatory): Decreased cardiac output/fluid volume excess Related to: Congestive heart failure.Manifested by: edema. Potential for sob (Shortness of Breath)Goal: Weights will remain stableApproach: Cardiac assessment prn (As Needed). Resp (Respiratory) assessment prn . Assess edema. alert nurse if weight is up 3# (3 pounds) in 1 week R2's medical record includes: [DATE] weight 170XXX[DATE] weight 176. Of note, this is a 6-pound weight gain in one week. On [DATE] at 9:23 AM, Surveyor interviewed RN E (Registered Nurse) regarding weights with a resident who has congestive heart failure. RN E indicated the facility completes weekly weights. RN E stated if a resident has a weight gain of more than 3 pounds, the nurse will assess the resident's symptoms and update the medical provider. RN E indicated the assessment would include looking for edema and a respiratory assessment. RN E indicated the medical provider may want to make medication adjustments or increase the frequency of weights for the resident to monitor the resident's condition. RN E indicated the assessment and medical provider notification with any order changes would be documented in the resident's medical chart. On [DATE] at 9:46 AM, Surveyor interviewed LPN O (Licensed Practical Nurse) regarding weights with a resident who has CHF. LPN O indicated residents are weighed weekly or more frequently depending on the residents' orders. LPN O indicated if there is a weight difference of 3 pounds the resident's weight is rechecked to ensure the weight difference is accurate. LPN O indicated a weight gain for a resident with CHF would cause the nurse to complete an assessment and notify the medical provider. LPN O stated the nurse would look for edema, encourage elevation of the resident's legs, listen to lung sounds and monitor for shortness of breath. LPN O indicated the assessment and the notification to the provider would be documented in the resident's medical record. On [DATE] at 9:50 AM, Surveyor

Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 49 residents who reside in the facility.Surveyor observed [NAME] U not allow thermometer to air dry before probing food.Surveyor observed [NAME] U reheat mashed potatoes in the microwave and then serve them without getting the internal temperature to 165 degrees F (Fahrenheit).Surveyor observed the facility's mixer to have food particles on the undercarriage.Surveyor observed [NAME] BB remove gloves, use a marker to label a plastic bag and then go back to working with food without washing his hands. Evidenced by:Example 1Facility policy, titled Food Handling, reviewed 5/7/26, includes: To take temperatures, a clean, rinsed, sanitized and air dried thermometer, which is the metal stem type, numerically scaled and accurate to plus or minus 2 degrees F, is needed. After taking the temperature the thermometer should be cleaned with a new alcohol pad.On 5/5/26 at 12:10 PM Surveyor observed [NAME] U use an alcohol wipe to wipe her thermometer and without allowing it to air dry she probed chicken noodle soup. She then used the same wipe to wipe the thermometer again. [NAME] U used another alcohol wipe to wipe the thermometer and without allowing it to air dry she probed mashed potatoes.On 5/7/26 at 10:15 AM Dietary Manager S indicated [NAME] U should allow the alcohol to sit on the surface of the thermometer until it air dries completely before probing the next food. Dietary Manager S also indicated [NAME] U should use a clean wipe every time she sanitizes the thermometer. Example 2Facility policy, titled Food Handling, reviewed 5/7/26, includes: Hot food temperatures. All hot food must be served to the residents at the temperature of 135 degrees F at the time the resident receives them. Hot food items may not fall below 135 degrees F. and reheated to at least 165 degrees F prior to next serving.On 5/5/26 at 12:10 PM Surveyor observed [NAME] U probe mash potatoes measuring the internal temperature. [NAME] U stated the internal temperature of the mashed potatoes was 121 degrees F. [NAME] U put the mashed potatoes in the microwave. [NAME] U probed the mashed potatoes again and indicated the internal temperature was 151 degrees F. [NAME] U served the mashed potatoes at this temperature.On 5/7/26 at 10:15 AM Dietary Manager S indicated [NAME] U should reheat items to 165 degrees F. Example 3Facility policy, titled Cleaning Mixers, reviewed 5/7/26, includes: the mixers will be cleaned and sanitized after each use. Wash and sanitize mixer stand and allow to air dry. Inspect the underside to ensure no areas were missed.On 5/5/26 at 10:00 AM Surveyor observed the facility's mixer to be stored uncovered with food particles on the undercarriage. Dietary Manager S indicated during interview that the mixer should be cleaned after each use. Example 4Facility policy, titled Handwashing and Sanitizing, effective date 8/1/1996, includes: . handwashing is the single most effective means of preventing the spread of bacteria and viruses. Each food handling employee is responsible to wash their hands. after touching any surface of contamination such as phone, money, door handles, soiled linen. after removing gloves. On 5/5/26 at 10:00 AM Surveyor observed [NAME] BB cutting onions with gloves on. [NAME] BB removed his gloves and used a marker to label a plastic bag. [NAME] BB then grabbed a new glove and used it like a patty paper to pick up the pieces of onion and place inside of the plastic bag.On 5/5/26 at 10:20 AM Dietary Manager S indicated [NAME] BB should have washed his hands after handling the marker and before returning to handling the onion pieces. Dietary Manager S indicated it is a good practice to wash hands every time you remove your gloves.

Based on record review and interview, the facility did not maintain a quality assessment and assurance committee consisting of the required members to identify issues through the committee. This deficient practice has the potential to affect all 49 residents currently in the facility.The IPC (Infection Prevention and Control nurse) did not attend Quality Assurance Performance Improvement (QAPI) meetings on 2 out of 4 quarterly meetings.This is evidenced by:The facility's policy Quality Assurance/Assessment and Performance Improvement Plan, undated, includes: The Quality Assessment and Assurance (QAA) Committee consist of the Director of Nursing Services, the Medical Director, the Administrator, at least two other members of the facility staff, and the infection control and prevention officer.On 5/4/26 at 10:00 AM during entrance conference, Surveyors asked DON B (Director of Nursing) and NHA A (Nursing Home Administrator) who is the facility's IPC. DON B indicated IPC T is the facility's infection prevention and control nurse.The facility's QA (Quality Assurance) Committee Attendance sign-in-sheet, dated 10/24/25, does not include an IPC.The facility's QA Committee Attendance sign-in-sheet, dated 4/24/26, does not include an IPC.On 5/5/26 at 4:28 PM, Surveyor asked DON B if she was certified in infection prevention and control. DON B indicated she was not.On 5/11/26 at 1:55 PM, Surveyor interviewed NHA A regarding the facility's QAPI program. NHA A indicated the Medical Director, the NHA, the pharmacist and the DON were the required members to be in the QAPI meeting. NHA A indicated IPC T does not always attend. Surveyor asked NHA A if IPC T should attend the QAPI meetings since the IPC is a required member of the QAPI committee and NHA A indicated IPC T should attend the meetings.

Based on observation, interview, and record review, the facility did not ensure that 1 of 19 Residents (R25) received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing.R25 requested side rails to aid in bed mobility and the facility did not provide the side rails to R25 timely.This is evidenced by:R25 admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive neurodegenerative disorder of the central nervous system), restless leg syndrome (a neurological disorder characterized by an irresistible urge to move the legs), rheumatoid arthritis (a chronic autoimmune disorder where the immune system attacks the joint lining causing inflammation, swelling, and stiffness) and chronic pain.R25's BIMS (Brief Interview for Mental Status), dated 3/11/26, has a score of 15, indicating R25 is cognitively intact.On 5/6/26 at 7:54 AM, Surveyor interviewed R25. R25 indicated he had requested side rails for bed mobility, and the facility has not provided him with side rails. R25 indicated he cannot get into bed without side rails. R25 indicated he needed side rails so he can reposition himself when he is in bed. R25 indicated he would lay in bed more if he had side rails so he could move himself around if he wanted. Surveyor observed R25's bed. R25's bed did not have side rails.R25's PT (Physical Therapy) Discharge summary, dated [DATE], includes: he had laid in his bed several times and then has not rested in bed since, unsure if he is refusing or if he is not requesting. Patient reports that he would lay in bed if he had bed rails to assist him in rolling and scootingOn 5/6/26 at 11:59 AM, Surveyor interviewed RN K (Registered Nurse) regarding side rails for R25. RN K indicated staff are encouraging R25 to spend time in bed and therapy is working with R25. RN K indicated they were working on getting side rails for R25. RN K indicated R25 is agreeable to lay down during the day. RN K indicated that a resident can usually have side rails installed on the same day the request is made.On 5/6/26 at 11:07 AM, Surveyor interviewed DOR P (Director of Rehab) regarding R25. DOR P stated at one point, therapy had encouraged side rails but R25 did not want a bed and chose to sleep in his recliner. DOR P stated a bed was put back into R25's room because he was unable to stand for personal cares and cares were then provided in the bed. DOR P indicated R25 did well in therapy with simulated side rails. DOR P indicated on 4/27/26, therapy put in a request to maintenance to install side rails to R25's bed. DOR P indicated therapy made the request for side rails so R25 can have increased independence with bed mobility. DOR P indicated therapy also spoke with nursing about getting side rails for R25.On 5/7/26 at 9:11 AM, Surveyor interviewed MT Q (Maintenance) regarding side rails. MT Q indicated either maintenance or housekeeping are notified by therapy or nursing if a resident needs side rails placed on their bed. MT Q indicated getting side rails attached to a bed takes a couple of hours after the request is made. MT Q indicated he is unaware of a request for side rails for R25. MT Q indicated there are 5 maintenance staff. MT Q indicated he spoke with the other maintenance staff, and all were unaware of the request.On 5/7/26 at 9:30 AM, Surveyor interviewed ESC R (Environmental Services Coordinator). ESC R indicated she was notified on 5/6/26 by therapy that R25 needed side rails. ESC R indicated once she was notified of the request, she transferred a new bed with side rails into R25's room. ESC R indicated side rails can be put on a bed usually the same day the request is made.On 5/7/26 at 9:17 AM, Surveyor interviewed DON B (Director of Nursing). DON B indicated once a request is made for side rails, housekeeping or maintenance will install the side rails. Surveyor informed DON B that therapy requested the side rails for R25 on 4/27/26 and the side rails were not placed until 5/6/26. DON B indicated R25's side rails should have been dealt with sooner. DON B indicated that installing the side rails should not have taken so long.

Based on interview and record review, the facility failed to have a system in place to ensure advance directive paperwork was on file for 1 of 19 sampled residents (R7) reviewed for advance directives.R7's chart did not contain a copy of her advance directive paperwork specifying her designated power of attorney.This is evidenced by:The facility's policy, titled Heath Care Power of Attorney, Advanced Directives and POST (Physician Orders for Scope of Treatment) Form Use, revised 5/8/26, states, in part: Policy: Rolling Hills Rehab Center recognizes the desires of a resident who is capable of making his/her own health care decisions supersedes the effect of an advance directive at all times. Advanced Directives can be a Health Care Power of Attorney (HCPOA) form, a POST Form, or a Living Will form. Procedure: 1. An Advance Directive is a written document representing the wishes and values of an adult, either while a resident in the nursing home or prior to becoming one, that: a) designates another person(s), i.e. agent, to make health care decisions on behalf of the resident if the resident is unable to make decisions for himself/herself; b) gives instructions to a health care professional as to the resident's desires about health care decisions; or both designates a surrogate and gives instructions. This will be reviewed on admission and offered on Quarterly assessments or as requested by resident if the resident does not have a Power of Attorney (POA).R7 admitted to the facility on [DATE]. R7 is her own person and does not have an activated POA. On 5/5/26 at 2:18 PM, during the record review portion of the initial pool process, Surveyor was unable to find documentation of a POAHC for R7 or evidence of a discussion with R7 about establishing one. On 5/6/26 at 4:45 PM, DON B (Director of Nursing) indicated that R7 does not have POA paperwork. On 5/7/26 at 11:00 AM, SW H (Social Worker) indicated the facility will get a copy of POA paperwork from the hospital if a resident is admitted from there. The facility offers assistance with completing POA documents when a resident is first admitted to the facility. During any point, a resident can request assistance with completing this paperwork. If a resident requests to change POA information, the facility can assist with that as well. If a resident would like to change POA information and the resident is already activated, the facility will work with an ethics committee on that.SW H confirmed they were unable to locate POA paperwork for R7. Surveyor asked what would happen if R7 had a sharp decline and was no longer able to make decisions for herself. SW H indicated without the POA documents, the facility would have to pursue a guardianship for R7. SW H indicated she would add POA documentation to a list of topics to discuss with R7 at her upcoming care conference.On 5/7/26 at 11:15 AM, Surveyor discussed POA paperwork with R7. R7 indicated she had previously completed POA paperwork and said one of her family members had it.On 5/11/26 at 12:15 PM, SW G located R7's POA paperwork in her clinical chart documents. SW G confirmed the facility never had the POA paperwork on file for R7 before today.On 5/11/26 at 2:25 PM, Surveyor discussed POA paperwork with NHA A (Nursing Home Administrator). NHA A confirmed the facility's process for advance directives is to offer assistance when a resident is admitted to the facility and then again if a resident is hospitalized or has something going on - like a decline. NHA A agreed a resident may forget about the paperwork if it is only discussed during admission. Surveyor discussed R7 being admitted to the facility in 2023 and not having POA paperwork on file until today. NHA A agreed that pursuing a guardianship for R7 if she did not have paperwork may not be something she would have wanted. NHA A indicated the facility's social services department modified their process and will now discuss POA paperwork and code status with residents/resident representatives on a quarterly basis and if a resident is hospitalized .

Based on interview and record review, the facility did not notify and consult with a resident's physician when there was a change in condition. This occurred for 1 of 19 Residents (R25) reviewed for notification of change in condition. R25 had unwitnessed falls on 1/2/26 and 3/26/26 with no notification to the medical provider. Evidenced by: Facility Policy Subject: Falls Assessment Procedure: 3. CONSULT WITH Physician if head injury or injury caused a significant change in status. R25 was admitted to the facility on the 10/29/24. Her diagnoses include: Hallucinations(a false sensory experience that feels readl, even though it is created by the mind), Generalized anxiety disorder(chronic uncontrollable and excessive worrying about everyday things that feels impossible to turn off).R25's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 1/28/26 indicates R25 has a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating she is cognitively moderately impaired. On 01/02/26 R25's nursing fall report stated in part: MD (medical doctor) notify: no need to notify, resident did not hit head. Of Note: this fall was unwitnessed. On 3/26/26 nursing fall report stated in part: MD notify: no need to notify, resident did not hit head.Of Note: this fall was unwitnessed(It should be noted that both falls were unwitnessed, there is no way to definitively know if R25 hit her head or not due to being unwitnessed.)On 5/11/26 at 10:36 AM Surveyor interviewed RN K (Registered Nurse). Surveyor asked RN K what is your process for when someone has a fall? RN K responded if an LPN is on the floor, an RN needs to come before getting the person up. Then I (RN) conduct my assessment and start the investigation. Surveyor asked RN K if a fall is unwitnessed, how do you know if the resident hit their head. RN K stated that she would do her own assessment looking at where the resident is seated, what is around them and their environment, but I don't know if you could be sure that they didn't hit their head. Surveyor asked RN K when you would notify the MD. RN K stated if injured would notify right away, within 4 hours if concerned for a head injury. On 5/11/26 at 10:53 AM Surveyor interviewed RN E. Surveyor asked RN E what is your process if someone falls. RN E reported that she would go down and assess the resident and continue with fall investigation. Surveyor asked if the fall was unwitnessed when should you notify the physician. RN E stated if the resident couldn't tell you if they hit their head or not you would notify the MD within 4 hours. On 5/11/26 surveyor interviewed DON B. Surveyor asked DON B when there is a fall is anyone notified. DON B stated the residents' representative is called. MD is called if there is an injury. Surveyor asked DON B Is a fall a COC (change of condition). DON B stated that they have never looked at a fall as a COC. Surveyor asked DON B does a physician need to be notified of a COC. DON B stated yes. Surveyor asked DON B if a resident had an unwitnessed fall, would there be a way to know if they hit their head? DON B stated that her nurses would use their critical thinking skills and assess the environment. Surveyor asked DON B when a fall is unwitnessed can you be sure the resident did not hit their head. DON B stated unwitnessed is unwitnessed. R25 had two unwitnessed falls without any indication a physician/MD was updated.

Based on interview and record review, the facility failed to fully prevent further potential abuse, neglect, exploitation, or mistreatment of residents while an investigation was in process for 1 of 3 residents (R7) investigated for an incident involving alleged abuse. A staff member involved in a facility reported incident was not directly supervised at all times while working to ensure protection of other residents after the facility became aware of an allegation of abuse made by R7.This is evidenced by: The facility's policy, titled Misconduct Investigation & Reporting, reviewed 2/24/25, states, in part: Policy: Rolling Hills Senior Living prohibits abuse, neglect, exploitation and misappropriation of resident property. We have established and implemented measures to prevent incidents from occurring through comprehensive background checks, credentialing, training and establishing a culture where residents are cared for with respect and dignity. All concerns will be thoroughly investigated and reported. Procedure: .7. The building supervisor must take action to protect the resident or other residents who may be at risk while the incident is being investigated. (I.e. staff person is sent home on administrative leave, is directly supervised to maintain all residents' safety, or is reassigned to non-resident duties.). R7 admitted to the facility on [DATE] with diagnoses that include: spinal stenosis - lumbar region with neurogenic claudication (narrowed spinal canal causing pain, weakness, or tingling in the legs that may get worse while walking or standing) and osteoarthritis (condition causing degenerative joint pain and stiffness and reduced mobility). R7's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 2/4/26 indicated R7 has a BIMS (Brief Interview for Mental Status) score of 15 out of 15, indicating R7 is cognitively intact. The facility self report states, in part: [R7] reported to [RN E] (Registered Nurse) that [CNA L] (Certified Nursing Assistant) was rough with her this morning and pushed her over to the side when she was on the toilet. This was reported to [RN E] at approximately 1:00 pm on 1/21/26 by the resident. It is noted that [CNA L] did report to the RN and LPN (Licensed Practical Nurse) this morning that [R7] was not transferring well and nearly fell getting onto the toilet. [CNA L] did report that she had to slide her over onto the toilet to keep her from falling. [CNA V] did enter the resident room to respond to the call light. She did witness the interaction and saw [CNA L] assist [R7] to the toilet when she had trouble standing. The resident complained to [CNA V] that she wanted to move out. This was reported to the RN.The resident, [R7], reported that [CNA L] was mean to her and was too rough.The accused CNA, [CNA L] was immediately instructed not to work with [R7] and to only provide care to other residents with a second staff person present during the course of the investigation.On 5/7/26 at 11:00 AM, Surveyor interviewed SW H (Social Worker) about this incident, as she had investigated it along with NHA A (Nursing Home Administrator). SW H indicated CNA L was not to work with R7 and had to be with another staff member when she went in to do cares with any other residents. CNA L could be seen by nursing staff on the unit when she was not with residents. CNA L would tell someone if she was going into a residents' room and they would go with her. Surveyor asked how the administrators could guarantee that CNA L wasn't around any residents by herself while the investigation was ongoing. SW H indicated this was not 100% guaranteed and indicated CNA L was usually respectful with following the rules; the facility did not have any issues with her in the past.On 5/11/26 at 11:41 AM, Surveyor interviewed CNA V. CNA V confirmed she was in the room with CNA L when the incident with R7 occurred. CNA V indicated CNA L had to push R7 onto the toilet so R7 didn't land on the floor when she got weak while standing up and holding the grab bar as she was being cleaned up. Surveyor asked what interventions were put in place after this occurred. CNA V indicated CNA L was required to do cares with residents with another staff member present. Surveyor asked if she was always with CNA V during this time. CNA L indicated that CNA V was required to do charting in the main room within sight of the nurses so she wasn't alone with residents and when she had to go into a resident's room, CNA L would get CNA V so she could go with her.On 5/11/26 at 11:55 AM, Surveyor interviewed CNA L about the incident with R7. CNA L indicated she was not allowed to do any cares with R7 following the incident. Administrators talked to her, other staff members, and residents. While the investigation was ongoing, CNA L indicated she had to get another staff member if she went into a resident's room. When not working with residents, she would stock linen carts, wipe down the hallway railings, and wipe down wheelchairs within viewing range of the nurses' station. Surveyor asked what CNA L would do if she had to go to a hallway closet or out of eyesight of the nurses. CNA L indicated she would notify a nurse that she'd be right back and they wouldn't follow her to where she was going.On 5/11/26 at 11:37 AM, Surveyor spoke with RN E regarding the incident with CNA L and R7. RN E indicated she remembered the incident but not the exact details. RN E indicated CNA L was removed from working with R7 and nursing staff was updated and told to keep an eye on staff members and residents to ensure no further incidents occurred.On 5/11/26 at 2:25 PM, Surveyor spoke with NHA A regarding the incident with CNA L and R7. NHA A indicated CNA L was not to be working with anyone or doing anything by herself; she was only supposed to work with other staff present - whether that was in a room doing cares with another staff member or with nurses keeping an eye on her. NHA A indicated administration felt like they had a good idea of what had occurred after speaking with CNA V, who had been present when the incident occurred. Surveyor brought up that CNA L indicated she would tell nursing staff if she had to go down the hallway to get something and they wouldn't go with her. NHA A indicated she was just going down the hallway and not into a resident's room. Surveyor indicated it was possible for CNA L to go into a resident's room during that time without someone watching her.

Based on observation, interview and record review, the facility did not ensure that a resident who needs respiratory care is provided with such care consistent with professional standards of practice for 1 of 2 residents (R6) reviewed for oxygen.R6 did not have oxygen tubing/nasal cannula changed on a monthly basis.Evidenced by:The facility's Oxygen Therapy policy, dated 1/2026, states, in part: .8. Replace nasal cannula monthly.R6 admitted to the facility on [DATE] and has diagnoses that include: acute and chronic respiratory failure with hypercapnia (a condition when the lungs cannot adequately supply oxygen to the blood or remove carbon dioxide); Cor pulmonale, chronic (the enlargement and failure of the right ventricle of the heart caused by high pressure in the lungs arteries, linked to lung disease); chronic obstructive pulmonary disease ( a progressive lung disease that makes breathing difficult by damaging airways)R6's Physician Orders include, in part:*2/18/26 Treatment: Respiratory: oxygen 2 l/pm (Liters per minute) at rest - 3 lpm with activity three times a day AM PM NOC (morning, evening, and night shifts) keep sats (oxygen saturation; the amount of oxygen in the blood) > (greater than) 90%. TX (treatment) first date: 1/27/26*5/5/26 Treatment: Respiratory: Change nasal cannula on portable and concentrator one time per month 3rd Thursday AM Hospice Supplies Tx first date: (blank)On 5/5/26 at 4:21 PM, Surveyor observed R6 during initial screening. R6 was sitting in his/her recliner in his/her room, wearing a nasal cannula attached to an oxygen concentrator. No date labeling noted on cannula/tubing. On 5/5/25 at 4:29 PM, Surveyor interviewed RN W (Registered Nurse) and asked about nasal cannula/oxygen tubing. RN W stated it is changed every 30 days, more often if it is dirty or defective. RN W stated the change is triggered by the resident's treatment record. Surveyor asked if the cannula/tubing is labeled with a date. RN W stated not sure. Surveyor asked when R6's was last changed. RN W reviewed R6's treatment record and stated there is no order for changing R6's cannula/tubing. Surveyor and RN W observed the nasal cannula that R6 was wearing and the cannula attached to the portable tank in R6's room. RN W stated there is not a label with date. Surveyor asked if there was any way to tell when the cannula was last changed. RN W stated I'd look at the treatment record to see when it was signed out and assume it was done. RN W stated it would be best practice to be labeled.Important to note: There was no order for changing of the cannula on R6's treatment record at the time of this observation.On 5/11/26 at 12:05 PM, Surveyor observed R6 sitting in bedroom recliner wearing a nasal cannula connected to the oxygen concentrator. No labeling was noted on this cannula tubing or the cannula connected to the portable in the room. On 5/11/26 at 12:12 PM, Surveyor and RN K observed R6's nasal cannula. RN K indicated there was no labeling on the cannula. Surveyor asked when cannulas are changed. RN K stated monthly. Surveyor asked when R6's cannula had last been changed. RN K stated it pops up on the orders, you cannot tell from the tubing. RN K reviewed R6's chart and stated it looks like it is to be changed the 3rd Thursday of the month, but I am having a hard time seeing it signed off. RN K confirmed that the order for changing the cannula had been added 5/7/26 and stated it should be entered when oxygen therapy starts. The cannula may have been changed, but there is no way to tell from looking at the tubing.On 5/11/26 at 1:39 PM, Surveyor interviewed DON B (Director of Nursing) and asked about changing oxygen tubing/nasal cannula. DON B stated that cannulas are changed monthly. Surveyor asked if tubing is unlabeled, can it be verified that the tubing was changed. DON B stated no.

Based on record review, interview, and policy review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, to other officials (including to the State Survey Agency) in accordance with State law through established procedures for one of five sampled residents (Resident (R)2) reviewed for allegations of abuse.The facility failed to notify the State Agency (SA) in a timely manner regarding an alleged incident involving R2. Findings include:Review of the facility's policy titled, Misconduct Investigation and Reporting, dated 02/24/25 indicated, . The staff member must immediately report the incident to the nurse on duty or other supervisory staff.The nurse/supervisor must notify the Administrator or Acting Administrator of the alleged incident/complaint immediately after ensuring the safety of the resident.If the allegation involves abuse or resulted in serious bodily injury the violation must be reported within 2 [sic] hours from when the issue is discovered.1.Review of R2's undated Face Sheet, located under the Face Sheet tab in the electronic medical record (EMR) indicated R2 was admitted to the facility on [DATE] with diagnoses of dementia and anxiety disorder.Review of R2's quarterly Minimum Data Set (MDS), located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 10/22/25 indicated R2 had a Brief Interview for Mental Status (BIMS) score of three out of 15 which indicated R2 was severely cognitively impaired. R2 was also coded for being mobile in the facility using a walker.Review of R2's Nursing Progress Note, located under the Progress Note tab in the EMR indicated on 12/19/25 at 3:00 PM, .DON [Director of Nursing] RH SW [Rolling Hills Social worker] updated.Review of the R2's Care Plan, dated 12/19/25 and located under the Care Plan tab in the EMR indicated, Keep resident an arms length away from [R1].2. Review of R1's undated Face Sheet, located under the Face Sheet in the EMR indicated R1 was admitted to the facility on [DATE] with the diagnoses of Cerebral Palsy and seizures. Review of R1's quarterly MDS, located under the MDS tab in the EMR indicated R1 was coded as having short term and long-term memory loss with moderate cognitive impairment.Review of the facility's Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, dated 12/19/25 and provided by the facility, indicated the Report Submitted Date was documented as being sent to the SA on 12/19/25 at 8:50 PM.During an interview on 01/20/26 at 10:30 AM, Registered Nurse (RN)1 was asked when she was made aware of R1 pinching R2's arm and RN1 stated, I don't have a specific time in there [progress note] but I know it was after breakfast. RN1 was asked when the incident was reported to management and RN1 replied, I don't remember, but I know I did. We usually report it right away after the situation is safe.During an interview on 01/20/26 at 10:50 AM, the Director of Nursing (DON) stated, Typically we report this under two hours. The DON stated the Administrator manages the reporting to the SA.During an interview on 01/20/26 at 11:52 AM, the Administrator was asked how long you have to report allegations of abuse to the SA and the Administrator stated, If there are any injuries or serious injuries then it has to be reported to the state within two hours. The Administrator was asked what would you call this incident between R1 and R2 that occurred on 12/19/26 and the Administrator replied, Not serious injuries so just report within two hours. [R1] and [R2] have always had a good relationship together and the intent and [R1's] understanding was not there. It was reported because of the way [R2] had responded and the staff intervened. In my mind, we were going to stop this from happening again. The Administrator confirmed that the initial report of this incident was on 12/19/25 at 8:50 PM.On 01/20/26 at approximately 1:00 PM, the Administrator provided the facility policy titled, Misconduct Investigation and Reporting, and stated, I read over the policy, and this should have been reported within two hours.

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections that has the ability to affect all 50 residents (R). -Facility staff failed to transport linens in a manner to prevent the spread of infection. -Facility staff did not properly doff personal protective equipment (PPE) for a resident on enhanced barrier precautions (EBP). -Facility staff demonstrated poor hand hygiene during medication administration. -Facility staff did not prep skin prior to administering a subcutaneous injection of insulin. This is evidenced by: Example 1 Federal Regulation S483.80(e) Linens state, Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. On 02/17/25 at 10:02 AM, Surveyor observed Nursing Support Aide (NSA) N passing clean linens in the hallway without the clean linen cart being covered. Surveyor asked NSA N if it is normal practice to pass out personal clean linen without them being covered. NSA N stated, Yes. I have not seen the carts covered in a long time. On 02/18/25 at 11:00 AM, Surveyor observed NSA N again passing out clean personal linens on a cart in the hallway without a cover. On 02/18/25 at 1:19 PM, Surveyor interviewed Nursing Home Administrator (NHA) A who stated the towels and bedding linens are sent out and covered all the time. Personal linens are done on each wing on PM and night shifts. They are then put on the carts and in the morning, the aides deliver them to the residents' rooms. NHA agreed that all clean linens should be covered, and NHA A will ensure personal linens are covered as well. NHA added that it probably slipped by us when we changed from sending out all linens to be cleaned, to the facility doing the personal clothing in house. On 02/18/25 at 1:59 PM, Surveyor interviewed Infection Control (IC) P nurse. IC P brought Surveyor to the laundry area and stated the clean linen carts are supposed to be covered. IC P retrieved a cover and placed it on the cart. 49353 Example 2 Facility policy titled, Enhanced Barrier Precautions (EBP), with a reviewed date of 10/23/24, stated in part: Policy statement: Rolling Hills Rehabilitation Center will utilize EBP to expand the use of PPE to resident care activities that have high potential for contaminating staff's hand and clothes with blood or bodily fluids . 3. Gown and gloves must be put on before entering room and taken off at room exit . 4. Position a trash can inside the resident room and near the exit for discarding PPE after removal (garbage and PPE removal bins in cupboard outside room), prior to exit of the room . The Centers for Disease Control and Prevention (CDC) guidelines for removal of PPE with EBP precautions states in part: Facilities should remember to have an appropriate disposal container available in the resident room to allow for removal of PPE inside the room. On 02/18/25 at 7:00 AM, Surveyor observed an Enhanced Barrier Precaution (EBP) sign on R2's door. The EBP sign indicated the use of personal protective equipment (PPE) of a gown and gloves be used when providing direct care for the resident. The PPE was stored just outside of R2's room behind closed doors. Underneath the PPE storage area was a separate compartment with a sign that stated 'Garbage.' On 02/18/25 at 9:02 AM, Surveyor observed Certified Nursing Assistant (CNA) C don a gown, gloves, and goggles and enter R2's room to assist R2 with toileting. On 02/18/25 at 9:10 AM, Surveyor observed CNA C exit R2's room wearing the gown, gloves and goggles. Surveyor observed CNA C open the garbage compartment outside of R2's room, remove and dispose of all the PPE she was wearing in garbage, and close garbage compartment door. Surveyor then observed CNA C complete hand hygiene. On 02/18/25 at 9:12 AM, Surveyor interviewed CNA C. Surveyor asked CNA C if it is common practice to remove PPE outside of resident room. CNA C stated yes because that is where the garbage is located. On 02/19/25 at 12:41 PM, Surveyor interviewed Director of Nursing (DON) B regarding EBP. Surveyor asked DON B what the expectation is for staff to don/doff PPE with EBP. DON B stated that staff are expected to don PPE before entering a resident's room and remove PPE just outside of resident's room. Surveyor asked DON B if this expectation met the facility's and current CDC guidelines. DON B stated that she felt this was acceptable as it is just outside of the room. Surveyor asked DON B if just outside the resident room was the same as the facility's policy of before exiting the resident's room. DON B then reluctantly stated that it did not. Surveyor asked DON B if this practice had the potential to transmit infection by staff touching equipment outside of room while wearing the contaminated PPE after providing direct care. DON B stated yes, she could see how that could be a potential concern. 51095 Example 3 The facility policy document titled: Hand Hygiene and Gloving, reviewed on 10/23/24, states in part, .All staff are required to wash their hands promptly and thoroughly between resident contacts and after contact with blood, body fluid, mucous membranes, secretions, excretions and equipment or articles contaminated by them. Gloves are also used for the above resident contacts and handwashing must follow both application and removal of gloves. The facility procedure document titled Insulin Injection, procedure reviewed date 2/25, states, in part, C. Injection of Insulin . 1. Take insulin alcohol pad to resident. Wash hands, put on gloves. 2. Cleanse injection site with alcohol pad. Allow to dry before injecting. On 2/18/25 at 7:28 AM, during medication administration pass, Surveyor observed Licensed Practical Nurse (LPN) J apply gloves without using hand hygiene prior to gloving. LPN J obtained a finger stick blood sample for R27. After performing the test, LPN J removed her gloves, did not sanitize or wash her hands and proceeded to move medication cart to the next resident's door. On 2/18/25 at 7:32 AM, Surveyor observed LPN J put on gloves, without hand hygiene prior, and obtain a finger stick blood sample for R11. LPN J then removed her gloves, did not sanitize or wash her hands, removed 2 insulin pens from the medication drawer and administer the insulins subcutaneously into R11's abdomen. LPN J did not use an alcohol pad to cleanse injection site prior to injecting. On 2/18/25 at 7:34 AM, Surveyor interviewed LPN J about hand hygiene practices, and she reported hand hygiene should be performed before and after gloving. LPN J stated, I did not do it, you make me nervous. Surveyor also asked if she used an alcohol wipe on the injection site prior to injecting insulin. LPN stated she did not wipe R11's injection site with alcohol prior to administering insulin. I usually do, I just forgot. On 2/18/25 at approximately 8:30 AM, Surveyor interviewed DON B. DON B reported her expectation would be that staff follow infection control procedures. DON B reported she is aware that LPN J did not follow appropriate infection control practices.

Based on observation, interview and record review, the facility did not ensure residents received appropriate treatment and services to maintain range of motion (ROM). This had the potential to affect four residents (R) reviewed for mobility (R25, R26, R30, and R31). -R25 was not provided restorative services at least three times per week as identified in her care plan. -R26's care plan did not identify the frequency and duration of restorative services needed. -R30 was not provided restorative services daily as identified in her care plan. -R31 was not provided restorative services five times per week as identified in her care plan. This is evidenced by: Per Appendix PP of the State Operations Manual (SOM), regulation F688 reads in part . The facility must develop resident care policies in collaboration with the medical director, director of nurses, and as appropriate, physical/occupational therapy consultant. This includes policies on restorative/rehabilitative treatments/services, based on professional standards of practice. The care plan must identify the type of treatments, frequency, and duration, as well as the measurable objectives and resident goals. Example 1 R25 admitted to facility on 05/13/24, with a diagnosis including arthritis. Minimum Data Set (MDS) assessment confirmed R25 scored 15/15 during Brief Interview for Mental Status (BIMS), indicating intact cognition. R25's MDS assessment completed on 01/24/25 indicated the following changes in functional abilities related to transfers, since admission: -Sit to stand, partial assistance increased to substantial assistance. -Chair to bed, partial assistance increased to substantial assistance. -Toilet transfer, partial assistance increased to substantial assistance. R25's Restorative Aide Program documentation indicated restorative goal to decrease joint pain, risk of falls, and decline in transfers and mobility. GOAL: Participate in restorative services at least three times per week to maintain strength and promote safe transfers and mobility. R25's Restorative Aide Program documentation indicated R25 participated in restorative program as follows: -12/2024, 6 of 31 days. -01/2025, 5 of 31 days. -02/20/25, 5 of 20 days. During the survey period of 02/17/25-02/20/2025, Surveyor did not observe R25 participating in restorative services. On 02/19/25 at 1:46 PM, Surveyor interviewed R25. R25 stated she participates in a restorative program to help strengthen her muscles. R25 reported she is supposed to receive exercises with Restorative Aide (RA) L, three times per week, but sometimes she doesn't come at all. Example 2 R26 was admitted to the facility on [DATE] and diagnoses included muscular dystrophy. MDS assessment confirmed R26 scored 15/15 during BIMS, indicating intact cognition. R26's MDS assessment completed on 01/22/25 indicated R25 is dependent on staff for all transfers. R26's Restorative Aide Program documentation indicated restorative goal to prevent decline, contractures, and falls. GOAL: Participate in exercises and transfers to maintain ability to safely transfer and ambulate with staff assist. (Surveyor noted R26's restorative care plan did not include a frequency or duration). R26's Restorative Aide Program documentation indicated R26 participated in restorative program as follows: -10/2024, 13 of 31 days. -11/2024, 8 of 30 days. -12/2024, 4 of 31 days. -01/2025, 7 of 31 days. -02/2025, 3 of 20 days. During the survey period of 02/17/25-02/20/2025, Surveyor did not observe R26 participating in restorative services. On 02/17/25 at 10:40 AM, Surveyor interviewed R26. R26 stated he had not received his exercise program last week. R26 reported he usually receives exercise program once weekly, but stated twice weekly would be better for him to maintain his abilities. R26 stated he reported this to a nurse sometime this winter but had not received any updates related to frequency of his weekly exercises. Example 3 R30 was admitted to the facility on [DATE]. Diagnoses included osteoarthritis, pain, and history of blood clot in limb. MDS assessment confirmed R30 scored 15/15 during BIMS, indicating intact cognition. R30's MDS assessment, completed on 11/06/2024, indicated R30 requires substantial assistance from staff with all transfers. R30's Restorative Aide Program documentation indicated restorative goal to reduce decline in functional transfers and contracture risk. GOAL: Participate in daily exercises to maintain safe transfer ability. R30's Restorative Aide Program documentation indicated the following: -10/2024, 5 of 31 days. -11/2024, 7 of 30 days. -12/2024, 9 of 31 days. -01/2025, 7 of 31 days. -02/2025, 3 of 20 days. During the survey period of 02/17/2025-02/20/2025, Surveyor did not observe R30 participating in restorative services. On 02/19/25 at 2:04 PM, Surveyor interviewed R30 regarding his restorative services. R30 responded, No, not too much. Not even once a week. I want to be able to transfer and stand. Example 4 R31 was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease and pain caused by compression fractures in back. MDS assessment confirmed R31 scored 13/15 during BIMS, indicating intact cognition. MDS assessment completed on 12/18/24 indicated R31 is dependent on staff for all transfers. Review of previous MDS assessment, completed on 09/18/24, confirmed R31 declined in toileting transfers from substantial assistance to dependent on staff. R31's Restorative Aide Program documentation included goal to reduce decline in range of motion, strength, and mobility. GOAL: Participate in restorative services five times per week to maintain strength and mobility as evidenced by ability to ambulate 50 feet with walker and staff assistance. R31's Restorative Aide documentation included the following: -11/2024, 12 of 30 days. -12/2024, 10 of 31 days. -01/2025, 5 of 31 days. -02/2025, 4 of 20 days. During the survey period of 02/17/2025-02/20/2025, Surveyor did not observe R31 participating in restorative services. On 02/18/25 at 1:00 PM, Surveyor interviewed Physical Therapy Assistant (PTA) O. PTA O reported Certified Nursing Assistant (CNA) tasks and restorative program exercises are separate. CNAs do not complete restorative program exercises; the facility has RA L complete restorative program exercises. The facility has a Restorative Aide Program binder, kept in the therapy department, to document how often services were provided to each resident. PTA O stated RA L's schedule recently changed to part-time schedule. PTA O reported if RA L cannot complete the restorative programs for all the residents, therapy staff try to complete what RA L could not. PTA O confirmed DON B is the 'head' of the restorative program. On 02/18/25 at 1:10 PM, Surveyor interviewed Director of Nursing (DON) B. DON B confirmed she oversees the facility's restorative program. DON B confirmed RA L's schedule was changed to part-time and not available full-time, and the facility was working on a plan to have more than one restorative aide to ensure a full-time schedule for restorative services. DON B confirmed if RA L is not able to complete the services, therapy staff assist with ensuring restorative services are completed. DON B stated the facility would like to offer residents restorative services daily, so the frequency is set as daily in the hopes the resident will participate in services 3-5 days per week. DON B stated the purpose of the restorative program is to maintain or prevent loss of a resident's current functioning. DON B stated each resident's restorative program is reviewed monthly when she changes out the documentation in the Restorative Aide Program binder, and the nurses document in the resident's record. Surveyor requested the facility's policy related to restorative services. Director of Nursing (DON) B reported the facility did not have a Restorative Services Policy. Surveyor reviewed records for R25, R26, R30, and R31. Surveyor was unable to find nursing documentation related to restorative services. On 02/20/25 at 7:04 AM, Surveyor interviewed RA L. RA L confirmed she works every Thursday and Friday and every other weekend. RA L reported there are approximately 13 residents participating in the restorative program, and she tries to get to all residents but sometimes it is difficult due to resident schedules, activities, mealtimes, or resident declination to participate. RA L stated it can be difficult to complete the restorative program as she gets pulled to work on the floor as a CNA a lot. RA L reported on average she works as a CNA about one day per week. RA L confirmed if she is unable to complete restorative exercises with a resident, therapy staff attempt to complete those services with the resident. RA L stated she reports to therapy staff which residents did not receive the services, by writing it on a whiteboard in the therapy department and documenting in the Restorative Aide Program binder. On 02/20/25 at 8:58 AM, Surveyor interviewed Certified Occupational Therapy Assistant (COTA) Q. COTA Q stated therapy staff are responsible for evaluating a resident's level of skill and the nursing department is responsible for putting the evaluations into place and into the plan of care. COTA Q explained CNAs are responsible for completing the functional restorative program tasks, to help residents benefit from participating in independence in daily tasks. The RA is responsible for the Functional Aide Program, which is the restorative exercises recommended by therapy staff. COTA Q stated, If a frequency is not identified, ideally residents would receive restorative services daily, so let's see if we can get to them at least 3 days per week.

Based on the interview and record review, the facility failed to implement its policies and procedures and did not protect 2 of 3 residents from abuse. (R43, R35). R43 was not protected from verbal abuse when Certified Nursing Assistant (CNA) D threatened R43 by stating CNA D would throw R43 over shoulder and carry out of room if R43 didn't do what CNA D wanted R43 to do. R36 was not protected from physical abuse when R35 grabbed R36's walker and then swung at R36, hitting R36 and grabbing R36's wrist. Findings include: Example 1 On 2/17/25, Surveyor reviewed R43's medical record. R43 was admitted on [DATE] with Alzheimer's dementia with delusional thought process. R43's Minimum Data Set (MDS) assessment, dated 10/23/24, had a Brief Interview for Mental Status (BIMS) score of 03 out of 15 which indicated R43 had severe impaired cognition. Surveyor reviewed grievance logs from 08/20/24 to 02/18/25. -On 09/11/24, grievance was filed that R44 reported that CNA D was yelling at R43 to get dressed in R43's pajamas and CNA D would not stop telling R43 to get dressed on 09/10/24. R44 also stated that CNA D said she could throw R43 over CNA D's shoulders if she needed to make R43 put on pajamas. On 02/17/25, Surveyor reviewed R44's medical record. R44 was admitted on [DATE] with status post amputation, diabetes mellitus, and heart failure. R44's Minimum Data Set (MDS) assessment, dated 11/20/24, had a BIMS score of 15 out of 15, which indicated R44 has intact cognition. On 02/19/25 at 11:51 AM, Surveyor interviewed R44 and asked if R44 remembers the event on 09/10/24. R44 indicated that R44 does remember the incident. R44 overheard CNA D speak to R43 with a stern voice and threatened R43. Surveyor asked R44 how CNA D threatened R43. R44 indicated that CNA D was barking orders at R43 about putting boot on and making sure to use walker. R44 indicated that R43 refused to wear the boot and use walker. R44 heard CNA D tell R43 that R43 better do what CNA D is asking or CNA D will throw R43 over CNA D's shoulder and carry R43 out. R44 indicated that CNA D would not give R43 a chance to respond and explain what R43 needed instead. R44 indicated that R44 was scared for R43, so R44 told CNA C. R44 indicated that CNA C told R44 to let the nurse on duty know. R44 stated, I did not know which nurse was on that night, but I told who I could and then the next day a social worker talked to me. R44 clarified that CNA D continued with behavior by walking down the hallway antagonizing R43. Surveyor asked how CNA D antagonized R43. R44 indicated that CNA D would come up to R43, touch R43's shoulders, smile extra big and purposely talk to her. R43 would tell CNA D to get away from R43, but CNA D kept coming up and touching R43's shoulders while smiling big. On 02/19/25 at 11:59 AM, Surveyor was unable to interview R43, due to BIMS of 3. R43 was not protected from verbal abuse from CNA D. Example 2 On 02/17/25, Surveyor's review of R35's medical record discovered a nursing progress note which notes the following: Nurse progress note states: .On 01/28/2025 at 4:38 PM, Late Entry for: 01/27/2025. DATE OF INCIDENT: 01/27/2025, TIME OF INCIDENT: 17:12, INJURY: no apparent injury There was an altercation during supper time. Resident was grabbing at [R36's] walker during supper, [R36] tried to stop him by talking loudly. [R35] grabbed [R36]. [R36] stated if he grabs him again, he was going to, punch him. Staff had intervened. At 4:39PM, Today there was no further altercations between [R35] and [R36], they were kept apart from each other. At 10:13 PM, [R35] was aggressive and combative at the beginning of the shift. Resident was found in another resident's room and will not follow redirection from the CNA. Instead, he swung his hand on the CNA hitting the CNA on the chest . On 02/19/25 at 10:25 AM, Surveyor interviewed R36 and asked R36 if there have been any resident-to-resident altercations that have occurred on the unit. R36 stated, Yes, [R35]! Who has not had an altercation with [R35]. One time [R35] came at me in the dining room, but I put him in his place. I yelled to tell him not to ever touch me again or I'd punch him. Surveyor asked R36 to explain the incident in the dining room with R35. R36 indicated that R35 came at R36 and grabbed R36's walker and then swung at R36 hitting R36 and grabbing R36's wrist. Surveyor asked if R36 was injured. R36 indicated that he was not injured but, R35 is very strong, and it did frighten me. Staff intervened and R36 grabbed walker and went to room. R36 indicated that R36 tends to stay in room more now because R36 doesn't want those interactions with R35 again. R36 indicated that R35 has outbursts all the time in the dining room. R36 indicated that R36 dislikes that kind of aggressive behavior and mostly stays in room because of the outbursts. On 02/20/25 at 8:02 AM, Surveyor interviewed Director of Nursing (DON) B and asked what the expectations are for resident to resident altercations and how residents are protected from abuse. DON B indicated that staff follow facility policy and staff should let DON B, NHA A, or Social Worker I know about any potential verbal or physical abuse. On 02/20/25 at 8:14 AM, Surveyor interviewed Nursing Home Administrator (NHA) A asking NHA A how residents are protected from abuse. Surveyor indicated to NHA A that the incident with R43 was verbal abuse. Surveyor indicated to NHA A that the incident with R36 did in fact happen, R36 was grabbed and hit by R35 which is physical abuse. Surveyor asked NHA A if NHA A thought abuse concerns from R35 had occurred. NHA A indicated that residents were not protected from abuse by not following through on the facility policy. NHA A indicated that everyone should be following the facility policy for abuse.

Based on interview and record review, the facility did not report 2 of 3 (R43, R36) potential misconduct incidents to the State's Office of Caregiver Quality (OCQ) via the State's Misconduct Incident Reporting (MIR) system immediately upon learning of the incident. *CNA D threatened R43 by stating CNA D would throw R43 over shoulder and carry out of room if R43 didn't do what CNA D wanted R43 to do. *R35 grabbed R36's walker and then swung at R36, hitting R36 and grabbing R36's wrist. Findings include: Facility policy titled Misconduct Investigation and Reporting, last revised 08/20/24, stated in part, -#4. The staff member must immediately report the incident to the nurse on duty or other supervisory staff. -#5. The nurse/supervisor must notify the Administrator of the alleged incident/complaint immediately after ensuring the safety of the resident. If administrator can't be reached, notify the DON or social services manager. -#19. The Administrator or his designee will immediately notify the DQA of all alleged incidents involving mistreatment, exploitation, neglect, or abuse. CMS defines immediately to be as soon as possible but not to exceed 24 hours after discovery of the incident. If the allegation involves abuse or resulted in serious bodily injury the violation must be reported within 2 hours from when the issue if discovered . Example 1 Surveyor reviewed grievance logs from 08/20/24 to 02/18/25. On 09/11/24, grievance was filed that R44 reported that CNA D was yelling at R43 to get dressed in R43's pajamas and CNA D would not stop telling R43 to get dressed on 09/10/24. R44 also stated that CNA D said she could throw R43 over CNA D's shoulders if she needed to make R43 put on pajamas. Surveyor reviewed facility investigation on the grievance filed and when CNA D was asked about the incident, CNA D did confirm what was said to R43 but CNA D said CNA D was only joking and would never actually do it. On 2/17/25, Surveyor reviewed R43's medical record. R43 was admitted on [DATE] with Alzheimer's dementia with delusional thought process. R43's Minimum Data Set (MDS) assessment, dated 10/23/24, had a Brief Interview for Mental Status (BIMS) score of 03 which indicated R43 had severe impaired cognition. On 02/17/25, Surveyor reviewed R44's medical record. R44 was admitted on [DATE] with status post amputation, diabetes mellitus, and heart failure. R44's Minimum Data Set (MDS) assessment, dated 11/20/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicates R44 has intact cognition. On 02/19/25 at 11:51 AM, Surveyor interviewed R44 and asked if R44 remembers the event on 09/10/24. R44 indicated that R44 does remember the incident. R44 overheard CNA D speak to R43 with a stern voice and threatened R43. Surveyor asked R44 how CNA D threatened R43. R44 indicated that CNA D was barking orders at R43 about putting boot on and making sure to use walker. R44 indicated that R43 refused to wear the boot and use walker. R44 heard CNA D tell R43 that R43 better do what CNA D is asking or CNA D will throw R43 over CNA D's shoulder and carry R43 out. R44 indicated that CNA D would not give R43 a chance to respond and explain what R43 needed instead. R44 indicated that R44 was scared for R43, so R44 told CNA C. R44 indicated that CNA C told R44 to let the nurse on duty know. R44 stated, I did not know which nurse was on that night, but I told who I could and then the next day a social worker talked to me. Surveyor asked R44 if CNA D kept working with R43 with cares and activities throughout the next couple days. R44 indicated to Surveyor that CNA D continued to come into room to assist R43, and CNA D walked down the hallway antagonizing R43. Surveyor asked how CNA D antagonized R43. R44 indicated that CNA D would come up to R43, touch R43's shoulders, smile extra big and purposely talk to her. R43 would tell CNA D to get away from R43, but CNA D kept coming up and touching R43's shoulders while smiling big. Surveyor asked R44 if R44 let any staff members know of the continual approaches from CNA D to R43. R44 indicated that R44 did not let any staff know about the incidents because R44 didn't know if it was ok to after trying to report the verbal abuse and CNA D continually providing care for R43 and R44. On 02/19/25 at 11:59 AM, Surveyor interviewed R43 and asked if R43 can R43 remember any incidents that have caused R43 any mental anguish, or physical harm. R43 stared at Surveyor and had confused look on face. Surveyor was unable to interview R43. Surveyor asked R43 if R43 felt safe in the facility in R43's home. R43 chuckled and stated, Ahh the facility is fine, and my roommate takes care of me as needed. Surveyor could not find any facility documentation of this incident as being reported to the State Agency. Example 2 On 02/17/25, Surveyor's review of R35's medical record discovered a nursing progress note which notes the following: Nurse progress note indicated, .On 01/10/2025 at 5:16 PM, PRN MED GIVEN: hydroxyzine HCl 25MG Tablet (1 tablet / 25mg) given for agitation tried to throw chair in dining room. 6:44PM PRN MED RESULT: at 6:44 PM, Improved but still present. At 9:00 PM BEHAVIOR: abusive behavior wandering behaviors Pushing /Grabbing Behavior occurred. Note: We were trying to direct [R35] over to his food at the table. [R35] did not want to come to the table but was trying to take plates from the dietetic worker instead. As we attempted to guide [R35] to the table, [R35] became agitated and attempted to pick up a chair as if [R35] was going to throw it. It was eased back to floor, and we directed [R35] back to tv area. There are three other residents at this table and two staff trying to feed residents and another resident that was not being too cooperative with eating. It seemed too much activity for [R35] at the time and [R35] got very agitated and angry. I then gave [R35] prn Atarax which had little effect tonight. About 7:30 [R35] grabbed another resident by the wrist and staff intervened before [R35] could hurt the resident. [R35] was angry because this resident grabbed [R35's] blanket [R35] was holding and so [R35] turned around quickly and grabbed her, and staff were standing there when [R35] grabbed her. I turned down lights early this evening to slow things down because residents seemed quite wound up tonight. Will continue to monitor [R35] closely around other residents . Surveyor did not find documentation to support that the facility reported the resident-to-resident altercation to DQA. Surveyor did not find documentation that staff notified a supervisor of the incident which occurred. Nurse progress note indicated, .On 01/28/2025 at 4:38 PM, Late Entry for: 01/27/2025. DATE OF INCIDENT: 01/27/2025, TIME OF INCIDENT: 17:12, INJURY: no apparent injury There was an altercation during supper time. Resident was grabbing at [R36's] walker during supper, [R36] tried to stop him by talking loudly. [R35] grabbed [R36]. [R36] stated if he grabs him again, he was going to, punch him. Staff had intervened. At 4:39PM, Today there was no further altercations between [R35] and [R36], they were kept apart from each other. At 10:13 PM, [R35] was aggressive and combative at the beginning of the shift. Resident was found in another resident's room and will not follow redirection from the CNA. Instead, he swung his hand on the CNA hitting the CNA on the chest . Surveyor did not find documentation to support that the facility reported the resident-to-resident altercation to DQA. Surveyor did not find documentation that staff notified a supervisor of the incident. On 02/19/25 at 10:25 AM, Surveyor interviewed R36 and asked R36 if there have been any resident-to-resident altercations that have occurred on the unit. R36 stated, [R35]! Who has not had an altercation with [R35]?. One-time [R35] came at me in the dining room, but I put him in his place. I yelled to tell him not to ever touch me again or I'd punch him. Surveyor asked R36 to explain the incident in the dining room with R35. R36 indicated that R35 came at R36 and grabbed R36's walker and then swung at R36 hitting R36 and grabbing R36's wrist. Surveyor asked if R36 was injured. R36 indicated that he was not injured but, R35 is very strong, and it did frighten me. Staff intervened and R36 grabbed walker and went to room. R36 indicated that R36 tends to stay in room more now because R36 doesn't want those interactions with R35 again. R36 indicated that R35 has outbursts all the time in the dining room. R36 indicated that R36 dislikes that kind of aggressive behavior and mostly stays in room because of the outbursts. On 02/19/25 at 10:30 AM, Surveyor interviewed CNA F and asked about process to report resident-to-resident altercations to administration. CNA F indicated that CNA F would then report this to CNA F's nurse on duty. On 02/19/25 at 11:27 AM, Surveyor interviewed Licensed Practical Nurse (LPN) G and asked if LPN G reports to the supervisor if there is a resident-to resident altercation. LPN G indicated if it is severe enough and needed more attention than LPN G would report to supervisor. On 02/20/25 at 7:21 AM, Surveyor interviewed Registered Nurse (RN) H and asked RN H what is RN H's process when there is a resident to resident altercation or if there is an incident that happens with a resident. RN H indicated, Of course I intervene and separate the aggressor and the victim or the aggressor and the aggressor, then we document the events very thoroughly in the computer, and then there is follow up on both residents for the next 24 hours. Surveyor asked RN H if RN H reports to the supervisor. RN H indicated that RN H is the supervisor on nights but should be reporting to DON B the next day if it's in the middle of the night. Surveyor asked RN H what is the facility procedure for determining if an incident is verbal or physical abuse? RN H indicated intervening and letting supervisor know when supervisor is available is the appropriate measures. On 02/20/25 at 8:02 AM, Surveyor interviewed Director of Nursing (DON) B and asked what the expectations are for resident-to resident altercations and how are potential abuse concerns handled with staff to resident incidents. DON B indicated that staff follow facility policy and staff should let DON B, NHA A, or Social Worker I know about any incidents that are a concern for potential verbal or physical abuse. DON B said DON B was unaware of some of the incidents since nursing staff did not report these except for the more recent ones that occurred this year. On 02/20/25 at 8:14 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked why facility did not report a few of the incidents of potential verbal and physical abuse concerns from staff to resident involving R43 and then R36 and then resident to resident altercations from R35 to the state. NHA A stated that usually staff report incidents and then between NHA A, DON B, and Social Worker I, us three decide the importance of the complaint and start a proper investigation if it's needed, and then report to state regulatory agency if needed. NHA A indicated that NHA A did not think the incidents with R43 or R36 were considered abuse concerns. Surveyor indicated to NHA A that the incident with R43 had concerns with verbal abuse, and CNA D even admitted to verbally saying the threat to R43 and that she continued to work with R43 and other residents before investigation was complete. NHA A indicated that CNA D was joking, but that NHA A didn't realize CNA D continued to work with R43. Surveyor asked NHA A if NHA A thought that some of the physical abuse concerns from R35 unto another unknown resident on Birchwood was concerning. NHA A indicated that NHA A was unaware of some of the incidents and that staff did not report this to administration. NHA A indicated that everyone should be following the facility policy for misconduct.

Based upon interview, policy review and record review, the facility did not ensure allegations of verbal and physical abuse were thoroughly investigated or prevent further potential abuse from occurring while the investigation was in progress for residents (R) (R43, R36) and other undocumented residents, which has the potential to affect all 19 residents on the Birchwood unit. Facility did not protect R43 when allowing Certified Nursing Assistant (CNA) D to continue to work with R43 when accused of verbal abuse. Facility allowed CNA D to continue to work with R43 during complaints of rough cares was being investigated. This is evidenced by: Facility policy titled Misconduct Investigation and Reporting, last revised 08/20/24, stated in part, .-2. If the issue could be considered verbal, sexual, or physical abuse the staff person is required to take action immediately to protect the resident and/or stop the occurrence. This includes incidents perpetrated by staff. The staff's primary responsibility is to always ensure the safety of the resident. Before all else protect the resident. -7. The building supervisor must take action to protect the resident or other residents who may be at risk while the incident is being investigated (I.e. staff person is sent home on administrative leave, is directly supervised to maintain all resident's safety, or is reassigned to non-resident duties). -#14. Investigation of the incident will proceed with interviews being conducted with residents and staff and information regarding the allegations being collected. The investigation may include documenting each step taken during the internal investigation and any conclusions made. Resident to resident altercation should look for causes or situations that may have contributed to the incident occurring. Misconduct Definitions dated, 07/2024 indicates: 'Abuse' is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, or mental anguish; Verbal abuse involves the use of speech, sound, writing, or gestures when communicating with residents or their families or when within their hearing or sight, regardless of their age ability to comprehend, or disability. Examples include but are not limited to threats of harm or frightening a resident; Physical harm includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. Note the federal definition of abuse indicates that the act needs to be willful and that it needs to have resulted in physical or psychosocial harm to the resident or-if the resident cannot provide a response-would be expected to have caused harm to a reasonable person. Example 1 Surveyor reviewed grievance logs from 08/20/24 to 02/18/25. On 09/11/24, grievance was filed that R44 reported that CNA D was yelling at R43 to get dressed in R43's pajamas and CNA D would not stop telling R43 to get dressed on 09/10/24. R44 also stated that CNA D said she could throw R43 over CNA D's shoulders if she needed to make R43 put on pajamas. Surveyor reviewed facility investigation on the grievance filed and when CNA D was asked about the incident, CNA D did confirm what was said to R43 but CNA D said CNA D was only joking and would never actually do it. On 02/17/25, Surveyor reviewed R43's medical record. R43 was admitted on [DATE] with Alzheimer's dementia with delusional thought process. R43's Minimum Data Set (MDS) assessment, dated 10/23/24, had a Brief Interview for Mental Status (BIMS) score of 03 out of 15, which indicates R43 has severe impaired cognition. On 02/17/25, Surveyor reviewed R44's medical record. R44 was admitted on [DATE] with status post amputation, Diabetes Mellitus, and heart failure. R44's Minimum Data Set (MDS) assessment, dated 11/20/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicates R44 has intact cognition. On 02/19/25 at 11:51 AM, Surveyor interviewed R44 and asked if R44 remembers the event on 09/10/24. R44 indicated that R44 does remember the incident. R44 overheard CNA D speak to R43 with a stern voice and threatened R43. Surveyor asked R44 how CNA D threatened R43. R44 indicated that CNA D was barking orders at R43 about putting boot on and making sure to use walker. R44 indicated that R43 refused to wear the boot and use walker. R44 heard CNA D tell R43 that R43 better do what CNA D is asking or CNA D will throw R43 over CNA D's shoulder and carry R43 out. R44 indicated that CNA D would not give R43 a chance to respond and explain what R43 needed instead. R44 indicated that R44 was scared for R43, so R44 told CNA C. R44 indicated that CNA C told R44 to let the nurse on duty know. R44 stated, I did not know which nurse was on that night, but I told who I could and then the next day a social worker talked to me. Surveyor asked R44 if CNA D kept working with R43 with cares and activities throughout the next couple days. R44 indicated to Surveyor that CNA D continued to come into room to assist R43, and CNA D walked down the hallway antagonizing R43. Surveyor asked how CNA D antagonized R43. R44 indicated that CNA D would come up to R43, touch R43's shoulders, smile extra big and purposely talk to her. R43 would tell CNA D to get away from R43, but CNA D kept coming up and touching R43's shoulders while smiling big. Surveyor asked R44 if R44 let any staff members know of the continual approaches from CNA D to R43. R44 indicated that R44 did not let any staff know about the incidents because R44 didn't know if it was ok to after trying to report the verbal abuse and CNA D continually providing care for R43 and R44. Surveyor reviewed investigation file dated 09/11/24 which indicates Social Worker I interviewed R44 about the events pertaining to CNA D and R43. On 09/12/24, Social Worker I interviewed staff that were on same shift when the incident occurred on 09/10/24. DON interviewed residents on 09/12/24. Surveyor reviewed CNA D's schedule and time punches from 09/01/24-09/14/24. CNA D worked on 09/10/24 on Pineview unit, then on 09/12/24 on Birchwood Unit, and again on 09/13/24 on [NAME] Lane unit. Surveyor did not find in the investigation if facility had removed CNA D from the Pineview unit and supervised CNA D with other residents on other units until investigation was complete to prevent further potential abuse concerns. Surveyor did not find a clear investigation complete date of the incident with R43 and CNA D. Example 2 On 02/17/25, Surveyor reviewed R36's medical record. R36 was admitted on [DATE] with atrial fibrillation, hypertension, and chronic obstructive pulmonary disease. R36's Minimum Data Set (MDS) assessment, dated 01/08/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicates R36 has intact cognition. On 02/17/25, Surveyor reviewed R35's medical record. R35 was admitted on [DATE] with diagnoses including dementia unspecified with behavioral disturbances, cataracts, hypertensive heart disease, and insomnia. R35's Minimum Data Set (MDS) assessment, dated 11/06/24, had a Brief Interview for Mental Status (BIMS) score of 00 which indicated R35 had severe impaired cognition and could not complete the BIMS test. Surveyor reviewed R35's nursing progress notes that indicated, .-On 06/22/2024 at 4:09 PM, Note: [R35] was sitting at the dining table eating and suddenly he yelled at resident across the table who was eating his meal and then kicked the table and was swearing. We were going to remove him from the area but then he continued to eat, and we stayed nearby. When he appeared not to be eating, we offered that he could go watch tv if he wanted to. He got up and started pacing the hallway. After residents were done eating one resident stayed in his chair by the dining room table to watch tv and [R35] came up behind him and hit the back of the chair hard. This frightened the resident in the chair, and he got up with his walker and went to his room . Surveyor did not find documentation that staff notified a supervisor of the incident that occurred, and did not find a proper investigation into the incident. Surveyor did not find a thorough investigation that identified who the affected resident was on Birchwood unit. Nurse progress note indicated, . On 09/16/24 at 9:30 PM, Note: [R35] spent first part of our shift outside. He did not eat much of his supper this evening. Given cold fluids as it was warm outside. Brought him in to get ready for bed but he has been very resistive to cares again his shift. I only now was able to get him to take his medications. Will attempt to change him again when he has had his meds in him for 30 minutes or so. CNA informed me that, [R35] walked by another resident and apparently swung as to hit him but did not. It is very difficult to address his cares even with two staff. Will continue to monitor behaviors and chart . Surveyor did not find a thorough investiation into R35 swinging at another residen. Unable to determine who the affected resident was. Nurse progress note indicated, .On 01/10/2025 at 5:16 PM, PRN MED GIVEN: hydroxyzine HCl 25MG Tablet (1 tablet / 25mg) given for agitation tried to throw chair in dining room. 6:44PM PRN MED RESULT: at 6:44 PM, Improved but still present. At 9:00 PM BEHAVIOR: abusive behavior wandering behaviors Pushing /Grabbing Behavior occurred. Note: We were trying to direct [R35] over to his food at the table. He did not want to come to the table but was trying to take plates from the dietetic worker instead. As we attempted to guide him to his table, he became agitated and attempted to pick up a chair as if he was going to throw it. It was eased back to floor, and we directed [R35] back to tv area. There are three other residents at his table and two staff trying to feed residents and another resident that was not being too cooperative with eating. It seemed too much activity for [R35] at the time and he got very agitated and angry. I then gave him his prn Atarax which had little effect tonight. About 7:30 he grabbed another resident by the wrist and staff intervened before he could hurt the resident. He was angry because this resident grabbed his blanket he was holding and so he turned around quickly and grabbed her, and staff were standing there when he grabbed her. I turned down lights early this evening to slow things down because residents seemed quite wound up tonight. Will continue to monitor him closely around other residents . Surveyor did not find a thorough investigation for R35's physical abuse towards others. The affected resident is not identified. Surveyor did not find documentation that staff notified a supervisor of the incident that occurred. Nurse progress note indicated, .On 01/28/2025 at 4:38 PM, Late Entry for: 01/27/2025. DATE OF INCIDENT: 01/27/2025, TIME OF INCIDENT: 17:12, INJURY: no apparent injury There was an altercation during supper time. Resident was grabbing at [R36's] walker during supper, [R36] tried to stop him by talking loudly. [R35] grabbed [R36]. [R36] stated if he grabs him again, he was going to, punch him. Staff had intervened. At 4:39PM, Today there was no further altercations between [R35] and [R36], they were kept apart from each other. At 10:13 PM, [R35] was aggressive and combative at the beginning of the shift. Resident was found in another resident's room and will not follow redirection from the CNA. Instead, he swung his hand on the CNA hitting the CNA on the chest . Surveyor did not find documentation of a thorough investigation into the incident, nor preventative measures put into place to prevent reoccurrence of incidents. On 02/19/25 at 10:25 AM, Surveyor interviewed R36 and asked R36 if there have been any resident-to-resident altercations that have occurred on the unit. R36 stated, [R35]! Who has not had an altercation with [R35]?. One time [R35] came at me in the dining room, but I put him in his place. I yelled to tell him not to ever touch me again or I'd punch him. Surveyor asked R36 to explain the incident in the dining room with R35. R36 indicated that R35 came at R36 and grabbed R36's walker and then swung at R36 hitting R36 and grabbing R36's wrist. Surveyor asked if R36 was injured. R36 indicated that he was not injured but, R35 is very strong, and it did frighten me. Staff intervened and R36 grabbed walker and went to room. R36 indicated that R36 tends to stay in room more now because R36 doesn't want those interactions with R35 again. R36 indicated that R35 has outbursts all the time in the dining room. R36 indicated that R36 dislikes that kind of aggressive behavior and mostly stays in room because of the outbursts. On 02/19/25 at 10:30 AM, Surveyor interviewed CNA F and asked about process to deal with R35 or any other residents that may have altercations of aggression or explosions. CNA F indicated that CNA F will intervene and separate residents or try to redirect residents. Surveyor asked what CNA F's next process is after intervening and making sure residents are safe. CNA F indicated that CNA F would then report this to CNA F's nurse on duty. CNA F indicated the nurse would do a formal assessment and then monitor going forward. On 02/19/25 at 11:27 AM, Surveyor interviewed Licensed Practical Nurse (LPN) G and asked LPN G what is LPN G's process when there is an altercation between a resident to resident or if there is an incident that happens with a resident. LPN G indicated LPN G will intervene if LPN G observes the resident-to-resident altercation. LPN G would try to redirect R35 or any other resident who is aggressive and acting out. LPN G will then assess both residents and manage the residents' care as appropriate. On 02/20/25 at 7:21 AM, Surveyor interviewed Registered Nurse (RN) H and asked RN H what is RN H's process when there is a resident to resident altercation or if there is an incident that happens with a resident. RN H indicated, Of course I intervene and separate the aggressor and the victim or the aggressor and the aggressor, then we document the events very thoroughly in the computer, and then there is follow up on both residents for the next 24 hours. On 02/20/25 at 8:02 AM, Surveyor interviewed Director of Nursing (DON) B and asked what the expectations are for resident-to resident altercations and how are potential abuse concerns handled with staff to resident incidents. DON B indicated that staff follow facility policy and staff should let DON B, NHA A, or Social Worker I know about any incidents that are a concern for potential verbal or physical abuse. Surveyor asked what the process is for properly investigating and preventing further abuse concerns from happening. DON B indicated that once a concern is reported DON B, NHA A, or Social Worker will open an investigation and interview all staff members involved and remove the staff member accused until investigation is complete. DON B indicated then staff will interview other residents for any concerns and complete a thorough investigation with a resolution plan. Surveyor asked DON B why the complaint of possible verbal abuse was not thoroughly investigated before allowing CNA D to continue to work with R43. DON B indicated that DON B was unaware of all the logistics of the incident and that Surveyor would need to speak with Social Worker I. Surveyor asked DON B about the resident-to-resident and staff altercations that involved R35 on 06/22/24, 09/16/24, 01/10/25, and 01/28/25. DON B indicated that DON B was unaware of some of the incidents since nursing staff did not report these except for the more recent ones that occurred this year. Surveyor asked DON B why proper investigations were not completed for 06/22/24, 09/16/24, 01/10/25 and 1/28/25, to prevent any further potential for physical abuse on the Birchwood unit. Surveyor indicated to DON B that on two different occasions on 06/22/24 and 01/10/25, R35 had resident to resident physical altercations and Surveyor could not find complete documentation of the event, the investigation for it, or who the other resident was that was affected. DON B indicated the investigation was not completed, and staff should have had more thorough documentation so that staff could process what had occurred. DON B indicated the affected residents that were not named in the incidents should have had better follow up as facility policy states to assess and document for the next 24-48 hours on both residents involved in altercation. On 02/20/25 at 8:09 AM, Surveyor interviewed Social Worker I and asked why the complaint of possible verbal abuse was not thoroughly investigated before allowing CNA D to continue to work with R43. Social Worker I indicated that Social Worker I was unaware CNA D continued to work with R43 but that Social Worker I does not make those decisions for staff and DON B makes scheduling decisions. Surveyor asked Social Worker I about the resident-to-resident and staff altercations that involved R35 on 06/22/24, 09/16/24, 01/10/25, and 01/28/25. Social Worker I indicated that Social Worker I was unaware of some of the incidents since nursing staff did not report these except for the more recent ones that occurred this year. Social Worker I indicated that thorough investigations were not completed for R35's incidents. On 02/20/25 at 8:14 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked why facility did not thoroughly investigate the incidents of potential verbal, physical abuse concerns from staff to resident involving R43 and the resident-to-resident altercations from R35. NHA A indicated that NHA A did not think the incidents with R43 or R36 were considered abuse concerns. Surveyor indicated to NHA A that the incident with R43 had concerns with verbal abuse, and CNA D admitted to verbally saying the threat to R43. CNA D continued to work with R43 and other residents before investigation was complete. NHA A indicated that CNA D was joking, but that NHA A didn't realize CNA D continued to work with R43.

Based on record review and interview, the facility did not transmit the Minimum Data Set (MDS) assessments within 14 days of completion for 3 residents (R) (R40, R47, and R31) out of 12 sampled residents. R40 had a Quarterly (Q) MDS assessment completed on 10/02/24 and a Quarterly MDS assessment completed on 12/31/25. Both assessments had not been transmitted as of end of survey, 02/20/25. R47 had a Prospective Payment System (PPS) discharge assessment completed 11/08/24 and a Quarterly MDS completed 12/23/24. MDS assessments had not been transmitted. R31 had a Quarterly MDS assessment completed on 10/02/24 and another Quarterly MDS completed on 12/31/24 which were not submitted by the facility. This is evidenced by: The requirements for the RAI are found at 42 CFR 483.20 and are applicable to all residents in Medicare and/or Medicaid certified long-term care facilities. The requirements are applicable regardless of age, diagnosis, length of stay, payment source or payer source. Federal RAI requirements are not applicable to individuals residing in non-certified units of long-term care facilities or licensed-only facilities. S483.20(f)(3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following: (i)Admission assessment. (ii) Annual assessment. (iii) Significant change in status assessment. (iv) Significant correction of prior full assessment. (v) Significant correction of prior quarterly assessment. (vi) Quarterly review. (vii) A subset of items upon a resident's transfer, reentry, discharge, and death. (viii) Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment. Example 1 R40 was admitted to the facility on [DATE] with diagnoses including pneumonia, atrial fibrillation, coronary artery disease, hypertension, and diabetes. On 02/19/25 at 7:59 AM, Surveyor reviewed R40's MDS assessments. R40's facility records identified the following: Quarterly (Q)90 was completed on 07/03/24. Status accepted. Q180 was completed on 10/02/24. Status completed. Q270 was completed on 12/31/24. Status completed. The Q180 and Q270 MDS assessments were never transmitted to Centers for Medicare & Medicaid Services (CMS). The Q180 assessment should have been transmitted on or before 10/16/24. Q270 assessment should have been transmitted on or before 01/14/25. R40's quarterly MDS's were marked as completed, but not transmitted or accepted by CMS. Example 2 R47 was admitted to the facility on [DATE] with diagnoses including COVID, atrial fibrillation, heart failure, hypertension, dementia, and diabetes. Surveyor reviewed R47's MDS assessments. R47's facility records identified the following: Admission 5 day was completed on 09/23/24. Status accepted. PPS discharge was completed on 11/08/24. Status completed. Q90 was completed on 12/23/24. Status completed. The PPS discharge and the Q90 MDS assessments were never transmitted to Centers for Medicare & Medicaid Services (CMS). The PPS discharge MDS assessment should have been transmitted on or before 11/22/24. Q90 assessment should have been transmitted on or before 01/06/25. R40's PPS discharge and Q90 MDS's were marked as completed, but not transmitted or accepted by CMS. Example 3 R31 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, atrial fibrillation, coronary artery disease, hypertension, and kidney disease. Surveyor reviewed R31's MDS assessments. R31's facility records identified the following: Admission-Not PPS was completed on 06/24/24. Status accepted. Q90 was completed on 10/02/24. Status completed. Q180 was completed on 12/31/24. Status completed. The Q90 and Q180 MDS assessments were never transmitted to Centers for Medicare & Medicaid Services (CMS). The Q90 MDS assessment should have been transmitted on or before 10/16/24. Q180 MDS assessment should have been transmitted on or before 01/14/25. R31's Q90 and Q180 MDS's were marked as completed, but not transmitted or accepted by CMS. On 02/19/25 at 9:09 AM, Surveyor interviewed Medical Records (MR) M who stated that MR M helps with MDS transmissions. MR M was provided a list of the residents above and asked for proof of transmissions for the MDS's completed but not transmitted. At 10:38 AM, MR M stated that the MDS assessments were not completed because those residents were self-pay or on a Medicare Advantage Plan and to speak with Nursing Home Administrator (NHA) A if there are more questions. On 02/19/25 at 1:10 PM, Surveyor interviewed NHA A and asked why the MDS's were not transmitted. NHA A stated it was due to payor source. Surveyor encouraged NHA A to visit chapter 5 of the Resident Assessment Instrument manual and F640 regulation. NHA A stated they will transmit them all from now on.

Based on observation, interview and record review, the facility did not ensure resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 15 residents (R13, R35) reviewed. R13 was left unattended while connected to mechanical lift equipment. R35 did not have increased supervision to prevent resident to resident altercations after incidents on 06/22/24, 09/16/24, 01/10/25, and 01/28/25. This is evidenced by: Example 1 The Food and Drug Administration (FDA) Safety Information guidance provided in Kwikpoints Patient Lifts Safety Guide, states in part: Do not leave patient unattended while in lift. Never keep patient suspended in sling for more than a few minutes. R13 was admitted to the facility on [DATE] with pertinent diagnoses of spastic quadriplegic cerebral palsy and muscle weakness of extremities. R13's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated that R13 has moderate cognitive impairment that requires cues and supervision and is dependent with assist for chair to bed transfers. On 02/18/25 at 12:45 PM, Surveyor observed R13 in his room, seated in broda chair, with mechanical lift sling positioned under him and attached to mechanical lift. Surveyor looked inside room and did not see a staff member present. On 02/18/25 at 12:51 PM, Surveyor observed Certified Nursing Assistant (CNA) C walking from around the corner of dining area from another resident hallway and enter R13's room. Surveyor observed CNA C check R13's sling attachment to mechanical lift by tugging slightly on sling strap. CNA C then walked to doorway, looked in both directions in hallway, and then returned to resident still suspended in sling attached to mechanical lift. On 02/18/25 at 12:53 PM, Surveyor observed another CNA enter R13's room to assist CNA C with transfer of R13. On 02/18/25 at 1:00 PM, Surveyor interviewed CNA C regarding observation. Surveyor asked CNA C why R13 was left unattended in his room while attached to the mechanical lift. CNA C stated she was waiting for her partner to assist with R13's transfer because he is a two person assist. Surveyor asked CNA C if this was a common practice for residents to be left unattended while connected to lift equipment. CNA C stated no. On 02/19/25 at 12:41 PM, Surveyor interviewed Director of Nursing (DON) B regarding observation and mechanical lift safety. Surveyor asked DON B if it would be an acceptable practice for staff to leave residents unattended while connected to lift equipment. DON B stated that other than an emergent situation, staff would be expected to stay with a resident while lift equipment is being used. Surveyor informed DON B of observation of R13 being left unattended for 6 minutes while attached to the lift machine. DON B stated disappointment and concern that this action could have resulted in harm from entrapment. 48793 Example 2 On 02/17/25, Surveyor reviewed R35's medical record. R35 was admitted on [DATE], with dementia unspecified with behavioral disturbances, cataracts, hypertensive heart disease, and insomnia. R35's Minimum Data Set (MDS) assessment, dated 11/06/24, had a Brief Interview for Mental Status (BIMS) score of 00 which indicated R35 had severe impaired cognition and could not complete the BIMS test. Surveyor reviewed R35's care plan for Alzheimer's disease major neurocognitive disorder due to medical condition with behavior disturbance: -On 11/16/22: Nurse to report any behavioral issues. Has wander management bracelet. -On 02/15/23: After wife visits monitor more closely for wandering or behaviors. -On 02/15/23: If attempt to swing fist may need to leave alone and reapproach later or get alternate staff. -On 02/21/24: Report to nurse if noting any behavioral issues or hitting peers. -On 06/25/24: Night shift to look in on him on rounds x 3. Keep door alarm on so as to alert staff to exiting room. On 1:1 visits as needed. -On 11/16/24: If pacing or restless, trying to go into peer's room offer to take toilet in his room. Redirect away from peers' rooms. -On 01/04/25: Turn on chime on outside door when he goes to bed, to alert staff when R35 exit seeks. -On 01/28/25: If in peers' room or noting to be touching peers, redirect R35. Surveyor reviewed R35's nursing progress notes that indicated, . -On 06/22/2024 at 4:09 PM, Note: [R35] was sitting at the dining table eating and suddenly he yelled at resident across the table who was eating his meal and then kicked the table and was swearing. We were going to remove him from the area but then he continued to eat, and we stayed nearby. When he appeared not to be eating, we offered that he could go watch tv if he wanted to. He got up and started pacing the hallway. After residents were done eating one resident stayed in his chair by the dining room table to watch tv and [R35] came up behind him and hit the back of the chair hard. This frightened the resident in the chair, and he got up with his walker and went to his room . Surveyor did not find documentation that staff implemented any new interventions to increase supervision or provide 1:1 for R35 after the resident altercation on 6/22/24. Nurse progress note indicated, -On 07/26/24: R35 was grabbing, pushing, and swinging. Attempted to put hands around writers' neck while trying to provide cares. Surveyor did not find documentation that staff implemented any new interventions to increase supervision for the other residents on the unit, when R35 exhibited increased aggressive behaviours on 7/26/24. Nurse progress note indicated, . On 09/16/24 at 9:30 PM, Note: [R35] spent first part of our shift outside. He did not eat much of his supper this evening. Given cold fluids as it was warm outside. Brought him in to get ready for bed but he has been very resistive to cares again his shift. I only now was able to get him to take his medications. Will attempt to change him again when he has had his meds in him for 30 minutes or so. CNA informed me that, [R35] walked by another resident and apparently swung as to hit him but did not. It is very difficult to address his cares even with two staff. Will continue to monitor behaviors and chart . Surveyor did not find documentation that staff updated any new interventions to increase supervision or provide 1:1 for R35 to protect other residents on the unit when R35 was observed swinging at another resident on 9/16/24. Nurse progress note indicated, .On 01/10/2025 at 5:16 PM, PRN MED GIVEN: hydrOXYzine HCl 25MG Tablet (1 tablet / 25mg) given for agitation tried to throw chair in dining room. 6:44PM PRN MED RESULT: at 6:44 PM, Improved but still present. At 9:00 PM BEHAVIOR: abusive behavior wandering behaviors Pushing /Grabbing Behavior occurred. Note: We were trying to direct [R35] over to his food at the table. He did not want to come to the table but was trying to take plates from the dietetic worker instead. As we attempted to guide him to his table, he became agitated and attempted to pick up a chair as if he was going to throw it. It was eased back to floor, and we directed [R35] back to tv area. There are three other residents at his table and two staff trying to feed residents and another resident that was not being too cooperative with eating. It seemed too much activity for [R35] at the time and he got very agitated and angry. I then gave him his prn atarax which had little effect tonight. About 7:30 he grabbed another resident by the wrist and staff intervened before he could hurt the resident. He was angry because this resident grabbed his blanket he was holding and so he turned around quickly and grabbed her, and staff were standing there when he grabbed her. I turned down lights early this evening to slow things down because residents seemed quite wound up tonight. Will continue to monitor him closely around other residents . Surveyor did not find documentation that staff updated any new interventions or increased supervision for R35 when he was exhibiting increased unsafe behaviors towards staff and residents on 1/10/25. Nurse progress note indicated, .On 01/28/2025 at 4:38 PM, Late Entry for: 01/27/2025. DATE OF INCIDENT: 01/27/2025, TIME OF INCIDENT: 17:12, INJURY: no apparent injury There was an altercation during supper time. Resident was grabbing at [R36] walker during supper, [R36] tried to stop him by talking loudly. [R35] grabbed [R36]. [R36] stated if he grabs him again, he was going to, punch him. Staff had intervened. At 4:39PM, Today there was no further altercations between [R35] and [R36], they were kept apart from each other. At 10:13 PM, [R35] was aggressive and combative at the beginning of the shift. Resident was found in another resident's room and will not follow redirection from the CNA. Instead, he swung his hand on the CNA hitting the CNA on the chest . Surveyor did not find any new intervention or increased supervision for R35 or 1:1 after R35 grabbed R36's walker and grabbed R36. Interviews: On 02/19/25 at 10:25 AM, Surveyor interviewed R36 and asked R36 if there have been any resident-to-resident altercations that have occurred on the unit. R36 stated, Yes, with [R35]! Who has not had an altercation with [R35]. One time [R35] came at me in the dining room, but I put him in his place. I yelled to tell him not to ever touch me again or I'd punch him. Surveyor asked R36 to explain the incident in the dining room with R35. R36 indicated that R35 came at R36 and grabbed R36's walker and then swung at R36, hitting R36 and grabbing R36's wrist. On 02/19/25 at 10:30 AM, Surveyor interviewed CNA F and asked how CNA F supervises difficult residents that may wander into others' rooms or become aggressive. CNA F indicated that CNA F tries to monitor residents such as R35 from becoming angry and wandering but sometimes CNA F is in rooms taking care of other residents and can't always monitor. On 02/19/25 at 11:27 AM, Surveyor interviewed Licensed Practical Nurse (LPN) G and asked LPN G what is LPN G's process when there is an altercation between a resident to resident or if there is an incident that happens with a resident that may need extra supervision. LPN G indicated LPN G will intervene if LPN G observes the resident-to-resident altercation. LPN G would try to redirect R35 or any other resident who is aggressive and acting out. Surveyor asked LPN G if LPN G does any kind of extra supervision for R35's outbursts. LPN G indicated that LPN G will try to observe from afar while in the common area. Surveyor asked LPN G how LPN G intervenes if R35 is from afar in the common area and R35 is about to swing at another resident. LPN G indicated that LPN G tries to make sure R35 is within close proximity but that is not always feasible when LPN G has to go into other rooms to pass medications. On 02/20/25 at 8:02 AM, Surveyor interviewed Director of Nursing (DON) B and asked what interventions for increased supervsion are in place for R35 due to his aggressive behaviors towards staff and residents. DON B indicated that sometimes staff will keep a close eye on R35 in the common area and kind of perform a 1:1. Surveyor asked DON B to explain what 1:1 means. DON B indicated that 1:1 means there is an actual staff member designated to 1:1 with R35 and staff do not let R35 out of sight. Surveyor asked DON B if 1:1 was utilized on 06/22/24, 09/16/24, 01/10/25, and 01/28/25. DON B indicated that DON B was unsure, but that DON B doubts it since some of these events occurred. Surveyor indicated to DON B that through review of documentation that Surveyor could not find that R35 was 1:1. DON B indicated that R35 was probably not 1:1 as we do not have enough staff to be 1:1 at this time. DON B acknowledged that increased supervision was not provided for R35 to prevent incidents with other residents.

Based on observation, interview and record review, the facility did not ensure a medication error rate of 5% or less. During the medication administration task, Surveyors observed 4 errors out of 35 medication opportunities, resulting in an error rate of 11.4%. This affected 2 out of 4 residents (R) observed for medication administration sample. (R11 and R39) R11 received two insulin injections by using injectable pens that were not primed before administration. R39's insulin was not primed prior to administration of insulin. Findings include: Manufacturer's instructions for Basaglar Kwikpen (insulin glargine) states in part, .Priming your pen: Priming means removing the air from the Needle and Cartridge that may collect during normal use. It is important to prime your Pen before each injection so that it will work correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime your Pen, turn the Dose Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. If you do not see insulin, repeat the priming steps, but not more than 4 times. If you still do not see insulin, change the Needle and repeat the priming steps . The facility procedure document entitled Insulin Injection, procedure reviewed date 2/25, states, in part, 9. If using an insulin pen, cleanse hub, apply needle, then prime pen with 2 units (dial 2 units\, hold pen upright, flick to bring air bubbles to top, push button all the way until dose returns to zero- you should see drop of insulin at needle tip\, if not change needle and repeat) Turn dial until desired dose. Example 1 R11 was admitted to the facility on [DATE] with a diagnosis including type 2 diabetes mellitus. R11 orders include, Insulin Aspart 100 unit/ML solution, Dose 12 units subcutaneously twice per day AM and noon and (Basaglar Kwik-pen) Insulin Glargine 100units/ml, Dose 18 units subcutaneously daily in the AM. R11 received two insulin injections via injectable pens that were not primed by Licensed Practical Nurse (LPN) J before administration of insulin dose. On 2/18/25 at 7:32 AM, Surveyor observed LPN J remove 2 insulin pens from the med drawer. LPN J dialed the Glargin pen (Basaglar 100units/ml) to 18units and the Aspart pen to 12 units without priming the pens first. Surveyor asked if the insulin pens needed to be primed. LPN J stated these insulin pens did not need to be primed. Surveyor observed LPN J administer the insulins subcutaneously into R11'S abdomen. On 2/18/25 at approximately 8:30 AM, Surveyor interviewed Director of Nursing (DON) B on the type of education and training that has been provided to nursing staff. DON B reported there had been a training on how to use an insulin pen in Dec. 2022. DON B reported her expectation would be that nursing staff prime the insulin pen prior to injecting a resident with insulin. DON B reported awareness of LPN J not understanding the need to prime insulin pens prior to injecting insulin. 48793 Example 2 On 02/18/25 at 8:00 AM, Surveyor observed LPN G administer a Humalog insulin pen into R39's abdomen. Surveyor did not observe an open date or expiration date label on the used Humalog pen. Surveyor did not observe LPN G prime the Humalog insulin pen with 2 units before prepping 6 units into the insulin pen. On 02/18/25 at 8:05 AM, Surveyor interviewed LPN G and asked what LPN G's process is for priming and administering insulin. LPN G indicated that LPN G forgot to prime and should have primed the Humalog insulin pen with 2 units and discard the 2 units first before prepping the 6 units for R39's Humalog insulin.

Based on observation, interview and record review, the facility did not ensure drugs and biologics were stored in accordance with current accepted professional practice. This had the potential to affect 2 out of 2 residents (R) for proper labeling. (R29 and R39) This is evidenced by: According to the Food and Drug Administration (FDA), insulin pens should be discarded 28 days after opening the pen to ensure effectiveness of the medication. According to the American Diabetes Association, insulin products contained in vials or cartridges supplied by the manufacturers (opened or unopened) may be left unrefrigerated at a temperature between 59 and 86 degrees F for up to 28 days and continue to work. After 28 days the insulin should be discarded. On 3/29/21, R29 was admitted to the facility with a diagnosis including type 2 diabetes mellitus. R29's orders included Tresiba FlexTouch/ Insulin Deglu[DATE]u/ml Solution Pen-injector Dose 45 unit subcutaneous twice per day. On 2/19/25 at 10:25 AM, during a tour of medication storage, with Registered Nurse (RN) K, Surveyor observed R29's insulin pen, Tresiba FlexTouch 100u/ml exp 8/31/26, pharmacy label reads, 45 units SQ BID, opened, not refrigerated, and not labeled with an opened date, in the drawer of the medication cart. Surveyor interviewed RN K, who reports she forgot to date it when it was originally opened. RN verbalized understanding that insulin pens should be labeled with an opened-on date when they are taken out of the refrigerator and used within 28 days. 48793 Example 2 On 02/18/25 at 8:00 AM, Surveyor observed Licensed Practical Nurse (LPN) G administer a Humalog insulin pen into R39's abdomen. Surveyor did not observe an open date or expiration date label on the used Humalog pen. On 02/18/25 at 8:05 AM, Surveyor interviewed LPN G and asked what LPN G's process is for administering insulin without an open date. LPN G stated, That is a good question. I guess I would figure out when the pen was opened before giving to [R39]. Surveyor asked LPN G was it the correct process to still give the Humalog insulin without an open date to R39. LPN G indicated that LPN G probably should have discarded the Humalog insulin and got another one, but LPN G did not.

Based on record review and interview, the facility did not conduct a thorough investigation of a resident-to-resident altercation by interviewing all residents who were in area at time of incident, did not provide follow up supervision for 48 hours per facility report to protect other residents, and did not provide staff education following an incident for 1 of 4 residents (R1). This is evidenced by: The facility policy, entitled Misconduct Investigation & Reporting last reviewed on 08/23/11 and states in part under section 14 of policy: All resident witnesses/victims should be interviewed as part of the investigation. Nursing or Social Services will assess the resident(s) and make official entries in client charts indicating any behavioral, emotional or changes from their baseline and recommend follow-up or longer if deemed necessary. R1 was admitted to facility on 03/21/21 and has diagnosis of cerebral vascular accident and aphasia. R1's quarterly Minimum Data Set completed on 06/19/24 indicated that R1 has a Brief Interview for Mental Status (BIMS) score of 6 (moderate cognitive impairment). On 08/20/24 at 8:45 AM, Surveyor reviewed facility investigation that occurred on 05/27/24 of a resident-to-resident altercation. R1 had turned off the TV in the resident living room while other residents were watching it and went back to own room. The TV was turned back on and R1 came back out of own room and got upset at inability to locate the TV remote. R1 threw items off the dining table and grabbed another resident's hand and squeezed it. On 08/20/24 at 8:50 AM, Surveyor requested evidence to support that the facility put interventions into place to prevent further resident abuse from occurring while the investigation was in progress. Surveyor asked for interviews conducted with residents that were witnesses to the event to thoroughly collect evidence to allow the facility to determine what actions are necessary (if any) for the protection of residents and education provided to staff following the incident of the findings. On 08/20/24 at 12:39 AM, Surveyor interviewed Nursing Home Administrator (NHA) A who stated interviews with residents that were witnesses to the event did not occur. The facility did not have evidence of R1's increased supervision for 48 hour per facility report and did not provide education to staff following the incident to prevent further potential abuse.

Based on interview and record review, the facility did not ensure adequate supervision to reduce risk of wandering/elopement for 1 of 3 residents (R) reviewed (R1). R1 left the facility without staff's knowledge and was not added to the facility's Wanderer's List for increased supervision after incident per facility policy. This is evidenced by: The facility's policy titled, Wanders-Identification, Observation, and Possible Search For, with most recent revision dated 08/2022 stated in part that required follow up following a wandering/elopement event nursing staff must include resident on Wanderer's List. R1 was admitted to the facility on [DATE] with pertinent diagnoses of hemiplegia (impaired body function) on right side due to cerebral infarction (blood clot in brain) and aphasia (impaired speech). R1's most recent quarterly Minimum Data Set (MDS) dated [DATE] indicated no verbal, physical, or wandering behaviors noted. R1's Brief Interview of Mental Status (BIMS) score was 06 indicating severe cognitive impairment. R1's care plan, dated 07/17/24 (implemented after elopement), states: Problem: Activities of Daily Living/Functional Safety Interventions: Wheelchair to be positioned next to head of bed locked related to self-transfer. If R1 is upset/angry about something, staff to initiate 15-minute checks until anger/upset is resolved. No care plan interventions for wandering/elopement risk for R1 were noted. Surveyor reviewed facility's self-report incident of R1 wandering from facility without supervision that occurred on 07/17/24. Surveyor reviewed R1's medical record for wandering/elopement risk assessment. No risk assessment noted. No prior incidents of elopement or exit seeking noted in the medical record. Following the event the care plan was updated to include implemented safety interventions of 15-minute safety checks and placement of wheelchair next to bed for safety. The Interdisciplinary Team (IDT) met to review incident and determined that R1 was upset about a chair being moved in his room causing R1 to become upset and purposefully leave facility. The IDT determined that R1 was not previously considered at-risk for wandering, had not displayed exit seeking behaviors prior to this incident, and was determined not be at-risk for wandering in the future. The IDT ultimately decided to discontinue the 15-minute safety checks with the exception of re-starting safety checks if R1 becomes agitated/upset again, the facility did not to add R1 to facility's wanderer's list. The facility determined through their investigation the use of other safety supervision interventions (such as a Wanderguard) were unnecessary. On 08/20/24, Surveyor reviewed facility's wanderer's list for residents identified as at-risk for wandering/elopement. R1 was not included on this list. On 08/20/24 at 12:37 PM, Surveyor interviewed Director of Nursing (DON) B and Nursing Home Administrator (NHA) A regarding wandering/elopement risk assessment procedure and R1 not being listed on wanderer's list. Surveyor asked if there was a policy for wandering/elopement risk assessment. DON B stated having no written policy, but current practice is that newly admitted residents are informed of any prior wandering/elopement incidents or at-risk behaviors from transferring facility, if applicable. Additionally, all new admissions are monitored for 72-hours for mood and behavior. This information is assessed by the IDT to determine safety risks (i.e. wandering) and the care plan will be updated with safety interventions. All residents are then routinely monitored by nursing staff documenting any change in mood or behavior which is then assessed during routine IDT meetings or immediately if nurse recognizes a risk to safety. Each resident is assessed individually by the IDT for appropriate safety interventions and not all residents at-risk for wandering will have a Wanderguard applied, as was the case with R1. DON B stated R1 had never showed signs of wandering or exit seeking prior to this event and therefore was never determined to be a risk. DON B and NHA A stated that R1 was assessed by the IDT not to be not appropriate for the wanderer's list or for use of a Wanderguard as this would upset R1 being questioned by staff every time R1 was observed roaming the facility grounds outside of R1's unit and restrict his rights. Surveyor asked DON B and NHA A the purpose of having the wanderer's list. DON B and NHA A both stated that the individuals on the list were at-risk for wandering and provide a picture for quick recognition by staff to intervene if observed attempting to wander or elope. Surveyor asked why R1 was not added to wanderer's list after the wandering event. DON B and NHA A stated that they felt appropriate post-incident safety measures were implemented at the time and it was not necessary, but now recognize R1 should have been added to the list.

Based on observation, interview, and record review, the facility staff failed to adequately assess and treat pain and provide necessary care and services to attain or maintain the highest practicable physical well being for 3 (R65, R72, and R21) of 3 residents reviewed for pain. R65 was diagnosed with [REDACTED]. R65's MD wrote new orders for R65's pain medication. A facility staff member wrote on the physician order [REDACTED]. This resulted in R65's as needed (PRN) narcotic pain medication being discontinued inappropriately. R65 was receiving only [MEDICATION NAME] after this date and complained of increased pain as a result. R72's Care Plan did not contain pain goals or interventions specific to R72's pain. R72 reported to be in pain that he rated 7 out of 10. Staff were not sure what to do or what they were allowed to do to assist him with pain management. R21 is not receiving effective pain management services; R21 has no care plan in place for pain. Evidenced by: Facility policy, entitled, Pain Management Program, revised 8/08, includes, in part: Unrelieved pain has a significant impact on quality of life of a resident. Therefore it is a goal of (facility name) that our residents have effective pain management. The facility's goal is interdisciplinary, taking into account all of the resident's strengths and needs. An effective program of pain management utilizes a balance of interventions individualized for each resident. One outcome is to balance pain relief interventions that provide an adequate sustained response in order to maintain as much functional ability as possible. Several individual resident factors should be used to supplement, but not replace pharmacological interventions. Cognitive and behavioral interventions such as relaxation, visual imagery, positioning, and distractions . Cultural and behavioral beliefs/meditation . Sensory interventions such as music, heat, cold, therapeutic tough, olfactory stimulation . Assessment is the foundation of a successful music program. Pain control should be the goal- possible addiction is not an issue. The goal of pain management is continuous comfort rather than peaks and valleys of pain . Pain refers to any type of physical pain or discomfort in any part of the body. Pain may be localized to one area, or may be more generalized. It may be acute or chronic, continuous or intermittent, or occur at rest or with movement. Acute pain is sudden sharp and severe in onset but expected to be short term. Chronic pain is pain persisting for a long period of time. For the individual, pain can be either subjective or objective. Objective pain or discomfort is measurable or visible by an observer. Subjective pain or discomfort is whatever the resident states it is . Pain measurement scales: . has adopted a combination of pain scales for resident use based on the preferences/abilities of the resident . In all scales if the pain is descriptive it can be measured numerically and this can be recorded in the MDS accordingly. Procedure: The Comprehensive Pain Assessment for will be initiated on pre-placement. Information will be gathered from the patient, family, and/or staff. The Comprehensive Pain Assessment form will be placed in the medical record under the assessment section. The RCC (Resident Care Coordinator) will finish the assessment form. A Non-Pharmacological Pain Intervention flow sheet will be initiated. These will be trialed prior to pain meds. Pain Treatment Intervention sheets will also be filled out with parameters for severity of pain with appropriate med to be given as prescribed . Ongoing observation, assessment, and documentation with appropriate changes will be done as needed to the care plan and intervention sheet. The time frame of 30 minutes for reassessment of interventions have been set as a guideline only. Documentation of a different time will over rule this time frame depending on physician order, the route, onset, and duration of effect for the pharmacologic agent used . The entire pain management program should incorporate the problem, goals, and approaches individualized for each resident. The care plan should clearly indicate when pain medication is to be given and that the pain treatment intervention sheet in the medex correlates to the care plan. Document all continued efforts to reach an appropriate pain control goal for the resident in order to demonstrate that control of all pain has been avoidable. Facility policy, entitled, Transcribing Physician Orders, effective date 6/21/02, no revision date, includes, in part: . Procedure: Check admission paperwork for physician orders. These may be found on a Physician Plan of Care record, on a discharge summary record, or written a physical form completed by the transferring physician. If the resident was transferred from the hospital or another nursing facility and there is any question about the orders the nurse transcribing the orders should call the facility to clarify the orders. If the orders are found on a Physician Plan Of Care sheet and on discharge summary sheet and there are variations between the two records, contact the physician to clarify the orders. Orders to include, medication, treatments, and further follow up appointments will be written on the Physician order [REDACTED]. Do this accurately ensuring that no order is changed in the process of the transcription. The nurse should indicate that the orders were copied from the Physician Plan Of Care, Discharge Summary or physical form, of/from which doctor, and by which nurse. Orders copied from Physician Plan of Care of (name of MD) always write clearly and legibly. Printing is preferred. Follow up by calling in medications to the pharmacy . indicate you have done so by placing a large X over the called in orders or by writing called in on the order sheet . After a physician appointment: Check doctor consult for or the physician's personal summary for new orders. Do this accurately ensuring that no order is changed in the process of the transcription. The nurse should indicate that the orders were copied from the consult form, of/from which MD, and by which nurse . Example 1 R65 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. R65 had a mandibulectomy (surgery to remove all of part of jaw) on 5/1/19. His admission MDS (Minimum Data Set), ARD (assessment Reference Date) of 5/10/19 indicates R65 is cognitively intact with a BIMS (Brief Interview for Mental Status) score of 13 out of 15. R65's MDS also indicates R65 was interviewed for pain and had no pain at any time in the previous five days and that he did not receive scheduled pain medications, but did receive as needed pain medication and non-pharmacological interventions for pain during the look back period. R65's MDS Care Area Assessment, associated with R65's MDS indicates that pain was not a triggered area nor did it check for care planning of pain. On 6/17/19 at 3:37 PM during an interview, R65 indicated that his MD discontinued his [MEDICATION NAME] after his appointment on 6/11/19 and Friday his pain was really bad and it continued to be bad over the weekend into the present. R65 stated that he has told staff of his pain, but he doesn't think the staff listen to him and they don't understand how bad the pain he is experiencing really is. R65 rated his pain over the weekend to be 10 out of 10 and at this moment it was still 10 out of 10. R65 explained that he was diagnosed with [REDACTED]. R65 indicated that he was admitted to the facility with approximately 26 staples and some stitches in his jaw and this condition has caused him more pain than he has ever experienced before. R65 stated, I have pain that is not being addressed. Friday night my pain was really bad and this place can't do a thing about it. They wouldn't just call my doctor, said I would need to go to ER. At this point, during the interview, a machine started to beep behind R65 and LPN S entered the room without knocking, stating to R65, I told you I was taking care of it. She is out there signing the order right now. LPN S indicated to Surveyor that she was aware R65 was having pain. LPN S stated the Nurse Practitioner is completing an order for [REDACTED]. When asked if staff offer R65 ice or heat for his pain, R65 indicated that they don't offer him heat or ice, but he puts his hand on his cheek and the warmth of his hand makes it feel better. R65's hospital discharge summary, dated 4/22/19, includes, in part: . He is clearly uncomfortable on exam, clutching his jaw, quite pale and chronically ill appearing. Ears/Nose/Throat:Left side of mandible swollen compared to right. Tender to palpation along jaw. Decreased range of motion of mandible due to pain. Eschar present on the underside of left jaw draining purulent material draining from underside of jaw coating most of neck . Skin:eschar on underside of left jaw. Greasy scale present on face and top of head . Skin intact? NO. [MEDICAL CONDITION] induced wound present on underside of left jaw . Imaging Impression: New cortical erosion at the junction of the posterior body of the left mandible and ramus with questionable fracture. Increasing erosion in the body of the left mandible anterior to the last molar. When correlated with the clinical history, both of these sites of cortical erosion may represent [MEDICAL CONDITION] osteonecrosis . R65's hospital discharge summary, dated 5/3/19, includes, in part: What goal do you have while you are hospitalized ? . Pt states, To have jaw pain under control by time of discharge. Pain: to left jaw and tongue. Worse with speech- feels like jaw is breaking when opening mouth- as needed [MEDICATION NAME] every 4 hours . Active problems/all Diagnoses: [REDACTED]. -[MEDICATION NAME] 5 mg/5mL (place 10mL in gastrostomy tube every 4 hours as needed for pain for up to 14 days. Summary of admission history of adenoid cystic [MEDICAL CONDITION] and [MEDICAL CONDITION] induced necrosis of left jaw who presents to (hospital name), who complains of pain in his left jaw. Hurts to talk, last 2 days. He says his jaw feels likes its broken and its been like this for a week, because he can hear/feel the bones shifting and grinding against each other. The pain was an 8 out of 10 before (dull ache and burn), but with pain meds it went down to a 2. (It is important to note R65 did not have an admission pain assessment in medical record.) R65's Baseline and Comprehensive Care Plan, initiated 5/3/19, includes, in part: Problem: Osteoradionecrosis of left mandible major procedure mandibulectomy, History of Chronic Pain after radiotherapy, open wound (oral cutaneous fistula) with necrosis and eschar . Goal: (no goals related to pain included on this Care Plan . Interventions: Provide adequate pain control. Report Pain Indicators . (It is important to note there are no non-pharmacological interventions, no pain goals, no explanation of what adequate pain control means, and no explanation of individualized pain indicators included in this care plan.) R65's Physician Orders, dated 5/1/19-6/10/19, include, in part: [MEDICATION NAME]/[MEDICATION NAME] 5MG solution (10 ml enteral tube every 4 hours as needed . start date: 5/3/19 . end date: 5/16/19 [MEDICATION NAME] 325 MG( 2 tablets/650 MG) enteral tube every 4 hours as needed . start date 5/19/19 . [MEDICATION NAME] 12 MCG/HR patch change every 3 days . start date 5/4/19 . end date: 6/11/19 (It is important to note that there was one day that patch was not recorded as changed out, missed dose on date of 5/7/19.) [MEDICATION NAME]/[MEDICATION NAME] 5 MG (give 5 to 10 mg) enteral tube every 4 hours as needed . start date 6/17/19 R65's physician progress notes [REDACTED]. And work towards weaning off his oral narcotic . R65's Physician Order, signed and dated 6/11/19, includes: #1 stop [MEDICATION NAME]es, #2 [MEDICATION NAME] to PRN, This is all written in small scratchy font with a ball point pen and signed by MD in same scratchy font with same pen. Also on the order written next to [MEDICATION NAME] PRN, with a large bubbly font and a dark black gel pen is D/C (discontinued). The gel pen was also used to cross off the letters PRN (as needed). (It is important to note that someone crossed off and changed the MD order.) R65's Physician order [REDACTED]. Copied from progress note (R65's MD), signed by LPN T. (It is important to note that R65's MD did not discontinue [MEDICATION NAME], but ordered it PRN.) R65's NN dated 6/11/19-6/19/19, include, in part: NN: 6/11/19=12:34 AM PRN given [MEDICATION NAME] . pain/discomfort . pain before med: 5 . location: head pain level after med: 3 . Action: continue to monitor. =4:47 PM current pain level 00 NN: 6/12/19= 6:02 PM PRN med given: [MEDICATION NAME] . pain level before med 4 . location: left jaw line . NN:6/13/19 =7:19 AM PRN given: [MEDICATION NAME] . given for pain . pain level before med: 5 . location: jaw pain . NN:6/14/19= No mention of pain monitoring on this date. NN: 6/15/19=6:48 AM PRN given [MEDICATION NAME] . pain/discomfort . pain before med: 4 . location: headache . pain level after med: 2 . Action: continue to observe . =10:32 AM PRN given [MEDICATION NAME] . given for pain . pain before med: 7 . location: left jaw . =6:45 PM PRN given [MEDICATION NAME] . pain/discomfort . pain before med: 8 . location: all over . NN: 6/16/19= 12:50 AM PRN given [MEDICATION NAME] . pain . pain before med: 6 . location: head . pain level after med: 2 . Action: continue to observe . = 8:18 AM PRN given [MEDICATION NAME] . given for pain . pain before med: 6 . location: jaw . = 9:13 PM PRN given [MEDICATION NAME] . given for pain . pain before med: 4 . NN: 6/17/19= 6:50 AM PRN given [MEDICATION NAME] . pain/discomfort . pain before med: 5 . location: head pain level after med: 4 . Action: continue to observe = 4:09 PM PRN given [MEDICATION NAME] . pain/discomfort . pain before med: 6 . location: left jaw . = 10:44 PM PRN given Oxyodone . pain/discomfort . pain before med: 7 location: left jaw NN: 6/18/19= 1:53PM PRN given [MEDICATION NAME] . pain/discomfort . pain before med: 6 . = 9:19 PM PRN given [MEDICATION NAME] . given for pain/discomfort . pain before med: 6 . location: left jaw cheek . NN:6/19/19= 3:09 AM PRN given [MEDICATION NAME] . pain/discomfort . pain before med: 6 . location: jaw . pain after med: 3 . Action: encourage to rest, continue to observe . =7:22 AM PRN given [MEDICATION NAME] . pain before med: 8/10 . location: left mouth . On 6/19/19 at 8:25 AM during an interview, R65 stated, I am having a so, so day. I have a lot of pain. Surveyor asked R65 if he told staff members that he was in pain, R65 indicated that he had and staff say they are working on it. R65 stated, I suffered all weekend. They gave me something now, less than an hour ago. It does seem to be helping a little. My pain was an 8 this morning. Right now it is a 7. I would like my pain at a 3. Some days I get there. We tried ice last night. I think heat would help, I hold my hand on there. R65 demonstrated by putting his hand up on his cheek. On 6/19/19 at 8:38 AM during an interview, CNA U indicated that she was unaware R65 was having pain. CNA U asked R65 if he was in pain. R65 stated, Yes I am in pain. CNA asked R65, Where? R65 motioned along his jaw. CNA U stated to R65, I will let (LPN V) know. I think she is pretty much aware of it.CNA U indicated that she doesn't usually ask him if he is in pain, but if he tells her she passes that on to the nurse. On 6/19/19 at 8:40 AM during an interview, LPN V indicated that she asks R65 to rate pain during every med pass and charts it on MAR. LPN V stated, We have 0-10 scale on there. I believe his pain goal is three to four. It might be documented in nursing assessment in nurse notes. Pain interventions should be on care plan, pain goal too. On 6/19/19 at 12:40 PM Surveyor interviewed DON B. DON B stated I wouldn't expect anyone to write on MD orders or change them after they are signed. Not sure where she got the order for [MEDICATION NAME] to be discontinued. DON B stated when resident is admitted the facility completes assessments for 72 hours. Residents are assessed for pain every shift . we draw the interventions for the care plan from the info gained. DON B stated staff should ask about pain with each med pass, rating their pain if able. DON B stated all residents should have their pain addressed on an ongoing basis. DON B stated pain assessments are created by gathering data collected from all three shifts or if pain triggers on the CAA. DON B stated interventions for pain should be on the care plan. Surveyor read R65's pain care plan to DON B and asked what does adequate pain control mean for R65? DON B stated it means if he says he is having pain provide pain medication as ordered. The care plan should also say if pain interventions are not effective alert provider. DON B stated a R65's pain goal should be on 72 hr assessment. DON B stated RN W is new and we need to educate her on this component. She is obviously missing the pain aspect. DON B stated I was unaware R65 was reporting pain over the weekend. On 6/19/19 at12:58 PM during an interview, RN W indicated R65 didn't have much pain in the beginning and he was NPO (nothing by mouth). RN W also indicated R65's [MEDICATION NAME] and Fentyanl were recently discontinued and at this point in time R65 has tylenol to assist in pain management. Surveyor and RN W reviewed physician progress notes [REDACTED]. RN W stated, Nurses should not write on a MD order or change it. I don't know why she did that. Maybe he should have had [MEDICATION NAME]. The MD note looks like he should have had [MEDICATION NAME]. I was unaware of his pain until Monday. They could have called MD on call over the weekend, but they probably wouldn't have spoke with his MD. The care plan should have pain goals and interventions. I don't know how I missed these two for pain assessments. I did them now. I need to work on my care plans. I know I need some help in this area. On 6/19/19 at 1:53 PM during an interview, DON B indicated she reviewed R65's MAR and it did not suggest that he was in excrutiating pain over the weekend. Surveyor asked what R65's pain goals are? DON B indicated that she was unsure what an acceptable level of pain is for R65 or what his goal is related to pain. DON B also indicated that R65's Care Plan should include pain goals and interventions related to pain and it does not. On 6/19/19 at 2:45 PM during a phone interview, R65's MD X indicated that he wanted the facility to discontinue use of R65's Fentynal patch and use [MEDICATION NAME] as needed for pain management and eventually be weaned off. MD X stated, I think he needs pain medication. He needs to be weaned and tapered off, not cold turkey. I did not intend for both to be discontiued cold turkey. He is going to continue having pain. He is only 4 weeks out. I did not cross off or write discontinue on order. If something out of ordinary was happening, I would expect them to call MD on call. On 6/19/19 at 3:00 PM during an interview, NHA A indicated that R65's Care Plan should have pain goals and pain related interventions on it. NHA A also indicated that R65 should have had a pain assessment done on admission. On 6/19/19 at 4:11 PM during an interview, NHA A stated, I dont know why (LPN T) wrote on that order or what happened with that. She should have called to clarify that order and run it by the pharmacy. That isn't even a legal order. he is saying now that his pain was a 10 out of 10 over the weekend, but all of our documentation says he did not have pain. On 6/19/19 at 4:13 PM during an interview RN C indicated that she worked a PM shift on Sunday on the 2nd floor, but she did go up to the 3rd floor and she did see and talk with R65. RN C indicated that R65 told her he wanted to see someone about this, touched his face, but that R65 never mentioned the word pain to RN C. RN C also indicated that she would never change a MD's signed order, but would call MD to get a clarification and then write that out on facility physician order [REDACTED]. On 6/19/19 at 4:44 PM NHA A stated, We certainly should have care planned the pain. (LPN T) said she put him on the Nurse Practicioner list to be seen Monday because he seemed to be having more pain since discontinuing fentynal patch. She also told me that she gave him tylenol a couple times over the weekend and that helped with the pain he was having. Example 2: R72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R72's MDS, ARD of 5/14/19, indicates R72's gonition is severly impaired with a BIMS score of 5 out of 15. R72's MDS also indicates during the look back period, he has had pain occasionally, pain has made it hard for R72 to sleep at night, R72 has limited his day to day activity due to pain, the worst pain R72 reported was 8 out of 10, and R72 received as needed pain medication and non pharmacological for pain in the 5 day look back period. On 6/17/19 at 2:31 PM R72 indicated that he has pain in leg and some staff are good while others not so good about pain management. R72 indicated he has a sore on his ankle and one sore on his backside that is terribly big and cause him pain. R72 rated his pain a 7 out of 10. When asked what was an acceptable level of pain for him to be at or a goal level, R72 stated, 3 or 4. R72's Baseline Care Plan, initiated 5/7/19, includes, in part: 5/9/19 Nurse Aide- report pain indicators. R72's 72 hour admission assessment, dated 5/7/19, includes, in part: current pain level:00 .been on scheduled pain medication regimen: No . received PRN pain medication: No . Received non-pharmacological pain interventions: Yes . Rest, position changes, elevation . effective . 5/8/19 current pain level:00 .been on scheduled pain medication regimen: No . received PRN pain medication: No . Offered PRN pain medication and declined: Yes . Received non-pharmacological pain interventions: Yes . Rest, position changes, elevation . effective . 5/8/19 current pain level:05 . been on scheduled pain medication regimen: Yes . received PRN pain medication: Yes . Received non-pharmacological pain interventions: Yes . Rest, position changes, cold packs . effective R72's Physicin Orders include, in part: 5/7/19 [MEDICATION NAME] 1000 mg three times a day for pain . 5/7/19 [MEDICATION NAME]/[MEDICATION NAME] 5MG every 4 hours as neded for chronic pain . [MEDICATION NAME] Sodium gel- one application four times a day to heels for joint damage causing pain . R72's Comprehensive Care Plan, initiated 5/7/19, includes in part: 5/9/19 Nurse Aide- report pain indicators. (It is important to note that there is no pain related goals or interventions on R72's Comprehensive Care Plan.) On 6/19/19 at 8:38 AM during an interview, CNA U indicated that R72 has made comments this morning about being in pain during transferring, but not excrutiating. If R72 reported excrutiating pain, CNA U would tell the nurse. CNA U indicated that she would look on R72's care plan for instructions on what to do for his pain. On 6/19/19 at 8:45 AM during an interview, LPN V indicated that she asks R72 each med pass about his pain and has him rate it. When asked about R72's pain goals, LPN V indicated that she thinks a 2 or 3 is a good goal, but she does not believe this is documented anywhere in R72's medical record and it should be. LPN V also indicated that pain interventions should be on care plan. On 6/19/19 at 1:53 PM during an interview with DON B, Surveyor asked what R72's pain goals are? DON B indicated that she was unsure what an acceptable level of pain is for R72 or what his goal is related to pain. DON B also indicated that R65's Care Plan should include pain goals and interventions related to pain and it does not. On 6/19/19 at 3:00 PM during an interview, NHA A indicated that R72's Comprehensive Care Plan should have pain goals and pain related interventions on it. Example 3 R21 is a long term care resident of this facility who resides on the dementia care unit. R21 has the following Diagnoses: [REDACTED]. The facility had no evidence of comprehensive pain assessments being completed for R21 for April-June 2019. R21's care plan entitled Cognitive Loss has an approached, dated 3/7/18, of Nurse Aide---Report any pain indicators to nurse. (It is important to note that there is no other mention of pain in R21's care plan, there is no pain goal or interventions to be utilized.) Per R21's current Physician order [REDACTED]. Per R21's MAR, he received the PRN [MEDICATION NAME] 15 times in (MONTH) (to date of 6/19/19), 26 times in (MONTH) and 24 times in April. R21's MAR includes a nursing order to Record pain level every shift; for June, 15 times it documents that R21 was in pain; for May, 22 times it documents that R21 was in pain; and for April, 26 times it documents that R21 was in pain. On 6/19/19 at 2:17 PM, Surveyor interviewed RN, RCC [NAME] (Registered Nurse, Resident Care Coordinator) and RN, RCC D. Surveyor asked in general do you feel like R21 is in pain. RN, RCC [NAME] stated, I think we have it very well managed with him, when he was admitted , he came with stage 3 and 4 wounds on his heels and right lateral leg, which contributed to his pain and they are all healed. Pain is assessed every shift and documented in the chart. Most of the time, if you ask in a straight forward way, he can tell you. Sometimes, if he is agitated, he has a hard time deciding if he is in pain. Surveyor asked how do you discern if agitation is from pain. RN, RCC [NAME] stated that with repositioning he gets a furrowed brow and irritable and then we treat that as pain with him. Surveyor asked how do you rate or assess R21's pain level if he is unable to tell you. RN, RCC D and RN, RCC [NAME] both said they use a version of Wong Baker faces, not sure of the exact name of the scale, but state that it is what is in their computer for them to use and it is documented with a numerical value. On 6/19/19 at 5:05 PM, Surveyor interviewed DON B. Surveyor asked DON B if residents' acceptable pain level is documented, DON B said no, we have been looking at beefing up the pain care plans. Surveyor asked DON B how the staff knows what interventions to use for each resident that may help alleviate pain; DON B said non-pharmacological interventions are in the care plan.

Based on observation, interview, and record review, the facility did not ensure that a resident who entered the facility without pressure injuries (PI) did not develop PI, and a resident who has a PI receives the necessary treatment and services to promote healing, prevent infection, and prevent new pressure ulcers from developing, for 4 of 4 sampled residents (R44, R38, R41, and R118) out of a total sample of 19. Resident 44 was admitted to the facility without a PI and was not consistently identified to be at risk for PI development. The facility did not take aggressive action in prevention, did not assess equipment being used or consider the manufacturer's warnings, did not meet standards of practice for monitoring and measuring wounds, did not correctly code MDS (Minimum Data Set), and R44 developed several stage 3 PIs and continues to have PIs to left and right buttocks. R38 was admitted to the facility without a PI and was identified to be at risk for PI development. R38 developed a PI while in the facility and was observed without care plan interventions in place. R38 was observed lying in bed on multiple layers of linen over his Panacea Clinical Mattress (foam mattress), and sitting on a ROHO (air filled cushion to relieve pressure) cushion with a soaker pad (impermeable multi-layer sheet with high absorbency that is used for incontinency), and the Hoyer sling (fabric material used to transport from bed to wheelchair (w/c)), while in the w/c. R38 did not have a dressing on his wound nor the ordered paper towel to cradle his scrotum while lying in bed. R41 acquired a stage 2 PI to her coccyx 3/19/18. R41 did not provide interventions of pressure reduction. R41 was observed with several layers on her bedding. R118 was admitted with PIs; interventions were not being followed to promote optimal pressure reduction with devices being used. Evidenced by: The facility's Skin Care / Risk Factors and Intervention Policy, with a revision date of 11/12, includes, in part: 1. Upon admission the Braden (predicting pressure sore risk) Scale and check list of Skin Risk Factors and Intervention sheets will be completed. A full body inspection will be done at bedtime on the admission day by a licensed nurse who will fill out the body check form and sign it. 3. When an ulcer exists notify the Wound Nurse. 4. Turn / reposition resident. Always use lift sheet. 7. Perform the wound treatment per provider order. 9. Re - evaluate the wounds to the response to the prescribed treatment. Inform MD (Medical Doctor) of changes in wound status. 11. Document wound assessment, treatment performed and response to treatment on the Skin Care Treatment sheets. According to the NPUAP (National Pressure Ulcer Advisory Panel), dated 6/13/12, includes, in part: recommends use of positioning devices and incontinence pads that are compatible with the support surface and to limit the amount of linen and pads placed on the bed. They also direct clinicians not to leave moving and handling equipment under the individual after use. Example 1 R44 was admitted on [DATE] with the following Diagnoses: [REDACTED]. R44's Admission MDS, dated [DATE], Brief Interview for Mental Status (BIMS) scored a 15, indicating R44 is cognitively intact. Section G110 - A. Bed mobility: indicates R44 requires extensive physical assistance with one staff for bed mobility. B. Transfer: indicates R44 is totally dependent on staff for transfers. Section M0150 indicates R44 is at risk for PI. Section M0210 indicates R44 does not have an unhealed PI. *It is important to note that R44's MDS, dated [DATE], 1/25/18, 2/1/18, 2/15/18, and 3/14/18, indicate in section M0150 that R44 is at risk for PIs and has no unhealed PIs. R44's Care Area Assessment (CAA), associated with R44's MDS, dated [DATE], includes, in part: Triggers: R44 requires extensive assistance. R44 is at risk of PI development. R44's Hospital Patient Assessment Report, dated 9/5/17, includes, in part: Braden Score Total- 16.0 (Note) Braden Scale not scoring correctly, score is 11 . Review of R44's Admission Skin Risk Factors and Intervention Assessment, dated 9/6/17, does not indicate there was any skin breakdown to R44's right (R) or left buttocks or posterior thighs. R44's Braden Scale, dated 9/6/17, scored a 17, indicating R44 is at little or no risk for PI development. Review of R44's Nurse Notes, dated 9/6/17, include, in part: skin problem: open area .location: right gluteal folds 4 open areas, biggest measure 2 centimeters (cm) x 2cm, then other ones measure 1cm x 1cm, cream applied to these areas .*It is important to note that there is no mention of open area on left buttocks. R44's Comprehensive Care Plan, initiated 9/6/17, included, in part: 9/6/17 - Goal: wounds will show signs of healing. Goal date: one week 9/6/17 - Nurse Aide - Skin Intervention: .Bensons butt cream to buttocks, moisturize dry skin, keep skin clean and dry. 9/6/17 - Nurse Aide - Skin Infection Risk: Be aware that resident is at risk for skin/wound infections. Monitor for rash, fever, heat, redness, swelling, increased tenderness, pain, and drainage from site. Notify nurse of any concerns. 9/6/17 - Problem (Pressure Ulcer): High risk for heel ulcer 9/6/17 - Self Care Deficit: needs minimal to moderate assist with Bed Mobility, Transfers, Toilet Use . R44's Current Treatment Plan, Left buttock Initialed 9/9/17 - 9/11/17 states: Left Buttock, change dressing daily and PRN (as needed). If saturated, cleanse with Safeclens and blot dry. [MEDICATION NAME] 7.5 x 7.5 dressing. *It is important to mention there are no treatments initialed out from 9/6/17-9/8/17. Initialed 9/12/17 - 9/25/17 states: Left Posterior Thigh, cleanse around daily with Safeclens (or equivalent), blot dry, apply Benson paste cover with ABD pad and secure. Diaper rash cream apply (SIC)/ collagen to the base of the wound and place [MEDICATION NAME] (SIC) foam or equivalent, place ABD pad and secure with 9/8/17 PA (Physician Assistant) Progress Note, includes, in part: .Patient has issues with ambulation . He spends a lot of time in a wheelchair or in a chair and in bed . Skin: right buttock there are areas of decubitus ulcer from pressure, but also I feel more so from skin shearing. #1. 1.5 x 0.9 cm, #2 1 x 1 cm, #3 0.4 x 0.4 cm, #4 3 x 1.5 cm .Wound bases have 100% granulation tissue no tunneling or undermining. No periwound [DIAGNOSES REDACTED] induration, tenderness, or calor. *It is important to note that there is no mention or measurements of left buttocks in this note. 9/11/17 Weekly Skin Assessment, includes, in part: . Checking out his buttocks skin this afternoon. 9/11/17 PA Progress Note, includes, in part: .follow-up wound care for decubitus ulcers of the right buttock. Patient has limited ambulation and uses a wheelchair. He stated that there is also an area on the left buttock that is tender as well .Skin: There are 4 wounds located on the right buttock. #1 1.2 x 0.8 cm #2 0.5 x 0.5cm #3 1.5 x 0.3cm #4 1.5 x 0.3 cm .There is a stage 1 decubitus ulcer that is blanchable on the left buttock approximately measure 6 x 1.5 cm. *It is important to note this is the first mention of PI on L buttocks. 9/13/17 Weekly Skin Assessment Note, includes, in part: Right buttock: medial area mid-line has open area present . measures approx. 1cm long by 1cm wide in 3-4 areas. Open superficially, surrounding skin bright red and outward further chafing .Left buttock sporadic open areas approximately 0.5 x 0.2 cm from peri area to mid-lower buttock, surrounding skin bright red, minimal serosanguinous drainage. 9/13/17 Wound Nurse Initial Assessment, includes: Partial thickness loss of skin layers that presents as an abrasion or blister (Pressure Stg. (Stage) 2). Area 1: median sacral crest . (R44) has 9 open areas that are circular in shape or oblong. Wound edges are defined. Peri would is dry/pale pink . Utilizing the clock method 12:00 - 1.5 x 0.7 x 0.1 cm wound bed red, moist 1:00 - 1.1 x 0.9 x 0.1 cm wound bed red, moist 3:00 - 1.5 x 1.5 x 0.1 cm wound bed red, moist 6:00 - 1.0 x 2.0 x 0.1 cm wound bed red, moist 7:00 - 1.2 x 1.5 x 0.1 cm wound bed red, moist 11:00 - 2.0 x 0.5 x 0.1 cm wound bed red, moist Inner most open area measuring 0.5 x 0.7 x 0.1 cm wound bed red, moist Drainage small amount, serosanguinous and contained in dressing . Area 2: left posterior thigh/inner thigh: excoriated tissue present. Area measures 10.5 x 9.5 x 0.1 cm. Appears superficial .educated to weight shifting every 15 minutes when up in chair/recliner .Has a ROHO cushion. R44's Comprehensive Care Plan was updated with the following: 9/14/17 Goal: wounds will show signs of healing and no signs and symptoms of infection. Goal date: Next review 9/14/17 Nurses - skin treatment as ordered .update wound clinic/Wound Nurse as needed, educate as needed, resident has preferences to do things a certain way, but if resident is educated at times willing to try alternate skin interventions/more cooperative with skin interventions/treatments. 9/14/17 Nurse Aide - skin intervention: Viva towel in groin folds after hygiene care done - change out two times a day or as needed, update nurse if no dressing noted on right or left buttocks or if dressing is compromised .moisture dry, keep skin clean and dry, use pressure relief devices: ROHO cushion in wheelchair and therapeutic mattress. 9/14/17 Nurse Aide - positioning-chair: Independent with weight shifting every 15 minutes. 9/14/17 Nurse Aide - repositioning-bed: assist of 1 with repositioning every 1.5 hours during daytime hours. 9/18/17 Weekly Skin Assessment Note, incudes: Right posterior thigh approximately 6 x 6 x .2 cm with granulation tissue and small amount bleeding to wound bed. Left posterior thigh approximately 5 x 6 cm lightly excoriated tissue .Posterior right upper thigh: Excoriated and dry from mid posterior thigh to buttock. Sporadic skin open throughout. Mid lower right buttock has open areas approximately 1 x 2 cm open superficial, wound bed red. Purulent drainage present on old bandage removed. No odor. Left posterior thigh less excoriated then right .opens superficially throughout. 9/18/17 PA Progress Note, includes, in part: Skin: Right buttock . Five wounds stage 3 decubitus ulcers from inferior to superficial #1 1.5 x 3.7 cm ulceration with 100% granulation tissue no undermining or tunneling. No [DIAGNOSES REDACTED], induration, tenderness, or calor to palpation. #2 1.6 x 3.4 cm ulceration with 100% granulation tissue no undermining or tunneling. No [DIAGNOSES REDACTED], induration, tenderness, or calor to palpation. #3 0.4 x 0.7 cm ulceration with 100% granulation tissue no undermining or tunneling. No [DIAGNOSES REDACTED], induration, tenderness, or calor to palpation. #4 1 x 1.5 cm ulceration with 100% granulation tissue no undermining or tunneling. No [DIAGNOSES REDACTED], induration, tenderness, or calor to palpation. #5 1 x 2.2 cm ulceration with 100% granulation tissue no undermining or tunneling. No [DIAGNOSES REDACTED], induration, tenderness, or calor to palpation. Left buttock . Three stage 3 decubitus ulcers #1 2.5 x 0.7 cm ulceration with 100% granulation tissue no undermining or tunneling. No [DIAGNOSES REDACTED], induration, tenderness, or calor to palpation. #2 1 x 0.3 cm ulceration with 100% granulation tissue no undermining or tunneling. No [DIAGNOSES REDACTED], induration, tenderness, or calor to palpation. #3 0.7 x 0.4 cm ulceration with 100% granulation tissue no undermining or tunneling. No [DIAGNOSES REDACTED], induration, tenderness, or calor to palpation. 9/25/17 PA Progress Note, includes, in part: The patient states that he has not had a dressing on today since 1:00 when he was in bed. I did discuss with him that I would like the dressings to be left on as the wounds dry when they are removed . Skin: three decubitus ulcers located on right buttock . #1 2.3 x 1 cm . no tunneling or undermining, has 100% granulation tissue, no periwound [DIAGNOSES REDACTED], induration, tenderness to palpation, or calor. #2 2 x 2 cm . no tunneling or undermining, has 100% granulation tissue, no periwound [DIAGNOSES REDACTED], induration, tenderness to palpation, or calor. #3 1 x 3 cm . no tunneling or undermining, has 100% granulation tissue, no periwound [DIAGNOSES REDACTED], induration, tenderness to palpation, or calor. Left buttock: #1 1.0 X 3 stage 2 decubitus ulcer . no tunneling or undermining, has 100% granulation tissue, no periwound [DIAGNOSES REDACTED], induration, tenderness to palpation, or calor. .Assessment and Plan: Patient instructions: Important to reposition in bed every one hour .Important to reposition in wheelchair every 15 minutes . *It is important to note that facility provided no evidence of these interventions being added to R44's Comprehensive Care Plan. Also, R44 relies on staff for physical assistance with bed mobility. 9/28/17 Follow-up Assessment (Skin) Note, includes, in part: Area 1: coccyx .onset/date of discovery 9/25/18 . pink intact scar tissue present, measures approximately 5 cm . Area 2: Left posterior thigh/inner left thigh . Dry, purple/pink discolored skin noted, measures approximately 11 x 10 cm, skin excoriation noted and measures approximately 2 x 3 x 0.1 cm . also has slitted area x 2 in folds in gluteal crease, area (#1) measures approximately 2 x 0.3 x 0.3 cm, area (#2) . measures approximately 1 x 0.3 x 0.3 cm .will update unit nurse to update wound clinic provider on new skin areas . Area (3): median sacral crest .wound type stage 2 . open areas noted today 12:00 1.2 x 0.5 x 0.1 cm 2:00 2.5 x 1.5 x 0.2 cm 3:00 1 x 1.2 x 0.2 cm 4-5:00 2.5 x 2.5 x 0.3 cm 6:00 1 x 2.5 x 0.2 cm Middle of clock area . 1 x 1.5 x 0.2 cm . all wound areas with red beefy tissue present, light drainage noted - serosanguinous, no odor, no signs or symptoms of infection, periwound skin purple/red in color . continues with incontinence of bladder . 10/2/17 PA Progress Note, includes, in part: three stage 3 PIs on right buttocks (includes measurements) and one area more towards the gluteal cleft . stage 3. (Includes measurements). 10/12/17 Follow-up Assessment (Skin) Note, includes, in part: Note writer dictated note from PA regarding staging of ulcer .he did stage wounds as stage 3. Wound Care nurse here staged as stage 2. Do agree this writer coded right buttock in error at stage 2 and should be a stage 3 related to granulation tissue present vs [MEDICATION NAME] tissue. (Wound measurements included for 3 wounds on right buttock, 1 middle of buttock area, 3 wounds to left buttock, and one to left mid gluteal cheek). *It is important to note the last wound measurements were recorded 10 days prior in PA Progress Note. This does not meet the standard of practice of weekly wound measurements. 10/23/17 PA Progress Note, includes, in part: Skin: . Right buttock, there are 3 wounds, stage 3 . (measurements included) .Area of chaffing along posterior thigh . Left buttock, at gluteal fold (one wound) stage 3 (measurements included). Areas of left posterior thigh chaffing . 10/26/17 Follow-up (skin) Assessment Note, includes, in part: Area 1: Full thickness of skin lost, exposing SubQ tissues- presents as a deep crater (Pressure Stage 3). Right buttock . (includes measurements of 7 wounds) .The region periwound is purple in color blanchable. Area 2: left buttocks, gluteal crease has open wound, area measures 0.3 x 0.7 x 0.2 cm. Wound bed beefy red/moist. The writer did not note this region with previous assessment on 10/12/17. There is an area that appears [MEDICATION NAME] stripping measuring 2.0 x 6.0 x >0.1 cm. Wound bed pale pink .This writer measure buttocks as best as able to identify chaffing/dry skin. Length right buttock/groin 32 cm long and left 18 cm long .unable to obtain width, however buttocks, inner thighs, groin involved. 10/27/17 Follow-up (skin) Assessment, includes, in part: Note: Open wound in left gluteal crease is stage 3 pressure ulcer . 11/06/17- 01/02/18 PA Progress Notes: continue with weekly wound measurements and consults. Notes were uneventful. 11/13/17, 11/120/17, 11/27/17, 12/04/17, 12/11/17, 12/18/17 Physician notes of skin measurements and consults. Uneventful. 12/18/17 - 1/2/18 Facility provided no evidence of measurements for this time period. On 1/2/18 PA Progress Note, includes, in part: Left buttock . 5 wounds with a lot of surrounding irritation. #1 0.2 x 0.4 cm .superficial .no tunneling or undermining .no periwound induration .there is calor but I feel that it is more due to skin chaffing in this area. #2 1 x 1 cm .100% granulation tissue .no tunneling or undermining .there is periwound [DIAGNOSES REDACTED], but more associated with skin abrasion .no tenderness .no discharge .no induration #3 0.2 x 0.4 cm superficial .100 % granulation .no tunneling or undermining .no periwound [DIAGNOSES REDACTED], except for abrasion .no tenderness .no induration. #4 1 x 1 cm superficial .no tunneling or undermining .no periwound [DIAGNOSES REDACTED], except for dryness and abrasion .no tenderness .no calor. #5 0.5 x 0.4 cm superficial . no tunneling or undermining .is periwound abrasion . no induration .no tenderness Because of the expanse of the abrasion and dry areas we will not apply a dressing today. We will use ABD pads that are lid in bed and on the wheelchair . Right buttock, 5 wounds #1 0.7 x 0.5 cm superficial .no tunneling or undermining .there is periwound abrasion . no induration .no calor . mild tenderness #2 0.2 x 0.7 cm superficial .no tunneling or undermining .there is periwound abrasion .no particular tenderness . no calor . no induration. #3 0.5 x 1.0 cm superficial .no tunneling or undermining .there is periwound abrasion .no calor . no particular tenderness .no induration. #4 1.4 x 0.2 cm no tunneling or undermining . no periwound induration or calor . there is periwound abrasion and tenderness . #5 0.2 x 0.4 cm superficial .no tunneling or undermining .there is periwound abrasion .no induration . no tenderness .no calor. 1/3/18 Skin Assessment Note, includes, in part: Staff reported decline in status of buttocks/wound care .left inner thigh had 6 slits in skin measure 2 cm .several pea sized holes .skin on left side is excoriated Right thigh and buttock are excoriated and also several pea sized holes .sleeps in air bed . 1/8/18 Weekly Skin Assessment Note, includes, in part: Dry, flaky skin on backs of left thigh and leg measures 37 x 15 cm Right thigh and leg dry, flaky, 32 x 12 cm Open areas on inner left leg near groin area 7 x 9 cm Right leg near groin area open areas slit in skin measures 5.5 x 8 cm 1/10/18 - 1/18/18 R44 was admitted to the hospital for respiratory concerns. *It is important to note no evidence was provided of an Admission Skin Assessment on 1/18/18 1/29/18 PA Progress Note includes in part: Left buttock, 4 wounds: #1 2 x 1.5 cm 100 % granulation tissue in base of wound .no tunneling or undermining .no periwound [DIAGNOSES REDACTED] .no tenderness .no induration . no calor. #2 0.7 x 1.0 cm 100 % granulation tissue .no tunneling or undermining .no periwound [DIAGNOSES REDACTED] .no tenderness .no induration . no calor. #3 0.7 x 0.4 cm 100 % granulation tissue .no tunneling or undermining .no periwound [DIAGNOSES REDACTED] .no tenderness .no induration .no calor. #4 0.4 x 0.4 cm 100 % granulation tissue .no tunneling or undermining .no periwound [DIAGNOSES REDACTED] .no tenderness .no induration . no calor. There is dryness around all of these wounds in the periwound. Right buttock, 2 wounds: #1 3.5 x 2 x 0.1 c .100 % granulation tissue .no tunneling or undermining .no periwound [DIAGNOSES REDACTED] .no tenderness .no induration . no calor. #2 0.3 x 0.2 superficial .100 % granulation tissue .no tunneling or undermining .no periwound [DIAGNOSES REDACTED] .no tenderness .no induration . no calor. 2/5/18 - 3/26/18 PA Progress Notes: continue with weekly wound measurements and consults. Notes were uneventful. 3/26/18 PA Progress Note, includes, in part: Left buttock .3 wounds. #1 2 x 1.5 cm #2 1.8 x 1.2 cm #3 0.5 x 0.6 cm Right posterior thigh . 3 wounds #1 2 x 1.5 cm #2 1.8 x 1.2 cm #3 0.4 x 0.5 cm 3/27/18 Weekly Skin Assessment Note, includes, in part: . Resident does not like to lie down so measurements were not performed to areas, but treated as ordered. On 4/3/18 at 4:25 PM, during initial interview, R44 indicated that he has several sores on his buttocks that won't heal. Surveyor observed R44 in bed; under him were two soaker pads, transfer slip sheet, bottom sheet, mattress pad, air mattress overlay, and mattress. Surveyor asked R44 if the transfer slip sheet usually stays under him when he is in bed and he stated yes and that it helps him move without breaking his skin open. *It is important to note the layers between R44 and his air mattress overlay. Manufacturer's recommendations for Panacea Air Overlay, include, in part: Warnings: Read and follow all directions and warnings before using this device . Failure to comply with all directions and warnings may result in injury or death .This device is not suitable for all individuals. Other devices may be required . This device is not designed to operate with patients weighing more than 250 lbs. *It is important to note that R44's weight since admission has ranged from 264.5lbs to 283.3lbs. On 4/5/18 at 1:43 PM, during an interview, DON B (Director of Nursing) indicated that she had not previously read the manufacturer's recommendations for the mattress overlay. She agreed that the air overlay is not recommended for use with people weighing over 250 lbs. On 4/4/18 at 8:53 AM, Surveyor observed R44 in his power w/c and under him was a soaker pad folded in half and a ROHO cushion. ROHO manufacturer's recommendations of use, includes, in part: .Obstructions: Do not place any obstructions between the user and the product, because it will reduce the effectiveness. *It is important to note the layers between R44 and the ROHO cushion. On 4/10/17 at 8:45 AM, during an interview, PA S, indicated that R44 had shared with him his history of having wounds open, close, and reopen on his right and left buttocks, since he became less mobile, while still living at home. PA S indicated that he felt the biggest issue with these wounds is shearing forces and R44's skin integrity (dryness). He also indicated that he performs weekly consults, education on repositioning, and wound care with R44 and when he can't be there, he does expect that the facility's Wound Nurse to monitor and measure wounds. PA S indicated that R44 does rely on staff for some positioning. Example 2 R38 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. R38's Quarterly MDS, BIMS, dated 2/7/18, score of 3, indicates that R38 has severe cognitive impairment. Section G0110 - Activities of Daily Living (ADL): A. Bed mobility: indicates that R38 requires extensive assist with one person physical assist, B. Transfer: Total dependence with 2 plus assist. Section M0150: Risk of PI. R38 is at risk for PI. Section M0210 indicates R38 does not have a PI. R38's Braden, dated 3/21/18, score of 15 (15-16 low risk). R38's Comprehensive Care Plan, dated 2/15/18, Potential for skin breakdown, includes, in part: inspect skin BID (twice a day) with cares for signs and symptoms of skin breakdown. Report to nurse as indicated. R38's Comprehensive Care Plan, dated 4/4/18, Skin Interventions, includes, in part: keep skin clean and dry. ROHO cushion in wheelchair. Alert nurse if no bandage to scrotum. Staff to cradle scrotum with pillow case or Viva (paper towel) when in bed. Facility fax to NP N (Nurse Practitioner), dated 3/22/18, includes, in part: open posterior scrotum, continue with [MEDICATION NAME] barrier ointment with cares and toileting PRN (as needed). Physician order [REDACTED]. Cradle scrotum when in bed with pillow case or Viva to keep off bed. Nursing Progress Notes dated 3/14/18 at 5:17 AM, include, in part: new excoriated area on posterior scrotum, skin barrier applied. Area measures 3cm (centimeters) x 2cm round. Will monitor until healed. Nursing Progress Notes, dated 3/21/18 at 11:02 AM, includes, in part: follow up excoriated scrotum. Did not visualize any open areas. Use of [MEDICATION NAME]. Continue with gel cushion. Nursing Progress Notes, dated 3/21/18 at 2:16 PM, includes, in part: R38 has open area on posterior scrotal sack. This area measures 1.5 cm x 0.5 cm x 0.1 cm. Wound bed is 100% pink tissue. Irregular shape. Treatment to scrotum is barrier r/t (related to) inability to keep dressing in place. Will obtain new cushion. Nursing Progress Notes, dated 3/21/18 at 4:32 PM, includes, in part: Wheelchair cushion changed to a foam/ gel therapeutic cushion. Nursing Progress Notes, dated 3/25/18 at 3:32 PM, includes, in part: ROHO cushion obtained for wheelchair. *Of note: there is no documentation of the scrotal wound until 4/2/18. Nursing Progress Notes, dated 4/2/18 at 2:12 PM, includes, in part: posterior scrotum measures 2.5 cm x 2.0 cm x 0.1 cm use of barrier ointment not assisting with improving. Will contact NP N. Will add to plan of care to ensure R38 is sitting correctly when in wheelchair. Nursing Progress Notes, dated 4/2/18 at 2:24 PM, includes, in part: R38 is independent with weight shifting in wheelchair (w/c). Ensure R38 is sitting comfortably in wheelchair, and that scrotum is not pinched. Nursing Progress Notes, dated 4/3/18 at 10:59 AM, includes, in part: alert nurse if no bandage to posterior scrotum. Staff to cradle scrotum with pillow case or Viva when in bed. R38's mattress is a Panacea Clinical Mattress, which is made of foam and considered to be used for pressure redistribution. On 4/3/18 at 12:42 PM, Surveyor observed R38's bed and noted a Panacea mattress, with a mattress pad, bottom sheet, soaker pad. On 4/3/18 at 3:13 PM, Surveyor observed R38 sleeping in his w/c. R38 was sitting on a Hoyer sling, which had a soaker pad below it followed by the ROHO cushion. On 4/4/18 at 9:20 AM, Surveyor observed wound treatment with LPN C (Licensed Practical Nurse) . Surveyor observed R38 lying on his back with a brief on. R38 was lying on a soaker pad, bed spread, top sheet, soaker pad, bottom sheet, mattress pad and the Panacea mattress. LPN C removed R38's brief. Surveyor observed there was not a dressing or cradle in place to R38's scrotum. Surveyor asked LPN C if there should have been a dressing intact. LPN C indicated the night shift does cares and should have reported this to him. Surveyor observed the area between the scrotum and the anus to be pink in color with two circular areas. Surveyor asked LPN C to describe the superior wound. LPN C indicated it looked dark and scabbed with granulation tissue surrounding. LPN C cleansed the scabbed area with wound cleanser, changed gloves, applied [MEDICATION NAME] with a 4 x 4 gauze, then covered with a foam dressing. Surveyor observed a second dark circular area inferior to the first area. Surveyor asked LPN C to describe the second area. LPN C indicated it looked purple. LPN C then placed a paper towel around R38's scrotum and indicated the new order was to use a paper towel to act as a cradle around the scrotum. Resident 38 was positioned on his right side and heels were floated. Surveyor observed a dressing on R38's back of left and right thigh. LPN C indicated the dressings were in place as a protective measure. On 4/5/18 at 7:18 AM, Surveyor observed R38 asleep on his back. On 4/5/18 at 8:47 AM, Surveyor asked DON B to observe R38's bed. Surveyor pointed out that the Panacea mattress was covered with a mattress pad, bottom sheet, and soaker pad. Surveyor asked DON B if the Panacea mattress is effective in prevention / treatment of [REDACTED]. DON B indicated she would have to review the manufacture's guidelines. Surveyor asked DON B if R38's dressings were to become soiled or come off, what the process would entail. DON B indicated that the dressing is in a hard location to stay on and if it would become soiled or come off the CNA (Certified Nursing Assistant) should alert the nurse. Surveyor indicated to DON B that R38's dressing was off when Surveyor observed the wound treatment yesterday with LPN C. On 4/5/18 at 8:52 AM, Surveyor and DON B observed R38 sitting in his wheelchair. Surveyor asked DON B if the ROHO cushion is effective in pressure redistribution when there is a soaker pad and Hoyer sling on top of the ROHO cushion. DON B indicated that the soaker pad and Hoyer pad would make the ROHO cushion less effective. Example 3 R41's care plan and CNA Kardex have the following skin interventions: lift, do not slide resident, encourage and assist with napping in bed between meals/offloading pressure to coccyx area, barrier ointments A and D and [MEDICATION NAME] together twice a day and with toileting, try to limit spreading of buttocks skin as able-use softest touch needed for tasks involving this area, float heels in bed, therapeutic wheelchair cushion, position body with pillow/support devices, protect bony prominences, keep skin clean and dry, moisturize dry skin, update nurse if no dressing in place to coccyx area. On 4/4/18 at 8:02 AM, Surveyor observed R41 in bed on top of all bedding, which included: R41's pants and brief, cloth incontinence pad, bedspread, sheet, cloth incontinence pad, fitted mattress sheet, mattress pad, then mattress of R41's bed. R41's heels were not floated off of bed at this time. Surveyor observed R41's wheelchair in room with cushion in wheelchair with cloth incontinence pad over the top. On 4/4/18 at 12:28 PM, Surveyor interviewed RN I (Registered Nurse). Surveyor asked RN I what type of mattress R41 was on, RN I stated it is a therapeutic mattress. Surveyor asked RN I what type of cushion is in R41's wheelchair, RN I stated it is a therapeutic cushion, not a ROHO cushion. On 4/4/18 at 2:09 PM, Surveyor observed RN I change R41's dressing to coccyx wound with assistance from CNA F. Surveyor observed R41 positioned on her left side on bed with her heels floated on pillows. The bedding resident was laying on top of again included; R41's pants and brief, cloth incontinence pad, bedspread, sheet, cloth incontinence pad, fitted mattress sheet, mattress pad, then mattress of R41's bed. Example 4 R118 requires extensive assistance of one or two staff for bed mobility. R118 is transferred using a mechanical total lift with two staff. R118 was admitted to the facility with PIs on his sacrum, both heels and on his right lateral lower leg. R118's sacrum ulcer has healed since he has been at the facility. The facility has assessed R118 as being at high risk for PI development. On 4/3/18 at 12:40 PM, Surveyor observed R118 in his Broda chair in the dining room. Surveyor noted the straps of the lift sling were between his upper legs and not pulled out to the sides, to prevent R118 from sitting on these straps. On 4/4/18 at 7:27 AM, Surveyor observed R118 in his Broda chair in his room with the straps of the lift sling between his upper legs. On 4/4/18 at 10:00 AM, Surveyor observed CNAs K and L transfer R118 from his Broda chair to bed, using

Based on observation, medical record review and interview, the facility did not ensure that residents receive the care and services to prevent the development of pressure ulcers, to promote healing and prevent infection of pressure ulcers, and/or to prevent new sores for developing for 5 of 5 residents reviewed who have pressure ulcers. Resident #6 was admitted to the facility at high risk for developing pressure ulcers and developed multiple pressure ulcers in the facility. The facility did not immediately put proper measures into place, did not update the comprehensive care plan when pressure ulcers were discovered on his heels and another on his right great toe, and did not provide wound care with aseptic technique. Resident #4 did not have timely appropriate interventions in place to prevent pressure ulcers to occur or worsen and weekly skin assessments were not completed. Resident #5 did not have timely appropriate interventions in place to prevent pressure ulcers to occur or worsen and daily skin inspection of diabetic heels. Resident #9 was admitted with unstageable pressure ulcers on her heels. The facility did not provide care and services to promote healing and adequately assess Resident #9's pressure ulcers. Resident #10 was admitted to the facility with what is described as intact skin. Resident #10's nurses' notes describe areas on the resident's heels and coccyx which are changing in condition. The facility put heel protectors in place to protect the resident's heels but these are not on the plan of care, and no interventions are put in place for the resident's changing coccyx. The physician was not notified related to these changes and no thorough assessment which would include measurements of the areas is completed. This is evidenced by: 1. Resident #6's medical record states he was admitted to the facility after being hospitalized in September 2015 for a large [MEDICAL CONDITION] in his right leg. This blood clot affected his right external iliac vein, the common femoral vein, the greater saphenous vein, the femoral vein and the popliteal vein. Resident #6 was admitted to the facility with orders for [MEDICATION NAME] injections, and currently receives the blood-thinning medication [MEDICATION NAME]. Resident #6 was also admitted with a superficial pressure ulcer on his right buttock, showing that he is pre-disposed for pressure ulcers. According to the admission skin assessment sheet, Resident #6's heels and toes were intact when he was admitted . Resident #6's medical record states he is diagnosed with [REDACTED]. Resident #6 developed and was hospitalized for [REDACTED]. On 09/15/15, a nurse's note states that Resident #6's right lower extremity was cooler than the left, but denies discomfort. One leg cooler than the other can be an indication of compromised circulation, which can affect blood flow to a person's feet. A nurse's note on 09/16/15 states that Resident #6 Continues to have LE (lower extremity) [MEDICAL CONDITION], more so on the right than the left. The facility did not provide precautionary measure to prevent pressure ulcers on Resident #6's feet. On 09/18/15, Resident #6 left the facility at 10:45 a.m. for a picnic, and returned at 2:00 p.m. On 09/24/15, a nurse's note states, Area noted on left anterior shin which measures approximately 4 cm (centimeters) long by 2 cm wide, open superficially .The lateral heel (does not specify which heel) has a blackened callous which measures approximately 0.75 CM (centimeters) round. Surrounding skin appears at baseline dry .Will update MD (Medical Doctor) on left shin and heel. Start [MEDICATION NAME] cream to Both Lower extremities bid (twice a day) during cares. Will continue to monitor via treatment sheet. This entry was written by Licensed Practical Nurse (LPN) Q. There is no documentation that Resident #6 was provided with pressure relieving measures at this time. Surveyor interviewed LPN Q on the morning of 01/28/16. LPN Q stated that she started a treatment sheet for the above callous, where the Certified Nursing Assistants (CNAs) were to apply the [MEDICATION NAME] cream twice a day. There are no further measurements of this callous documented in Resident #6's chart. On 10/06/15, a nurse's note, which is a late entry for 10/05/15, states that Resident #6's sacral area wound has healed, and that wound care was completed on his shin. There was no mention of the callous on Resident #6's heel. The weekly skin charting on 10/07/15 does not mention Resident #6's heels. On 10/18/15, a nurse's note states, Reddened, 1 cm areas noted over great toes bilaterally where toe rubs against shoe. Skin remains intact, but right side appears dusky. Socks loosened. Does not weight bear as is transferred per E-Z Stand. Will continue to observe. The treatment sheet started 10/19/15 instructed nurses to apply foam daily to Resident #6's right great toe. In November 2015, the treatment sheet which the nurses use states, TREATMENT: #1 Left anterior shin: zero Form, Foam dressing, gauze wrap p (after) cleansing. This treatment was to be done on the morning shift. There are nine days out of the month of November that this treatment was not initialed. The treatment sheet also has written: #2: check feet callouses and ensure CNA using [MEDICATION NAME] for moisture to both lower extremities: both great toes. This does not mention the callous which was on Resident #6's heel. This entry was not initialed for the month of November. For the month of December, this treatment was initialed all but three days; there were no measurements or descriptions charted for the callous on Resident #6's heel. On 12/04/15, Registered Nurse (RN) M assessed Resident #6's shin. RN M stated, Staff verbalize contributing factor to area originated r/t (related to) non compliance, behavioral concerns during transfers. Transfers with the EZ stand .Further assessment notes bilateral lower extremities are cool to touch, not able to palpate pedal pulses. He is flexing and extending toes during assessment which may be impacting. He has 3+ pitting on the right and 2+ pitting on the left. His legs are cool to touch and lack hair growth, he has thickened toe nails. His legs are dry. Staff has been applying [MEDICATION NAME] and RCC (Resident Care Coordinator) feels this has been beneficial for dryness. Left great toe tip has a callous which measures 0.5 cm L (in length) by 0.5 cm W (width). His lower legs do have venous stasis discoloration. He has a bunion left foot .His long underwear is tight and RCC will be asking family to bring in larger ones for him. Despite the above concerns for potential for decreased circulation to Resident #6's feet, the facility did not provide pressure-relief measures for Resident #6. There is no documentation that RN M visualized Resident #6's heels during this assessment. There is no indication that RN M observed a transfer of Resident #6 in the EZ Stand lift. Surveyor observed CNAs C and D provide personal cares for Resident #6 on 01/25/16 at 1:45 p.m. Resident #6 was wearing gripper socks, and heel lift boots on his feet. The CNAs placed a sit-to-stand lift sling around Resident #6, buckled the waist belt and attached it to the lift. There was a metal ledge on the base of the lift that Resident #6's toes pressed into. Resident #6 has a dime-sized black spot on the tip of his right great toe. When the CNAs were moving his feet on the stand, Resident 36 was saying, Ow ow and the CNAs said, Bend your feet, (Resident #6's name). Resident #6 was resistive to moving his feet. The CNAs buckled the leg belt around Resident #6's legs and raised him to a standing position, and removed his disposable brief and performed peri care while he was standing in the lift, with his toes pressing into the ledge. On 01/04/16, LPN Q wrote a general skin condition note, describing Resident #6's shin wound. LPN Q stated that no [MEDICAL CONDITION] was noted in either lower extremity, and that [MEDICATION NAME] cream was applied. Nothing was written about Resident #6's heels. On 01/06/16, RN M assessed Resident #6's shin wound, and documented at 12:07 p.m. (There is no documentation regarding Resident #6's heels in this note.) RN M stated that [MEDICATION NAME] were in place over Resident #6's lower extremities. Resident #6 left for an appointment for the podiatrist to cut his toenails at 1:25 p.m. and returned at 3:00 p.m. The note from the podiatrist stated that Resident #6's lower extremity skin was thin shiny and hairless, and he had decreased skin turger. Resident #6 had no dorsalis pedis or posterior tibial pulses in his feet, he had [MEDICAL CONDITION], and his toenails were thickened, discolored, and brittle. Resident #6's toenails were debrided manually and mechanically, and there was no documentation that the podiatrist visualized his heels. The [MEDICATION NAME] were open at the ends, and would not need to be completely removed for the service provided, so the heels would not be exposed. For the month of January 2016, the nurses initialed almost daily that the CNAs were applying the [MEDICATION NAME] cream to Resident #6's feet. On 01/06/16 at 10:39 p.m., a nurse's note states, A large blister broke on the back of his right heel when staff took off Ted hose ([MEDICATION NAME]). Skin was cleansed and Telpha applied with [MEDICATION NAME], then wrapped with gauze. Supervisor was notified. On 01/07/16, RN L assessed Resident #6's feet, and wrote the following: PRESSURE ULCER: Has partial thickness loss of skin layers that presents as an abrasion or blister (Pressure Stg (stage) 2) .AREA 2: bottom inner aspect of right heel, bottom of right heel, bottom outer aspect of right heel, WOUND TYPE: Stage 2 WOUND TISSUE: pink SURROUNDING TISSUE: reddened, boggy HEALING PROGRESS: N/A (not applicable) (new area) DESCRIPTION: AREA: length (cm) 6.5 width (cm) 6.5 depth: 0.1 length x width (sq cm) = 42.25 .AREA 2 PUSH SCORE 13 RN L also wrote, RCC updated this writer on new open area to bottom of R (right) heel, per staff resident has had on and off discoloration to area since admission (note that this has not been documented), resident seen by podiatry clinic yesterday and nail care was performed per progress note .per staff resident had blister to area that opened, today has intact lower bottom edges of skin with skin to inner wound and to mid wound area non intact/loose, did approximate these edges as able and skin up to top 2/3 wound bed upper 1/3 of wound with no cover and pink granulation tissue present, area moist, resident did verbalize pain with donning/doffing of sock today, new larger gripper socks were obtained for his use and no verbalizations or s/s (signs/symptoms) pain noted with these, unit nurse also did obtain pressure heel relief boots for resident today and these are to be worn at all times, staff had been attempting to float heels on pillows (note - there is no documentation of this) but resident independently would remove feet off pillows, also using slippers vs (versus) shoes, he does have [MEDICAL CONDITION] to lower legs 2+ /wears [MEDICATION NAME] .he also has an intact blood blister/area dry approx (approximately) 1.5 cm 1.25 cm to outer edge of upper R great toe, area OTA (open to air), no regular shoes to be worn at this time. The above note continues, now regarding Resident #6's left heel. L heel approx 6.7 cm x 5.7 cm area dark purple intact possible deep tissue injury surrounding skin pink, using pressure relief heel boot for this area also, did review with RCC r/t tx (treatment) sheets to monitor areas for changes/worsening/healing s/s, recommendations for open area to bottom of R heel are cleanse area with normal saline or wound cleanser and pat dry, skin prep to periwound, apply [MEDICATION NAME] to wound bed and cover with foam, wrap with kling, dressing change to be done daily and prn (as needed), no s/s of infection to area, [MEDICATION NAME] to protect wound bed provide healing moist environment, foam to provide warmth and healing to area and contain possible drainage, wrap with kling for comfort, did review with unit RCC, fax to (Resident #6's physician) . On 01/14/16, the measurement for the left heel was 7.2 by 5.5 cm. The right great toe tip Has purplish-colored area that appears dry .Son updated on resident's skin condition. He is in agreement to open leg seam of tight leggings so as to not put pressure on feet and legs during dressing. In an interview with the RCC, RN I on 01/28/16 at 10:35, RN I told Surveyor that when Resident #6 was first admitted to the facility, he wore farmer shoes and the facility convinced Resident #6's son to switch to slippers. The most recent descriptions and measurements of Resident #6's pressure ulcers provided to Surveyor were documented on 01/20/16, as follows. Right heel: surrounding tissue red, boggy, 7 x 4.5 cm . and this note states that within this area there is a darkened area at 2 - 3 o' clock approximately 1.5 by 1 cm, also dark intact dry area noted from approximately 4 - 8 o' clock of wound, intact pink tissue approx 4 x 3 x 0.1 cm with moderate amount of serosang/pink drainage on dressing removed, area moist, intact dark pink skin approx 2.5 x 3 cm . Right great toe: possible deep tissue injury, dry black dark tissue, 1.5 by 1/8 cm Left heel: noted blood blister, at this time fluid has absorbed, dry, intact dark eschar, boggy. Surveyor reviewed Resident #6's care plan which was provided by the facility during the annual survey. Resident #6 was admitted to the facility with a pressure ulcer on his buttock, and has a care plan addressing this, but his comprehensive care plan does not mention that he has blackened areas on his heels. When this was discussed with RN I on 01/27/16, RN I stated, That's my fault. Observation of wound care Surveyor observed RN I perform wound care on Resident #6's blackened heel pressure ulcers and on the blackened tip of his right great toe on 01/27/16 beginning at 7:20 a.m. RN I took two bins of wound care supplies from the clean utility/supply room and placed it on the medication cart in the hallway outside of Resident #6's room. RN I then took several pairs of gloves out of a box without first sanitizing her hands, and brought the bins and the gloves into Resident #6's room and placed them on his tray table without a barrier. Resident #6 had kicked off his left boot, and his heel was resting directly on the mattress. Resident #6 had a boot on his right foot, and there was a pillow covered by sheepskin on the right lower side of the bed, and Resident #6's heel rested directly on the pillow, versus being floated off the pillow. When RN I removed the boot from the right foot, Resident #6 called out, Ahhhh! and RN I asked, Does that hurt? Resident #6 said, Yah. RN I stated, We keep pestering you all the time, don't we? RN I then washed her hands and placed two paper towels on the tray table to be used as a barrier. The observation continued, and RN I tore several strips of tape, and attached them to the edge of the tray table. RN I used a scissor from the bin to cut a wide strip of tape. RN I then donned gloves from the pile on the tray table without first sanitizing her hands. When RN I removed the gripper sock from Resident #6's right foot, he scowled and said, Ow, ow and pulled up his right foot. RN I tried to straighten Resident #6's right knee and said, I bet your knees get stiff, don't they? Those knees just don't bend very much for you. RN I then used the same scissor to cut off the dressing which covered the right heel. There was a moderate amount of reddish-brown drainage on the soiled dressing. RN I wore the same gloves, and picked up a gauze 3 by 3, sprayed it with a normal saline wound cleanser, and dabbed the heel. The 3 x 3 had bloody drainage on it. RN I dabbed the heel with a dry 3 x 3. RN I then wore the same gloves to perform wound care for the right great toe, which has a dime-size area of black eschar on the tip of the toe. The skin on Resident #6's feet was very dry, and Surveyor asked RN I if staff lotion his feet. RN I stated the CNAs are to apply [MEDICATION NAME] cream to his feet and legs twice a day. RN I also noted that his feet looked dry, and applied A and D ointment to the bottom of Resident #6's foot. RN I applied [MEDICATION NAME] (oil [MEDICATION NAME]) dressing to the right heel while wearing the same gloves, followed by a foam dressing, and wrapped the heel with a flexicon stretch bandage (versus with Kling gauze wrap as ordered) and taped it in place. Surveyor verified that the wrap was a stretch bandage. RN I cut the bandage with the same scissor she used to cut the soiled dressing, and did not sanitize the scissor. Resident #6 said, Ow when wound care was performed on his heel and on his right great toe. RN I put the gripper sock back on Resident #6's right foot, and then placed the boot back on the foot. Resident #6 grimaced and drew up his right leg and RN I said, I'm sorry, (Resident #6's first name), I wish your knees bent better. RN I removed her gloves, but did not wash or sanitize her hands. RN I then took off the left gripper sock, and Resident #6 drew up his left leg and said Ow. Resident #6's left heel is also blackened. RN I donned gloves from the tray table and used the same bandage scissors to cut off the dressing from the left heel and from around the left shin. RN I wore the same gloves to clean the heel, again picking up gauze 3 x 3s and the bottle of wound cleanser, sprayed the 3 x 3s and cleaned the pressure ulcer. While wearing the same gloves, RN I applied A & D to the periwound on the heel, and then around the wound on Resident #6's left shin. RN I applied a foam dressing to the left heel, wrapped it with stretch gauze, and cut the gauze with the unsanitized scissor, and taped it in place. Resident #6 said Ow during wound care on his left heel, and Surveyor asked RN I when Resident #6 had his last pain medication. RN O stated, He says no every time we ask him if he has pain. We have it scheduled twice a day now. He has a tremendous pain tolerance. We started the Tylenol because of his behaviors. He just doesn't like to be fussed with. RN I stated, He got therapy when he was first here because his son wanted to take him home, but his knees just won't bend. Now we're floating his heels and playing catch up. RN I then wore the same gloves, and used a cotton-tipped swab to apply Carasol gel to the wound on Resident #6's shin. RN I placed a foam dressing over the wound on Resident #6's shin, then wrapped the lower leg with a role of stretch gauze. RN I cut the stretch gauze with the contaminated scissor. RN I then wore the same gloves to put Resident #6's gripper sock and boot back on his left foot. RN I then removed her gloves, then picked up the package of 3 x 3s, the container of A & D, and the scissor, and placed them all back in the bin. RN I washed her hands for eight seconds (facility policy is to wash for 20 seconds). Surveyor discussed the above observation with RN I when the observation was completed. RN I stated, We need to be more proactive, regarding preventing pressure ulcers. Concerns regarding Resident #6's pain and pressure ulcers were discussed with the Director of Nursing (DON) on 01/27/16 at 2:10 p.m., and again with RN I on 01/28/16 at 10:35 a.m. 2. Review of Resident #4's medical record identified initial admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the initial Minimum Data Set (MDS), dated [DATE], identified Resident #4 as needing assistance of one staff for bed mobility and two staff for transfers. Resident #4 is assessed as being at risk for pressure ulcer and did not have current pressure ulcers. Resident #4's Brief Interview for Mental Status (BIMS) score is 4, identifying severe cognitive impairment. Review of nurses' notes document on 11/04/15 read in part: He has a sore bottom around the coccyx and left upper buttock. Skin appears intact, reddened and shiny. Resident encouraged to lay on his sides in bed. Review of Braden scale, dated 11/12/15, documented a score of 13 which identifies Resident #4 having moderate risk to develop a pressure ulcer. On 11/13/15: Late Entry for : 11/12/15 WEEKLY SKIN ASSESSMENT: .buttock with approx 0.5cm x0.25cm black area to L buttock, surrounding skin 9cm x10.5cm reddened area, R buttock with approx 5cm x2cm pink and scarred skin area noted, denied pain to buttocks .braden score of 13, will review poc/skin interventions, Review of Resident #4's care plans did not identify new intervention for 11/13/15 of the discovery of a pressure ulcer. Review of Resident #4's Resident Skin Care Treatment Plan for Nurses documented: #1) Monitor black skin area to L buttock daily. First date initialed 11/12/15 and 11/13, 14, 15 and 17. This was noted to be Resolved Healed 11-17-15 Surveyor was unable to identify an 11/19/15 weekly skin assessment. Nurse's note, dated 11/27/15 at 9:25 p.m., read in part: Note: Resident has open area on buttock that is 2 1/2 x 3 1/4 cm 1 1/4 of the 2 1/2 side is open. The other 1 1/4 is black and hard to touch. There are 3 small closed areas that are also closed, black, and hard to the touch that are less than 1 cm in diameter. There is also 1cm long open area in the upper crack of his buttock. Applied Stoma Surveyor was unable to identify documentation of the stage of the ulcer. 11/28/15 9:47 p.m. Note: Wound on left buttock is seeping serosanguineous drainage. The stoma is soaking in and up changing residents depend it pulls on the wound from being stuck to it. It is also red and hot to the touch around the area of the wound. Surveyor was unable to identify if the facility updated the physician with the wound being red and hot to the touch. Nurse's note, dated 11/30/15 12:05 p.m., GENERAL SKIN CONDITION: Open skin are noted to L buttock, approx 4.5cm x3cm x0.1cm, wound bed with red tissue noted, outside edges from a from approx 7:00 to 2:00 black, wound bed with moderate amt of serosang drainage, no odor present, scabbed area approx 0.75cm x0.3cm and red area noted approx 1.3cm x0.5cm, red/purplish discoloration noted approx 12cm x10cm, area denies pain to area, no open skin noted to crack of buttocks/coccyx area today, resident has been utilizing broda w/c and per staff preference to lay supine in bed vs side, will roll himself back to supine independently, .resident also agreeable to laying in bed at least 2x am shift to help with this, has therapeutic mattress on bed .will review and increase repositioning to q 1.5hr and prn, . On 11/30/15, Resident #4's care plan was updated and read in part: Nurse Aide ---Repositioning: q 1 - 1.5 hours in w/c, Bed--encourage and assist q rounds during hs or as he allows during hs, q 1-1/2 hours during daytime hours/naps, does not like to be awoken during hs when sleeping. Nurse's note, dated 12/03/15 1:37 p.m., ASSESSMENT TYPE: Initial assessment 12/02/15 AREA 1: left buttock, DESCRIPTION: Assessment completed with (Resident #4's name) left side lying area left buttock measures 3.1 cm L by 4.5 cm W. The superior portion of wound tissue is purple -red in color. This are measures 1.4 cm L by 3.0 cm W. Skin intact. Inferior to this the tissue is open. Depth 0.1 cm. this tissue is 100% pink tissue. Edges of wound are open. Peri wound is discolored bluish hue and is firm to touch. Area is blanchable . Nurse's note, dated 12/07/15 2:40 p.m., WEEKLY SKIN ASSESSMENT: Continues with open are to L buttock, area today measures approx 3cm x4cm x0.1cm, area with pink wound bed, near 12:00 area approx 1 cm x1cm dark purple/firm with open area, moderate serosang drainage noted on dressing removed, no odor, denies pain to are , surrounding periwound purple/red, .did obtain air overlay mattress for bed, .will have pm shift apply mattress this evening before hs for use, continue current skin interventions/tx, On 12/10/15, Resident #4's care plan was updated and read in part: Nurse Aide --- SKIN INTERVENTIONS: float heels in bed position body with pillows / support devices, protect bony prominences keep skin clean and dry, moisturize dry skin, therapeutic cushion, therapeutic mattress, ensure repositioning side to side also when in bed as he allows/encourage and assist to keep of L buttocks as he allows, encourage and assist to lay down in bed between meals to help offload pressure to L buttocks, air overlay mattress on bed. The next skin assessment is dated 12/23/15 at 12:09 p.m., and read in part: ASSESSMENT TYPE: Follow-up assessment AREA 1: left buttock, WOUND TISSUE: yellow / pink SURROUNDING TISSUE: Pink but intact, palpated firm HEALING PROGRESS: improving DESCRIPTION: becoming smaller AREA: length (cm): 2.5 width (cm) 1.4 depth: 0.1 length x width (sq cm) 3.5 .are is improving however the wound bed does appear dry, wound edges appear rolled. With in the wound bed at the superior region the skin is purplish in color and this measures 0.6 cm L by 0.3 cm W below this region is an area that is yellow slightly raised and firm to touch . The next skin assessment is dated 01/12/16 7:56 a.m., and read in part: ASSESSMENT TYPE: Follow-up assessment AREA 1: L buttock WOUND TISSUE: yellow slough 100% SURROUNDING TISSUE: pink/intact HEALING PROGRESS: improving circumference, slough continues to wound bed at this time .AREA: length (cm): 1.3 width (cm): 1.2 depth: unstageable length x width (sq cm) - 1.56 . 01/18/16 at 3:03 p.m., ASSESSMENT TYPE: Follow-up assessment AREA 1: L buttock WOUND TISSUE: yellow slough 50% o'clock to 9 o'clock, pink tissue 50% 9 o'clock to 3 o'clock SURROUNDING TISSUE: reddened, pink, [MEDICAL CONDITION], approximate are around wound bed 3cm x4cm, .AREA: length (cm): 1.3 width (cm): 1.2 depth: 0/1 length x width (sq cm) = 1.56 . On 01/27/16 at 8:34 a.m., Surveyor interviewed RN L about Resident #4's pressure ulcer. Surveyor asked for information of what interventions were initiated at the time of admission when knowing Resident #4 was at risk for pressure ulcers, when the black areas presented and when the pressure ulcers increased in size. Surveyor asked for information if the physician was updated when the pressure ulcer became red and hot to touch. Surveyor asked the DON and the Nursing Home Administrator for any further information. No further information was provided. 3. Review of Resident #5's medical record identified initial admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the initial MDS, dated [DATE], identified Resident #5 as needing limited assistance of one staff for bed mobility, transfers and dressing. Resident #5 is assessed as being not at risk for pressure ulcer and did not have current pressure ulcers. Resident #5's BIMS score identified him as being moderately impaired. Review of nurse's notes document on 01/19/16 read in part: GENERAL SKIN CONDITION: Week 4 skin. Today while assessing resident's feet and legs for skin issues, found a fluid filled blister on the plantar heel of right foot. Size approximately 3 cm round. Pin point open area present in center, draining clear sanguinous fluid. Pain noted during cleansing. Surrounding skin has redness noted mainly on the lateral aspect of blister outward approximately 1 cm He did have on shoes, gripper socks and regular socks. Shoes fit okay with one pair of socks on. Will have staff take gripper socks off in AM if able, on at HS only. Will use heel booties in bed as resident allows. Will float heels while in bed .Wound nurse to assess in AM . 01/22/16 at 3:39 p.m., ASSESSMENT TYPE: Follow-up assessment PRESSURE ULCER: Has partial thickness loss of skin layers that presents as an abrasion or blister (Pressure Stg. 2) AREA 1: bottom of right heel, WOUND TYPE: Stage 2 Area: length (cm) 3.8 width (cm) 5.8 length x width (sq cm) = 22.04 . Review of Braden scale dated 12/31/15 documented a score of 19-20 which identifies Resident #5 as not having risk for skin break down. Review of Resident #5's care plan documents on 01/21/16 Nurses ---treatment as noted on treatment sheet, encourage use of pressure relief boots. If refuses assist with floating of heels. Can provide education to (Resident #5's name) however this may cause irritability. On 01/25/16 at 2:12 p.m., Surveyor observed RN M provide wound care to Resident #5's right foot. Resident #5 is in bed on a facility standard mattress. Resident #5 refused heel protectors and allowed RN M to elevate heels. On 01/27/16 at 2:05 p.m., Surveyor interviewed RN M about Resident #5's pressure ulcer. RN M indicated Resident #5's heels should be inspected daily. Surveyor requested any skin inspection documentation prior to the right heel pressure area developed. RN M indicated Resident #5 is non-compliant with the heel boots and floating of heels. RN M indicated an air over lay mattress was added on 01/26/16. Surveyor asked if this should have been put into place earlier knowing Resident #5 is non-compliant with cares. RN M indicated last week on wound rounds they had talked about the air over lay mattress and waited to see if Resident #5 was compliant with the heel boots and floating. No further information was provided. 4. On 01/25/16 at 1:50 p.m., Resident # 9 was observed by Surveyor , to be pushed from her bedroom into the therapy room (a distance of approximately 40 feet) by Occupational Therapy (OTR) N. Resident #9 was observed wearing gripper socks on her feet, and her feet were sliding along the floor as she was seated in her wheelchair. Resident #9 was not encouraged to hold her feet up, nor was she provided with wheelchair pedals to raise her feet off the floor. During review of Resident #9's medical record beginning on 01/26/16, Surveyor identified Resident #9 was admitted to the facility on [DATE], with an unstageable pressure ulcer on each heel and abrasions to some of her toes. During further review of Resident #9's medical record, Surveyor was unable to locate weekly assessments and measurements of Resident #9's unstageable pressure ulcers on her heels. Surveyor reviewed a 12/15/15, Body Check Sheet for Resident #9. This had been done on the date Resident #9 was admitted to the facility. This document included a shaded area on the left heel diagram and a notation for Resident #9's left heel read 3 cm (centimeter) x 2 cm open. The same document included a shaded area on the right heel diagram and the notation of 3 x 4 cm. Surveyor looked at Resident #9's 12/15/15, nurses' notes to see if there was more detailed information documented on Resident #9's unstageable heel ulcers. There was no further information regarding Resident #9's heel ulcer status in the 12/15/15 nurse's note. A nurse's note of 12/16/15 read in part, She has sore areas on her heels bilateral. Areas are being painted with iodine. A 12/17/15 nurse's note read in part, Staff are treating pressure areas to both heels. The next nurse's note that addressed Resident #9's heel ulcers was on 01/06/16 at 1:48 p.m. This note was written by RN M. RN M is a Wound Care Certified nurse. RN M's 01/06/16 nurse's note included measurements and detailed descriptions of RN M's assessments of Resident #9's heel pressure ulcers and toes. A nurse's note on 01/07/16 identified Resident #9 was seen by the Nurse Practitioner and her right heel treatment was changed to [MEDICATION NAME]. An order was also written for Heel protectors on at bedtime or at rest in bed. Through interviews, Surveyor learned heel protectors had been in use since Resident #9 was admitted . A nurse's note on 01/10/16 read in part, Resident does have treatments that i (sic) will be doing later to her heels. A nurses' note charted later on 01/10/16, read in part right heel open area . treatment done to right heel no odor noted. On 01/14/16, Resident #9 went to an appointment with a Podiatrist. A nurse's note of 01/1

Based on interview, medical record review and facility policy review, the facility staff did not ensure each resident received adequate supervision and assistive devices to prevent accidents for 2 of 5 residents reviewed for falls. Resident #3 had five falls from [DATE]-[DATE]. On [DATE], Resident #3 fell and hit her head. Resident #3 required three staples to close the head laceration sustained in the fall. Resident #3's alarm did not sound at the time of the fall. Resident #4 had fall two falls from [DATE]-[DATE]. When the [DATE] fall occurred, Resident #4 did not have an alarm in use as his care plan directed. The facility did not thoroughly investigate the root cause of these falls, determine why alarms were not on or working to alert staff or determine the specific details surroundings the falls. This is evidenced by: The [DATE] "Alarm Systems For Resident Use" policy read in part: The alarm systems are a method alerting staff that the resident is attempting to stand, is up standing, and/or the resident is ambulating without assist or that the resident is on the floor. The facility realizes that timely response to the residents' alerting device is vital in preventing a fall but not a guarantee regardless of staff availability. Therefore, on a routine basis, the facility will assess proper placement and function to assure optimal performance. As with any equipment, alerting devices (resident alarms) are not fool proof or fail safe and knowing this, Rolling Hills Rehabilitation Center will keep abreast with current technology. ? At the beginning of their shift, CNA's (Certified Nursing Assistants) are responsible for checking the alarms to ensure proper placement and to test the alarms for proper function. Moreover, the alarms are tested before interchanging the sensor pad and/or the alarm box from one location to another. If a resident is sleeping, the CNA will ensure the alarm is attached and the red light indicator is on. The CNA will document on the flow record that the alarms were checked as stated in this policy. ? Alarm use is placed on the Medication Administration Record (MAR). The nurse will check the alarm currently in use while administrating medications to ensure alarm(s) is properly placed and functioning and will document on the MAR. Assigned times to check alarms are 0800 (8:00 a.m.), 1200 (12:00 p.m.), 1600 (4:00 p.m.), 2000 (8:00 p.m.), and NOC's (nights). ? The Licensed Nurse will do a thorough investigation to determine causation if a fall occurs and the alarm did not sound. Findings will be written on the incident report under comments. If it is determined the alarm did not sound because the caregiver did not follow protocol, the employee is to be immediately counseled and social services is to be notified and/or leave a message. The manufacturer's directions for the bed and chair alarms read in part: ALWAYS TEST BEFORE EACH USE and LOW BATTERY INDICATOR WILL FLASH WHEN BATTERY NEEDS TO BE REPLACED 1. On [DATE], Surveyor began review of Resident #3's medical record and identified Resident #3 had the following falls. -On [DATE] at 5:35 a.m., Resident #3 was found sitting on the floor in the solarium. The nurse's note identified this fall was witnessed by staff and read in part: "POSSIBLE CAUSE: slid from chair ... SAFETY MEASURES IN PLACE AT TIME OF OCCURRENCE Chair Alarm (which did not sound because the battery had died --did work prior to this situation)." The plan of action after this fall was to place Dycem in seat of chair to prevent slipping. The note identified no injury was found. Surveyor interviewed the Director of Nursing (DON) on [DATE] beginning at 9:25 a.m. and asked for further information about the above fall. Surveyor pointed out the nurse's note identified the fall was witnessed by staff yet there were no details of where the staff member was in relation to the resident when the fall occurred. The alarm did not sound because the battery had died . The note said it did work prior to this situation but no time was given when it was working and when the alarm had last been checked for proper functioning. The note identified the battery had died . According to the manufacturer's information, a low battery indicator light will flash when the battery is low and needs to be replaced. It was not identified if the low battery light had been flashing prior to the fall. The incident/nurse's note did not identify when Resident #3 had been toileted last before this fall. Surveyor told the DON, when Surveyor observed Resident #3's transfer on [DATE], Surveyor did not recall seeing any Dycem in the seat of Resident #3's wheelchair, as Surveyor made note that Resident #3 did not have a pressure reduction cushion in her wheelchair. On [DATE] at approximately 6:00 p.m., the DON told Surveyor Resident #3 had been last toileted around 4:00 a.m. on [DATE]. Surveyor asked the DON how she learned that information, if she had found documentation of it that Surveyor did not see. The DON said she called the night nurse and discussed it with him on [DATE]. -[DATE] at 1:00 a.m., Resident #3 was found lying on her left side on the floor in her room. Resident #3 stated, "My head hurts." The incident/nurse's note read in part: "CONTUSION: Bleeding from and bump on left side of head. ... BODY CHECK: There is a bruise on her left wrist and she has the aforementioned bump and wound to the head. INJURY: Hit head, has a bump on left side of head which has a cut from which a significant amount of blood came." First aid was immediately applied. The plan of action was listed as "Move tray table away from bed." During the 9:25 a.m. [DATE] interview with the DON, Surveyor pointed out the nurse's note did not identify if Resident #3's alarm was sounding at the time of the fall, what the position of her bed was, when Resident #3 had last been checked on/seen or when Resident #3 had last been toileted. On [DATE] at approximately 6:00 p.m., the DON told Surveyor staff had contact with Resident #3 at 11:30 p.m. and Resident #3 had been toileted at 11:00 p.m. on [DATE]. The DON stated she learned this additional information from speaking with the night nurse on [DATE]. [DATE] at 6:45 a.m., Resident #3 was found lying on her left side on the floor in her room next to her floor mat. The nurse's note identified staff had just been in Resident #3's room to check on her and she was resting. The time of that check was not documented. The note also identified Resident #3's brief was wet when the nurse was assessing her after the fall. The note did not identify when Resident #3 had been toileted prior to the fall. The note also did not identify if the alarm was sounding at the time of the fall. These concerns were shared with the DON during the [DATE] interview. The [DATE] 11:48 p.m. nurse's note identified "Small bump on left side of forehead." The note does not identify the measurement of the small bump or when the bump was first found. The DON provided a copy of Resident #3's neuro check sheet for [DATE] and it was documented on that sheet that Resident #3 had a small bump on the left side of her forehead. On [DATE] at approximately 6:00 p.m., the DON told Surveyor Resident #3's alarm was sounding at the time of this fall, they had contact with her at 6:40 a.m. and she had been toileted around 5:30 a.m. on [DATE]. This information was obtained on [DATE] by the DON speaking with the night nurse that was on duty [DATE]. -[DATE] at 10:25 a.m. Resident #3 was found lying on her right side, on the floor of her room next to her bed, after a CNA heard a loud noise and responded to Resident #3's room. Resident #3 stated, "My head hurts." The note also identified "Bed Alarm - did not sound, non skid rug at bedside, bed was at an appropriate height for resident. ... "PAIN ON MOVEMENT: c/o (complained of) head hurting. CONTUSION: approx (approximate) 4 cm (centimeter) laceration to back of her head with active bleeding noted." Resident #3 was sent to the Sparta emergency room by ambulance at approximately 12:20 p.m. A 3:11 p.m. [DATE] nurse's note identified Resident #3 returned to the facility at approximately 2:40 p.m. on [DATE]. Resident #3 had been diagnosed with [REDACTED]. During an interview with the DON on [DATE], Surveyor explained the detail of what Resident #3 may have hit her head on was not identified. Surveyor questioned where the tray table was located at the time of the [DATE] fall, as an intervention after the [DATE] fall was to move the tray table away from Resident #3's bed. Surveyor also pointed out the note identified the bed alarm box was working adequately during a.m. checks, but the time the alarm was last checked and was working were not identified. The note identified the bed alarm pad was found bent. The note did not identify when staff had last checked on Resident #3 or when Resident #3 had last been toileted before the fall. On [DATE] at approximately 6:00 p.m., the DON told Surveyor she had found out Resident #3 was a few steps away from the end of the bed and they found blood on the floor. The tray table was not by where Resident #3 fell . The bed alarm had activated the call light but the alarm did not sound. The DON said it was hooked up correctly but they changed it all out after the fall. The documentation in Resident #3's medical record did not identify additional measures or increased supervision were implemented after the [DATE] fall, to prevent further falls. This concern was shared with the DON on [DATE]. Later on [DATE], Surveyor was provided with an undated computerized IDT (interdisciplinary team) meeting note for Resident #3. This note was accompanied by a IDT staffing attendance record that identified a special IDT meeting for falls was held [DATE]. The note read: "(Resident #3 had a fall on [DATE] unassisted transferring to bed. There was no injury. Gray matt (sic (spelling incorrect)) switched to non skid rug. Checked for UA (urinalysis)." "Another fall occurred on ,[DATE]. Per staff the bed alarm did not appear to sound as she was getting up from bed. The alarm was switched out. (Resident #3) did receive stapes (sic) (staples) for a laceration on her head. Staff will check pad to ensure it is working when (Resident #3) lies down. Also discussed potential move closer to nurses station with family permission when room is available. RCC (Resident Care Coordinator) to update care plan." -[DATE] at 4:25 a.m. a CNA heard Resident #3 fall from bed. She was found lying on her left side leaning on her left elbow next to her bed and night stand. The nurse's note read in part: "EQUIPMENT INVOLVED: alarm was on bed and had worked all NOC shift. Did not work this time. ... SAFETY MEASURES IN PLACE AT TIME OF OCCURRENCE Nonskid rug Low bed Bed Alarm." After the fall Resident #3 complained of her back hurting and had two pencil size scratches with one having a small abrasion like a tiny scrape. "PLAN OF ACTION: Bed alarm will be replaced. Mini-staffing: Resident is one to one at this time (it was not identified how long the one on one continued) POC (plan of care) remains appropriate Monitor x 72 hrs (hours) PATTERN NOTED: Hx (history) of falls Same time frame and other times. Two in May and one in July and another in August. Same type falls." The documentation regarding the [DATE] fall did not identify when the pad and alarm had been checked last for proper functioning, what the height of the bed actually was at the time of the fall, when she had last been seen/checked on and when she had last been toileted prior to the fall. These concerns were shared with the DON on [DATE] as well as questioning the interventions in use being effective given the number of times Resident #3 did have falls from her bed. The DON stated they did add the personal alarm after the [DATE] fall. Upon review of Resident #3's care plan on [DATE], Surveyor identified the following: Resident #3's care plan problem for ADL (activities of daily living) Functional Deficit contained an approach, dated [DATE], that read "CNA- toilet q2h (every 2 hours)." 2. On [DATE], Surveyor began review of Resident #4's medical record and identified Resident #4 had the following falls: -[DATE] at 1:05 p.m., Resident #4 was found lying on the floor just inside the doorway of another resident's room. The [DATE] incident/nurse's note identified Resident #4 had been seated in a chair in the dining room prior to the fall. The note read: "POSSIBLE CAUSE: without assistive device, without staff assist. Responding to bowel and/or bladder urgency EQUIPMENT INVOLVED: other: no alarm in place at lunch, was able to get up and ambulate unnoticed. ... SAFETY MEASURES IN PLACE AT TIME OF OCCURRENCE: None (did not have personal alarm at lunch table) ... CONTUSION: did hit head = small ,[DATE] cm (centimeter) to left forehead small amount (couple drops) of blood. ... INJURY: laceration Hit head ,[DATE] cm to left forehead. ... PLAN OF ACTION: Personal alarm placed on resident (new plan; trial) Chair alarm while at table." Surveyor later learned on [DATE], this was not a new intervention through review of Resident #4's care plan that was in place prior to/at the time of Resident #4's [DATE] fall. His care plan read "Resident on 15 minute checks to ensure safety. Utilizes bed and chair alarm Personal alarm pinned to resident in all chairs." This approach was dated [DATE]. Surveyor identified the documentation of Resident #4's [DATE] fall did not identify when Resident #4 had last been seen prior to the fall and when Resident #4 had been toileted prior to the fall. This information was shared with the DON on [DATE] during a 4:35 p.m. interview. During this interview, the DON was asked to clarify if Resident #4 should have had an alarm on while seated in the dining room chair. The DON stated we re-educated because it was not clear what to have on because the care plan said bed/chair/personal alarm. After reviewing Resident #4's care plan that was in place at the time of the [DATE] fall, Surveyor pointed out to the DON later on [DATE] the care plan approach at that time was clear as it read "Utilizes bed and chair alarm Personal alarm pinned to resident in all chairs." -[DATE] at 8:45 p.m., Resident #4 fell from a recliner in the solarium. Resident #4's alarm did sound and staff responded but were unable to get to him fast enough to prevent the fall. On [DATE] at 9:10 a.m., Surveyor spoke with the DON and pointed out the documentation for Resident #4's [DATE] fall did not identify when Resident #4 had last been seen prior to the fall and when Resident #4 had been last toileted prior to the fall. At 11:52 a.m. on [DATE], the DON told Surveyor Resident #4 had been toileted around 6:00 p.m. on [DATE] before going in the recliner. (This information was obtained by the DON talking with staff on [DATE].) As far as checking on him, staff were in and out of rooms. The DON did not know a specific time he had been checked on prior to the fall. The nurse was on the other hall passing meds at the time of Resident #4's [DATE] fall.

Based on observation, interview and facility policy review, the facility failed to ensure 1 of 6 residents reviewed for pressure ulcers received the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Resident #2 was assessed by the facility as not at risk/low risk for pressure ulcers. Resident #2 developed a pressure ulcer on 07/04/13 on the left calf that became infected. The facility did not document or assess the wounds until 07/18/13 and did not implement interventions until 07/29/13. This is evidenced by: Surveyor reviewed the facility policy: Skin Care Treatment Sheet Procedure with revised date of 8/05 reads in part: Objective: To provide accurate and complete documentation regarding skin care treatments on our residents so that continuity of care and improved comparison can be made to enhance nursing assessment of the affected area. Procedure: 1. When the affected area is discovered, the nurse will carry out the wound care protocol and write a narrative nurses note describing the wound. 3. Assess the area; is the ulcer stage 1,2,3,4, or not stageable. 15. Ulcers: Write in the #. Hour: write in the time the treatment is to be completed and under the correct day of the month, place your initials when completed. 16. On the back of the sheet, fill in all the area that are indicative of the ulcer, this will be done weekly. Document progress only on a nurse's note weekly. Documentation other than what is mandated in this policy will be done at the nurse's discretion. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's Braden scale score on 06/18/13, 09/11/13 and 12/04/13 was 16 - 17. A score of 15 or 16 identifies a low risk of developing a pressure ulcer and over 16 identified as no risk of developing a pressure ulcer. Resident #2's most recent Minimum Data Set (MDS) assessment dated [DATE] identified she required extensive assist of 2 staff for bed mobility, transfers and hygiene needs. This MDS also identified Resident #2 was at risk for pressure ulcers and had a one stage II pressure ulcer, one stage IV pressure ulcer and one venous ulcer. Surveyor reviewed Resident #2's medical record. On 07/02/13 an Orthotist note reads in part: Resident #2 was fit with bilateral size large multi podus boots which will keep the heels in suspension and allow healing. She (Resident #2) was initially concerned that these would cause more pressure sores, but finds them quite comfortable to wear... She was instructed to wear these only when not walking, but they can be used when transferring... She chose to wear the multi podus boots out from the appointment today. Nurses note dated 07/04/13 at 11:35 p.m. reads in part: This writer also noticed a reddened area on resident Left Lower Extremity (LLE) about 5" (inches) by (X) 6" irregular boarder. Possibly due to (d/t) podust boot. This writer did mark boarders so to monitor any changes. Resident denies any pain in that area. Leg area does feel warm not hot. Resident has been refusing to wear her podust boot. States, "it is uncomfortable and I think it is causing my leg to be red and irritated." We have had the boot removed all this shift and redness appears to have decreased slightly Heels continue to elevated. This note does not indicate notification to the physician. Nurses' note dated 07/05/13 at 4:59 p.m. reads in part: Physician orders [REDACTED]. A resident routine treatment sheet - Nurses identify on 07/04/13 LLE site 1 centimeter (cm) X 1/2 cm old scab opened. Cleansed [MEDICATION NAME] kling. This sheet identified by staff initials the treatment was completed on the p.m. shift on 07/04/13 and 07/05/13, and the a.m. shift on 07/05/13 and 07/06/13. A new resident routine treatment sheet was established on 07/06/13 and identified the left calf as problem number 2. This sheet identified by staff initials the treatment was completed once on 07/06/13 and once on 07/07/13. The treatment sheets on the reverse side were blank. Surveyor was unable to identify in the medical record if treatments were continued. Nurses' note dated 07/08/13 at 6:06 p.m. reads in part: infection follow-up: date infection first noted: 07/07/13 site of infections: skin resident condition:...Temperature 98.8 left dorsal calf has small open area surrounded by redness and warmth. Slightly tender to touch. Physician orders/treatment plan: [REDACTED].Was sent to ER per MD F for eval and treatment. Review of physician progress notes [REDACTED]. She has been fitted with multipodus boots and is wearing them now... Assessment:...2. New lateral leg ulcer which appears to be ulcerated varicose vein. Plan:...Wet to dry dressing left lateral leg. A resident skin care treatment plan dated 07/17/13 identify current treatment plan: [REDACTED]. Protect peri wound with either Vaseline or skin prep. Cover wound with foam, cling wrap. Perform every day. Encourage ace wrap or compression for [MEDICAL CONDITION] control. This sheet identified by staff initials the treatment was completed on the a.m. shift from 07/18-22/13. The treatment sheets on the reverse side were blank. Surveyor reviewed Resident #2's individualized plan of cares and was unable to identify changes to the plan of care when the open area on the left lateral calf was identified on 07/04/13. Surveyor reviewed the medical record, no nurses wound documentation or nurses notes for Resident #2 from 07/08/13 until 7/18/13 were identified. Nurses notes on 07/18/13 at 11:07 a.m. reads in part:...Left lateral calf wound measure 2.8 cm length by 3.2 cm width by 0.2 cm wound bed is 75% black eschar and 25% red granulation tissue/peri wound shows scar tissue/appears fragile. Moderate serous drainage. Current treatment is normal saline wet to dry three times a day (TID)/gauze and kling....She is able to feel staff palpating foot. Review of Wound Center consultation note dated 07/23/13 reads in part: ... 3.5 by 3.5; some necrotic dry eschar in base; does not appear cellulitic; is tender. ...Impression: [MEDICAL CONDITION] ulcer - first assessment; left lateral leg ...does not appear vasculitic or in typical pressure area. Plan: ...Would change to [MEDICATION NAME]/[MEDICATION NAME]; then secondary. Change once daily. Surveyor reviewed the medical record, no nurses wound documentation or nurse notes for Resident #2 from 07/18/13 until 07/27/13 were identified. On 7/27/13 at 11:12 a.m. reads in part: Skin/feet assessment: Resident has increased complaints of pain at LLE posterior ulcer. Area treatment done today with approximate measurement are 6 cm length by 3 cm width and 0.5 cm deep. Scant amount of bloody drainage. Peri wound is reddened from wound edges out approximately 3 cm surround wound edges. Area of increase [MEDICAL CONDITION] noted below wound towards ankle, are to touch. The wound bed has a black necrotic area measuring approximately 6 cm length by 1.75 cm width. The remainder of the wound bed is covered with yellow slough measuring approximately 4.5 by 1.5 cm. The podus boot has a rigid backing that appears to be causing increased pressure on LLE ulcer. The anterior portion of the foot/ankle fold has a 5 cm by 5 cm square area that is bright pink in color, skin closed. This area is in line with the podus boot strapping. Wound appears to have declined since last seen by this nurse on 07/24/13. Call to supervisor to report decline. Will off-load pressure this weekend with podus boot off, assess right LE for any problems re: pressure from boot on that foot. Update MD on call. Email to be sent to wound care nurse for RH. Nurses' Note dated 07/29/13 at 2:20 p.m. reads in part: Skin/feet assessment: ...Measurements today 5.0 cm length by 3.2 cm width not able to assess related to (r/t) eschar in wound bed. Wound bed has dark eschar measuring 4.8 cm length by 1.8 cm width. Eschar is dry/Medially tissue is yellow staring at 7:00 and going to 10:00. Measurement 1.5 cm length by 0.8 cm width 90% of this wound is dark eschar/peri wound has slight maceration and redness....Resident #2 complain of pain with dressing removal...We are now utilizing pressure relief boots. Nurses' Note date 08/02/13 at 2:11 p.m. reads in part: Skin/feet assessment: ...Left lower calf ulcer measuring 5.8 cm length by 4.0 cm width- depth not assessed r/t wound be containing eschar. Wound bed is 100% eschar....Drainage moderate amount serous. No odor, does have some pain with dressing removal and cleaning....Resident #2 does follow the WCT but does not follow up with them til mid month. Continue with current plan. Nurses' Note date 08/05/13 at 10:49 a.m. reads in part: Skin/feet assessment: Unit nurse requested assessment of left lateral calf ulcer. Drainage is large amount of [MEDICAL CONDITION] drainage. No noted odor. Resident #2 does c/o pain in her leg. Offers complaints of burning at ulcer site...Ulcer is getting larger. Measurements today 6.5 cm length by 5.5 cm width. The black eschar remains in the center of the wound bed and measures 5.5 cm length by 2.0 cm width. Cont with yellow eschar medially and this measurement is 4/5 cm length by 1.2 cm width. Peri wound cont with redness/not warmth. Redness approx measurement is 9.0 cm length by 9.0 cm width. Staff report her temp today 99.5 tympanic and baseline temp is 97 degrees. Placing call to wound care team to report change in character of drainage, increase in size of wound. Wound Center follow up note dated 08/07/13 reads in part:...Wound procedure #2: Left posterior calf eschar and slough debrided sharply (excisional) to subcutaneous tissue depth with continual attendance after verification of the correct patient, site and procedure. ... Impression: Left posterior calf wound secondary to pressure, [MEDICAL CONDITION] and [MEDICAL CONDITION] ...Plan: ...Use 1/4 strength Dakin's dampened gauze to both wounds twice a day (bid). Continue pressure reduction measure with protective boot. Encourage not to sleep on back to keep pressure off posterior leg wound. Started on [MEDICATION NAME] 875 mg bid for 7 days. Surveyor was unable to identify in the care plan to encourage not to sleep on back to keep pressure off posterior leg wound. Nurses' note dated 08/10/13 at 4:15 p.m. reads in part: Note: ...Pain is rated at an 8-9 with dressing changes and reduces to a 4-5 after pain meds are administered. Surveyor review the next wound assessment that is 9 days later on 08/14/13 at 8:38 a.m. reads in part: Skin/feet assessment: ...left lateral calf ulcer measuring 6.0 cm length by 4.0 cm width granular portion of wound measures 0.5 cm depth. Wound bed is 50% yellow eschar and 50% granulation tissue... Drainage large amount of [MEDICAL CONDITION] drainage. Surveyor reviewed the next wound assessment that is 12 days later on 08/26/13 at 6:29 p.m. reads in part: Skin/feet assessment: left leg wound measures 4 cm width by 5 cm length wound bed is beefy red. Surveyor reviewed the next wound assessment that is 10 days later on 09/05/13 at 1:11 p.m. reads in part: Skin/feet assessment: ... left later ulcer measurement 4.1 cm length by 3.0 cm width by 0.3 cm depth tendon visible. Surveyor reviewed the next wound assessment that is 7 days later on 09/12/13 at 5:48 p.m. reads in part: ulcer on left out leg measures 4 cm length by 3 cm width by 0.5 deep. Surveyor reviewed the following wound assessments documentation dates: 09/18/13 then 19 days later another wound assessment on 10/07/13. 15 days later wound assessment on 10/22/13. 6 days later wound assessment on 10/28/13. Then 15 days later another wound assessment on 11/12/13. No further wound documentation was provided to Surveyor . Surveyor was unable to identify pressure ulcer staging in the facility assessment documentations. On 12/09/13 at 1:35 p.m. Surveyor interviewed Register Nurse (RN) A. RN A indicated wound assessments are completed by her on the first and third weeks of the month and a narrative noted is done at that time. RN A indicated that the RCC or the License Practical Nurse (LPN) looks at the wounds the other weeks and documents. RN A indicated she was requested to evaluate Resident #2 on 07/18/13. Surveyor asked RN A for any additional documentation related to Resident #2's LLE calf wound. Resident #2's individualized plan of care for Activities of Daily Living (ADL) functional deficit identified changes on 07/29/13 reads: "Certified Nursing Assistant (CNA) -- encourage Resident #2 to wear the pressure relief boots to bilateral lower extremities. Ensure her heel is positioned properly in the opening. Staff can complete this with placing her leg/foot in the boot than pulling up on the boot and ensuring her heel is placed in the open hole." CNA -- If Resident #2 is not wanting to wear the pressure relief boots encourage use of pillows and float heels. CNA -- Staff may place rolled towel lateral leg or parallel to leg to assist with keeping leg in proper alignment/do not place rolled towel under her leg which can cause pressure. On 12/10/13 Surveyor reviewed with the Director of Nursing (DON) the missing weekly wound assessments, assessing for root cause timely, staging, documentation of wound treatments, interventions and updating care plans. DON indicated the only interventions initiated are on the care plans. Surveyor asked for any additional documentation of wound assessments. DON indicated all information was provided.