Every finding on record at Saint Johns on the Lake

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 1 (R1) of 1 allegations of abuse or neglect reviewed.*The care plan was delayed in being updated and a key intervention was not added after the investigation was completed. The investigation was not thorough, no like-resident interviews were conducted and the five days of wellness checks facility proposed to monitor R1 after the incident were not completed.Findings include:The Facility Policy and Procedure titled Misconduct last revised 11/2025, documents: Purpose: To provide guidance to assure that all alleged violations involving resident abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are immediately acted upon, reported and investigated in a manner consistent with federal and state regulations to assure resident safety.E. Investigation Components.Procedure: The facility will immediately begin a thorough investigation of any reported incident, collect information that corroborates or disproves the incident and document the findings for the incident. The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. A thorough investigation is an investigation that adequately addresses the circumstances of the allegation. The investigation will include the facts necessary to form a reasoned conclusion as to what happened.a. Investigation of abuse.The investigation will include.iii. What happenedd. Involved staff and witness statements of eventsi. Identifying and interviewing other staff or residents in the immediate area at the time of the incident who may have witnessed what occurred.v. How did it happen? .a. A description of the resident's behavior and environment at the time of the incident.x. Conclusion based upon findings F. Protection ComponentsProcedures must be in place to provide the resident with a safe, protected environment during the investigation.:iv. Examine, assess and interview the resident and other residents potentially affected immediately to determine any injury and identify any immediate clinical interventions necessary.R1 was readmitted to the facility on [DATE] with diagnoses that include type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood), diastolic heart failure (occurs when the heart muscle doesn't pump blood as well as it should), and dementia (a syndrome that can be caused by a number of diseases which over time destroy nerve cells and damage the brain, typically leading to deterioration in cognitive function (i.e. the ability to process thought) beyond what might be expected from the usual consequences of biological ageing).R1's Minimum Data Set (MDS) with an assessment reference date of 2/27/26 documents a Brief Interview for Mental Status score of 11, indicating that R1 is moderately cognitively impaired. Per the MDS, R1 is assessed as makes self understood and understands others and documents that R1 exhibited no behaviors during the assessment period.Surveyor reviewed the Investigation Report Form dated 3/12/26, provided by the facility. The Description of Incident/Concern is documented as NHA-A received a call by DON-B around 4:23pm on 3/12/26 that RN-D informed her that R1 alleged that RN-D swatted him after she tried to assist him from falling. Investigation procedures began immediately and RN-D was not allowed to take care of any residents while the investigation occurred. DON (Director of Nursing)-B and Chief Clinical Officer-C remained onsite to ensure RN-D did not provide care.Under 7. Findings, the box for Not Substantiated is checked. The Summary of Findings documents: after a thorough investigation, we could not substantiate the allegation of abuse due to lack of evidence, inconsistent recollection of events stated by R1, and a witness statement. Wellness checks have been implemented for 5 days and will continue if necessary. We are committed to ensuring R1's wellbeing by implementing a buddy system to help best serve his sense of protection and safety.R1's care plan documents I have the potential to report allegations of staff mistreatment/abuse that are not substantiated upon investigation. I may experience misperceptions, confusion, or emotional distress. Date initiated: 3/30/26. The intervention is: Acknowledge and validate feelings about claims. Document all allegations promptly and factually in my perspective. Notify appropriate supervisory and administrative staff immediately. Date Initiated: 3/30/26. Surveyor noted the incident happened on 3/12/26 and the care plan was not updated until 3/30/26. Surveyor noted the intervention of a buddy system was not included.Surveyor reviewed interviews conducted with Registered Nurse (RN)-D who R1 accused of swatting R1 and an interview with R1 in which he alleges RN-D swatted him.Surveyor reviewed an interview conducted with Licensed Practical Nurse (LPN)-E who stated I went into R1's room because he seemed upset as I was walking by and at the time I wasn't sure about what he was upset about. However, I went to see if I could help. Upon entering, I observed RN-D taking her hand out of her pocket and I heard R1 say to her don't swat at me which I did not observe her do. Also, RN-D was not even in arm's length of R1 when he stated that.Surveyor noted three interviews were conducted after the incident.On 4/1/26, at 2:08pm, Surveyor interviewed LPN-E who is the witness of the incident. LPN-E shared that while passing medications to other residents LPN-E could hear R1 getting loud so LPN-E went to R1's room and asked what was going on. R1 stated she (RN-D) swatted me. R1 was looking for something and could not find it. RN-D was far away from R1, there is no way RN-D could have swatted R1.Surveyor noted LPN-E was not in the room and entered after R1 got loud. Surveyor noted that RN-D could have moved back in the time LPN-E was coming to room and noted that LPN-E did not visually witness the incident.On 4/1/26, at 2:23pm, Surveyor interviewed DON-B and asked if other resident interviews were conducted and was told by DON-B that she was not sure. Surveyor asked about documentation of the wellness checks that were completed for five days after the incident. DON-B replied if they weren't done as progress notes an assessment may have been used and DON-B stated she will look into. Surveyor asked about the buddy system being implemented and if that had been added to R1's care plan. DON-B stated she will look into it. Surveyor asked what else was done to investigate the alleged swat and was told it was partly witnessed so the two staff and resident involved were interviewed.On 4/1/26, at 2:44pm, Surveyor interviewed NHA-A and asked about the investigation about the alleged swat if there were like-resident interviews done and was told no because this situation was witnessed by another staff member who stated the swat did not happen. Surveyor inquired about documentation on the wellness checks that were to be completed and was told that would be in PCC (the Electronic Health Record). NHA-A was asked about the care plan being updated and the buddy system being added and was told NHA-A would look into that. Surveyor asked if anything else had been done to investigate the incident and was told no, nobody else would have known anything.On 4/1/26, at 3:30pm, NHA-A followed up with Surveyor and stated that there should have been wellness checks done, but there is no documentation. After review, the buddy system was not included as an intervention on the care plan.On 4/1/26, at 3:50pm, Surveyor meet with DON-B and NHA-A and let them know the concerns that the investigation was lacking as there were only three interviews conducted and no like-residents were interviewed. The witness of the incident was outside of the room and heard yelling then went to the room, and it was not visually witnessed. Resident protection measures were not documented for the five days of wellness checks. The care plan was updated two weeks after the incident occurred and the intervention of buddy checks was not included.No additional information was provided regarding the investigation not being thorough as no like-resident interviews were conducted, the five days of wellness checks facility proposed to monitor R1 after the incident were not completed, and R1's care plan was delayed in being updated and a key intervention was not added.

Based on observation, interview, and record review, the facility did not store and prepare food in accordance with professional standards for food service safety potentially affecting all 20 residents that eat food prepared by the facility. *In the facility's main kitchen, observations of partially used and undated food were observed in the walk-in cooler. Open food was observed in the refrigerator in the resident floor main kitchen with no open or use by date. Findings include: The facility policy and procedure titled Food Storage, dated 5/29/2025 documents: Policy, Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored in an area that is clean, dry and free of contaminants. Food is stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination or cross-contamination. 14. Refrigerated food storage: . All foods should be covered, labeled and dated. All foods will be checked to assure that foods left quotation mark including leftovers) patient [NAME] will be consumed by their safe use by dates, or frozen (where applicable), or discarded. 15. Frozen foods: . All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. Food Storage Observations: On 5/29/2025, at 9:11 AM, Surveyor observed dinner rolls in the kitchen walk in freezer, not labeled or dated with an open or use by date. Surveyor observed the dinner roll package torn open on one side and wrapped with saran wrap, Surveyor informed Director of Dining-H of the concern. Director of Dining-H also observed that the package was open, and not dated. Director of Dining-H stated that the food is supposed to be dated after opening. Director of Dining-H pulled food from the freezer and asked staff to place a date on the dinner rolls. On 6/2/2025, at 7:57 AM, Surveyor observed sausage in the kitchen walk in freezer, not labeled or dated with an open or use by date. Surveyor observed the sausage package torn open on one side and wrapped with saran wrap, Surveyor informed Director of Dining-H, who observed that the package was open, and stated that the food is supposed to be dated after opening. Director of Dining-H pulled the sausage from the freezer and said it was supposed to be dated. On 6/2/2025, at 11:44 AM, Surveyor made observations of the resident's (main floor) refrigerator that was in the kitchenette located in the main dining area. Surveyor observed yogurt containers in the refrigerator that were not labeled or dated. Surveyor interviewed Kitchen Director-C, who stated that the yogurts will be getting tossed out and Kitchen Director-C stated that the dates may have been rubbed off. Director of Dining-H stated that the facility will now be labeling the dates on all yogurts, so this does not happen again. On 06/3/2025, at 03:02 PM, Surveyor informed Director of Nursing (DON)-B, of the concerns with the food storage including items in the refrigerator and freezer not having dates on them.

Based on interview, and record review, the facility did not establish and maintain an infection prevention and control program based on current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to affect all 21 residents in the facility. *The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: - Include the infection preventionist as part of the water management plan committee. - Identify corrective actions when control limits do not meet acceptable ranges of control limits (temperature ranges). *The facility does not monitor the dryer ventilation going to the outside of the facility from the facility dryers in the basement laundry room to make sure the vent remains clear and free of debris. Findings include: The facility policy titled Water Management Procedures: Legionella Prevention Procedures issued 5/2024 documents: 1. Water Management Program: a. [Facility name] has developed a water management plan (WMP) to: i. Identify ways to minimize growth and spread waterborne pathogens. ii. Conduct routine checks of control measures to monitor areas at risk. iii. Take corrective action if a problem is found. iv. Verify that a WMP is working as intended. b. The WMP is governed and directed by the organization's Safety Committee. The Safety Committee includes administrative and maintenance personnel who are knowledgeable about the facility's water system. On 5/29/2025, Surveyor reviewed the facility's WMP binder. Surveyor noted that the WMP/ safety committee did not list the employees that participated in the meetings. Surveyor also noted that the facility did not identify what actions are to be taken when the facility's control limits were not met according to the acceptable ranges that were documented. On 6/3/2025, at 9:18 AM, Surveyor interviewed the Director of Facilities (DoF)-E, who was recently employed about 30 days ago, along with the Facility and Maintenance Director- F who was recently promoted to the role about 3 months ago but employed with the facility in the maintenance department for about 9 years. Surveyor asked how often the WMP committee met and who attends the meetings. Maintenance Director- F stated that there are weekly operations meetings held with maintenance and laundry and that the water is discussed at times. Maintenance Director-F stated that the safety committee also has the option to participate in those meetings. Surveyor asked what staff make up the safety committee. Maintenance Director-F stated that it is campus wide and usually consists of someone from each department. Surveyor asked if the Infection Preventionist (IP) is included in any of the WMP discussions or safety committee. Maintenance Director-F stated that the IP is not included that they are aware of. Maintenance Director-F stated that the IP is not communicated with regarding the meetings or collaborated with regarding infection prevention concerns with the water systems. Maintenance Director-F stated that that the facility is trying to get the requirements worked out. Surveyor asked what protocols are in place when the control limits (for example water temperatures) are not within the control limits. Maintenance Director-F stated they are alerted and will try to find out what the cause is. Surveyor asked if there are any protocols in place to do extra testing or stop use of water etc. Maintenance Director-F stated that administration would be contacted, but not sure if further requirements are needed. Maintenance Director-F stated that they would need to check into that and again stated they know the facility is trying to get the requirements worked out. On 6/3/2025, at 12:47 PM, Surveyor interviewed Infection Preventionist (IP)-D who stated IP-D is not part of the WMP or anything that discusses the water risks. IP-D stated that the maintenance department is in charge of the water flushes and monitoring but not aware if there is a committee or not. Surveyor shared importance of the IP involvement with the WMP because any concerns of legionella or other water borne pathogens can affect the residents and IP should have involvement to assist in the safety of the residents with whomever is managing the WMP. IP-D stated they are aware of the importance and would love to be part of it, if the facility developed one, but currently not aware of anything. Surveyor asked if there is a process in place if the facility had a positive legionella case or other water borne pathogen concern. IP-D stated they would follow any guidance from the centers of disease control (CDC), but had no specifics at current time, just would look online. On 6/3/2025, at 2:00 PM, Director of Nursing (DON)-B was made aware of Surveyors concerns that the WMP did not Include the infection preventionist as part of the water management committee and the facility did not identify corrective actions when control limits do not meet acceptable ranges of control limits (temperature ranges). DON-B acknowledged Surveyor's concerns. On 6/3/2025, at 9:18 AM, Surveyor toured the basement laundry room with Director of Facilities (DoF)-E and Maintenance Director- F. Surveyor asked about the vent leading from the facility dryers to the outside of the building and how often that is checked. Maintenance Director-F stated they do not check that vent. Surveyor asked if Maintenance Director-F knew where it vented out to. Maintenance Director-F stated somewhere above and on the side. Maintenance Director-F stated that the facility has a company come in to monitor all the vents from the facility to the outside, but does not think the dryer vent is on the list for the company to inspect. Surveyor asked if it is known if there is any build up or debris around the vent. Maintenance Director-F stated no but would reach out to the company to see if that is one of the vents the company looks at. On 6/3/2025, at 2:00 PM, Director of Nursing (DON)-B was made aware of Surveyors concerns that the facility does not monitor the dryer ventilation going to the outside of the facility from the facility dryers in the basement laundry room to make sure the vent remains clear and free of debris. DON-B acknowledged Surveyor's concern.

Based upon observation, interview and record review the facility did not ensure they had a system in place to ensure monitoring of and maintaining of laundry vents that extended up from the laundry room to the outside. This has the potential to effect all 21 Residents residing in the facility. *The facility does not monitor the dryer ventilation going to the outside of the facility from the facility dryers in the basement laundry room to make sure the vent remains clear and free of debris. Findings include: On 6/3/2025, at 9:18 AM, Surveyor toured the basement laundry room with Director of Facilities (DoF)-E and Maintenance Director- F. Surveyor asked about the vent leading from the facility dryers to the outside of the building and how often that is checked. Maintenance Director-F stated they do not check that vent. Surveyor asked if Maintenance Director-F knew where it vented out to. Maintenance Director-F stated somewhere above and on the side. Maintenance Director-F stated that the facility has a company come in to monitor all the vents from the facility to the outside, but does not think the dryer vent is on the list for the company to inspect. Surveyor asked if it is known if there is any build up or debris around the vent. Maintenance Director-F stated no but would reach out to the company to see if that is one of the vents the company looks at. On 6/3/2025, at 2:00 PM, Director of Nursing (DON)-B was made aware of Surveyors concerns that the facility does not monitor the dryer ventilation going to the outside of the facility from the facility dryers in the basement laundry room to make sure the vent remains clear and free of debris. DON-B acknowledged Surveyor's concern.

Based on interview and record review, the facility did not ensure a resident who uses a psychotropic PRN (as needed) drug had an order limited to 14 days for 1 (R6) of 5 residents reviewed for unnecessary medications. R6 had an order for PRN Ativan with a start date of 5/17/2025 and no end date. Findings include: The facility policy and procedure titled, Psychotropic Medication Use and last revised 1/2025, documents, in part: Policy Statement Residents will not receive medications that are not clinically indicated to treat a specific condition. Policy Interpretation and Implementation 1. A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior . 12. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. 4. PRN orders for psychotropic medications are limited to 14 days. 1. For psychotropic medications that are NOT antipsychotic's: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. 2. For psychotropic medications that ARE antipsychotic's: PRN orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication . R6 was admitted to the facility on [DATE] with pertinent diagnoses that include dementia (a syndrome that can be caused by a number of diseases which over time destroy nerve cells and damage the brain, typically leading to deterioration in cognitive function (i.e. the ability to process thought) beyond what might be expected from the usual consequences of biological ageing), depression (a mental health condition characterized by persistent sadness, loss of interest or pleasure in activities, and other symptoms that significantly affect daily life), and insomnia (common sleep disorder that can make it hard to fall asleep or stay asleep). R6's Quarterly Minimum Data Set (MDS) with an assessment reference date of 4/1/25, documents a Brief Interview for Mental Status score of 03 (severe cognitive impairment). R6 has an activated Power of Attorney for decision making. R6's MDS documents a patient depression questionnaire (PHQ-9) score of 01, indicating no depressive symptoms. R6's MDS documents that R6 is usually understood and usually understands others. R6 was documented as having no behaviors exhibited during the look back period. R6's care plan documents I have the potential for having a behavior problem related to dx (diagnosis) dementia aeb (as evidenced by) inappropriately touching others, inappropriate comments to others, attempts to kiss female staff, smears feces, revision on 1/22/2024. The pertinent intervention is administer medications as ordered. Monitor/document for side effects and effectiveness, date initiated: 12/12/2023. R6's physician order dated 5/17/25 documents Ativan Oral Tablet 0.5 MG (Lorazepam) Give 0.5 mg by mouth every 1 hours as needed for restlessness/anxiety. The Ativan had been administered to R6 in May on 5/20, 5/21, 5/26, 5/27, 5/30 and 5/31. Surveyor noted that the PRN order date was beyond 14 days and still active. Surveyor noted R6's medical record did not include documentation from the attending physician or the prescribing practitioner justifying the need for R6 to receive the medication beyond a 14 day timeframe. On 06/03/25, at 12:25 PM, Surveyor interviewed Director of Nursing (DON)-B regarding the PRN Ativan order for R6 not having a stop date. DON-B responded it was entered by a new to us nurse, the nurse needs some education. Usually, hospice has a 6-month extension they can write out for order. DON-B will look into issue and get back to Surveyor. On 06/03/25, at 12:38 PM, DON-B stated that the Ativan order was incorrectly put in and DON-B will need to provide education on entering a stop date to that nurse. Per DON-B the order has been discontinued. On 06/03/25, at 12:52 PM, Surveyor interviewed Register Nurse (RN) Nursing Supervisor-G and confirmed R6 would still be getting the Ativan as R6 was using it frequently PRN. Per RN Nursing Supervisor-G they had just called hospice for a reorder, R6 will not be without the order.

Based on interview and record review, the facility did not ensure for 1 (R16) of 1 residents reviewed for a level 1 and level 2 PASARR (Preadmission Screening and Resident Review) had the screenings completed as required. *R16 did not have a PASARR level 1 screen completed prior to admission to the facility. A level 1 screen was completed on the day of admission. Additionally, the facility did not ensure a level 2 screen was completed based upon the results of the level 1 screen. Findings include: The facility policy and procedure titled admission Criteria, dated January 2025 documents: policy statement. Our facility admits only resident who's medical and nursing care needs can be met. Policy interpretation and implementation. 9. All the admissions and readmissions are screened for mental disorders, intellectual disabilities or related disorders per the Medicaid preadmission screening and resident review process. 2. If the level I screen indicates that the individual may meet the criteria for a mental disorder, intellectual disability or related disorder he or she is referred to the state PASARR representative for the level II screening process. R16 was admitted to the facility on [DATE] and has diagnosis of Depression. R16 had a level 1 screen completed on 8/21/2024. There is no documentation found by surveyor of a level II screening following the completed level 1. On 8/21/2024, The Facility completed a level 1 pre-admission screen and resident review (PASARR) for R16. The form titled: Pre-admission Screen and Resident Review (PASARR) Level 1 Screen Summary, dated 8/21/2024, documents in part: Does the person have a major mental disorder? YES. Has this person received psychotropic medications to treat symptoms or behaviors of a major mental disorder? Yes. Surveyor noted, the box checked Yes for both questions. Surveyor noted in Section titled: screening result which documents, resident is suspected of having a serious mental illness. Provider response: AGREE On 6/2/2025, at 1:46 PM, Surveyor requested the Level 2 PASARR from Director of Nursing (DON)-B as the PASARR was not observed in R16's electronic record. On 6/2/2025, at 1:59 PM, Surveyor was informed by DON-B that the level 2 was not completed, that the level 1 was just sent out to the agency that completes the level 2. This was an oversight on our behalf. DON-B stated this was just sent out by us, it should have been completed 30 days after the level one.

Based on interview, and record review the facility did not include 1 (R15) of 2 residents reviewed for antibiotic stewardship on the facility line listing to ensure antibiotic use was monitored per facility protocols and ensure the antibiotic administration was included as part of the overall facility infection prevention and control program. *R15 was receiving an intravenous (IV) Antibiotic (ABT) and was not added to the antibiotic/infection control line list. The line list is part of the antibiotic stewardship program which allows the facility to monitor and track antibiotic use and infections. Findings include: The facility policy and procedure titled Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, dated January 2025 documents: Policy. Antibiotic usage and outcome data will be collected and documented using a facility approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility wide antibiotic stewardship. Implementation: . 4. All resident antibiotic regimens will be documented on the facility approved antibiotic surveillance tracking form. The information gathered will include: A. Resident name and medical record number; B. Unit and room number; C. Date symptoms appeared; D. Name of antibiotic. R15 was admitted to the facility on [DATE] with diagnosis of atrial fibrillation, dementia. Surveyor reviewed R15's discharge paperwork from the hospital dated: 4/2/2025 which documented, IV antibiotic orders for discharge: diagnosis: right wrist presumptive septic arthritis, no culture able to be obtained. Prescription: Ceftriaxone 2 grams, IV daily duration 2 weeks. The discharge diagnoses documented as sepsis without acute organ dysfunction, due to unspecified organism. Surveyor reviewed R15's medication administration record (MAR) from April 2025. The order for Ceftriaxone Sodium 2 grams, IV infusion to administer over 10 minutes, was documented as administered on 4/3/2025 through 4/13/2025. On 6/03/2025, at 12:54 PM, Surveyor interviewed Infection Preventionist- D, who stated that all residents receiving antibiotics will be added to the line list for the antibiotic stewardship program. Infection Preventionist- D stated, even if the resident's antibiotic was started at the hospital, they are still added to the facility line list. On 6/03/2025, at 1:11 PM, Surveyor and Infection Preventionist- D both reviewed the antibiotic stewardship binder for the month of April 2025. Surveyor noted R15 was not on the line list. Infection Preventionist- D stated R15 should have been added to the antibiotic stewardship program and most likely R15 wasn't added because she was presumptive (The administration of antibiotics when an infection is suspected but not yet confirmed.) for use. Infection Preventionist- D indicated even if presumptive, R15 still should have been added to the list for the antibiotic stewardship program. On 6/3/2025, at 2:00 PM, Surveyor informed Director of Nursing (DON)-B, of the concern with R15 not being added to the line list of the antibiotic stewardship program.

Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program based on current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to effect all 21 residents in the facility. *The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: -Include water management team members who were knowledgeable about the facility's water system -Describe the building's water system using text and an accurate flow diagram of the system -Include an assessment of the facility's water system to identify all locations were Legionella could grow and spread -Identify where control measures should be applied based on where Legionella could grow and spread -Identify acceptable ranges of control limits (temperature ranges) and corrective actions when control limits are not met -Include a process to confirm the WMP is being implemented and is effective *Facility staff did not follow facility infection prevention and control policies and guidance related to hand hygiene. Findings include: On 4/22/24, Surveyor reviewed the facility assessment. Surveyor notes there is no Water Management Plan or Procedure within the facility assessment. On 4/23/24 at 12:10 PM, Surveyor interviewed Infection Prevention Registered Nurse (RN)-E who indicates she is not aware of an active Water Management Plan within the facility. Infection Prevention RN-E indicates she recalls a Water Management Plan at her previous position at a different facility but states she is not aware of a Water Management Plan at the current facility and suggested Surveyor speak with Director of Nursing (DON)-B or Director of Maintenance-D. On 4/23/24 at 1:26 PM, Surveyor met with Director of Maintenance-D and DON-B to review the facility's Water Management Plan. Director of Maintenance-D indicated a facility plumber will tour the facility every 2 weeks to flush water through the drains of the unoccupied rooms. The plumber then generates a work order. Surveyor requested documentation, policy, and procedures for the facility's Water Management Plan. Director of Maintenance-D and DON-B were unable to provide plans, documentation, a policy, or a procedure for the facility's Water Management Plan. There is no documentation of control measures for the water/plumbing that has not been used within the facility. Director of Maintenance-D indicated they do not have a documentation, policy, or procedure for the facility's Water Management Plan. On 4/23/24 at 3:00 PM, Surveyor shared concerns related to the facility not having documentation, a policy and procedure for a Water Management Plan with DON-B. Surveyor requested additional information if available. No further information was provided. 38146 2) The facility Policy and Procedure titled Handwashing/Hand Hygiene revised/reviewed 3/2024 documents (in part) . .This facility considers hand hygiene the primary means to prevent the spread of infections. 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. 3. Hand hygiene products and supplies (sinks, soaps, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. When hands are visibly soiled; and b. After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. difficile. 7. Use an alcohol-based rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: . b. Before and after direct contact with residents; c. Before preparing or handling medications; . i. After contact with a resident's intact skin; j. After contact with blood or bodily fluids; . l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident. m. After removing gloves 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routing hand hygiene is recognized as the best practice for preventing healthcare-associated infections. On 4/23/24, at 7:57 AM, Surveyor observed Registered Nurse (RN)-C prepare medications for R2. Medications prepared included Olopatadine Hydrochloride 0.1% eye drops. The remaining medication tablets were placed in a medication cup. RN-C also poured liquid Prosource supplement into a medication cup for R2. On 4/23/24, at 8:02 AM, Surveyor observed RN-C don gloves and administer the medication tablets to R2 a few at a time, on a spoon, with applesauce followed by water. After administering the tablets, RN-C removed her gloves, and discarded the empty cups and gloves in the garbage can. RN-C bent over and with her bare hands, adjusted the garbage bag around the rim of the can. RN-C did not wash or sanitize her hands after touching the garbage can and donned new gloves. RN-C picked up the medication cup containing Prosource liquid and administered it to R2 followed by water. RN-C obtained a tissue and wiped R2's mouth. RN-C then changed her gloves, but did not wash or sanitize her hands. RN-C picked up the Olopatadine Hydrochloride 0.1% eye drops and while holding R2's right eyelid open with one hand, administered 1 drop into her eye. RN-C then proceeded to hold R2's left eyelid open with one hand and administered 1 drop into her eye. RN-C removed her gloves, but did not wash or sanitize her hands. RN-C did not don a new pair of gloves, picked up a tissue and proceeded to wipe R2's left eye, then right eye with the tissue. RN-C sanitized her hands upon leaving the room. On 4/23/24, at 11:36 AM, Surveyor advised RN-C of the above observation and concern regarding handwashing. RN-C stated I hear what your saying. I did change my gloves, but I didn't wash my hands in between. On 4/23/24, at 3:06 PM, Director of Nursing (DON)-B was advised of the above observations and concern regarding handwashing. No additional information was provided.

Based on observation, interview, and record review, the facility did not ensure 1 (R11) of 2 residents reviewed for pressure injuries had pressure injuries assessed in accordance with current standards of practice to ensure ongoing monitoring to help progress towards improvement. R11 developed a deep tissue injury (DTI) to both heels on 7/26/22. The weekly wound assessment had documentation with no measurements of the wound to show the weekly progression of the pressure injury. On 1/25/23, R11 was assessed by the wound physician to have unstageable pressure injuries. Findings include: The facility policy and procedure entitled, Pressure Injury: Prevention and Management (Risk Assessment, Skin Assessment, and Prevention and Treatment Strategies for pressure injuries) dated 7/2016 states: POLICY - Factors which may lead to the development of pressure injuries will be assessed and measures instituted to prevent the formation of pressure injuries. Residents with pressure injuries will receive appropriate treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing. DEFINITIONS - Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration - Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or stage 4). PROCEDURE #4. The Windsor Nurse will perform rounds on all residents weekly with the wound care physician. An additional resource the facility uses for pressure injury care is Ostendorf, A.R, Perry, A.G & Potter, P.A (2014). Wound Care and Irrigation in Clinical Nursing Skills & Techniques, 8th Edition. (pp. 920-941). St. Louis, MO: Elsevier Mosby. It states: Performing A Wound Assessment #10 (b) (1) Assess anatomic location of wound. (2) Assess wound dimensions: Measure size of wound (including length, width, and depth) using a centimeter measuring guide. R11 was admitted to the facility on [DATE] with the following diagnoses: type 2 diabetes, chronic kidney disease with heart failure, and obesity. The Admission Minimum Data Set (MDS) dated [DATE] documents R11 entered the facility with no unhealed pressure injuries/ulcers. The Quarterly MDS dated [DATE], documents R11's Brief Interview for Mental Status (BIMS) score of 14 indicating R11 is cognitively intact. Section G documents bed mobility, transfers, and toilet use as extensive assist, 2 + person physical assist. Section M documents R11 is at risk for pressure ulcers/injuries and has a current unhealed pressure ulcer/injury. The number of unstageable pressure ulcers due to coverage of wound bed by slough and or eschar is documented as 1. The MDS does not indicate any deep tissue injuries or other pressure injuries. The MDS does not indicate R11 refused cares. On 2/15/23 at 10:23 AM, Surveyor interviewed R11 in her bedroom. R11 informed Surveyor that there were two pressure injuries on both of her feet and that staff puts a medication and cream on them. R11 stated that she just started to be seen by a wound doctor. R11 stated that she uses boots on her feet and pillows under her heels. Surveyor asked R11 if she could see her feet and treatment and R11 told Surveyor no, however R11 did let Surveyor lift the covers and see that she was wearing the EZ boots. R11's Potential for Impaired Skin Integrity as evidenced by Braden Scale for Predicting Pressure Ulcer Risk High for Pressure Ulcers Care Plan, initiated 9/5/21 has the following interventions: - Educate resident/Representative about proper skin care to prevent skin breakdown, date initiated 9/5/21. - Float heels when in bed on pillows, date initiated 1/12/22. R11's Pressure ulcer or potential for pressure ulcer development because of immobility Care Plan, initiated 7/26/22 and DTI to bilateral heels Care Plan initiated 7/26/22 has the following interventions: - Administer treatments as ordered and monitor for effectiveness, date initiated 7/26/22. - Assess, record, and monitor wound healing with each dressing change. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress, date initiated 7/26/22. - Weekly treatment documentation is to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate, date initiated 7/26/22. - Provide education to me and my family on some of the causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, date initiated 7/26/22. - If (R11) refuses treatment, confer with (R11), the IDT, and family to determine why and try alternative methods to gain compliance, date initiated 7/26/22. - Float heels in EZ boots at all times, date initiated 10/25/22. - Float heels when in bed on pillows, date initiated 11/25/22. R11's current Physician Orders documents, Record wound measurements weekly and record one time a day every Wednesday, date ordered 2/6/23. Betadine swab to bilateral heels daily in the morning for unstageable wound, start date 2/2/23. Limit sitting to 60 minutes, off load wound, every shift, start date 1/26/23. EZ boot to be worn in bed and chair to off load wound, every shift, start date 1/27/23. Float heels on pillows every shift, start date 9/22/21. R11's discontinued Physician Orders document, Apply skin prep to heels bilaterally BID until healed for DTI, two times a day for DTI, start date 9/28/22 and discontinued 12/6/22. Record wound measurements every Monday and record one time a day every Monday, date ordered 11/1/22 and discontinued 2/6/23. Betadine swab to bilateral heels BID every morning and at bedtime for DTI, start date 12/9/22 and discontinued 1/26/23. Apply skin prep to left heel daily in the morning, start date 1/27/23 and discontinued 2/1/23. Betadine swab to right heel daily in the morning for unstageable wound, start date 1/27/23 and discontinued 2/1/23. Surveyor reviewed R11's Weekly Skin Observation Tool forms from September 30, 2022 to February 15, 2023. - Skin Observation Tool, dated 9/30/22, is left blank under site, type, and measurement of wound. The notes section documents, Mild discoloration to bilateral heels. - Skin Observation Tool, dated 10/4/22, documents right heel suspected deep tissue injury measuring 1 cm (centimeters) x 0.5 cm and left heel suspected deep tissue injury measuring 2 cm x 1.5 cm. - Skin Observation Tool, dated 10/11/22, documents right heel DTI measuring 0.5 cm x 1 cm and left heel DTI measuring 1.5 cm x 1 cm. - Skin Observation Tool, dated 10/20/22, is left blank under site, type, and measurement of wound. The notes section documents, Mild DTI to bilateral heels. - Skin Observation Tool, dated 10/25/22, documents right heel DTI measuring 1 cm x 1.2 cm x 0 cm and left heel DTI measuring 2 cm x 1 cm. - Skin Observation Tool, dated 11/1/22, is left blank under site, type, and measurement of wound. The notes section documents, Right heel DTI is resolved. Mild discoloration to left heel. Skin prep applied to both heels. - Skin Observation Tool, dated 11/7/22, is left blank under site, type, and measurement of wound. The notes section documents, Res (resident) continues to have treatment in place to bilateral heels, had small scab on lt (left) heel. Surveyor noted a DTI would not include a description of a scab. - Skin Observation Tool, dated 11/22/22, documents right heel as a DTI measuring 3.5 cm x 4 cm and left heel as a blister 3.8 cm x 4.5 cm. The notes section is blank. - Skin Observation Tool, dated 11/29/22, documents left heel pressure and right heel pressure. Measurement section is left blank. Documented in the notes section is, Left heel blister remain intact. DTI to the right heel. - Skin Observation Tool, dated 12/6/22, documents left heel pressure and right heel pressure. Measurement section is left blank. Documented in the notes section is, DTI to bilateral heels. Both appear black in color and necrotic. Betadine applied. - Skin Observation Tool, dated 12/12/22, documents right heel as suspected deep tissue injury measuring 3 cm x 4 cm x 0 cm and left heel as suspected deep tissue injury measuring 4.3 cm x 5.0 cm. The notes section does not document anything regarding the characteristics of the pressure injuries. - Skin Observation Tool, dated 12/13/22, documents right heel pressure and left heel pressure. Measurement section is left blank. Documentation in the notes section is, DTI bilateral heels. - Skin Observation Tool, dated 12/20/22, is left blank under site, type, and measurement of wound. The notes section documents, DTI's resolving slowly to bilateral heels. Treatment done as ordered. No complaints of pain. Heels floated on pillows. - Skin Observation Tool, dated 12/23/22, is left blank under site, type, and measurement of wound. The notes section documents, DTI to right heel. Left heel resolved DTI. - Skin Observation Tool, dated 12/28/22, is left blank under site, type, and measurement of wound. The notes section documents, Resolving DTI to left heel. DTI to right heel. Heels floated on pillows. - Skin Observation Tool, dated 1/3/23, is left blank under site, type, and measurement of wound. The notes section documents, Bilateral heel DTI's. Treatment applied as ordered. Heels floated on pillows. - Skin Observation Tool, dated 1/10/23, is left blank under site, type, and measurement of wound. The notes section documents, DTI to bilateral heels. Betadine swab applied as ordered. Resident noncompliant with treatment and cares. - Skin Observation Tool, dated 1/17/23, is left blank under site, type, and measurement of wound. The notes section documents, DTI to bilateral heels. - Skin Observation Tool, dated 1/23/23, documents right heel suspected DTI measuring 1 cm x 1 cm x 0 cm and left heel suspected DTI measuring 0.8 cm x 0.8 cm x 0 cm. The notes section is left blank. Surveyor noted the above weekly wound observation tools do not consistently assess R11's pressure injuries to include characteristics of the wound bed including percentage of tissue, presence of drainage, and correct stage. The facility continued to document a deep tissue injury despite the wound deteriorating and/or opening up and notations of a scab. On 1/25/23, a Wound Physician conducted an initial wound evaluation. The summary documents an unstageable (due to necrosis) to the right heel full thickness pressure injury measuring 0.8 cm x 0.8 cm x not measurable with 100% eschar. Recommendations include: Betadine apply once daily for 30 days, float heels in bed, off load wound, EZ boots to be worn in bed and chair to off-load wound. It also documents an unstageable DTI of the left heel partial thickness measuring 0.6 cm x 0.6 cm x not measurable with no exudate. Recommendations include: skin prep apply once daily for 30 days, float heels in bed, off-load wound, EZ boots to be worn in bed and chair to off-load wound. The Wound Physician conducted an assessment on 2/1/23, which documents an unstageable (due to necrosis) of the right heel full thickness measuring 1.0 cm x 0.3 cm x not measurable with 100% thick adherent black necrotic tissue. Recommendations include: betadine once daily, float heels in bed, off-load wound, EZ boots to be worn in bed and chair to off-load wound. Wound progress: improved. It also documents an unstageable DTI of the left heel partial thickness measuring 0.6 cm x 0.6 cm x not measurable. Recommendations include: betadine once daily, float heels in bed, off-load wound, EZ boots to be worn in bed and chair to off-load wound. Wound progress: no change. The Wound Physician conducted an assessment on 2/8/23, which documents an unstageable (due to necrosis) of the right heel full thickness measuring 1.0 cm x 0.5 cm x not measurable with 100% thick adherent black necrotic tissue. Recommendations include: betadine once daily, float heels in bed, off-load wound, EZ boots to be worn in bed and chair to off-load wound. Wound progress: no change. It also documents an unstageable DTI of the left heel resolved on 2/8/23. The Wound Physician conducted an assessment on 2/15/23, which documents an unstageable (due to necrosis) of the right heel full thickness measuring 1.0 cm x 0.5 cm x not measurable with 100% thick adherent black necrotic tissue. Recommendations include: betadine once daily, float heels in bed, off-load wound, EZ boots to be worn in bed and chair to off-load wound. Wound progress: no change. On 2/15/23, at 2:39 PM, Surveyor reviewed R11's Progress Notes. - Progress Note dated 1/25/23 documents, Resident's wounds evaluated and assessed by wound care MD. NNO (no new order). Continue with plan of care. - Progress Note dated 2/1/23 documents, Seen by wound care MD, (name of doctor). heel wounds assessed and evaluated. Progressing slowly with current plan of care. - Progress Note dated 2/8/23 documents, Seen by wound care MD, (name of doctor).heel wounds assessed and re-evaluated. Left heel DTI epithelialized and resolved. TX discontinued to left heel. Will continue to float heels with EZ boots. Right heel has 100% eschar. Wound remains dry. No noted drainage. Resident remains noncompliant with offloading and repositioning. Risk and benefits explained r/t immobility, incontinence, and diabetes. Resident verbalized understanding well. - Progress Note dated 2/15/23 documents, Seen by wound care MD, (name of doctor) . right heel pressure wound assessed and evaluated. NNO. Continue with present plan of care. Surveyor noted upon review of R11's progress notes there is occasional reference to R11 refusing to wear boots or refusal of care. Surveyor noted the documentation does not consistently indicate if family or the IDT was conferred with to discuss refusals. Surveyor noted the facility does not monitor the actual frequency of refusals by R11. On 2/21/23 at 9:16 AM, Surveyor reviewed R11's Skin Observation Tool forms with Director of Nursing (DON)-B. Surveyor shared concerns that on numerous forms the wounds had no measurements documented on the weekly skin observation form after the initial assessment of bilateral DTI to R11's heels. DON-B informed Surveyor that R11's heels were being assessed weekly and that the wound was slowly healing even though R11 was resistive to treatments at times. DON-B told Surveyor that the DTIs to the heels would at times heal and then a week later they would reoccur. Surveyor asked DON-B what the expectations are for wound care and DON-B explained that nurses are documenting in the Skin Assessment in the medical record and notifying the physician of progress. DON-B stated that they did just start employing the use of a wound doctor which started at the end of January. The DON further explained that the Registered Nurse (RN) does the weekly assessment, and the (Licensed Practical Nurses) LPNs are doing the treatments. DON-B informed Surveyor that it is expected that the RN is documenting the wound measurement once a week, this would include determining if there is discharge, what that wound bed looks like, and determining if the treatment is working or not working. DON-B told Surveyor that she would have to ask where the measurements are since they should have been on the weekly skin observation tool. Surveyor asked DON-B who is responsible to ensure documentation of wounds is occurring accurately and DON-B stated that the quality assurance department will do occasional chart auditing and will alert her if there is documentation that is missing or if a nurse needs some counseling if they are found to be documenting inaccurately. Surveyor requested the facility policy and procedures for wound care. On 2/21/23 at 10:22 AM, DON-C came to Surveyor and stated that clearly, we were not measuring wounds weekly. DON-C informed Surveyor that they were aware of the problem and started to make some changes earlier this year. DON-C stated that they did education on assessment and measuring with nurses and started having wound physicians coming into the facility weekly to do the assessments. She stated this started at the end of January 2023. DON-C stated that nurses are going through a 6-week self-paced class. She was unaware of what nurses completed this program already. On 2/21/23 at 11:41 AM, Surveyor spoke with DON-B. She explained that she does not have an updated policy on wound care at this time which, is why we are having the current problem we are in right now. DON-B showed Surveyor a policy the facility uses which references the clinical standard of practice that they follow which is in the textbook of Perry and Potter, 2014. Surveyor stated that there still must be a current policy and procedure if the policy has not been updated yet. DON-B stated she would continue to look for something. On 2/21/23 at 12:01 PM, Surveyor requested a wound care policy and procedure from DON-C. DON-C explained to Surveyor that they are currently updating their policy and procedures and have not yet updated wound care. DON-C informed Surveyor that they are currently just following the clinical standards of practice outlined in the textbook Perry and Potter, 2014. DON-C stated she would continue to look for an up to date policy and procedure. On 2/21/23 at 12:24 PM, Surveyor informed Nursing Home Administrator-A of concerns regarding R11's DTI to the heels and the lack of weekly documentation of measurement and wound description. Surveyor also informed NHA-A of the concern regarding the lack of a facility policy and procedure for wound care and staff not being able to access it. NHA-A informed Surveyor that they are doing some changes and upgrades to policies at this time, but they should still have something to refer to. NHA-A stated he would look into this. On 2/21/23 at 12:44 PM, DON-C spoke with Surveyor. She explained that they noticed some areas of improvement and are in the process of redeveloping many of their policies and procedures. DON-C provided a policy entitled, Clinical Nursing Skills: Wound Care. She informed Surveyor that this is the clinical standard of practice followed by Skilled Nursing Facility Wound Care. DON-C stated that nursing staff are currently going through the curriculum and several nurses have obtained their certificate. DON-C stated that policy development is reviewed at QAPI and that the Medical Director sits in on that meeting and is part of policy development and approval of new policy and procedures. On 2/21/23 at 1:30 PM, the facility was able to provide Surveyor with a policy and procedure for wound care. No additional information was provided at this time.

Based on observation, record review and interview, the facility did not ensure staff working in the kitchen followed standards of practice for proper handling of food while maintaining hand hygiene. This had the potential to effect 8 out of 23 residents who eat food prepared in the main kitchen. Cook-F was observed donning gloves after washing her hands, Cook-F then proceeded to touch menus, contaminating her hands. Cook-F did not change gloves or rewash her hands before proceeding to prepare sandwiches for residents. Findings include: The facility policy, entitled Gloves, Use of bare Hand Contact with Food and Use of Plastic Gloves, dated 11/2018, states: Single-use gloves will be worn when handling food directly with hands to assure that bacteria are not transferred from the food handlers' hands to the food product being served. Procedure: #3. Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task (such as working with ready-to-eat food or with raw animal food), used for no other purposes, and discarded when damaged or soiled, or when interruptions occur in the operation. #6. Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed. G. During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. On 2/20/23, at 12:03 PM, Surveyor observed Cook-F prepare and serve lunch from the kitchen on the unit. Cook-F was preparing turkey club sandwiches. On 2/20/23, at 12:03 PM, Surveyor observed Cook-F wash her hands and put gloves on. Cook-F then picked up a pile of resident menus and sorted through them, Cook F laid the resident menus back down on the countertop and proceeded to grab four slices of bread from the bread bag with her gloved hand and walked to the toaster where she removed four slices of toast and put in the four slices of bread into the toaster. Cook-F then used a spatula to spread mayonnaise onto the 4 pieces of toasted bread. Cook-F then picked up pre-made stacks of deli turkey meat, Swiss cheese, lettuce and a tomato slice and placed it onto the toasted bread with the same gloves on her hands. She did this to all four pieces of toasted bread. Cook-F then removed the gloves and washed her hands. Surveyor noted that Cook-F did not remove gloves and wash hands after contaminating her hands after touching resident menus, before preparing four resident turkey club sandwiches. On 2/20/23, at 12:20 PM, Surveyor observed Cook-F pick up and sort through resident menus with gloved hands. Cook-F then removed four slices of toast from toaster with her gloved hands and placed the toast onto the countertop. She then used a spatula to spread mayonnaise onto the 4 pieces of toasted bread. Cook-F then removed the gloves and washed her hands. Surveyor noted that Cook-F did not remove gloves and wash hands after contaminating her hands after touching resident menus, before preparing toast for resident turkey club sandwiches. On 2/20/23, at 12:23 PM, Surveyor observed Cook-F with gloved hands pick up several resident menus and sort through them. She then set the menus down and picked up a stack of deli turkey meat with Swiss chess, lettuce and a sliced tomato with gloved hand and placed it on a plate. Cook-F then used gloved hand to reach into a large bag of potato chips and pull out a handful of chips and added them to the plate. Cook-F then proceeded to apply mayonnaise with a spatula on two slices of toasted bread and then top it with the deli turkey meat, Swiss cheese, lettuce, and sliced tomato. Cook-F plated the turkey club sandwich on the plates and removed her gloves and washed her hands. Surveyor noted that Cook-F did not remove gloves and wash hands after contaminating her hands after touching resident menus, before preparing resident turkey club sandwiches. On 2/20/23, at 12:54 PM, Surveyor interviewed Dietary Manager-E (DM) regarding the facility's policy on touching ready to eat food. DM-E informed Surveyor that it's their policy to wash hands and then apply gloves and that in between tasks if the gloves get dirty then they have to remove the gloves and rewash the hands and apply new gloves. Surveyor informed DM-E of earlier observations of Cook-F touching resident menus with gloved hands and then preparing bread in the toaster and making turkey club sandwiches with the same gloved hands. DM-E informed Surveyor that that is not their practice, and she should have stopped the task and removed her gloves, rewashed, and gloved up again. On 2/20/23, at 3:10 PM, at the end of the day meeting, Surveyor informed the Nursing Home Administer-A, Director of Nursing-B and Director of Nursing-C of the observations. No further information was provided at the time.

Based on interview and record review the facility did not ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 2 of 2 (R6 and R10) residents reviewed for weights. R6 did not have monthly weights done as ordered. R10 did not have weekly weights done as ordered. Findings include: The facility policy titled Clinical Nursing Skills: Weight revised 4/11/11 documents (in part) . .Policy: Residents' weight will remain stable within 3% (percent) of baseline. Purpose: To identify, monitor and implement a plan of care for residents who may be at nutritional risk. Procedure: 1. Resident's weights will be obtained and recorded as follows: - upon admission: Weigh for 4 consecutive weeks to obtain a baseline. - Upon readmission: Weight for 4 consecutive weeks to obtain a baseline. - Upon significant weight loss: Weigh 4 consecutive weeks or until back to baseline. 4. Resident Assistants (RA) will weigh residents according to the RA care card and document the weights on the weekly/monthly weight work sheet. The RA will report the residents weight to the Person First Nurse Specialist (PFNS)/designee before the end of the shift. 6. The dietetic technician will review all resident weekly/monthly weights and calculate the % of weight change from the previous weight. If the weight is plus or minus a 3% change, the dietetic technician will notify the PFNS/designee in writing on the Dietary Communication form with any recommendations. 7. The PFNS/designee will document this information in the medical record, update the nursing care plan, notify the physician, POA-HC (Power of Attorney for Health Care) or guardian as needed and inform the neighborhood team and implement daily I&O (intake and output). 8. If a weight gain or loss of 5% in 30 day period, 7.5% in a 3 month period, or 10% in a 6 month period is noted, the dietetic technician will notify the PFNS/designee in writing on a Dietary Communication form with recommendations. 9. The PFNS/designee will document the change in the nurses notes, assess the resident, consult with the Registered Dietician (RD) and notify the physician, POA-HC, or guardian of the significant gain or loss; and whether or not the resident is at risk for dehydration. The PFNS/designee will implement medical orders form the physician. 13. The PFNS/designee, RD and Dietetic technician will meet at minimum twice per month to: - review significant weight changes. - identify residents with significant weight loss/gain and place on I&O 1.) R10 admitted to the facility on [DATE] and has diagnoses that include Left Femur fracture, Parkinson's Disease, Orthostatic Hypotension, Alzheimer's Disease, Chronic Kidney Disease stage 3 and Hypertension. On 2/15/23 at 10:19 AM, during initial pool, Surveyor noted R10 had a BIMS (Brief Interview for Mental Status) score of 5, indicating cognitive impairment/not interviewable. Surveyor spoke with R10's spouse who reported R10 admitted to the facility following a fall with hip fracture. She reported R10 had to go back to the hospital to drain 30 liters of fluid from his heart and lungs. Review of facility progress notes documented: 1/3/2023 2:22 PM (physician) called regarding residents recent BNP (B-Type Natriuretic Peptide) lab results. BNP levels are elevated, MD (Medical Doctor) recommended resident be seen by cardiologist. Writer informed family who stated resident has seen (named physician) for cardiology in the past. (scheduler) notified to schedule an appointment for resident to be seen by (cardiologist). 1/5/2023 at 2:26 PM RN (Registered Nurse) assessed resident lungs and noted crackles mid lung bilaterally, use of accessory muscles, audible inspiratory wheeze, and A&O (alert and oriented) x1. RN discussed with (another) RN. RN stated she had phoned (medical doctor) to notify and was waiting for a call back. (Medical Doctor) called back and discussed resident condition, labs, potential order for chest x-ray. After discussion (Medical Doctor) determined that this was a change in condition that needed to be evaluated further in the ER (emergency room ). Family requested to go to (hospital) where cardio medical doctor is located. 1/5/2023 at 3:00 PM Resident was observed using accessory muscles to breath. Inspiratory wheezing heard. SOB (short of breath). Crackles upon auscultation. POX (pulse oximetry) was 85% RA (room air). POX 95% on 3L (liters) via NC (nasal cannula). A/O x1 abnormal to baseline. Bowel sounds audible x 4 quadrants. Denies pain. C/o (complaint of) minor discomfort. Change in condition warranted resident being sent out to ER for further evaluation and treatment. MD aware and consulted on decision via phone. Bell ambulance called for transportation. Family accompanied him to hospital. 1/5/2023 at 11:13 PM Called (hospital) for resident update. Resident is admitted overnight with diagnosis of hypoxia and CHF (Congestive Heart Failure). R10's physician orders documented: Admission weight x 1 every shift for 1 Day until finished. Admission weight x 1 start date 11/17/2022. Admission Weight x 4 weeks one time a day every Thursday for 4 weeks start date 11/24/2022. Surveyor review of R10's weights revealed a weight entered on 11/21/22 of 100.0 which was crossed out. Surveyor noted no other weights recorded until 1/3/23 of 166.8. R10's current weight on 2/19/23 was 164.2 Surveyor review of R10's November discharge summary and hospital records revealed no diagnosis of previous CHF. The hospital records included no documentation R10's weight, thus Surveyor was not able to confirm a weight change/gain occurred from admission to the facility to 1/3/23. R10's hospital discharge summary documented: Acute HF (Heart Failure) EF (ejection fraction) resolved. Acute hypoxic respiratory failure due to above-resolved. There was no documentation regarding any amount of fluid removed from heart/lungs as residents' spouse reported. R10's readmission orders included an order for daily weights. Call MD if 3 lbs (pounds) weight gain in 1 day or 5 lbs weight gain in 1 week in the morning. Surveyor noted documentation reveals R10's daily weight is consistently completed along with lung assessments and MD notification. On 2/15/23 at 11:44 AM Surveyor spoke with Director of Nursing (DON)-B regarding R10's weights. DON-B reported the weight entered in November was entered incorrectly, crossed out and another one was not entered. Surveyor confirmed with DON-B that R10's first weight entered was on 1/3/23. Surveyor asked if R10 was not weighed after admission to the facility until 1/3/23. DON-B stated: I don't think so, but he was combative. Surveyor located no evidence or documentation R10's weight was not obtained due to refusal or R10 being combative with staff. On 2/20/23 at approximately 3:00 PM Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were advised of concern R10 was not weighed weekly as ordered. No additional information was provided. 20025 2.) R6 was admitted to the facility on [DATE] with diagnoses of COPD (chronic obstructive pulmonary disease), hypertensive heart disease and myelodysplastic syndrome. The quarterly MDS (minimum data set) dated 12/13/22 indicates R6 is cognitively intact and needs supervision with eating. Surveyor reviewed R6 weights since admission. On 9/7/22 R6 weighed 131.6 lbs and another weight was not obtained until 1/2/23, which was 123 lbs. Then on 2/1/23 R6 weighed at 120 lbs. The 12/12/22 nutritional note indicates (R6) reports no recent barriers to intake, notes increased intake as she no longer has to prepare her own meals (prior to coming to (name of unit), notes inability to cook for self, weight loss). Resident declines Boost this visit, notes goal of increased intake of food. Continue to offer general diet with thin liquids, honor food preferences. Goal is to maintain body weight within 5% of CBW. Will continue to monitor tolerance of diet, weight status. On 2/21/23 at 8:00 a.m. Surveyor interviewed DON B regarding R6 weights. Surveyor asked DON B what is the expectation regarding weighing residents. DON B stated residents should be weighed monthly at the beginning of every month. Surveyor explained to DON B R6 was not weighed in October, November and December 2022. Surveyor asked DON B, who is responsible for monitoring resident weights and DON B stated the dietician is responsible. DON B stated the current dietician started in December 2022. Surveyor explained to DON B the concern weights were not obtained for R6 for 3 months and during that time R6 had weight loss. DON B reiterated she is not responsible monitoring resident weights. On 2/21/23 at 9:00 a.m. Surveyor interviewed RD (registered dietician) D. RD D stated she started working at the facility on 11/28/22. RD D stated she runs a monthly weight report to look for signs of any significant weight loss. RD D stated the CNAs weigh all residents a week before she runs the monthly report. RD D stated if there are missing weights she will go to the nurse or CNA and ask for the resident to be weighed. RD D stated R6 did not have a significant weight loss, which is why there are no interventions in place to prevent weight loss. RD D stated right now she is just monitoring R6 weights.

Based on interview and record review the facility did not ensure 2 (R6 and R10) of 12 residents had physician orders transcribed correctly. R6 was admitted to the facility on [DATE] and had an order for Tobramycin that was not transcribed correctly and then was not administered as ordered. R10 had an order for an antibiotic that was not transcribed correctly and was given the medication past the prescribed stop date. Findings include: 1.) R6 was admitted to the facility on [DATE] with diagnoses of COPD (chronic obstructive pulmonary disease), hypertensive heart disease and myelodysplastic syndrome. The quarterly MDS (minimum data set) dated 12/13/22 indicates R6 is cognitively intact. The hospital discharge list dated 8/31/22 indicates Tobramycin 300 mg (milligrams)/5 ml (milliliters) nebulizer solution, inhale 5 ml (300 mg total) every 12 hours. Inhale 5 mls via nebulizer BID f(twice daily) or 28 days then stop for 28 days and repeat the cycle. The September 2022 MAR (medication administration record) indicates Tobramycin 300 mg/5 ml was given BID from 9/8/22 through 10/5/22. Tobramycin 300 mg/5 ml then was stopped until 10/17/22 and was given for another 28 days. The physician order indicates this medication was to stop for 28 days then begin again for 28 days. The stop days were only 11 days. The nurses note dated 10/14/22 indicates nursing called pharmacy regarding Tobramycin. It indicates unable to find the medication at the facility. (Pharmacy) stated that Medication will be delivered on 10/17/2022. Resident made aware of above. On 2/21/23 at 8:00 a.m. Surveyor interviewed DON B regarding R6's medication. Surveyor asked DON B in October 2022, why did the Tobramycin restart after 11 days instead of the 28 days as prescribed. DON B stated she's not sure why it was restarted after 11 days. DON B stated she thinks the order was confusing for the nurses but the medication is now being given as prescribed. Surveyor asked DON B who is the prescribing provider for the Tobramycin and she stated it was R6's pulmonologist. Surveyor asked DON B if R6's pulmonologist was notified that the order was not transcribed correctly and the Tobramycin was not given as ordered and she stated she's not sure because it wasn't documented. 38146 2.) The facility policy and procedure titled Antibiotic Stewardship dated 7/2016 documents (in part) . . Policy: (facility) recommends the judicious use of antimicrobial and antibiotic agents to promote optimal clinical outcomes and prevent the development of pathogenic organisms and the emergence of resistance. Procedure: 1. McGeer's criteria will be used to guide physicians and staff to determine if resident symptoms meet the criteria for antibiotic treatment. 2. Basic premises: Residents will not be treated with antibiotics on the basis of a culture result if there are not clinical signs or symptoms supporting an infection. 4. If the nurse receiving the antibiotic order questions the appropriateness of the medication ordered, the Infection Preventionist (IP), RN (Registered Nurse) care manager/supervisor or Director of Nursing (DON) should be called to review the order. 5. If the antibiotic is inappropriate and the physician still wants the resident to have the antibiotic, the nurse will document in the medical record: - MD is aware that resident symptoms do not meet McGeer's criteria. - MD wishes to continue current antibiotic treatment. 7. The IP will routinely review all antibiotic orders. The DON and the pharmacist will be consulted as needed. 8. If necessary the IP, DON or Nurse Care Manager will contact the ordering practitioner to discuss the order. R10 admitted to the facility on [DATE] and has diagnoses that include Left Femur fracture, Parkinson's Disease, Orthostatic Hypotension, Alzheimer's Disease, Chronic Kidney Disease stage 3 and Hypertension. The hospital discharge medication list included an order to continue Levofloxacin (Levaquin) 500 mg (milligrams) by mouth every day. Surveyor noted there was no diagnosis or indication for use of the Levaquin and no stop date. R10's Medication Administration Record (MAR) documented the order for Levofloxacin 500 mg give 1 tablet by mouth one time a day for Prophylactic TX for UTI which was signed out as administered from R10's admission in November 2022, through 2/20/23 while survey was in progress. R10 was hospitalized on [DATE] and readmitted to the facility on [DATE]. The hospital discharge summary dated 1/12/23 documented an order for Levofloxacin 250 mg 1 tablet by mouth daily, do not start before 1/13/23. Start date 1/13/23, end date 2/12/23. Surveyor noted the facility did not transcribe the new order/changed dose of Levaquin 250 mg onto R10's MAR upon readmission to the facility. In addition, the facility did not enter a stop date of 2/12/23 as ordered. R10's January and February MAR documented the previous order for Levaquin 500 mg by mouth daily, signed out as having been administered from 1/13/23 to 2/20/23 while survey was in progress. On 2/21/23 at 8:26 AM Surveyor spoke with Infection Preventionist (IP)-H and asked for additional information regarding R10's Levaquin order. IP-H reported when R10 came back from the hospital in January, the Hospitalist discharged him on the medication for a month and said do not contact for renewal. IP-H showed surveyor the order which read: Renewal requests to authorizing provider (hospitalist) prohibited. IP-H stated: I took that to mean do not contact him for renewal of the medication. He was supposed to follow up with his urologist 2 weeks after discharge, but his family canceled the appointment, so his primary doctor continued the medication. Surveyor asked if the facility spoke to R10's primary physician to discuss why the resident was taking Levaquin. IP-H reported the facility did not call the physician. The facility sends the orders to the doctor on the first of every month, they are then signed and scanned in. IP-H stated: We took that to mean to continue the order. Surveyor showed IP-H the hospital discharge summary which documented a change in the Levaquin dosage to 250 mg and a stop date of 2/12/23, both of which were not transcribed onto the MAR. Surveyor asked why the medication was not stopped as ordered. IP-H stated: Because the primary doctor signed the monthly orders and it was on the orders, so it was continued. Surveyor asked if the facility informed R10's primary physician of the stop date ordered on the hospital discharge summary. IP-H stated: No, he may not have been aware of stop date. Surveyor advised IP-H of concern the facility did not transcribe the Levaquin order correctly, resulting in R10 receiving 500 mg instead of 250 mg as ordered. In addition, a stop date was not entered as ordered, resulting in R10 receiving Levaquin past the recommended end date. IP-H reported she understood and agrees with Surveyors' concerns. No additional information was provided.

Based on interview and record review the facility did not ensure each resident's drug regimen was free from unnecessary drugs for 1 of 5 (R10) residents reviewed. R10 received Levofloxacin (antibiotic) for an excessive duration and without adequate indications for its use. Findings include: The facility policy and procedure titled Antibiotic Stewardship dated 7/2016 documents (in part) . . Policy: (facility) recommends the judicious use of antimicrobial and antibiotic agents to promote optimal clinical outcomes and prevent the development of pathogenic organisms and the emergence of resistance. Procedure: 1. McGeer's criteria will be used to guide physicians and staff to determine if resident symptoms meet the criteria for antibiotic treatment. 2. Basic premises: Residents will not be treated with antibiotics on the basis of a culture result if there are not clinical signs or symptoms supporting an infection. 4. If the nurse receiving the antibiotic order questions the appropriateness of the medication ordered, the Infection Preventionist (IP), RN (Registered Nurse) care manager/supervisor or Director of Nursing (DON) should be called to review the order. 5. If the antibiotic is inappropriate and the physician still wants the resident to have the antibiotic, the nurse will document in the medical record: - MD is aware that resident symptoms do not meet McGeer's criteria. - MD wishes to continue current antibiotic treatment. 7. The IP will routinely review all antibiotic orders. The DON and the pharmacist will be consulted as needed. 8. If necessary the IP, DON or Nurse Care Manager will contact the ordering practitioner to discuss the order. R10 admitted to the facility on [DATE] and has diagnoses that include Left Femur fracture, Parkinson's Disease, Orthostatic Hypotension, Alzheimer's Disease, Chronic Kidney Disease stage 3 and Hypertension. The hospital discharge medication list included an order to continue Levofloxacin (Levaquin) 500 mg (milligrams) by mouth every day. Surveyor noted there was no diagnosis or indication for use of the Levaquin. R10's Active Physician's orders as of 2/20/23 document: Levofloxacin 500 mg give 1 tablet by mouth in the afternoon for prophylactic TX (treatment) for UTI (urinary tract infection). Surveyor was unable to locate urology progress notes or any documentation indicating R10's Levaquin was for prophylactic treatment for UTI. R10's Medication Administration Record (MAR) documented the order for Levofloxacin 500 mg give 1 tablet by mouth one time a day for Prophylactic TX for UTI which was signed out as administered from R10's admission in November 2022, through 2/20/23 while survey was in progress. On 2/20/23 at 10:03 AM Surveyor spoke with Director of Nursing (DON)-B regarding R10's Levaquin order. DON-B reported R10 came from the hospital on the prophylactic antibiotic. She reported R10 was to follow up with urology, however due to health concerns of pneumonia then Covid, he was very weak and family did not want him going out for the appointment until he was stronger. Surveyor advised DON-B the hospital order did not include a diagnosis or indication for use as prophylactic treatment for UTI. Surveyor asked for any additional information regarding the Levaquin order and it's indication for use. On 2/20/23 at 3:00 PM during the daily exit meeting, Surveyor advised Nursing Home Administrator (NHA)-A and DON-B of concern related to Levaquin having been administered for an extended period of time and not having clear indication for use. Surveyor advised the hospital discharge summary did not include a diagnosis or indication for use as prophylactic treatment for UTI. Surveyor asked where the addition of prophylactic treatment on the order originated. DON-B reported she thought R10 admitted on the Levaquin for that reason. On 2/21/23 at 8:13 AM Surveyor spoke with DON-B and asked if there was any additional information regarding R10's Levaquin. DON-B reported Infection Preventionist (IP)-H was working on it and she would check. On 2/21/23 at 8:26 AM Surveyor spoke with IP-H and asked if she can provide any additional information regarding R10's Levaquin. IP-H stated: I'm confused too. He was on it from the beginning when he admitted in November for prophylactic treatment of UTI. Surveyor asked if the facility spoke to R10's primary physician to inquire why R10 was taking the antibiotic. IP-H stated: No. We send the orders to the doctor on the 1st of every month, they sign them and they are scanned in. Surveyor confirmed the facility did not call the physician to obtain a diagnosis or indication for use of Levaquin. IP-H stated: No. No-one called him regarding the order, he just signed the orders, we took that to mean to continue the order. Surveyor advised IP-H the hospital discharge summary did not document a diagnosis for the Levaquin, nor does it document it's use as prophylactic treatment for UTI. Surveyor asked where the addition of prophylactic treatment for UTI came from. IP-H reported she did not know, but she was not a fan of prophylactic antibiotic orders. IP-H reported the facility has a meeting every month with the medical director and they are meeting next week. IP-H stated: We'll talk about it and get it discontinued. Surveyor clarified instruction to discontinue the medication was not given by Surveyor. Surveyor reported concern is that Levaquin has been given to R10 for an extended period of time without adequate indications for it's use. IP-H reported she understood and agrees with Surveyors' concerns. On 2/21/23 at 8:49 AM Surveyor spoke with DON-B and asked what criteria the facility uses to identify infections. DON-B asked what Surveyor meant. Surveyor provided example of McGeer's. DON-B stated: I'm not sure, I'll have to find out, I don't want to give you the wrong information. No additional information was provided.

Based on observation, interview and record review the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This deficient practice had the potential to affect 3 of 3 residents (R4, R11 and R124) residing on the unit. The glucometer, which is shared between residents, was not cleaned according to the label instructions. Findings include: The facility policy titled Cleaning and Disinfection of Resident Care Items and Equipment revised 6/2022 documents (in part) . .Resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to manufacturer recommendations for disinfection and the OSHA bloodborne pathogens standard. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). 2. Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident. The Sani-Cloth bleach germicidal disposable wipe label read (in part) . .Kills HIV-1 (Aids virus), Hepatitis B virus (HBV) and Hepatitis C virus (HCV) on environmental surfaces/objects previously soiled with blood/body fluids in one (1) minute. Cleaning procedure: All blood and other body fluids must be thoroughly cleaned from surfaces and objects before disinfection by the germicidal wipe. Hospital, Healthcare and Critical Care use sites: May be used on hard nonporus surfaces of blood glucose meters. To clean, disinfect and deodorize: Use a wipe to remove heavy soil. Unfold a clean wipe and thoroughly wet surface. Treated surface must remain visibly wet for a full four (4) minutes. Use additional wipe(s) if needed to assure continuous 4 minute wet contact time. On 2/20/23 at 7:43 AM, during medication pass observation, Surveyor observed Licensed Practical Nurse (LPN)-G prepare blood sugar testing for R4. LPN-G gathered supplies which included a glucometer, test strip, alcohol wipe and lancet and proceeded to R4's room. LPN-G sanitized her hands, donned gloves and obtained R4's blood sugar. No concerns were identified with procedure. LPN-G removed her gloves and washed her hands. She picked up the glucometer and walked back to the medication cart (A). LPN-G proceeded to wipe the glucometer with an alcohol wipe while saying aloud I don't know where the bleach wipes are. A second nurse standing nearby went into the medication room and returned with a container with an orange top labeled Sani Cloth bleach germicidal disposable wipe. LPN-G removed 1 wipe from the container and proceeded to wipe the glucometer for approximately 5 seconds before placing the glucometer on top of the medication cart. Surveyor asked LPN-G if she had any more resident blood sugars to do. LPN-G reported she needed to get 2 more residents' blood sugars, but one was not awake yet and the other likes it done later. Surveyor asked if residents have their own glucometers or if the same glucometer is used on every resident. LPN-G reported the glucometer is shared between residents. On 2/20/23 at 8:40 AM Surveyor spoke with LPN-G and confirmed residents share the glucometer. Surveyor asked how the glucometer is cleaned. LPN-G reported she was always taught to wipe it with an alcohol wipe first, then wipe it with a bleach wipe. Surveyor asked if she knew the facility policy for cleaning the glucometer, to which she replied: No. I thought it was to use the bleach wipe. Surveyor advised LPN-G of observation wiping glucometer with the bleach wipe for 5 seconds. LPN-G reported she did not know the label instructions indicated the glucometer needed to remain visibly wet for a period of time. Surveyor advised LPN-G to read the the instructions on the label for contact time to remain wet. LPN-G reported she would read the label and clean the glucometer before proceeding to do any other blood sugars. On 2/20/23 at 8:45 AM Surveyor spoke with Infection Preventionist (IP)-H and advised her of the concern observed regarding cleaning of the glucometer. IP-H reported she thought the residents had their own glucometers. Surveyor asked for a container of the Sani Cloth bleach wipes, facility policy and procedure for cleaning of glucometers, a list of residents that require blood sugar testing and if any of those residents have bloodborne pathogens. Surveyor received the requested information and confirmed none of the residents that utilize the shared glucometer have bloodborne pathogens. On 2/20/23 at approximately 3:00 PM, Surveyor advised Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the above concern regarding cleaning of the shared glucometer. No additional information was provided.

Based on interview and record review, the facility did not provide basic life support, including CPR (Cardiopulmonary Resuscitation), for 1 (R220) of 1 residents reviewed, in accordance with the resident's advance directives. R220 died at the facility on [DATE] without being provided CPR according to physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's failure to ensure that R220 received basic life support, including CPR, in accordance with their advance directives and wishes created a finding of Immediate Jeopardy beginning on [DATE]. NHA-A (Nursing Home Administrator) and DON-B (Director of Nursing)-B were informed of the Immediate Jeopardy finding on [DATE] at 11:10 a.m. The facility removed the immediacy on [DATE] with the implementation of their action plan. The deficient practice continues at a scope and severity of an E (potential for harm/pattern) as the facility continues to implement their plan to ensure 5 of 17 residents residing at the facility who are full code and desire CPR per their advance directives receive emergency care as desired. Findings include: The facility policy, CPR, dated [DATE], indicated the purpose to assure level of emergency interventions are consistent with resident's wishes. To assure emergency response is consistent with CPR training. Definition: Dependent Lividity is the purplish coloration assumed by the lowest lying parts of a recently dead body due to pooling of blood. Rigor Mortis is the presence of hardening of the muscles or rigidity of the jaw, shoulder, elbows or knees then a finding of dependent lividity is not required. The RN (Registered Nurse) or LPN (License Practical Nurse) will determine code status by assessing respirations, pulse, pupillary dilatation, dependent lividity, when there is no response when the resident is tapped on the shoulder and asked are you all right? Clinical signs to watch for: 1. No respirations as determined by opening the airway, using the head tilt chin lift maneuver or jaw thrust if a cervical spine injury is suspected and observing for the rise and fall of the chest wall while listening and feeling for breath for 30 seconds. 2. No pulse as determined by palpation of the carotid or auscultation of the apical pulse for at least 30 seconds. 3. Dilated bilateral pupils are unresponsive to bright light. 4. Dependent lividity. If rigor mortis is present, then a finding of dependent lividity is not required. Determine code status & follow accordingly: Resident is Full Code status: The nurse will withhold CPR when ALL of the clinical signs listed above are present. Notify the MD, Report assessment from findings-code status, responsiveness, respiratory status, cardiac status, pupillary responsiveness, presence of dependent lividity and/or rigor mortis that substantiates the nurse's determination of irreversible death. (Follow appendix B Resident Death Procedure Checklist). Resident is Full Code status: The nurse will initiate CPR as long as not all of the clinical signs listed above are present. Delegate the first staff members to: call 911 & Code One, grab CPR fast grab equipment bag located in the Windsor report room, grab and go oxygen tank located in the [NAME] oxygen room. Delegate the next responding nurse to: begin recording the time and events of the rescue. Delegate second staff member to wait at the front door to direct the rescue team when they arrive (Follow appendix A for steps to perform CPR). R220 was admitted to the facility on [DATE] following lumbar spinal fusion on [DATE] for PT/OT (Physical Therapy/Occupational Therapy). R220 was Full code on preadmission paperwork and facility admission medical preferences form with a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R220 had [CONDITION(S)] ([CONDITION(S)]), [CONDITION(S)], Hypertension, Back Pain, and Lung Cancer with [CONDITION(S)] treatment on hold until after rehab (about 3 weeks per oncology note [DATE]). R220's Admission MDS (Minimum Data Set), dated [DATE], indicated a BIMS (Brief Interview Mental Status) score of 14 showing R220 was cognitively intact. R220 had an unwitnessed fall on [DATE] without injury while ambulating to bathroom, who stated did not hit head. X-rays of lumbar spine were negative. On [DATE], R220 died without CPR being done. DON-B wrote a note on [DATE] at 11:30 AM, entered and dated for the time she walked into the facility at 6:25 AM. This progress noted dated [DATE] at 6:25 AM indicated R220 observed to have no pulse, no blood pressure, no respirations during last rounds. resident appears cool to the touch. Per night shift, resident did not wish to be disturbed during the night. resident would put on call light if assistance was needed. night shift had completed rounds and observed resident sleeping. resident last observed around 1am. resident would normally put the call light on around 5am or so, when resident did not, staff observed that resident was cool to the touch and no vital signs. staff nurse then called RN (Registered Nurse) supervisor as well as this writer. Staff nurse then called family to update as well as Medical examiners office, and call for physician. DON-B arrived to facility. R220 pronounced. Medical examiner stated it was ok to release body to funeral home, funeral home aware. On [DATE], at 10:14 AM, Surveyor interviewed DON-B who stated R220 passed away suddenly on [DATE]. DON-B stated it was an unusual situation. During rounds, R220 was found passed away in sleep, night shift found her at 0500 (5:00 a.m.) and called DON-B. DON-B stated she came in early to the facility. DON-B was the RN supervisor on [DATE]. Surveyor questioned DON-B on R220's Code status. DON-B stated full code but no CPR was done and no documentation by night shift staff. DON-B stated CPR was not done per policy due to rigor mortis but there was no documentation of rigor mortis. DON-B stated R220 was dead at 6:30 AM but there was no documentation of lividity. DON-B stated there was no way to tell what the nurse at 5:00 AM saw in R220 regarding lividity or rigor mortis. Surveyor asked if the nurses and facility followed the policy? DON-B stated: No we did not follow the CPR policy. DON-B stated no investigation was done into R220's death as R220 was already going down the path of decline. Surveyor asked How do we know the last time R220 was seen? DON-B stated she was told verbally that the staff had last seen her at 1:00 AM and the next time was 5:00 AM when R220 was dead. Surveyor asked if the staff should have done CPR for a full code resident like R220? DON-B stated no, not if R220 looked like she did when I saw her at 6:30 AM which was approximately 90 minutes later. DON-B stated there was no written investigation into death or follow up - only what was documented that day by her in the progress notes. DON-B stated she would follow up with staffing and the nurse who worked that night, she does not know who the nurse was at this time and was unable to ascertain from the chart. Surveyor reviewed the ,d+[DATE]-24 2021 schedules which noted 2 CNAs (Certified Nursing Assistant), and LPN (Licensed Practical Nurse) on R220's 2nd floor unit and an RN (Registered Nurse) Supervisor working on the 4th floor. On [DATE], at 1:51 PM, Surveyor interviewed CNA-C who stated she worked the other hallway and heard that someone died but did not work that side so would not know who or what happened. On [DATE], at 2:08 PM, Surveyor interviewed CNA-D who stated R220 kept more to herself, did not like to be bothered, and normally put on call light if needed anything. CNA-D stated she made safety rounds around 10 PM and R220 was sitting up with purse at side. CNA-D stated around 12ish or 1, CNA-D peeked back in and R220 was sleeping. CNA-D stated she told LPN-F that R220 had not used the call light so around 3 or 4 AM, CNA-D went to check on R220 to see if she needed the bathroom and R220 was gone already. CNA-D stated she got LPN-F and the nurse confirmed R220 was not alive no more. LPN-F called around to others. Surveyor asked CNA-D if she knew R220 was a Full Code and she stated she did not know but she does know where to get the emergency equipment. RN-E came to check R220 later. CNA-D stated she was in R220s' room when LPN-F came in and the nurse touched the body. CNA-D stated she did not know if LPN-F got a stethoscope out and does not recall if LPN-F stated R220 was cool to touch. CNA-D stated she didn't know if R220 was full code or not, and she don't usually know that information. On [DATE], at 4:15 PM, Surveyor interviewed LPN-F who stated she remembered R220 who was not there long and she did not have a whole lot of interaction with R220. LPN-F stated she only saw R220 at 5:45 AM for meds as she work nights. LPN-F stated the night R220 died , CNA-D went her room around 5 am & said I think R220 is dead. LPN-F stated she went to R220, touched her, she was cold. LPN-F stated she was a newer nurse, so she didn't know the protocol. LPN-F stated she didn't remember if R220 was a Full Code or DNR (Do Not Resuscitate), but it can be found in the chart. LPN-F stated R220 had no pulse, so she called DON-B who stated call RN-E. LPN-F called RN-E to assist and she listened for heart sounds or lung sounds-nothing. LPN-F stated she called DON-B after RN-E came to ascertain the protocol. DON-B told me to fill out the death forms, call medical examiner. LPN-F stated she called the niece and the funeral home for the niece as she did not want to call. LPN-F stated she had a stethoscope, but she did not use it. LPN-F stated she was trained on protocol for CPR at the facility, but didn't remember much as it was a few months ago. LPN-F stated she would do CPR for a full code, but RN-E didn't hear anything so LPN-F didn't start CPR. LPN-F stated she completed the death protocol but no documentation on the death. On [DATE], at 2:01 PM, RN-E stated she was working on a different unit, the 4th floor Assisted Living. LPN-F called me close to the change of shift around 6 am, stated she called DON-B. DON-B told LPN-F that DON-B needed an RN to pronounce death so I grabbed my stethoscope and went down to the 2nd floor. R220 was cold, with no pulse. Later that am ([DATE]), RN-E stated she emailed DON-B because she did not know if she could really pronounce like a hospice RN but DON-B said it was OK. Surveyor reviewed R220's death protocol checklist completed, the removal of corpse certification [DATE] indicated R220 was pronounced at 6:45 AM on [DATE] signed by DON-B. The physician discharge summary, dated [DATE], stated cause of death to be lung cancer. The [DATE] physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Signed by the physician on [DATE] On [DATE], at 7:50 AM, Surveyor interviewed LPN-G who stated there is no AED (automated external defibrillator) on this unit and all emergency equipment is in the South Tower so we would need to have someone go downstairs and take the elevator to get it. There is no AED in the facility. On [DATE], at 7:58 AM, Surveyor interviewed DON-B who stated there is emergency equipment on the 1st floor behind the receptionist desk so someone could go down and get it. DON-B stated that the paramedics come right away so the facility staff usually just do chest compressions with our backboard which is kept in the shower room and we add oxygen. DON-B stated we keep oxygen in a room which 90% of staff can access. DON-B demonstrated the oxygen room to Surveyor who observed oxygen masks and tubing, oxygen cylinders, and oxygen concentrators but no AMBU bag to give breaths. DON-B demonstrated the shower room where the backboard was supposed to be found but no backboard was seen/identified. DON-B stated it must have been moved to another room. DON-B took Surveyor to another room where DON-B thought the backboard might be but only observed a commode and air mattress. DON-B stated there was cleaning and reorganization but she does not know where the backboard is right now. Surveyor questioned if anyone working on the unit on that day and would respond to a code would they be able to know where the backboard would be. DON-B stated no one would know where to find it as we cannot find it. DON-B stated the facility does not have an AED. On [DATE], the Facility Census was 17 with 12 residents having a Do Not Resuscitate (DNR)status and 5 residents with full code status. Surveyor noted that the facility did not provide any contemporaneous documentation and/or assessment documenting that R220 did not require CPR due to the presence of rigor mortis, dependent lividity, and dilated bilateral pupils unresponsive to bright light. No additional information was provided why the facility did not provide R220 with basic life support, including CPR, in accordance with the R220's advance directives and wishes. There was no investigation of this resident's death and no subsequent staff training. The facility's failure to ensure R220 received CPR per R220's advance directives and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility removed the immediacy on [DATE] when the facility implemented the following steps: Policies & Protocols: 1. Reviewed and revised Cardiopulmonary Resuscitation (CPR) policy. 2. All licensed nursing staff have a current CPR certification. 3. Affirmed the location of Code Status within the electronic medical record. 4. Relocated all necessary equipment to perform CPR to a central location, accessible by all nursing staff members. 5. Reviewed and updated where necessary, the care plans for the other 5 residents who have not enacted DNR orders. Education: 1a. All nursing staff members were educated on the CPR policy and the new location of CPR equipment. 1b. All nursing staff was educated on the importance of timely and accurate documentation. 2. All nursing staff were educated on identification of those residents who wish to be resuscitated, if necessary and appropriate. 3. All education was continued until all nursing staff members completed the education. Any nursing staff member who did not complete the education will not be scheduled until it is complete. 4. All education was conducted by nursing management and/or a nurse who has demonstrated understanding of the CPR policy and has been designated to perform the education. Audits & Quality Assurance: Starting [DATE], the DON or their delegate will conduct a daily audit of the staff work schedule to ensure licensed nursing staff have a current CPR certification. Daily audits will continue for two weeks, then will transition to a monthly audit conducted by our Human Resources department. The HR Department's audits will be ongoing. Starting [DATE], the DON or Charge Nurse will conduct a per-shift audit of the location of the CPR equipment to ensure all necessary supplies are present. These per-shift audits will continue for two weeks. Starting February 4, the DON or Charge Nurse will conduct a daily audit of the location for a period of four weeks. Starting [DATE], the DON will begin conducting once-weekly audits of the location on an ongoing basis. An audit will be conducted on [DATE] by the DON to ensure the electronic medical record properly displays the Code status of every resident. All resident's Code Status will be reviewed as part of their quarterly care plan reviews on an ongoing basis. All audit results will be maintained by the Quality Assurance Committee and reviewed regularly to ensure compliance with policy and regulation. The QA Committee may increase the frequency, or extend the requirements, for auditing as it deems appropriate. As an ongoing commitment to honoring the Code Status of each resident, the QA Committee will audit the nursing documentation for any resident who dies within the SNF for the next year. Results of the audits will be shared with the entire committee and be used to inform future educational needs or systemic changes.

Based on observation, interview, and record review, the Facility did not ensure 1 (R1) of 3 Residents received adequate supervision and assistive devices to prevent accidents. R1 had falls on 7/2/21, 8/3/21, and 10/11/21. On 8/3/21, R1 was reported she slid to the floor from her wheelchair. R1 was noted to have both a ROHO and an Gel cushion in her wheelchair at the time of this incident. There was no documentation in R1's record as to why R1 had both a ROHO and a Gel cushion in her wheelchair at the same time, which is not a standard of practice. On 8/5/21 X-ray's were ordered due to swelling and pain. On 8/6/21, R1 was diagnosed with a right wrist fracture including the distal radius and ulnar bones. According to the Director of Nursing (DON)-B the fracture was not reported to the state agency because it probably came from a fall and we knew the source (being the fall). The facility did not have a fall policy. The staff did not consistently address each fall with assessment and documentation or when it was appropriate to initiate neurological checks. Findings include: The facility did not have a fall policy. The facility utilized a post fall huddle tool, dated 8/22/2018. R1 was admitted to the facility on [DATE] with diagnoses including Hypertension, [CONDITION(S)], Depression, Anxiety, Dizziness and Giddiness, and [CONDITION(S)]. R1's Admission MDS (Minimum Data Set), dated 10/7/21, indicated a BIMS (Brief Interview Mental Status) score of 11 which is cognitively moderately impairment. R1's Care plan indicated: Category: Falls-I am at risk for falling R/T (related to) use of antidepressant medication, IBS with weakness, initiated 10/9/19, revised 6/1/21. Goal: I will remain free from injury, initiate 10/9/19, revised 10/21/21, target date 1/19/22. Interventions: Encourage R1 to use the bathroom around 3 AM, initiated 10/11/21. Assure that R1 has only one pressure relieving cushion in W/C. [Fall on 8/3/21], initiated 8/3/21. Assure the floor is free of glare, liquids, foreign objects, initiated 10/9/19, revised 6/1/21. Educate R1 to sleep in the middle of the bed, initiated 6/6/20, revised 6/1/21. Educate staff to keep frequently used items within reach, initiated 5/1/21, revised 6/1/21. Encourage R1 to assume a standing position slowly, initiated 10/9/19, revised 6/1/21. Give R1 verbal reminders not to ambulate/transfer without assistance, initiated 10/9/19, revised 6/1/21. I wear gripper socks in place of slippers at times, initiated 10/9/19, revised 6/1/21. I will change my undergarments in the bathroom where I can hold onto the grab bars, initiated 10/9/19, revised 6/1/21. Keep bed in lowest position with brakes locked, initiated 10/9/19, revised 6/1/21. Keep call light in reach at all times, initiated 10/9/19, revised 6/1/21. Leave night light on in room, initiated 10/9/19, revised 6/1/21. Provide me with an environment free of clutter, initiated 10/9/19, revised 6/1/21. Provide proper, well maintained and non-skid footwear, initiated 10/9/19, revised 6/1/21. Provide R1 to use bedside commode, initiated 4/16/21, revised 6/1/21. Provide toileting assistance upon rising, after meals, before bed and prn, initiated 10/9/19, revised 6/1/21. Provide verbal reminders to use call light and wait for assistance [fall on 7/2/21], initiated 7/2/21. Replace call don't fall sign in my room to remind me to use my call light for assistance, initiated 6/3/20, revised 6/1/21. Surveyor reviewed the documentation of R1's falls. 1. R1's progress note on 7/2/2021, at 10:46 AM, indicated R1 observed sitting on the floor next to the bed at 10:20 AM. R1 A/O (alert and oriented) x4. R1 stated that she was transferring from bed to wheelchair and lost balance. No noted injuries. ROM (Range of Motion) WNL (Within Normal Limits) x4 without having pain. No rotation, shortening, or deformities noted. Denies hitting head. No c/o pain. Educated R1 to use call light and wait for assistance. Assisted resident to get up with assist of two. Emergency contact made aware of incident. Physician informed of incident via fax. On 7/2/2021, a Post Fall Evaluation was Completed. On 7/2/2021, R1's MORSE FALL SCALE was completed indicating R1 was High Risk for Falling with a score of 65.0. On 7/2/21, R1's fall care plan interventions was updated: Provide verbal reminders to use call light and wait for assistance. This is essentially the same as the approach already on the care plan that said Give R1 verbal reminders not to ambulate/transfer without assistance, initiated 10/9/19, revised 6/1/21. 2. R1's progress note on 8/3/2021, at 8:53 PM, indicated R1 observed sitting on the floor in front of the wheelchair at 8:30 PM. R1 stated that I slid to the floor from the wheelchair. No noted injuries. No c/o pain. No indications of acute distress. ROM x4 without pain or discomfort. No rotation, deformity, or shortening observed. Assisted resident to stand up with assist of two. Resident has Roho cushion and Gel cushion in wheelchair. Writer removed Roho cushion from wheelchair to prevent sliding. Emergency contact notified of above incident and plan of care. Physician made aware via fax. On 8/3/2021, a Post Fall Evaluation was completed. On 8/3/2021, R1's MORSE FALL SCALE was completed indicating R1 was High Risk for Falling with a score of 50.0. On 8/3/21, R1's fall care plan interventions was updated: Assure that R1 has only one pressure relieving cushion in wheelchair. On 8/5/21, Physician ordered x-rays of R1's right wrist due to swelling and pain. On 8/6/21, R1 had an appointment with orthopedic physician for right wrist pain. The orthopedic physician diagnosed R1 with distal radius and ulnar fractures. Orders and Plan of Care included Non-Weight Bearing for right arm and right wrist. Cast for 6 weeks, OK to remove for for hygiene, Ice and elevate, next visit 3 weeks. On 9/17/21, R1 had a follow up appointment with orthopedic physician for right wrist fractures. Orders and Plan of Care included Continue to wear splint on Right hand. X-ray today shows healed fractures, no fracture tenderness. Plan use right hand/wrist as tolerated, wear brace as needed. On 1/19/22, at 10:14 AM, Surveyor interviewed DON-B (Director of Nursing) who stated R1's fall on 8/3/21 was unwitnessed with no injury. DON-B stated if there were any Neurological checks, then they would be in drop chart (paper in medical records). DON-B was unable to state whether an unwitnessed fall should get Neurological checks. DON-B stated the facility does not provide incident reports, just give huddle tools. Surveyor asked if R1's wrist fracture was attributed to 8/3/21 fall with bruising on 8/4/21, Physician order for x-rays on 8/5/21. DON-B stated remembering the sequence of events and didn't report the fracture because it probably came from a fall and we knew the source (being the fall). DON-B stated she did not document anywhere that R1's fracture was from the fall, but that was the correlation in her brain. Surveyor also noted on 8/3/21, R1 had a Roho cushion and a gel cushion in her wheelchair at the same time when she slid out of wheelchair and was found on the floor. It is not a standard of practice to use a Roho cushion and a gel cushion in a wheelchair at the same time. R1 did not have any documentation regarding why there were 2 wheelchair cushions in the chair. According to Common Mistakes Made When Using a Pressure Cushion, If a pressure cushion has been stacked on top of an existing standard cushion, or placed on a chair which is too wide, it can reduce the effectiveness of the arms, lateral supports and head rests in holding the person in a good posture. https://seatingmatters.com/learn/blog/mistakes-made-pressure-cushions 3. R1's progress on 10/11/2021, at 3:47 AM, indicated R1 was found sitting on the floor knees to chest naked on top of her gown. The gown and the carpet where R1 was sitting was saturated with urine. R1 had indicated that she was attempting to toilet herself. The brief that R1 was wearing was noted in the trash can next to her. Assisted the resident, off of the floor and back into bed. The resident indicated that she was not in any pain or discomfort. The resident was able to move all extremities without error. Vitals were all WNL. On 10/11/2021, a Post Fall Evaluation was noted to be In Progress. On 10/11/2021, R1 did not have a MORSE FALL SCALE completed. On 10/11/21, R1's fall care plan interventions was updated: Encourage R1 to use the bathroom around 3 AM. On 1/19/22, at 3:08 PM, DON-B stated no fall policy. NHA-A (Nursing Home Administrator) stated obviously we probably had one in the past but we do not have an active policy now. The staff did not consistently address each fall with assessment and documentation or when it was appropriate to initiate neurological checks.

Based on record review and staff interview, the facility did not ensure there was a meeting held at least quarterly and identify issues through the committee. This deficient practice had the potential to effect all 17 residents currently in the facility. Findings include: The facility's Quality Assurance policy and procedure dated 7/2016 was reviewed at this time. The Community QAPI (Quality Assurance Process Improvement) will meet every other month. On 01/20/22 at 08:37 AM Surveyor met with Administrator-A and DON-B (Director of Nurses). They have not had a QA meeting since July 8 2021. They are aware of the requirement for quarterly meetings. There was a shift in management roles. They have hired a new personnel to restructure the facility's QA (Quality Assurance) meetings. They recognized there was concerns with the QA process. They are in the process of overhauling the facility's QA process. The facility has been having subcommittees meetings at least monthly. These subcommittee meetings consisted of a resident chat with the Adminstrator and the DON keeping an eye on things. There was no formailzed subcommitte group or members who make up the submittee group. There was no process to identify issues through the subcommittees. The facility has not utilized the QA committee process since July 8 2021.

Based on record review and interview, the facility did not establish or maintain an infection control program that included identifying, reporting, or investigating infectious processes, have written policies and procedures for the surveillance of residents or employees to identify possible infections, and report timely a respiratory outbreak in the facility potentially affecting all 44 of 44 residents in the facility. Residents with active infections were not identified on the facility's monthly surveillance tool and rates of infection were calculated with inaccurate data. A respiratory outbreak affecting four residents that started 2/18/2019 was not reported to the Public Health Department. Findings: On 11/5/2019 at 3:06 PM, Surveyor requested the Infection Control Policies and Procedures to review. Director of Nursing (DON)-B provided the Antimicrobial Stewardship policy and procedure and stated that was the only policy and procedure the facility had for infection control. On 11/6/2019 at 8:57 AM, Surveyor met with DON-B to review the facility's Infection Prevention and Control program. Surveyor asked DON-B to explain how surveillance of infections is done in the facility. DON-B stated the staff know the residents and know when they aren't feeling well. If a resident isn't feeling well, they are put on the 24-hour report board with the signs and symptoms they are experiencing for extra surveillance. DON-B stated residents with signs and symptoms of infections are discussed every day at the morning meeting; the nurses on the floor complete the McGeer's criteria form and monitor the resident on the 24-hour board for the duration of the antibiotic with an additional three days after the antibiotic has been completed. DON-B stated a line list is only used when there is an outbreak. DON-B stated each month for each unit, a map of the floor plan is used to trend infections and, using a color-coded key, a dot is placed on the room indicating the type of infection the resident has. The color key is as follows: black - urinary tract infection; blue - respiratory infection; green - skin and subcutaneous infection; orange - eye, ear, sinus, mouth infection; red - gastrointestinal infection; purple - systemic infection; yellow - other type of infection. Surveyor reviewed multiple months of dots on monthly maps in the infection control binder. August 2019 the first floor unit had one blue dot indicating 1 respiratory infection and three black dots indicating 3 urinary infections. Hand-written on the paper stated 1361 total patient days, 43.9 average daily census. Total infections: 4 with an infection rate of 9.1% and 2.94/1,000 patient days. Urinary tract infections only: 1 with an infection rate of 2.28% HAI (healthcare acquired infection) and 0.735/1,000 patient days. The facility calculated a UTI rate using only 1 UTI rather than calculating the rate reflecting the 3 UTIs which they had in August. No respiratory infection rate was documented, even though the facility (MONTH) monthly map had one blue dot indicating 1 respiratory infection. Surveyor asked if the residents with urinary infections had a catheter or not. DON-B did not know if the residents had catheters or not. The urinary infection rate calculated on the paper only calculated one resident with an infection and did not designate if the resident had a catheter. DON-B stated the rates written on the floor plans are the statistics that are reported to the QAA (Quality Assessment and Assurance) committee. The colored dots on the floor map did not have start dates for each infection which are needed to accurately trend infections to determine if there is an outbreak. Surveyor asked who puts the dots on the floor plan map and when are they put on the map. DON-B was not sure who puts the dots on the map or when they are put on. DON-B stated the Infection Preventionist had been putting the dots on, but the Infection Preventionist is no longer working at the facility and DON-B had taken over those responsibilities, but didn't know the specifics of the program. Surveyor asked if the information on the floor plans are reviewed each month to track and trend infections. DON-B stated no, the information is not reviewed monthly. R35 was diagnosed [DATE] with pneumonia and 10/19/2019 with a urinary tract infection. Review of R35's unit floor map for October, 2019 had two blue dots indicating respiratory infections and one black dot indicating a urinary tract infection. R35's room had a blue dot indicating a respiratory infection but did not have a black dot indicating a urinary infection. On 11/6/2019 at 8:57 AM, Surveyor interviewed DON-B regarding R35's infections and the surveillance tool. DON-B stated she was not sure who was supposed to put the black dot on the map indicating a urinary tract infection or why it wasn't done. DON-B provided the McGeer's forms that had been completed for the respiratory and the urinary infections. DON-B agreed the calculation rates of infection were not accurate because not all infections were indicated on the floor plan maps. Review of the floor map for the other unit dated October, 2019 showed three black dots indicating urinary tract infections. DON-B stated one resident had a catheter, one resident did not have a catheter, and the third resident had an infection before the catheter was placed. The infection rates do not separate the residents with or without a catheter. On 11/6/2019 at 8:57 AM, Surveyor reviewed the facility's outbreak information provided by DON-B. No month or date was on the line lists provided. DON-B stated the facility had two outbreaks in February, 2019. Documentation the facility provided to the Public Health Department was reviewed. The first floor unit had a respiratory outbreak 2/15/2019 and the Department of Public Health was notified. A respiratory panel was completed on one resident that was positive for RSVB (respiratory [MEDICAL CONDITION]-B) and residents were placed in isolation as soon as symptomatic. Signs were posted at entries notifying the public of the outbreak and housekeeping implemented extra cleaning with bleach. A total of 4 residents were affected. No information was provided for employees affected during the outbreak. DON-B stated the second floor unit had a respiratory outbreak and provided the line list indicating the residents affected. Four residents were listed on the line list. No onset date was listed for the first resident and the date could not be determined for the second resident. The third resident had an onset date of 2/17/2019 with cough and nasal congestion. The fourth resident had an onset date of 2/18/2019 with cough and nasal congestion. No documentation was provided that the Public Health Department was notified. No laboratory tests were given to the third or fourth residents. All four residents had a well-date of 2/26/2019. No employee line list was provided to show infections to employees. Surveyor asked DON-B how visitors got to the second floor if there was an outbreak on the first floor; the elevator is in the middle of the first floor unit. DON-B was not sure what the procedure was in that circumstance, but would find out the answer. On 11/6/2019 at 12:06 PM, DON-B stated there is a second elevator in a separate section of the building that visitors can access, take to the third floor, walk to the central elevator, and take that elevator to the second floor to get to the unit for visiting the residents on the second floor. On 11/6/2019 at 3:04 PM, Surveyor discussed the above findings with Nursing Home Administrator (NHA)-A and the concern with the surveillance of potentially infected residents not being assessed timely in regards to a potential outbreak and the inaccurate calculations of infection rates that are reported to the QAA committee. Surveyor informed NHA-A that no policy and procedure was provided for infection surveillance. NHA-A stated there are more policies and procedures for infection control and those would be provided. On 11/7/2019 at 10:12 AM, Surveyor met with DON-B to review policies and procedures. Policies and procedures for Standard Precautions, Implementing Isolation Precautions, Pneumonia, and Gastroenteritis were provided along with the Department of Health Services memo for reporting, preventing and control of acute respiratory illness outbreaks in long-term care facilities. DON-B provided the following document stating this is what the facility uses as their policy and procedure for infection control and prevention: Guidelines for infection control and prevention .: The infection control and prevention program is designed to protect everyone who comes to our facility, including residents, healthcare workers, and the public. Our program is multidisciplinary and incorporates evidence-based practices from leading authorities in infection prevention including: the Centers for Disease Control and Prevention (CDC), The Association for Professionals in Infection Control and Epidemiology (APIC), and the American Medical Directors Association (AMDA). In addition, we comply with regulations from government agencies such as the state and local health departments the Occupational Safety and Health Administration (OSHA) and the Centers for Medicare and Medicaid Services (CMS). Here are the steps we use at our facility: -Rigorous hand hygiene practices that ensure healthcare providers clean their hands before and after providing resident care and after having contact with the resident's environment. -Residents as well as visitors are encouraged to be partners in their care and practice good hand hygiene as well as talk with healthcare providers about hand hygiene. -Use of transmission based precautions, such as Standard, Contact and Droplet isolation. -Appropriate use of personal protective equipment such as gloves, gowns, masks, etc. (PPE). *hair covers worn by Food Service personal. -Environmental cleaning and decontamination per environmental control and housekeeping. -Staff education on best practices to prevent infections; and training to identify any breaks in infection prevention and to intervene if such breaks occur. -Staff education will include the sharing of information with residents and families so they understand the importance of infection prevention practices in all healthcare settings and at home. Updated (MONTH) 21, (YEAR) Surveyor asked DON-B if there was a specific policy and procedure for surveillance. DON-B stated there was nothing in writing, but the staff knew to put a sick resident on the 24-hour board; that is their surveillance. On 11/7/2019 at 3:00 PM, Surveyor met with NHA-A and discussed the above findings. No further information was provided at that time.

Based on observation, interviews, and record reviews, the facility did not develop/implement a comprehensive care plan to meet the resident's medical, nursing, and mental and psychosocial needs for 10 (R26, R24, R5, R36, R3, R28, R2, R13, R35, and R6) of 12 sampled residents. *R26 did not have a care plan created for activities of daily living until a month after the comprehensive assessment was completed. *R24 was admitted to hospice 8/28/2019 and did not have a hospice care plan in place. *R5 had a [DIAGNOSES REDACTED]. R5's care plan did not have individualized interventions for behaviors. *R36 had [DIAGNOSES REDACTED]. R36's care plan did not have individualized interventions for behaviors. *R3 had a [DIAGNOSES REDACTED]. R3's care plan did not have individualized interventions for behaviors. *R28 had chronic pain and did not have a pain care plan in place. *R2 had a [DIAGNOSES REDACTED]. R2's care plan did not have an anxiety or depression care plan in place. *R13 had [DIAGNOSES REDACTED]. *R35 had [DIAGNOSES REDACTED]. R35 had a [DIAGNOSES REDACTED]. R35 had a stop sign banner across the door frame; this was not addressed in a care plan. *R6 had weight loss and did not have a nutrition care plan in place. R6 did not have a mood care plan in place. Findings: On 11/5/2019 at 3:06 PM, Surveyor interviewed Director of Nursing (DON)-B regarding care plans for residents. DON-B stated with the old program for electronic medical records (EMR) that the facility was using, the staff would look behind the resident's door where the care card was hung; the care cards were updated with any changing information. DON-B stated with the new EMR, the information for each resident is on the electronic tablet used by the staff where interventions from the care plans are pulled from. DON-B stated the facility decided to create a basic needs and preferences care plan in the new system and over the next three months, when a resident would be due for an Minimum Data Set (MDS) review, the facility staff would create complete care plans for residents. DON-B stated by the end of the year all care plans for the residents should be in the new system. DON-B stated the unit managers went through each resident and had a basic needs care plan entered into the new system so staff would know how to care for the residents. When asked what type of information was entered, DON-B stated it was a case-by-case basis for what was put into their basic needs care plan. On 11/6/19 at 9:02 AM, Surveyor interviewed DON-B, who stated: When the facility decided to change EMR programs to a new EMR, the facility did not print out complete care plans from the old system as they transitioned to the new system. DON-B stated the change in EMR programs occurred on 8/21/19. On 11/6/19 at 2:25 PM, DON-B informed Surveyor, the facility does not have a policy and procedure for creating care plans for residents as care plans were not a problem for the facility until the transition to the new EMR. DON-B stated staff is still learning the new EMR system. On 11/7/2019 at 12:44 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-G regarding the care of residents on the unit. Surveyor asked how does staff know how to take care of a resident. LPN-G stated the resident's care plan is on the back of the door. Surveyor asked LPN-G to show where a care plan could be found in a resident's room. LPN-G went into two individual resident rooms and was unable to locate a care plan. LPN-G stated, I am not sure where they are. Oh, yeah. They are on the tablets now. 1. R26 was admitted to the facility 3/25/2019 with [DIAGNOSES REDACTED]. R26's quarterly Minimum Data Set (MDS) assessment dated [DATE] coded R26 as needing extensive assistance with all activities of daily living (ADLs) including eating and was frequently incontinent of both bowel and bladder. R26's ADL care plan was not initiated until 10/14/2019. From 8/21/2019 when the new EMR program was implemented until 10/14/2019, the facility did not have an ADL care plan for R26. R26's care plan was not reviewed or completed after the quarterly MDS assessment on 9/15/2019. 2. R24 was admitted to the facility 2/25/2019 with [DIAGNOSES REDACTED]. R24's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R24 was receiving hospice services. On 8/29/2019 at 10:40 AM in the progress notes, social services documented R24 was admitted to hospice services on 8/28/2019 for comfort care. No hospice care plan was initiated. On 11/7/2019 at 8:10 AM, Director of Nursing (DON)-B provided a hospice care plan dated 11/7/2019. DON-B stated a care plan should have been initiated when R24 started on hospice but didn't create one until this morning. 3. R5 was admitted to the facility 12/27/2018 with [DIAGNOSES REDACTED]. R5's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R5 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, had no behaviors, and received an antidepressant daily. R5 has a physician order [REDACTED]. A [MEDICAL CONDITION] Drug Use care plan was initiated 10/8/2019 with the following interventions: -Monitor for effectiveness of medication. Increase dosage gradually if needed. -Monitor my mood and response to medication. -Pharmacy consultant review quarterly. A Mood State care plan was initiated 10/8/2019 with the following interventions: -Administer [MEDICATION NAME] as ordered and monitor for effectiveness and side effects and report to my physician as needed -Allow me to verbalize my feelings and offer TLC (tender loving care) as needed -Monitor my behaviors and observe for patterns or triggers of sadness On 11/7/2019 at 10:36 AM, Surveyor interviewed Registered Nurse (RN) Supervisor-C regarding R5's behaviors with depression. RN Supervisor-C stated R5 can get sad if there is a set-back to their health such as a fall. RN Supervisor-C stated if something like that should happen, R5 will want to stay in bed for days. RN Supervisor-C stated what triggers R5 into depression and R5's reaction to those triggers should be put in R5's care plan to make it individualized. R5 didn't have any care plan to address the depression from 8/21/2019 until 10/8/2019. 4. R36 was admitted to the facility 7/30/2016 with [DIAGNOSES REDACTED]. R36's quarterly Minimum Data Set (MDS) assessment dated [DATE] coded R36 as having moderate cognitive impairment per staff, no behaviors, and receiving daily antianxiety medication and daily antidepressant medication. R36 has a physician order [REDACTED]. A Mood State care plan was initiated 9/25/2019 with the following interventions: -Encourage R36 to become involved with physical activities and social interactions. -Support appropriate moods/behavior. -Work with resident to identify effective coping mechanisms. -Administer medications: [REDACTED]. Monitor and record effectiveness. Report adverse side effects. (added 10/5/2019) A Behaviors care plan was initiated 9/29/2019 with the following interventions: -I will allow the staff to put a scent tab on my shirt to help reduce my anxiety. The scent tabs contain non-toxic essential oils such as [MEDICATION NAME], relaxation, and stress reduction. The scent tab can stay on for as long as I am willing to wear it. It will only be used to help prevent or reduce a behavior. If I want to take it off staff will help me to remove it. -Please sing to me or offer music to me to help ease my anxiety. (added 10/2/2019) -administer [MEDICATION NAME] twice daily and once daily as needed for 2 weeks, [MEDICATION NAME] daily and [MEDICATION NAME] daily per physician orders. Monitor for effectiveness and side effects. (added 10/5/2019) A [MEDICAL CONDITION] Drug Use care plan was initiated 10/5/2019 with the following interventions: -Consult with pharmacy and physician to consider dosage reduction when clinically appropriate. -psych services through outside psych service -Monitor for target behaviors/symptoms and document per protocol. -Observe document, and report to physician any signs or symptoms of drug related complications. -See Fall care plan. On 10/28/2019 at 6:13 PM in the progress notes, nursing charted R36 had been pacing the halls, entering other residents' rooms, claiming to be sick, dizzy, sweating, and in unbearable pain everywhere. Staff was unable to calm or redirect R36. On 11/7/2019 at 10:39 AM, Surveyor interviewed Registered Nurse (RN) Supervisor-C regarding R36's behaviors. RN Supervisor-C stated R36 constantly complains of abdominal pain and attributes that behavior as anxiety because when R36's spouse leaves, the behavior intensifies. RN Supervisor-C stated R36's behavior of calling out with abdominal pain should have been in the care plan as a targeted behavior. R36 didn't have any care plan in place for depression or anxiety from 8/21/2019 through 9/29/2019. 5. R3 was admitted to the facility 4/22/2019 with [DIAGNOSES REDACTED]. R3's quarterly Minimum Data Set (MDS) assessment dated [DATE] coded R3 as being cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, no behaviors, and receiving a daily antidepressant medication. R3 had an order for [REDACTED]. A [MEDICAL CONDITION] Drug Use care plan was initiated 10/9/2019 with the following interventions: -Assess/record effectiveness of drug treatment. Monitor and report signs of sedation, hyptension, or [MEDICATION NAME] symptoms. -Consult with pharmacy and my physician to consider dosage reduction when clinically appropriate -I will receive the lowest therapeutic dose for control of my symptoms -Monitor my mood and response to medications. -Pharmacy consultant review quarterly. -See Fall care plan A Mood State care plan was initiated 10/9/2019 with the following interventions: -Administer my antidepressant medication as ordered and monitor for effectiveness and side effects. Update physician as needed. -Monitor behaviors and observe for triggers and patterns. R3's Progress Notes were reviewed 8/20/2019 to present with no behaviors documented. On 11/7/2019 at 10:38 AM, Surveyor interviewed Registered Nurse (RN) Supervisor-C regarding R3's behaviors. RN Supervisor-C stated R3 has had major life changes recently and has brought about a depression where R3 doesn't want to participate in things. RN Supervisor-C stated those events should have been in R3's care plan along with R3's reaction to those stressful life events. R3 didn't have any care plan in place for depression from 8/21/2019 through 10/9/2019. 6. R28 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R28's Change in Condition Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/10/19 documents: A Brief Interview of Mental Status (BIMS) score of 14, indicating R28 is cognitively intact; a Patient Health Questionnaire (PHQ-9) score of 2, indicating R28 does not have depressive symptoms; is dependent on 2 staff for transfers, dependent on 1 staff for toilet use, requires extensive assist for 2 staff for bed mobility, extensive assist of 1 staff for dressing and personal hygiene; has range of motion impairment on both lower extremities; receives scheduled pain medication regimen, receives PRN (as needed) pain medication, has received non-medication interventions for pain, has experienced occasionally experienced pain and rated the worst pain at an 8/10. R28's Care Area Assessments (CAAs), dated 10/10/19 document: #19 Pain: R28 has pain due to metastatic [MEDICAL CONDITION]. She has experienced pain occasionally during the past 5 days, with dexrtiptor scale of 2 to 8. R28's pain is acute and chronic. R28 has started that over the past 5 days pain has limited her day to day activities. R28 is medicated with a scheduled [MEDICATION NAME] daily. Non-pharmacological interventions are implemented to reduce and relieve pain. Doctor has ordered PRN [MEDICATION NAME] for breakthrough pain. Pain and the effectiveness of R28's [MEDICATION NAME] are assessed every shift and as needed by the nursing staff. Doctor will be consulted with any unrelieved pain. Proceed to the plan of care. R28's most recent Care Plan, dated 10/4/19 does not address R28's reported pain and need for a pain management regimen. On 11/04/19 at 1:16 PM, Surveyor interviewed R28 who stated: She does have pelvic pain related [MEDICAL CONDITION] and their are no medications that can take that away. R28 stated the staff area aware of her pain and do address it but [MEDICAL CONDITION] [DIAGNOSES REDACTED]. On 11/7/19, at 8:32 AM, Director of Nursing (DON)-B provided Surveyor with a copy of a care plan dated 11/6/19 at 7:54 PM, that addressed R28's pain related to complaints of chronic pain r/t (related to) MS ([MEDICAL CONDITION]) and history of bone mets. 7. R2 has a [DIAGNOSES REDACTED]. R2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R2's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/14/19, documents: A Brief Interview of Mental Status (BIMS) score of 15, indicating R2 is cognitively intact; a Patient Health Questionnaire (PHQ-9) score of 0, indicating no depressive symptoms; active [DIAGNOSES REDACTED]. R2's Care Plan dated 10/12/19-10/14/19 does not document R2's [DIAGNOSES REDACTED]. R2's Hospital Discharge Summary, dated 10/11/19, documents: . Discharge Plan, Discharge medications: [REDACTED]. [MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg oral tablet: 1 tab PO BID (twice a day) PRN (as needed) for anxiety duration 3 day(s). The PRN 0.5 mg [MEDICATION NAME] remained an active physician's orders [REDACTED]. (Cross Reference F758) R2's Medication Administration Record [REDACTED]. This medication was on hold and not administered while R2 was hospitalized from [DATE]-10/11/19. The order was restarted on 10/12/19 but never administered. The same MAR indicated [REDACTED]. This medication was administered 14 times from 10/12/19-10/31/19 and 6 times from 11/1/19-11/7/19. 8. R13 has a [DIAGNOSES REDACTED]. R13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R13's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 8/18/19 documents: A Brief Interview of Mental Status (BIMS) score of 14, indicating R13 is cognitively intact; Patient Health Questionnaire (PHQ-9) score of 3, indicating no depressive mood symptoms; requires extensive assist of 1 staff for bed mobility, transfers and toilet use and limited assistance of one staff for personal hygiene; receives insulin injections 7 days a week; and antidepressant medication 7 days a week. R13's Care Plan, last updated on 10/16/19, does not address R13's [DIAGNOSES REDACTED]. 9. R35 was admitted to the facility 4/27/19 with [DIAGNOSES REDACTED]. tract symptoms. Surveyor reviewed R35's Care Area Assessments (CAA) with an assessment date of 4/24/19. There is no CAA for mood or behavior. Surveyor reviewed R35's Care Plan Historical Copy with a discontinued date of 8/9/19. Documented under Problem was I have a mood state problem related to (diagnosis) of mild cognitive impairment. Goal: I will demonstrate optimal participation in daily decisions. Surveyor reviewed R35's current Comprehensive Care Plan with a start date of 9/29/19. Documented was Category: Mood State. PROBLEM: I have a mood state problem related to my dx (diagnosis) of depression and anxiety as evidenced by my use of [MEDICATION NAME] and [MEDICATION NAME] daily. GOAL: I will demonstrate a reduction in presenting physiological, emotional, or cognitive manifestations of anxiety. There is no care plan in place between 8/9/19 and 9/29/19. Surveyor reviewed R35's Care Area Assessments (CAA) with an assessment date of 4/24/19. Documented under Urinary Incontinence and Indwelling Catheter was (R35) is occasionally incontinent of bladder and wears incontinence products. He needs extensive assistance for toilet use .(R35's) type of incontinence and toileting plan reevaluation are underway. After determination of the type of incontinence and selection of his toileting plan his care plan will be updated and interventions will be implemented. Proceed to Plan of Care. Surveyor reviewed R35's Care Plan Historical Copy with a discontinued date of 8/9/19. A problem area of Urinary Incontinence was started 7/14/19. Documented was I have urinary incontinence related to [MEDICAL CONDITION] and urge incontinence due to [MEDICAL CONDITION] and (history) of recent Foley catheter. Surveyor reviewed R35's current Care Plan with a start date of 9/26/19. Documented was Category: Urinary Incontinence. PROBLEM: Urge urinary incontinence (related to) [MEDICAL CONDITION] with recent urolift procedure, [MEDICAL CONDITION]. GOAL: Resident will establish a routine for urinary elimination and my skin will remain clean, dry and intact. There is no care plan in place between 8/9/19 and 9/26/19. Surveyor observed R35's room during survey. Surveyor observed a banner STOP sign across the front of R35's room on 11/04/19 at 10:34 AM, 11/04/19 at 2:32 PM, and 11/05/19 at 7:50 AM. Surveyor reviewed R35's Care Plan Historical Copy with a discontinued date of 8/9/19. There is no care plan for stop sign. Surveyor reviewed R35's current Care Plan with a start date of 9/26/19. There is no care plan for stop sign. On 11/06/19 at 9:52 AM, Surveyor interviewed Registered Nurse (RN)-C. Surveyor asked why there was a stop sign across R35's door. RN-C stated that it was a new thing. RN-C stated another resident comes down the hall and tries to get in his room and he is unable to assist her to leave so he requested that we put that up. How would staff know to put the stop sign up. RN-C stated the care plan. Surveyor noted it is not on the care plan. RN-C stated OK. Well it is relatively new. 10. R6 was admitted to the facility 4/27/19 with [DIAGNOSES REDACTED]. Surveyor reviewed R6's Care Area Assessments (CAA) with an assessment date of 5/4/19. Documented under Nutritional Status was Care Plan: Yes. Care Plan Reason: Resident has triggered for a CAA (do to) a 8.7% significant wt in 30 days. Resident has been experiencing fluid imbalances and ascites and has had more than one paracentesis, triggering the (significant) weight loss. Resident is tolerating a general diet with no (signs or symptoms) of chewing or swallowing difficulties. Resident's appetite has been poor and she is not meeting her needs, (Registered Dietician (RD)) will explore high calorie supplement options. RD will monitor meal intakes, weekly wts, and labs as obtained. RD will (follow up) quarterly and PRN. R6 weighed 141.0 pounds on 9/4/19. R6 had lost 8.46% in 30 days. On 10/24/19 R6 weighed 138.0 pounds. R6 had lost an additional 2.17% in 30 days for a total of 10.51% in 60 days. R6's weight on 11/4/19 was 134.4 for an addition weight loss of 2.99% in 10 days. Surveyor reviewed R6's Care Plan Historical Copy with a discontinued date of 8/9/19. A problem area of Nutritional Status was started 7/28/19. Documented was I am at risk for weight loss related to my [MEDICAL CONDITION] and impaired cognition. I will maintain current admission weight of 152 +/- 5%. Surveyor reviewed R6's current Care Plan with a start date of 10/20/19. There is no nutritional care plan for weight loss. On 11/07/19 at 1:06 PM Surveyor interviewed current RD-F. Surveyor asked if she had assessed R6. RD-F stated that she did not assess her. RD-F stated I know she did have some weight loss because I just reviewed the weights from the facility. RD-F stated in the past R6 had some fluid removed due to her ascites. Surveyor asked if a resident had weight loss would they have a care plan. RD-F stated Absolutely, I have a care plan for everyone. Surveyor noted that there is no care plan for R6. RD-F stated there should be, I will fix that tomorrow. On 11/07/19 at 2:01 PM, Surveyor interviewed Registered Nurse (RN)-C. Surveyor asked why R6 had weight loss. RN-C said most of it was ascites, she was being [MEDICATION NAME] and having paracenteses every other week and increasing her spiralactone. Surveyor asked if it was planned should there be a Care Plan. RN-C stated the RD would do that care plan. Surveyor asked if R6 would need one for that. RN-C stated yes. Surveyor reviewed R6's Care Plan Historical Copy with a discontinued date of 8/9/19. Documented under Problem with a start date of 7/28/19 was (R6) has disturbed sleep pattern due to ([DIAGNOSES REDACTED].) Surveyor reviewed R6's current Comprehensive Care Plan with a start date of 10/19/19. Documented was Category: Mood State. PROBLEM: I have a mood disturbance related to my anxiety and [MEDICAL CONDITION]. GOAL: I will experience decreased anxiety and less calling out and improved sleep enhancement. There is no care plan in place between 8/9/19 and 10/19/19.

Based on interview and record review the facility did not ensure 4 (R2, R5, R36, R3) of 5 residents reviewed had a medication regimen free from unnecessary [MEDICAL CONDITION] medications. R2 continued to received PRN (As Needed) [MEDICATION NAME] past the 3 day physician order. R5 receives [MEDICAL CONDITION] medication without proper monitoring or adequate indications. R36 receives [MEDICAL CONDITION] medication without proper monitoring or adequate indications. R3 receives [MEDICAL CONDITION] medication without proper monitoring or adequate indications. Findings include: 1. R2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R2's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/14/19, documents: A Brief Interview of Mental Status (BIMS) score of 15, indicating R2 is cognitively intact; a Patient Health Questionnaire (PHQ-9) score of 0, indicating no depressive symptoms; active [DIAGNOSES REDACTED]. R2's Care Plan dated 10/12/19-10/14/19 does not document R2's [DIAGNOSES REDACTED]. (Cross Reference F656) R2's Hospital Discharge Summary, dated 10/11/19, documents: . Discharge Plan, Discharge . [MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg oral tablet: 1 tab PO BID (twice a day) PRN (as needed) for anxiety duration 3 day(s). The PRN 0.5 mg [MEDICATION NAME] ([MEDICATION NAME]) remained an active physician's orders [REDACTED]. R2's Medication Administration Record (MAR), dated 10/1/19-10/31/19, documents physician orders [REDACTED]. This medication was on hold and not administered while R2 was hospitalized from [DATE]-10/11/19. The order was restarted on 10/12/19 but never administered. The same MAR documents a physician's orders [REDACTED]. This medication was administered 14 times from 10/12/19-10/31/19 and 6 times from 11/1/19-11/7/19. The PRN [MEDICATION NAME] order was written for longer than the 3 day duration as initially prescribed on R2's hospital discharge summary, dated 10/11/19. Surveyor was unable to locate documentation R2's physician ordered the PRN [MEDICATION NAME] for a longer specified duration past the initial 3 days. On 11/07/19, at 8:57 am, Director of Nursing (DON)-B , who stated, she believes R2's doctor extended the PRN [MEDICATION NAME] order but she isn't certain and will check into it. DON-B stated the doctor's dictated progress is not filed in R2's chart yet. On 11/07/19, at 9:30 am, DON-B stated, R2 had an order for [REDACTED]. Upon return from the hospital R2 continued with the 2:00 am scheduled [MEDICATION NAME] and a new order for PRN [MEDICATION NAME]. The PRN [MEDICATION NAME] order did not reflect the 3 day duration the hospital physician ordered. DON-B reviewed R2's (MONTH) and (MONTH) MAR with Surveyor and informed Surveyor, the facility did not administer R2's 2:00 am scheduled [MEDICATION NAME]. However, staff have been using the PRN [MEDICATION NAME] order and administering the medication around the 2:00 am timeframe. DON-B stated, due to the confusion with the 2 [MEDICATION NAME] orders, R2 has missed 6 prescribed doses of [MEDICATION NAME] between his return from the hospital and today and staff are signing out the scheduled [MEDICATION NAME] does under the PRN order area on the MAR and confirmed the PRN order of [MEDICATION NAME] has continued passed the hospital discharge summary prescribed timeframe of 3 days. DON-B also provided Surveyor with R2's physician's dictated progress note dated 10/31/19. An undated, hand written note was added to the end of the dictated progress note stating, Pt (patient) on PRN [MEDICATION NAME] now can be scheduled at 2 am for night time anxiety. The 2:00 am [MEDICATION NAME] dose was already ordered upon readmission 10/12/19 and the progress note does not address the duration of the PRN [MEDICATION NAME] ordered on [DATE] past the initial 3 days or 14 days per regulations. DON-B stated she is aware that PRN [MEDICAL CONDITION] medications can only be used for 14 days and the physician needs to review at that time. DON-B states R2's orders were mixed up and the PRN [MEDICATION NAME] order was over looked and not discontinued. On 11/06/19, at 3:04 PM, Administrator-A and Director of Nursing-B, were informed of the above concern. 2. R5 was admitted to the facility 12/27/2018 with [DIAGNOSES REDACTED]. R5's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R5 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, had a PHQ-9 (Patient Health Questionnaire) score of 0 indicating no depressive symptoms, had no behaviors, and received an antidepressant daily. R5 has a physician order [REDACTED]. R5's Treatment Administration Record (TAR) shows staff are monitoring R5's behaviors every shift. There is no documentation of what specific behaviors are being monitored. A [MEDICAL CONDITION] Drug Use care plan was initiated 10/8/2019 with the following interventions: -Monitor for effectiveness of medication. Increase dosage gradually if needed. -Monitor my mood and response to medication. -Pharmacy consultant review quarterly. A Mood State care plan was initiated 10/8/2019 with the following interventions: -Administer [MEDICATION NAME] as ordered and monitor for effectiveness and side effects and report to my physician as needed -Allow me to verbalize my feelings and offer TLC (tender loving care) as needed -Monitor my behaviors and observe for patterns or triggers of sadness R5's Progress Notes were reviewed from 8/20/2019 to present. There was no documentation of behaviors elicited by R5. On 11/7/2019 at 10:36 AM, Surveyor interviewed Registered Nurse (RN) Supervisor-C regarding R5's behaviors with depression. RN Supervisor-C stated R5 can get sad if there is a set-back to their health such as a fall. RN Supervisor-C stated if something like that should happen, R5 will want to stay in bed for days. RN Supervisor-C stated what triggers R5 into depression and R5's reaction to those triggers should be put in R5's care plan and TAR to make it individualized so staff know what behaviors should be monitored. 3. R36 was admitted to the facility 7/30/2016 with [DIAGNOSES REDACTED]. R36's quarterly Minimum Data Set (MDS) assessment dated [DATE] coded R36 as having moderate cognitive impairment per staff, had a PHQ-9 (Patient Health Questionnaire) score of 03 indicating minimal depressive symptoms, no behaviors, and receiving daily antianxiety medication and daily antidepressant medication. R36 has a physician order [REDACTED]. R36's Treatment Administration Record (TAR) shows staff are monitoring R36's behaviors every shift. There is no documentation of what specific behaviors are being monitored. A Mood State care plan was initiated 9/25/2019 with the following interventions: -Encourage R36 to become involved with physical activities and social interactions. -Support appropriate moods/behavior. -Work with resident to identify effective coping mechanisms. -Administer medications: [MEDICATION NAME] daily for depression and pain and [MEDICATION NAME] for depression and [MEDICAL CONDITION] and weight loss. Monitor and record effectiveness. Report adverse side effects. (added 10/5/2019) A Behaviors care plan was initiated 9/29/2019 with the following interventions: -I will allow the staff to put a scent tab on my shirt to help reduce my anxiety. The scent tabs contain non-toxic essential oils such as [MEDICATION NAME], relaxation, and stress reduction. The scent tab can stay on for as long as I am willing to wear it. It will only be used to help prevent or reduce a behavior. If I want to take it off staff will help me to remove it. -Please sing to me or offer music to me to help ease my anxiety. (added 10/2/2019) -administer [MEDICATION NAME] twice daily and once daily as needed for 2 weeks, [MEDICATION NAME] daily and [MEDICATION NAME] daily per physician orders. Monitor for effectiveness and side effects. (added 10/5/2019) A [MEDICAL CONDITION] Drug Use care plan was initiated 10/5/2019 with the following interventions: -Consult with pharmacy and physician to consider dosage reduction when clinically appropriate. -psych services through outside psych service -Monitor for target behaviors/symptoms and document per protocol. -Observe document, and report to physician any signs or symptoms of drug related complications. -See Fall care plan. On 10/28/2019 at 6:13 PM in the progress notes, nursing charted R36 had been pacing the halls, entering other residents' rooms, claiming to be sick, dizzy, sweating, and in unbearable pain everywhere. Staff was unable to calm or redirect R36. On 11/7/2019 at 10:39 AM, Surveyor interviewed Registered Nurse (RN) Supervisor-C regarding R36's behaviors. RN Supervisor-C stated R36 constantly complains of abdominal pain and attributes that behavior as anxiety rather than actual pain because when R36's spouse leaves, the behavior intensifies. RN Supervisor-C stated R36's behavior of calling out with abdominal pain should have been in the care plan as a targeted behavior with the specific triggers that cause R36 to have the behaviors. RN Supervisor-C stated those triggers should be put in R36's TAR to make it individualized so staff know what triggers and behaviors should be monitored. 4. R3 was admitted to the facility 4/22/2019 with [DIAGNOSES REDACTED]. R3's quarterly Minimum Data Set (MDS) assessment dated [DATE] coded R3 as being cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, had a PHQ-9 (Patient Health Questionnaire) score of 02 indicating minimal depressive symptoms, no behaviors, and receiving a daily antidepressant medication. R3 had an order for [REDACTED]. R3's Treatment Administration Record (TAR) shows staff are monitoring R3's behaviors every shift. There is no documentation of what specific behaviors are being monitored. A [MEDICAL CONDITION] Drug Use care plan was initiated 10/9/2019 with the following interventions: -Assess/record effectiveness of drug treatment. Monitor and report signs of sedation, [MEDICAL CONDITION], or [MEDICATION NAME] symptoms. -Consult with pharmacy and my physician to consider dosage reduction when clinically appropriate -I will receive the lowest therapeutic dose for control of my symptoms -Monitor my mood and response to medications. -Pharmacy consultant review quarterly. -See Fall care plan A Mood State care plan was initiated 10/9/2019 with the following interventions: -Administer my antidepressant medication as ordered and monitor for effectiveness and side effects. Update physician as needed. -Monitor behaviors and observe for triggers and patterns. R3's Progress Notes were reviewed 8/20/2019 to present with no behaviors documented. On 11/7/2019 at 10:38 AM, Surveyor interviewed Registered Nurse (RN) Supervisor-C regarding R3's behaviors. RN Supervisor-C stated R3 has had major life changes recently and has brought about a depression where R3 doesn't want to participate in things. RN Supervisor-C stated those events should have been in R3's care plan along with R3's reaction to those stressful life events. RN Supervisor-C stated those triggers should be put in R3's TAR to make it individualized so staff know what triggers and behaviors should be monitored.

Based on observation, interview, and record review, the Facility did not provide the necessary care and services to promote healing of a pressure injury and prevent a pressure injury from developing for 5 (Resident #4, #5, #9, #6, #1) of 5 sampled Residents with pressure injuries. ~Resident #4 developed an avoidable, unstageable pressure injury on the left heel and a stage 2 pressure injury to the coccyx. Resident #4's care plan was not revised to reflect the need for change in care. The pressure injuries were not correctly identified upon assessment and discovery of the wounds. ~Resident #5 developed a stage 2 pressure injury to the left heel, which healed and then re-developed. The care plan was not revised to reflect the need for change in care. Facility staff did not regularly or correctly assess and document the pressure injury. ~Resident #9 developed a stage 2 pressure injury on the left hip. Staff did not revise the care plan to reflect the need for change in care. Facility staff did not regularly or correctly assess and document the pressure injury. ~Facility staff did not regularly assess Resident #6's stage 2 pressure injury. ~Facility staff did not regularly or correctly document Resident #1's pressure injury. Examples 1 and 2 involving Resident #4 and Resident #5 are cited at actual harm/isolated. Findings include: The Facility Policy entitled, Wound Care, revised 6/2012 states, .Residents with pressure sores will receive appropriate treatment and services to promote healing prevent infection and prevent new sores from developing. The procedure states, .The nurse or designee defines appropriate ulcer management strategies as the resident status changes. Provides continuing education for all staff. Evaluates the effectiveness of the current ulcer treatment management. Meets with the DON ((director of nursing)), Person First Specialists, and the dietician to discuss the status if any open areas. Each open area is assessed and the care plan is updated as needed. Works with other caregivers to establish and appropriate plan of care for each resident with an ulcer. Provides consultation for difficult to treat ulcers The facility policy also defines the stages of pressure injuries. Staging starts as a stage 1 and increases in severity to stage 4. The facility defines pressure injury stages as follows: Stage I Reddened Area: A persistent area if skin redness (without a break in the skin) that does not disappear when pressure is relieved. Stage II Break in Skin: A partial thickness loss of skin layers that presents clinically as an abrasion, or shallow crater. Stage III Loss of skin with deep tissue involvement and possible necrosis. A full thickness of skin is lost, exposing the subcutaneous tissues, presents as a steep crater with or without undermining adjacent tissue. Stage IV Full skin loss extensive destruction tissue necrosis with possible muscle or bone damage: A full thickness of skin and subcutaneous tissue is lost exposing muscle or bone. During the survey, the Director of Nursing (DON)-B provided the survey team with a policy that was created during the survey noting how to use the new Pressure Sore Report which was to go in effect the week of the survey. The Policy had no date and states, Documentation will be completed accurately for all pressure areas. Separate report forms are used for pressure ulcers and non-pressure skin conditions. This will ensure residents receive proper treatment of [REDACTED]. The procedure states, .Measurements and documentation will be done weekly by the PFNS ((unsure of abbreviation)) or RN ((Registered Nurse)) designee . The procedure also states, Information regarding presence of open areas will be transferred to the care plan. This must be done as soon as area is identified. Follow definition for staging of open areas. During the survey, Surveyor # asked the DON-B to provide the standard of practice the facility used when assessing, documenting, and caring for pressure injuries. DON-B stated Perry and Potter which is a textbook. The citation for the textbook reads below: Perry, A., Potter, P.A., Ostendorf, W. 8th Edition. (2014). Clinical Nursing Skills & Techniques. St. Louis, MO. Elsevier. The following is taken from Perry, Potter, Ostendorf, 2014 regarding wound assessment and staging: The following parameters are included in a wound assessment: · Location: Note the anatomic position of the wound on the body · Type of wound: If possible, note the etiology of the wound (i.e, surgical, pressure, trauma). · Extent of the tissue involvement: Full-thickness wound involves both the dermis only the [MEDICATION NAME] layer. If it is a pressure ulcer use the staging system of the European Pressure Ulcer Advisory Panel (EPUAP) and the National Pressure Ulcer Advisory Panel (NPUAP) (EPUAP and NPUAP, 2009; see Chapter 18). · Type and percentage of tissue in wound base: Describe the type of tissue (i.e. granulation, slough, eschar) and the approximate amount. · Wound size: Follow agency policy to measure wound dimensions, which includes width, length, and depth. · Wound exudate: Describe the amount, color, and consistency. Serous drainage is clear like plasma; sanguineous or bright red drainage indicates fresh bleeding, serosanguineous drainage is pink; and purulent drainage is thick yellow, pale green, or white. · Presence of odor: Note the presence or absence of odor, which may indicate infection · Periwound area: Assess the color, temperature, and integrity of the skin. · Pain: Use a valid pain assessment scale to evaluate pain. Surveyor # noted: The facility's standard of practice for pressure injury references the NPUAP 2009 edition which is outdated ; it does not reflect the current standard for NPUAP as the 2014 edition. Chapter 18 of the textbook also references NPUAP 2009 several times. Chapter 18 is titled Pressure Ulcer Care. 1.) Surveyor # reviewed Resident #4's record from 7/25/16-8/1/16. Resident #4 was admitted to the facility on [DATE] with a most recent re-admission date of [DATE]. Resident #4 had [DIAGNOSES REDACTED]. Resident #4's Quarterly Minimum Data Set ((MDS) dated [DATE] indicates Resident #4 is at risk for pressure injuries but does not have a pressure injury. Resident #4's significant change Minimum Data Set (MDS) assessment dated [DATE] indicates that Resident #4 required extensive assistance from one staff member for bed mobility and transferring. The MDS indicates that Resident #4 required extensive assistance and the assistance of one staff member for locomotion on and off the unit. The MDS indicates that Resident #4 did not walk, and had a Brief Interview for Mental Status Score of 14 out 15 which indicates Resident #4 is cognitively intact. The MDS indicates Resident #4 is at risk for pressure injuries and has 1 unstageable pressure injury measuring 5 cm x 4 cm. Resident #4 began to be followed by Hospice services on 5/12/16 prompting the significant change MDS. Prior to 5/12/16, Resident #4 was not on hospice. On 7/25/16, the Director of Nursing (DON)-B provided the survey team with a list of people with pressure injuries within the facility. Resident #4 was on the list as having a facility acquired pressure injury. STAGE 2 COCCYX WOUND: Documentation related to Resident #4's to the opening of the pressure injury and the measurements of Resident #4's coccyx stage 2 pressure ulcer are as follows: Nurse's notes dated 4/1/16, at 9:37P.M. indicate: OA (open area) remains on L heel. No s/s of infection. No drng (drainage) or active bleeding reported on drsg (dressing). Drsg remains C/D/I (clean/dry/intact). Resident offers no c/o (complaint of) of pain or discomfort. As reported per AM shift Resident has reddened area on buttocks. Found red area to the R of coccyx. N.O. (new order) written for Baza cream BID (twice daily) and (prn). Baza cream applied. Resident encouraged to off load area frequently. Afebrile. Please note, there is no documentation from the initial discovery of the pressure injury. Surveyor # noted this is the first documentation of the pressure injury and this assessment does not follow the recommendations of NPUAP 2014 guidelines for pressure ulcer assessment. Measurements of the area are not obtained and no stage is identified. Nurse's note dated 4/6/16, at 3:41 P.M. indicates: Area right buttock measures 1.2 x 1.0 superficial no drainage, no redness present. Cleansed and small [MEDICATION NAME] applied nurse manager aware. Resident encouraged to lay on side when in bed. This writer observed resident in bed several times throughout shift he was compliant with request. Surveyor # noted this is the first documented measurement of the pressure injury. On 4/15/16, Resident #4 is seen by the wound clinic. Resident #4's wound clinic physician orders [REDACTED]. Nurse's note dated 4/20/16, at 3:51 P.M. indicates: routine dressing done to deep tissue injury on left heel, no changes noted since 4/19/16. Open area on buttock is closed. Surveyor # noted that a Skin Evaluation Form was completed for the coccyx pressure injury on 4/6/16 which includes the stage of the pressure injury, the measurements and description of the wound; this is 3 days after the documentation indicating Resident #4 had a pressure injury. There is no other Skin Evaluation Form for the coccyx stage 2 pressure injury completed by the facility in Resident #4's medical record. Surveyor # reviewed Resident #4's pressure ulcer care plans to review for changes made after the discovery of pressure injuries. Resident #4's general care plan was revised on 4/4/16 which is 3 days after the date of discovery of the coccyx pressure injury. With the 4/4/16 update, no changes were made to the pressure ulcer care plan to indicate that Resident #4 had a stage 2 pressure injury on the coccyx. The pressure ulcer care plan stated, I am at risk for skin breakdown due to incontinence and needs help for bed mobility. no open areas at this time. The listed problem was started 3/24/16, and was not updated upon discovery of the stage 2 pressure ulcer. The interventions listed include the following: Reposition every 1 hours during the day when in bed or chair. Reposition during the night. See Urinary incontinence care plan for toileting schedule. Monitor skin during baths, and weekly. Apply house barrier after each incontinent episode. Use the following positioning/pressure reducing mattress on bed and cushion on wheelchair. Free float heels when in bed to relieve pressure. Surveyor # reviewed the care plan updated on 4/19/16 which also makes no indication of Resident #4 having a stage 2 pressure ulcer to the coccyx. The coccyx pressure ulcer healed on 4/20/16. There is no evidence that the facility updated Resident #4's plan of care to include that Resident #4 had a stage 2 pressure ulcer. UNSTAGEABLE LEFT HEEL WOUND Resident #4's nursing notes include the following documentation related to measurements and assessments of Resident #4's pressure injury in to the left heel: Nurse's Notes on 3/31/16, at 3:40 A.M. indicates: Resident showed his foot to typer (sic)and stated you need to look at it it hurts. Typer checked left foot observed first layer for skin off RN looked at it stated it is an open blister. WASHED AREA APPLIED [MEDICATION NAME] AND KERLIX AROUND IT. Will update DR in am and get an order for [REDACTED].>Nurse's Notes on 3/31/16, at 4:43 P.M. indicate, Red raw open blister left heel measures 5.5cm x 4.0cm small amount of serosanguineous drainage noted coming from area. Examined by DON (Director of Nursing) decision made to tx (treat) with [MEDICATION NAME] and kerlix wrap daily. (Doctor name) on unit and agreed with Tx plan orders written. Resident denies pain, no s/s of infection present. Resident #4's Skin Evaluation Form dated 3/31/16, which is the initial date of discovery, notes a skin category of Partial Thickness Wound which indicates a pressure injury, but for type of skin condition the document states, other. Next to the category, Stage, it states, inapplicable. There are measurements listed, but there is no evidence of an assessment and subsequent documentation aligned with the NPUAP 2014 recommendations for a pressure injury. On 4/15/16 Resident #4 was seen in a wound clinic who measured the pressure injury on the heel as 5cm x 2 cm x 0.1cm. Surveyor # noted this is the first documented measurement and indication of any assessment of the heel since 3/31/16. Resident #4's wound clinic physician orders [REDACTED]. L (left) heel deep tissue injury-1) [MEDICATION NAME] 2) kerlix wrap daily. Wear prevalon boots on feet when sitting supine. The note also states the following related to left heel ulcer, The patient also has an ulcer on his left heel that has been present for 2-3 weeks. The note indicates that Resident #4 was not wearing prevalon boots for protection consistently stating, It sounds like he has prevalon boots at home but he is not wearing these consistently. I have recommended that prevalon boots be worn to both feet when he is sitting or supine to help offload the heels. On 4/25/16, at 4:12 P.M., the facility performs the first follow up on the pressure injury excluding the wound clinic assessment. The nursing note states, routine dressing left heel. This area was assessed by the wound clinic several weeks ago and was determined to be a deep tissue injury. Resident has a 3.5cm x 3.5cm black area consistent with eschar tissue. No s/s (signs/symptoms) of infection noted. Surrounding tissue is circular around the black area, consistent with dry/calloused skin. Resident denies pain. No drainage, no s/s of infection. Surveyor # noted this is more than seven days since any previous assessment. Resident #4's Skin Evaluation Form dated 4/25/16, is the next Skin Evaluation Form documented for Resident #4's left heel pressure injury. There is no Skin Evaluation Form after 3/31/16 until 4/25/16. On this form, there is no pressure injury stage listed and the wound is not called a pressure injury/ulcer on this document. There are measurements listed, but there is no evidence of an assessment and subsequent documentation aligned with the NPUAP 2014 recommendations for a pressure injury. The facility had been given the wound clinic documentation on 4/15/16, calling the left heel wound a deep tissue injury, but this is not relayed to the Skin Evaluation Form in follow up. Nurse's note dated 5/4/16, at 2:21 P.M. indicates: Routine assessment of left heel. Area is 3cm 3xcm (sic). Area continues to be black in color. Peri wound has dry skin around it. No s/s of infection noted. Overall area unchanged from last seen by this writer. Surveyor # noted this is more than seven days since the previous assessment. Resident #4's left heel Skin Evaluation Form dated 5/4/16 indicates the wound category as skin condition, and the type of skin condition as, other. There is no stage listed. The Pressure injury is not called a pressure injury/ulcer on this document. There are measurements listed, but there is no evidence of an assessment and subsequent documentation aligned with the NPUAP 2014 recommendations for a pressure injury. Nurse's note dated 5/11/16, at 11:41 A.M. indicates:, Resident continues with an area of eschar on left heel. This writer had resident soak foot in warm water prior to dressing change. Eschar is 3cm x 3cm. unable to see any tissue under eschar. Surrounding tissue around eschar is thick and yellow and hard. Surround (sic) this then is clear skin, with some areas of peeling skin on rest of the foot. No s/s of infection noted. No pain noted. Surveyor # noted that soaking the Resident's foot in warm water at dressing change is not consistent with current standards of practice related to eschar. Surveyor # noted there is no documentation or assessment to indicate a treatment order was obtained to soak the foot with eschar. The 2014 NPUAP and EPUAP Prevention and treatment of [REDACTED]. Preventive Skin Care (page 17): #3 - Keep the skin clean and dry #5 - Protect the skin from exposure to excessive moisture with a barrier product to reduce the risk of pressure damage. It is important to note that skin damage from moisture is not a pressure ulcer, but that presence of skin damage from moisture may increase the risk of pressure ulceration. Wound Care: Cleansing (page 39) #1 - Cleanse the pressure ulcer at the time of each dressing change Cleanse most pressure ulcers with potable water or normal saline. Debridement (page 40) #12 - Do not debride stable, hard, dry eschar in ischemic limbs 12.1 - Assess stable, hard, dry eschar at each wound dressing change and as clinically indicated.§ Assessment of an ulcer covered with dry, stale eschar should be performed at each dressing change and as clinically indicated to detect the first signs of any developing infection. Clinical indications that the dry, stable eschar requires assessment and intervention include signs and symptoms of [DIAGNOSES REDACTED], tenderness, [MEDICAL CONDITION], purulence, fluctuance, crepitus, and/or malodor (i.e., signs of infection) in the area. 12.2 - Consult a medical practitioner/vascular surgeon urgently in the presence of the above symptoms 12.3 - Debride the ulcer urgently in the presence of the above symptoms (i.e., [DIAGNOSES REDACTED], tenderness, [MEDICAL CONDITION], purulence, fluctuance, and . or malodor). Nurse's note dated 5/18/16, at 9:56 A.M. indicates: routine dressing changed to left heel. The whole open area is 5cm x 5cm. The area of eschar is 3.6cm x 3cm. This remains unchanged. No s/s of infection noted. Peri wound continues with some hard skin, but not as much as compared with last week. Area of peri-wound that does not have hard skin, is clean and regular intact skin. Hospice RN present during dressing change. Surveyor # noted that there is an increase in the size of eschar from 5/11/16 to 5/18/16 and the wound measurement of 5cm x 5cm is larger than the last entire wound measurement taken by the wound clinic on 4/15/16. From 4/15/16 to 5/18/16, the facility did not measure the entire area, only the eschar size which did increase in size according to the documentation. Nurse's note dated 5/25/16, at 11:08A.M. indicates: routine dressing changed to left heel. Whole open area is 5cm x 4cm. This is smaller. The eschar continues to be 3cm x 3cm. The peri wound continues with dry and hard yellow skin. Some of this was able to be removed during wound cleansing. Overall eschar unchanged, decrease in open skin around eschar, as skin around eschar is closed. Nurse's note dated 6/1/16, at 10:58 A.M. indicates: Routine dressing change to open area on left heel. This writer as well as RN from hospice present during dressing change. The eschar of this area is 3cm x 3.5cm. The eschar is surrounded by dry hard and flaky skin. The whole open area is 4cm x 4cm. No s/s of infection, no pain. Eschar remains intact with tissue consistent with slough around some of the edges. Hospice RN will continue to follow up with her team. Surveyor # noted this is the first reference to slough associated with the wound. There is no indication the physician was consulted with when the pressure injury presented with slough. Nurse's notes dated 6/15/16, at 11:28 A.M. indicate: Routine dressing changed to left heel done with this writer, hospice RN and hospice wound care (name). Area noted to have a slight odor, not as bad as last week. Old dressing has a light drainage of slough. Area cleansed. Wound care nurse states that eschar can be cut as it becomes softer. This writer and hospice RN did cut a small piece of eschar. New measurements eschar 2.8 x 3cm. there appears to be slough under eschar. Peri wound intact, no open skin noted on peri wound. No s/s of infection. wound nurse made new recommendations. This writer swabbed eschar with [MEDICATION NAME] and covered with 4x4 and wrapped with kerlix. See chart for new treatment. Surveyor # noted there is no documentation of a wound assessment from 6/1/16 to 6/15/16. The above note dated 6/15/16 indicates a change in condition for the wound after 6/1/16, there is no indication the physician was consulted with when the pressure injury is noted to have slough, unstable eschar and an odor. Nurse's note dated 6/22/16, at 12:07 P.M. indicates: Routine dressing changed to open area on left heel with hospice nurse. Eschar is 2cm x 2.5cm. Eschar is smaller. There appears to be an odor from the eschar area. whole open area is 3.5cm x 3.5cm. There appears to be tissue consistent with slough at 12 oclock where the eschar was. At 6 oclock there appears to be granulation tissue in the area that had been covered with eschar. No s/s of infection. Area appears clean. New treatment started with this dressing changed. Resident is aware that dressing is only changed on Wednesdays and Saturdays. Peri-wound has some yellow colored tissue in a circular fashion surrounding overall open area. No s/s of infection noted. No pain noted during dressing change. Nurse's note dated 6/24/16, at 11:04 A.M. indicates: Resident's left heel dressing was changed yesterday because it had come off while he was outside. His heel was found to be more reddened around the wound margins, extending approximately 3cm beyond the wound. Dressing change was repeated today; the heel again was reddened beyond the wound area, however, not as much as observed yesterday. Sup is aware and will update hospice RN. Nurse's note dated 6/29/16, at 2:30 P.M. indicates: Routine dressing changed to open area left heel. This writer as well as hospice nurse did dressing change. Old dressing had come off heel. There is an odor coming from left heel. There appeared to be some drainage on residents sock. Wound cleansed with wound cleanser. Small amount of eschar removed. Eschar measures 1.5cm x 1.9cm. The whole wound is 3.3cm x 3.0cm. wound remains circular in shape. There is granulation tissue noted on the outer rim of the wound, followed by slough, then the eschar. There is also redness noted medial to wound and lateral. No pain or discomfort noted. Hospice nurse will discuss with hospice wound nurse to review options. New dressing applied . 7/6/16, at 7:38 P.M., Resident was seen by hospice RN today; left heel wound measured at 4 cm diameter with granulation tissue present; will continue same treatment/dressing. Resident #4's skin evaluation form dated 7/6/16 indicates for Resident #4's left heel: Category: full thickness wound. Type: Pressure ulcer. Measuring: 4cm x 4cm. Wound edge: undermining. Drainage type: blank. Color: Brown. Odor: mild. Exudate amt: inapplicable. Stage: unstageable slough and/or eschar. The evaluation notes: Some granulation tissue noted around black eschar. Surveyor # noted the wound description now includes undermining and a mild odor continues to be present. Resident #4's skin evaluation form dated 7/15/16 indicates for Resident #4's left heel: Category: full thickness wound. Type: Pressure ulcer. Measuring: 3.5cm x 3.0cm. Wound edge: undermining. Tissue type: slough. Drain type: blank. Color: inapplicable. Odor: inapplicable. Exudate amt: moderate. Stage: unstageable slough and/or eschar. The evaluation notes: routine dressing change to open area left heel. Moderate amount of bloody drainage noted on old dressing. No eschar noted on wound. Wound base is 75% slough. The remainder of wound is beefy red, with some active bleeding noted. There is an odor from wound, unchanged from previous time this writer assessed wound. There continues to be redness medial to open area. no pain noted. Call out to hospice nurse to review assessment. Resident #4's skin evaluation form dated 7/20/16 indicates for Resident #4's left heel: Category: full thickness wound. Type: Pressure ulcer. Measuring: 3.5cm x 3.0cm depth 0. Wound edge: undermining. Tissue type: slough. Drain type: blank. Color: inapplicable. Odor: inapplicable Exudate amt: moderate. Stage: unstageable slough and/or eschar. The skin evaluation notes: routine dressing change done by this writer. Hospice RN unable to be present. Resident had increase in drainage from wound on old dressing. Drainage is sero-sangious and has a slight odor. Wound bed has increase slough as compared with 7/18. There is also increase redness noted on medial and lateral aspects of wound. MD aware, new odors received. Hospice also aware of new odors. Resident #4's skin evaluation form dated 7/27/16 indicates for Resident #4's left heel: Category: full thickness wound. Type: Pressure ulcer. Measuring: 3.0cm x 3.0cm depth 0.1cm. Wound edge: undermining. Tissue type: granulation. Drain type: blank. Color: inapplicable. Odor: inapplicable. Exudate amt: moderate. Stage: unstageable slough and/or eschar. The skin evaluation form notes: routine dressing changed to open area on left heel. Hospice nurse and wound team present during dressing changed. Old dressing noted to have a moderate amount of sero-sanguineous drainage. Wound is 3cm x 3cm with 0.1cm depth. Wound base continues to have about 15% slough tissue. The rest of the tissue is beefy red. Wound edges are rolled an slight maceration noted. Surrounding tissue is pink in color. No odor noted. New dressing applied. Resident reports no pain at any time. CARE PLAN REVIEW RELATED TO HEEL PRESSURE INJURY Resident #4's care plan was revised on 4/4/16, after the date of discovery of the heel blister on 3/31/16 however, no changes were made to the care plan to indicate that Resident #4 had a pressure injury (blister) on left heel. The care plan stated, I am at risk for skin breakdown due to incontinence and needs help for bed mobility. No open areas at this time. The listed problem was started 3/24/16, and was not updated upon discovery of the pressure injury. The interventions listed include the following: Reposition every 1 hours during the day when in bed or chair. Reposition during the night. See Urinary incontinence care plan for toileting schedule. Monitor skin during baths, and weekly. Apply house barrier after each incontinent episode. Use the following positioning/pressure reducing devices mattress on bed and cushion on wheelchair. Free Float heels when in bed to relieve pressure. Surveyor # reviewed the care plan update from 4/19/16 and at that time, the pressure ulcer care plan was not updated to indicate that Resident #4 had a pressure injury. Surveyor # reviewed the care plan update from 5/24/16 and 6/1/16, and at the time of those updates to the care plan, the pressure ulcer care plan was not changed and did not indicate that Resident #4 had a pressure injury. On 6/11/16, over two months after the initial discovery of the pressure injury that became an unstageable pressure injury, the care plan was updated to reflect that Resident #4 had an unstageable pressure ulcer to the left heel. The following interventions were added at that time: Wound care/dressing change as ordered. Describe: left heel, primarily eschar. See weekly skin notes for more info . Assess wound and report concerns to physician. Provide measures to decrease pressure/irritation to skin. Describe: prevalon boot to left foot at night. Turn and reposition in bed every 2 hours Free float heels when in bed to decrease pressure. Complete assessment of wound weekly, indicating wound size, depth, color, and drainage present until wound is closed. Surveyor # noted the use of Prevalon boots was recommended at the wound clinic on 4/15/16. On 7/25/16, at 10:53 A.M., Surveyor # observed Resident #4 receive a dressing change to the left heel with RN-D. At that time, Surveyor # observed slough in the wound bed and no dark, black eschar. On 7/27/16, at 1:34 P.M., Surveyor # interviewed Resident #4 regarding the use of pressure relieving boots and the heel wound. Resident #4 stated that staff assist him when needed, and also indicated to Surveyor # that he is aware that the boot needs to be present on the left heel. Resident #4 indicated no concerns with the overall care at the Facility, but stated the only concern was this as Resident #4 gestured to the left heel. On 7/27/16, at 8:28 A.M., Surveyor # interviewed Registered Nurse (RN)-D regarding Resident #4's pressure injury to his heel. RN-D indicated to Surveyor # that Resident #4's pressure injury started as a blister, and remained as a blister. The blister would drain fluid. RN-D indicated to Surveyor # that for blisters, staff don't usually do measurements. RN-D indicated to Surveyor that staff thought the blister was something else not related to pressure. RN-D indicated that Resident #4 was diagnosed with [REDACTED].#4 went to the wound clinic. RN-D indicated that staff do not do measurements for a deep tissue injury. Surveyor # asked RN-D what the follow up or change in care was after the wound clinic delivered a [DIAGNOSES REDACTED]. RN-D did not recall what the follow up plan was. RN-D indicated that the family did not want Resident #4 going back to the wound clinic. RN-D noted that they wanted to keep the wound stable and clean after hearing it was a deep tissue injury. At this time RN-D indicated that the primary doctor for Resident #5 comes in weekly and that the facility staff speak to the doctor daily. RN-D indicated that RN-E is wound care certified and comes to morning meetings where wounds are discussed and knew about the wounds. RN-D indicated that wound rounds did not occur until last week. RN-D indicated that Resident #4 is on hospice and once Resident #4 went onto hospice, the hospice wound care nurse had seen Resident #4 and was making recommendations for the care and treatment of [REDACTED].# asked RN-D about removing the eschar from Resident #4's heel ulcer. RN-D indicated that the hospice nurse was wound certified and noted that since the eschar was hanging on by a tiny thread that it could be cut off. On 7/27/16, at 12:34 P.M., Surveyor # briefly interviewed DON-B and asked if there were measurements from 3/31/16 to April 26th or 27th related to Resident #4's pressure injury. DON-B stated, no. The above information was shared with the Facility NHA-A and DON-B throughout the survey and upon final exit from the building on 8/1/16. 2.) Surveyor # reviewed Resident #5's record from 7/25/16-8/1/16. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5's significant change Minimum Data Set ((MDS) dated [DATE] indicates Resident #5 is at risk for pressure injuries and has a stage 1 or greater. Resident #5 has 1 unstageable pressure injury measuring 1 cm x 1 cm with eschar as the most severe tissue type. The MDS indicates this area was not on the previous assessment. Resident #5's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicates Resident #5 was fully dependent on two staff members for bed mobility, toilet use, and transferring. The MDS also indicated that Resident #5 had a Brief Interview for Mental Status Score of 7 out 15 which indicates Resident #5 is severely cognitively impaired. The MDS indicates Resident #5 has a stage 1 or greater pressure injury with a Stage 2 pressure injury being the oldest injury going back to a date of 4/25/16. The most severe tissue type is identified as granulation. On 7/25/16, the Director of Nursing (DON)-B provided the survey team with a list of Residents with pressure injuries within the facility. Resident #5 was on the list as having a facility acquired pressure injury. LEFT HEEL PRESSURE INJURY Nurse's notes dated 4/5/16, at 10:10 A.M. indicate: Dry blister, skin intact to left heel. No complaints of pain to the area. Size: 2.9 cm x 2.1 cm Resident #5's Skin Evaluation Form dated 4/5/16, which is the initial date of discovery, notes a skin category of Skin condition

Based on a complaint investigation, medical record reviews and staff interviews, the facility did not ensure each resident received the necessary supervision to prevent accidents for 3 (Residents #2, #3 & #5) of 5 sampled residents identified as being at risk for falls. *Resident #2 had been identified as a high risk for falls and has care planned falls interventions of a bed and chair alarm, keep call light within reach, keep bed in low position when in bed and place walker/wheelchair beside bed. Resident #2 fell on [DATE], 12/16/14, 12/30/14 (sustaining a fractured clavicle), 02/08/15 and 02/12/15. Through review of incident reports, progress note documentation and staff interviews, the facility did not complete thorough assessments of each fall including attempts to determine reasons for self-transferring or if care planned fall interventions had been in place at the time of each fall. No additional documentation was found to indicate whether Resident #2's falls plan of care was reviewed and/or updated following each fall. Facility staff were unable to supply Surveyor # this information despite repeated requests. *Resident #3 has been identified as a high risk for falls and has care planned falls interventions of a bed and chair alarm, place walker/wheelchair beside the bed and place fall mat beside the bed. Resident #3 fell on [DATE] and 01/22/15. Through review of incident reports, progress note documentation and staff interviews, the facility did not complete thorough assessments of each fall including attempts to determine reasons for self-transferring or if care planned fall interventions had been in place at the time of each fall. No additional documentation was found to indicate whether Resident #3's falls plan of care was reviewed and/or updated following each fall. Facility staff were unable to supply Surveyor # this information despite repeated requests. * Resident #5 has a history of falls, balance problem while standing and is at high risk for falls. Through review of incident reports, progress note documentation and staff interviews, the facility did not complete thorough assessments of each fall including attempts to determine reasons for self-transferring or if care planned fall interventions had been in place at the time of each fall. No additional documentation was found to indicate whether Resident #5's falls plan of care was reviewed and/or updated following each fall. Facility staff were unable to supply Surveyor # this information despite repeated requests. Findings include: 1.) Surveyor # reviewed Resident #2's medical record on 03/10/15. Review of Resident #2's falls plan of care (undated) indicates Resident #2 has had a history of [REDACTED]. Progress note documentation dated 12/07/14 at 1:53p.m., indicates, "Resident sitting on floor in room at 9:30a.m. "Slipped from low bed to floor. Denies hitting head...." Progress note documentation dated 12/16/14 at 10:59p.m., indicates, "Resident was alert and oriented x3 throughout the evening. Friend informed of fall...Resident denies hitting head. ROM (Range of Motion) and Neuro exam within normal limits for resident." Progress note documentation dated 12/30/14 at 5:08p.m., indicates, "Resident fell at 3:00p.m. in room. Resident was found by agency nurse...Resident stated she was trying to get out of bed and into wheelchair and she accidentally fell out of bed...Did complain of left shoulder pain. MD contacted and left shoulder x-ray ordered..." A progress note on 12/30/14 at 6:13p.m., indicates, Received call from radiologist that resident has a left medial clavicle fracture." Resident #2 was then sent to the emergency room for evaluation and treatment. Progress note documentation dated 02/08/15 at 7:10p.m., indicates, "Called to resident room. Observed resident in sitting position leaning her left elbow to the carpet floor..." Resident #2 stated, "my head is too low so I try to get out of bed." Progress note documentation dated 02/12/15 at 3:00p.m., indicates, "Resident was sitting in her wheelchair at her tray table listening to her book on tape, when she states she wanted to sit in the chair in the corner in her room. Resident then told this writer she "made a mistake." Resident states she then slid to the floor..." On 3/10/15 at 10:45a.m., Surveyor # spoke with Registered Nurse (RN)-C and requested any information regarding Resident #2's falls. Surveyor # requested information regarding details of the fall, if the facility knew if care planned interventions were in place at the time of the fall, and if an assessment of the fall was conducted leading to any new falls interventions being put into place to keep Resident #2 safe and free from falls. Surveyors # and # re-interviewed Registered Nurse- C on 3/10/15 at 12:45 p.m.. RN- C stated that she would have to double check any documentation to be sure if interventions were in place at the time of Resident #2's falls . RN- C then provided Surveyor # with a copy of a nursing note dated 12/16/15 that indicated, "Resident #2 observed on floor next to bed, resident states she was trying to get up and walk." On 3/10/15 at 3:30 p.m. DON -B then provided Surveyor # with a copy of an "Incident Report", dated 12/16/14. The report indicates, "Resident observed on floor next to bed, resident states she was trying to get up and walk." The report does not contain information regarding what fall interventions were in place at the time of the fall. Additionally, the sections entitled "Was care plan modified" and "Follow-up Action" were blank. The report did not contain additional information that the facility provided thorough analysis and assessment of the fall. There was no information or staff statement stating if the alarm was sounding or if the low bed was in place. The report does not indicate what Resident #2 was doing prior to the fall, or the last time staff had assisted her. The report also does not provide any information if there was any follow-up action or new interventions put in place as a result of conducting a thorough assessment of this fall. On 3/10/15 at 3:30 p.m. DON -B also provided Surveyor # with a copy of an "Incident Report", dated 12/30/14. The report does not contain information regarding what fall interventions were in place at the time of the fall. Additionally, the section entitled "Was care plan modified" indicates "no" and the section entitled "Follow-up Action" was blank. The report did not contain additional information that the facility provided thorough analysis and assessment of the fall. There were no information or staff statements stating if the alarm was sounding or if the low bed was in place. The report does not indicate what Resident #2 was doing prior to the fall, or the last time staff had assisted her. The report also does not provide any information if there was any follow-up action or new interventions put in place as a result of conducting a thorough assessment of this fall. On 3/10/15 at 3:30 p.m. DON -B then provided Surveyor # with a copy of an "Incident Report", dated 02/08/15. The report does not contain information regarding what fall interventions were in place at the time of the fall. Additionally, the section entitled "Was care plan modified" indicates "no" and the section entitled "Follow-up Action" was blank. The report did not contain additional information that the facility provided thorough analysis and assessment of the fall. There was no information or staff statement stating if the alarm was sounding or if the low bed was in place. The report does not indicate what Resident #2 was doing prior to the fall, or the last time staff had assisted her. The report also does not provide any information if there was any follow-up action or new interventions put in place as a result of conducting a thorough assessment of this fall. On 3/10/15 at 2:10 p.m., Surveyor # interviewed Director of Nursing ( DON )- B in regards to how the facility investigates and assesses falls . DON- B stated that falls are reviewed in Quality Assurance, which meets every 3 months. DON- B stated that the facility staff also discuss all falls in a morning meeting. DON- B stated that RN-C gathers all falls information and reports on the falls. The team then decides if any new interventions need to be put into place. DON- B stated that the facility does not have a formal investigation form that they document falls information on, or any type of assessment or analysis of the fall. 2.) Surveyor # reviewed Resident #3's medical record on 03/10/15. Review of Resident #3's falls plan of care (undated) indicates Resident #3 has a history of multiple falls. Care planned falls interventions include the use of a bed and chair alarm, place walker/wheelchair beside the bed and place fall mat beside the bed. Progress note documentation dated 12/31/14 at 10:16p.m., indicates, "Resident found on floor at approx. 6:30p.m. Resident was assessed by RN..." Progress note documentation dated 01/22/15 at 1:15a.m., indicates, "observed resident lying on his chest with his right arm underneath his body on the floor by the bed." On 3/10/15 at 10:45a.m., Surveyor # spoke with Registered Nurse (RN)-C and requested any information regarding Resident #3's fall on 12/31/14 and 1/22/15. Surveyor # requested information regarding details of the fall, if the facility knew if care planned interventions were in place at the time of the fall, and if an assessment of the fall was conducting leading to any new falls interventions put into place to keep Resident #3 safe and free from falls. Surveyors # and # re-interviewed Registered Nurse- C on 3/10/15 at 12:45 p.m.. RN- C stated that she would have to double check any documentation to be sure if interventions were in place at the time of Resident #3's fall on 12/31/14 and 1/22/15. On 3/10/15 at 3:30 p.m. DON -B then provided Surveyor # with a copy of an "Incident Report", dated 12/31/14. The report indicates, "Resident observed on floor next to bed, resident states she was trying to get up and walk." The report does not contain information regarding what fall interventions were in place at the time of the fall. Additionally, the section entitled "Follow-up Action" was blank. The report did not contain additional information that the facility provided thorough analysis and assessment of the fall. There was no information or staff statement stating if the alarm was sounding or if the low bed was in place. The report does not indicate what Resident #3 was doing prior to the fall, or the last time staff had assisted her. The report also does not provide any information if there was any follow-up action or new interventions put in place as a result of conducting a thorough assessment of this fall. 3.) Surveyor # initiated a medical record review of Resident #5 on 3/10/15. Resident #5 was originally admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. According to the most recent "Falls Risk Assessment", dated 12/21/14, Resident #5 has intermittent confusion, history of falls, balance problem while standing and is at high risk for falls. Resident #5's plan of care, (date unknown) states that Resident #5 has the potential for falls related to poor safety judgement and balance. Listed interventions include hi/low bed, non-skid footwear and bed alarm. A review of the nursing notes showed that on 1/25/15 at 9:30 p.m., Resident #5 had an unwitnessed fall. Nursing note dated 1/25/15 states, "at 9:30 a.m., (Resident #5) observed on the floor in his room in a sitting position near his bed and head against the grab bar. Body check done. Vitals taken. Noted a slight redness to right hip. Initiated cran check. Range of Motion within normal limit. Denies any pain. Assisted back to bed." Surveyor # made a request to the facility administrative staff for any information regarding Resident #5's fall on 1/25/15. Surveyor # requested information about the fall itself, if the facility knew if interventions were in place at the time of the fall, and if an assessment of the fall was conducting leading to any new interventions put into place to keep Resident #5 safe and free from falls. Surveyor # interviewed Registered Nurse- C on 3/10/15 at 12:45 p.m.. RN- C stated that she would have to double check any documentation to be sure if interventions were in place at the time of Resident #5's fall on 1/25/15. RN- C stated she believed they were , but was not entirely sure. RN- C then provided Surveyor # with a copy of a nursing note dated 1/27/15 that stated Resident #5's bed alarm was intact. It was noted that this documentation did not pertain to any information for the fall on 1/25/15. On 3/10/15 at 2:10 p.m., Surveyor # interviewed Director of Nursing ( DON )- B in regards to how the facility investigates and assesses falls . DON- B stated that falls are reviewed in Quality Assurance, which meets every 3 months. DON- B stated that the facility staff also discuss all falls in a morning meeting. DON- B stated that RN-C gathers all falls information and reports on the falls. The team then decides in any new interventions need to be put into place. DON- B stated that the facility does not have a formal investigation form that they document falls information on, or any type of assessment or analysis of the fall. On 3/10/15 at 2:15 p.m. DON -B then provided Surveyor # with a copy of an "Incident Report", dated 1/25/15. The report states that Resident #5 had a fall without injury in his room on 1/25/15. Resident #5 was observed sitting on the floor with his head against the grab bar. The report is prepared by RN- C on 1/26/15. The investigation notes states that Resident #5 has a bed alarm as well as a scoop mattress and grab bars. Will discuss with p.m. shift how to prevent further falls. Further review of the incident report did not show any additional information to indicate that the facility completed a thorough analysis and assessment of the fall. There was no information or staff statements stating if the alarm was sounding or if the low bed was in place or if Resident #5 had his gripper socks on. The report does not indicate what Resident #5 was doing prior to the fall, or the last time staff had assisted him. The report also does not provide any information if there was any follow-up action or new interventions put in place as a result of conducting a thorough assessment of this fall.