Every finding on record at Sheridan Health and Rehabilitation Center

Based on interview and record review the facility did not provide pharmaceutical services to meet the needs of each resident for 1 (R4) of 1 sample resident.R4's blood sugar was not monitored to determine whether R4 required Novolog sliding scale three times daily and R4's Lantus 4 units at bedtime was not administered on 2/6/26 and 3/18/26.Findings include:R4's diagnoses include type 1 diabetes mellitus with diabetic neuropathy and type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema.R4's physician orders with an order date 1/21/26 documents Lantus Subcutaneous Solution 100 unit/ml (milliliter) (Insulin Glargine) Inject 4 unit subcutaneously at bedtime for DM (diabetes mellitus).R4's physician orders with an order date of 1/21/26 documents Novolog injection solution 100 unit/ml (Insulin Aspart) Inject as per sliding scale: if 0-150 = 0 units; 151-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units and call MD (medical doctor), subcutaneously with meals for DM.On 6/18/26, at 12:33 p.m., Surveyor reviewed R4's January 2026, February 2026, March 2026 and April 2026 MARs (medication administration record)Surveyor noted for R4's Novolog sliding scale on 1/30/26 at 8:00 a.m. and 12:00 p.m. the blood sugar is documented as NA. On 1/31/26 at 8:00 a.m. the blood sugar is documented as NA. Surveyor did not note any code on the MAR for NA.On 2/6/26 R4's scheduled Lantus 4 units at 2000 (8:00 p.m.) documents BS. According to chart codes on the February MAR, BS (blood sugar) no coverage required per scale. Lantus is a scheduled insulin and not sliding scale.Surveyor noted during February 2026 for R4's Novolog sliding scale blood sugar documents the following:On 2/2/26 8:00 am the blood sugar is documented as NA and 12:00 p.m. the blood sugar is blank.On 2/3/26 at 1200 the blood sugar is documented as NA.On 2/4/26 at 8:00 a.m. the blood sugar is documented as NA and 12:00 p.m. the blood sugar is blank.On 2/5/26 at 8:00 a.m. the blood sugar is documented as NA.On 2/9/26 at 8:00 a.m. the blood sugar is documented as NA.On 2/10/26 at 8:00 a.m. the blood sugar is documented as NA and at 12:00 p.m. the blood sugar is blank.On 2/13/26 at 8:00 a.m. the blood sugar is documented as NA.On 2/16/26 at 12:00 p.m. the blood sugar is blank.On 2/18/26 at 12:00 p.m. the blood sugar is documented as NA.On 2/23/26 at 8:00 a.m. the blood sugar is documented as NA.On 2/27/26 at 12:00 p.m. the blood sugar is documented as NA.On 2/28/26 at 0800 a.m. the blood sugar is documented as NA.On 3/18/26 R4's scheduled Lantus 4 units at 2000 (8:00 p.m.) is blank.Surveyor noted during March 2026 for R4's Novolog sliding scale the following:On 3/2/26 at 8:00 a.m. the blood sugar is documented as NA.On 3/5/26 at 8:00 a.m. and 1700 (5:00 p.m.) the blood sugar is documented as NA.On 3/9/26 at 12:00 p.m. the blood sugar is documented as NA.On 3/10/26 at 8:00 a.m. and 12:00 p.m. the blood sugar is documented as NA.On 3/16/26 at 12:00 p.m. the blood sugar is blank.On 3/17/26 at 8:00 a.m. the blood sugar is NA.On 3/18/26 at 12:00 p.m. the blood sugar is blank.On 3/19/26 at 8:00 a.m. the blood sugar is documented as NA and at 12:00 p.m. the blood sugar is blank.On 3/24/26 at 12:00 p.m. the blood sugar is blank.On 3/27/26 at 12:00 p.m. the blood sugar is blank.On 3/28/26 at 8:00 a.m. and 12:00 p.m. the blood sugar is blank.On 3/30/26 at 8:00 a.m. and 12:00 p.m. the blood sugar is blank.Surveyor noted during April 2026 for R4's Novolog sliding scale blood sugar documents the following:On 4/1/26 at 12:00 p.m. the blood sugar is blank.On 4/2/26 at 8:00 a.m. the blood sugar is documented as NA and at 12:00 p.m. the blood sugar is blank.On 4/4/26 at 12:00 p.m. the blood sugar is blank.On 4/6/26 at 8:00 a.m. and 12:00 p.m. blood sugar is blank.On 4/7/26 at 12:00 p.m. the blood sugar is blank.On 4/13/26 at 8:00 a.m. and 12:00 p.m. the blood sugar is blank.On 4/20/26 at 8:00 a.m. the blood sugar is documented as NA.On 4/21/26 at 12:00 p.m. the blood sugar is documented as NA.On 4/28/26 at 8:00 a.m. the blood sugar is documented as NA, at 12:00 p.m. the blood sugar is blank and at 1700 (5:00 p.m.) the blood sugar is documented as NA.On 4/30/26 at 8:00 a.m. and 12:00 p.m. the blood sugar is documented as NA.On 6/18/26, at 1:46 p.m., Surveyor spoke with Director of Nursing-B (DON). Surveyor asked DON-B why R4's blood sugars were documented as NA. DON-B informed surveyor Novolog is in their contingency medications. DON-B informed Surveyor she was looking at R4's MAR and then R4's nurses notes and stated to surveyor I can't even answer. I can look into this and get back to you. Surveyor then informed DON-B on 2/6/26 R4's Lantus which is scheduled has no coverage. DON-B informed surveyor she will look into this. Surveyor then informed DON-B of the dates for February & March when R4's blood sugar is documented as NA or blank. DON-B informed surveyor this is not acceptable, blank is also a problem R4's a type 1, if it's not documented it's not done. On 6/18/26 at 2:49 p.m. DON-B telephoned surveyor. DON-B informed surveyor every single one of those dates are one nurse. DON-B informed Surveyor she called and interviewed LPN-C who told her R4's blood sugars were always below parameters, NA is not administered, and there are no nurses' notes including the 3/18/26 Lantus. DON-B informed Surveyor the nurse she didn't know she had to document the actual blood sugar number. DON-B informed Surveyor there were times when it was done correctly. DON-B indicated LPN-C reported it takes too much time to pull up the progress note and write everything as she is very busy in the morning and afternoon. DON-B stated to Surveyor all she can say is, it's deficient practice.On 6/18/26 at 3:04 p.m., surveyor interviewed LPN-C on the telephone. LPN-C informed Surveyor she always checked R4's blood sugar and her blood sugars usually ran low. LPN-C informed Surveyor she clicked on not applicable. LPN-C informed surveyor that she didn't put in a progress note and the blank ones may have been an oversight.

Based on interview and record review, the facility did not provide behavioral health services to ensure a resident received the highest practicable mental and psychosocial well-being. The facility did not implement person centered interventions for substance use disorder (SUD) for 1 of 1 resident (R2) reviewed for SUDs.Based on interview and record review, the facility did not provide behavioral health services to ensure a resident received the highest practicable mental and psychosocial well-being. The facility did not implement person centered interventions for substance use disorder (SUD) for 1 of 1 resident (R2) reviewed for SUDs.Findings include:The facility's undated Social Services policy and procedure documented: .k. Identifying and seeking ways to support resident's dignity in full recognition of each resident's individuality.5.The facility should provide social services or obtain needed services from outside entities during situations that include but not limited to the following:c.Abuse of any kind(e.g. alcohol or other drugs).The facility's reviewed/revised 8/12/25 Trauma Informed Care documented: .7.Trauma-specific care plan interventions will recognize the interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression and anxiety. These interventions will also recognize the survivor's need to be respected, informed, connected, and hopeful regarding their own recovery.The Facility Assessment reviewed 4/27/26 documented:.The facility provided care to residents with psychosis, impaired cognition, mental disorder, depression, bi-polar disorder, schizophrenia, post-traumatic stress disorder(PTSD), history of alcohol abuse, anxiety disorder, expressions that need interventions.Manage medical conditions and medical-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment care of individuals with depression, trauma/PTSD, other psychiatric diagnosis, alcohol/drug abuse, intellectual or developmental disabilities, behavior contracts.R2 was admitted to the facility on [DATE] with diagnoses of Psychoactive substance abuse, Anxiety Disorder, and Depression.R2's Annual Minimum Data Set (MDS) completed 5/25/26 documented R2's Brief Interview for Mental Status (BIMS) score to be 15, indicating R2 was cognitively intact for daily decision making.Surveyor reviewed R2's comprehensive care plan:R2 presents with (history/current) of alcohol/drug abuse. R2 engages in this behavior(weekly). R2 is a risk for alcohol/drug abuse related complications.Initiated 2/17/23Interventions:-Notify social worker to assist with services and offer as needed 2/17/23-Staff should not pass judgement and offer reassurance to R2 2/17/23-Contact doctor for next steps 2/17/23-If R2 is found to be intoxicated staff should contact facility administrator right away 2/17/23-Nurse should ensure incident report is completed, progress note completed and all notifications are made in real time 2/17/23-R2 supplied with facility alcohol anonymous meeting calendar 11/3/23R2 is at risk for substance abuse related current/historical use of other psychoactive substance abuseInitiated 8/6/24Interventions:-Educate resident(R2) on ways to utilize coping skills to deal with feelings of desire for my(R2) preferred substance of choice 8/6/24-Report any suspected use of substances to my(R2) physician 8/6/24R2's Social Services Evaluation completed 4/14/26 documented:R2 had a history of alcohol use and family had a history of substance use. R2 currently or had a history of misusing prescription drugs.R2's Bedside Kardex as of 6/16/26 documented: .If you suspect R2 had been using non-prescribed substances, notify supervisor immediately.Surveyor reviewed R2's progress notes located in R2's electronic medical record.5/6/26, at 7:15 AM, R2 in dining room in wheelchair. Arms flaccid. Not responding to verbal stimuli. Mumbling with eyes closed. Shallow breaths. Narcan given for suspected overdose. 911 called. When EMTs arrived, R2 became more alert at this time. Transfer to emergency room for further evaluation and treatment.On 5/6/26, at 11:36 AM, R2 discharged to 911 transfer due to altered mental status possible overdose.R2's hospital Discharge summary dated [DATE] documented:.R2 with known history of chronic pain issues who ingested some pain medications of sorts and quite somnolent and given intranasal Narcan while in the emergency room. R2 relates that R2 had been very tired and apparently takes oxycodone consistently R2 vapes and R2 also pockets pills and may have actually taken stronger dose than R2 was supposed to. Suicidal or homicidal. R2 denies any drug usage outside of what is prescribed. After Narcan R2 was awake and alert and responsive. R2 presented likely overmedicated or took excessive amounts of R2's pain medications and subsequently became obtunded and lethargic. Regardless R2 was given Narcan and improved significantly supporting the initial consideration.Surveyor noted R2's labs documented in R2's hospital discharge summary noted R2 tested positive for Barbiturates and Cannabinoids.On 5/8/26, Nurse Practitioner (NP)-L documented:.R2 had a history of opioid abuse who was seen today per the nurse's request with reports of opioid abuse. R2 took oxycodone-acetaminophen 325 mg every 6 hours as needed for chronic pain. R2 admits to pocketing the medication and had an overdose requiring Narcan.Plan:Opioid abuse: Monitor for withdrawal. Evaluate need. Assess for sweating, stomach pain, nausea, and emesis. Use Narcan as needed and discontinue the Percocet. Start Tramadol 100mg three times a day and refer to pain management.On 6/17/26, at 9:08 AM, Surveyor interviewed NP-M. NP-M was informed that R2 had been pocketing and snorting pills. NP-M did not want to jeopardize NP-M's license so switched R2 to Tramadol. NP-M informed Surveyor that NP-M was unaware of any prior history of opioid abuse.On 5/25/26, R2 was seen for an individual psychotherapy follow-up session by Psychologist Nurse Practitioner (Psych NP)-M. Psych NP-M documented .R2 has a history of opioid addiction and abuse. Currently has no access to these medications. Continue to monitor status.On 6/17/26, at 9:19 AM, Surveyor interviewed Psych NP-M via telephone. NP-M was aware that NP-M was aware that R2 had overdosed on medications and needed Narcan but did not believe it was a suicide attempt. NP-M was unable to inform Surveyor why NP-M had no documentation of the drug overdose being addressed.On 6/16/26, at 12:24 PM, Surveyor interviewed Resident Care Coordinator (RCC)-N. RCC-N was familiar with R2 but was surprised that R2 had a drug overdose and was not aware of any prior incident with alcohol or drugs.On 6/16/26, at 12:55 PM, Surveyor interviewed Unit Manager (UM)-J in regard to R2. UM-J believed R2's overdose was undetermined. UM-J was aware that R2 required a Narcan at the facility and at the hospital. UM-J believed the overdose was a Delta 8 and UM-J did report to NP-L. UM-J agreed that nursing staff should watch R2 take medications and should not be left at the bedside.On 6/16/26, at 1:12 PM, Surveyor interviewed Social Worker (SW)-I. SW-I was told that R2 had overdosed on gas station THC. SW-I confirmed that SW-I was not aware that the hospital discharge summary documented R2 had been pocketing R2's medications.On 6/16/26, at 3:20 PM, Director of Nursing (DON)-B informed Surveyor that the facility could not prove R2 had an overdose of pain medications. DON-B stated that Delta 8 was the cause of the overdose but agreed that Narcan would have only worked on an overdose of pain medications. DON-B informed Surveyor that DON-B was unaware that the hospital record indicated that R2 had hoarded medications and overdosed.On 6/17/26, at 8:07 AM, both Nursing Home Administration (NHA)-A and DON-B informed Surveyor that NHA-A and DON-B was unaware of what was written in R2's hospital discharge summary. DON-B stated UM-J completed an investigation but was not formal. The facility had no documented investigation of R2's drug overdose to provide Surveyor for review. UM-J made NP-L aware of the hospital documentation. Surveyor shared the concern that UM-J did not communicate the hospital documentation to administration of the facility. DON-B stated, I just found out about it last night. NHA-A stated, it is a problem that we did not know about the documentation from the hospital discharge summary.NHA-A informed Surveyor that a formal investigation should have been completed. Surveyor shared without a formal investigation it was not clear if R2 had been pocketing medications and nursing staff were not watching R2 take, or were they left at bedside. DON-B stated that R2 was always at the nurse's cart asking for R2's pain medications.On 6/17/26, at 8:55 AM, SW-I informed Surveyor that SW-I believed Psych-NP-M was aware of R2's overdose, but SW-I had no documentation to provide. SW-I again informed Surveyor that SW-I was not aware of the hospital discharge summary documentation that R2 of R2's overdosing on pain medications. SW-I confirmed the facility was aware of a history of alcohol and opioid abuse.On 6/17/26, at 12:41 PM, Surveyor shared the concern that the facility was aware of R2's history of alcohol and opioid abuse. Interventions were not implemented and R2 had an overdose while a resident in the facility. Surveyor shared that a formal investigation was not completed and R2's overdose was not addressed upon R2's return from the hospital. NHA-A and DON-B understood the concern.

Based upon observation, interview and record review, the facility did not ensure 2 (R1 and R11) of 4 sampled residents reviewed received medically related social services to address individual Resident needs in order to maintain the highest practicable physical, mental, and psychosocial well-being.*R1and R11were in an intimate relationship and the facility did not complete an Intimate and Sexual History and did not complete a comprehensive care plan with person centered interventions. Findings include:The facility's Social Services undated policy and procedure documented:.2.The facility, regardless of size, will provide medically-related social services to each resident, to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.3.The social worker, will complete an initial and quarterly assessment of each resident, identifying any need for medically-related social services of the resident. Any need for medically-related social services will be documented in the medical record.a.Advocating for residents and assisting them in assertion of their rights withing the facility.k.Identifying and seeking ways to support residents' individual needs through the assessment and care planning process.1)R1 was admitted to the facility on [DATE] with diagnoses of Anxiety Disorder, and Depression.R1's Annual Minimum Data Set (MDS) completed 5/15/26 documented R1's Brief Interview for Mental Status (BIMS) score to be 15, indicating R1 was cognitively intact for daily decision making.2)R11 was admitted to the facility on [DATE] with diagnoses of Anemia, Essential Hypertension, and Hypokalemia.R11's Annual Minimum Data Set (MDS) completed 5/19/26 documented R11's Brief Interview for Mental Status (BIMS) score to be 15, indicating R11 was cognitively intact for daily decision making.On 6/16/26, at 8:54 AM, Surveyor observed R1 and R11 holding hands in R1's room. Both R1 and R11 sitting in wheelchairs close together in the doorway of R1.On 6/16/26, at 10:55 AM, Surveyor interviewed R1. R1 informed Surveyor that R1 and R11 had been in a serious relationship since about October 2025. R1 shared that R1 and R11 sign up for private time in the conference room.On 6/16/26, at 12:24 PM, Surveyor interviewed Resident Care Coordinator (RCC)-N. RCC-N had been aware that R1 and R11 had been in a relationship.On 6/16/26, at 12:55 PM, Surveyor interviewed Unit Manager (UM)-J in regard to R1 and R11's relationship status. UM-J was aware that R11 is R1's boyfriend and had been for a while. UM-J displayed happiness for both R1 and R11 during the discussion with Surveyor.On 6/16/26, at 1:12 PM, Surveyor interviewed Social Worker (SW)-I. SW-I stated SW-I was aware that R1 and R11 had been spending more time together and had been getting closer in the past couple of weeks. SW-I was aware that R1 and R11 had been using the conference room for privacy. SW-I stated, I guess I will have to talk to them about their relationship. SW-I stated SW-I just started completing Intimacy and Sexual History assessments but everyone should have had one completed by now. SW-I stated the Intimacy and Sexual History assessments are completed on admission. SW-I stated a care plan would be initiated based on the outcome of the Intimacy and Sexual History assessment.Surveyor noted that both R1 and R11 did not have a completed Intimacy and Sexual History assessment and both R1 and R11 did not have a completed intimate relationship care plan initiated with person centered interventions.On 6/16/26, at 1:36 PM, Surveyor observed both R1 and R11 outside on the patio holding hands.On 6/16/26, at 3:38 PM, Surveyor interviewed Director of Activities (DA)-O in regard to R1 and R11. DA-O had been aware of R1 and R11's relationship and displayed happiness while discussing the relationship. DA-O stated R1 and R11 were very good together, very cute. DA-O stated R1 and R11 had been serious since about February and was very happy for R1 and R11's recent engagement.On 6/17/26, at 12:41 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that staff were aware that R1 and R11 were in an intimate relationship and both R1 and R11 did not have a completed Intimacy and Sexual History assessment and both R1 and R11 did not have a completed intimate relationship care plan initiated with person centered interventions.

Based on observation, interview, and record review, the facility did not ensure 2 (R3 of R7) of 4 residents had a comprehensive assessment and care plan to either prevent and/or heal pressure injuries.R7 had a deep tissue injury upon admission. On 4/2/26 Wound Physician-G assessed R7's pressure injury as a Stage 3 left buttocks pressure injury and ordered a treatment. The order wasn't picked up until 4/4/26 and was transcribed incorrectly. R7's pressure injury was documented as healed on 4/9/26. There was no update to the care plan to address the potential for impaired skin integrity. The pressure injury reopened on 4/23/26. The facility didn't revise R7's pressure injury care plan nor was there any evidence the facility reviewed the care plan and determined the care plan remained appropriate after R7's pressure injury reopened. R3's admission evaluation on 1/15/26 did not comprehensively assess wounds (skin tear and pressure injury) present upon admission with no documentation of characteristics/description of wound bed or staging. R3 was not adequately assessed until seven days later, on 1/22/26 when the pressure injury had worsened and new treatment physician orders were obtained. The facility did not contact the wound physician when pressure injury worsened. Findings: The facility's policy titled, Pressure Injury Prevention and Management, dated 2/14/23, states, .The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate .Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. Findings should include the type of wound, wound measurements (measured upon discovery and at least weekly thereafter), other wound characteristics (color, exudate, odor, pain, tissue type in wound bed), and treatment and interventions implemented .After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. b. Interventions will be based on specific factors identified in the risk assessment (e.g. moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). 1) R7's diagnoses include functional quadriplegia, moderate protein calorie malnutrition and schizoaffective disorder bipolar type. R7's admission/readmission/routine head to toe assessment dated [DATE] completed by Registered Nurse (RN)-P under the skin integrity section, identifies site 23 (coccyx) as a Stage 2, 3.5 x (by) 3.5 cm (centimeter). R7's admission minimum data set (MDS) with an assessment reference date of 4/2/26 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R7 requires substantial/maximal assistance for roll left & right, and is dependent for toileting hygiene, chair to bed transfer & toilet transfer. R7 has an indwelling urinary catheter and is always incontinent of bowel. R7 is at risk for pressure injuries and is assessed as having one Stage 3 pressure injury which was present upon admission. R7's pressure injury care area assessment (CAA) dated 4/3/26 documents that R7 has potential/actual skin impairment related to a number of diagnoses including functional quadriplegia, adult failure to thrive, intervertebral disc degeneration lumbar region with discogenic back pain only, pressure wound left buttock, trauma wound to BLE bilateral lower extremity. The care plan considerations section was not completed. R7'scare plan initiated and revised on 4/2/26 includes a problem area of, The resident has pressure injury left of the coccyx/buttock r/t (related to).history of ulcers, immobility, deconditioning, and weakness. The complete list of interventions were all initiated on 4/2/26: *Administer medications as ordered. Monitor/document the side effects and effectiveness. *Administered treatments as ordered and monitor for effectiveness. *Follow facility policies/protocols for the prevention/treatment of skin breakdown. *Inform the resident/family/caregivers of any new area of skin breakdown. *Monitor nutritional status. Serve diet as ordered, monitor intake and record. *Obtain and monitor lab/diagnostic work as ordered. Report results to MD (medical doctor) and follow up as indicated. *Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. *The resident requires supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. * Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. *Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Wound Physician-G's assessment dated [DATE] for left buttocks documents for etiology Pressure Ulcer Stage 3. ~Wound bed assessment documents granulation 51-75%, slough 1-25%. Measurements were length 1.29 cm, width 0.89 cm and depth 0.10 cm. ~Treatment: Protect peri wound with skin prep. Cleanse with 1/2 strength Dakin's solution. Secondary dressings: Cover wound with Bordered foam. ~Dressing frequency: Change daily and PRN (as needed) soiling/saturation of dressing. Surveyor reviewed R7's April 2026 Treatment Administration Record (TAR). The TAR indicated R7's treatment of the pressure injury had a start dated of 4/4/26, which is 2 days after the order was placed. The treatment included, cleanse left buttocks wound with 1/2 strength Dakins solution and pat dry. Skin Prep peri wound. Cover wound with foam dressing. every day shift every Tue (Tuesday), Thu (Thursday), Sat (Saturday) for wound care. The treatment documented in the TAR is not consistent with Wound Physician-G's order to complete the dressing change daily. On 6/17/26, at 11:40 a.m., Surveyor asked Unit Manager (UM)-D who is responsible for entering Wound Physician-G's orders into the TAR. UM-D stated Wound Registered Nurse (WRN)-G would enter them. Surveyor reviewed the TAR with UM-D and shared that Wound Physician-D's orders were not implemented for 2 days and the TAR did not reflect the correct frequency for the treatment. R7's left buttock pressure injury healed on 4/9/26. R7's Braden Assessment has a score of 17 which indicates at risk for pressure injury development. There were no updates to the care plan to address the risk of pressure ulcer development or interventions to prevent development/redevelopment of a pressure injury. On 4/23/26, Wound Physician-G assessed R7's left buttocks and documented wound bed was fully granulated and measures length 4.72 cm, width 2.03 cm, and depth 0.10 cm. On 4/23/26 at 12:33 p.m., WRN-E documented R7 was seen by Wound MD (medical doctor) – left buttocks has re-opened. New treatment ordered.Resident is aware of orders and encouraged need to reposition and offload. Primary MD aware. Review of R7's care plan found no revisions were made once the pressure injury redeveloped. On 6/17/26, at 12:33 p.m., surveyor asked UM-D, who is responsible for revising a resident's pressure injury care plan. UM-D indicated it would be updated by WRN-E. Surveyor asked UM-D if anyone reviews a resident's care plan to ensure the care plan has been revised or reviewed after a resident develops a pressure injury. UM-D thought it was DON (Director of Nursing) - B or the MDS nurse, but was not certain. Surveyor informed UM-D that after R7's left buttock pressure injury reopened on 4/23/26 there was no revision in pressure injury care plan or evidence the care plan was reviewed. On 6/17/26 Surveyor reviewed R7's TARs for April, May, and June 2026. 4/5/26-4/30/26: Cleanse left buttocks wound with saline and pat dry. Skin prep peri wound. Cover with foam dressing. Every Tue, Thu, and Sat *Wound care is blank on 4/28/26. 5/8/26-5/21/26: Cleanse left buttocks wound with saline and pat dry. Skin prep peri wound. Cover wound with foam dressing every day shift. *Wound care is blank on 5/8/26, 5/11/26, 5/12/26, 5/15/26, 5/18/26, and 5/19/26. 5/22/26-5/28/26: Santyl external ointment 250 unit/gm (gram) (Collagenase) Apply to left buttocks wound topically every day shift for wound care. Cleanse wound with saline and pat dry. Apply zinc oxide cream around peri wound. Apply Santyl-nickel thick to wound bed and cover with ABD (abdominal) pad and secure with tape. *Wound care is blank 5/27/26 and 6/2/26. 6/5/26-Present: Cleanse left buttocks wound with saline and pat dry. Skin prep peri wound. Cover wound with foam dressing every day shift for wound care related to pressure ulcer of left buttock, Stage 3. *Wound care is blank on 6/9/26, 6/11/26, and 6/12/26. On 6/17/26, at 11:40 a.m., surveyor asked UM-D how the nurses know what treatment they need to complete on their shift. UM-D informed surveyor it is documented on the TAR for them and they sign off on the treatment record. Surveyor asked what it means if the TAR does not have a check and initial. UM-D stated if it's not charted it's not done. 2) R3 was admitted to the facility on [DATE] with restlessness and agitation, malnutrition, and stroke. R3's comprehensive MDS (Material Data System) dated 1/21/26, documented, R3 was severely cognitively impaired, dependent on staff for mobility, incontinent of bladder and bowel, had 1 pressure injury and was at risk for pressure injuries. R3's Progress Note dated,1/15/2026 12:27 PM, documented, Resident arrived to facility .Resident has hx (history) of strokes and seizures .Resident a 0.5cm by 0.5cm OA (Open Area) to coccyx . R3's admission Head-to-toe Evaluation was completed by Licensed Practical Nurse (LPN)-Y dated 1/15/26, documented R3 is at risk for skin alterations and has skin alterations. R3 was identified as having a coccyx wound. The assessment did not include characteristics of the wound such as color, exudate, odor, pain, tissue type in wound bed. The assessment also does not include the stage of the pressure injury. R3's Physician Orders dated 1/15/26 included: ~clean coccyx with NS (normal saline) and place boarder foam 3x (times) a week T, TH, SAT (Tuesday, Thursday, and Saturday) for wound care one time a day . ~Weekly skin check by licensed nurse every day shift every Thu for Preventative Wound Care. ~Braden Scale is to be completed weekly for 4 weeks every day shift every Thu for 4 Weeks Please ensure a Braden Scale Assessment is opened and completed. R3's Physicain Orders were updated on 1/16/26 and included: ~FOOT CHECK (PVD): Visual check of skin condition of both feet, toes, and heels, including color and temperature. ~Air Mattress- Check functioning every shift every shift for Monitoring. R3's care plan dated 1/15/26 included a focus area of actual impairment to skin integrity. Interventions included: Assist to turn and/or reposition every 2-3 hours. Date initiated: 01/15/2026. Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Date Initiated: 01/15/2026. Encourage good nutrition and hydration in order to promote healthier skin. Date Initiated: 01/15/2026. Float heels if resident cannot turn and reposition themselves. Date Initiated: 01/15/2026. Monitor skin during cares. Report to nurse any changes. Date Initiated: 01/15/2026. Pressure reduction mattress. Date Initiated: 01/15/2026. The resident needs pressure reducing cushion to protect the skin while up in wheelchair. Date Initiated: 01/15/2026. Weekly licensed nurse skin evaluation. Date Initiated: 01/15/2026. R3's Wound Summary dated 1/22/26, documented by Wound Registered Nurse (Wound RN)-E, stated R3 wound site was changed from Coccyx to Sacrum and clinically staged as unstageable. The tissue type was slough loosely adherent 100% with moderate-serous exudate. Wound measuring at 3.0 x1.2 x .10 and no signs and symptoms of infection. R3's Physician Order, dated 1/22/26, documented, Santyl External Ointment 250 UNIT/GM (Collagenase) Apply to Sacral wound topically every evening shift for Wound care Cleanse wound to Sacrum with 1/2 strength Dakins solution and pat dry. Skin prep peri wound. Apply Santyl-Nickel thick to wound bed and cover with Bordered gauze. On 6/16/26 at 3:09 PM, Surveyor interviewed Director of Nursing (DON)-B and asked if there was any evidence of a comprehensive wound assessment upon R3's admission on [DATE]. DON-B stated that when R3 was admitted on [DATE], wound rounds had already been completed and the next time the Wound Physician and Wound Nurse would be at the facility would have been on 1/22/26. DON-B stated that was when the wounds were comprehensively assessed. DON-B was asked if a nurse was to asses R3's wounds upon admission and complete a comprehensive assessment to include measurements, wound bed characteristics/description and staging. DON-B stated the admitting nurse is responsible to assess all of this and it is not appropriate that this did not occur. On 6/17/26 at 9:04 AM, Surveyor asked DON-B if there was any additional information for R3's comprehensive assessment. DON-B stated that they could not find any evidence. DON-B stated it was an LPN who did the admission assessment for R3, so this is why the comprehensive wound assessment was not completed.

Based on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 1 (R7) of 2 Residents.*Staff were not wearing gowns during care observations for R7 who is on EBP (enhanced barrier precautions) and appropriate hand hygiene was not observed during pressure injury treatment. Findings include:The facility's policy titled, Enhanced Barrier Precautions and last revised 9/9/25 under guidelines documents It is the guideline of this facility to implement enhanced barrier precaution for the prevention of transmission of multidrug-resistant organisms. Under explanation and compliance guidelines for 3. Implementation of Enhanced Barrier Precautions documents.b. PPE (personal protective equipment) for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. 4. High-contact resident care activities include a. Dressing; b. Bathing; c. Transferring; d. Proving hygiene; e. Changing linens; f. Changing briefs or assisting with toileting; g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC (peripherally inserted central catheter) lines, midline catheters; h. Wound care: any skin opening requiring a dressing.The facility's policy titled, Hand Hygiene and last revised 3/27/25 under guidelines documents All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Under 6. Additional considerations documents a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.R7's diagnoses include functional quadriplegia and schizoaffective disorder bipolar type.R7's physician orders dated 3/27/26 documents Enhanced Barrier Precautions r/t (related to) wound.R7's admission minimum data set (MDS) with an assessment reference date of 4/2/26 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R7 requires substantial/maximal assistance for roll left & right, and is dependent on toileting hygiene, chair to bed transfer & toilet transfer. R7 has an indwelling urinary catheter and is always incontinent of bowel. R7 is at risk for pressure injuries and is assessed as having one Stage 3 pressure injury which was present upon admission.On 6/16/26, at 10:12 a.m., Surveyor observed an enhanced barrier precaution sign posted outside R7's room.On 6/16/26, at 10:50 a.m., Surveyor observed Certified Nursing Assistant (CNA)-F in the process of providing morning cares for R7. CNA-F handed R7 a washcloth and R7 washed their own face. After R7 face was washed, CNA-F positioned R7 on the left side, washed R7's back and removed the incontinence product. Surveyor observed CNA-F is not wearing appropriate Personal Protective Equipment (PPE) as CNA-F has gloves on but is not wearing a gown. CNA-F removed the dressing from R7's left buttocks, washed R7's buttocks and placed an incontinent product under R7.On 6/16/26, at 10:56 a.m., Licensed Practical Nurse (LPN)-C entered R7's room, placed a gown on, washed her hands, and placed gloves on. LPN-C placed the treatment supplies on the overbed table. Surveyor observed LPN-C did not disinfect the overbed table prior to placing the treatment supplies on the overbed table. LPN-C opened her treatment supplies and asked CNA-F to turn R7 on the side. LPN-C cleansed R7's left buttock pressure injury with normal saline, padded the wound bed with gauze and asked R7 if he was okay. LPN-C did not remove her gloves and perform hand hygiene. LPN-C applied skin prep around the peri wound stating it's going to be a little cold. LPN-C removed her gloves and placed gloves on. LPN-C did not perform any hand hygiene. LPN-C placed a border foam dressing over R7's pressure injury, removed her gloves, reached into her pocket for a marker & dated the dressing.At 11:03 a.m., R7 was positioned on their back and CNA-F pulled the incontinence product up between R7's legs. R7 spoke to CNA-F about the foley catheter and then CNA-F asked LPN-C if she could do R7's foley. LPN-C replied I can, stated she needed an alcohol wipe, removed her PPE and left R7's room. Surveyor observed LPN-C did not perform any hand hygiene prior to leaving R7's room. At 11:05 a.m., LPN-C entered R7's room and placed appropriate PPE on. LPN-C cleaned the end of R7's foley catheter, flushed the catheter and then stated okay now I'm done. LPN-C removed her PPE, washed her hands, and left R7's room. CNA-F fastened R7's incontinence product, placed pants & shirt on R7, and a Hoyer sling under R7. CNA-F removed her gloves & washed her hands. CNA-F returned with a Hoyer lift and CNA-Q entered R7's room shortly after. Surveyor observed CNA-F & CNA-Q only had gloves on and are not wearing a gown. The sling was attached to the Hoyer lift and CNA-F & CNA-Q transferred R7 into the wheelchair. CNA-Q placed the Hoyer lift in the hallway and did not return to R7's room. CNA-F placed R7's feet on the foot pedals, brushed R7's hair and placed R7's wheelchair alongside the bed. CNA-F removed her gloves, washed her hands and left R7's room.On 6/16/26, at 11:21 a.m., Surveyor asked CNA-F why she wasn't wearing a gown when she was providing cares & transferring R7 into the wheelchair. CNA-F replied I'm pretty sure it's for bed B and he's in the hospital.On 6/17/26, at 7:48 a.m., Surveyor observed CNA-F in R7's room. Surveyor observed CNA-F was not wearing a gown. CNA-F stated we're finished and placed pants on R7. CNA-F stated to R7 we're going over and R7 was positioned from side to side to place a Hoyer sling under R7.At 7:51 a.m., CNA-F left R7's room with soiled items in a bag.At 7:53 a.m., CNA-F and CNA-R entered R7's room with a Hoyer lift and placed gloves on. Surveyor observed CNA-F & CNA-R were not wearing a gown. The Hoyer sling was attached to the lift and R7 was transferred into the wheelchair. CNA-R placed the Hoyer lift in the hallway, removed his gloves & washed his hands. CNA-F brushed R7's hair, removed her gloves and wheeled R7 out of the room towards the dining room.On 6/17/26, at 11:51 a.m., Surveyor asked Unit Manager (UM)-D how a CNA is aware a resident is on enhanced barrier precautions. UM-D informed surveyor there is PPE outside the door and a sign on the door. Surveyor informed UM-D of the observations with CNA-F, CNA-Q & CNA-R not wearing appropriate PPE and CNA-F informing Surveyor she believed it was R7's roommate who is on enhanced barrier precautions and that resident is in the hospital. Surveyor asked UM-D after a pressure injury is cleansed with normal saline should the nurse remove her gloves & perform hand hygiene and after removing gloves should hand hygiene be performed. UM-D replied yes. Surveyor asked UM-D where a nurse should place treatment supplies in a resident's room. UM-D informed surveyor the nurse should clean off the over bed table before placing treatments supplies on the overbed table. Surveyor informed UM-D of the observations of UM-D not performing hand hygiene and not disinfecting the overbed table prior to placing treatment supplies on the overbed table.

Based on interview and record review the facility did not ensure that 1 (R4) of 5 sampled residents reviewed for activities of daily living (ADL) assistance received the necessary services to maintain ability to practice good grooming and personal hygiene.*R4 did not receive weekly shower on 1/27/26 and 3/10/26.Findings include:The facility's policy titled, Resident Showers last revised 6/11/25 documents 1. Residents will be provided with showers as per request and within reasonable accommodation, or as per facility schedule protocols (at least offered weekly) and based upon resident safety.R4's admission Minimum Data Set (MDS) with an assessment reference date of 1/27/26 has a BIMS of 15 which indicates cognitively intact and R4 is not assessed as having any behavior. R4 is assessed as requiring partial/moderate assistance for shower/bath and chair/bed to chair transfer.On 6/16/26 at 9:37 a.m. and at 9:58 a.m., Surveyor spoke with anonymous family members. During these conversations, Surveyor was informed that R4 complained of not receiving showers. Family indicated they spoke to a nurse about R4 not receiving showers but was unable to provide Surveyor with the name of the nurse they spoke to.On 6/16/26, at 2:03 p.m., during record review surveyor was unable to locate evidence when R4 received a shower.On 6/16/26, at 3:21 p.m., Surveyor requested R4's shower sheets from Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B surveyor asked for shower sheets.On 6/17/26, at 8:36 a.m., surveyor reviewed R4's shower sheets. Surveyor noted the shower sheets dated 1/27/26, 2/3/26, 2/17/26, 3/3/26, 3/10/26, 4/7/26, 4/14/26, and 4/21/26 are blank and do not indicate whether R4 received a shower or refused.On 6/17/26, at 9:01 a.m., surveyor asked Certified Nursing Assistant (CNA)-F about resident showers. CNA-F explained there is a shower binder, every morning the nurse fills out the shower sheets, so they know who has a shower. CNA-F informed Surveyor if a resident refuses, they let the nurse know and would write on the shower sheet refused, or if agree shower or bed bath. Surveyor asked CNA-F if she ever provided R4 with a shower. CNA-F replied yes and explained R4 refused some showers and received some showers.On 6/17/26, at 11:37 a.m., Surveyor asked Unit Manager (UM)-D the process for resident showers. UM-D explained when a resident is admitted they are assigned shower by their room & bed, and this is put in the task section. UM-D informed Surveyor if a resident refuses the shower, it is documented on the sheet and the CNA has to chart under the task. Surveyor informed UM-D that R4's shower sheets had been reviewed and noted multiple days when the shower sheets do not indicate R4 received a shower or refused. UM-D informed surveyor she remembers R4 family said she hadn't had a shower but R4 refused it. UM-D informed surveyor she will look into R4's showers and get back to surveyor.On 6/17/26, Surveyor was provided with additional documentation regarding R4's showers. Surveyor was not provided with documentation for 1/27/26 and 3/10/26 as to whether R4 had received a shower or evidence R4 refused.

Based on interview and record review the facility did not provide a comprehensive care plan for 3 (R1, R2, and R10) of 11 residents reviewed for care plans*R1 had a history of trauma and did not have a comprehensive care plan with person centered interventions for trauma.*R2 had a history of trauma and did not have a comprehensive care plan with person centered interventions for trauma. R2 had been in an intimate relationship with R10 and did not have a comprehensive care plan with person centered interventions for an intimate relationship.*R10 had been in an intimate relationship with R2 and did not have a comprehensive care plan with person centered interventions for an intimate relationshipBased on interview and record review the facility did not provide a comprehensive care plan for 3 (R1, R2, and R10) of 11 sampled residents reviewed for care plans*R1 had a history of trauma and did not have a comprehensive care plan with person centered interventions for trauma.*R2 had a history of trauma and did not have a comprehensive care plan with person centered interventions for trauma. R2 had been in an intimate relationship with R10 and did not have a comprehensive care plan with person centered interventions for an intimate relationship.*R10 had been in an intimate relationship with R2 and did not have a comprehensive care plan with person centered interventions for an intimate relationshipFindings include:The facility's undated Social Services policy and procedure documented: .k. Identifying and seeking ways to support resident's dignity in full recognition of each resident's individuality.6.The resident's plan of care will reflect any ongoing medically-related social service needs, and how these needs are being addressed.The facility's reviewed/revised 8/12/25 Trauma Informed Care documented: .6.The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well ad identify ways to mitigate or decrease the effect of the trigger on the resident, and will be added to the resident's care plan.7.Trauma-specific care plan interventions will recognize the interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression and anxiety.8. The facility will evaluate whether the interventions have been able to mitigate(or reduce) the impact of identified triggers on the resident that may cause re-traumatization.1) R1 was admitted to the facility on [DATE] with diagnoses of Anxiety Disorder and Depression.R1's Annual Minimum Data Set (MDS) completed 5/15/26 documented R1's Brief Interview for Mental Status (BIMS) score to be 15, indicating R1 was cognitively intact for daily decision making.R1's Social Service Evaluation completed 5/12/26 documented R1 had experienced physical assault. The Trauma Informed Care assessment documented verbal and some physical abuse with husband. Surveyor reviewed R1's comprehensive care plan and noted that R1's care plan did not document R1's history of trauma and did not have a comprehensive care plan with person centered interventions for trauma.On 6/17/26, at 8:55 AM, Surveyor interviewed Social Worker (SW)-I in regard to the development of comprehensive care plans. SW-I informed Surveyor that SW-I was responsible for the development of smoking, behaviors, elopement, code status, mood, cognitive, trauma, and substance abuse comprehensive care plans. Surveyor asked SW-I if R1's trauma would be something that should be part of R1's comprehensive care plan. SW-I confirmed that R1's trauma should be documented in R1's comprehensive care plan including person centered interventions for R1's trauma.On 6/17/26, at 12:41 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that R1's trauma was not part of R1's care plan and included person centered interventions care plan. NHA-A and DON-B understood the concern.2) R2 was admitted to the facility on [DATE] with diagnoses of Psychoactive substance abuse, Anxiety Disorder, and Depression.R2's Annual Minimum Data Set (MDS) completed 5/25/26 documented R2's Brief Interview for Mental Status (BIMS) score to be 15, indicating R2 was cognitively intact for daily decision making.R2's Social Service Evaluation completed 4/14/26 documented R2 had experienced physical assault and assault with a weapon. The Trauma Informed Care assessment documented physical assaults with a belt and loss of mom and aunt unexpectedly passed.R2's Intimacy and Sexual History completed 1/30/26 documented R2 was in an intimate relationship with another resident.Surveyor reviewed R2's comprehensive care plan and noted that R2's care plan did not document R2's history of trauma and did not have a comprehensive care plan with person centered interventions for trauma. Further, R2's care plan did not document that R2 was in an intimate relationship with R10 with person centered interventions for an intimate relationship.On 6/17/26, at 8:55 AM, Surveyor interviewed Social Worker (SW)-I in regard to the development of comprehensive care plans. SW-I informed Surveyor that SW-I was responsible for the development of smoking, behaviors, elopement, code status, mood, cognitive, psychosocial, trauma, and substance abuse comprehensive care plans. Surveyor asked SW-I if R2's trauma with person centered triggers would be something that should be part of R2's comprehensive care plan. SW-I confirmed that R2's trauma person centered triggers should be documented in R2's comprehensive care plan. SW-I also confirmed that R2's intimate relationship with R10 should have been part of R2's comprehensive care plan which included person centered interventions. SW-I agreed that an intimate relationship would be a psychosocial concern to be included in a comprehensive care plan.On 6/17/26, at 12:41 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that R2's trauma was not part of R2's care plan and did not have an intimate relationship with person centered interventions care plan. NHA-A and DON-B understood the concern.3)R10 was admitted to the facility on [DATE] with diagnoses of Depression.R10's Quarterly Minimum Data Set (MDS) completed 4/1/26 documented R10's Brief Interview for Mental Status (BIMS) score to be 14, indicating R10 was cognitively intact for daily decision making. R10's Intimacy and Sexual History completed 1/30/26 documented R10 was in an intimate relationship with another resident.Surveyor reviewed R10's comprehensive care plan and noted that R10's care plan did not document R10's intimate relationship with person interventions for an intimate relationship. On 6/17/26, at 8:55 AM, Surveyor interviewed Social Worker (SW)-I in regard to the development of comprehensive care plans. SW-I informed Surveyor that SW-I was responsible for the development of smoking, behaviors, elopement, code status, mood, cognitive, psychosocial, trauma, and substance abuse comprehensive care plans. SW-I confirmed that R10's intimate relationship with R2 should have been part of R10's comprehensive care plan which included person centered interventions. SW-I agreed that an intimate relationship would be a psychosocial concern to be included in a comprehensive care plan.On 6/17/26, at 12:41 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that R10 did not have an intimate relationship with person centered interventions care plan. NHA-A and DON-B understood the concern.

Based on record review and staff interviews, the facility did not ensure all allegations involving potential abuse, neglect, and misappropriation of resident property were thoroughly investigated for 2 of 2 Residents (R1 and R2) of 11 sampled residents.A facility reported incident (FRI) submitted to the State Agency on 5/8/26 stated that R1 had communicated that R2 had been harassing R1 which included R2 watching R1 when R1 slept. The FRI did not contain staff interviews or statements of who may have witnessed inappropriate behaviors from R2 directed at R1 or other residents.Based on record review and staff interviews, the facility did not ensure all allegations involving potential abuse, neglect, and misappropriation of resident property were thoroughly investigated for 2 of 2 Residents (R1 and R2) of 11 sampled residents.A facility reported incident (FRI) submitted to the State Agency on 5/8/26 stated that R1 had communicated that R2 had been harassing R1which included R2 watching R1 when R1 slept. The FRI did not contain staff interviews or statements of who may have witnessed inappropriate behaviors from R2 directed at R1 or other residents.Findings include:The facility's Abuse, Neglect and Exploitation policy and procedure reviewed/revised 5/13/26 documented:Explanation and Compliance Guidelines:.1.The facility will develop and implement written policies and procedures that:b.Establish policies and procedures to investigate any such allegationsV.Investigation of Alleged Abuse, Neglect and ExploitationA. An immediate investigation is warranted when suspicion abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.B. Written procedures for investigations include:1.Identifying staff responsible for the investigation;2.Exercising caution in handling evidence that could be used in a criminal investigation;3.Investigating different types of alleged violations;4.Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations;5.Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause;6.Providing complete and thorough documentation of the investigation;7.Investigations involving alleged financial exploitation or misappropriation should include review of available financial records, copies/images of checks or transaction records, witness interviews, assessment of resident cognition and vulnerability, review of prior staff boundary concerns, and evaluation of whether additional residents may have been affected.R1 was admitted to the facility on [DATE] with diagnoses of Acquired Absence of Right Leg Below Knee, Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Lymphedema, Anxiety Disorder, and Depression.R1's Annual Minimum Data Set (MDS) completed 5/15/26 documented R1's Brief Interview for Mental Status (BIMS) score to be 15, indicating R1 was cognitively intact for daily decision making.R2 was admitted to the facility on [DATE] with diagnoses of Chronic Kidney Disease, Peripheral Vascular Disease, Type 2 Diabetes Mellitus, Psychoactive substance abuse, Anxiety Disorder, and Depression.R2's Annual Minimum Data Set (MDS) completed 5/25/26 documented R2's Brief Interview for Mental Status (BIMS) score to be 15, indicating R2 was cognitively intact for daily decision making.A facility reported incident (FRI) submitted to the State Agency on 5/8/26 stated that R1 had communicated that R2 had been harassing R1which included R2 watching R1 when R1 slept. The FRI documented the facility could substantiate that R2 made unwelcome sexual comments to R1.The facility obtained one staff statement from Registered Nurse (RN)-K. RN-K documented that RN-K observed R1 crying and asked R1 what was wrong. R1 had stated that R2 had been harassing R1 and had told R1 R2 had watched R1 while R1 had slept and wanted to record R1.Surveyor noted the facility's investigation did not include any other staff statements. On 6/16/26, at 1:12 PM, Surveyor interviewed Social Worker (SW)-J in regard to the process of investigating FRIs. SW-J stated that SW-J obtains resident statements, and the Director of Nursing (DON)-B obtains the staff interviews.On 6/16/26, at 3:20 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON-B) in regard to the process of investigating FRIs. Surveyor was informed that NHA-A or DON-B completes staff interviews and sometimes the unit manager. Surveyor was also informed that statements should be obtained from all staff members on shift. Surveyor shared that the FRI that involved R1 and R2 contained only one staff statement. Surveyor shared the concern that had the facility obtained other staff statements, the facility may have determined a pattern of R2's inappropriate behavior. Surveyor shared other staff members may have observed R2 demonstrating inappropriate behavior prior to the incident between R1 and R2 or R2 displaying inappropriate behavior toward other residents. Surveyor expressed that other staff statements may have indicated that R2 may have displayed inappropriate behavior toward vulnerable residents who had not been able to be interviewed.On 6/17/26, at 12:41 PM, Surveyor shared the concern with NHA-A and DON-B that the facility did not complete a thorough investigation of the FRI involving R1 and R2 as evidenced by the facility obtaining only one staff statement.

Based on observation and interview the facility did not provide a safe, clean, comfortable and home-like environment for 1 (R7) of 4 resident's rooms observed.On 6/15/26 and 6/16/26 food crumbs, paper, and other debris were observed under & around R7's bed and under the bedside dresser.Findings include:On 6/16/26, at 10:12 a.m., Surveyor observed R7 in bed. Surveyor observed under R7's bed near the baseboard there is an accumulation of food crumbs, pieces of paper and other debris. On the floor near the head of R7's bed is a roll of tape. On the floor between the bed and the bedside dresser there is a treatment bottle, multiple straw papers and other debris. Under the bedside dresser there is an accumulation of dust, dirt and other debris.On 6/16/26, at 11:17 a.m., 1:12 p.m., and at 3:10 p.m., Surveyor observed R7's room under the bed as previously observed at 10:12 a.m. On 6/17/26, at 7:57 a.m. and at 12:03 p.m., Surveyor observed R7's room. The debris noted on 6/16/26 remained as previously described. On 6/17/26, at 12:06 p.m., while Surveyor was in R7's room, Nursing Home Administrator (NHA)-A approached and asked if everything was alright. Surveyor showed NHA-A food crumbs, paper, & other debris under R7's bed, roll of tape on the floor near the headboard, treatment bottle, multiple straw paper & other debris and under the bedside dresser an accumulation of dust, dirt & other debris. Surveyor informed NHA-A surveyor observed this yesterday during multiple observations. On 6/17/26, at 12:07 p.m., Surveyor asked Housekeeping Manager (HM)-H how she ensures resident's rooms are clean. HM-H explained they have a 5 to 7 step process. HM-H explained they grab the garbage, check supplies, wipe things down vertically & horizontally, dust mop, & damp mop. Surveyor asked HM-H to accompany surveyor to R7's room. When Surveyor & HM-H arrived at R7's room, the housekeeper was in the process of sweeping R7 room. Surveyor informed HM-H the observations of food particles, paper, dust, & other debris observed multiple times on 6/16/26 and 6/17/26. On 6/17/26, at 12:44 p.m., surveyor asked R7 if it was important to him to have a clean room. R7 replied yes, I like a clean room.

Based on interview and record review the facility did not notify 2 of 6 (R1 and R5) resident's representatives of the need to transfer to the hospital. R5's representative was not notified when they were transferred to the hospital.R1's representative was not notified when they were transferred to the hospital. Findings include: The facility policy titled Notification of Changes revised12/22/25 documents, .Circumstances requiring notification include: .2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: .4. A transfer or discharge of the resident from the facility .1. Competent individuals: a. The facility must still contact the resident's physician and notify the resident's representative, if known .c. When a resident is mentally competent, such a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident. 1) R5 was admitted to the facility on [DATE] with an activated POAHC (Power of Attorney for Health Care). On 6/16/26 at 11:00 AM, Surveyor spoke with R5's POAHC. She told surveyor that R5 was in and out of the hospital and the facility never called her whenever R5's health changed. Review of R5's medical record documented R5 was sent to the emergency room and/or hospitalized multiple times: 1/15/26 – sent to the emergency room for evaluation related to amputation site bleeding. There was no evidence that R5's representative/POA was notified of the transfer. 2/3/26 – sent to the emergency room for a change in condition/altered mental status. The Situation, Background, Appearance, Review and Notify (SBAR) form documented: Name of family/health care agent notified – Self. There was no evidence that R5's representative/POA was notified of the transfer. 2/21/26 – sent to the emergency room for a change in condition/altered mental status. The SBAR form documented: Name of family/health care agent notified – Self. There was no evidence that R5's representative/POA was notified of the transfer. 2/24/26 – sent to the emergency room due to hypoglycemia. There was no evidence that R5's representative/POA was notified of the transfer. On 6/17/26 at 9:30 AM, Surveyor spoke with Director of Nursing (DON)-B related to notification of R5's POAHC. DON-B told Surveyor R5 didn't have a POA, that she was her own person. Surveyor asked if a resident is their own person and they are sent to the hospital for a change in condition, if the facility notifies the resident representative/emergency contact. DON-B stated, No, if they're their own person we don't have to call. Surveyor reviewed the facility's policy and procedure with DON-B which indicates notification should be completed. DON-B stated, Well I can tell you that my nurses do not call if they (residents) are their own person, and I can tell you she (R5) wouldn't have wanted her family notified. Surveyor asked DON-B if R5 was asked if she wanted her family notified and DON-B replied, No, but I just know. On 6/17/26 at 10:30 AM, DON-B provided Surveyor R5's POAHC document. DON-B told Surveyor the facility was not aware R5 had an activated POA until the hospital sent the paperwork after she was discharged . 2) R1 was admitted to the facility on [DATE]. R1's Annual Minimum Data Set (MDS) completed 5/15/26 documented R1's Brief Interview for Mental Status (BIMS) score to be 15, indicating R1 was cognitively intact for daily decision making. R1's ex-spouse was listed on R1's face sheet as R1's representative contact. On 5/13/26, R1 had a fall and R1 had informed staff they hit their head on the floor. R1 was sent to the emergency room. Surveyor reviewed the facility's fall investigation and noted there was no documentation that R1's representative contact had been notified by the facility that R1 had been sent to the emergency room. On 6/16/26, at 12:55 PM, Surveyor interviewed Unit Manager (UM)-J. UM-J informed Surveyor that the nurses should be contacting the representative contact when a resident goes to the emergency room. On 6/16/26, at 3:20 PM, Surveyor spoke with DON-B who explained that when a resident is their own person, the representative is not notified when a resident goes out to the hospital. On 6/17/26, at 9:37 AM, Surveyor asked R1 if R1 would like R1's representative contact notified in the event R1 would need to go to the hospital. R1 informed Surveyor: Yes, he is my ex-husband, but I would want him to know.

Based on interview and record review the facility did not ensure a resident's physician was promptly notified of laboratory results that fall outside of clinical reference ranges for 1 (R4) of 1 sample resident.R4's physician was not notified of abnormal laboratory results on 4/10/26 and 4/21/26.Findings include:The facility's policy titled, Provider Lab Notification and last revised 05/07/26 under guideline documents It is the expectation of this facility to ensure the timely receipt, review, interpretation, and communication of laboratory results, and prompt notification of the provider (physician, physician assistant, nurse practitioner, or clinical nurse specialist) in accordance with professional standards of practice and resident condition. Under explanation and compliance guidelines documents 1. The facility must promptly notify provider of lab results that fall outside of clinical reference ranges and/or critical labs per ordering physician's orders. Delayed notification may contribute to delays in changing the course of treatment or care plan. 4. If lab results are outside of clinical reference range, indicated on lab result report, provider will be notified within 4-8 hours of receiving results. Notifications and recommendations will be documented in the medical record. If new orders are received, orders will be entered into the medical record and new orders implemented as directed.R4's diagnoses include hyperkalemia and chronic kidney disease, stage 4.R4's physician order dated 3/3/26 documents BMP (basic metabolic panel) every 2 weeks r/t (related to) hypokalemia, sodium levels.R4's nurses note dated 4/8/26 at 11:19 a.m. written by Unit Manager (UM)-J documents K+ (potassium) noted at 6.2. Writer spoke with MD (medical doctor) and N.O. (new order) for Kayexalate obtained. Order placed. First dose obtained from contingency. Repeat BMP 4/10.On 6/16/26 surveyor reviewed R4's medical record and was unable to locate R4's BMP from 4/10/26On 6/16/26, at 3:21 p.m., during the end of the day meeting surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B surveyor was unable to locate R4's BMP in the medical record for 4/10/26 and asked for R4's lab results.On 6/17/26, at 8:22 a.m., Surveyor reviewed R4's comprehensive metabolic panel results dated 4/9/26 which were not within clinical reference range for potassium 5.3 (3.4-5.1), chloride 120 (97-110), carbon dioxide 14 (21-32), glucose 140 (70-99), BUN 67 (6-20), creatinine 5.34 (0.51-0.95), glomerular filtration rate 11 (>= (greater equal) 60) and calcium 7.2 (8.4-10.2). Surveyor was unable to locate in R4's medical record that R4's physician was notified of these results.Surveyor reviewed R4's comprehensive metabolic panel results dated 4/21/26 which were not within clinical reference range for potassium 5.8 (3.4-5.1), chloride 121 (97-110), carbon dioxide 13 (21-32), BUN 60 (6-20), creatinine 5.47 (0.51-0.95), glomerular filtration rate 10 (>= 60) and calcium 7.5 (8.4-10.2). Surveyor was unable to locate in R4's medical record that R4's physician was notified of these results.On 6/17/26, at 9:17 a.m., Surveyor asked Licensed Practical Nurse (LPN)-C asked about resident's labs. LPN-C informed surveyor the unit managers are handling the labs right now. Surveyor asked LPN-C who would notify the physician of resident's labs. LPN-C informed surveyor if the labs are critical she would. If abnormal not critical name of Unit Manager (UM)-D would.On 6/17/26, at 9:20 a.m., Surveyor asked UM-D to explain the facility's lab process. UM-D informed surveyor everyone is suppose to have a log for the lab but for whatever reason some floor nurses don't initiate the log. UM-D informed surveyor when the nurse gets an order for labs, they give it to her, and she puts the lab orders in. Surveyor asked where lab results are received. UM-D explained the labs are faxed to the printer by the receptionist. Sometimes the floor nurses will get the lab results and sometimes they are in her mailbox. Surveyor asked UM-D who notifies the physician when the lab results are abnormal. UM-D informed surveyor the floor nurse once they get the results. Surveyor informed UM-D that LPN-C reported Surveyor UM-D completes the notification. UM-D replied no, explaining it's the floor nurse. Surveyor informed UM-D R4's labs were not within range on 4/9/26 and 4/21/26 and Surveyor was unable to locate when R4's physician was notified of these abnormal labs. UM-D informed surveyor she will look into this and get back to surveyor.On 6/17/26, at 9:47 a.m., UM-D informed surveyor she didn't see anything charted regarding R4's abnormal labs on 4/9/26 and 4/21/26.

Based on interview, and record review, the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection. *Infection surveillance for July 2025, did not include date of onset, criteria met, culture, results or treatment (if any) for every listed resident.*Infection surveillance for September 2025, did not include signs/symptoms, criteria met, date of onset, culture taken, resulted organism or date infection resolved for every resident listed.Findings:The facility's undated policy titled, Infection Prevention and Control Program documents: The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious disease, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious disease. 3. Surveillance: a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all resident, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. B. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee c. The RNs and LPNs participate in surveillance through assessment of residents and reporting changes in condition to residents' physicians and management staff, per protocol for notification of changes and in-house reporting of communicable diseases and infections.On 01/06/2026, at 8:50 AM, Surveyor reviewed the facility provided infection surveillance documents from January 2025 through December 2025. Surveyor noted there was no infection surveillance logs, infection rates or summary reports for July 2025, August 2025 and September 2025.On 01/06/2026, at 11:36 AM, Surveyor met with Infection Preventionist (IP)-J to go over the infection surveillance logs. IP-J started in the Infection Preventionist role in October 2025 and indicated the former Director of Nursing (DON) was the IP during July, August and September 2025. Surveyor asked about the missing surveillance logs and infection rates, IP-J informed Surveyor the data for July, August and September 2025 are unavailable due to the former DON/IP's record keeping.On 01/06/2026, at 3:12 PM, Surveyor informed Nursing Home Administrator (NHA)-A and DON-B of the concerns regarding missing infection surveillance data for the above months. DON-B informed Surveyor, that DON-B started in September and the missing documentation and information was from the previous DON.On 1/15/2026, at 1:35 PM, Surveyor received additional information from DON-B via email. DON-B sent Surveyor July, August and September 2025 infection surveillance data.Surveyor reviewed the documents provided and noted, the document titled, July- Monthly Infection Surveillance Log for year 2025, did not include: date of onset, if criteria was met, if a culture was preformed/resulted, if precautions were initiated, if treatment was started and when infection resolved for 4 of 7 residents listed. Surveyor reviewed the provided document, titled September-Monthly Infection Surveillance Log for 2025, and noted signs/symptoms, if criteria was met, date of onset, if a cultured and when infection resolved, was not included for 9 of 14 residents listed. In the email sent by DON-B to Surveyor, DON-B informed Surveyor, Here is what I found on my computer. The graphs for September were not completed. Graphs also have 2024 on them but they are from 2025.No additional information was provided as to why the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection.

Based on interview and record review, the facility did not ensure it completed accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to the Centers for Medicare and Medicaid Services (CMS).Staffing information for Quarter 4 (July 1 - September 30, 2025) of the Payroll Based Journal (PBJ) was not accurately submitted to CMS.This deficient practice has the potential to affect all 61 residents residing in the facility.Findings include:The CMS Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2025, documents: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS .1.2 Submission Timelines and Accuracy. Direct care staffing and census data will be collected quarterly and is required to be timely and accurate .Report Quarter: staffing and census data will be collected for each fiscal quarter. Staffing data includes the number of hours paid to work by each staff member each day within a quarter. Census data includes the facility's census on the last day of each of the three months in a quarter. The fiscal quarters are as follows: Fiscal Quarter, Date range: (quarter) 1 October 1-December 31, (quarter) 2 January 1-March 31, (quarter) 3 April 1-June 30, (quarter) 4 July 1-September 30.Surveyor reviewed the PBJ Staffing Data Report for Fiscal year 2025 that documented the facility had excessively low weekend staffing and a one star staffing rating for the 4th Quarter (July 1 - September 30, 2025) of 2025.Surveyor reviewed the facility's weekend scheduled and nurse postings for July 1 - September 30, 2025. Surveyor noted licensed nurses and certified nursing assistants present on each shift and for each unit. Surveyor noted the schedules included call ins/ no shows and documented staff that picked up the open shift. Surveyor noted it did not appear to be excessive with the call ins/ no shows.Surveyor reviewed the facility assessment, documented staffing ratios were compared to the Quarter 4 weekend schedules. No discrepancies were noted or low weekend staffing as reported to CMS.On 1/7/2026, at 11:23 AM, Surveyor interviewed Human Resources (HR)-G who stated corporate offices submit data for the PBJ reports. Surveyor asked HR-G what the process was for submitting the PBJ data. HR-G stated HR-G submits information to the corporate offices and they take care of all the submission. HR-G stated if a registered nurse/ licensed practical nurse (RN/LPN) unit manager, or director of nursing (DON) works an evening shift, night shift, or weekend shift then a spreadsheet gets completed and send it to corporate, otherwise all schedules and nursing hours are submitted through corporate. HR-G stated corporate will contact HR-G if they get notification of a possible staffing issue such as low weekend staffing, then corporate, scheduler-F, and HR-G will look and review schedules to determine what the issue could be, however corporate has not had any concerns with staff. Surveyor asked what could have been the concern with quarter 4 submission of PBJ data. HR-G stated will reach out to corporate and determine what could have been the issue and will follow up with Surveyor.On 1/7/2026, at 2:05 PM, HR-G informed Surveyor HR-G and corporate went over the quarter 4 staffing schedules and stated the ranges are within the facility census and policy and not sure why the facility is flagging for low weekend staffing for quarter 4. HR-G stated corporate would have to look more into it, but at this time was unsure why the facility was flagging excessively low weekends staffing for quarter 4. On 1/7/2026, at 3:00 PM, Surveyor shared concern with Administrator (NHA)-A, and Director of Nursing (DON)-B that the facility flagged for excessively low weekend staffing for quarter 4, despite no low staffing noted on the actual schedules provided by the facility. No additional information was provided.

Based on interview and record review, the facility did not ensure a registered nurse (RN) worked at the facility for at least eight (8) consecutive hours a day, seven days a week, on 1 of 30 days reviewed. This deficient practice had the potential to affect all 56 residents residing at the facility on 12/14/2025. The facility did not have a RN working in the facility for at least 8 consecutive hours on 12/14/2025. Findings include:Surveyor reviewed the facility staff scheduled and nurse posting for the last 30 days (December 2025). Surveyor noted on 12/14/2025 (Sunday) there was not a registered nurse (RN scheduled for 8 consecutive hours. On 1/7/2026, at 8:10 AM, Surveyor interviewed scheduler-K who stated scheduler- K completes the staffing schedules and if there is a call-in during scheduler-K's working hours, then scheduler-K would find a replacement. If a call in occurs after hours, weekends, or holidays then the person on call would be responsible for finding coverage. 12/14/2025 was a Sunday, so whoever was on call that day would be responsible for looking at the schedules to ensure there was coverage and making sure when finding coverage all the requirements were met such as making sure a RN had worked for 8 consecutive hours. Scheduler-K stated 12/14/2025 must have been missed in making sure there was RN coverage and would look into it because scheduler-K always makes sure there is at least 8 consecutive RN hours.On 1/7/2026, at 8:39 AM, scheduler-K stated a RN was scheduled to work night shift on 12/14/2025 however the RN called in and the on-call staff replaced the shift with a licensed practical nurse (LPN) and did not confirm or check to see and make sure another RN replaced the shift or if a RN worked previous shifts. On 1/7/2026, at 3:00 PM, Surveyor shared concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B there was not 8 consecutive hours of RN coverage on 12/14/2025. No further information was provided at the time of this write up.

Based on observation, interview, and record review, the facility did not ensure that drugs and biologicals used in the facility were stored in accordance with currently accepted professional standards for 1 of 2 medication refrigerators located in the medication room.*The North unit refrigerator, located in the medication room, did not have a temperature log to ensure proper temperature range.*R3's insulin vial was not stored in the medication refrigerator.Findings:The Facility policy, titled Medication Storage, with a last reviewed date of 11/12/2024, indicated the following: . 6. Refrigerated Products: a. All medications requiring refrigeration are stored in refrigerators located in the pharmacy and in each medication room. b. Temperatures are maintained 36-46 degrees F (Fahrenheit). Charts are kept on each refrigerator and temperature levels recorded daily by the charge nurse or other designee. On 01/08/2026, at 8:40 AM, Surveyor toured the medication room on the North Unit with Director of Nursing (DON)-B. Surveyor noted there was no temperature log for the medication refrigerator. Surveyor asked DON-B if there is a log kept for the medication refrigerator. DON-B informed Surveyor there is no temperature log for the medication refrigerator and indicated there should be. Surveyor also observed an unopened insulin vial, belonging to R3, in a drawer in the medication room. Surveyor asked DON-B if the insulin is properly store. DON-B informed Surveyor R3's insulin should be in the refrigerator and placed R3's insulin into the refrigerator.Surveyor informed the Facility of the above concern. No further information provided at time of write up.

Based on interview and record review, the facility did not inform residents when changes in coverage was made from Medicare Part A to items and services offered by the facility for which the resident may be charged and the amount of charges for those services by providing the residents with a Notice of Medicare Non-Coverage (NOMNC) and/or the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) for 2 (R23 and R48) of 3 residents reviewed for requiring the NOMNC and SNF ABN to be provided.*R23 was not provided a SNF ABN prior to ending Medicare Part A coverage for services and the NOMNC was emailed to R23's Guardian with no verification of receipt.*R48 was not provided a SNF ABN prior to ending Medicare Part A coverage for services.Findings include:1.) R23 received Medicare Part A coverage for services from 9/6/2025 through 9/13/2025. On 9/11/2025 at 10:58 AM, in the progress notes, Social Service Coordinator (SSC)-I documented R23's Guardian was issued a NOMNC via email. R23's Guardian was provided with the number to call and instructions on how to file an appeal. No appeal would be filed; R23 will be covered by Medicaid.On 1/5/2025, Surveyor requested from Nursing Home Administrator (NHA)-A a copy of R23's SNF ABN and NOMNC. NHA-A provided a copy of the emails sent to R23's Guardian dated 9/10/2025 and 1/5/2026. No SNF ABN was provided to R23's Guardian. The email dated 9/10/2025 to R23's Guardian from SSC-I requested R23's Guardian to sign and return the NOMNC for the facility records and documented R23 would be covered by community care (payment for services), and the notice is to inform them that one insurance will be ending from the hospital stay and billing community care would begin. The email dated 1/5/2026 to R23's Guardian from SSC-I documented an audit was done and a signature was needed on the NOMNC from 9/2025 for their records. SSC-I documented the initial NOMNC was sent to the wrong email address. Surveyor noted the email and audit that was conducted on 1/5/2026 was after Surveyor had requested the information.In an interview on 1/7/2026 at 11:23 AM, Surveyor asked SSC-I about R23's SNF ABN and NOMNC notices. SSC-I stated the emails to R23's Guardian were printed and provided to Surveyor to show they were sent with the NOMNC attachment. Surveyor asked SSC-I why no SNF ABN was provided. SSC-I was not sure of the exact circumstances and would find out more information. Surveyor asked if SSC-I R23's Guardian was contacted by phone along with the email to verify the email had been received. SSC-I stated usually SSC-I will call the resident representative and would put a note in the resident's progress notes. SSC-I stated R23's Guardian's preferred method of communication was through email. SSC-I reviewed the progress note entered on 9/11/2025 and determined R23's Guardian was not talked to over the phone. Surveyor shared with SSC-I the concern R23's Guardian was not provided the SNF ABN to make the determination if an appeal was wanted or needed and there was no verification R23's Guardian received the email. SSC-I stated SSC-I was still waiting to hear back from R23's Guardian from the email that was sent on 1/5/2026.In an interview on 1/7/2026 at 11:43 AM, Surveyor met with Minimum Data Set Coordinator (MDS)-E, Business Office Manager (BOM)-C, SSC-I and NHA-A. MDS-E stated R23 was under skilled observation meaning R23 was observed for eight days and determined therapy was not needed so they put R23 back on the Medicaid payor source. Surveyor shared the concern R23 was using Medicare services and had a change in payor source so should have been given the rights of appeal if that was what they wanted. BOM-C agreed R23 should have been given the SNF ABN notice. Surveyor shared the concern the facility does not have any verification R23's Guardian received the NOMNC. NHA-A and SSC-I agreed the facility did not have any signed documents from R23's Guardian.2.) R48 received Medicare Part A coverage for services from 9/1/2025 through 9/18/2025. R48 did not have an activated Power of Attorney.No documentation was found in R48's progress notes that any notification was provided to R48 with the ending of Medicare services. A NOMNC was provided and signed by R48 on 9/16/2025. No SNF ABN was provided to R48 for R48 to select if an appeal would be wanted to extend Medicare services.In an interview on 1/7/2026 at 11:23 AM, Surveyor asked Social Services Coordinator (SSC)-I about R48's SNF ABN notice. SSC-I stated Medicaid was pending for R48 at the time R48 discontinued Medicare services. SSC-I stated the SNF ABN was not given and that was an error. SSC-I stated there had been a lot of conversations with corporate on when a notice should be given, and it was unclear to SSC-I when the notice should or should not be given.In an interview on 1/7/2026 at 11:43 AM, Surveyor met with Minimum Data Set Coordinator (MDS)-E, Business Office Manager (BOM)-C, SSC-I and Nursing Home Administrator (NHA)-A. MDS-E stated R48 had not maxed out of Medicare days and Medicaid was pending. Surveyor shared the concern R48 was using Medicare services and if Medicaid had not been approved, R48 would have been responsible for payment and had not been given the proper documentation to appeal their rights. NHA-A and BOM-C agreed R48 should have been given the SNF ABN notice.

Based on interview and record review, the facility did not ensure 1 (R9) of 6 resident's reviewed for hospitalization received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, and name and address (mailing and email) with telephone number of the Office of the State Long-Term Care Ombudsman. In addition, the facility did not ensure R9 and/or their representative received written information on the duration of the bed hold policy, the reserve bed payment policy, and the right to return to the facility.R9 was transported and admitted to the hospital on [DATE]. There was no evidence of a transfer notice or bed hold policy being provided to R9 and or R9's representative. Findings include:The facility policy titled Bed Hold Notice last reviewed/ revised on 5/1/2025 documents: Guideline: It is the guideline of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of, a transfer for hospitalization . Explanation and Compliance Guidelines: 1. At the time of transfer to the hospital . the facility will provide the resident and/or resident representative written information that specifies: a. The duration of the State bed hold policy, if any, during which the resident is permitted to return and resume residence at the facility.b. The reserve bed payment policy in the state plan policy.2. In the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed hold policies to the resident and/or resident representative within 24 hours. The facility will document multiple attempts to reach the resident's representative in cases where the facility was unable to notify the representative.3. The facility will keep a signed copy of the bed hold notice information given to the resident and/or resident representative in the resident's file and/or medical record.R9 was admitted to the facility on [DATE]. R9's quarterly Minimum Data Set (MDS) dated [DATE] indicated R9 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 14. R9 did not have an activated power of attorney (POA) and is their own person.On 10/29/2025 R9 had an unwitnessed fall and was sent to the hospital for further evaluation; R9 was admitted to the hospital. R9 was re-admitted to the facility on [DATE].Surveyor reviewed R9's medical record and was unable to locate a transfer notice or bed hold for R9's hospitalization on 10/29/2025 - 11/3/2025. On 1/7/2026, at 3:00PM, Surveyor requested to reviewed R9's transfer and bed hold notice for R9's hospitalization on 10/29/2025. Nursing home administrator (NHA)-A and director of nursing (DON)-B replied they would look for it if it was not uploaded into R9's medical record. On 1/8/2026, at 8:38 AM, Surveyor received the facility policy titled Bed Hold Notice.On 1/8/2026, at 9:04 AM, Surveyor asked DON-B what the process was if a resident was sent to the hospital and admitted . DON-B stated the floor nurse would fill out the transfer notice and bed hold, and the business office manager would follow up with the transfer notice and bed hold to complete it. Surveyor asked DON-B if the bed hold transfer notice could be located for R9's hospitalization on 10/29/2025. DON-B stated they could not locate the transfer notice or bed hold for R9. DON-B stated nursing did not fill one out when R9 was sent to the hospital on [DATE] and the business office manager never followed up after that for R9 to complete a bed hold/ transfer notice on 10/29/2025. Surveyor shared there was a concern R9 did not receive a transfer notice or bed hold policy for R9's hospitalization on 10/29/2025.

Based on interview and record review, the facility did not ensure 1 (R12) of 35 residents reviewed had a comprehensive care plan developed and implemented so that residents can attain their highest practicable physical, mental and psychosocial well-being.* R12 has a diagnosis of vision loss. R12's care plan for impaired visual function did not include person-centered interventions to address R12's needs.Findings:R12 was admitted to the facility on [DATE] with diagnoses including vision loss.R12's Minimum Data Set (MDS) assessment, dated 8/18/2025, documents R12 has a Brief Interview for Mental Status score of 8, indicating moderate cognitive impairment; has moderate vision impairment, cannot see newspaper headlines but can identify objects and does not wear glasses.On 01/05/2026, at 11:25 AM, Surveyor interviews R12 who complains of being blind and needs mail read to her, which staff is not doing.Surveyor reviewed the facility provided document, titled Care Plan Report for R12 and noted a focus area for impaired visual function, with an initiation date of 2/20/2025.Surveyor noted the following as an intervention Identify/record factors affecting visual function including Physiological (glaucoma, Crohn's, macular degeneration, cataracts, color discrimination, light sensitivity, dry eyes); Environmental (poor lighting, monochromatic color scheme), choice (refuses to wear glasses, use mag glass, turn on lights) etc. Surveyor noted no interventions specific to R12's needs and expressed concern for staff reading her mail to her. On 01/06/2026, at 1:03 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-H regarding R12's vision needs. CNA-H informed Surveyor that R12 does have visual deficits, which include having a hard time when watching TV but will let staff know when R12 needs help with changing DVD.On 01/07/2026, at 7:08 AM, Surveyor interviewed Licensed Practical Nurse (LPN) Unit Manager (UM)-D who indicated R12 does have close up visual interventions, optometry appointments, needs assistance with close up with crafts like knitting but is able to read consents and does not use visual aids per physician request. On 01/07/2026, at 7:20 AM, Surveyor informed Director of Nursing (DON)-B of the concerns related to R12's care plan not being specific to R12's visual needs. DON-B indicated DON-B would look into it. On 01/07/2026, at 8:56 AM, Surveyor reviewed the Facility provided Kardex for R12. Surveyor noted R12 now has a special need intervention to offer support with tasks such as crafts, reading, knitting if needed.The Facility was made aware of the above concerns; no further information was provided at time of write up.

Based on observation, interview, and record review the facility did not ensure residents at risk for pressure injuries received necessary treatment and services consistent with professional standards of practice to prevent the development of pressure injuries for 1 (R1) of 4 residents reviewed for pressure injuries.R1's heels were observed to be directly on the mattress and not offloaded according to R1's plan of care.Findings include:The facility policy titled Pressure Injury Prevention and Management last reviewed/revised on 12/3/2024 documents: Policy: This facility is committed to the prevention of avoidable pressure injuries . 4. Interventions for Prevention and to Promote Healing: a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. c. Evidenced- based interventions for prevention will be implemented for all residents who are assessed at risk.R1 was admitted to the facility on [DATE] and has diagnoses that include rheumatoid arthritis, muscle weakness, fibromyalgia, chronic pain syndrome, and adult failure to thrive. R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 10 and the facility assessed R1 as being dependent on 1 staff member for repositioning in bed. R1 has an indwelling catheter and is always incontinent of bowel. R1's preference was to stay confined to R1's bed. The facility assessed R1 on 9/20/2025 to be at moderate risk for pressure injury development with a Braden score of 14.0.R1'a Care Area assessment dated [DATE] documents the following:- Functional Abilities: (R1) has a self-care deficit and requires assistance with activities of daily living (ADLs) due to impaired mobility and weakness. (R1) relies on staff for all transfers and mobility.- Pressure Injury: (R1) is at risk for pressure ulcers related to impaired physical mobility and incontinence. (R1) is assisted to turn and reposition often.R1's potential/actual impairment to skin integrity related to decreased mobility, and history of pressure wounds and rash to bilateral lower extremities care plan was initiated on 2/7/2025 with the following interventions: .- Assist to turn and reposition every 2-3 hours.- Educate resident/ family/ caregivers causative factors and measures to prevent skin injury.- Float heels if resident cannot turn and reposition themselves.On 1/5/2026, at 10:08 AM, Surveyor observed R1 lying in bed. R1's heels were not offloaded and lying directly on the mattress. Surveyor asked R1 if R1's heels should be offloaded. R1 stated R1 rarely gets heels offloaded. Surveyor asked R1 if R1 is able to move around in bed. R1 stated R1 is unable to move around in bed without staff assistance. Surveyor asked if R1 has ever had a pressure injury to the heels or any concerns regarding R1's heels. R1 stated R1 has never had pressure injuries to the heels, but at times the heels do hurt.On 1/6/2026, at 1:12 PM, Surveyor observed R1 lying in bed and R1's heels were not offloaded and were directly on the mattress.On 1/7/2026, at 8:45 AM and 1:28 PM, Surveyor observed R1 lying in bed and R1's heels were not offloaded and were directly on the mattress.On 1/7/2026, at 3:00 PM, Surveyor shared concerns and observations with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of R1's heels not being offloaded according to care plan several days of the survey. DON-B agreed R1's heels should have been offloaded. On 1/8/2026, at 9:14AM, Surveyor observed R1's lower legs on a pillow, however R1's heels were still lying on the mattress and were not offloaded.

Based on interviews and record review the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 1 (R30) resident reviewed for accidents.*R30 was observed self-transferring from R30's bed to wheelchair.Findings:R30 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness on one side of the body).R30 admission Minimum Data Set (MDS), dated [DATE], indicates R30 has ok long and short term memory, has impairment on one side of upper and lower extremities, requires substantial/maximal assistance with lying to sitting, substantial/maximal assistance with sit to stand, substantial/maximal assistance from bed to chair transfer and has had 1 fall since admission to the Facility.Surveyor reviewed the Facility's provided document titled SBAR Communication Form and Progress Note dated 3/1/2025. Surveyor noted R30 sustained a unwitnessed fall while self-transferring.Surveyor reviewed the Facility provided document, titled Care Plan Report for R30, Surveyor noted a Focus area for Activities of Daily Living (ADL) indicating R30 requires assistance of 1 with a gait bely, pivot transfer due to R30's right side flaccid. Surveyor noted another focus area indicating R30 is at risk for falls, with interventions including remove wheelchair from R30's room while R30 is in bed, initiated on 3/4/2025 after R30's previous fall.On 01/05/2026, at 1:03 PM, Surveyor observed R30 in the middle of self-transferring from R30's bed to R30's wheelchair at R30's bedside. On 01/05/2026, at 1:23 PM, Surveyor observed R30 self-transfer from R30's wheelchair back into R30's bed.On 01/06/2026, at 1:00 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-H. CNA-H informed Surveyor that R30 is not considered a fall risk now but was a fall risk upon admission. CNA-H indicated R30 is able to stand unassisted, CNA-H will put the wheelchair on R30's strong side and will stand by in case R30 requires assistance. CNA-H was not aware of R30 being a fall risk or the interventions of R30 not having R30's wheelchair at bed side while R30 is in bed. CNA-H indicated CNA-H would review R30's Care Plan.On 01/07/2026, at 7:01 AM, Surveyor observed R30 in bed with R30's wheelchair at bed side.On 01/07/2026, at 7:05 AM, Surveyor asked Licensed Practical Nurse (LPN) Unit Manager (UM)-D about R30's fall risk status and interventions. LPN UM-D informed Surveyor that R30 is a fall risk, and all interventions are valid and active. LPN UM-D indicated R30 has an intervention to not leave R30's wheelchair at bedside while R30 is in bed to prevent R30 from attempting to self-transfer and possibly falling.On 01/07/2026, at 7:22 AM, Surveyor interviewed Director of Nursing (DON)-B regarding R30 self-transfer and fall interventions not being followed. DON-B informed Surveyor that DON-B believes the fall risk interventions may have been meant for another resident and would get back to Surveyor with more information.On 01/07/2026, at 3:06 PM, Surveyor informed the Facility of the above concerns. Surveyor was informed a therapy evaluation was ordered to evaluate R30's transfer status.No further information was provided as of time of write up.

Based on observation, interview, and record review, the facility did not ensure that 3 of 6 residents (R36, R8, R48) reviewed for accidents received adequate supervision and assistance devices to prevent residents from sustaining continued falls. * The facility did not complete a fall investigation for a second fall R36 sustained on 2/12/2023 and there was no root cause analysis completed for a fall that occurred on 4/27/2023. On 5/4/23, R36 was noted to have been drinking alcohol and exhibiting intoxicated type behaviors. On 5/4/23, R36 had a fall with a head injury, requiring staples. There was no indication the facility increased supervision and monitoring of R36 when R36 was noted with intoxicated type behaviors. There was no indication if care planned interventions were in place at the time of the fall. * R8 was missing a fall investigation for a fall on 12/31/2022, and the physician was not updated regarding R8's falls until several hours later for falls that occurred on 12/26/2023. * On 5/18/23 at approximately 7:30 pm, R48 crawled out of a window and left the facility. The off duty Kitchen Manager (KM)-M saw R48 outside the facility but did not report it to anyone until the following morning. Certified Nursing Assistant (CNA)-N stated she was given a report shortly after the elopement from Licensed Practical Nurse (LPN)-I that R48 left the building. LPN-I denied giving this report or seeing R48 outside the building. Staff did not immediately notify administration of R48's elopement and return to the facility thus delaying interventions being put in place for closer supervision to prevent further elope and to provide for a safe environment. Example 1 regarding R36 rises to a scope and severity level of G (harm/isolated.) Findings include: The facility policy, titled Accidents and Supervision, dated 12/29/2022, states: The resident environment will remain as free of accident hazards as possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazards and risks 2. Evaluating and analyzing hazards and risks 3. Implementing interventions to reduce hazards and risks 4. Monitoring for effectiveness and modifying interventions when necessary . Policy Explanation and Compliance Guidelines: The facility shall establish and utilize a systemic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. 1. Identification of Hazards and Risks - the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. a. All staff . are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. b. The facility should make a reasonable effort to identify the hazards and risk factors for each resident . 2. Evaluation and Analysis - the process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents. Interdisciplinary involvement is a critical component of this process . 3. Implementation of Interventions - using specific interventions to try to reduce a resident's risk from hazards in the environment . 4. Monitoring and Modification - monitoring is the process of evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks . 5. Supervision - Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents . The facility should apply the systemic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. The following steps are necessary in preparation for application of the systemic approach: . 2. The licensed nurse will: a. Conduct an assessment of the resident b. Document inside the medical record c. Consult with physician and resident representative d. Initiate a plan of care to address the known history and/ or observation 3. A root cause analysis should be completed to determine: a. Causal or contributing factor . b. Determine individualized interventions . 1. R36 was admitted to the facility on [DATE] and has diagnoses that include alcohol dependence, alcoholic hepatitis with ascites and hepatic failure, attention deficit hyperactivity disorder, major depressive disorder, anxiety disorder, schizoaffective disorder, convulsions, quadriplegia, multiple sclerosis, muscle weakness, and cognitive communication deficit. R36's quarterly minimum data set (MDS) dated [DATE] indicated R36 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 13 and the facility assessed R36 needing extensive assist with bathing, and supervision with transferring, dressing, toileting, and hygiene. R36 is wheelchair bound and not steady and has to be stabilized with staff present. R36 is sometimes incontinent of bowel and bladder and will usually wear an adult brief. R36 has alcohol dependence and has frequent episodes of being intoxicated in the facility. R36's Risk for falls care plan, initiated on 10/19/2021, had the following interventions in place: - Anticipate and meet the resident's needs (initiated 10/19/2021) - Complete 3 day bowel and bladder diary and schedule toileting if appropriate - Encourage resident to ask for assistance - Fall assessment to be completed upon admission, after falls, quarterly, and as needed - Follow therapy recommendations for transfers and mobility - Place call light within reach - Review information on past falls and attempt to determine cause of falls - Place Dycem under wheelchair seat cushion to prevent sliding (initiated 10/31/2021) - Keep all routinely/always used items within reach (initiated 11/12/2021) - Therapy to evaluate for positioning when using manual wheelchair as needed (initiated 3/4/2022) - Encourage resident to limit alcohol intake as it attributed impaired safety awareness (initiated 4/8/2022) - Encourage resident to limit alcohol intake; offer counseling/cessation treatment (initiated 5/5/2022) - Monitor for intoxication, maintain resident safety, ensure all pathways are free of obstacles and clutter (initiated 6/3/2022) - Encourage resident to wear non-skid shoes or grippy socks when up in manual wheelchair (initiated 7/27/2022) - Replace old Dycem to seat of wheelchair (initiated 8/14/2022) - Place body pillow to left side when resident in bed to provide security and assist in defining parameter (initiated 10/23/2022) - Provide and encourage resident to contact resources for alcohol addiction/abuse and encourage (R36) to call when in crisis. (Initiated 10/24/2022) - Medication review (initiated 1/16/2023) - Resident moved to a room closer to nursing station for increased supervision (initiated 1/22/2023) - Recommend Antabuse (initiated 2/13/2023) - Non prescribed medications removed from room and held for resident. Resident aware and ok wth removal (initiated 3/10/2023) - Place visual cue - Call Don't Fall sign, non-prescribed medications removed. - (R36) is to be one assist with using bathroom. Encourage to use call light for assist through all shifts (initiated 4/28/2023) - Resident encouraged to have door remain open when intoxicated (initiated 5/10/2023) R36's orders for alcohol are as follows: - R36 may have 3 drinks a day. One ounce liquor per drink. Maximum of the three ounces within two hours in a 24 hour period. Hold liquor if R36 appears to be intoxicated or impaired as needed. Started on 4/12/2023 - Hold medications until sober every shift for intoxication. Started 4/15/2023 On 2/12/2023 at 12:53 PM in the progress notes, nursing charted that R36 was found on R36's bedroom floor. R36 was halfway under R36's bed and snoring. Nursing was unable to wake R36 with verbal stimuli. R36 was lethargic and R36's eyes were opening and closing. Nursing noted that R36 did not smell of alcohol and was unable to determine if R36 hit head. 911 was called and R36 was sent to the emergency room for evaluation and treatment. On 2/12/2023 at 6:26 PM in the progress notes, nursing charted R36 returned from the emergency roiagnom on a stretcher and was transferred to R36's bed. Nursing charted about ten minutes later R36 fell out of bed and hit R36's head which resulted in two large bumps. Nursing charted that R36's roommate witnessed R36 having seizure like activity and fell out of bed. 911 was called and R36 was taken back to the emergency room . On 7/12/2023 at 2:34 PM, Surveyor reviewed the fall investigation report for R36's two falls that occurred on 2/12/2023. Surveyor noted there was no fall investigation report for R36's second fall on 2/12/2023. On 7/13/2023 at 10:37 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-F who stated LPN-F slightly recalled R36's second fall on 2/12/2023. LPN-F stated the nurse that was on duty at time of the fall would initiate a fall packet and investigation right after the fall. LPN-F was not sure why there was not a fall investigation for R36's second fall on 2/12/2023. On 7/12/2023 at 3:43 PM, Surveyor received a fall investigation report for a fall R36 had on 4/27/2023. Surveyor noted there was no charting in progress notes regarding R36's fall on 4/27/2023. Surveyor reviewed the fall investigation and noted there was no fall investigation form started or root cause analysis to determine how/why R36 fell . Surveyor noted a Therapy screening tool from 5/2/2023 stating R36 had a fall in the bathroom and therapy to evaluate. On 5/4/2023 at 12:26 AM in the progress notes, nursing charted that R36 signed out and left the facility. Nursing charted that two staff went to look for R36. R36 was found behind the facility with another resident. R36 and the other resident were brought back inside the facility. Nursing charted it appeared that R36 had been drinking. On 5/4/2023 at 6:37 AM in the progress notes, nursing charted R36 slept through night. On 5/4/2023 at 9:39 AM in the progress notes, nursing charted R36 was overly giggly and talkative in the morning. Nursing charted that R36 was flopping around in R36's wheelchair and rummaging through R36's belongings. Nursing tried to determine when/what was R36's last drink but R36 could not remember. On 5/4/2023 at 10:58 AM in the progress notes, nursing charted that R36 was in R36's bathroom and nursing heard a thud and R36's roommate began to yell. Nursing charted that R36 was found lying on R36's back, and blood was pooling around R36's head. Nursing observed a laceration to the back of R36's head and R36's wheelchair was tipped over. 911 was called and R36 was transported to the emergency room . On 5/4/2023 at 3:19 PM in the progress notes, nursing charted that R36 returned to facility from the emergency room and had 6 staples to R36's posterior scalp. Nursing charted R36's neurological status was intact and at R36's baseline. Surveyor noted R36 had been suspected of drinking alcohol on 5/4/23 at 12:26 am. Even though R36 was noted to have slept throughout the night, nursing charting at 9:39 am described R36 as exhibiting intoxicated behaviors such as overly giggly, talkative, flopping around in her wheelchair, and rummaging through belongings. Surveyor did not notice the facility increasing their supervision and/or monitoring of R36 in order to maintain her safety when she was exhibiting intoxicated type behaviors. Surveyor noted the facility's 5/4/23 fall investigation indicated a root cause analysis of R36 being intoxicated stating to EMS (emergency medical services) she drank a couple of bottles today. The facility's fall investigation indicated R36 did not know how her wheelchair tipped over while she was in the bathroom. R36 was noted wearing heeled ankle boots without socks. R36 is noted to sometimes be incontinent of bowel and bladder wearing an adult brief. R36 is assessed to be able to self toilet. The facility's investigation does not indicate if R36 was incontinent at the time of this fall. The facility's investigation does not indicate if increased supervision and monitoring of R36 was conducted to maintain R36's safety. There was no indication if the fall prevention strategies identified in R36's care plan were in place at the time of the fall such as ensuring pathways were free of obstacles and clutter, whether R36 was encouraged to wear non-skid shoes or grippy socks, whether there was Dycem in R36's wheelchair, and whether R36's door to her room was open. On 7/12/2023 at 11:18 AM, Surveyor interviewed Registered Nurse (RN)-K who stated staff try to keep an eye on R36 especially when R36 is intoxicated. Staff are not able to remove alcohol from R36's room unless the alcohol is out in the open and observed. RN-K stated R36's intoxication has improved since getting a physician order for PRN (as needed) drinks. RN-K stated it is probably because R36 knows R36 can have it and does not feel like R36 has to hide it then. On 7/13/2023 at 1:07 PM, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of Surveyor's serious concerns with R36's falls, and intoxication with falls and head injury. DON-B stated they tried to implement a 1:1 for R36 but it made R36 more agitated and anxious, so they stopped. Moving R36's room closer to nursing station has helped. Surveyor stated that the fall with head injury happened in the room across from nursing station. 2. R8 was admitted to the facility on [DATE] with the following diagnoses type 2 diabetes mellitus with complications and polyneuropathy, bilateral above the knee amputations, cerebral infarct, congestive heart failure, altered mental status, major depressive disorder, seizures, and peripheral vascular disease. R8's quarterly Minimum Data Set (MDS) dated [DATE] indicated R8 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 14 and assessed R8 needing limited assist with bed mobility, transferring, dressing, toileting, and hygiene. R8 frequently went outside to smoke and R8 rolled R8's own cigarettes. R8's fall care plan, initiated on 3/28/2022, had the following interventions in place: - Anticipate and meet resident's needs (initiated 3/28/2022) - Be sure residents call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance - educate resident/family/caregivers about safety reminders and what to do if a fall occurs - Physical therapy to evaluate and treat as ordered and as needed - review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter/ remove any potential causes if possible. Educate resident/family/caregivers/ interdisciplinary team as to causes. - move resident to high traffic area for better observation (initiated 5/14/2022) - place Dycem to seat in wheelchair to prevent sliding, replace Dycem to wheelchair (initiated 9/18/2022) - therapy to assess wheelchair appropriateness for sleeping/safety and address as indicated (initiated 10/27/2022) - educate resident to ensure wheelchair is locked before transferring (initiated 11/29/2022) - when resident in room at bedside, ensure all personal items are within reach (initiated 12/26/2022) - monitor when up in wheelchair; if resident is napping encourage to lie down in bed (initiated 1/14/2023) - 3 day bowel and bladder program quarterly and with change in condition (initiated 3/23/2023) - bed to wall for room management and tray table to side of bed allowing view of TV On 12/26/2022 at 9:42 PM in the progress notes nursing charted that R8 had an unwitnessed fall in R8's room. R8 stated R8 was reaching for coffee on R8's side table and fell out of the wheelchair. R8 denied hitting R8's head but got a cut on bridge of nose when sunglasses R8 was wearing bumped into the side table. On 7/12/2023 at 11:42 AM Surveyor reviewed the fall investigation report and noted that the physician was not updated about R8's fall until the next morning on 12/27/2022 at 11:00 AM. On 12/31/2022 at 7:13 PM in the progress notes nursing charted R8 had unwitnessed fall in R8's bedroom. R8 stated R8 slid out of wheelchair. A fall investigation report was not able to be found for R8's fall on 12/31/2022. On 7/13/2023 at 10:37 AM Surveyor interviewed Licensed Practical Nurse (LPN)-F who stated LPN-F slightly recalled R8's fall on 12/31/2022. LPN-F stated the nurse that was on duty at time of the fall would initiate a fall packet and investigation right after the fall. LPN-F was not sure why there was not a fall investigation for R8 fall on 12/31/2022. On 7/13/2023 at 1:07 PM Surveyor informed Nursing Home Administrator (NHA)-A and DON-B of Surveyor's concerns regarding R8's missing fall report for 12/31/2022 fall. DON-B stated DON-B is unable to locate information for falls prior to DON-B starting the DON position on 3/28/2023. No further information was provided at this time. 40533 3. R48 was admitted to the facility on [DATE] with diagnoses that included Contracture of Muscle, Left Hand, Moderate Protein-Calorie Malnutrition, Encephalopathy, Anxiety and Alcohol Dependency. Surveyor reviewed R48's Annual Minimum Data Set (MDS) with an assessment reference date of 6/9/23. Documented under Cognition was a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. Surveyor reviewed Comprehensive Care Plan with an initiation date of 4/7/23. Documented was: Focus: Elopement: [R48] is at risk for elopement related to [alcohol (etoh)] abuse history and resistant to having a [activated power of attorney (APOA)] and resistive to environment. Goal: Resident will not leave the facility without a staff member, family member, or other approved person present. Interventions: o Monitor resident for signs that [she] may be planning on leaving the facility such as wearing a coat or jacket, carrying a bag with possessions in it, or makes statements that [she] is going to leave. Intervene by asking [R48] if [she] is going somewhere and offer an alternative activity. o Wander guard on left leg Check function every shift and [as needed (PRN)]. o Activated POA included in treatment plan. Update as indicated by change in condition or treatment. Surveyor reviewed an Investigation Report prepared by Nursing Home Administrator (NHA)-A. Documented was: Description of event: On 5/18/2023 at approximately 7:30 PM resident R48 exited the facility and came back at approximately 7:50 PM. no injuries noted, POA and MD have been updated. Resident Information: R48 was admitted to this facility on 6/9/2021 and currently has the following dx: Contractor of muscle (left hand), moderate protein calorie malnutrition, AKI, A-fib, Hypokalemia, hypomagnesemia, Anemia, Hypothyroidism, Alcohol Dependence, change in bowel habit, chronic pain, SIRS. [R48's daughter], is her activated POA-HC. [R48] has a BIMS (Brief Interview for Mental Status) score of 10 meaning R48's cognition is moderately impaired. [R48] has a wander guard in place but has not shown any signs of exit seeking. Actions Taken: o Skin assessment was completed, no new areas were noted. o Pain assessment was completed, no new pain was identified. o The elopement risk was completed; 1:1 placed initially. o [R48] statement was taken by this writer and [Director of Nursing (DON)-B]. Per [R48], she climbed out of the window of resident [R41's] room at approximately 7:30 PM and returned around 7:55 PM. [R48] stated that she went to the liquor store and did not do anywhere else. Per [R48], she climbed back in the window. [R48] denied falling or hurting herself when doing this. [R48] was providing verbal risks of her behavior and verbalized understanding. o The window that [R48] climbed out of was immediately assessed to ensure it opened and closed properly. o Staff Statements were collected which indicated that staff was unaware of [R48] leaving the facility. o Staff member, [KM-M], (who was picking her children up from work) stated she did see [R48] outside of the facility around 7:55 PM walking to the side of the building but was unaware that she was not suppose to be out. [KM-D] was re-educated regarding notification to Administrator. o [CNA-N] stated that [LPN-I] informed her that [R48] was out of the facility and was going to get her. o [LPN-I] stated that she was not aware that [R48] was out of the facility that night. Per [LPN-I], she recalls seeing a shadow, by a resident's window in their room, but was unable to recall what room she saw this in. o POA was notified and care conference has been scheduled for 5/31/2023 at 11:00AM o MD was notified o Staff statements were collected. Investigation conclusion: After this investigation it was concluded that [R48] exited the building via bedroom window to go to the liquor store. Per [R48], she was only gone for about 25 minutes. A skin assessment and pain assessment were completed which resulted in no new concerns. [R48's POA] updated the situation. A care conference was scheduled for 5/31/2023 to discuss a plan for discharge to a less restrictive environment for [R48] to assist to increase her sense of autonomy. [R48] was placed on a 1:1 until 5/24/2023 when Maintenance completed house wide audit to ensure all windows opened and closed appropriately for resident safety. [R48] has continued to socialize with other residents and participates in the activities of her choice. On 07/12/23 at 3:35 PM Surveyor interviewed CNA-N. Surveyor asked about the night of 5/18/23 when R48 eloped. CNA-N stated that LPN-I asked if she saw that R48 was outside. CNA-N stated LPN-I said to her I think I just saw her outside and I am going to go check. CNA-N stated LPN-I brought R48 back inside. Surveyor asked if she notified Administration. CNA-N stated no, LPN-I would do that. Surveyor asked if any increased supervision of R48 was put in place or any other interventions at that time. CNA-N stated no, she was put on 1:1 the next day, 5/19/23. On 7/13/23 at 7:33 AM Surveyor interviewed LPN-I. Surveyor asked about the night of 5/18/23 when R48 eloped. LPN-I stated she did not know R48 eloped. LPN-I stated she was walking past one room and saw a shadow out a window but thought it was one of the employees. Surveyor asked if she ever told CNA-N that R48 was outside. LPN-I stated someone (not sure who) asked her where [R48] was at one point but she did not know and just assumed she was smoking. Surveyor asked if she checks on R48 frequently. LPN-I stated no, R48 can walk by herself and she goes to the courtyard to smoke a lot. Surveyor asked if she notified Administration. LPN-I stated no because she was unaware she left the building. On 7/13/23 at 9:47 AM Surveyor interviewed KM-M. Surveyor asked about the night of 5/18/23 when R48 eloped. KM-M stated she was off work but came to the facility to give another employee a ride home. KM-M stated she saw R48 walk from the back of building to the front door. KM-M stated she was carrying a black bag. Surveyor asked if she notified Administration or any staff currently working. KM-M stated No, but I should have reported it immediately. KM-M stated she let management know at morning meeting on 5/19/23. KM-M stated she was reeducated on the situation. On 7/13/23 at 1:06 PM Surveyor interviewed Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, Consultant-C and Consultant-D. Surveyor asked when the 5/18/23 elopement was reported to them. NHA-A stated 5/19/23. Surveyor asked if the staff were trained on reporting elopement immediately to prevent further elopement and protect the resident. NHA-A stated yes, especially KM-M because she is a member of management.

Based on interview and record review, the facility did not ensure 1 of 3 residents (R2) reviewed who displayed or had diagnoses of a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain their highest practicable mental and psychosocial well-being. R2 has self-injurious behavior, hallucinations, delusions, and suicidal and homicidal ideations including threats to staff and R3 (a peer.) There are multiple notes, including from [DATE], [DATE], [DATE], [DATE], & [DATE] from Psychologist-J documenting the facility is not an appropriate placement for R2. There is no evidence the facility addressed alternative placement except to refer to other nursing homes in the Milwaukee area. Progress notes in August document R2 engaging in self-injurious behavior to include chewing on and eating his fingers including removing bandages to further injure himself. A nurse's note dated [DATE] documents: Resident came back from [Name of] Hospital with orders to start Amoxicillin ,d+[DATE] mg 1 tablet PO (by mouth) 2 x (two times) day for 14 days for eating his own finger. Psychologist-J's progress notes dated [DATE] document: R2 has significant delusions which are violent in nature. Psychologist-J's progress note dated [DATE] documents: R2's mind is racing and he's broken. There was no assessment for R2 and no revisions in R2's care plan. On [DATE], the psych PA (physician assistant) recommended adding melatonin 3 mg (milligrams) at hour of sleep and increasing R2's Buspirone to 20 mg three times daily. This recommendation was not implemented. This was reordered on [DATE]. This recommendation was still not implemented until [DATE]. On [DATE], R2 called 911. EMTs determined R2 was having a mental health issue, he was hearing voices and the voices were taunting him. R2's physician was not notified, there was no assessment, and R2's care plan was not revised. On [DATE], R2 indicated to LPN/UM-N he calls 911 due to panic attacks and the voices being too loud in his head. LPN/UM-N discussed non medication interventions with R2. These interventions were not incorporated into R2's plan of care and R2's physician was not notified regarding the voices in his head being too loud. On [DATE], R2 was involved in a resident-to-resident altercation with R3. R2 made homicidal statements after this altercation. There is no evidence crisis was called and no revisions in R2's plan of care. On [DATE], Psychologist-J saw R2. During this session R2 made homicidal ideations toward a staff member he had a verbal argument with and toward R3. Psychologist-J indicated the staff would call the police regarding these statements. The police were not contacted after, there was no plan implemented to protect staff, & resident's and R2's plans of care were not revised. Psychologist-J's note dated [DATE] documents: R2 needs an activated power of attorney as well as long term commitment. The facility did not start the process for activating R2's power of attorney. On [DATE], R2 called 911 stating his head hurts, he was having chest pain, and no one is taking care of him. In the hospital R2 voiced suicidal and homicidal ideations and was transferred to a mental health institute. Upon return the facility did not implement a plan of what staff should be aware of with regard to R2's prior suicidal and homicidal ideations. The failure of staff to provide services to R2 for his mental health issues including assessments and revisions in his care plan after R2 made suicidal statements and homicidal statements regarding staff and R3, not implementing recommendations regarding R2's severe eating disorder, R2 not being appropriately placed, and activating a power of attorney created a finding of immediate jeopardy that began on [DATE]. Administrator-A, DON (Director of Nursing)-B, RN (Registered Nurse) Regional Educator-L, & Sr. (Senior) Dir. (Director) of Clinical Services-M were notified of the immediate jeopardy on [DATE] at 11:03 a.m. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope/severity of E (potential for more than minimal harm/pattern) as the facility continues to implement and monitor their action plan. Findings include: The Behavioral Assessment, Intervention, and Monitoring policy 2001 Med Pass inc (Revised [DATE]) under Management documents: 1. The interdisciplinary team will evaluate behavioral symptoms in resident to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. a. Atypical behavior will be differentiated from behavior that is dangerous or problematic for the resident(s) or staff, or behavior that signals underlying distress. b. If the behavior is atypical but not problematic or dangerous and the resident does not appear to be in distress, then the IDT (interdisciplinary team) will monitor for changes but not necessarily intervene to normalize the behavior. 7. Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities. 8. Interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior. The care plan will include, as a minimum: a. A description of the behavioral symptoms, including: (1) Frequency; (2) Intensity; (3) Duration; (4) Outcomes; (5) Location; (6) Environment; and (7) Precipitating factors or situations. b. Targeted and individualized interventions for the behavioral and/or psychosocial symptoms; c. The rationale for the interventions and approaches; d. Specific and measurable goals for targeted behaviors; and e. How the staff will monitor for effectiveness of the interventions. The Suicide & Homicidal Prevent policy dated [DATE] under Policy Explanation and Compliance Guidelines documents: 1. All staff members will immediately report any suicidal or homicidal ideation to the resident's charge nurse and facility social worker. 2. Immediately notify the resident's physician or physician extender if the resident presents with suicidal or homicidal ideation, even if he or she isn't specific about a plan or intent. 3. If applicable, notify the resident's responsible party of the resident's suicidal or homicidal ideation and any orders received from the resident's physician. 4. The resident will not be left alone. One on one care will be provided until arrangements can be made for the resident to receive emergency psychiatric care, or until the resident's physician determines that the risk of suicide is no longer present. 5. Objectively and thoroughly document the resident's mood and behaviors as well as all actions taken, in the medical record. 6. If the resident requires inpatient psychiatric services, State specific guidelines and requirements will be followed. Law enforcement to be notified if warranted. R2 was admitted to the facility on [DATE]. Diagnoses includes major depressive disorder, anxiety disorder, bipolar disorder, attention deficit hyperactivity disorder, and personality disorder. R2's psychotropic medications include Abilify 25 mg (milligrams) administered at hour of sleep with an order date of [DATE], Buspirone 20 mg three times a day with an order date of [DATE], Lamotrigine 25 mg one time a day for 14 days, 50 mg one time a day for next 14 days and then 100 mg one time a day with an order date of [DATE]. R2's care plan includes: Resident has a behavior problem r/t (related to) attention seeking [DATE] noted to be intoxicated, declined AA (alcoholics anonymous) states incident was isolated. Altercation with another resident. Initiated [DATE] & revised [DATE]. Interventions documented are: * Explain all procedures to the resident, before starting and allow me, the resident, to adjust to changes. Initiated [DATE]. Revised [DATE] without any change to verbiage of intervention. * If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Initiated [DATE]. Revised [DATE] without any change to verbiage of intervention. * Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Initiated [DATE]. Revised [DATE] without any change to verbiage of intervention. The Resident is/has potential to demonstrate physical behaviors biting fingers and finger nails r/t poor impulse control and attention seeking behavior [DATE] declining medication care plan initiated [DATE] and revised [DATE]. Interventions documented are: * Redirect resident from concentrating on fingers to another activity. Initiated [DATE]. * Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. Initiated [DATE]. * Give the resident as many choices as possible about care and activities. Initiated [DATE]. Revised [DATE] without any change to verbiage of intervention. * Monitor resident's fingers for biting/chewing. Redirect when visualized to be chewing/biting on fingers. Initiated [DATE]. * Psych services consult as needed. Initiated [DATE]. * When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Initiated [DATE]. Revised [DATE] without any change to verbiage of intervention. The E-MAR (electronic medication administration record) dated [DATE] documents: Biting fingers and taking off treatment to effected areas intentionally. The nurses note dated [DATE] includes documentation of Very agitated, wanting staff to call 911 said he was bleeding. It was where he chewed on his fingers Crawled out of bed and crawled around his room, refusing to be assisted back to bed for 30 minutes. The nurses note dated [DATE] documents: Resident came back from [Name of] Hospital with orders to start Amoxicillin ,d+[DATE] mg 1 tablet PO (by mouth) 2 x (two times) day for 14 days for eating his own finger. The nurses note dated [DATE] indicates, Resident approached the nurses station and states he had a dream that their fingers tasted like chicken so the resident stated they wanted a bandage to cover their finger. The resident then showed this nurse their middle finger where the resident chewed their finger. This nurse cleansed the finger with normal saline and applied a bandage. Will monitor. The nurses note dated [DATE] documents, Psych services notified of residents behavior of biting finger(s). Request sent for resident to be seen next time provider is in. The nurses note dated [DATE] includes documentation of, Resident came out to nurses station. Needed R (right) middle finger cleaned, and bandage applied to tip. Resident stated was hungry and started to chew on finger, slight bleeding noted gave snacks now. Surveyor noted R2's care plan was not revised until [DATE] regarding R2 chewing on his finger although there is a nurses note dated [DATE] regarding biting off the nail and skin of the right middle finger. The nurses note dated [DATE] documents, Seen by in house wound MD (medical doctor). Wound improved, treatment changed, resident aware of treatment change and encouraged not to bite on finger. Psychologist-J note dated [DATE] documents [R2's first name] continues to self-abuse by eating his fingers and excessive caloric intake. He complains continually about being hungry and feels that he has no option other than to eat his fingers or food. He is unable to attempt learned stress reducing techniques. He presents with significant delusions, which, at times are violent in nature. [R2's first name] is not appropriately placed in his current facility, and in my professional opinion, would be better served at a state agency. The nurses note dated [DATE] documents, Pt (patient) constantly asked to call 911 because he was having pain. Upon assessment pt did not appear to be distressed and started laughing when asked about pain and reason he felt the need to be sent out. He stated that he needed to get to Milwaukee by his mother that was in the hospital and ambulance on the way. Pain medication offered but refused and 911 was not called. Psychologist-J note dated [DATE] documents, [R2's first name] presented as angry. He stated that his roommate kicked me out of the room. I asked him why the roommate would attempt to kick him out of his room, to which he stated that he was not sure. (Note: The roommate is hospitalized at this time). He continues fearing that his cousin is attempting to kill him. He complains of possible auditory hallucinations; however, the authenticity of his complaints have not been determined. He has been systematically destroying the blinds on his windows. He states for no reason for this behavior. [R2's first name] is not appropriately placed in his current placement. He would be better served in a long-term mental health facility. Psychologist-J note dated [DATE] documents, [R2's first name] was eating his hospital gown when I entered his room. He was waiting for breakfast and stated that he was hungry and could not wait. Significant delusions were noted, as were hallucinations. [R2's first name] refuses to discuss the future and appears to have no plans or goals for himself, other than to remain in his current placement and talk with his family. His attention, concentration and judgement are severely impaired. On [DATE], R2 was involved in a resident-to-resident altercation with R1. The facility's investigation revealed both residents were intoxicated. Psychologist-J note dated [DATE] documents, [R2's first name] has been, by self-reporting, sleeping excessively. He states he has no interest in getting up or socially interacting with others. He did not eat breakfast, and stated that he was not hungry, which is unusual for [R2's first name]. He denied SI (suicidal ideations) or intent. The nurses note dated [DATE] at 12:20 a.m. documents, Resident presented with c/o (complaint of) anxiety. Resident stated, I was watching television and I saw something walk pass him out the corner of my eye. Writer assured Resident that no one was in his room. Resident stated to writer that whatever walked pass him had wings. Resident stated that he was scared, his body was shaking, his body was vibrating within, and that he felt like someone was sitting on his chest. Writer assessed resident's vitals BP (blood pressure) ,d+[DATE], P (pulse)-96 (right), ,d+[DATE] (left), P-82, T (temperature) 98.6, R (respirations)-20 POX (pulse oximetry)- 97% room air. Resident did not appear to be in any physical distress. Writer contacted [name] NP (nurse practitioner) and received one time order for Hydroxyzine 25 mg. Writer administered to resident as indicated. Resident was noted speaking to mother on the phone for a while but is now in bed sleeping. The NP (Nurse Practitioner) note dated [DATE] under history of present illness documents, [AGE] year old male seen today for reports of increased anxiety last night with reports of hallucinations from patient. Patient also reports increased alcohol use. Patient is stable in no acute distress. Under assessment/plan documents 1. anxiety, stable on meds reports symptoms to psych. 2. bipolar disorder, stable reports increased symptoms to psych. 3. hallucinations. stable alcohol use discouraged. Surveyor noted R2's care plan was not revised to include interventions regarding alcohol use after R2 reported increase in alcohol use to the NP on [DATE]. The nurses note dated [DATE] at 12:51 a.m. documents, Resident reportedly called 911 and was transported to hospital. Writer called to get report from ER (emergency room ) nurse but was placed on hold and left. Resident to return to facility per ambulance service. The nurses note dated [DATE] at 2:16 a.m. documents, Resident returned from [hospital name] ER with NNOs (no new orders). Labs were drawn and per ambulance service creatinine and WBC (white blood count) slightly elevated. No results sent with resident discharge. Psych PA (Physician Assistant)-K note dated [DATE] under history of present illness documents, [AGE] year old male Patient seen at [Facility's name] for increase in anxiety. He has been calling 911 multiple times without an emergency. This is per the Director of Nursing. Patient states he gets irritated with other residents, and he has had a room change. He states he likes to chew on his fingers and eat junk food. He states his mood has been down. He talks about a new girlfriend. He states he is having some family difficulty and usually talks on the phone with them regularly. He continues on BuSpar on 15 mg (milligrams) three times a day and Abilify 25 mg a day. He denies any suicidal or homicidal ideation. Vital signs are blood pressure ,d+[DATE], temperature 96.9, weight is 312 pounds. Nursing documentation states that he did go out of the facility on pass recently. Under Review of System for Psychiatric: + (positive) anxiety; +depression; denies suicidal ideation; +insomnia; +hallucinations; +paranoia; +delusions; Under Assessment & Plan includes Other insomnia [G47.09] (unchanged) Plan: Consider adding melatonin 3 mg QHS (every hour sleep), work on good sleep hygiene. He should try listening to calm music or trying noise canceling headphones. For Disposition: documents For increase in anxiety recommend increase buspirone to 20 mg TID (three times daily) (max 60 mg/day) continue to maintain good support and CBT (cognitive behavioral therapy). Would consider next to increase Abilify to 15 mg BID (twice daily) (max 30 mg/day). Goal to use lowest effective dose for managing his symptoms, feel he is manic/anxious at today's visit. Surveyor noted Psych PA-K's recommendation to add Melatonin 3 mg QHS and increase Buspirone to 20 mg TID was not implemented until [DATE]. The nurses note dated [DATE] at 1:12 a.m. documents, Resident called 911 for nausea. When the EMTs (emergency medical technicians) arrived, it was determined that resident is having mental health issues. He was hearing voices and he reported that the voices were taunting him. Resident agreed to stay at the facility. His mom spoke to him on the phone and is going to try to get the names of his psych doctors he has seen in the past. Will monitor resident. The nurses note dated [DATE] at 6:17 a.m. documents, Resident has been asleep since shortly after the EMTs left. No further reports of hallucinations. Will monitor. The IDT (interdisciplinary team) note dated [DATE] at 1:40 p.m. documents, IDT meeting with resident to review 911 calls and request to go to ED without symptoms. Resident stated the food was better and my mom will have to pay the bill, she owes me. Review with resident that he is self-responsible and when bills are issues, he would be responsible. Resident verbalized understanding of education regarding alerting staff to needs. Resident pleasant and verbalizing willingness to communicate with staff for any needs. The nurses note dated [DATE] at 4:15 a.m. documents, Resident displayed signs of anxiety at beginning of shift, resident went into room and stated that they were sleepy. Resident currently sleeping in bed with call light within reach. The nurses note dated [DATE] at 4:22 a.m. documents, Writer received report that resident called 911 with c/o lung pain and anxiety and that resident was transported to [hospital name] ER. Resident returned to facility per Ambulance service at 0300 (3:00 a.m.) Resident currently sitting up in w/c (wheelchair) watching movie on his phone. VSS (vital signs stable) ,d+[DATE], 95, 97.9, 95% room air. Offer no c/o anxiety, of lung pain. The nurses note dated [DATE] at 11:29 a.m. documents, Discussion with resident regarding his frequent calls to 911. He indicates he called because he was having a panic attack, and the voices were too loud in his head. Writer educated resident of some non-medication interventions to try when he has these issues as an alternative to calling emergent services such as notifying the nurse on duty first, then trying ice (applying to back of neck, wrists, or drinking something cold or chewing ice), moving to a quiet room where he can decompress and lay down. Education regarding breathing techniques to help him relax (breathe in through nose for 4 counts, hold for 4 counts and breathe out of mouth for 4 counts). After much discussion, resident then indicated that the reasons he calls 911 is because he wants to go to Milwaukee to be closer to his family (grandfather?) and he is hoping one of the hospitals will transfer him closer to the family. Educated resident to indicate this is not the appropriate channel or path to take if he wants to be moved closer to his family and is tying up emergent services in the community. This note was written by LPN/UM (Licensed Practical Nurse/Unit Manager)-N. There is no evidence R2's physician was notified regarding the voices being loud in his head and R2's care plan was not revised to include non-medication interventions. Surveyor was unable to interview LPN/UM-N as she is no longer employed at the facility. The nurses note dated [DATE] at 11:58 a.m. documents, Message to Social Services to discuss potential DC (discharge) options for resident to be nearer to family. The social service note dated [DATE] at 1:23 p.m. documents, SSC (social service coordinator) met with resident to go over risk vs benefit of calling 911 when not appropriate. If resident feels he is having a health issue or a change of condition to notify his nurse for assessment and treatment and the nurse will determine if emergency services are necessary. Resident verbalized understanding. Psychologist-J note dated [DATE] documents, [R2's first name] states that people are talking about his brother. He is using his phone to make calls to threaten the individuals that are responsible. [R2's first name] used significant profanity throughout the session, and described himself as a [NAME], racist and having a big mouth. He further states, My mind is racing, and I'm broken, and I want to go for a 72 hour hold. After our session, I determined that he is not suicidal, and not a danger to others in the facility. Later in the same day, he was observed repeatedly singing 18 Men On a Dead Man's Chest, Away we Go. [R2's first name] is not appropriately placed at this facility. The social service note dated [DATE] at 12:45 p.m. documents, SSC sent referrals per resident and family to facilities in Milwaukee area, [nursing home name] and [nursing home name]. Psychologist-J note dated [DATE] documents, [R2's first name] would like to relocate to be closer to family in Milwaukee. He states that if he is not relocated by next week, he will leave the facility go to my grandpa's in Milwaukee, stand on his doorstep, and he'll have to let me in. We reviewed the pros and cons of this plan, focusing on the negative consequences and the lack of planning. He has not slept for at least 48 hours. He was escorted to his room this morning, and told to go to bed; however, he continued to roam the hallways. He is frustrated that he does not like the food in the facility, and no one will give him money to purchase take-out food. Delusions were noted. Psychologist-J note dated [DATE] documents, [R2's first name] was talking with his family when I entered his room. His phone was on his bed, and his family could be heard screaming and swearing from his phone. [R2's first name] insisted that this type of interaction was normal when he spoke with his family, and that at this point in time, They were trying to kill my sister. I asked [R2's first name] to end the phone conversation so that we could talk, and he did so without delay. He expressed his anger towards several staff members, as he feels that they are not helpful to him. He states that he requires extra assistance, because my hands don't work. It should be noted that he spends most of his day typing on his phone. He informed me that he planned to call 911 regarding the staff, (Note: He has called 911 on several occasions). I suggested that he speak with the DON prior to making any further 911 calls. He agreed to consider my suggestion. The nurses note dated [DATE] at 1:20 a.m. documents, Resident had an altercation with another resident [R3's initials]. Resident alleged physical assault by [R3's initials]. Resident called [initials of police department]. [Initials of police department] arrived and took a statement from resident. Resident made homicidal statements. Resident was educated of outcome by [initials of police department] when making homicidal statements. Resident now in room, sitting in wheelchair eating pizza. Resident shows no signs of injury. The nurses note dated [DATE] at 8:49 a.m. documents, Res (Resident) propelling self in wheelchair using profanity. Res states, I'm just pissed off at my ex-girlfriend. Resident was redirected. Psychologist-J note dated [DATE] documents [R2's first name] was engaged in a physical altercation last night with an elderly resident. He stated that the man attacked him for no reason. [R2's first name] called 911, and after investigating, the police sent him to their respective rooms. This morning [R2's first name] engaged in a verbal altercation with a staff member, which I witnessed. [R2's first name] made threats, stating that he was going to kill both the worker and the man he had the physical altercation with. He has gone so far as to make a plan for the attack. The staff will contact the police with this information today. [R2's first name] does not like the food provided by the facility, and often begs staff for money needed to order food. Unfortunately, the staff often will give him the money he requests. [R2's first name] has a severe eating disorder, and he should not be verbally or financially encouraged to purchase outside of the meals provided. [R2's first name] is not appropriately placed. The social service note dated [DATE] at 11:35 a.m. documents, SSC resident met with psych services today to follow up after reported incident. The behavior evaluation dated [DATE] is check for history of behavior, behavior occurs less than daily. Verbal, repetitive & other is checked. Under other information documents Resident repetitive & food seeking constantly. Resistive to long term care, attention seeking. The nurses note dated [DATE] at 1:21 p.m. documents, Res agitated this morning. Upset his room is being deep cleaned and floors waxed. Worried his belongings will be misplaced. Res redirected. In activity at this time. The nurses note dated [DATE] at 11:22 p.m. documents, Resident very agitated that a DVD, cords, CD's clothing and condiments are missing after his room was cleaned. The admin (Administrator), DON (Director of Nursing) and Business Office Mgr (Manager) are aware. Resident called and spoke with [initials of police department]. Resident has been loud all shift complaining about his missing items. He has been complaining to fell ow residents, staff, and people on the phone. When asked to lower his voice because people are sleeping, he continued to speak loudly. Unable to redirect resident to wait until the morning about his missing items. Staff has searched his room already. Psych PA-K's note dated [DATE] under history of present illness documents, [AGE] year old male seen for f/u (follow up) at [Facility's name]. He is alert, self-propelling in the hallway, asks to see writer. He asks for food; states he is hungry. He then asks another resident for food. He is smiling, in a good mood. He then beginning sic (began) to swear/use profanity in the hallway. Nursing staff asks him to stop using profanity and he says excuse me, I will stop. He tells provider have a good day and self-propels down the hallway. States mood and sleep are down/difficult. Speech is quick, jumps from topic to topic. Does fabricate per staff. No SI/HI (suicidal ideations/homicidal ideations). VS (vital signs) BP ,d+[DATE] T (temperature) 97.9 W (weight) 311.6 lb (pounds). Under Review of System for Psychiatric documents +anxiety; +depression; denies suicidal ideation; +insomnia; +hallucinations; +paranoia; +delusions; Under Assessment & Plan includes Other insomnia [G47.09] (unchanged) Plan: Consider adding melatonin 3 mg QHS (every hour sleep), work on good sleep hygiene. He should try listening to calm music or trying noise canceling headphones. For Disposition: documents For increase in anxiety recommend increase buspirone to 20 mg TID (max 60 mg/day) continue to maintain good support and CBT. Would consider next to increase Abilify to 15 mg BID (max 30 mg/day). Goal to use lowest effective dose for managing his symptoms, feel he is manic/anxious at today's visit. Surveyor noted Psych PA-K's recommendation to add Melatonin 3 mg QHS and increase Buspirone to 20 mg TID was not implemented until [DATE]. The APNP (Advanced Practice Nurse Prescriber) note dated [DATE] under history of present illness documents, [AGE] year old male seen today for recent ER visit for anxiety symptoms of chest pain, coping skills discussed with patient at length. Patient is stable in no acute distress but is asking for more food and staff said he does this often. He is also asking for a prescription for Xanax and I explained that his psych doctor would need to address this issue. Under assessment/plan documents 1. anxiety, stable on meds coping technique to reduce anxiety discussed. 2. bipolar disorder, stable reports increased symptoms to psych. 3. hallucinations. stable alcohol use discouraged. Psychologist-J note dated [DATE] documents [R2's first name] brother and uncle died within the past week. He states that he has only met his brother a few times, but he is grieving the loss of his uncle. He has not been sleeping well, and states that he has flashbacks and nightmares at night. He told me that he was depressed and tired. He denied SI or intent. He wanted to be placed in a 72 hour hold at a mental health unit. He was only interested in being placed at a facility where he had previously been a patient. I told him there were several hospitals that had mental health units, and that he would mostly likely be placed closer to this facility. He rejected that idea, stating that he didn't want to go anywhere but Milwaukee. He stated that he needed something, but he could not articulate what it was. [R2's first name] needs an active POA (power of attorney), as well as a long-term psychiatric commitment. The social service note dated [DATE] at 10:59 a.m. documents, Resident verbalizing that his little brother on his dad's side passed away that he never met. Resident has a history of attention seeking behaviors and telling unsubstantiated stories. SSC unable to verify but placed a call to resident's mother to confirm SSC awaiting call back. Resident was seen by psych services today and resident verbalized no concerns or trauma or ill effects. The social services note dated [DATE] at 4:00 p.m. documents, Resident PHQ9 today of 20 and psych services updated, and resident seen today. A PHQ9 score of 20 indicates severe depression. The [R2's first name] has a potential to have a psychosocial well-being problem as it relates to his PHQ-9 of score of 20 and dx (diagnosis) of anxiety, bipolar, MDD (major depressive disorder) care plan initiated & revised [DATE] has the following intervention [TRUNCATED]

Based on observation, interview and record review, the facility was not administered in a manner to ensure residents attained or maintained their highest level of practicable well-being. This deficient practice had the potential to affect all 69 residents residing in the facility at the time of the survey. During a complaint survey conducted on 2/8/2023-2/14/2023, it was determined 14 deficiencies existed including the deficient practice at F835 (Administration). Each of the deficiencies identified systemic issues within the faclity that were not addressed by facility administration through established processes. Five of the deficiencies have been identified to be deficient at a severity level of immediate jeopardy at a scope of isolated, pattern, and widespread. Additionally, systemic concerns were identified regarding notification of changes of condition, the environment, allegations of abuse, reporting and investigating allegations of abuse, pharmacy services, significant medication errors, laboratory services, and radiology and other diagnostic services. Staff Member-F completed coursework on 6/9/2022 at a nursing school and graduated with a diploma for Practical Nursing on 8/30/2022. Staff Member-F applied for a temporary Licensed Practical Nurse (LPN) license with the assistance of Director of Nursing (DON)-B on 7/20/2022. DON-B submitted the temporary license application and never verified Staff Member-F received the temporary LPN license. Staff Member-F was never granted the temporary LPN license. Staff Member-F never took the LPN boards to obtain an LPN license. Staff Member-F was not certified as a Certified Nursing Assistant. Staff Member-F worked as an LPN at the facility from 7/25/2022 until 12/16/2022 without an LPN license for a total of 90 days and 121 shifts. Staff Member-F worked without a Registered Nurse in the building for 16 shifts and was designated as the charge nurse for 6 shifts. Staff Member-F performed all duties assigned to LPN staff without having an LPN license, including passing medication, doing wound care, and monitoring residents with a change in condition. *R8 was sent to the hospital on 11/27/2022 via 911 for shortness of breath and low oxygenation. R8 was under the care of Staff Member-F at the time of the change of condition. R8 was not comprehensively assessed by a licensed professional at the time of the change of condition, no vital signs were documented, and no circumstances around the change of condition were documented. A timeline of events could not be determined due to lack of documentation. R8 passed away in the hospital on 11/28/2022. *R9 had a change in condition on 11/27/2022 with an oxygen saturation level of 74%. R9 was under the care of Staff Member-F at the time of the change of condition. R9 was not comprehensively assessed by a licensed professional at the time of the change in condition. Staff Member-F contacted the Nurse Practitioner who ordered R9 to be sent to the hospital for evaluation and treatment. R9 refused to go to the hospital at that time. Staff Member-F did not notify the Nurse Practitioner of this refusal. R9 was sent out to the hospital by an LPN on 11/28/2022 at 1:45 AM with an oxygen saturation level of 70-71%. Complete vital signs were not documented at the time when the change of condition was first noted on 11/27/2022 or prior to leaving the facility on 11/28/2022 and no documentation was found describing the circumstances around the change of condition or between the time the change of condition was first noted and when R9 was sent to the hospital. A timeline of events could not be determined due to lack of documentation. R9 did not return to the facility. *R19 was sent to the hospital on 10/25/2022 for a change in condition. R19 was under the care of Staff Member-F at the time of the change of condition. R19's medical record did not have any documentation on 10/25/2022 indicating R19 had a change in condition that would require hospitalization : no progress note, no change of condition evaluation documentation, and no vital signs. A timeline of events could not be determined due to lack of documentation. The failure of administration to ensure the building was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable level of physical, mental, and psychosocial well-being of each resident created a situation of immediate jeopardy that began on 7/25/2022. Surveyor notified Nursing Home Administrator (NHA)-A of the immediate jeopardy on 2/13/2023 at 4:15 PM. The immediate jeopardy was removed on 2/21/23. However, the deficient practice continues at a scope/severity of F (potential for harm/widespread) as the facility continues to implement its action plan. Findings include: The Wisconsin Department of Safety and Professional Services website https://dsps.wi.gov/Credentialing/Health/info3087.pdf states: BOARD OF NURSING CREDENTIALING INFORMATION FOR REGISTERED NURSE/LICENSED PRACTICAL NURSE APPLICANTS . 4. Temporary Permit for Exam Applicants (Form #2434) (optional) - In addition to Form #2434 and the $10.00 temporary permit fee, the Department also requires a completed application for permanent licensure and proof of graduation from a WI Board-approved school or comparable school of professional/ practical nursing prior to granting a temporary permit. A temporary permit cannot be processed until all of those requirements are satisfied. Exam applicants must have a supervising RN and the department must receive proof of graduation/ completion from the school prior to issuance. A temporary permit is valid for a period of three months or until the holder receives notification of failing the NCLEX examination. An applicant for RN/LPN licensure who holds a valid permit under this Temporary Permit section or Subchapter IV of Wis. Admin. Code ch. N2 may use the title Graduate Nurse/Graduate Practical Nurse or the letters GN/GPN and shall not practice beyond the scope of the license the holder is seeking to obtain. The holder is required to practice under the direct supervision of an RN. The supervisor must be on-site and immediately available at all times. You may not practice as an RN/LPN in Wisconsin unless you have either a permanent license or temporary permit. The facility policy and procedure entitled Competency of Nursing Staff revised 10/2017 from the MED-PASS manual (C)2001 states: Policy Statement: 1. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law. 2. In addition, licensed nurses and nursing assistants employed (or contracted) by the facility will: a. participate in a facility-specific, competency-based staff development and training program; and b. demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in plans of care. Policy Interpretation and Implementation: 1. The staff development and training program is created by the nursing leadership, with input from the medical director, and is designed to train nursing staff to deliver individualized, safe, quality care and services for the residents. 2. The following factors are considered in the creation of the competency-based staff development and training program: a. An evaluation of the current program to ensure basic nursing competencies; b. Any gaps in education or training that may be contributing to poor outcomes; c. Specialized skills or training needed based on the resident population; d. A method to track, assess, plan, implement and evaluate the effectiveness of training; and e. A method to evaluate critical thinking skills and management of care in complex environments with multiple interruptions. 3. The facility assessment includes an evaluation of the staff competencies that are necessary to provide the level and types of care specific to the resident population. 4. Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as: a. Preventing abuse, neglect and exploitation of resident property; b. Dementia management; c. Resident rights; d. Person centered care; e. Communication; f. Basic nursing skills; g. Basic restorative services; h. Skin and wound care; i. Medication management; j. Pain management; k. Infection control; 1. Identification of changes in condition; and m. Cultural competency. 5. Facility and resident-specific competency evaluations will be conducted upon hire, annually and as deemed necessary based on the facility assessment. 6. Facility and resident-specific competency evaluations will include: a. Lecture with return demonstration for physical activities; b. A pre- and post-test for documentation issues; c. Demonstrated ability to use tools, devices, or equipment used to care for residents; d. Reviewing adverse events that occurred as an indication of gaps in competency; or e. Demonstrated ability to perform activities that are within the scope of practice an individual is licensed or certified to perform. 7. Competency demonstrations will be evaluated based on the staff member's ability to use and integrate knowledge and skills obtained in training, which will be evaluated by staff already deemed competent in that skill or knowledge. 8. Inquiries concerning staff competency evaluations should be referred to the Director of Nursing Services or to the Personnel Director. Surveyor noted this policy and procedure was not dated by the facility or signed by the Medical Director. The facility policy and procedure entitled Quality Assurance and Performance Improvement (QAPI) Program revised 4/2014 from the MED-PASS manual (C)2001 states: Policy Statement: This facility shall develop, implement, and maintain an ongoing, facility-wide Quality Assurance and Performance Improvement (QAPI) program that builds on the Quality Assessment and Assurance Program to actively pursue quality of care and quality of life goals. Policy Interpretation and Implementation: The primary purpose of the Quality Assurance and Performance Improvement Program is to establish data-driven, facility-wide processes that improve the quality of care, quality of life and clinical outcomes of our residents. Five Strategic Elements: The QAPI program has been developed with five strategic elements in mind. 1. Design and scope: a. The program is ongoing and comprehensive. b. It involves the full range of services and departments in the facility. c. It covers all systems of care and management practices, with priority given to quality care, quality of life and resident choice. d. Goals, targets and benchmarks are established and measured based on the best available evidence. 2. Governance and leadership: a. Input is sought from facility staff, residents, family members and individuals who are involved in the care of residents. b. Resources are allocated to conduct QAPI efforts. c. Members of the facility leadership are accountable for QAPI efforts. d. Staff are trained in QAPI systems and culture. e. Staff are encouraged to identify and report quality concerns as well as opportunities for improvement. 3. Feedback, data systems and monitoring: a. Systems are in place to monitor care and services. b. Systems are designed to incorporate feedback from caregivers, residents, family and staff as appropriate. c. Care processes and outcomes are monitored using performance indicators. These performance indicators are measured against quality benchmarks and targets that the facility has established. d. Adverse events are tracked, monitored and investigated as they occur. e. Action plans are implemented to prevent recurrence of adverse events. 4. Performance improvement projects: a. Performance improvement projects (PIPs) are initiated when problems are identified. b. PIPs involve systematically gathering information to clarify issues and to intervene for improvements. 5. Systematic analysis and systematic action: a. Root Cause Analysis (RCA) is used to determine whether identified issues are exacerbated by the way care and services are organized or delivered, and if so, how. b. RCA serves as a highly structured approach to fully understanding the nature of an identified problem, its cause and the implications of making changes to improve the problem. QAPI Action Steps: The following steps are employed or will be employed to support and enhance the facility QAPI program: 1. Establishing a QAPI Committee/sub-committee that works in tandem with the facility leadership and the QA&A Committee. 2. Allocating resources for QAPI initiatives. 3. Providing staff, family members and residents with information about the QAPI program and inviting them to meet with QAPI leadership. 4. Providing concrete channels of communication between staff, residents, family members and leadership. 5. Establishing a zero tolerance policy for retaliation against individuals who appropriately report or communicate quality concerns. 6. Creating task-oriented or goal-oriented teams for QAPI: a. Establishing a clear purpose for each team. b. Defining specific roles for each team member. 7. Utilizing established QAPI self-assessment tools to initiate and then periodically re-evaluate the QAPI program. 8. Identifying this facility's Guiding Principles and the [sic] using them to guide decision-making and set priorities. 9. Establishing a QAPI Plan that guides quality efforts and serves as the main document that supports the QAPI implementation. 10. Communicating the QAPI plan and principles to all caregivers, including consultants, contractors and business associates. 11. Communicating the QAPI plan and principles to residents and families, and encouraging their participation in the systems. 12. Providing frequent leadership and staff training on the QAPI plan and its underlying principles, including the concept that systems of care and business practices must support quality care or be changed. 13. Gathering and using QAPI data in an organized and meaningful way. Areas that may be appropriate to monitor and evaluate include: a. Clinical outcomes: pressure ulcers, infections, medication use, pain, falls, etc.) [sic]; b. Complaints from residents and families; c. Re-hospitalization s; d. Staff turnover and assignments; e. Staff satisfaction; f. Care plans; g. State surveys and deficiencies; and h. MDS assessment data. 14. Setting measurable goals for improvement that may include percentage of reductions (or increases) from the measured baseline of a particular goal. 15. Identifying benchmarks of performance and comparing facility data with national and state performance benchmarks. 16. Recognizing patterns in systems of care that can be associated with quality problems. 17. Prioritizing identified quality issues based on risk of harm and frequency of occurrence, and determining which will become the focus of PIPs. 18. Planning, conducting and documenting PIPs. 19. Conducting Root Cause Analysis to identify the underlying issues that contribute to recognized problems. 20. Taking systematic action targeted at the root causes of identified problems. This encompasses the utilization of corrective actions that provide significant and meaningful steps to improve processes and do not depend on staff to simply 'do the right thing.' Surveyor noted this policy and procedure was not dated by the facility or signed by the Medical Director. The Facility Assessment Tool dated 8/18/2017 was provided to Surveyor. The Facility Assessment Tool was not a completed Facility Assessment. The Facility Assessment Tool was used by the facility on 1/2022 and updated on 2/1/2022 and 2/8/2023. The facility assessment tool did not have a date that it was reviewed with QAA/QAPI committee. The Facility Assessment Tool was completed for the resident population in the following areas: the number of beds, the average daily census, the average range of residents being admitted /discharged on a weekday and a weekend, the Major RUG-IV Categories the residents were categorized as, the number of residents receiving special treatments, and the breakdown of the extent of assistance residents needed with Activities of Daily Living. The Facility Assessment Tool was completed for the overall staffing needed in the facility with no other specific hourly or shift breakdown of staffing needs. The Facility Assessment Tool had suggestions for developing an individualized Facility Assessment, but was just a tool to be used and was not a comprehensive assessment of the facility's resident population, staffing needs, or any detailed breakdown of what the facility could manage to provide quality care for their residents. Surveyor was investigating a change in condition R8 had on 11/27/2022 and noted Staff Member-F had charted in the progress notes regarding the change in condition. Surveyor reviewed the facility employee list and noted Staff Member-F was listed as a current employee with a status of LPN. On 2/7/2023 at 1:52 PM, Surveyor requested from DON-B to speak to Staff Member-F regarding R8's change in condition. DON-B stated Staff Member-F no longer worked at the facility because Staff Member-F did not pass the nursing boards and did not want to work as a caregiver so did not return to work. In an interview on 2/8/2023 at 8:30 AM, LPN Unit Manager (UM)-G stated Staff Member-F did not have a CNA license. LPN UM-G stated Staff Member-F worked as a Graduate Nurse after going to school for an LPN but let the temporary license expire and no longer works at the facility. On 2/9/2023 at 9:13 AM, Surveyor called the Department of Safety and Professional Services (DSPS) and inquired if Staff Member-F had received a temporary LPN license. The DSPS staff member stated no license was found for Staff Member-F. The DSPS staff member stated Staff Member-F had submitted an application for a temporary LPN license and a notation was attached to the application that read pending applicant input. The DSPS staff member stated the temporary application had been submitted on 7/20/2022 but no other supporting documentation, such as a diploma or transcript, had been submitted and therefore a temporary license was not issued. The Temporary Permit Request for Registered Nurse or Licensed Practical Nurse states: Applicants who wish to practice under the supervision of more than one RN must submit an additional (Form #2434) for each supervising RN. I, the above-named applicant, will be employed to work as a RN/LPN at the address listed below under the direct supervision of a RN who has an active Wisconsin RN license. The form was signed by Staff Member-F, dated 7/20/2022, and DON-B information written in DON-B's handwriting was provided as the RN Supervisor for Staff Member-F. Surveyor reviewed all staffing schedules from 7/25/2022 through 12/16/2022. Staff Member-F worked a total of 90 days and 121 shifts in that timeframe. From 7/25/2022 through 8/31/2022, Staff Member-F worked with an RN or LPN except for three shifts where Staff Member-F was listed on the staffing schedule as an LPN working independently without shadowing a nurse. From 9/1/2022 through 12/16/2022, Staff Member-F was listed on the staffing schedule as working independently as an LPN without being paired up with a nurse. Staff Member-F worked 16 shifts with no RN on the schedule and Staff Member-F was listed as the charge nurse for 6 shifts. In an interview on 2/9/2023 at 2:59 PM, Surveyor asked Human Resources (HR)-Q, who works for a sister facility, what the process was for hiring an individual to work for that company. HR-Q stated when an individual applies for employment, the application is reviewed by HR. HR-Q stated the HR department is responsible for running the individual's background check, checking their licensure or certification depending on their position, and checking references. HR-Q stated once the background check and references are cleared, the individual's information is forwarded the Director of Nursing (DON) to schedule an interview. HR-Q stated once the interview is completed, the applicant is called to set up orientation. Surveyor asked HR-Q if the hiring process was the same for a Certified Nursing Assistant (CNA), LPN, or RN. HR-Q stated yes, the process is the same. HR-Q stated HR-Q always checks on the licensure or certification before the interview is scheduled because it has happened in the past where the individual was not certified, and they do not want to waste anyone's time by going through the interview process and not being qualified for the job. Surveyor asked HR-Q what the process was for an individual who has graduated from nursing school but has not yet taken their licensure exam. HR-Q stated the individual's information is given to the DON along with a copy of their diploma and transcript. HR-Q stated the DON helps the individual apply for a temporary license. HR-Q stated they get a test date for the exam and then follow up to get the results. Surveyor asked HR-Q what the process was for someone with a temporary license while working at the facility. HR-Q stated until the test is completed and passed, the graduate nurse must work with an RN on the same schedule and on the same unit because the RN is responsible for the graduate nurse. HR-Q stated the DON gets an email verification of the temporary license, and if they want to check on the status, there is a phone number and email address they can use to contact the licensing agency. HR-Q stated you can also go online to look up the licensure as well. Surveyor shared with HR-Q that Surveyor had been unable to find any confirmation that Staff Member-F had any type of nursing license or CNA certification. HR-Q agreed that HR-Q had the same results: no CNA certification, temporary LPN license, or official LPN license. On 2/9/2023 at 3:15 PM at the daily exit meeting with the facility, Surveyor shared with Nursing Home Administrator (NHA)-A the concern Staff Member-F did not have a temporary LPN license, was not always working under an RN while employed, was a charge nurse on the schedule at times, and no training, competencies, or orientation packet had been provided to Surveyor. Surveyor shared Staff Member-F was the employee caring for residents when they had a change in condition and was not licensed to care for residents. In an interview on 2/13/2023 at 7:55 AM, Surveyor asked HR-R, the HR for the facility, what happened with the hiring process of Staff Member-F. HR-R stated Staff Member-F was the first graduate nurse the facility had hired; typically, they do not hire anyone until they are licensed. Surveyor asked HR-R what job description Staff Member-F signed when hired. HR-R thought Staff Member-F had signed a job description for Graduate Nurse and stated HR-R would get a copy of it. (Surveyor was provided a copy of the job description Staff Member-F had signed; the job description was for an LPN.) HR-R stated Staff Member-F put in an application for employment and HR-R put Staff Member-F in the computer and got the pay situated. HR-R stated DON-B interviewed Staff Member-F and DON-B did the paperwork that was faxed for a temporary LPN license. HR-R stated HR-R followed up on the temporary LPN license in December 2022 and found out there was a mistake on the application, so it was never processed. HR-R stated once they found that out, they took Staff Member-F off the working schedule. Surveyor asked HR-R if the facility had a copy of Staff Member-F's diploma or transcript from nursing school. HR-R stated no, they did not have either of those documents. HR-R stated HR-R thought Staff Member-F was still in school and about to graduate. Surveyor asked HR-R if Staff Member-F had any training records or competencies completed while working at the facility, such as an orientation packet. HR-R stated DON-B would have training information. In an interview on 2/13/2023 at 8:10 AM, DON-B stated DON-B interviewed Staff Member-F prior to hiring Staff Member-F and found out Staff Member-F was a Graduate Nurse. DON-B stated Staff Member-F showed DON-B their credentials. DON-B was unable to provide Staff Member-F's diploma or transcript from nursing school to Surveyor. DON-B stated Staff Member-F showed DON-B their notice of graduation stating Staff Member-F finished the nursing program and was eligible to be a Graduate Nurse. DON-B stated DON-B and Staff Member-F completed the application for temporary LPN license and Staff Member-F told DON-B that Staff Member-F would pay for the temporary license. DON-B stated DON-B thought Staff Member-F had completed the application process. DON-B stated Staff Member-F had scheduled a date for the LPN boards which was in mid to late summer of 2022, and then told DON-B Staff Member-F had rescheduled the boards to a later date. Surveyor asked DON-B if DON-B ever got confirmation Staff Member-F had received the temporary LPN license. DON-B stated no. Surveyor asked DON-B if DON-B ever followed up on the temporary LPN license by contacting the licensing agency. DON-B stated no. Surveyor shared with DON-B the observation of Staff Member-F being listed on the working schedule as being the charge nurse. DON-B stated Staff Member-F was a regular employee and so was designated as a charge nurse if the other nurses working were agency staff. Surveyor asked DON-B if Staff Member-F worked only when there was an RN in the building. DON-B stated it was possible there were no RNs in the building when Staff Member-F was working. Surveyor asked DON-B to see the job description for a Graduate Nurse. DON-B stated they do not have a job description for a Graduate Nurse. Surveyor asked DON-B if there were any other Graduate Nurses working at the facility. DON-B stated Staff Member-F was the first Graduate Nurse working for the facility and there will not be any more after this. Surveyor asked DON-B if Staff Member-F had provided the facility with a copy of the diploma or transcript from nursing school. DON-B stated no, but DON-B saw the transcript and knew that Staff Member-F had passed the pharmacology course. Surveyor asked DON-B to see Staff Member-F's orientation packet, training, and competencies. DON-B stated HR would have that information. Surveyor noted HR-R had said DON-B would have that information. In an interview on 2/13/2023 at 8:27 AM, Scheduler-S stated Staff Member-F was an LPN that had just graduated. Surveyor asked Scheduler-S if Staff Member-F had worked part-time or full-time. Schedule-S stated Staff Member-F worked part-time but would pick up shifts. Surveyor asked Scheduler-S if Staff Member-F could work any time or did Staff Member-F have to be scheduled when any certain nurse worked. Scheduler-S stated Staff Member-F did not have any restrictions; Staff Member-F could work anywhere with anyone. Surveyor asked Scheduler-S if Staff Member-F was ever the nurse in charge when working. Scheduler-S stated if Staff Member-F was the only nurse working that was not from an agency, then Staff Member-F would be listed as the charge nurse. Surveyor asked Scheduler-S if an RN had to be working when Staff Member-F was working. Scheduler-S stated no. In a phone interview on 2/13/2023 at 9:03 AM, University Registrar-T stated Staff Member-F completed all courses of the nursing program on 6/9/2022, but the date of 8/30/2022 was the last date of the semester and therefore the date used for official graduation. The facility provided to Surveyor Staff Member-F's orientation packet with signed materials on 7/25/2022. No competencies were provided. No copy of a diploma or transcript was provided. Surveyor noted the LPN job description stated date of hire was 8/22/2022 for 40 hours per week and was signed by Staff Member-F on 10/19/2022. No signed job description was provided for Staff Member-F when Staff Member-F was hired on 7/25/2022. R8 was admitted to the facility on [DATE] with diagnoses of spastic quadriplegic cerebral palsy, anxiety, schizophrenia, intellectual disabilities, scoliosis, gastro-esophageal reflux disease, and dysphagia requiring a gastrostomy feeding tube for nutrition. R8's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R8 was severely cognitively impaired per staff assessment and was dependent for all activities of daily living. On 11/22/2022 at 12:23 PM in the progress notes, nursing charted R8 was visited by a community Case Manager and R8's Guardian. Nursing charted R8 was placed in a Broda chair with a Hoyer lift and positioned with pillows. Nursing charted R8 was able to tolerate being reclined and upright in the Broda chair for approximately one hour before being transferred back to bed. On 11/22/2022, R8's vital signs were as follows: blood pressure 129/67, temperature 97.6, pulse 71, respirations 18, and oxygen saturation 97%. Surveyor noted the vital signs were obtained on 11/22/2022 because there was a physician order to obtain vital signs and monitor edema weekly on Tuesday PM shift. Surveyor noted a physician order was in place to monitor temperature and oxygen saturation every shift and notify the physician and Director of Nursing (DON) immediately if any symptoms were present such as cough, fever greater than 100.0, decreased oxygen saturation. Surveyor noted checkmarks were placed on the Medication Administration Record/Treatment Administration Record (MAR/TAR) and no values were documented of the temperature or oxygen saturation level. No documentation was found in the progress notes between 11/22/2022 and 11/27/2022. No vital signs were documented after 11/22/2022. Surveyor noted Staff Member-F was assigned to work on 11/22/2022, 11/23/2022, 11/24/2022, 11/25/2022 (AM and PM shift), 11/26/2022 (AM and PM shift) and 11/27/2022. No RN was on the schedule for 11/23/2022, 11/24/2022, and 11/25/2022 when Staff Member-F was working and Staff Member-F was listed as the charge nurse with no RN on the schedule for 11/27/2022 AM shift. On 11/27/2022 at 11:34 AM in the progress notes, Staff Member-F, an unlicensed employee, charted R8 was sent out 911 at 11:00 AM for shortness of breath and low oxygen saturation. Staff Member-F charted the community Case Manager was unavailable and a message was left for them to call the facility for an update on the changes in R8. Staff Member-F charted R8's Guardian was called and notified of changes, the Nurse Practitioner was updated, and the DON was aware. Surveyor did not find any documentation of Staff Member-F contacting a Registered Nurse to do an assessment of R8 for the change in status. No vital signs were documented. No details surrounding the change in condition were documented. Surveyor requested and received the Emergency Medical Service (EMS) report of R8's change of condition on 11/27/2022. The report states the following: EMS received the 911 call on 11/27/2022 at 11:11 AM and an ambulance unit and fire engine were dispatched to the scene for a call regarding a resident with complaints of difficulty breathing. On arrival, R8 was lying in bed in the care of staff. R8 was noted to have an altered mental status with the last known well time being 30 minutes ago. Staff stated R8 was not verbal and normally with an altered mentation, but this morning when giving R8 a bath, R8 became more altered than normal and was gasping for air. Staff stated R8's oxygen saturation was in the 70's and they applied oxygen via nasal cannula with no relief. R8's past medical history of cerebral palsy and scoliosis was noted. At 11:25 AM, R8's vital signs were assessed: blood pressure 98/58, oxygen saturation 71%, pulse 140 and regular, respirations 24 and rapid, blood glucose over 500, and temperature 98.0. (Surveyor noted R8's blood pressure and oxygen saturation were low and R8's pulse, respirations, and blood glucose were high.) R8's lungs were noted

Based on record review and interview, the facility did not ensure nursing staff had the specific competencies and skill sets necessary to care for residents' needs including nursing licensure affecting 3 of 4 residents (R8, R9, and R19) who had a change in condition and potentially affecting all 69 residents in the facility. Staff Member-F completed coursework on 6/9/2022 at a nursing school and graduated with a diploma for Practical Nursing on 8/30/2022. Staff Member-F applied for a temporary Licensed Practical Nurse (LPN) license with the assistance of Director of Nursing (DON)-B on 7/20/2022. Staff Member-F was never granted the temporary LPN license. Staff Member-F never took the LPN boards to obtain an LPN license. Staff Member-F was not certified as a Certified Nursing Assistant. Staff Member-F worked as an LPN at the facility from 7/25/2022 until 12/16/2022 without an LPN license for a total of 90 days and 121 shifts. Staff Member-F worked without a Registered Nurse in the building for 16 shifts and was designated as the charge nurse for 6 shifts. Staff Member-F performed all duties assigned to LPN staff without having an LPN license, including passing medication, doing wound care, and monitoring residents with a change in condition. R8 had a change in condition on 11/27/2022. Non-nurse, Staff Member-F was assigned to R8 during R8's change in condition. On 11/27/2022, Staff Member-F did not contact an RN to conduct an assessment of R8's change in condition. On 11/27/2022, R8 was sent to the hospital. R8 passed away in the hospital on 11/28/2022. R9 had a change in condition on 11/27/2022. Non-nurse, Staff Member-F was assigned to R9 on 11/27/2022 when R9 experienced a change of condition. Staff Member-F did not obtain a complete set of vitals on 11/27/2022. On 11/27/2022, Staff Member-F did not sign out on the Medication Administration record as having administered an albuterol inhaler due to R9's decrease in oxygen saturation. Staff Member-F did not have an RN assess R9's change in condition. Staff Member-F contacted the Nurse Practitioner due to R9's shortness of breath. The Nurse Practitioner ordered R9 to be sent to the hospital. R9 refused going to the hospital. Staff Member-F did not contact the Nurse Practitioner to inform of R9's refusal to go to the hospital. On 11/28/2022, R9 continued to have low oxygen saturations levels and R9 was transferred to the hospital and did not return. R19 was sent to the hospital on 10/25/2022 for a change in condition. Staff Member-F was assigned to R19's unit on 10/25/2022. The medication administration record for 10/25/2022 indicates Staff Member-F administered some of R19's morning medication. On 10/25/2023 R19's oxygen saturation level was 63%. R19's medical record did not have any documentation on 10/25/2022 indicating R19 had a change in condition that would require hospitalization : no progress note, no change of condition evaluation documentation, and no vital signs. A timeline of events could not be determined due to lack of documentation. R19 was admitted into the hospital on 10/25/2022. The facility failure to verify licensure of Staff Member-F, to ensure nursing staff had the appropriate competencies and skills to provide for the care of residents, and to assure resident safety created a finding of immediate jeopardy that began on 7/25/2022. Surveyor notified Nursing Home Administrator (NHA)-P of the immediate jeopardy on 2/13/2023 at 4:35 PM. The immediate jeopardy was removed on 2/17/23. The deficient practice continues at a scope/severity of F (potential for harm/widespread) as the facility continues to implement and monitor its action plan. Findings include: Cross-reference F684 for Quality of Care. Staff Member-F was involved in changes of condition for three residents (R8, R9, and R19). The Wisconsin Department of Safety and Professional Services website https://dsps.wi.gov/Credentialing/Health/info3087.pdf states: BOARD OF NURSING CREDENTIALING INFORMATION FOR REGISTERED NURSE/LICENSED PRACTICAL NURSE APPLICANTS documents in part . 4. Temporary Permit for Exam Applicants (Form #2434) (optional) - In addition to Form #2434 and the $10.00 temporary permit fee, the Department also requires a completed application for permanent licensure and proof of graduation from a WI Board-approved school or comparable school of professional/ practical nursing prior to granting a temporary permit. A temporary permit cannot be processed until all of those requirements are satisfied. Exam applicants must have a supervising RN and the department must receive proof of graduation/ completion from the school prior to issuance. A temporary permit is valid for a period of three months or until the holder receives notification of failing the NCLEX (National Council Licensure Examination) examination. An applicant for RN/LPN licensure who holds a valid permit under this Temporary Permit section or Subchapter IV of Wis. Admin. Code ch. N2 may use the title Graduate Nurse/Graduate Practical Nurse or the letters GN/GPN and shall not practice beyond the scope of the license the holder is seeking to obtain. The holder is required to practice under the direct supervision of an RN. The supervisor must be on-site and immediately available at all times. You may not practice as an RN/LPN in Wisconsin unless you have either a permanent license or temporary permit. The facility policy and procedure entitled Competency of Nursing Staff revised 10/2017 from the MED-PASS manual (C)2001 states: Policy Statement: 1. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law. 2. In addition, licensed nurses and nursing assistants employed (or contracted) by the facility will: a. participate in a facility-specific, competency-based staff development and training program; and b. demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in plans of care. Policy Interpretation and Implementation: 1. The staff development and training program is created by the nursing leadership, with input from the medical director, and is designed to train nursing staff to deliver individualized, safe, quality care and services for the residents. 2. The following factors are considered in the creation of the competency-based staff development and training program: a. An evaluation of the current program to ensure basic nursing competencies; b. Any gaps in education or training that may be contributing to poor outcomes; c. Specialized skills or training needed based on the resident population; d. A method to track, assess, plan, implement and evaluate the effectiveness of training; and e. A method to evaluate critical thinking skills and management of care in complex environments with multiple interruptions. 3. The facility assessment includes an evaluation of the staff competencies that are necessary to provide the level and types of care specific to the resident population. 4. Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as: a. Preventing abuse, neglect and exploitation of resident property; b. Dementia management; c. Resident rights; d. Person centered care; e. Communication; f. Basic nursing skills; g. Basic restorative services; h. Skin and wound care; i. Medication management; j. Pain management; k. Infection control; l. Identification of changes in condition; and m. Cultural competency. 5. Facility and resident-specific competency evaluations will be conducted upon hire, annually and as deemed necessary based on the facility assessment. 6. Facility and resident-specific competency evaluations will include: a. Lecture with return demonstration for physical activities; b. A pre- and post-test for documentation issues; c. Demonstrated ability to use tools, devices, or equipment used to care for residents; d. Reviewing adverse events that occurred as an indication of gaps in competency; or e. Demonstrated ability to perform activities that are within the scope of practice an individual is licensed or certified to perform. 7. Competency demonstrations will be evaluated based on the staff member's ability to use and integrate knowledge and skills obtained in training, which will be evaluated by staff already deemed competent in that skill or knowledge. 8. Inquiries concerning staff competency evaluations should be referred to the Director of Nursing Services or to the Personnel Director. Surveyor noted this policy and procedure was not dated by the facility or signed by the Medical Director. Surveyor reviewed the medical records for R8, R9, and R19 all whom experienced a change in condition and required hospitalization . Surveyor noted non-nurse staff member F, was working as a Licensed Practical Nurse during R8, R9, and R19's changes in condition and did not have the competencies and skills necessary to care for the residents. 1. R8 was sent to the hospital on 11/27/2022 via 911 for shortness of breath and low oxygenation. A non-nurse (Staff Member-F) was working as a Licensed Practical Nurse (LPN) from 11/22/2022 through 11/27/2022. Staff Member-F was assigned to R8 on 11/27/2022 when R8 experienced a change of condition. On 11/27/2022, Staff Member-F did not contact an RN to conduct an assessment of R8's change in condition. The Medication/Treatment records had no values documented for R8's saturation levels. Staff Member-F did not contact an RN to conduct an assessment of R8's change in condition. and at the time of the change of condition, no vital signs were documented, At the time of the change in condition there was documentation in R8's medical record regarding the circumstances of the change of condition. On 11/27/2022, R8 and was sent to the hospital. R8 passed away in the hospital on 11/28/2022. 2. R9 had a change in condition on 11/27/2022 with an oxygen saturation level of 74%. A non-nurse (Staff Member- F) was assigned to R9 on 11/27/2022 when R9 experienced a change of condition. Staff Member-F did not obtain a complete set of vitals on 11/27/2022. On 11/27/2022, Staff Member-F did not sign out on the Medication Administration record as having administered an albuterol inhaler due to R9's decrease in oxygen saturation. Staff Member- F did not have an RN assess R9's change in condition. Staff Member-F contacted the Nurse Practitioner due to R9's shortness of breath. The Nurse Practitioner ordered R9 to be sent to the hospital. R9 refused going to the hospital. Staff Member-F did not contact the Nurse Practitioner to inform of R9's refusal to go to the hospital. On 11/28/2022 R9 continued to have low oxygen saturations levels and R9 was transferred to the hospital and did not return. 3. R19 was sent to the hospital on 10/25/2022 for a change in condition. Staff Member-F was assigned to R19 unit on 10/25/2022. The medication administration record for 10/25/2022 indicates Staff Member-F administered some of R19's morning medication. On 10/25/2023 R19's oxygen saturation level was 63%. R19's medical record did not have any documentation on 10/25/2022 indicating R19 had a change in condition that would require hospitalization : no progress note, no change of condition evaluation documentation, and no vital signs. A timeline of events could not be determined due to lack of documentation. R19 was admitted into the hospital on 10/25/2022. (Cross Reference F684) During R8's record review, Surveyor noted Staff Member-F charted a progress note on 11/27/2022 regarding R8's change in condition. Surveyor reviewed the facility employee list and noted Staff Member-F was listed as a current employee with a status of LPN. On 2/7/2023 at 1:52 PM, Surveyor requested from DON-B to speak to Staff Member-F regarding R8's change in condition. DON-B stated Staff Member-F no longer worked at the facility because Staff Member-F did not pass the nursing boards and did not want to work as a caregiver so did not return to work. In an interview on 2/8/2023 at 8:30 AM, LPN Unit Manager (UM)-G stated Staff Member-F did not have a CNA license. LPN UM-G stated Staff Member-F worked as a Graduate Nurse after going to school for an LPN but let the temporary license expire and no longer works at the facility. On 2/9/2023 at 9:13 AM, Surveyor called the Wisconsin Department of Safety and Professional Services (DSPS) and inquired if Staff Member-F had received a temporary LPN license. The DSPS staff member stated no license was found for Staff Member-F. The DSPS staff member stated Staff Member-F had submitted an application for a temporary LPN license and a notation was attached to the application that read pending applicant input. The DSPS staff member stated the temporary application had been submitted on 7/20/2022 but no other supporting documentation, such as a diploma or transcript, had been submitted and therefore a temporary license was not issued. Surveyor reviewed all staffing schedules from 7/25/2022 through 12/16/2022. Staff Member-F worked a total of 90 days and 121 shifts in that timeframe. From 7/25/2022 through 8/31/2022, Staff Member-F worked with an RN or LPN except for three shifts where Staff Member-F was listed on the staffing schedule as an LPN working independently without shadowing a nurse. From 9/1/2022 through 12/16/2022, Staff Member-F was listed on the staffing schedule as working independently as an LPN without being paired up with a nurse. Staff Member-F worked 16 shifts with no RN on the schedule and Staff Member-F was listed as the charge nurse for 6 shifts. In an interview on 2/9/2023 at 2:59 PM, Surveyor asked Human Resources (HR)-Q, who works for a sister facility, what the process was for hiring an individual to work for that company. HR-Q stated when an individual applies for employment, the application is reviewed by HR. HR-Q stated the HR department is responsible for running the individual's background check, checking their licensure or certification depending on their position, and checking references. HR-Q stated once the background check and references are cleared, the individual's information is forwarded the Director of Nursing (DON) to schedule an interview. HR-Q stated once the interview is completed, the applicant is called to set up orientation. Surveyor asked HR-Q if the hiring process was the same for a Certified Nursing Assistant (CNA), LPN, or RN. HR-Q stated yes, the process is the same. HR-Q stated HR-Q always checks on the licensure or certification before the interview is scheduled because it has happened in the past where the individual was not certified, and they do not want to waste anyone's time by going through the interview process and not being qualified for the job. Surveyor asked HR-Q what the process was for an individual who has graduated from nursing school but has not yet taken their licensure exam. HR-Q stated the individual's information is given to the DON along with a copy of their diploma and transcript. HR-Q stated the DON helps the individual apply for a temporary license. HR-Q stated they get a test date for the exam and then follow up to get the results. Surveyor asked HR-Q what the process was for someone with a temporary license while working at the facility. HR-Q stated until the test is completed and passed, the graduate nurse must work with an RN on the same schedule and on the same unit because the RN is responsible for the graduate nurse. HR-Q stated the DON gets an email verification of the temporary license, and if they want to check on the status, there is a phone number and email address they can use to contact the licensing agency. HR-Q stated you can also go online to look up the licensure as well. Surveyor shared with HR-Q that Surveyor had been unable to find any confirmation that Staff Member-F had any type of nursing license or CNA certification. HR-Q agreed that HR-Q had the same results: no CNA certification, no temporary LPN license, and no official LPN license. On 2/9/2023 at 3:15 PM at the daily exit meeting with the facility, Surveyor shared with Nursing Home Administrator (NHA)-A the concern Staff Member-F did not have a temporary LPN license, was not always working under an RN while employed, was a charge nurse on the schedule at times, and no training, competencies, or orientation packet had been provided to Surveyor. Surveyor shared Staff Member-F was the employee caring for residents when they had a change in condition and was not licensed to care for residents. In an interview on 2/13/2023 at 7:55 AM, Surveyor asked HR-R, the HR for the facility, what happened with the hiring process of Staff Member-F. HR-R stated Staff Member-F was the first graduate nurse the facility had hired; typically, they do not hire anyone until they are licensed. Surveyor asked HR-R what job description Staff Member-F signed when hired. HR-R thought Staff Member-F had signed a job description for Graduate Nurse and stated HR-R would get a copy of it. (Surveyor was provided a copy of the job description Staff Member-F had signed; the job description was for an LPN.) HR-R stated Staff Member-F put in an application for employment and HR-R put Staff Member-F in the computer and got the pay situated. HR-R stated DON-B interviewed Staff Member-F and DON-B did the paperwork that was faxed for a temporary LPN license. HR-R stated HR-R followed up on the temporary LPN license in December 2022 and found out there was a mistake on the application, so it was never processed. HR-R stated once they found that out, they took Staff Member-F off the working schedule. Surveyor asked HR-R if the facility had a copy of Staff Member-F's diploma or transcript from nursing school. HR-R stated no, they did not have either of those documents. HR-R stated HR-R thought Staff Member-F was still in school and about to graduate. Surveyor asked HR-R if Staff Member-F had any training records or competencies completed while working at the facility, such as an orientation packet. HR-R stated DON-B would have training information. In an interview on 2/13/2023 at 8:10 AM, DON-B stated DON-B interviewed Staff Member-F prior to hiring Staff Member-F and found out Staff Member-F was a Graduate Nurse. DON-B stated Staff Member-F showed DON-B their credentials. DON-B was unable to provide Staff Member-F's diploma or transcript from nursing school to Surveyor. DON-B stated Staff Member-F showed DON-B their notice of graduation stating Staff Member-F finished the nursing program and was eligible to be a Graduate Nurse. DON-B stated DON-B and Staff Member-F completed the application for temporary LPN license and Staff Member-F told DON-B that Staff Member-F would pay for the temporary license. DON-B stated DON-B thought Staff Member-F had completed the application process. DON-B stated Staff Member-F had scheduled a date for the LPN boards which was in mid to late summer of 2022, and then told DON-B Staff Member-F had rescheduled the boards to a later date. Surveyor asked DON-B if DON-B ever got confirmation Staff Member-F had received the temporary LPN license. DON-B stated no. Surveyor asked DON-B if DON-B ever followed up on the temporary LPN license by contacting the licensing agency. DON-B stated no. Surveyor shared with DON-B the observation of Staff Member-F being listed on the working schedule as being the charge nurse. DON-B stated Staff Member-F was a regular employee and so was designated as a charge nurse if the other nurses working were agency staff. Surveyor asked DON-B if Staff Member-F worked only when there was an RN in the building. DON-B stated it was possible there were no RNs in the building when Staff Member-F was working. Surveyor asked DON-B to see the job description for a Graduate Nurse. DON-B stated they do not have a job description for a Graduate Nurse. Surveyor asked DON-B if there were any other Graduate Nurses working at the facility. DON-B stated Staff Member-F was the first Graduate Nurse working for the facility and there will not be any more after this. Surveyor asked DON-B if Staff Member-F had provided the facility with a copy of the diploma or transcript from nursing school. DON-B stated no, but DON-B saw the transcript and knew that Staff Member-F had passed the pharmacology course. Surveyor asked DON-B to see Staff Member-F's orientation packet, training, and competencies. DON-B stated HR would have that information. Surveyor noted HR-R had said DON-B would have that information. In an interview on 2/13/2023 at 8:27 AM, Scheduler-S stated Staff Member-F was an LPN that had just graduated. Surveyor asked Scheduler-S if Staff Member-F had worked part-time or full-time. Schedule-S stated Staff Member-F worked part-time but would pick up shifts. Surveyor asked Scheduler-S if Staff Member-F could work any time or did Staff Member-F have to be scheduled when any certain nurse worked. Scheduler-S stated Staff Member-F did not have any restrictions; Staff Member-F could work anywhere with anyone. Surveyor asked Scheduler-S if Staff Member-F was ever the nurse in charge when working. Scheduler-S stated if Staff Member-F was the only nurse working that was not from an agency, then Staff Member-F would be listed as the charge nurse. Surveyor asked Scheduler-S if an RN had to be working when Staff Member-F was working. Scheduler-S stated no. In a phone interview on 2/13/2023 at 9:03 AM, University Registrar-T stated Staff Member-F completed all courses of the (LPN) nursing program on 6/9/2022, but the date of 8/30/2022 was the last date of the semester and therefore the date used for official graduation. The facility provided to Surveyor Staff Member-F's orientation packet with signed materials on 7/25/2022. No competencies were provided. No copy of a diploma or transcript was provided. Surveyor noted the LPN job description stated date of hire was 8/22/2022 for 40 hours per week and was signed by Staff Member-F on 10/19/2022. On 2/13/2023 at 4:35 PM, Surveyor shared with NHA-A and DON-B the concern Staff Member-F worked as an LPN at the facility from 7/25/2022 until 12/16/2022 without an LPN license. Staff Member-F worked without a Registered Nurse in the building for 16 shifts and was designated as the charge nurse for 6 shifts. Staff Member-F performed all duties assigned to LPN staff without having an LPN license, including passing medication, doing wound care, and monitoring residents with a change in condition. No further information was provided at that time. The Facility failure to verify licensure of Staff Member-F, to ensure nursing staff had the appropriate competencies and skills to provide for the care of residents and to assure resident safety created a finding of Immediate Jeopardy. The facility removed the jeopardy on 2/17/23 when it had completed the following: Actions for Potentially Affected Residents: -Center in-house residents reviewed by physician or physician extender for ill effects. -Current employees reviewed for active licensure and/or credentialing, upon discovery of any employees found to be not in compliance would result in the immediate removal from the schedule until requirements are met and in employee file. Systemic Actions: -Facility reviewed current practice of hiring licensed/credentialed nursing staff and updated process flow to include: Staff member will not be placed on the schedule until validation of licensed/credentials are obtained and available in employee file; At this time the facility will no longer utilize graduate nurses or nurses who had temporary licenses. -Facility conducts monthly education on various topics to include, but not limited to, Communication, Change of Conditions, Caregiver Misconduct. Each educational session includes a post quiz to validate competencies and retention of the information provided. Education: -Re-education to Human Resource Director, Administrator, and Director of Nursing by Regional Leadership applicable facility policies and procedures, which include the: Expectations around the hiring process of licensed/credential staff hiring process. -The Administrator and/or designee to audit: new hires for licenses/credentials 8 weekly times 4 weeks. Results of audits/monitoring will be provided to QAPI (Quality Assurance Performance Improvement), which may further modify audit expectations based on results of initial audits. -AD HOC QAPI meeting - the QAPI Committee (composed of but not limited to Administrator, Director of Nursing, Assisted Director of Nursing, and Medical Director) to be held to review the alleged deficiency, discuss above action items and planned audits related to findings. The following Policy & Procedures were also reviewed: Licensure, Certification, and Registration of Personnel.

Based on interview and record review, the facility did not ensure residents received treatment and care based on a comprehensive assessment in accordance with professional standards of practice for residents experiencing changes in condition and for diabetic care for 4 of 14 sampled residents (R8, R9, R19, and R1.) There were no Registered Nurse (RN) assessments and there was a lack of monitoring by a competent licensed nursing staff for residents (R8, R9, R19) who experienced a change in condition requiring hospitalization . Additionally, the facility was not monitoring R1's blood sugars closely and was not conducting diabetic foot checks. R1 was hospitalized and was found to have gangrene on the toes of his left foot extending onto the dorsum of the foot as well as plantar surface. *R8 was sent to the hospital on 11/27/2022 via 911 for shortness of breath and low oxygenation. A timeline of events leading up to R8's hospitalization could not be determined due to lack of documentation. The last vital sign assessment of R8 was on 11/22/22. A physician order was in place to monitor temperature and oxygen saturation every shift and notify the physician and Director of Nursing (DON) immediately if any symptoms were present such as cough, fever greater than 100.0, and/or decreased oxygen saturation. Checkmarks were placed on the Medication Administration Record/Treatment Administration Record (MAR/TAR) with no values documented of the temperature or oxygen saturation levels. R8 was not comprehensively assessed by a licensed professional prior to hospitalization on [DATE] and at the time of the change of condition, no vital signs were documented, and no circumstances around the change of condition were documented. A non-nurse (Staff Member F) was working as a Licensed Practical Nurse (LPN) from 11/22/2022 through 11/27/2022 and was assigned to R8 on 11/27/22 during R8's change in condition. R8 passed away in the hospital on 11/28/2022. *R9 had a change in condition on 11/27/2022 with an oxygen saturation level of 74%. R9 was not comprehensively assessed by a licensed professional at the time of the change in condition. A non-nurse (Staff Member F) was assigned to R9 on 11/27/2023. Staff Member F did not get a Registered Nurse (RN) to assess R9 during this change in condition. Staff Member F contacted the Nurse Practitioner who ordered R9 to be sent to the hospital for evaluation and treatment. R9 refused to go to the hospital at that time. Staff Member F did not notify the Nurse Practitioner of R9's refusal. R9 was sent out to the hospital on 11/28/2022 at 1:45 AM with an oxygen saturation level of 70-71%. Complete vital signs were not documented at the time when the change of condition was first noted on 11/27/2022 or prior to leaving the facility on 11/28/2022 and no documentation was found describing the circumstances around the change of condition or between the time the change of condition was first noted and when R9 was sent to the hospital. A timeline of events could not be determined due to lack of documentation. R9 did not return to the facility. * R19 was sent to the hospital on 10/25/2022 for a change in condition. A non-nurse (Staff Member F) was assigned to R19's unit on 10/25/2022. The medication administration record for 10/25/2022 indicates Staff Member F administered some of R19's morning medication. On 10/25/2023 R19's oxygen saturation level was 63%. R19's medical record did not have any documentation on 10/25/2022 indicating R19 had a change in condition that would require hospitalization : no progress note, no change of condition evaluation documentation, and no vital signs. A timeline of events could not be determined due to lack of documentation. R19 was admitted into the hospital on 10/25/2022. Cross-reference F726 for Competent Nursing Staff. Staff Member-F was not a licensed nurse or a Certified Nursing Assistant. *R1 was admitted to the facility on [DATE] without any skin concerns. The hospital discharge summary dated 11/23/22 under the section Follow Up Items for PCP (Primary Care Physician)/Outpatient Providers includes documentation of - Patient should have his DM (diabetes mellitus) meds (medications) optimized, he is noted to have diarrhea from Metformin, recommend PCP to consider alternate PO (by mouth) meds. There is no evidence the facility discussed this recommendation with R1's physician or physician extender to monitor R1's blood sugars closely. This physician's note was not scanned into the electronic medical record and the facility only obtained blood sugar for R1 one time which was on 12/4/22. Diabetic foot checks were not being completed, staff were not removing R1's gripper socks during cares and weekly skin assessments were not consistently being completed. On 1/7/23, R1 was transferred to the hospital. The emergency department note dated 1/7/23 documents - Left foot with toes 3 through 5 completely gangrenous and the distal portion of 2nd toe gangrenous. This extends little bit onto the dorsum of the foot as well as plantar surface. Proximal redness. The facility was unaware of R1's left foot gangrene until the hospital notified facility staff of this. The facility failure to have a licensed professional (RN) comprehensively assess residents (R8, R9, and R19) who were having a change in condition, the failure of the facility to have licensed professional staff monitoring residents with changes in condition, the failure to closely monitor R1's diabetic status to include the monitoring of blood sugars, and the failure to conduct diabetic foot checks and the monitoring of pain, created a finding of immediate jeopardy that began on 11/22/2022. Surveyor notified Nursing Home Administrator (NHA)-P and Director of Nursing (DON)-B of the immediate jeopardy on 2/13/2023 at 4:35 PM. The immediate jeopardy was removed on 2/21/23. The deficient practice continues at a scope/severity of E (potential for harm/pattern) as the facility continues to implement and monitor the effectiveness of their removal plan. Findings: The facility policy and procedure entitled Change in a Resident's Condition or Status dated with revision 5/2017 states: Policy Interpretation and Implementation: 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a (an): . d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; . g. need to transfer the resident to a hospital/treatment center; . 2. A 'significant change' of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not 'self-limiting'); b. Impacts more than one area of the resident's health status; c. Requires interdisciplinary review and/or revision to the care plan; and d. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: . b. There is a significant change in the resident's physical, mental or psychosocial status; . e. It is necessary to transfer the resident to a hospital/treatment center. 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 1. R8 was admitted to the facility on [DATE] with diagnoses of spastic quadriplegic cerebral palsy, anxiety, schizophrenia, intellectual disabilities, scoliosis, gastro-esophageal reflux disease, and dysphagia requiring a gastrostomy feeding tube for nutrition. R8's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R8 was severely cognitively impaired per staff assessment and was dependent for all activities of daily living. On 11/22/2022 at 12:23 PM in the progress notes, nursing charted R8 was visited by a community Case Manager and R8's Guardian. Nursing charted R8 was placed in a Broda chair with a Hoyer lift and positioned with pillows. Nursing charted R8 was able to tolerate being reclined and upright in the Broda chair for approximately one hour before being transferred back to bed. On 11/22/2022 (pm shift,) R8's vital signs were as follows: blood pressure 129/67, temperature 97.6, pulse 71, respirations 18, and oxygen saturation 97%. Surveyor noted the vital signs were obtained on 11/22/2022 because there was a physician order to obtain vital signs and monitor edema weekly on Tuesday PM shift. Surveyor noted a physician order was in place to monitor temperature and oxygen saturation every shift and notify the physician and Director of Nursing (DON) immediately if any symptoms were present such as cough, fever greater than 100.0, and/or decreased oxygen saturation. Surveyor noted checkmarks were placed on the Medication Administration Record/Treatment Administration Record (MAR/TAR) and no values were documented of the temperature or oxygen saturation level. R8 was not comprehensively assessed by a licensed professional prior to hospitalization on [DATE] and at the time of the change of condition, no vital signs were documented, and no circumstances around the change of condition were documented. A non-nurse was working as a Licensed Practical Nurse (LPN) from 11/22/2022 through 11/27/2022 and was assigned to R8's unit during this timeframe. There was no documentation in the progress notes between 11/22/2022 and 11/26/2022. No vital signs were documented after 11/22/2022. On 11/27/2022 at 11:34 AM in the progress notes, Staff Member-F, an unlicensed employee, charted R8 was sent out 911 at 11:00 AM for shortness of breath and low oxygen saturation. Staff Member-F charted the community Case Manager was unavailable and a message was left for them to call the facility for an update on the changes in R8. Staff Member-F charted R8's guardian was called and notified of changes, the Nurse Practitioner was updated, and the DON was aware. Surveyor did not find any documentation of Staff Member-F contacting a Registered Nurse to do an assessment of R8 for the change in status. No vital signs were documented. No details surrounding the change in condition were documented. Surveyor requested and received the Emergency Medical Service (EMS) report of R8's change of condition on 11/27/2022. The report states the following: EMS received the 911 call on 11/27/2022 at 11:11 AM and an ambulance unit and fire engine were dispatched to the scene for a call regarding a resident with complaints of difficulty breathing. On arrival, R8 was lying in bed in the care of staff. R8 was noted to have an altered mental status with the last known well time being 30 minutes ago. Staff stated R8 was not verbal and normally with an altered mentation, but this morning when giving R8 a bath, R8 became more altered than normal and was gasping for air. Staff stated R8's oxygen saturation was in the 70's and they applied oxygen via nasal cannula with no relief. R8's past medical history of cerebral palsy and scoliosis was noted. At 11:25 AM, R8's vital signs were assessed: blood pressure 98/58, oxygen saturation 71%, pulse 140 and regular, respirations 24 and rapid, blood glucose over 500, and temperature 98.0. (Surveyor noted R8's blood pressure and oxygen saturation were low and R8's pulse, respirations, and blood glucose were high.) R8's lungs were noted with rhonchi bilaterally, and R8 was placed on a mask with high flow oxygen. R8 was then moved to the ambulance for a further assessment. Once in the ambulance, vital signs were noted again, and R8's blood glucose read high on the glucose monitor. Intravenous (IV) access was attempted twice but was unsuccessful. R8's Glasgow Coma Scale was 8 and inconclusive on the stroke scale. R8 was placed on a heart monitor that showed sinus tachycardia (fast heart rate.) R8's oxygen saturation was 96% with the high flow oxygen. During the secondary assessment, no new issues were found. R8 was placed in a position of comfort and transported to the hospital at 11:34 AM. Surveyor requested and received the hospital record of R8's change of condition on 11/27/2022. The hospital medical record states the following: -The Emergency Department (ED) Triage note on 11/27/2022 at 12:04 PM states: R8 presented to the ED for shortness of breath. Staff stated R8 was having shortness of breath and was turning blue and they put oxygen at 2 liters per nasal cannula on R8 with no increase in oxygen saturations. R8 was placed on a non-rebreather oxygen mask in the rescue squad and the oxygen saturation increased to 96%. R8 was alert and oriented times two which was baseline for R8 per nursing home staff. -The Death Summary Note on 11/28/2022 at 7:16 PM describes R8's hospital course and states: R8 was a [AGE] year-old patient with a history of mental retardation, cerebral palsy, seizure disorder, anxiety, spastic quadriplegia, and scoliosis that presented with shortness of breath and hypoxia. R8 was noted to be turning blue at the nursing home. R8 did not improve with oxygen at 2 liters per nasal cannula and EMS was called. R8 was placed on BiPAP, tested negative for influenza and COVID, and was found to be febrile with a temperature of 100.8. R8 was started on empiric Rocephin. R8 coded and was intubated. R8 responded to epinephrine and then coded a second time. An epinephrine drip was started. Dark drainage was noted around the gastrostomy tube site and tested positive for occult blood. R8 was started on a Protonix drip. R8 was too unstable for any type of procedure and due to renal function and instability, they were unable to proceed with a CT scan. R8 was able to be weaned off the insulin drip and started on Lantus insulin and sliding scale insulin. R8 remained acidotic with worsening lactic acid. R8 was started on a Bicarb drip and nephrology was consulted. A conversation was had with R8's family about R8's poor prognosis and multiorgan failure with R8 requiring to be on four full dose pressors. R8 coded again on 11/28/2022; the ED was the first to respond to the room. LUCAS (an external automated chest compression device) was placed for compressions. R8 began to lose a large amount of blood from the mouth from compressions. R8 was already on multiple pressors, and no shockable rhythm was detected. Time of death was called at 4:44 PM (on 11/28/2022). Surveyor reviewed the 24-hour board that lists the residents in the facility that were being monitored for a change in condition, new medication, new skin area of concern, or any other focused monitoring for 11/22/2022 through 11/27/2022. R8 was not on the 24-hour board for monitoring of any condition. Surveyor requested the staff schedule for 11/27/2022. DON-B was the manager on call that day. Staff Member-F was listed as working day shift and was listed as the Charge Nurse for the day shift. Registered Nurse (RN)-X and two Licensed Practical Nurses (LPNs) from an agency were on the staff schedule on day shift. Certified Nursing Assistant (CNA)-W, CNA-Y, and CNA-Z were listed as the CNA staff on the unit Staff Member-F was working on day shift. In an interview on 2/2/2023 at 1:52 PM, Surveyor asked DON-B if DON-B recalled R8. DON-B stated R8 was on continuous tube feeding and needed to have everything done for R8. DON-B stated R8 liked to be in the fetal position and was non-verbal but moaned when uncomfortable. Surveyor noted DON-B was the manager on call for that day. Surveyor asked DON-B if DON-B recalled R8's change of condition on 11/27/2022. DON-B did not remember R8's change of condition. Surveyor asked DON-B if DON-B was called by Staff Member-F on 11/27/2022 either before, during, or after R8 was transferred to the hospital. DON-B did not remember being called on 11/27/2022. Surveyor asked DON-B if Staff Member-F was available for an interview. DON-B stated Staff Member-F no longer worked at the facility. DON-B stated Staff Member-F did not pass the Practical Nursing boards exam and did not return to work at the facility after failing the boards. Surveyor shared with DON-B the concerns that when R8 had difficulty breathing with low oxygen saturations, no RN was notified of R8's change in condition and R8 was not assessed by an RN, no vital signs were documented, and no documentation was found describing the events prior to the change in condition or the change in condition itself. DON-B stated DON-B would see if more information could be found regarding that incident. In an interview on 2/8/2023 at 1:17 PM, Surveyor asked CNA-W if CNA-W recalled R8. CNA-W stated R8 was very contracted and needed to be repositioned every two hours to make R8 comfortable. Surveyor asked CNA-W if CNA-W could recall what happened with R8 on 11/27/2022. CNA-W stated R8 was fine on first shift and R8 was sent out on second shift. Surveyor clarified with CNA-W that R8 was sent out 911 on day shift. CNA-W agreed R8 was a full code but could not really remember that day. CNA-W stated R8 was not verbal and could not track with the eyes; R8 would moan sometimes but really did not have any communication. Surveyor asked CNA-W if CNA-W could recall working with Staff Member-F. CNA-W stated Staff Member-F would float between the two units. CNA-W remembered on 11/27/2022 an oxygen mask was placed on R8 because the oxygen levels were low. Surveyor asked CNA-W if R8 looked blue or distressed. CNA-W could not remember R8 looking blue or having difficulty breathing. Surveyor asked CNA-W if Staff Member-F called any other nurses to come and assess R8. CNA-W could not recall any other nurses being called to assess R8. In an interview on 2/8/2023 at 1:28 PM, Surveyor asked RN-X if RN-X recalled R8. RN-X recalled R8 had tube feeding for nutrition and would not really respond to staff because R8 was non-verbal. RN-X stated R8 resided on the unit RN-X did not work on. Surveyor asked RN-X if RN-X was called to assess R8 when R8 had a change in condition on 11/27/2022. RN-X stated RN-X did not get a call to assess R8 but heard R8 had desaturated. RN-X stated usually an LPN would call an RN before calling 911, but RN-X did not assess R8 before R8 left the building. RN-X stated RN-X was the only RN in the building at that time. Surveyor reviewed the time clock punches for 11/27/2022. RN-X was not working day shift on 11/27/2022 as was stated on the staffing schedule provided to Surveyor by the facility and was not in the building when R8 had a change in condition. During the daily meeting with the facility on 2/8/2023 at 2:49 PM, Surveyor shared with Nursing Home Administrator-P, Licensed Practical Nurse Unit Manager (LPN UM)-G, Regional Director of Operations (RDO)-U, and RN Regional Educator-V the concerns regarding R8's change of condition on 11/27/2022. On 11/27/2022, R8 had a change in condition with respiratory status. Staff Member-F did not have R8 assessed by an RN or any licensed staff with that change in condition, no vital signs were documented, and nothing was documented as to the circumstances prior to or during the change of condition. Surveyor shared DON-B did not recall being notified of the change of condition and was the manager on call that day. In an interview on 2/9/2023 at 9:24 AM, CNA-Y and CNA-Z talked to Surveyor together and had the same recollection of R8 and the events on 11/27/2022. CNA-Y and CNA-Z stated all R8 did was lie in bed in the fetal position and they would reposition R8 every two hours. CNA-Y stated R8 was usually a screamer when cares were being provided and CNA-Y recalled R8 was not screaming out like normal. CNA-Z stated it was like R8 had a cold, like R8 had nasal congestion. CNA-Y stated they noticed that R8 was different than normal and told Staff Member-F. CNA-Y stated Staff Member-F went in to do vital signs and R8's oxygen level was low, so they gave R8 oxygen and then Staff Member-F called the doctor and 911. Surveyor asked CNA-Y and CNA-Z if they remember R8 turning blue or gasping for air. CNA-Y and CNA-Z stated R8 was having a hard time breathing, but R8 was not blue. In an interview on 2/13/2023 at 10:18 AM, Surveyor asked Nurse Practitioner (NP)-M if NP-M was called on 11/27/2022 when R8 was having a change of condition. NP-M stated NP-M did not recall being notified of R8 being sent out and did not know any details of the transfer. On 2/13/2023 at 11:52 AM, Surveyor shared with NHA-P and RN Educator-V the serious concerns regarding R8's change of condition on 11/27/2022 with the lack of assessment by any licensed professional, the lack of documentation at that time with no vital signs or description of preceding events, and R8 passing away in the hospital on 11/28/2022. No further information was provided at that time. 2. R9 was admitted to the facility on [DATE] with diagnoses of blastomycosis and chronic obstructive pulmonary disease. On 11/25/2022 at 7:56 PM, R9's temperature was 98.1 and respirations were 19. On 11/26/2022 at 8:42 PM in the progress notes, Registered Nurse (RN)-X charted R9 visited with family and had issues with anxiety. R9 refused medications and refused to eat dinner but took sips of fluids. R9 verbalized wanting to be Hospice. On 11/27/2022 at 4:44 AM, R9's oxygen saturation was 93%. On 11/27/2022 at 9:15 AM, R9's blood pressure was 144/87 and pulse was 73. On 11/27/2022 at 10:48 AM, R9's oxygen saturation was 97%. On 11/27/2022 at 4:22 PM, R9's oxygen saturation was 92%. Surveyor noted a complete set of vital signs was not obtained at any one time from 11/25/2022 through 11/27/2022. On 11/27/2022 at 4:24 PM in the progress notes, Staff Member-F, an unlicensed employee, charted R9's oxygen saturation was 74% and R9 was positioned in high fowler (sitting upright). Staff Member-F charted an albuterol inhaler was administered and the oxygen saturation did not increase. (Surveyor noted the albuterol inhaler on the Medication Administration Record was not signed out as being administered.) Staff Member-F charted the Nurse Practitioner (NP) was contacted and the NP requested R9 be sent to the hospital. Staff Member-F charted R9 refused to go to the hospital and the NP was notified of the refusal. Surveyor noted no Registered Nurse (RN) was contacted to do an assessment of R9 at the time of the change of condition and no vital signs were documented. Per the staffing schedule, RN-X was in the building at the time of R9's change of condition. On 11/28/2022 at 12:49 AM in the progress notes, Licensed Practical Nurse (LPN)-E charted R9 had an oxygen saturation of 70-71% on 4 liters of oxygen per nasal cannula and R9 was tachypneic (fast heart rate). On 11/28/2022 at 12:54 AM, R9's oxygen saturation was 71%. Surveyor noted no other vital signs were documented. On 11/28/2022 at 5:44 AM in the progress notes, LPN-E charted R9 was transported to the hospital for evaluation at 1:45 AM. The LPN charted the NP had instructed R9 to be sent out during the previous shift due to shortness of breath, but R9 refused to go at that time. The LPN charted a message was left for the NP and the Director of Nursing of R9's transfer to the hospital. Surveyor noted per the staffing schedule, no RN was in the building at the time R9 was sent out to the hospital. R9 did not return to the facility. On 2/8/2023 at 7:50 AM, Surveyor conducted a telephone interview with LPN-E, who completed the documentation on 11/28/22 at 12:49 AM and 5:44 AM. LPN-E stated LPN-E could not recall R9 or the incident. LPN-E stated there is not an RN in the facility at all times, but the Director of Nursing (DON) can be called if needed. On 2/8/2023 at 8:20 AM, Surveyor interviewed Licensed Practical Nurse Unit Manager (LPN UM)-G. LPN UM-G indicated when a resident presents with a change in condition the facility does not call a resident assessment an assessment. LPN UM-G stated the facility uses the term an evaluation and LPNs can complete evaluations. LPN UM-G did indicate a head-to-toe evaluation should have been completed. LPN UM-G reviewed R9's medical record and verified an evaluation had not been completed. In an interview on 2/13/2023 at 10:18 AM, Surveyor asked NP-M if NP-M was notified on 11/27/2022 of R9 refusing to go to the hospital. NP-M stated NP-M did not recall R9 refusing. Surveyor shared with NP-M that R9 was sent out a few hours later with oxygen saturations in the low 70's. NP-M stated NP-M was glad someone sent R9 out with oxygen saturation levels that low. On 2/13/2023 at 4:35 PM, Surveyor shared with Nursing Home Administrator (NHA)-P, DON-B, RN Regional Educator-V, and LPN Unit Manager-G the concern with R9 not being comprehensively assessed by an RN with a change in condition on 11/27/2022 when Staff Member-F, an unlicensed employee, was caring for R9, no vital signs were obtained on 11/27/2022 and 11/28/2022 when R9 was in distress, and NP-M was not notified R9 had refused transfer to the hospital on 11/27/2022. No further information was provided at that time. 3. R19 was admitted to the facility on [DATE] with diagnoses of acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), diabetes, emphysema, alcoholic cirrhosis of the liver, metabolic encephalopathy, bipolar disorder, anxiety, alcohol abuse, nicotine dependence, and depression. On 10/21/2022 at 12:13 AM in the progress notes, Registered Nurse (RN)-X charted R19 went outside to smoke and had been following the safety rules to remove oxygen when smoking. On 10/23/2022 at 7:46 AM in the progress notes, a Licensed Practical Nurse (LPN) charted R19 had removed oxygen multiple times throughout the night shift to smoke cigarettes; R19 was educated on what occurs when not having oxygen on for periods of time while smoking. The LPN charted R19 would continue to be monitored for oxygen saturation levels and document as necessary. On 10/23/2022 at 8:18 AM in the electronic Medication Administration note, an LPN charted oxygen was on at that time and the LPN had to consistently remind R19 to keep the oxygen on due to R19 taking the oxygen off multiple times to smoke. No documentation was found in R19's progress notes from 10/23/2022 until 10/28/2022. On 10/25/2022 at 8:50 AM, R19's oxygen saturation was 63%. No other vital signs were noted. Surveyor noted R19 had a Discharge Return Anticipated Minimum Data Set (MDS) assessment completed with a date of 10/25/2022. Surveyor could not find any documentation in R19's medical record on 10/25/2022: no progress note, no vital signs other than low oxygenation at 8:50 AM, and no change of condition SBAR (Situation-Background-Assessment-Recommendation) form showing the details of the change in status or notification to the physician, Nurse Practitioner, or family member. Surveyor reviewed R19's Medication Administration Record (MAR). R19 received medication on the night shift of 10/24/2022 and did not receive all the morning medications on 10/25/2022. The medication documentation for the morning of 10/25/2022 was written by Staff Member-F, an unlicensed employee. Surveyor asked for the nursing schedule for 10/25/2022. Staff Member-F was assigned to R19's unit on that date. Surveyor reviewed R19's Hospital Discharge Summary dated 10/27/2022. R19 was admitted to the hospital on 10/25/2022 with hypoxemia and increased respiratory distress. R19 was placed on BiPAP in the emergency room and had slow progressive improvement. R19 was weaned off to an oxygen mask followed by nasal cannula and required an average of 2 to 5 liters per minute by nasal cannula. R19 was placed on intravenous (IV) antibiotics to cover HCAP (healthcare associated pneumonia) due to recent hospitalization for pneumonia and COPD exacerbation as well as respiratory failure that required mechanical ventilation as well as residing at a nursing home facility. R19 had significant improvement in respiratory status. On 10/27/2022, R19 was clinically stable and at baseline and was discharged back to the nursing home. On 2/13/2023 at 4:35 PM, Surveyor shared with Nursing Home Administrator (NHA)-P, DON-B, RN Regional Educator-V, and LPN Unit Manager-G the concern with R19 not having any documentation of a change of condition on 10/25/2022 that required hospitalization . Surveyor was not able to find any progress notes, vital signs other than low oxygenation, or change of condition SBAR form indicating what had occurred requiring hospitalization and lack of documentation of who was notified. Surveyor shared the concern Staff Member-F was the employee listed on the schedule to care for R19 and Staff Member-F was not licensed as a nurse. No further information was provided at that time. 20483 The Nursing Care of the Resident with Diabetes Mellitus 2001 Med-Pass, Inc. (Revised December 2015) under Glucose Monitoring includes documentation of; 1. The management of individuals with diabetes mellitus should follow relevant protocols and guidelines. 2. The physician will order the frequency of glucose monitoring. Under Medication Management documents; 1. Insulin (injectable or inhaled) is required for individuals with type I diabetes. 2. Insulin (injectable) can be administered via syringe, pump, or pen. 3. Medication management of type II diabetes may include oral hypoglycemic agents with or without insulin. Under documentation includes; Documentation should reflect the carefully assessed diabetic resident and include the following: 1. Vital signs as ordered; 2. Level of consciousness; 3. Assessment of the skin including the following: a. Color, moisture, and temperature; and b. Any redness, ulcers, irritation, abrasions, and/or pruritus (itching). 4. Accurate intake and output; 5. Percentage of meals consumed; 6. Emotional reactions, moods; 7. Careful assessment of pain (including symptoms such as discomfort and/or paresthesia (numbness, tingling) should include the following: a. Characteristics of pain: (1) Intensity of pain (as measured on a standardized pain scale); (2) Descriptors of pain; (3) Pattern of pain (e.g., constant or intermittent); (4) Location and radiation of pain; and (5) Frequency, timing and duration of pain. b. Impact of pain on quality of life; c. Factors that precipitates or exacerbate pain; d. Factors and strategies that reduce pain; and e. Symptoms that accompany pain (e.g., nausea, anxiety). 8. Motor weakness; 9. Urinary symptoms including retention and incontinence; 10. Bowel dysfunction including diarrhea and constipation; 11. Blood pressure problems including orthostatic hypotension; 12. Assessment of the feet should include the following: a. Hygiene; b. Temperature; c. Color; d. Circulation (e.g., pedal pulses, toe capillary refill); e. Any abrasions, sores and/or injuries; f. Any corns or calluses; and g. The condition of the toes and toenails. 13. Injection site rotation (if insulin is ordered); and 14. Blood sugar results and other pertinent laboratory studies. The foot care policy 2001 Med Pass, Inc. (Revised March 2018) under Policy Interpretation and Implementation includes documentation of; 1. Residents will be provided with foot care and treatment in accordance with professional standards of practice. 2. Overall foot care will include the care and treatment of medical conditions associated with foot complications (e.g., diabetes, peripheral vascular disease, etc.). 4. R1 was admitted to the facility on [DATE]. Diagnoses includes diabetes mellitus, morbid obesity [TRUNCATED]

Based on observation, interview and record review, the facility did not ensure residents with pressure injuries received appropriate care and treatment to promote healing, prevent infection and prevent new pressure injuries from developing for 2 (R13 and R7) of 6 residents reviewed for pressure injuries. 1. R13 was admitted to the facility 5/26/22 and assessed to be at high risk for pressure injuries. On 10/6/22, the facility documented R13 had a healed pressure injury to the sacrum. Between 10/6/22 and 10/20/22 there were no skin assessments documented for R13. R13 was hospitalized on [DATE] and the hospital identified a 6 cm (centimeter) abscess due to pressure ulceration on R13's right gluteal area. R13 required surgery including debridement of skin, subcutaneous tissue, muscle, fascia perineum, right buttocks, bilateral groin and bilateral scrotum. R13 required a colostomy for wound healing and was transferred back to the facility on [DATE]. Upon readmission the wound was not comprehensively assessed until 11/10/22. Multiple wound treatments were not documented as being completed in November. R13 was hospitalized again 11/28/22 for a dislodged G-tube but wounds were noted by the hospital to be deteriorating and R13 was diagnosed with osteomyelitis. A PICC line was placed and F13 was transferred back to the facility on [DATE] with orders for 4 weeks of antibiotics for the wound infection and weekly labs. Upon readmission the wound was not comprehensively assessed until 12/8/22 and a fourth wound, a Deep Tissue Injury (DTI) was identified to the left heel. Multiple wound treatments were not documented as being completed in December nor were the weekly labs requested by the Infectious Disease MD obtained. The facility identified wound treatments were not being completed but the problem continued. On 12/29/22, an additional wound was identified to the left upper buttocks. On 1/4/23 R13 went to the Infectious Disease MD who had to extend the use of the antibiotics for the wound infection for another 2 weeks. By 1/5/23 the wound to the left heel had deteriorated from DTI to Stage 3, the left upper buttocks wound from Stage 2 to unstageable and undermining to the sacral wound. The left heel wound was healed by February 2023 but all other wounds noted deterioration on 1/26/23 or 2/2/23. Multiple wound treatments were not documented as completed in January and the facility again identified that wound treatments were not being completed but the problem continued through February. On 2/4/23, R13 was again transferred to the hospital and admitted . At time of the onsite survey R13 remained in the hospital with plans for surgical debridement of the wounds again. 2. R7 was admitted to the facility in 2018 and had a history of pressure injuries. On 3/30/22 a wound was found to his right gluteal fold and assessed as trauma. On 4/20/22 the Wound MD(Medical Doctor) assessed the wound as an Unstageable pressure injury and then a Stage 4. The wound deteriorated needing debridement due to necrotic tissue, undermining and became infected. The infection needed to be treated with IV (intravenous) antibiotics and then a wound vac. The wound improved to the point that it was almost healed on 2/2/23 according to the Wound MD. On 2/7/23 Surveyor observed wound care completed to R7 and when the nurse went to remove the bandage it was dated 2/2/23, was completely saturated, malodorous and had been on for 5 days even though the treatment was scheduled for daily. The facility had been aware in previous months that wound treatments were not being completed. Although they implemented at PIP (Performance Improvement Plan), it was not effective noted by the current observations. On 2/9/23, Surveyor again observed the wound with the Wound MD and the wound had deteriorated, had a 20% increase in length and was again necrotic and needed to be chemically debrided. The facility's failure to comprehensively assess the wounds and skin timely, complete wound treatments as ordered, prevent new wounds from forming, prevent deterioration of existing wounds and prevent infections for these wounds created a finding of Immediate Jeopardy (IJ) that began on 10/20/22. Surveyor notified Current Nursing Home Administrator (NHA)-P, Director of Nursing (DON)-B and RN (Registered Nurse) Regional Educator (RN)-V of the IJ on 2/13/22 at 4:35 PM. The IJ was removed on 2/21/23, however the deficient practice continues at a scope/severity level of E (Potential for Harm/pattern) as the facility continues to implement its action plan. The AMDA (American Medical Directors Association) clinical practice guideline entitled Pressure Ulcers and Other Wounds, dated 2017, states in part: .A pressure ulcer [Injury] is localized damage to the skin or underlying soft tissue, usually over a bony prominence or related to a medical or other device. The ulcer may present as intact skin or as an open ulcer and may be painful. The ulcer occurs as a result of intense or prolonged pressure or pressure in combination with shear. Recognition: Early recognition of pressure ulcers and of any risk associated with the development of pressure ulcers and other wounds is critical to their successful prevention and management. Assessment: The purpose of the assessment is to collect enough information to evaluate the patient's general condition, characterize a pressure ulcer; and identify related causes and complications. Step 2. Examine the patient's skin thoroughly to identify existing pressure ulcers. Examine the patient's skin upon admission or readmission. Step 3. Assess the patient's overall physical and psychosocial health and characterize the pressure ulcers. A pressure ulcer should be assessed along with the patient's overall clinical, functional, and cognitive status weekly reassessment and documentation of ulcer characteristics is recommended. More frequent assessment may be necessary for ulcers that are not responding to treatment or are worsening despite treatment. Step 4. Identify factors that can influence ulcer treatment and healing.functional status. Functional factors, including impaired mobility, a self-care deficit, and incontinence (especially fecal incontinence), may influence the severity, duration, and healing of a pressure ulcer. Step 5.Documentation should cover all pertinent characteristics of existing pressure ulcers, including location; size; depth; maceration; color of the ulcer and surrounding tissues; a description of any drainage, eschar, necrosis, odor, tunneling, or undermining; tissue types covering the wound bed; .and a description of the peri-wound skin .including type and amount of drainage. Step 6. Identifying priorities in managing the ulcer and the patient .Pain control related to the ulcer and any comorbid conditions.The same factors that increase a patient's susceptibility to developing pressure ulcers .may also impair the healing of an existing pressure ulcer . Surveyor reviewed facility's Pressure Ulcer/Skin Breakdown - Clinical Protocol policy with a revision date of April 2018. Documented was: Assessment and Recognition 1. The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; and e. All active diagnoses. 3. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. 4. The physician will assist the staff to identify the type (for example, arterial or stasis ulcer) and characteristics (presence of necrotic tissue, status of wound bed, etc.) of an ulcer. 5. The physician will help identify and define any complications related to pressure ulcers. Cause Identification 1. The physician will help identify factors contributing or predisposing residents to skin breakdown; for example, medical comorbidities such as diabetes or congestive heart failure, overall medical instability, cancer or sepsis causing a catabolic state, and macerated or friable skin. 2. The physician will clarify the status of relevant medical issues; for example, whether there is a soft tissue infection or just wound colonization, whether the wound has necrotic tissue, and the impact of comorbid conditions on healing an existing wound. Treatment/Management 1. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. 2. The physician will help identify medical interventions related to wound management; for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, managing pain related to the wound or to wound treatment, etc . 3. The physician will help staff characterize the likelihood of wound healing, based on a review of pertinent factors; for example: a. Healing or Prevention Likely: The resident's underlying physical condition, prognosis, personal goals and wishes, care instructions, and ability to cooperate with the treatment plan make wound healing and subsequent wound prevention realistic. b. Healing or Prevention Possible: Healing may be delayed or may occur only partially; wounds may occur despite appropriate preventive efforts. c. Healing or Prevention Unlikely: The resident is likely to decline or die because of his/her overall medical instability; wounds reflect the individual's overall medical instability; an existing wound is unlikely to improve significantly; additional wounds are likely to occur despite preventive efforts . Monitoring 1. During resident visits, the physician will evaluate and document the progress of wound healing especially for those with complicated, extensive, or poorly-healing wounds. 2. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. a. Healing may be delayed or may not occur, or additional ulcers may occur because of other factors which cannot be modified. b. Current approaches should be reviewed for whether they remain pertinent to the resident/patient's medical conditions, are affected by factors influencing wound development or healing, and the impact of specific treatment choices made by the resident/patient or a substitute decision-maker. 1. R13 was admitted to the facility on [DATE] with diagnoses that included Unspecified Cord Compression, Quadriplegia due to Motor Vehicle Accident, Type 2 Diabetes Mellitus (DM) with Diabetic Neuropathy, Chronic Obstructive Respiratory Failure (COPD), Congestive Heart Failure (CHF) and Chronic Kidney Disease (CKD). Surveyor reviewed R13's Braden Scale for Predicting Pressure Sore Risks with an effective date of 5/26/22, documented a score of 9 indicating R13 is at very high risk for the development of pressure injuries. Surveyor reviewed R13's Quarterly Minimum Data Set (MDS) with an assessment reference date of 6/1/22, which documents a Brief Interview for Mental Status (BIMS) score of 13 which indicates R13 is cognitively intact; requires total assist of 2 + staff for bed mobility and transfers; is at risk for the development of pressure ulcers/injuries. Surveyor reviewed R16's Care Area Assessment (CAA) related to Pressure Ulcer/Injury with an assessment date of 6/1/22. Documented under Nature of the Problem/Condition was Resident is at risk for impaired skin integrity [related to (R/T)] Quadriplegia [status post (s/p)] Spinal cord compression, CHF (Congestive Heart Failure), CKD (Chronic Kidney Disease), COPD (Chronic Obstructive Pulmonary Disease), DM (Diabetes Mellitus) type 2, Oxygen use, Medication use, Dependent on staff for all [activities of daily living (ADL's)], and Bowel incontinence. Surveyor reviewed R13's Comprehensive Care Plan with initiation date of 6/5/22. Documented was Focus: Resident has Actual impaired skin integrity R/T Quadriplegia s/p Spinal cord compression, CHF, CKD, COPD, DM type 2, Oxygen use, Medication use, Dependent on staff for all ADL's, and Bowel incontinence. History of pressure related skin breakdown. Resident prefers to lay on back. Refuses repositioning at times. Goal: Resident will have intact skin, free of redness, blisters or discoloration by/through review date [as evidenced by (AEB)] weekly skin audits. Interventions: - Air mattress set to 360 check functioning every shift - I need assistance to turn/reposition at least every 2-3 hours with rounds, more often as needed or requested. - Monitor nutritional status. Serve diet as ordered, monitor intake and record. - Monitor, document and report [signs and symptoms (s/s)] of skin breakdown/impairment. - Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Surveyor reviewed R13's wound documentation. In June, July, August and September of 2022, R13 is documented as having a Stage 3 pressure injury to sacrum. It was assessed, monitored and a treatment was in place. Surveyor reviewed MD (Medical Doctor) orders for R7 for prevention of pressure injuries's. Documented with a start date of 8/26/22 was Zinc Oxide Cream 15 % Apply to PERI-RECTAL AREA topically every 8 hours as needed for SKIN PROTECTION and Head to toe skin assessment weekly one time a day every Fri (Friday) for Skin Monitoring. On 9/29/22, Wound MD-J assessed R13's pressure injury on the sacrum. Wound MD-J reclassified it Wound Status: HEALED. Observations of the wound were documented by Wound MD-J as Woundbed assessment: Fully granulated. Surveyor reviewed R13's Weekly Wound Assessment with an assessment date of 9/29/22. Documented was .B. Wound Description. 1. Type of wound: Pressure. 2. Wound Description: Site: 53) Sacrum. Type: Pressure. Length: 2.9 cm. (centimeter) Width: 2.0 cm. Depth: 0.1 cm. Stage: III. 3a. Percentage of granulation: 70. 3b. Percentage of slough: 0. 3c. Percentage of eschar: 0. 3d. Percentage of epithelialization: 30 . Surveyor notes this contradicted the Wound MD's assessment on the same day that documented the wound was healed. Survyeor was unable to locate documentation the facility addressed the discrepancy in the two assessments. Surveyor reviewed R13's Weekly Wound Assessment with an assessment date of 10/6/22. Documented was .B. Wound Description. 1. Type of wound: Pressure. 2. Wound Description: Site: 53) Sacrum. Type: Pressure. Length: 0 cm. Width: 0 cm. Depth: 0 cm. Stage: III. 3a. Percentage of granulation: 100. Surveyor noted the facility stated the wound was healed on 10/6/22. Surveyor reviewed MD orders for R7 for prevention of the wound site. Documented with a start date of 10/8/22 was Apply foam dressing to Sacrum for protection. Every day shift every Tue (Tuesday), Thu (Thursday), Sat (Saturday). Surveyor reviewed R13's Treatment Administration Record (TAR) for October 2022. The sacrum dressing was signed out as completed 10/8/22, 10/11/22, 10/13/22, 10/15/22, 10/18/22, and 10/20/22. Surveyor reviewed R13's TAR for October 2022. The Head to Toe Skin Assessment was blank and not documented as completed 10/7/22 and 10/14/22. Surveyor reviewed Evaluations and Progress Notes for R13 and there were no skin assessments documented as completed between 10/7/22 and 10/20/22. Documented 10/20/2022, at 9:23 AM, in R13's Progress Notes was Patient is alert with acute confusion and lethargy noted. Vital signs 133/69, 99, 18, 91% 2l, 100.8. He is being treated for upper resp (respiratory) infection with oral [antibiotics (ABT) at this time. Upon observation patient is speaking incoherently. His mentation changes from acute confusion and yelling to lethargy and uneasily aroused within minutes. Stated Please get me off the mill. Lung sound adventitious no s/sx (signs/symptoms) of resp distress noted at this time. Writer placed a call to [Nurse Practitioner (NP)-M] with updates. New order placed to send him to the ER (emergency room ) for eval (evaluation) and treat . Surveyor reviewed R13's Hospital Report from admission on 10/20/22. Documented by General Surgery on 10/20/22 was Impression . right buttocks abscess secondary to what appears to be a pressure ulceration. Assessment and Plan: Right buttocks abscess with what appears to be acute nonviable skin overlying this region. Recommend incision and drainage and debridement. Plan on incision and drainage and debridement right buttocks . Documented on 10/21/22 in Hospital Progress Notes was: Assessment/Diagnostic and Therapeutic Plan: Patient Active Hospital Problem List: [status post (s/p)] debridement of wound of perineum, scrotum, right buttock, Fournier's gangrene of perineum, Abscess of right-sided buttock, Leukocytosis, Fever, AMS (altered mental status). -Patient presents to the emergency department w/(with). Altered mental status -Fever, temp of 102F, tachycardia, AMS on admission. -Leukocytosis w/ left shift, elevated [creatine phosphate] and procalcitonin on admission. -Blood cultures w/ [no growth to date (NGTD)] on admission. -CT (Computerized Tomography) of [anterior/posterior (A/P)] w/ 6 cm partially imaged soft tissue abscess [within] right medial gluteal region, suspected acute proctocolitis, G-tube more anterior than expected in location relative to stomach (functioning properly thus far) on admission. -Underwent debridement of skin, subcutaneous tissue, muscle, fascia perineum, right buttocks, bilateral groin and bilateral scrotum by General surgery on 10/20 by [MD]. -Found to have extensive necrotizing infection of skin, subcutaneous tissues of perineum, scrotum, buttocks. -Noted to be spiking fevers this AM, temp of 101F and 102F, given Tylenol w/improvement -Continue Vancomycin, pharmacy to dose, Zosyn for antimicrobial coverage. -General surgery following, will abide by their recommendations . Documented on R13's Patient Discharge Summary with a date of 11/3/22 was Discharge Diagnoses: -Fournier's gangrene in male (10/20/2022) POA (Power of Attorney): Yes -Right buttock abscess s/p debridement -Fournier's gangrene of perineum -Coccyx pressure ulcer -S/p colostomy creation 10/25 -Probable sepsis -Acute blood loss anemia -Iron deficiency anemia -Thrombocytosis -Urinary tract infection -Altered mental status resolved . R13 was readmitted to the facility on [DATE]. Documented in Progress Notes on 11/3/2022 at 2:13 PM was Patient is alert and able to make needs known. readmitted to facility from [hospital.] Arrived via stretcher and assisted to bed with 4 staff members. Readmission dx (diagnoses) include: Fournier gangrene of the perineum, UTI (urinary tract infection), Sepsis, colostomy, altered mental status, and acute blood loss . Wound observation and measurements performed . Coccyx wound 6 x 3.5 50% slough, 25% eschar Left buttocks: 3.0 x4.0 x 3.0 right buttocks: 6.0 x10.0 x 4.5, under scrotum 6.0 x3.1 x 0.4. moderate amounts of drainage noted with dressing change. No foul odor noted . Surveyor notes there were no assessments of the wound bed or any description of the type of wounds. Surveyor reviewed R13's Admission/Readmission Evaluation with a date of 11/3/22. Documented under the Skin Integrity section was an assessment date of 11/10/22. Surveyor notes this is 7 days after R13's readmission to the facility. Documented was Site: 32) Left buttocks. Type: Surgical Incision. Length: 5.0 cm. Width: 4.0 cm. Depth: 1.0 cm. Stage: N/A. Site: 53) Sacrum. Type: Pressure. Length: 6 cm. Width: 3.5 cm. Depth: 0.1 cm. Stage: Unstageable. Site: Other (specify): Rt (right) butt to Scrotum. Type: Surgical Incision. Length: 15.0 cm. Width: 10.0 cm. Depth: 4.5 cm. Stage: N/A. Surveyor notes there were no comprehensive assessments of the wound beds upon R13's readmission to the facility. MD orders documented Clean wound to coccyx, left buttocks, right buttocks, scrotum and perineum with normal saline wash. [followed by (F/B)] pat dry F/B wet to dry dressing with Vashe wash [twice daily (BID) and [as needed (PRN)] two times a day with a start date of 11/3/2022. Surveyor notes this order was not documented on R13's November TAR and there was no documentation that it was completed 11/3/22 through 11/10/22. Surveyor reviewed R13's Weekly Skin Check with a date of 11/4/22. Documented was Resident admitted with open areas to coccyx, left buttocks, right buttocks. and scrotum. Areas were surgically debrided at hospital. There were no assessments of the wounds on 11/4/22. MD orders documented Head to toe skin assessment weekly one time a day every Thu (Thursday) with a start date of 11/10/2022. Wound MD-J and the facility assessed the wounds and surgical incisions on 11/10/22. Survyeor notes this is 1 week after readmission. Surveyor reviewed R13's Weekly Wound Assessments dated 11/10/22. Documented was .B. Wound Description. 1. Type of wound: Non-Pressure. 2. Wound Description: Site: Other (specify): Rt buttocks-Scrotum. Type: Surgical Incision. Length: 14.7 cm. Width: 10.0 cm. Depth: 3.2 cm. Stage: N/A. 3a. Percentage of granulation, new connective tissue and small blood vessels that form on the surface of a wound during the healing process that presents as shiny red tissue: 75. 3b. Percentage of slough: A layer of yellow, gray or brown non-viable tissue: 25. 3c. Percentage of eschar: A crust of thick, hard black non-viable tissue: 0. 3d. Percentage of epithelialization: Pearly pink new tissue present over the wound bed: 0 . Documented was .B. Wound Description. 1. Type of wound: Pressure. 2. Wound Description: Site: 53) Sacrum. Type: Pressure. Length: 3.6 cm. Width: 4.0 cm. Depth: 0.1 cm. Stage: Unstageable. 3a. Percentage of granulation: 25. 3b. Percentage of slough: 75. 3c. Percentage of eschar: 0. 3d. Percentage of epithelialization: 0 . Documented was .B. Wound Description. 1. Type of wound: Non-Pressure. 2. Wound Description: Site: Other (specify): Left buttocks. Type: Surgical Incision. Length: 5.0 cm. Width: 3.2 cm. Depth: 1.9 cm. Stage: N/A. 3a. Percentage of granulation: 75. 3b. Percentage of slough: 25. 3c. Percentage of eschar: 0. 3d. Percentage of epithelialization: 0 . Wound MD-J changed the treatments and MD orders were placed in chart. Documented with a start date of 11/10/22 was Wash right buttocks-Scrotum wound with 1/2 strength Dakin's solution and pat dry. Pack wound with Alginate AG and cover with [abdominal dressing (ABD)] and secure with tape. Every day and evening shift for wound care, Santyl Ointment 250 UNIT/GM (gram) (Collagenase) Apply to Sacral wound topically every day shift for wound care Wash wound with 1/2 strength Dakin's solution and pat dry. Skin prep per wound. Apply Santyl to wound bed followed by Bordered Gauze and Santyl Ointment 250 UNIT/GM (Collagenase) Apply to Left buttocks wound topically every day shift for wound care Wash wound with 1/2 strength Dakin's solution and pat dry. Skin prep peri wound. Apply Santyl to wound bed followed by Calcium Alginate and cover with Bordered gauze. R13's Care Plan was updated on 11/10/22 to include: Focus: readmitted [DATE] with Surgical wounds to Left buttocks and right buttocks/Scrotum and an Unstageable pressure wound to Sacrum Interventions: - Administer medications as ordered. Monitor/document for side effects and effectiveness. - Administer treatments as ordered and monitor for effectiveness. - Assess/record/monitor wound healing (FREQ) (frequency). Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Wound MD-J and the facility assessed the wounds and surgical incisions on 11/17/22. Documented on R13's Weekly Wound Assessments dated 11/17/22 was .B. Wound Description. 1. Type of wound: Non-Pressure. 2. Wound Description: Site: Other (specify): Rt buttocks-Scrotum. Type: Surgical Incision. Length: 10.9 cm. Width: 8.7 cm. Depth: 3.7 cm. Stage: N/A. 3a. Percentage of granulation: 75. 3b. Percentage of slough: 25. 3c. Percentage of eschar: 0. 3d. Percentage of epithelialization: 0 . Documented was .B. Wound Description. 1. Type of wound: Pressure. 2. Wound Description: Site: 53) Sacrum. Type: Pressure. Length: 3.4 cm. Width: 3.1 cm. Depth: 0.1 cm. Stage: Unstageable. 3a. Percentage of granulation: 25. 3b. Percentage of slough: 75. 3c. Percentage of eschar: 0. 3d. Percentage of epithelialization: 0 . Documented was .B. Wound Description. 1. Type of wound: Non-Pressure. 2. Wound Description: Site: Other (specify): Left buttocks. Type: Surgical Incision. Length: 5.7 cm. Width: 2.9 cm. Depth: 1.7 cm. Stage: N/A. 3a. Percentage of granulation: 75. 3b. Percentage of slough: 25. 3c. Percentage of eschar: 0. 3d. Percentage of epithelialization: 0 . Wound MD-J changed the treatment to the right buttocks - scrotum wound. Documented with a start date of 11/18/22 was Wash right buttocks-Scrotum wound with 1/2 strength Dakin's solution and pat dry. Pack wound with Moistened Dakin's Gauze and cover with ABD and secure with tape every day and evening shift for wound care. The facility assessed the wounds and surgical incisions on 11/23/22. Documented on R13's Weekly Wound Assessments dated 11/23/22 was .B. Wound Description. 1. Type of wound: Non-Pressure. 2. Wound Description: Site: Other (specify): Rt buttocks-Scrotum. Type: Surgical Incision. Length: 16 cm. Width: 6.0 cm. Depth: 2.2 cm. Stage: N/A. 3a. Percentage of granulation: 75. 3b. Percentage of slough: 25. 3c. Percentage of eschar: 0. 3d. Percentage of epithelialization: 0 . Documented was .B. Wound Description. 1. Type of wound: Pressure. 2. Wound Description: Site: 53) Sacrum. Type: Pressure. Length: 3.5 cm. Width: 4.0 cm. Depth: 0.1 cm. Stage: Unstageable. 3a. Percentage of granulation: 25. 3b. Percentage of slough: 75. 3c. Percentage of eschar: 0. 3d. Percentage of epithelialization: 0 . Documented was .B. Wound Description. 1. Type of wound: Non-Pressure. 2. Wound Description: Site: Other (specify): Left buttocks. Type: Surgical Incision. Length: 6.0 cm. Width: 1.9 cm. Depth: 1.3 cm. Stage: N/A. 3a. Percentage of granulation: 75. 3b. Percentage of slough: 25. 3c. Percentage of eschar: 0. 3d. Percentage of epithelialization: 0 . R13 was sent out and admitted to the Hospital on 11/26/22 for a dislodged G-tube. Surveyor reviewed TAR for R13 from 11/11/22 when wound treatments started through 11/26/22. There were 13 dates blank and 1 documented refusal of 32 possible treatment dates for right buttocks-scrotum wound treatment noting only 17 wound treatments as documented completed. There were 10 dates blank and 1 documented refusal of 16 possible treatment dates for left buttocks wound treatment noting only 5 wound treatments as documented completed. The order for the sacral wound was not documented on November TAR. R13 was hospitalized from 11/26/22 through 12/3/22. Documented in the Hospital Discharge Summary was .Discharge Diagnoses: Principle Problem: Dislodged gastronomy tube. Active Problems: . Sacral and ischial decubitus ulcers. Right ischial osteomyelitis .Hospital Course: . Patient also has known decubitus ulcers of his coccyx and left buttocks. Imaging was performed to the area, with concerns about osteomyelitis in the right ischium. It was previously debrided 1 month prior. After discussion with [infectious disease (ID)], patient will have a PICC (Peripherally Inserted Central Catheter) line placed today, will continue Zosyn upon discharge and it will be needed for 6 weeks. It has been requested that he has weekly [complete blood count lab (CBC)], [basic metabolic panel (BMP)] and [C-Reactive Protein lab (CRP)] checks, for results to be sent to [ID MD]. Also follow-up with [ID MD] will need to be coordinated with wound care as they have the ability to turn and position him for better examination . Documented in Progress Notes on 12/3/2022 was Resident returned from hospital via stretcher. Resident now has PICC line in R. (right) arm. Returning with order for IV antibiotic q. (every) 8 hours. Continue with soft diet, nectar thickened liquids. Wound clinic and Infectious Disease want appointment scheduled; papers left on reception desk for scheduling . Added to MD orders with a start date of 12/3/22 and end date of 1/3/22 was Piperacillin Sod-Tazobactam So Solution Reconstituted 3.375 (3-0.375) GM Use 3.375 gram intravenously every 8 hours related to OSTEOMYELITIS, UNSPECIFIED (M86.9) until 01/02/2023. Surveyor reviewed R13's Admission/Readmission Evaluation with a date of 12/3/22. Documented was Site: 32) Left buttocks. Type: Surgical Incision. Length: Blank. Width: Blank. Depth: Blank. Stage: Blank. Site: 53) Sacrum. Type: Pressure. Length: Blank. Width: Blank. Depth: Blank. Stage: Unstageable. Other (specify): Rt arm. Type: IV/Sub q/Implanted Port. Length: Blank. Width: Blank. Depth: Blank. Stage: Blank. Site: Other (specify): Rt butt to Scrotum. Type: Surgical Incision. Length: Blank. Width: Blank. Depth: Blank. Stage: Blank. There were no assessments of the wounds or measurements on the readmission assessment. Surveyor reviewed R13's Initial Wound Assessment with a date of 12/3/22. Documented was A. Onset. 1. Date wound was identified: 12/3/2022. 2. Where was the wound acquired? 2. Present upon admission/readmission to facility. B. Wound Description. 1. Type of wound: Pressure. 2. Wound Description: Site: 53) Sacrum. Type: Pressure. Length: 16 cm. Width: 5 cm. Depth: Blank. Stage: Unstageable. 3a. Percentage of granulation: Blank. 3b. Percentage of slough: Blank. 3c. Percentage of eschar: Blank. 3d. Percentage of epithelialization: Blank . There were no other assessments of the wounds or measurements on this assessment. The sacral wound was the only one mentioned and there was no assessment of the wound bed. Upon readmission the wound treatment orders were not changed. Documented with a start date of 11/18/22 and end date of 12/8/22 was Wash right buttocks-Scrotum wound with 1/2 strength Dakin's solution and pat dry. Pack wound with Moistened Dakin's Gauze and cover with ABD and secure with tape. Every day and evening shift for wound care. Documented with a start date of 11/10/22 and end date of 12/8/22 was Santyl Ointment 250 UNIT/GM (Collagenase) Apply to Left buttocks wound topically every day shift for wound care Wash wound with 1/2 strength Dakin's solution and pat dry. Skin prep peri wound. Apply Santyl to wound bed followed by Calcium Alginate and cover with Bordered gauze. Surveyor notes there was no order for the sacral wound and was not documented on the December TAR. Antibiotic order was documented as Piperacillin Sod-Tazobactam So Solution Reconstituted 3.375 (3-0.375) GM Use 3.375 gram intravenously every 8 hours related to OSTEOMYELITIS, UNSPECIFIED (M86.9) until 01/03/2023. Also documented with a start date of 12/7/22 was CRP: one time a day every Wed (Wednesday) related to OSTEOMYELITIS, UNSPECIFIED (M86.9) until 01/02/2023. BMP: one time a day every Wed related to OSTEOMYELITIS, UNSPECIFIED (M86.9) until 01/02/2023. CBC: one time a day every Wed until 01/02/2023. Documented with a start date of 12/7/22 and end date of 1/4/23 was Please fax weekly lab results drawn on Wednesday (CBC, BMP CRP) to [ID MD] @ [phone number] one time a day every Wed, Thu. Surveyor reviewed TAR for R13 from 12/3/22 through 12/8/22. There were 3 dates blank and 2 documented other' of 11 possible treatment dates for right buttocks-scrotum wound treatment noting only 6 wound treatments documented as completed. There were 3 dates blank of 5 possible treatment dates for left buttocks wound treatment not [TRUNCATED]

Based on interview and record review, the facility did not ensure 1 (R13) of 4 residents reviewed had care and treatment based upon current standards of practice for indwelling catheter care to prevent urinary tract infections (UTI's.) R13 had an indwelling foley catheter placed on 5/27/22 for urinary retention and was noted to have signs and symptoms of a UTI at that time. The facility did not put orders and preventative measures in place to prevent R13 from Urinary Tract Infections (UTIs). R13 was noted to have a UTI but treatment was delayed by 5 days. On 8/16/22 R13 had blood in his urine, the Nurse Practitioner (NP)-M was notified and a Urine Analysis (UA) with Culture and Sensitivity (C&S) was ordered. The UA was sent out 8/17/22 but the C&S was never evaluated even though it was sent to the facility on [DATE]. NP-M was not aware and ordered a resistive antibiotic for the UTI that was not effective and the infection continued. R13 had a change of condition including altered metal status (AMS) and was hospitalized with sepsis and septic shock due to a UTI and the infection spread to his kidneys resulting in pyelonephritis and an upper UTI. There was no update to the care plan or catheter care to reflect the UTI, further monitoring or consistent cleaning. R13 returned to the facility and hospitalized again 10/20/22 through 11/3/22 with multiple problems including UTI. R13 returned to the facility and hospitalized again 11/28/22 through 12/3/22 with multiple problems including another UTI. On 2/2/23 R13 had nausea and vomiting and orders were received to monitor vital signs that was not completed. On 2/4/23 resident had another change of condition that included AMS, hypotension and hyperglycemia that was not reported timely to the MD or NP. The facility did not recognize the continued pattern of hypotension and AMS related to R13's history of UTIs. Hours later NP-M was updated and resident was sent to the hospital and admitted to the ICU with hypotension and sepsis related to a UTI. The facility's failure to address signs and symptoms of a UTI, follow up on labs orders to effectively treat UTIs and daily care and prevention of catheter associated UTIs created a finding of Immediate Jeopardy (IJ) that began on 8/22/22. Surveyor notified Current Nursing Home Administrator (NHA)-P, Director of Nursing (DON)-B and RN Regional Educator (RN)-V of the IJ on 2/13/22 at 4:35 PM. The IJ was removed on 2/17/23, however; the deficient practice continues at a scope/severity level of D (Potential for Harm/Isolated) as the facility continues to implement their action plan. Findings include: Surveyor reviewed facility's Urinary Tract Infections/Bacteriuria - Clinical Protocol policy with a revision date of April 2018. Documented was: Assessment and Recognition 1. The physician and staff will identify individuals with a history of symptomatic urinary tract infections, and those who have risk factors for example, an indwelling urinary catheter, kidney stones, urinary outflow obstruction, ete,) for UTIs. 2. The staff and practitioner will identify individuals with possible signs and symptoms of a UTI. a. Signs and symptoms of a UTI may be specific to the urinary tract and/or generalized. The presentation of symptomatic UTIs varies. b. Nurses should observe, document, and report signs and symptoms (for example, fever or hematuria) in detail and avoid premature diagnostic conclusions. c. New onset of nonspecific or general symptoms alone (change in mental status, decline in appetite, etc.) is not enough to diagnose a UTI, Urine odor, color and clarity also are not adequate to indicate bacteriuria or a UTI. d. Acute deterioration in previously stable chronic urinary symptoms may indicate an acute infection. Multiple concurrent findings such as fever with hematuria or catheter obstruction are more likely to be due to a urinary source. c. A positive urine culture in someone with chronic genitourinary symptoms is not enough to diagnose a symptomatic UTI. The presence of either pyuria or a positive leukocyte esterase test alone are not enough to prove that the individual has a UTI, but the absence of pyuria or a negative leukocyte esterase test is fairly strong evidence that a UTI is not present. Cause Identification 1. The physician will help nursing staff interpret any signs, symptoms, and lab test results. Diagnosis must be based on the entire picture and not just on one or several findings in isolation. a. Before diagnosing a UTI or urosepsis and ordering antibiotics, the physician should consider a resident's overall picture including specific evidence that helps confirm or refute the diagnosis of a UTI (as discussed above). 3. The physician will help identify causes of, and factors contributing to, bacteriuria or UTIs such as bladder outlet obstruction, kidney stones, neurological impairments, and medications that can cause urinary retention. 4. Because nonspecific or systemic symptoms can be due to diverse factors either instead of or along with a UTI, the staff and practitioner will also consider additional or alternative causes regardless of whether bacteriuria or urinary symptoms is present. a. For example, a patient with a UTI could also have confusion caused by fluid and electrolyte imbalance such as hypernatremia as a result of several days of inadequate food and fluid intake. Treatment/Management 1. The physician will order appropriate treatment for verified or suspected UTIs and/or urosepsis based on a pertinent assessment. a. Empirical treatment should be based on a documented description of an individual's symptoms and on consideration of relevant test results, co-existing illnesses and conditions, and pertinent risk factors. b. Generally, symptomatic UTIs should be treated. Bacteriuria alone (an asymptomatic UTI*) should not be treated routinely, because treating it does not materially change outcomes, improve longevity, or correct underlying problems. c. In select situations, empirical antimicrobial therapy may be warranted if urosepsis or other complications are suspected. f. In select situations, empirical antimicrobial therapy may be warranted for febrile individuals with non-specific symptoms. 5. The physician will not treat asymptomatic individuals whose urine is colonized with yeast or with multidrug-resistant organisms such as methicillin-resistant Staphylococcus aureus or enterococcus without careful review and clinical rationale. 6. The physician should consider stopping antibiotics or switching parenteral to oral antibiotics in individuals with uncomplicated UTIs who have been febrile and asymptomatic for at least 48 hours. 7. The physician will help the staff identify suspected sepsis related to a UTI and identify whether hospitalization may be warranted. 8. Fever and change in mental status alone do not automatically warrant hospitalization , nor is there compelling evidence that hospitalization improves the ultimate outcomes in individuals with symptomatic UTIs. Sepsis, however, may sometimes warrant more aggressive inpatient treatment. Monitoring 1. The physician and nursing staff will review the status of individuals who are being treated for a UTI and adjust treatment accordingly. a. Decisions should be made primarily on the basis of clinical signs and symptoms. The goal of treatment in most cases is to control signs and symptoms of infection, not to eliminate bacteriuria. g. Follow-up urine cultures after antibiotic treatment are not indicated routinely, but may be helpful if the symptoms are not resolving or complications are present. 2. When a resident has a persistent or recurrent urinary tract infection after treatment with antibiotics, the physician will review the situation carefully with the nursing staff and consider other or additional issues (such as urinary obstruction or indwelling catheter change or removal) before prescribing additional courses of antibiotics. a. Physicians should justify continuing or resuming antibiotic treatment beyond an initial course. Surveyor reviewed facility's Catheter Care, Urinary policy with a revision date of September 2014. Documented was: .Documentation The following information should be recorded in the resident's medical record: 1. The date and time that catheter care was given. 41. The name and title of the individual(s) giving the catheter care. 42. All assessment data obtained when giving catheter care. 43. Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid pa and odor. 44. Any problems noted at the catheter-urethral junction during perineal care such as bleeding, irritation, crusting, or pain. 45. Any problems or complaints made by the resident related to the procedure. 46. How the resident tolerated the procedure. 47. If the resident refused the procedure, the reason(s) why and the intervention taken. 48. The signature and title of the person recording the data . Surveyor reviewed facility's Change in a Resident's Condition or Status policy with a revision date of May 2017. Documented was: Policy Statement Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation a. accident or incident involving the resident; b. discovery of injuries of an unknown source; c. adverse reaction to medication; d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; f. refusal of treatment or medications two (2) or more consecutive times); g. need to transfer the resident to a hospital/treatment center; h. discharge without proper medical authority; and/or i. specific instruction to notify the Physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b. Impacts more than one area of the resident's health status; c. Requires interdisciplinary review and/or revision to the care plan; and d. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form . R13 was admitted to the facility on [DATE] with diagnoses that included Unspecified Cord Compression, Quadriplegia due to Motor Vehicle Accident, Type 2 Diabetes Mellitus (DM) with Diabetic Neuropathy, Chronic Obstructive Respiratory Failure (COPD), Congestive Heart Failure (CHF), Neuromuscular Dysfunction of Bladder, Retention of Urine and Chronic Kidney Disease (CKD). Surveyor reviewed R13's most recent Quarterly Minimum Data Set (MDS) with an assessment reference date of 6/1/22. Documented under Section C, Cognition a Brief Interview for Mental Status (BIMS) score of 13 which indicated cognitively intact. Documented under Section G, Functional Status for Bed Mobility and Transfers was 4/3 which indicated Total dependence - full staff performance every time during entire 7-day period; Two plus persons physical assist. Documented under Section H, Appliances was A. Indwelling catheter (including suprapubic catheter and nephrostomy tube): Yes. Surveyor reviewed R16's Care Area Assessment (CAA) related to Urinary Incontinence and Indwelling Catheter with an assessment date of 6/1/22. Documented under Nature of the Problem/Condition was Resident is at risk for complication [related to (R/T) having a Foley Catheter. Surveyor reviewed MD orders for R13 for catheter care. Documented with a start date of 5/26/22 was Record foley output every shift, May irrigate foley catheter with 30 cc H20 (water) for catheter malfunction, Foley catheter care with soap and water every shift for INDWELLING CATHETER CARE AND as needed for Prophylaxis, and Maintain 16 FR/ 5 ML bulb foley catheter to straight drain. Change every month and PRN (as needed). Surveyor reviewed R13's Comprehensive Care Plan with initiation date of 6/5/22. Documented was Focus: Resident is at risk for complication R/T (related to) having a Foley Catheter. Goal: Resident will be free from adverse complications associated with catheter use through the next review date [as evidenced by (AEB)] clinical documentation. Interventions: Monitor for [signs and symptoms (s/s)] of UTI (pelvic pain, increased urge to urinate, pain with urination, blood in urine) and report to physician if noted. Provide catheter care to prevent urinary tract infections: Maintain a closed, sterile system, maintain catheter tubing below level of the bladder, ensure that catheter tubing does not have kinks or twists. Perform catheter care [every (Q)] shift and [as needed (PRN)]. Change catheter and catheter drainage/collection system per order/policy. Maintain resident dignity. Cover Catheter bag when out of bed in social areas of facility. Empty residents catheter bag Q shift and PRN. Record and monitor output. Surveyor reviewed Tasks for CNA (Certified Nursing Assistant) completion for R13. Documented was Catheter: Document output in mLs. There were no other tasks for CNA's to complete. Documented 5/27/2022 at 3:42 PM in R13's Progress Notes was Resident vital signs stable. No signs of distress at this time. Straight cath this AM was 350cc output. Foley inserted this afternoon. 250cc output. Obtained new order for insulin glargine. Obtained order for temporary bolus feeds. Urine output cloudy. Obtained order for UA. 30 minute checks completed today. No complaints from resident at this time. Added to MD orders for R13 on 5/27/22 was UA one time only for cloudy urine for 5 Days. There was no UA charting, collection of sample or evaluations of cloudy urine on 5/28/22, 5/29/22, 5/30/22 or 5/31/22. The sample was collected 6/1/22 but treatment was not started until 6/7/22 when an order was placed for Cipro Tablet 500 MG (Ciprofloxacin HCl) Give 1 tablet via G-Tube one time a day for UTI until 06/09/2022. On 6/15/22 R13 was hospitalized for Pneumonia. He was readmitted to the facility 6/20/22. MD orders for catheter care were not put in place except Maintain 16 FR/ 5 ML bulb foley catheter to straight drain. Change every month and PRN for Neurogenic Bladder and Intake and output every shift. There were no orders for cleansing, emptying or general catheter care. Documented in R13's Progress Notes on 8/16/2022 at 5:17 PM was Resident had considerable amount of blood in urine. [NP-M] notified, UA ordered. Added to MD orders for R13 on 8/16/22 was Urinalysis w/ C&S. Documented in R13's Progress Notes on 8/17/2022 at 1:22 AM was 97.5 98%3L [alert and orientated (A/O)] x3 . Writer encouraging fluids: given now. Foley patent: clear light amber urine in bag: no s/s of blood in urine. Waiting to get a good U/A sample soon . Surveyor noted R13 had a catheter and UA sample could be obtained by closed system at any time. Documented in R13's Progress Notes on 8/17/2022 at 5:42 AM was Writer obtained U/A sample now: will call for [pick up]. R13's UA sample was sent to the lab and results that were positive for bacteria/UTI were sent back to the facility 8/17/22 at 11:12 AM. The C&S would be processed due to positive bacteria. Documented in R13's Progress Notes on 8/19/2022 at 5:42 AM was Patient is alert with increased confused noted from baseline. Writer called to the room by CNA. Patient screaming I am not going to the strip bar. T-99.8, b/p-143/66 SP02-95% 2L 02 via [nasal cannula.] Foley cath patent draining clear yellow urine with foul smell. A U/A was collected that reveal + [positive]for bacteria however culture and sensitivity is pending. Writer placed a call to [NP-M]. She is advised of his symptoms. New order to start Cipro 500mg PO daily x3 days. Writer left a message for his brother [name of] to call facility for updates . An MD order was added for R13 and started 8/19/22 was Cipro 500mg [by mouth (PO)] Q day x3 days DX [diagnosis]: UTI, one time a day for UTI for 3 Days. Documented in Progress Notes on 8/19/2022 at 7:32 PM was Resident's 1600 blood sugar [BS] was elevated at 487. 18 units were given per sliding scale for BS over 450 and then MD was contacted. On call MD gave [order] to give an additional 4 units of insulin which were given. Will recheck BS at HS to see the effects of the additional units. No s/s of hyperglycemia seen or reported by resident. Will continue to monitor. Documented in Progress Notes on 8/21/2022 at 1:58 AM was 98.8 now: PRN Tylenol and cool compress effective: 99.0 at start. A/O x3 at start. Sleeping well in bed now. No c/o any. No c/o pain now. Foley patent: clear light amber urine noted: No s/s of blood in urine noted. No adverse s/s with PO ATB [by mouth antibiotic] use for UTI noted. No confusion noted. Resident drinking fluids: also pushed in G-tube . Surveyor reviewed R13's lab results printed for Surveyor on 2/9/23. Surveyor reviewed C&S originally reported to facility from lab on 8/20/22 at 7:33 AM. This report was not part of R13's medical record. Documented was an abnormal urine culture growing Proteus Mirabilis and Providencia Stuartii organisms. The Culture and Sensitivity results showed both organisms were resistant to treatment by Cipro antibiotic prescribed for the UTI on 8/19/22 and was an ineffective treatment for the UTI. There is no documentation this report was given to NP-M or any other MD for follow-up on the ineffective antibiotic. On 8/22/22 R13 had a change of condition and an SBAR [Situation Background Assessment Recommendation] was completed at 12:43 PM. Documented was: eINTERACT SBAR Summary for Providers Situation: The Change In Condition/s reported on this CIC [change in condition] Evaluation are/were: Altered mental status Behavioral symptoms (e.g. agitation, psychosis) At the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP 114/69- 8/22/2022 12:32 Position: Lying r/arm - Pulse: P 129 - 8/22/2022 12:32 Pulse Type: Regular - RR: R 22.0 - 8/22/2022 12:32 - Temp: T 101.0 - 8/22/2022 12:32 . - Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) Other symptoms or signs of delirium(e.g. inability to pay attention, disorganized thinking) - Functional Status Evaluation: No changes observed - Behavioral Status Evaluation: Other behavioral symptoms - Respiratory Status Evaluation: - Cardiovascular Status Evaluation: Resting pulse greater than 100 or less than 50 - Abdominal/GI Status Evaluation: - GU/Urine Status Evaluation: - Skin Status Evaluation: - Pain Status Evaluation: Does the resident/patient have pain? - Neurological Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) Abnormal speech Nursing observations, evaluation, and recommendations are: Resident presents with AMS, incoherent non-sensical speech, inability to follow direction or describe condition associated with change in mentation Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Send to ED [emergency department] for evaluation and possible treatment . NP-M visited the resident on 8/22/22 and documented in her visit note .ASSESSMENT/PLAN: 1. UTI-stable on cipro. 2. Altered mental status-unstable send to ER for eval. R13 was admitted to the hospital 8/22/22 through 8/26/22 for Sepsis, Acute pyelonephritis, fever, infectious encephalopathy and DM2 [type 2 diabetes mellitis]. Documented in Hospital Discharge Summary was: .Patient presented to emergency department w/ AMS, fever, hypotension -Met [Systemic inflammatory response syndrome (SIRS)] and [every] [Sequential Organ Failure Assessment (SOFA)] criteria for sepsis w/ temp or 101.3F, tachypnea w/ RR [respiration rate] of 31, AMS, SBP [systolic blood pressure] < [greater than] 90, white count of 21, lactic acid of 2.8 on admission -UA w/ moderate [Leukocyte esterase (LE)], [white blood cells (WBC)] 6-10, moderate bacteria on admission -CT [computerized tomography] [Anterior/Posterior] w/ mild bilateral hydronephrosis w/ enhancing renal pelves, ureters suggesting an upper tract infection, some heterogenous enhancement evident w/in both kidneys suggesting pyelonephritis, bladder wall thickening consistent w/ cystitis an admission -Started on Zosyn for antimicrobial coverage, [vital signs stable (vss)], mentation improved following initiation of ABX; transitioned to Cefdinir prior to discharge, per urine culture sensitivities -Patient was deemed appropriate for discharge on 08/26. He was instructed to f/u w/ [primary care physician (PCP)] within the week . R13 was admitted back to the facility with an order for Cefdinir Capsule 300 MG Give 1 capsule via PEG-Tube two times a day for UTI for 20 Administrations with a start date of 8/27/22 and an end date of 9/5/22. MD orders for catheter care were not put in place except Maintain 16 FR/ 5 ML bulb foley catheter to straight drain. Change every month and PRN for Neurogenic Bladder. There were no orders for cleansing, emptying or general catheter care. There was no other documentation besides intermittent catheter output. There were no revisions to the care plan or other documentation to monitor for infection. Documented in Progress Notes on 10/20/2022 at 9:23 AM for R13 was Patient is alert with acute confusion and lethargy noted. Vital signs 133/69, 99, 18, 91% 2l, 100.8. He is being treated for upper resp [respiratory] infection with oral ABT at this time. Upon observation patient is speaking incoherently. His mentation changes from acute confusion and yelling to lethargy and uneasily aroused within minutes. Stated Please get me off the mill . R13 was admitted to the hospital 10/20/22 through 11/3/22 for multiple diagnoses and was noted to have another UTI. Documented in Hospital Discharge Summary was: .Urinary tract infection Altered mental status-resolved Presented to ED with AMS & fever Vitals and labs as pen above Urine culture greater than 100,000 Pseudomonas aeruginosa Sensitive to Zosyn, completed course Patient's UA + still for UTI he is being placed on Cefdinir and Cipro Via G-tube for 5 days as d/w my attending MD-this is why patient's discharge was held overnight . R13 was admitted back to the facility with an order for Cipro Tablet 500 MG (Ciprofloxacin HCl) Give 1 tablet via G-Tube two times a day for UTI for 5 Days and Cefdinir Capsule 300 MG Give 1 capsule via G-Tube two times a day for UTI for 5 Days with end dates of 11/8/2022. MD orders for catheter care were added back into the TAR [treatment administration record] on readmission. Documented with a start date of 11/3/22 was Record foley output every shift every shift for Monitoring, May irrigate foley catheter with 30 ml H2O for obstruction, Maintain 16 FR/ 5 ML bulb foley catheter to straight drain. Change every month and PRN and Foley catheter care with soap and water every shift for Indwelling Urinary Catheter Care AND as needed for Prophylaxis. Surveyor reviewed November TAR for R13 for documentation of completed Foley catheter care with soap and water. There were 12 dates blank of 65 possible treatment entries and no PRN entries. R13 was admitted to the hospital 11/26/22 through 12/3/22 for multiple diagnoses with another UTI. Documented in Progress Notes on 11/28/2022 at 12:42 PM was call placed to [name of hospital] regarding resident status. [G-Tube (GT)] was removed and he is eating. He has a nutritional consult pending and thus it is pending when he will be having GT re-inserted. He is on IV abt for a + UA (organism not specified to this writer), some BP meds were held as he is running low BP's while in hospital and his hemoglobin is dropping also. Diflucan and Vanco are ongoing at this time. R13 was admitted back to the facility with MD orders continuing for Record foley output every shift every shift for Monitoring, May irrigate foley catheter with 30 ml H2O for obstruction, Maintain 16 FR/ 5 ML bulb foley catheter to straight drain. Change every month and PRN and Foley catheter care with soap and water every shift for Indwelling Urinary Catheter Care AND as needed for Prophylaxis. Surveyor reviewed December 2022 TAR for R13 for documentation of completed Foley catheter care with soap and water. There were 19 dates blank of 83 possible treatment entries and no PRN entries. Documented in Progress Notes on 1/4/2023 at 2:36 AM was Writer changed foley and foley bag now: had 300cc clear yellow urine in old bag: new tube patent now. Surveyor reviewed January 2023 TAR for R13 for documentation of completed Foley catheter care with soap and water. There were 20 dates blank of 93 possible treatment entries and no PRN entries. On 2/2/23 R13 had a change of condition and an SBAR was completed at 1:31 PM. Documented was: eINTERACT SBAR Summary for Providers Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Nausea/Vomiting At the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP 139/78 - 1/19/2023 21:01 Position: Lying r/arm - Pulse: P90 - 1/19/2023 21:01 Pulse Type: Regular - RR: R 18.0 - 1/13/2023 18:15 - Temp: T 97.0 - 2/2/2023 01:42 Route: Forehead (non-contact) . - Mental Status Evaluation: No changes observed - Functional Status Evaluation: No changes observed - Behavioral Status Evaluation: - Respiratory Status Evaluation: - Cardiovascular Status Evaluation: - Abdominal/GI Status Evaluation: No changes observed - GU/Urine Status Evaluation: - Skin Status Evaluation: - Pain Status Evaluation: Does the resident/patient have pain? - Neurological Status Evaluation: Nursing observations, evaluation, and recommendations are: c/o nausea, no emesis as of yet. ongoing monitoring for emesis or changes Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: new order for PRN zofran, monitoring for changes in vital signs or emesis. Surveyor noted the vital signs were not current including BP and pulse on the SBAR were from 1/19/22 and RR from 1/13/22 and not at time of change of condition. There were no other vital signs documented even though the recommendations included monitor vital signs. There were no updates to the care plan or increased monitoring of the resident. Documented on 2/3/2023 at 1:22 AM was 97.1 98% RA [room air] A/O [alert and oriented] x3. Sleeping well in bed since start. No c/o any. No c/o pain. Writer did dressing change to sacrum/buttock now. 400cc clear yellow urine from foley now and MED soft formed BM from colostomy now. Air mattress working well. Pillows in place. P boots on. No SOB or coughing noted. Fluids given. Pleasant with staff. There was no BP or RR included in the charting and no mention of nausea or vomiting. Surveyor reviewed R13's vital signs taken 2/14/23 at 1:43 AM. Documented was: Blood Pressure: 95 / 52 mmHg Temperature: 97.9 F Pulse: 92 bpm Respirations: 20 Breaths/min Blood Sugar: 423.0 mg/dL O2 Saturation: 98.0 % Documented in Progress Notes on 2/4/2023 at 3:54 AM was Resident appeared drowsy during [night] shift. This writer obtained vital signs from resident and placed them in the chart. Resident hypotensive and hyperglycemic. Resident able to respond to verbal stimuli. Resident was provided fluids and fluids pushed through g-tube. Will continue to monitor and document as necessary. Surveyor noted the vital signs of low BP and high BS were flagged as abnormal on the electronic medical record but no MD was contacted. Also the resident was noted as drowsy which may have indicated AMS but there was no assessments completed. Also, documented as part of R13's Insulin Order was if Blood glucose > [greater than] 400 give 12 units and call MD/NP for additional orders . No NP or MD was contacted. Documented in Progress Notes on 2/4/2023 at 7:06 AM was Resident blood pressure currently reading at 76/50 with blood present in foley. Assessment done with another nurse. [NP-M] notified. [Former LPN-L] aware. There was no other assessments or evaluations documented in R13's medical record. Documented in Progress Notes on 2/4/2023 at 10:58 AM was Call placed to [name of hospital] ER [emergency room ] requesting report on resident status. Resident admitted to ICU for sepsis. Surveyor reviewed R13's hospital record from 2/4/23 admission. Documented was: .Patient Active Hospital Problem List: Sepsis (CMS-HCC) (2/4/2023) [present on admission (POA)]: Yes Assessment: Unstable with several episodes of hypotension raising suspicion of septic shock. Not requiring pressors at the present time. Seems to be responding fairly to IV fluid resuscitation. Plan: Continue IV fluid resuscitation. Close monitor position of electrolytes given his hyponatremia and hypochloremia. Consider pressors if refractory to IV fluid resuscitation. Consider stress dose steroids if septic shock persistent Continue IV antibiotics with Zosyn UTI (urinary tract infection) (2/4/2023) POA: Yes Assessment: UTI with secondary sepsis and likely septic shock Plan: Continue IV antibiotics. Continue IV fluid resuscitation Serial labs Careful monitoring of electrolytes given his hyponatremia and hypochloremia . On 2/9/23 at 1:26 PM Surveyor interviewed Former Unit Manager LPN-L. Surveyor asked about R13's history of UTI's and the interventions that were in place. LPN-L stated R13 had a long history of sepsis with UTI's and was treated with antibiotics at least twice. Surveyor asked what catheter care was being done for R13. LPN-L stated I hope he was getting it cleaned. LPN-L stated she was not sure if the CNA's or the nurses on the unit were in charge. LPN-L stated if she was working the floor she would do it but not sure about the other nurses. Surveyor asked where staff would know what catheter care to do and when. LPN-L stated it should be in the orders and the care plan. Surveyor asked how you know that catheter care was completed. LPN-L stated it would be signed out as completed on the TAR. On 2/13/23 at 10:10 AM Surveyor interviewed NP-M. Surveyor asked about ordering R13's Cipro antibiotic back in August. NP-M stated she did not exactly remember the situation but remember ordering the Cipro to be proactive about the symptoms of the UTI. Surveyor asked if she ever saw the C&S that stated Cipro was resistant to the UTI organisms. NP-M stated no, and if she would have she would have changed the order immediately. Surveyor asked if she remembered ordering Zofran and monitoring vitals on 2/2/23 for R13. NP-M stated not exactly but it sounds like something I would do. Surveyor asked what was expected by staff when it was recommended to monitor vital signs. NP-M stated a Blood Pressure, Pulse, Temperature, Pulse Ox and Blood Sugar if they are diabetic every shift and be updated with any significant changes. Surveyor asked if a temperature and pulse ox was acceptable. NP-M stated no. Surveyor asked about R13's low BP and high blood sugar at 1:43 AM on 2/4/23. NP-M stated someone on staff should have called the on-call MD right away. On 2/13/23 at 11:13 AM Surveyor interviewed Director of Nursing (DON)-B and LPN-G. Surveyor asked how staff know that labs were followed up on and sent to the appropriate MD or NP. DON-B stated there should be a progress note. Surveyor noted R13's 8/20/22 C&S not being reported to NP-M as there was[TRUNCATED]

Based on observation, interview, record review, and facility policy review the facility failed to ensure the resident environment remained as free of accident hazards and possible for two of five residents (Resident (R) 12 and R8) reviewed for accidents. The facility failed to thoroughly investigate an incident when facility staff served R12 hot noodles and subsequently sustained 3rd degree burns from the noodles. Additionally, the facility did not ensure R12's interventions for accidents were consistently implemented. The facility failed to ensure R8 had an electric blanket assessed and monitored prior to use. R8 was at high risk for skin damage. Findings include: 1. Review of R12's Admission Record, undated, located in the electronic medical record (EMR) under the Profile tab, revealed an admitted [DATE] with medical diagnosis that included primary osteoarthritis, unspecified hand. a. Review of the facility policy titled Foods Brought by Family/Visitors, dated 10/2017, revealed Facility staff will assist the resident with accessing his or her food if unable to do so independently. Family/visitors are asked to prepare and transport food using safe food handling practices. including: Safe cooling and reheating processes . all personnel involved in preparing handling serving or assisting the resident with meals or snacks will be trained in safe food handling practices. The facility provided a copy of an incident report, for an incident on 09/27/22 with R12. The Description stated [R12] observed with burn injuries to right lower quadrant, mid-chest, and upper chest. The Immediate action revealed the area was cleaned, dried, and treated. The Nurse Practitioner and wound care doctor were notified. The report indicated R12 did not go to the hospital. Under pre-disposing environment factors other was checked but the form did not indicate what other factors were. Under pre-disposing psychological factors, weakness/fainting was checked. A note on the form documented Resident states she may have missed the edge of the overbed table and spilled on herself. A note on the report by the Director of Nursing (DON) documented . resident indicated she requested staff to make noodles for her . original container [Styrofoam cup] placed in second container so resident can handle independently. resident unaware of injury and did not experience pain . advised to screen for service needs . mild pain noted on assessment. [new interventions] apply clothing protector, encourage resident to allow foods to cool prior to handling. The report lacked documentation of the name of the staff who discovered the incident, circumstances around the situation at time of discovery, how long R12's call light had been on, vital signs, and if the staff member serving the noodles had heated them in accordance with facility polices. In response to a request for additional information regarding the investigation, the Administrator provided an in-service given to the staff after the incident on handling hot liquids. No additional investigation was provided. During an interview on 11/20/22 at 2:34 PM, R12 verbalized she needed assistance when eating because she had pain in her shoulders, her hands were numb and painful in September leading to her having carpel tunnel surgery in October. R12 stated a concern that it took a long time for the staff to answer the call light when she spilled hot noodles on herself causing a burn. R12 stated she could not feel the heat from the burn until staff moved her clothing to examine the area. Review of the R12's medical record lacked documentation of the incident resulting in injury from the hot noodle soup on 09/27/22. Review of R12's quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 07/30/22 revealed facility staff coded R12 as having no upper extremity impairment and requiring only set up assistance with meals. During an interview on 11/21/22 at 4:47 PM, MDS Coordinator-E explained R12 had not been identified as having upper extremity impairment on the MDS due to having gross motor movement. Fine motor movement impairment was not identified on the MDS but R12 did have fine motor movement impairment. During an interview on 11/22/22 at 9:34 AM, Registered Nurse (RN)-N confirmed the dressing changes were still being done on the chest and abdomen for R12 since the incident with the hot soup on 09/27/22. RN-N confirmed the soup with noodles served was too hot and caused the burns on R12 and should have been documented in the progress notes. During an interview on 11/22/22 at 12:05 PM, DON-B confirmed that an agency staff prepared the ramen for R12 and served it to her, DON-B could not identify the name of the staff who served the resident. During an interview on 11/22/22 at 12:44 PM, Registered Nurse-Wound Nurse-S confirmed treating the wounds on R12 and confirmed the injuries to R12 were third degree burns on her right breast and two areas on her upper abdomen. Review of R12's medical record indicates R12's burns are being treated with Silvadene which is a topical treatment used for partial or full thickness burns to prevent infection. b. During an interview on 11/20/22 at 2:34 PM, R12 verbalized she needed assistance when eating because she had pain in her shoulders, her hands were numb, and her right dominate hand was in a splint following carpel tunnel surgery. R12 had carpel tunnel surgery on 10/12/22. Review of R12's quarterly MDS located in the EMR under the MDS tab with an ARD of 10/23/22, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R12 was cognitively intact. The MDS documented R12 had no upper body limitations and required set up assistance for meals. Review of the physician orders under the Orders tab in the EMR revealed an order dated 11/04/22 to ensure clothing protector is placed on resident with all meals and all hot snacks for protection every shift for prevention [of burns]. Review of R12's EMR Care Plan, located under the Care Plan tab revealed a care plan that addressed accidents related to general weakness, on 09/27/22 interventions were added to have R12 wear a clothing protector and to encourage the resident to allow foods to cool. Interventions included to keep call light within reach. During an observation on 11/21/22 at 8:30 AM, R12 was in bed and the call light was out of reach for the resident, on the floor. During an observation on 11/21/22 at 9:07 AM, R12 was sitting in bed eating a banana with her left hand. The breakfast tray was on the overbed table in front of the resident and included a hot beverage. R12 did not have a clothing protector. During an interview on 11/21/22 at 9:07 AM, R12 verbalized sometimes staff placed a towel on her chest between her neck and the food tray. On 11/21/22 at 9:10AM, Assistant Director of Nursing (ADON)-C came into the room asking R12 do you need assistance today? and R12 replied I need it every day. During an observation on 11/21/22 at 10:39 AM, R12 was in bed and her call light was on the floor, not hooked to the bed to be within reach for the resident. During an interview on 11/21/22 at 4:47 PM, MDS Coordinator-E confirmed R12 was to have a clothing protector in place with meals. 2. Review of a document provided by the facility titled Electrical Appliances, dated January 2019, indicated . Only authorized electrical appliances will be permitted in resident living areas. Should electrical appliances be permitted, each must be in good working order, free of frayed cords, and UL (underwriter's laboratory) approved. The apparatus must be clearly labeled with UL certifications and./or standards confirming external and internal credibility. Facility must identify and evaluate hazards and risks and implement interventions and monitoring for safe use. Review of R8's EMR's titled Admission Record indicated R8 was admitted to the facility on [DATE] with diagnoses that included type II diabetes mellitus and neuropathy. Review of R8's EMR quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/19/22 located under the (MDS) tab indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which revealed the resident was cognitively intact. This assessment indicated the resident was extensive assistance of two staff for bed mobility and was totally dependent on two staff for transfers. This assessment revealed the resident had an ostomy. Review of R8's electronic medical record (EMR) Care Plan, located under the Care Plan tab failed to indicate the resident used an electric blanket. Review of R8's EMR, failed to indicate the resident was assessed for the use of an electric blanket nor did the clinical record indicate a discussion with the resident on the risks verses benefits of the use of an electric blanket. During an observation on 11/20/22 at 2:19 PM, R8 had a heating blanket on him. R8 stated staff have not done any assessment with him for the use of a heating blanket. During an observation on 11/21/22 at 8:25 AM, R8 still had a heating blanket on. During an interview on 11/21/22 at 5:05 PM, Administrator-A stated a heating blanket was a potential accident hazard. At 5:40 PM, Administrator-A and surveyor entered R8's room and Administrator-A stated he was not aware of R8's use of a heating blanket. Administrator-A stated there was no risk assessment done for the use of the heating blanket. R8 informed Administrator-A and surveyor that he had the blanket at the facility for several months and that facility staff had washed it several times for him. A request was made for the manufacturer's guidelines for the heating blanket and this document was not provided by the end of the survey. During an interview on 11/22/22 at 8:35 AM, Maintenance Director-T stated he was not aware of R8's use of a heating blanket. Maintenance Director-T stated the heating blanket was not monitored. Maintenance Director-T stated it was important to monitor a heating blanket for frayed wires. 39540

Based on interview and record review the facility did not ensure that 1 (R3) of 5 Residents reviewed for pain management received pain management consistent with professional standards of practice and Resident choice related to pain management. R3 was admitted to hospice on 10/23/21. On 3/11/22 R3 pain medication was increased. R3 did not receive requested and prescribed pain medication until 3/18/22. Findings Include: The facility policy, entitled Pain Assessment and Management dated as revised March 2015, states: Purpose The purpose of this procedure are to help the staff identify pain in the Resident, and to develop interventions that are consistent with the Resident's goals and needs and that address the underlying causes of pain . Defining Goals and Appropriate Interventions: 1. The pain management interventions shall be consistent with the Resident's goals for treatment. Such goals will be specifically defined and documented. 2. Pain management interventions shall reflect the sources, type, and severity of pain. 3. Pain management interventions shall address the underlying causes of the Resident's pain. Implementing Pain Management Strategies: 6. Implement the medication regimen as ordered, carefully documenting the results of the interventions. Monitoring and Modifying Approaches: 1. Re-assess the Resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. 2. Monitor the following factors to determine if the Resident's pain is being adequately controlled: a. The Resident's response to interventions and level of comfort over time b. The status of underlying cause(s) of pain c. The presence of adverse consequences to treatment Documentation 1. Document the Resident's reported level of pain with adequate detail (enough information to gauge the status of pain and effectiveness of interventions for pain) as necessary and in accordance with the pain management program . Reporting 1. Significant change in the level of the Resident's pain . 3. Prolonged, unrelieved pain despite care plan interventions . R3 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3 is her own person. R3's Interim Care Plan dated 10/8/21, documents R3 has pain and is taking pain medications. Surveyor notes that R3's comprehensive care plan reflects a focused problem that R3 is at risk/potential for pain due to generalized discomfort, [CONDITION(S)] initiated: on 10/18/21, along with all interventions put in place on 10/18/21. Surveyor notes this focused problem along with interventions for R3 has not been revised since 10/18/21. Surveyor notes that R3 elected to accept hospice care on 10/23/21. R3's Significant Change Minimum Data Set (MDS), dated [DATE], documents R3's short and long term memory is impaired, and R3 demonstrates severely impaired skills for daily decision making. Surveyor notes that R3's MDS documents R3 is receiving hospice care. The MDS also documents that R3 requires total dependence for bed mobility, transfers, dressing, toileting, and bathing. The MDS also documents that R3's PHQ-9 (Mood Score for the Patient Health Questionnaire) is 14 indicating that R3 has moderate depressive symptoms. R3's MDS documents R3 is receiving scheduled pain medication regimen. R3's pain assessment dated [DATE], documents R3 has vocal complaints of pain. Surveyor notes R3's pain in February ranged from 2-8 on a scale of 1-10, 10 being high pain. Surveyor notes R3's pain in March, prior to the increase in pain medication, ranged from 2-10. Surveyor noted R3 was receiving the ordered [MEDICATION(S)] Tablet 5-325 MG two times per day for pain. Surveyor notes per R3's MARs, R3 had Acetaminophen Tablet and Ibuprofen Tablet ordered as needed. On 3/10/2022, the following was documented by R3's physician: PATIENT ENCOUNTER History of Present Illness: Patient is a [AGE] year-old status post [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)] , [CONDITION(S)] (Hypertension) , depression. Her oral intake is poor hardly eating or drinking. She states that she has pain all over unable to localize it denies shortness of breath does have a cough. She is sleeping a lot on and and off all day and at night. Looks uncomfortable and is reluctant to engage in conversation. REVIEW OF SYSTEMS Constitutional Displays Fatigue, Displays Poor Appetite, Displays Weight Loss, Displays Weakness Extrem, Psychiatric Displays Anxiety, Displays Depression, Displays Memory Loss, Displays Mood Changes, Pain 5 Physical Exam: Constitutional: thin, alert not cooperative, uncomfortable Psychiatric: Oriented x 3, cognition intact, mood sad CARE PLAN / ASSESSMENT ICD 10 or DX: Chronic obstructive pulmonary disease, unspecified, Adult failure to thrive, Essential, primary hypertension, major depressive disorder, recurrent severe w/o (without) psych (psychotic) features, generalized anxiety disorder, Polyosteoarthritis, unspecified, other specified polyneuropathies, COVID-19. Patient is a [AGE] year-old status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Is very uncomfortable at this time has generalized pain. On 3/11/22, R3 transferred to a new hospice provider. Surveyor reviewed R3's hospice progress notes and noted the following: On 3/14/22, R3's medical record documents: Chaplain visit for assessment. R3 is bed, states that R3 hurts all over. Surveyor noted that there is a fax communication in R3's hospice binder dated 3/13/22, documenting R3's [MEDICATION(S)] Tablet 5-325 MG (milligrams) two times daily to be discontinued and changed to [MEDICATION(S)] Tablet 5-325 MG four times daily for pain and a new order for [MEDICATION(S)] oral concentrate 20 MG/1 mL (milliliter). Give 10 MG (0.5mL) every 2 hours as needed sublingual. Surveyor reviewed R3's current MARs (Medication Administration Records) and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/16/22, at 1:17 PM, Surveyor spoke to R3 who stated that R3 was having pain. On 3/16/22, at 1:19 PM, Surveyor spoke to Certified Nursing Assistant (CNA-M) who stated that R3 often complains of pain. On 3/16/22, at 1:42 PM, Surveyor confirmed with Medication Technician (MT-N) that R3's Medication Administration Record (MAR) documented R3 was to receive [MEDICATION(S)] Tablet 5-325 MG two times a day for pain. On 3/17/22, at 8:55 AM, Surveyor spoke to R3 who stated R3's pain is constant and Surveyor observed grimacing by R3. On 3/17/22, at 12:50 PM, Surveyor interviewed hospice nurse (RN-J) who confirmed that on 3/11/22 RN-J initiated the change of R3's pain medication. RN-J stated RN-J verbally informed DON-B of the medication change on 3/11/22. RN-J stated that RN-J always faxes the medication changes to the pharmacy and the facility and that is what RN-J did with R3's medication changes on 3/11/22. RN-J states that RN-J visited R3 on 3/13/22 and checked to make sure the facility's MAR for R3 reflected the medication change. RN-J stated RN-J was informed by the 2nd shift agency nurse that the change in pain medication had been done. Surveyor notes the fax communicating the change in R3's medication was sent on 3/13/22 to the attention of DON-B. Surveyor notes there is no documentation of the conversation between RN-J and the 2nd shift agency nurse. On 3/17/22, at 1:15 PM, Surveyor shared with Administrator (NHA-A) and Corporate Registered Nurse (RN-O) that R3's pain medication had been changed significantly on 3/11/22 and the facility had not made the change as reflected in R3's current MAR and physician orders, thus R3 had not been receiving pain medication as prescribed by hospice. Surveyor shared the concern at this time of the break down in communication between hospice and the facility. On 3/17/22, at 1:39 PM, DON-B brought to Surveyor, R3's 'Medication Profile' and stated to Surveyor, I am telling you the [MEDICATION(S)] is not on there. Surveyor showed DON-B the fax dated 3/13/22, at 3:57 PM from hospice to DON-B reflecting the requested medication changes for R3 . DON-B stated, well it must be still up on the fax machine. Surveyor notes that R3's electronic medical record (EMR) contains a note dated 3/17/2022, at 7:00 PM stating the following: Spoke with Hospice RN-J, discussed current regimen, made aware of Medication Error with no adverse effects. Son was called with message left to update, [name of nurse] RN to also attempt to call Son [name of son] to discuss. All medications reviewed for accuracy with no new changes at this time. R3's pain assessment dated [DATE], documents R3 has been in pain or hurting in the last 5 days and movement causes pain, lying on either side and R3 winces when turned. R3's hospice progress notes note dated 3/17/22 noted R3 was in a lot of pain. On 3/21/22, at 9:29 AM, Surveyor observed R3 in bed with eyes closed. Surveyor observed R3 to be restless and had facial grimacing. On 3/21/22, at 11:15 AM, Surveyor interviewed R3. R3 stated the following to Surveyor: I am so upset. I haven't been out of bed in 3 months and I wish I could get up. Its probably too late now. I have pain all the time no matter what time of the day. It bothers me all through my body, all day. I have a bedsore that hurts. They don't give me meds before they put the bandage on, before they put the pads on. Surveyor asked R3 on a scale of of 1-10 where is your pain at this time. I know all about those pain scales. I am at between a 9 and 10. Everything is so painful. I'm so alone, the grief is so bad. I can't see my TV, I'm losing my eyesight, but it's not even plugged in for me to listen to. I feel like suicide, I know I can't do anything. I will be 98 in 2 days. I know people have it worse than me, but I am miserable. Every morning I don't want to get up and face another day. On 3/21/22, at 11:40 AM, Surveyor interviewed CNA-L who stated that R3 complains of a lot of pain, especially with repositioning. On 3/21/22, at 1:48 PM, Surveyor spoke to RN-J again. RN-J stated RN-J sent the [MEDICATION(S)] order on 3/11/22, and called the pharmacy about 6:30 PM. RN-J stated RN-J wanted the medications sent out that night. RN-J was informed the facility got the medications. RN-J recalls talking to the floor nurse, and talked to DON-B who was in the building on 3/11/22 regarding the pain medication changes with follow up by fax on 3/13/22. RN-J stated DON-B acknowledged understanding. RN-J stated RN-J informed DON-B the medications were coming for R3. RN-J felt comfortable R3 would be getting the medications right away. RN-J is not sure why it did not happen. RN-J stated the family had expressed concerns with R3's pain. R3 is alert and oriented and had expressed that R3 was having pain with R3's wound. R3 is able to express what R3 wants and needs. R3 wanted to keep the [MEDICATION(S)] because R3 felt R3 was getting some relief and didn't want to change the pain medication so RN-J increased the dosage. RN-J stated R3 was clearly in pain when RN-J assessed R3. RN-J stated the [MEDICATION(S)] was ordered for R3's breakthrough pain and is part of the comfort package. On 3/21/22, at 3:14 PM, Surveyor shared the concern with NHA-A and DON-B that R3's pain had not been managed by the facility as evidenced by verbal and physical signs that R3 was in pain frequently throughout the day. Surveyor shared the concern that hospice had ordered for an increase in R3's pain medication along with [MEDICATION(S)] added as needed for breakthrough pain on 3/11/22 with follow up fax on 3/13/22 and the facility did not make the change until 3/17/22 when Surveyor brought it to the facility's attention. Surveyor shared that R3 has verbalized being in constant pain, evident during the survey process and as a result R3 is expressing emotional and psychosocial distress.

Based on observation, interview and record review, the facility did not ensure that 2 (R31 & R2) of 11 residents reviewed and at risk for developing pressure injuries received consistent measures to prevent the development of pressure injuries. * R31 did not have a coccyx/sacrum stage II pressure injury assessed or provided with treatment from admission to 2/2/22. R31's sacrum pressure injury then progressed to a stage III. * R2 did not have initial left heel pressure injury assessed by an RN (Registered Nurse). R2 did not have his left heel pressure injury assessed on the week of 1/5/22. Findings include: 1. R31 was admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R31's Admission MDS (Minimum Data Set) dated 1/12/22, documents that R31 has short and long term memory problems, has severely impaired cognitive skills for daily decision making, and requires extensive assistance and a one person physical assist for his bed mobility needs. Section M (Skin Conditions) documents that R31 has no unhealed pressure ulcers/injuries and that he is not at risk for the development of pressure injuries/ulcers. R31's Pressure Injury/Ulcer CAA (Care Area Assessment), dated 1/12/22, documents under the Care Plan Considerations section, No presence of pressure areas, ongoing interventions to reduce risks for potential skin integrity impairment weakness present and reliance on staff for assist with adls (activities of daily living) and mobility. In contrast, R31's admission assessment, dated 1/5/22, documents that R31 had a coccyx stage II, and right and left heel pressure injuries present on admission the facility. R31's nursing note, dated 1/5/22, documents, Nurses Note Text: Resident arrived by stretcher per Ambulance services. Admitting Dx: Hematuria r/t (related to) blood clot formed from newly placed suprapubic catheter 12/22/22 .Rarely verbalizes d/t (due to) dementia .Reported pressure areas to bilateral heels, and pink stage 2 to coccyx. [MEDICATION(S)] in place for protection. R31's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . He was recently hospitalized from 12/4/21 to 01/05/22 for [CONDITION(S)], hematuria, and [CONDITION(S)] (urinary tract infection) . He is non-verbal at baseline. He is awake and alert resting in bed grinding his teeth at this time. He has suprapubic foley catheter draining blood tinged urine with noted blood clots. He has a wound to his right heel that is dressed. Surveyor noted that despite R31's admission assessment and nursing note dated 1/5/22, and R31's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor also noted that despite the above documentation, R31's Pressure Ulcer/Injury CAA dated 1/12/22 incorrectly documents under the Care Plan Considerations sections that R31 did not have any open pressure areas. R31's Admission Braden Scale For Predicting Pressure Sore/Injury Risk, assessment dated [DATE], documents a score of 12, indicating that R31 is at high risk for the development of pressure injuries. R31's nursing note, dated 1/29/22, documents, Nurses Note Text: 97.3 (degrees Fahrenheit) .Dressing change now to coccyx: no BM (bowel movement) now .Turned off coccyx: air mattress and P (Prevalon) boots used. Surveyor was unable to locate any documentation that facility nursing staff assessed, measured or staged R31's pressure injuries upon R31's readmission to the facility on [DATE] through 2/2/22. Surveyor was unable to locate any wound treatments ordered for R31's sacrum pressure injury from 1/5/22 to 2/2/22. R31's initial wound assessment, completed by Wound physician and dated 2/2/22 documents, Wound Location: Sacrum; Length: 4.24 cm (centimeters); Width: 3.62 cm; Maximum Depth: 0.2 cm; Etiology: Pressure Ulcer-Unstageable; Woundbed assessment: Granulation 1-25%, Slough 51-75 %.; Formularies: Cleanse with 1/2 strength Dakin's solution, Protect Periwound with Skin Prep, apply Santyl to wound bed, cover with bordered gauze, change daily. Surveyor noted that R31 had pressure injury interventions, weekly wound assessments and treatments as ordered by the wound physician from 2/2/22 to 2/23/22. R31's wound physician assessment dated [DATE] documents, Wound Location: Sacrum; Length: 2.13 cm (centimeters); Width: 2.06 cm; Maximum Depth: 0.2 cm; Etiology: Pressure Ulcer-Stage 3; Woundbed assessment: Granulation 76-100%.; Formularies: Cleanse with saline, protect periwound with skin prep, apply alginate to wound bed, cover wound with bordered gauze, change daily, change PRN (as needed) for soiling and/or saturation. Surveyor noted that R31 had pressure injury interventions, weekly wound assessments and treatments as ordered by the wound physician from 2/24/22 to 3/16/22. Surveyor noted that despite the facility's lack of initial assessment and treatment to R31's sacrum/coccyx wound, R31's sacrum pressure injury started improving when treatment was started on 2/2/22. On 3/21/22, at 11:44 a.m., Surveyor informed ADON (Assistant Director of Nursing)-D, whom was in charge of wound care at the facility, of the above findings. Surveyor asked ADON-D if the facility had done any weekly assessments and or daily treatments of R31's coccyx/sacrum pressure injury from 1/5/22 to 2/2/22, as Surveyor was unable to locate any in R31's medial record. ADON-D informed Surveyor that she could not recall if R31 had any pressure injuries upon admission. ADON-D informed Surveyor that around 1/29/22, a facility staff member came up to her and informed her R31 had a pressure injury to his sacrum. ADON-D informed Surveyor that she could not provide any information regarding R31's sacrum pressure injury prior to 1/29/22. ADON-D informed Surveyor that she and wound physician did not formally assess R31's sacrum pressure injury until 2/2/22. ADON-D informed Surveyor that if facility staff were aware of open areas when R31 was admitted to the facility, they should have notified her so she could assess and get a treatment in place. No additional information was provided as to why the facility did not ensure R31 received necessary treatment and services from 1/5/22 to 2/2/22, to promote healing of a pressure injury. 2. R2 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Quarterly MDS (Minimum Data Set), dated 3/4/22, documents a BIMS (Brief Interview for Mental Status) score of 3, indicating that R2 is severely cognitively impaired. Section G (Functional Status) documents that R2 requires extensive assistance and a one personal physical assist for his bed mobility needs. Section G also documents that R2 has total dependence on staff and requires a one person physical assist for his transfer needs. Section G0400 (Functional Limitation in Range of Motion) documents that R2 has no impairment to either side of both his upper and lower extremities. Section M (Skin) documents that R2 is at risk for the development of pressure injuries. R2's Pressure Ulcer CAA (Care Area Assessment), dated 12/2/21, documents under the Care Plan Considerations section, Resident has episodes of incontinence and relies on staff for assist with mobility and presence of weakness. R2's Braden Scale for Predicting Pressure Sore/Injury Risk Assessment, dated 6/5/21, documents a score of 15, indicating that R2 is at moderate risk for the development of pressure injuries. R2's skin integrity plan of care, dated 12/7/20, documents the following interventions as in place prior to 12/5/21, Turn and Reposition Q (every) 2-3 hours; Prevalon boots or pillow to offload heels; Skin Prep to heels for protection; avoid friction and shearing-use lift sheet for transfers. R2's nursing note completed by LPN-R and dated 12/5/21 documents, Nurses Note Text: Writer was walking past resident room in beginning of shift when it was noticed that prevlon boot was off. Writer went to put boot back on resident left foot and the suspected deep tissue injury was seen. Boot was reapplied and scheduled skin prep applied. Area measures 3.5 cm x 4 cm. On call NP (nurse practitioner) with [name of medical group] notified, DON (Director of Nursing) notified, and healthcare POA (power of attorney) updated. On call NP with [name of medical group] said to continue with keeping the prevlon boot on and skin prep to both heels. Resident was compliant with keeping prevlon boot on left foot. Resident denies having any pain on the suspected deep tissue injury area. Surveyor was unable to locate any RN (Registered Nurse) assessment for R2's initial wound assessment dated [DATE]. R2's initial wound assessment completed by Wound physician and dated 12/8/21 documents, Wound Location: Left Medial Heel; Length: 4.19 cm (centimeters); Width: 3.71 cm; Maximum Depth: 0.0 cm; Etiology: Pressure Ulcer-Suspected DTI (deep tissue injury); Woundbed assessment: Purple; Formularies: Change daily, cleanse with [MEDICATION(S)]. Surveyor noted that R2 had pressure injury interventions, weekly wound assessments and treatments as ordered by the wound physician from 12/8/22 to 1/5/22. Surveyor was unable to locate a weekly wound assessment for R2's left heel pressure injury for the week of 1/5/22. Surveyor also noted that despite the facility's lack of weekly wound assessment of R2's left heel, R2's left heel pressure injury continued healing while R2 resided at the facility. R2's Weekly Pressure Ulcer Log dated 3/16/22 documents, Site: Left Heel; Unstageable, 0.75 cm length; width: 1.25 cm Depth: 0.1 cm, Comments: Improvement. On 3/21/22 at 11:44 a.m., Surveyor informed ADON (Assistant Director of Nursing)-D, whom was in charge of wound care at the facility, of the above findings. Surveyor asked ADON-D if the facility had done any weekly assessment on R2's left heel pressure injury for the week of 1/5/22, as Surveyor was unable to locate any in R2's medial record. ADON-D informed Surveyor that she was out sick and not working at the facility for the week of 1/5/22 and that she could not provide any additional information as to why R2 did not have a weekly assessment on his left heel pressure injury for the week of 1/5/22. Surveyor asked ADON-D if R2's left heel had been assessed by an RN on 12/5/21, as Surveyor noted that the initial finding of the wound was only assessed by LPN-R. ADON-D informed Surveyor that she could not provide any information as to if there was an RN assessment of R2's left heel on 12/5/21. ADON-D informed Surveyor that there should have been an RN assessment following up LPN-R's initial left heel pressure injury assessment on 12/5/21. On 3/21/22 at 4:11 p.m., Surveyor informed DON (Director of Nursing)-B of the above findings. No additional information was provided as to why the facility did not ensure that R2 received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new injuries from developing.

Based on record review and interview, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for diabetic and rehabilitation residents for 2 (R6 and R4) of 7 sampled residents. R6 had a change in condition including an elevated blood sugar on 9/17/2021 that was not thoroughly assessed or documented to identify timely interventions to prevent further decline or events from happening. Documentation did not show a timeline of events to determine when the change of condition occurred or if interventions were implemented. R4 had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 had orders schedule appointments with both optometry and podiatry dated 10/20/21 and these were not completed. Findings: The facility policy and procedure entitled Change in a Resident's Condition or Status dated 5/2017 states: 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): . d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; . i. specific instruction to notify the Physician of changes in the resident's condition. 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR (Situation, Background, Assessment, Recommendation) Communication Form. 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Per the American Diabetes Association, https://www.diabetes.org/diabetes/dka-ketoacidosis-ketones, Diabetic Ketoacidosis (DKA) usually develops slowly, but can be life-threatening. Early symptoms include thirst or very dry mouth, frequent urination, high blood sugar levels, and high levels of ketones in the urine. Later symptoms include constantly feeling tired, dry or flushed skin, nausea/vomiting/abdominal pain, difficulty breathing, fruity odor on breath, and a hard time paying attention or confusion. Warning! DKA is dangerous and serious. If you have any of the above symptoms, contact your health care provider IMMEDIATELY, or go to the nearest emergency room of your local hospital. R6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] indicated R6 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 4 and R6 needed extensive assistance with all activities of daily living and took insulin daily. R6 had an activated Power of Attorney and had a Full Code status. On 9/2/2021 on the hospital Discharge Summary, the discharge medication list and orders included: -insulin [MEDICATION(S)] ([MEDICATION(S)]): Inject 6 Units subcutaneously 3 times daily with meals. Max Daily Dose= 30 units. Use based insulin dosing chart: Breakfast= 6+2; Lunch= 6+2; Supper= 6+2. -insulin [MEDICATION(S)] ([MEDICATION(S)]): Inject 20 units subcutaneously every morning. -Test blood sugars four times daily. Surveyor reviewed the September 2021 Medication Administration Record (MAR) and the order for the [MEDICATION(S)] insulin was not found while R6 was a resident at the facility. R6 had admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] -to check blood sugars four times daily, before each meal and at bedtime, and -notify the physician if the blood sugar was less than 60 or greater than 400. Surveyor identified R6's blood sugars ranged from 138 to 496 with an average of 277. (An average was calculated with the fifty blood sugar checks recorded in R6's Blood Sugar Summary from 9/2/2021 until discharge on [DATE].) The blood sugars were trending upwards from 9/14/2021 to 9/17/2021 ranging from 215 to 496 with an average of 365. (An average was calculated with the thirteen blood sugar checks recorded in R6's Blood Sugar Summary from 9/14/2021 to 9/17/2021.) On 9/14/2021 at 11:58 AM, R6's Blood Sugar Summary documented R6 had a blood sugar of 437. Per the physician orders, the physician was to be notified of a blood sugar greater than 400. No documentation was found indicating the physician was notified of this elevated blood sugar. The blood sugar result was documented on the Medication Administration Record (MAR) and signed by Registered Nurse (RN)-D. In an interview on 1/19/2022 at 2:45 PM, Surveyor asked RN-D if the physician had been notified on 9/14/2021 when R6's blood sugar was 437. RN-D could not recall if the physician had been called on 9/14/2021 to report the elevated blood sugar. RN-D agreed documentation should have been completed if and when the physician was notified. On 9/17/2021 at 8:04 AM R6's Blood Sugar Summary documented, R6 had a blood sugar of 389. On 9/17/2021 at 11:00 AM on the September 2021 MAR, R6 was documented as having a blood sugar of 496. No documentation was found indicating the physician was notified of this elevated blood sugar. On 9/17/2021 at 2:27 PM in the progress notes, nursing charted the Nurse Practitioner (NP) was spoken to regarding R6's blood sugar of 505; the nurse gave insulin and was advised to wait and monitor R6 and then recheck the blood sugar in 15 minutes. Nursing charted the updated blood sugar 15 minutes later as 493 and the NP was updated with the blood sugar reading. Nursing charted the NP gave a verbal order to start [MEDICATION(S)] 500 mg, an oral hypoglycemic medication, once daily. The nurse documented R6 would continue to be monitored. No other interventions were put into place that would lower R6's blood sugar. The new order obtained to start [MEDICATION(S)] 500 mg was scheduled to be started on 9/18/2021. The documentation in the progress note on 9/17/2021 at 2:27 PM indicated blood sugar readings of 505 and 493 were not documented on the Blood Sugar Summary and the time was not documented to indicate when the elevated blood sugars occurred. The note does not include the type of insulin given, the dose of insulin given, or when the insulin was given. The note does not indicate the insulin given was effective in lowering the blood sugar and no other immediate interventions were put into place to lower R6's blood sugar. No comprehensive assessment was completed to determine the cause of the high blood sugar or how R6 presented medically with the high blood sugar. Review of the September 2021 MAR did not document any additional type of insulin was ordered or administered on 9/17/2021 other than [MEDICATION(S)] 20 units at 9:00 AM per admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] The nurse that wrote the progress note on 9/17/2021 was no longer employed by the facility and was unavailable for interview at the time of survey. The NP that gave the order for insulin was no longer employed by the facility and was unavailable for interview at the time of survey. On 9/17/2021 at 4:03 PM, R6's Blood Sugar Summary documented R6 had a blood sugar of 496. No documentation was found indicating R6's physician was notified of the elevated blood sugar of over 400 per physician orders. No documentation could be found that indicated a comprehensive assessment of R6 was completed. On 9/17/2021 at 5:47 PM in the progress notes, the Medical Director (MD) documented R6 was visited that day for an initial visit. The actual time of the visit was not documented. The MD documented R6's blood sugar levels range from 180 to 437 and R6 was sleeping soundly at the time of the visit and when awakened, did not contribute to the medical history given R6 had dementia and was non-verbal at baseline. The MD documented under the Assessment/Plan section of the note: T2DM (Type 2 Diabetes Mellitus): IDDM (Insulin-Dependent Diabetes Mellitus) . increase [MEDICATION(S)] 25 mg qd (daily), [MEDICATION(S)] ([MEDICATION(S)]) TID (three times daily) AC (before meals) per SSI (sliding scale insulin). Start [MEDICATION(S)] 25 mg qd. Review of the September 2021 MAR documented the [MEDICATION(S)] was increased from 20 units to 25 units with a start date of 9/18/2021 and [MEDICATION(S)] 25 mg was scheduled to start on 9/18/2021. The MAR did not document an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's hospital discharge orders documented [MEDICATION(S)] ([MEDICATION(S)]) to be ordered as: Inject 6 Units subcutaneously 3 times daily with meals. Max Daily Dose= 30 units. Use based insulin dosing chart: Breakfast= 6+2; Lunch= 6+2; Supper= 6+2. However, [MEDICATION(S)] ([MEDICATION(S)]) was not included as part of R6's facility admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/17/2021 at 8:45 PM in the progress notes, Director of Nursing (DON)-B documented R6 was seen remotely by the MD and no concerns were noted or expressed; R6 remained in stable condition. DON-B documented new orders were provided to adjust the long-acting insulin and add an oral hypoglycemic mediation to the current medication regimen. The progress note did not address any sliding scale insulin. On 9/17/2021 at 8:45 PM on the Blood Sugar Summary, R6 had a blood sugar of 492. On 9/17/2021 at 9:53 PM in the progress notes, RN-C charted the NP was called regarding a change in condition for R6; blood sugar 482, temperature 97.7, respirations 20, blood pressure 117/65, and heart rate 112. The NP ordered R6 to go to the emergency room for further evaluation and treatment. These vital signs were documented only in the progress notes and were not documented in the Vital Sign section of the electronic charting system. (When a resident is transferred out of the facility, the pertinent vital signs are pulled from the Vital Sign Summary and if the vital signs are only documented in the Progress Notes, they will not be available for review at the accepting facility.) The blood sugar of 482 in the 9/17/2021 9:53 PM progress note did not correlate with the blood sugar of 492 charted on 9/17/2021 at 8:45 PM on Blood Sugar Summary. Surveyor could not locate documentation that the Nurse Practitioner was called regarding the 492 blood sugar at 8:45 PM. No documentation was found on 9/17/2021 indicating, other than an elevated blood sugar and an elevated heart rate, what the change in condition consisted of for R6 at 9:53 PM, such as mentation, alertness, responsiveness, or general presentation. No documentation was found indicating what time the change of condition occurred, what time the NP was notified, who was called for transport (911 or a local ambulance company), or what time emergency personnel arrived. On 9/17/2021 at 9:58 PM, the Fire Administration Emergency Medical Service (EMS) report documented 911 was activated by the facility. Per the report, R6 had altered mental status that started on 9/17/2021 at 9:41 PM. The narrative section of the report stated: MED2 E2 DISPATCHED TO MANAGED CARE FACILITY FOR (R6) W/ (with) DIABETIC ISSUE. ARRIVED TO FIND (R6) LYING IN BED RESPONSIVE TO PAIN. STAFF STATES THAT PT (patient) IS SUPPOSED TO RECEIVE 8 UNITS OF [MEDICATION(S)] 3X (three times) DAILY. STAFF STATE THAT (R6) HAS ONLY HAD 8 UNITS ONE TIME TODAY. STAFF UNABLE TO STATE WHY. UNABLE TO GET FURTHER PT (patient) HX (history) FROM STAFF. PT VITALS TAKEN. BG (blood glucose) 486. IV STARTED. 200CC BOLUS ADMIN TO CONTERRACT HYPERGYLCEMIA. Surveyor could not determine if any [MEDICATION(S)] insulin had been administered as stated on the EMS report. In an interview on 1/18/2022 at 2:04 PM, Surveyor reviewed with DON-B the documentation completed by DON-B on 9/17/2021. DON-B stated R6 was cognitively impaired and when asked a yes or no question, would not answer consistently with a yes or a no appropriately. Surveyor asked DON-B how R6 presented on 9/17/2021. DON-B stated DON-B was with R6 during the tele-visit with the MD and R6 was at baseline with minimal verbalization. Surveyor asked DON-B at what time of day was the MD visit. DON-B could not recall the exact time of day, but thought it was in the morning. DON-B stated the MD would document on all the residents that were seen that day after all the rounds were completed so the note was not done in real time but at the end of the day. DON-B stated the charting DON-B did on 9/17/2021 was completed remotely from home after leaving the facility and not right after the visit occurred. Surveyor asked DON-B if DON-B was aware of R6's elevated blood sugars and change in condition that caused R6 to be transferred to the hospital. DON-B stated the staff should have notified DON-B of any resident going out of the facility and DON-B could not recall having a conversation with RN-C on 9/17/2021 indicating R6 was being transferred to the hospital or of having a conversation about elevated blood sugars. Surveyor shared with DON-B the concern the documentation surrounding R6's change of condition on 9/17/2021 was not descriptive of the events that happened with a timeline showing the progression of what occurred and what was done by facility staff when the change of condition was discovered. DON-B agreed the documentation was lacking and could not tell the extent of the change of condition just by reading what was documented in R6's medical record. In an interview on 1/19/2022 at 9:10 AM, Surveyor asked DON-B what hospital R6 was transferred to since R6's medical record did not have that information documented and did R6 go out of the facility with 911 or was an ambulance service called. DON-B stated R6 would have gone to the closest hospital and provided that information, but agreed there was no documentation to confirm where R6 was transferred to. DON-B stated DON-B did not know if 911 was called for R6 or if an ambulance service was called to transport R6 to the hospital. In an interview on 1/19/2022 at 10:20 AM, RN-C stated on 9/17/2021 RN-C started work late on second shift around 4:30 PM or 5:00 PM. RN-C stated the day shift nurse had written down report on all the residents prior to leaving the facility and R6 was being monitored for high blood sugar. RN-C stated the report from the day shift nurse did not state if R6 was exhibiting any symptoms of high blood sugar. RN-C stated when RN-C was passing medications at approximately 5:00 PM, R6 was not responding like R6 normally did. RN-C stated that was the first time RN-C had worked with R6 and discussed with a Certified Nursing Assistant (CNA) if that was normal behavior for R6. RN-C stated the CNA informed RN-C that R6 usually talked and R6 was not responding verbally to anything. Surveyor asked RN-C if R6 was alert or if eyes were open and for more details of how R6 was acting. RN-C stated R6 was in bed with eyes open and head lifted, but could tell something was not right when RN-C was talking to R6. RN-C did not elaborate any more with what RN-C thought was not right with R6, but denied R6 was coding or anything like that. RN-C stated R6 had a high blood sugar and when RN-C noticed the change of condition at about 5:00 PM, called the Nurse Practitioner right away, called 911, and sent R6 immediately to the hospital. (Per the EMS report, 911 was not activated until 9:58 PM.) Surveyor reviewed the staff schedule for 9/17/2021 and the day shift nurse was scheduled from 6:30 AM to 3:00 PM and RN-C was on the schedule to start the shift at 2:30 PM. There was no indication on the schedule that RN-C would be reporting at 4:30 PM or 5:00 PM after the shift started. There was no indication on the schedule who was covering the residents from 3:00 PM until RN-C arrived between 4:30 PM and 5:00 PM. R6 was to be monitored for signs and symptoms of [CONDITION(S)] and Surveyor could not determine what staff member was monitoring R6 for one and a half to two hours from 3:00 PM until 4:30/5:00 PM. In an interview on 1/19/2022 at 3:20 PM, CNA-E stated on 9/17/2021 R6 was sleepy and tired and not responsive like usual. CNA-E stated R6 felt hot to the touch so CNA-E told the nurse. CNA-E stated R6's eyes were open, but R6 did not respond like usual. CNA-E stated R6 would not eat anything at supper time. Surveyor asked CNA-E what time was R6 sent out to the hospital. CNA-E stated R6 was sent out after supper but could not recall the exact time. In an interview on 1/21/2022 at 11:04 AM, Surveyor asked DON-B to clarify how tele-visit was completed with the MD and R6 on 9/17/2021. DON-B stated there is a computer-type device that DON-B logs into and connects with the MD and the device is brought to the resident room. DON-B stated there are two cameras on the device, one on the computer itself and one on a wand-like device. DON-B stated the camera on the computer allows the MD to see the staff member and the camera on the wand allows a close-up view of the resident to see a wound or in the ears, whatever the MD wants to see close up. DON-B stated there is a stethoscope connected to the computer that allows the MD to hear the heart and lungs. Surveyor asked DON-B how new orders are conveyed during a tele-visit. DON-B stated DON-B takes notes while doing rounds with the MD and then at the end of the day, the MD will email or fax any new orders for the resident; the faxed or emailed orders are kept in the resident's medical record. DON-B stated the MD changed the amount of [MEDICATION(S)] insulin that was ordered and started [MEDICATION(S)] on 9/17/2021. DON-B provided the faxed order dated 9/17/2021 at 4:51 PM that showed those two orders. The orders were signed by DON-B on 9/17/2021 at 8:53 PM. [MEDICATION(S)] sliding scale was not ordered per that fax. Surveyor asked DON-B about the [MEDICATION(S)] that was on the hospital Discharge Summary and written in the MD progress note on 9/17/2021. DON-B stated the NP discontinued the [MEDICATION(S)] order on admission and was monitoring the blood sugars, but DON-B did not know what happened with the [MEDICATION(S)] three times daily order that the MD documented in the progress note on 9/17/2021. Surveyor shared with DON-B the concerns surrounding R6's change in condition on 9/17/2021 and the inability to determine when the change of condition happened starting with the progress note on 9/17/2021 at 2:27 PM and continuing through the final progress note on 9/17/2021 at 9:53 PM. DON-B stated the nurses have a habit of doing all their documentation at the end of their shift so nothing is charted in real time. DON-B agreed it was difficult to determine when the blood sugar was elevated and when the NP was notified. Surveyor shared with DON-B the following concerns. R6 had an elevated blood sugar of 505 at some time on 9/17/2021 but there is no documentation as to when that blood sugar was obtained. No orders were transcribed to administer insulin, the blood sugar continued at the elevated rate with no further interventions completed to bring the blood sugar to a range that was not dangerous, and no comprehensive assessments were completed or documented to show how R6 was reacting to the elevated blood sugars. Surveyor was unable to determine when the change of condition started, who was notified of the continuing elevated blood sugars, and R6 was not being monitored at the change of shift from day shift to pm shift on 9/17/2021 for up to two hours. Through interview, RN-C stated R6 had a significant change in condition at 5:00 PM when RN-C was doing rounds and passing medications, but per the EMS record, the change of condition started at 9:41 PM and 911 was called at 9:58 PM. Per the EMS record the nursing staff was unable to give any accounts of the day that led to the change in condition and was unable to provide any of R6's medical history to EMS. Surveyor was unable to determine the accuracy of the statement to EMS that the change of condition started at 9:41 PM. No further information was provided at that time. On 1/28/2022 at 2:58 PM, DON-B sent additional information to Surveyor for review. The information consisted of a statement from RN-C that read as follows: After reviewing the Medical Record and Charting I am making this statement, it is an estimate of the events that took place on 9/17/2021 during my shift. -8:45PM-9PM Administered medications to Resident, Resident was alert and consistent with earlier assessment, no changes were noted; alert & responsive, appropriate. -9:15PM-9:30PM- Went to Resident's Room to obtain HS (Hour of Sleep) BGL (bedtime blood glucose level) which was 482, Resident appeared more Lethargic, VS (vital signs) taken. -9:30PM-9:45PM- Call was placed to (medical service), spoke with (Physician Assistant) and orders were obtained to send Resident to ER (emergency room ) for further evaluation. -9:53PM- 911 called. -10PM- EMS (emergency medical services) arrived; Resident taken to (hospital) ER. The statement was signed by RN-C and was undated. Surveyor reviewed statement provided. RN-C entered the BGL into R6's medical record at 8:45 PM, not 9:15 PM-9:30 PM indicating the blood sugar was obtained at least half an hour prior to what the statement indicated. 911 was called at 9:58 PM after the progress note was written at 9:53 PM indicating over an hour had gone by from the time the blood sugar level was obtained and 911 was called. The statement provided does not indicate the NP or physician was notified earlier in the day or earlier in the shift when blood sugar levels remained extremely elevated and no interventions were put in place to lower the blood sugar levels. 2) Surveyor reviewed the facility's policy and procedure on physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Purpose: To provide guidance to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Policy: 10. A monthly review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor also reviewed the facility's policy and procedure on physician service dated April 2013 and notes the following: Policy Interpretation and Implementation 5. Physician visits, frequency of visits, emergency care of Residents, etc., are provided in accordance with current OBRA (Omnibus Budget Reconciliation Act) regulations and facility policy. Consultative services shall be made available from community-based consultants or from a local hospital or medical center. R4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 is her own decision maker. R4's Admission Minimum Data Set (MDS) dated [DATE] documents R4's Brief Interview for Mental Status (BIMS) score of 15, indicating R4's decision making skills are intact. R4's MDS also documents that R4 requires extensive assistance for bed mobility and dressing and requires total assistance for transfers and toileting. Surveyor reviewed R4's electronic medical record (EMR) and notes the following physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] History of Present Illness: R4 reports that R4 needs to see podiatrist for routine nail care. States R4 has very long toenails on R4's right foot. R4 also complains of poor vision and states that R4 has not seen an eye doctor in some time due to prolonged hospitalization . Additional Orders: Podiatry evaluation for routine nail care Schedule eye exam for routine evaluation Surveyor reviewed R4's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Set up Optometry appointment-Annual Wellness Check-Order date 10/20/21 Set-Up Podiatry Appointment-Routine Foot Care-Order date 10/20/21 R4's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Opthamology consult-Diabetic with worsening eyesight-Order date 12/14/21 Podiatry consult-Diabetic with overgrown toenails-Order date 12/14/21 Surveyor reviewed R4's electronic medical record (EMR) and notes the following physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] History of Present Illness: R4 has been getting increased clouding of vision has not seen an ophthalmologist in several years. R4 has not been getting therapy since in the building the last time I tried to see R4 she was at [CONDITION(S)]. R4 is very discouraged. Care Plan/Assessment: Needs to see podiatrist as well as ophthalmologist for ongoing care and will get out of bed 3 times a day and ask Physical Therapy(PT) and Occupational Therapy(OT) to see. Surveyor reviewed R4's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] PT/OT Eval and Treat-Order dated 12/14/21 On 1/18/22 at 1:27 PM, Surveyor interviewed R4 who confirmed R4 has not seen a podiatrist or an eye doctor. R4 stated that R4 had a couple of weeks of PT and OT when first admitted to the facility but has not had any PT or OT since. On 1/19/22 at 9:10 AM, Surveyor spoke with Social Worker (SW-G) in regards to R4 receiving podiatry and eye services. SW-G confirmed that SW-G manages the eye, podiatry, and dental services. SW-G stated R4 has been put on a list to be seen by the eye doctor on 1/28/22. SW-G stated that R4 had been seen by the podiatrist on 12/17/21. Surveyor requested documentation of the podiatrist visit. SW-G was unaware there was a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor reviewed the progress note from the podiatrist dated 12/17/21 which states, R4 was scheduled to be treated today, but was not treated. Reason: R4 was unavailable: at [CONDITION(S)]. On 1/19/22 at 9:31 AM, Surveyor spoke with Rehabilitation Manager (RM-H) who confirmed that R4 had received both PT and OT upon admission (10/13/21) and was discharged from therapy on 11/12/21. RM-H completed a therapy screen on R4 on 12/22/21 because she kept asking for therapy. RM-H explained that a therapy screen is very different from an evaluation and treat order. RM-H explained that a screen is based on a request of a Resident. With an order, therapy has to get prior approval from insurance. RM-H stated if this had been done for R4, R4 would most likely have been denied by insurance due to history, but there would be documentation of that denial. RM-H confirmed there is no documentation of that being done for R4. RM-H stated new orders for therapy are gone over in morning meeting and the therapy department is notified of any new orders for a Resident. RM-H confirmed that RM-H was unaware there was an order dated 12/14/21 for an evaluation and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Surveyor notes that RM-H explained that R4 was discharged from therapy due to making no progress and being uncooperative with therapy's plan of care. Surveyor reviewed OT's initial evaluation and plan of treatment dated 10/14/21 Goals: R4 will wash upper body with mod (moderate) assist max (maximum) assist-baseline R4 will tolerate 10 minutes of bilateral upper extremity activity to complete upper body cares-assist of 2 for bed mobility, R4 made no movement to assist-baseline R4 will wash upper body seated at the sink-dependent, R4 stated R4 has been bedridden for years-baseline The initial OT evaluation documents that R4 had received therapy at other facilities and the hospital. It is documented that R4 was refusing to answers to how long R4 had been bedbound or when the last time R4 was in R4's home. R4 unrealistic since therapist was told R4 has been bedridden for years and would not answer last time R4 walked. Surveyor reviewed OT's discharge summary dated 11/12/21. Goals: R4 refused to wash upper body-max assist R4 made no movement to assist with bilateral upper extremity activity to complete upper body cares R4 does not get out of bed except to go to [CONDITION(S)]-mod-total assist The OT summary documents R4 did not make any progress and was discharged due to being non-compliant. Surveyor reviewed PT's initial evaluation and plan of treatment dated 10/16/21: R4 to improve bilateral lower extremity to facilitate bed mobility and transfers R4 able to roll with max assist to facilitate progression-max assist x2 (with 2 staff)/total R4 to improve bilateral lower extremity to facilitate bed mobility and transfers R4 able to roll with mod assist to facilitate progression-max assist x 2/dependent R4 to complete supine sit with max assist-unable R4 to tolerate sit to stand x 1 minute to facilitate transfers-unable Surveyor reviewed R4's PT discharge summary dated 11/12/21 and R4 made no improvement in the above goals with refusals. It is documented that a restorative program was not indicated at the time of discharge. On 1/19/22 at 4:14 PM, Surveyor shared the concern with Administrator (NHA-A) and Director of Nursing (DON-B) that R4 had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor shared the concern that these physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review the facility failed to ensure 1 (R14) of 2 residents reviewed for weight loss had their nutritional care needs recognized, evaluated, and addressed to provide adequate parameters of nutritional status. R14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Upon admission to the facility on [DATE] R14 is documented as weighing 137 pounds. On 1/9/21 R14 was admitted to the hospital weighing 112.2 pounds. This is a 24.8 pound weight loss from when R2 was admitted to the facility on [DATE] at 137 pounds, an 18.1% weight loss, indicating severe weight loss. Upon admission to the hospital R14's electrolytes were off, and required admission to the ICU. The facility failed to: -Provide a nutritional supplement twice a day as recommended by the hospital due to R14's poor intake. -Note that R14 was lactose intolerant. -Ensure meal intakes were always documented. -Ensure an accurate assessment was completed by a registered dietitian timely. A nutritional history was completed by a dietary manager who indicated they had no certification or degrees in food service on 12/11/20 (Cross reference F801.) A nutritional assessment is not documented as being completed by a dietitian until 1/4/21, at which time the dietitian inaccurately noted R14 was consuming 50-100% of meals and did not address R14's refusals of meals or poor intake. -Update the dietitian or physician when R14 was refusing meals and having poor oral intake as well as loose stools. -Update R14's plan of care or preferences when R14 was refusing meals and having poor meal intake. -Monitor R14's weight despite R14's meal refusals and poor meal intakes. The facility's failure to provide nutritional care to R14 resulted in a finding of immediate jeopardy starting on 1/4/21. The DON (Director of Nursing)-B and Nurse Consultant-G were informed of the immediate jeopardy on 3/24/21 at 4:20 pm. The immediate jeopardy was removed on 3/24/21, however the deficient practice continues at a scope/severity of E (potential for more than minimal harm/pattern) as the facility continues to implement its action plan. Findings include: The facility's Weight Assessment and Intervention policy and procedure, revised September 2008, documents The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents .the Nursing staff will measure resident weights within two days of admission, then per dietician recommendation or monthly .The threshold for significant unplanned and undesired weight loss will be based on the following criteria .a. 1 month- 5% weight loss is significant, greater than 5% is severe. R14 was admitted to the facility following a hospitalization from [DATE]-[DATE]. Hospital physical exam notes document Well developed female appears stated age. Hospital course notes document Patient has significant [CONDITION(S)] his [sic] difficulty with oral intake, she states she does not have an appetite. Discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Concurrent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital discharge exam documents the resident's weight as 65.9 kg (145.2 pounds). R14's potassium level on 12/11/20 is documented as being 4.1. Under Patient Instructions documents Needs lactose-free supplements, has had low oral intake. R14's diet listed under the After Visit Summary-Transition documents Daily w [with] Dinner; Prosource Gelatin 20/Gelatin, High Protein, Sugar Free, Fruit Punch Oral Nutrition Supplement and Daily w Lunch; Ensure Clear Generic/Clear Liquid Supplement Oral Nutrition Supplement. R14's weight upon admission to the facility on [DATE] is documented as being 137 lbs. The surveyor noted R14 has no other documented weights at the facility during her admission. According to the State Operations Manual, Current standards of practice recommend weighing the resident on admission or readmission (to establish a baseline weight), weekly for the first 4 weeks after admission and at least monthly thereafter to help identify and document trends such as insidious weight loss. Weighing may also be pertinent if there is a significant change in condition, food intake has declined and persisted (e.g., for more than a week), or there is other evidence of altered nutritional status or fluid and electrolyte imbalance. The surveyor reviewed R14's admission physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R14's diet orders upon admission to the facility on [DATE] is documented as Consistent Carbohydrate diet REGULAR texture, REGULAR THIN consistency. The surveyor reviewed R14's Medication and Treatment Administration Records for December 2020 and January 2021 and noted no supplement is documented as being administered. A Nutrition History by Dietary Manager-D, with an effective date of 12/11/20, documents R14's Diet Order being LCS [low concentrated sweets], Diet, Regular Texture, Thin Liquids. Under Supplements, Diagnosis, Medications, Most Recent Height, Most Recent Weight, and Recommended Weight Range, the document is empty. The document lists No under does the resident have food intolerances, despite R14 being lactose intolerant. The document is blank under the sections for daily food preferences and least favorite foods. Under Does Resident have a good appetite? is documented No. The document states under Are there complaints of diarrhea or constipation? No. On 3/24/21 at 1:46 pm the surveyor interviewed Dietary Manager-D. Dietary Manager-D informed the surveyor she became the manager a year and a half ago. The surveyor asked Dietary Manager-D if she had any degrees or certifications in food services. Dietary Manager-D informed the surveyor no, that she had been planning to do schooling, but then COVID-19 hit and there were more pressing issues in the building. Dietary Manager-D informed the surveyor when she completes a nutrition history she meets with the resident to find out likes and dislikes to get a better idea what to serve them. Dietary Manager-D informed the surveyor she could not recall R14 much, just that she had been on the facility's COVID-19 unit. Dietary Manager-D informed the surveyor she would inform RD-C if she had dietary questions. (Cross-Reference cite F801.) R14's Nutritional Care Area Analysis, signed as completed by RD-C on 12/21/20, documents Res [resident] is on a HCC (high consistent carbohydrate) diet for DM [diabetes mellitus] control .Will cont [continue] to provide a HCC diet for DM control. Progress notes on 12/28/20 document .Resident refusing to eat food, states she has no appetite. Encouraged fluid intake. Will continue to monitor. A Nutritional Assessment, with an effective date of 1/4/21, signed as completed by RD-C, documents under Food Allergy or Intolerance NKFA[no known food allergies] despite R14 being lactose intolerant. The assessment documents R14's most recent weight as 137, the weight R14 was noted to be upon admission to the facility, and documents R14 being within their recommended weight range. The assessment documents R14's estimated nutritional needs being between 1560-1870 calories a day. The assessment documents Res [resident] is a 49 yo [year old] F [female] adm [admitted ] w/ [with]COVID-19 and DM dx. Adm on a HCC diet. Eating 50-100% of meals. Current wt [weight]: 137.0# [pounds], BMI [body mass index]: 20.8 (normal). Weight maintenance is desired. Skin intact. No new labs. Will cont [continue] to monitor weight, intakes, and labs. The assessment documents goals as being Weight maintenance Consume 50-100% of meals. The assessment documents a Plan/Recommendations as Cont [continue] on a HCC diet. On 1/4/21 a focus area related to Resident has an altered nutritional status r/t [related to] need for therapeutic diet d/t [due to] DM [diabetes mellitus] dx [diagnosis]. Interventions added on 1/4/21 include Monitor/record/report to MD PRN s/sx [signs/symptoms] of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months and Provide, serve diet as ordered. Monitor intake and record q [every] meal. This documentation also noted, RD [registered dietitian] to evaluate and make diet change recommendations PRN [as needed]. The surveyor reviewed R14's documented meal intakes for December 2020. Out of 61 opportunities for meals; 28 meals were blank and not documented, 10 meals were documented as refused, 6 were documented as 0-25% eaten, 2 were documented as 26-50% eaten, 8 were documented as 51-75% eaten, and 7 were documented as 75-100% eaten. The surveyor reviewed R14's documented meal intakes for January 2021. Out of 24 opportunities for meals; 14 meals were blank and not documented, 2 meals were documented as refused, 4 meals were documented as 0-25% eaten, 1 meal was documented 26-50% eaten, 2 meals were documented as 51-75% eaten, and 1 meals was documented 75-100% eaten. Review of R14's bowel documentation documents the resident as having loose/watery stools 5 times in January 2021 and 12 times in December 2020. On 3/23/21 at 3:01 pm the surveyor interviewed LPN (licensed practical nurse)-E. LPN-E recalled the resident and recalled she didn't eat much at a time, as R14 said she would throw up. The surveyor noted a discrepancy between R14's documented meal intakes and RD-C's nutritional assessment on 1/4/21 documenting R14 was consuming between 50-100% meals, noting R14 was only documented as eating 51-100% 18 times out of 85 opportunities (21%) for meals in December 2020 and January 2021. Progress notes on 1/9/21 at 2:46 am document Resident refuses meals. States she can't tolerate PO [by mouth] intake r/t [related to] nausea. Refuses PRN [as needed] nausea meds. PO PRN [MEDICATION(S)]-acetaminophen taken for migraine. VSS [vital signs stable] A&Ox3 [alert and oriented times three] C/o [complained of] emesis. Small amounts bile and spit noted in basin. Resident encouraged to try to increase fluid intake. Skin turgor good. Oral mucosa pink, moist. BS [bowel sounds] hypoactive x4. Abdomen soft, non-tender. Progress notes on 1/9/21 at 7:55 am document Emesis x3 noted this am, black coffee ground emesis noted. VS [vital signs] [blood pressure] 163/90 [pulse] 110 [respirations] 18 [temperature] 97.2 [oxygen level] 97%ra [room air] c/o [complained of] increased nausea and abd [abdominal] discomfort. Offered nausea medication and res [resident] declined. Res requested to be sent to ER [emergency room ] for eval [evaluation] .Transport arrived around 0820 [8:20 am] and transported res to [emergency room ] for eval and treat . The surveyor reviewed R14's medical record and noted no documentation the physician was notified of R14's poor intake until 1/9/21 when the resident requested to go to the hospital. The surveyor noted no changes to R14's plan of care to increase intake, despite the resident being documented as refusing meals. The surveyor reviewed R14's dietary meal slip and noted the slip indicated R14 was on a low concentrated sweet regular diet with regular beverage texture. The surveyor noted the dietary slip did not document any supplements, or preferences of R14. The surveyor noted the dietary slip did not indicate R14 was lactose intolerant. R14 was hospitalized from 1/9/21-1/18/21. R14's hospital weight on 1/9/21 is documented as being 51kg (112.2 pounds). This is a 24.8 pound weight loss from when R2 was admitted to the on 12/11/20 at 137 pounds, an 18.1% weight loss. Hospital notes on 1/9/21 document .Patient was brought in secondary to decreased oral intake and failure to thrive. Patient stating that she might be having DKA [diabetic ketoacidosis] since she has not had anything to eat or drink for 2 weeks. Complains of feeling nauseous and few episodes of emesis .Unintentional weight loss of 32 lb [pounds] overs the past 1 month. Workup reveals the patient to be severe [CONDITION(S)], clinically dehydrated, potassium 2.2, mild [CONDITION(S)] .unintentional weight loss and poor p.o. [by mouth] intake over the past 2-3 weeks secondary to nausea and vomiting .Patient admitted to the hospitalist service for severe [CONDITION(S)], DKA, uti [urinary tract infection]. R14's [MEDICATION(S)] is documented as being 2.6 on 1/9/21. R14 was admitted to the intensive care unit. Discharge diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/24/21 at 1:00 pm the surveyor interviewed RD-C. The surveyor asked how and when RD-C does his nutritional assessments. RD-C informed the surveyor when the resident first comes in within the first 7 days, quarterly, and as needed. The surveyor informed RD-C of R14 being admitted to the facility on [DATE] and was unable to find a nutritional assessment completed until 1/4/21. RD-C informed the surveyor he was off for two weeks during December. The surveyor asked if another dietitian is available if he is out. RD-C stated there was another corporate dietitian in another region, but was unsure if they were able to come down, and that his supervisor had been aware that he was out. RD-C informed the surveyor for his assessments he reviews the hospital record, labs, weights, charting of meal intakes, and does visual observations. The surveyor informed RD-C of the discrepancy noted between his documented assessment indicating R14 was consuming 50-100% and the charting documented, and showed RD-C the documentation reviewed. RD-C stated the meal documentation reviewed did not look like the documentation he had looked at. The surveyor asked RD-C what he would consider R14's meal intake to be looking at the charting received. RD-C stated it didn't look as good as the one he had had. The surveyor asked if someone has protein malnutrition what is done. RD-C stated if intakes look good, 75-100% most meals that should meet their intake. RD-C stated if not eating or meeting needs would add a supplement or snack. The surveyor asked RD-C if that was something he would do looking at R14's intakes the surveyor had received. RD-C stated if they saw not eating 50-100%, yes. RD-C informed the surveyor weights are done monthly unless ordered otherwise by the physician. On 3/24/21 at 2:00 pm RD-C informed the surveyor he was unable to find any other documented meal intakes for R14. On 3/24/21 at 2:00 pm NHA (nursing home administrator)-A informed the surveyor R14 did have a refrigerator in the room with snacks. NHA-A indicated if RD-C is unavailable, there is another dietitian within the company. The facility's failure to document R14's meal intakes, failure to implement a recommended supplement, failure to accurately assess R14's meal intakes, failure to involve the dietitian and physician when R14 was refusing meals, failure to update R14's plan of care to try to promote intake, and failure to monitor R14's weight despite having poor intake resulting in abnormal lab levels, severe weight loss, and admission to the intensive care unit, resulted in a finding of immediate jeopardy beginning on 1/4/21. The immediate jeopardy was removed on 3/24/21 when the facility implemented the following: -Ad Hoc Quality assurance meeting was held to educate the entire leadership team on our plan and follow up. -All licensed and unlicensed personnel were educated on the facility policy regarding obtaining admission weights to establish a baseline, meal documentation, and MD notifications regarding intake concerns and potential weight loss. Dietitian was provided education to regarding assessment and utilization of correct information to accurately determine the resident's needs and preferences. All licensed personnel were educated regarding thorough review of discharge summaries to ensure any supplementation required is included dietary orders. All education will be completed with staff in the building currently and all other staff will be educations prior to his/her next scheduled shift. -All residents at risk for nutritional concerns were assessed and individualized care plans were created to ensure individual needs are met. The facility's nutritional policies and procedures were reviewed to ensure they are based upon current standards of practice. The facility will ensure all admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Licensed staff were educated on the new form; all education will be completed with staff in the building currently and all other staff will be educated prior to his/her next scheduled shift. The completed form should be submitted for reviewed by the DON or designee. -The facility will ensure that timely assessment and monitoring by the Registered Dietitian are based upon accurate resident information. Registered Dietitian was educated regarding timely assessment completion and utilizing accurate resident informed. -The facility will education all staff on how to recognize a resident with nutritional change (dry lips, meal refusal, decreased intake, increased lethargy, and change in bowel and bladder habits). All education will be completed with staff in the building currently and all other staff will be educated prior to his/her next scheduled shift. -All residents were weighed and all weights were documented in the electronic medical record to establish a new baseline. Dietitian reviewed all weights and meal intakes for the past 30 days; one resident was identified as needing an increase in supplementation; all resident's determined to be at risk had a nutritional assessment completed and care plan reviewed for individualized needs. All education will be completed with staff in the building currently and all other staff will be educated prior to his/her next scheduled shift. -IDT revised the new admission weight policy to include obtaining weight upon admission and weekly every week for four weeks then the dietitian will review. All education completed with staff in the building currently and all other staff will be educated prior to his/her next schedule shift. -IDT initiated a new admission/readmission checklist for licensed nurses to ensure orders are reviewed on admission and reconciled for implementation. All education will be completed with nursing staff currently in the building and all other nursing staff will be educated prior to his/her next scheduled shift. -DON/Designee will audit new admission for weights, dietary needs, and or supplements for the next 30 days then bring to QAPI (quality assurance and performance improvement) for review. DON/Designee will audit to ensure a timely assessment and comprehensive individualized care plan is developed to meet the resident's needs for the next 30 days then bring to QAPI for review. DON/Designee will randomly audit oral intake to ensure accurate and complete weekly for 3 weeks then bring to QAPI for review. DON/Designees will audit resident's regarding weight-loss/oral intake concerns. Residents identified to be at risk will be reviewed during weekly resident-at-risk meeting until IDT determines there is no longer risk identified. The immediate jeopardy continues at a scope severity level of E (potential for more than minimal harm/pattern) as the facility continues to monitor their removal plan with the results reviewed at the QAPI committee.

Based on observation, record review and interview, the facility did not ensure residents received care to prevent pressure injuries or prevent further deterioration of pressure injuries in 5 (R23, R28, R55, R160, and R46) of 6 residents reviewed for pressure injuries. R23 developed an unstageable pressure injury to the left inner ankle. R28 developed a pressure injury to the sacrum that the facility categorized as a stage 3, stage 2 and stage 4 pressure injury not based upon standards of practice. R28 was observed with interventions from the care plan for repositioning not being followed. R55 developed a Stage 3 pressure injury to the coccyx after being readmitted to the facility following a hospitalization with a Stage 2 pressure injury. R160 was observed with heels not being off-loaded and oxygen tubing not padded around the ears causing discomfort. R46 had a Stage 2 pressure injury to the coccyx and the ordered dressing was not in place. R46 was observed with heels not being off-loaded and a healed area of the buttock was re-opened. Findings include: The facility policy and procedure entitled Skin Management Guidelines Practice Guidelines dated 6/1/2018 states: Newly admitted Residents: Upon admission, all residents are assessed for skin integrity within 2 hours of admission by completing a head to toe physical assessment and documenting on the admission assessment and completing the Braden Scale - For Predicting Pressure Sore Risk . in Point Click Care (PCC). Following admission; the Braden Scale - For Predicting Pressure Injury Risk in (PCC) will be completed weekly for 3 additional weeks (for a total of 4 weeks including admission), quarterly, annually, and with a change of condition, for their risk for development of pressure injury. A resident risk may increase due to an acute illness or condition changes (URI, Pneumonia, or exacerbation of underlying [MEDICAL CONDITION], etc) and may require additional evaluation. Therefore it is recommended a repeat Braden assessment be completed if a resident has a significant change of condition. Nurse aides will complete body audits at least weekly, but preferably with every bathing opportunity. The body audits post shower will be turned into the licensed nurse to review for changes in skin condition. Appropriate preventive measures will be implemented on all residents identified at risk (score of 18 or less on the Braden Scale - For Predicting Pressure Injury Risk), and the interventions documented on the Care Plan. Residents admitted with skin impairments will have: Appropriate interventions implemented to promote healing; A physician's orders [REDACTED].>Wound location and characteristics documented on the Weekly Wound Assessment (PCC); Referral to Rehabilitation Services; Registered Dietician to review (Nutritional Risk Assessment-PCC); Their family notified of presence of skin impairment; Care plan implemented. In addition, the following forms are completed and placed with the resident's Treatment Record: Wound Assessment Risk Factor Form will be completed weekly while being followed for wound care .; Weekly log will be completed and distributed to Administrator, DON, MDS, Dietician; Pressure injury: Weekly Wound assessment in PCC .; Lower Extremity Ulcer: Weekly Wound Assessment in PCC .; Skin tears and all other significant skin impairment: Weekly Wound Assessment in PCC . A Care Plan is developed upon admission, identifying the contributing risks for breakdown, including history of skin impairment or the actual impairment (there should be separate care plans for Risk of and actual), and the interventions implemented to promote healing and prevent further breakdown. Wounds are tracked as acquired (developed in-house or admitted with) and are assessed and documented on the Weekly Wound Assessment in PCC . These records are maintained in the resident's Treatment Record or in PCC while being followed. The Licensed Nurse will document daily monitoring of all pressure ulcers on the Treatment Administration Record (TAR). A physician's orders [REDACTED]. The Licensed Nurse will record his/her initials on the TAR to reflect the monitoring of each wound regardless of the findings. A nutritional evaluation will be completed by a Registered Dietician within 7 days of admission on all residents identified at risk or with compromised skin integrity in PCC . Ongoing monitoring and continuous quality improvement will be achieved by the Interdisciplinary Team. Skin Assessments: Weekly Skin Check will be transcribed onto the Head to Toe Weekly skin check form including the day and shift on which the check will be conducted. Completion of the weekly skin assessment will be noted on the Treatment Administration Record (TAR) with the Licensed Nurse's initials. A SBAR form (PCC) is to be completed and new physician's orders [REDACTED]. The nurse will assure treatments, interventions, Care Plan, and the appropriate skin documentation records are initiated in a timely manner according to Practice Guidelines. Pressure injuries are measured and staged weekly in accordance with the Practice Guidelines. The DON/designee will distribute follow up assignments to the IDT following the At-Risk Review Meeting. Important: Failure to demonstrate progress in healing within fourteen (14) days calls for reassessment regarding the adequacy of the overall treatment plan and the need for modification of the treatment plan. Lower Extremity Ulcers: Resident, family and attending physician are notified of the development of the vascular ulcer. Etiology of the ulcer is determined as well as the treatment plan. This is achieved via the attending physician. Care Plan is updated to reflect the new problem and interventions with evaluation and revision documented on an ongoing basis. Ulcers will be assessed weekly and status/progress documented on the Weekly Wound Assessment in PCC . Resident is assessed for pain, and appropriate interventions implemented and care planned. Resident is added to 24 Hour Report (Briggs). Care is actively planned and discussed during shift report with all members of the nursing team (include direct care staff). Monitor the area closely during treatment to evaluate appropriateness of treatment regime. Monitor placement of the affected limb to prevent further injury. This is especially important if [MEDICAL CONDITION] is a factor. Consult with Rehab for evaluation and options for treatment intervention and options for treatment, especially for [MEDICAL CONDITION] management. Consultation with Certified Wound Care Nurse or surgeon may be appropriate. 1.) R23 was admitted to the facility 8/10/2018 after surgical repair of the right hip. No other open areas were present at time of admission. R23 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] indicates R23 needs extensive assistance with bed mobility, with impairment to both legs. All wound documentation was requested of the Director of Nursing (DON)-B by Surveyor on 3/25/2019 at 3:00 PM. On 8/10/2018, R23's Skin Care Plan was initiated with interventions: avoid scratching and keep hands and body parts from excessive moisture; keep fingernails short; encourage good nutrition and hydration in order to promote healthier skin; identify/document potential causative factors and eliminate/resolve where possible; keep skin clean and dry; use lotion on dry skin. On 8/21/2018 R23's Skin Care Plan was revised to include: continue to monitor right hip surgical infection; notify physician of changes; and R23 is to lie in bed after meals to decrease the risk of skin breakdown. On 11/30/2018, a wound culture was ordered of the left ankle pressure injury due to purulent drainage, pain, and redness that started the previous day. On 12/1/2018, the physician ordered a treatment for [REDACTED]. The Treatment Administration Record (TAR) did not have initials on 12/7/2018 for either dressing change to indicate the treatment had been completed. On 12/10/2019, the physician changed the treatment for [REDACTED]. The TAR did not have initials on 12/26/2018 and 1/2/2019 to indicate the treatment had been completed. On 12/21/2018, R23's Skin Care Plan was updated with an intervention to not apply lotion to the left hip and foot. (The surgical infection was to the right hip.) The care plan did not address the new pressure area to the left inner ankle. No wound documentation was provided prior to 12/27/2018. No initial assessment of the wound or follow-up assessments were provided. On 12/27/2018 on the Weekly Wound Assessment form, nursing charted R23's vascular wound to the left medial ankle measured 0.8 cm x 0.5 cm x 0 cm with 100% [MEDICATION NAME] tissue with no exudate stating the wound had improved and the area was resolving. The wound was not a vascular wound; it was a pressure wound and no prior measurements were available for comparison. No documentation of an assessment was provided for 1/3/2019. On 1/9/2019 on the Weekly Wound Assessment form, nursing charted R23's Stage 2 pressure wound to the left medial ankle measured 0.7 cm x 0.7 cm x 0 cm with 25% granulation tissue, 50% slough, and 25% [MEDICATION NAME] tissue with scant serous exudate stating the wound was stable. DON-B on 3/27/2019 at 9:25 stated the wound should have been documented as a Stage 3 pressure injury due to the slough present in the wound. The wound had deteriorated now that slough was present. On 1/11/2019, the physician changed the treatment to the left inner ankle pressure injury: cleanse the wound with normal saline, apply skin prep to the peri-wound, cut [MEDICATION NAME] Blue to the size of the wound, cover with and ABD pad and wrap with Kerlix daily. The TAR did not have initials on 1/15/2019 1/17/2019,1/26/2019, 1/27/2019, 1/31/2019, 2/9/2019 and 2/10/2019 to indicate the treatment had been completed. The treatment was started two days after the presentation of slough in the wound bed. On 1/17/2019 on the Weekly Wound Assessment form, nursing charted R23's Stage 2 (should be documented Stage 3) pressure wound to the left medial ankle measured 0.5 cm x 0.6 cm x 0 cm with 25% granulation tissue, 25% slough, and 50% [MEDICATION NAME] tissue with scant serous exudate stating the wound had improved. On 1/23/2019 on the Weekly Wound Assessment form, nursing charted R23's Stage 2 (should be documented Stage 3) pressure wound to the left medial ankle measured 0.4 cm x 0.5 cm x 0 cm with 25% granulation tissue, 25% slough, and 50% [MEDICATION NAME] tissue with no exudate stating the wound was stable. No documentation of an assessment was provided for 1/31/2019, 2/7/2019, and 2/14/2019. On 2/16/2019, the physician changed the treatment to the left inner ankle pressure injury: cleanse with normal saline, pat dry, apply iodasorb to the wound base followed by a dry dressing daily. On 2/21/2019 on the Weekly Wound Assessment form, nursing charted R23's Unstageable pressure wound to the left medial ankle measured 1.5 cm x 1.7 cm x 0.2 cm with 100% granulation tissue with moderate serous exudate stating the wound was improved and R23 was being seen by the wound physician. DON-B on 3/27/2019 at 9:25 AM stated the wound would not be considered unstageable since there was 100% granulation tissue in the wound base. The wound measurement had increased greatly since 1/23/2019, but with no documentation for three weeks, the progression could not be followed. On 2/28/2019 on the Weekly Wound Assessment form, nursing charted R23's Unstageable (inaccurate staging) pressure wound to the left medial ankle measured 1.7 cm x 1.7 cm x 0.3 cm with 100% granulation tissue with a small amount of serous exudate stating the wound was stable. On 3/7/2019 on the Tissue Analytics form, nursing charted R23's Unstageable pressure wound to the left medial ankle measured 1.69 cm x 2.82 cm x 0.3 cm. No description of the wound base was documented, but pictures were attached. DON-B on 3/27/2019 at 9:25 AM stated the wound physician uses the Tissue Analytics form and the Weekly Wound Assessment form was not found for that date. On 3/14/2019 on the Weekly Wound Assessment form, nursing charted R23's Unstageable pressure wound to the left medial ankle measured 2.4 cm x 3.0 cm x 0.5 cm with 50% granulation tissue and 50% slough with moderate serosanguineous exudate stating the wound had deteriorated. R23 had been seen by the wound physician the previous week, but no documentation stating the physician was notified of the deterioration of the wound. On 3/21/2019 on the Weekly Wound Assessment form, nursing charted R23's Unstageable pressure wound to the left medial ankle measured 2.2 cm x 2.9 cm x 0.5 cm with 50% granulation tissue and 50% slough with moderate serosanguineous exudate stating the wound had deteriorated. (The measurements had decreased and the percentage of slough remained the same.) On 3/22/2019, the physician changed the treatment to the left inner ankle pressure injury: cleanse with normal saline, apply iodasorb to the wound base, cover with ABD pad and wrap with Kerlix every Monday, Wednesday, and Friday. During record review, Surveyor noted a treatment ordered for the left heel on 3/7/2019 through 3/22/2019: cleanse with normal saline, apply Iodasorb to the wound base, cover with and ABD pad and wrap with Kerlix daily. The treatment was signed out daily. No wound documentation was provided for R23's left heel. On 3/27/2019 at 9:25 AM, Surveyor met with DON-B regarding R23's wound documentation and Care Plan. R23 developed a pressure injury to the left inner ankle on 11/30/2018. The care plan was not revised to incorporate this new area. No interventions were added to address footwear or relief of pressure areas. Treatment was not provided as ordered and the staging of the wound was incorrect. DON-B agreed the documentation was not adequate and there was no change in plan of care for R23. 2.) R28 was admitted to the facility 6/17/2014. R28 has the following Diagnoses: [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] and 2/15/2019 indicate R28 needs extensive assistance with bed mobility and is always incontinent of bowel and bladder. A Skin Care Plan was initiated on 6/30/2014 for potential skin breakdown. Interventions include: assist R28 with bed mobility; low air loss mattress on bed; pressure reducing cushion in wheelchair; and weekly skin check by licensed nurse. On 3/18/2015 R28's Skin Care Plan was revised to include elevating heels off of the bed, heel boots on, and R28 is non-compliant refusing interventions at times and to inform the nurse. On 9/17/2016 R28's Skin Care Plan was revised to include prompting R28 to use the toilet upon waking, before and after meals, and before bed to decrease episodes of incontinence, and to check and change R28 every two hours. On 10/25/2016 R28's Skin Care Plan was revised to include treatment as ordered by the physician. On 11/17/2017 R28's Skin Care Plan was revised to include a ROHO cushion in R28's wheelchair and to check the cushion is properly inflated. On 2/22/2018, the physician ordered ProStat 30 cc three times a day to be administered to R28 for wound healing. The Treatment Administration Record (TAR) did not have initials for 19 of 93 opportunities in October, (YEAR), for 23 of 90 opportunities in November, (YEAR), for 32 of 93 opportunities in December, (YEAR), for 24 of 93 opportunities in January, 2019, for 11 of 84 opportunities in February, 2019, and for 9 of 78 opportunities in March, 2019 indicating R28 did not receive the ordered protein supplement. On 6/7/2018, R28's physician ordered R28 to be up in wheelchair one hour at a time three times a day every shift for wound. After reviewing R28's medical record, Surveyor was unable to determine the onset of the pressure injury to R28's sacrum. 6/7/2018 was the first treatment order found. On 6/7/2018, the physician ordered R28 to be up in a wheelchair for one hour at a time three times a day because of the wound to R28's sacrum. On 6/8/2018 R28's Skin Care Plan was revised to include getting R28 in a wheelchair one hour at a time three times a day. No other wound treatments were documented at that time. On 6/30/2018, the physician ordered a treatment to R28's sacral wound: sterile water cleanse followed by skin prep to the peri-wound followed by [MEDICATION NAME] flex 3 or 7 followed by bordered foam to sacrum wound every Tuesday, Thursday, and Saturday. All of R28's wound documentation was requested from the Director of Nursing (DON)-B by Surveyor on 3/25/2019 at 3:00 PM. 9/5/2018 was the first documentation provided. On 9/5/2018 on the Weekly Wound Assessment form, nursing charted R28's Stage 3 pressure wound to the sacrum measured 0.4 cm x 0.3 cm x 0.3 cm with a small amount of serosanguineous exudate stating the wound was stable. On 9/12/2018 on the Weekly Wound Assessment form, nursing charted R28's Stage 3 pressure wound to the sacrum measured 0.3 cm x 0.2 cm x 1.0 cm with a small amount of serosanguineous exudate stating the wound was stable. On 9/19/2018 on the Weekly Wound Assessment form, nursing charted R28's Stage 2 (previously charted Stage 3) pressure wound to the sacrum measured 0.4 cm x 0.3 cm x 0.3 cm with moderate serosanguineous exudate stating the wound was stable. On 9/30/2018 on the Weekly Wound Assessment form, nursing charted R28's Stage 2 pressure wound to the sacrum measured 0.4 cm x 0.3 cm x 0.3 cm with a small amount of serosanguineous exudate stating the wound was stable. No description of the wound base had been documented. On 10/4/2018 on the Weekly Wound Assessment form, nursing charted R28's Stage 2 pressure wound to the sacrum measured 0.3 cm x 0.3 cm x 0.3 cm with a small amount of serous exudate stating the wound was stable. On 10/9/2018 on the Weekly Wound Assessment form, nursing charted R28's Stage 2 pressure wound to the sacrum measured 0.3 cm x 0.3 cm x 0.2 cm with 100% granulation tissue and scant serous exudate stating the wound was stable. On 10/12/2018, the physician changed the treatment to the sacrum: apply Iodasorb gel to the sacrum wound and cover with foam dressing daily. The TAR did not have initials on 11/8/2018, 11/11/2018, 11/30/2018, and 12/10/2018 to indicate the treatment had been completed. On 10/17/2018 on the Weekly Wound Assessment form, nursing charted R28's Stage 2 pressure wound to the sacrum measured 0.3 cm x 0.3 cm x 0.2 cm with 100% granulation tissue and scant serous exudate stating the wound was stable. On 10/24/2018 on the Weekly Wound Assessment form, nursing charted R28's Stage 2 pressure wound to the sacrum measured 0.3 cm x 0.3 cm x 0.2 cm with 100% granulation tissue and scant serous exudate stating the wound was stable. R28 was being seen by a wound physician at the facility. On 10/31/2018 on the Weekly Wound Assessment form, nursing charted R28's Stage 2 pressure wound to the sacrum measured 0.3 cm x 0.3 cm x 0.2 cm with 100% granulation tissue and scant serous exudate stating the wound was stable. On 11/7/2018 on the Weekly Wound Assessment form, nursing charted R28's Stage 2 pressure wound to the sacrum measured 0.3 cm x 0.3 cm x 0.2 cm with 100% granulation tissue and scant serous exudate stating the wound was stable. On 11/14/2018 on the Weekly Wound Assessment form, nursing charted R28's Stage 2 pressure wound to the sacrum measured 0.3 cm x 0.3 cm x 0.1 cm with 100% granulation tissue and scant serous exudate stating the wound was stable. On 11/16/2018 at 2:18 PM in the progress notes, dietary charted R28 had non-significant weight changes and is receiving ProStat three times a day for improved skin integrity. On 11/21/2018 on the Weekly Wound Assessment form, nursing charted R28's Stage 2 pressure wound to the sacrum measured 0.2 cm x 0.3 cm x 0.1 cm with 100% granulation tissue and scant serous exudate stating the wound was stable. On 11/28/2018 on the Weekly Wound Assessment form, nursing charted R28's Stage 2 pressure wound to the sacrum measured 0.2 cm x 0.3 cm x 0.3 cm with 100% granulation tissue and a small amount of serous exudate stating the wound was stable. On 12/5/2018 on the Weekly Wound Assessment form, nursing charted R28's Stage 2 pressure wound to the sacrum measured 0.2 cm x 0.3 cm x 0.4 cm with 100% granulation tissue and a small amount of serous exudate stating the wound was stable. On 12/12/2019, the physician changed the treatment to R28's sacral pressure injury: flush the sacral wound with normal saline, apply [MEDICATION NAME] with a Q-tip before securing with bordered gauze daily for unstageable pressure injury. (Documentation had staged the wound a Stage 3 and then a Stage 2.) The TAR did not have initials on 12/14/2018, 12/16/2018, 12/20/2018, 12/21/2018, 12/22/2018, 12/23/2018, 12/28/2018, 12/31/2018, 1/2/2019, and 1/3/2019 to indicate the treatment had been completed. On 12/12/2018 on the Weekly Wound Assessment form, nursing charted R28's Stage 2 pressure wound to the sacrum measured 0.2 cm x 0.3 cm x 0.4 cm with 100% granulation tissue and a small amount of serous exudate stating the wound was stable. On 12/18/2018 on the Nutritional Assessment form, the dietician documented R28 was underweight and relies on a therapeutic diet due to diabetes and use of protein supplement due to R28's history of compromised skin and low body weight. The dietician indicated R28 did not have any pressure injuries. No documentation of an assessment was provided for 12/19/2018. On 12/27/2018 on the Weekly Wound Assessment form, nursing charted R28's Stage 2 pressure wound to the sacrum measured 0.2 cm x 0.2 cm x 0.4 cm with 100% granulation tissue and no exudate stating the wound had improved. On 1/2/2019 on the Weekly Wound Assessment form, nursing charted R28's Stage 2 pressure wound to the sacrum measured 0.2 cm x 0.2 cm x 0.4 cm with 100% granulation tissue and no exudate stating the wound had improved. (All measurements and description was the same as the prior week.) From 1/3/2019 to 1/7/2019 no treatment was ordered for R28's sacral pressure wound. On 1/8/2019, the physician ordered a treatment for [REDACTED]. The TAR did not have initials on 2/1/2019 and 2/8/2019 indicating the treatment had not been completed. On 1/9/2019 on the Weekly Wound Assessment form, nursing charted R28's Stage 2 pressure wound to the sacrum measured 0.2 cm x 0.2 cm x 0.3 cm with 100% granulation tissue and scant serous exudate stating the wound had improved. On 1/16/2019 on the Weekly Wound Assessment form, nursing charted R28's Stage 2 pressure wound to the sacrum measured 0.2 cm x 0.2 cm x 0.4 cm with 100% granulation tissue and a small amount of serous exudate stating the wound was stable. On 1/23/2019 on the Weekly Wound Assessment form, nursing charted R28's Stage 2 pressure wound to the sacrum measured 0.2 cm x 0.2 cm x 0.3 cm with 100% granulation tissue and a small amount of serous exudate stating the wound was stable. On 1/30/2019 on the Weekly Wound Assessment form, nursing charted R28's Stage 4 pressure wound to the sacrum measured 0.4 cm x 0.4 cm x 0.4 cm with 100% granulation tissue and a small amount of serosanguineous exudate stating the wound was stable. The description of the wound base did not change from the prior week but the wound was now documented as a Stage 4 pressure injury. The facility indicated the pressure injury to R28's sacrum deteriorated to a Stage 4 pressure injury on 1/30/2019. The Skin Care Plan was not updated and no new treatment was ordered. DON-B on 3/27/2019 at 9:39 AM agreed the documentation did not accurately describe why there was a change in staging of the wound. On 2/6/2019 on the Weekly Wound Assessment form, nursing charted R28's Stage 4 pressure wound to the sacrum measured 0.5 cm x 0.5 cm x 0.5 cm with 100% granulation tissue and a small amount of serous exudate stating the wound was stable. On 2/13/2019 on the Weekly Wound Assessment form, nursing charted R28's Stage 4 pressure wound to the sacrum measured 0.5 cm x 0.5 cm x 0.5 cm with 100% granulation tissue and a small amount of serous exudate stating the wound was stable. The MDS dated [DATE] in Section M: Skin, R28 was coded as having a Stage 3 pressure injury. On 2/21/2019 on the Weekly Wound Assessment form, nursing charted R28's Unstageable pressure wound to the sacrum measured 0.1 cm x 0.1 cm x 0.4 cm with 100% [MEDICATION NAME] tissue and moderate serous exudate stating the wound had improved. The wound physician had been to see R28 and new orders had been received. The documentation of an unstageable pressure injury with 100% [MEDICATION NAME] is contradictory. DON-B on 3/27/2019 at 9:39 AM agreed the staging and description of the wound base was inaccurate. On 2/22/2019, the physician changed the treatment order for R28's sacral wound: pack the coccyx wound with Iodasorb and cover with a dry dressing daily. On 2/27/2019 on the Weekly Wound Assessment form, nursing charted R28's Unstageable pressure wound to the sacrum measured 0.1 cm x 0.1 cm x 0.4 cm with 100% [MEDICATION NAME] tissue and a small amount of serous exudate stating the wound was stable. On 3/7/2019 on the Weekly Wound Assessment form, nursing charted R28's Stage 4 pressure wound to the sacrum measured 0.6 cm x 0.6 cm x 0.6 cm with 100% slough and moderate serous exudate stating the wound was stable. The wound was restaged a Stage 4. On 3/8/2019, the physician changed the treatment order for R28's sacral pressure wound: cleanse with normal saline, pack with Iodasorb with a tongue depressor and cover with foam dressing daily. On 3/13/2019 in the progress notes, dietary charted R28 triggered for a significant weight loss of 8% in one month and 11.8% in 6 months. Additional snacks were recommended to increase the calorie intake. On 3/14/2019 on the Weekly Wound Assessment form, nursing charted R28's Stage 4 pressure wound to the sacrum measured 0.5 cm x 0.5 cm x 0.6 cm with 100% granulation tissue and a small amount of serosanguineous exudate stating the wound had improved. On 3/21/2019 on the Weekly Wound Assessment form, nursing charted R28's Stage 4 pressure wound to the sacrum measured 0.5 cm x 0.5 cm x 0.6 cm with 100% granulation tissue and a small amount of serosanguineous exudate stating the wound was stable. On 3/24/2019 from 9:00 AM to 3:00 PM, R28 was observed sitting in the wheelchair in the dining room eating meals and attending activities. R28 was not observed in bed during that time as the care plan states. On 3/25/2019 from 8:00 AM to 3:00 PM, R28 was observed sitting in the wheelchair in the dining room eating meals and attending activities. On 3/26/2019 from 8:00 AM to 3:00 PM, R28 was observed sitting in the wheelchair in the dining room eating meals and attending activities. On 3/27/2019 from 8:00 AM to 1:00 PM, R28 was observed sitting in the wheelchair in the dining room eating meals and attending activities. On 3/27/2019 at 9:25 AM, Surveyor met with Director of Nursing (DON)-B regarding R28's wound documentation and Care Plan. R28 developed a pressure injury to the sacrum in approximately June, (YEAR). The care plan was not revised when the pressure wound deteriorated 1/30/2019. Observations of R28 were made sitting in the wheelchair for extended hours, not following the care plan or orders. Treatment orders were not followed as evidenced in the TAR. DON-B agreed the documentation did not reflect the correct staging of the wound and R28's plan of care was not updated for the change in wound status. 3.) R55 was admitted to the facility on [DATE] for respite care. R55 has the following Diagnoses: [REDACTED]. The Minimum Data Set (MDS) assessments dated 9/11/2018 and 1/16/2019 indicates R55 needs extensive assistance with bed mobility, frequently incontinent of bladder and always incontinent of bowel. A Skin Care Plan was initiated on 9/5/2018 with interventions that include: complete Braden scale upon admission, weekly times four, quarterly, with significant change of condition and as needed; monitor skin with all cares and report any changes to the nurse; update physician as needed; and keep nails short to reduce the risk of scratching or injury from picking at skin. R55 was transferred to the hospital 1/2/2019 to 1/9/2019 for an upper respiratory infection. When R55 was readmitted to the facility on [DATE], R55 had a Stage 2 pressure injury to the coccyx. On 1/9/2019 on the Initial Wound Assessment form, nursing charted R55 had a Stage 2 pressure injury to the coccyx measuring 2.0 cm x 1.0 cm. No description was given of the wound base. The physician was notified of the open area. R55's Skin Care Plan was not updated to address the new pressure area. No treatment was obtained until 1/11/2019. On 1/10/2019, the physician ordered Ensure daily for a supplement. The TAR shows the Ensure supplement was not administered until 1/22/2019. On 1/11/2019, the physician ordered a treatment for [REDACTED]. The Treatment Administration Record (TAR) did not have initials on 1/27/2019, 2/2/2019, 2/3/2019, 2/8/2019, 2/12/2019, 2/25/2019, 2/28/2019, 3/1/2019, 3/7/2019, and 3/9/2019 to indicate the treatment had been completed. On 1/16/2019 on the Weekly Wound Assessment form, nursing charted R55's Stage 2 pressure wound to the coccyx measured 2.5 cm x 1.3 cm x 0 cm with 100% slough with no exudate stating the wound had deteriorated. (The wound would have been unstageable with 100% slough in the wound base.) Director of Nursing (DON)-B on 3/27/2019 at 9:46 AM stated the staging and the wound description are inaccurate. R55's Skin Care Plan was not updated with the deterioration of the wound and no change in treatment was obtained. On 1/16/2019, the physician ordered 2.0 supplement twice daily. The TAR shows the 2.0 supplement was not administered until 1/22/2019. On 1/23/2019 on the Weekly Wound Assessment form, nursing charted R55's Stage 2 pressure wound to the coccyx measured 3.1 cm x 2.9 cm x 0 cm with 50% granulation tissue and 50% slough with scant serous exudate stating the wound deteriorated and R55 will be referred to the wound physician at the facility. On 1/30/2019 on the Weekly Wound Assessment form, nursing charted R55's Stage 2 pressure wound to the coccyx measured 3.2 cm x 2.7 cm x 0.1 cm with 50% granulation tissue and 50% slough with scant serous exudate stating the wound was stable. On 2/6/2019 on the Weekly Wound Assessment form, nursing charted R55's Stage 3 pressure wound to the coccyx measured 3.0 cm x 2.4 cm x 0.5 cm with 75% granulation tissue and 25% slough with a small amount of serosanguineous exudate stating the wound had improved. On 2/8/2019 at 12:59 PM in the progress notes, dietary charted R55 did not have any pressure injuries. On 2/13/2019 on the Weekly Wound Assessment form, nursing charted R55's Stage 3 pressure wound to the coccyx measured 2.8 cm x 2.2 cm x 0.4 cm with 100% granulation tissue with a small amount of serosanguineous exudate stating the wound had i (TRUNCATED)

Based on record review and interview, facility staff did not promptly consult with the physician for 1 (Resident #1) of 4 Residents with a significant change of condition. Resident #1 had an elevated temperature of 102.6 on 6/20/15 at 11:00 a.m. Resident #1's physician was not contacted for 29 hours- at 4:00 p.m. on 6/21/15. During that time, Resident #1 also had temperatures of 100.4, 102.8, 101.2, 99.7, 101.1, 99.4, 101.1, and 102.3. Resident #1 was given Tylenol and ice packs, which temporarily brought Resident #1's temperature down, but the underlying condition causing the elevated temperature still remained. Resident #1 was admitted to the hospital with [REDACTED]. Findings include: 1.) Resident #1 was admitted to the facility in January, 2015 for continued rehabilitation following a gunshot wound in July, 2014. Resident #1 also has [DIAGNOSES REDACTED]. Surveyor # reviewed Resident #1's medical record. Resident #1 was hospitalized in March with pneumonia, and again 6/1/15 -6/2/15 for chest pains, which were diagnosed as musculoskeletal in nature, and profound [MEDICAL CONDITION]. On 6/3/15, Resident #1 was started on the antibiotic [MEDICATION NAME] 875 mg. (milligrams), ordered by the nephrologist, for 10 days for pneumonia diagnosed by a chest x-ray in the hospital. Nurses' Notes dated 6/3/15 at 7:50 p.m. indicate Tylenol was given for a temperature of 100.6, ice packs were given to Resident #1 per his request, and the [MEDICATION NAME] was started with no adverse effects. Resident #1 was again hospitalized [DATE]- 6/19/15 following problems with his [MEDICAL TREATMENT] fistula in his left arm (infiltrates and clots). Resident #1 returned to the facility on [DATE] at 5:45 p.m. with a Permacath catheter inserted in his right groin for [MEDICAL TREATMENT]. A dressing covered the catheter insertion site. Resident #1's medical record included a report of a chest x-ray obtained 6/19/15 showing Probable bilateral mid to lower lung patchy infiltrates- meaning his pneumonia/ URI (upper respiratory infection) had not cleared from the 6/3 to 6/13/15 treatment with [MEDICATION NAME] ([MEDICATION NAME] and clavulanate potassium). The following temperatures were documented in the Nurses' Notes while Resident #1 was on the antibiotics for pneumonia, (route noted if route was identified in Nurses' Notes): 6/4/15: 96.8, 98.1; 6/5/15: 98.0, 97.4, 100.0 oral; 6/6/15: 98.0, 97.8; 6/7/15: 98.8, 98.2, 97.9; 6/8/15: 96.4, 96.9, 98.2; 6/9/15: 97.2; 6/10/15: 97.2, 97.3; 6/11/15: 99.8, 100.5 (Tylenol given), then 99.8; 6/12/15: 6:00 a.m. note-100.0 (Resident states 'that's normal for me, I'm fine'); note at 7:50 p.m.: Returned from [MEDICAL TREATMENT] with temperature of 101.3. Refused all meds including antibiotic. Risks of skipping doses of antibiotic discussed at length resident who continues to refuse the antibiotic. States I only want my pain medicine, my pill to relax and [MEDICATION NAME]. 6/13/15: 100.0, 97.9, 96.0. Note at 8:00 p.m. - antibiotic completed at this time for URI (upper respiratory infection) . 6/14/15: 98.8 Nurse's Notes on 6/17/15 indicate Resident #1 went out to [MEDICAL TREATMENT] on 6/17/15 but was not able to receive the [MEDICAL TREATMENT] due to an infiltrate above his AV (arteriovenus) fistula site. Staff made necessary appointments to follow up regarding [MEDICAL TREATMENT] access issues, but sometime after 6:00 a.m. on 6/18/15, Resident #1 complained of chest pains and had a temperature of 104.9 (documented on SBAR Communication Form-described further below) and was sent to the ED (Emergency Department) on 6/18/15 at 7:45 a.m. Nurses' Notes state Resident #1 was readmitted to the facility on [DATE] at 5:45 p.m. with [DIAGNOSES REDACTED]. Resident #1 underwent a procedure to insert a Mahurkar catheter in his right groin for [MEDICAL TREATMENT] access. Many references,including the book Vascular Access: Principles and Practice by Samuel E. Wilson, note that while the groin may be the best option given a particular situation, it does have a higher incidence of infection (than insertion in the neck) due to the warm, moist environment conducive to bacterial growth. This would indicate the heightened need to be monitoring for signs and symptoms of infection. The nurse documented [MEDICAL TREATMENT] Mahurkar port to right groin. Dressing intact. The note quotes Resident #1 as saying Quit touching me and quit looking there. Nurses' Notes state Resident #1's temperature on readmission was 99.0 (no route indicated), BP (blood pressure) 140/80, P (pulse) 91, R (respirations) 21 . Notes at 10:00 p.m. state Resident #1 refused his medications except his prn (as needed) oxy ([MEDICATION NAME]) 30 mg. Night shift documented on 6/20/15 at 4:00 a.m. that Resident #1 was alert and oriented X 4 .[MEDICAL TREATMENT] no s/s (sign/symptom) of infection. [MEDICATION NAME] in place. It's so painful to have it there. BP 148/66, P 60, R 18, Temperature 98.0 . Day shift LPN (Licensed Practical Nurse)-Q documented on 6/20/15 at 3:05 p.m. that Resident #1 Access port to right groin. C/O (complaint of ) discomfort to the area. Prn oxy and [MEDICATION NAME] given along with ice pack requested by resident. Effective results. Temp of 98.4 at 9:30, 102.6 at 11:00, 100.4 at 1300 (1:00 p.m.). Tylenol extra strength given. Resident thinks that ports are coming out. Reminded several times that [MEDICATION NAME] is in place holding portacath in place. Will continue to monitor. Surveyor # was unable to interview LPN-Q as she was off on vacation. On 7/14/15 at 9:05 a.m. Surveyor # interviewed RN-S by phone. RN-S stated she was the charge nurse on 6/20/15, while also working on a unit. RN-S stated she was informed that Resident #1 wanted to see the RN so she went to see him. Resident #1 told her he wanted something for pain and he said he had a fever. RN-S said LPN-Q was there when she (RN-S) went out in the hall to get a thermometer. LPN-Q said she already obtained Resident #1's temperature and it was 98 something earlier. RN-S stated she took Resident #1's temperature and it was over 100 F. (RN-S was not at the facility during the interview. Surveyor # could not read her documentation to her because she did not document anything regarding Resident #1 on 6/20/15 or 6/21/15.) RN-S stated she saw Resident #1 around 11:00 a.m. Surveyor # noted there is no documentation in Resident #1's medical record regarding her interaction with Resident #1. RN-S stated I know I should have documented. (LPN-Q documented Resident #1's temperature as 102.6 F at 11:00 a.m. on 6/20/15.). When asked by Surveyor # , RN-S stated she did not call Resident #1's doctor, nor did she complete an SBAR; she thought the LPNs did that. Nurses' Notes continue with a note on 6/20/15 at 11:00 p.m. by RN-R, stating .New access port on right groin area. Complained of mild discomfort at port site. Pain medication administered. Pain level acceptable after administration. Temp of 102.8 at 2030 (8:30 p.m.), administered 2 extra strength Tylenol. Effective. Results temp 101.2 at 2200 (10:00 p.m.). Pt. requested ice packs to place on groin and under arms. Pt. comfortable in bed. Will continue to monitor. On 7/10/15 at 12:55 p.m., Surveyor # interviewed RN-R by phone. RN-R stated Resident #1 did not want her to call the doctor because he had just been in the hospital and didn't want to go back, so she did not call the MD. (Surveyor # noted a nurse has an obligation to inform the physician of a change in a resident's condition. The practitioner would then develop a plan, which may or may not include a recommendation to go to the hospital, but may also include lab work, IV's etc. that could be done in the facility. The Resident always has the option to refuse the practitioner's recommendations at that time, once they are given.) Nurses' Notes on 6/21/15 at 6:00 a.m. state Resident #1 slept through the night, no complaints of pain or discomfort, temperature 99.7. Resident refused BP medication [MEDICATION NAME] 0.1 mg. BP 110/67. Resident resting comfortably, call light within reach. Will continue to monitor. The next Nurses' Notes is dated 6/21/15 (no time documented, appears to be from day shift) and states .Pain managed with prn [MEDICATION NAME]. Dressing to groin C/D/I (clean, dry, intact). Resident noted to have elevated temp 101.1. Tylenol given . Temp reassessed 99.4, P78, R18, SPO2 (saturation of oxygen in blood) 93%- 4 L (liters).O2 (oxygen) Will continue to monitor. On 7/13/15 at 9:33 a.m., Surveyor # interviewed LPN (Licensed Practical Nurse)-T by phone. Surveyor # read LPN-T the note she documented on 6/21/15 day shift (no time documented). The note states: .Resident noted to have an elevated temp 101.1 Tylenol given .Reassessed 99.4 .Will continue to monitor. Surveyor # asked if LPN-T called Resident #1's doctor regarding the temperature of 101.1, LPN-T stated she did not call because Resident #1 did not want her to call because he did not want to go back to the hospital. LPN-T stated she said to Resident #1 that she has to call someone, but Resident #1 told her not to, that he was just hot. Resident #1 told LPN-T to open the window and turn on the fan, and he requested an ice pack that LPN-T obtained for Resident #1. LPN-T stated sometimes she can get Resident #1 to do things; sometimes not. The next Nurses' Note is dated 6/21/15 at 2230 (10:30 p.m.) by RN-R stating Resident noted to have elevated temp of 101.1 or higher today. Doctor (MD-Y) page and NP (nurse practitioner called back and ordered blood cultures x 2, chest x-ray, and CBC (complete blood count). KMH (Kenosha Memorial Hospital) lab was unable to come to do lab draws so Pt. was sent to KMH ER by ambulance. Later noted that resident was admitted to the hospital. Report called to ED nurse. The 24 hour report for Resident #1 is blank for evening shift on 6/21/15. A SBAR (Situation, background, assessment, request) Communication Form (part of the INTERACT tool (interventions to prevent acute care transfer) completed by RN-R and dated 6/21/15 at 1600 (4:00 p.m.) states: SITUATION: The change in condition, symptoms, or signs I'm calling about is: elevated temperatures. This started on: 6/21/15. Since this time is has gotten: worse/better/stayed the same -(left blank). (Surveyor noted the elevated temperature started by 11:00 a.m. on 6/20/15). Things that make the condition or symptom better are: Tylenol 650 mg. This condition has occurred before: yes. treatment for [REDACTED]., ice packs under arms and between legs in groin area. BACKGROUND: Primary Diagnosis: [REDACTED]. Other pertinent history: [MEDICAL CONDITION], cerebral ischemia, muscle weakness. Vital signs: BP 167/90, pulse 101, apical heart rate 100, respiratory rate 22, temperature 102.3, pulse oximetry 96% on 6 liters oxygen, alert and oriented x 3. Full code status . ASSESSMENT: What do you think is going on with the Resident? [MEDICAL TREATMENT] port recently placed near groin area. I believe infection has set in. REQUEST: I suggest or request: Lab work; Transfer to hospital. Reported to (MD-Y) 6/21/15 at 1600. On 7/10/15 at 12:55 p.m., Surveyor # interviewed RN-R by phone. RN-R stated Resident #1 did not want her to call the doctor on the second day (Sunday, 6/21/15) either, but I had to because of the length of time Resident #1 had a fever. RN-R stated she paged Resident #1's doctor and the nurse practitioner (NP) called back with orders for blood cultures and other lab work. RN-R stated the whole point of sending him out was just for labs to be drawn, not send him to the hospital. The NP wanted the labs to be drawn in the facility, but when RN-R called the hospital to arrange the lab draw, she learned no phlebotomist was available to come to the facility. The hospital would draw the labs if they could transport Resident #1 to the hospital. RN-R stated she consulted with the charge nurse (RN-BB), asking if they could transport Resident #1 to the hospital for the lab draw. The charge nurse advised RN-R to call an ambulance for transportation. RN-R stated the charge nurse did not come to assess Resident #1 or have any other involvement with Resident #1's care- she just advised on the transportation issue. On 7/10/15, Surveyor # reviewed Resident #1's ambulance and local hospital records. The ambulance record indicates they were called on 6/21/15 at 4:06 p.m. for a resident with an infection/fever, arrived at facility at 4:14 p.m., and arrived at the hospital at 4:55 p.m. The hospital record indicates Resident #1 was triaged in the ED at 5:02 p.m. and had a temperature of 102.6 F orally, BP 134/63, heart rate 117 beats per minute, respiratory rate of 20, and SPO2 (oxygen saturation) 99% on 6 liters of oxygen via nasal canula. Resident #1 rated the pain in his right groin at 7 on a scale of 0-10 (zero meaning no pain, 10 the worst pain imaginable); and his acceptable level of pain rating is 3/10. The hospital History and Physical indicates Resident #1 was [MEDICAL CONDITION] (fast heart rate) of 120s-130s, and became hypotensive (low blood pressure often seen [MEDICAL CONDITION]), had leukocytosis (elevated white blood cell count-WBCs), fever and purulent drainage coming from the right inguinal (groin) region where the catheter was placed. The ED notes state: There is a [MEDICAL TREATMENT] catheter in the patient's right femoral region. There is a slight amount of blood mixed with purulent material which was expressed when I gently squeezed around the area. The area is non-tender. There is no surrounding [DIAGNOSES REDACTED]. There is no frank purulent discharge; however it does appear there is blood mixed with purulent material. The ED documentation also indicates Resident #1's WBCs are 18.1 (normal range 4.0-10.5, elevated values indicates infection). The ED report Disposition states: Given the fever and suspected catheter infection, the right femoral [MEDICAL TREATMENT] catheter was removed and the tip sent for culture . Resident #1 was quickly admitted to the ICU and given multiple antibiotics. There was difficulty establishing a central line despite multiple attempts on right and left sides. They were successful in establishing access in the right external jugular and fluids were started. However, this access became dislodged overnight and Resident #1 was sent to a tertiary hospital on [DATE] for further procedures to establish [MEDICAL TREATMENT] access. Resident #1's local hospital record documents blood cultures, cultures from the groin and catheter tip are all positive for staphylococcus aureus, MSSA ([MEDICAL CONDITION] susceptible staphylococcus aureus- resistant to [MEDICATION NAME], and [MEDICATION NAME] but susceptible to other [MEDICATION NAME]-ase stable [MEDICATION NAME] ([MEDICATION NAME], dicloxacin), betalactam combinations, cephalosporins and carbapenems.) Resident #1's Discharge [DIAGNOSES REDACTED]. On 7/7/15, Surveyor # asked DON (Director of Nursing)-B for any policies and procedures pertaining to resident change of condition and treatment/nursing response to fevers. On 7/8/15, DON-B informed Surveyor # that they have no policies pertaining to change of condition, nor have they adopted a Standard of Practice to follow. Nurses are expected to use their nursing assessment skills and nursing judgment in each situation because each situation is different. The nurses are expected to use the SBAR form as only a tool to help them with their assessment. Surveyor # asked if they use other components of the INTERACT tool, or just the SBAR. DON-B stated they only use the SBAR form. Surveyor # noted facilities need policies and procedures based on current standards of practice to manage and address clinical conditions. DON-B stated she would look on her computer for additional policies. The SBAR is part of the INTERACT program. According to https://interact2.net/about.html, INTERACT is an acronym for Interventions to Reduce Acute Care Transfers. The interventions is a quality improvement program designed to improve the identification, evaluation, and communication about changes in resident status. INTERACT was first designed in a project supported by the Centers for Medicare and Medicaid Services (CMS). There are three basic types of tools: 1) Communication tools; 2) Care Paths or Clinical tools; and 3) Advance Care Planning tools. The SBAR is a Communication Tool. SBAR stands for Situation, Background, Assessment and Request. On 7/9/15 at approximately 9:00 a.m., Surveyor # noted the nurses' do not usually document the route through which they obtained a resident's temperature, and asked DON-B if they have a standard route to be used, or a way to determine what route was used. DON-B stated she would think it is orally unless otherwise stated. Surveyor # again asked DON-B if the facility has any policies and procedures or Standard of Practice they follow that addresses a resident's change of condition and fever. DON-B stated no, only the SBAR form. Corporate RN-U was in the room at the time and stated the company does follow the INTERACT program, including the Change of Condition Care Paths. RN-U showed Surveyor # the INTERACT program materials she carries with her and stated there is a similar binder at both nurses' stations. Surveyor # confirmed there were binders with the INTERACT materials at both stations. Both unit managers, RN-D and RN-E, were familiar with the INTERACT program and tools. When asked specifically about the Care Paths, RN-E stated if a Resident had a fever, she would expect the nurse to pull out the Fever Care Path and use it to fill out the SBAR and help guide decisions. The INTERACT 3.0 (the version the facility uses according to the SBAR forms) Decision Support Tool Change of Condition File Card states: -Change of Condition: When to report to the MD/NP/PA: Immediate Notification: Any symptom, sign or apparent discomfort that is: ~Acute of sudden in onset, and: ~ a marked change (i.e., more severe) in relation to usual symptoms and signs, or ~ Unrelieved by measures already prescribed. (Surveyor noted: The underlying cause of Resident #1's fever was unrelieved as evidenced by repeat spikes of temperatures of 102.8, 101.2, 101.1 twice, and 102.3, following the initial temperature of 102.6 on 6/20/15 at 11:00 a.m.) Vital Signs: Report Immediately (unless these values are stable and known by the primary care clinician): Temperature-Oral temp > (greater than) 100.5. Fever: Immediate reporting-New onset T >100.5 regardless of any other symptoms (unless under treatment already and clinician already aware). See INTERACT Fever Care Path. Care Path- Fever: Fever Definition: One temp >100 F (37.8 C); two temps >99 F (>37.2 C) oral or 99.5 F (>37.5 C) rectal; Increase in temp of 2 degrees F (1.1 C) over baseline. If the Resident meets the fever definition, the Care Path directs them (via arrow) to a box labeled Take Vital Signs; including BP, pulse, apical heart rate (if pulse irregular), respirations, oxygen saturation, fingerstick glucose (if diabetic). The Care Path arrow then leads to a box labeled Vital Sign Criteria (any met?), which includes Temp >100.5 F. If yes, the arrow directs them to Notify MD/NP/PA. If no vital sign criteria were met, the Care Path directs them to conduct further assessments. On 7/10/15 at 12:55 p.m., Surveyor # interviewed RN-R by phone. RN-R worked the evening shifts on both 6/20/15 and 6/21/15. RN-R stated she was familiar with and did complete a SBAR Communication Form on 6/21/15 regarding Resident #1 prior to her paging MD-Y, but she was not familiar with or nor had she heard of INTERACT, or its Care Paths. RN-R stated she was told the SBAR is only a guide, not strict rules. Surveyor # described the Fever Care Path in INTERACT as a decision-support pathway assisting the nurse make decisions on when to call the doctor, and read to RN-R the INTERACT definition of fever, that if the resident's temperature meets that definition, it instructs staff to take full vital sings, and if any of the vital signs meet criteria (including temperature of >100.5 F), they are to call the MD/NP/PA immediately. RN-R again stated she had not seen nor heard of INTERACT or the Fever Care Path, but she recently came to work at the facility after working in a hospital where the physicians would set parameters on when they wanted to be called (i.e. fever of X, etc.). RN-R stated there were no parameters listed indicating when Resident #1's physician should be called. RN-R stated she did not ask the charge nurse about parameters or call the doctor asking about parameters. On 7/14/15 at 9:05 a.m. Surveyor # interviewed RN-S by phone. RN-S stated she was the charge nurse on 6/20/15, while also working on a unit. RN-S stated she was not aware of and had not heard of the INTERACT tools or program. Surveyor # spoke with MD-CC on 7/13/15 at 10:25 a.m. to clarify what, if any, policy and/or standards of practice the facility had regarding change of condition and fever. MD-CC stated they do have a Policy regarding Change of Condition from (the corporation) since last summer when the new owners took over. While it is a corporate policy, MD-CC stated she has reviewed and approved the policy. Surveyor # asked when the nurses should call the physician regarding an elevated temperature. MD-CC stated she would expect nurses to call with any elevated temperature and give Tylenol, but it is difficult to give a number because any elevated temperature, even 100 F, could be very serious. For a Resident with a baseline temperature of 98.4, even 99.4 could be elevated for that resident. MD-CC stated nurses should call with any change of condition or changes in vital signs. MD-CC stated most of the nurses have been working at the facility for a while and know this. On 7/13/15 at 3:56 p.m. Surveyor # spoke with MD (Medical Doctor)-Y, who is Resident #1's physician. MD-Y stated in principle, nurses should call the doctor to update them on changes in a resident's condition and changes in vital signs, but as he understands it, Resident #1 did not want the doctor called. MD-Y stated Resident #1 is non-compliant with recommendations at times. Surveyor # noted nurses have an obligation to inform the doctor of changes and the Resident then has the right to refuse the plan the doctor develops, but the resident cannot dictate to the nurse not to carry out obligations. On 7/10/15 at approximately 2:00 p.m., Surveyor # and # informed NHA (Nursing Home Administrator)-A and DON-B of serious concerns regarding the 29-hour delay in notifying Resident #1's physician of his fever on 6/20/15 when his temperature was 102.6 at 11:00 a.m., 102.8 at 8:30 p.m. and other elevated temperatures on 6/20/15 and 6/21/15. Resident #1 was diagnosed with [REDACTED]. The American College of Chest Physicians (ACCP) and the Society of Critical Care Medicine (SCCM) introduced definitions for systemic [MEDICAL CONDITION] response syndrome (SIRS). In http://emedicine.medscape.com/article/ 3-overview . SIRS is defined as 2 or more of the following variables: · Fever of more than 38°C (100.4°F) or less than 36°C (96.8°F) · Heart rate of more than 90 beats per minute · Respiratory rate of more than 20 breaths per minute or arterial carbon [MEDICATION NAME] tension (PaCO 2) of less than 32 mm Hg · Abnormal white blood cell count (>12,000/µL or < 4,000/µL or >10% immature (band) forms) ACCP and SCCM state:[MEDICAL CONDITION] is the systemic response to infection and is defined as the presence of SIRS in addition to a documented or presumed infection. According to <http://www.webmd.com/a-to-z-guides/sepsis-[MEDICAL CONDITION]-blood-infection> Sepsis is a serious medical condition caused by an overwhelming immune response to infection. Chemicals released into the blood to fight infection trigger widespread inflammation. Inflammation may result in organ damage. Blood clotting [MEDICAL CONDITION] reduces blood flow to limbs and internal organs, depriving them of nutrients and oxygen. In severe cases, one or more organs fail. In the worst cases, infection leads to a life-threatening drop in blood pressure, called septic shock. This can quickly lead to the failure of several organs -- lungs, kidneys, and liver -- causing death [MEDICAL CONDITION] affects more than a million Americans each year. Up to half of these people will die from this condition. According to www.mayoclinic.org <http://www.mayoclinic.org>,[MEDICAL CONDITION] is more common and more dangerous if you .have invasive devices, such as intravenous catheters or breathing tubes. This resident had recently undergone an invasive procedure to insert a [MEDICAL TREATMENT] catheter in his right groin. On 7/13/15 at 8:25 a.m., NHA-A informed Surveyors that since 7/10/15, they have provided inservice education regarding the corporate Policy on Change of Condition to all nursing staff except those on leave or vacation, and they will receive the education before they work their next shift. NHA-A stated when they talked to RN-R, she stated Resident #1 said no, don't call the doctor on 6/20, but on 6/21, RN-R talked him in to letting her call the MD. NHA-A also stated RN-R informed them that LPN-Q reported off to her (from day shift to PM shift) on 6/20/15 that Resident #1 had an elevated temperature but he did not want staff to call the MD. (LPN-Q is on vacation). NHA-A provided Surveyors with an Inservice and Meeting Attendance Log dated 7/11/15, signed by the nurses in attendance. Attached to it was the corporate Policy and Procedure Change in Condition, Issued 1/1/14. The Purpose states: To ensure prompt notification of the resident, the attending physician, and Durable Power of Attorney/ Responsible Party of changes in the resident's physical, psychosocial and/or mental condition and/or status. Procedure: 1. The physician and Durable Power of Attorney/responsible party will be notified when there has been a change that is sudden in onset, a change that is a marked difference in usual sign/symptoms and/or the signs/symptoms are unrelieved by measures already prescribed. 2. Specific information that requires prompt notification include, but is not limited to: a. Significant change (additional examples are listed through letter r.) Page 2 of the Policy states Notification parameters are based on Interact II Change in Condition File Cards referencing AMDA (American Medical Director Association) Clinical Practice Guidelines- Acute Changes in Condition in the Long-Term Care Setting 2003, as attached to the policy and found at: <http://interact2.net/docs/INTERACT%20Version%203.0%20Tools/Decision%20Support%20Tools/Acute%20Cahnge%20in%20Condition%20File%20Cards/INTERACT%20Change_in_Condition_%20file%20cards%20Jan%2019% 3.pdf> The Training materials include: Describe and Document Symptoms and/or Condition Changes- When assessing the resident with signs and symptoms that may indicate an ACOC (Acute Change of Condition) nursing staff at a minimum should: - Regardless of Resident's cognitive level, ask the resident how he or she is feeling or how the symptoms developed; -Take vital signs: Temperature, Blood pressure, pulse, respirations, O2 saturation and blood sugar if diabetic or currently receiving [MEDICAL CONDITION] medications; -Assess the resident's overall condition, level of consciousness, and function -Seek information that may help to identify possible causes of the symptoms to help determine which body system to evaluate further. The section on Communicating Critical Information: includes We will be providing the facility with written guidelines for the licensed nursing to determine what signs and symptoms to report to the physician. Refer to Handout: Examples of Condition Changes to Report to the Physician and Framework for Reporting Changes in Vital Signs or Laboratory Values to a Physician. The Training materials conclude with What are your responsibilities? The Licensed Nurse/Charge Nurse and/or Director of Nurses has the responsibility to assess for acute changes in condition and promptly notify the physician, resident and the resident's responsible party and DOCUMENT your assessment and notification. ACT upon these assessments and notify the appropriate MD, family/responsible party. Notify the DON/ Administrator of an acute change in condition and the action being taken. On 7/13/15, RN-U informed Surveyors the Handout referenced above is the AMDA Acute Change in Condition in the Long-Term Care Setting Clinical Practice Guideline that was attached to their policy. The Guideline includes: Table 14 Framework for Reporting Changes in Vital Signs or Laboratory Values to a Practitioner. Acute Sign/Lab value: Vital Signs: Report Immediately: Oral temperature of >101 degrees F.

Based on record review and interview, facility staff did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 4 of 13 sampled Residents (Residents #1, 12, 7, and 13). Resident #1 had an elevated temperature of 102.6 on 6/20/15 at 11:00 a.m. Resident #1's physician was not contacted for 29 hours- at 4:00 p.m. on 6/21/15. During that time, Resident #1 also had temperatures of 100.4, 102.8, 101.2, 99.7, 101.1, 99.4, 101.1, and 102.3. Resident #1 was given Tylenol and ice packs which temporarily brought Resident #1's temperature down, but the underlying condition causing the elevated temperature still remained. Staff did not always ensure that Resident #1 was assessed by an RN, did not always obtain a complete set of vital signs, and did not promptly consult with the physician for Resident #1 when he experienced a significant change of condition. Resident #1 was admitted to the hospital with [REDACTED]. Residents #12 and #7 have [DIAGNOSES REDACTED]. The facility did not develop a plan of care to provide non-pharmacological approaches and behavioral interventions to treat and provide services to these residents' in regards to their behaviors. Resident #13 had a dislocation of the left shoulder, which caused pain and was not comprehensively assessed for pain by the facility. Findings include: 1.) Resident #1 was admitted to the facility in January, 2015 for continued rehabilitation following a gunshot wound in July, 2014. Resident #1 also has [DIAGNOSES REDACTED]. Surveyor # reviewed Resident #1's medical record. Resident #1 was hospitalized in March with pneumonia, and again 6/1/15 -6/2/15 for chest pains, which were diagnosed as musculoskeletal in nature, and profound [MEDICAL CONDITION]. On 6/3/15, Resident #1 was started on the antibiotic [MEDICATION NAME] 875 mg. (milligrams), ordered by the nephrologist, for 10 days for pneumonia diagnosed by a chest x-ray in the hospital. Nurses' Notes dated 6/3/15 at 7:50 p.m. indicate Tylenol was given for a temperature of 100.6, ice packs were given to Resident #1 per his request, and the [MEDICATION NAME] was started with no adverse effects. Resident #1 was again hospitalized [DATE]- 6/19/15 following problems with his [MEDICAL TREATMENT] fistula in his left arm (infiltrates and clots). Resident #1 returned to the facility on [DATE] at 5:45 p.m. with a Permacath catheter inserted in his right groin for [MEDICAL TREATMENT]. A dressing covered the catheter insertion site. Resident #1's medical record included a report of a chest x-ray obtained 6/19/15 showing Probable bilateral mid to lower lung patchy infiltrates- meaning his pneumonia/ URI (upper respiratory infection) had not cleared from the 6/3 to 6/13/15 treatment with [MEDICATION NAME] ([MEDICATION NAME] and clavulanate potassium). The following temperatures were documented in the Nurses' Notes while Resident #1 was on the antibiotics for pneumonia, (route noted if route was identified in Nurses' Notes): 6/4/15: 96.8, 98.1; 6/5/15: 98.0, 97.4, 100.0 oral; 6/6/15: 98.0, 97.8; 6/7/15: 98.8, 98.2, 97.9; 6/8/15: 96.4, 96.9, 98.2; 6/9/15: 97.2; 6/10/15: 97.2, 97.3; 6/11/15: 99.8, 100.5 (Tylenol given), then 99.8; 6/12/15: 6:00 a.m. note-100.0 (Resident states 'that's normal for me, I'm fine'); note at 7:50 p.m.: Returned from [MEDICAL TREATMENT] with temperature of 101.3. Refused all meds including antibiotic. Risks of skipping doses of antibiotic discussed at length resident who continues to refuse the antibiotic. States I only want my pain medicine, my pill to relax and [MEDICATION NAME]. 6/13/15: 100.0, 97.9, 96.0. Note at 8:00 p.m. - antibiotic completed at this time for URI (upper respiratory infection) . 6/14/15: 98.8 Nurse's Notes on 6/17/15 indicate Resident #1 went out to [MEDICAL TREATMENT] on 6/17/15 but was not able to receive the [MEDICAL TREATMENT] due to an infiltrate above his AV (arteriovenus) fistula site. Staff made necessary appointments to follow up regarding [MEDICAL TREATMENT] access issues, but sometime after 6:00 a.m. on 6/18/15, Resident #1 complained of chest pains and had a temperature of 104.9 (documented on SBAR Communication Form-described further below) and was sent to the ED (Emergency Department) on 6/18/15 at 7:45 a.m. Nurses' Notes state Resident #1 was readmitted to the facility on [DATE] at 5:45 p.m. with [DIAGNOSES REDACTED]. Resident #1 underwent a procedure to insert a Mahurkar catheter in his right groin for [MEDICAL TREATMENT] access. Many references, including the book Vascular Access: Principles and Practice by Samuel E. Wilson, note that while the groin may be the best option given a particular situation, it does have a higher incidence of infection (than insertion in the neck) due to the warm, moist environment conducive to bacterial growth. This would indicate the heightened need to be monitoring for signs and symptoms of infection. The nurse documented [MEDICAL TREATMENT] Mahurkar port to right groin. Dressing intact. The note quotes Resident #1 as saying Quit touching me and quit looking there. Nurses' Notes state Resident #1's temperature on readmission was 99.0 (no route indicated), BP (blood pressure) 140/80, P (pulse) 91, R (respirations) 21 . Notes at 10:00 p.m. state Resident #1 refused his medications except his prn (as needed) oxy ([MEDICATION NAME]) 30 mg. Night shift documented on 6/20/15 at 4:00 a.m. that Resident #1 was alert and oriented X 4 .[MEDICAL TREATMENT] no s/s (sign/symptom) of infection. [MEDICATION NAME] in place. It's so painful to have it there. BP 148/66, P 60, R 18, Temperature 98.0 . Day shift LPN (Licensed Practical Nurse)-Q documented on 6/20/15 at 3:05 p.m. that Resident #1 Access port to right groin. C/O (complaint of) discomfort to the area. Prn oxy and [MEDICATION NAME] given along with ice pack requested by resident. Effective results. Temp of 98.4 at 9:30, 102.6 at 11:00, 100.4 at 1300 (1:00 p.m.). Tylenol extra strength given. Resident thinks that ports are coming out. Reminded several times that [MEDICATION NAME] is in place holding portacath in place. Will continue to monitor. Surveyor # reviewed the facility's 24 hour report for 6/20/15 and noted blood pressures were documented either in the Nurses' Notes or on the 24 hour report for night shift and evening shift, but not for day shift when Resident #1 had a temperature of 102.6. Evening shift documented a BP of 117/54 on the 24 hour report. No other vital signs were documented in either location for Resident #1 on day shift- only temperature. Surveyor # was unable to interview LPN-Q as she was off on vacation. On 7/14/15 at 9:05 a.m. Surveyor # interviewed RN-S by phone. RN-S stated she was the charge nurse on 6/20/15, while also working on a unit. RN-S stated she was informed that Resident #1 wanted to see the RN so she went to see him. Resident #1 told her he wanted something for pain and he said he had a fever. RN-S said LPN-Q was there when she (RN-S) went out in the hall to get a thermometer. LPN-Q said she already obtained Resident #1's temperature and it was 98 something earlier. RN-S stated she took Resident #1's temperature and it was over 100 F. (RN-S was not at the facility during the interview. Surveyor # could not read her documentation to her because she did not document anything regarding Resident #1 on 6/20/15 or 6/21/15.) RN-S stated she saw Resident #1 around 11:00 a.m. Surveyor # noted there is no documentation in Resident #1's medical record regarding her interaction with Resident #1. RN-S stated I know I should have documented. (LPN-Q documented Resident #1's temperature as 102.6 F at 11:00 a.m. on 6/20/15.). When asked by Surveyor # , RN-S stated she did not comprehensively assess Resident #1; she just took his temperature and checked his groin dressing. RN-S stated she did not call Resident #1's doctor, nor did she complete an SBAR-stating she thought the LPNs did that. Nurses' Notes continue with a note on 6/20/15 at 11:00 p.m. by RN-R, stating .New access port on right groin area. Complained of mild discomfort at port site. Pain medication administered. Pain level acceptable after administration. Temp of 102.8 at 2030 (8:30 p.m.), administered 2 extra strength Tylenol. Effective. Results temp 101.2 at 2200 (10:00 p.m.). Pt. requested ice packs to place on groin and under arms. Pt. comfortable in bed. Will continue to monitor. On 7/10/15 at 12:55 p.m., Surveyor # interviewed RN-R by phone. RN-R stated she completed a nursing assessment on 6/20/15 and was only able to assess the dressing from Resident #1's groin catheter insertion site because Resident #1 did not want her to look at the site. RN-R stated Resident #1 did not appear in any distress, and she does not recall discussing Resident #1 with any other RN or charge nurse on Saturday 6/20/15. RN-R stated the Tylenol and ice were effective bringing the temperature down on 6/20. (Surveyor # noted it came down from 102.8 at 8:30 p.m. to 101.2 at 10:00 p.m., but that is still above the temperature when nurses should call the doctor immediately) (100.5, -and indicates there is still an underlying process causing elevated temperatures going on). When asked, RN-R stated the temperatures were taken orally (no routes documented). RN-R stated Resident #1 did not want her to call the doctor because he had just been in the hospital and didn't want to go back, so she did not call the MD. (Surveyor # noted a nurse has an obligation to inform the physician of a change in a resident's condition. The practitioner would then develop a plan, which may or may not include a recommendation to go to the hospital, but may also include lab work, IV's etc. that could be done in the facility. The Resident always has the option to refuse the practitioner's recommendations at that time, once they are given.) Nurses' Notes on 6/21/15 at 6:00 a.m. state Resident #1 slept through the night, no complaints of pain or discomfort, temperature 99.7. Resident refused BP medication [MEDICATION NAME] 0.1 mg. BP 110/67. Resident resting comfortably, call light within reach. Will continue to monitor. The next Nurses' Notes is dated 6/21/15 (no time documented, appears to be from day shift) and states .Pain managed with prn [MEDICATION NAME]. Dressing to groin C/D/I (clean, dry, intact). Resident noted to have elevated temp 101.1. Tylenol given . Temp reassessed 99.4, P78, R18, SPO2 (saturation of oxygen in blood) 93%- 4 L (liters).O2 (oxygen) Will continue to monitor. On 7/13/15 at 9:33 a.m., Surveyor # interviewed LPN (Licensed Practical Nurse)-T by phone. Surveyor # read LPN-T the note she documented on 6/21/15 day shift (no time documented). The note states: .Resident noted to have an elevated temp 101.1 Tylenol given .Reassessed 99.4 .Will continue to monitor. Surveyor # asked if LPN-T called Resident #1's doctor regarding the temperature of 101.1, LPN-T stated she did not call because Resident #1 did not want her to call because he did not want to go back to the hospital. LPN-T stated she said to Resident #1 that she has to call someone, but Resident #1 told her not to, that he was just hot. Resident #1 told LPN-T to open the window and turn on the fan, and he requested an ice pack that LPN-T obtained for Resident #1. LPN-T stated sometimes she can get Resident #1 to do things; sometimes not. There is no documentation to indicate that an RN assessed Resident #1.The facility 24 hour report for day shift states 101.1- Tylenol given. Neither Nurses' Notes nor the 24 hour report includes Resident #1's blood pressure. The next Nurses' Note is dated 6/21/15 at 2230 (10:30 p.m.) by RN-R stating Resident noted to have elevated temp of 101.1 or higher today. Doctor (MD-Y) page and NP (nurse practitioner called back and ordered blood cultures x 2, chest x-ray, and CBC (complete blood count). KMH (Kenosha Memorial Hospital) lab was unable to come to do lab draws so Pt. was sent to KMH ER by ambulance. Later noted that resident was admitted to the hospital. Report called to ED nurse. The 24 hour report for Resident #1 is blank for evening shift on 6/21/15. A SBAR (Situation, background, assessment, request) Communication Form (part of the INTERACT tool (interventions to prevent acute care transfer) completed by RN-R and dated 6/21/15 at 1600 (4:00 p.m.) states: SITUATION: The change in condition, symptoms, or signs I'm calling about is: elevated temperatures. This started on: 6/21/15. Since this time is has gotten: worse/better/stayed the same - (left blank). (Surveyor noted the elevated temperature started by 11:00 a.m. on 6/20/15). Things that make the condition or symptom better are: Tylenol 650 mg. This condition has occurred before: yes. treatment for [REDACTED]. ice packs under arms and between legs in groin area. BACKGROUND: Primary Diagnosis: [REDACTED]. Other pertinent history: [MEDICAL CONDITION], cerebral ischemia, muscle weakness. Vital signs: BP 167/90, pulse 101, apical heart rate 100, respiratory rate 22, temperature 102.3, pulse oximetry 96% on 6 liters oxygen, alert and oriented x 3. Full code status . ASSESSMENT: What do you think is going on with the Resident? [MEDICAL TREATMENT] port recently placed near groin area. I believe infection has set in. REQUEST: I suggest or request: Lab work; Transfer to hospital. Reported to (MD-Y) 6/21/15 at 1600. On 7/10/15 at 12:55 p.m., Surveyor # interviewed RN-R by phone. RN-R stated Resident #1 did not want her to call the doctor on the second day (Sunday, 6/21/15) either, but I had to because of the length of time Resident #1 had a fever. RN-R stated she paged Resident #1's doctor and the nurse practitioner (NP) called back with orders for blood cultures and other lab work. RN-R stated the whole point of sending him out was just for labs to be drawn, not send him to the hospital. The NP wanted the labs to be drawn in the facility, but when RN-R called the hospital to arrange the lab draw, she learned no phlebotomist was available to come to the facility. The hospital would draw the labs if they could transport Resident #1 to the hospital. RN-R stated she consulted with the charge nurse (RN-BB), asking if they could transport Resident #1 to the hospital for the lab draw. The charge nurse advised RN-R to call an ambulance for transportation. RN-R stated the charge nurse did not come to assess Resident #1 or have any other involvement with Resident #1's care- she just advised on the transportation issue. RN-R stated Resident #1 didn't want to let her obtain his vital signs. On 7/10/15, Surveyor # reviewed Resident #1's ambulance and local hospital records. The ambulance record indicates they were called on 6/21/15 at 4:06 p.m. for a resident with an infection/fever, arrived at facility at 4:14 p.m., and arrived at the hospital at 4:55 p.m. The hospital record indicates Resident #1 was triaged in the ED at 5:02 p.m. and had a temperature of 102.6 F orally, BP 134/63, heart rate 117 beats per minute, respiratory rate of 20, and SPO2 (oxygen saturation) 99% on 6 liters of oxygen via nasal cannula. Resident #1 rated the pain in his right groin at 7 on a scale of 0-10 (zero meaning no pain, 10 the worst pain imaginable); and his acceptable level of pain rating is 3/10. The hospital History and Physical indicates Resident #1 was [MEDICAL CONDITION] (fast heart rate) of 120s-130s, and became hypotensive (low blood pressure often seen [MEDICAL CONDITION]), had leukocytosis (elevated white blood cell count-WBCs), fever and purulent drainage coming from the right inguinal (groin) region where the catheter was placed. The ED notes state: There is a [MEDICAL TREATMENT] catheter in the patient's right femoral region. There is a slight amount of blood mixed with purulent material which was expressed when I gently squeezed around the area. The area is non-tender. There is no surrounding [DIAGNOSES REDACTED]. There is no frank purulent discharge; however it does appear there is blood mixed with purulent material. The ED documentation also indicates Resident #1's WBCs are 18.1 (normal range 4.0-10.5, elevated values indicates infection). The ED report Disposition states: Given the fever and suspected catheter infection, the right femoral [MEDICAL TREATMENT] catheter was removed and the tip sent for culture . Resident #1 was quickly admitted to the ICU and given multiple antibiotics. There was difficulty establishing a central line despite multiple attempts on right and left sides. They were successful in establishing access in the right external jugular and fluids were started. However, this access became dislodged overnight and Resident #1 was sent to a tertiary hospital on [DATE] for further procedures to establish [MEDICAL TREATMENT] access. Resident #1's local hospital record documents blood cultures, cultures from the groin and catheter tip are all positive for staphylococcus aureus, MSSA ([MEDICAL CONDITION] susceptible staphylococcus aureus- resistant to [MEDICATION NAME], and [MEDICATION NAME] but susceptible to other [MEDICATION NAME]-ase stable [MEDICATION NAME] ([MEDICATION NAME], dicloxacin), betalactam combinations, cephalosporins and carbapenems.) Resident #1's Discharge [DIAGNOSES REDACTED]. On 7/7/15, Surveyor # asked DON (Director of Nursing)-B for any policies and procedures pertaining to resident change of condition and treatment/nursing response to fevers. On 7/8/15, DON-B informed Surveyor # that they have no policies pertaining to change of condition, nor have they adopted a Standard of Practice to follow. Nurses are expected to use their nursing assessment skills and nursing judgment in each situation because each situation is different. The nurses are expected to use the SBAR form as only a tool to help them with their assessment. Surveyor # asked if they use other components of the INTERACT tool, or just the SBAR. DON-B stated they only use the SBAR form. Surveyor # noted facilities need policies and procedures based on current standards of practice to manage and address clinical conditions. DON-B stated she would look on her computer for additional policies. The SBAR is part of the INTERACT program. According to <https://interact2.net/about.html>, INTERACT is an acronym for Interventions to Reduce Acute Care Transfers. The intervention is a quality improvement program designed to improve the identification, evaluation, and communication about changes in resident status. INTERACT was first designed in a project supported by the Centers for Medicare and Medicaid Services (CMS). There are three basic types of tools: 1) Communication tools; 2) Care Paths or Clinical tools; and 3) Advance Care Planning tools. The SBAR is a Communication Tool. SBAR stands for Situation, Background, Assessment and Request. On 7/9/15 at approximately 9:00 a.m., Surveyor # noted the nurses' do not usually document the route through which they obtained a resident's temperature, and asked DON-B if they have a standard route to be used, or a way to determine what route was used. DON-B stated she would think it is orally unless otherwise stated. Surveyor # again asked DON-B if the facility has any policies and procedures or Standard of Practice they follow that addresses a resident's change of condition and fever. DON-B stated no, only the SBAR form. Corporate RN-U was in the room at the time and stated the company does follow the INTERACT program, including the Change of Condition Care Paths. RN-U showed Surveyor # the INTERACT program materials she carries with her and stated there is a similar binder at both nurses' stations. Surveyor # confirmed there were binders with the INTERACT materials at both stations. Both unit managers, RN-D and RN-E, were familiar with the INTERACT program and tools. When asked specifically about the Care Paths, RN-E stated if a Resident had a fever, she would expect the nurse to pull out the Fever Care Path and use it to fill out the SBAR and help guide decisions. The INTERACT 3.0 (the version the facility uses according to the SBAR forms) Decision Support Tool Change of Condition File Card states: -Change of Condition: When to report to the MD/NP/PA: Immediate Notification: Any symptom, sign or apparent discomfort that is: ~Acute of sudden in onset, and: ~ a marked change (i.e., more severe) in relation to usual symptoms and signs, or ~ Unrelieved by measures already prescribed. (Surveyor noted: The underlying cause of Resident #1's fever was unrelieved as evidenced by repeat spikes of temperatures of 102.8, 101.2, 101.1 twice, and 102.3, following the initial temperature of 102.6 on 6/20/15 at 11:00 a.m.) Vital Signs: Report immediately (unless these values are stable and known by the primary care clinician): Temperature-Oral temp > (greater than) 100.5. Fever: Immediate reporting-New onset T >100.5 regardless of any other symptoms (unless under treatment already and clinician already aware). See INTERACT Fever Care Path. Care Path- Fever: Fever Definition: One temp >100 F (37.8 C); two temps >99 F (>37.2 C) oral or 99.5 F (>37.5 C) rectal; Increase in temp of 2 degrees F (1.1 C) over baseline. If the Resident meets the fever definition, the Care Path directs them (via arrow) to a box labeled Take Vital Signs; including BP, pulse, apical heart rate (if pulse irregular), respirations, oxygen saturation, finger stick glucose (if diabetic). The Care Path arrow then leads to a box labeled Vital Sign Criteria (any met?), which includes Temp >100.5 F. If yes, the arrow directs them to Notify MD/NP/PA. If no vital sign criteria were met, the Care Path directs them to conduct further assessments. On 7/10/15 at 12:55 p.m., Surveyor # interviewed RN-R by phone. RN-R worked the evening shifts on both 6/20/15 and 6/21/15. RN-R stated she was familiar with and did complete a SBAR Communication Form on 6/21/15 regarding Resident #1 prior to her paging MD-Y, but she was not familiar with or nor had she heard of INTERACT, or its Care Paths. RN-R stated she was told the SBAR is only a guide, not strict rules. Surveyor # described the Fever Care Path in INTERACT as a decision-support pathway assisting the nurse make decisions on when to call the doctor, and read to RN-R the INTERACT definition of fever, that if the resident's temperature meets that definition, it instructs staff to take full vital sings, and if any of the vital signs meet criteria (including temperature of >100.5 F), they are to call the MD/NP/PA immediately. RN-R again stated she had not seen nor heard of INTERACT or the Fever Care Path, but she recently came to work at the facility after working in a hospital where the physicians would set parameters on when they wanted to be called (i.e. fever of X, etc.). RN-R stated there were no parameters listed indicating when Resident #1's physician should be called. RN-R stated she did not ask the charge nurse about parameters or call the doctor asking about parameters. On 7/14/15 at 9:05 a.m. Surveyor # interviewed RN-S by phone. RN-S stated she was the charge nurse on 6/20/15, while also working on a unit. RN-S stated she was not aware of and had not heard of the INTERACT tools or program. Surveyor # spoke with MD-CC on 7/13/15 at 10:25 a.m. to clarify what, if any, policy and/or standards of practice the facility had regarding change of condition and fever. MD-CC stated they do have a Policy regarding Change of Condition from (the corporation) since last summer when the new owners took over. While it is a corporate policy, MD-CC stated she has reviewed and approved the policy. Surveyor # asked when the nurses should call the physician regarding an elevated temperature. MD-CC stated she would expect nurses to call with any elevated temperature and give Tylenol, but it is difficult to give a number because any elevated temperature, even 100 F, could be very serious. For a Resident with a baseline temperature of 98.4, even 99.4 could be elevated for that resident. MD-CC stated nurses should call with any change of condition or changes in vital signs. MD-CC stated most of the nurses have been working at the facility for a while and know this. On 7/13/15 at 3:56 p.m. Surveyor # spoke with MD (Medical Doctor)-Y, who is Resident #1's physician. MD-Y stated in principle, nurses should call the doctor to update them on changes in a resident's condition and changes in vital signs, but as he understands it, Resident #1 did not want the doctor called. MD-Y stated Resident #1 is non-compliant with recommendations at times. Surveyor # noted nurses have an obligation to inform the doctor of changes and the Resident then has the right to refuse the plan the doctor develops, but the resident cannot dictate to the nurse not to carry out obligations. On 7/10/15 at approximately 2:00 p.m., Surveyor # and # informed NHA (Nursing Home Administrator)-A and DON-B of serious concerns regarding the 29-hour delay in notifying Resident #1's physician of his fever on 6/20/15 when his temperature was 102.6 at 11:00 a.m., 102.8 at 8:30 p.m. and other elevated temperatures on 6/20/15 and 6/21/15. Resident #1 was diagnosed with [REDACTED]. The American College of Chest Physicians (ACCP) and the Society of Critical Care Medicine (SCCM) introduced definitions for systemic [MEDICAL CONDITION] response syndrome (SIRS. In http://emedicine.medscape.com/article/ 3-overview . SIRS is defined as 2 or more of the following variables: · Fever of more than 38°C (100.4°F) or less than 36°C (96.8°F) · Heart rate of more than 90 beats per minute · Respiratory rate of more than 20 breaths per minute or arterial carbon [MEDICATION NAME] tension (PaCO 2) of less than 32 mm Hg · Abnormal white blood cell count (>12,000/µL or < 4,000/µL or >10% immature (band) forms) ACCP and SCCM state:[MEDICAL CONDITION] is the systemic response to infection and is defined as the presence of SIRS in addition to a docuented or presumed infection. According to <http://www.webmd.com/a-to-z-guides/sepsis-[MEDICAL CONDITION]-blood-infection> Sepsis is a serious medical condition caused by an overwhelming immune response to infection. Chemicals released into the blood to fight infection trigger widespread inflammation. Inflammation may result in organ damage. Blood clotting [MEDICAL CONDITION] reduces blood flow to limbs and internal organs, depriving them of nutrients and oxygen. In severe cases, one or more organs fail. In the worst cases, infection leads to a life-threatening drop in blood pressure, called septic shock. This can quickly lead to the failure of several organs -- lungs, kidneys, and liver -- causing death. [MEDICAL CONDITION] affects more than a million Americans each year. Up to half of these people will die from this condition. According to www.mayoclinic.org,[MEDICAL CONDITION] is more common and more dangerous if you .have invasive devices, such as intravenous catheters or breathing tubes. This resident had recently undergone an invasive procedure to insert a [MEDICAL TREATMENT] catheter in his right groin. On 7/13/15 at 8:25 a.m., NHA-A informed Surveyors that since 7/10/15, they have provided inservice education regarding the corporate Policy on Change of Condition to all nursing staff except those on leave or vacation, and they will receive the education before they work their next shift. NHA-A stated when they talked to RN-R, she stated Resident #1 said no, don't call the doctor on 6/20, but on 6/21, RN-R talked him in to letting her call the MD. NHA-A also stated RN-R informed them that LPN-Q reported off to her (from day shift to PM shift) on 6/20/15 that Resident #1 had an elevated temperature but he did not want staff to call the MD. (LPN-Q is on vacation). NHA-A provided Surveyors with an Inservice and Meeting Attendance Log dated 7/11/15, signed by the nurses in attendance. Attached to it was the corporate Policy and Procedure Change in Condition, Issued 1/1/14. The Purpose states: To ensure prompt notification of the resident, the attending physician, and Durable Power of Attorney/ Responsible Party of changes in the resident's physical, psychosocial and/or mental condition and/or status. Procedure: 1. The physician and Durable Power of Attorney/responsible party will be notified when there has been a change that is sudden in onset, a change that is a marked difference in usual sign/symptoms and/or the signs/symptoms are unrelieved by measures already prescribed. 2. Specific information that requires prompt notification includes, but is not limited to: a. Significant change (additional examples are listed through letter r.) Page 2 of the Policy states Notification parameters are based on Interact II Change in Condition File Cards referencing AMDA (American Medical Director Association) Clinical Practice Guidelines- Acute Changes in Condition in the Long-Term Care Setting 2003, as attached to the policy and found at: <http://interact2.net/docs/INTERACT%20Version%203.0%20Tools/Decision%20Support%20Tools/Acute%20Cahnge%20in%20Condition%20File%20Cards/INTERACT%20Change_in_Condition_%20file%20cards%20Jan%2019% 3.pdf> The Training materials include: Describe and Document Symptoms and/or Condition Changes- When assessing the resident with signs and symptoms that may indicate an ACOC (Acute Change of Condition) nursing staff at a minimum should: - Regardless of Resident's cognitive level, ask the resident how he or she is feeling or how the symptoms developed; -Take vital signs: Temperature, Blood pressure, pulse, respirations, O2 saturation and blood sugar if diabetic or currently receiving [MEDICAL CONDITION] medications; -Assess the resident's overall condition, level of consciousness, and function -Seek information that may help to identify possible causes of the symptoms to help determine which body system to evaluate further. The section on Communicating Critical Information: includes We will be providing the facility with written guidelines for the licensed nursing to determine what signs and symptoms to report to the physician. Refer to Handout: Examples of Condition Changes to Report to the Physician and Framework for Reporting Changes in Vital Signs or Laboratory Values to a Physician. The Training materials conclude with What are your responsibilities? The Licensed Nurse/Charge Nurse and/or Director of Nurses has the responsibility to assess for acute changes in condition and promptly notify the physician, resident and the resident's responsible party and DOCUMENT your assessment and notification. ACT upon these assessments and notify the appropriate MD, family/responsible party. Notify the DON/ Administrator of an acute change in condition and the action being taken. On 7/13/15, RN-U informed Surveyors the Handout referenced above is the AMDA Acute Change in Condition in the Long-Term Care Setting Clinical Practice Guideline that was attached to their policy. The Guideline includes: Table 14 Framework for Reporting Chang

Based on observation, interview and record review, the facility did not always ensure that 2 out of 6 Residents (Resident # 13 and Resident # 7) at risk for falls, had environments that remained free of accident hazards and received adequate supervision and assistive devices to prevent accidents. ~ Resident #13 did not have the tennis balls used to assist his walker in sliding appropriately on the floor routinely checked for wear. Resident #13 had an accident during a transfer into his wheelchair on 9/4/14 when it was determined that the walker not sliding and the staff member assisting Resident #13 without a gait belt contributed to an improper assist, thus causing and accident with outcome of fractured toes to occur. Resident #13 has to wear an immobilizer boot and has temporarily lost his ability to pivot transfer and must currently use a mechanical lift to transfer while this fracture heals. Resident #13 has also experienced pain due to the fractured toes. This example involving Resident #13 is being cited at a scope and severity (s/s) at a G (actual harm/isolated). The additional example involving Resident #7 is being cited at a s/s of a D (potential for actual harm/isolated). ~ Resident #7 was found on the floor in his room with a facial laceration that was treated with basic first aide. The facility has not assessed the circumstances of this fall to determine how the Resident fell , what he fell from (bed or chair) and why the Resident fell or has provided corrective measures since the fall to prevent another fall from occurring other than not allowing Resident to be unsupervised. There is no evidence that any assessment into Resident #7's ability to safely sit was conducted, or if therapy was involved to conduct any modifications to the wheelchair, if there is knowledge the fall occurred from the wheelchair. The current measure being used to prevent a fall for Resident #7 is to not leave him alone in his wheelchair, thus Resident #7 spends all of his time now in the hallway supervised. Because the facility did not conduct any post fall assessment, Resident is not able to sit in his room and watch television as he did before. The facility began to interview staff involved on 9/16 and 9/17/14, regarding Resident #7 after the Surveyors began to ask for investigation and assessment into this fall. There is no evidence this assessment and investigation was conducted at the time the Resident was found down in his room with a facial laceration. Findings include: Surveyor reviewed the facility policy, dated 1/1/14, titled "Policy and Procedure Accident and Incident Investigation" on 9/15/14. This policy indicates it is in place to ensure that all accidents, incidents and allegations of abuse involving Residents, visitors or employees are investigated and reported to the facility administration. The procedure identifies approaches, such as; 1. All accidents, incidents, and allegations of abuse including injuries of unknown source, shall be reported to the department supervision as soon as it is discovered or when information of occurrence is learned. 4. The assigned nurse or nursing supervisor shall complete an assessment and provide medical interventions as warranted. 10. Complete the Incident/Event Investigation Form or the Investigation follow-up form, including specifics as indicated, such as: a. date, time and location the accident/event or abuse allegation occurred b. nature of the injury/illness c. circumstances surrounding the occurrence. d. Name(s) of witness(s) and their account of the occurrence-account should be conducted by an in-person or phone interview. e. The injured person's account of the occurrence, if they are able to convey the information. f. Date and time the physician/responsible party notification g. Condition of the Resident-including vital signs. h. Disposition of the Resident- sent to ER, portable X-ray taken, returned to work, went home, no medical care required, etc. i. Corrective action taken. j. Documentation in medical record completed, recorded on the 24 hour report k. care plan updated if indicated. l. follow up information - such as 72 hour assessment and charting, equipment ordered, etc. m. other pertinent data as required. n. Signature and title of the person completing the form. 1.) Resident #13 was reviewed by Surveyor Resident #13 was recently admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident was observed by Surveyor to be independently mobile with his electric wheelchair. Resident was observed during this survey to be wearing a hard-shelled short leg immobilizer on his right leg. Resident #13 had a plan of care, with dates of 5/29/13, that indicated Resident #13 was at risk for falls, had impaired mobility due to incomplete quadriplegia. Resident has a history of falls/injuries such as falling during a family transfer on 5/29/13 and bumping his motorized wheelchair into a door on 7/10/13. On 9/4/14 at 7:30 AM, an incident occurred with Resident #13 when being assisted from the bed to stand and walk with the walker to his wheelchair. During the course of walking, the walker got caught on the floor while moving to the wheelchair, the Resident lost his balance and the resident was lowered into the wheelchair by a nurse aide. The Resident believed that the walker got caught on the floor moving to his wheelchair. Initially, it was believed that Resident had no injury related to this event and was not having any pain related to this event. Throughout the course of the day, Resident began to have increased complaints of pain to the right ankle. The physician was notified and xrays were taken on 9/4/14 at 8:05 PM that revealed a fracture to the right ankle bone and 4th and 5th toes of the right foot. The physician was notified of these findings and plan was to follow up with orthopedic physician. Investigation and assessment into this fall by facility administration revealed that Certified Nursing Assistant (CNA)-R did not use a gait belt during this transfer. This was found out from interviewing the resident. It was also determined that the walker legs had worn through the tennis balls preventing the walker from gliding on the floor properly. This caused Resident #13 to lose balance and fall sideways. Immediately following this accident, the walker was modified with new skid plates. The investigation revealed after speaking with the Resident and his family member, with the tennis balls being worn out causing the walker to stick to the floor and a gait belt not being used during this transfer/ambulation with this resident, who needs the assistance of a staff member, lead to this avoidable accident. The nurse aide care card did identify a gait belt to be used with assistance of one staff with walker. A therapy/nursing communication sheet, dated 7/17/14, indicated Resident #13 is to be transferred with moderate assistance of 1 person and to apply a gait belt. A statement was received and signed on 9/8/14 by CNA-R regarding the accident. CNA-R admitted not using the gait belt and firmly grasped Resident #13's trousers instead and felt at that time it was sufficient. CNA-R acknowledged that this practice was unacceptable. The facility did show evidence that it inspected all other walkers in the facility following this accident and made necessary changes. The facility did show evidence that it began to inservice staff regarding the use of gait belts following this incident, and is planning another inservice on gait belt use and care card instructions on 9/25/14. 2.) On 9/16/14 Surveyor # began an investigation into a complaint related to Resident #7's fall. The complaint indicates that Resident #7 had a fall with injury on 8/24/24 that required steri-strips due to a laceration. On 9/16/14 at 10:53am Surveyor # spoke with Unit Manager-J and requested the investigation related to this fall. At this time Surveyor # was provided with an incident report dated 8/24/14, that indicated that Resident #7 was found by a CNA in his room on the floor with a laceration to the right side of his face and a small scratch on the left side of the cheek. The incident report also indicated that the actions taken were to apply a chair alarm to the Resident's wheelchair, keep the Resident at the nurse's station, and to apply steri-strips to open area. Surveyor # was also provided with a body check assessment for Resident #7 that was completed at the time of the incident. This report indicated that at the time of the incident the Resident was observed to have no injuries and was in no pain. The report then indicates below that post incident, the Resident was observed to have a laceration to the face, with no pain but does not indicate the location or description of the laceration or does not make any mention of the scratch on the side of the Resident's nose. Surveyor # also reviewed the skin reports dated 8/24/14 that list both injuries but also provides no further description and has an update on 8/25/14 that states, "no scratch noted" and "no laceration noted". Surveyor # asked Unit manager-J if she had any additional information or statements from staff related to how the fall occurred or which staff person responded upon the Resident falling. She stated that she was not able to find any statements from the staff working on the day of the incident and was not sure which staff person found the Resident on the floor. Surveyor # reviewed the nurse's note dated 8/24/14 with the Unit manager-J which indicated that a staff person charted about the incident but it was unclear of who and what actually occurred to cause the fall, she agreed that the notes were unclear. On 9/16/14 at 2:38pm Surveyor # conducted a final interview with Unit Manager-J to inquire about any additional information related to this fall and was provided with 2 statements from staff dated 9/16/14. The first statement indicated that this staff person was on lunch during the time of the fall but the last place she saw him (Resident #7) was at the nurse's station. The second statement indicated that this staff person had brought Resident #7 to the wing and left him sitting across from the nurse's station, then went into another Resident's room to do cares. The statement then indicates that when she came out of the other Resident's room she found out that Resident #7 had fallen in his room. Review of the statements provided at this time still do not provide clarity as to how this incident occurred or who responded to Resident #7 after the incident. Surveyor # reviewed the care plan, which was updated on 8/25/14 to reflect that the Resident is no longer allowed to be left in his room in his wheelchair unattended. Resident #7 prefers to be allowed to be in his room watching his television. Due to the lack of investigation the facility was unaware of how this fall actually occurred or the position of the Resident prior to this fall in order to implement the appropriate intervention. On 9/17/14 the state survey office received additional information from the facility related to this incident and the document contains a statement from a Resident assistant who provided assistance to Resident #7 on the day of the incident. The statement indicated that the staff person had taken Resident #7 into his room, turned on the television, and then proceeded to exit the room. The staff person then reports that around 15-20 minutes later he returned to the room to find Resident #7 on the floor, he stated that it appeared the Resident was "reaching for something on his dresser and fell forward". This statement was obtained on 9/17/14 and does not specifically state where the Resident was placed prior to the fall (i.e. wheelchair, bed, recliner chair), therefore Surveyor # remains unable to determine if the appropriate intervention for preventing this accident was in place. Additionally, the facility still has not completed a thorough analysis of Resident #7's fall to determine what would be appropriate and non-restrictive supervision measures to prevent future falls and still allow Resident #7 access to his personal living space.