Every finding on record at St Dominic Villa

1 of 9 reviewed for bedrailsBased on interview and record review, the facility did not ensure other alternatives were tried prior to installing/utilizing bed rails, failed to accurately assess the risk of possible entrapment, failed to identify and recognize the use of an air mattress with bed rails increases the risk for entrapment, failed to re-assess and obtain an updated consent after the installation of an air mattress with bed rails, and care plan the need and use of bed rails for 1 of 9 residents (R11) reviewed for bed rails.R11 did not have alternatives attempted prior to the facility installing and utilizing bed rails.R11's bed rail assessment was not completed accurately.R11's bed rail assessment and consent form were not updated after the installation of an air mattress.R11's comprehensive care plan was not updated with the need and use of bed rails.R11 became entrapped in the bed rail resulting in multiple abrasions, bruises, and redness on R11's inner upper arm, neck, under jaw, face and torso.The facility failed to ensure other alternatives were tried prior to installing/utilizing bed rails, failed to accurately assess the risk of possible entrapment, failed to identify and recognize the use of an air mattress with bed rails increases the risk for entrapment, failed to re-assess and obtain an updated consent after the installation of an air mattress with bed rails, and care plan the need and use of bed rails. This created a finding of immediate jeopardy that began on 11/16/25 when R11 became entrapped in the bed rail. NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were notified of the immediate jeopardy on 12/11/25 at 2:00 PM. The immediate jeopardy was removed on 12/11/25. However, the deficient practice continues at a scope/severity of D (Potential for harm/Isolated) as the facility continues to implement its action plan.This is evidenced by:On 12/11/25 at 12:10 PM, Surveyor requested the facility's policy on bed rails. DON B indicated the facility does not have a policy for bed rails.According to the Food and Drug Administration (FDA), The FDA recommends the following actions to prevent deaths and injuries from entrapment and falls from adult portable bed rails: When installing and using bed rails: Confirm that the age, size, and weight of the person using the bed rails are appropriate for the bed rails used. Install bed rails using the manufacturer's instructions to ensure a proper fit. Check bed rails regularly to make sure they are still installed correctly as rails may shift or loosen over time. Potential Zones of Entrapment. This guidance describes seven zones in the hospital bed system where there is a potential for patient entrapment. Entrapment may occur in flat or articulated bed positions, with the rails fully raised or in intermediate positions. The seven areas in the bed system where there is a potential for entrapment are . Zone 1: Within the Rail.https://www.fda.gov/medical-devices/adult-portable-bed-rail-safety/recommendations-consumers-and-caregivers-about-adult-portable-bed-rails.According to the Food and Drug Administration (FDA), Recommendations for consumers and caregivers about adult portable bed rails, dated 2/27/2023, indicates the following: Some people are at a high-risk for entrapment, falls or other injury from adult portable bed rails. High-risk people include those with pre-existing conditions such as confusion, restlessness, lack of muscle control, or a combination of these factors. Additionally, people who are cognitively impaired from the use of medication or from a medical condition, such as Alzheimer's or dementia, Parkinson's disease, Multiple Sclerosis (MS), balance disorders, stroke, or low blood pressure (hypotension), are at a higher risk of entrapment and injury. Consider other alternatives when bed rails are not appropriate. Alternatives include roll guards, foam bumpers, lowering the bed as near to the floor as possible, using concave mattresses that can help reduce rolling off the bed, or a bed trapeze to help reposition while in bed and to get in and out of bed.Adult portable bed rails should not be used as a substitute for proper monitoring, especially for people at high risk for entrapment and falls.If your loved one is in a long-term care facility, make sure that a comprehensive assessment and care plan is in place before using bed rails (see information under Recommendations for Health Care Providers).The FDA recommends the following actions to prevent deaths and injuries from entrapment and falls from adult portable bed rails:Before you install bed rails:Check whether the adult portable bed rails you are using comply with ASTM F3186-17: Standard Specification for Adult Portable Bed Rails and Related Products. This FDA-recognized international consensus standard establishes performance criteria for adult portable bed rails including resistance to entrapment.Be aware that not all bed rails, mattresses, and bed frames are interchangeable, and not all bed rails fit all size beds.Check with the manufacturers to make sure the bed rails, mattress, and bed frame are compatible, since most bed rails and mattresses are purchased separately from the bed frame.Rails should be selected and placed to discourage climbing over rails to get in and out of bed, which could lead to falls.When installing and using bed rails:Confirm that the age, size, and weight of the person using the bed rails are appropriate for the bed rails used.Install bed rails using the manufacturer's instructions to ensure a proper fit.Ensure that the safety strap or bed rail retention system is permanently attached to the rail and secured to the bed frame according to the manufacturer's instructions.Regularly inspect the mattress and bed rails for gaps and areas of possible entrapment. Regardless of mattress width, length, and depth, the bed frame, bed rail and mattress should leave no gap wide enough to entrap a patient's head or body.Use caution when using bed rails with a soft mattress as this may increase risk of entrapment between the mattress and bed rail.Be aware that gaps can be created by movement or compression of the mattress which may be caused by patient weight, patient movement or bed position, or by using a specialty mattress, such as an air mattress, mattress pad or waterbed.Check bed rails regularly to make sure they are still installed correctly as rails may shift or loosen over time.R11 admitted to the facility on [DATE] with diagnoses including atrial fibrillation (a heart arrhythmia causing the upper chambers to quiver chaotically instead of beating effectively), stage 3 chronic kidney disease, metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance from an underlying illness, like kidney failure), history of falling, and macular degeneration (an eye disease that blurs central vision).R11's admission record printed on 12/11/25 indicates R11's height is 63 inches (5 feet 3 inches). R11's weight on 12/1/25 was 123.4 pounds.R11's BIMS (Brief Interview for Mental Status) on 8/7/25 has a score of 2, indicating severe cognitive impairment. R11's BIMS on 11/7/25 has a score of 99, indicating R11 was unable to complete the assessment due to cognitive impairment.R11's Side Rail Assessment & Risk Screen dated 8/1/25 includes:Does the resident have an alteration in safety awareness due to cognitive deficit? No.Does the resident use the half side rail or bed bar for positioning, turning or support? No.Based on this assessment, is the use of half side rail or bed bar indicated? No.What kind of adaptive equipment? Side rail or Grab bar. Grab bar was selected.Are any of the following hazards applicable? Resident could attempt to climb over, around, between, or through the rails, or over the foot board. Resident or part of his/her body could be caught between rails, the openings of the rails, or between the bed rails and mattress. No was selected.Of note, the assessment indicates R11 does not have a cognitive deficit and does not use the side rail or bed bar for position, turning, or support. R11's assessment indicates a side rail or grab bar is not indicated. R11's assessment indicates a grab bar for adaptive equipment. R11's assessment indicates R11 could not be caught between the rails or the openings of the rails.R11's assessment states informed consent shall be obtained after alternatives are attempted and what medical need the bed rails would be addressing and what alternatives were attempted but failed and which were not attempted because they were considered inappropriate. Despite not having attempted alternatives or having alternatives that failed, R11's bed rail consent form was signed by resident representative on 8/1/25. This is a standardized form.The consent form includes: Side Rail Benefits include: Security: can provide resident with a sense of security if the resident has a fear of falling, his/her movement is compromised or he/she is accustomed to sleeping in a larger bed. Mobility aid: Can enable resident to reposition self, or to assist in repositioning self either from side to side or upward and downward. Can assist the resident in safely entering and exiting the bed. Potential Negative Outcomes: I understand that the use of the side rail(s) may involve risks such as getting caught in the side rails, getting caught between mattress and side rails, strangulation, hitting the side rails that may cause skin tears, and/or bruising, or crawling over the top of the side rails pose an increased risk of harm or death. Alternatives: Positioning, mat on the floor, specialty bed/mattress. Procedure: It is the standard of practice at [Facility Name] to use side rails as an enabling tool to assist resident/patients and for safety. It is our goal to have appropriate treatment of the resident/patients symptoms by maintaining the highest level of practicable physical and psychosocial well-being interventions in our facility. In all instances, the least restrictive devices will be used - rails, when in use, will be no larger than 1/2 partial rail. I agree to use side rails while at [Facility Name]. I am responsible for the medical treatment/decisions of the above named resident. The risks and alternatives of using side rails, as they apply to this residents' particular condition and circumstances, have been clearly explained to me and/or responsible party and I consent to the use of assist rails.R11's comprehensive care plan includes:Focus: The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) valvular heart disease.Interventions: Bed Mobility: The resident is dependent.R11's physician orders include:Start date 8/1/25. Physical Therapy evaluate and treat per discretion of licensed therapist.Start date 8/1/25. Occupational Therapy evaluate and treat per discretion of licensed therapist.On 12/10/25 at 2:20 PM, Surveyor interviewed DON B (Director of Nursing) regarding R11's bed rail assessment. DON B indicated alternatives were not attempted because of R11's condition. DON B indicated a trapeze or therapy is what the facility attempts as alternatives to bed rails. DON B indicated R11 had poor trunk control and would not be able to utilize a trapeze and therapy was not attempted because R11 was admitted to hospice. DON B indicated the bed rail assessment could have been more accurate to describe R11's condition. However, physician orders indicate R11 was not admitted to hospice until 8/7/25. No physical therapy was attempted between admission on [DATE] and admission to hospice on 8/7/25.R11 had no alternatives to bed rails attempted prior to installing/utilizing bed rails.R11's physician orders include: Start date 8/25/25. Check air mattress function every shift. If not functioning properly notify on call/charge nurse.R11's comprehensive care plan, printed on 12/11/25, includes:Focus: The resident is at risk for impaired skin integrity r/t (related to) fragile skin.Interventions: Air alternating mattress.Of note, R11's comprehensive care plan does not include the use of bed rails, the medical needs to be addressed by the use of bed rails, or the alternatives attempted prior to the use of bed rails. There was no assessment of the appropriateness of the bed rails with the air mattress or assessment of entrapment risks with the air mattress.On 12/10/25 at 2:20 PM, Surveyor interviewed DON B. DON B indicated a new assessment for bed rails was not completed because there was no change with the side rail usage. DON B indicated bed rail assessments are completed quarterly with resident's care plan conferences. DON B indicated R11's quarterly care conference had not been held yet. DON B indicated a new consent with risk versus benefits was not completed because the risk for entrapment did not change when the mattress switched from a regular mattress to an alternating air mattress.Of note, a new Side Rail Assessment and Risk Screen was not completed after the installation of an air mattress on 8/25/25 and a new risk versus benefits consent was not reviewed and updated. Per the FDA, the addition of an air mattress with bed rails can increase the risks of entrapment.On 11/16/25, R11's nurse progress notes, written by LPN C (Licensed Practical Nurse), state: At 1700 (5:00 PM) this shift, this nurse called, via walkie, to resident's room. Resident in bed with padded side rails up. Left arm was wedged under side rail bar with head wedged through side rail bars. Resident was turned on left side with feet hanging over bed. Staff already in room and sliding resident back onto bed. Head and arm able to be wedged back through side rail and resident was repositioned back safely to supine position. Multiple abrasions, bruises, redness noted over multiple areas including, lower left leg, inner upper left arm, neck, under jaw, face, left side of torso. Side rails are in use with consent from family who are aware of risks of injury and entrapment to resident. Hospice notified and informed this nurse they would be here today to assess. DON (Director of Nursing) notified. Pastoral team notified. Resident not able to describe incident. PRN Tylenol given due to painad (Pain assessment in Advanced Dementia, observational tool for rating pain) 8/10.On 12/10/25 at 1:54 PM, Surveyor interviewed LPN C regarding R11's entrapment. LPN C indicated R11 had padded 1/2 bed rails on her bed. LPN C indicated on 11/16/25, he was called to R11's room by staff through the walkie. LPN C stated when he entered R11's room, her arm and head were through the bed rail. LPN C indicated R11's left arm was through the lower portion of the bed rail and her head was through the upper portion of the bed rail. LPN C indicated he had to push down on the middle part of the rail and lift up on the top part of the rail to unwedge R11's head to get her head back through the bed rail. LPN C indicated he did not know how she was able to get her head through the rail. LPN C indicated R11 had significant bruising and some abrasions from the incident. LPN C indicated R11's responsible party had signed a consent form for the bed rails. LPN C indicated he contacted R11's provider and the director of nursing. LPN C indicated he did not complete an incident report, as it was not a fall. On 11/16/25 R11's Risk management report states in part: .Incident description: At 1700 (5:00PM) this shift, this nurse called, via walkie, to residents room. Resident in bed with padded side rails up. Left arm was wedged under side rail bar with head wedged through side rail bars. Resident was turned on left side with feet hanging over bed. Resident Description: Resident unable to give description. was this incident witnessed: N (no). Immediate actions taken: .Resident taken to hospital? N. Injuries observed at time of incident: Injury type.injury location. 16) left antecubital.42)left lower leg (front).64) other (describe). (of note no description given and no injury type selected for any of the 3 locations).predisposing physiological factors.confused.incontinent.impaired member.weakness/fainted.Predisposing situation factors. side rails up. Notes: 11/16/2025 Resident and resident family requested use of siderails due to the thought of it assisting her maintaining some independence with bed mobility. Education provided to residents POA/Care team of the negative outcomes and risk of keeping side rails on bed. Family agreed to these risks prior to this incidence [sic] and signed a risk benefit form to continue to use. At this time this writer has requested the side rails to be removed from residents bed. Fall matt was placed at bedside to be proactive with any falls. On 12/10/25 at 1:31 PM, Surveyor interviewed Maintenance J (MNT) regarding side rails. MNT J indicated he cannot add or remove side rails unless approved by the ADON (assistant Director of Nursing) or DON (Director of nursing). MNT J indicated for an air mattress they put in a work order, and MNT J tries to get it done at meal time. MNT J indicated they have 2 (two) different types of safety rails, clip rail that folds up and down, 12-inch rail that has 2 bolts. MNT J indicated the ADON/DON will tell him which one to put on. MNT J indicated they do not have a tool for it (measuring), we can't have a big gap between the head. There are no gaps, because they could get wedged between side rails and bed. MNT indicated he has never come across a gap and they're all the same width even with air mattresses. MNT j indicated he has never come across a gap even with air mattress, not on the sides or top and bottom. MNT J indicated he installs the mattress and pump, but the nurses set the settings. MNT J indicated R11's side rails were removed on 11/17/25. On 12/10/25 at 2:21 PM, Surveyor interviewed DON B. DON B indicated they assess side rails quarterly with care conferences. DON B indicated R11 was due, her care conference was yesterday (12/9) but she expired before then. DON B indicated they added side rails after assessment because she was assisting with turning and repositioning. DON B indicated R11's family wanted the side rails even if she was unable to use them. On 10/1 discussed as IDT (interdisciplinary team) why resident needed side rails, resident needed them for bed mobility, alternative not attempted due to resident's condition. DON B indicated no therapy due to being hospice. DON B indicated no trapeze due to R11's trunk control. On 12/11/25 at 7:41 AM, Surveyor interviewed DON B again. DON B indicated R11 rolled out of bed the day of admission and that fall was reviewed with no concerns. DON B indicated that R11's mattress was changed to a convertible mattress with tubes inside and a foamy border. DON B indicated there was no difference in risk vs benefits with the change of R11's mattress. DON B indicated audits were completed on side rails in June and December was the next planned audit to be reviewed with care conference. DON B indicated the bed rails are compatible with the bed. DON B indicated after R11 became entrapped in the bed rails, the facility removed the bed rails and placed a floor mat next to R11's bed due to terminal restlessness.The facility failed to ensure other alternatives were tried prior to installing/utilizing bed rails, failed to accurately assess the risk of possible entrapment, failed to identify and recognize the use of an air mattress with bed rails increases the risk for entrapment, failed to re-assess and obtain an updated consent after the installation of an air mattress with bed rails, and care plan the need and use of bed rails. This created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The facility removed the jeopardy on 12/11/25 when the facility completed the following: All residents with siderails will have a side rail assessment completed and a measurement evaluation completed. All consents and risk vs benefits have been reviewed and validated. All residents with siderails have care plans for entrapment risk. Any future siderail or mattress changes will be authorized by the NHA/DON who will ensure alternative modalities, proper documentation, assessments and consents are in place. On 12/11/25, standard operating procedures will include review of alterative modalities trailed, side rail assessment, maintenance measurements evaluation, consent and risk vs benefit document, care plan for risk of entrapment. On 12/11/25, a sweep of all residents with siderails completed with assessment, maintenance measurement evaluation, consent risk vs benefit and care plan for risk of entrapment completed. On 12/11/25, education to all staff before the start of their next shift includes a picture showing area that may cause risk to resident for injury of entrapment, the risk of using siderails with an air mattress as an increase risk for entrapment, residents with cognitive impairment having an increased risk for entrapment, when to alert nursing staff when changes to residents bed mobility and bed mattress change, proper measurement following FDA and CMS guidelines for siderails. On 12/11/25, education to licensed nursing staff before the start of their next shift on updated side rail assessment to ensure accuracy in completion. On 12/11/25, all residents with siderails have completed care plans including risk for entrapment. On 12/11/25, all staff educated before the start of their shift on alternative modalities that can be trialed prior to side rails being placed. On 12/11/25, All risk benefits and consents for side rails will be completed when a new mattress/ air alternating mattress is applied. On 12/11/25, Updated side rail assessment form, initiating maintenance measurement form and ensuring risk for entrapment care plans are completed. On 12/12/25, DON or NHA will conduct audits for changes in mattresses/additions and side rail additions or removals daily at stand-up for 14 days, weekly for 4 weeks and monthly for 3 months. DON or NHA will conduct audits of 5 resident siderails and air mattresses for compliance weekly for 4 weeks and monthly for 3 months.

Based on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 59 residents.Visible dust was observed over a food preparation area. Food was improperly dated. Example 1On 12/9/25 at 11:01 AM, Surveyor observed, with DM E (Dietary Manager), the main kitchen's hood vents with visible clumps of dust on them and hanging off. Directly underneath the hood vents is a stove top and griddle where two pots of food were observed cooking. DM E was asked if he felt the hood vents were clean to which he replied, No, I can see some dust bunnies up there. Example 2 On 12/9/25 at 10:40 AM, Surveyor observed the following food items and corresponding dates:*Cocoa in a container dated 8/8 with no use by or expiration date.*Cheerios in a container, dated 11/25 with no use by or expiration date.*Modified bread mix in a container, dated 6/20, use by 7/20.*Three containers of pasta, one marked 10/25, use by 11/25, another marked 10/10, use by 11/10, and a third with no opened, use by or expiration dates. At this time, DM E indicated that those food items were marked that way as he felt they would be used by the stated use by date. Additionally, DM E indicated that the cocoa should have a use by/expiration date

Based on interview and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 wound care observations. Staff did not perform hand hygiene in between glove changes during wound care for R48. Evidenced by:The facility policy entitled Hand Hygiene, dated 12/5/2024, states, in part: . I. Policy: The organization will promote clean hands as the single most important factor in preventing the spread of pathogens, antibiotic resistance, and incidence of infections. II. Procedure: A. Specific Indications for Hand Hygiene.4. After touching a patient or the patient's immediate environment.6. Immediately after glove removal. Evidenced by:R48 admitted to the facility on [DATE] and has diagnoses that include Type II Diabetes Mellitus (Type 2 diabetes happens when the body cannot use insulin correctly and sugar builds up in the blood) and pressure ulcer of left ankle stage 3 (involves full-thickness skin loss, where the wound extends through the dermis into the fatty (subcutaneous) tissue, creating a crater). R48's Minimum Data Set (MDS) Quarterly Assessment, dated 11/4/2025, shows no score of a Brief Interview of Mental Status (BIMS) score indicating R48 is not cognitively intact. On 12/10/25 at 9:52 AM, Surveyor observed LPN C (Licensed Practical Nurse) perform wound care on R48. During wound care LPN C removed gloves and applied new gloves without performing hand hygiene in between. LPN C pulled R48's curtain and raised bed with foot board control and then proceeded with wound care without changing gloves or completing hand hygiene. On 12/10/25 at 10:14AM, Surveyor interviewed LPN C and asked when hand hygiene should be performed during wound care. LPN C indicated when going from dirty to clean. Surveyor asked LPN C if hand hygiene should be performed with removal of gloves, and LPN C indicated yes, and he should have performed hand hygiene with glove removals. On 12/10/25 at 10:16A M, Surveyor interviewed ADON D (Assistant Director of Nursing) and asked if hand hygiene would be expected in between glove changes. ADON D indicated yes if touching things in between. Surveyor informed ADON D of observation of LPN C with no hand hygiene in between glove changes and touching R48's curtain and bed control with no hand hygiene and glove change. ADON D indicated she would have expected hand hygiene in between glove changes.

Based on interview and record review, the facility did not provide behavioral health services to ensure the highest practicable mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 of 15 residents (R6) reviewed. R6 admitted to the facility with a history of post-traumatic stress disorder (PTSD). The facility failed to include PTSD on R6's comprehensive plan of care, nor were staff aware of any of R6's PTSD triggers. This is evidenced by: The National Institutes for Health states, in part: .PTSD can develop after exposure to a potentially traumatic event that is beyond a typical stressor. Events that may lead to PTSD include, but are not limited to, violent personal assaults, natural or human-caused disasters, accidents, combat, and other forms of violence. Exposure to events like these is common. People who experience PTSD may have persistent, frightening thoughts and memories of the event(s), experience sleep problems, feel detached or numb, or may be easily startled. In severe forms, PTSD can significantly impair a person's ability to function at work, at home, and socially. The State Operations Manual, Appendix PP states, in part: Providing behavioral health care and services is an integral part of the person-centered environment. This involves an interdisciplinary approach to care, with qualified staff that demonstrate the competencies and skills necessary to provide appropriate services to the resident. Individualized approaches to care (including direct care and activities) are provided as part of a supportive physical, mental, and psychosocial environment, and are directed toward understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities. In addition to the facility-wide approaches that address residents' emotional and psychosocial well-being, facilities are expected to ensure that residents' individualized behavioral health needs are met. Behavioral health care and services could include: Ensuring that the necessary care and services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety; Ensuring that direct care staff interact and communicate in a manner that promotes mental and psychosocial well-being. The facility policy, entitled, Comprehensive Person Centered Care Plan, dated 7/9/19 with most recent review date of 5/8/25, states, in part: Policy: The Comprehensive Person Centered Care Plan will reflect the individual's needs and preferences to facilitate care. Procedure: . B. Within 21 consecutive days after admission, and in correlation with the Minimum Data Set (MDS), a comprehensive assessment will be completed and a written care plan will be developed based on the individual's history, preferences, and assessments from appropriate disciplines and the physician's evaluation and orders. The facility policy, entitled, Trauma Informed Care, dated 8/28/19 with most recent review date of 2/21/24, states, in part: Policy: Entity will establish a trauma-informed approach that will recognize signs and symptoms of trauma in individuals. Entity will treat all individuals with dignity and respect and will promote a culture of trauma-informed care. Procedure: A. Individuals: i. Upon admission individuals will be screened for trauma exposure and/or related symptoms. v. Care plan will be established collaboratively with the Individual with trauma-informed care in mind. B. Employees: i. Will be educated on Trauma Informed Care upon hire and as needed. ii. Will be assessed on their acquired knowledge of Trauma Informed Care. R6 was admitted to the facility on [DATE], with diagnosis that include, in part: Type 2 Diabetes Mellitus, Unspecified Dementia with Anxiety, Bipolar Disorder, unspecified, Obsessive-Compulsive Disorder, unspecified, Post-Traumatic Stress Disorder, unspecified, Insomnia, unspecified, Fibromyalgia, Suicidal Ideations, Personal History of Suicidal Behavior, and Anxiety Disorder, unspecified. R6's most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/8/25 states in part, R6 has a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating that R6 is cognitively intact. Section I of R6's an active diagnosis of Post-Traumatic Stress Disorder. R6's Trauma Informed Care Screening, dated 9/21/23, states, in part: A. What have been the most difficult time(s) in your life? States relocating to the US from [NAME]. States she has ran an adult family home with her husband for the developmentally disabled. States their house manager began carving swastikas into her vehicle and raped her in the driveway. Stated her mother-in-law forced her to change her name to [NAME] as she did not want her friends/neighbors to know her son had married a [NAME]. B. Have you ever been through anything life threatening or traumatic? Yes.C. Do you ever experience disturbing memories, thoughts, dreams or other side effects (such as heart pounding, trouble breathing, or sweating) related to this (these) difficult experiences? Yes. R6's Psych admission Evaluation Note from Southwest IP (Inpatient) provided by the facility, dated 8/31/23 (prior to R6's admission to the facility), states, in part: Patient born in [NAME]. Reported history of two rapes., and included the diagnosis of Post-Traumatic Stress Disorder. R6's Behavioral Health Note, dated 11/2/25, states, in part: pertinent mental health problems: anxiety disorder, PTSD (Post Traumatic Stress Syndrome) and depression. Of note: At the time of Survey, R6's Comprehensive Care Plan did not include anything about PTSD or R6's triggers, despite R6 having a diagnosis of PTSD prior to admission, PTSD being indicated on the facility's trauma informed care assessment, PTSD being included on her facility diagnosis list, PTSD indicated on her MDS, and PTSD being listed as an active problem on a recent behavioral health note that was included in R6's medical record and provided to surveyor by the facility. On 12/10/25 at 8:58 AM, Surveyor interviewed R6, who stated that she grew up in [NAME] during a war zone and a British officer shot her and shot and killed the horse she was riding on. R6 pointed to a scar on her interior forearm and indicated that scar was from the bullet. R6 stated that her ulnar nerve was damaged during the surgery that was performed to remove the bullet from her arm. R6 stated, I've seen things that you can't unsee. R6 indicated that the facility staff were not aware of her PTSD or her triggers. R6 stated that food was a trigger for her because her hands were starting to cripple because of the damage done to her ulnar nerve, and can only use special adaptive silverware and even with that it is difficult for her to eat without spilling on herself. R6 stated she just cannot eat in front of other people and staff try to make her, and then she becomes a weeping, screaming mess, really putting on a show. R6 indicated that the staff don't do anything for her PTSD. On 12/10/25 at 12:55 PM, Surveyor interviewed MT F (Med Tech). Med Tech F indicated that R6 never ate in dining room. Surveyor asked MT F if she knew why R6 never ate in the dining room. MT F stated that she had no idea, she just knew that R6 prefers to eat in her room, and when they try to get her to eat in the dining room, R6 becomes very anxious and upset about it. Surveyor asked MT F how she would know if a resident were a trauma survivor and what she would need to do differently for that resident. MT F stated she would watch the resident, their routine and see if something specific triggers them, such as if they seem anxious about who is coming into their room or anxious about certain situations. MT F indicated she would also watch to see if the resident had bouts of crying or self-isolation. Surveyor asked MT F if she was aware that R6 had a diagnosis of PTSD. MT F stated she wasn't aware, but she wasn't surprised based on some of R6's behaviors. Surveyor asked MT F if R6's PTSD was something that should be on her care plan. MT F indicated that was something that should probably be on R6's care plan, but that R6 did have a lot of other things like anxiety and depression that she took medication for and that had interventions on her care plan. On 12/10/25 at 1:01 PM, Surveyor interviewed CNA G (Certified Nursing Assistant). Surveyor asked CNA G if R6 ever ate in the dining room. CNA G stated no, that R6 always eats her meals in her room. Surveyor asked CNA G if she knew why R6 never ate in the dining room. CNA G stated she wasn't sure and would have to ask the nurses. Surveyor asked CNA G how she would know if a resident were a trauma survivor and what she would need to do differently for that resident. CNA G stated she would ask one of the nurses. Surveyor asked CNA G if she was aware that R6 had a diagnosis of PTSD. CNA G stated no, that she was not aware of that. On 12/10/25 at 1:07 PM, Surveyor interviewed CNA H. Surveyor asked CNA H if R6 ever ate in the dining room. CNA H stated no, that R6 always eats her meals in her room. Surveyor asked CNA H if she knew why R6 never ate in the dining room. CNA H stated she thought it was just R6's personal preference. Surveyor asked CNA H how she would know if a resident were a trauma survivor and what she would need to do differently for that resident. CNA H stated she would check their CNA Kardex and care plan. Surveyor asked CNA H if PTSD was on R6's Kardex. CNA H reviewed R6's Kardex with Surveyor and indicated that it did not say PTSD anywhere on the Kardex. On 12/10/25 at 2:22 PM, Surveyor interviewed SW I (Social Worker). Surveyor asked SW I how he would know if a resident is a trauma survivor? SW I stated that when residents come in there is a form that is trauma informed care and social history that he completes with the resident. Surveyor asked SW I what he would need to do differently for a resident who was a trauma survivor. SWI stated that PTSD was his specialty, and that everyone is different. SW I indicated that observation is important and seeing if someone is in distress or something causes them distress and identify the triggers so that you can reduce those from occurring. SW I stated that he tries to establish a relationship with the residents and observe if anything appears to make them uncomfortable. SW I stated that he watches the resident for nonverbal cues and then its important to get those triggers on the resident's care plan. Surveyor asked SW I about R6's PTSD diagnosis and if that was on R6's care plan. SW I indicated that with R6 it was difficult because she can be very guarded and that R6 sometimes changes her story. SW I stated that R6 told him that she was born in [NAME] and that the British soldiers had raped her and that she didn't like British people. Surveyor asked if that was on R6's care plan so that staff could be made aware that R6 may be triggered by British accents, etc. SW I stated that he didn't think it was but that he doesn't update the care plans. Surveyor asked SW I if he was aware of R6's trigger about not wanting to eat in the dining room. SW I stated that he was aware that R6 had a lot of apprehension because she doesn't eat pork or has a special diet and she doesn't want people to know about that. SW I indicated that R6 likes to sit in her room with her own particular diet and that R6 told him that she is more comfortable in her room with her dietary restrictions so she doesn't have to explain that to everybody. Surveyor asked SW I if he was aware that R6 was triggered by eating in the dining room because of her fear of making a mess with her food in front of her peers. SW I stated he had never heard that, but that R6 was very inconsistent in what she does. SW I stated that his job was to validate the resident's reality, not question them, and that R6's diagnosis of PTSD and her triggers should absolutely be integrated into her care plan. On 12/10/25 at 3:21 PM, Surveyor interviewed DON B (Director of Nursing) and asked her if R6's diagnosis should be on her care plan. DON B reviewed R6's care plan and stated that she did not see PTSD on her care plan. DON B indicated that it would be a good idea to have that on R6's care plan. DON B stated that R6 does have behavioral issues and they are on the CNA Kardex, which indicates that staff is to be respectful of her beliefs, etc. DON B indicated that MDS Coordinator/ADON D (Assistant Director of Nursing) was responsible for updating the resident's care plans. On 12/10/25 at 3:30 PM, Surveyor interviewed ADON D, who stated that she is responsible for updating the care plans, but that R6 was admitted before she started with the facility in that role. ADON D stated that typically she will update the resident's care plans with new medications, therapy, etc. Surveyor asked ADON D if R6 had a current diagnosis of PTSD, should it be included on her care plan. ADON D stated yes, that should be on R6's care plan.

Based on observation, interview, and record review, the facility did not ensure that 2 of 2 residents (R) reviewed for pressure injuries (PI) (R36 and R8) received care consistent with professional standards of practice to prevent the development of a new pressure injury and promote healing of existing PIs. R36 was at risk for PI development. R36 developed multiple stage 3 PI's. The facility failed to evaluate the effectiveness of current interventions R36 had in place. The facility did not reposition R36 for several hours, did not find PI's until they were at a Stage 3, missed weekly wound treatments, and did not provide proper infection control measures during wound dressing change. R8 was at risk for PI development. R8 developed multiple stage 3 PI's. The facility failed to evaluate the effectiveness of current interventions R8 had in place. The facility did not reposition R8 for several hours, did not find PI's until they were at a Stage 3, missed weekly wound treatments, and did not provide proper infection control measures during wound dressing change. The facility's failure to monitor and re-evaluate R36 and R8 plan of care, implement aggressive PI prevention measures after re-evaluation and monitor the effectiveness of the interventions, ensure R36 and R8 were repositioned per poc or standards of practice, identify PIs prior to Stage 3, complete weekly measurements created a finding of immediate jeopardy which began on 3/4/24. Surveyors notified NHA A (Nursing Home Administrator), DON B (Director of Nursing), and Regional Nurse of the immediate jeopardy on 8/15/24 at 12:58 PM. The immediate jeopardy was removed on 8/15/24; however, the deficient practice continues at a severity/scope of D (Potential for Harm/Isolated) as the facility continues to implement its action plan. Findings include: Guidelines from the National Pressure Injury Advisory Panel (NPIAP) 2016, Pressure Injury Prevention Points, accessed 07, March 2024, Prevention Points | National Pressure Ulcer Advisory Panel (npiap.com), states in part: Turn and reposition all individuals at risk for pressure injury, turn the individual into a 30-degree side-lying position and use your hand to determine if the sacrum is off the bed, ensure that the heels are free from the bed, use heel offloading devices for high-risk pressure injuries. The facility policy entitled, Pressure Injury Prevention and Managing Skin Integrity, dated 08/10/23, states in part: .a. Identify interventions. i. The care and intervention for any identified skin breakdown or wound is intended to prevent any further advancement of the wound or additional skin breakdown. -There will be collaboration with the IDT regarding the presence of breakdown and the intervention plan. -Identification of risk factors present or acquired that compromise skin integrity will be considered . 1. R36 was admitted to the facility on [DATE] with diagnoses including, in part, unspecified dementia, neuromuscular dysfunction of the bladder, cerebral infarction, and diabetes mellitus. R36's Minimum Data Set (MDS) assessment, dated 5/23/23, identified on admission that R36 had a Brief Interview for Mental Status (BIMS) score of 6. This indicated R36 had severe cognition impairment. The MDS assessment also identified R36 required total dependent assistance of two people for bed mobility, taking on and off footwear, rolling left to right, sit to lying, chair to bed, toileting, and for transfers. MDS also indicated that R36 was determined to be at risk for PI's. MDS dated on 2/22/22 indicated that R36 but did not have any active PIs on admission. Surveyor reviewed R36's Activities of Daily Living care plan: BED MOBILITY Initiated on 8/9/24, revised on 8/9/24: -The resident is totally dependent on staff for bed mobility and repositioning and turning in bed 1-2 person assist. TOLIET USE Initiated on 2/23/22 revised on 2/09/23: -2 assist. TRANSFER Initiated on 2/23/22, revised on 2/10/23: -2 assist and Hoyer. Surveyor reviewed R36's IMPAIRED SKIN Care Plan: -Administer treatments as ordered and monitor for effectiveness initiated on 2/23/22. -Blue boots while in bed and chair if possible initiated on 5/4/23. -Follow facility policies/protocols for the prevention/treatment of skin breakdown initiated on 2/23/24. -If up in chair for more than 60 mins, the weight must be off loaded by reclining while sitting in the Broda chair initiated on 10/26/23 and revised on 7/25/24. -Monitor/document/report as needed any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length x width x depth), stage initiated on 2/23/22. -Staff to assist with check/change and skincare incontinence initiated on 2/23/22. -Staff to assist with turning and repositioning initiated on 2/23/22, revised on 8/9/24. -The resident needs assistance to turn/reposition, as needed or requested initiated on 2/26/22, revised on 10/25/23. -The resident requires pressure relieving/reducing device/air mattress on bed, and pressure relieving cushion in wheelchair initiated on 2/26/22, revised on 2/9/23. Surveyor reviewed Activities of Daily Living (ADL) CNA Kardex sheet: -If up in chair for more than 60 mins, the weight must be off loaded by reclining while sitting in the Broda chair -Lay resident down after lunch. -Transfer Hoyer with 2 assists. -The resident is totally dependent on staff for bed mobility and repositioning and turning in bed 1-2 person assist. -Staff is to assist with turning and repositioning. -Turn and reposition. limit sitting to 60 minutes. -Turn and reposition resident every 2 hours while in bed. Surveyor reviewed physician orders, which include: .-5/29/22-Blue boots to float heels to be on at all times in bed and when possible, when in chair. -10/24/23- limit sitting to 60 minutes, off load wound every shift. -7/11/24- Complete skin only assessment, ensure that bath is completed and document refusals. -7/15/24-Apply calcium alginate and cover with gauze island dressing daily to left ankle. Every evening shift for IC, Wound care. When doing wound care we need to make sure we are putting a wound note in every time about the location, appearance of wound, drainage, s/sx of infection, pain, and what was applied to the area . Surveyor reviewed wound care notes: -On 7/24/23- Initial assessment of a non pressure wound to the left sacrum, right buttock, and left buttock. There is no description of these non pressure areas, no assessment or measurements describing the non pressure areas. -On 7/31/23-Initial assessment of a Stage III pressure wound to the coccyx full thickness 2.0 cm x 0.5 cm x 0.2 cm. non-pressure wound of the right buttock full thickness 7.0 cm x 1.5 cm x 0.1 cm. Of note, the facility does not mention the left sacrum or left buttock. The facility did not discover R36's coccyx until it was a Stage 3. R36 had already presented with non pressure areas to the left sacrum, and right and left buttocks. This should have put the facility on notice to do robust skin checks on R36 every shift. *Physician recommendations reposition per facility protocol, offload wound, Group-2 Mattress, upgrade offloading chair cushion. Primary dressing: Leptospermum honey apply once daily for 30 days. Foam silicone border apply once daily for 30 days. -On 8/21/23-Wound care assessment was missed. -On 10/23/23-the right buttock non-pressure deteriorated to an unstageable deep tissue injury to the right buttock 4.5 cm x 5.5 cm x 0.1 cm. *Physician recommendations limit sitting to 60 minutes, reposition per facility protocol, off load wound, upgrade offloading chair cushion. Primary dressing: Leptospermum honey apply once daily for 30 days. Gauze island w border apply once daily for 30 days. -On 10/24/23 a physician order was given to limit sitting to 60 minutes, offload wound every shift. -On 10/26/23 intervention put into place on care plan: -If up in chair for more than 60 mins, the weight must be offloaded by reclining while sitting in the Broda chair. On 12/4/23- Right buttock wound was described as a Stage III pressure wound of the right buttock full thickness 4 cm x 1.3 cm x 0.2 cm. (Wound is smaller in size but deeper than it had been on 10/23/23.) *Physician recommendations limit sitting to 60 minutes, reposition per facility protocol, off load wound, upgrade offloading chair cushion. Primary dressing: Leptospermum honey apply once daily for 16 days. Gauze island with border apply once daily for 16 days. -On 12/11/23-Stage III pressure wound of the right buttock full thickness 2 cm x 2 cm x 0.3 cm. Initial assessment of a Stage III pressure wound to the coccyx full thickness 2 cm x 0.5 cm x 0.2 cm. *Physician recommendations limit sitting to 60 minutes, reposition per facility protocol, off load wound, upgrade offloading chair cushion. Primary dressing: Leptospermum honey apply once daily for 9 days. Gauze island w border apply once daily for 9 days. Of note, R36 now presents with two Stage 3 PI's. -On 12/25/23- Wound care assessment was missed. -On 1/24/24-Stage III pressure wound of the coccyx full thickness resolved. -On 2/19/24- Assessment of a Stage II pressure wound to the left Buttock partial thickness 3 cm x 1 cm x 0.05 cm. Of note, R36 is now presenting with third PI, now a Stage 2, to the left buttock. Physician recommendations reposition per facility protocol, off load wound. Primary dressing: Leptospermum honey apply once daily for 30 days. Gauze island w border apply once daily for 30 days. Despite the care planned interventions, R36 continues to develop PI's. There is no evidence in R36's medical record to indicate the Interdiscplinary Team (IDT) evaluated the effectiveness of the current interventions and if the interventions were effective. -On 3/25/24- Wound care assessment was missed. Facility did not re-evaluate effectiveness of current interventions or placed new interventions in place. -On 4/1/24- Stage III pressure wound of the left ankle full thickness 3x2x0.2 cm. Of note, this is the 4th PI for R36. The facility did not discover this PI until it was a Stage 3. Physician recommendations reposition per facility protocol, off load wound, pressure off-loading boot. Primary dressing: Alginate calcium w/silver apply once daily for 30 days. Gauze island with border apply once daily for 30 days. Facility found R36 to have a new stage III PI to the left ankle and no new interventions were put into place. -On 4/29/24- Assessment of Stage II pressure wound to the left buttock partial thickness 1.5 cm x 0.76 cm x 0.1 cm. (Wound is smaller but deeper than it had been on 2/19/24.) *Physician recommendations limit sitting to 60 minutes, reposition per facility protocol, off load wound, upgrade offloading chair cushion. Primary dressing: zinc ointment apply Q-shift 3x day for 9 days. -On 6/17/24- Wound care assessment was missed. -On 6/24/24- Non pressure wound of the right buttock full thickness 4.8 cm x 1.83 cm x 0.1 cm. Physician recommendations reposition per facility protocol, and off load wound. Primary dressing: zinc ointment applies Q-shift 3x day for 16 days. Facility found R36 to have a new non pressure injury to the right buttock and no new interventions were put into place. -On 7/1/24- Stage II pressure wound of the right buttock partial thickness 2.45 cm x 2.02 cm x 0.1 cm. Physician recommendations reposition per facility protocol, and off load wound. Primary dressing: zinc ointment applies Q-shift 3x day for 9 days. Physician ordered: -On 7/11/24 to complete skin only assessment, ensure that bath is completed and document refusals. No other interventions were put into place to off-load the PI area. -On 7/15/24-Apply calcium alginate and cover with gauze island dressing daily to left ankle. Every evening shift for IC, Wound care. When doing wound care, we need to make sure we are putting a wound note in every time about the location, appearance of wound, drainage, s/sx of infection, pain, and what was applied to the area . Wound care notes continue: -7/29/24-Stage III pressure wound of the left ankle full thickness 1.99x0.92x0.2 cm, Stage II pressure wound of the right buttock partial thickness 8.06x4.37x0.1cm. Wound notes indicate that R36's PI to the left ankle and R36's PI to the right buttock is getting bigger and there were no further interventions were put into place. Observations: On 8/13/24 at 8:13 AM, Surveyor observed R36 lying on back supine in bed, staring at ceiling. Surveyor introduced self but R36 did not respond. R36 was non-interviewable. Surveyor observed an air mattress in place on bed. Surveyor observed no pillow under R36's head and R36 lying crooked in bed. On 8/13/24 at 8:20 AM, Surveyor observed CNA K enter R36's room with CNA M. CNA K and CNA M began turning and rolling R36. R36 was lying in bed staring at ceiling with pants pulled down to knees. CNA K looked at brief and stated out loud, Dry, so she is good to get up. CNA K and CNA M began rolling R36 and tucking Hoyer sling under R36. CNA K and CNA M transferred R36 into wheelchair and pushed R36 out to the dining room for breakfast. On 8/13/24 at 9:21 AM, Surveyor observed R36 sitting in lounge after breakfast parked next to TV in Broda chair with Podus boots in place on feet, but feet positioned outwards with R36's ankles applying pressure to ankles bilaterally. Surveyor did not observe staff lay R36 down or reposition R36 for pressure relief interventions. On 8/13/24 at 10:12 AM, Surveyor observed activities staff take R36 outside for the activity. R36 sitting in Broda chair with Podus boots in place on feet but feet positioned outwards with R36's ankles applying pressure to ankles bilaterally. Surveyor did not observe R36 repositioned or toileted. On 8/13/24 at 12:10 PM, Surveyor observed staff take R36 to the dining room for lunch. R36 sitting in Broda chair with Podus boots in place on feet but feet positioned outwards with R36's ankles applying pressure to ankles bilaterally. Surveyor did not observe R36 repositioned or toileted. On 8/13/24 at 1:30 PM, Surveyor observed R36 sitting in dining room for music activities. R36 sitting in Broda chair with Podus boots in place on feet but feet positioned outwards with R36's ankles applying pressure to ankles bilaterally. On 8/13/24 at 2:43 PM, Surveyor interviewed CNA K and asked CNA K if CNA K or CNA M had laid R36 down in bed, checked and changed R36, or repositioned R36 since getting R36 into wheelchair. CNA K indicated that CNA K and CNA M did not have time to lay R36 down or reposition R36 as CNA K and CNA M were swamped with their duties and every time CNA K went to grab R36 to take her to reposition, R36 was in activities. On 8/13/24 at 3:08 PM, Surveyor interviewed CNA O and CNA H and asked if CNA O and CNA H are aware that R36 has not been repositioned or toileted since 8:40 AM. CNA O and CNA H indicated that it was given to them in report from day shift that R36 has not been repositioned or toileted. CNA O and CNA H indicated they could lay R36 down now if Surveyor would like. CNA O and CNA H grabbed Hoyer lift and entered R36's room with R36. CNA O and CNA H transferred R36 from wheelchair to the bed. During observation Surveyor observed R36 grimacing once CNA O and CNA H started lifting R36 up into the air. Once CNA O and CNA H lowered R36 to bed, R36 stopped grimacing. CNA O and CNA H began rolling R36 to the right side and R36 grimaced again and jerked hands close to body. CNA H started pulling Hoyer sling out from under R36. CNA H rolled R36 to the right side and CNA O finished pulling Hoyer sling out. CNA O and CNA H placed pillow under R36's legs, and then covered R36 with sheet. Surveyor observed CNA O and CNA H start to doff (take off) PPE (Personal Protective Equipment) and clean up room to leave. Surveyor interviewed CNA O and CNA H and ask what process they utilize to check to see if R36 has a Bowel Movement (BM). CNA H indicated that R36 is on a bowel routine. Surveyor asked CNA H to clarify what a bowel routine is. CNA H indicated that R36 has a BM in the morning when staff are rolling R36 and usually at night time when rolling. Surveyor asked CNA H if CNA H and CNA O plan on checking R36's brief to see if R36 had BM in brief since CNA H and CNA O were rolling R36 in bed. CNA H and CNA O placed new pair of gloves on and indicated that they would roll R36 now before they leave and check to see if R36 has had a BM. CNA H and CNA O rolled R36 and took brief off. Surveyor observed dried medium BM on R36's bottom. Surveyor also observed R36 to have a reddened purple quarter-size wound on the right buttock. Surveyor did not observe a bandage or covering for R36's wound on the buttock. Surveyor observed CNA O and CNA H clean R36 with wet wash cloths and CNA O applied barrier cream to the lower part of R36's buttocks but did not apply barrier cream on R36's upper buttock area and where the wound is located on R36's right buttock. Surveyor observed CNA H and CNA O reposition R36 to R36's left side and propped a pillow behind R36's hips. Surveyor observed R36 to have Podus boots in place while in bed. On 8/13/24 at 3:52 PM, Surveyor interviewed Registered Nurse (RN) I and asked how often R36 receives wound dressing care. RN I indicated that weekly wound rounds are completed by outside consultant and RN I every Monday of the week. RN I utilizes an app on phone that captures a picture of the wound and calculates measurements that links to the Electronic Health Record (EHR). Surveyor asked RN I if RN I could explain R36's wounds to Surveyor. RN I indicated that R36 has a stage III on ankle that started April 1st, 2024. RN I indicated that interventions put into place is wound care orders, pressure relieving devices such as the air mattress and blue Podus boots, off-loading, and limit 60 minutes up at a time. RN I indicated to Surveyor that RN I is aware that the pressure relieving devices were put into place on admission but RN I indicated that RN I encourages staff to utilize pressure relieving devices. RN I indicated that R36 has a stage II on right buttock that keeps healing and reopening that originally started in October 2023. Surveyor indicated to RN I that through observation on 8/13/24 from 8:20 AM - 3:08 PM Surveyor observed R36 not repositioned or toileted for 6.5 hours. Surveyor asked RN I what expectation would be for staff when repositioning and off- loading R36. RN I indicated that expectation would be to reposition R36 while in bed every 2 hours and if R36 is up in wheelchair that R36 does not stay up for more than 60 minutes at a time for off-loading R36 off of R36's pressure injuries. On 8/14/24 at 7:40 AM, Surveyor observed CNA Z, CNA BB, and CNA AA bring R36 out of room for breakfast. R36 was in a Broda chair. On 8/14/24 at 10:10 AM, Surveyor observed R36 in Broda chair sitting in lounge. Surveyor did not observe staff reposition or toilet R36 between observations. On 8/14/24 at 2:38 PM, LPN L (Licensed Practical Nurse) reviewed supplies and then gathered the contaminated wound cleanser bottle and contaminated calcium alginate package LPN L previously used from R8's wound dressing change and entered into R36's room. LPN L set supplies on bedside table and went into bathroom and grabbed gloves. Surveyor did not observe LPN L wash hands before applying gloves. Surveyor did not observe LPN L don PPE in R36 Enhanced Barrier Precaution (EBP) room. LPN L uncovered R36 and took boot off of R36. Surveyor did not observe LPN L place a barrier down under R36's leg. Surveyor observed a saturated bloody brown tinged meplix rolled half off R36's left ankle wound exposing the left malleolus dime size wound. LPN L removed the saturated dressing and threw in the trash. LPN L set R36's left ankle back down on the contaminated bed. Surveyor observed R36's open wounds on left ankle lay directly down on contaminated mattress sheet. LPN L took gloves off and washed hands for 8 seconds. Surveyor observed 3 open dime size wounds on R36's left ankle. Surveyor observed about a dime size open wound with depth and was noticeable metal hardware like in the wound bed located on R36's left ankle lateral malleolus with eschar noted. Surveyor noted hardware showing in the lateral malleolus, but no measurements of depth were assessed at the time by LPN L. Surveyor noted second dime size open area located superior to the first wound. Surveyor observed third pea size open area located to the left of the second wound on R36's left ankle area. Surveyor asked LPN L when R36 developed the 3 open spots near the left ankle wound observed. LPN L indicated that LPN L thought there was only one open wound. LPN L grabbed scissors and began cutting calcium alginate. LPN L cut two pieces to cover the 3 open wounds on R36's left ankle. LPN L lifted R36's leg up and grabbed a piece of gauze and re-wiped all 3 open wounds with the same piece of gauze. LPN L laid contaminated gauze on R36's mattress. LPN L then took the calcium alginate strips and applied the strips to R36's wounds. Surveyor observed one calcium alginate strip fall onto R36's mattress on top of the contaminated gauze. LPN L picked the fallen strip on the contaminated gauze up and reapplied it to R36's left ankle wound. LPN L then grabbed meplix foam dressing and applied the dressing to R36's left ankle. LPN L reapplied R36's sock and placed Podus boot on R36. LPN L took gloves off and exited R36's room. Surveyor observed LPN L place gauze package, wound cleanser, and scissors in treatment cart. Surveyor observed LPN L only sanitize scissors and did not sanitize wound cleanser bottle or throw the gauze package away that was brought into R36's room. On 8/14/24 at 2:48 PM, Surveyor interviewed LPN L and asked what expectation was for wearing PPE in R36's room on EBP (Enhanced Barrier Precautions). LPN L indicated that LPN L only wears PPE when providing cares for catheter care. Surveyor asked LPN L does LPN L not wear PPE during wound care. LPN L indicated that LPN L did not realize that staff are to wear PPE during wound care. Surveyor asked LPN L if LPN L wore PPE in R36's room when LPN L provided wound care. LPN L indicated that LPN L did not wear PPE in R36 room. Surveyor asked LPN L why LPN L did not clean surface of R36's bedside table before placing wound supplies on bedside table. LPN L indicated that LPN L usually does wipe the bedside tables down, but LPN L did not wipe R36's bedside table off before placing wound supplies down. Surveyor asked LPN L was it common practice to not place a barrier down underneath the wound before completing wound care on R36. LPN L indicated that LPN L usually LPN L will place a barrier pad underneath the residents wound when performing wound care, and LPN L did not place barrier pad underneath R36's left ankle. Surveyor asked LPN L what normal practice is when LPN L dropped the calcium alginate strip unto the contaminated gauze and picked the calcium alginate strip and placed it on R36's open wound. LPN L indicated that LPN L should not have placed the contaminated calcium alginate strip back unto R36's wound. LPN L indicated that LPN L should have re-cut a new strip, but LPN L did not. On 8/14/24 at 2:50 PM, Surveyor interviewed RN I (Registered Nurse) and asked for description of R36's wound bed. RN I indicated that the provider and RN I are aware that there is some kind of hardware in R36's ankle and it is showing but that wound has improved. RN I indicated that R36's left ankle wound is noted to be stage III. Surveyor asked expectation for staff wearing PPE in R36 and R8's room on EBP. RN I indicated that all staff are to wear PPE when providing cares to R36 and R8 as both have open wounds and R36 has catheter. Surveyor asked RN I expectation for staff utilizing wound supplies between residents. RN I indicated that supplies should be used for each resident individually and if there is a supply that is shared that the item is wiped down with antibacterial wipes and sanitized appropriately before using the supplies for other residents. RN I indicated that LPN L should have sanitized wound supplies and not brought in contaminated wound supplies from R8's room into R36 's room. RN I indicated that LPN L not sanitizing the scissors that dropped on the floor was a huge infection control issue and LPN L should never have used to cut calcium alginate for R8's wound without properly disinfecting the scissors. Surveyor asked RN I expectation for staff when changing wound dressings. RN I indicated that proper hand hygiene is performed, bedside tables are sanitized, and barriers are placed under the residents wounds to prevent contamination of the wound. RN I indicated that if there was a break in the infection control measures that staff are to stop and start over to prevent further infection from spreading. Surveyor indicated to RN I that LPN L did not wipe bedside table, did not place a barrier pad underneath residents wound, and allowed a strip of calcium alginate to fall on contaminated mattress and then used the contaminated strip to place in a wound. RN I indicated that LPN L should not have performed the wound dressing change. RN I indicated that both wound dressing changes were not performed correctly by LPN L. On 8/14/24 at 3:15 PM, Surveyor called provider who has been following R36's wound description and measurements every Monday. No answer. Surveyor left message in voicemail. On 8/15/24 at 9:17 AM, Surveyor interviewed DON B and asked expectation for repositioning and toileting residents. DON B indicated that all residents are to be repositioned every two hours who need the assistance. All residents should be helped toilet or toileted if dependent every two hours. On 8/15/24 at 10:39 AM, Surveyor interviewed RN I who indicated that RN I changed R36's ankle wound. RN I indicated that RN I did assess the two new open areas near R36's ankle. RN I indicates that RN I thinks the new open areas were most likely from the gauze island dressing the provider ordered for the dressing change. Surveyor asked where the documentation was for R36's new open areas on ankle. RN I indicated that the two new open areas were not documented. On 8/15/24 at 11:40 AM, Surveyor interviewed the Wound Care Provider and asked Wound Care Provider to explain what Wound Care provider thinks is happening with R36's left ankle PI. Wound care provider indicated R36 has hardware eroded through the ankle - it will be hard to heal. Family elected not to remove the hardware, so it is more of a palliative approach right now. Surveyor asked Wound Care Provider if R36's left ankle PI was due to pressure. Wound Care Provider indicated that R36's left ankle is from pressure, and it could be from external means and a portion could be internal means from the hardware. Surveyor asked Wound Care Provider what expectation is for staff to reposition R36. Wound Care Provider indicated that the expectation would be residents be repositioned frequently as part of the plan of care. Surveyor indicated to Wound Care Provider that R36 was observed sitting in Broda chair for 6 hours not repositioned. Wound Care Provider indicated that if R36 had not been being repositioned then the pressure injury to the left ankle would be avoidable. Surveyor asked Wound Care Provider about the accuracy of the measurements completed on a weekly basis. Wound Care Provider indicated that Wound Care Provider is not allowed to measure but that Wound Care Provider must use the software the facility has. Wound Care Provider indicated that Wound Care Provider does not always agree with the measurements of total surface area. Surveyor indicated that through observation of wound dressing change R36 had two more open areas on the left ankle that were not documented on the 08/12/24 wound assessment measurements. Wound Care Provider indicated that Wound Care Provider did not document the two opens sores as it was related to moisture and bandage adhesive not pressure. 2. R8 was admitted to the facility on [DATE] with diagnoses including, in part, traumatic brain injury affecting right dominant side, contracture of right upper arm, unsteadiness on feet, and weakness. R8's Minimum Data Set (MDS) assessment, dated 3/20/24, identified that R8 had a Brief Interview for Mental Status (BIMS) score of 11. This indicated R8 had moderate cognitive impairment. The MDS assessment also identified R8 is dependent on staff requiring total assistance for toileting hygiene, chair to bed transfer, and lower body dressing. Substantial/maximal assistance with putting on and taking off footwear, rolling from left to right in bed, sitting to lying, lying to sitting, sit to stand, and toilet transfer. MDS also indicated that R8 was determined to be at risk for PI's. Surveyor reviewed R8's Activities of Daily Living care plan: BED MOBILITY Initiated on 2/23/22, revised on 6/27/24 -1 assist. TOLIET USE Initiated on 2/23/22 revised on 7/24/24: -1 assist with EZ-stand. TRANSFER Initiated on 2/23/22, revised on 7/24/24: -1 assist with EZ-stand. Surveyor reviewed R8's STAGE III pressure ulcer to right and left coccyx Care Plan: -Staff to assist with turning and repositioning initiated on 3/21/24. -The resident requires pressure relieving mattress and pressure relieving cushion in w/c. Surveyor reviewed R8's IMPAIRED SKIN Care Plan: -Follow facility protocols for treatment of injury initiated on 6/13/23. -Keep skin clean and dry. Use lotion on dry skin initiated on 6/13/23. -Treatment to skin as ordered initiated on 6/14/23. -Use a draw sheet or lifting device to move resident initiated on 6/13/23. -Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface initiated on 6/13/23. Surveyor reviewed Activities of Daily Living (ADL) CNA Kardex sheet: -Encourage to get out of W/C after lunch. Offer to place in recliner or bed, side lying prefer to release pressure off bottom. -Keep skin clean and dry. Use lotion on dry skin. Surveyor reviewed physician orders include: .-2/17/23-Apply soft boot to the right lower extremity. Float heels while in bed. -8/23/23-Complete skin only assessment one time a day every Monday. -6/4/24- ROHO cushion to be placed in wheelchair at all times. - 7/1/24-Apply Calcium Alginate and cover with foam silicone dressing 3x per week to right and left Ischium. Every evening shift every Mon, Wed, Sat for Infection Control, Wound Care When doing wound care we need to make sure we are putting a wound note in every time about the location, appearance of wound, drainage, s/sx of infection, pain, and what was applied to the area. -7/11/24-Complete skin only assessment, Ensure that bath is completed and document refusals. Every night shift every Thursday for Prophylaxis .If any new skin issues open risk management and complete. Surveyor reviewed Skin Only Evaluation Assessment: -On 2/18/22 admission assessment completed. R8 had no skin issues present on admission. -On 8/12/24 skin only assessment completed. R8 has Stage III pressure injury to the right ischium, and Stage III pressure injury to the left ischium. No documentation on appearance, measurements, or description. -On 8/14/23-Initial assessment of a non-pressure wound to the left ischium full thickness 2 cm x 2 cm x 0.1 cm and a non-pressure wound to the right ischium full thickness 3x2x0.1cm. *Physician recommendations Upgrade offloading chair cushion; Group-2 Mattress; Reposition per facility protocol; Off-Load Wound. Primary dressing: zinc ointment applies Q-shift 3x day for 30 days. -On 8/23/23 physician order to Complete skin only assessment one time a day every Monday. -On 9/4/23- Wound care assessment was missed. -On 9/18/23- Initial assessment of a non-pressure wound to the scrotum partial thickness. -On 9/25/23-- Initial assessment of a non-pressure wound to the left ischium partial

Based on interview and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents reviewed for accidents (R54). R54 was a known fall risk and the facility did not follow her plan of care, resulting in a fall with fracture. Findings include: The facilities fall policy states the following: *Prevention measures are put in place to reduce the occurrence of falls in risk of injury from falls. *Licensed nurse completes electronic documentation of the fall instant report *The care plan will be updated with an identified intervention *Registered nurse reviews and completes the fall assessment and interventions *Fall follow up assessments completed as indicated *The interdisciplinary team will review fall incident report and utilize root cause analysis to make further recommendations. *The director of nursing and executive director to review & fall incident reports. R54 was admitted to the facility on [DATE] and has diagnoses that include dementia. Her most recent Minimum Data Set (MDS), dated [DATE], includes a Brief Interview for Mental Status (BIMS) score of 4, indicating R54 is severely cognitively impaired. R54's care plan states, The resident is a high risk for falls related to confusion .Interventions: Keep Resident in view during high risk/sun downing times (initiated 3/4/24). Additionally, R54's care plan states, The resident has an ADL (Activities of Daily Living) self-care performance deficit related to confusion .Interventions: Wheelchair Management: Supervision while in wheelchair without pedals (initiated 4/1/24). A historical physician's progress note provided by the facility, dated 9/8/23, states, .she had a fall last week and may be worse since then. She fell forward but states bumped the back of right hip. She has a history of T11 compression fracture sustained after a fall on 4/24/23. Between 3/1/24 and 4/27/24, R54 experienced 10 falls at the approximate times: *3/1 at 1:00 PM *3/2 at 3:00 PM and then again at 11:30 PM *3/17 at 3:45 PM *3/21 at 10:45 AM *3/24 at 4:10 PM *4/7 at 3:30 PM *4/13 at 4:40 PM *4/21 at 2:31 PM *4/23 at 8:08 AM After the fall on 3/17, the facility put a request in for physical therapy to screen R54 in hopes to strengthen and lessen any further falls. A form, titled Therapy Recommendations to Nursing, states, Wheelchair management: supervision .Use pedals?: NO On 4/27/24 at 12:52 PM, a fall report for R54 states, Visitor saw resident fall to floor at the end of the hallway--near visitor's wife's room .Has superficial abrasion to left forearm. No apparent additional injuries, resident was lying on back . Later, at 3:30 PM, R54 fell again with resulting fall report stating, Another resident alerted me that R54 was laying on the floor .She reported discomfort in right hip area. Due to her altered cognitive status she was unable to rate pain nor did she exhibit any facial reaction to pain, but did place her hand on her right hip. R54 was sent to the Emergency Department (ED) where it was revealed that she had suffered a Mild L2 compression fracture with ED documentation stating, This is new since April 2023. R54 returned to the facility the same day (4/27/24). The facility's plan of action after the second 4/27 fall states, Order requested from MD to have bed/chair alarm used on resident until full affects of medication are known as an audible reminder to wait for staff assistance. This was documented on the fall report on 4/29/24. On 5/2/24, R54 fell again at 4:30 PM. This unwitnessed fall report states, Resident was found sitting on her wheelchair pedals by this writer and CNA (Certified Nursing Assistant) in the hallway by the right door between nurse's station. Resident was just sitting on her pedals . The notes on the fall report, dated 5/6/24, state, Resident continues to self transfer. Dycem replaced in the wheelchair. Bed alarm was not in stock at facility. in stock today. Will apply new chair alarm. Added intervention of toileting every 2 hours. Surveyors gathered the following interviews on 8/14/24: *At 1:08 PM, LPN L (Licensed Practical Nurse) stated that R54 gets restless so she'll (LPN L) take her (R54) out and pick flowers and try to keep her busy. LPN L stated R54 gets restless like she wants to get up, especially when she is sundowning, which she starts to do in the early afternoon. *At 2:06 PM, RN R (Registered Nurse) stated R54 is very antsy and it doesn't matter if she's in bed, wheelchair, or recliner. RN R stated that sometimes staff can give her things to do, or fold items, play cards, or have her do some coloring and other times staff will take her for a walk. RN R stated R54's agitation is all over the place, but this has generally been pretty consistent over the last few months. *At 2:52 PM, ADON P (Assistant Director of Nursing), who wrote the fall reports for the 3/1 and 3/2 falls, stated that she would consider any time after lunch to around 2:00 PM to be about the time, in general, that sundowning behaviors begin. ADON P stated afternoon would apply to R54 for sundowning. *At 3:02 PM, LPN C stated R54 forgets her physical limitations and will just get up out of her wheelchair. LPN C stated R54 is most agitated in the evening when family visits and leaves. *At 3:21 PM, PTA Q (Physical Therapy Assistant) stated that if therapy recommendations state use pedals .no then resident is not to have pedals on wheelchair unless resident is being transported. *At 3:46 PM RN J stated that R54 is very impulsive and she doesn't realize that she is not strong enough to stand. RN J stated that R54 will constantly try to get up and her (R54) impulsiveness is a lot worse in the afternoon/early evening and that is generally when she has most of her behaviors. RN J also stated that she considers sundowning to be around 2-4 in the afternoon. Additionally, RN J stated that she thinks R54 should not have foot pedals on her wheelchair as she would most likely trip and fall. On 8/14/24 at 3:56 PM, Surveyor interviewed DON B (Director of Nursing) who stated that R54 is impulsive and that she has always been on the go; she can't seem to sit still. DON B stated that if you turn your back for one second and she's running down the hall. DON B stated that a lot of R54's falls occur around lunch time. DON B stated that she would consider around 3:00 PM to be the time when sundowning behaviors typically begin. Additionally, DON B stated that she considered resident in view to mean that staff members need to be able to see her. When asked if that was the case when reviewing the second 4/27 fall, DON B stated, no, and also stated that, aside from 1:1, it is hard to keep eyes on any resident consistently due to the care needs of the other residents. DON B also stated that the bed alarm that she had wanted put into action after the second 4/27 fall was unavailable until 5/6/24 and that the process of getting the order signed and then getting the alarm in place took a while. The facility was aware that R54 was a fall risk and had experienced multiple falls. Staff did not have visuals on R54 for either one of her falls on 4/27/24, which resulted in a new fracture of her spine. The facility intervention after the 4/27 falls was a bed/chair alarm that was not implemented until 5/6/24 after R54 had fallen once again on 5/2/24. Additionally, R54 was not to have foot rests on her wheelchair but she was found sitting on the footrests on 5/2/24.

Based on interview and record review, the facility failed to ensure that there was a system in place for standard transmission-based precautions to be followed to prevent the spread of infections. This had the potential to affect all 59 residents. The facility failed to do the following: The facility has one (2) resident's that tested positive for COVID 19. The facility did not complete contact tracing or broad-base testing of all residents to identify if others were COVID positive. The facility is only testing residents when they are symptomatic therefore the facility would have no way to know if they are in an outbreak due to not testing all residents. The facility is not utilizing source control on the affected unit. The facility does not have their agency staff N95 fit tested . Surveyor observed KN95s were not available in the COVID positive room's isolation cart where an agency staff was on duty. Surveyor observed staff not don (put on) appropriate personal protective equipment (PPE) when entering a COVID positive resident's room. Surveyor observed COVID resident's garbage can outside of the room was overflowing with PPE with the lid open. R55 tested COVID positive and was removed from isolation on day 9. The facility has not updated their pneumococcal policy to reflect the Centers for Disease Control's (CDC) recommendations to include PCV15: 15-valent pneumococcal conjugate vaccine (Vaxneuvance) and PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar20) R23 was placed on an antibiotic at the hospital and the facility did not have record of whether it was appropriate. R4 is COVID positive - the physician (MD) entered R4's room without wearing PPE. Equipment was not sanitized between uses. This is evidenced by: The facility's Infection Control policy reviewed 9/20/23, documents the following in part: Policy: The entity will follow the recommendations of the Center for Disease Control (CDC) around Outbreak Procedures. Procedure: 1. Outbreak Definitions that warrant notification to Infection Preventionist (IP) or Designee b. COVID-19 Outbreak is considered one (1) staff and/or individual with a positive test result. 2. The following control measures are considered for outbreak and isolation management: a. Collaboration and notification will occur between Medical Director, Director of Nursing, IP, Administration, and Public Health regarding the interdisciplinary facility management of the outbreak. b. Initiate timeline documentation of outbreak management. c. Implement designated precautions including standard and transmission-based precautions. d. Manage employee assignments e. Provide employees on all three shifts information regarding type of outbreak, how transmitted and review of infection control measures including standard precautions and transmissions and transmission-based precautions. g. Post visual alerts for visitors/vendors on necessary precaution practices during outbreak. The facility's policy, Individual Immunizations, reviewed 9/20/23, documents the following part: Prophylactic immunizations will be offered to individuals to promote the absence of Health Care Acquired Infections. Procedure: Immunization - Upon admission, the organization will verify the individual's immunization status, update Primary Care Provider (PCP) as indicated, and administer immunizations as ordered. Individual will be offered immunizations based on the Center for Disease Control (CDC) recommendations and guidelines and as prescribed by their PCP. Other prophylactic treatments or immunizations will be offered to individuals per medical director recommendations, as indicated. Education - Vaccination information sheet (VIS) will be provided an reviewed with individuals including benefits, risks, and potential side effects associated with vaccination. Documentation - Immunizations administered in house shall be reported to Wisconsin Immunization Registry (WIR). Immunization consent and or refusal shall be documented within the Electronic Medical Record. The CDC, updated March 2024, includes the following guidance: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html states in part; Nursing Homes Assign one or more individuals with training in IPC (Infection Prevention/Control) to provide on-site management of the IPC program Stay connected with the healthcare-associated infection program in your state health department, as well as your local health department, and their notification requirements. Report SARS-CoV-2 infection data to National Healthcare Safety Network (NHSN) Long-term Care Facility (LTCF) COVID-19 Module. See Centers for Medicare & Medicaid Services (CMS) COVID-19 reporting requirements. Responding to a newly identified SARS-CoV-2-infected HCP (Health Care Provider) or resident. When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, respectively. However, source control should be worn by all individuals being tested . In the event of ongoing transmission within a facility that is not controlled with initial interventions, strong consideration should be given to use of Empiric use of Transmission-Based Precautions for residents and work restriction of HCP with higher-risk exposures. In addition, there might be other circumstances for which the jurisdiction's public authority recommends these and additional precautions. If no additional cases are identified during contact tracing or the broad-based testing, no further testing is indicated. Empiric use of Transmission-Based Precautions for residents and work restriction for HCP who met criteria can be discontinued as described in Section 2 and the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, respectively. If additional cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing should continue on affected unit(s) or facility-wide every 3-7 days until there are no new cases for 14 days. If antigen testing is used, more frequent testing (every 3 days), should be considered. Example 1 The facility's Infection Control line list documents the following resident COVID positive cases: R55 (300 unit) Infection onset: 7/30/24 Infection: COVID positive Signs and symptoms: Weakness Status: Closed 8/8/24 (Resolved) Comments: tested per pyrises [SIC] request due to weakness, no other symptoms. 10 day isolation to end 8/9/24 It is important to note, it appears R55 was removed based on documentation from isolation on day 9 versus day 10. Surveyor asked IP/ADON P, how long was R55 on isolation. IP/ADON P stated, 10 days. Surveyor reviewed the documentation with IP/ADON P. IP/ADON P stated, she knows R55 was on Droplet isolation for 10 days however, the documentation demonstrates R55 was only on isolation for 9 days due to unclear wording and no further documentation. R4 (300 unit) Infection onset: 8/4/24 Infection: COVID Signs and Symptoms: Hoarseness or loss of voice, sore throat Status: Open - (Confirmed) Comments: Isolation to end 8/14/24 (Of note, the facility extended her isolation through 8/14/24) On 8/12/24 at 10:20 AM, Surveyor observed staff not using any source control on the 300 unit where R4 resides. Surveyor observed the isolation bin next to R4's door to contain only N95s (3M 8200 N95s) and no KN95s available for use by staff. On 8/12/24 at 10:20 AM, Surveyor observed Care Partner U inside R4's room with the door open. R4 was sitting in a chair right next to the door. Surveyor observed R4's door open as Care Partner U was inside the room assisting R4. After Care Partner U exited the R4's room, Surveyor asked if the door should be kept closed when a resident is on isolation for COVID. Care Partner U stated, yes. Surveyor asked Care Partner U, what PPE should you wear when going in a COVID positive resident room. Care Partner U stated, gown, gloves, N95 and shield. On 8/12/24 at 10:25 AM, Surveyor observed CNA K (Certified Nursing Assistant) enter R4's room and don PPE (Personal Protective Equipment). Surveyor observed CNA K did not don eye protection (e.g. goggles or face shield). R4 has tested COVID positive and is currently on Droplet Precautions. Surveyor spoke with CNA K. Surveyor asked CNA K, did you wear eye protection when you entered R4's room to provide care and transport her outside. CNA K stated, No, I did not and I don't have any goggles over there. CNA K added, I don't believe it's mandatory. CNA K stated, the last time she worked on this hall the goggles were available on the isolation cart. Note, Surveyor observed two (2) face shields available in the isolation cart. On 8/12/24 at 3:18 PM, Surveyor spoke with IP/ADON P (Infection Preventionist/Assistant Director of Nursing). Surveyor asked IP/ADON P, would you expect CNA K (and all staff) to wear eye protection when going into in a COVID positive isolation room. IP/ADON P stated, Yes, I would have. Surveyor asked IP/ADON C, what do you consider a COVID outbreak. IP/ADON P stated, We follow the CDC (Centers for Disease Control and Prevention) recommendations which is 3 positives (cases) in 72 hours. Surveyor asked IP/ADON P, what do you do when there's an outbreak. IP/ADON P stated, we put the resident on isolation, notify staff immediately, don appropriate gown, gloves, face shield/goggles and N95. Surveyor asked IP/ADON P, what PPE should staff on the affected unit be wearing during an outbreak. IP/ADON P stated, we've had 2 COVID cases (residents) so it's not a full outbreak status. Surveyor asked IP/ADON P, do staff on the affected unit don any PPE. IP/ADON P stated, not unless we're in outbreak. IP/ADON C stated, staff just wear precautions (PPE) in the resident's room that is on isolation. Surveyor asked IP/ADON P, should there be signage on the front door alerting visitors of the positive cases. IP/ADON P stated, Yes. Surveyor asked IP/ADON P, what PPE should staff be donning when caring for a COVID resident. IP/ADON P stated, If we were to be in outbreak our staff would wear a mask (clarified surgical mask) on the floor. On 8/12/24 at 3:38 PM, Surveyor spoke with Med Tech T (Medication Technician). Surveyor asked Med Tech T how long she has worked at the facility. Med Tech T stated she has worked at the facility for 1 month. Surveyor asked Med Tech T, if you are going in a COVID positive resident's room what PPE do you don. Med Tech T stated she would don an N95 and per her discretion a face shield, gown, and gloves. Med Tech T stated, I don't know what the policy is here. Surveyor observed Med Tech T (Medication Technician) wearing a surgical mask. Surveyor asked Med Tech T when she was instructed to wear a surgical mask. Med Tech T stated, IP/ADON P instructed her to wear a surgical mask about 1-2 minutes ago. On 8/12/24 at 3:45 PM, Surveyor spoke with CNA M (Certified Nursing Assistant). Surveyor observed CNA M to be wearing a surgical mask. Surveyor asked CNA M, when were you instructed to wear a surgical mask. CNA M stated, we were just informed by IP/ADON P that we need to wear these all over the place; however, when we go in a COVID positive room we need to don an N95, gown, gloves, and face shield. Surveyor observed CNA M earlier during her shift to not be wearing a mask. On 8/12/24 at 3:50 PM, Surveyor spoke with RN R (Registered Nurse). RN R is a traveling nurse that has been working at the facility for 9 months and is caring for R4 during his shift. Surveyor asked RN R, have you been fit tested for an N95. RN R stated, No, no. Surveyor asked RN R, what mask do you don before entering R4's room. RN R stated, The ones in the bin. Surveyor observed only N95s (3M 8200 N95s) available in the isolation bin and no KN95s available for use by staff. Surveyor observed RN R wearing a surgical mask. Surveyor asked RN R when he was instructed to wear a surgical mask. RN R stated, IP/ADON P just spoke with him and gave him a mask. RN R stated prior to this he has not been wearing any mask except when he enters R4's room. On 8/12/24 at 3:53 PM, Surveyor spoke with IP/ADON P (Infection Preventionist/Assistant Director of Nursing). Surveyor asked IP/ADON P, when are staff and agency staff fit tested for N95s. IP/ADON P stated, she will check and let Surveyor know. On 8/12/24 at 4:11 PM, Surveyor spoke with IP/ADON P (Infection Preventionist/Assistant Director of Nursing). IP/ADON P stated everybody gets fit tested as part of our orientation. Surveyor asked IP/ADON P, how do agency/contracted staff get fit tested . IP/ADON P stated, I do not know how they get fit tested . Surveyor asked IP/ADON P, how often are staff/agency/contracted staff fit tested . IP/ADON P stated she is not sure and will check on that. IP/ADON P stated she will be having RN R wear a KN95. IP/ADON P stated, the KN95s were not stocked in the cart but the facility has a supply and will put them in the cart for RN R to use. Surveyor asked IP/ADON P, was RN R educated previously to use a KN95 vs. an N95 because he was not fit tested . IP/ADON P stated, No, he said he was just wearing whatever was in the cart. IP/ADON P stated, she just now let RN R know to use the KN95s. IP/ADON P stated, Staff (not agency/contracted) are fit tested annually at the skills fair. On 8/14/24 at 8:13 AM, Surveyor observed Hskp/Laundry S (Housekeeper/Laundry) enter R4's room wearing a surgical mask, gown, and gloves. Surveyor observed Hskp/Laundry S to not be wearing an N95. On 8/14/24 at 8:15 AM, Surveyor spoke with Hskp/Laundry S. Laundry S stated she entered R4's room to grab laundry in the bathroom. Surveyor asked Hskp/Laundry S, how do you know if a resident is on isolation. Hskp/Laundry S stated, the isolation cart outside the door and staff tell us ahead of time. Surveyor asked Hskp/Laundry S, what is R4 on isolation for. Hskp/Laundry S, stated COVID. Surveyor asked Hskp/Laundry S, what PPE (Personal Protective Equipment) should you don before entering R4's room. Hskp/Laundry S stated, The one thing I forgot was to put on an N95, I did put on the gown and gloves (and eye protection). Surveyor asked Hskp/Laundry S, why is it important to don an N95 before entering a COVID room. Hskp/Laundry S stated, They're more effective. Surveyor asked Hskp/Laundry S, should you don an N95 when going in a COVID positive room. Hskp/Laundry S stated, Yes. On 8/14/24 at 8:19 AM, Surveyor observed R4's door open while R4 was sitting in her recliner with her back to the door (a few feet from the door). Surveyor observed R4's garbage can outside her door with an open lid and overflowing with used PPE. On 8/14/24 at 8:25 AM, Surveyor asked IP/ADON P, has the facility tested the residents for COVID since they had two (2) residents that tested positive. IP/ADON P stated, no, we only test residents when they are symptomatic. IP/ADON P stated, the two residents that tested positive attended a funeral and the priest was COVID positive. Surveyor asked IP/ADON P, has the facility completed contract tracing to determine who the two residents have been in contact with in order to test them. IP/ADON P stated, No. It is important to note, the facility has no way of knowing if other staff or residents are COVID positive in the facility as they did no complete broad-base testing or complete contact tracing. Surveyor asked IP/ADON C if R23's door should be closed as she is on Droplet Isolation. IP/ADON C stated, R23 should be able to come off isolation as she tested negative on day 1 and day 3. Surveyor asked IP/ADON P if the facility has updated their pneumococcal policy to reflect the Centers for Disease Control's (CDC) recommendations to include PCV15: 15-valent pneumococcal conjugate vaccine (Vaxneuvance) and PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar20). IP/ADON P stated, No, the facility does not have any detailed pneumo vaccination policy and procedure. The facility has not been offering these to residents. IP/ADON P stated, she realized the facility does not have a process to administer pneumococcal vaccines. IP/ADON P stated, she had an idea to have a pharmacy come to the facility to administer these vaccines. Surveyor asked IP/ADON P, do you have documentation to demonstrate you have been working on this. IP/ADON P stated, There's no documentation just an idea we expressed. 36253 Example 2: The facility's Antibiotic Stewardship policy states: *The Infection Preventionist will collaborate with the Medical Director, Administrator, Director of Nursing, pharmacy consultant, and laboratory representative as needed to: 1) Review infections and monitor antibiotic usage patterns through Quality Assurance Performance Improvement (QAPI) process 2) Obtain and review antibiograms for institutional trends of residents as available 3) Monitor antibiotic resistance patterns and infections *Appropriateness of use and duration of antibiotic(s) will be monitored and reviewed as needed. R23 was admitted to the facility on [DATE]. On 5/19/22, R23 was having pain, discomfort and generally lethargic and was sent to hospital where she was found to have a UTI (Urinary Tract Infection). R23 was sent back to the facility on [DATE] with orders for Doxycycline 100 MG two times daily for 7 days for the UTI. Facility MAR (Medication Administration Records) indicate R23 took the full 14 doses of the antibiotic. Surveyor was unable to find a sensitivity report for the antibiotic's use. On 8/14/24 at 11:38 AM Surveyor interviewed DON B (Director of Nursing) who stated that the facility did not have a sensitivity for culture in relation to the UTI as this was all done at the hospital. DON B stated that they usually don't get the sensitivity report when a resident is put on antibiotics at the hospital. DON B stated that the facility relies on the doctors at the hospital to ensure appropriateness of the antibiotic prescribed. 48793 Example 3: On 08/13/24 at 8:22 AM, Surveyor observed CNA K (Certified Nursing Assistant) and CNA M don PPE (Personal Protective Equipment). CNA K and CNA M entered R36's room. CNA K and CNA M rolled R36 and placed a sling underneath R36's back side. Once CNA K and CNA M were ready to transfer, CNA M exited R36's room with PPE on and walked down the hallway to grab the Hoyer lift. CNA M entered R36's room with Hoyer and began hooking up R36 to the sling and Hoyer. CNA M and CNA K transferred R36 to the wheelchair. CNA M exited R36's room and walked down the hallway pushing the Hoyer lift. Surveyor did not observe the Hoyer lift being wiped down. Surveyor observed CNA M and CNA K doff the PPE, sanitize hands, and walk down the hallway. Example 4: On 8/13/24 at 11:02 AM, R4 is COVID positive. Surveyor observed R4's physician enter into R4's room without donning personal protective equipment. On 8/13/24 at 11:05 AM, Surveyor interviewed RN Y and asked RN Y who the person is who entered R4's room without PPE. RN Y indicated that it is R4's physician who is doing rounds. Surveyor asked how visitors or staff are suppose to know when a resident is on isolation or transmission based precautions. RN Y indicated that usually signage is out on the door. RN Y and Surveyor reviewed the sign on R4's door and RN Y confirmed that the signage on R4's door does not specify to wear all PPE. Signage does not say if its droplet, contact, or airborne precautions.

Based on staff interview and record review, the facility did not ensure a staff person designated as the Infection Preventionist (IP) completed specialized training in infection prevention and control. This practice had the potential to affect all 59 residents residing in the facility. IP/ADON P (Infection Preventionist) and DON B (Director of Nursing) did not complete specialized training for infection prevention and control. Findings include: The facility's Infection Prevention and Control policy and procedure, last reviewed September 2023, indicates: The IP (Infection Preventionist) will maintain current knowledge in the field of infectious disease and epidemiology through training provided through the CDC (Centers for Disease Control and Prevention) in collaboration with Centers for Medicare and Medicaid (CMS). On 8/14/24 at 9:35 AM, Surveyor interviewed IP/ADON P who verified IP/ADON P started as the IP in June of 2024 and did not have specialized infection control training. IP/ADON P stated IP/ADON P was informed about the required training and she has started working on the Centers for Disease Control and Prevention (CDC) training modules. IP/ADON P stated she goes to DON B (Director of Nursing) with any infection prevention related questions. IP/ADON P provided her CDC training certificates and has not completed the course. IP/ADON P has completed the following modules: Module 1: Infection Prevention and Control Program Date: 7/24/24 Module 2: The Infection Preventionist Date: 7/24/24 Module 3: Integrating Infection Prevention and Control into the Quality Assurance Performance Improvement Program Date: 7/24/24 Module 4: Infection Surveillance Date: 8/12/24 (*It is important to note, this was completed during survey after Infection Control concern were identified.) Module 5: Outbreaks Date: 8/14/24 (*It is important to note, this was completed during survey after Infection Control concern were identified.) Module 10C: Infection Prevention during Wound Care Date 7/22/24 On 8/14/24 at 4:30 PM, Surveyor interviewed DON B (Director of Nursing). DON B served as the Infection Preventionist from February - June 2024 until IP/ADON P took over. Surveyor asked DON B if she has completed the Centers for Disease Control and Prevention (CDC) training modules. DON B stated, No. Surveyor asked DON B, do you have any training in infection control. DON B stated, No. IP/ADON P has not completed all the required training and IP/ADON P's back-up DON B has not completed any of the required training,

Based on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 59 residents. Food items were found undated or beyond their use by date in various locations in the facility. Staff were observed in the kitchen without hair nets. Findings include The facility policy titled Food from Outside Sources, states, All cooked or prepared food brought in for a resident and stored in the unit's pantry refrigerator or personal room refrigerator will be dated when accepted for storage and discarded after five days. Nursing staff will monitor resident's room, unit pantry, and refrigeration units for food and beverage disposal. Example 1 On 8/12/24 at 9:48 AM, during initial tour of the facility's main kitchen, Surveyors observed the following: *A bag of flour open with an open date of 6/17 and use by date of 7/17 with no year indicated. *8 oz thickened chocolate milk, opened, with no open date and manufacturer's use by date of 9/25/24 *Lemonade with no dates *A pitcher of tomato juice and a pitcher of fruit punch with no preparation or use by date *An opened 32 oz container of apple juice, dated 8/9 on the cap, but no open date or use by date *An opened 32 oz container of grape juice, dated 5/7 on the cap, but no open date or use by date On 8/12/24 at 10:04 AM, Surveyor interviewed DM E (Dietary Manager) who stated he was not sure how long the facility had had the flour. Additionally, DM E stated that the milk should be dated when opened, the thickened milk is usually good for 2 days once opened, and the juices should be dated when opened, and the dates on the caps of the apple and grape juices were when those products were received from the food distributor. On 8/13/24 at 8:30 AM, Surveyor observed the following in the memory care kitchen refrigerator: *A pitcher of orange juice, prepared 7/11 and a use by date of 7/19 *A Wendy's double bacon cheeseburger in a plastic container with no received or use by date. Surveyor interviewed CNA G (Certified Nursing Assistant) at this time who stated she did not know who the cheeseburger belonged to or how long it had been in the refrigerator. On 8/13/24 at 9:08 AM, Surveyor observed the following in the facility's main dining room refrigerator: *2 pitchers of prepared juice, one cranberry and one orange, both dated 7/11 with a use by date of 7/15. *A plastic bag with kiwi, blueberries, and strawberries in it with no date on the bag. Example 2 On 8/12/24 at 2:24 PM, Surveyor observed CNA F in the facility's main kitchen, near a food preparation counter, with no hair net on, conversing with other dietary staff. CNA F's hair was down and approximately halfway between her shoulders and waist.

Based on record review and interview, the facility did not implement policy and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 4 (LPN C, LPN W, Maintenance Supervisor X, RN V) of 8 employees reviewed. The facility did not ensure their abuse policy was implemented when four employees' background information disclosure (BID) was not obtained before employees started working at facility. (LPN C, LPN W, Maintenance Supervisor X, and RN V). Findings include: The facility policy, entitled Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, revised, December 2022 states in part Employee screening and training: a. Before new employees are permitted to work with resident's board registrations and certifications regarding prospective employee's background will be checked. d. A criminal background check will be conducted on all prospective employees as provided by the facility's policy on criminal background checks. On 08/13/24 at 8:14 AM, Surveyor reviewed 8 random staff Background Information Disclosures (BID). LPN C (Licensed Practical Nurse) was hired on 07/11/24. Surveyor was reviewing a BID for LPN C, the form was dated 05/01/24 with the question, Have you resided outside the state of Wisconsin in the last 3 years. The box was marked yes and stated in Texas. Surveyor reviewed the BID and found no BID was completed for the state of Texas. LPN W was hired on 07/30/23. Surveyor was reviewing background information on LPN W and there was no BID form completed until 08/14/24 by the facility. Maintenance Supervisor X was hired on 09/13/21. Surveyor was reviewing background information form dated 08/13/24 on Maintenance Supervisor X. Surveyor observed there was no BID completed. RN V (Registered Nurse) was hired on 01/30/24. Surveyor was reviewing a BID for RN V. The form was dated 01/22/24 with the question, Have you resided outside the state of Wisconsin in the last 3 years. The box was marked yes and stated in Iowa. Surveyor reviewed the BID and found no BID was completed for the state of Iowa. On 8/14/24 at about 1:30 PM, Surveyor interviewed Scheduler and asked if they had an updated BID for LPN C, LPN W, Maintenance Supervisor X, and RN V. Scheduler contacted Human Resource Supervisor (HR) who was out of the office for the week and asked HR to look through LPN C, LPN W, Maintenance Supervisor X, and RN V 's personnel file. Scheduler reported to Surveyor that LPN C, LPN W, Maintenance Supervisor X, and RN V 's were missing the background check information. Scheduler completed the updated form on 8/13/24 and 8/14/24. On 8/14/24 at 3:06 PM, Surveyor interviewed NHA A (Nursing Home Administrator) regarding why the BID for LPN C, LPN W, Maintenance Supervisor X, and RN V was not complete. NHA A indicated that they were not complete, but that facility completed BID, IBIS, and checks in the other states for LPN C, LPN W, Maintenance Supervisor X, and RN V.

Based on interview and record review, the facility failed to ensure a comprehensive assessment was completed for 1 (R21) of 7 residents reviewed for change of condition. R21 had an unresponsive episode, and the facility did not complete a full assessment or notify the physician (MD). R21 could not find his words the facility did not complete a full assessment or notify the MD. This is evidenced by: The facility utilizes Interventions to Reduce Acute Care Transfers, or Interact, as the facility's standard of practice. According to Interact II Signs and Symptoms to report immediately to a physician include: Consciousness, altered: Sudden change in level of consciousness or responsiveness. Speech Abnormality: Abrupt change in speech with or without other neurological findings. R21 was admitted to the facility on [DATE] with diagnoses including Bipolar disorder, Diabetes Mellitus, History of TIA (Transient Ischemic Attack-Mini stroke), seizure disorder, obesity, and sleep apnea. It should be noted R21 wishes to have Cardiopulmonary Resuscitation (CPR) performed in the event of a cardiac arrest. R21 has been transferred out of the facility for acute changes of condition 3 times since [DATE]. R21's Minimal Data Set (MDS) with and Assessment Reference Date (ARD) of [DATE] indicates R21 has moderate cognitive impairment. On [DATE] at 2:34 AM, R21's Nurse's Notes state in part; unresponsive, T 98.3 (Temperature) P 74 (Pulse) and regular R14 (Respirations) and even, non-labored. BP ,d+[DATE] (Blood Pressure). Pupils equal and reactive. Eye blinking resident eyes open. R21 has a history of TIA's and seizure disorder, yet the facility did not complete a full comprehensive assessment and did not notify the physician regarding R21's sudden onset of unresponsiveness. According to Interact II, a sudden onset of Loss of Consciousness (LOC) requires immediate MD notification. On [DATE] at 4:15 PM, R21's Nurse's Notes stated in part; today resident was yelling Hey! from his bed multiple times. When staff would enter room to ask what resident wanted or needed, resident would struggle with his words and swore at the CNA's (Certified Nursing Assistants) twice, two separate occasions. O2 (Oxygen) was running on 3 L (liters), 92% via NC (Nasal Cannula). R21 has a history of TIA's and seizure disorder yet the facility did not complete a full comprehensive assessment and did not notify the physician regarding R21's sudden onset of inability to find words. According to Interact II, a sudden onset in change of speech requires immediate MD notification. On [DATE] at 3:30 PM, Surveyor interviewed LPN C (Licensed Practical Nurse) regarding change of condition. LPN C stated if a resident had a change in LOC (Level of Consciousness) or speech that was sudden or new onset he would immediately notify the physician. LPN C stated if R21 was noted to be unresponsive or having trouble finding words this would require a full assessment and immediately notify the MD of findings. [DATE] at 3:56 PM, Surveyor interviewed DON B (Director of Nursing) regarding change of condition and MD notification. DON B stated that R21 has behaviors and issues and being unresponsive or not able to find words is normal behavior for R21. Surveyor asked DON B if R21 was found to be unresponsive, would you expect a full assessment or MD notification. DON B stated I understand this was a poor choice of words. DON B stated I understand you would not know if this was a medical issue; we should be doing an assessment and notifying the MD.

Based on observation, interview, and record review, the facility did not ensure Residents are free of significant medication errors, for 1 of 1 supplemental resident's reviewed for significant medication errors (R31). Surveyor observed RN D (Registered Nurse) crush R31's Metoprolol extended release and administer it to R31. Evidenced by: The facility policy, entitled, Medication Administration - Medication Error, reviewed 6/13/23, states in part: Entity shall adhere to the rights of medication administration and review. Investigate, and document any medication error. The facility policy, Medication Administration, revised December 2019, states in part, as follows: Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. FIVE RIGHTS: . right dose, . Orders to crush medications should not be applied to medications which, if crushed, present a risk to the resident. For example, Long-acting (extended release) or enteric-coated dosage forms should not be crushed, an alternative should be sought. R31's Physician Orders, signed 8/13/24, include, in part, the following medication: Metoprolol Succinate ER Tablet extended release 24 Hour 25 mg (milligram) Give 1 tablet by mouth one time a day related to Essential (Primary) Hypertension On 8/13/24 at 8:48 AM, Surveyor observed RN D (Registered Nurse) crush R31's Metoprolol Succinate Extended Release 25 mg tablet and administer it to R31. It is important to note, extended-release medications are not to be crushed. On 8/13/24 at 3:45 PM, Surveyor spoke with RN D. Surveyor asked RN D if extended-release medications should be crushed. RN D stated, No. Surveyor asked RN D, should she have crushed R31's Metoprolol Succinate extended release. RN D stated, No. On 8/13/24 at 12:56 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, if she expects staff to follow Physician orders. DON B stated, Yes. Surveyor asked DON B, is it acceptable for Metoprolol extended release to be crushed. DON B stated, No, not unless we have a physician order specifically to crush it. Surveyor asked DON B, to review R31's physician orders. Surveyor asked DON B, does R31 have a physician order to crush Metoprolol extended release. DON B stated, No. Surveyor asked DON B, is it acceptable for nurses to crush R31's Metoprolol extended-release tablet. DON B stated, No. DON B stated, she was made aware of the significant dosing medication error by RN D after her discussion with Surveyor on 8/13/24.

Based on observation, interview, and record review, the facility did not ensure that its medication error rate was 5% or less for 39 medication pass opportunities and 1 of 3 sampled residents (R35) and 2 of 2 supplemental residents observed for medication pass (R18 and R31). The facility's medication error rate was 10.26% with four (4) errors observed for R18, R31, and R35. This is evidenced by: The facility policy, Medication Administration, revised December 2019, states in part, as follows: Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. FIVE RIGHTS: Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away. Tablet Crushing/Capsule Opening: Crushing tablets may require a physician's order, per facility policy. If it is safe to do so, medication tables may be crushed or capsules emptied out when a resident has difficulty swallowing or is tube-fed, using the following guidelines: An individualized approach should be used when altering dosage forms by crushing or opening capsules. Working with the resident or representative and appropriate clinicians (e.g., the consultant pharmacist, attending physician, medical director) the facility should determine the most appropriate method for administering medications which considers each resident's safety, needs, medication schedule, preferences, and functional ability. An order to crush medications may be required or preferred in accordance with State regulations of facility preference. Orders to crush medications should not be applied to medications which, if crushed, present a risk to the resident. For example, Long-acting (extended release) or enteric-coated dosage forms should not be crushed, an alternative should be sought. Example 1 R18's Physician Orders, signed 8/13/24, include, in part, the following medication: Humalog Injection Solution 100 unit/ml (milliliter) Inject 12 unit subcutaneously with meals for Type 2 Diabetes. On 8/13/24 at 8:11 AM, Surveyor observed RN D (Registered Nurse) administer Humalog Injection Solution to R18. On 8/13/24 at 8:33 AM, staff started serving breakfast trays on R18's hall. On 8/13/24 at 8:36 AM, staff served R18 her breakfast tray in her room. R18 started eating breakfast at 8:38 AM. R18 waited 25 minutes for her meal to arrive. Per physician orders, R18's Humalog Injection Solution was not administered with meals. On 8/13/24 at 3:45 PM, Surveyor asked RN D when she administers R18's Humalog. RN D stated, she usually waits until she eats. Surveyor stated, R18's orders indicate Humalog is to be administered with meals, should the medication be given with meals. RN D stated, yes. This resulted in a timing error. Example 2 R31's Physician Orders, signed 8/13/24, include, in part, the following medication: Metoprolol Succinate ER Tablet extended release 24 Hour 25 mg (milligram) Give 1 tablet by mouth one time a day related to Essential (Primary) Hypertension On 8/13/24 at 8:48 AM, Surveyor observed RN D (Registered Nurse) crush R31's Metoprolol Succinate extended release 25 mg tablet and administer it to R31. It is important to note, extended-release medications are not to be crushed. On 8/13/24 at 3:45 PM, Surveyor spoke with RN D (Registered Nurse). Surveyor asked RN D if extended-release medications should be crushed. RN D stated, No. Surveyor asked RN D, should she have crushed R31's Metoprolol Succinate extended release. RN D stated, No. This resulted in a dosing error. Example 3 R35's Physician Orders, signed 7/11/24, include, in part, the following medications: Sennosides-Docusate Sodium Tablet 8.6-50 mg Give 4 tablets by mouth two times a day for constipation. Artificial Tear Solution Instill 1 drop in both eyes every day and evening shift for dry eyes. Artificial Tear Solution Instill 1 drop in both eyes every 6 hours as needed for dry eye. On 8/13/24 at 9:01 AM, Surveyor observed RN D (Registered Nurse) administer Medline senna natural vegetable laxative 8.6 mg (with no docusate sodium). RN D stated R35's Artificial Tear Solution was on order and unavailable to administer. RN D added, R35's Artificial Tear Solution is expected to arrive at 6:00 PM tonight. During the Medication Pass Task, Surveyor observed R35 voice concern to RN D that she did not receive her eye drops on 8/12/24 or 8/13/24. Surveyor asked RN D, should residents receive medications per physician orders. RN D stated, yes. R35's Artificial Tear Solution not being available resulted in an omission medication error. On 8/13/24 at 2:25 PM, Surveyor spoke with RN D. Surveyor asked RN D, should R35 should receive sennosides with docusate sodium versus senna alone. RN D reviewed the Medication Administration Record (MAR) and order. RN D stated, yes, she should have administered Sennosides-Docusate Sodium. Surveyor asked RN D, if she was able to locate R35's Artificial Tear Solution. RN D stated, no, she was not. RN D added, she is charting now and will notify R35's physician of the omission. This resulted in a wrong drug medication error. On 8/13/24 at 12:56 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor informed DON B of the medication error rate of 10.26%. Surveyor asked DON B, if she expects staff to follow Physician orders. DON B stated, Yes. Surveyor asked DON B if a medication is scheduled to be administered with meals would you expect it to be administered with meals. DON B stated, Yes. DON B added, she would expect R18's insulin to be administered with meals or within 15 minutes before the meal. Surveyor asked DON B, is it acceptable for Metoprolol extended release to be crushed. DON B stated, No, not unless we have a physician order specifically to crush it. Surveyor asked DON B, to review R31's physician orders. Surveyor asked DON B, does R31 have a physician order to crush Metoprolol extended release. DON B stated, No. Surveyor asked DON B, is it acceptable for nurses to crush R31's Metoprolol Extended-Release tablet. DON B stated, No. Surveyor asked DON B, if a resident has an order for Sennosides-Docusate Sodium would you expect staff to administer Senna-Docusate Sodium vs senna alone. DON B stated, Yes. Surveyor asked DON B, is it your expectation that R35 should have received the physician ordered Sennosides-Docusate Sodium versus senna alone. DON B stated, Yes. Surveyor asked DON B, should medication be available for nurses to administer. DON B stated, Yes, that goes for any administration. Surveyor asked DON B, should R35's eye drops be available for nurses to administer. DON B stated, yes.

Based on interview and record review, the facility failed to consult with the physician related to a significant change of condition for 1 of 7 residents (R46) out of 15 residents reviewed for physician notification. The facility did not consult with R46's physician after a culture and sensitivity (C&S) report confirmed he had a urinary tract infection. As evidenced by The facility's policy, Change of Condition and Provider Notification, reviewed 8/10/23, indicates, in part, the following: Upon individual change of condition, proper assessment and provider notification will occur to provide timely delivery of clinical care. Procedure: Change of Condition (COC) is a deviation from an individual's baseline in physical, cognitive, behavioral, or functional status. Clinically important means a deviation that, without intervention, may result in complications or death. Notification: Primary Care Provider (PCP) will be contacted for notification and obtain further orders from provider as necessary. If PCP cannot be reached, on-call provider will be contacted. If PCP and/or on-call provider are not able to be contacted, Medical Director will be contacted for notification. R46 was admitted to the facility on [DATE] with diagnoses including, but not limited to, the following: Benign prostatic hyperplasia and urinary retention. Of note, R46 was diagnosed with malignant neoplasm (cancer) of right kidney in April 2024. R46 is his own person. On 7/21/24 at 9:40 PM, R46's Progress Note indicates the following: Resident has a temp of 101.6. Contacted on call and got order from NP (Nurse Practitioner) for UA+C&S (urinalysis culture and sensitivity) and to continue PRN (as needed) Tylenol for temp. Results to be sent to Nurse Practitioner or Urologist. Resident had a cath (catheter) change earlier this day at the hospital. On 7/22/24 at 2:34 PM, R46's Progress Note indicates the following: Call placed to Urology ordered from on-call on 7/21/24. Urology will call back on 7/23/24 with instructions from Urologist if urine sample is necessary and if Urology would like to address. On 7/22/24 at 2:37 PM, R46's Progress Note indicates the following: Call placed to (provider name) to inquire on UA (urinalysis) sample is to be collected or if they would like instructions to be sent to Urology. Residents catheter is draining well, urine is dark yellow in color, no pain or discomfort noted at this time. Awaiting response at this time. On 7/23/24 at 6:02 AM, R46's Progress Note indicates the following: UA+ culture send to lab within 4 hours of collecting. One time only for order by NP for temp of 101.6 related to retention of urine for 1 day. On 7/23/24 at 10:20 AM, R46's Progress Note indicates the following: Minimal hematuria in catheter tubing-irrigates without issue. On 7/23/24 at 10:52 AM, R46's Progress Note indicates the following: UA specimen to lab for analysis. On 7/24/24 at 1:12 PM, R46's Urinalysis culture and sensitivity indicates the following result: >100,000 CFU/ml Gram-negative bacilli (Abnormal) and >10,000 but <100,000 CFU/ml mixed flora - Probable contaminants - No further identification. On 7/24/24 at 2:48 PM, R46's Progress Note indicates the following: Urine preliminary results on culture came back >100,000 gram-negative bacilli, call out to Urology, awaiting response. On 7/25/24 at 12:04 PM, R46's Progress Note indicates the following: UA culture and sensitivity sent to Urologist via fax and called to office to notify. Awaiting call back. On 7/25/24 at 4:11 PM, R46's UA C&S final results indicate the following: >100,000 CFU/ml Escherichia coli and >10,000 but <100,000 CFU/ml mixed flora - probable contaminants - No further identification On 7/25/24 at 5:28 PM, a Nurse Practitioner (not Urology) documented the following note: Facility resident - please forward to facility. Facility staff please notify resident of results and forward results to Urology - who treats his UTI's. Attempted to contact facility - only getting Vm (voice mail). Detailed message left with results and recommendations. Message texted to DON (Director of Nursing) regarding inability to reach staff. On 7/26/24 at 1:09 PM, R46's Progress Note indicates the following: Received progress note from Nurse Practitioner about UA results, stated to forward results to Urology, results have been forwarded and scanned to HIS (health information system). On 7/29/24 at 1:27 PM, R46' Progress Note indicates the following: Order from Urology office to start on Bactrim DS 1 tab PO (by mouth) Q12 hrs. (every 12 hours) for 10 days. Noted and scanned to HIS. Entered into PCC (PointClickCare). It is important to note, from 7/26/24 to 7/29/24 (3 days/72 hours) the facility did not notify Urology via phone or follow up to obtain a necessary order for antibiotics. On 7/29/24 at 1:33 PM, R46's Progress Note indicates the following: The system has identified a possible drug allergy for the following order: Bactrim DS oral tablet 800-160 mg (milligrams) (Sulfamethoxazole-Trimethoprim). Give 1 tablet by mouth every 12 hours for UTI. On 7/29/24 at 4:09 PM, R46's Progress Note indicates the following: Resident is allergic to Sulfa antibiotics. Urology notified, awaiting further instructions on antibiotic at this time. New orders will be entered when received. On 7/30/24 at 3:23 PM, R46's Progress Note indicates the following: Urology (Physician Assistant) ordered ABX (antibiotic) for 10 days in relation to recent urine results. Pharmacy and MAR (Medication Administration Record) updated. Order: Nitrofurantoin Macrocrystal Capsule 100 mg Give 1 capsule by mouth two times a day for UTI for 10 days. On 7/30/24 at 5:42 PM, R46's Progress Note indicates the following: This order is outside of the recommended dose or frequency. Nitrofurantoin Monohyd Macro Oral Capsule 100 mg Give 1 capsule by mouth two times a day for UTI for 10 days enter infection note. On 7/30/24 at 5:43 PM, R46's Progress Note indicates the following: Received order from Urology PA (Physician Assistant) to change to Macrobid 100 mg (milligrams) BID x 10 days PCC (PointClickCare) updated. It is important to note, from 7/26/24 to 7/29/24 (3 days/72 hours) the facility did not notify Urology via phone or follow up to obtain a necessary order for antibiotics. In total, R46's waited five (5) days before receiving the antibiotics necessary to treat a diagnosed UTI (urinary tract infection). On 8/14/24 at 8:25 AM, Surveyor spoke to IP/ADON P (Infection Preventionist/Assistant Director of Nursing). Surveyor asked IP/ADON P, to discuss R46's UTI in July 2024. IP/ADON P stated, on 7/23/24 the facility noted minimal hematuria in R46's catheter tubing. IP/ADON P stated, a UA (urinalysis) was collected with a preliminary result on 7/25/24 of >100,000-gram negative bacilli. IP/ADON P stated, R46's primary physician stated to contacted Urology (R46 has a foley and sees Urology). IP/ADON P stated, on 7/24/24 the facility sent the preliminary results to Urology and called Urology. IP/ADON P stated, on 7/25/24 the facility sent the culture and sensitivity to Urology. IP/ADON P stated, on 7/29/24 the facility received an order from Urology for antibiotic for R46. Surveyor asked IP/ADON P, did the facility contact Urology prior to this. IP/ADON P stated, no, that's when the provider responded. Surveyor asked IP/ADON P, did anybody call to notify Urology between 7/25-7/29/24. IP/ADON P stated, No, and, It's not documented. Surveyor asked IP/ADON P, would you expect staff to call/consult with the Urology on 7/25/24. IP/ADON P stated, Yes. Surveyor asked IP/ADON P, why is this important. IP/ADON P stated, To be treating it immediately being he's symptomatic and we have confirmed lab results.

Based on record review and interview, the facility did not ensure that 1 CNA T (Certified Nursing Assistant) of 5 staff reviewed for verification of a current Nurse Aide Registry were on the Wisconsin registry before starting work in the facility. CNA T was not on the Wisconsin Nurse Aide Registry and was working in the facility at the time of the discovery. Findings include: On 8/13/24, Surveyor reviewed five (5) random CNA's as part of the background check process. CNA T was hired on 6/3/24. NHA A (Nursing Home Administrator) provided a state of Iowa CNA registry certificate for CNA T. CNA T was not on the Wisconsin CNA registry. On 8/13/24 at 11:15 AM, Surveyor interviewed NHA A about the missing Wisconsin CNA Registry for CNA T. NHA A stated CNA T had applied for the Wisconsin registry on 8/9/24. NHA A did not provide a copy of the Wisconsin registry application as requested. NHA A thought CNA T could work in the facility while the application was pending. According to the Wisconsin Nurse Aide Training and Registry, nurse aides must be listed on the Wisconsin Nurse Aide Registry in order to be employed in any federally eligible health care setting in Wisconsin. There is no grace period for individuals whose out-of-state application is pending approval for reciprocity. On 8/14/24 at approximately 1:00 PM, Surveyor checked the Wisconsin Nurse Aide Registry and found CNA T was still not listed on the registry. On 8/13/24 at 1:24 PM, Surveyor interviewed Scheduler N and asked when CNA T was hired and when CNA T's first day was working the floor. Scheduler N indicated that CNA T started working the floor with residents on 6/15/24.

Based on observation, interview, and record review, the facility did not ensure that each resident's environment remains as free of accident hazards as possible for 1 of 1 residents (R1). R1 resided in the facility's memory care unit and has a history of tossing her leg onto the heat register next to her bed. On 1/15/24, R1 was found to have placed her foot on the heat register next to her bed. This resulted in burns to R1's left lateral foot (full thickness), left foot (undetermined thickness) and right foot (undetermined thickness) that required physician intervention. The facility does not routinely monitor the temperature of the heat registers. The facility's failure to provide proper safety interventions to prevent accidents and monitor resident's rooms and environment created a finding of Immediate Jeopardy that began on 1/15/24. Surveyor notified the NHA A (Nursing Home Administrator) of the Immediate Jeopardy on 2/1/24 at 6:00 PM. The Immediate Jeopardy was removed on 2/2/24; however, the deficient practice continues at a scope/severity of a E (potential for more than minimal harm/pattern) as evidenced by the observation that an additional 17 residents currently residing in the facility's memory care unit (R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, and R22) had their beds next to the heat registers in their rooms Findings include: According to John Hopkins University (https://www.hopkinsmedicine.org/health/conditions-and-diseases/burns), Both infants and the older adults are at the greatest risk for burn injury . Burns are classified as first-, second-, or third-degree, depending on how deep and severely they penetrate the skin's surface. First-degree (superficial) burns: First-degree burns affect only the epidermis, or outer layer of skin. The burn site is red, painful, dry, and with no blisters. Mild sunburn is an example. Long-term tissue damage is rare and usually involves an increase or decrease in the skin color. Second-degree (partial thickness) burns: Second-degree burns involve the epidermis and part of the dermis layer of skin. The burn site appears red, blistered, and may be swollen and painful. Third-degree (full thickness) burns: Third-degree burns destroy the epidermis and dermis. Third-degree burns may also damage the underlying bones, muscles, and tendons. When bones, muscles, or tendons are also burned, this may be referred to as a fourth-degree burn. The burn site appears white or charred. There is no feeling in the area since the nerve endings are destroyed. Burns that are more severe and extensive need specialized treatment. Because the age of a burn victim and the percentage of the body's surface area that has been burned are the most important factors affecting the outlook of a burn injury, the American Burn Association recommends that burn patients who meet the following criteria should be treated at a specialized burn center: Individuals with partial-thickness burns over 10% or more of the total body surface area (TBSA) Any age with full-thickness burns (emphasis intended). Burns of the face, hands, feet, or groin, or genital area, or burns that extend all the way around a portion of the body. R1 was admitted to the facility on [DATE] and has diagnosis including dementia. Her most recent Minimum Data Set (MDS), dated [DATE], shows that the facility did not conduct a Brief Interview for Mental Status (BIMS) as R1 is rarely understood. R1's fall care plan, dated 7/6/23, states, .is at risk for falls related to confusion .unaware of safety needs. R1 has a history of tossing her legs and feet onto the heat register. The facility documented the following progress notes on 1/15/24: *6:37 AM: Residents left foot was bleeding. Skin was peeling off. Wound cleaned and new dressing applied. *8:27 AM: this writer was notified by night nurse that resident has a wound to her left outer foot. Night nurse stated, I changed her dressing. *9:24 AM: Wound doctor here to assess wounds to bilateral feet. He noted that they are burn wounds to the left lateral foot, left foot and right foot. The wound doctor's notes from 1/15/24 on R1's feet read: *Site 1, Burn wound of the left lateral foot .full thickness .wound size 3 x 9 x.01 cm (length, width, depth), light serosanguineous with 100% granulation tissue. *Site 2, burn wound of the left foot, undetermined thickness .1 x 3 x not measurable cm (centimeters) .dried fibrinous exudate (scab) *Site 3, burn wound of the right foot, undetermined thickness .1 x 3 x not measurable cm .dried fibrinous exudate (scab) A 1/15/24 follow-up investigatory note by the previous Director of Nursing (DON), who is no longer working at the facility, states, Resident has several open areas on the outer aspect of the side of the left foot and some old scabs on the toes. Some areas on the toes are open. There is not current drainage from foot. Resident cannot give history but overnight the resident had kicked foot free of the bed linens and bilateral body pillows. She had flung her foot to the wall register. She screamed out and the night CNA (Certified Nursing Assistant) found her with a bloody foot. She went and got the nurse .One side of the residents bed is up againt (sic) the wall .The bed is up against the register that delivers the heat. At some point the resident was able to [NAME] her left foot out of the bed. Originally, it was thought that she had burned her foot on the register, but the wound did not look like a burn nor was it feasible with where the marks were on her foot and toes. There was blood on the register. When the bed was moved, it was noted that the metal juncture between two registers had been disturbed, most likely became hotter than a pleasant warmth. Upon further inspection the ben [sic] piece of metal and part of the radiator were removed. In the juncture piece, there was a large piece of accordioned skin inside it. It looked like the resident had flung her foot out of the bed and then rubbed it on the rough metal. There were several more small pieces of skin that looked about the size of the wound .The area looks like a scrape or abrasion .Bed was moved and the area will be assessed for new furniture arrangement. Radiator was cleaned and put back together and piece is now fitting the register correctly and safely. Surveyors conducted the following interviews on 2/1/24: *At 12:24 PM, RN H (Registered Nurse), who was the nurse working the night shift into 1/15/24 and wrote the first note on R1's wound, stated that the CNA had gotten her out of bed (time unknown, but close to first shift) and the foot was visibly bleeding. RN H stated that she then put a bandage on R1 and she (R1) began moaning in pain. RN H stated she passed the information onto LPN I (Licensed Practical Nurse). *At 12:34 PM, LPN I stated that she received report as she came onto her first shift on 1/15/24 and RN H reported to her that R1 had a wound on her foot. LPN I stated that she told the wound doctor at that time, as he was in the building and is typically in the building between 6-7 AM when he is rounding. LPN I stated that she assisted the wound doctor with his treatment of R1 and then proceeded to check all the other resident room heat registers on the memory care unit, but did not check R1's. LPN I stated she did not think any of the other registers she checked were hot. *At 12:01 PM, Prioress J (head of the order of nuns) stated that on 1/15/24, LPN I had told her about the wound on R1 and that's when they decided to move the bed away from the register on the wall. Prioress J stated that is when she saw a lot of blood on the heating register and wall and what appeared to be either a chunk of skin or coagulated blood stuck on the heating register. Prioress J stated that she was told that R1 was calling out on the previous shift so the CNA checked her and found the blood and the nurse intervened. Prioress J also stated that after the bed had been moved from the wall and heat register, she checked the register and it didn't seem hot so she believed that R1 had rested her foot on the register and it burned over time. Prioress J stated that maintenance and NHA A (Nursing Home Administrator) began checking all the other heat registers on the unit. *At 9:00 AM, RN K, who provided Hospice services to R1, stated that she arrived to the memory care unit on 1/15/24 on the first shift and was told by a nurse that R1 had burned her foot. RN K went to R1's room and the bed was still against the wall and the radiator. RN K also stated that she was in the room when the bed was moved and she could see blood and skin stuck on the heating register. At that time, she put her hand over the register and she couldn't keep it there, it was so hot. RN K also stated that she looked at R1's wound prior to the wound doctor and R1 pulled away when she (RN K) touched the bandage on R1's foot. RN K stated that the main wound (site 1 as mentioned in wound doctor's note) was a burn. *At 2:00 PM, ML L (Maintenance Lead) stated that he and NHA A began gathering temperatures on 1/15/24 after it was discovered that R1 had burned her foot. ML L stated that they did not write any temperatures down but none were very hot. ML L stated that he has not regularly gathered the temperatures of the heating registers before the incident or after the incident. ML L stated that he regularly checks water temperatures and room air, but does not check the registers unless a complaint is made about the temperature in a resident room. *At 2:07 PM, RN C (with NHA A), who is a clinical nurse consultant, stated that the previous DON's note on 1/15/24 noting R1's injury as an abrasion was not regarded as accurate and considered the wound doctor's assessment and notes to be accurate and correct. NHA A stated that he and ML L took temperature readings of all the heat registers on the memory care unit on 1/15/24 after R1 was burned and no temperatures even reached 100 degrees Fahrenheit and they (NHA A and ML L) ensured all the heat registers were in good order and no parts or jagged edges of the registers were apparent. NHA A stated he did not record the temperatures. NHA A stated that the location of resident beds was due to resident preference and that it would be difficult to move those beds and he didn't believe the heat registers would get very hot and were in good working order. NHA A and RN C stated no staff were educated on the heat registers, where bed should be, or the risks the heat registers posed to residents. On 2/1/24 at 2:21 PM, Surveyor interviewed MD M who stated that when he was asked to look at R1's foot on 1/15/24, he was told by staff that she commonly would swing her leg off the bed and onto the heat register next to the bed. MD M stated that given that answer and what he saw on R1's foot, it was consistent with a burn and treated the wound as such. When asked if it's possible for such a burn to occur over a long period of time if the heat register was warm (vs hot), MD M stated that it was possible. The Michigan State Agency sent a memo to its survey staff in 2004, which noted the following: Based on research by our Health Facilities Engineering Section, it has been determined that a temperature of 125 degrees Fahrenheit is normally acceptable on the surface of a heating unit in a nursing home or long-term care facility. This memo continues by noting, This temperature was determined from information found in ASTM International Standard C1055-03, titled Standard Guide for Heated System Surface Conditions that Produce Contact Burn Injuries. American Society for Testing and Materials (ASTM) Standard C 1055 -03 is largely based on the work of [NAME] and [NAME]. This maximum acceptable temperature is based on a maximum acceptable injury level of a first-degree burn, which is reversible, and causes no permanent tissue damage, and a maximum contact time with the heated surface of 60 seconds, to reflect the slower reaction times of the elderly or the infirm. At this temperature, one must recognize that there is some risk. While those who can react should have sufficient time to remove themselves from contact with the heated surface without sustaining permanent damage, it is incumbent upon the facilities to identify those residents who may be unable to recognize the danger or pull away from the heat source and provide extra protective measures for those residents as needed. (Emphasis added.) https://www.michigan.gov/-/media/Project/Websites/[NAME]/bchs/Folder2/BHS_NHM_Heating_Unit_Temperature1.pdf?rev=0c6e67303a1746349f096eaf0c3ba0d3 The temperature of the heat registers here was less than 125 degrees F. However, as noted in the bolded statement above, it was incumbent upon the facility to recognize the danger that even a lower temperature could pose to a resident who may not be able to feel the heat or recognize that s/he is being burned and especially one with a known history of swinging her leg onto the heat register. The failure to ensure a safe environment for a resident with a history of swinging her leg onto the heat register created a reasonable likelihood for serious harm, resulting in a finding of immediate jeopardy. The facility was aware that R1 burned her foot on the heat register, which was against her bed. Despite this, facility did not take measures to educate staff and did not put measures into place to ensure other residents on the memory care unit were not burned. Surveyors observed 17 of 20 resident beds to be against the wall, sandwiching the heat registers. The facility removed the immediate jeopardy on 2/2/24 when it had completed the following: ~All staff with the exception of the dietary department are educated before their next shift on keeping beds away from the baseboard heat registry. Staff education consisted of the newly created baseboard heat registry protocol. ~All beds in facility have been moved away from baseboard heat registers as of 2/2/2024. No other residents affected. ~ Facility created a baseboard heat registry protocol on 02/02/24 focused on bed clearance in relation to the baseboard heat register. The facility will utilize the risk management tool to investigate incidents, determine the root cause, implement interventions, prevent reoccurrence and ensure the primary physician is notified timely with any changes in condition. Risk management will be reviewed daily on business days by the DON, NHA or designee to ensure compliance. ~All resident rooms will be audited to ensure resident beds are not in close proximity to baseboard heat registries. The audit schedule will follow daily for 1 week, 2x per week for 4 weeks and 1x monthly for 2 months. It is the responsibility of the NHA, DON or Maintenance Lead to ensure compliance. The audit will then be reviewed by the QA committee. The facilty will also audit register temperatures of all rooms in the morning and in the evening. Temperatures will be recorded using an infrared heat gun. It is the responsibility of the Maintenance Lead, NHA, or DON to record temperatures. The audit schedule will be weekly for 8 weeks. The temperature audit will then be reviewed by the QA committee.

Based on observation, interview, and record review the facility did not provide the necessary behavioral health 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 2 of 3 resident (R2 and R3). R2 required behavior health services that were not provided as indicated and recommended by R2's PASRR (Preadmission Screening and Resident Review). R2's care plan does not address R2's PTSD (post-traumatic stress disorder) and history of suicidal ideation and suicide attempts. R3's care plan does not address R3's OCD (obsessive compulsive disorder), history of suicidal behavior or history of physical and sexual abuse. Evidenced by: The facility policy titled, Comprehensive Person-Centered Care Plan, reviewed 8/10/23, states in part . I. Policy: The Comprehensive Person-Centered Care Plan will reflect the individual's needs and preferences to facilitate care. II. Procedure: B. Within 21 consecutive days after admission, and in correlation with the Minimum Data Set (MDS), a comprehensive assessment will be completed, and a written care plan will be developed based on the individual's history, preferences, and assessments for appropriate disciplines and the physician's evaluation and orders. C. Care plans will be reviewed and revised quarterly, upon change of condition, and/or as needed. D. Individual and/or Individual Representative and direct care staff will participate in development of the comprehensive person-centered care plan. ** All policies and procedures must be applied in light of the specific situation and the individual. These general guidelines may be applicable in all situations. The needs of each individual must be considered in light of the guidelines established by these policies and procedures. The facility policy titled, Trauma Informed Care, reviewed 3/08/23, states in part . I. Policy: Entity will establish a trauma-informed approach that will recognize signs and symptoms of trauma in individuals, families, staff, and others involved with the system. Entity will treat all individuals with dignity and respect and will promote a culture of trauma-informed care. II. Procedure: i. Upon admission individuals will be screened for trauma exposure and/or related symptoms. v. Care plan will be established collaboratively with the individual with trauma-informed care in mind. The purpose of a Level I screen is to identify individuals whose total needs require that they receive additional services for their intellectual disabilities or serious mental illness. Individuals who test positive at Level I are then evaluated in depth to confirm the determination of an intellectual disability or mental illness for PASRR purposes. This is a Level II screen. This assessment produces a set of recommendations for necessary services that are meant to inform the individual's plan of care. Example 1 R2 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, recurrent, moderate, obsessive-compulsive disorder, PTSD, suicidal ideations, and history of suicidal behavior. R2's comprehensive care plan related to mental health state in part . Focus: The resident has a behavior problem and can exaggerate details of her life and incidents that take place. She is also very inconsistent in retelling of events and makes frequent accusations against staff. Stories can evolve and change, and the members of staff may also change. Goal: R2 will have fewer episodes of accusations and exaggerating stories by review date. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet R2's needs. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Staff will enter a room [ROOM NUMBER] by 2. If this is an issue with the resident, the 2nd person needs to stand where the interaction can be observed, but not seen. Focus: R2 uses antidepressant medication r/t (related to) Depression. Goal: The resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. Interventions: Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. Educate the R2/family/caregivers about risks, benefits, and the side effects and/or toxic symptoms of anti-depressant drugs being given. Monitor/document/report PRN (as needed) adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes; rigid muscles, balance probs (problems), movement problems, tremors, muscle cramps, falls, dizziness/vertigo; fatigue, insomnia; appetite loss, wt. (weight) loss, n/v (nausea and vomiting), dry mouth, dry eyes. Focus: R2 uses anti-anxiety medications r/t anxiety disorder. Goal: The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions: Administer ANTI-ANXIETY medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Monitor/document/report PRN any adverse reactions to ANTI-ANXIETY therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. UNEXPECTED SIDE EFFECTS: Mania, hostility, rage, aggression or impulsive behavior, hallucinations. Monitor/record occurrence of for target behaviors symptoms and document per facility protocol. On 1/10/24 the facility put in monitoring of targeted behaviors for R2. Targeted behaviors being monitored include . yelling, rude to others, wandering, agitation, restlessness every shift. The frequency, intensity and how resident responded to redirection. Facility provided Surveyor with a copy of R2's behavior monitoring from 1/1/24 to 2/2/24. There was only one date that R2 was noted to have documented behaviors. On 1/29/24, documentation shows R2 exhibited threatening behavior and rejection of care. On 11/23/23 R2 had a PASRR Level II completed which states the following in part . Specialized Services Determination: This person needs specialized psychiatric rehabilitation services to address his/her mental health needs. This decision was based primarily on the following: The facility that admits/retains R2 should have the appropriate staff and resources to meet her mental health needs. Level II PASRR evaluation summary and notice of appeal rights: Based on the federal regulations, at 42 CFR 483, 134, and 483.136, it was determined that I need services of a lesser intensity than specialized services, called specialized psychiatric rehabilitation services for my mental illness. If I want to appeal this decision, the Division of Hearings Appeals must receive my appeal letter within 45 days of the day I receive this notice. This decision is based primarily on the following: R2 is referred to BCS (behavioral care services) due to her diagnosis of major depressive disorder, obsessive compulsive disorder, post-traumatic stress disorder, and anxiety, currently receiving sertraline, lorazepam, aripiprazole, clonazepam, and mirtazapine. She is in need of specialized psychiatric rehabilitation services (SPRS). The focus of SPRS is to maintain or improve current level of functioning. SPRS should include a thorough assessment of this individual's unique capabilities, psychiatric symptoms, and behaviors, if any, by a QMHP (qualified medical healthcare professional). Contributing factors include longstanding history of depression; history of multiple chronic medical issues overdose attempts; multiple psychiatric hospitalization s; endorses feels of helplessness, hopelessness, and suicidal thoughts; psychiatrist medications review notes, ongoing benzodiazepines use can lead to prescription drug dependency. Antidepressant use directs clinicians to monitor for worsening depression and suicidal ideation. SSRI use directs clinicians to monitor for worsening depression and suicidal ideation. R2 may benefit from group therapy, 1:1 (one on one) talk therapy, med management, coping skill/problem solving techniques, behavioral management, and therapy for building self-esteem. On 2/1/24 at 10:30 AM, Surveyor spoke with R2. Surveyor asked R2 how everything was going in the facility and if she had any concerns. R2 shrugged her shoulders and continued to talk about concerns she had with care over the last 5-[AGE] years at various places. R2 reports that she wants to leave the facility and go to an assisted living where she can have her cats with her. R2 also reported concerns with the social worker and issues she has had with staff in the past that have already been investigated. On 2/1/24 at 2:00 PM, Surveyor interviewed DON B (Director of Nursing) and CNC C (Clinical Nurse Consultant) regarding R2. Surveyor asked DON B and CNC C if they are aware if R2 is receiving psychiatric services as indicated in her PASRR II. CNC C stated, I am not aware of R2 being offered any psychiatric services. She may have refused but I would need to see if there is documentation to show that. Surveyor asked DON B and CNC C what should be done if a resident refuses service's that are identified as needed by the resident. CNC C stated, staff should keep offering and education, if declined. Surveyor asked DON B and CNC C if R2's care plan should address her psychiatric diagnoses and interventions for each diagnosis. CNC C stated, Interventions should be care planned. Along with any behavior monitoring. I will look for any offering of psych services to R2. On 2/1/24 at 2:45 PM, CNC C brought in paperwork showing on 1/10/24 facility implemented targeted behaviors for yelling, rude to others, wandering, agitation, and restlessness. Note: The targeted behaviors do not include R2's history of PTSD, history of suicidal ideations and past suicide attempts. CNC C also reports at that time that she has been unable to find any documentation of refusals by R2 for psych services. On 2/1/24 at 4:00 PM, Surveyor interviewed MT (med tech)/CNA (certified nursing assistant) D. Surveyor asked MT/CNA D if R2 has any behaviors including suicidal ideations. MT/CNA D stated, R2 will talk about her daughter-in-law and that she is going to die. R1 does not talk about suicide in relation to herself, at least not to me. Surveyor asked MT/CNA D where she would find behavioral interventions for R2. MT/CNA D states, she would look in the care plan for interventions and progress notes. Surveyor asked MT/CNA D who updates the care plans with interventions. MT/CNA D states, the ADON (assist director of nursing) updates the care plans. On 2/1/24 at 4:05 PM, Surveyor interviewed CNA E. Surveyor asked CNA E if she is aware of any behaviors with R2 including suicidal ideation. CNA E states, I am not aware of R2 having any such behavioral issues only hallucinations. Surveyor asked CNA E where she would look for care plan interventions related to behaviors for R2. CNA E stated, I would go the care plan and report behaviors to the nurse. On 2/01/24 at 4:15 PM, Surveyor interviewed RN (registered nurse) G. Surveyor asked RN G where he would look for interventions for residents with behaviors including suicidal ideation, past abuse, and PTSD. RN G states, often the care plans are not up to date so I would make my own interventions. Example 2 R3 was admitted to the facility on [DATE] with diagnoses including, depressive disorder, obsessive compulsive disorder, history of suicidal ideation and history of physical and sexual abuse. R2's comprehensive care plan related to mental health states in part . Focus: R3 has a hx (history) of obsessive-compulsive disorder. Goal: The resident will have 3 or less episodes weekly through review date. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet the resident's needs. Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by. Explain all procedures to the resident before starting and allow the resident time to adjust to changes. Focus: R3 uses antidepressant medication. Goal: The resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. Interventions: Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. Educate the resident/family/caregivers about risks, benefits, and the side effects and/or toxic symptoms. Monitor/document/report PRN adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt. loss, n/v, dry mouth, dry eyes. Focus: R2 uses psychotropic medications r/t behavior management, disease process (specify). Goal: The resident will be/remain free of psychotropic drug related complications, including movement disorder, discomfort. Interventions: Administer PSYCHOPROPIC medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Discuss with MD, family re ongoing need for use of medication. Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy. Monitor/document/report PRN any adverse reactions of PSYCHOTROPIC medications: unsteady gait tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Monitor/record occurrences of for target behavior symptoms and document per facility protocol. Focus: R3 has depression r/t Dementia and Anxiety. Goal: R3 will have fewer s/sx of distress, symptoms of depression, anxiety, or sad mood by/through review date. Interventions: Administer medication as ordered. Monitor/document for side effects and effectiveness. Monitor/document/report PRN any risk of harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment, or safety awareness. Monitor/document/report PRN any s/sx of depression, including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness. Monitor/record/report to MD (medical doctor) prn risk for harming others: increased anger, labile mood, or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons. Facility provided Surveyor with a copy of R3's behavior monitoring from 1/01/24 to 2/02/24. There was only one date that R3 was noted to have documented behaviors. On 1/22/24, documentation shows R3 exhibited repeated movements and wandering. On 2/1/24 at 3:40 PM, Surveyor interviewed CNC C. Surveyor asked CNC C if R3 should have had a care plan for suicidal behavior and a history of physical and sexual abuse. CNC C stated individual care plans for R3 on her history of suicidal ideation and her history of physical and sexual assault should have been developed. On 2/1/24 at 4:00 PM, Surveyor interviewed MT/CNA D. Surveyor asked MT/CNA D if R3 has any suicidal ideations or other behavior concerns. MT/CNA D stated, R3 does bring up suicidal thoughts. R3 believes that her husband is/was with another woman, and she should kill herself. Surveyor asked MT/CNA D if she notifies anyone of the comments R3 makes or what she does when R3 makes the comments. MT/CNA D stated, I will check her room for items to causes her harm and do 1:1 until calm. R3 has made any of these comments for approximately 6 months. Surveyor asked MT/CNA D where she would look for care plan interventions for R3's behaviors and comments. MT/CNA D stated, I would look in the care plan for interventions and do 1:1 with gradual reduction. On 2/1/24 at 4:10 PM, Surveyor interviewed CNA E. Surveyor asked CNA E about R3's behaviors and if she was aware of any suicidal ideations with R3. CNA E stated, R3 pushed me on Tuesday (1/30/24) but I have not heard her voice any concerns other than at that time. Surveyor asked where CNA E would look for behavior interventions. CNA E stated, I would look in the care plan and report any issues to the nurse. The facility failed to ensure R2 received psychiatric services as recommended on admission from her PASRR II. The facility failed to develop comprehensive care plans for R2's history of suicidal ideation and past suicide attempts. The facility failed to develop a comprehensive care plan for R3's history of sexual and physical abuse and her history of having suicidal ideations.

Based on interview and record review the facility did not ensure physician orders were signed monthly for 1 of 1 Resident reviewed (R1). R1 did not have signed monthly orders for August 2023, September 2023, October 2023, November 2023, December 2023, or January 2024. This is evidenced by: R1 was admitted on [DATE]. R1 discharged on [DATE]. R1 had physician signed monthly orders dated 7/7/2023. No monthly signed physician orders noted in R1's medical chart for the following months: August 2023 September 2023 October 2023 November 2023 December 2023 January 2024 On 2/12/2024 at 11:47 AM, Surveyor interviewed DON B (Director of Nursing). DON B indicated the physician made rounds routinely and would include a review of medications in the physician progress notes. DON B indicated the physician progress notes do not specifically include all physician orders in the review. DON B indicated that physician signed orders would be good for 30 days and would expect the orders to be reviewed. Surveyor requested policy on signed physician orders. DON B indicated there is no policy regarding physician orders being signed. On 2/12/24 at 11:50 AM Surveyor interviewed NHA A (Nursing Home Administrator). NHA A indicated the computer system allows physicians to sign orders electronically but R1's physician does not utilize that feature. NHA A indicates R1's physician signs verbal orders and will put his own orders into the computer directly.

Based on interview and record review, the facility did not ensure that a resident receives treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 4 sampled Residents (R2). R2 had a change in condition that was not identified timely by nursing staff resulting in hospitalization for fluid overload. This is evidenced by: The facility policy entitled, 'Change of Condition and Provider Notification,' states in part: .Upon individual change of condition, proper assessment and provider notification will occur to provide timely delivery of clinical care. II. Procedure: 1. Change of condition. a) change of condition (COC) is a deviation from an individual's baseline in physical, cognitive, behavioral, or functional status. Clinically important means a deviation that, without intervention, may result in complications or death. 2. Assessment. a) licensed nurse is involved in the assessment process and contributes to the collection of the data base, the planning of interventions and evaluation of individual's response to condition change. b) a licensed nurse is to complete the initial assessment and follow-up evaluation as indicated by the complexity and stability of the individual's condition. c) change of condition assessment shall be reviewed by Registered Nurse. 3. Notification. a) primary care provider (PCP) will be contacted for notification and obtain further orders from provider as necessary. 1. if PCP cannot be reached, on call provider will be contacted. 2. If PCP and/or on-call provider are not able to be contacted, Medical Director will be contacted for notification.4. Documentation. a) individual with a change of condition will be monitored as appropriate. b) licensed nurse shall complete the change of condition assessment in the individual's electronic medical record. 5. Care Plan. a) Care plan and interventions will be updated as indicated. Resources: SBAR Communication Form, AMDA (American Medical Directors Association) . R2 was admitted on [DATE] with diagnoses to include: fracture around internal prosthetic hip joint (left), fracture of shaft of humerus (left), mild cognitive impairment, reduced mobility, unspecified diastolic (congestive) heart failure, atrial fibrillation (abnormal heart beat), cardiomegaly (enlarged heart), and chronic pain. R2's weight on 9/1/23 was 199.8 pounds (#). R2's Minimum Data Set (MDS) dated [DATE] indicates R2 has a Brief interview of Mental Status (BIMS) of 14 out of 15 indicating he is cognitively intact. Section G indicates that R2 has impairment to one side of his upper and lower extremities. R2's Care Plan, indicates the following: Focus: (R2) has congestive heart failure, date initiated 9/8/23. Goals sections states in part: .The resident will be free of peripheral edema through the review date.The resident will have clear lung sounds, heart rate and rhythm within normal limits through the review date.the Residents body weight will remain within normal limits through the review date. the residents electrolyte levels will be within normal limits through the review date . Intervention section states in part: .check breath sounds and monitor/document for labored breathing . Monitor intake and output . monitor/document/report PRN (as needed) any s/sx (signs and symptoms) of congestive heart failure: dependent edema of legs and feet, periorbital edema, SOB upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, orthopnea, weakness and/or fatigue, increased heart rate (tachycardia) lethargy and disorientation . .Focus: (R2) has nutritional problem or potential nutritional problem potential for weight loss/weight gain r/t (related to) new environment. Goal section states in part: .The resident will maintain adequate nutritional status as evidenced by maintaining weight within 5% of 200#, no s/sx of malnutrition, and consuming at least 75% of meals daily through review date . Intervention section states in part: .monitor and record weight as ordered. Notify MD/responsible party of significant weight changes. R2's weight on 9/25/23 is documented as 198.8 pounds. R2's weight on 10/1/23 is documented at 220.4 pounds. There is no documentation of a reweight being obtained, a follow up assessment related to weight gain, or notification to R2's provider. On 10/3/23, 16:22 (4:22 PM) Nurse note states in part: significant weight gain of 10.3% in one month. 10/1/23; 220.4# (pounds), 9/1/23 199.8#, weight 9/11/123 was 145.2# and 9/25/23 was 198.8#. There are obvious errors . we will continue to monitor weights and notify provider. (Signed by Dietitian) On 10/6/23, 12:03 PM Progress note, states in part: OT (Occupational Therapy) notified of RN re: concern with persisting cough, increased SOB, continued edema of BLE (bilateral lower extremities) including discoloration at B (both) feet. Pt (patient) reports feeling SOB is more limiting than prior weeks. (Signed by OT H (Occupational Therapist).) R2's weight on 10/10/23 is documented as 206.2 pounds. Note, this is a 7.4-pound gain since 9/25/23; there is no reweight taken or a follow up assessment related to R2's weight gain. On 10/10/23, at 13:44 (1:44 PM) Progress note, states in part: .at 1140 writer called (name) office in regard to residents change in condition. Writer had faxed yesterday regarding a dry non-productive cough and had not heard back. Upon assessment today, resident found to still have dry non-productive cough. After coughing episode resident found to have increased SOB (shortness of breath) and RR (respiratory rate). BLE (Bilateral Lower Extremities) with 1+ pitting edema. Increased weakness (Requires 2 extensive assist at this time). Bilateral feet purple in color, cool to the touch. Increased weight. Vitals as charted. Phone orders per (name) to draw CBC (complete blood count), CMP (Complete metabolic panel), BNP (brain neutropenic peptide) and D-Dimer (check for blood clot). Also received order for 2 view chest x-rays. (name) X-ray was in house and notified. X-ray collected at 1300 (1:00 PM), awaiting results. Labs collected and sent, waiting on results. On 10/10/23, 16:52 (4:52 PM) progress note states in part: .(Name) called with new orders due to elevation of WBC (white blood cells) and CXR (chest Xray) positive for pneumonia. R2's vitals on 10/10/23 are documented at 11:41 AM as a Blood pressure of 113/64, Temp 98.3, pulse 64, respirations 20, and oxygen saturation of 100% on room air. No further documentation, vitals, or assessments were completed on R2 on 10/10/23. R2's October 2023 Medication Administration Record (MAR) states, Daily weight in the morning due to Lasix use. Start date 10/11/2023. Lasix oral tablet 20mg (milligram) (furosemide) give 1 tablet by mouth in the morning related to unspecified diastolic (congestive) heart failure . for 3 days start date 10/11/2023. Intake and output every shift for 7 days. Start date 10/10/2023. Doxycycline hyclate oral tablet 100mg . give 1 tablet by mouth two times a day for pneumonia for 7 days start date 10/10/2023. On 10/11/23, 0006 (12:06 AM) Progress note states in part: 2 view cxr (chest x-ray) back, indication: weakness the lateral view is suboptimal for assessment. The lungs are adequately expanded. There is a focal left suprahilar pneumonic process spur there is right basilar pleural effusion. Faxed to MD awaiting on new orders. No follow up assessments or vitals were documented on R2 on 10/11/23 related to having pneumonia, weight gain, or being treated with an antibiotic. R2's weight was not obtained. On 10/12/23 at 11:23 AM, progress note for care conference states in part: Late Entry, note text: care conference held today. Care plan reviewed.update provided on resident's functional status and residents progression towards goals to return home. Family shocked to hear resident has pneumonia. OT expressed concerns about edema in legs and resident expressed that he is having right left [sic] pain just above the knee. Nursing will follow up.Name and title of meeting attendees: Resident, Brother (name), Sister in-law (name), DON (Director of Nursing) . On 10/12/23, 15:09 (3:09 PM) Progress note states in part: a significant weight change notification received from Dietician and faxed to primary MD. 10/12/23 Fax to Provider, states in part: Significant weight gain of 10.3% in 1 month. 10/1/23; 220.4#, 9/1/23; 199.8# weight 9/11/23 was 145.2# and 9/25/23 was 198.8#. There are obvious errors. he is eating well, mostly 75-100% .Resident is a recent admit. Recommend no changes at this time . (faxed 10/12/23). Note this is a 4.2 pound weight gain from 10/10/23 to 10/12/23. R2's October 2023 MAR shows Intakes and Outputs were not documented on 10/12/23 for evening or night shift. No follow up assessments or vitals were documented on R2 on 10/12/23 related to edema, pain, weight gain, having pneumonia, or being treated with an antibiotic. On 10/13/23, R2's Intake and Outputs were not documented for evening or night shift. Evening shift is blank, and the night shift indicated NA (not applicable). On 10/13/23, R2's weight is documented as 211.6 pounds On 10/14/23, R2's intake and outputs were documented as not applicable for all 3 shifts. No weight was documented on R2 as being obtained. R2 was not weighed. On 10/15/23, R2's intake and outputs were documented as not applicable for all 3 shifts. No weight was documented on R2 as being obtained. R2 was not weighed. On 10/16/23, R2's intake and outputs were documented as not applicable on evening and night shift. R2's weight is documented as 209 pounds. On 10/16/23, Occupational Therapy (OT) notes state in part: .(R2) is encountered in bed awake, confused again this morning with odd statements throughout the first half until more lucid and accurately oriented. Seems with increased widespread edema, nrsg (nursing) reports weight is down ~2# (approximately 2 pounds) after session. Coughing less but overall, more weak than ~2 wks. (approximately 2 weeks) ago . There is no evidence of a nursing assessment related to widespread edema noted by OT or any notification to R2's Provider. On 10/17/23, R2's intake and outputs were documented only for day shift, and the evening shift was blank. R2's intake and outputs ended after evening shift on 10/17/23. R2's weight is documented as 211 pounds. R2 finished his last dose of Doxycycline 100mg twice a day (antibiotic) on day shift on 10/17/23. No update was made to the provider letting them know 7 days of intake and outputs were not completed as ordered. On 10/17/23, 11:29 AM Progress notes states in part: Late entry note text: writer received update from floor staff, (MA H) that resident's family is present and looking for update.stated that d/t (due to) resident pneumonia and OT expressing concern r/t (related to) increased edema that resident needs longer time for strengthening. Family requested further information on edema and pneumonia status - state they have not heard anything since care conference. Writer passed message along to ADON and DON, informed them that family is waiting and requested follow - up. On 10/17/23, OT note states in part: .(R2) is encountered awake in bed, appears wide awake and reports he's been up most the night. Continues with inconsistent sleep patterns, confusion, still weaker than prior to pneumonia onset but seeing somewhat less SOB (short of breath) today. Widespread increased edema persists . On 10/17/23, R2's weight is documented as 211 pounds. On 10/18/23, OT Note states in part: .Less coughing today and overall, with improved task tolerance, seeming less SOB with activity . On 10/18/23, R2's weight is documented as 210.5 pounds No follow up assessments or vitals were documented as being done on R2 on 10/16, 10/17, or 10/18 related to edema, weight gain, having pneumonia, or being treated with an antibiotic. On 10/19/23, R2's weight is documented as 211.2 pounds. This is an increase of 12.4 pounds in less than 30 days. On 10/19/23, OT note states in part: .L (left) side widespread edema persists appearing increased from last week. OT called in RN to further assess.SOB seeming improved but overall, still seeming medically limited with ongoing cognitive inconsistencies impacting further progression. 10/19/23 fax to provider, states in part: .(R2) . notes: update. Residents weight is stable; however, his LLE (left lower extremity) has 3+ pitting edema all the way up the leg, thigh and LLQ (left lower quadrant). The edema to LLQ is firm and slightly tender. RLE (right lower extremity) has nonpitting edema that stops below the knee. (no) chest pain, mild pain breathing. Nurse signature .date 10/19/23. No evidence of a response from R2's provider or contact with R2's provider regarding having increase in edema or having LLQ edema that was firm and slightly tender. R2 had a change in condition that was not communicated to the provider timely. There are no follow up assessments documented after this fax was sent to the provider on any of the shifts leading up to R2 being sent out on 10/20/23. On 10/20/23, 1:16 PM R2's Nurse's note states in part: .Therapist notified nurse, (LPN D) at 1030 that resident had very edematous legs and purple feet. The skin does blanch and has pitting edema. The left leg is significantly larger than the right now. There is also a large fluid pocket on the left flank area. (LPN D) then called a second nurse to give a 2nd opinion. Upon listening to the lungs of the resident, (LPN D) found the left side to have a loud friction rub and rhonchi. At 1038 a call was placed to (Physician name) in (place). After being on hold he hung up to try and call for transport to the ER (emergency room ). At 1040 he came and spoke with this nurse, (DON B), who agreed that resident needed to go out to the ER. He then placed a call to (name), and they were not able to come in a timely manner. At that point, he called 911 at 1047. Upon returning to the resident's room, (LPN D) found that the resident's brother was there and moving the resident out. (LPN D) notified this writer and (Nursing Home Administrator (NHA)) .Brother was told that we had called 911 and an ambulance was on the way and that resident needed medical attention.at 1121 ambulance arrived. Ambulance personnel eventually came to front door and brother tried to keep (LPN D) from talking to EMT (Emergency Medical Technicians). (LPN D) was able to talk to the EMTs and update on resident's condition. They also tried to get brother to allow resident to go via ambulance.Brother signed a refusal of medical treatment and/or transport. He was educated that resident needed medical care, and if he took him from facility it was leaving against medical advice. He refused to sign any paperwork for the facility. It was impressed upon the brother to take him directly to the ER . allowed ambulance crew to help lift resident into very large and tall truck and they drove off. (Signed by DON B (Director of Nursing)). 10/24/23, 8:29 AM R2's Discharge/transfer note, states in part: Discharge with return not anticipated. Resident left against medical advice.wt. (weight) = 211# general diet with regular consistency and thin liquids. Meal intakes were good. Significant weight gain in one month but he had a lot of edema when he left. Admit weight 199.8#. (Signed by dietician) R2 was admitted to the hospital on 10/20/23 with a diagnosis of fluid overload (condition where you have too much fluid volume in your body) and anasarca (accumulation of serous fluid in various tissues and body cavities characterized by swelling of the whole body). Emergency department note dated 10/20/23 at 3:57 PM indicates in part, Chief complaint patient and brother arrived by personal car. Brother is reporting patient left leg has been getting more swollen and harder. Patient reports pain 8 out of 10 in the left leg that is constant. History or present illness, Brother states the patient has had continuing left lower extremity swelling which has worsened over the last several weeks, he also states that the patient is not getting up and actually participating in any rehab and seems to be going downhill overall. An approximate weight of 95.5 kg or 210.1 pounds. Skin: warm, dry. Dry mucous membranes. Musculoskeletal system: there is 3+ pitting edema to the entire left lower extremity. On 11/29/23 at 9:20 AM, Surveyor interviewed OT H (Occupational Therapist). OT H indicated that she brought up R2's edema multiple days in a row as it was worsening. OT H indicated that LPN D finally called and got R2 sent out. OT H indicated that R2's edema was getting worse and that he had a large amount of edema on his side. OT H indicated that for multiple days R2 was not assessed, no vitals were taken on R2, and the physician was not called. OT H indicated that staff would tell her, I don't know, I haven't worked with him since last week, when reporting the edema to staff. OT H indicated that R2 did have a chest x-ray done and they did treat R2 for pneumonia. OT H indicated she reported her concerns to Nurse (name). OT H indicated that Physical Therapy and Occupational Therapy were reporting more shortness of breath and then he was treated for pneumonia which R2 began to look better then he got worse. OT H indicated that R2 did not leave against medical advice, as R2's brother came in and was taking him to the emergency room . Please note the nurse OT H reported her concerns to is not actually a nurse, the individual is MA F (Medication Aide). On 11/29/23 at 1:20 PM, Surveyor interviewed MA F related to R2. MA F indicated she will report concerns to the nurse on 300 hall when there is an issue or a concern with a resident. Surveyor asked if MA F noticed shortness of breath or edema, MA F indicated OT showed her R2's legs. MA F indicated she told the OT staff they would reweigh the resident and that she would pass it on to the nurse (Registered Nurse E). MA F indicated R2's feet were discolored, they put his feet up and the discoloration went away. MA F indicated they weighed R2 two times that day and told therapy his weight didn't change. MA F indicated she did not notice any increase in edema. MA F indicated R2 had increased confusion at times. MA F indicated they did not do vitals on R2 daily but did begin doing weights daily. On 11/29/23 at 1:30 PM, Surveyor interviewed RN E (Registered Nurse) regarding R2. RN E stated nurses would assess a resident being treated with an antibiotic for pneumonia including checking vital signs, lung sounds, monitor for increased confusion, and document that information in the computer. RN E indicated that if there was no improvement you would notify the physician/provider. RN E indicated that R2 had swelling since admission and his swelling (edema) was increased right before he left. RN E indicated you would check if the edema is pitting, check if the resident needs compression stockings, encourage elevation of legs, and check if skin is blanchable due to R2's legs turning colors when he got up. RN E indicated she could feel pedal pulse. Surveyor asked if that was documented anywhere; RN E indicated there should be a progress note. Surveyor asked RN E if therapy reported an increase in edema? RN E indicated she remembers a nurse contacting the MD when they were getting ready to send him out. RN E indicated if increase in edema was reported to her, RN E would assess and get a hold of the MD for an update. RN E indicated for a resident with heart failure and weight gain you would need parameters from the MD. RN E indicated, usually 3 pounds in a day or 5 pounds in a week you're to update the MD. RN E indicated that the nurse is responsible for notifying the MD about weight changes. RN E indicated change of condition notes and assessments are in the nurses' notes. RN E indicated that R2 seemed confused. RN E indicated if a resident is on an antibiotic you would chart on that resident each shift along with vital signs, lung sounds. RN E indicated for a resident with heart failure you would check daily for edema and chart if there was edema present along with a daily weight. Surveyor asked RN E how she would know if a resident had a change in condition, RN E indicated through verbal report, RN E indicated she would not know of any changes of condition if it's not reported to her or unless she checked everyone's charting. On 11/29/23 at 1:47 PM, Surveyor interviewed CNA I (Certified Nursing Assistant) regarding R2. CNA I indicated she worked with R2 once per week. CNA I indicated R2 had very little swelling but that if R2's feet were down they would get red and swell. CNA I indicated once they put R2's feet up the discoloration would go away. CNA I indicated staff are to reweigh residents if the weight is off by three pounds. On 11/29/23 at 1:58 PM, Surveyor interviewed CNA J regarding R2. CNA J indicated R2 had swelling the day he left and that the nurse called 911 to take him to the hospital. CNA J indicated R2's brother came and indicated he was taking him somewhere he wasn't going to die. Surveyor asked if R2 had swelling prior to this? CNA J indicated not consistently, we would elevate his legs and swelling would go down. CNA J indicated R2 had shortness of breath after transfers and after working with therapy and would recover quickly. CNA J indicated she would report increased edema and shortness of breath to the nurse. CNA J indicated increase or decrease of 3 pounds in a day or 5 pounds in a week, the resident needs to be reweighed and let the nurse know. On 11/29/23 at 2:45 PM, Surveyor interviewed RN K regarding R2. RN K indicated he worked with R2 two to three times and that he contacted the physician related to respiratory concerns. RN K indicated if a resident has swelling you would need to measure the swelling, assess the resident, get a hold of the MD, and elevate the legs and document your findings in the computer. RN K indicated for an antibiotic you would monitor temperature, signs, and symptoms of adverse effects from the antibiotic, if signs and symptoms are improving or worsening and document that information. RN K indicated he would only know if a resident is on an antibiotic or had an infection if it was passed on in report, checked documentation, or if he was giving the antibiotic himself to a resident. RN K indicated changes in condition are reported verbally in report or if a nurse notices a change by assessing the resident. RN K indicated they no longer have a 24-hour board. RN K indicated if he noticed weight gain, a nurse would assess for edema, check lung sounds, and contact the MD to let them know of the weight gain, and document it. On 11/29/23 at 4:11 PM, Surveyor interviewed LPN D (Licensed Practical Nurse) regarding R2. LPN D indicated he worked two shifts with R2. LPN D indicated edema was reported about a week and a half before he left. LPN D indicated a Medication Aide (MA) came to him asking, have you seen his legs they're very purple. LPN D went to look and R2's legs were really purple and he checked pedal pulses and went to get RN E. LPN D indicated RN E did not go down to look at R2 but told LPN D that when R2's feet are down they get purple, when his feet are up it goes away. LPN D was the nurse on the day R2 was being sent out/left the building. LPN D indicated that Therapy came to him and asked if I (LPN D) could look at his legs and that he had a pocket of fluid on his left side. LPN D indicated he checked R2's lungs and heard rubbing and checked his feet they were very, very swollen and he had fluid on his side. LPN D indicated he got RN E to come to the room and informed RN E that LPN D was calling 911. DON B (Director of Nursing) was informed of calling 911. LPN D indicated within 10 minutes of calling 911, R2's brother was in the room and was packing up R2's belongings. LPN D informed the brother that R2 needs to go to the hospital and that 911 was called. R2's brother took R2 away in his truck after EMS (emergency medical staff) assisted R2 into the vehicle. LPN D indicated the brother said he was taking R2 to the hospital himself. LPN D indicated R2's fluid started at his waistline and under his rib cage, and that R2 was very full of fluid, you could hear gurgling and rubbing. LPN D indicated you could not feel pedal pulses on R2, and his feet were cold, both legs were swollen a large amount, the left leg greater than the right. LPN D indicated he would say 6 plus pitting edema if that was a thing, as it was greater than 4 plus pitting. LPN D indicated for antibiotics for pneumonia you would monitor for adverse reactions, vital signs, lung sounds, and cognition and document that information even if there are no changes. LPN D indicated he knows if there is a change in condition in report at the end of the shift. LPN D indicated things get missed in report, for example a resident receiving antibiotics in the morning, wouldn't know that unless you worked the morning shift and gave that antibiotic to the resident. LPN D indicated for someone with edema you would check for pedal pulses, if pitting or not, ensure legs elevated, and relay that information to the MD if needed and document it. LPN D indicated that weekly and daily weights aren't always obtained due to staffing as they're not able to get to them all before breakfast. LPN D indicated plus/minus 3 pounds in a day or 5 pounds in a week, if there are no parameters on the weight, then a nurse should request clarification on the parameters. On 11/29/23 at 3:47 PM, Surveyor placed a call to R2's brother, a message was left for a return call. As of 12/11/23, no return call has been received. On 11/30/23 at 9:01 AM, Surveyor placed a call to MD G (Medical Doctor) and a message was left with MD G's nurse. On 11/30/23 at 9:25 AM, Surveyor interviewed ADON L (Assistant Director of Nursing) regarding R2 and R2's nurses notes. ADON L indicated they had a nursing meeting in the morning, and he wasn't really improving and had more confusion. ADON L indicated that she knew R2 had edema when he came from the hospital. Surveyor asked if anyone went down to assess R2 after the care conference on 10/17/23. ADON L indicated she believes she brought it to the attention of the floor nurse, who should have assessed. ADON L indicated they should check vitals, check cognition, lung sounds, CMS (circulation, movement, sensation) to ensure intact, and for edema. ADON L indicated that as the day went on R2 would have more confusion. ADON L indicated for R2 being on an antibiotic, staff should be putting in a note, check a temperature, document side effects, and chart on if improvement. ADON L indicated if an increase in swelling occurred a condition report or SBAR (situation, background, assessment, and recommendation) needs to be filled out and sent to the MD. Surveyor reviewed the nurses note from 10/6 with ADON L. ADON L indicated she would expect nursing staff to go in and assess R2 and notify the MD of the change in condition. ADON L reviewed 10/10/23 note with Surveyor. ADON L indicated staff should be monitoring for signs and symptoms, side effects and temperature every shift when on an antibiotic. ADON L reviewed the note on 10/12/23 and indicated nursing staff should have assessed, follow up with additional assessments, and reported it to the MD. ADON L indicated a daily weight is supposed to be gotten in the am, if it's off to call the MD per parameters. If not parameters, then the nurse is to be looking at the weight as when you put in a weight a notification of weight gain or loss pops up and the nurse should see they need to notify an MD. On 11/20/23 at 10:36 AM, Surveyor interviewed NC C (Nurse Consultant) and DON B (Director of Nursing) regarding R2. DON B indicated R2 was admitted with a fracture, not able to get up on his own, had 2 plus edema upon admission, then unremarkable and R2's edema continues off and on. DON B indicated on 10/9 or 10/10 R2 had a chest x-ray and staff called about edema and then he started on an antibiotic for pneumonia, had a dry cough and no remarkable weight changes. DON B indicated R2 had remarkable edema the day he had to go out and that R2 was resistant to elevating legs and discussed refusal at care conference. (Please note there is no documentation of refusals for elevating legs in R2's notes or chart.) DON B indicated R2's edema was not new, and he had an increase in edema noted the day he went out. DON B indicated if for antibiotic for pneumonia she would expect lung sounds, pulse oxygen, temperature, general pain, hydration, skin turgor, thirst, and nausea to be assessed and expected it to be documented. NC C nodding head yes when asked if expected documentation on monitoring for antibiotic use and if improvement or decline while on antibiotic. DON B indicated assessments should be done each shift and documented each shift. Surveyor had DON B look at R2's note from 10/12. DON B indicated at this time edema was at baseline for him. Surveyor asked if a follow up assessment or note should be documented based on 10/12 note; DON B indicated yes. Surveyor asked DON B to review 10/16/23 OT note. DON B indicated she would expect nursing to follow up and would expect a note documented. Surveyor asked DON B regarding 10/18 note; DON B indicated she would expect staff to investigate it and put a note in. Surveyor asked if R2 should have had vitals taken more frequently since 10/10; DON B indicated yes. Surveyor asked if Daily weights should be done daily; DON B replied yes. DON B indicated the process for weight changes is to reweigh the resident and verify if the weight is correct. DON B indicated R2's weight on 10/12 should have been called to the MD. Surveyor asked about R2's Heart failure care plan. DON B indicated based on the care plan, would ideally have lung sounds daily and as needed. Surveyor asked DON B and NC C to review R2's intake and output (I&O) documentation. DON B indicated I&Os should have been done. DON B indicated she was told by OT on 10/20/23 and that the note OT put into the chart for 10/18 was a late entry on 10/20/23. DON B and NC C indicated for a change in condition you would investigate it, document if the change of condition is brought to them whether it was a change or not a change, do an SBAR (situation, background, assessment, and recommendations) and send it to the MD. DON B indicated investigate it means to go in and look at the resident, check vitals, breathing, skin if it's all okay, document it and check on them, if changes noted, staff to take it further. NC C indicated she was not able to find any additional information regarding R2's change in condition, vitals, weights, or assessments. On 12/4/23 at 8:30 AM, Surveyor interviewed MD G regarding R2. MD G indicated R2 was admitted to the hospital approximately three weeks ago with edematous legs, edematous scrotum. MD G indicated R2 was given diuretics. MD G indicated R2's family was upset and brought him to the ER. MD G indicated R2 had fluid overload and anasarca unable to say how long it took. MD G indicated he would expect nursing staff to assess and notify him with a change of condition, increase in weight, and increase in edema, and concerns should have been addressed. MD G would expect nurses to assess at least daily when diagnosed with pneumonia. MD G indicated he would expect I&Os to be documented and reviewed. MD G indicated that staff could have recognized and treated R2's change in condition sooner. R2 was admitted with known heart failure and experienced an increase in edema that was reported to the nursing staff by therapy on multiple occasions. Nursing staff failed to assess R2 at the appropriate times related to weight gain, increased edema, and antibiotic use for pneumonia. Staff did not monitor R2's intake and outputs in relation to his weight gain or increased edema. The staff's failure to continue to assess R2 resulted in R2 being hos [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure that 5 of 13 sampled residents (R2, R10, R13, R9, R14) were free from neglect. Numerous staff expressed concerns about low staffing levels and not being able to provide all needed care because there isn't enough staff. R2 had a history of recurrent Urinary Tract Infections (UTIs). The facility failed to follow the physician orders for monitoring R2's output. The facility does not have evidence that staff provided catheter care to R2 on 4/21/23. On 4/21/23 at 5:00 PM, the facility called 911 after finding R2 unresponsive while delivering her supper tray. Emergency Medical Services (EMS) found R2 covered with ants. According to the emergency room (ER) nurse, there were ants embedded in her skin, the catheter bag was dated 4/12/23 and the urine in the bag did not appear fresh; after removing the foley, thick mucus with blood and black sediments was seen in the urine, which smelled of ammonia. After the sludge came out, the urine continued to drain all over R2's bed. The ER nurse could not measure the amount of urine because it poured all over her bed. R2 was admitted to the hospital in septic shock with urosepsis and a urinary tract infection. The facility's failure to ensure R2 was free from neglect created a finding of immediate jeopardy that began on 4/21/23. Surveyor notified NHA A (Nursing Home Administrator) and DON B (Director of Nursing) of the immediate jeopardy on 9/21/23 at 4:12 PM. The immediate jeopardy was removed on 9/25/23; however, the deficient practice continues as a scope/severity of an E (pattern, potential for no more than minimal harm) as the facility continues to implement its action plan and as evidenced by the following: R10 has multiple stage 3 pressure injuries (PIs) and is at risk for developing more pressure injuries. Surveyor observed R10 for over 5 hours and during this time staff did not assist R10 with repositioning/turning. R13 is at moderate risk for developing pressure injuries and is dependent on staff to meet her needs in repositioning/turning. Surveyor observed R13 lying in bed for over 3 hours and during this time staff did not offer R13 assistance with repositioning and turning. R9 has a history of aspiration pneumonia and Traumatic Brain Injury. R9's Physician Orders and Speech Therapy recommendations to provide supervision while R9 was eating were not followed. Staff also gave R9 the wrong consistency of liquid when he was ordered to have nectar thick liquids. R14 is at risk for falls and requires prompt assistance. R14 indicates waiting 45 minutes or longer for assistance 5-6 times per week, placing R14 at risk for falling. This is evidenced by: The facility policy titled, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, with a revision date of 12/1/22, indicates, in part: Policy: It is the policy of the facility that each individual will be free from 'Abuse'. The term abuse will be used throughout this Policy and Comprehensive Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Program to relate to: mental, sexual, or physical abuse; neglect; exploitation; involuntary seclusion; misappropriation of individual property; injuries of unknown origin; corporal punishment; or involuntary seclusion. The individual will also be free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the individual's medical condition. Procedure: A. Individuals will be protected from abuse, neglect and harm while they are residing at the facility. B. No abuse or harm of any type will be tolerated. C. Individuals and staff will be monitored for Protection. D. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties. E. The facility will encourage and support all individuals, staff, families, visitors, volunteers and individual representatives in reporting any suspected acts of abuse to the Nursing Home Administrator or designee. F. The Nursing Home Administrator or designee will report abuse to the state agency per State and Federal Guidelines. G. The facility will follow the attached Comprehensive Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Program to comply with the seven-step approach to abuse and neglect detection and prevention. H. The abuse Policy and Comprehensive Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Program will be reviewed on at least an annual basis and will be integrated into the facility Quality Assurance and Performance Improvement (QAPI) program. R2 was admitted to the facility on [DATE] as a long term resident to the memory care unit, with diagnoses that include, in part: paraplegia (a paralysis affects all or part of the trunk, legs and pelvic organs), neuromuscular dysfunction of the bladder (a complete disruption of both motor and sensory nervous system control over the bladder), urinary tract infection (an infection in any part of the urinary system that includes the kidneys, ureters, bladder and urethra), colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall to the outside of the body as known as a stoma, so as to bypass a damaged part of the colon), and an unspecified fracture of the lower end of the right femur. R2's change of condition Minimum Data Set (MDS) assessment, dated 4/6/23, indicated a Brief Interview of Mental Status (BIMS) score of 12, indicating moderately impaired cognition. R2's Comprehensive Care Plan indicates, in part; . The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) paraplegia, date initiated 12/4/22 . Interventions: . AM Routine: The resident's preferred dressing/grooming routine is to get up after breakfast. Bathing/Showering: The resident requires extensive assistance of 1 by staff with bathing. Dressing: The resident requires extensive assistance by 1 staff to dress. Eating: The resident is able to feed herself after set up. Personal Hygiene/Oral Care: The resident requires extensive assistance of 1 with oral/personal hygiene. Transfer: The resident requires Mechanical lift (hoyer) with 2 staff assistance The resident has an indwelling catheter r/t Neurogenic bladder, paraplegia, and pressure ulcer to buttock and hip, date initialed 12/5/23 . Goal: The resident will show no s/sx (signs or symptoms) of urinary infections through review date . Interventions: Monitor and document intake and output as per facility policy. Monitor for s/sx of discomfort on urination and frequency. Monitor/document for pain/discomfort due to catheter. Monitor/record/report to MD (medical doctor) for s/sx UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp (temperature), urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns . The resident has pressure ulcer to right and left heel, right and left calf r/t immobility, date initiated 4/18/23 . Interventions: Educate the resident/family/caregivers as to causes of skin breakdown including: transfer/positioning requirement; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning . Reposition every 2 hours and prn (as needed) to relieve pressure . Physician Orders from R2's facility Electronic Health Record (EHR): Start date 12/1/22, Change drainage bag every night shift every 2 weeks on Sat, date bag when changing. Start date 3/22/23, Reposition every 2 hours. CNA or nurse to burp (manually remove gas) osteomyelitis [colostomy] bag every 2 hours with repositioning. Every shift for skin integrity. Start date 3/30/23, Keflex (cephalexin) 500mg, 1 tablet every day for 7 days for UTI. End date 4/6/23. Repeat UA (Urine Analysis) with culture after ATB (antibiotic) therapy for bacteria resolution, one time only for 1 day, start date 4/7/23, located in the TAR. [On 4/9/23, urine culture results that was collected on 4/7/23, indicates 10,000 CFU/ml (colony forming unit per milliliter) Proteus mirabilis, an abnormal result and 10,000-100,000 CFU/ml Enterococcus species, an abnormal result. Note: Colonies greater than 100,000 CFU/ml represents a urinary tract infection.] Start date 4/13/23, Catheter care every shift. (Note: Resident was admitted with a catheter on 12/1/22.) Start date 4/13/23, Monitor catheter output. (Note: No documentation provided of catheter output being monitored.) On 9/20/23 at 5:53 PM, Surveyor interviewed RN J (Registered Nurse). When Surveyor asked RN J who does the catheter care and how often is it completed, she indicated the CNAs (Certified Nursing Assistant) do the care and it is done twice per day. Surveyor asked RN J if a resident came into the facility would you expect the care to be in the care plan; she indicated yes, and would see the reason, the goal, the intervention, a leg strap attachment, and to empty every shift with catheter care. When Surveyor asked RN J if a physician order is needed to monitor intake and output, she indicated no, and stated, it's kinda a given to monitor, there is a standard in the software to click for standing orders for catheters. Surveyor asked RN J the process for obtaining a verbal order from the physician, she indicated the order is put in the software under the order tab, then print out and send the order to the physician's office to be signed. On 9/25/23 at 12:07 PM, Surveyor interviewed Nurse Consultant Z. Surveyor asked Nurse Consultant Z if she would expect staff to follow physician orders, she indicated yes. When Surveyor asked Nurse Consultant Z if a resident has a history of UTIs, if she would monitor the output, she indicated she would, and the catheter care would be performed daily. When Surveyor asked Nurse Consultant Z if staff are checking off boxes of care that is completed, should the staff verify that the care was completed, she indicated yes. R2's CNA Bowel and Bladder Elimination Documentation dated April 2023 provided by the facility indicates documentation performed 23 missed opportunities out of 62 opportunities. R2's CNA Documentation of Bed Mobility, Dressing, Eating, Locomotion off Unit, Personal Hygiene, Toilet Use, Transferring, Bowel and Bladder, Monitor Behavior have blank boxes, indicating no documentation of cares completed during the shift of 2:00 PM-10:00 PM on 4/21/23. On 9/21/23 at 9:46 AM, Surveyor interviewed CNA R. Surveyor asked CNA R how was R2 to care for, she indicated R2 was very nice, able to converse, and that she was [NAME]. CNA R further indicated R2's room was by the nurse's station. Surveyor asked CNA R if she was in R2's room on 4/21/23, she indicated she went in that morning at about 6:00 AM-7:00 AM as R2 is on an overnight check and change schedule. CNA R further indicated when she made rounds, it was so early that she did not move her. When Surveyor asked CNA R when she checked on R2 in the morning round if she looked for cleanliness, she indicated she did not go in the peri area. CNA R indicated that R2 informed her that she did not feel good, she was tired and then CNA R informed the medication technician and the other CNA that R2 did not look good or feel good. Surveyor asked CNA R if R2 was checked on the rest of the day, she indicated she saw R2 a second time about mid-day and that she was sleeping. When Surveyor asked CNA R if R2 ate breakfast or lunch, she was not able to recall. Surveyor asked CNA R if R2 had a shower, and CNA R indicated no. Surveyor asked CNA R is she was assigned to R2, she indicated no. On 9/21/23 at 10:32 AM, Surveyor interviewed CNA S. When Surveyor asked CNA S if she worked on 4/21/23, she indicated she did. CNA S indicated that the 2 CNAS working that day were CNA R and CNA S. CNA S further indicated that each CNA will take a side of the unit and that CNA S was not on that side. When Surveyor asked CNA S if R2 ate at breakfast or lunch, she was not able to recall. When Surveyor asked CNA S if she performed catheter care on R2, she indicated no. Surveyor asked if CNA S charted on R2 on 4/21/23; she indicated that CNA R did not have a log in when she first started, so CNA S would log in and then let CNA R chart on the residents she needed to chart on. Surveyor asked CNA S when she saw R2 on 4/21/23, she stated, The only time I saw her that day was prior to giving her that supper tray. When Surveyor asked CNA S what happened with the supper tray, she indicated she went in to give R2 supper, she did not respond, there was not a nurse on the floor that day, so CNA S called the Former ADON T who then came to the room. On 9/21/23 at 8:05 AM, Surveyor interviewed RN U. When Surveyor asked RN U if she worked on 4/21/23 when R2 was transported to the hospital, she indicated she worked the shift prior. Surveyor asked RN U if R2 had breakfast on 4/21/23; she indicated she could not remember. Surveyor asked RN U if R2 had lunch on 4/21/23: she indicated she did not remember. Surveyor asked RN U who does the catheter care, she indicated the aides usually do the care and stated, I just verify it's done. Surveyor asked RN U if she verified the catheter care was done, she indicated she could not verify as there was staff that did not come in that day. RN U further indicated she tried to take care of as much as she could and then stated, I signed it without even knowing the catheter care was done. (It is important to note that CNA S and CNA R indicated they are the only CNAs on the unit, and neither was assigned to R2. Surveyor cannot identify that catheter care was completed by CNA S and CNA R, and RN U indicates she signed completion of catheter care without verifying.) On 9/21/23 at 10:49 AM, Surveyor interviewed Former ADON T (Assistant Director of Nursing). Surveyor asked Former ADON T to describe the events related to sending R2 to the hospital. She indicated the medication technician came for her, the resident was lethargic. Former ADON T further indicated vital signs were taken and when they pulled back R2's covers, she had little tiny sugar black ants all over her bed. When Surveyor asked Former ADON T who was the CNA taking care of her on 4/21/23, she indicated there were 2 CNAs on the unit but could not recall which CNA. Surveyor asked the Former ADON T if R2 ate lunch, she was not able to recall. When Surveyor asked the Former ADON T if a resident has a history of UTIs should the intake and output be monitored, she indicated yes. Surveyor asked the Former ADON T if R2 was being monitored, she indicated she could not answer without seeing the orders. Surveyor asked the Former ADON T when the last time R2 was checked on, she indicated a CNA informed her they did rounds at 5:00 PM and she was changed due to an incontinent episode. (It is important to note that Surveyor was unable to locate documentation of an incontinence episode for 4/21/23 at 5:00 PM.) Facility provided further information on 10/2/23 a statement dated 4/21/23 from Former ADON T, entitled, Statement on Events on 4/21/23, states, in part; . I interviewed [medication technician's name] as to the last time she had completed cares or seen the resident and she stated that she had completed cares on her just 30 minutes before she came to get me and the resident was fine and did not have ants in her bed at that time. This document is signed by a recoverable signature of Former ADON T. (Surveyor requested the medication technicians contact information on 9/20/23 and was not provided prior to exit. Further, no statement was provided from the medication technician.) Progress Notes from R2's EHR: On 4/21/23 at 5:20 PM, (Of note, this discharge transfer note was written at 7:54 PM), CNA came and reported that resident was unable to speak and normally is verbal. Upon entering the room, resident was staring at the ceiling and unable to speak verbally. She responded to her name but could not squeeze my hands. She responded to painful stimuli with a frown. She was unable to follow directions. Pupils were normal and reactive. VS were 179/82-135-34, 90% on RA (room air). Her heart rate was irregular and elevated. Contacted MD (medical doctor) and order received to send to the ED for evaluation and treatment. Ems arrived and departed via stretcher with the resident enroute to [hospital name] . EMS Notes: Ambulance report dated 4/21/23 indicates the following response times: 5:13 PM Call Received (911 call received) 5:14 PM En Route (heading to the facility) 5:23 PM On scene (at the facility) 5:25 PM At patient 5:36 PM Leave scene (leaving the facility heading to the hospital) 5:48 PM At destination (arrival at the hospital) On 9/20/23 at 7:51 AM, Surveyor interviewed EMT V (Emergency Medical Technician). EMT V indicated they were called by 911 for an unresponsive person. EMT V continues to report to the Surveyor that when they arrived at the facility, staff is supposed to be at the foyer entrance to open the locked doors and there was not, so they had to pry the doors open which set off the alarms. EMT V then walked into R2's room and the staff member in the room introduced herself as a traveler nurse. (Note: This traveler nurse was identified as Former ADON T.) EMT V further described that when she pulled back R2's banket she stated: she was covered in ants, completely covered. EMT V indicated to the Surveyor she initially jumped back and the ADON T stated, Oh my god, if this is how it is here, I'm outta here. EMT V indicated to the Surveyor that she received minimal report, staff did not know the last time of when she was acting different, she asked staff about R2's output and they didn't know, R2's urine was bad and very dark. EMT V asked the facility staff of R2's code status and one staff informed her R2 was a full code, another staff told her R2 was a DNR (Do Not Resuscitate). Surveyor asked EMT V if the family was notified, she indicated the staff said they were going to call and was not sure if they did call. EMT V notified the son while in the ambulance due to the facility unsure if they notified the family and family indicated they would be going to the hospital. On 9/26/23 at 1:51 PM, Surveyor interviewed EMT V again. Surveyor asked EMT V to describe when she pulled back R2's blanket, she indicated after she jumped back and then looked closer, they were ants. R2 was wearing a brief and a T-shirt; the ants were on her lower abdomen and groin. EMT V indicated to the Surveyor she could continue to see them while transporting in the ambulance. The ants were crawling around her, on the cot, and on the sheets. Surveyor asked EMT V approximately how many ants and to describe them, she indicated there were about 50-100, black in color, about a couple of centimeters long. Surveyor asked EMT V the appearance of R2's room, she indicated there was a wadded-up blanket in the corner, R2 did not have many belongings, no wrappers anywhere or laying around. EMT V further indicated there was a meal tray that had a dome cover on it. The first hospital emergency room progress notes dated 4/21/23 timeline of events, states in part: At 6:50 PM, Pt (patient) presents to the ER (emergency room ) do (sic) to having an unresponsive episode while at the nursing home that she is from. The staff there [their] states that she was LKWT (last known well time) was 1200 (12:00 PM) after lunch. She is usually talking and active. The patient was sleeping since lunch and not active since then. She is paralyzed from the hips on down after having a fall [AGE] years ago. The patient was stated to have a deficit on the Right Side. The patient is responding to painful stimuli like a sternal rub and the pinch test. They stated that the Right Sided arm weakness and deficit is chronic. The patient is unable to respond to anything that we are asking and is comatose. At 7:00 PM, When the patient arrived, she was covered in ants. EMS stated this is how she was when they got there. At 9:49 PM, When removing the foley catheter that the patient came in with, while taking the NS (normal saline) out of the balloon, the urine started to come out everywhere. The urine was thick, mucusy [mucousy], and smelled like ammonia very badly. After reinserting a new catheter, the urine was very much bloody with specs of sediment easily seen throughout the urine there. The new foley catheter was inserted with little trouble . At 11:50 PM, Abuse/Neglect Screening states, in part; . Clinical/Family/Abuse/Neglect/Exploit May Exist: Yes. Abuse/Neglect/Exploitation Comment: Patient was covered in ants on arrival. The EMS stated that her bed was also covered in ants. Her Foley Catheter was clogged and dirty. See Nursing Progress notes. On 4/22/23 at 12:46 AM, Patient's sons notified of the ants found on the patient and her belongings. They were told by EMS that her bed sheets up at her home were covered in them. On 4/22/23 at 12:53 AM, Patient;s [patients] fully [foley] was very dirty and not clean around the insertion site nd [and] the bag. On the bag it had labeled 04/12. This was changed and removed with [CNA name] and [CNA name] present and in the room helping me. On 4/22/23 at 2:10 AM, Medical Intensive Care Unit (MICU) Admit note, . present to the MICU for septic shock of likely urinary source . Patient was found with somnolent at her nursing home, reportedly covered by ants, so she was taken . as a code stroke . Indwelling foley was removed with a volcano of pus noted around the catheter while removing. After foley exchange, she became more hypotensive and somnolent prompting sepsis work up . On 4/22/23 at 2:20 AM, Blood transfusion started with the consent of the patient's son. On 4/22/23 at 11:24 AM, ER follow up lab result, 4/22/23 lab called reporting that pt had positive blood cultures, + (positive) for gram - (negative) rods. Pt was transferred . On 4/22/23 at 12:29 PM, emergency room physician notes, states, in part; . female presenting with weakness, concern for stoke or possible UTI. Patient was last seen in the noon hour at lunchtime, then reportedly napped in her room and when she was found by the nurse, she was aphasic where she is normally able to speak, had some residual right-sided weakness but now has new left-sided weakness, will open her eyes and sometimes track but is not responding otherwise. Has an indwelling foley catheter that reportedly had darker urine output than usual. No other symptoms reported . She had arrived to the ED (Emergency Department) as a code stroke, however the CT brain and CT head/neck were unrevealing . Patient's foley catheter was replaced by nursing staff. The tip of the foley appeared occluded and there was return of purulent appearing urine She became hypotensive . She was evaluated by our hospitalist . we do not have ICU beds available. Patient will require transfer for higher level of care. A right IJ (Internal Jugular) triple-lumen central line was placed at the bedside per the associated procedure note . patient remained hypotensive . Patient was accepted to transfer . We attempted to transfer her by air . could not fly due to adverse weather conditions. We contacted . EMS . all of which have inadequate staffing to facilitate transfer at this time Patient's children are aware of this . We will continue with vasopressor support at this time. R2 was found to be in septic shock with urosepsis and a UTI. Due to a lack of receiving personal cares, she had black ants embedded in her groin. According to information on the Cleveland Clinic's website: What is septic shock? Septic shock is a serious medical condition that can occur when an infection in your body causes extremely low blood pressure and organ failure due to sepsis. Septic shock is life-threatening and requires immediate medical treatment. It's the most severe stage of sepsis. What's the difference between septic shock and sepsis? Septic shock is the last and most dangerous stage of sepsis. Sepsis can be divided into three stages: sepsis, severe sepsis, and septic shock. Sepsis: Sepsis is life-threatening. It happens when your immune system overreacts to an infection. Severe sepsis: This is when sepsis causes your organs to malfunction. This is usually because of low blood pressure, a result of inflammation throughout your body. Septic shock: Septic shock is the last stage of sepsis and is defined by extremely low blood pressure, despite lots of IV (intravenous) fluids. What causes septic shock? Any infection can lead to sepsis which can then develop into septic shock if it worsens. Not every infection will lead to sepsis or septic shock. But, if an infection causes enough inflammation, it can develop into sepsis. Most of the common infections are from bacteria, but both viruses and fungi can also cause infections and sepsis. Infections can start anywhere but commonly begin in your lungs, bladder, or stomach. What are the risk factors for septic shock? Your septic shock risk increases if you have a weakened immune system which increases your risk for sepsis. People with weakened immune systems include: Newborns. Those over age 65. People who are pregnant. People who use recreational drugs. People with artificial joints or heart valves . What are the complications of septic shock? Septic shock is a very serious medical condition. It's the most severe stage of sepsis. Septic shock can lead to: Brain damage. Lung failure. Heart failure. Kidney failure. Gangrene. Death. https://my.clevelandclinic.org/health/diseases/23255-septic-shock On 9/22/23 at 10:01 AM, Surveyor interviewed MD KK (Medical Doctor). Surveyor asked MD KK the time of the visit on 4/21/23, he indicated he was first at the facility at about 9:00 AM. Surveyor asked MD KK if he had seen any ants on R2 during the wound visit on 4/21/23, he indicated he debrided the wound and looked at her lower legs only. MD KK further indicated he recalls a facility with ants but could not remember. MD KK further indicated that he stayed focused on the area he was working on and could have missed it, but if the ants were in the wound, he definitely would have made a note. On 9/22/23 at 10:15 AM, Surveyor interviewed Former ADON LL. Surveyor asked Former ADON LL if he was present with the wound care visit on 4/21/23, he indicated he was with MD KK. Surveyor asked Former ADON LL if he had seen any ants in R2's bed, he indicated he did not and that R2 was not moved or repositioned. Former ADON LL indicated they pulled the covers back over her feet. On 9/20/23 at 2:19 PM, Surveyor interviewed ER RN W (emergency room Registered Nurse). Surveyor asked ER RN W the events that occurred during the care of R2, he indicated he was informed by EMS that R2 had ants crawling on her and they were going to report it to the state. ER RN W indicated R2 presented to the ER as a code/stroke protocol with right sided weakness, comatose, had the smell of stale urine, like not cleaned recently, like not getting taken care of. ER RN W indicated to the Surveyor that R2 was urgently transported to the CT (computerized tomography) scanner (combines a series of X-ray images taken from different angles around your body) to rule out a stroke. ER RN W indicated to the Surveyor that the facility did not know the last known well check and thought maybe around noon or after lunch on 4/21/23. Upon R2's return from the CT scans ER RN W noted of seeing ants in R2's ER bed and on R2's CT scanner bed and stated: but we didn't think it would keep coming. Surveyor asked ER RN W to continue describing the events, he indicated he informed the physician there was not any urine output for an hour. ER RN W was informed by the physician to remove the foley catheter. ER RN W reports the catheter bag was dated 4/12/23 and the urine in the bag did not appear fresh. ER RN W further explained after removing the foley, thick mucus, that smelled of ammonia, with blood and black sediments that was seen in the urine. After the sludge came out, the urine continued to drain all over R2's bed. Surveyor asked ER RN W approximately how much urine drained and indicated he could not measure because it poured all over her bed and it was something he has never seen before. ER RN W stated to the Surveyor, Clearly, she was not getting the hygienic cares she needed, the foley catheter was filthy itself. Surveyor asked ER RN W to describe the care needed due to the ants, he indicated the ants left their mark on R2's skin, they were embedded, and he had to use a little force to get the ants off. Surveyor asked ER RN W what was further done with the ants, he indicated that he and with the help of aids would turn R2 and change her sheets. Every time we turned her, we would check and cleaned her with wipes and wash cloths to get the ants off. There were more ants each time. Surveyor asked ER RN W if the family had voiced any concerns, he indicated at this point, the sons were irritated with the cares at the facility. ER RN W indicated to the Surveyor that R2 was started on vasopressors due to blood pressures being very low, Zosyn, an antibiotic for UTI, and an intrajugular catheter was inserted for the vasopressors administrations and the blood culture returned from the lab as proteus marabilis positive. ER RN W indicated to the Surveyor that the hospital was full of ICU (Intensive Care Unit) beds and requested several helicopters to transport R2 to another hospital and were not able to fly due to the weather. ER RN W reported to the Surveyor that numerous unsuccessful attempts were made for ground transportation to get R2 to another hospital for an ICU. ER RN W indicated to the Surveyor that FM GG asked ER RN W for a plan as FM GG did not know what to do in this case and he then stated, I don't even want to step foot in that place again. ER RN W indicated to the Surveyor that when he called the receiving hospital to provide report, he informed the nurse that he would be reporting this case to the state. On 9/26/23 at 12:46 PM, Surveyor interviewed ER RN W again. Surveyor asked ER RN W to identify the ants that were seen, he indicated they were approximately the size of pencil lead, black in color, and was not able to say how many and stated, Because there was so many, and we killed a good amount. Surveyor asked ER RN W where the ants were mostly located on R2's body, he indicated they were in the pubic area, in the seams along her legs, and crawling on the catheter tubing. On 9/20/23 at 10:08 AM, Surveyor interviewed FM GG (Family Member). Surveyor asked FM GG to describe the events that occurred when R2 went to the hospital, he indicated the rescue squad had called and informed him there were black ants in her sheets. The ER physician and nurse informed him that there were black ants embedded in her skin in her Depends. FM GG further indicated the staff told him there was black stuff in catheter and that the catheter was not changed in days. ER staff informed FM GG when the catheter was removed, it exploded. The ER staff informed FM GG that R2 had a bad UTI infection from the catheter not being changed. The weather was bad, and the ER wanted R2 to go by helicopter but was not able to fly, so FM GG waited for the ambulance to transport her to another hospital. FM GG further indicated they drove to the next hospital as the ER staff indicated to FM GG that R2 may not make it through the night. FM GG indicated the ER staff informed him to file a complaint with the Department of Health. On 9/20/23 at 8:19 AM, Surveyor interviewed FM HH (Family Member). FM HH explained to the Surveyor that he was informed of the ants that were found in R2's private parts. Surveyor asked FM HH how he feels, he stated, Not good, how do you know what to say if that happened to your Mom or Dad? On 9/25/23 at 1:54 PM, Surveyor interviewed Nurse Consultant Z again. Nurse Consultant Z reported t[TRUNCATED]

Based on interview and record review the facility failed to immediately consult with physician when needed to alter treatment for 2 (R22 & R26) of 2 residents with change of condition out of a total sample of 18 residents. R22 had a change of condition due to an unwitnessed fall on the evening of 1/24/22 which was evidenced by consistent and increased pain. The fall resulted in a right [CONDITION(S)]. R22 had complaints of right hip and right leg pain at time of fall and had consistent pain (1/24/22- 1/25/22). The Registered Nurse (RN) working did not notify R22's physician at time of fall or during the night with a change of condition. Physician was notified of fall and pain on 1/25/22 at 11:30 AM where an x-ray was ordered. R22's condition continued to deteriorate and R22 was transferred to the hospital and found to have a [CONDITION(S)]. R26 had a change in blood sugars and weight. Physician was not notified on 2/28/22. This is evidenced by: The facility's policy and procedure entitled Change of Condition and Provider Notification, undated, states, in part: . I. Policy: Upon resident change of condition, proper assessment and provider notification will occur to provide timely delivery of clinical care. II. Procedure: 1. Acute Change of Condition . a) Acute Change of Condition (ACOC) is a sudden deviation from a patient's baseline in physical, cognitive, behavioral, or functional status . b) Residents exhibiting acute changes will be evaluated by licensed nurse and the information will be reported to the resident's provider. c) Licensed nurse will obtain further orders from provider as necessary . 3. Notification a) Primary Care Provider (PCP) will be contacted for notification. 1) If PCP cannot be reached, on-call provider will be contacted. 2. If PCP and/or on-call provider are not able to be contacted, Medical Director will be contacted for notification . The facility's policy and procedure entitled Falls, undated, states, in part: .II. Procedure: . 2. Procedure of Fall Event and Implementation of Intervention: .c. Medical Provider and responsible parties updated . The facility's policy and procedure entitled Pain, undated, states, in part: .I. Policy: Nursing staff will identify appropriate treatment and services for each resident's pain management . 4) Communication a. The medical provider will be consulted if pain interventions are not effective . AMDA (American Medical Directors Association) guidelines, state, in part: .Examples of Staff Roles and Responsibilities in Monitoring Patients With ACOCs (Acute Change of Condition) .Staff nurse *Recognize condition change early, *Assess the patient's symptoms and physical function and document detailed descriptions of observations and symptoms, * Update the charge nurse or supervisor if patient's condition deteriorates or patient fails to improve within expected time frame, * Report patient status to practitioner as appropriate . Example 1 R22 was admitted to the facility on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R22's MDS (Minimum Data Set) Annual Assessment, dated 10/26/2021, indicated that R22 had a BIMS (Brief Interview of Mental Status) score of 5 indicating severe cognitive impairment. Section G indicated R22 transfers with extensive assist of two and locomotion on/off the unit with extensive assist of two. R22's Care Plan, with a revision date of 02/17/2022, states, in part: .Focus: The resident has chronic pain r/t (related to) DX. (diagnosis) of [CONDITION(S)] Date Initiated: 06/9/2020 Revision on: 06/9/2020 *Resident will have a Pain AD with a level of comfort of 4 or less out of 0-10 Pain AD scale . Revision on: 02/17/2022 R22's Incident Report dated 1/24/22 at 9:12 PM, states, in part: .Type/Nature of Incident: Unwitnessed Fall Resident: (Resident Name) R22 Incident Location: Resident's Room Person Preparing Report: (Registered Nurse (RN) Name) RN O Nursing Description: Resident heard calling out and found lying on right side between bookshelf and recliner. Resident Description: Resident states she tried to self-transfer and when she stood up out of recliner, she fell against the bookshelf and then landed on the floor. She is a poor historian; however, her statement fits with how she was found. Immediate Action Taken Description: Resident assisted from floor and to bed via Hoyer. She complained of pain alternating between right knee and right hip. At times, resident states knee hurts, then states hip hurts. PRN APAP (acetaminophen) given. Right hip and knee do not appear to be maligned. ROM of right hip appears normal and pain level does not increase or decrease with movement. No bruising noted . Level of Pain: PAINAD: 6 Item Score Detail Breathing 0 Normal Negative Vocalization 1 Occasional Moan or Groan, Low Level of Speech Quality with a negative Facial Expression 2 Facial Grimacing Body Language 1 Tensed, Distressed Pacing Consolability 2 Unable to Console, Distract or Reassure . Agencies/People Notified: POA (Power of Attorney): 1/25/2022 4:35 PM Physician: 1/25/2022 4:35 PM Neurological Check List dated 1/24/22 at 9:12 PM indicated neurological assessments and ROM (Range of Motion) were normal and R22 had pain rated at a 4 to right hip and knee. Acetaminophen administered at this time. Neurological Check List dated 1/24/22, at 9:30 PM indicated neurological assessments and ROM were normal and R22 had pain to right hip and leg rated 6. Note pain level increased from 4 to 6 within 18 minutes. No physician notification at this time. Neurological Check Lists indicate R22 continued to complain of right hip and right knee pain from 1/24/22 at 9:30 PM through 1/25/22 at 12:15 AM. Neurological Check List dated 1/25/22, at 12:15 AM indicated neurological assessments and ROM were normal. R22 requested more acetaminophen and was informed R22 could not have more acetaminophen until after 1:00 AM. Neurological Check List dated 1/25/22, at 2:00 AM indicated R22 moves right leg with difficulty and pain. Acetaminophen administered. Pain assessment in R22's medical record on 1/25/22, at 4:00 AM, indicated R22 had a pain rating of 4 to right hip and right knee. Pain assessment in R22's medical record on 1/25/22, at 6:21 AM, indicated R22 had a pain rating of 6. Note R22's pain increased from a rating of 4 on 1/25/22 at 4:00 AM to a pain rating of 6 at 1/25/22 at 6:21 AM. No physician notification with increased pain to right hip and right knee. R22's EMAR (Electronic Medication Administration Record) for January 24, 2022, indicates R22 received acetaminophen 650 mg (milligrams) at 9:19 PM and not again until January 25, 2022, at 6:27 AM. Pain assessment in R22's medical record dated 1/25/22, at 7:32 AM indicated R22 had a pain rating of 5. Nurses Note dated 1/25/2022 at 11:30AM, states, in part: Call to doctor regarding fall yesterday. Order received for x-ray right hip and knee. Accurate Imaging to come this day. Pain assessment in R22's medical record dated 1/25/22 at 3:50 PM indicates R22 had a pain rating of 10. Nurse Note dated 1/25/22 at 4:04 PM, states, in part: Uncontrolled right hip pain and knee. Per family . we will send to hospital for eval. MD (Medical Doctor) updated. Accurate Imaging called and cancelled in house x-ray. Pain assessment in R22's medical record dated 1/25/22 at 4:32 PM, indicated R22 had a pain rating of 6. Nurse Note dated 1/25/22 at 9:49 PM, states, in part: Spoke with nurse at (Hospital Name) .Resident being admitted for a right [CONDITION(S)] .Plan for surgery tomorrow. POA notified. R22's History & Physical states, in part: .admitted : 01/25/2022 Chief Complaint: Right Hip Pain . The patient . who had an unwitnessed fall yesterday . x-rays revealed a displaced femoral neck fracture of the right hip .Physical Examination: . Extremities: Right leg reveals pain with any movement of the right hip R22's Discharge Summary dated 1/29/22, states, in part: . R22 . presented to the emergency department on January 25, 2022, after an unwitnessed fall that resulted in right hip pain. Imaging completed in the emergency department revealed a displaced femoral neck fracture of the right hip .Hospital course: 1. Unwitnessed fall that resulted in a displaced femoral neck fracture of the right hip. She is status post [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/7/2022, at 1:25 PM, Surveyor interviewed PH M (Physician) and asked if he would expect to be notified of R22's fall with a change of condition of pain to right hip and right knee at the time the fall. PH M indicated yes and indicated it is also standard for physician notification after a fall. Surveyor asked PH M if he would expect notification of R22 having increased and consistent pain throughout the night of that fall. PH M indicated yes, if the pain was escalating, I would expect notification. On 3/7/2022, at 3:55 PM, Surveyor interviewed DON B (Director of Nursing) Surveyor asked DON B if she would expect physician notification at the time of R22's fall on 1/24/22 knowing R22 was complaining of right hip and right knee pain. DON B indicated yes. Surveyor asked DON B if she would expect physician notification with consistent and increased pain of right hip and knee pain occurring throughout the night. DON B indicated yes. Surveyor asked DON B if notifying the physician, the next day at 11:30 AM is acceptable and DON B indicated no. R22 had a change of condition due to an unwitnessed fall on the evening of 1/24/22 which was evidenced by consistent and increased pain. The fall resulted in a right [CONDITION(S)]. R22 had complaints of right hip and right leg pain at time of fall and had consistent pain (1/24/22- 1/25/22). The RN working did not notify R22's physician at time of fall or during the night with a change of condition. Physician was notified of fall and pain on 1/25/22 at 11:30 AM where an x-ray was ordered. R22's condition continued to deteriorate and R22 was transferred to the hospital and found to have a [CONDITION(S)]. The following example is isolated/no actual harm Example 2 R26 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R26's most recent BIMS (Brief Interview of Mental Status) score is 15, indicating R26 is cognitively intact. R26 is own person, making own decisions. R26's Transfer Orders on Admission indicated the following . Notify Physician for a blood sugar reading higher than 350 or less than 60. Notify Physician if patient's weight increases or decreases by 3 lbs. [pounds] in one day or 3 lbs. in one week. Surveyor reviewed R26's weights and blood sugars from her admitted until 3/7/22. On 2/28/22 R26 was noted to have a blood sugar of 379. There is no documentation indicating the facility contacted the Physician. On 2/28/22 R26 was noted to have a weight of 242.2, which was up 8.6 lbs. from her last weight on 2/16/22. The facility had no documentation that the Physician was updated on R26's weight gain until 3/2/22. On 3/2/22 (no time listed), MD/Nursing Communications was sent to PCP (Primary Care Provider) stating the following . Resident had weight gain from 2/16/22 of 233.6 and on 2/28/22 was 242.2 [+3.7 percent, 8.6 lbs.]. She was reweighed on 3/2/22 and was 240 lbs. Resident has increased [CONDITION(S)] BLE [bilateral lower extremities]. Called on call, MD ordered one time prn [as needed] [MEDICATION(S)] [diuretic] 20 mg [milligram] tablet. Changed ordered to 40 mg BID [twice a day] for 7 days then review. On 3/2/22 at 10:00 PM, Communication sent to the Physician stating, Today Resident has refused to eat breakfast, lunch, supper, and hs [bedtime] snack. Not eating foods, she has in her room. Poor eye contact. Crying a lot. Upset because feet swelling not decreasing. [MEDICATION(S)] [pain medication] given as directed. No [MEDICATION(S)] or [MEDICATION(S)] given today. On 3/2/22 at 10:58 PM, Nurse's Notes state, after speaking to the on-call doctor I went and spoke to the resident to let her know of the prn order for [MEDICATION(S)] and her change in prescription. She agreed this was a good course of action. On 3/07/22 at 3:12 PM, Surveyor interviewed DON B. Surveyor asked DON B what SOP (Standard of Practice) the facility uses for Physician Notification. DON B stated, We generally fax the Physician, some Physician's do not want to be called. Surveyor asked DON B if there was a specific SOP that they go by, example Interact. DON B states, We use eInteract (eInteract is a set of dashboards, checklists, and automatic triggers designed to work together to assess care teams in preventing unnecessary hospitalization s and to promote positive resident outcomes) to update the Physician. The Nurse would assess. We have parameters and we go by those but nothing specific. On 3/8/22 at 11:01 AM, Surveyor interviewed PCP H (Primary Care Physician). Surveyor asked PCP H if he had been notified of increased weight and blood sugar on 2/28/22 for R26. PCP H stated, I know I was recently updated on the weight increase. I think I didn't get notified though until 3/2/22. If she had an increase in weight I would be concerned. I would want to have a lung assessment indicating if R26 was experiencing any [CONDITION(S)], shortness of breath, and/or crackles. Surveyor asked PCP H how often R26 should have a weight done. PCP H stated, I would expect daily weights if the order were to update if an increase of more than 3 lbs. in a day or 3 lbs. in a week. Surveyor asked PCP H if he had been updated on R26's blood sugar of 379 on 2/28/22. PCP H stated, he can't find anywhere in the charting where he was updated on the high blood sugar. Surveyor asked PCP H if he would have expected that staff update him on the increases. PCP H stated, Yes. The facility failed to ensure they updated the PCP on R26's high blood sugar and increased weight as indicated on the Transfer Orders.

Based on record review and interview the facility failed to provide adequate supervision and interventions to prevent accidents resulting in serious injury and death to 1 of 5 sampled residents (Resident 15). Resident 15 was assessed to be a high risk for falls and had recently sustained a fall with a hip fracture. Upon return from the hospital Resident 15 required the assistance of 2 to transfer, but was observed by facility staff multiple times attempting to self-transfer. Although the staff was aware of Resident 15's self-transfer attempts and high risk for falls, the facility failed to revise Resident 15's fall care plan. Resident 15 fell a second time and dislocated her surgically-repaired right hip requiring surgical reduction. Resident 15 expired on [DATE] related to weakness secondary to her fall. Resident 15 showed warning signs that she might attempt to self-transfer, the facility did not revise Resident 15's safety/fall care plan after she fell and sustained a hip fracture. Facility failure to provide adequate supervision and fall prevention interventions for Resident 15 who was identified as being at high risk for fall, created a finding of immediate jeopardy that began on [DATE]. Nursing Home Administrator (NHA) A was notified of the immediate jeopardy on [DATE] at 2:30PM. The immediate jeopardy was removed on [DATE], however the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated). This is evidenced by: According to For Elderly, Even Short Falls Can Be Deadly: Adults 70-Plus Three Times as Likely to Die Following Low-Level Falls (Science Daily [DATE]), .ground level falls, essentially falls from a standing position, with feet touching the ground prior to the fall, have traditionally been considered minor injuries. But, the new study found elderly adults - [AGE] years of older - who experience ground-level falls are much more likely to be severely injured and less likely to survive their injuries compared to adults younger than [AGE] years. Elderly patients are three times as likely to die following a ground-level fall compared to their under-70 counterparts .approximately 4.5 percent of elderly patients ([AGE] years and above) died following a ground-level fall, compared to 1.5 percent of non-elderly patients. Elderly patients remained in the hospital and the intensive care unit longer and only 22 percent were able to function on their own after they left the hospital, compared to 41 percent of non-elderly patients. Example 1 Resident 15 was [AGE] years old, was admitted to the facility on [DATE] and readmitted on [DATE] and [DATE] with [DIAGNOSES REDACTED]. Resident 15's MDS assessment, dated [DATE], indicated the following: Resident 15's BIMS (Brief interview of mental status) was a 6, which indicates Resident 15 has a severely impaired mental status. Section G indicated: Supervision --oversight, encouragement or cueing with setup help only for bed mobility, transfers, walking in room and toilet use. Independent without setup or help for walking in corridor, locomotion on unit, Supervision- oversight, encouragement, or cueing with one-person physical assist for locomotion off unit. Resident 15's balance was steady at all times, and no limitation in range of motion. Resident 15's Morse Fall Scale dated [DATE] at 11:07PM states in part: Score: 55, Morse Fall Scoring: High Risk 45 and higher. Unplanned Occurrence Report, dated [DATE] states in part: time of incident 6:30PM .Resident was found in hallway without her walker, sitting up on the floor. Patient stated she was going to put something away somewhere. VSS (vital signs stable). When asked how she landed she stated she landed on her right hip. At the time she had no complaints of pain. After being assessed she walked back to her room. About 20 min (minutes) later she was complaining of severe right hip pain . Name of physician contacted: (physician name) Help Nurse Date: [DATE] Time: 7:32PM .Interdisciplinary Post-fall review: Resident had fall was transferred to hospital. Will review when she returns. Resident 15's Morse Fall Scale dated [DATE] at 7:25PM states in part: Score: 70, has the Resident ever fallen before? Yes .Mental status measures the resident's self-assessment of his/her own ability to ambulate. Ask the resident, Are you able to go to the bathroom alone or do you need assistance? 2. Overestimates or forgets limits .Morse Fall Scoring: High Risk 45 and higher Final Report from Patient Services Phone call (Help Nurse) states in part: Call time: [DATE] 07:33PM Call advice: Nurse (name) calls stating (Resident 15) had an unwitnessed fall around 6:30pm in the carpeted hallway. They found her sitting up in the middle of the hallway floor. She uses a walker but did not have it with her when she fell . She told (Nurse's name) she landed on her right hip, but was denying any pain and in fact ambulated back to her room to sit in her chair without any c/o (complaints). After sitting in her chair for 30 minutes, she began to cry out in severe pain, holding her right hip. VSS (vital signs stable). I suggested she should be evaluated for hip fx (fracture). They will try to get portable x-ray to come there to the (facility), if unable will bring her to (Hospital ER) per ambulance. Call ended by (clinic nurse) RN (Registered Nurse). Progress note dated [DATE] at 8:25PM states: Note Text: Sister (Resident 15) had an unwitnessed fall at 1830 (6:30PM). I found her sitting in the middle of the hallway without her walker and she was continent. When asking what happened she stated she was going to put something away somewhere. VSS (vital signs stable). Got her up with the full body lift to a chair. She stated she didn't have any pain and she was ok. About 20 min (minutes) later she was sitting in her chair moaning in pain. State it was ,[DATE]. (Name of power of attorney) and (physician name) help nurse notified at 1930 (7:30PM). Sister (Resident 15) transferred out to (Hospital ED name) at 2018 (8:18PM) by ambulance. Progress note dated [DATE] at 11:30PM states: Note text: Nurse from (Hospital) called to update facility that resident had a rt (right) hip fracture and is scheduled for surgery tomorrow at 1500. Discharge Summary final report states in part: discharge date : [DATE] .Discharge Diagnosis: [REDACTED].Hospital Course: on [DATE] the patient underwent a right hip hemiarthroplasty (joint surface is replaced with artificial material) .Hospital course was complicated by acute blood loss anemia. It was noted that the patient's hemoglobin was 7.8. She (Resident 15) was transfused 1 unit of packed red blood cells before surgery. Progress note dated [DATE] at 2:26PM states in part: Return from hospital via ambulance came back on oxygen. Unable to get O2 (oxygen) above 88%. Resident 15's MDS assessment after her fall on [DATE] is as follows: Resident 15's MDS assessment, target date [DATE], indicated that Resident 15's BIMS (Brief interview of mental status) was a 4, which indicates Resident 15's mental status is severely impaired. Section G indicated: Resident 15 needed 2 person physical extensive assistance with bed mobility, transfers, locomotion on unit, and toilet use. Walking in room and corridor did not occur. Resident 15's balance was not steady, only able to stabilize with assistance and had limitation in range of motion of lower extremities indicated impaired on one side. Resident 15's care plan, date initiated [DATE], Revision on [DATE], with a target date of [DATE], states in part: The resident is at risk for falls r/t (related to) Gait/balance problems. Interventions include: make sure light is on when resident is in room, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, encourage door to be open for closer monitoring, ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c (wheel chair), and open blinds in am, close in pm. Progress note dated [DATE] at 2:34PM states in part: Weight bearing up 2 assist gait belt and walker. Per hospital nurse. Therapy notified. Progress note dated [DATE] at 1:00PM states in part: does tend to throw legs over the side of the bed when has to toilet/forgets to use call light Progress note dated [DATE] at 1:30PM states in part: Resident pivot transfers with assist two does forget that she needs assist with transfers/does swing legs out of bed at times or move wheel chair pedal as if to ambulate independently. Progress note dated [DATE] at 1:30PM states in part: some restlessness at times. On [DATE] at 1:39PM Surveyor interviewed Registered Nurse (RN) D regarding Resident 15's actions after she returned from hospital on [DATE]. RN D indicated she worked with Resident 15 after she returned on [DATE]. RN D indicated that Resident 15 was restless at times and would get anxious. On [DATE] at 1:42PM Surveyor interviewed Registered Nurse (RN) E regarding Resident 15's actions after she returned from hospital on [DATE]. RN E indicated Resident 15 had dementia and was a little confused. When asked if Resident 15 attempted to self-transfer after her hip fracture, RN E stated Oh yes all the time. RN E indicated that Resident 15 did not remember she fell and that Resident 15 only knew that she had pain. RN E indicated to writer that Resident 15 tried to self-transfer ,[DATE] times per shift. RN E indicated Resident 15 would throw her legs over the side of the bed, was always independent before her fall on [DATE], and that Resident 15 did not realize she broke her hip. RN E also indicated that Resident 15 would try to self-transfer only from the bed. On [DATE] at 1:50PM Surveyor interviewed CNA (Certified Nursing Assistant) F regarding Resident 15's actions after she returned from hospital on [DATE]. CNA F stated Oh yeah she would after she started to heal indicating Resident 15 would try to self-transfer. CNA F indicated that Resident 15 would bring legs over the edge of the bed. CNA F also indicated that she only saw Resident 15 trying to get up from bed. On [DATE] at 1:55PM Surveyor interviewed CNA G regarding Resident 15's actions after she returned from hospital on [DATE]. CNA G indicated that Resident 15 would throw her legs over the side of the bed. CNA G recalled Resident 15 would try to get up from bed. On [DATE] at 1:57PM Surveyor interviewed CNA H regarding Resident 15's actions after she returned from hospital on [DATE]. CNA H indicated she witnessed Resident 15 having her legs over the side of the bed, did not witness Resident 15 self-transfer and stated but getting there. On [DATE] at 2:03PM Surveyor interviewed CNA I regarding Resident 15's actions after she returned from hospital on [DATE]. CNA I indicated that Resident 15 would put her feet on the floor as if she was going to self-transfer. CNA I stated yes indicating Resident 15 would put her legs over the edge of the bed. Despite knowledge that Resident 15 required the assist of 2 to transfer but was making multiple attempts to self-transfer, the facility did not revise the care plan and implement greater supervision or assistive devices that would prevent another fall. Progress note dated [DATE] at 12:06AM states: Night CNA observed resident (Resident 15) was not in her bed @ 22:50pm (at 10:50PM). Bathroom door closed with resident leaning up against it, abrasion on lower back, right leg rotated. (Recent right hip repair, returned to facility on [DATE]). Three assist transfer carefully to bed, AROM WNL (active range of motion with in normal limits) for her (Resident 15) except right leg. VSS. Pillow position for comfort, pain medication given. Notified help nurse, for (Physician name) agreed if comfortable let stay here, reevaluate tomorrow morning. Progress note dated [DATE] at 02:17AM states: 22:50PM CNA noticed resident wasn't in bed, bathroom door shut with resident bracing herself with it. Lower back abrasion, internal rotation of recently repaired right hip, more pronounced. Complaints back hurt. Transferred to bed, pillow positioning for comfort, AROM WNL except RLE. Message left with (POA's name), help nurse for (Physician name) (help nurses name) monitor tonight, update condition report to (physician name) & surgeon Monday morning. Pain medication given, VSS. Of note the following is the facility's fall report: Unplanned Occurrence Report, dated [DATE] states in part: time of incident: 22:50PM (10:50PM) (checked) not witnessed Reddened abrasion lower back recent Rt hip repair, potential dislocation. (See surgeon [DATE] on call (physicians name) (Nurse name) RN staff to call (physician name) and surgeon Monday morning to check if want to see resident sooner) Name of Physician contacted: on call help nurse (name) for (Physician) Date [DATE] Time: 23:10 (11:10PM) Care plan updated: No Final Report from Patient Services Phone call (Help Nurse) states: Call time: [DATE] 11:46PM Disposition: Advice verbalized and understands advice Call advice: Broke her right femoral neck fracture following a fall on [DATE]. She was readmitted back to the nursing home where tonight she was found in the bathroom which appears to be an unwitnessed fall. She is back in bed and resting comfortably at this time. The nurse is unsure if the hip is slightly more rotated than it had been. Prior to this incident she was able to ambulate with a walker, gait belt and two man assist. Since the fall there has been no attempt to see if she is able to ambulate. The nurse said she is in bed now, appears comfortable and does not feel that getting her up to assess at this time (11:55PM) is warranted. Will determine if her ambulation is impacted by the fall in the morning and if so will take her to the ER at that time. Call ended by (Help nurses name) Resident 15's Morse Fall Scale dated [DATE] at 5:30AM states in part: Score: 80, Morse Fall Scoring: High Risk 45 and higher Pain scale ratings and Medication Administration Record (MAR) are as follows: [DATE] 23:18 (11:18PM) ,[DATE] (Numerical) - Acetaminophen 325mg give 2 tablet by mouth every 4 hours as needed-signed out on [DATE] at 2318 (11:18PM). [DATE] 03:57 (3:57AM), ,[DATE] (Numerical) -- Acetaminophen 325mg give 2 tablet by mouth every 4 hours as needed-signed out on [DATE] at 0357 (3:57AM) and Lorazepam tablet 0.5mg give 0.25mg by mouth every 12 hours as needed - was signed out as administered on [DATE] at 0200 (2:00AM). Please note Resident 15's Lorazepam administration is after she sustained a fall on [DATE]. Prior to this fall Lorazepam had not been signed out on Resident 15's [DATE] MARs. [DATE] 07:02 (7:02AM) ,[DATE] (Numerical) - Acetaminophen 325mg tablet give 2 tablet by mouth three times a day --- signed out [DATE] for AM dose, no time specification on MAR. [DATE] 07:28 (7:28AM) ,[DATE] (Numerical) Resident 15's MAR also indicates that on [DATE] Enoxaparin Sodium Solution 30MG/0.3ML inject 0.3ml subcutaneously one time a day AM dose was signed out as administered, no specific time specified on MAR. Progress note dated [DATE] at 11:00 AM states: (Resident 15) complaining of severe lower back and RT (right) leg pain, same leg as previous hip fracture, RT leg was internally rotated. Sister had an unwitnessed fall in the night while ambulating to the bathroom on her own. Sister is very confused. (POA's Name) notified. Rescue squad, and (Hospital ER) notified. Sister transferred to hospital. Report from hospital included that sister's RT hip is dislocated and she will be having surgery this afternoon. Emergency Department (ED) final report printed on [DATE] states in part: History of present illness Location: Right hip pain, dislocation. The character of symptoms is pain and swelling. The degree at onset was moderate. The degree at present is moderate .Review of systems .She has obvious deformity to the right hip .Musculoskeletal symptoms: Right hip pain and deformity, swelling. Re-examination/Re-evaluation .Patient complaining of pain in the right hip. There is obvious deformity. Patient has significant dislocation to the right hip .She most likely needs to have reduction performed in the OR (operating room). Impression and Plan status [REDACTED]. Hospital Diagnostic Radiology done on [DATE] at 09:06AM states in part: FINDINGS: there is posterior and superior dislocation of the right total hip prosthesis .IMPRESSION: Right total hip prosthesis is posteriorly and superiorly dislocated . Hospital Diagnostic Radiology done on [DATE] at 12:19PM Reason for exam . intra-op (intraoperative) .FINDINGS: Patient's right THA (total hip arthroplasty) is partially imaged there is an uncemented acetabular component. The previous dislocated acetabular cup and femoral prosthesis has been reduced. IMPRESSION: Anatomic alignment post reduction right THA. Progress note dated [DATE] at 12:17PM states: Report from hospital included that surgery went well and sister (Resident 15) will be staying overnight at hospital. Progress note dated [DATE] at 1:04PM FOCUS note states in part: Cognitive functioning: Alert with short and long term memory impairment .Physical functioning: Resident is assist of 2. Weight bearing as tolerated Behavior: 1 episode of restlessness since readmission Care plan interventions: Resident's room was moved closer to nurse's station for closer observation. On [DATE] at 10:06AM, Surveyor interviewed Director of Nursing (DON) B regarding Resident 15's falls. DON B indicated that Resident 15 should not have been up walking after her fall on [DATE]. Surveyor asked DON B regarding fall risks DON B stated High risk for falls after she returned definitely and indicated Resident 15 was not one to remember to use a call light. Of note Resident 15 returned to the facility on [DATE] and expired on [DATE] the Coroner's Case History Report dated [DATE] states in part: Cause of Death: .Weakness from fall. Contact with Doctor .Called the office of (Physician) reference a cause of death for (Resident 15) Told by (RN Name) Doctor (name) nurse that he had stated the cause of death as asystole, hypoxemia, aspiration pneumonia, and weakness from fall The failure to provide adequate supervision and fall prevention interventions for Resident 15 who was identified as being at high risk for fall, created a finding of immediate jeopardy. The facility removed the jeopardy on [DATE], when it had completed the following: 1. Immediately re-educated all professional nursing staff regarding MD notification, interact care paths standard of practice for change of condition guidelines will be followed, Change of condition to include SBAR completion, when a nurse identifies a resident change in condition, must request the on-call nurse notify the MD or personal notification to MD by facility RN, Immediately consult the Medical Director regarding developing guidelines when to notify the help nurse and when to notify the physician, Any change of condition immediately call to physician until above protocol in place, all nursing staff on duty will immediately receive education and all other nursing staff will receive education prior to assuming their duties. 2. Immediate re-education of Certified Nursing Assistants to report their supervisor observations of resident self-transfer attempts that could lead to falls. 3. After a resident fall, facility staff will identify the fall risk factor and immediately implement an intervention to protect the resident from reoccurrence of another fall. Nursing staff will evaluate the effectiveness of the current interventions in place and update the care plan. 4. QA: DON/designee will audit all change of conditions and falls daily through review of SBAR's and 24 hour reports. Daily x (times) 1 week, Three x per week x1 week, weekly x 1 week, Monthly x 3 months Audit results to be reviewed and shared with QA meetings.

Based on record review and interview the facility did not immediately consult with the resident's physician when there was an accident involving the resident that resulted in injury and had the potential for requiring physician intervention for 1 of 15 sampled Residents (Resident 15). Resident 15 had fallen on [DATE] and sustained a fractured right hip, requiring surgical repair. Resident 15 returned to the facility on on [DATE] on [MEDICATION NAME] (an anticoagulant that prevents blood clotting and can increase bleeding risk). Resident 15 fell again on [DATE] and her surgically repaired leg appeared more rotated. The facility called the on-call Help Nurse but did not immediately consult with a physician. Resident 15 remained at the facility during the night, during which time Resident 15's pain increased from 4 out of 10 to a 9 out of 10 pain. Approximately 8 hours after her fall, Resident 15 was transferred to the emergency room around 8:00 AM. Resident 15 was hospitalized and underwent reduction surgery to repair her dislocated hip. Resident 15's treatment was delayed due to not notifying/consulting a physician immediately. Facility failure to immediately consult with the physician following Resident 15's fall on [DATE], when Resident 15's leg became internally rotated, delayed medical evaluation of the extent of injuries, created the potential for increased pain (pain increased that night from a 4 to a 9) and placed the resident at risk for internal bleeding as well as clot formation, which could result in death. This created a finding of immediate jeopardy that began on [DATE]. Nursing Home Administrator (NHA) A was notified of the immediate jeopardy on [DATE] at 2:30PM. The immediate jeopardy was removed on [DATE], however the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement its removal plan. This is evidenced by: According to Drugs.com (<https://www.drugs.com/cons/[MEDICATION NAME].html>) [MEDICATION NAME] use in Geriatric states in part Elderly patients are more likely to have bleeding problems . Precautions while Using [MEDICATION NAME] ([MEDICATION NAME]) states in part: You may bleed or bruise more easily while you are using this medicine. Stay away from rough sports or other situations where you could be bruised, cut, or injured .Tell your doctor if you have recently Fallen or suffered a blow to the body or head, or had medical or dental surgery. These events may increase the risk of serious bleeding while you are taking [MEDICATION NAME]. According to Moira Davenport, MD at emedicine (<http://emedicine.medscape.com/article/ 3-clinical#b4>) Up to 70% of patients with femoral head fracture-dislocations experienced major associated injuries, including other extremity injuries, intra-abdominal or intrapelvic injuries, neck injuries, and head injuries . [MEDICAL CONDITION] are associated with blood volume losses of up to 1500 mL. Traumatic dislocations of the hip are an orthopedic emergency . Multiple studies have shown that timely reduction plays a significant role in reducing later complications and associated comorbidity. Avascular necrosis (<http://www.mayoclinic.org/diseases-conditions/avascular-necrosis/basics/definition/con- 517>) is the death of bone tissue due to a lack of blood supply. The blood flow to a section of bone can be interrupted if the bone is fractured or the joint becomes dislocated. Pain can be mild or severe and usually develops gradually. Pain associated with avascular necrosis of the hip may be focused in the groin, thigh or buttock .Seek immediate medical attention if you believe you have a broken bone or a dislocated joint. Example 1 Resident 15 was [AGE] years old. She was admitted to the facility on [DATE] and readmitted on [DATE] following surgical repair of a right [MEDICAL CONDITION] sustained after falling at the facility on [DATE]. Resident 15's [DIAGNOSES REDACTED]. Resident 15's medications included [MEDICATION NAME] 30mg/0.3ML (30 milligrams per 0.3 milliliters) inject 0.3ml subcutaneously one time a day for [MEDICATION NAME] (prevention) until [DATE]. [MEDICATION NAME] is an anticoagulant that can increase bleeding risk. Resident 15's Medication Administration Record [REDACTED]. Progress note dated [DATE] at 12:06AM states: Night CNA observed resident (Resident 15) was not in her bed @ 22:50pm (at 10:50PM). Bathroom door closed with resident leaning, up against it, abrasion on lower back, right leg rotated. (Recent right hip repair, returned on [DATE]) Three assist transfer carefully to bed, AROM WNL (active range of motion with in normal limits) for her (Resident 15) except right leg. VSS. Pillow position for comfort, pain medication given. Notified help nurse, for (Physician name) agreed if comfortable let stay here, reevaluate tomorrow morning. Progress note dated [DATE] at 02:17AM states: 22:50PM CNA noticed resident wasn't in bed, bathroom door shut with resident bracing herself with it. Lower back abrasion, internal rotation of recently repaired right hip, more pronounced. Complaints back hurt. Transferred to bed, pillow positioning for comfort, AROM WNL except RLE. Message left with (POA's name), help nurse for (Physician name) (help nurses name) monitor tonight, update condition report to (physician name) & surgeon Monday morning. Pain medication given, VSS. Final Report from Patient Services Phone call (Help Nurse) states: Call time: [DATE] 11:46PM Disposition: Advice, verbalized and understands advice Call advice: right femoral neck fracture following a fall on [DATE]. She was readmitted back to the nursing home where tonight she was found in the bathroom which appears to be an unwitnessed fall. She is back in bed and resting comfortably at this time. The nurse is unsure if the hip is slightly more rotated than it had been. Prior to this incident she was able to ambulate with a walker, gait belt and two man assist. Since the fall there has been no attempt to see if she is able to ambulate. The nurse said she is in bed now, appears comfortable and does not feel that getting her up to assess at this time (11:55PM) is warranted. Will determine if her ambulation is impacted by the fall in the morning and if so will take her to the ER at that time. Call ended by (Help nurses name). Please note the [DATE] final Patient Services Phone call from [DATE] was electronically signed by a Registered Nurse not a Physician/Medical Doctor (MD). There is no physician or MD electronic signature associated with this final report. The following is the facility's fall report: Unplanned Occurrence Report, dated [DATE] states in part: time of incident: 22:50PM (10:50PM) (checked) not witnessed Reddened abrasion lower back recent Rt hip repair, potential dislocation. (see surgeon [DATE] on call (physicians name) (Nurse name) RN staff to call (physician name) and surgeon Monday morning to check if want to see resident sooner) Name of Physician contacted: on call help nurse (name) for (Physician) Date [DATE] Time: 23:10 (11:10PM) Care plan updated: No. Facility staff called the Help Nurse at the clinic but did not promptly consult with a physician despite the fact that this was an accident resulting in injury that had the potential for requiring physician intervention. Progress note dated [DATE] at 11:00 AM states: (Resident 15) complaining of severe lower back and RT (right) leg pain. Same leg as previous [MEDICAL CONDITION]. RT leg was internally rotated. On [DATE] at 1:15PM Surveyor received a typed document from DON B regarding (Town) Rescue squad notifications. (Town) Rescue squad notified at 7:50PM on [DATE] and arrived at 8:04PM. (Town) Rescue squad notified at 6:50AM on [DATE] and arrived at 7:11am. (Please note that Resident 15 was sent via rescue squad to the hospital 8 hours after her fall on [DATE]) Resident 15 lay in bed for 8 hours with a dislocated hip. Hip dislocation is a medical emergency when it occurs in adults. It is very painful and can result in significant blood loss into the joint and tissues. Resident 15 was at an increased risk for blood loss due to receiving a daily anticoagulant. If not evaluated and treated, the risk of damage to blood vessels and nerves is quite significant. There is a chance of permanent interruption of the blood supply to the socket joint due to Avascular Necrosis. Resident 15's pain increased from a 4 to a 9 on a scale of 10 during the 8 hours following the accident, as evidenced by the pain scale ratings in the Medication Administration Record [REDACTED] [DATE] 23:18 (11:18PM) ,[DATE] (Numerical) - [MEDICATION NAME] 325mg give 2 tablet by mouth every 4 hours as needed-signed out on [DATE] at 2318 (11:18PM) [DATE] 03:57 (3:57AM) ,[DATE] (Numerical) -- [MEDICATION NAME] 325mg give 2 tablet by mouth every 4 hours as needed and [MEDICATION NAME] tablet 0.5mg give 0.25mg by mouth every 12 hours as needed - was signed out as administered on [DATE] at 0200 (2:00AM). Please note Resident 15's [MEDICATION NAME] administration is after she sustained a fall on [DATE]. Prior to this fall [MEDICATION NAME] had not been signed out on Resident 15's [DATE] MARs. [DATE] 07:02 (7:02AM) ,[DATE] (Numerical) - [MEDICATION NAME] 325mg tablet give 2 tablet by mouth three times a day --- signed out [DATE] for AM dose, no time specification on MAR. Resident 15's pain has increased from a 4 to a 7. [DATE] 07:28 (7:28AM) ,[DATE] (Numerical) Emergency Department (ED) final report printed on [DATE] states in part: History of present illness .Location: Right hip pain, dislocation. The character of symptoms is pain and swelling. The degree at onset was moderate. The degree at present is moderate .Review of systems .She has obvious deformity to the right hip .Musculoskeletal symptoms: Right hip pain and deformity, swelling. Reexamination/Reevaluation .Patient complaining of pain in the right hip. There is obvious deformity. Patient has significant dislocation to the right hip .She most likely needs to have reduction performed in the OR (operating room). Impression and Plan status [REDACTED]. Hospital Diagnostic Radiology done on [DATE] at 09:06AM states in part: FINDINGS: there is posterior and superior dislocation of the right total hip prosthesis IMPRESSION: Right total hip prosthesis is posteriorly and superiorly dislocated Hospital Diagnostic Radiology done on [DATE] at 12:19PM Reason for exam: . intra-op (intraoperative) . FINDINGS: Patient's right THA (total hip arthroplasty) is partially imaged there is an uncemented acetabular component. The previous dislocated acetabular cup and femoral prosthesis has been reduced. IMPRESSION: Anatomic alignment post reduction right THA. Progress note dated [DATE] at 12:17PM states: Report from hospital included that surgery went well and sister (Resident 15) will be staying overnight at hospital. Of note Resident 15 returned to the facility on [DATE] and expired on [DATE] the Coroner's Case History Report dated [DATE] states in part: Cause of Death: .Weakness from fall. Contact with Doctor .Called the office of (Physician) reference a cause of death for (Resident 15) Told by (RN Name) Doctor (name) nurse that he had stated the cause of death as asystole, hypoxemia, aspiration pneumonia, and weakness from fall. On [DATE] at 10:06AM, Surveyor interviewed Director of Nursing (DON) B regarding Resident 15's falls. DON B indicated to Surveyor that the Help Nurse is an answering service at the clinic. DON B indicated that on [DATE] staff should have gone straight to the MD and Surgeon, and that staff should have called the surgeon rather than Resident 15's physician or the help nurse after hours. Surveyor asked DON B regarding orders/advice given from the help nurse. DON B stated No indicating the Help nurse cannot give orders without talking with a physician. DON B indicated that the nurse here (at facility) should have talked with the MD if help nurse would not. DON B stated to Surveyor Do I think she should have been sent out earlier than she was? Yes DON B indicated that Resident 15 went out before 8'oclock that morning ([DATE]). On [DATE] at 11:30AM Surveyor interviewed DON B regarding Resident 15's falls and Help nurse. DON B indicated that the Help Nurse is for the entire clinic to call after hours and she takes information and uses standing orders; if no standing orders then the Help Nurse calls the physician and is a go between. On [DATE] at 1:00PM, Surveyor , clarified with DON B that the Helper Nurse for both calls was a Registered Nurse, DON B stated yes On [DATE] at 5:00PM, DON B reported to Surveyor that the Help Nurse does not have standing orders and that the Help Nurse goes by the facility's standing orders. DON B also indicated that the nurses are to use interact care path for falls and change in condition. Resident 15 had a fall after a recent right [MEDICAL CONDITION]; Resident 15 had a noted internal rotation of the affected right hip, increased pain and was at increased risk for bleeding due to the daily use of [MEDICATION NAME] an anticoagulant. Resident 15 lay in bed for 8 hours, without treatment due to facility failure to immediately notify the physician of Resident 15's fall and assessment findings. This failure increased Resident 15's potential risk for bleeding and Avascular Necrosis (the death of bone tissue due to a lack of blood supply) and increased pain. Resident 15 expired on [DATE] secondary to weakness related to the fall. The failure to provide adequate supervision and fall prevention interventions for Resident 15 who was identified as being at high risk for falls, created a finding of immediate jeopardy. The facility removed the jeopardy on [DATE], when it had completed the following: 1. Immediately re-educated all professional nursing staff regarding MD notification. a. when a change in condition occurs there will be immediate notification to primary care physician and POA. i. interact care paths standard of practice for change of condition guidelines will be followed. ii. Change of condition to include SBAR completion. b. When a nurse identifies a resident change in condition, must request the on-call nurse notify the MD or personal notification to MD by facility RN. c. Immediately consult the Medical Director regarding developing guidelines when to notify the help nurse and when to notify the physician of any change of condition until above protocol in place. d. all nursing staff on duty will immediately receive education and all other nursing staff will receive education prior to assuming their duties. 2. Immediate re-education of Certified Nursing Assistants to report their supervisor observations of resident self-transfer attempts that could lead to falls. 3. After a resident fall, facility staff will identify the fall risk factor and immediately implement an intervention to protect the resident from reoccurrence of another fall. Nursing staff will evaluate the effectiveness of the current interventions in place and update the care plan. 4. QA: DON/designee will audit all change of conditions and falls daily through review of SBAR's and 24 hour reports. Daily x (times)1 week, three x per week x 1 week, weekly x 1 week, and monthly x 3 months Audit results to be reviewed and shared with QA meetings.

Based on observation, interviews and record review the facility did not ensure that 3 of 10 residents reviewed for falls (Residents 6, 9, and 14) received adequate supervision and assistive devices to prevent falls and that the residents environment remained free of accidents as possible. Resident 6 was assessed to need chair and bed alarms. Resident 6 experienced 8 falls from 11/8/09 to 10/22/10. In 4 of these falls Resident 6's alarm was not functioning or in place. The facility did not perform thorough investigations after each incident, consider interventions to prevent further falls, reassess risk factors that placed Resident 6 at high risk, or modify the care plan according to Resident 6's needs. As a result of a fall on 9/29/10, Resident 6 received a sacral alar (lower end of spine) bilateral fracture. Additionally, Resident 6 was observed with fall interventions not in place. Resident 9 experienced 3 falls where there was not the correct number of staff assisting with the transfer and/or the wheelchair was not in place behind Resident 9 as indicated on the care plan to prevent falls. Resident 14 did not have pillows in place to prevent her from falling on 2 occasions. This is evidence by the following: The facility policy "Fall Assessment" dated 8/1/99 indicates: "Policy: Fall assessment. Purpose: To identify resident's risk factors for falls and to properly assess a resident when a fall has occurred. To develop a plan to reduce the number of falls. Procedure: Method of Procedure: When a Resident falls the Nurse is to: ......Complete the Fall Assessment by clicking on all pertinent information. Summarize finding and develop a plan to prevent future falls. Identified interventions shall be placed on the resident's care plan and the CNA (Certified Nursing Assistant) worksheet. The Director of Nursing or designee is to review the fall assessments daily and additional comment and interventions as needed. Fall committee to review fall assessment weekly at a minimum." The facility's policy titled "Fall Committee" dated 6/1/07 indicates: Policy; as part of QAA (Quality Assurance Assessment), the Falls Committee has been established. Purpose: The Falls Committee will meet weekly with the purpose of collecting, analyzing, and trending data related to resident falls with a goal of resident specific fall prevention. Procedures indicate that the committee shall meet on a weekly basis at a minimum. The Fall Committee is responsible for reviewing each initial fall assessment completed each week to insure accuracy of assessment and mandatory requirements of the assessment were completed. Additionally, the fall Committee will review each initial fall assessment to try to obtain the root cause of the fall, will review the care plan has been reviewed and update it to reflect any new interventions. On 11/9/10 at 1:30 PM Surveyor requested the Policy "Yellow Sun" from DON (Director of Nursing) B. DON B stated the facility did not have a policy for the Yellow Sun program. On 11/9/10 at 2:30 PM the DON B handed a single piece of paper to Surveyor and stated this is the information we gave to the facility staff at the in-service. The Paper indicated: "Survey Reminders" (no date indicated) Yellow Sun outside resident room - Any staff should check resident frequently. May be at risk for falls, safety concerns. Example 1 Resident 6 was admitted to the facility for therapy on 11/6/09. Resident 6 has [DIAGNOSES REDACTED]. Resident 6 was admitted on anti-coagulant therapy due to Atrial Fibrillation. Resident 6 has history of falls to include rib fractures related to the fall on 2/22/10 and Sacral alar (lower end of spine) fractures bilaterally related to the fall on 9/29/10. Resident 6's medication record dated 10/1/10 indicates Resident 6's current medications are as follows: Coumadin 3 mg (Milligrams) every day with 1.5 mg on Thursdays, Prozac 40 mg daily, Lasix 40 mg twice daily, and Lisinopril 5 mg daily... Resident 6's readmission MDS (Minimum Data Set) dated 10/27/10 indicates short term memory problems and modified independent (some difficulty in new situations only) impaired cognitive skills. Resident 6's Mobility Care plan dated 1/19/10 indicates: Resident 6 ambulates independently with a wheeled walker to all destinations. On 2/22/10 Resident 6's Mobility Care Plan was updated to read ambulate with one assist, walker, gait belt, to all destinations. On 3/5/10 Resident 6's Mobility Care plan was again updated to use chair pad alarm, and on 3/10/10 a tabs alarm on bed at night was added. Resident 6's current mobility care plan dated 3/10/10 indicates: Resident 6 is 1 assist for ambulation with use of wheeled walker, gait belt to all destinations, tabs alarm on in bed at night and chair pad alarm in chair. Resident 6 sustained falls at the facility on the following dates: 3/14/10, 6/13/10, 9/29/10, when the alarm was placed by the facility staff but removed by Resident 6 prior to each of these falls, preventing the alarm from sounding. Resident 6 also experienced a fall on 10/22/10 where the alarm was in place and did not sound when Resident 6 fell . Incident 1 The facility's incident documentation titled "Administration Investigation" for the fall dated 3/14/10 at 1:00 AM states Resident 6 was found in Resident 6's room lying on the floor rolled in blankets. The alarm was not sounding. The follow up documentation indicated the Tabs alarm was unhooked from her (Resident 6) body. Follow up documentation indicates Resident 6 was recovering from an URI (upper respiratory infection) and fractured ribs. Resident 6 is currently in Physical therapy and the facility will place the bed in low position. No further documentation was located as to the follow up on the nonfunctioning alarm. Incident 2 According to the facility incident documentation titled "Administrator Investigation", on 6/13/10 at 10:00 AM Resident 6 experienced a fall in Resident 6's room. Resident 6 was found in Resident 6's bathroom lying on the floor with her clothing removed from the waist down. Follow up documentation indicated Resident 6 was in her recliner with a sensor pad and a tab unit hooked on Resident 6. At the time of the fall Resident 6 was found sitting on the bathroom floor. The chair pad and tabs alarm were disconnected from the control box and the chair pad remained in the recliner not sounding. Follow up documentation further indicates Resident 6's blood sugar was "negative." A 4 day bowel and bladder tracking was implemented, and one half hour checks on Resident 6 were discontinued. On 11/9/10 at 3:50 PM Surveyor asked DON B why one half hour checks were discontinued DON B was unable to explain why checks were discontinued. No further documentation was located as to the follow up on the nonfunctioning alarm. On 9/24/10 at 5:16 AM Resident 6's nursing notes state: Resident is at high risk for falls. Resident 6 has gait and balance problems. Resident 6 receives medications that increase her fall risk, and she has predisposing disease that increases her fall risk, Resident takes her tabs alarm off and gets up by self at least once per day despite instructions about safety precautions. Resident 6 uses assistive devices; her bed is in low position. Resident 6 has a tab alarm to her bed and chair, and chair pad alarm. Incident 3 According to the facility incident documented titled "Administrator Investigation" on 9/29/10 at 12:45 AM Resident 6 experienced a fall in Resident 6's room. Resident 6 was found lying on the floor. The follow up documentation states Resident 6's chair pad alarm and tabs alarm were applied when Resident 6 was assisted to her recliner after lunch. The documentation states that Resident 6 removed both the pad alarm and chair alarm. Resident 6 was re-educated regarding the risk of not waiting for assistance and getting up alone. Resident 6's follow up continued to document that a "Yellow Sun" be applied outside Resident 6's room door to alert staff to check frequently as Resident 6 is high risk for falls.. On 9/29/10 Resident 6's nursing note indicates at the time of the above fall Resident 6's tabs alarm was disconnected and the alarm string was wrapped around the tabs device causing the alarm not to sound. The tabs alarm was tested and was working, but Resident 6 removed alarm from self. "Previous interventions not effective." No further documentation was located as to the follow up on the self removal of the alarm. On 10/5/10 at 2:06 AM Resident 6's nursing notes indicates "Resident 6 continues to be at high risk for falls. Alarms are in place, personal and chair. Resident 6 will remove alarms herself at times." On 10/13/10 Resident 6's nursing notes indicate: Resident 6 rates her pain at an 8 prior to taking the Vicodin, and 5 after taking the Vicodin. Resident 6's pain is worse with her attempts at standing or ambulation. Resident 6 had a fall on 9/29/10 in which indicated no apparent injury was sustained and was ambulating prior to 10/6/10. Resident 6 was transferring from the wheel chair to the therapy work table; Resident 6 would not bear weight on her right leg. The Physician's office was contacted today with an update condition report; the physician is out of the office until 10/27/10 and the report was given to a triage nurse. Another physician was covering and returned the call with orders to transfer Resident 6 to the emergency room for evaluation. Resident 6 was admitted to Mercy Medical Center for Sacral alar (lower Spine) fractures bilaterally. Incident 4 According to the facility incident documented titled "Administrator Investigation" on 10/22/10 at 2:00 AM Resident 6 experienced a fall in Resident 6's room. Resident 6 was found lying on the floor. The follow up incident documentation indicates Resident 6 was checked on previous rounds. Previous fall interventions for Resident 6 were in place prior to the fall to include: tabs alarm and bed in low position. The tabs alarm was properly functioning but was not sounding due to the long length of the cord on the alarm and the bed in the low position. Bed mattress pad alarm was implemented to Resident 6 after of the fall by the nurse; however the fall committee removed the alarm later that day as other interventions were effective after the cord to the alarm was replaced with a shorter cord. On 11/8/10 at 2:30 PM Surveyor observed Resident 6 sitting in a recliner in Resident 6's room. However, Resident 6's chair pad alarm was noted in the wheel chair in Resident 6's room. Resident 6 has a tabs alarm connected to her right pant leg with the use of a clip. Surveyor observed Resident 6 remove the tab alarm clip from her pants, straightened her leg, and Resident 6 reapplied the alarm clip. On 11/9/10 at 10:45 AM Surveyor accompanied RN (Registered Nurse) C to Resident 6's room. Surveyor spoke with RN C regarding Resident 6's tabs alarm and chair pad alarm. RN C stated she hoped Resident 6's chair pad alarm was in place due to Resident 6 removing the pad alarm, rolling it up, putting it in the chair and placing the alarm in other places. RN C continued to state Resident 6 knows how to remove it (chair pad alarm) and will undo it and stick it places. Upon entering Resident 6's room Surveyor observed Resident 6's tabs alarm not attached to Resident 6. Resident 6's chair pad alarm was in place. Surveyor spoke with RN C regarding the tab alarm and the appropriate placement. RN C stated the tab alarm should be connected to Resident 6's body. RN C reconnected the tab alarm to Resident 6's pant leg. On 11/9/10 at 3:50 PM Surveyor interviewed DON (Director of Nursing) B regarding the follow up related to Resident 6's falls with non functioning safety devices and safety devices not being in place. DON B stated the facility looked at all Resident 6's falls and have implemented the following fall interventions: tabs alarm to the chair and bed, and a chair pad alarm. DON B stated the expectation is that Resident 6 is to have both the chair pad alarm and the chair tabs alarm on when Resident 6 is left alone in Resident 6's room when sitting in a chair. DON B continued to state all of Resident 6's falls have happened in her room and to her (DON B's) knowledge Resident 6 has never self removed the chair pad alarm. On 11/9/10 at 3:50 PM Surveyor spoke with DON B regarding Resident 6 and how the facility staff communicate to DON B a change in the resident's care plan and self removing alarm of Resident 6. DON B stated the facility staff are to leave her a voice mail with any known resident changes, or inform her during walking rounds. DON B stated the expectation is for the facility staff to notify DON B whenever a resident self removes an alarm. No further information was provided on follow up of non functioning and self removal of Resident 6's alarm. On 11/9/10 at 4:00 PM Surveyor spoke with DON B regarding Resident 6's admission to the hospital and the [DIAGNOSES REDACTED]. DON B stated the facility could not get control of the pain and the physician sent Resident 6 to the hospital for another X-ray. DON B continued to state the fracture was a result of the fall on 9/29/10. No further investigation was completed because it was felt the facility knew how the fracture happened. On 11/10/10 at 9:00 AM Surveyor spoke with CNA (Certified nursing assistant) E regarding Resident 6 chair alarms. CNA E stated Resident 6 is to have a tabs alarm and a chair pad when she is alone in her room. CNA E continued to state Resident 6 has self removed the tabs alarm and the chair pad alarm. Example 2 Incident 1 The facility's incident report indicates on 6/14/10, at 6:50 AM, Resident 9 was lowered to the floor by Certified Occupational Therapy Assistant (COTA) G. COTA G's statement indicates Resident 9 was ambulated by COTA G to the bathroom with a walker and stand by assist when Resident 9's leg gave out and Resident 9 was eased to the floor. No injury was sustained. The incident report also notes that the nurse explained to COTA G that the care plan (requiring 2 assist with transfers) is to be followed. The fall committee note, dated 6/15/10, indicates that Resident 9's care plan states "2 assist with all transfers and walking with w/c (wheelchair) to follow. OT (Occupational Therapist) was re-educated with care plan expectations and acknowledged understanding." Incident 2 The facility's incident report indicates on 8/12/10, at 7:15 AM, Resident 9 was lowered to the floor by Certified Occupational Therapy Assistant (COTA) G. COTA G's statement indicates during therapy COTA G was ambulating with Resident 9 to the bathroom with a front wheel walker and gait belt. Resident 9's knees gave out and Resident 9 was lowered to the floor. Resident 9's fall assessment notes, 8/12/10, indicated Summary of fall "OT (occupational therapy) was walking resident (Resident 9) to her bathroom, one person was being used (and) the wheelchair was not in place, residents knees were paining her, her knees buckled (and) she could not move, she was lowered to the floor..." The fall committee note, 8/12/10, indicates "Resident (Resident 9) was working with OT and was eased to the floor. Ccurrent (SIC) care plan interventions were not being addressed and immediate re-education was given..." Incident 3 The facility's incident report indicates on 10/6/10 Resident 9 was lowered to the floor. The statement indicates that 2 Certified Nursing Assistants (CNA) were walking with Resident 9 to the bathroom. Once they reached the bathroom, Resident 9's knees gave out and Resident 9 was lowered to the floor. Resident 9's fall note indicates "Resident was ambulating to bathroom and wheelchair was not in place behind resident." CNAs were reinstructed to make sure wheelchair is behind Resident 9 at all times when ambulating. On 11/10/10, at 10:23 AM, Surveyor interviewed Director of Nursing (DON) B about the falls. DON B stated COTA G should have followed Resident 9's care plan and had two staff with a wheelchair during both transfers, 6/14/10 and 8/12/10. DON B stated the care plans are located in the residents' rooms and all staff are expected to review and follow them. Example 3 Resident 14 has current [DIAGNOSES REDACTED]. According to the Resident Assessment Instrument including the annual Minimum Data Set 2.0 (MDS), R2b date 3/30/10, Resident 14 needs extensive assistance of 1 staff for transferring and total assistance of 1 staff for bed mobility. Resident 14 has short term and long term memory problems. Resident 14's impaired decision making skills are poor. These indicators have been the same since Resident 14's prior annual MDS with R2b date 5/27/09. On 11/22/09 the facility's "Fall Assessment" document states Resident 14 fell from her bed. The facility added to the care plan the intervention "use pillows on both sides for bed positioning" on 11/23/09. Incident 1 The "Fall Assessment", dated 3/2/10, indicates that Resident 14 fell from her bed and the assessment states "Not in place (at) time of fall, explain: Didn't have pillows on the sides of resident." In a written statement on 3/3/10 from the fall investigation of Resident 14, CNA (Certified Nursing Assistant) K stated, "I completed rounds at 2100 (9:00 PM) and (Resident 14) was positioned in the middle of the bed (pillows were not used on her sides) ... My failure to read the care plan to use positioning pillows may have contributed to this fall ..." In a statement from the fall investigation dated 3/2/10 from CNA J stated, "The pillows that were supposed to be along the sides of her (Resident 14) were not present because we pulled them out of the closet after we put her (Resident 14) back in bed." Resident 14's care plan was updated 3/4/10 to "rest better on side, position side to side with pillows." Incident 2 Initial Fall Assessment, dated 9/3/10, stated Resident 14 fell and was found "Lying on left side on floor next to bed ...Not in place (at) time of fall, explain: only had one pillow ..." The Fall Committee note on 9/8/10 states, "Resident (14) did not have proper pillows being used for positioning." On 11/10/10 at 10:55 AM Surveyor interviewed Director of Nursing (DON) B who stated she expects that care plan interventions be in place to prevent falls.