Every finding on record at Sunrise Health Services

Based on interview, record review, and review of facility policy, the facility failed to thoroughly investigate an allegation of neglect for one resident (Resident (R)4) in a total sample of eight residents. This failure placed residents at risk of further neglect and a diminished quality of life.Findings include:Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R4 had readmitted to the facility on [DATE] with diagnoses that included a stroke and diabetes.Review of the 11/26/24 Activities Daily Living (ADL) Care Plan revealed, ADL self-care deficit as evidenced by: weakness related to COPD [chronic obstructive pulmonary disease], CHF [congestive heart failure], pulmonary hypertensions, right side weakness and aphasia [a communication disorder]. Intervention: Toileting: Assist of 2.Review of the significant change Minimum Data Set (MDS) located in the MDS tab of the EMR with an assessment reference date (ARD) of 01/16/26 revealed R4 had a Brief Interview of Mental Status (BIMS) score of 10 out of 15 which indicated R4 was moderately impaired in cognition and was dependent on staff for toileting.Review of the Facility Investigation provided by the Administrator, dated 01/14/26 revealed, .R4's Family Member [FM]3 reported that R4 has not been changed and that R4 has been calling FM3 more often to express concerns. FM3 expressed that a CNA [certified nurse aide] spoke to R4 in a rude approach and water was not given to R4 .Further review of the Facility Investigation did not show that other residents in the facility had been interviewed to determine if they had any concerns with cares provided by the CNAs.During an interview on 02/23/26 at 12:15 PM, the Director of Nursing (DON) was asked if any other residents were interviewed for the investigation as this was not included in the investigation file provided to the survey team. At 1:18 PM, the DON provided resident interviews to the survey team and stated, I think they were in another folder.On 02/23/26 at 1:31 PM, follow-up interviews were conducted with three residents identified as having been questioned by the Social Service Coordinator (SSC) for the investigation. After the residents were interviewed, it was determined that the SSC had interviewed the residents regarding their cares on 02/23/26 and not at the time of the investigation.During an interview on 02/25/26 at 8:30 AM, the Administrator acknowledged that the resident interviews were not obtained at the time of the investigation.Review of the facility policy titled, Abuse, Neglect, and Exploitation, dated 07/15/22 revealed, .An immediate investigation is warranted when allegation or suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur .Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s) .

Based on observation, interview and record review, the facility did not ensure food and beverages were maintained in a sanitary manner. This was observed with 2 of 2 kitchenette serving areas. *The lunch meal food temperatures were not obtained in a sanitary manner. * The coolers and freezers in the 1st and 2nd floor kitchenettes were not maintained in a sanitary manner. Findings include:The facility's policy and procedure for Food Storage, dated 9/2017, documented, . 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. The facility's policy and procedure for Food Preparation dated 9/2017, documented, . 3. All utensils, food contact equipment, and food contact surfaces will be cleaned and sanitized after every use.On 7/21/2025, at 11:54 AM, Surveyor observed the 1st floor kitchenette refrigerator. The freezer has undated, and opened, popsicles. An unlabeled Styrofoam container. The fridge section has a deli container of a brownish-green substance with no labeling. There were 2 plastic bagged containers with no labeling. There was an open jar of queso with no label. There was a Styrofoam drink with a straw with no labeling. There was a sliced raw onion in loose saran wrap with no label. There was a brown bag with purple grapes inside with no labeling.On 7/21/2025, at 12:06 PM, Surveyor observed food temperatures by Dietary Aide (DA)-M on 1st floor kitchenette. The DA-M placed all the hot food in a steam table and removed the foil covering. The DA-M obtained a food thermometer and placed it into the turkey alfredo. The DA-M then wiped off the thermometer with a paper towel. The DA-M then placed the thermometer into the mechanical soft turkey alfredo. The DA-M then wiped off the thermometer with the same paper towel. The DA-M then placed the thermometer into puree noodles. The DA-M wiped off the thermometer with the same paper towel. Surveyor observed DA-M did not sanitize the thermometer between foods. DA-M then placed the thermometer into puree carrots. DA-M wiped off the thermometer with the same paper towel. The DA-M did not sanitize the thermometer between foods. The DA-M then placed the thermometer into mechanical soft carrots. The DA-M then wiped off the thermometer with the same paper towels. Surveyor observed DA-M did not sanitize the thermometer. DA-M then placed the thermometer into a carrot and cauliflower mix and DA-M wiped the thermometer with the same paper towel. Surveyor observed DA-M did not sanitize the thermometer between foods. DA-M then placed the thermometer into puree strawberry shortcake. Surveyor observed DA-M did not sanitize the thermometer between foods.On 7/21/2025, at 1:25 PM, Surveyor observed the 2nd floor kitchenette. The freezer has an opened fast-food container with no label, a large frozen red colored Styrofoam drinking cup with lid and no label, a frozen, used dessert icing bag with no label, a frozen Italian Ice pop box with no label, a yellow tied up grocery bag with frozen items in it unlabeled. The fridge section has 1 opened honey container with no label, a quart of opened chocolate milk with no open date, one loose apple, a gray tied up bag of 2 small oranges with no label.On 7/22/202, at 9:51 AM, Surveyor interviewed Dietary Manager (DM) - K. DM-K stated they do check the kitchenette refrigerators every day. DM-K stated they have been busy cooking lately. DM-K stated their process is to sanitize the food thermometer between foods when taking food temperatures.On 7/22/2025, at 10:18 AM, Surveyor shared the menu concerns with Director of Nurses (DON)-B and Senior [NAME] President of Success (SVPOS) -C. On 7/22/2025, at 12:48 PM, DM-K and Regional Director (RD)-L, provided Surveyor with policy and procedures related to food preparation and storage. RD-L stated they have started training the kitchen staff on these procedures.

Based on observation, interview and record review, the facility did not ensure menu items were followed. This was observed with 7 (R31, R16, R54, R88, R50, R26 and R10) of 7 residents receiving an altered textured diet. * R31, R16, R54, R88, R50, R26 and R10 have altered textured diets and did not receive a dinner roll with their lunch meal as stated on the menu.Findings include:The facility's policy and procedure titled, Menus dated 9/2017, documents, . The menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal.On 7/21/2025, at 12:06 PM, Surveyor observed the serving of the lunch meal on the 1st floor by Dietary Aide (DA)-M. The menu documented for lunch: Turkey Alfredo, parslied fettuccini, Tuscany blend vegetables, garlic dinner roll and strawberry shortcake for dessert. Surveyor observed DA-M assemble the food into a steam table and take temperatures of the food. Surveyor noted there was not a puree or mechanically altered dinner roll option available. The DA-M used divided plates for R31, R16, R54, R88, R50, R26 and R10. Surveyor observed these residents did not receive a garlic dinner roll or substitution. DA-M did provide a dinner roll with butter to all resident that received regular textured diets. On 7/22/2025, at 9:51 AM, Surveyor interviewed Dietary Manager (DM)-K. DM-K stated the usual staff was not serving the noon meal yesterday. DM-K stated they do have textured consistency options for dinner rolls. DM-K stated they forgot to make the altered textured dinner rolls. DM-K stated all residents get all the same menu items. On 7/22/2025, at 10:18 AM, Surveyor shared the menu concerns with Director of Nurses (DON)-B and Senior [NAME] President of Success (SVPOS) -C. On 7/22/2025, at 12:48 PM, Regional Director (RD)-L and DM-K provided Surveyor with policy and procedures related to concerns in the kitchen meal service. RD-L stated they have started education for the kitchen staff.

Based on observation, interview, and record review, the facility did not ensure 1 (R2) of 1 resident reviewed for indwelling catheters received appropriate treatment and services.R2's catheter collection bag and tubing were observed during multiple observations to be laying directly on the floor with no barrier.Findings include:R2 was admitted to the facility on [DATE] and has diagnoses that include hemiplegia/ hemiparesis following cerebral infarction affecting right dominant side (Stroke with right sided paralysis), dysphagia (difficulty swallowing), aphasia (difficulty communicating), type 2 diabetes mellitus, Spinal stenosis, presence of urogenital implants, and Alzheimer's disease, and Dementia. R2's admission Minimum Data Set (MDS) dated [DATE] indicated R2 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 0 and the facility assessed R2 requiring total assist with one staff member for all activities of daily living (ADL) care. R2 was admitted with a foley catheter. R2 has an activated power of attorney (POA).R2's care plan documents the use of indwelling urinary catheter- Foley needed due to disease process recent stroke with deficits was initiated on 4/29/2025 with the following interventions:-Catheter care .On 7/22/2025, at 7:46 AM, Surveyor observed R2 lying in bed sleeping. R2's catheter bag was lying on the right side of the bed directly on the floor. Surveyor did not observe any barrier between the catheter drainage system and the floor.On 7/23/2025, at 7:50 AM, Surveyor observed R2 lying in bed sleeping. R2's catheter bag was hooked onto the right side of R2's bed the bottoms half of the catheter bag that included the catheter drainage system was observed touching the floor. Surveyor did not observe a barrier between the catheter drainage system and the floor. On 7/23/2025, at 10:45 AM, Surveyor interviewed director of nursing (DON)-B and licensed practical nurse unit manager (LPNUM)-D. Surveyor asked what intervention of catheter care means on a resident's care plan. LPNUM-D stated staff are made aware a resident has a catheter and to provide cares, emptying the catheter, making sure the catheter bag has a privacy cover, and that the catheter bag does not touch the floor, etc. Surveyor shared concerns with DON-B and LPNUM-D that R2's catheter bag was observed lying on the floor and touching the floor without a barrier between the catheter drainage system and the floor the mornings of 7/22/2025 and 7/23/2025. DON-B stated that should not have happened, and education will be started with facility staff.

Based on interviews and record review, the facility did not ensure residents right to formulate an advance directive for do not resuscitate (DNR) was implemented for 1 of 18 (R8) residents advanced directives reviewed.R8 electronic health record indicated full code, CPR preference form date [DATE] indicated R8 was a DNRFindings include: The facility Policy titled Cardiopulmonary Resuscitation (CPR) dated [DATE] documents (in part) . It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR). 2. If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and: a. In accordance with the resident's advance directives, orb. In the absence of advance directives or a Do Not Resuscitate order. R8's Care plan dated [DATE] documents: Resident has an advanced directive in place. Follow advanced directive per MD (Medical Doctor) orders. Follow facility protocol for identification of code status. On [DATE], at 10:44 AM, while reviewing R8's electronic health record (EHR), Surveyor noted R8's code status was listed as Full Code. R8's Physician order dated [DATE] documents Full Code. Surveyor located a CPR (Cardiopulmonary Resuscitation)/DNR (Do Not Resuscitate) preference form signed by R8's Guardian/legal decision maker dated [DATE] which documents an X next to I do NOT want CPR attempted (DNR order). On [DATE], at 11:57 AM, Surveyor interviewed Registered Nurse (RN)-F. Surveyor asked if RN-F if he observed a resident not breathing/without a pulse or if he was advised by a CNA (Certified Nursing Assistant) that a resident was coding, where would he look to find their code status? RN-F showed Surveyor on the computer/EHR and stated, I would look right here, on their dashboard it lists their advanced directive, it's the same place for every resident. Surveyor asked to view R8's code status. RN-F brought up R8's dashboard on the computer. RN-F pointed to the advanced directives section and stated, It says it right here, she's a full code. Surveyor asked RN-F if there was anywhere else, he would look to find R8's code status. RN-F stated, No, this is where I would look. Surveyor verified with RN-F that R8 is a full code. Surveyor asked RN-F if residents wear DNR bracelets at the facility. RN-F reported he did not think so. Surveyor verified with RN-F, if a resident coded, he would look at the computer dashboard to verify their code status. RN-F stated, yes. On [DATE] at 12:10 PM, Surveyor spoke with Licensed Practical Nurse (LPN)-G and asked if residents wear DNR bracelets. LPN-F stated, No, maybe some of them do but mostly no. Surveyor asked what he would do if a resident coded. LPN-G stated, I would look at the computer, it says their code status on the main screen. Surveyor asked if he meant the dashboard, LPN-G stated, Yes, if I saw a resident with a DNR bracelet on, I would still come look at the computer to make sure, because you never know - sometimes things get messed up. Surveyor asked which location he would trust as accurate. LPN-G stated, The computer. On [DATE], at 12:15 PM, Surveyor observed R8 seated in the dining room. R8 had an allergy bracelet on her left wrist and was not wearing a DNR bracelet. On [DATE], at 9:13 AM, Surveyor noted R8's code status on the EHR dashboard was changed to DNR. On [DATE], at 11:33 AM, Director of Nursing (DON)-B was advised of concern R8's Guardian signed the CPR/DNR preference form on [DATE] indicating DNR. R8's EHR was not revised to include the DNR order. As of [DATE] (1 week later) R8's code status indicated Full Code and was not changed to DNR until notified by Surveyor. On [DATE] at 3:43 PM, the facility was notified of the above concerns. No additional information was provided.

Based on interview and record review the Facility did not ensure a resident's hospice notes were readily available for communication and collaboration of care in accordance with professional standards of practice for 1 (R88) of 3 residents reviewed for hospice services. Hospice visit notes were not updated in R88's medical record or in R88's hospice binder until Surveyor requested the information.R88 was admitted to the facility on [DATE] with pertinent diagnoses that include type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood), dementia (a syndrome that can be caused by a number of diseases which over time destroy nerve cells and damage the brain, typically leading to deterioration in cognitive function (i.e. the ability to process thought) beyond what might be expected from the usual consequences of biological ageing), and hypertensive chronic kidney disease (kidney damage caused by long-term high blood pressure (hypertension)).R88's Quarterly Minimum Data Set (MDS) with an assessment reference date of 6/8/25 documents a Brief Interview for Mental Status (BIMS) score of 00, indicating R88 has severe cognitive impairment. The MDS documents R88 rarely or never makes self-understood or has ability to understand others. No behavior concerns were exhibited during the 7 day look back period; always incontinent of bowel and bladder; has range of motion impairment on both sides of upper and lower extremities. R88 is documented to receive hospice care.R88 has a care plan for hospice care needs due to end of life, initiated on 1/10/2023. Interventions include: -Allow resident/family to discuss feelings, etc.-Assist with ADL (activities of daily living) care and pain management as needed-Encourage to participate in activities as able-Honor advanced directives-Hospice staff to visit to provide care, assistance, and/or evaluation On 07/23/2025, at 9:20 am, Surveyor observed the hospice binders for residents within the facility. Surveyor was unable to locate a binder for R88.On 7/23/25, at 9:27 am, Surveyor interviewed Unit Manager (UM)-D regarding R88's hospice binder not being with the other residents. UM-D stated another resident from the facility is not at the facility anymore and hospice picked up the binder, UM-D thinks they may have taken the wrong one. UM-D will follow up and find out.On 7/23/25, at 1:01 pm, Surveyor interviewed Certified Nursing Assistant (CNA)-J and asked how CNA-J communicates with R88's hospice provider and was told if the hospice staff have questions about cares CNA-J answers them, otherwise they ask nurses their questions.On 7/23/25, at 1:16 pm, Surveyor interviewed Licensed Practical Nurse (LPN)-G about how they communicate with R88's hospice provider and was told there is a phone number in R88's hospice binder otherwise when hospice staff are here, they talk to in person.On 7/23/25, at 1:30 pm, Surveyor followed up with UM-D regarding the location of R88's hospice communication binder and was told that UM-D had not received a call back.On 7/23/25, at 3:09 pm, during the end of day meeting, with Director of Nursing (DON)-B, 1st and 2nd floor Unit Managers and Senior [NAME] President of Success-C, Surveyor relayed concern of R88's missing hospice communication binder.On 7/24/25, at 8:36 am, Surveyor observed the hospice binder for R88 with the other hospice binders. Surveyor noted the last visit logged for R88 was a CNA visit on 7/7/25. Surveyor was unable to locate documented nursing visit notes.On 7/24/25, at 8:40 am, Surveyor interviewed UM -D regarding the hospice binder lacking communication information from nurses visiting R88. Surveyor gave UM-D the binder and pointed out it contained another resident's records in R88's binder which UM-D removed. UM-D told Surveyor to ask DON-B if there's more documentation as DON-B requested hospice email it last night.On 7/24/25, at 8:58 am, Surveyor interviewed DON-B and Senior [NAME] President of Success-C regarding the concern R88's binder did not have nurse visit notes documented as they occurred and R88's binder was not available for staff review for continued communication and coordination of care with hospice until surveyor requested such. Per DON-B they let the hospice service know that last night.Surveyor noted before exiting the facility nurse visit notes were provided and DON-B stated they would be added to R88's hospice binder.Surveyor noted no further information regarding R88's hospice visit notes not being updated in R88's medical record or in R88's hospice binder was provided.

Based on observation, interview and record review, the facility did not ensure drugs and biologicals used in the facility were be labeled in accordance with currently accepted professional principles and include the expiration date when applicable for 1 of 2 medication carts observed. Insulin in the medication cart was not labeled and/or was expired. Findings include:The facility policy titled Medication Administration Injectable Vials and Ampules dated 01/23 documents (in part) .Vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations or the providers pharmacy's directions for storage, use and disposal. 3. The date opened and the initials of the first person to use the vial are recorded on multi-dose vials (on the vial label or an accessory label affixed for that purpose).9. Discard multi-dose vials when empty, when suspected or visible contamination occurs or when the manufacturer's stated expiration date is reached, providing the manufacturer's storage conditions have been maintained. Expiration dating not specifically referenced in the manufacturer's package insert should not exceed 28 days once the vial has been opened. Medications with shortened expiration dates:Humalog (Lispro) insulin: Vial and Kwik pen - once opened, product expires 28 days. Aspart (Novolog): Vial and Flex pen - product expires 28 days after first use. On [DATE], at 2:43 PM, Surveyor observed the 2nd floor medication cart B. In the right middle drawer, Surveyor located the following:-Aspart insulin pen labeled with R3's first name. The insulin pen was open and used, dated opened [DATE]. Surveyor noted another date written in black marker [DATE]. Licensed Practical Nurse (LPN)-G reported the insulin belonged to R3 and he was not sure why there were 2 dates written or which one is correct. -Humalog insulin pen not labeled with a resident name. The insulin pen was open and used, dated opened [DATE]. LPN-G was not sure why the insulin was not labeled with a resident name. -Lispro insulin vial labeled with R1's name. The insulin vial was open and used, dated opened [DATE]. Surveyor asked LPN-G how long insulin is good for once opened. LPN-G stated, 30 days. I think almost all insulins are good for only 30 days. Surveyor showed LPN-G the above insulins and the dates opened. LPN-G stated, I guess they're expired.On [DATE], at 3:42 PM, Surveyor shared concerns with Nursing Home Administrator-A and Director of Nursing-B regarding the above insulins that were not labeled and/or were expired. No additional information was provided.

Based on interview and record review the facility did not ensure 1 (R2) of 18 residents care plans reviewed were revised after each assessment or determined by resident's needs.R2' care plan was not revised to indicate R2 did not require the use of an abdominal protector with monitoring and need to release the binder due to the need for the use of a gastrointestinal (G-tube) tube. Findings include:The facility policy titled Comprehensive Care Plan with a reviewed/revision date of 9/23/2022 documents: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a residents medical, nursing, and mental and psychological needs that are identified in the residents comprehensive assessment. 5. The comprehensive care plan will be reviewed and revised as appropriate by the interdisciplinary team after each comprehensive and quarterly minimum data set (MDS) assessment, and as needed with changes in condition.R2 was admitted to the facility on [DATE] and has diagnoses that include hemiplegia/ hemiparesis following cerebral infarction affecting right dominant side (Stroke with right sided paralysis), dysphagia (difficulty swallowing), aphasia (difficulty communicating), type 2 diabetes mellitus, protein-calorie malnutrition, Alzheimer's disease, and Dementia.R2's admission Minimum Data Set (MDS) dated [DATE] indicated R2 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 0. R2 was assessed to require total assistance with one staff member for all activities of daily living (ADL) care. R2 was admitted with a gastrointestinal (G-tube) tube that delivered continuous feedings and a foley catheter. R2 has an activated power of attorney (POA).R2's care plan documented a need for a feeding tube/potential for complications of feeding tube use related to swallowing impairment initiated 5/2/2025 documents that R2 pulls at G-tube at times and has the following intervention:-Abdominal binder to keep G-tube from being pulled out.On 5/2/2025 R2 had a physical restraint assessment completed which documented: .- Abdominal binder to be worn at all times to prevent dislodgement of G-tube.- Frequent monitoring has been performed, continues to pull at G-tube between checks.- For safety and nutritional purposes decision was made to have abdominal binder in place.- Monitor and open abdominal binder every 2 (two) hours.R2 has the following order implemented on 5/2/2025:- Abdominal binder to be released for 15 minutes every 2 hours while being utilized. Check for any skin irritation/ impairment and proper circulation, if any changes noted notify medical doctor/nurse practitioner (MD/NP) every 2 hours for monitoring. Start date: 5/2/2025.On 7/22/2025, at 1:20 PM, Surveyor interviewed certified nursing assistant (CNA)-H who stated R2 was not wearing an abdominal binder this morning. Surveyor asked who was responsible for putting on the abdominal binder and checking the abdominal binder for R2. CNA-H stated R2 does not wear an abdominal binder, and CNA-H did not see one in R2's room. CNA-H stated CNA-H does not work with R2 often but never has seen an abdominal binder on R2. On 7/22/2025, at 1:23 PM, Surveyor interviewed licensed practical nurse (LPN)-F who stated R2 does not have an abdominal binder on and R2 does not wear an abdominal binder. Surveyor asked if R2 pulls at the g-tubing or if there is concern of the tubing being pulled out. LPN-F stated R2 has never pulled at the tubing or attempted to pull the tubing out. Surveyor reviewed R2's May, June, and July 2025 medication administration/ treatment administration records (MAR/TARs) and noted nursing initialing R2's abdominal binder being taken off 15 minutes every two hours per physician order. On 7/23/2025, at 8:58 AM, Surveyor observed CNA-I assisting R2 with getting up for the day. Surveyor asked if R2 was to get an abdominal binder in place to prevent pulling on R2's G-tube. CNA-I stated R2 had an abdominal binder in the past but not sure if R2 ever wore it and no longer wears it currently.On 7/23/2025, at 8:50 AM, Surveyor interviewed LPN-G who stated R2 came from the hospital with an abdominal binder and may have worn it in the beginning but then did not because R2 never pulled or tried to take tubing out. LPN-G stated LPN-G checks to make sure R2 is not starting to pull on tubing and R2's hands are visible but R2 does not move much so staff just monitor.On 7/23/2025, at 10:42 AM, Surveyor interviewed LPN Unit Manager (LPNUM)-D and Director of Nursing (DON)-B who stated R2 never came to the facility with an order to wear an abdominal binder. LPNUM-D stated it was brought up in a care conference from R2's activated POA. DON-B stated R2's POA wanted R2 to wear one because R2 got it from the hospital. DON-B stated everyone that comes to the facility from the hospital is provided an abdominal binder from the hospital in the event the resident would start to pull at the tubing. LPNUM-D and DON-B stated they got the order to appease R2's POA because the POA was worried R2 would start pulling the G-tube out. Surveyor shared concern staff was documenting in the MAR/TAR that they were checking every 2 hours and releasing the abdominal binder for 15 minutes however surveyor could not see any documentation R2 was not wearing a binder or t R2 was pulling at the tubing. DON-B and LPNUM-D stated they would check into the concern as to why staff were documenting on an order that was not being followed through.On 7/23/2025, at 4:16 PM, DON-B stated that staff were documenting on R2's MAR/TAR and singing out every two hours because the order states if R2 would utilize the abdominal binder and that staff were checking to make sure R2 as not pulling on tubing. Surveyor informed DON-B the order and care plan imply R2 pulls at R2's G-tube site and R2 should be wearing the abdominal binder with 2-hour checks with 15 minutes release of the binder. Surveyor stated the care plan was not revised to indicate if R2 were to start pulling at the tubing or that there is an abdominal binder in the event R2 starts to pull at the tubing. DON-B understood concern and how it was not clear and would look to revise the care plan or discontinue the order to prevent further confusion to staff. No further information was provided at the time of this write up.

Based on record review and staff interviews, the facility did not ensure residents had access to their personal funds when requested. The facility did not have petty cash funds available during the evenings, weekends or holidays. Findings include: admission Agreement: H.) Personal Funds. Residents should consider limiting the amount of cash kept in their room. Upon written authorization, the Center will agree to hold personal funds for you in a manner consistent with federal and state laws and regulations. You are not required to allow us to hold your personal funds for you as a condition of admission or continued stay in our center. We will provide you our policies, procedures and authorization forms if you chose to do so. On 7/1/25 at 10:15 a.m., Surveyor conducted an interview with Business Office Manager (BOM)-C regarding residents having access to their personal funds that are held in an account with the facility. BOM-C stated she manages the resident funds and typically there is just a handful of residents who request to withdraw money from their accounts on a weekly basis. BOM-C stated that she typically works Monday through Friday from 7:45 AM/ 8:15 AM to 6:00 PM. BOM-C stated that she is not at the facility on holidays. Surveyor asked BOM-C what if residents want to withdraw money in the evenings or on the weekends when she is not at the facility. BOM- C stated that Social Services Coordinator (SSC)-D has access to the safe and can access the money envelope if BOM- C is not at the facility. Surveyor confirmed that SSC-D works during the days on Monday, Tuesday, Thursday and Fridays. Both BOM-C and SSC-D do not work on the weekends. BOM-C stated that she will let the residents know that they need to withdraw money ahead of time if she is not going to be at the facility . BOM-C stated that they don't keep a petty cash fund for residents to withdraw from when she is not at the facility and that there has never been an issue with not having money available in her absence. BOM-C stated that there is not anything posted regarding the banking hours and availability to withdraw money. BOM-C was able to confirm that there are currently 42 residents who have personal funds managed by the facility. On 7/1/25 at 11:04 AM, Surveyor interviewed SSC-D regarding residents having access to their personal funds. SSC-D stated that she would need to get clarification from the Business Office, but she believes residents can just ask to withdraw money, sign the receipt and be on their way. SSC-D stated she doesn't know what would happen if a resident wanted to withdraw money on the weekends or evenings. SSC-D stated that she will help if she can as she use to work in the business office prior to working in Social Services. On 7/1/25 at 11:30 AM, Surveyor interviewed Administrator- A regarding residents having access to their personal funds. Administrator- A stated BOM-C has a schedule figured out with those residents that frequently withdraw money from their account. Administrator- A stated that she goes to the bank 1 or 2 times a month to get cash to have on hand for the residents. Administrator- A stated that she does have access to the money if BOM-C is not available. Surveyor asked Administrator- A what would happen if a resident wanted to withdraw personal funds on a weekend when BOM-C, SSC-D and Administrator- A are not at the facility. Administrator- A stated they have never had an instance where that happened but understands that maybe they need to keep a small petty cash fund with nursing on the weekends and evenings. As of the time of exit on 7/1/25, the facility did not provide additional information as to why Residents did not have access to petty cash on an on-going basis to honor residents request to withdraw funds as soon as possible.

Based on observation, interview, and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 1 (R2) of 1 resident reviewed for pressure injuries. * R2 was admitted to the facility 1/20/25 without any pressure injuries. Upon admission R2 was identified as being at high risk for pressure injury development. The facility did not develop a potential for skin integrity care plan and R2's care plans do not address repositioning or offloading R2's feet/heels. The endocrine system care plan initiated 1/24/25 includes an intervention of: inspect feet daily for open areas, sores, pressure areas, blisters, edema, or redness. This intervention was not implemented as diabetic orders were not ordered for R2. On 2/28/25, R2 was identified with unstageable pressure injuries on the right lateral ankle and right heel and suspected deep tissue injury on the right inner ankle and top of the right foot. Treatments for these pressure injuries were not ordered until 3/2/25, two days later, and R2's March TAR (Treatment Administration Record) is not checked and initialed as being completed on 3/2/25 and 3/3/25. During the survey, observations were made of R2 not wearing Prevalon boots and/or R2's heels were not being offloaded. The facility's failure to provide care to prevent the development of pressure injuries and promote the healing of pressure injuries and the failure to develop and/or update resident's pressure injury care plans created a finding of Immediate Jeopardy (IJ) that began on 1/20/25. Surveyor notified Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, [NAME] President of Success (VPS)-C, and Unit Manager (UM)-D of the immediate jeopardy on 3/13/25 at 2:23 p.m. The immediate jeopardy was removed on 3/13/25. The deficient practice continues at a scope and severity of D (potential for harm/isolated) as the facility continues to implement its action plan. Findings include: The facility's policy titled, Pressure Injuries and Non pressure Injuries and reviewed/revised 7/20/22 documents under policy: This center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measures intended to achieve the goal of prevention of pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity. The following protocols should guide prevention and treatment efforts, unless specified by a physician otherwise. Documented under Policy Explanation and Compliance Guidelines: c. Initiate the baseline plan of care related to current skin status and skin risk level. (The comprehensive care plan will be developed within seven days of the completion of the comprehensive assessment - see below for additional information related to the comprehensive care plan). When determining skin risk status and appropriate interventions, consider the following: i. Braden Scale Score. ii. Co-morbid conditions, such as end stage renal disease, thyroid disease, or diabetes mellitus; iii. Drugs such as steroids that may affect healing; iv. Impaired diffuse or localized blood flow, for example, generalized atherosclerosis or lower extremity arterial insufficiency; v. Resident declination of some aspects of care and treatment; vi. Cognitive impairment; vii. Use of splints/braces or presence of a cast; viii. Presence of a medical device(s) such as an indwelling catheter, trach, nasal cannula, or CPAP (Continuous Positive Airway Pressure)/BiPAP (Bilevel Positive Airway Pressure) mask; ix. The need or request to elevate the HOB (head of bed); x. Exposure of skin to urinary and fecal incontinence; xi. Under nutrition, malnutrition, and hydration deficits; and xii. The presence of a previously healed PU (Pressure Ulcer)/PI (Pressure Injury). The history of any healed PU/PI, its origin, treatment, its stages [if known] is important assessment information since areas of healed Stage 3 or 4 PU/PIs are more likely to have recurrent breakdown. Documented under Care Planning: A Comprehensive Skin Integrity Care Plan is based on resident history, review of Skin Assessment, Braden Scale Scoring, Nutritional Assessments, resident and family interviews, and staff observations. Consider the areas of risk, as well as overall risk assessment score of the Braden Scale. Communicate identified risk factors and interventions to direct care staff . 2. Develop interventions based on individual Risk Factors including, but not limited to, weight, presence of edema, overall health status/comorbidities, use of medical devices, presence of acute infection, end of life/hospice, resident choice/preferences, or medications that may impact healing. R2 was admitted to the facility on [DATE] with diagnoses to include fracture of right femur, Diabetes Mellitus, Chronic Kidney Disease Stage 5, Peripheral Vascular Disease, Depressive Disorder, Anxiety Disorder, and Restless Leg Syndrome. R2's Power of Attorney for healthcare was activated on 1/29/25. Staff communicate with R2 by writing their question or what they are going to do on a whiteboard. R2's Braden assessment dated [DATE] has a score of 12. A score of 10 to 12 is high risk for development of a pressure injury. R2 was admitted with a right leg immobilizer with orders dated 1/21/25 of Immobilizer to right lower extremity at all times, may remove for skin checks Q (every) shift and PRN (as needed). R2's care plan documents endocrine system related to DM (diabetes mellitus) 2 initiated and revised on 1/24/25 includes an intervention of: Inspect feet daily for open areas, sores, pressure areas, blisters, edema, or redness. Initiated 1/24/25. Surveyor reviewed R2's January 2025, February 2025, and March 2025 MAR/TAR (Medication Administration Record/Treatment Administration Record). There is no evidence staff were inspecting R2's feet daily for open areas, sores, pressure areas, blisters, edema, or redness on these MARs/TARs. The facility did not develop a potential for skin integrity care plan upon admission. A potential for skin integrity care plan was not developed until 3/10/25, after R2 developed multiple pressure injuries. R2's ADL (Activities Daily Living) self-care deficit initiated 1/20/25 and revised 1/21/25 does not include an intervention for repositioning. R2's admission MDS (Minimum Data Set) with an assessment reference date of 1/26/25 has a BIMS (Brief Interview for Mental Status) score of 11 which indicates moderate cognitive impairment. R2 is assessed as requiring supervision or touching assistance for eating, substantial/maximum assistance to roll left and right, and is dependent for toileting hygiene, chair/bed to chair transfer, and toilet transfer. R2 is always incontinent of urine and occasionally incontinent of bowel. R2 is at risk for pressure injury development and is assessed as not having any pressure injuries. R2's pressure ulcer/injury CAA (care area assessment) dated 1/29/25 documents under analysis of findings for nature of the problem/condition: Pressure Ulcers CAA triggered secondary to potential for pressure ulcers. Contributing factors include ADL/functional/mobility impairment and incontinence. Risk factors include pain, development of PU/skin condition, and fluid deficit risk. A licensed nurse assesses skin each week and puts proper interventions in place to prevent skin breakdown. Skin is also assessed by caregivers with each bath and each time the resident is dressed. The physician is to be notified of any abnormal findings and treatment orders are obtained. The dietitian is monitoring her food and fluid intake, and implementing dietary interventions, as necessary. Caregivers assist with repositioning at least every two hours and as needed for comfort. Care plan will be initiated or reviewed to improve or maintain current ADL status and functional ability, maintain continence status, prevent pain, and decrease pressure ulcer/fluid deficit risk. Location of documentation: see NN (nurses notes)/Braden/TAR for the look back period. Resident has increased risk for skin impairment related to increased need for help with ADL such as bed mobility which can decrease blood flow and increase pressure leading to wounds. Documented under care plan considerations for describe impact of this problem/need on the resident and your rationale for care plan decision is the same wording as under analysis of findings for nature of the problem/condition. R2's Braden assessment dated [DATE] has a score of 14 which indicates moderate risk for the development of pressure injuries. R2's physical medicine and rehabilitation note dated 2/7/25 under history of present illness documents: Patient seen and examined. History provided partially via nursing staff and pt (patient) family. Has some improvement of appetite today. No pain today. She has been intermittent up in her chair participating in therapy. Daughter is concerned her brace on her R (right) leg is too long and irritating her skin both proximally and distally - padding has helped some. I did then reach put [sic] (out) to the orthopedic clinic and they recommend that she come out and visit for them to assess her splint and decide her weight bearing status. Her family and primary team were informed. R2's Braden assessment dated [DATE] has a score of 15 which indicates at risk for the development of pressure injuries. On 2/24/25, R2 went to an orthopedic appointment and R2's immobilizer was discontinued. R2's nurses note dated 2/28/25, at 11:38 a.m., and written by Unit Manager (UM)-D documents: Writer was called to resident's room by floor nurse. Daughter reported an area on resident's R (right) ankle. RN (Registered Nurse) and writer went in to assess. Found 4 DTIs (deep tissue injury). Resident has no description d/t (due to) cognition. Daughter stated she thought it was from the immobilizer but that was discontinued 2/24/25 and wound NP (nurse practitioner) saw resident on 2/25/25 and assessed R (right) hip incision OA (open area), assessed feet and circulation, no wounds were present. Writer and RN measured and assessed wound. NP here and aware. New treatment orders ordered and performed. POA (Power of Attorney) in agreement for wound NP to follow wounds. Prevalon boots when in bed ordered and put on Resident today. Pressure Injury #1 R2's pressure injury weekly tracker dated 2/28/25 for pressure injury, acquired in house is indicated. Under location for site documents: 47) Right ankle (outer), type is pressure, under units of measure: centimeters for length is 1.9, width 1.5, and depth 0.1. Stage is documented as Unstageable. Tissue type is 100% necrotic. Drainage is none. Documented under additional interventions/plans: Prevalon boots when in bed order obtained, applied today during assessment and treatment. NP notified and treatment ordered. POA aware. Air mattress ordered. R2's physician order with an order date of 3/2/25 documents wound care: Betadine R outer ankle and R heel, cover with Mepilex QD (every day) and PRN (as needed). Surveyor notes this order is 2 days after R2's pressure injury was identified, and the treatment is not checked and initialed as being completed on 3/2/25 and 3/3/25. On 2/28/25, the resident has a Stage IV (4) pressure ulcer to R outer ankle. Care plan developed and revised on 3/4/25 with documented interventions all initiated on 2/28/25 of: Administer medication as ordered. Monitor/document for side effects and effectiveness. Administer treatments as ordered and monitor for effectiveness. Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/position requirements; importance of taking care during ambulating/mobility, good nutrition, and frequent repositioning. If the resident refuses treatment, confer with the resident, IDT (interdisciplinary team) and family to determine why and try alternative methods to gain compliance. Document alternative methods. Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length x width x depth), stage. Obtain and monitor lab/diagnostic as ordered. Report results to MD and follow up as indicated. Prevalon boots on when in bed. On 3/5/25, an intervention of: the resident requires Air Mattress: Check function and setting every shift. Settings are 150, was initiated. Pressure Injury #2 R2's pressure injury weekly tracker dated 2/28/25 for pressure injury acquired in house with date acquired documents 2/28/25. Under location for site documents: 49) Right heel, type is Pressure, and units of measure: centimeters for length is 4.5, width 1.5. Stage is Unstageable. Tissue type is 100% necrotic. Drainage is none. Under additional interventions/plans documents: Prevalon boots when in bed order obtained, applied today during assessment and treatment. NP notified and treatment ordered. POA aware. Air mattress ordered. R2's physician order with an order date of 3/2/24 documents wound care: Betadine R outer ankle and R heel, cover with Mepilex QD (every day) and PRN (as needed). This order is 2 days after R2's pressure injury was identified, and the treatment is not checked and initialed as being completed on 3/2/25 and 3/3/25. On 2/28/25, the resident has an unstageable pressure ulcer to R heel care plan developed and revised on 3/4/25 with documented interventions all initiated on 2/28/25 of: Administer medication as ordered. Monitor/document for side effects and effectiveness. Administer treatments as ordered and monitor for effectiveness. Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/position requirements; importance of taking care during ambulating/mobility, good nutrition, and frequent repositioning. If the resident refuses treatment, confer with the resident, IDT (interdisciplinary team) and family to determine why and try alternative methods to gain compliance. Document alternative methods. Inform the resident/family/caregivers of any new area of skin breakdown. Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length x width x depth), stage. Obtain and monitor lab/diagnostic as ordered. Report results to MD and follow up as indicated. Pressure Injury #3 R2's pressure injury weekly tracker dated 2/28/25 for pressure injury acquired in house with date acquired documents 2/28/25. Under location for site documents: 45) Right ankle (inner), type is Pressure and units of measure: centimeters for length 0.7 and width 0.8. Under Stage documents Suspected Deep Tissue Injury. Skin is 100% purple. Drainage is none. Under additional interventions/plans documents: Prevalon boots when in bed order obtained, applied today during assessment and treatment. NP notified and treatment ordered. POA aware. Air mattress ordered. R2's physician order with an order date of 3/2/25 documents: Skin prep to R inner ankle and top of R foot QD (every day) at bedtime. This order is 2 days after R2's pressure injury was identified, and the treatment is not checked and initialed as being completed on 3/2/25 and 3/3/25. On 2/28/25, the resident has a DTI R inner ankle care plan developed and revised on 3/4/25 with documented interventions all initiated on 2/28/25 of: Administer medication as ordered. Monitor/document for side effects and effectiveness. Administer treatments as ordered and monitor for effectiveness. If the resident refuses treatment, confer with the resident, IDT (interdisciplinary team) and family to determine why and try alternative methods to gain compliance. Document alternative methods. Inform the resident/family/caregivers of any new area of skin breakdown. Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection wound size (length x width x depth), stage. Obtain and monitor lab/diagnostic as ordered. Report results to MD and follow up as indicated. Pressure Injury #4 R2's pressure injury weekly tracker dated 2/28/25 for pressure injury acquired in house is indicated with date acquired 2/28/25. Under location for site documents: Other (specify) Top of R foot, type is Pressure, and units of measure: centimeters for length 1.0 and width 0.5. Stage documents Suspected Deep Tissue Injury. Drainage is none. Under additional interventions/plans documents: Prevalon boots when in bed order obtained, applied today during assessment and treatment. NP notified and treatment ordered. POA aware. Air mattress ordered. R2's physician order with an order date of 3/2/25 documents: Skin prep to R inner ankle and top of R foot QD (every day) at bedtime. This order is 2 days after R2's pressure injury was identified, and the treatment is not checked and initialed as being completed on 3/2/25 and 3/3/25. On 2/28/25, the resident has a DTI top of R foot care plan developed with documented interventions all initiated on 2/28/25 of: Administer medication as ordered. Monitor/document for side effects and effectiveness. Administer treatments as ordered and monitor for effectiveness. Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. If the resident refuses treatment, confer with the resident, IDT (interdisciplinary team) and family to determine why and try alternative methods to gain compliance. Document alternative methods. Inform the resident/family/caregivers of any new area of skin breakdown. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Pressure Injury #5 R2's nurses notes dated 3/4/25 at 12:11 p.m. and written by Unit Manager (UM)-D documents: During wound rounds with wound NP found new Unstageable DTI of the right toe. Wound NP measured and assessed. Treatment ordered and in place. POA aware. In house NP aware. Prevalon boots in place in bed. Wound NP-Q's assessment dated [DATE] for Stage 4 pressure wound of the right lateral ankle for wound size documents: 2.4 x 1.8 x not measurable cm (centimeters). Thick adherent black necrotic tissue (eschar) 80% and Slough 20%. Under additional note documents: Post-debridement assessment of this previously unstageable necrotic wound has revealed the underlying deep tissue at the muscle/fascia level, which had been obscured by necrosis prior to this point. This wound has now revealed itself to be a Stage 4 pressure injury. This is not a wound deterioration. Wound NP-Q's assessment dated [DATE] for Unstageable DTI of the right heel for wound size documents: 4.4 x 4.1 x not measurable. Skin is intact with purple/maroon discoloration. Wound NP-Q's assessment dated [DATE] for Unstageable DTI of right medial ankle for wound size documents: 1.0 x 0.9 x not measurable. Skin is intact with purple/maroon discoloration. Wound NP-Q's assessment dated [DATE] for Unstageable DTI of right dorsal foot for wound size documents: 2.2 x 1.4 x not measurable. Skin is intact with purple/maroon discoloration. Wound NP-Q's assessment dated [DATE] for Unstageable DTI of right toe for wound size documents: 0.4 x 0.8 x not measurable. Skin is intact with purple/maroon discoloration. On 3/4/25, the facility developed and revised the resident's DTI pressure ulcer R toe care plan with all interventions initiated on 3/4/25 of: Administer medications as ordered. Monitor/document for side effects and effectiveness. Administer treatments as ordered and monitor for effectiveness. Frequent repositioning. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue, and exudate. The facility's pressure injury weekly tracker dated 3/4/25 assessment of R2's right ankle (outer), right ankle (inner), top of R foot, and right toe document the same stage, measurements and description of wound bed as Wound NP-Q's assessment. The assessment of R2's right heel has the same measurements, but the stage and tissue type are different than Wound NP-Q. The facility's assessment documents the stage as Unstageable and tissue type 100% necrotic tissue. R2's nurses note dated 3/11/25 at 13:45 (1:45 p.m.) and written by UM-D documents: Wound rounds done with wound NP, exposed hardware from a previous surgery to R ankle exposed. MD updated. [First name] POA updated talked about referral to orthopedics per POA family decided on comfort care for resident and keeping her comfortable. Will be pursuing Hospice at home. MD aware. On 3/10/25 at 9:49 a.m., Surveyor observed R2 in bed on her back with the head of the bed elevated and R2's breakfast tray on the over bed table. Surveyor observed R2 has eaten 100% of her breakfast which was on the plate. Surveyor observed R2 has bare feet and R2's heels are resting directly on the mattress. R2's heels are not being offloaded and R2 is not wearing Prevalon boots according to R2's plan of care. On 3/10/25 at 10:01 a.m., Surveyor observed Certified Nursing Assistant (CNA)-R enter R2's room. CNA-R covered R2 with a sheet and blanket and then left R2's room. During this observation Surveyor noted CNA-R did not offer to put on R2's Prevalon boots and did not offload R2's heels. On 3/10/25 at 10:19 a.m., Surveyor observed R2's POA in the room. R2 continues to be in bed on her back with her heels not offloaded and R2 is not wearing Prevalon boots. During conversation with R2's POA, Surveyor was informed they aren't here 24/7 but she is at the facility during the week from around 9:00 a.m. to about 6:00 p.m. and after she leaves other family members come, and they also come on the weekend. Surveyor inquired how often staff changes R2. R2's POA informed Surveyor they are supposed to every two hours but if we are here we change her, sometimes we are here all morning and they, (referring to staff,) aren't in. At 10:34 a.m., R2's POA checked R2's incontinence product stating, she's pretty wet. At 10:37 a.m., R2's POA put the call light on, and CNA-R responded. From 10:39 a.m. to 10:48 a.m. Surveyor observed CNA-R wash R2 and provide continence cares to R2. During this observation at 10:46 a.m., CNA-R placed a pillow under R2's lower right leg, then removed and folded the pillow in half and placed under R2's right leg. Surveyor observed the right heel is being offloaded but the left heel is resting directly on the mattress. On 3/10/25 at 2:11 p.m., Surveyor observed R2 in bed on her back with the head of the bed elevated sleeping with R2's POA at the bedside. Surveyor observed R2 is not wearing Prevalon boots. R2's heels are resting directly on the mattress; the right foot is bare and the left foot has a slipper/sock on. On 3/10/25 at 3:21 p.m., Surveyor observed R2 continues to be in bed on her back with the head of the bed elevated and R2's POA at the bedside. R2 is still not wearing the Prevalon boots and R2's heels are resting directly on the mattress. On 3/11/25 at 7:49 a.m., Surveyor observed R2 in bed on her back with the head of the bed elevated. Surveyor observed R2 is not wearing the Prevalon boots as they are in the chair. R2's heels are not being offloaded. On 3/11/25 at 7:50 a.m., Surveyor observed CNA-R enter R2's room. CNA-R wrote on the white board asking R2 if she was ready to get washed up. CNA-R raised the height of the bed. Surveyor asked CNA-R if Surveyor could see R2's feet. Surveyor observed R2 has bare feet and R2's heels are resting directly on the mattress. CNA-R then placed a pillow under R2's lower legs but R2's heels are resting directly on the pillow and are not being offloaded. CNA-R did not offer to place R2's Prevalon boots on. CNA-R wrote on the white board can I get you up. R2 responded no. CNA-R lowered the height of the bed and left R2's room. On 3/11/25 at 8:00 a.m., Surveyor asked Licensed Practical Nurse (LPN)-G if she is doing treatments today. LPN-G replied, I don't have to do them today, its wound care day, the wound nurse will do them. Surveyor asked LPN-G how R2 developed the pressure injuries. LPN-G informed Surveyor she didn't know and explained she's not over here, (referring to R2's unit,) often. On 3/11/25 at 9:09 a.m., Surveyor observed CNA-R enter R2's room with her breakfast tray, which CNA-R placed on the over bed table and left R2's room. R2 is in bed with the head of the bed elevated and a family member in the room. R2's heels are not being offloaded and R2 is not wearing the Prevalon boots. On 3/11/25 at 9:12 a.m., Surveyor asked CNA-R if she has to assist R2 with eating. CNA-R replied, she can eat herself. Surveyor asked CNA-R if R2 has any pain. CNA-R replied in the right leg, she won't let you put anything on her leg. On 3/11/25 at 10:17 a.m., Surveyor spoke with CNA-U on the telephone regarding R2. CNA-U informed Surveyor she takes care of R2 daily along with CNA-R. Surveyor asked CNA-U if she has observed any pressure injuries on R2's feet. CNA-U stated, I'm the one that discovered the sore on the bottom of her foot when I took socks off. Surveyor asked CNA-U if she remembers when this was. CNA-U replied, last week or the week before, can't remember the exact date. Surveyor asked if she reported this to anyone. CNA-U informed Surveyor she believes [first name of RN-I] was on the floor and UM-D was there. CNA-U informed Surveyor she told UM-D first as RN-I was talking to someone. Surveyor asked CNA-U before the pressure injury had developed did she take off R2's socks when doing cares. CNA-U replied we try to, but she screams out, there could be days when we did not remove the socks because she was in too much pain. Surveyor asked when R2 was in pain did she report this to the nurse. CNA-U informed Surveyor she reported each time to the nurse. CNA-U informed Surveyor R2 did start to wear the boots after the area developed. On 3/11/25 at 10:56 a.m., Surveyor observed R2 in bed on her back with the head of the bed elevated. There is a pillow under R2's right leg, length wise and R2's right heel on the pillow. R2's left heel is on the mattress. Surveyor observed R2's heels are not being offloaded and R2 is not wearing Prevalon boots. On 3/11/25 at 11:18 a.m., Surveyor observed wound rounds for R2 with Wound NP-Q and UM-D. Surveyor observed R2's wound supplies are on the over bed table. Wound NP-Q removed the dressing from R2's right knee (surgical) and right ankle. Wound NP-Q then measured R2's wounds, stating the measurements out loud. Surveyor noted the following measurements: The right knee (surgical) 1.8 x 1.2, right outer ankle 2.4 x 1.7 with hardware exposed. Surveyor observed Wound NP-Q did not measure the depth of the right outer ankle. Right heel 2 x 3.7, right medial ankle 1.8 and right dorsal foot blanching 2.5 x 1.5. During this observation, Wound NP-Q did not measure R2's right toe and did not describe the wound bed of any R2's pressure injuries. After measuring, Wound NP-Q left R2's room to document and UM-D did the treatment to R2's surgical wound and R2's pressure injuries according to physician orders. During this observation at 11:32 a.m., UM-D informed Surveyor she was going to skin prep the right heel. Surveyor asked UM-D if R2's right heel pressure injury is 100% necrotic. UM-D replied yes. At 11:38 a.m. after UM-D completed the treatment for all R2's pressure injuries, UM-D stated, I know the daughter took the boots off, but I need to find them. UM-D removed her gloves and cleansed her hands. Surveyor noted as of this time, R2's daughter has not been at the facility. UM-D located R2's Prevalon boots and placed them on R2. Surveyor asked UM-D how staff know R2 is supposed to be wearing the boots. UM-D replied, it's on the Kardex. UM-D lowered R2's bed down low, placed the call light in reach, and left R2's room. On 3/11/25 at 1:41 p.m., Surveyor observed R2 in bed on her back, wearing Prevalon boots, and a family friend is sitting next to R2's bed in a chair. On 3/11/25 at 2:27 p.m., Surveyor interviewed Wound NP-Q regarding R2. Wound NP-Q informed Surveyor 2/25/25 was her first consult with R2 as she was a new orthopedic patient. Surveyor asked Wound NP-Q when she saw R2 on 2/25/25 did she assess R2's feet. Wound NP-Q replied yes, the lower leg and feet. Surveyor asked Wound NP-Q if she observed any skin impairment areas. Wound NP-Q replied on the dorsal foot, 1st and 2nd toe had little area and believes this was all that was noted at the time. Surveyor asked Wound NP-Q how a treatment is ordered if she is not at the facility. Wound NP-Q informed Surveyor they notify her via phone, she will give a treatment order and then will assess the next week. Surveyor asked Wound NP-Q today during wound rounds why didn't she measure the depth for the right outer ankle. Wound NP-Q informed Surveyor it looked exactly the same, so she left it at the same depth. Surveyor inquired about description of the wound bed. Wound NP-Q informed Surveyor she charts them in her computer and after wound rounds she manually synchs and uploads into PCC (pointclickcare). Surveyor asked Wound NP-Q how she thought R2 developed these pressure injuries. Wound NP-Q informed Surveyor it's probably a mix of pressure, in so much pain, not willing to have cares done, repositioning, and stated to Surveyor you saw today when you touch her leg. Wound NP-Q also informed Surveyor R2 was not eating well. Wound NP-Q informed Surveyor they did order Prevalon boots after they developed. After Surveyor met with Wound NP-Q, Surveyor reviewed Wound NP-Q's initial wound evaluation dated 2/25/25. For examination of right lower extremities documents foot warm, no edema. Wound present. See focused wound exam below. There is no documentation regarding this wound, on Wound NP-Q's evaluation. On 3/12/25 at 9:09 a.m., Surveyor observed R2 eating breakfast in bed on her back with the head of the bed elevated. R2 has yellow gripper socks on her feet, R2's heels are resting directly on the mattress, and R2 is not wearing Prevalon boots. Surveyor observed the Prevalon boots are in a chair. On 3/12/25 at 9:11 a.m., Surveyor observed CNA-S enter R2's room, CNA-S informed Surveyor she usually works upstairs and was floated down. CNA-S asked R2 if she was done eating. R2 yelled I can't hear you. Surveyor informed CNA-S she has to write on the white board as R2 can't hear her. CNA-S stated they didn't even tell me that. CNA-S then wrote on the communication board if she was done eating and then if she needed anything. CNA-S removed the over bed table, which was across R2, lowered the leg portion and the head of bed and lowered the height of the bed. CNA-S then wrote on the communication board can I put a pillow on your side. CNA-S lowered the head of the bed down so the bed was flat, raised the height of the bed, and assisted R2 with rolling on her right side. CNA-S placed a pillow under R2's left side, covered R2, raised the head of the bed and lowered the bed back down. Surveyor observed R2's heels are not being offloaded and CNA-S did not offer to place R2's Prevalon boots on. On 3/12/25 at 9:23 a.m., Surveyor asked CNA-S if she has provided incontinence cares to R2 this morning. CNA-S informed Surveyor R2 was one of the first residents she washed up and changed. Surveyor asked CNA-S why R2 was not wearing Prevalon boots according to her care plan. CNA-S informed Surveyor R2 takes them off and then stated, I don't know if she is supposed to wear them.<b [TRUNCATED]

Based on interview and record review, the facility did not ensure 7 of 7 facility staff chosen at random received behavioral health training. Dietary Aide (DA)-DD, Licensed Practical Nurse (LPN)-EE, Certified Nursing Assistants(CNA) CNA-X, CNA-Y, CNA-Z, CNA-AA, CNA-BB did not receive behavioral health training. In addition, contracted employee, Speech Language Pathologist (SLP)-CC did not receive behavioral health training. This practice had the potential to affect all Residents with a psychiatric diagnosis and/or behavioral health issues in the facility. The facility did not provide staff with the required behavioral health training for the following staff: CNA-X, CNA-Y, CNA-Z, CNA-AA, CNA-BB, DA-DD, LPN-EE, and SLP-CC. Findings Include: The facility was unable to provide a facility policy and procedure for training requirements for all staff either employed at the facility or contracted. The facility's assessment last reviewed 8/5/24, documents: The facility documents a facility training program which includes orientation and ongoing training for all new and existing staff and for individuals providing services under contractual arrangement. The assessment lists various training topics to meet regulatory requirements. Surveyor notes that behavioral health is not listed as a training topic. However, according to the facility assessment: .c. Training and skills unique to Resident population: Each employee is educated on the below topics upon hire and on an as needed basis during the duration of employment. -Caring for Residents with mental and psychosocial disorders, as well as Residents with history of trauma and/or post-traumatic stress disorder, and implementing nonpharmacological interventions. .Services provided such as behavioral health -Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities. The facility assessment documents that the facility has an average of 57% (34-146) Residents with a psychiatric diagnosis. On 3/19/25, at 10:51 AM, Surveyor randomly selected 7 facility staff and 1 contracted employee for review. Surveyor reviewed the employee records DA-DD, LPN-EE, CNA-X, CNA-Y, CNA-Z, CNA-AA and CNA-BB, and SLP-CC. The facility was unable to provide documentation that DA-DD, LPN-EE, CNA-X, CNA-Y, CNA-Z, CNA-AA, CNA-BB, and SLP-CC received the required effective behavioral health training within the year based on hire date. DA-DD - date of hire 3/10/24 LPN-EE - date of hire 12/28/23 SLP - date of hire 2/1/23 CNA-X - date of hire 10/22/19 CNA-Y - date of hire 3/13/23 CNA-Z - date of hire 3/1/23 CNA-AA - date of hire 3/6/24 CNA-BB - date of hire 2/9/23 On 3/19/25, at 1:12 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A in regards to DA-DD, LPN-EE, CNA-X, CNA-Y, CNA-Z, CNA-AA, CNA-BB, and SLP-CC not having the required behavioral health training. NHA-A explained that monitoring of the required trainings was human resources responsibility, but human resources is no longer employed at the facility and NHA-A took over monitoring of the trainings a couple of months ago. NHA-A informed Surveyor that the corporation chooses what training topics staff are required to receive. Surveyor asked NHA-A to define 57% Residents with a psychiatric diagnosis. NHA-A explained that would be 57% of 88 Residents have a psychiatric diagnosis. On 3/19/25, at 2:07 PM, NHA-A confirmed the facility does not have a formal behavioral health training to address the needs of Residents with a psychiatric diagnosis and/or behavioral health behaviors. NHA-A provided the following documentation of the number of Residents with the following diagnoses: -Anxiety-41 -Bipolar-8 -Mood Disorder-1 -Schizoaffective-5 -Schizophrenia-6 -Depression-26 -Developmental Disorder-1 On 3/19/25, at 3:15 PM, Surveyor shared the concern that DA-DD, LPN-EE, CNA-X, CNA-Y, CNA-Z, CNA-AA, CNA-BB, and SLP-CC did not receive the required behavioral health training to help facilitate staff to address the mental, psychosocial, psychiatric, and behavioral needs of Residents with a psychiatric diagnosis and/or behaviors with NHA-A, Director of Nursing (DON)-B, and [NAME] President of Success (VPS)-C. No further information was provided at this time. On 3/19/25, at 4:54 PM, Surveyor was provided additional information documenting an inservice on abuse. Documentation states that Residents displaying aggressive behaviors should have extra supervision, to offer diversional activities, and to report to a supervisor. However, there is no documentation that staff were provided specific training on the various psychiatric diagnoses that Residents in the facility have along with specific interventions based on the conditions listed in the facility assessment.

Based on interview and record review the facility did not provide pharmaceutical services to meet the needs of each resident for 1 (R2) of 4 Residents. * R2's order from nephrology on 1/31/25 for Sodium Bicarbonate 1300 mg (milligrams) three times a day was never picked up by the facility. On 3/11/25 Surveyor observed R2's morning medication in a medication cup with pudding & crushed medication on an over bed table. Family Friend (FF)-P informed Surveyor the nurse left the medication and she will give R2 the medication. Findings include: The facility's policy titled, Medication Administration and dated 1/25 under policy documents Medications are administered as prescribed in accordance with manufacturers' specifications, 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 familiarized themselves with the medication. Under procedures documents 5. The person who prepares the dose for administration is the person who administers the dose. R2's diagnoses includes chronic kidney disease, diabetes mellitus, depressive disorder, anxiety disorder, and restless leg syndrome. * R2's physician order dated 1/20/25 documents Sodium Bicarbonate Oral Tablet 650 mg (milligram) (Sodium Bicarbonate (Antacid)) Give 1 tablet by mouth two times a day for heartburn. R2's nephrology note dated 1/31/25 documents: Her renal function as measured by GFR (glomerular filtration rate) is about the same (8-10 ml/min (milliliter per minute)). Her bicarb is much lower. From the ER (emergency room ) note from 1/22/25 she was on sodium bicarb 650 BID (twice daily). Previously she was on 1300 mg BID Potassium mildly increased but OK. I would suggest increasing the bicarb to 1300 TID (three times daily). Under medication list at end of visit as of 1/31/25 with a start date of 1/31/25 documents sodium bicarbonate 650 mg tablet. Take 2 tablets (1,300 mg total) by mouth 3 times daily. Oral Notes to Pharmacy: Dose increase. R2's nurses note dated 1/31/25, at 13:46 (1:46 p.m.), written by Licensed Practical Nurse (LPN)-J documents Received call from [first name] who's with resident nephrologist. [First name] call with prescription update increase, sodium bicarbonate to 1300mg (milligram) 3X (three times) a day. Prescription is being fax over to facility. Resident nurse for today has been notified of this and is aware. Surveyor reviewed R2's physician orders and February 2025 MAR (medication administration record) and noted the facility never picked up R2' sodium bicarbonate 1300 mg three times a day dated 1/31/25. The facility continued to administer sodium bicarbonate 650 mg twice a day until 2/7/25 when R2's sodium bicarbonate order was changed to 1300 mg twice a day. On 3/11/25, at 1:03 p.m., Surveyor asked Unit Manager (UM)-D why the facility did not pick up R2's sodium bicarbonate order on 1/31/25 to increase the dosage to 1300 mg three times a day. UM-D replied I didn't get that one, we should of put it in. UM-D informed Surveyor she doesn't know why it wasn't put in correctly and if she had noticed it she would of changed the order and notified the doctor. UM-D informed Surveyor typically she gets the papers when a resident goes out and transcribes the orders. UM-D informed Surveyor she doesn't know why the [first name of LPN-J] didn't transcribe it correctly. * R2's admission MDS (minimum data set) with an assessment reference date of 1/26/25 has a BIMS (brief interview mental status) score of 11 which indicates moderate cognitive impairment. On 3/11/25, at 10:56 a.m., Surveyor observed R2 in bed on her back with the head of the bed elevated. Family Friend (FF)-P was sitting in a chair next to R2's bed. Surveyor observed on the over bed table is a medication cup containing vanilla pudding with crushed medication. FF-P informed Surveyor the nurse came in and gave [first name of R2] pain pills. FF-P informed Surveyor the nurse left the other medication and FF-P stated I will give it to her. FF-P stated to Surveyor I'm her lucky charm, she will take it, referring to the medication, for me. FF-P informed Surveyor the nurse will be back in. Surveyor reviewed R2's physician orders and noted the following medications are administered in the morning for R2: Allopurinol 300 mg, Aspirin EC (enteric coated) 81 mg, Citalopram Hydrobromide 15 mg, Co Q-10 100 mg, Folic Acid 0.8 mg, Pantoprazole Sodium 40 mg, Rosuvastatin Calcium 10 mg, Vitamin D3 25 mcg (microgram) 2 tablets, Doxycycline Hyclate 100 mg, Metoprolol Tartrate 25 mg, Acetaminophen 650 mg, & Sodium Bicarbonate 1950 mg. Surveyor reviewed R2's medical record and did not note any education provided to family and/or family friend regarding administering R2's medication to R2. There is no care plan regarding family and/or family friend administering R2's medication. On 3/11/25, at 11:45 a.m., Surveyor asked Licensed Practical Nurse (LPN)-G if R2's family or family friend give R2 her medication. LPN-G replied sometimes they do. LPN-G informed Surveyor they, family, won't accept the fact R2 tells us no. They say just leave it and we'll give it. R2 has been refusing to take her medication. They can usually get her to take it but it takes awhile. Surveyor informed LPN-G the reason Surveyor is asking is because Surveyor observed a medication cup with pudding & crushed medication left on the over bed table. LPN-G informed Surveyor yes she left it, went back in later and took the medication cup as R2 didn't take the medication. On 3/11/25, at 3:07 p.m., Surveyor asked Director of Nursing (DON)-B if a resident's medication should be left with family or family friend to be administered. DON-B replied no. Surveyor informed DON-B of the observation with R2's morning medication being left for FF-P to give R2 the medication. Surveyor spoke with LPN-G who informed Surveyor the medication has been left in the past for family and/or family friend to give R2 her medication. No additional information was provided to Surveyor as to why R2's sodium bicarbonate order was not picked up by the facility and why R2's morning medication on 3/11/25 was left for FF-P to give R2 her medication.

Based on observation, interview, and record review the facility did not ensure 1 (R5) of 4 residents reviewed for accidents received adequate supervision and assistance devices to prevent future accidents. On 11/20/24, at 1:37 PM, R5 had an unwitnessed fall (UWF) while toileting. R5 was assessed to requires partial/moderate assistance for toilet transferring. R5 was left alone while toileting and had an UWF while attempting to self-transfer. Findings include: The facility's policy titled, Fall Prevention and Management Guidelines dated 11/8/22, last reviewed on 7/18/24, documents: . 4. Suggested standard interventions may include: . g. Complete a fall risk assessment quarterly, post-fall, and as with a significant change of condition. 7. When any resident experiences a fall, the facility will: a. Complete a post-fall assessment and review: 4. Resident and/or witness statements regarding fall f. Obtain witness statements from other staff with possible knowledge or relevant information. R5 is an [AGE] year-old resident who was admitted to the facility on [DATE]. R5's diagnoses include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, muscle wasting and atrophy, dysphagia following cerebral infarction, dementia with anxiety, and history of traumatic fracture. R5's Quarterly Minimum Data Set (MDS) completed on 9/29/24 documents R5 has a history of falls, is frequently incontinent of urine, requires substantial/maximal assistance with toileting hygiene, transfers, and rolling left to right. R5 was documented as having a Brief Interview for Mental Status (BIMS) score of 3, indicating R5 has severe cognitive impairment. R5's Falls Care Area Assessment (CAA) on the 6/29/24 Admission MDS documents the following: Falls CAA triggered secondary to impaired gait and mobility and level of assistance required with transfers. Contributing factors include history of falls prior to admission, weakness and physical limitations affecting balance, gait, strength, and muscle endurance. Risk factors include falls and other major/minor injuries related to falls. The care plan will be initiated/reviewed to improve/maintain current physical function as it relates to ADLs, gait stability, strength and endurance, mobility, decrease fall risk and minimize injury related to falls. R5's Urinary Incontinence CAA on the 6/29/24 Admission MDS documents the following: Urinary Incontinence CAA triggered secondary to always incontinent of bladder and dependence of staff for incontinent care. Contributing factors include weakness, impaired mobility, and cognitive loss. Risk factors include skin breakdown, falls, and recurrent Urinary Tract Infections (UTI)s. Care plan will be initiated/reviewed to maintain check and change for incontinent episodes, reduction of pressure ulcer and fall risk, and reduce the risk for UTI. R5's Cognitive Loss/Dementia CAA on the 6/29/24 Admission MDS documents the following: Resident does not have a diagnosis of dementia or cognitive loss. Surveyor notes R5 was documented as having a BIMS of 3 (severe cognitive impairment) on the Admission MDS dated [DATE]. R5's care plan, dated 6/23/24, documents: R5 is at risk for falls due to history of falls, weakness, limited mobility, Type 2 Diabetes, hemiplegia, hemiparesis, and ventricular premature depolarization, dated 6/29/24. Interventions include: Ensure R5 is wearing appropriate footwear including shoes or gripper socks, dated 6/25/24. Have commonly used articles within reach, dated 6/25/24. Medications as ordered, dated 6/25/24. Provide assistance to transfer and ambulate as needed (PRN), dated 6/25/24. Reinforce the need to call for assistance, dated 6/25/24. R5 is to not be left alone if toileting. Offer toileting every two to three hours, dated 11/24/24. Therapy evaluation and treatment as ordered, dated 6/25/24. R5's Kardex documents R5 requires assistance of 1 with toileting and assistance of 1 with a gait belt for mobility. On 3/10/25, at 9:57 AM, Surveyor observed R5 in the common room with four other residents. R5 was observed to be watching TV. R5 was dressed in personal clothing, appears comfortable, has slippers on both feet, and is sitting in a manual wheelchair. R5 was observed to have her hair pulled back in a braid with socks on both feet and feet in a dependent position. On 3/10/25, at 10:11 AM, Surveyor observed R5's room which had a low bed, personal belongings on the side table, call light laying on the bed, and Prevalon boots on the chair across the room. R5 was in the common area at the time of R5's room observation. On 3/10/25, 11:51 AM, Surveyor interviewed R5 who was sitting in her wheelchair in the common area. R5 denied concerns with Surveyor and appeared comfortable. Surveyor observed socks and shoes on both feet with multiple staff members present in the common area assisting other residents. On 3/10/25, at 11:53 AM, Surveyor interviewed Certified Nursing Assistant (CNA)- M who states she knows when residents are at risk for falls when she sees a low bed and will also look in the computer. CNA- M states she will call the nurse right away if a resident has a fall. CNA- M will also give report to the oncoming CNA with any recent fall or change in condition. CNA- M states staff will monitor residents more closely if they are a fall risk. On 3/10/25, at 3:03 PM, Surveyor asked Director of Nursing (DON)- B where Fall Risk Assessments are found in the Electronic Medical Record (EMR). DON- B states Fall Risk Assessments are completed on the admission and quarterly evaluations. DON- B states Fall Risks Assessments are included on the Admission Evaluation assessment and Quarterly Clinical Review assessments. Surveyor notes the following Fall Risk Assessments: *Admission Evaluation dated 6/23/24, documents the following: R5 has had a fall in the last 30 days. R5 is not at risk for falls. Surveyor notes R5 is documented as not being at risk for falls, even though R5's Admission MDS dated [DATE], documents R5 having a fall prior to admission. *Quarterly Clinical Review dated 9/26/24, documents the following: R5 uses a standard wheelchair, has no falls in the last 0-6 months, is frequently incontinent of bladder and is at risk for falls. R5 requires assistance of 1 staff member for toileting and transfers. Surveyor notes R5 is noted as having no falls in the last 0-6 months, even though R5's Admission MDS dated [DATE], documents R5 having a fall prior to admission. *Quarterly Clinical Review dated 12/28/24, documents the following: R5 uses a standard wheelchair, has no falls in the last 0-6 months, is frequently incontinent of bladder, and is not at risk for falls. Surveyor notes R5 is noted as having no falls in the last 0-6 months with documentation of R5 sustaining an UWF on 11/20/24. Surveyor notes R5 is documented as not being at risk for falls. Surveyor reviewed the facility Fall Investigation for R5's UWF on 11/20/24, which documents Licensed Practical Nurse (LPN)- N heard R5 yelling for help and upon entering the room LPN- N noted R5 laying on her back on the bathroom floor. R5's wheelchair was located on her left side and R5 stated she was done using the bathroom and trying to get back into her chair. The facility fall investigation indicates the CNA placed R5 on the toilet and told R5 to pull the call light when she was done toileting. The CNA left the bathroom and left R5 alone on the toilet. R5 stated she slid down and did not hit her head. LPN- N notified the facility provider, unit manager, and R5's family. Surveyor notes R5 was documented as having gripper socks on at the time of her fall. The root cause was determined to be R5 self-transferring from the toilet. The fall investigation included when the resident was last seen, which was by the CNA who placed her on the toilet prior to her unwitnessed fall. Neuro checks were completed with no concerns noted. Care plan interventions to include R5 is not to be left alone if toileting and to offer toileting every two to three hours, were updated on R5's care plan. Surveyor notes R5 requires assistance of one with toileting and transfers and the CNA left R5 alone on the toilet. Surveyor notes R5 as having a low BIMS score indicating severe cognitive impairment at the time of the UWF. Surveyor notes there is no post fall assessment completed after R5's 11/20/24 UWF. On 3/11/25, at 8:54 AM, Surveyor interviewed Registered Nurse (RN)- O who states he will look at the Kardex or Care Plan to determine if a resident is at risk for falls. RN- O states staff on the 2nd floor also know the residents well as they are long term care, and the 2nd floor doesn't have a big turnover of residents. On 3/11/25, at 10:18 AM, Surveyor interviewed LPN- N who indicates staff will get a set of vitals with every resident that has a fall along with neuro checks, if the resident hits their head or the fall is unwitnessed. LPN- N states an RN assessment is completed after a resident fall. Staff will complete a post fall assessment, notify the unit manager, DON, family, and MD. LPN- N recalls the CNA put R5 on the toilet and left R5 on the toilet instructing them to press the call light when they were done using the bathroom. LPN- N heard R5's roommate yelling for help. LPN- N entered the room and found R5 lying on her back in the bathroom. LPN- N indicates she notified the unit manager right away who performed an assessment, got vitals, and performed neuro checks. LPN- N states R5 indicated she was attempting to go to the bathroom and self-transferring herself back to the wheelchair which was later determined as the root cause. On 3/11/25, at 12:46 PM, Surveyor interviewed Unit Manager (UM)- D who states Fall Assessments are completed on Admission and Quarterly. UM- D states Fall Risks assessments completed on admission are included on the Admission Evaluation assessment and Quarterly Fall Risk Assessments are included in the Quarterly Clinical Review assessments. Surveyor asked how a resident is determined to be a fall risk. UM- D states she usually puts everyone at risk for falls. Surveyor asked how staff know whether to check the resident as being at risk or not being at risk for falls. UM- D states there is no numbering scale on the Admission and Quarterly Assessments to help the staff determine if the resident is at a risk for falls. Surveyor notified UM- D that R5's 6/23/24 Admission Evaluation and 12/28/24 Quarterly Clinical Review both indicate R5 was not at risk for falls even though R5 experienced a fall prior to admission and in the facility on 11/20/24. Surveyor also notified UM- D of concerns with R5 being left alone while toileting on 11/20/24 and having an UWF. Surveyor notified UM- D that R5 was documented as having severe cognitive impairment and requiring assistance of 1 for toileting transfers and was left alone. Surveyor also notified UM- D of concerns with no post fall assessment being completed after R5's 11/20/24 UWF. UM- D acknowledge these concerns. On 3/11/25, at 3:04 PM, Surveyor notified Nursing Home Administrator (NHA)- A, DON- B, [NAME] President of Success (VPS)- C, and UM- D of concerns with R5 being left alone while toileting and having an UWF on 11/20/24. Surveyor reviewed that R5 was documented as having severe cognitive impairment and assistance of 1 for toileting transfers at the time of her fall. Surveyor noted the following to NHA- A, DON- B, VPS- C, and UM - D: *R5 was documented as not being at risk for falls on her Admission Evaluation dated 6/23/24, even though she was documented as having a fall in the last 30 days prior to her admission. *R5 was documented as not having falls in the last 0-6 months on her Quarterly Clinical Review dated 9/26/24. *R5 was documented as not having falls in the last 0-6 months and is not at risk for falls on her Quarterly Clinical Review dated 12/28/24, even though R5 had an UWF at the facility on 11/20/24. *R5 did not have a post fall assessment completed, which is noted in the facility policy. NHA- A, DON- B, VPS- C, and UM - D acknowledge these concerns.

Based on interview and record review, the Facility did not ensure 1 (R1) of 2 residents reviewed received care and treatment in accordance with goals for care, including identifying risk factors and implementing interventions to address the risk factors. The Facility did not recognize or assess the risk factor of R1's knee brace frequently slipping out of place, implement interventions to address the risk factors, and assess the effectiveness of the interventions thus placing Rat increased risk for poor healing. R1's surgical repair of the left patella (kneecap) failed. R1's orthopedic surgeon identified the failure likely occurred due to the fact R1's immobilizer was often not in the correct position. Findings include: The Facility policy, entitled, Use of Assistive Devices, dated 9/19/22, documents, in part . The purpose of this policy is to provide a process for the proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function and/or dignity . Policy Explanation and Compliance Guidelines: . 3. The facility will provide assistive devices or obtain referral to specialist, for residents who need them. Nursing, dietary, social services, and therapy departments will work together to ensure availability of devices, such as for ordering and/or replacement. 4. Facility staff will provide appropriate assistance to ensure that the resident can use the assistive devices. This may include education or therapy sessions for training on the use of the device, set up assistance, supervision, or physical assistance as needed. 5. Direct care staff will be trained on the use of the devices as needed to carry out their roles and responsibilities regarding the devices. Training will also include when to refer to other departments for changes in condition or problems with the device. 6. A nurse with responsibility for the resident will monitor for the consistent use of the device and safety in the use of the device. Refusals of use, or problems with the device, will be documented in the medical record. Modification to the plan of care will be made as needed. R1 was admitted to the facility on [DATE] with diagnoses that include displaced transverse fracture of left patella, subsequent encounter for closed fracture with routine healing, and Parkinson's disease without dyskinesia without mention of fluctuations. R1's MDS (Minimum Data Set) comprehensive admission assessment, dated 1/8/25, documents R1 has a BIMS (Brief Interview for Mental Status) score of 11, indicating moderate cognitive impairment, a PHQ-9 (Patient Health Questionnaire) score of 0, indicating no depressive symptoms, and no indicators of psychosis including no hallucinations or delusions, use of both wheelchair and walker. R1's toileting, showering/bathing, lower body dressing, all require substantial maximum assistance. R1's CAA (Care Area Assessment), dated 1/8/25, documents, ADL (Assistance with Daily Living) function CAA triggered secondary to assistance required in ADL's, transfers, and ambulation. Contributing factors include further ADL decline, falls, incontinence, skin breakdown, and pain. Care plan will be initiated/reviewed to improve/maintain current ADL status and functional ability, maintain continence status, decrease pain, and decrease risk of falls and skin breakdown. R1's Care Plan, dated 1/13/25, documents, Focus: ADL, self-care deficits evidenced by weakness related to left fracture of patella with ORIF (Open Reduction and Internal Fixation), history of falls and Parkinson's disease. Interventions include, ambulation/locomotion assist of 2 with device, bathing/showering, assist of 1, bed mobility, assist of 1, personal hygiene, assist of 1, toileting, assist of 1, and transfer, assist of 2. Focus: At risk of loss of range of motion r/t (related to) left patella. Goal: Will tolerate application of splint/orthotic device when worn. Interventions include, apply device immobilizer to LLE (left lower extremity). May take off for care. Monitor skin each shift. R1's Physician orders, dated 1/2/25, documented, PT (Physical Therapy) evaluation and treat as indicated, LLE (Left Lower Extremity) weight bearing as tolerated, keep in knee immobilizer at all times. May remove for skin checks every shift and PRN (as needed). R1's Physician order, dated, 1/4/25, documented, Cyclobenzaprine 5 mg (milligrams) daily for muscle spasms. R1's Hospital After Visit Summary, dated 1/2/25, documents in part .YOU (sic) are the most important factor in your recovery. Follow your instructions carefully, take your medications as prescribed, talk with your doctor/provider if you have any questions or if you have problems getting or taking your medications, follow up with your doctor/provider as instructed, and contact your doctor/provider for health care concerns. Call your Surgeons office if you have: a temperature greater than 101.0F, Increasing pain or numbness at the incision or on your operated leg, increasing redness or drainage of the wound, You WILL (sic) be swollen 4-6 weeks after surgery; however, swelling that continues to get worse to your surgical leg or the opposite leg and is accompanied by discomfort or redness should be reported. Activity: You may place as much weight as you can tolerate to your operative leg. Wear your immobilizer AT ALL TIMES (sic). R1's Facility Physical Therapy Treatment Encounter Note dated 1/3/25, documented by Physical Therapist (PT)-V in part .Tremors noted secondary to Parkinson's which impacted mobility and stability throughout session. PT performed SPT (Stand, Pivot, Transfer) with 2 WW (Two Wheel Walker) and minimal assistance into wheelchair. Readjusted extension brace and educated patient on brace positioning. R1's, x-ray exam dated 1/16/25, documented findings to include, two screws have been placed at the site of the mid patellar fracture. There is persistent diastases of at least 10 mm (millimeters) posterior and 3.3 cm (centimeters) anteriorly which is slightly improved from the previous study. Skin staples are in place. Small amount of joint fluid is noted. Impression to include, interval surgical change of the left patella. Persistent diastases. R1's Hospital Ambulatory Progress Note dated 1/16/25, for services personally performed by Orthopedic Surgeon (OS)- FF, in part . R1 is a [age] old male who presents roughly three weeks status post ORIF left transverse patella fracture. R1 is currently in rehab at facility. R1 reports that he has been compliant with his knee immobilizer at all times but admits the immobilizer often slides down. He also recalls an event about four days ago where he bent his knee while sleeping and woke up to significant pain. Once again, he confirms the immobilizer was on but was slid down allowing for him to flex his knee. Denies any wound drainage or incisional changes. He has been taking Aspirin for DVT (deep vein thrombosis) as prescribed and denies any CP (chest pain), SOB (shortness of breath), or calf pain. States the physical therapy has been going well other than some buckling of his knee with ambulation . The assessment/plan documented, Unfortunately the ORIF of the patella fracture has failed. This likely occurred due to the fact that his immobilizer was often not in the correct position. I will recommend that he follow up with my trauma colleague to discuss surgical intervention. He will continue to wear the immobilizer, and I stressed the importance of making sure his immobilizer is in the appropriate position. R1's Treatment Administration Record (TAR) dated 1/2/25, documents R1's LLE (left lower extremity) weight bearing as tolerated, in knee immobilizer at all times. May remove for skin checks every shift and PRN (as needed) every shift. Surveyor notes, staff checked off three times per day (day, evening and night shift). Surveyor notes it is documented R1 had his immobilizer on except for night shift on 1/2/25 and 1/3/25 and day shift 1/22/25. R1's Facility Progress Note dated 1/17/25, documented R1 went out for a follow-up appointment with ortho yesterday and x-rays showed failure of his patellar ORIF. He may need a revision surgery and is considering seeking a second opinion. He states he followed the postop guidelines, but his knee brace did slip down at times. Per therapy he also experiences spasms in that leg related to his Parkinson's. He denies pain at this time and no other concerns. R1 's Hospital Ambulatory Progress Note, dated 1/20/25, documented by Orthopedic Surgeon (OS)-GG, in part .when R1 presented for a postoperative appointment on 1/16/25, x-rays showed complete loss of reduction with failure of fixation. R1 does not recall any new specific injury. R1 had been ambulating with a knee immobilizer but would have trouble keeping the knee immobilizer up over the knee. It sometimes slipped down to the ankle. Additionally, he had been doing stairs with physical therapy. R1 recalls an incident where his brace slipped down to his ankle while ascending stairs, but it was promptly readjusted by the physical therapist. He did not experience any sensation of a fracture at that time. Prior to the refracture, he had been ambulating with a walker. R1 also has a known diagnosis of Parkinson's disease, which primarily manifests as a hand tremor and spasms in his leg. He experienced a particularly painful spasm during his hospital stay, characterized by curling of his foot and overall muscle tightening. Imaging studies reviewed and the pertinent positives are there is a transverse patella fracture status post open reduction fixation with to cannulated screws. This was well reduced on the interoperative fluoroscopy. On x-rays from 1/16/25, there is a pending complete loss of reduction and failure fixation. Assessment/Plan documented, closed displaced transverse fracture of left patella with delayed healing, subsequent encounter, failed orthopedic implant, initial encounter. The patient's ability to maintain leg extension is better than anticipated. The boned has pulled out over the screw heads, interrupting the link between the quadriceps muscle and the lower leg. This has resulted in an angulated kneecap, affecting its interaction with the femur. The optimal treatment plan for long-term knee function and strength would involve a surgical procedure to removes the screws, realign the bone fragments, and secure them in place. On 3/11/25, at 8:1 0 am, Surveyor interviewed, PT -V, who stated, there is a circle whole in the immobilizer that needs to be kept centered to the knee. R1 was fit with a generic immobilizer based on his height and weight which was determined and fitted at the hospital prior to discharge. Immobilizers can slip when a resident moves around a lot. R1 was very active. R1 had many transfers with toileting, to and from wheelchair and was always wheeling around the facility and going to activities. Before R1 would get out of bed, either PT or another staff member would adjust the immobilizer if it slipped. PT-V stated they did have concerns regarding the immobilizer because R1 had a lot of spasms in his legs and, rigidity and restlessness and it is going to move. On 3/11/25, at 9:50 am, Surveyor interviewed Certified Nursing Assistant (CNA)-R, who stated, she mostly sees immobilizer's out of place after a resident has been sleeping. When this happens, she just straightens it up. On 3/11/25, at 9:53 am, Surveyor interviewed Registered Nurse (RN)-T who stated, the immobilizer opening should be kept at the knee cap. Immobilizer's cannot be too tight as skin break down can occur. RN-T stated R1 always had his immobilizer twisted to the side or sliding because of all his movement. He moved and rolled around a lot in bed which displaced his immobilizer. R1 would sometimes hang one leg off the bed or both legs. On 3/11/25, at 10:04 am, Surveyor interviewed, PT-V, who stated, there is nothing PT can do if R1 moves around a lot at night. R1 always keeps his immobilizer on but staff cannot readjust all night long if it becomes displaced. If R1 puts his call light on, staff will come to readjust it. PT-V stated in their professional opinion, R1 should have had a cast rather than an immobilizer as he would not have the problem with continual slipping, but it is not in her scope of practice to question what the surgeon orders. PT-V stated, on R1 s first day of PT on 1/3/25 that he had tremors due to Parkinson's disease that impacted his stability. PT-V states she reeducated R1 on importance of keeping brace in position. On 3/11/25, at 12:43 pm, Surveyor interviewed, RN-T, who stated when R1's immobilizer would slip out of place, she did not notify anyone. I am not going to notify anyone if an immobilizer needs to be adjusted. I just do it. R1 is of sound mind and has a lot of movement so expected to be readjusting. When asked if she ever updated surgeon or unit manager of R1's immobilizer slipping, RN-T stated, No, I just adjust. On 3/11/25, at 11:14 am, Surveyor interviewed, PTA (Physical Therapy Assistant)-W, along with PT-V. PTA-W stated R1's movement is lots of jerking in his legs. PTA-W stated, generic immobilizers have lots of give and have some degree of movement. She stated, she did not call the surgeon with any updates regarding the immobilizer slipping because it was R1's normal movement that was causing it to slip and R1 was not moving enough to warrant concern. PT-V stated, she followed the physician orders and did not question his directive. PT-V stated, she had an example of time when she did call a surgeon regarding another resident's immobilizer that did not fit well and requested a custom immobilizer, but this was for a resident who would be wearing one long term and R1 would not have an immobilizer long term. PT-V stated she would frequently adjust R1's immobilizer while he was in the hallways. PT-V states everyone was always readjusting R1's immobilizer. On 3/12/25, at 9:22 am, Surveyor interviewed Director of Nursing (DON)-B, who stated when she first met R1 on 1/3/25 he was, kicking like a horse, like wild. R1 was in his room, and she could see him kicking from the hallway. DON-B entered R1 's room and asked if he was ok and R1 stated his leg involuntary kicks quite often because of his Parkinson's disease. DON-B contacted the NP, (Nurse Practitioner) to see if she could get a muscle relaxer for R1 and on 1/4/25, Cyclobenzaprine 5 mg was ordered. DON-B stated she asked R1 if the muscle relaxer was helping, and R1 said it was and it decreased his spasms. DON-B stated the surgeon clearly knew how the immobilizer fit and knew R1 tremored. DON-B stated she questioned in her head, did they not notice his tremors? DON-B stated she did not notify R1 of her concerns regarding surgeon's order for the immobilizer nor did she contact the surgeon. On 3/12/25, at 9:25 am, Surveyor interviewed Licensed Practical Nurse (LPN)- G, who stated when she makes a check mark on the TAR for R1, she is indicating she has verified the immobilizer is on R1's left leg. LPN-G stated if the immobilizer is not placed correctly, she will just adjust it and then check off on the TAR. On 3/12/25, at 3:05 pm, Surveyor notified Nursing Home Administrator (NHA)-A and DON-B of the concern facility staff did not identified the risk factor of R1's immobolizers continuously slipping and how it would impact R1's recovery and healing. The facility staff did not implement interventions to address the risk factors nor did staff speak to R1's orthopedic surgeon or provider regarding the continual slipping of R1's immobilizer which negatively impacted R1's healing.

Based on record review and interviews, the facility did not ensure staff were qualified to provide CPR (cardiopulmonary resuscitation) and where not aware of licensed staffs' CPR certification status. This was observed with 1(R3) of 1 residents who required CPR in the facility. -R3 was observed non-responsive by facility staff and had prior written wishes to have CPR performed. The facility did not ensure Licensed Practical Nurse (LPN)- G was certified to perform CPR. LPN-G was the first to respond to R3's unresponsive, pulseless change of condition. Findings include: The facility's policy and procedure titled Cardiopulmonary Resuscitation, dated [DATE] documents: . 3. CPR certified staff will be available at all times. 4. Staff will maintain current CPR certification for healthcare providers through a CPR provider who evaluates proper technique through in-person demonstration of skills. CPR certification which includes an online knowledge component yet still requires in-person skills demonstrations to obtain certification or recertification is also acceptable. R3's medical record documents in the Progress Note (PN) on [DATE], at 10:40 AM , a late entry on [DATE], by Unit Manager (UM)-D which documents Staff went into room around 0745 (7:45 AM) to get Resident ready for breakfast. Resident was unresponsive with no pulse code blue called. Full code, CPR initiated by 2 nurses. 911 called. AED (automated external defibrillator) obtained as paramedics entered building. Paramedics took over compressions. Health history given to Paramedics. Husband called to update. Resident (sic) stated he was on his way and hung up the phone. MD (Medical Doctor) called and updated on situation. Resident was pronounced deceased around 0900 (9:00 AM). R3 was admitted to the facility on [DATE] and had an order to have CPR performed in the event of an emergency. On [DATE], at 10:50 AM, Surveyor interviewed UM-D. UM-D stated they did not participate in the performance of CPR on R3. The CPR was already being performed by Licensed Practical Nurse (LPN)-G and LPN-F. UM-D stated they just documented the summary of the event and was not present when it occurred. On [DATE], at 10:00 AM, Surveyor interviewed Director of Nurses (DON) - B. DON-B stated they reviewed the summary of R3's CPR event and did not discover any concerns. Surveyor requested a list of facility staff that are CPR certified. On [DATE], at 3:35 PM, Surveyor interviewed Scheduler- L. Scheduler-L stated the Human Resource (HR) staff track CPR certification for staff. Scheduler-L stated HR will let them know if a staff member was not CPR certified. Scheduler - L stated she does not know what staff are CPR certified in the facility. On [DATE], at 8:25 AM, Surveyor interviewed DON-B. DON-B stated the HR staff left employment last week and they are still trying to locate CPR certifications for staff. On [DATE], at 9:14 AM, Surveyor interviewed DON-B and LPN-F. DON-B stated the staff involved with R3's CPR event had CPR certification, except LPN-G. LPN-F showed Surveyor their CPR certification, via their personal phone. The DON-B was in the process of gathering facility staff CPR certifications. On [DATE], at 9:26 AM, Surveyor interviewed LPN-G. LPN-G stated their CPR certification expired in 2023 and they have been meaning to get the recertification completed. Surveyor notes LPN-G assisted in performing CPR on R3, and was not currently certified to do so, when the event occurred. Surveyor notes R3's 911 fire department report related to the CPR event on [DATE] documents the following: Bystander: CPR was being performed of low quality and the arrest was not witnessed. On [DATE], at 12:42 PM, Surveyor interviewed the Assistant Fire Chief (AFC) - K via phone. AFC-K stated when low quality CPR is documented it means a component of CPR was not observed to be done correctly. AFC-K stated their staff took over the CPR and R3 remained in asytole (no pulse). R3 passed away. On [DATE], at 9:45 PM, Surveyor met with Nursing Home Administrator (NHA) - A, [NAME] President of Success (VPS) - C, and DON-B, regarding R3's CPR event. The VPS-C stated there were other certified staff in the facility during R3's CPR event. Surveyor shared concerns regarding LPN-G performing a component of CPR on R3 and was not currently certified.

Based on interview and record review the Facility did not provide appropriate treatment and services for 1 (R1) of 1 resident with a diagnosis of dementia with behavioral symptoms to allow them to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. R1 has a diagnosis of Alzheimer's Disease and dementia. The December 2023, January 2024, February 2024, & March 2024 MAR (medication administration record) for daily behavior monitoring per shift does not document any behavior. On 4/4/24 R1's behaviors began & escalated. There was no comprehensive assessment with individualized interventions of R1's behaviors, the Facility did not assess the behavior change to identify the cause of R1's behavior, and the care plan was not revised until after R1 chased another Resident down the hall & ran over this resident's foot with her wheelchair. The Facility does not conduct dementia or trauma assessments. Failure to comprehensively assess R1's behavior and to conduct dementia & trauma assessments created a finding of Immediate Jeopardy (IJ), which began on 4/4/24. NHA (Nursing Home Administrator)-A , DON (Director of Nursing)-B, VP (Vice President) of Success-AA, and Operations-BB were notified of the immediate jeopardy on 4/24/24 at 12:55 p.m. The immediate jeopardy was removed on 4/25/24. However, the deficient practice continues at a severity/scope level of E (potential for harm/pattern) as the facility continues to implement its removal plan. Findings include: Although NHA-A informed Surveyor on 4/23/24 at 12:24 p.m. the Facility does not have a dementia care policy, on 4/24/24 at 1:48 p.m. NHA-A provided Surveyor with a dementia care policy. The Dementia Care policy dated 4/23/24 under policy documents It is the policy of this facility to provide the appropriate treatment and services for residents who display signs of, or are diagnosed with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being. Under Policy Explanation and Compliance Guidelines documents: 1. The Facility will assess, develop, and implement care plans through an interdisciplinary team (IDT) approach that includes the resident, their family, and/or resident representative, to the extent possible. 2. The care plan goals will be achievable, and the facility will provide resources necessary for the resident to be successful in meeting their goals. 3. The care plan interventions will be related to each resident's individual symptomology. 4. Care and services will be person-centered and reflect each resident's individual goals while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. 5. Individualized, non-pharmacological approaches to care will be utilized, to include meaningful activities aimed at enhancing the resident's well-being. 6. If needed, the environment will be modified to accommodate individual resident care needs. 7. The care plan goals and interventions will be monitored on an ongoing basis for effectiveness and will be reviewed/revised as necessary. 8. Appropriate referrals will be made if current interventions are ineffective or resident shows a decline in psychosocial, mood, or behavioral status (i.e. physician, mental health provider, licensed counselor, pharmacist, social worker). 9. Staff will be trained on dementia and dementia care practices upon hire, annually, and as needed to ensure they have the appropriate competencies and skill sets to ensure residents' safety and help residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. R1's diagnoses includes Alzheimer's disease, depression, anxiety disorder, and dementia. R1's power of attorney for healthcare was activated on 4/27/22. R1's care plan documents cognitive loss as evidence by (specify) r/t (related to): Alzheimer's disease/dementia initiated & revised on 3/30/21 documents the following interventions: * Allow adequate time to respond. Do not rush or supply words. Initiated 3/30/21. * Approach/speak in a calm, positive/reassuring manner. Initiated 3/30/21 & revised 4/27/21. * Encourage low stress activities such as music, small group activities. Initiated 3/20/21. * Invite to participate in activities such as trivia, reminiscence, current events/newspapers. Initiated 3/30/21. * Repeat communication using more than one method (words, gestures, facial expressions). Initiated 3/30/21. * Use resident's name when addressing. Initiated 3/30/21. R1's care plan documents at risk for behavior symptoms r/t: (specify) Alzheimer's disease/dementia and depression. Resident can become angry with no provocation Swear at staff, Throw items at staff, Insult other Residents, Grab other residents clothing, Will use wheelchair to get to other residents and staff to antagonize care plan initiated 9/8/23 & revised on 4/7/24 documents the following interventions: * Administer medications per physician order. Initiated 9/8/23. * Attempt psychotropic drug reduction per physicians orders. Initiated 9/8/23. * Do not seat near Resident [first name of resident with last name's initial]. Initiated 9/8/23. * Re approach resident at a later time if she becomes verbally or physically aggressive towards staff. Initiated 1/6/24. * Use consistent approaches when giving care. Initiated 1/6/24. * When Resident experiences an episode of anger ensure surrounding residents maintain an appropriate distance from Resident. Initiated 1/6/24. * Resident can become easily triggered by other residents with dementia-please monitor environment when she is amongst peers. Initiated 3/7/24. * Room change on 3/1/24 for a quieter space. Initiated 3/7/24. * Staff to not allow res (resident) by [first name of resident with last name's initial]. Initiated 4/6/24. * When res in bed-staff to attempt to pad the bed with pillows to create border to protect from hard surfaces if res. allows. Initiated 4/7/24. R1's MAR (medication administration record) documents the following: Behaviors Monitor for the following: itching, picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cursing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care. If any new behavior observed document in progress notes every shift for depression/medication. Surveyor noted during the months of December 2023, January 2024, February 2024, and March 2024 there are no behaviors documented. The annual MDS (minimum data set) with an assessment reference date of 2/7/24 has a BIMS (brief interview mental status) score of 7 which indicates severe impairment. R1 is assessed as not having any behaviors including refusal of care. R1 is assessed as being independent for eating and rolling left to right, and requires supervision or touching assistance for toileting, & chair/bed to chair transfer. Yes is checked for does the resident use a wheelchair or scooter and is assessed as being independent with wheeling the wheelchair. R1 is assessed as being frequently incontinent of urine and always incontinent of bowel. The cognitive loss/dementia CAA (care area assessment) dated 2/9/24 under nature of the problem/condition is blank. Under care plan considerations documents cognitive loss will be addressed on the care plan. Resident has a dx (diagnosis) of dementia. Interventions in place. The nurses note dated 3/1/24, at 22:29 (10:29 a.m.), created 3/2/24 at 00:32 (12:32 a.m.), document Res was found standing over roommate grasping roommate's gown by her neck. Roommate was screaming for help as 2 CNAs (Certified Nursing Assistant) came to separate the two residents. Res was taken out of room and monitored at nurses station for behaviors. Room to be changed when res to lay down. At this time res calm and sitting at nurses station. Roommate in room and asking for snacks. Res in good spirits at this time. The psychosocial assessment dated [DATE] for Section B Mental Cognitive Status yes is answered for the question any psychosocial symptoms related to cognitive status. Under additional comments documents depression. Section C. Mood and Behavior Status for mood or behavior concerns since last assessment documents Res (Resident) acted out in physical aggression towards roommate. No is answered for is resident on any psychotropic medications and for mental health services Psychologist/other counselor involvement is checked. Under additional comments documents Res sees in house psych IPC (independent psychiatric consultant). Under Section D Psychosocial Status Check all those that apply: 1. Difficulty accepting placement and circumstances. 2. Difficulty with roommate. 3. Concerns with other Residents. 4. Concerns with Staff members. 5. Participates in Living Center Programs. 6. Pursues Independent Activities. 7. Maintains Supportive Relationships. 8. Has no Current Supportive Relationships. & 9. Grieving Loss of Loved One or Grieving Other Loss. Surveyor noted none of these are checked. Under Comments documents Res can often become agitated without warning. APNP (Advanced Practice Nurse Prescriber)-Z psych consult dated 3/6/24 under chief complaint documents f/u (follow up) Alzheimer's Dz (disease) Depression Dementia in other Dz classified elsewhere with Anxiety. Under narrative documents this is a f/u visit to assess pt meds and Dx as listed under Chief Complaint; Staff reports pt had aggressive encounter with peer - VPA (valproic acid) was started and pts (patients) separated to different rooms; At visit pt reports sleeps/eats good no pain why are you here-what do you want-am I in trouble-leave me alone. SSRI (selective serotonin reuptake inhibitor) recent GDR (gradual dose reduction). Under general appearance and manner documents pt up w/c - alert mild moody with mild anxiety - testy at visit. For thought process documents mod (moderate)-severe impoverished. Judgment and insight documents severe impairment. Mood and affect documents mild moody/mild anxiety. For major neurocognitive disorder Alzheimer's, moderate/severe, & without behavioral disturbances are circled. Under recommendations/plan of treatment documents Increase Lexapro back to 15mg (milligrams) q (every) day continue to monitor mood/anxiety - goal is to improve mood. The next nurses note Surveyor was able to locate regarding R1's behavior is dated 4/4/24. The nurses note dated 4/4/24, at 17:16 (5:16 p.m.), documents Describe Behavior/Mood: resident propelling self throughout hallway using profanity to all staff and residents. Unable to redirect, calling staff names, residents names. Was in the dining room for dinner and starting throwing meal and fluids. Refusing to take medications. Observed kicking and striking out at staff. Writer offered to call son and agreed, on the phone talking to son at this time. What was the resident doing prior to or at the time of behavior/mood: sitting in w/c (wheelchair) in common area. Interventions attempted: Redirected all shift, one on one with resident attempted but unsuccessful. Effectiveness of the interventions: Ineffective. This note was written by LPN (Licensed Practical Nurse)-T. The nurses note dated 4/4/24, at 21:23 (9:23 p.m.), documents Describe Behavior/Mood: Resident continues to use profanity at staff. Staff offered toileting, food and fluids. Resident declined all of above. Resident throwing items at peer, staff. Resident banging on windows in common area, bumping chair against wall, pushing empty w/c (wheelchair) towards staff. Unable to redirect. Resident propelling self in w/c taking items off of medication carts. Resident observed rolling in hallway B in and out of residents rooms and observed kicking door open after resident attempted to close door to keep resident out of their space. Following behind staff and calling staff names. Offered snack, but threw it at staff. What was the resident doing prior to or at the time of behavior/mood: sitting in w/c. Interventions attempted: Redirected resident not to throw items at staff or peers. Effectiveness of the interventions: Ineffective. This note was written by LPN-T. The nurses note dated 4/5/24, at 00:34 (12:34 a.m.), documents Res (Resident) remains up, belittling everyone she sees. Asked to speak to her son, so we called [Name] so she could talk to him. He will be in today. This note was written by LPN-S. The nurses note dated 4/5/24, at 05:38 (5:38 a.m.), documents Res has been up all night. Talking constantly!! Res is belligerent, condescending, sarcastic, downright nasty with her comments. She goes to each one of us, then to any other residents who are up. We are stupid, ugly, nasty, smell, etc., not worth her time. She is pushing carts around, chairs, throwing med (medication) cups on the floor and blaming us. Res refused morning Thyroid med, stating You don't know what you are doing, I wouldn't take anything from you!. This note was written by LPN-S. The nurses note dated 4/5/24, at 10:15 (10:15 a.m.), documents Late entry for 4/4/24, 0600-1400 (6:00 a.m.-2:00 p.m.) shift: resident refused to eat breakfast. Continued with verbal aggression: insulting staff and students calling to son of b_tch, ugly fat, liars etc. Also threatened to hit staff. Continues to wander up and down halls. This note was written by LPN-U. The nurses note dated 4/5/24, at 10:18 (10:18 a.m.), documents Resident continues to verbally abuse staff: called several staff members and students b__ches because staff tried redirecting her from leaving the unit. Resident scratch staff member on her arms during the redirecting process. Increase supervision provided Refused morning medications x (times) 3. Message left for [Name] NP (Nurse Practitioner). Per shift to shift report, resident son and MPOA (medical power of attorney) aware and will visit resident today. This note was written by LPN-U. The nurses note dated 4/5/24, at 12:37 (12:37 p.m.), documents Staff tried multiple times to administer medications. Son/NP aware resident continues to refuse medications. This note was written by LPN-U. The nurses note dated 4/6/24, at 20:36 (8:36 p.m.), documents Resident up calling staff names, using profanity, pushing over chairs, kicking medication cart. Resident rolling throughout hallway screaming, nobody is sleeping tonight. Resident kicked open door while male peer was undressed and getting washed up for bed. Resident threw shoe at staff, resident threw medications on floor. Resident offered snack and then threw on floor. Resident refused meal this shift, resident in w/c antagonizing staff. Resident observed pushing empty w/c towards staff. This note was written by LPN-T. The nurses note dated 4/6/24, at 21:38 (9:38 p.m.), documents Resident ran over right foot of peer while chasing peer down the hallway. Peer then observed hitting resident due to resident running over foot. Resident observed antagonizing peer. Resident continued to follow peer and call her names. Unable to redirect behavior. Resident continued to follow peer and propel self up and down hallway turning over chairs, pulling garbage out of medication cart and throw on the floor. Resident observed standing up several times this shift and turning around with no brief on and telling staff to kiss her _ss. Unable to assist resident with putting on undergarment due to behavior. Resident at this time banging on windows in common area. This note was written by LPN-T. The administration note dated 4/7/24, at 05:55 (5:55 a.m.), documents Restless, agitated cussing, psychotic, refusing care, condescending, spiteful, mean, belligerent, throwing things around, etc. This note was written by LPN-S. The nurses note dated 4/7/24, at 06:03 (6:03 a.m.), documents Res has been up all night in w/c. Res has been belligerent, sarcastic, mean, nasty, etc with the staff. She goes from one to the other and starts over again, non stop. We are all dumb, fat smelly, lazy b_tches. Res has been throwing things from the med carts, tearing up paper, pounding on the windows, throwing offered snacks and water on the floor. Res. going up and down halls, singing, wondering why no one was up. Needing to be removed from other rooms at times. Writer attempted to do pain assessment, but res uncooperative. Also uncooperative with skin assessment, although she did show me her _ss and stated I could kiss it. Res has red scratches on both buttocks, not new. Res nodded off about 20 minutes in w/c. Refused AM (morning) Synthroid med. This note was written by LPN-S. The nurses note dated 4/7/24, at 13:13 (1:13 p.m.), documents Resident is 15 min (minute) checks 2 shift she is very verbal name calling writer got order for CBC (complete blood count) UA/C&S (urinalysis/culture and sensitivity) urine (urine) picked up 4/7/24 at about 12:30. CBC will be drawn 4/8/24. This note was written by LPN-N. The nurses note dated 4/7/24, at 15:36 (3:36 p.m.), documents Resident hurt her elbow on the head board while failing her arms and hit her left elbow on heard sic (head) board while writer was attempting to straight cath (catheter) her while staff helped, she c/o (complained of) pain to the area writer called on call [medical group name] Doc (doctor) or nurse practitioner she stated give some resident Tylenol. This note was written by LPN-N. The nurses note dated 4/7/24, at 18:15 (6:15 p.m.), documents Resident continues to verbally abuse staff and residents. Resident continues to call staff fat _sses and b_tches. Resident continues to call other residents dumb_sses. Staff has attempted to redirect resident multiple times. Resident continues to harass residents and staff nonstop. This note was written by LPN-V. The psychosocial assessment dated [DATE] for Section B Mental Cognitive Status yes is answered for the question any psychosocial symptoms related to cognitive status. Under additional comments documents BIMS: 7 Resident diagnosed with Dementia and Alzheimer's Disease. Section C Mood and Behavior Status for 1. Mood or Behavior concerns since last assessment documents Resident sometimes acts out in physical aggression and swears at other residents and staff members. Resident can become agitated at times and confused. Resident recently had an altercation with another resident. For the question is resident on any psychotropic medications yes is answered. If yes to psychotropic medications, list psychotropic medications and target behaviors documents Escitalopram Oxalate Tablet Depakote Tablet Target Behavior 3: Depression/Sadness Intervention #1: Redirect as able. Intervention #2 One on one conversation. Intervention #3 Offer appropriate activities. For the statement if yes to psychotropic medication list resident non-pharmacological interventions utilized documents Non-pharm interventions for behaviors: 1. Address in a calm manner. 2. Attempt to orientate to place and time. 3. Allow resident to express feelings or frustrations and provide reassurance as needed. 4. Provide assistance as needed. 5. Family visits. 6. Offer activities of choice. 7. Provide emotional support to resident as needed. 8. Offer to close door and curtains to facilitate sleep. For mental health services Psychologist/other counselor involvement is checked. Under additional comments documents Resident is seen by psych in facility. Under Psychosocial Status the following are checked: 1. Difficulty accepting placement and circumstances. 3. Concerns with other residents. 4. Concerns with staff members. 5. Participates in Living Center Programs. 6. Pursues independent activities. and 7. Maintains supportive relationships. Under Comments documents Resident recently had altercation with peer. Resident observed by staff using foul language and calling staff/residents derogatory names. Staff attempted to redirect resident, but resident proceeded to approach peer which caused peer to become upset. Resident ran over peers toe with wheelchair and staff witnessed peer striking resident. Staff separated residents and continued to monitor. Writer followed up with resident today, who stated she has no concerns. DON (Director of Nursing), psych NP, and family notified. The change of condition note dated 4/8/24, at 00:33 (12:33 a.m.), documents Situation: Left elbow painful, shiny brown and swollen. Right foot, middle toe, purpose, painful when moved. Urinalysis positive, C&S pending. Background: Res with behavior issues since Thursday, Verbally abusive towards staff and residents, physical at times. Assessment (RN) (Registered Nurse)/Appearance (LPN): Res up again at start of night shift, belligerent, complaining. Finally stated she was tired. CNA (Certified Nursing Assistant) helped her to bed. Noted elbow, res crying, limited ROM (range of motion), brown in color, swollen. Tylenol given and ice applied. Further investigation, bruising on arms from holding for straight cathing, tender. Noted right foot middle toe is purple, pain with PROM (passive range of motion). Recommendations: 0030 (12:30 a.m.) On call for [medical group name], [Name] aware. New order for X-ray of elbow in AM (morning), cont (continue) to monitor toe, wait for C&S results. Response: [Medical group name] on call [Name] updated. Res calm at this time, remaining in bed. The nurses note dated 4/8/24, at 23:13 (11:13 p.m.), documents D/T (due to) res increased aggressive behaviors with dementia, [Name] Psych NP increased her Depakote to 250 mg (milligrams) BID (twice daily). Nursing to monitor. This note was written by DON (Director of Nursing)-B. The nurses note dated 4/9/24, at 10:08 (10:08 a.m.), documents Writer updated POA with X-ray results indicating there is a fracture of the proximal ulna. POA would like resident to have a follow up/consult with ortho but unsure at this time if wanting surgical intervention if indicated. NP also made aware of results and NOR (new order received) to set up a consult with ortho. Will continue to monitor. This note was written by RN/ADON (Registered Nurse/Assistant Director of Nursing)-O. The nurses note dated 4/10/24, at 02:40 (2:40 a.m.), documents Pt (patient) with fracture to proximal ulna. Pt propelling self about unit for a couple hours using both arms. No c/o pain or discomfort. Pt with sensitivity pending on urine culture. No c/o dysuria. Pt was verbally hostile towards staff calling staff, stupid and lazy. Multiple attempts to redirect pt to her bedroom. About 2am pt finally went to bed. This note was written by RN-Y. The nurses note dated 4/11/24, at 05:53 (5:53 a.m.), documents Res has remained in bed this night shift. She is still being verbally belligerent, stated to writer to leave, she does not have nor never has had a urinary infection. You don't know what you're talking about. Res did take abt (antibiotic) and thyroid med earlier this AM when half asleep. Left arm remains bruised, elbow area swollen. Grimaces with movement. Denied need for meds. No new issues. This note was written by LPN-S. The nurses note dated 4/11/24, at 22:36 (10:36 p.m.), documents Resident alert and responsive. Resident refused cares, meds, and vital signs this PM shift. Resident strike out at writer after attempting to assess vital signs. This note was written by LPN-X. The administration note dated 4/12/24, at 01:15 (1:15 a.m.), documents agitation. This note was written by LPN-S. The administration note dated 4/12/24, at 01:16 (1:16 a.m.), documents restless, cussing, slurs, psychosis, aggression, refusing cares. The nurses note dated 4/12/24, at 06:24 (6:24 a.m.), documents Res has remained up in w/c, at desk, the entire night shift. Res has been talking non-stop to staff, or no-one, or Buddy about whatever is on her mind. How incompetent we are, dumb, fat, smelly, anything derogatory she can think of, over and over again. Refused cares, finally take water. Does not live here so she would not go to bed or lie down. Wanted to speak with the police. She would scream if we asked her to go away from the desk or be quiet. Refused AM med and offered analgesic. This note was written by LPN-S. R1 was discharged to the hospital on 4/16/24 for altered mental status and returned during the afternoon on 4/23/24. The hospital discharge summary dated 4/23/24 under the Admission Information section documents Reason for Admission: Closed Fracture of olecranon process of left ulna, initial encounter [S52.022A], Urinary tract infection without hematuria, site unspecified [N39.0] Dementia with agitation, unspecified dementia severity, unspecified dementia type (CMD) [F03.911]. Under hospital course documents [R1's name, sex and age] with past medical history significant for CAD (coronary artery disease), sinus bradycardia, hypothyroidism, depression, Alzheimer's dementia who is living in nursing home and noted having more encephalopathic/combative than her usual. In the outpatient setting the patient had fallen, however there are inconsistent reports of the nature of the fall. Recently urine sample consistent with infection/UTI (urinary tract infection) and combative per the staff/son which is not her usual, and out of concern for recent fall as well as the concern of not receiving the appropriate medication, son brought her to ED (emergency department) at [Hospital name] . On 4/22/24 at 10:56 a.m. Surveyor spoke with NP (Nurse Practitioner)-CC regarding R1. NP-CC informed Surveyor R1 was confused, refused cares & medication, had behavior problems with psych involved. NP-CC informed Surveyor she was trying to get R1 to take her medication. Surveyor inquired when she was informed of R1's behaviors. NP-CC informed Surveyor she didn't know when but was aware. Surveyor asked NP-CC if she was notified of R1 refusing her medication. NP-CC replied yes, I was notified. NP-CC explained nursing would call her or would let her know when she was in the facility. NP-CC informed Surveyor some nurses were able to give R1 her medication and some weren't. Surveyor inquired when the last time she was notified of R1's medication refusals. NP-CC was unable to provide Surveyor the last time she was notified. Surveyor asked NP-CC about R1's fracture. NP-CC informed Surveyor RN/ADON-O informed her they were trying to straight cath R1 and R1 hit her elbow. NP-CC indicated she can't remember if it was on the wall or headboard of the bed. NP-CC informed Surveyor they got an X-ray and had an ortho appointment which R1 refused to go to. Surveyor asked NP-CC when was the last time she saw R1. NP-CC informed Surveyor 4/15. Surveyor asked NP-CC if she examined R1. NP-CC informed Surveyor she kind of went in she was trying to get R1's antibiotic switched. On 4/22/24, at 11:08 a.m., Surveyor asked CNA (Certified Nursing Assistant)-P to tell Surveyor about R1. CNA-P informed Surveyor before R1 went to the hospital she was acting anxious, had behaviors, was feisty, screaming out, cursing, getting up out of her chair & walking around. Surveyor asked CNA-P if she could redirect R1. CNA-P replied no. Surveyor informed CNA-P Surveyor had noted R1 was straight cath on 4/7/24 and asked if she was there during this. CNA-P informed Surveyor she and another CNA (CNA-M) tried helping R1 in getting R1 into bed. CNA-P explained she let R1 know the nurse was going to straight cath her. Surveyor inquired who the nurse was. CNA-P informed Surveyor the first name of LPN (Licensed Practical Nurse)-N. Surveyor asked if R1 let them put her in bed. CNA-P informed Surveyor she was feisty at first then calmed down. Surveyor asked CNA-P what she meant by being feisty. CNA-P replied yelling & screaming. CNA-P explained they let R1 know it was for her own good. CNA-P explained LPN-N tried putting the catheter in but couldn't get it. We had to try to redirect R1 and after she calmed down she told us to hurry up. CNA-P informed Surveyor LPN-N tried again to get the urine, R1's arm swung, hit the head board it was like a loud boom. LPN-N asked R1 if she could move her arm which R1 was able to. CNA-P indicated LPN-N never got the urine, they cleaned R1 and took R1 to the toilet. CNA-P informed Surveyor there was a hat in the toilet and they were able to get the urine. Surveyor asked while LPN-N was trying to straight cath R1 where was she. CNA-P informed Surveyor she was on one side of R1 and CNA-M was on the other side and they both were holding R1's arms so she wouldn't swing, she was like fighting. Surveyor asked CNA-P why they had to hold R1's arms. CNA-P informed Surveyor R1 was fighting & swinging. Surveyor asked CNA-P if she was ever involved with R1 being straight cath before. CNA-P replied no and explained R1 wasn't on her side. Surveyor asked CNA-P if she knew why R1 was fighting them. CNA-P replied no cause she normally not like that, normally a sweet little lady. On 4/22/24, at 12:09 p.m., Surveyor spoke with LPN-N on the telephone. Surveyor asked LPN-N what he could tell Surveyor about R1. LPN-N informed Surveyor R1 was confused, in a wheelchair and would roll around, talk with other residents & staff sometimes would say bad stuff other times good never would know what R1 was going to say. R1 recently had a UTI, at one time was taking her medications and then didn't take them. LPN-N explained when he came back from work R1 was diagnosed with a UTI, had me wondering if had a UTI as sometimes act normal then R1 got worse and went to the hospital. Surveyor asked LPN-N if he straight cathed R1. LPN-N informed Surveyor the names of CNA-M, CNA-P and CNA-Q. LPN-N informed Surveyor he told R1 okay [first name of R1] going to straight cath you and told her he had to do the procedure. LPN-N informed Surveyor he attempted to straight cath her and R1 was saying a bunch of stuff. LPN-N informed Surveyor no one was really holding her down because that's how she hit her arm. LPN-N informed Surveyor they had to hold her legs open but couldn't get it. LPN-N informed Surveyor he said lets put her on the toilet. They put R1 on the toilet, turned on the water and R1 said going to put on the water so I can pee. LPN-N informed Surveyor they were able to get the urine sample. Surveyor asked LPN-N if the CNAs had their hands on R1's arms. LPN-N replied no they weren't forcing her, R1 knew what they were going to do. They weren't holding her down that's why she hit her elbow if they were holding her down she wouldn't have been able to hit her elbow. Sometimes during the procedure she wasn't cooperative and other times she was. Sometimes she was kicking her legs and saying all kinds of stuff. Surveyor asked LPN-N how many times he attempted to straight cath R1 before placing her on the toilet. LPN-N informed Surveyor 3 or 4 times and was surprised he couldn't get R1's urine. LPN-N informed Surveyor he called DON (Director of Nursing)-B and [name of medical group] after R1 hit her elbow. On 4/22/24, at 1:20 p.m., Surveyor spoke with CNA-Q regarding R1. CNA-Q informed Surveyor R1 was a very sweet lady, has moods, gets depressed & sad, looking for her husband and son. Surveyor inquired if R1 had any behaviors. CNA-Q replied not on everyday basis. CNA-Q explained R1 stopped taking her medication, was hitting & fighting. CNA-Q informed Surveyor she thought R1's behavior was happening more frequently and she spoke with the night nurse who told her R1 was not sleeping, not taking her medication, stopped eating, and thought they were trying to kill her. Surveyor asked CNA-Q when R1 was having her episodes of behavior could she redirect R1. CNA-Q replied no and explained would get worse and call her fat a_s. CNA-Q informed Surveyor she would ask R1 what was wrong, if she wanted to talk with her son or if she was in pain. CNA-Q informed Surveyor R1's behavior just got worse & worse. Surveyor asked CNA-Q if she was working when R1 was straight cathed on 4/7/24. CNA-Q replied no was off that day. On 4/23/24, at 8:46 a.m., Surveyor spoke with CNA-M regarding R1. CNA-M informed Surveyor before R1 got sick she was a nice lady. They said she had an UTI. [TRUNCATED]

Based on observation, interview, and record review, the facility did not ensure 1(R2) of 1 Resident was as free of accident hazards as is possible and that R2 received adequate supervision and assistance devices to prevent accidents, resulting in a fall from bed *On [DATE] at approximately 1:07 PM, R2 was found on the floor next to R2's bed on the right side unresponsive and with no pulse. The medical examiner's (ME) preliminary autopsy report dated [DATE] documents that R2 suffered possible positional asphyxia, small epidural hemorrhage of spinal cord and hemorrhage of posterior right neck soft tissue which resulted in R2's death. The report documents that R2 was found lying prone on the floor of R2's room upon first observation of the ME. R2's head was tucked under R2's chest and was bent at an extreme angle. The weight of R2's upper body was on R2's head. R2's Kardex and comprehensive care plan documented that R2 required to be in a low bed due to being a fall risk. Based on interviews and police body camera images, R2's bed was not in the low position and the head of the bed was elevated at ,d+[DATE] degrees or more at the time of the incident. Surveyor notes that several staff members knew R2 leaned to the right when in bed. Surveyor was informed that R2 had no trunk support so if leaning to the right, R2 would have been unable to re-position R2's self or stop from rolling. Surveyor notes that there were no interventions put into place to create a barrier so R2 would be less likely to roll out of bed. Staff were aware that R2 was to be in a low bed, but needed it elevated to watch television which R2 liked to do. Surveyor notes there was no environmental adjustments with positioning and level of R2's television so R2 could safely watch television. Failure to follow the care plan and to provide an environment that was free of accident hazards based on R2's positioning needs created a finding of Immediate Jeopardy (IJ), which began on [DATE]. NHA (Nursing Home Administrator)-A , DON (Director of Nursing)-B were notified of the immediate jeopardy on [DATE] at 12:55 P.M. The immediate jeopardy was removed on [DATE]. However, the deficient practice continues at a severity/scope level of an E as the facility continues to implement their action plan. Findings Include: Surveyor reviewed the facility's Fall Prevention and Management Guidelines reviewed/revised [DATE] policy and procedure provided on [DATE] at 1:48 PM and notes the following applicable: Policy: Each Resident will be assessed for fall risk and will receive care and services in accordance with their individualized plan of care to minimize the likelihood of falls to reduce the possibility/severity of injury. Policy Explanation and Compliance Guidelines: 1. The facility utilizes a standardized risk assessment for determining a Resident's fall risk. 2. Upon admission, the nurse will complete a fall risk assessment. a. Review the Resident's medical record for any diagnosis that may contribute to an increase in fall risk. The list of common diagnosis applicable to R2 include Dementia, Atrial Fibrillation, Cerebrovascular Accident (CVA) 3. The nurse will initiate interventions to help prevent falls on the Resident's baseline care plan. 4. Suggested standard interventions may include: a. Implement universal environmental interventions that decrease the risk of Resident falling, including, but not limited to: a. Implement universal environmental interventions that decrease the risk of Resident falling, including, but not limited to: i. A clear pathway to the bathroom and bedroom doors. ii. Bed is locked and lowered to a level that allows the Resident's feet to be flat on the floor when the Resident is sitting on the edge of the bed. iii. Call light and frequently used items are within reach. iv. Adequate lighting. v. Wheelchairs and assistive devices are in good repair. b. Implement routine rounding schedule. c. Monitor for changes in Resident's cognition, gait, ability to rise/sit, and balance. d. Encourage Residents to wear shoes or slippers with non-slip soles when ambulating. e. Ensure eyeglasses, if applicable, are clean and the Resident wears them when ambulating. f. Monitor vital signs in accordance with facility policy. g. Complete a fall risk assessment quarterly, post-fall, and as with a significant change of condition. 5. Suggested interventions for Residents determined to be at higher risk for falls may include: a. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. b. Provide additional interventions as directed by the Resident's assessment and based on input from the Resident or family members, including but not limited to: i. Assistive devices ii. Increased frequency of rounds iii. Increased supervision, if indicated iv. Medication regiment review v. Low bed vi. Alternate call system access vii. Scheduled ambulation or toileting assistance viii. Family/caregiver or Resident education ix. Therapy services referral x. Scheduled rest periods xi. Environmental modifications(s) including furniture, e.g. recliners. 6. Each Resident's risk factors and environmental hazards will be evaluated when developing the Resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed and should be communicated to the staff, Resident, and Resident's family/responsible party. R2 was admitted to the facility on [DATE] with diagnoses of Hypertensive Heart Disease, Type 2 Diabetes Mellitus, Anemia, Chronic Atrial Fibrillation, and Vascular Dementia, Moderate with Mood Disturbance. R2 was her own person while at the facility. On [DATE], R2 discharged to the hospital with a UTI (urinary tract infection). R2 returned to the facility on [DATE] with a diagnosis of Sepsis. A Brief Interview for Mental Status (BIMS) was completed on [DATE] upon return from the hospital. R2 scored an 8 indicating R2 demonstrated moderately impaired skills for daily decision making. Surveyor reviewed R2's most recent quarterly Minimum Data Set (MDS) dated [DATE]. R2's BIMS was a 3 indicating R2 was demonstrating severely impaired skills for daily decision making. R2's MDS documented no behaviors. The following is documented for R2's level of physical assistance: Upper dressing-substantial/maximum assist Lower dressing-dependent Left to Right roll in bed-substantial/maximum assist Lying to sitting-dependent Transfers-dependent R2's Usual/Customary Functional IDT Summary-Discharge assessment dated [DATE] documents that R2 required the following physical assistance: Mobility- Substantial/Maximum Assist Sit to lying-Dependent Transfers-dependent Eating-set-up R2's Readmission Evaluation assessment dated [DATE] documents that R2 now required the following physical assistance: Bed Mobility-Total assist of 2-staff uses muscle-R2 does not help Transfers-total assist of 2- staff uses muscle-resident does not help Eating-extensive assist of 1-staff uses muscle-resident helps Ability to change and control body position-completely immobile-does not make even slight changes in body or extremity position but unable to make frequent or significant changes independently. R2's Kardex dated [DATE] documents that R2 was an assist of 1. R2 required a hoyer lift for transfers. The Kardex documents bed in low position and was a fall risk. R2 required assist of 1 for personal hygiene and to turn and reposition R2 every,d+[DATE] hours when in bed. R2 was assist of 2 for bathing/showering and was assist of 1 for toileting. R2 was set up for eating. R2's comprehensive care plan had the following focused problems: 1. At risk for falls due to decreased mobility-Initiated [DATE] Interventions all on [DATE] -bed in low position -encourage to transfer and change positions slowly -fall risk -have commonly used articles within easy reach -reinforce need to call for assistance 2. ADL self-care deficit as evidenced by: weakness related to:CVA-Initiated [DATE] Interventions all on [DATE] -ambulation/locomotion: with device wheelchair -bathing showering: assist of 2 -bed mobility: assist of 1 -personal hygiene-assist of 1 -toileting: assist of 1 -transfer: mechanical lift xlarge sling 3. At risk for loss of range of motion due to prior CVA-Initiated [DATE] Interventions established on [DATE]: -administer analgesia per physician's orders -therapy evaluation and treatment as ordered. Surveyor notes that R2 had an alternating pressure reducing mattress. Surveyor notes that physician orders dated [DATE] upon return from hospital document R2 was to have an evaluation and treat as indicated for physical therapy, occupational therapy, and speech therapy. This evaluation did not occur. Surveyor reviewed the initial (Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report) facility reported incident dated [DATE] at 2:50 PM and the Misconduct Incident Report dated [DATE] at 3:38 P.M for R2 falling out of bed. The facility documents R2 was found on [DATE] at approximately 1:07 PM unresponsive and no pulse. The facility indicates the alternating air mattress was functioning correctly, there were no siderails or repositioning bars on the bed, and bed was in low position. The facility provided a timeline of events leading up to R2's death on [DATE]. The following is documentation of the timeline, and interviews obtained by Surveyor during the survey process. At 7:15 AM, Housekeeper (House-C) entered R2's room and observed R2 sleeping in bed per facility documentation. On [DATE] at 11:00 AM, Surveyor interviewed House-C over the phone. House-C stated House-C was in R2's room cleaning for about 15 minutes. House-C stated that R2 was in the middle of the bed, on R2's back like always. House-C stated R2 was in a low bed like usual and was sound asleep. Between ,d+[DATE] AM, Certified Nursing Assistant (CNA-D) per facility documentation, entered the room and noted R2 seemed to be confused and was making statements about being robbed and waiting two hours for the police. CNA-D provided reassurance to R2 and reported R2's confusion to Licensed Practical Nurse (LPN-E). LPN-E received orders to obtain a UA, CBC, and BMP. On [DATE] at 11:35 AM, Surveyor interviewed CNA-D. CNA-D described R2 as quiet and a little stand offish. CNA-D stated that R2 did not move much. CNA-D stated R2 was a full assist with cares and mobility requiring 2 person assist. CNA-D informed Surveyor that R2 would frequently lean to the right side and would need to be repositioned. CNA-D stated that R2 never got out of bed per R2's choice and was alert to R2's needs. CNA-D stated that R2 had no bars on the bed and no mat on the floor next to the bed. CNA-D stated R2's bed was to be in the low position at all times. CNA-D stated the morning of [DATE], R2 was confused saying someone had robbed R2 and kept looking at the wall. CNA-D stated R2 appeared to be more confused than usual. CNA-D helped R2's roommate and told LPN-E about R2's confusion. CNA-D stated R2 was in a low bed and lying flat at this time. CNA-D confirmed that CNA-D responded to R2's incident. CNA-D observed R2 on the floor, R2's head was under R2's body. CNA-D stated the bed was at an angle and does not recall if the head of the bed was elevated. At 9:00 AM, LPN-E collected urine from R2's clean foley catheter bag and was noted to be sleeping in bed per facility documentation. At 11:00 AM, LPN-E and lab tech entered R2's room to obtain the blood samples for the labs that were ordered per facility documentation. On [DATE] at 9:17 AM, Surveyor interviewed LPN-E. LPN-E stated that R2 was confused and seeing things. Made delusional statements that men were chasing R2. LPN-E notified the physician on call and was instructed to get labs. LPN-E went to change the foley catheter bag to get clean urine. Collected the urine and gave R2 morning medications. About ,d+[DATE] hour later the lab came. The lab technician stated that R2 was not able to identify who R2 was so requested LPN-E go to the room with LPN-E to identify R2. LPN-E informed Surveyor that LPN-E verified it was R2 and left the room, not staying with the lab technician. LPN-E stated that after R2 was deceased , towards the end of LPN-E's shift is when LPN-E learned that the lab technician was not able to obtain the labs. LPN-E stated the lab technician alleges they told LPN-E but LPN-E does not remember this. LPN-E states LPN-E realized when another lab technician showed up later to obtain the labs. LPN-E stated that LPN-E observed R2 in bed, R2's right leg was hanging off of the bed. LPN-E stated that R2 would consistently lean to the right always. LPN-E stated that R2 was to be in a low bed and remembers R2's bed was elevated on [DATE]. LPN-E stated that R2 was confused that day, and who knows why R2 fell out of bed. At 11:00 AM, Activities Aide (ACT-G) entered the room to invite R2's roommate to church per facility documentation. On [DATE] at 1:20 PM, Surveyor interviewed ACT-G. ACT-G talked to R2's roommate and invited R2's roommate(R6) to church. ACT-G stated R2 was observed in bed flat, sleeping. ACT-G stated that R2's head of bed was not elevated and R2's bed was in a regular position, not a low bed. ACT-G thought the bed was parallel to the wall. ACT-G states ACT-G was in the room at 10:45 AM because church started at 11:00 AM. Surveyor notes that there is probability that the time of lab draw may not be accurate. At 12:30 PM, R2's roommate(R6) left the room to go to the dining room. A CNA had overheard R6 complaining about R2's behaviors and the CNA informed LPN-E. Staff were instructed to keep an eye on both. On [DATE] at 3:27 PM, Surveyor interviewed R2's roommate(R6). R6 stated R2's bed was against the wall and that R2 would always lean over to the right side. R6 stated R6 would always get help to reposition R2. R6 stated that R2 never moved. R6 stated R2 and R6 got along well. R6 stated the call light was never within reach of R2 so R6 would frequently get things for R2. R6 stated on [DATE], R6 recalls R2's bed being elevated but nothing else. Surveyor notes that R6's [DATE] quarterly MDS documents R6's BIMS to be a 15, indicating R6 is cognitively intact for decision making. The facility's timeline documents at 1:07 PM, CNA-F was passing meal trays and entered R2's room. CNA-F found R2 on the floor and immediately called for help. LPN-E responded first and called 911. R2 was noted to have apparent head/neck injury and was pulseless. Registered Nurse (RN-K) also responded. RN-K confirmed R2 was breathless and pulseless. On [DATE] at 12:48 PM, Surveyor interviewed CNA-F. CNA-F stated CNA-F did not take care of R2 on a regular basis but knew R2 was immobile and rarely moved. CNA-F stated that R2 never got out of bed. R2 would move R2's arms only and would feed R2's self. CNA-F stated that R2 was in a low bed with no bars. CNA-F stated that R2 did not use the bed remote and would like to lay flat. CNA-F stated the morning of [DATE], R2 did not appear to be in any distress. CNA-F provided cares about 10:00 AM on [DATE]. CNA-F stated CNA-F provided cares and did not have the assistance of any other caregivers. CNA-F was informed of the alleged roommate problem. CNA-F stated CNA-F went to give R2, R2's lunch tray and found R2 on the floor on the right side of the bed. CNA-F stated CNA-F could not find R2's head, looked like it was lost. CNA-F stated the bed at this time was not in low position and the head of the bed was elevated. CNA-F confirmed the air mattress was working. CNA-F informed Surveyor, I don't understand how this happened, especially if R2 doesn't move. CNA-F stated, never seen anything like this. The facility's summary provided by the facility only concludes there was no misconduct but does not give information that may establish what happened or why. Surveyor notes the interviews provided in the facility self report do not ask important questions like, exactly what did you do for R2, what did R2 say, what was the height of the bed when you saw R2, was the head of the bed elevated, was the call light within reach, were R2's items within reach. On [DATE] at 3:05 PM, the survey team met with Administrator (NHA-A) and Director of Nursing (DON-B). DON-B stated that caregivers would heighten a low bed to do cares. DON-B described a low bed as being close to the ground. NHA-A informed Surveyor that the facility cameras have not been working for about a month. Surveyor obtained other pertinent interviews in regard to R2's incident. On [DATE] at 1:50 PM, Unit Manager (UM-H) stated that R2 liked to lay in bed and watch TV. R2's bed was angled in the room. R2 could not sit up on own or move head. R2 could not move self in bed. UM-H stated that R2 was in a low bed meaning the bed should be lowest to the ground. UM-H stated R2 would lean more to the right side. UM-H indicated that R2's bed would be elevated to ,d+[DATE] degree angle when eating meals. UM-H stated that if R2 was flat R2 would not be able to see the television which R2 liked to do. UM-H stated that after R2's hospitalization from [DATE]-[DATE], R2 was more tired. UM-H was in shock to hear that R2 had rolled out of bed, On [DATE] at 7:45 AM, physical therapist (PT-I) stated that R2 had no range of motion (ROM) in both lower extremities. PI-I stated that R2's legs were stuck in a straight position. PT-I stated that R2 could not tolerate sitting. PT-I stated R2 had difficulty rolling side to side. PT-I talked about pillows and relied on R2 to educate the staff in regard to pillows. PT-I stated R2 was a fall risk due to lack of mobility. PT-I confirmed R2 had the potential to lean to 1 side or the other, most likely due to being weak. PT-I stated R2 was a heavy log roll and had no activation in legs. PT-I described R2 to be very rigid and stiff and very little activation in arms. PT-I stated would typically have 2 people if helping with changing R2. PT-I informed Surveyor that R2 was a potential for fall risk if elevated in bed because of no strength. PT-I confirmed that therapy did not evaluate or screen R2 upon return from hospital on [DATE] despite having physician orders to be evaluated and treated as indicated for physical, occupational, and speech therapy. On [DATE] at 8:25 AM, Surveyor interviewed LPN-J who is familiar with R2. LPN-J stated R2 barely got out bed and needed a lot of assistance. LPN-J stated, for some, 2 would assist with cares for R2. LPN- J stated R2 would frequently lean to the right side often. LPN-J stated R2's bed should be at low level. LPN-J stated, It was a surprise that R2 fell out bed. LPN-J stated maybe R2 rolled out of bed because the head of the bed was elevated and R2 didn't have upper body strength. On [DATE] at 9:56 AM, Surveyor interviewed RN-K who responded to the incident of R2 on [DATE]. RN-K stated R2 was in the corner between the wall and the bed. RN-K stated R2's bed was at a slant. When RN-K responded, RN-K observed R2's bed was at regular height and elevated ,d+[DATE] degrees. RN-K stated R2's head was tucked under R2's body. RN-K stated, Never want to see that again. It was very unnatural looking, freaky. R2's neck was clearly broken. Surveyor had RN-K set up R2's room as RN-K observed it on [DATE]. R2's bed was at an angle and the head of the bed was in the corner where the 2 walls meet. R2's TV was high on a armoire stand across from the bed. The bedside dresser was on the left of the bed. Surveyor notes that in all the interviews obtained, nobody was able to recall where the over bedside table was. Surveyor reviewed the documented police report dated [DATE]. Surveyor was also able to obtain the police body camera images. Surveyor viewed these images on [DATE] and notes the most remarkable images: -The first image is audio and you can hear someone say, oh shit, now I see it as the sheet is pulled off of R2. To the left of the screen, you can see the height of the bed which is clearly not in a low position and the head of the bed is elevated. -The 2nd, 3rd, and 6th image you can see the height of the bed and that it is elevated at the head, and not in a low position. -7th image- You can't see R2's head, R2 is close up against the wall, right arm at side, palm up. -8th image-You can't see R2's head. -11th image-You can see the space between the bed and the height of the bed. On [DATE] at 10:22 AM, Surveyor spoke to the Medical Examiner (ME-L) over the phone. ME-L stated an autopsy was completed and the final report is pending toxicology results. ME-L informed Surveyor that R2 died from positional asphyxiation, small epidural hemorrhage of spinal cord, and hemorrhage of posterior right neck. Surveyor received the ME documented report on [DATE]. The report documents the following: R2 was found lying prone on the floor of R2's room upon first observation of the ME. R2's head was tucked under R2's chest and was bent at an extreme angle. The weight of R2's upper body was on R2's head. Contusions were noted to R2's anterior left arm near the antecubital fossa. Faint blanching purple-colored lividity was noted to R2's shoulders and forehead. R2's left eye was injected. The report also documents that the headboard of the bed was flush with the walls that formed the corner of the bedroom. R2 was lying on the floor parallel to the edge of the bed. R2's bed was measured to be 30 inches off the ground. Surveyor notes that several staff members knew R2 leaned to the right when in bed. Surveyor was informed that R2 had no trunk support so if leaning to the right, R2 would have been unable to re-position R2's self or stop from rolling. Surveyor notes that there were no interventions put into place to create a barrier so R2 would be less likely to roll out of bed. Staff were aware that R2 was to be in a low bed, but needed it elevated to watch television which R2 liked to do. Surveyor notes there was no environmental adjustments with positioning and level of R2's television so R2 could safely watch television. Surveyor also notes that R2 was being provided cares by 1 or 2 caregivers but was not consistently either way. DON-B stated the safest way to provide cares to R2 was a 2 person assist. On [DATE] at 9:07 AM, Surveyor asked CNA-M to demonstrate what a bed would like if a Resident's Kardex read low bed. CNA-M stated if there is a mat listed, the bed is put to the lowest to the floor. If a Resident does not need a mat, then CNA-M raised the bed. CNA-M demonstrated the level of the bed. Surveyor measured about 7 inches from the ground. On [DATE] at 10:10 AM, Surveyor had CNA-D demonstrate for Surveyor where a low bed should be. CNA-D stated for a low bed it goes all the way down to the ground right before the wheels touch the ground and demonstrated this for Surveyor. When the wheels drop the bed rolls easily. Surveyor asked CNA-D if everyone knows how to put a bed in low position. CNA-D stated, I assume if they are a CNA. On [DATE] at 2:27 PM, Surveyor had DON-B show Surveyor an alternating pressure mattress like what R2 had. Surveyor observed the bed the mattress was on and asked DON-B if this was what DON-B would consider a low bed. DON-B confirmed the bed was in a low position. Surveyor measured approximately 11 inches from ground. Surveyor notes that the facility does not have a standard practice for what level from the ground is considered a low bed. Surveyor was shown from approximately 7 to 11 inches from ground for a low bed. Surveyor notes ME-L's written report documents the bed was measured at 30 inches. On [DATE] at 2:06 PM, Surveyor shared the serious concern of R2 falling out of bed which resulted in death with NHA-A and DON-B. Surveyor interviewed DON-B and asked what type of assistance did R2 require. DON-B stated that the CNAs would usually do 2 assist due to R2's weight. DON-B stated that would be the safest way to provide cares to R2. DON-B confirmed that R2 required a low bed. Surveyor shared the concern that the facility investigation summary did not indicate specific aspects of the bed as it looked on [DATE]. DON-B shared that R2 had to have the bed in a certain position to watch television. The facility stated they don't know what caused R2 to roll out of bed, but maybe it was R2's urinary tract infection or some other medical issue. No further information was provided by the facility at this time. Facility failure to address the positioning needs of R2 given that R2 would often lean to the right and given that R2 could not see the TV if lying flat and its failure to ensure that R2's bed was in the low position on [DATE] created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The facility removed the jeopardy on [DATE] when the facility implemented the following: Nursing staff will receive re-education on the Fall prevention and Management Guideline Policy. Education will include but is not limited to: - Each resident's risk factors will be evaluated when developing an individualized plan of care - Interventions will be monitored for effectiveness - Monitoring changes in residents condition including balance and positioning Re-education was initiated [DATE] and will continue prior to employees next shift to work. Staff will receive re-education on definition of low bed and bed in low position On [DATE] the ED, DON, and VPS reviewed the Fall Prevention and Management Guidelines policy and determined the policy identifies the compliance guidelines to provide services to minimize the likelihood of falls or reduce the possibility/severity of injury. No changes were required. Nursing management will re-evaluate residents with a care plan for bed in low position to determine if intervention is appropriate. Care plans will be updated based on the findings of the evaluations. DON and/or designee will complete audits on new admissions 5x weekly for 4 weeks and then 3x weekly for 4 weeks to ensure resident's at risk for falls have plans of care that are individualized and implemented by staff. DON and/or Designee will review 24 Hour Nursing Report/EMR Clinical Alerts 5x weekly for 4 weeks and then 3x weekly for 4 weeks to identify residents with a change of condition resulting in the need to re-evaluate fall risk and interventions. DON and/or Designee will audit 5 Residents per week to determine if fall interventions are in place as per plan of care for 4 weeks and then 3 Residents per week for 4 weeks Results of the audits will be brought to QAPI for further review and recommendations. ADHOC QAPI held with IDT and Medical Director telephonically on [DATE].

Based on interview and record review the Facility did not ensure 1(R1) of 5 Resident's reviewed resident representative was notified when a new treatment was ordered. R1's POA (power of attorney) was not notified when a CBC (complete blood count) and urinalysis was ordered for R1 on 4/7/24. Findings include: The Change in Condition of the Resident policy last revised 9/20/22 under Policy documents A facility should immediately inform the resident; consult with the resident's physician' and notify, consistent with his or her authority, the resident representative(s) when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); or a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). Under Policy and Compliance Guidelines documents 4. Notify resident's family/responsible party as applicable and in accordance with resident's wishes. R1's diagnoses includes Alzheimer's disease, depression, anxiety disorder, and dementia. R1's power of attorney for healthcare was activated on 4/27/22. The annual MDS (minimum data set) with an assessment reference date of 2/7/24 has a BIMS (brief interview mental status) score of 7 which indicates severe impairment. The nurses note dated 4/7/24, at 13:13 (1:13 p.m.) documents Resident is 15 min (minute) checks 2 [nd] shift she is very verbal name calling writer got order for CBC (complete blood count) UA/C&S (urinalysis/culture and sensitivity) urine (urine) picked up 4/7/24 at about 12:30 CBC will be drawn 4/8/24. This note was written by LPN-N. On 4/22/24, at 4:27 p.m., Surveyor called R1's POA and asked R1's POA if he was notified the physician ordered a CBC and UA/C&S on 4/7/24 for R1. R1's POA informed Surveyor he was not informed of the CBC and only knew about the UA after the fact. R1's POA explained he found out when he was called about R1's injury. R1's POA explained he was told they had done a UA because they thought R1 might have a UTI for her behavior which made sense. R1's POA stated no didn't know about the CBC and UA after the fact. On 4/23/24, at 9:25 a.m., Surveyor met with RN/ADON (Registered Nurse/Assistant Director of Nursing)-O to discuss R1. Surveyor informed RN/ADON-O Surveyor was unable to locate when R1's POA was notified of the CBC and UA/C&S was ordered for R1 on 4/7/24. Surveyor asked RN/ADON-O to look into this and get back to Surveyor with any information regarding notification. No information was provided to Surveyor regarding notification to R1's POA.

Based on staff interviews, and record review, the facility did not ensure therapy services were provided in a timely manner for 1 Resident (R2) of 1 Resident reviewed for therapy services. *R2 was readmitted into the facility on [DATE]. R2 had physician orders dated [DATE] for evaluation and treatment as indicated and R2 was not evaluated and/or screened for speech (ST), physical (PT) therapy, and occupational (OT) therapy. R2's comprehensive care plan indicated R2 was at risk for loss of range of motion due to prior CVA (cerebral vascular accident) and the intervention established on [DATE] was for therapy evaluation and treatment as ordered. Findings Include: Surveyor was provided the facility's Rehabilitation Services Screening Policy and Procedure effective ,d+[DATE] on [DATE] at 1:48 PM and notes the following applicable to R2: Policy . The purpose of the policy is to define the process and timing of Rehabilitation Services Resident screening completion. Procedure 1. Timing: a. Routine Screens* are completed on a quarterly basis b. On Demand Screens occur as a result of a Resident change in status that may require Rehabilitation Services Intervention i. A best practice is that Rehabilitations Services staff complete On Demand screens the same day the request is received whenever clinically appropriate and no later than 48 hours during regular therapy business hours. 2. Workflow: a. Routine Screens are initiated by the Resident Care Management Director (RCDM) with the Resident name, date, reason for screen and ADL (Activities of Daily Living) index range completed and provided to the Director of Rehabilitation (DOR) on a quarterly basis. Completed Routine Screens are reviewed in the facility morning meeting with the IDT (Interdisciplinary Team) at least weekly. Surveyor requested a policy and procedure for following physician's order and/or a policy for receiving Rehabilitation Services when ordered. Nursing Home Administrator (NHA)-A stated the facility had neither policy and procedure. R2 was admitted to the facility on [DATE] with diagnoses of Hypertensive Heart Disease, Type 2 Diabetes Mellitus, Anemia, Chronic Atrial Fibrillation, and Vascular Dementia, Moderate with Mood Disturbance. R2 expired in the facility on [DATE]. R2 was her own person while at the facility. On [DATE], R2 discharged to the hospital with a UTI (Urinary Tract Infection). R2 returned to the facility on [DATE] with a diagnosis of Sepsis. A Brief Interview for Mental Status (BIMS) assessment was completed on [DATE] upon return from the hospital. R2 scored an 8 indicating R2 demonstrated moderately impaired skills for daily decision making. Surveyor reviewed R2's most recent quarterly Minimum Data Set (MDS) dated [DATE]. R2's BIMS was a 3 indicating R2 was demonstrating severely impaired skills for daily decision making. R2's MDS documented no behaviors. The following is documented for R2's level of physical assistance: -Upper extremity dressing-Substantial/maximum assist -Lower extremity dressing-Dependent -Left to Right roll in bed-substantial/maximum assist -Lying to sitting-Dependent -Transfers-Dependent R2's Usual/Customary Functional IDT Summary-Discharge assessment dated [DATE] documents R2 required the following physical assistance: -Mobility- Substantial/Maximum Assist -Sit to lying-Dependent -Transfers-Dependent -Eating-Set-up assistance R2's Readmission Evaluation assessment dated [DATE] documents R2 required the following physical assistance: -Bed Mobility-Total assist of 2-staff uses muscle-R2 does not help -Transfers-total assist of 2- staff uses muscle-resident does not help -Eating-extensive assist of 1-staff uses muscle-resident helps -Ability to change and control body position-completely immobile-does not make even slight changes in body or extremity position but unable to make frequent or significant changes independently. R2's Certified Nursing Assistant (CNA) Kardex (instructions to care for residents) dated [DATE] documents R2 required an assist of 1 staff. R2 required a hoyer lift for transfers; bed in low position and was a fall risk; required assist of 1 staff for personal hygiene and to turn and reposition Q (every),d+[DATE] hours when in bed; assist of 2 for bathing/showering and assist of 1 for toileting; set up assistance for eating. R2's comprehensive care plan had the following focused problems: 1. At risk for falls due to decreased mobility-Initiated [DATE] Interventions all on [DATE] -bed in low position -encourage to transfer and change positions slowly -fall risk -have commonly used articles within easy reach -reinforce need to call for assistance 2. ADL self-care deficit as evidenced by: weakness related to: CVA-Initiated [DATE] Interventions all on [DATE] -ambulation/locomotion: with device: wheelchair -bathing showering: assist of 2 -bed mobility: assist of 1 -personal hygiene-assist of 1 -toileting: assist of 1 -transfer: mechanical lift xlarge (extra large) sling 3. At risk for loss of range of motion due to prior CVA-Initiated [DATE] Interventions established on [DATE] -administer analgesia per physician's orders -therapy evaluation and treatment as ordered. Surveyor notes R2 had an alternating pressure reducing mattress. R2's Physician Orders document the following: ST, PT, OT evaluation and treat as indicated dated [DATE]. On [DATE], at 3:05 PM, Surveyor requested therapy notes from Director of Nursing (DON)-B and Administrator (NHA-A) from the [DATE] evaluation order. On [DATE], at 7:45 AM, Physical Therapist (PT)-I provided documentation of a PT treatment encounter dated [DATE]. Within this documentation R2 is identified as bedbound and a fall risk. R2 was educated on proper ways to reposition and pressure spots that can be prone to sores. Surveyor interviewed PT-I and asked why R2 had not been evaluated based on the physician orders dated [DATE] for PT, OT, and ST evaluation and treat as indicated. PT-I stated PT-I was not aware of R2's physician orders from [DATE]. PT-I stated the Rehabilitation Director is responsible for the orders but is not available for interview. PT-I stated R2 should have been evaluated at minimum upon return from the hospital on [DATE]. Surveyor requested from PT-I any additional documentation identifying R2 has been evaluated or screened since [DATE]. Surveyor notes R2 had a decline in status related to bed mobility. On [DATE], R2's discharge assessment documented R2 required an assist of 1 staff and on [DATE], when R2 returns from the hospital, R2 requires an assist of 2 staff for bed mobility. Surveyor also notes per facility policy R2 should have been screened on a quarterly basis to identify a possible need for therapy services. Surveyor notes R2 should have been screened in [DATE] and January of 2024 and R2 was not evaluated per physician's order dated [DATE]. On [DATE], at 2:06 PM, Surveyor shared the concern with NHA-A and DON-B that R2 had not been screened at a minimum on a quarterly basis and that there is no documentation R2 had been evaluated per physician's order dated [DATE]. DON-B stated therapy orders automatically generate when a Resident returns from the hospital. DON-B understands the concern. No further information was provided at this time.

Based on interview and record review the Facility did not ensure quality of care was provided for 1 (R1) of 5 Residents. R1 sustained a fracture of the left forearm after hitting her elbow on the head board of the bed. The Facility did not consistently monitor R1's left arm and did not implement a care plan regarding R1's fracture. R1 was identified with a concern to the right middle toe which was documented as being purple & painful. There was no monitoring of this toe. Findings include: R1's diagnoses includes Alzheimer's disease, depression, anxiety disorder, and dementia. The annual MDS (minimum data set) with an assessment reference date of 2/7/24 has a BIMS (brief interview mental status) score of 7 which indicates severe impairment. The nurses note dated 4/7/24 at 15:36 (3:36 p.m.) documents Resident hurt her elbow on the head board while flailing her arms and hit her left elbow on head board while writer was attempting to straight cath her while staff helped, she c/o (complained of) pain to the area writer called on call [Medical group's name] DOC (doctor) or NURSE practitioner she stated give some resident Tylenol. This nurses note was written by LPN (Licensed Practical Nurse)-N. The SBAR (situation, background, assessment, recommendations) note dated 4/8/24 at 00:33 (12:33 a.m.) documents Situation: Left elbow painful, shiny brown and swollen. Right foot middle toe, purple, painful when moved. Urinalysis positive, C&S (culture and sensitivity) pending. Background: Res (Resident) with behavioral issues since Thursday, Verbally abusive towards staff and residents, physical at times. Assessment (RN) (Registered Nurse)/Appearance (LPN) (Licensed Practical Nurse): Res up again start of night shift, belligerent, complaining. Finally stated she was tired. CNA helped her to bed. Noted elbow, res crying, limited ROM (range of motion), brown in color, swollen. Tylenol given and ice applied. Further investigation, bruising on arms from holding for straight cathing, tender. Noted right foot middle toe is purple, pain with PROM (passive range of motion). Recommendations: 0030, On call at [Medical group name] [Name], aware, New order for X-ray of elbow in AM (morning), cont (continue) to monitor toe, wait for C&S results Response: [Medical group name] on call, [Name] updated. Res calm at this time, remaining in bed. This SBAR noted was written by LPN-S. The nurses note dated 4/8/24, at 06:08 (6:08 a.m.), documents Res has remained in bed this night. Lab was here to draw blood, res was cooperative. Res took AM Thyroid med (medication). No adverse behaviors as yet. X-ray to be done today. Fluids to be encouraged. Urine C&S pending. This nurses note was written by LPN-S. The nurses note dated 4/8/24, at 12:36 (12:36 p.m.), documents X-RAY to L (left) elbow completed today. Res has been resting affected arm. X-RAY results pending. This nurses note was written by DON (Director of Nursing)-B. Physician-W's note dated 4/9/24 under subjective includes documentation of Patient is sitting in the chair, with no complaints of pain. Left arm has ecchymosis, slightly decreased ROM (range of motion) at the wrist, otherwise she is using the arm and hand to propel her walker. She refusing any intervention and refusing to see any doctor. Reports no shortness of breath or cough. No chills, nausea, vomiting, chest pain or chest tightness. Plan of care discussed with nursing staff with no additional concerns. Under assessment and plan includes Left forearm fracture. No vascular compromise seen. Slight deformity and tenderness and decreased ROM. Patient refusing interventions. POA (power of attorney) aware. Patient to see Ortho on 15th. Surveyor notes R1's care plan was not revised to include R1's left forearm fracture and right middle toe which was identified as being purple and painful. The nurses note dated 4/9/24, at 18:38 (6:38 p.m.), documents [Physician-W] in to evaluate resident earlier in shift. Per Physician-W request resident able to move fingers/wrist and arm without difficulty. Grimacing noted with movement CMS (circulation, motion, sensation) WNL (within normal limits). CRT (capillary refill time) less than 3 secs. (seconds). Purplish/bluish/reddish discoloration noted entire forearm. Resident continue to refuse ice pack and Tylenol when offered. This nurses note was written by LPN-U. The nurses note dated 4/10/24, at 02:40 (2:40 a.m.), documents Pt (patient) with fracture to proximal ulna. Pt propelling self about unit for a couple of hours using both arms. No c/o pain or discomfort. Pt with sensitivity pending on urine culture. No c/o dysuria. Pt was verbally hostile towards staff calling staff, stupid and lazy. Multiple attempts to redirect pt to her bedroom. About 2am pt finally went to bed. This nurses note was written by RN-Y. The nurses note dated 4/10/24, at 20:22 (8:22 p.m.), documents left elbow tender to touch, prn (as needed) Tylenol administered for reports of pain. Left ue (upper extremity) is bruised and red in color. In bed this shift resting, had visit with son this afternoon. No distress or behaviors this shift. This nurses note was written by LPN-T. The nurses note dated 4/11/24, at 05:53 (5:53 a.m.), documents Res has remained in bed this night shift. She is still being verbally belligerent, stated to writer to leave, she does not have nor never has had a urinary infection. You don't know what you're talking about. Res did take abt (antibiotic) and thyroid med earlier this AM when half asleep. Left arm remains bruised, elbow area swollen. Grimaces with movement. Denied need for meds. No new issues. This nurses note was written by LPN-S. The nurses note dated 4/11/24, at 14:17 (2:17 p.m.), documents Monitoring q (every) shift resident is on ABT no adverse reactions. This nurses note was written by LPN-N. The nurses note dated 4/11/24, at 22:36 (10:36 p.m.), documents Resident alert and responsive. Resident refused cares, meds, and vital signs this pm (evening) shift. Resident striked out at writer after attempting to assess vital signs. This nurses note was written by LPN-X. The nurses note dated 4/12/24, at 12:38 (12:38 p.m.), documents ABT/UTI monitoring with treatment for UTI has confusion talking a lot. This nurses note was written by LPN-N. The nurses note dated 4/12/24, at 21:15 (9:15 p.m.), documents Resident refused all medication, spitting them out saying that she cannot tolerate the medication. Tried a number of methods to get resident to resident to take her medication but resident still refused and wouldn't comply. Resident did not receive any ABT this PM shift. This nurses note was written by LPN-DD. The nurses note dated 4/13/24, at 12:36 (12:36 p.m.), documents Residents was very quiet and slept a lot this AM shift, was able to get resident to take medications without any issue, resident did not complaint of pain or discomfort. This nurses note was written by LPN-DD. The nurses note dated 4/14/24, at 19:07 (7:07 p.m.), documents Resident stable, however resident still refusing to take medication and refusing to eat, resident had visit from son, resident talk about making peace with God and wanting to die, son attempted to give resident meds she refused it from him as well. Resident did not complain of any pain or discomfort this AM shift. This nurses note was written by LPN-DD. The general note dated 4/15/24, at 13:47 (1:47 p.m.), documents Resident elbow propped up in wheelchair. Resident denied pain to writer and refused Tylenol with the nurse. This note was written by NHA (Nursing Home Administrator)-A. The nurses note dated 4/16/24, at 04:59 (4:59 a.m.), documents Pt refusing medications. To receive IM (intramuscular) ABT therapy for UTI. Pt is afebrile. No c/o pain or discomfort. Sleeping well throughout the night. This nurses note was written by RN-Y. The nurses note dated 4/16/24, at 15:54 (3:54 p.m.), documents Resident is on ABT/UTI resident refuses to take her meds q shift she does take them far and in between for pain to left elbow [NAME]. (Tylenol). This nurses note was written by LPN-N. Surveyor reviewed the Facility's 24 hour sheets from 4/7/24 to 4/16/24. Surveyor did not note any monitoring of R1's left arm bruising & swelling or the right middle toe on these 24 hour sheets. On 4/16/24 R1 was discharged to the hospital. The hospital ED (emergency department) not dated 4/16/24 at 4:40 p.m. under physical exam for Musculoskeletal documents General: Normal range of motion. Cervical back: Normal range of motion and neck supple. Comments: Old bruising of the left forearm. Left elbow has swelling and tenderness. During R1's record review Surveyor was unable to locate consistent monitoring of R1's left arm after R1 sustained a fracture and monitoring of R1's right foot middle toe which was documented as being purple & painful on 4/8/24. On 4/23/24, at 9:25 a.m., Surveyor asked RN/ADON (Registered Nurse/Assistant Director of Nursing)-O who is responsible for revising care plans. RN/ADON-O replied the IDT (interdisciplinary team). I play a role as well as [First name of DON (Director of Nursing)-B] and [First name of LPN (Licensed Practical Nurse)-H] does also. Surveyor informed RN/ADON-O Surveyor was unable to locate a care plan after R1 fractured her arm. Surveyor asked RN/ADON-O where Surveyor would be able to locate assessments, monitoring. and the plan for treating of R1's arm after R1 was diagnosed with the fracture. Surveyor asked RN/ADON-O if she could look into this and get back to Surveyor. On 4/23/24, at 12:14 p.m., RN/ADON-O informed Surveyor in regarding to R1's fracture there were no other MD (medical doctor) orders other than the order for Tylenol which was a previous order. The nurse had contacted the MD and they said to give Tylenol. RN/ADON-O informed Surveyor maybe now going forward she could push for a brace or ice. On 4/23/24, at 1:42 p.m., Surveyor met with NHA-A and DON-B regarding R1. Surveyor informed NHA-A and DON-B Surveyor had noted a nurses note dated 4/9/24 indicating the NP was aware of R1's fracture and there was a new order for ortho consult. Surveyor informed NHA-A and DON-B Surveyor did note there is not a care plan for the fracture, there was no plan on how to consistently monitor R1's left elbow bruising & swelling and no monitoring of the right middle toe which was purple & painful. Surveyor was not provided with any additional information regarding R1's left elbow and right middle toe On 4/23/24 at 2:34 p.m. Surveyor asked Physician-W's what interventions was she referring to in her note dated 4/9/24 that R1 was refusing. Physician-W informed Surveyor when she came she noticed swelling and the nurse was offering ice, trying to hold on to it. Physician-W indicated she asked if she can help, had to talk to R1 like she was a child and tried tying the bandage to keep the ice in place. Physician-W informed Surveyor she literally took two steps and the ice was off R1's arm. Physician-W indicated she asked R1 what happened and R1 replied I don't need this crap. Physician-W informed Surveyor R1 was propelling her chair with her arm so she guessed it wasn't painful.

Based on observation, record review, and interview, the facility did not thoroughly assess, document, and provide services consistent with professional standards of practice to prevent development or worsening of pressure injuries for 2 (R2 and R3) of 2 residents reviewed for pressure injuries. *R2 developed a Stage 2 pressure injury to the coccyx on 8/5/2021. On 8/11/2021 the pressure injury was seen by the wound physician and determined the pressure injury was a Stage 4. The wound on 8/5/2021 and 8/11/2021 did not have a description of the wound base. The Skin Integrity Care Plan was not revised with interventions individualized to R2. *R3 developed a Deep Tissue Pressure Injury to the left buttock on 7/23/2021. The wound progressed to an Unstageable pressure injury on 8/4/2021. The wound on 8/4/2021 and 8/11/2021 did not have a description of the wound base. The Skin Integrity Care Plan was not revised with interventions individualized to R3. Findings include: The facility policy and procedure entitled Pressure and Non-pressure Injuries dated 8/2/2021 states: The staging of pressure injury is consistent with the recommendations of National Pressure Injury Advisory Panel (NPIAP) and the RAI Manual, Section M. Deep Tissue Pressure Injury (DTPI): Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or [MEDICATION(S)] separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures is visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Assess current wounds at least every seven days, or more frequently as needed (e.g., decline in wound, presence of infection, wound healed). A Comprehensive Skin Integrity Care Plan is based on resident history, review of Skin Assessment, Braden Scale Scoring, Nutritional Assessments, resident and family interviews, and staff observations. Consider the areas of risk, as well as overall risk assessment score of the Braden Scale. Communicate identified risk factors and interventions to direct care staff. Develop interventions based on individual Risk Factors including, but not limited to, weight, presence of [CONDITION(S)], overall health status/comorbidities, use of medical devices, presence of acute infection, end-of life/hospice, resident choice/preferences, or medications that may impact healing. 1.) R2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 had a suprapubic catheter for neuromuscular dysfunction of the bladder. R2 was dependent on staff for bed mobility and bowel incontinence care. R2 had an Actual Skin Integrity and At Risk Care Plan initiated on 9/14/2018. The following interventions were in place on 8/5/2021: -Apply alternating pressure air mattress to bed at 100; assure and maintain proper inflation controls -Apply alternating pressure air mattress to bed if indicated; assure proper inflation, check frequently -Avoid friction/shearing while repositioning; if (R2) is unable to assist, use at least two staff members, use lift sheet, bed should be as flat as possible with lifting -Check skin for redness or pressure related changes with each care encounter; report any changes immediately -Conduct pressure injury skin assessments as indicated -Dry gangrene to left foot second toe; monitor every shift -Float heels with pillows or heels off device as tolerated -Frequent repositioning in bed and chair -Head to toe assessment by Licensed Nurse preformed weekly at minimum -Keep (R2) clean and dry; use barrier cream after good per-care; apply proper incontinent products as indicated -Moisture associated skin damage to buttocks related to incontinence of bowel; barrier cream with incontinence care -Monitor all toes daily for changes and update physician with any changes -Monitor every shift for placement of suprapubic catheter tubing and use securement device -Monitor penis for any changes and report to physician -Preventative/proactive treatment: Magic butt to buttocks topically every day shift for preventative treatment; apply topically to buttock, cover area with [MEDICATION(S)] -(R2) can be non-compliant with dressing/wound treatment changes -Skin prep to bilateral feet for preventative -Treatment orders as ordered by wound physician R2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/6/2021 at 12:41 PM in the progress notes, the dietitian charted R2 remained at risk for nutritional status change related to impaired skin integrity, adult failure to thrive, muscle wasting and atrophy. Supplements had been adjusted on 6/22/2021 due to R2 reporting low tolerance of fluid volume following 8 ounces of Boost supplements ordered. R2 continued with 120 ml of MedPass twice daily and Magic Cup once daily. Dietitian met with R2 to discuss the importance of nutrition. R2 expressed understanding. R2 continued with Prostat 30 ml three times daily. On 7/22/2021 at 1:26 PM in the progress notes, the dietitian charted R2 had been refusing MedPass and Magic Cup. R2 no longer liked to receive those supplements. R2 continued to receive ProStat three times daily. The dietitian charted R2's skin remained intact. On 8/5/2021 at 12:06 PM in the progress notes, nursing charted R2 had an open area to the bottom. The area was assessed as a Stage 2 pressure injury and was measured and cleaned. The wound had no exudate, no complaints of pain at the site, no signs or symptoms of infection, and no tunneling. The surrounding skin was red at baseline for R2. A foam dressing was placed. The floor nurse was to notify the physician and family. The wound physician would evaluate R2 on the next visit. On 8/5/2021 on the Wound Evaluation Tracker form, the Stage 2 pressure injury to the coccyx measured 0.6 cm x 0.7 cm x 0.2 cm. The wound bed had no description of tissue type documented. A treatment order was obtained to cleanse the area with normal saline and apply a foam dressing daily and as needed. R2 had an Actual Skin Integrity Care Plan for a pressure injury to the coccyx revised on 8/5/2021 with the following interventions: -Follow pressure ulcer prevention guidelines to prevent additional skin problems, promote healing and prevent complications -Monitor and report any new open areas, drainage, increased drainage or pain to nurse immediately -Monitor for complaints of pain; medicate as needed and offer pain medication prior to treatment; update physician regarding effectiveness and increased need for pain medications -Provide treatment to wound(s) per current treatment order; assess wound(s) for sign and symptoms of infection with each dressing change/treatment; report findings of redness, warmth, swelling, increased drainage or increased pain to physician immediately -Report wound progress or decline to physician with any changes or lack of response to treatment per facility guidelines -Apply chair cushion to wheelchair, Geri Chair or Broda chair; ensure proper placement and clean daily -Assess and measure all skin integrity areas per policy -Initiate skin monitoring forms per facility policy -Initiate treatment per physician order On 8/11/2021 on the Wound Evaluation Tracker form, the pressure injury was documented as a Stage 4 pressure injury that measured 1.5 cm x 1.5 cm x 0.5 cm with a moderate amount of serous drainage. The peri-wound was excoriated. The wound bed had no description of tissue type documented. The treatment was changed to Iodosorb to wound bed and cover with foam daily and as needed. On 8/11/2021, the wound physician assessed the wound and documented the wound was manually measured at 1.5 cm x 1.5 cm x 0.5 with early/partial granulation. On 8/11/2021 at 3:54 PM in the progress notes, nursing charted R2 was seen by the wound physician for the sacral wound and was classified as a Stage 4 pressure injury. The wound physician was unable to obtain a picture at that time due to camera malfunction. On 8/12/2021 at 10:40 AM in the progress notes, nursing charted the interdisciplinary team met to discuss the Weekly At Risk residents. R2 had a new Stage 4 pressure injury to the sacrum with discoloration: black, necrotic tissue. R2 was being followed by the wound physician. The dietitian was to review R2 for the new pressure injury. On 8/12/2021 at 12:44 PM on the Risk vs Benefit form, nursing documented R2 was educated on the risks and benefits of repositioning and offloading to improve skin integrity. The risks associated with choosing not to follow repositioning and offloading would be skin alterations, infections up to death, decreased mobility, risk for decreased muscle tone, and the potential for staff to miss skin alterations due to skin check refusals. R2's response to the risk vs. benefit discussion was R2 was aware, but prefers to remain in one position per preference for comfort. Interventions to minimize risk of not following recommendations were re-education, offload and slight repositioning with pillows and blankets. The physician was updated. Surveyor noted R2's care plan was not updated to include R2's positioning preferences and how the facility would accommodate those preferences until after the area reopened. On 8/16/2021 at 3:55 PM, Surveyor observed R2 in bed on an air mattress with heels elevated. R2 was positioned with multiple pillows and rolled blankets under extremities and behind the back. R2 did not have any complaints of pain or discomfort. Surveyor asked R2 if a treatment was done daily to R2's sacrum. R2 stated the nurse changes the dressing every day. In an interview on 8/17/2021 at 9:25 AM, Licensed Practical Nurse (LPN)-D stated R2 had a small open area to the sacrum that opens and then heals and then opens again. LPN-D stated R2 had very fragile skin and the area to the sacrum recently reopened. Surveyor observed LPN-D provide wound care to R2's sacrum. R2's bilateral buttocks and coccyx was discolored red measuring approximately 20 cm x 25 cm with multiple areas of concern in that region. The coccyx had an open area that measured approximately 1 cm x 1 cm x 0.5 cm with wrinkled skin that flapped over the open area. The wound base was dark red. The left buttock had a red slit measuring approximately 0.5 cm x 2.5 cm with a thin layer of skin over it that appeared to be about to open. The right inner buttock had a red area with a thin layer of skin over it that measured approximately 0.5 cm x 0.5 cm. Above the coccyx wound was a yellow intact skin area that measured approximately 2 cm x 2 cm. The right and left ischial tuberosities were indented and appeared to have scar tissue over both regions. LPN-D stated the skin on R2's buttocks starts to open in an area and then the rest opens up, too. LPN-D stated R2's skin started to open on the left side and LPN-D pointed to the left and right buttock wounds that had a thin layer of skin over the areas. LPN-D stated it will just be a little bit of time before those areas open. On 8/17/2021 at 3:20 PM, Surveyor met with Director of Nursing (DON)-B and Clinical Consultant (CC)-C. Surveyor reviewed the documentation of R2's coccyx pressure injury and shared the concern the wound base had no documentation since it was discovered on 8/5/2021 and progressed from a Stage 2 pressure injury to a Stage 4 pressure injury in one week. DON-B stated the initial assessment of R2's coccyx pressure injury was completed by DON-B and was staged at a Stage 2 because the wound base was pink. DON-B stated DON-B was unaware of R2's pressure injury history and stated the wound should have been staged at a Stage 4 when it was first assessed. CC-C stated R2 had a Stage 4 pressure injury to the coccyx in 2019, 2020, and 2021 and agreed the wound should have been staged a Stage 4 on 8/5/2021. Surveyor shared the concern the wound base had not been documented since it was discovered on 8/5/2021 and on 8/12/2021, the progress notes documented the wound base was black and necrotic tissue. DON-B stated she was not aware of the wound base looking like that and agreed the wound base should be described when being assessed. Surveyor shared the concern R2's Skin Integrity Care Plan was revised on 8/5/2021 but the interventions were not specific to R2's individual needs including no care plan to address R2's preferred position and the risks and benefits to balance wound care with resident preferences. DON-B agreed the care plan should be more individualized. On 8/18/21 the facility sent additional information including a summary of R2's history of recurrent open areas and tissue analytic documents. The facility requested consideration of R2's spinal disorder and body position as R2 is most comfortable in one position. 2 ) R3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's quarterly Minimum Data Set (MDS) assessment dated [DATE] coded R3 as needing extensive assistance with bed mobility and was completely dependent for toileting. R3 was always incontinent of bowel and bladder. R3's Actual Skin Integrity Care Plan was initiated on 2/9/2018 and had the following interventions in place on 7/23/2021: -Air mattress to bed, check inflation every shift 350 setting -Assess skin for redness or pressure related changes with each care encounter; report any changes immediately -Assess skin under splint daily; notify nursing of changes -Dietitian consult as needed -Encourage R3 to float heels with pillows or heels up device as tolerated -Geri chair -Grab bars x2 -Keep (R3) clean and dry; use barrier cream after good peri-care -(R3) has intermittent episodes of scratching self that may result in self-inflicted scratches -(R3) has preference for the over bed table location; honor preferences -Scab to left forehead Surveyor noted there is no indication R3's care plan included any interventions on repositioning and/or frequency to offload pressure. On 7/23/2021 on the Wound Evaluation Tracker form, nursing documented R3 developed a Deep Tissue Injury to the left buttock that measured 5 cm x 1 cm. The wound was described as a blue/purple non-blanchable area, no pain with palpation, and no signs or symptoms of infection. The physician was notified and a treatment obtained: normal saline wash to left buttocks discoloration, pat dry, skin prep followed by foam border gauze daily and as needed. On 7/23/2021, R3's Actual Skin Integrity Care Plan was revised to include a deep tissue injury to the left buttock. No further interventions were implemented. On 7/29/2021 at 6:12 PM in the progress notes, the dietitian charted R3 was reviewed related to nursing reporting a new deep tissue injury to the left buttock. R3 had last been reviewed on 7/16/2021 with no nutritional concerns. R3 received fortified foods with meals, Boost 8 ounces three times daily, and House Shake 4 ounces daily. The dietitian recommended multivitamins with minerals. On 7/30/2021 on the Wound Evaluation Tracker form, nursing documented R3's Deep Tissue Injury measured 2.5 cm x 3 cm with no depth. The wound had scant serous drainage and the additional comments section stated, No purple discoloration noted, healing well. Area is scabbed over at this time. (A Deep Tissue Injury does not have exudate or scabbing.) On 8/4/2021 on the Wound Evaluation Tracker form, nursing documented R3 had an Unstageable pressure injury to the left buttock that measured 2.57 cm x 1.81 cm x 0.1 cm. The wound bed had no description of tissue type documented. The treatment was changed by the wound physician on that date. On 8/4/2021 on the Tissue Analytics form, the wound physician documented the Unstageable pressure injury to the left buttock had early/partial granulation. The tissue type was coded red and pink. No description was given for the colors. On 8/11/2021 on the Wound Evaluation Tracker form, nursing documented the Unstageable pressure injury measured 1.94 cm x 2.32 cm x 0.1 cm. The wound bed had no description of tissue type documented. On 8/11/2021 on the Tissue Analytics form, the wound physician documented the Unstageable pressure injury to the left buttock had early/partial granulation. The tissue type was coded red, yellow, pink, and other. No description was given for the colors or other. On 8/16/2021 at 3:50 PM, Surveyor observed R3 in bed with an air mattress in place and heels floated. R3 stated there is a wound on the backside that nurses do a treatment to daily. On 8/17/2021 at 8:45 AM, Surveyor observed Licensed Practical Nurse (LPN)-D do R3's treatment with the assistance of LPN Unit Coordinator-E. R3 had a pillow under the right side and the heels were floated using a heels up device. The left buttock wound had a dressing in place. The sacral area had excoriation with no bleeding. The left buttock wound measured approximately 3 cm x 2 cm with 40% yellow slough. LPN-D washed the wound with Dakin's, sprayed skin prep to the peri wound, and applied a foam dressing to the area with tape. R3 complained of pain when the skin prep was applied. LPN Unit Coordinator-E stated they would call the wound physician to see if there was something other than skin protectant that could be applied because of the burning R3 complained of. LPN Unit Manager-E stated R3 is seen by the wound physician every Wednesday. On 8/17/2021 at 3:46 PM, Surveyor met with Director of Nursing (DON)-B and Clinical Consultant (CC)-C. Surveyor reviewed the documentation of R3's left buttock pressure injury and shared the concern on 7/30/2021 the pressure injury was described as a deep tissue injury and had exudate and scabbing. DON-B stated a deep tissue injury does not have exudate or scabbing and agreed the documentation was confusing. DON-B stated the nurse that did the assessment was not in the building at that time and was not sure why it was charted that way. Surveyor shared the concern the wound base had no documentation on 8/4/2021 and 8/11/2021 and the care plan was not revised with interventions that were specific to R3. DON-B agreed the wound base should be documented on and the care plan should be more individualized. CC-C stated the facility was in the process of changing from one type of skin documentation form to another and the information may have been put in one place and not the other. CC-C was unable to find any documentation regarding the wound base for those dates at that time. CC-C stated the nurse that did the assessment may have the wound base description in their own notes and just didn't get put into the record. On 8/18/21 the facility submitted additional information to review asking for consideration that the deficient practice was not related to a failure to treat but more related to documentation.

Based on interview and record review, the Facility did not provide the necessary care and services to prevent development of pressure injuries and promote healing of pressure injuries for 1 (R12) of 2 sampled Residents. R12 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/16/21 wounds were identified on R12 by a Licensed Practical Nurse (LPN) who found bruising on her back, an opened blister and a blister on her right anterior ankle. There was no RN assessment of the wounds, no measurements, and no updates to the resident's care plan. There was a message left for the MD but no documentation of the MD being notified. A treatment was not put in place until 3/19/21. On 3/23/21 a significant change MDS was completed related to significant weight loss and identified areas caused by shear and cuts possibly caused by the resident pressing fingers into skin. The facility did not assess the resident and implement individualized interventions to prevent shear or self pressure/wounds or review for additional interventions/changes to the care plan to prevent pressure injuries/wounds. On 3/25/21 an unstageable pressure injury was also found to the left gluteal fold. Interventions such as heelz up and repositioning were in place but resident refused often. Resident frequently repositioned self into the fetal position which was not updated on the care plan. On 3/30/21 an additional unstageable pressure injury was found on the anterior right foot. R12 was transferred to the hospital that morning where 15 wounds including 7 unstageable pressure injuries were found on R12. The facility's failure to identify PI's, development and the deterioration of PI's, the failure to properly update the physician of the development of a PI and to implement treatment created a finding of Immediate Jeopardy (IJ) that began on 3/16/20. Surveyor notified Nursing Home Administrator (NHA)-A and Director of Clinical Services (DCS)-C of the IJ on 4/16/21 at 3:08 PM. The IJ was removed on 4/16/21, however; the deficient practice continues at a scope/severity level of D (potential for actual harm/isolated) as the facility continues to work through their action plan. Findings include: Surveyor reviewed facility's Pressure Ulcer/Injury, Prevention of policy with an Original Effective Date of June 2017. Documented was: PURPOSE: To prevent skin breakdown and development of pressure ulcers/injuries. PROCEDURE: 1. Assess for risk of pressure ulcer/injury development. a. Identify high and low risk residents. 2. Assess and identify complicating conditions that may contribute to pressure ulcer/injury development. 3. Develop care plan to eliminate or minimize risk factors including: a. Diet. b. Nutritional supplementation. c. Hydration. d. Pressure relief measures . 8. Use pressure reducing or relieving devices in resident's bed and chair. 9. Use foot cradle as necessary . DOCUMENTATION GUIDELINES: Documentation may include: * Date, time, approaches to prevent pressure ulcer/injury development. * Preventative equipment used. * Condition of the resident's skin. * Physician notification when change in condition is observed. * If a pressure ulcer/injury is present, the Licensed Nurse is responsible to record condition of the skin, including stage, size, site, depth, color, drainage and odor as well as the treatment provided. Notification of the physician is required when a new pressure ulcer/injury is identified as well as when treatment is not effective. * Signature and title. CARE PLAN DOCUMENTATION GUIDELINES: Problem: * Identify the appropriate problem under which to list the pressure ulcer/injury care as an approach. * Identify and treat the underlying cause of the pressure ulcer/injury. * Consider listing complicating conditions, as well as possible risks and complications. Goal: * List measureable goal(s) to be accomplished. If a pressure ulcer/injury is present this may be resolution of the cause of the pressure ulcer/injury as well as healing of the pressure ulcer/injury. * Identify target date. Approaches: * Identify responsible discipline for each approach. * Record instructions unique to this resident. * Identify approaches to optimal nutrition and nutritional support. * Monitoring of weight. * Appropriate diagnostic tests. * Record approached to promote adequate hydration. * Monitoring of appropriate diagnostic tests. * Identify necessary monitoring and observation of the underlying condition. * Record treatment as ordered. * Record all pressure reducing or relieving surfaces. * Identify frequency of positioning. * Record behavior management if appropriate. NOTE: Inspect skin upon admission and once a shift, particularly over bony prominences. Heels and sacrum are most common areas for skin breakdown. Use Braden or Norton scale for assessment of risk for development of pressure ulcers/injuries. Either scale should be completed weekly x4 then at least quarterly or upon clinical change in resident status. Document assessment findings . R12 is a [AGE] year old female admitted on [DATE] from a previous Skilled Nursing Home with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor reviewed R12's Admission Minimum Data Set (MDS) with a date of 3/23/20. Documented for R12 under Cognitive skills for daily decision making R12 was moderately impaired. Documented under Functional Status for Bed Mobility was 3/3 which indicated Extensive Assistance - resident involved in activity, staff provide weight-bearing support; Two plus persons physical assist. Documented under Skin Conditions: Is the resident at risk for pressure injury? Yes and Number of unhealed pressure injuries: 0. R12's Care Area Assessment (CAA) for Pressure Injuries with a date of 3/23/20 triggered and documented Resident is at risk for skin integrity condition, or pressure sores [related to (r/t)]: Cognitive deficit, [history of (hx)] seizures, dementia, vitamin deficiency's (sic) . Alteration in elimination of bowel and bladder r/t Cognitive deficit, hx seizures, dementia, vitamin deficiency's (sic). R12's Comprehensive Care Plan with a start date of 3/16/20 documents: Focus: Resident is at risk for skin integrity condition, or pressure sores r/t: Cognitive deficit, hx seizures, dementia, vitamin deficiency's /(sic). Goal: The resident will not develop pressure related tissue injury through next care plan review date. Interventions: Conduct pressure injury skin assessments (i.e. Braden) as indicated. Head to toe assessment by licensed nurse weekly at minimum. The care plan was revised 8/22/20 to include treatment to left foot callus as ordered. Surveyor reviewed R12's Progress Notes. Documented on 9/3/20 at 1:07 PM was [Interdisciplinary Team (IDT)] team met to discuss new pressure injury. While completing treatment to left foot callus on her interior mid-foot I noted the other side of her foot has new areas of pressure. Posterior ankle, posterior toes, posterior mid-foot and heel of left foot. MD updated on new pressure areas and orders for treatment, air mattress, multivitamin and prostate (sic) daily obtained. Therapy to [evaluate] and treat for positioning and heels to be floated when in bed. R12's Comprehensive Care Plan was updated 9/3/20, 9/4/20 and 10/2/20 to include Focus: Resident has actual skin integrity break and/or pressure sore(s) r/t contractive movements, spastic movements and [CONDITION(S)] activity. 9/3/20 left foot [suspected deep tissue injury (SDTI)] (resolved) 9/3/20 left ankle SDTI (resolved 9/16/20) 9/3/20 left heel stage 2 (resolved) 9/4/20 excoriation buttocks 10/2/20 bruising to bilateral breasts - self inflicted (resolved) Goal: The skin integrity areas will show signs of progressive healing without signs of infection or complication through review date. Interventions: 9/3/20 Apply alternating pressure air mattress to bed if indicated. Assure and maintain proper inflation controls. 9/3/20 Assess and measure all skin integrity areas per policy. 9/3/20 Float heels with heels off device. 9/3/20 Follow pressure ulcer prevention guidelines to prevent additional skin problems. 9/3/20 Initiate skin monitoring forms per facility policy. 9/3/20 Initiate treatment per physician order. 9/3/20 Monitor and report any new open areas, drainage, increased drainage or pain to nurse immediately. 9/3/20 Monitor for [complaints of (c/o)] pain. Medication [as needed (PRN)] and offer pain medication prior to treatment. Update Physician regarding effectiveness and increased need for pain medications. 9/3/20 Provide treatment to wound(s) per current treatment orders. Assess wounds for s/s (signs/symptoms) of infection with each dressing change/treatment. Report findings of redness, warmth, swelling, increased drainage or increased pain to physician immediately. 9/3/20 Report wound progress or decline to MD with any changes or lack of response to treatment per facility guidelines. 9/3/20 Therapy to eval for positioning in bed and [wheelchair (w/c)] 9/3/20 Vitamin and protein supplements 9/4/20 Excoriation buttocks. Happy Butt cream for protection. 9/11/20 Resident repeatedly kicks heels off device off bed to lay in fetal position. 10/2/20 Monitor bruising to bilateral breasts, Hospice discussion with family. Surveyor reviewed R12's Braden Scale for Predicting Pressure Sore Risks with an effective date of 1/10/21. Documented was a score of 15 which indicated at risk for pressure injuries. Surveyor reviewed R12's Braden Scale for Predicting Pressure Sore Risks with an effective date of 2/10/21. Documented was a score of 19 which indicated not at risk for pressure injuries. This contradicted the 1/10/21 assessment of at risk for pressure injury and the documented history of SDTI's and pressure injuries. Surveyor reviewed R12's Skin Review - Weekly assessment with a date of 3/6/21. Documented was Skin Condition: Skin Intact. Surveyor reviewed R12's Braden Scale for Predicting Pressure Sore Risks with an effective date of 3/10/21. Documented was a score of 19 which indicated not at risk for pressure injuries. This contradicted the 1/10/21 assessment of at risk for pressure injury and the documented history of SDTI's and pressure injuries. On 3/11/21 R12 was noted to have a low [MEDICATION(S)] of 1.7 (normal 3.8 - 5.0). On 3/12/21 she was diagnosed with [CONDITION(S)]. Previous weights had shown that she had lost 49 lbs. from admission on 3/16/20 to 107 lbs. on 12/24/20 and was continuing to lose weight. Despite these risk factors, the facility did not reassess the resident's risk for pressure injury development. Poor nutrition and dehydration are known risk factors for pressure injury development because the individual may not have the proper vitamins, nutrients, and proteins to sustain healthy skin. Similarly, if enough [MEDICATION(S)] is not available in the body, it could hinder the healing process and prolong inflammation in a pressure injury. (Cross reference F692.) Surveyor reviewed R12's Skin Review - Weekly assessment with a date of 3/13/21. Documented was Skin Condition: Skin Intact. Surveyor reviewed R12's Progress Notes. Documented by Licensed Practical Nurse (LPN)-M on 3/16/21 at 10:34 was Aides assisted resident's ADLs and found bruising on her back and opened blister on her back and R (right) anterior ankle. Per [Former Director of Nursing (DON)-P], similar injuries noted a couple months back. Where patient put too much pressure self by clenching hand. In this injury, resident likes to lay on ride side the most. Hx (history) of recurrent swelling possibly causing the blisters especially on ankle. Resident has new ABX (antibiotic) med, but does not appear to be the cause of injuries. No distress noted. Called and informed [MD-O] no answer. Left a message. [POA] aware. Surveyor noted there is no indication of an RN assessment. Surveyor noted there was no treatment put in place. There is no documentation that the MD was updated and gave treatment orders after the telephone call with no answer. Surveyor interviewed LPN-M on 4/15/21 at 12:31 PM, who had identified the opened areas on 3/16/21. Surveyor asked what she did when she found the wounds. LPN-M stated she was a newer nurse and was not sure what exactly to do. LPN-M stated she updated the POA and left a message for MD-O. LPN-M stated she wrote a Progress Note and wrote the information on the 24 hour board. LPN-M stated she updated Former DON-P who stated she had the same wounds in the past. Surveyor asked if she put a treatment order in the EHR (electronic health record. LPN-M stated she was not sure how to do that so she entered it the next time she worked on 3/19/21. There was no order for wound treatment 3/16/21 through 3/18/21. Assessment and measurement of wound was not completed. An MD order was in place 3/19/21 through 3/25/21. Order read Clean open area with NS (normal saline), debride as needed. Apply wound cleanser, skin prep. Place gauze. Open areas at left anterior ankle and back. R12's Comprehensive Care Plan was updated 3/16/21 and 3/19/21 to include Focus: Resident has actual skin integrity break and/or pressure sore(s) r/t contractive movements, spastic movements and [CONDITION(S)] activity. Interventions: 3/16/21 Float heels with heelz up device - resident may kick out, attempt use of pillow if not allowing heelz up. 3/19/21 Reposition per policy. 3/19/21 Encourage resident to use small pillow/blanket between arms and body to prevent self-harm. Surveyor noted float heelz up device was put in place 9/3/20 and deemed ineffective on 9/11/20 due to resident kicking it off the bed. Reposition intervention was already in place as of 9/3/20 and would be ineffective because the resident would roll back into a fetal position. (See interviews below.) Small pillow/blanket intervention does not address the ankle or back wounds wound on 3/16/21. Surveyor reviewed R12's Skin Review - Weekly assessment with a date of 3/20/21. Documented was Skin Condition: Other: excoriation to buttocks. There is no mention of the ankle or back wounds. On 3/23/21 a Significant Change MDS was completed. Documented under Functional Status for Bed Mobility was 3/3 which indicated Extensive Assistance - resident involved in activity, staff provide weight-bearing support; Two plus persons physical assist. Documented under Skin Conditions: Is the resident at risk for pressure injury? Yes. Number of Pressure Injuries? 0. and Other Ulcers, Wounds and Skin Problems: None of the above. R12's CAA for Pressure Injuries with a date of 3/23/21 triggered and documented Resident has a history of Dementia, Pneumonia, Developmental delay, Antipsychotic use, is non ambulatory, is non-verbal, requires the assistance of staff for all ADL's and has low PO intake at times. Resident is incontinent of bowel and bladder. These factors put the resident at risk for pressure Ulcers. Resident currently has areas of blistering on her ankle as well as her back. Resident has been noted to dig her fingertips/fingernails into her skin, causing open areas. Resident receiving Magic Butt cream to excoriation on buttocks. Staff will continue to provide MD ordered skin treatments and report any new concerns to the MD. Surveyor noted the MDS assessment information was inconsistent with information referenced in the CAA. Surveyor also noted despite referencing R12's possible self inflicted wounds there is no indication R12 was assessed for long nails for interventions to prevent such injury. No care plan was developed or implemented. On 3/25/21 Director of Clinical Services (DCS)-C documented in Progress Notes: at 12:39 PM, Resident is on follow up for: Resident has 2 new skin issues. Left hip ecchymosis with 2 areas of shearing inside ecchymosis. Unstageable to left glut (gluteus). The current status is newly assessed, areas cleansed, measured and dressings applied. MD/POA notified. New dressing orders obtained. Surveyor reviewed R12's Wound Evaluation Tracker for wounds with an effective date of 3/25/21 documented by DCS-C. Documented was Site: Left gluteal fold. Type: Pressure. Length: 3.0 cm. Width: 3.75 cm. Depth: 0.1 cm. Stage: Unstageable. Additional Description documented very thin translucent to slightly yellow slough with darker shaded area (1.75 x 1.560 cm) noted inside wound borders. Wound bed was documented 100% slough. Documented was Site: Left trochanter (hip). Type: Other: shearing. Length: 2.5 cm. Width: 0.75 cm. Depth: 0.1 cm. Stage: N/A. Wound bed was documented 100% epithelial. Documented was Site: Left trochanter (hip). Type: Other: shearing inside ecchymotic area. Length: 2.75 cm. Width: 2.5 cm. Depth: 0.1 cm. Stage: N/A. Wound bed was documented 100% epithelial. Treatments were put in place for these wounds. R12's Comprehensive Care Plan was updated 3/25/21 and 3/26/21 to include Focus: Resident has actual skin integrity break and/or pressure sore(s) r/t contractive movements, spastic movements and [CONDITION(S)] activity. Interventions: 3/25/21 Air loss mattress to bed setting 3. 3/25/21 Roho cushion to Broda chair (discontinued on 3/26/21) 3/26/21 Pillow between resident and chair to left side due to leaning. 3/26/21 Pt to eval for need for w/c. 3/26/21 Therapy to eval for positioning in bed and w/c. Surveyor noted there was no assessment to determine if shearing was caused only by the Broda chair or if shearing was occurring while in bed or when using a Hoyer for transfers. Surveyor noted there is no care plan to address shearing specifically. Surveyor also noted there was no care plan addressing R12's refusal to be repositioned and repositioning herself back into fetal position. On 4/14/21 at 10:49 AM Surveyor interviewed Certified Nursing Assistant (CNA)-I. Surveyor asked if R12 had wounds prior to discharge on 3/30/21. CNA-I stated yes but was unaware where they were located besides her hip which had a bandage on it. CNA-I stated her bottom as well that they would put barrier cream on it. Surveyor asked how the resident was repositioned. CNA-I stated every 2 hours but she would not allow them to reposition her. She stated she would immediately go back into a fetal position and kick any pillows out. On 4/14/21 at 11:10 AM Surveyor interviewed CNA-J. Surveyor asked if R12 had wounds prior to discharge on 3/30/21. CNA-J stated she yes, last month she had redness to her bottom and they would apply A&D ointment to her bottom. Surveyor reviewed MD orders and R12 had no order for A&D ointment. On 4/14/21 at 11:22 AM Surveyor interviewed CNA-K. Surveyor asked if R12 had wounds prior to discharge on 3/30/21. CNA-K stated yes. Surveyor asked what interventions were done for R12. CNA-K stated they repositioned her but she would move back to the same fetal position shortly after repositioning her. On 3/25/21 the treatment to ankle and back wounds that were discovered on 3/16/21 were discontinued. There is no documentation as to why these treatments were discontinued. There was never a measurement or assessment of the wounds. On 3/26/21 a Progress Note was written that documented Physical Therapy evaluation. Documented was Upon pt eval no Roho cushion will be applied to Broda chair as the cushion on chair is a pressure relieving cushion will be picked up for w/c positioning in pt for at least one . Surveyor reviewed MAR for MD order for Roho cushion and noted that continued to be documented as completed through discharge on 3/30/21. Surveyor reviewed Care Delivery Guide for R12 with an updated date of 3/26/21. Documented under Locomotion/Transfer/Positioning was: Assist: 1 Special Equipment: Broda chair Assist transfer: 2 Special transfer aids: Hoyer, 2 assist Assist positioning: 1 Every (blank) hours Surveyor noted this contradicted the MDS for bed mobility that noted R12 as extensive assist of 2 not 1. Surveyor noted that specific time frame for positioning was left blank. On 3/26/21 a Progress Note was written by LPN-L. Documented was Resident is on follow up for: f/u (follow up) left hip, left gluteal fold, [CONDITION(S)]. The current status is resident shows no evidence of pain or discomfort, [dressing] changed to left hip and left gluteal fold, left hip remains discolored with skin shear healing on top epidermis layer formed noted, no active bleeding or signs of infection, left gluteal fold pressure area dressing changed, area remains half necrotic with slough, increase fluids given, intake without difficulty, no signs or symptoms of [CONDITION(S)], resident resting comfortably at this time. On 3/26/21 a Progress Note was written by DCS-D. Documented was .Area to left buttock noted to be a stage 2 with a small area of necrosis at distal end no change in wound as of yesterday's assessment following [Physical Therapy] eval they will be picking up for at least a week related to w/c positioning. Surveyor noted left buttock wound was an unstageable wound with 100% slough on 3/25/21. Note documents no change in wound but contradicts with necrotic area that was not noted in 3/25/21 assessment. Surveyor also noted the wound to left buttock is documented as a stage 2 which is not consistent with the 3/25/21 assessment of an unstageable pressure injury with slough. Surveyor reviewed R12's Nutrition/Dietary note with a date of 3/26/21. Registered Dietitian (RD)-F documented Resident reviewed for nursing reporting new unstageable pressure injury to left buttock. Existing ecchymotic area with shearing [NAME] (open areas) to left hip. Annual review completed 3/23/21. Resident receives Regular diet/Dys (dysphagia) Puree texture/Fortified foods with all meals continues b/t (between) 0-25% (~575 kcal, 23g protein). She requires extensive 1:1 assistance with meals. Per staff, meal intakes may vary depending on staff member and/or day which is expected r/t dementia. Tolerates Regular diet/Dys Puree texture well. Receives Boost TID and accepts well (100% to provide additional 720 kcal, 24 g pro). 30 mL ProStat BID ordered 3/26 to assist with wound healing. Supplement to provide 200 kcal, 30g protein. Will monitor acceptance and adjust intervention prn. Resident drinks fluids better than pureed meals - offer other higher-calorie beverages such as chocolate milk, whole milk, etc. between or with meals. Continue to honor food preferences. Staff anticipate needs as resident is essentially non-verbal. Estimated needs at CBW of 47 kg with BMI of 16.6 (underweight) and increased needs d/t impaired skin integrity: 1257 kcal (Mifflin St. [NAME] x 1.3), 47-56 g [protein] (1-1.2 g/kg), 1500 mL minimum recommended [fluids.] Combined intake of average meals and supplements predicted to provide ~1495 kcal, 77g protein, which meets/exceeds estimated needs for compromised skin integrity and wt maintenance. Wt gain would be welcome 2/2 to low BMI. Will monitor and follow up prn. Surveyor noted R12's daily intake was not adequate for daily intake as recommended by RD-F. (Cross reference-F692). On 3/30/21 at 9:27 AM an eINTERACT SBAR Summary for Providers was documented by LPN-L and DCS-C. Documented was Situation: The Change In Condition/s reported on this CIC (change in condition) Evaluation are/were: Skin wound or ulcer. NSW (normal saline wash), pat dry, skin prep around wound edges, apply santyl to slough f/b border gauze drsg daily and prn (as needed). On 3/30/21 an MD order was also entered in R12's medical record. Documented was NSW to anterior right foot [open area (o/a), pat dry with gauze, apply skin prep around wound edges, apply santyl to o/a, f/b border gauze daily and prn. There is no measurements or assessment of the wound. On 3/30/21 a set of labs was drawn. R12's sodium came back at 158 as critical. MD was updated on critical sodium level and low Potassium level and an order was received to send R12 to the hospital for treatment. On 4/30/21 at 4:26 PM Surveyor interviewed Emergency Department Physician (MD)-X. Surveyor asked what initial assessments were completed for R12 on admission to the ED. MD-X stated R12 was hypotensive, hypernatremic and hypokalemic upon arrival at the emergency department. MD-X stated they needed to get her blood pressure, electrolytes stable and that was the main concern. MD-X stated the facility did not send much paperwork along with R12 so he was also focused on code status and how extensively to treat the patient. MD-X stated when he looked at her skin he noted multiple skin [CONDITION(S)] to her whole body including one to the sacral/coccyx area I remember. MD-X stated R12 was quickly looked over to make sure none of the wounds were infected by noting odors and appearance but were not measured or assessed. MD-X stated that would be done upon transferring her to the medical floor once stable. MD-X stated she was transferred to the medical floor at 6:00 PM. R12's hospital medical record indicates a Wound Consult was completed 3/31/21 at 12:04 PM but noted all wounds were identified 3/30/21 at 6:00 PM in the Emergency Department. The Wound consult documented [R12] is a 78 y.o. (year old) female who presents today for wound consult for multiple wounds. Patient has multiple Un-stageable Pressure Injuries on all turning surfaces. Non pressure wounds also noted on right chest, scabbing present, some linear indicating possible scratching. Patient has > (greater than) 11 wounds. All wounds were cleansed, Medi-honey for wounds with slough, wound gel to left hip pressure injury which is open. Patient moaned when back dressing removed and when position changed. No signs of discomfort during treatments. Heel lift boots were on. Removed for assessment. Assist of 2 to turn patient utilizing paper pad. Patient was repositioned onto left side at 30 degrees to off load hips and ischial areas. Feet were totally offloaded utilizing pillows. Foam border heel dressings for protection. Patient is repositioned by staff. Foley catheter present. To have air mattress. Current symptoms: Patient with an electrolyte imbalance. Cognitive delay, unable to use numerical pain scale. Non-verbal. Monitored for overt signs of pain. Interventions to date: Resides in [long term care] . Assessment: Wound Type: Wound Documentation: 1. Location: Ankle, right, medial Stage: Unstageable pressure injury Wound bed: 100% eschar Measurement: 1 x 1 x 0.1 cm 2. Location: Back, right, lateral, upper Stage: Unstageable Wound bed: 80% slough Measurement: 4.2 x 4.5 x 0.1 cm 3. Location: Back, right, medial, upper Stage: Stage 2 Wound bed: Pink Measurement: 1 x 1 x 0.1 cm 4. Location: Back, right, mid, lateral Stage: Unstageable Wound bed: Slough Measurement: 1.5 x 3.2 x 0.1 cm 5. Location: Back, mid, right, medial Stage: Unstageable Wound bed: 10% slough Measurement: 1.5 x 3 x 0.1 cm 6. Location: Back, mid, right, lateral Stage: Stage 2 Wound bed: 70% epithelial Measurement: 1.5 x 3.5 x 0.1 cm 7. Location: Ishium, left, posterior Stage: Unstageable Wound bed: 90% slough, 5% eschar Measurement: 2 x 2.7 x 0.1 cm 8. Location: Heel, right Stage: (Deep Tissue Injury) DTI Wound bed: Purple Measurement: 2.8 x 4.1 cm 9. Location: Heel, left Stage: DTI open Wound bed: Maroon Measurement: 3.8 x 4.2 x 0.1 cm 10. Location: Right hip Stage: Stage 2 Wound bed: Maroon Measurement: 6.5 x 6.5 x 0.1 cm 11. Location: Foot, right, dorsal Stage: Unstageable Wound bed: 100% slough Measurement: 1.8 x 5.2 x 0.1 cm 12. Location: Chest, right anterior Stage: Unstageable Wound bed: 100% slough Measurement: 1 x 1 x 0.1 cm 13. Scab to Right Knee 14. Scab to Right Lower Leg 15. Location: Chest, right, linear distal Stage: Stage 2 Wound bed: 90% epithelial Measurement: 4.3 x 0.6 x 0.1 cm On 4/30/21 at 4:26 pm MD-X stated he reviewed the wound documentation for R12 in her hospital medical record. MD-X stated there was less than 6 hours between her arrival to the ED and transferring up to the floor. MD-X stated in that amount of time there is no chance she could have developed that many wounds. MD-X stated even if she was laying on the floor for 6 hours she could not have developed that many deep wounds. Surveyor asked if he put in a wound consult. MD-X stated no, that also would be done on the floor unless they are infected, which MD-X stated he did not see any signs of infection in the ED. MD-X stated a wound consult was put in the computer on 3/30/21 by the staff on the medical floor that was completed 3/31/21. Surveyor reviewed Hospital Case Manager (CM)-Q Hospital Progress Notes who interviewed R12's family regarding concerns. CM-Q documents on 4/1/21 interview with R12's POA via a Spanish interpreter. Documented was .[POA reported many concerns regarding the pt's care while at (name of facility). To note, this is a high risk pt- d/t her high personal care needs and inability to verbalize her basic needs. Reported concerns are as follows: > Poor skin integrity. Pt noted to have >11 wounds (skin tears/bed sores) . On 4/13/21 at 11:05 AM Surveyor interviewed CM-Q who interviewed R12's family/POA for concerns with the facility. CM-Q stated R12's family was concerned with the dramatic weight loss, wounds they were unaware of and overall care at the facility. CM-Q updated family that R12 had over 11 wounds. CM-Q stated family was unaware of wounds. CM-Q stated she updated Hospital Liaison (HL)-R on 4/1/21 who shared the information back to the facility. DCS-C reported to HL-R she was only aware of 3 wounds. CM-Q stated she asked nursing in the hospital about the wounds and was told the level of slough/necrosis in the wounds would not have happened in the time of transfer to ED to floor. On 4/14/21 at 8:21 AM Surveyor interviewed DCS-C. Surveyor asked what wound audits were completed in March 2021. DCS-C stated all residents were reviewed for treatment orders and that the transcription of the MD order into electronic medical record (EMR) was correct. DCS-C stated care plans were also reviewed to make sure interventions were updated with any change in the wounds. Surveyor asked if there was a house wide skin sweep done to assess all residents for wounds. DCS-C stated no. If a resident was assessed it was individual and charted under Skin Assessments in their EMR. On 4/15/21 at 1:39 PM Surveyor interviewed DCS-C. Surveyor asked when she became aware of the wounds on R12's hip and left gluteus. DCS-C stated on 3/25/21, the day she assessed them and started the wound tracker. Surveyor asked if she did a head to toe assessment. DCS-C stated R12 was wearing a hospital gown so she looked her over. Surveyor asked if she saw the right ankle or back wounds that were documented on 3/16/21. DCS-C stated she did not observe any wounds on her back or ankle. Surveyor asked what the process is when a wound is found. DCS-C stated if it is an LPN they alert a RN. An assessment is completed by an RN and a Wound Tracker is opened in EMR. DCS-C stated the care plan is updated and MD is updated and treatment put in place. Surveyor asked what preventative measures were in place prior to 3/25/21. DCS-C stated heelz up device, air mattress, repositioning and the dietitian was working with her. Surveyor asked about the wound found 3/30/21 to the anterior right foot and why it was not assessed. DCS-C stated the resident went to the hospital and she did not have time before she left. Surveyor noted LPN-L called the MD for an order prior to any assessment being done at 9:27 AM. R12 was taken by ambulance to the hospital at 11:30 AM. Surveyor asked what DCS-C did with the information after HL-R contacted her. DCS-C stated she gave the information to NHA-A who opened an investigation. The facility's failure to provide care necessary to prevent the development [TRUNCATED]

Based on record review and interview, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight and desirable body weight range, and failed to maintain proper parameters of hydration, such as electrolyte balance, for 1 (R12) of 2 residents reviewed for nutritional status. On 3/16/20 R12 was discharged from another facility. Her weight on discharge was 154 lbs. On admission to this facility her weight was recorded as 156 lbs. From March through November 2020 this facility recorded her weight each month in the 155-158 lb. range. On 12/24/20 the resident was weighed at 107 lbs. R12 was ultimately hospitalized with [CONDITION(S)], [CONDITION(S)], severe protein-calorie malnutrition of chronic illness related to dementia, dysphagia as evidenced by mild to moderate fat wasting, moderate to severe muscle wasting, and intake providing < (less than) 50% of estimated needs for at least 6 days. Certified nursing assistants (CNAs) were aware the resident was not eating and monthly documentation showed the resident was eating a smaller percentage of each meal. There was no plan to encourage the resident to eat more or assessment as to why she ate more for some staff. There was no follow up with speech therapy, which the physician had thought was occurring. When a significant weight loss was identified 12/24/20, facility staff attributed this to having taken inaccurate weights from March through November and did not do a root cause analysis to determine if the scale was inaccurate, if weights were accurately recorded, if the resident had, in fact, lost 49 lbs. from 11/9/20 to 12/24/20 or if this had been a progressive weight loss all along and that weights had not been accurately recorded each month. After this measurement, R12 continued losing weight. When lab values suggesting dehydration first appeared on 3/11 and 3/15/21, the facility staff did not know specifically what push fluids meant, and there was no care plan directing staff on how they should be doing this or how they would monitor the resident's fluid intake. The facility's failure to ensure R12 maintained acceptable parameters of nutrition and hydration created a finding of Immediate Jeopardy (IJ) that began on 12/24/20. Surveyor notified Nursing Home Administrator (NHA)-A and Director of Clinical Services (DCS)-C of the IJ on 4/16/21 at 3:08 PM. The immediacy was removed on 4/16/21; 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 action plan. Findings include: Review of the facility's policy titled, Weight Assessment and Intervention, originally effective on January, 2017 and revised on 10/14/2020, states in part; Policy: The interdisciplinary team will strive to prevent, monitor, and intervene for undesirable weight change for our residents. Procedure: Weight Assessment (includes but not limited too); 1. The nursing staff will measure resident weights on admission, the next 2 days, and weekly for 3 additional weeks thereafter. 2. If no weight concerns are noted after the initial 3 days and 3 weeks after, routine weights will be measured monthly thereafter, unless ordered more frequently by the physician. 6. Any weight change of five (5) pounds or more since the last weight assessment will be retaken for confirmation. 7. The Dietitian will review the monthly weights to follow individual weight trends over time. Weight trends will be evaluated by the interdisciplinary team whether or not the criteria for significant weight change has been met. Analysis: 1. The Physician and the interdisciplinary team will identify conditions and medications that may be causing weight change For example: b.) chewing or swallowing abnormalities; c.) pain; g.) Psychosocial factors (such as depression) h.) Increased need for calories and/ or protein Care Planning: 1. Care planning for weight change or impaired nutrition will be an interdisciplinary effort and may include the following members' of the interdisciplinary team: Physician, nursing staff, the Dietitian, the Consultant Pharmacist, Therapy, and the resident or resident's legal representative. 2. Individualized care plans shall address, to the extent possible: a.) The identified causes of the weight change b.) Goals and benchmarks for improvement; and c.) Time frames and parameters for monitoring and reassessment. Interventions: 1. Interventions for undesirable weight change shall be based on careful consideration of the following: a.) Resident choice and preferences; b.) Nutrition and hydration needs of the resident; c.) Functional factors that may inhibit independent eating with referral to therapy if applicable; d.) Chewing and swallowing abnormalities and the need for diet modifications with referral to therapy if applicable. 2. The undesired weight change will be discussed with the resident and/or responsible party. 3. Interventions for undesired weight change should consider resident preferences and rights. A weight change regimen should not be initiated for a cognitively capable resident without his/ her approval and involvement. 4. If a resident declines to participate in a weight loss or weight gain goal, a nurse or RD (Registered Dietician) will document the resident's wishes and those wishes will be respected. Note: The last weight obtained in the hospital may differ markedly from the initial weight upon admission to a nursing center and is not to be used in lieu of actually weighing the individual. R12 is a [AGE] year old female admitted to the facility on [DATE] following transfer from a different Skilled Nursing Facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . History and Physical from R12's Primary Physician (MD)-O dated 12/14/19 and 3/8/20 in admission/transfer paperwork document R12 had a height of 5'6 and a weight of 156 lbs. with orders for diet as puree food and thin liquids served in nosey cup. Minimum Data Set (MDS) assessments from the other Skilled Nursing Facility lists weight as 162 lbs. on 11/22/19 and 154 lbs. on 3/16/20 (date of transfer). Surveyor reviewed R12's MD-O visit note with a date of 3/22/20. Documented was Assessment and Plan - Dysphagia: The patient is currently on a pureed diet. Because of this she would be at risk for malnutrition. Nursing and dietary will be monitoring her nutritional status and oral intake. Surveyor reviewed R12's Admission MDS with a date of 3/23/20. Documented for R12 under Cognitive skills for daily decision making was moderately impaired. Under Functional Status was Eating: one person extensive assist. Swallowing/Nutritional Status documents a height of 5'6 and weight 156 lbs. and indicated swallowing disorder of loss of liquids/solids from mouth when eating or drinking which required a mechanically altered diet. R12's Care Area Assessment (CAA) for Nutritional Status with a date of 3/23/20 triggered and documented History difficulty swallowing related to dysphagia as Resident doesn't tolerate food textures of Regular or dysphagia advanced Mechanically Soft diets. Resident receives a Regular diet with dysphagia Puree texture and thin liquids. Staff feed Resident using regular utensils and nosey cups used for beverage consumption. Overall meal intake thus far 76%, intake meets/exceeds nutritional needs. Safety with [by mouth (PO)] intake anticipated outcome for Resident. Surveyor reviewed R12's Nutritional Assessment with an assessment date of 3/23/20. Documented was a height of 5'6 and weight of 155.9 lbs. Documented was: Regular diet with dysphagia Puree texture and thin liquids per order nosey cups for beverages staff feed Resident foods and fluids monitor intake all meals monitor tolerance to food textures and fluid consistencies in diet during meals, notify nurse of increased chewing or swallowing difficulties monitor labs as available monitor weights as directed notify MD of significant weight variances medications per order vitamin/mineral supplements per order . Total intake: 1772-2126 calories, 71 g protein, 1625-1950cc fluids. Surveyor reviewed R12's Comprehensive Care Plan with an assessment date of 3/25/20. Documented was Sporadic appetite changes related to dementia disease progressive [as evidenced by (AEB)] variable PO intake of meals which may vary depending on staff members and/or day. Inadequate oral intake r/t decreased appetite AEB oral intake 44% was 76%. Interventions: notify MD of significant weight variances, monitor labs as available, po intake, tolerance of food textures, swallowing difficulties, weight as directed. Surveyor reviewed R12's MD-O visit note with a date of 4/28/20. Documented was .Nursing tells me that at times she does not eat but this seems to be because of her mood; nursing will attempt to feed her a little later and she will eat her meal . Assessment and Plan: Dysphagia - The pt is at risk for aspiration. Monitor safety of swallowing and adequacy of nutritional intake. Await further speech recommendations. There was no referral to Speech Therapy or MD order for Speech Therapy evaluation. Surveyor reviewed May weight as 155.1 lbs. On 5/21/20 a MD Order was placed for R12 that documented Fortified foods with meals. Surveyor reviewed June weight as 155.0 lbs. On 6/18/20 an MD Order was placed for R12 that documented Magic cup twice daily. Surveyor reviewed July weight as 155.1 lbs. Surveyor reviewed August weight as 155.0 lbs. Surveyor reviewed September weight as 158.4 lbs. Surveyor reviewed Care Plan with a date of 9/10/20. Documented was oral intake 40% (was 44%). Oral intake has decreased from 76% to 44% to 40%. On 9/11/20 a MD Order was placed for R12 that documented Magic cup: to offer after meals (3x daily) and Prostat 30 ml daily for protein supplement. Surveyor reviewed Nutritional Assessment with a date of 9/23/20 that was documented by Former Registered Dietician (RD)-E. The assessment indicates: .staff feed resident using regular utensils . weight is up 2.2% 30 and 90 days and up 1.6% 180 days. Estimated Nutritional Needs were documented as calories: 2160, protein: 72-94g, and fluids: 2160 +/- 250. Surveyor reviewed R12's MD-O visit note with a date of 9/28/20. Documented was Oropharyngeal dysphagia: The patient is at risk for aspiration pneumonia. On a downgraded diet oral intake is expected to be less. Continue to monitor swallowing safety and monitor for adequate oral intake. From time to time she should be assessed by Speech therapy . Weight was documented as 158.4 lbs. MD note also added an additional diagnosis. Documented was .Moderate protein calorie malnutrition (weight for age 60-74% of standard). This is to be discussed further with nursing. The patient is at nutritional risk because of developmental delay. Follow weights and laboratory parameters with regard to nutrition and intervene accordingly . There was no speech therapy evaluation noted and no documentation of discussion with nursing. Surveyor reviewed R12's Nutrition: Amount Eaten for September 2020. Out of 90 opportunities total, 3 were blank, 50 were documented at 0-25% eaten (44%), 13 were documented at 25-50% eaten, 12 were documented at 50-75% eaten, and 12 were documented at 75-100% eaten (13%). Surveyor reviewed R12's Nutrition: Snacks Eaten for September 2020. Out of 90 opportunities total, 8 were blank, 23 were documented Yes, snack was eaten and 59 (66%) were documented No, snack was not eaten. Surveyor reviewed October weight as 156.4 lbs. Surveyor reviewed R12's Nutrition: Amount Eaten for October 2020. Out of 93 opportunities total, 6 were blank, 48 were documented at 0-25% eaten (52%), 13 were documented at 25-50% eaten, 5 were documented at 50-75% eaten, and 20 were documented at 75-100% eaten (22%). Surveyor reviewed R12's Nutrition: Snacks Eaten for October 2020. Out of 93 opportunities total, 8 were blank, 13 were documented Yes, snack was eaten and 72 (77%) were documented No, snack was not eaten. Surveyor reviewed R12's Nutrition/Dietary note with a date of 10/29/20. Documented by Former RD-E was Nutrition Update: Weight 156.4# stable in 155-158# range. See MD orders, [Treatment Administration Record (TAR)], weekly skin reviews, wound evaluation tracker, nurse progress notes regarding skin integrity of buttocks, [left (L)] heel, L lateral foot, L callus area and L ankle. Staff feed Resident meals and supplements using regular utensils. Nosey cups used for beverage intake. Resident receives a Regular diet with dysphagia Puree texture and thin liquids, is tolerating food textures and fluid consistencies in diet without increased chewing or swallowing difficulties noted. Overall meal intake 38% (was 46% in 9/23 reassessment) which yields ~884 calories and 39g protein. Receives Magic cup supplement x3/day after meals and per review of the [Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Is also receiving Prostat 30cc every day and Resident accepts this as well which adds 100 calories and 17g protein to daily intake. Estimated nutritional needs: 2133 calories (30/71.1kg), 71-92g protein (1-1.3g/71.1kg) and 2133cc +/-250cc fluids (30cc/71.1kg). Combined intake yields ~1884 calories and 83g protein. Will add fortified foods to diet order. POC reviewed and updated. Will follow and assist as needed. Combined intake was 249 calories short of estimated needs. Surveyor noted former RD-E added fortified foods which had already been added to meal on 6/15/20. Please note that this dietary assessment and plan was based on the premise that the resident's weight has been stable in the 155-158 lb. range. Surveyor reviewed Care Plan with a date of 10/29/20. Documented was oral intake 38% (was 40%). Oral intake has decreased from 76% to 44% to 40% to 38%. Surveyor reviewed R12's MD-O visit note with a date of 11/4/20. Documented was Oropharyngeal dysphagia: The pt is at risk for aspiration PNA (pneumonia). On a downgraded diet oral intake is expected to be less. Cont to monitor swallowing safety and monitor for adequate oral intake. From time to time she should be assessed by Speech therapy . Weight 156 lbs . Moderate protein calorie malnutrition (weight for age 60-74% of standard). This is to be discussed further with nursing. The patient is at nutritional risk because of developmental delay. Follow weights and laboratory parameters with regard to nutrition and intervene accordingly. Surveyor noted there was no speech therapy evaluation noted and no documentation of discussion with nursing. Surveyor reviewed November weight as 156.0 lbs. The documented date was 11/9/20. Surveyor reviewed R12's MD-O visit note with a date of 11/20/20. Documented was Appetite is about the same . Oropharyngeal dysphagia: The pt is at risk for aspiration PNA. On a downgraded diet oral intake is expected to be less. Cont to monitor swallowing safety and monitor for adequate oral intake. From time to time she should be assessed by Speech therapy . Weight 156 lbs . Moderate protein calorie malnutrition (weight for age 60-74% of standard). This is to be discussed further with nursing. The patient is at nutritional risk because of developmental delay. Follow weights and laboratory parameters with regard to nutrition and intervene accordingly. Surveyor noted there was no speech therapy evaluation noted and no documentation of discussion with nursing. Surveyor reviewed R12's Nutrition: Amount Eaten for November 2020. Out of 90 opportunities total, 5 were blank, 60 (67%) were documented at 0-25% eaten, 11 were documented at 25-50% eaten, 4 were documented at 50-75% eaten, and 10 (11%) were documented at 75-100% eaten. Surveyor reviewed R12's Nutrition: Snacks Eaten for November 2020. Out of 90 opportunities total, 7 were blank, 10 were documented Yes, snack was eaten and 73 (81%) were documented No, snack was not eaten. Surveyor reviewed R12's 12/18/20 Dehydration Risk Screener assessment. Documented score was 6.0: not at risk. Surveyor reviewed R12's Nutrition/Dietary note with an assessment date of 12/23/20 and a locked/signed date of 12/24/21. Documented by Former RD-E was Nutrition Assessment .Most recent weight: 107.2 12/24/20 . Estimated calories needs: 1773, protein 59, fluids 1477-1773. Overall intake from meals yields ~1223 calories and 48g protein. Per review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] ~57% which adds ~513 calories and 15g protein to daily intake. Combined intake ~1736 calories and 63g protein. Intake from meals 46% or more coupled with magic cup supplement will meet energy needs. Inadequate oral intake from meals related to decreased appetite as evidenced by overall meal intake 45%; supplement ordered to increase provision of calories and protein and overall acceptance 57%. Documentation of meals eaten stated that 60 out of 90 times resident ate 0-25% of meals short of 57% needed. No added documentation, interventions or care plan items were added for the resident. There is no documentation of the dramatic weight loss or explanation of weight loss. Another weight was taken and documented on 12/29/20 at 109.4 Lbs. Surveyor reviewed R12's MD-O visit note with a date of 12/29/20. Documented was Appetite is about the same. Oropharyngeal dysphagia: The pt is at risk for aspiration PNA. On a downgraded diet oral intake is expected to be less. [Continue] to monitor swallowing safety and monitor for adequate oral intake. From time to time she should be assessed by Speech therapy. Weight 107.2 . Moderate protein calorie malnutrition (weight for age 60-74% of standard). This is to be discussed further with nursing. The patient is at nutritional risk because of developmental delay. Follow weights and laboratory parameters with regard to nutrition and intervene accordingly. Surveyor noted there was no speech therapy evaluation noted and no documentation of discussion with nursing. There is no documentation of the dramatic weight loss or explanation of weight loss. Surveyor reviewed R12's Nutrition: Amount Eaten for December 2020. Out of 93 opportunities total, 9 were blank, 60 (65%) were documented at 0-25% eaten, 7 were documented at 25-50% eaten, 2 were documented at 50-75% eaten, and 15 (16%) were documented at 75-100% eaten. Surveyor reviewed R12's Nutrition: Snacks Eaten for December 2020. Out of 93 opportunities total, 19 were blank, 12 were documented Yes, snack was eaten and 62 (67%) were documented No, snack was not eaten. Surveyor reviewed R12's Progress Notes. On 1/7/2021 at 11:56 AM Former Director of Nursing (DON)-P documented Weight Note: A review of weights was completed at the facility. Writer questions the accuracy of some of the recorded weights. The Physician and responsible party were notified of these potential inaccuracies. Residents with a weight that was deemed potentially inaccurate will be weighed daily x3, and weekly x3 to establish a new baseline weight. Surveyor noted there was no indication of an assessment of prior weights, nutrition notes, or history of documented monthly weights that were in the 154 to 156 lbs. to determine possible reasons for weight loss beyond indicating 9 months of previous weights and assessments were inaccurate. Surveyor reviewed R12's January weights. Documented was 1/8/21 107.8 lbs., 1/9/21 107.9 lbs., 1/10/21 107.9 lbs., 1/16/2021 108.8 lbs., 1/23/21 109.0 lbs and 1/30/21 109.0 lbs. Surveyor reviewed R12's Nutrition/Dietary note with a date of 1/28/21. Documented by Former RD-E was Nutrition Update: Weight 109#; up 1.7% 30 days, down 30.3% 90 days and down 29.7% 180 days (unplanned). PMH: dementia. Staff feed Resident and nosey cups used for beverages. Regular utensils are used during meals. Resident receives a Regular diet with dysphagia Puree texture and thin liquids-fortified foods all meals. Chews/swallows effectively. Overall intake from meals 26% which yields ~706 calories and 28g protein. Receives Magic Cup supplement after meals and per review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] ~63% (was 57%) which adds 567 calories and 17g protein to daily intake. Skin intact and no [CONDITION(S)] noted for Resident. Estimated nutritional needs: 1486-1734 calories (30-35/49.5kg), 50-59g protein (1-1.2g/49.5kg) and 1500cc fluids(minimal). Combined intake ~1273 calories and 45g protein. Intake from meals needs to be 34% or better coupled with current acceptance of magic cup supplement to meet nutritional needs. POC reviewed and updated. As dementia process progresses Resident may continue to demonstrate decreased appetite. Will follow and assist as needed. Surveyor noted the combined intake was 213 to 461 calories and 5 to 14 grams of protein short of estimated needs. Former RD-E did not add any additional interventions. Surveyor reviewed Care Plan with a date of 1/28/21. Documented was oral intake 26% (was 38%). Oral intake has decreased from 76% to 44% to 40% to 38% and now to 26%. Surveyor reviewed R12's Nutrition: Amount Eaten for January 2021. Out of 90 opportunities total, 10 were blank, 45 (50%) were documented at 0-25% eaten, 16 were documented at 25-50% eaten, 15 were documented at 50-75% eaten, and 9 (10%) were documented at 75-100% eaten. Surveyor reviewed R12's Nutrition: Snacks Eaten for January 2021. Out of 90 opportunities total, 20 were blank, 16 were documented Yes, snack was eaten and 54 (60%) were documented No, snack was not eaten. Surveyor reviewed weight documented on 2/1/21 as 105.4 lbs. On 2/8/21, R12's Care Plan was updated. Documented was At risk for alteration in nutritional status weight loss and/or gain r/t dramatic cog impairment, [CONDITION(S)], seizures, delusions. Interventions included Determine likes/dislikes, Document amount of meals consumed, Provide set up and adaptive equipment as specified, total assist with meals, Weight per protocol, update MD if 5 lb. gain or loss. Surveyor reviewed R12's Progress Notes. Documented on 2/9/21 was Resident alert and pleasant. More active when resident is up in broda chair. Mainly prefers drinking fluid, occasionally eats pureed meals. Given magic cup/magic cup supplement after meals and milk shake. % listed on MAR. Documented on 2/10/21 was Resident did not eat, or ate less than 50%, 3 meals in a 72 hour time period. Supplement taken. On 2/10/21 a Food Preference Assessment was completed. Documented was Adaptive Equipment: Nosey Cup: Breakfast, Lunch, Dinner. Surveyor reviewed R12's Nutrition/Dietary note with a date of 2/11/21. Documented by Former RD-G was Resident reviewed for 3.6# weight loss 1/30-2/1. Weight was within 107-109# range since 12/24. Goal is weight maintenance AEB no [significant weight (sig wt)] changes x 30-180 days. Will be monitored on daily x3, weekly until 3/19 per MD order to establish new baseline. Goal is wt maintenance AEB no sig wt changes x 30-180 days however gradual wt gain towards normal BMI would be desirable. Est. needs at [Current Body Weight (CBW)]: 1440-1680 cals (30-35 cal/kg), 48g pro (1.0 g/kg), 1440-1680 ml fluid (30-35 ml/kg). Resident on pureed diet with fortified foods. PO intakes 25% on average overall. Increased intakes noted for 2 meals today, 2/11. Receives total feeding assistance at meals. Dx dementia may negatively impact po intakes. To meet est needs, res receives Magic Cup TID after meals. 25-100% acceptance per eMAR. Encourage resident to consume at least 50% of meals and supplement to meet est needs. Continue to monitor and follow up prn . An order was put in for R12 on 2/11/21 with a start date of 2/12/21. Documented was WEIGHT - daily - Call MD if wt change of +/- 5 pounds; one time a day for 3 days. A weight was taken 2/12/21 and 2/14/21 but not 2/13/21. An order was put in for R12 on 2/11/21 with a start date of 2/26/21. Documented was WEIGHT - daily - Call MD if wt change of +/- 5 pounds; one time a day every Friday for 3 weeks. Per RD recommendation, weights should have been taken 2/19/21 and 2/26/21. There is no documented weight on these dates. The next weight was taken 3/5/21. On 2/15/21 an MD Order was placed for R12 that documented Boost supplement after meals. The resident was noted to consistently drink 100% of Boost. On 2/24/21 a set of labs were drawn for R12. R12's [MEDICATION(S)] was noted to be low at 1.9 g/dL with a normal range of 3.8-5.0 g/dL. According to the University of Rochester Medical Center documented in What do my test results mean? was [MEDICATION(S)] .Results are given in grams per deciliter (g/dL). A normal [MEDICATION(S)] range is 3.4 to 5.4 g/dL. If you have a lower [MEDICATION(S)] level, you may have malnutrition. It can also mean that you have liver disease or an [CONDITION(S)] disease. Higher [MEDICATION(S)] levels may be caused by acute infections, [CONDITION(S)], and stress from surgery or a [CONDITION(S)]. https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=167&contentid=albumin_blood Surveyor reviewed R12's Nutrition: Amount Eaten for February 2021. Out of 84 opportunities total, 7 were blank, 55 (65%) were documented at 0-25% eaten, 10 were documented at 25-50% eaten, 6 were documented at 50-75% eaten, and 6 (7%) were documented at 75-100% eaten. Surveyor reviewed R12's Nutrition: Snacks Eaten for January 2021. Out of 84 opportunities total, 16 were blank, 7 were documented Yes, snack was eaten and 61 (73%) were documented No, snack was not eaten. Surveyor reviewed weight documented on 3/5/21 as 103.0 lbs. Surveyor reviewed R12's Nutrition/Dietary note with a date of 3/11/21. Documented by Former RD-G was Resident's weight loss reviewed at WAR on this date. Triggered for significant weight loss x180 days however 11/9-12/24 weight loss inaccurate. Weight has been trending down 12/29-3/5 which was discussed. R/t poor appetite, advanced dementia. PO intakes 0-25%. She requires extensive assistance at meals. Per staff, meal intakes may vary depending on staff member and/or day which is expected r/t dementia. Receives Boost TID and accepts well (100% to provide additional 720 cals, 24g pro). Average intake with supplement providing ~1270 cals/day. Resident drinks fluids better than pureed meals- offer other high calorie beverages such as chocolate milk, whole milk, etc. Continue to honor food preferences. Follow up prn. Surveyor noted these interventions were not added to the care plan or the Certified Nursing Assistant (CNA) care plan. On 4/14/21 at 12:55 PM Surveyor interviewed Former RD-G. Surveyor asked when she completes Nutritional Assessments. RD-G stated quarterly and as needed. RD-G stated she did a note on 2/11/21 and 3/11/21 after establishing a new baseline. Surveyor asked if she was aware of past weights in the 150's. RD-G stated no, she was told those were inaccurate. Surveyor noted that resident's history and physical from the time of admission documented her weight in the 150's. RD-G stated she was unaware of that. Surveyor asked about R12's appetite. RD-G stated the CNAs that fed her reported it as poor and eating 0 to 25% on average. Surveyor asked what was done to address the poor appetite. RD-G stated in February she discontinued the Magic Cup and added Boost since she liked drinking Boost. Surveyor asked if she was aware of critical sodium lab values. RD-G stated no she was unaware. Surveyor asked if she would usually be updated on lab values. RD-G stated not necessarily all labs but she should be informed of hydration and nutritional labs that affect intake. On 3/11/21 a set of labs were drawn for R12. R12's [MEDICATION(S)] was noted to be low at 1.7 g/dL with a normal range of 3.8-5.0 g/dL. On 3/11/21 MD-O wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Former RD-G and Current RD-F were unaware of this order. On 3/11/21 Former DON-P documented in Progress notes. MD contacted and notified of weight variance. MD changed order to complete monthly weights only. RD/[Power of Attorney (POA)] notified of change. There are no added interventions or assessment of weight loss noted in R12's chart. Also in Progress Notes was on 3/11/21 documented MD updated on lab results and results of [chest x-ray (CXR)] with impression of right lower lobe infiltrate with possible small volume pleural effusion may be due to pneumonia or atelectasis. New order received for [MEDICATION(S)] 500mg po [daily (QD)] x's 7 days and repeat labs in a.m. Pharmacy and Lab updated. [POA] updated on condition and new orders received per MD. On 3/12/21 another set of labs were drawn for R12. R12's Sodium was noted to be high at 147 mmol/L with a normal range of 136-145. According to Medical News Today, [CONDITION(S)] occurs when the serum sodium concentration is higher than 145 milliequivalents per liter (mEq/l) . It means that the level of sodium in a person's blood is too high. Two common causes of [CONDITION(S)] are insufficient fluid intake and too much water loss. In rare cases, consuming too much sodium can cause [CONDITION(S)] to occur. https://www.medicalnewstoday.com/articles/[CONDITION(S)] On 3/15/21 an MD Order was placed for R12 that documented Speech therapy evaluation and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor noted despite MD notes stating Speech evaluation from time to time going back to 2020, this is the first Speech evaluation order noted for R12. Speech Therapy evaluated and treated R12 3/16/21 through 3/30/21. On 3/15/21 another set of labs was drawn. Sodium came back at 151 and continued to trend up. MD wrote on lab results sheet Please PUSH FLUIDS, Sodium is going up. Please check CBC and CMP in one week. Push fluids was not added to MD orders and not transcribed onto MAR (Medication Administration Record). Fluid intake for R12 at baseline per Nutritional Assessment was 1500 cc per day. Surveyor reviewed R12's fluid intake for starting 3/15/21 when MD order for PUSH FLUIDS was in place. Fluids intake was documented as: 3/15/21: 1020 cc (480 cc short of 1500 cc) 3/16/21: 1360 cc (140 cc short of 1500 cc) 3/17/21: 960 cc (540 cc short of 1500 cc) 3/18/21: 1320 cc (180 cc short of 1500 cc) Surveyor reviewed R12's 3/18/21 Dehydration Risk Screener assessment. Documented score was 6.0: not at risk. The assessment was blank for WEIGHT and RISK FACTORS and did not address weight loss, history of dehydration, female, low BMI which would have put the resident at risk. Surveyor reviewed R12's fluid intake for starting 3/19/21. Fluids intake was documented as: 3/19/21: 680 cc (820 cc short of 1500 cc) 3/20/21: 1320 cc (180 cc short of 1500 cc) 3/21/21: 1080 cc (420 cc short of 1500 cc) 3/22/21: 2160 cc (660 cc over 1500 cc) 3/23/21: 960 cc (540 cc short of 1500 cc) Surveyor reviewed R12's Nutrition/Dietary note with a date of 3/23/21. RD-F documented Resident last reviewed 3/11 r/t triggered for significant weight loss x180 days however 11/9-12/24 weight loss inaccurate. Wt trending down from 12/29-3/5. Wt loss r/t poor appetite, advanced dementia. PO intakes of Regular diet/Dys Puree texture/Fortified foods with all meals continues b/t 0-25%. She requires extensive 1:1 assistance with meals. Per staff, meal intakes may vary depending on staff member and/or day which is expected r/t dementia. Receives Boost TID and accepts well (100% to provide additional 720 kcal, 24 g pro). Combined intake of avg meals and supplement providing ~1290 kcal/day. 1500 mL fluids. Tolerates Regular diet/Dys Puree texture well. Resident drinks fluids better than pureed meals - offer other high calorie beverages such as chocolate milk, whole milk, etc. Continue to honor food preferences. She is predicted to be meeting estimated needs for goal of wt maintenance (1160-1257 kcal, 47-56g pro). CBW: 103# BMI: 16.6 (underweight) Continue with current poc and adjust prn (as needed). Assessment noted that R12 was underweight and does not address plan for weight gain, only weight maintenanc [TRUNCATED]

Based on interview, and record review, the facility did not provide necessary treatment and services to promote healing for 1 (R11) of 5 residents reviewed for pressure injuries. R11's treatment was incorrectly transcribed on 3/11/21 and the care plan was not revised. Surveyor observed the incorrect cleansing solution being applied to R11's pressure injury on 3/16/21 according to Wound Doctor-I's orders and noted R11 has been receiving the incorrect treatment since 3/11/21. Findings include: R11's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R11 has a history of pressure injuries and R11's stage 3 pressure injury was healed on 5/7/20. R11's care delivery guide not dated under behavior includes Chronic complaints due to borderline personality disorder refuse psych services, resistive to cares and showers refuses to be repositioned. Under the skin section is checked for air mattress, wheelchair cushion, heels off, black foam pad to right leg on wheelchair and catheter tubing off skin. R11's at risk for skin integrity care plan initiated 3/16/18 & revised 9/12/19 documents interventions of: Assess skin for redness or pressure related changes with each care encounter. Report any changes immediately to nurse. Initiated & revised on 3/16/18. Avoid friction/shearing while repositioning: if Resident is unable to assist, use at least two staff members, use lift sheet, bed should be as flat as possible with lifting. Initiated 3/16/18. Barrier cream is applied to buttock and peri area for protection with adls (activities daily living). Initiated 3/16/18 & revised 8/26/19. Before transferring, be sure roho cushion is in wheelchair. Ensure cushion is properly placed, clean and dry. Initiated & revised 3/16/18. Blood sugar checks to be done, per MD (medical doctor) order, and assess for s/s (signs/symptoms) of hypo/[CONDITION(S)]. Report to MD results that are out of parameter ordered by MD. Initiated 3/16/18. Check skin surrounding both suprapubic catheter and [CONDITION(S)] for changes with cares. Report any skin changes to nurse. Initiated 3/16/18. Conduct pressure injury skin assessments (i.e. Braden Scale) per protocol. Initiated 3/16/18. Encourage to only be up in wheelchair for only 2 hours. Initiated 3/16/18 & revised 8/26/19. Ensure foley tubing not resting on skin after repositioning. Initiated 8/28/18. Float heels in bed. Risk vs benefit completed on using heels off device vs pillows. Initiated 3/16/18 & revised 3/9/21. Frequent repositioning in bed and chair. Is on repositioning program every 2 hours and prn (as needed). Initiated & revised 3/16/18. Gripper socks initiated 9/4/18 & revised 8/26/19. Move remote off bed prior to cares 8/31/18. Initiated 9/4/18 & revised 8/26/19. Resident has air mattress. Assure proper inflation Check frequently to be sure inflated at correct pressure. Initiated 3/16/18 & revised 9/12/19. RESOLVED: Resident left great toe remain clean and dry at all times. Initiated 1/29/19, revised & resolved on 3/21/19. Resident spends time in bed watching TV, playing electronic games, puzzle books and visits with friends and staff, comes out of room for BINGO and MD appointments. Initiated 9/12/19. RESOLVED: Staff nurse will complete treatment to left great toenail bed as ordered every other day until f/u (follow up) with podiatry on 10/17/18. Initiated 10/8/18, revised & resolved on 3/21/19. Treatments will be completed as ordered by physician. Initiated 6/20/18. The actual skin integrity care plan initiated 3/20/19 and revised 2/17/21 documents interventions of: Apply alternating pressure air mattress to bed if indicated. Assure and maintain proper inflation controls. Initiated 3/20/19. CANCELED: Apply chair cushion to wheelchair (roho cushion). Ensure proper placement and clean daily. Initiated 3/20/19, revised and canceled on 9/12/19. Assess and measure all skin integrity areas per policy. Initiated 3/20/19. Follow pressure ulcer prevention guidelines to prevent additional skin problems, promote healing and prevent complications. Initiated 3/20/19. Initiate skin monitoring forms per facility policy. Initiated 3/20/19. Initiate treatment per Physician order. Initiated 3/20/19. Monitor and report any new open areas, drainage, increased drainage or pan to nurse immediately. Initiated 3/20/19. Monitor for c/o (complaint of) pain. Medicate PRN and offer pain medication prior to treatment. Update Physician regarding effectiveness and increased need for pain medications. Initiated 3/20/19. Provide treatment to wound(s) per current treatment order. Assess wound(s) for s/s of infection with each dressing change/treatment, Report findings of redness, warmth, swelling, increased drainage or increased pain to physician immediately. Initiated 3/20/19 and revised 8/26/19. Report wound progress or decline to MD with any changes or lack of response to treatment per facility guidelines. Initiated 3/20/19. RESOLVED Res (resident) put on isolation 9/21/20. Initiated 9/21/20, revised and resolved 2/28/21. Roho cushion to w/c (wheelchair). Ensure proper inflation before placing resident into w/c. Initiated 3/20/19. Staff member to be educated to have machines all moved to proper sides of the hall or have fell ow staff members move peers out of way for all safety. Initiated 4/28/19. The nurses note dated 1/28/21 documents IDT (interdisciplinary team) met to discuss recent re-opening of chronic coccyx wound 4 cm (centimeters) x (times) 6 cm open with white patches, red patches, scan sero-sang drainage. Resident has history of refusing to be repositioned. Alternating Pressure Air mattress and heels off device used at all times. Staff will continue to encourage resident to be repositioned. Treatment will be completed as ordered until healed. The nurses note dated 1/28/21 documents Res (Resident) resting in bed. Coccyx dressing intact. Does not want to be awakened at night. She feels the mattress should be doing enough to alternate the pressure. Encouraged to be turned. The wound evaluation tracker dated 1/28/21 documents site as; 53) Sacrum, type Pressure, Length 4, Width 6, and Stage IV (4). Under wound bed is 100% skin. Under additional descriptions documents, Recurrent stage 4 pressure injury. Under current wound status/additional comments documents, Area to sacrum presents as healing sheering injury, 100% scarred, intact skin with no noted break in skin, drainage or s/s of infection. Wound edges defined and intact, surrounding skin warm dry intact with scar formation. Resident denies pain to area when questioned. Resident has previous healed sacrum wound. Within the previous scar tissue filled wound resident has a break in skin caused by sheering. The wound evaluation tracker dated 2/4/21 for the Sacrum documents, Length 4, Width 6and Depth is blank. Under wound bed is 100% skin. The wound evaluation tracker dated 2/11/21 for the Sacrum documents, Length 4, Width 6and Depth is blank. Under wound bed is 100% skin. The Annual MDS (minimum data set) with an assessment reference date of 2/13/21 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R11 requires extensive assistance with two plus person physical assist for bed mobility & toilet use, is dependent with two plus person physical assist for transfer, and does not ambulate. R11 is checked for indwelling catheter and ostomy. R11 is at risk for developing pressure injuries and is coded as having 1 Stage 4 pressure injury. The pressure injury CAA (care area assessment) under care plan considerations documents Resident has a chronic pressure ulcer on her sacrum that requires daily treatment. Resident refuses to get out of bed most days. Resident also refuses repositioning frequently. Resident is on air mattress, receives prostat and MVI (multivitamin) for wound healing. Staff will continue to encourage repositioning as well as providing MD ordered wound care daily. The wound evaluation tracker dated 2/18/21 for the Sacrum documents Length 4, Width 6and Depth is blank. Under wound bed is 100% skin. The wound evaluation tracker dated 2/25/21 for the Sacrum documents, Length 3.9, Width 8.9 and Depth is blank. The wound bed is 100% granulation. Under current wound status/additional comments documents, Area to sacrum presents as healing sheering injury, 100% scarred, intact skin with no noted break in skin, drainage or s/s of infection. Wound edges defined and intact, surrounding skin warm dry intact with scar formation. Resident denies pain to area when questioned. Resident had previous healed sacrum wound. Within the previous scar tissue filled wound resident has a break in skin caused by sheering. Resident had appointment with wound care that stated wound is recurrent stage 4 pressure. Trackers updated. The wound evaluation tracker dated 3/4/21 documents for site; 53) Sacrum, Type Pressure, Length 4, Width 2, Depth is blank, and Stage IV (4). The wound bed is not described. Under current wound status/additional comments documents, Area to sacrum presents as healing sheering injury, 100% scarred, intact skin with no noted break in skin, drainage or s/s of infection. Wound edges defined and intact, surrounding skin warm dry intact with scar formation. Resident denies pain to area when questioned. Resident had previous healed sacrum wound. Within the previous scar tissue filled wound resident has a break in skin caused by sheering. Resident had appointment with wound care that stated wound is recurrent stage 4 pressure. Trackers updated. Wound Doctor-I's wound evaluation dated 3/10/21 under orders for wound cleansing and dressing documents, Cleanse with 1/4 strength Dakin's solution, Protect periwound with Skin Prep, Apply [MEDICATION(S)] Blue (cut to size) to wound bed, Cover with ABD (abdominal), Secure dressing with Medi/[MEDICATION(S)], Change Daily, Change PRN (as needed) for soiling and/or saturation. Under notes documents, Bed rest except for appointments please. Recommend stretcher transport for appointments. and May use DermaBlue. Surveyor noted R11's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor reviewed R11's March 2021 MAR (medication administration record) and noted with a start date 3/11/21 documents, wash coccyx wound with NS pat dry followed by skin prep to peri area and Derma-blue foam to wound bed followed by gauze to wound bed covered with hypoflex daily in the morning for wound care. Surveyor noted this treatment is checked, which indicates administered, & initialed on the 11th, 12th, 13th, 14th, 15th, 16th, & 17th. Surveyor noted a discrepancy between the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound evaluation tracker dated 3/11/21 for sacrum documents for Length 3.2, Width 2.88, Depth 2.10. Wound bed is 100% granulation. Under current wound status/additional comments documents see wound note. Surveyor noted R11's skin integrity care plan was not revised after R11's sacrum deteriorated and there is now a depth of 2.1. On 3/16/21 at 10:05 a.m. Surveyor observed R11 in bed on her back with the head of the bed up high. There is a pillow under R11's right shoulder. Surveyor asked R11 if she has anything on her feet. R11 replied no and explained she doesn't want anything on her feet. Surveyor asked if staff floats her heels. R11 informed Surveyor her feet are on a pillow. Surveyor observed a heels up pad underneath linen on the chair and asked R11 about the heels up pad. R11 informed Surveyor she won't use it as it makes her urinate and then she's wet. Surveyor inquired if staff has completed her treatment. R11 replied no. Surveyor asked R11 if Surveyor could observe her treatment. R11 replied I wish someone would. Surveyor asked how often the nurses do her treatment. R11 informed Surveyor one time a day sometimes twice if it's soiled. Surveyor observed R11 has an air mattress on her bed. On 3/16/21 at 11:27 a.m. Surveyor observed R11's sacrum treatment with LPN (Licensed Practical Nurse)-G with the assistance of DON (Director of Nursing)-B. LPN-G placed a basin containing treatment supplies on top of a paper towel on the over bed table. LPN-G washed her hands and placed gloves on. DON-B positioned R11 on her left side. Surveyor observed CNA (Certified Nursing Assistant)-F had removed the dressing over R11's sacrum pressure injury during personal cares prior to LPN-G entering R11's room. LPN-G pour normal saline in R11's pressure injury, cleansed the pressure injury with gauze, and dried the pressure injury & peri wound with gauze. LPN-G sprayed skin prep around the peri wound, removed scissors from her pocket and cleaned the scissors with an alcohol pad. LPN-G poured normal saline on [MEDICATION(S)] blue dressing and placed the [MEDICATION(S)] blue on the wound bed. LPN-G stated she needed a shorter piece, removed her gloves, washed her hands and placed gloves on. LPN-G cut a piece of gauze and placed the gauze over the [MEDICATION(S)] blue foam dressing. DON-B held the gauze in place while LPN-G placed a clear dressing on. On 3/16/21 at 2:27 p.m. Surveyor verified with LPN-G she used normal saline during R11's treatment. On 3/17/21 at 9:17 a.m. Surveyor met with DON-B to discuss R11's pressure injury. DON-B informed Surveyor R11's pressure injury it's a recurrent area that opens. DON-B indicated she believes the opening is the scar tissue shifting inside the previous wound. Surveyor inquired what happened that R11's pressure injury was identified as being open on 3/11/21. DON-B informed Surveyor R11 goes out for appointments and was sitting in her wheelchair. DON-B indicated prior R11 had been placed in wheelchair to go to appointments but since Wound Doctor-I saw her last week she hasn't been in the wheelchair and when she goes out for appointments she will go out on a stretcher. Surveyor informed DON-B Surveyor did not see any revisions in R11's care plan after the pressure injury declined and now had depth. Surveyor inquired about the pressure injury being staged as a Stage 4 when the skin was intact. DON-B informed Surveyor R11 went out to the wound clinic in February and they classified R11's pressure injury as a recurrent Stage 4. Surveyor asked where R11's treatment orders come from. DON-B informed Surveyor originally R11's pressure injury was being treated with [MEDICATION(S)] from the outside wound doctor a month ago. R11 agreed to see Wound Doctor-I and he changed the order to derma blue. DON-B informed Surveyor they follow Wound Doctor-I's orders. Surveyor asked who transcribes Wound Doctor-I's orders. DON-B replied I do. Surveyor asked why Wound Doctor-I's orders dated 3/10/21 are not the same orders on the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/17/21 at 10:16 a.m. DON-B informed Surveyor she transcribed the portion for normal saline incorrectly. DON-B explained they were using gauze instead of the ABD to hold the hydroblue in place as the ABD was not holding the hydroblue in place. Surveyor noted staff has been using the incorrect product to cleanse R11's pressure injury on 3/11, 3/12, 3/13, 3/14, 3/15, & 3/16. On 3/18/21 at 4:29 p.m. Surveyor received additional information from Administrator-A via email. Information includes the Facility does not dispute that a transcription error occurred related to the reoccurring stage 4 pressure injury. Surveyor noted as a result of transcribing Wound Doctor-I's order incorrectly R11 did not receive the correct care and treatment on on 3/10, 3/11, 3/12, 3/13, 3/14, 3/15, & 3/16/21. The Facility also indicated R11's care plans are reviewed on a quarterly basis by all departments to review and acknowledge that care plan focus goals and interventions have been reviewed and are still applicable for R11 to help maintain and improve skin integrity for R11. Dates provided are 7/29/20, 10/28/20, 1/28/21, 4/26/21, & 5/24/21. Surveyor noted R11's Stage 4 sacrum pressure injury identified on 1/28/21 caused by shearing was 100% skin and had no depth. Depth was not identified until 3/10/21 by Wound Doctor-I's note and wound evaluation tracker dated 3/11/21 which documents depth of 2.1. The dates of 4/26/21 & 5/24/21 are in the future. The Facility also indicated care plan reviews were conducted by the Director of Clinical Services on 2/25/21 & 3/9/21. Both of these dates are prior to the pressure injuring opening and having a depth of 2.1. Surveyor also noted R11's care plan does not address R11's preferences of how & when to be repositioned which may not align with Facility's interventions.

Based on interview, observation and record review, the facility did not ensure 1 (R2) of 3 residents reviewed for pressure injuries (PI) received care consistent with professional standards of practice to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. * R2 was admitted to the facility with a Stage 2 PI to the coccyx. R2 was at risk for developing further pressure injuries but did not have interventions in place to prevent PI's timely. The coccyx PI healed (on 1/21/21) and then reopened (1/29/21 as indicateed by the hospital record) and was not reassessed. R2 developed Deep Tissue Injuries to both heels. The PI's were not assessed timely, no updates were made to the care plan or MD until 7 days after they were identified. Findings included: The AMDA (American Medical Directors Association) clinical practice guideline entitled 'Pressure Ulcers and Other Wounds,' dated 2017, states in part: .A pressure ulcer [Injury] is localized damage to the skin or underlying soft tissue, usually over a bony prominence or related to a medical or other device. The ulcer may present as intact skin or as an open ulcer and may be painful. The ulcer occurs as a result of intense or prolonged pressure or pressure in combination with shear. Recognition: Early recognition of pressure ulcers and of any risk associated with the development of pressure ulcers and other wounds is critical to their successful prevention and management. Assessment: The purpose of the assessment is to collect enough information to evaluate the patient's general condition, characterize a pressure ulcer; and identify related causes and complications. Step 2. Examine the patient's skin thoroughly to identify existing pressure ulcers. Examine the patient's skin upon admission or readmission. Step 3. Assess the patient's overall physical and psychosocial health and characterize the pressure ulcers. A pressure ulcer should be assessed along with the patient's overall clinical, functional, and cognitive status weekly reassessment and documentation of ulcer characteristics is recommended. More frequent assessment may be necessary for ulcers that are not responding to treatment or are worsening despite treatment. Step 4. Identify factors that can influence ulcer treatment and healing.functional status. Functional factors, including impaired mobility, a self-care deficit, and incontinence (especially fecal incontinence), may influence the severity, duration, and healing of a pressure ulcer. Step 5.Documentation should cover all pertinent characteristics of existing pressure ulcers, including location; size; depth; maceration; color of the ulcer and surrounding tissues; a description of any drainage, eschar, necrosis, odor, tunneling, or undermining; tissue types covering the wound bed; .and a description of the peri-wound skin .including type and amount of drainage. Step 6. Identifying priorities in managing the ulcer and the patient .Pain control related to the ulcer and any comorbid conditions.The same factors that increase a patient's susceptibility to developing pressure ulcers .may also impair the healing of an existing pressure ulcer . Surveyor reviewed the facility's Pressure Ulcer/Injury, Prevention of policy with an Original Effective Date of June 2017. Documented was: PURPOSE: To prevent skin breakdown and development of pressure ulcers/injuries. PROCEDURE: 1. Assess for risk of pressure ulcer/injury development. a. Identify high and low risk residents. 2. Assess and identify complicating conditions that may contribute to pressure ulcer/injury development. 3. Develop care plan to eliminate or minimize risk factors including: a. Diet. b. Nutritional supplementation. c. Hydration. d. Pressure relief measures . 8. Use pressure reducing or relieving devices in resident's bed and chair. 9. Use foot cradle as necessary . DOCUMENTATION GUIDELINES: Documentation may include: * Date, time, approaches to prevent pressure ulcer/injury development. * Preventative equipment used. * Condition of the resident's skin. * Physician notification when change in condition is observed. * If a pressure ulcer/injury is present, the Licensed Nurse is responsible to record condition of the skin, including stage, size, site, depth, color, drainage and odor as well as the treatment provided. Notification of the physician is required when a new pressure ulcer/injury is identified as well as when treatment is not effective. * Signature and title. CARE PLAN DOCUMENTATION GUIDELINES: Problem: * Identify the appropriate problem under which to list the pressure ulcer/injury care as an approach. * Identify and treat the underlying cause of the pressure ulcer/injury. * Consider listing complicating conditions, as well as possible risks and complications. Goal: * List measureable goal(s) to be accomplished. If a pressure ulcer/injury is present this may be resolution of the cause of the pressure ulcer/injury as well as healing of the pressure ulcer/injury. * Identify target date. Approaches: * Identify responsible discipline for each approach. * Record instructions unique to this resident. * Identify approaches to optimal nutrition and nutritional support. * Monitoring of weight. * Appropriate diagnostic tests. * Record approached to promote adequate hydration. * Monitoring of appropriate diagnostic tests. * Identify necessary monitoring and observation of the underlying condition. * Record treatment as ordered. * Record all pressure reducing or relieving surfaces. * Identify frequency of positioning. * Record behavior management if appropriate. NOTE: Inspect skin upon admission and once a shift, particularly over bony prominences. Heels and sacrum are most common areas for skin breakdown. Use Braden or Norton scale for assessment of risk for development of pressure ulcers/injuries. Either scale should be completed weekly x4 then at least quarterly or upon clinical change in resident status. Document assessment findings . Surveyor reviewed R2's Hospital Discharge Summary with a discharge date of [DATE]. Documented under Plan was Pressure Wound: Present on arrival. Stage 2 on his coccyx. Air mattress and offloading. R2 was admitted to the facility on [DATE]. R2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor reviewed R2's Admission/Readmission Evaluation with a date of 1/7/21. Documented under Skin Integrity/Braden Scale was Braden Scale Total Score: 18 which indicated at risk for pressure injuries. Documented under Integrity was Site: Coccyx. Type: Pressure. Length: 1.0 cm. Width: 0.4 cm. Depth: 0.1 cm. Stage: II. No other wounds were documented. Documented under Heel Inspect was Dry/cracked but did not document any open [CONDITION(S)] or pressure areas. Surveyor reviewed the Admission Skin Assessment with a date of 1/7/21. The Assessment had a body drawn on it for front and back to label and mark open areas. On the coccyx was an X. On both heels was a circle around them and written purple area next to each circle. Documented under comments was Stage 2 on coccyx, 1cm X 0.4cm X 0.5cm. Dry feet and heels. Has boots for foot drop [with] no order. Boots were identified as blue soft boots used to protect heels from breakdown. Surveyor reviewed R2's Comprehensive Care Plan with initiation date of 1/8/21. Documented was Focus: Resident has actual skin integrity break and/or pressure sore(s) - See wound assessment Pressure Sore coccyx. Goal: The skin integrity areas will show signs of progressive healing without signs of infection or complication through review date. Interventions: - Apply chair cushion to wheelchair, Geri Chair or Broda Chair. Ensure proper placement and clean daily. - Monitor and report any new open areas, drainage, increased drainage or pain to nurse immediately. - Monitor for [complaints of] pain. Medicate [as needed (PRN)] and offer pain medication prior to treatment. Update Physician regarding effectiveness and increased need for pain medications. - Prostat, multi vitamin daily to promote wound healing. - Provide treatment to wound(s) per current treatment order. Assess wound(s) for [signs and symptoms (s/s)] of infection with each dressing change/treatment. Report findings of redness, warmth, swelling, increased drainage or increased pain to physician immediately. - Report wound progress or decline to MD with any changes or lack of response to treatment per facility guidelines. Hospital Discharge instructions of air mattress and offloading were not addressed. Surveyor reviewed R2's Wound Evaluation Tracker for coccyx PI with an effective date of 1/8/21 documented by Director of Nursing (DON)-B. Documented was Site: Coccyx. Type: Pressure. Length: 1.0 cm. Width: 0.3 cm. Depth: 0.0 cm. Stage: I. Current treatment was documented as Happy Butt Cream [twice daily] and PRN. Documented under Current Preventative Interventions was [wheelchair] cushion. Hospital Discharge instructions of air mattress and offloading were not addressed. Pressure Redistribution Mattress, Specific turn/reposition program, and heel protectors were not marked. Surveyor reviewed R2's MDS (Minimum Date Set) annual assessment with an assessment reference date of 1/12/21. Documented under Cognition was a BIMS (brief interview mental status) score of 15 which indicated cognitively intact. Documented under Functional Status for Bed Mobility was 3/3 which indicated Extensive Assistance - resident involved in activity, staff provide weight-bearing support; Two plus persons physical assist. Documented under Functional Status for Transfer was 4/3 which indicated Total dependence - full staff performance every time during entire 7-day period; Two plus persons physical assist. Surveyor reviewed R2's Care Area Assessment (CAA) related to Pressure Ulcer/Injury with an assessment date of 1/12/21. Documented under Care Plan Considerations was CAA triggered due to resident currently has an open area and is at risk for pressure wounds due to dependent with transfers and toileting, staff to monitor skin integrity, working with [Physical Therapy (PT)/Occupational Therapy (OT)] [per plan of care] no referrals at this time. Surveyor reviewed R2's Braden Scale for Predicting Pressure Sore Risks with an effective date of 1/14/21. Documented was a score of 20 which indicated not at risk. This contradicted the admission assessment of at risk for PI and the documented Stage 2 PI to coccyx. Surveyor reviewed R2's Skin Review - Weekly assessment with a date of 1/14/21 documented by DON-B. Documented was Skin Condition: .8a. Open Area. 8b. Pre-existing. 9. Other: see wound tracker. The rest of the assessment form was blank. Surveyor reviewed R2's Wound Evaluation Tracker for coccyx PI with an effective date of 1/14/21 documented by DON-B. Documented was Length: 0.8 cm. Width: 0.3 cm. Depth: 0. Current treatment was documented as cleanse with [normal saline] then pat dry followed by Happy Butt Cream. Documented under Current Preventative Interventions was [wheelchair] cushion. Hospital Discharge instructions of air mattress and offloading were not addressed. Pressure Redistribution Mattress, Specific turn/reposition program, positioning devices and heel boots were not marked. Surveyor reviewed R2's Daily Skilled Observation for 1/19/21 documented by Licensed Practical Nurse (LPN)-J. Documented under Skin Conditions Comments was Resident has a pressure ulcer forming on right heel of foot. Slightly blue/purplish. Applied pressure boots on resident to keep pressure off heel. No update to MD, change in care plan, order for boots, order for treatment or assessment was completed to right heel. LPN-J was unavailable for interview. Surveyor reviewed R2's Physical Therapy note for 1/20/21 documented by PT-G. Documented was Rounded with nursing regarding skin breakdown on heels - nursing will put skin protection cream on and discuss with staff regarding donning soft boots when in bed. [R2] reported someone telling him not to wear the soft boots when lying in bed, despite therapy advising to don boots when supine in bed to prevent skin breakdown . Surveyor reviewed R2's Skin Review - Weekly assessment with a date of 1/21/21 documented by DON-B. Documented was Skin Condition: Skin intact. The rest of the assessment form was blank. There was no documentation of skin breakdown on heels. Surveyor reviewed R2's Wound Evaluation Tracker for coccyx PI with an effective date of 1/21/21 documented by DON-B. Documented was Date wound healed: 1/21/2021. The rest of the assessment form was blank. Surveyor reviewed R2's Braden Scale for Predicting Pressure Sore Risks with an effective date of 1/21/21. Documented was a score of 20 which indicated not at risk. This contradicted the admission assessment of at risk for PI and the fact he had a Stage 2 PI to coccyx and documented breakdown to heels. Surveyor reviewed R2's Daily Skilled Observation for 1/26/21 documented by LPN-J. Documented under Summary was .Has pressure ulcer on bottom of both heels. Will monitor bleeding. Cleaned and applied dressing. No [signs and symptoms] of pain or distress. [Will continue to monitor.] Surveyor reviewed MD orders for R2. Documented with a start date of 1/26/21 was Wash heels with [normal saline] and pat dry. Apply skin prep to bilateral heels then cover with border gauze Daily and PRN. Surveyor reviewed R2's Skin Review - Weekly assessment with a date of 1/28/21 documented by LPN-F. Documented was Skin Condition: 2b. Pre-existing. 3a. Rash. 4a. Redness. 8a. Open Area. 9. All pre-existing are on sacrum, buttocks. The rest of the assessment form was blank. There was no documentation of skin breakdown on heels. There was no assessment of any wound. Last documentation on 1/21/21 noted the coccyx area was closed. Surveyor reviewed R2's Braden Scale for Predicting Pressure Sore Risks with an effective date of 1/28/21. Documented was a score of 20 which indicated not at risk. This contradicted the admission assessment of at risk for PI and has heel breakdown and documented open area to buttocks not addressed in scoring. Surveyor reviewed R2's Wound Evaluation Tracker for left heel PI with an effective date of 1/28/21 documented by DON-B. Documented was Site: Left heel. Type: Pressure. Length: 4 cm. Width: 3 cm. Depth: [blank]. Stage: Suspected Deep Tissue Injury. Current treatment was documented as wash with [normal saline] pat dry spray with skin prep and cover with border gauze. Documented under Date Treatment Ordered was 01/27/2021. There is no documented assessment of the wound on 1/19/21, 1/20/21 and on 1/25/21. Surveyor reviewed R2's Wound Evaluation Tracker for right heel PI with an effective date of 1/28/21 documented by DON-B. Documented was Site: Right heel. Type: Pressure. Length: 6 cm. Width: 3 cm. Depth: [blank]. Stage: Suspected Deep Tissue Injury. Current treatment was documented as wash with [normal saline] pat dry spray with skin prep and cover with border gauze. Documented under Date Treatment Ordered was 01/28/2021. There is no documented assessment of the wound on 1/25/21 when it was found. R2 was discharged to the hospital on 1/29/21 with Altered Mental Status and admitted . Hospital admission nursing charting documented a Stage 2 PI to coccyx 1.2cm x 0.5cm, unstageable PI to left heel 4cm x 2cm and unstageable PI to right heel 5cm x 3cm. On 2/3/21 Surveyor interviewed LPN-E. Surveyor asked about R2's PI to heels. LPN-E stated she works every Wednesday and every other weekend so she does not see R2 daily but remembers on 1/20/21 she noted his heels were red and mushy. LPN-E stated she went and retrieved a heel lift to float his heels on. Surveyor asked if his heels were being floated prior to 1/20/21. LPN-E stated every once in a while he would have a rolled up blanket under his legs but he did not have the heel lift in place until she put it there on 1/20/21. LPN-E stated he had blue boots in his room but they were not used. LPN-E stated DON-B had told her not to use them. Surveyor asked why they did not use them. LPN-E was unsure but was told the facility does not use the blue soft boots. Surveyor asked what LPN-E did with the assessment of the red and mushy heels. LPN-E stated she either passed the information on to second shift or put it on the 24 hour board. On 2/3/21 Surveyor interviewed LPN-F who documented the Admission Skin Assessment with a date of 1/7/21. Surveyor asked about R2's heels on admission. LPN-F stated he had red blanchable heels. LPN-F stated she did not write purple area on the sheet next to circled heels and was unaware who wrote that. LPN-F stated they were red and since he could not feel his legs she was afraid they would breakdown. LPN-F stated when she would work with him she would put a pillow under his legs. LPN-F stated there was no heel lift in place until after the wounds were found. Surveyor asked about R2's blue soft boots. LPN-F stated he had them but they were not used. On 2/4/21 at 10:53 AM Surveyor interviewed PT-G who documented R2's Physical Therapy note for 1/20/21. Surveyor asked about R2's heels. PT-G stated she was rounding with LPN-J on 1/20/21 and they looked at R2's heels. PT-G stated R2's heels were purple with blood blisters on both heels. Surveyor asked if R2's heels were floated. PT-G stated she had not seen his heels floated in bed until after this visit. Then the heel lift was in place. Surveyor asked about soft blue boots for the resident and her recommendation to wear them. PT-G stated R2 came from the hospital with blue boots. PT-G stated he had them on the first day but never after. PT-G stated DON-B told her they do not use them at the facility because they suck in moisture and can cause breakdown. PT-G suggested still using them but they were not used. Surveyor asked if she passed on the information about the observation of both heels being purple with blood blisters. PT-G stated she updated the Therapy team and LPN-J was going to update the nursing team. LPN-J was unavailable for interview during survey. A voicemail was left on 2/4/21 with no return phone call. On 2/3/21 at 3:50 PM and 2/4/21 at 12:03 PM Surveyor interviewed DON-B and Nursing Home Administrator (NHA)-A. Surveyor asked when DON-B was made aware of PI to heels. DON-B stated on 1/25/21 the wife was in the building working with R2 and PT on transfers for when he went home. DON-B stated the wife called her in to the room because she was concerned with his heels. DON-B stated the wife told her R2's heels did not look like they did now on discharge from the hospital. Surveyor asked what was done for his bilateral heel PI's on 1/25/21. DON-B stated she started the Wound Tracker, assessed the wounds, called the NP and put a treatment in place. Surveyor noted that the treatment was not started until 1/26/21 and Wound Tracker was not started until 1/28/21. Surveyor asked when the NP was contacted. DON-B stated she texted her on 1/26/21 at 10:26 AM. Surveyor asked when the treatment was put in place. DON-B stated 1/26/21. Surveyor asked why there was a delay. DON-B stated starting the Wound Tracker, assessing the wounds, calling the NP and putting a treatment in place should have been completed on 1/25/21. DON-B stated I did not assess them appropriately. Surveyor noted heel breakdown was found 1/19/21 by LPN-J. DON-B stated she was not aware and no one reported that to her. Surveyor asked what the process was if staff finds a wound. DON-B stated on their shift it should be assessed, NP/MD updated, treatment put in place and update her so she can assess it when she comes in. Surveyor asked what was being done to prevent heel breakdown prior to finding the wounds on R2's heels. DON-B stated an air mattress and heel lift. Surveyor asked when the air mattress was put in place. DON-B stated 1/11/21. Surveyor noted R2 was admitted [DATE] and there was a 4 day delay. DON-B was unsure why. Surveyor noted the heel lift was not in place until 1/20/21 when LPN-E put it there. Surveyor asked why she discouraged the use of blue boots for R2. DON-B stated I was told they are not favored to be used by the former DON because heels do not get checked. Surveyor asked if this was a facility policy. DON-B stated no, just what she was told. Surveyor asked about R2's Skin Review - Weekly assessment with a date of 1/21/21 documented by DON-B. Documented was Skin Condition: Skin intact. The rest of the assessment form was blank. There was no documentation of skin breakdown on heels. DON-B stated that was my fault. I must have not seen [his heels.] Surveyor asked about updating the Care Plan for R2's PI's to heels. DON-B stated he should have had a Care Plan for PI after they were found.

Based on record review and staff interviews, the facility did not always ensure that 1 out of 2 residents reviewed ( R1) for weight loss was provided with a comprehensive assessment and care planning to ensure a resident maintains acceptable parameters of nutritional status such as usual body weight or desirable body weight. R1 was admitted to the facility from the hospital after having surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was to wear a cervical collar at all times and also noted to have very limited use of both arms. R1's nutritional assessment, conducted [DATE] stated that R1's usual body weight (UBW) was ,d+[DATE] pounds and the ideal body weight (IBW) for R1 was ,d+[DATE] pounds. The admission Minimum Data Set (MDS), dated [DATE], states that R1 is in need of extensive 1 person physical assistance with meals. It was noted that the plan of care did not indicate what type of assistance R1 would need with his meal intake. On [DATE], R1 was readmitted to the facility after being in the hospital for A-Fib (Atrial Fibrillation). The re-admission nutritional assessment identified R1's weight is now 133.8 pounds and there is noted weight loss, although not significant. R1's meal intake is documented to be 75 %. The plan of care did not indicate that R1 was at risk for potentially losing more weight and also did not address the level of assistance R1 required with meals. A Quarterly Nutrition Assessment, dated [DATE], states R1 now weighs 128.6 pounds as of [DATE] and is consuming only 25% of his meals. The plan of care was not updated to reflect the continued weight loss and approaches to help maintain or increase R1's weight. The plan of care also did not address R1's significant decrease in meal consumption from 75% to 25%. The Dietician stated that she never personally spoke with R1 to determine why he was not consuming his meals and what may help to make eating better for him. R1's record does not indicate Nursing or Dietary addressed this issue either. On [DATE], R1 was noted to now weigh 101.6 pounds. This weight loss represented a 21% weight loss in 30 days. R1's family requested he be sent to the hospital for further evaluation of this significant change. R1 was admitted for weakness and loss of appetite and was assessed to have severe protein calorie malnutrition. R1 was placed on palliative care at another facility after his discharge from the hospital and expired [DATE]. The facility failed to ensure R1 maintained acceptable parameters of nutritional status. The facility did not: * conduct comprehensive nutritional assessments, which included input from R1 * develop a plan of care to address the weight loss * provide consistent levels of assistance with eating, and * implement a system that would identify and report significant decline in meal consumption. This resulted in a finding of Immediate Jeopardy, which began on [DATE]. On [DATE] at 3:15 p.m., Administrator - A and Director of Nursing - B were informed of the Immediate Jeopardy and Substandard Quality of Care. The Immediate Jeopardy was removed on [DATE] and continues at a scope and severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement its removal plan. This is evidenced by: Review of the facility's policy titled, Weight Assessment and Intervention, originally effective on January, 2017 and revised on [DATE], states in part; Policy: The interdisciplinary team will strive to prevent, monitor, and intervene for undesirable weight change for our residents. Procedure: Weight Assessment (includes but not limited too); 1. The nursing staff will measure resident weights on admission, the next 2 days, and weekly for 3 additional weeks thereafter. 2. If no weight concerns are noted after the initial 3 days and 3 weeks after, routine weights will be measured monthly thereafter, unless ordered more frequently by the physician. 6. Any weight change of five (5) pounds or more since the last weight assessment will be retaken for confirmation. 7. The Dietitian will review the monthly weights to follow individual weight trends over time. Weight trends will be evaluated by the interdisciplinary team whether or not the criteria for significant weight change has been met. Analysis: 1. The Physician and the interdisciplinary team will identify conditions and medications that may be causing weight change For example: b.) chewing or swallowing abnormalities; c.) pain; g.) Psychosocial factors (such as depression) h.) Increased need for calories and/ or protein Care Planning: 1. Care planning for weight change or impaired nutrition will be an interdisciplinary effort and may include the following members' of the interdisciplinary team: Physician, nursing staff, the Dietitian, the Consultant Pharmacist, Therapy, and the resident or resident's legal representative. 2. Individualized care plans shall address, to the extent possible: a.) The identified causes of the weight change b.) Goals and benchmarks for improvement; and c.) Time frames and parameters for monitoring and reassessment. Interventions: 1. Interventions for undesirable weight change shall be based on careful consideration of the following: a.) Resident choice and preferences; b.) Nutrition and hydration needs of the resident; c.) Functional factors that may inhibit independent eating with referral to therapy if applicable; d.) Chewing and swallowing abnormalities and the need for diet modifications with referral to therapy if applicable. 2. The undesired weight change will be discussed with the resident and/or responsible party. 3. Interventions for undesired weight change should consider resident preferences and rights. A weight change regimen should not be initiated for a cognitively capable resident without his/ her approval and involvement. 4. If a resident declines to participate in a weight loss or weight gain goal, a nurse or RDN (registered Dietician) will document the resident's wishes and those wishes will be respected. Note: The last weight obtained in the hospital may differ markedly from the initial weight upon admission to a nursing center and is not to be used in lieu of actually weighing the individual. R1 was admitted to the facility on [DATE] post surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the hospital discharge medications and instructions, dated [DATE], states that R1's discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Weight noted to be 67.5 kilograms (148.8 pounds), Diet: Nursing to pass tray- feed patient regular diet. Clinical follow-up note, dated [DATE], states that R1's nutritional status includes: Good Appetite- Eats 75%-100% of meals, assistance with oral hygiene, own teeth. This note was written by Director of Nursing (DON) - B (noted to be ADON at the time of notation) Clinical follow-up note, dated [DATE] and entered by DON- B, states R1 is here for therapy post fusion of vertebra. R1 wears C- Collar (cervical collar) at all times. R1 has limited mobility in arms due to surgery. R1 skilled for incision monitoring, therapy and pain management. Nutritional status includes: good appetite- eats 75% - 100% of meals. It is noted that the clinical follow-up notes from [DATE] to [DATE], [DATE] and [DATE] have the same documentation written by DON- B. Nursing note dated [DATE] at 12:18 p.m. states R1 is adjusting well. Getting better with pain management. As needed pain medication given on day shift at 10:30 a.m. with good results. Communicating well with staff, ate about 40% today. Struggles to get food down because he is afraid to swallow with C- Collar. Writer encouraged him to try to eat a little more as well as pushed fluids. The following documentation was noted in the Weights and Vitals Summary; [DATE] 148# (pounds) [DATE] 138.98 #'s [DATE] 10:43 a.m. noted data entry error by DON- B stating weight on [DATE] was 138.9 #'s [DATE] 133.98 #'s (mechanical lift scale) [DATE] 133.9 #'s [DATE] 133.7 #'s [DATE] 133.8 #'s [DATE] 128.6 #s [DATE] 101.6 #'s (mechanical lift) Surveyor noted facility staff did not follow the policy/ procedure for weight assessment by obtaining weight on admission, the next 2 days and weekly for 3 additional weeks thereafter. If the weight had been taken on admission and as per facility policy, the data entry error could have been verified sooner, and the data error would not be used in the following assessments of R1 in both the admission Minimum Data Set (MDS) and admission nutritional assessment. A Nutrition assessment dated [DATE] states that R1 is 5 ft. 7 inches tall and the admission weight is noted to be 148 pounds (date [DATE] at 12:54 p.m.). The usual body weight range is noted to be ,d+[DATE] pounds and the ideal weight range is noted to be ,d+[DATE] pounds. R1 is noted to be [AGE] years old. Average meal intake is 32% (clinical follow-up notes indicate 75%-100 %). Estimated nutrient needs: total calories 2018, total protein ,d+[DATE] grams, total fluid 2019 cc +/- 250 cc. Does total nutrition intake meet estimated needs- no. Overall intake from meals yields 744 calories and 33 grams of protein. Nutrition Risk- nothing indicated for focus, goals or interventions. Weight status - no change, Own teeth noted, no dental or swallowing disorders. Daily [MEDICATION(S)] use. Preferences provided by resident- ongoing can make needs/requests known to staff. Dietary Manager updates meal tickets with food/beverage preferences as needed. Summary: Evaluation of Nutritional Status: No known food allergies or intolerances noted, staff assist R1 with meals as needed and regular utensils used during meals. R1 is blind in left eye, right eye is adequate and hearing appears adequate. Goal Summary: will consume 87 % or more all foods served at meals. Plan: Regular diet with regular texture and thin liquids per order, staff assist with meals as needed, monitor intake all meals, monitor tolerance to food textures and fluid consistencies in diet during meals, notify nurse of increased chewing or swallowing difficulties, monitor labs as available, monitor weights as directed, notify MD of significant weight variances, medications per order vitamin/mineral supplements per order, obtain food/beverage preferences as needed. Signed by Dietician- C on [DATE]. (Note: assessment was completed [DATE] but did not reflect the data entry error made for the admission weight noted on [DATE]). Review of the admission MDS, dated [DATE], states that R1 needs extensive assist/ 1 person physical assistance for eating. Section K- swallowing and nutrition states that R1 weighs 148 pounds and no noted weight loss. Section GG0130 states that R1 is dependent for the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow. Goal is to be independent. The CAA (Care Area Assessment) did not trigger for further assessment for Nutrition and the CAA for ADL's states that R1 requires assist with ADL's and is working with therapy. Surveyor conducted a review of the Care Delivery Guide also known as the CNA (Certified Nursing Assistant) care card. This care card was initiated on [DATE]. Under Nutritional Status, there are no checks for snacks, encourage fluids, diet type, tube feeding or restrict fluids- this section is blank. Under Dining room- there is nothing checked for breakfast, lunch, dinner, independent, set-up or assist. This section is blank. Under oral problems- nothing is checked for chewing, swallowing, mouth pain and adaptive equipment. This section is left blank. This care card was said to have been used the entire time of R1's stay at the facility ([DATE] to [DATE]). The CNA care card did not identify that R1 needed extensive assistance with eating or any preferences for snacks. Review of the Individual Plan of Care, initiated [DATE] and revised on [DATE] states, Medication as ordered Monitor for meal consumption daily Monitor weights as directed Obtain and update food and beverage preferences Regular diet, regular texture Thin liquids as ordered and Staff assist resident with intake of foods, beverages and supplements. Surveyor noted the plan of care did not indicate what type of assistance R1 needed with food and beverage intake and that earlier assessment of R1 indicated very limited use of R1's arms and extensive assistance of 1 needed for eating. A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing notes dated [DATE] states that R1, who had been hospitalized on [DATE], was readmitted from St. Luke's Hospital with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Minimal medication changes and wound acquired while at hospital. Orders to follow. R1 is alert and orientated. Able to make needs known. Grab bars added to R1 can assist with mobility. No concerns at this time. Clinical note dated [DATE] at 1:18 p.m. states; Nutritional status includes: poor- eats less than 50% of meals. Chewing or swallowing problems and/or need for thickened liquids. Note states that R1 struggles to swallow food at times, not because he can't, but does not feel comfortable with neck brace on. Staff will continue to monitor. It was noted after this clinical note there was no updates to the plan of care for the decrease in food consumption or that R1 was struggling with swallowing food at times. A Nutrition assessment dated [DATE]- type: re-admission. Assessment states that admission weight is 133.9 pounds and that the most recent admission weight is 133.98 taken on [DATE]. (It should be noted that the original admission weight 138.9 pounds on [DATE].) Usual body weight range ,d+[DATE] pounds. (Admission assessment states the usual body weight range is ,d+[DATE] pounds on [DATE]). Ideal body weight range is noted to be ,d+[DATE] pounds. (Admission assessment dated [DATE] states Ideal body weight range is ,d+[DATE] pounds.) There is no indication for the change in the usual body weight range and ideal body weight range from [DATE] to [DATE] assessment. The average meal intake percentage per day is 76 %. Does the total nutrition intake meet estimated nutrient needs?- answered Yes. Nutrition risk- left blank. Weight status states there was a change in weight- weight loss indicated. Does not identify as a weight loss of 5% or more in 30 days. Assessment identifies that R1 has a Stage #2 pressure ulcer to the left buttock and is receiving treatment. Conditions impacting oral intake- swallowing disorder not checked, states own teeth, no problems noted. Preferences provided by R1- ongoing can make needs /requests known to staff, Dietary Manager updates meal tracker with food/ beverage preferences as needed. No pertinent labs since last review- other noted that R1's [MEDICATION(S)] level is below normal limits in hospital. Summary evaluation of Nutritional status states: Overall intake from meals thus far - 1767 calories and 78 grams protein, Boost 3 times a day after meals ordered and acceptance thus far is 100 % which adds 720 calories and 30 grams of protein to daily intake. On readmission use of Prostat 30 cc everyday ordered which adds 100 calories and 17 grams protein to daily intake. Combined intake is 2587 calories and 125 grams of protein, exceeds needs to promote intact skin integrity and replenish nutritional stores. Staff assist R1 with meals and using regular utensils. Cervical collar worn at all times. Plan: regular diet, regular texture and thin liquids per order. Boost 3 times a day after meals and Prostat 30 cc every day. Record acceptance in the MAR, staff assist R1 with meals, snacks and supplements, monitor intake all meals, monitor intolerance to food textures and fluid consistencies in diet during meals. Notify nurse if increased chewing or swallowing difficulties, monitor labs as available, monitor weights as directed and notify MD of significant weight variances. Medications per order, vitamin/ mineral supplements per order. Obtain food/ beverage preferences as needed. It was noted that following this re-admission assessment on [DATE], the plan of care did not identify that R1 may be at risk for further weight based on the fact that R1 had a 5 pound weight loss (3.59%) from [DATE] to [DATE] and on the fact that he was at or below both his ideal body weight and his usual body weight. (According to the Nutrition assessment dated [DATE], the ideal body weight for R1 is ,d+[DATE] pounds, indicating R1 is right on the border of his ideal body weight range. According to the original admission nutrition assessment R1's ideal body weight is between ,d+[DATE] pounds and R1's usual body weight is ,d+[DATE] pounds. This would identify R1 to be both below the ideal weight and his usual body weight.) Review of the plan of care stating R1's Increased protein - energy needs related to skin integrity as evidenced by receiving treatment to pressure ulcer and [MEDICATION(S)] level in hospital is 2.6 below normal level documents the following additional interventions: Boost supplement 3 times a day after meals record acceptance- initiated on [DATE] (noted this order was originally written [DATE]). Prostat supplement per order- acceptance in MAR, date initiated [DATE]. The plan of care was not updated with R1's need for extensive assistance with eating and did not include the level of assistance a CNA is to provide with meals. Nursing note dated [DATE] states; observed by writer, R1 has difficulty swallowing and chewing food, no issues with fluids, R1 able to intake 100 % of nutritional supplement with assist without difficulty, diet change to puree/thin liquids. Nurse Practitioner aware, new order for speech therapy to evaluate and treat. R1 aware, son made aware. The EMR (electronic medical record) contained a copy of the Diet Requisition Form, dated [DATE]. This form requested the texture of R1's diet be changed to dysphasia puree and thin liquids. This form is used to communicate the diet order change from nursing to Dietary Manager. Further review of the plan of care and CNA care card did not show that R1's diet had been down-graded to dysphasia puree diet from a regular consistency diet and what level of assistance or supervision needed to be provided to R1 while eating his meals in his room. A Speech Therapy Evaluation and Plan of Treatment, dated [DATE], states that R1's goal is to safely return to general diet consistency, with no difficulty / discomfort. Frequency of treatments will be ,d+[DATE] times a week for a period of 4 weeks. The referral states that R1 was in need of speech therapy services due to recent dysphasia deficits noted by nursing staff, resulting in diet downgrade .R1 demonstrates mod level structural dysfunction and reports significant difficulty/ discomfort in oral cavity . R1's care plan was not updated, nor the CNA care card updated, to reflect the need for close supervision with oral intake or the onset of discomfort in the oral cavity. Cause of oral discomfort is unknown. Speech Skilled Therapy Notes dated [DATE] and [DATE] state R1 continues to demonstrate significant increased fatigue and continues to report discomfort in oral cavity and discomfort with intake. Details provided by R1 regarding etiology are very vague. Speech Skilled Therapy note dated [DATE] states that R1 reported he did not wish to continue with puree consistency and declined all offers of it. R1 seen with trial of mechanical soft consistency, R1 demonstrated good clearance and reported no difficulties/ discomfort. When asked about previous soreness in oral cavity, R1 reported that he was now fine. Diet Requisition Form dated [DATE] indicates that R1 is now to have a Dysphasia Advanced diet (mechanical soft) and thin liquids. No other requests for services noted. It was noted that the plan of care and the CNA care card were not updated to reflect the change is diet consistency for food. R1 was discharged from speech therapy services on [DATE] after safely demonstrating with general diet no overt signs/ symptoms of aspiration. A quarterly Nutrition assessment dated [DATE] states that R1's admission weight is 133.9 pounds. (Noted this is the re-admission weight; original admission weight noted to be 138.9 pounds.) Most recent weight is 128.6 pounds as of [DATE]. The usual body weight for R1 is noted to be ,d+[DATE] pounds and the ideal body weight for R1 is noted to be ,d+[DATE] pounds. (Previous assessment on [DATE] states the usual body weight is ,d+[DATE] pounds and the assessment dated [DATE] states the usual body weight is ,d+[DATE] pounds. No explanation of discrepancies between 3 assessments.) Average meal intake is noted to be 25% and was 76 % during the readmission assessment dated [DATE]. Does total nutrition intake meet estimated nutrient needs?- answered No . Nutrition Risk- blank. Weight loss is noted, but not to be less than 5% in 30 days or 7.4 % in 90 days. (Surveyor noted if using the admission weight from [DATE] of 138.9 pounds there would be a 10.3 pound weight loss, which is 7.4 % in 69 days. A significant weight loss is 7.5%.) The treatment continues to the pressure ulcer to the left buttock, evaluations do show decrease in size. Oral intake Conditions- none noted, own teeth no problems noted. Preferences provided by R1 ongoing and can make needs/ requests know to staff. Dietary Manager updates meal tracker with food/ beverage preferences as needed. No new labs reported. Evaluation of Nutritional Status: R1 has functional [CONDITION(S)]- staff feed R1 and regular utensils used during meals. Both vision and hearing impaired, no glasses or hearing aids worn. Weight is down 3.8 % in 30 days. Inadequate oral energy intake from meals related to decreased appetite as evidenced by overall meal intake 25%, last [MEDICATION(S)] level below normal limits- supplement acceptance provides balance of protein needs. Plan: regular diet with regular texture and thin liquids per order. Boost supplement 3 times a day after meals, record acceptance in MAR. Prostat 30 cc each day, record acceptance in MAR. Staff assist with eating foods, drinking beverages and supplements. Monitor intake all meals, monitor tolerance to food textures and fluid consistencies in diet during meals. Notify nurse of increased chewing or swallowing difficulties. Monitor labs as available, monitor weights as directed. Notify MD of significant weight variances. Medications per order vitamin/ mineral supplements per order. Obtain food/ beverage preferences as needed. Review of the individual plan of care for R1 shows that on [DATE] the facility initiated an intervention to assist R1 with intake of foods, beverages and supplements. Surveyor noted the plan of care did not address the significant decrease in meal consumption and the continued risk for additional weight loss. Surveyor conducted a review of the ADL documentation that is provided by the assigned CNAc, which indicates what level of services were provided on a shift by shift basis. Surveyor noted that level of assistance provided to R1 with eating varied from total dependence, to independent, supervision or that activity did not occur. When R1 was first admitted [DATE], it was noted that R1 had very limited use of his arms following his surgery and placement of the cervical collar. The entries were reviewed from [DATE] to [DATE] noting that there was never any consistency in the level of assistance with meals that R1 was receiving from staff. The plan of care only stated R1 needs assistance with meals, although the MDS indicates extensive, 1 person assistance is needed with eating. DON-B was unable to explain why staff provided different levels of assistance to R1. Surveyor conducted a review of the daily food intake reports. These reports were filled out by the CNA staff after each meal to document the percentage of food intake by R1. Surveyor observed for the month of [DATE], facility staff document 66 times out of 90 opportunities (73%) that R1 ate only ,d+[DATE]% of his meals. A review of the meal intake for [DATE] showed that facility staff documented 58 out of 85 (68%) opportunities that R1 ate only ,d+[DATE] % of his meals. For the period of [DATE] to [DATE] (discharged ), staff document that 16 out of 22 opportunities (73%) R1 ate only ,d+[DATE] % of his meals. Further review of the record did not indicate that the CNAs notified nursing staff so that the nursing staff could have alerted Dietician-C or Dietary Manager-D of the fact that R1's meal consumption was often ,d+[DATE] % intake. It was noted on the quarterly Nutrition Assessment, dated [DATE], that R1's meal consumption had significantly declined, but there is no indication that staff or the dietician approached R1 as to why he was not eating more than 25 % of his meals. There is no indication that the meal/beverage preferences were updated, (as directed on the plan of care and nutrition assessment intervention) and there was no indication of the need to increase resident weight monitoring or to increase supplements. Surveyor also reviewed the documents that state if R1 accepted a snack, when offered, and how much of the snack was consumed by the resident. For [DATE], the staff document that R1 accepted a snack 10 times out of 81 (12.3% acceptance) times a snack was offered to him. The document in which staff are to indicate how much of the snack was consumed states, for the majority of the entries, response not required. For [DATE], the staff document that R1 accepted a snack 14 times out of 81 (17% acceptance) times being offered a snack. The document in which staff are to indicate how much of the snack was consumed states, for the majority of the entries, response not required. For [DATE], the staff document that R1 accepted 1 snack out of being offered 17 (5.9% acceptance) times. The document in which staff are to indicate how much of the snack was consumed states, for all entries except 1, response not required. Further review of the record did not indicate that the CNAs notified nursing staff of the fact that R1 was rarely accepting a snack. R1 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was received [DATE]. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . For the month of November, 2020 the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MAR for [DATE] showed that R1 was offered the Boost supplement 25 times and only consumed 100% 5 times (20%). Surveyor noted R1 continued to have weight loss even with the Boost as ordered. Surveyor conducted a review of the Nurse Practitioner (NP) notes which provided assessments of R1. On [DATE], the NP note indicates that R1's weight has been stable since [DATE] and that R1 reports that he is continuing to try to eat. NP documentation for [DATE] states to monitor weights, has been stable. R1 reports to the NP that he feels he is able to eat better but he still does not have much of an appetite. NP documentation for visit on [DATE] states; monitor weights, has been stable. R1 reports he is starting to use his hands more. R1 states his appetite is improving and would like some help opening candy to eat. NP documentation on [DATE] states; monitor weights, has been stable. R1 reports that he is trying to eat more. On [DATE], the facility obtained a monthly weight for R1. The weight is documented as 101.6 pounds. The previous weight on [DATE] was documented at 128.6 pounds. This is a weight loss of 27 pounds in 30 days or 21%. Nursing note dated [DATE] states that Nurse Practitioner made aware of weight loss and son wants father to go to emergency room for further evaluation. New order obtained to send R1 for further evaluation, R1 made aware. Surveyor conducted a review of the hospital paper work for St. Luke's Milwaukee for admitted [DATE]. The following was noted: Chief Complaint: weakness/ loss of appetite. The patient (R1) says he feels weak but not too different than baseline. They have noticed weight loss over the past several weeks. Pt (R1) is bed bound and non-ambulatory at baseline due to the cervical [CONDITION(S)]. He (R1) states he doesn't like the food there (nursing facility). No fevers, chills, abdominal pain, cough, dysuria, urinary frequency, diarrhea, no loss of smell or taste. He denies chest pain, palpitations, and dyspnea. Further review of the record indicates lab work was obtained at the hospital on [DATE] and the [MEDICATION(S)] level, main protein in your blood, was 2.4. (Previous [MEDICATION(S)] levels were 2.9 on [DATE] and 2.6 on [DATE] - previous hospital lab work). The assessment and plan included that R1 has Severe protein calorie malnutrition (about 20 pound weight loss in the last year)- consult nutrition. Assessment does not indicate where the information comes from regarding 20 pounds if it was based on medical record or R1's statement. Further review of the assessment/ plan states that [CONDITION(S)], likely related to dehydration and Afib. Initially, slightly improved with fluids. Given history of HFrEF (pulmonary [CONDITION(S)]), will avoid giving more fluids. Will try [MEDICATION(S)] to see if it helps. Severe protein calorie malnutrition, Dietician on board. Planned discharge notes that Social Worker is following discharge planning. Continuing to monitor R1's intake and Palliative Care to discuss goals of care with pt. (R1) today. Possible discharge over weekend pending improved intake. Hospital Nutrition Care Plan dated [DATE]: Nutrition Diagnosis- Severe Protein Calorie Malnutrition related to dislike of food at facility and poor fitting dentures (facility has indicated that R1 has his own teeth) as evidenced by report of reduced intake for weeks prior to admit. Less than 75% of EEE for (estimated energy expenditure) for greater than 1 month, loss of 19.7 kg (43.3 pounds) 29% body weight over 3 months, generalized muscle wasting, weakness, and need for altered textured diet. Goal is no further weight loss. R1 was discharged from the hospital under the care of Aurora Hospice in Milwaukee. It was stated in an interview that R1 expired on [DATE]. On [DATE] at 3:10 p.m., Surveyor interviewed Dietician- C via telephone in regards to R1. Dietician- C stated she is a consultant Dietician for the facility and works with this particular facility 2 times a week, usually Thursday and Fridays. Dietician - C stated she has worked entirely via telework and has not physically been in the building at all due to the Covid pandemic. Dietician- C stated she has access to remotely review the electronic medical records and will communicate with nursing via email or telephone as needed. Dietician- C was asked about R1's weights. Dietician- C stated there were a few changes to the weight policy in October, 2020 (unable to state specific changes) and that the expectation for weights was that a resident be weighed on admission and the following 2 days after. Then a resident is to be weighed weekly for 3 weeks and if the weight is stable then monthly weights after this. Dietician- C stated that the admission weight for R1 was documented as 148 poun [TRUNCATED]

Based on interview, observation and record review, the facility did not ensure treatment and services were in place in order to provide appropriate incontinence/indwelling catheter services according to professional standards of practice to prevent urinary tract infections (UTI) for 1 (R2) of 2 residents reviewed for indwelling catheters. * R2 was readmitted to the facility with an indwelling Foley catheter after a hospitalization for urinary retention. The facility did not put MD orders in place for catheter care, changing catheter, as needed care for blockage or size/type of catheter. The facility did not put a care plan in place for indwelling catheter or care of indwelling catheter. The facility did not put Point of Care charting in Electronic Medical Record (EMR) for aides to complete catheter care. There is no documentation of catheter care being completed resulting in R2 being hospitalized again 12 days later for [CONDITION(S)] secondary to UTI. Findings include: Surveyor reviewed facility's Catheter Care, Indwelling Catheter policy with an Original Effective Date of June 2017. Documented was: PURPOSE: * To prevent infection * To reduce irritation POLICY PROCEDURE: 1. Position resident on bedpan in semi-fowler's position if tolerated. Alternate position: place resident in lateral Sims position facing towards you. 2. Put on gloves. 3. Pour warm water over perineal area. 4. Wash perineum well with soap and warm water, taking care to wash from front to back. NOTE: Do not contaminate area with feces. If resident has had an involuntary bowel movement, clean that area first. Wash your hands and obtain clean equipment for catheter care. 5. Cleanse area well at catheter insertion, taking care not to pull on catheter or advance further into urethra. 6. All debris must be removed from catheter at insertion site. 7. Rinse well with warm water and pat dry gently with clean towel. 8. Empty, clean and store bedpan or measuring device properly. 9. Remove gloves and discard in appropriate container. 10. Position resident comfortably with call light within reach. ASSESSMENT GUIDELINES May include, but are not limited to: * Color, consistency, amount of urine. * Condition of skin at site of insertion. * Pain, burning, discomfort. * Level of activity. * Nutritional intake. * Hydration and fluid balance status. EQUIPMENT * Bed protector. * Basin with warm water and soap. * Towel and washcloth. * Disposable gloves. * Bedpan or measuring device. * Catheter care kit per facility procedure. NOTE: Handwashing remains the single most important step in preventing the spread of infection. DOCUMENTATION GUIDELINES Documentation may include: * Date, time, procedure, condition of the perineum and catheter insertion site. * Any unusual condition or change in condition. * Color, amount, consistency of urine. * Notification of physician of any condition change. * Intake and output and evaluation of intake and output per facility procedure. * Signature and title. CARE PLAN DOCUMENTATION GUIDELINES Enter the catheter care as an approach under the appropriate underlying problem on the resident's care plan. Identifying the underlying problem will assist the nursing staff to develop an individualized care plan. The use of an indwelling catheter is an approach to a specific problem. Develop a care plan with the objective of removing the catheter when the problem is resolved, whenever possible . Surveyor reviewed R2's Hospital Discharge Summary with a discharge date of [DATE]. Documented under Plan was Started on empiric [MEDICATION(S)] x7 days ([end of treatment 1/11/21]) for UTI. R2 was admitted to the facility on [DATE]. R2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor reviewed R2's Admission/Readmission Evaluation with a date of 1/7/21. Documented under Bladder/Bowel was 1. Catheter Type/Size: straight catheter. 2. Diagnosis/Reason for Catheter: [CONDITION(S)]. Surveyor reviewed R2's MD orders. Documented with a start date of 1/8/21 was straight cath for urination every 6 hours for [CONDITION(S)]. Surveyor reviewed R2's Comprehensive Care Plan with initiation date of 1/8/21. Documented was Focus: Alteration in elimination of bowel and bladder [due to] [CONDITION(S)]. Goal: - I will be free of UTI. - I will have a soft formed bowel movement at least every three days. Interventions: - Call bell within reach and reminders to use callbell as needed. - Catheterize as ordered - [every (Q)] 6 hour straight [catheter (cath).] - Encourage fluids. - Labs as ordered. Surveyor reviewed Former facility Nurse Practitioner (NP)-K's visit note with a date of 1/11/21. Documented under NP note was UTI: treated empirically with [MEDICATION(S)] x7 days. discharged on [MEDICATION(S)]. Monitor for recurrent symptoms, remains high risk given intermittent self cathing. Surveyor reviewed R2's Care Area Assessment (CAA) related to Urinary Incontinence and Indwelling Catheter with an assessment date of 1/12/21. Documented under Care Plan Considerations was CAA triggered due to straight cath Q 6 total assist, at risk for UTI will encourage fluids and have water at bedside, staff to monitor skin integrity, working with therapy [per plan of care] no referrals at this time. Surveyor reviewed R2's Progress Notes. Documented on 1/17/21 at 12:10 PM was [Patient (pt)] being sent out to the hospital for no urine output in >6 hours and distended [abdomen.] MD was called and updated on pts condition per MD would like pt sent out to be evaluated. MD was called at 11:47 AM and wife was notified after at 11:52 AM. Pt will be taken via bell ambulance to Froedtert main campus hospital in [Milwaukee] for further evaluation. Surveyor reviewed R2's Emergency Department documentation from 1/17/21. Documented was Presents from rehabilitation facility due to concerns of urinary retention. Has [CONDITION(S)] bowel and bladder typically straight cath every 6 hours. States the staff at the facility attempted a straight catheterization at 6:00 AM as well as noon today and were unable to drain any urine. Patient reports this has happened a few times in the past though eventually they are able to drain urine . A urinalysis was taken and was negative. R2 was discharged back to the facility on [DATE] with an indwelling Foley catheter. Surveyor reviewed R2's EMR from readmission after 1/17/21. There was no Admission/Readmission Evaluation completed. There was no update to the Care Plan to include indwelling Foley catheter. A Bladder/Incontinence Evaluation was completed on 1/17/21, Documented was 1. Admission Information Regarding Urinary Continence Status. Resident is currently continent of bladder: Yes. The rest of the assessment is blank. There was no documentation in EMR documenting catheter care was completed by nursing staff. Surveyor reviewed Care Delivery Guide for CNAs. Documented under Bladder was straight cath [discontinued 1/17/21]. Foley cath. There was no specific guidelines or instructions for cath care. Surveyor reviewed Point of Care CNA Tasks in EMR. There were no Tasks related to Foley catheter care for CNAs to chart on or instructions on frequency of Foley catheter care. There was no documentation of input or output of Foley catheter. There was no documentation in EMR documenting catheter care was completed by CNAs. Surveyor reviewed R2's MD orders. There were no orders for catheter care, changing catheter, as needed care for blockage or size/type of catheter. The only order put in after hospitalization was on 1/19/21 and documents add [diagnosis] of [CONDITION(S)] to justify the indwelling Foley catheter. Surveyor reviewed SBAR (Situation, Background, Assessment, Recommendation) Communication Form for R2 for 1/29/21. Documented was The change in condition, symptoms, or signs observed and evaluated is/are: Altered mental status (AMS), Tired, Weak, Confused, or Drowsy. Surveyor reviewed R2's Progress Notes. Documented on 1/29/21 at 1:41 PM was Patient transferred to Froedtert hospital via Bell ambulance. Patient was very confused, lethargic, and shaky. [NP-K] and [wife] aware. Surveyor reviewed R2's hospital paperwork from 1/29/21 admission. Documented on 1/29/21 was Primary reason for Medicine admission / Working Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Active problems with [Emergency Department (ED)] interventions(s): [CONDITION(S)] 2/2 UTI. Presents w/ AMS and fever, [Temperature] 102.9. ED workup reveals leukocytosis w/ [White Blood Cell count] 23.7. Blood Pressure stable with MAP (mean arterial pressure) 65. [MEDICATION(S)] 3.3. [Intravenous Fluids (IVF)] resuscitation initiated in ED. [MEDICATION(S)] improved to 0.9. Has chronic indwelling Foley. [Urinalysis] [consistent with] UTI (after Foley exchanged). Given [MEDICATION(S)] . [CONDITION(S)] Absolute: 21.03 . Leukocytes Urine: 500 . According to Froedtert Hospital, normal lab values for R2 should be the following: WBC: 3.3 to 11.2 10e3/uL; [MEDICATION(S)]: 0.5 to 2.2 mmol/L; [CONDITION(S)] Absolute: 1.90 to 7.80 10e3/uL; Leukocytes Urine: </= 25 /uL. According to National Library of Medicine, an Evaluation of [MEDICATION(S)], white blood cell count, [CONDITION(S)] count, procalcitonin and immature granulocyte count as biomarkers for [CONDITION(S)] in emergency department patients. https://pubmed.ncbi.nlm.nih.gov/ 399/ On 2/3/21 at 2:11 PM Surveyor interviewed Licensed Practical Nurse (LPN)-E. Surveyor asked who completes catheter care for a resident with an indwelling catheter. LPN-E stated she does on her shifts because she does not know when it was done last. Surveyor asked how she cleaned the catheter. LPN-E stated clean around the insertion site with a washcloth and then apply lubricant so it is more comfortable. Surveyor asked how often this is done. LPN-E stated she does it every shift but is not sure what other Nurses do. Surveyor asked what the CNAs are expected to do for catheter care. LPN-E stated the CNAs empty the Foley bag. On 2/3/21 at 2:45 PM Surveyor interviewed LPN-F. Surveyor asked who completes catheter care for a resident with an indwelling Foley catheter. LPN-F stated the CNAs empty the Foley bag and do catheter care. LPN-F stated the Nurses do not have a lot to with catheter care. Surveyor asked about R2's indwelling catheter. LPN-F stated she looked at it and cleaned it with soap and water once after he came back from the hospital because I wasn't sure when it was done last. Surveyor asked where catheter care is charted to check that it was completed. LPN-F stated in Point of Care charting under Catheter Care. On 2/4/21 at 11:10 AM Surveyor interviewed CNA-H. Surveyor asked who completes catheter care for a resident with an indwelling Foley catheter. CNA-H stated the CNAs do. Surveyor asked what she does for catheter care. CNA-H stated make sure it is clean and not leaking and wash around the insertion site with soap and water. Surveyor asked how often this is done. CNA-H stated every 2 hours. Surveyor asked if CNA-H ever took care of R2. CNA-H stated no. Surveyor asked where CNAs would chart cares completed. CNA-H stated Point of Care. On 2/4/21 at 11:41 AM Surveyor interviewed CNA-I. Surveyor asked who completes catheter care for a resident with an indwelling Foley catheter. CNA-I stated the CNAs do. Surveyor asked what she does for catheter care. CNA-I stated clean around the insertion site with soap and water. Surveyor asked how often this is done. CNA-I stated every 2 hours with cares. Surveyor asked if CNA-I ever took care of R2. CNA-I stated no. Surveyor asked where CNAs would chart cares completed. CNA-I stated Point of Care. On 2/4/21 at 12:03 PM Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked who completes catheter care for a resident with an indwelling Foley catheter. DON-B stated the CNAs do. Surveyor asked what CNAs do for catheter care and how often. DON-B stated during every 2 hours check and change they empty the Foley bag, make sure the tube is secure to the patients leg and if not alert the nurse, clean the catheter by wiping it off with soap and water, make sure no feces is on it. Surveyor asked how the CNAs would know to do this task. DON-B stated the Care Delivery Guide for CNAs or Point of Care but Point of Care was never updated. Surveyor asked how the CNAs know what to do when the Care Delivery Guide just says cath care. DON-B stated there should have been training on catheter care and there are standing orders. Surveyor noted to DON-B that 2 CNAs and 2 Nurses had conflicting answers on who and what was done for catheter care. Surveyor asked how staff would know that catheter care was completed. DON-B stated we wouldn't know because it was not in Point of Care. DON-B stated the facility should have had Point of Care Tasks, MD standing orders and a Care Plan for R2's indwelling catheter. Surveyor asked for standing orders and Care Plan interventions that should have been put in. DON-B provided copy of standing orders that included Cath Care - every shift; Change catheter system for blockage, leakage or encrustation [size/type of catheter] as needed. Care Plan goals and interventions included Goal: Will have no acute complications of urinary catheter. Interventions: Catheter care; catheter collection bag placed in dignity bag holder on bed/wheelchair; change urinary bag as needed; report any changes in amount and color or odor of urine.

Based on observation, interview and record review the facility failed to provide supervision and assistive devices to prevent falls, including not identifying, implementing and evaluating hazards and risk to prevent falls for 2 (R58 and R31) of 2 residents reviewed with falls. ~ From (MONTH) 1, (YEAR) through (MONTH) 22nd, (YEAR) R58 fell 26 times The facility did not always complete a root cause analysis of the fall including addressing R58's incontinence as it relates to falls. The facility failed to ensure interventions were established and in place to prevent falls and the facility did not increase supervision to prevent falls. During the survey, facility staff were observed not implementing care planned interventions to prevent falls On 1/28/18 R58 fell 5 times and required emergency room services to have his hip put back into place after becoming dislocated. R58 was hospitalized [DATE]-4/6/18 requiring surgical intervention (a hip arthroplasty) after a fall. Upon return from the hospitalization R58 was noted to have a pressure injury that eventually deteriorated to a stage 4 pressure injury (Cross-reference F686). R58 was hospitalized again on 4/26-5/8/18 after his right leg was noted to be shortened and turned inwards were he required a revision of his arthroplasty. R58 was observed by the surveyor on multiple occasions with his bathroom alarm not on per his plan of care. Staff was also unaware of R58's care planned interventions related to toileting. The facility's failure to ensure adequate supervision, assistive devices, and an environment to prevent accidents for R58 created a finding of Immediate Jeopardy, beginning on 1/28/18. Nursing Home Administrator-A and Director of Nursing (DON)-B were informed of the Immediate Jeopardy and substandard quality of care on 8/21/18 at 2:52 pm. The immediate jeopardy was removed on 8/23/18 as the facility implemented their action plan however, the deficient practice continues at a scope/severity of a G (actual harm/isolated) for the example related to R31. ~ R31 had 7 falls between 6/23/18 and 7/18/18. R31 was transported to the hospital following the fall on 6/23/18 and required 2 sutures to the head. The falls investigations did not provide a cause analysis for the falls, include interventions that address the reason for the falls and prevent future falls and interventions that were initiated were not addressed on the care plan. 6 of R31's 7 falls were a result of R31 falling out of bed. Findings Include: The facility's Fall Prevention and Management Guidelines policy, dated 2/2017, states The facility will maintain a fall prevention and management program. In as much as it is in the power of the facility, the facility will prevent and/or manage the resident's risk for falls. The elderly are at increased risk for falls related to several different factors. The facility will implement a fall program for residents determined to be at risk for falls in order to better manage these factors and prevent and/or manage as much as is possible the resident from falling and/or sustaining injuries related to falls .Details of Key Elements 3. Continence protocol as indicated 1. Toilet schedule: implement as needed a. bladder training, as indicated .C. Evaluation 1. Complete post fall evaluation after every fall or near fall or assisted fall a. A fall Investigation and Post Fall Assessment must be completed. These need to include: 1. Physical assessment 2. All contributing factors to the fall 3. Medication changes (new or discontinued) 4. Mental status changes 5. New [DIAGNOSES REDACTED]. A facility Fall log needs to be completed. Each fall needs to be tracked. b. Actions of the interdisciplinary team 1. Timely modifications to the treatment plan and re-in-servicing of staff. 2. Family/resident conferences: timely notification of family of an incident. 3. Timely notification of physician of the fall 4. Physical adaptation to room, wheelchair, and/or walking devices c. Collective review, identification, and analysis of trends in resident falls throughout the facility (see Quality Improvement, below) 3. Facility protocol must include falls management review and analysis by one or more of the following: the safety committee, falls committee, interdisciplinary care (IDC) plan committee, quality improvement committee, or other established interdisciplinary group 1.) R58's fall care area analysis, signed 1/24/18, documents Resident is long term care resident with [DIAGNOSES REDACTED]. Resident has had multiple falls this past quarter. Resident has rolled out of bed. Resident has also been found sitting in front of nightstand with bottoms off and linen off of the bed. When asked what happened .resident says he doesn't know. Resident has mat to floor and low bed in place. Resident was sent to hosp. (hospital) for tests after falling multiple times in one day and tests were negative CT scan of the head. Resident is cognitively impaired and is on scheduled check and change every 2 hours and prn (as needed) with toileting/inc. care. Resident is assist of one with transfers and toileting. Resident is on medication for [MEDICAL CONDITION]. Will proceed to care plan. R58's urinary incontinence care area analysis, signed 1/24/2018, documents Resident is long term care resident with [DIAGNOSES REDACTED]. Of right hip dislocation, abd hernia, anal fissure, gout, depression, [MEDICAL CONDITIONS], GERD, htn, and [MEDICAL CONDITION]. Resident is cognitively impaired and is on scheduled check and change every 2 hours and prn with toileting/inc care. Resident is assist of one with transfers and toileting. Resident is on medication for [MEDICAL CONDITION]. Will proceed to care plan. R58's plan of care included a focused area that Resident is at risk for falls r/t (related to) cognition-unaware of safety needs, gait balance, problems, History of falls, Incontinence, Pain with an initiation date of 11/20/2017. On 4/9/18 the focus area was revised to also include Refuses to comply with interventions put into place for safety. Resident verbally abusive to staff when attempts are made assist him or redirect him. History of hip displacement; admitted [DATE]- Revision of rt total hip replacement. Interventions on the plan of care include Ensure that the Resident is wearing appropriate footwear with an initiation date of 11/20/2017. The surveyor reviewed R58's falls from 1/2018-8/2018. An incident report documents on 1/3/18 at 3pm R58 was walking by self in room, stated to CNA walking by that his knees were going to buckle. CNA lowered him to the floor. CNA came to get writer and then staff with use of hoyer got resident off the floor into bed. Immediate action taken is documented as Hoyer brought to residents room, large sling used. Resident positioned in sling and resident put into bed. Predisposing physiological factors documented include that R58 was incontinent. Other information ion documented on the incident report includes Resident did not have call light on. Res (resident) ambulated by himself in room without assistance, res is not to be ambulating at all. Res uses wheelchair and needs assistance for transfer. Resident has poor memory which contributes to not using call light asking for help. The notes section of the incident report states 1/9/2018 .Reminded resident to use of call light. The incident report does not assess the last time that R58 was checked for incontinence. The incident report does not document a root cause of the fall, or an intervention put into place based on the fall. On 1/3/18 at 7:10pm R58 fell a second time that day. An incident report document Writer was doing 20 minute checks on resident as well as vitals from previous incident of residents (sic) being lowered to the floor. Writer walked into resident's room to find resident sitting on his floor in front of his night stand with no bottoms on, all the bedding stripped off his bed, the bed in lowest position. All the bedding was saturated with urine and bowel movement. Immediate action taken on the incident report documents Writer had staff obtain the hoyer lift and the sling, resident put onto the sling and hoyered into bed. Predisposing physiological factors include incontinence. The other info section of the incident report documents Residents bed was in the lowest position. Res had stripped all of his bedding off of his bed and taken off his clothes on his bottom. Res states he slipped out of his wheelchair, however, residents wheelchair was not in his room and res was in his bed. The notes section of the incident report documents 1/9/2018 Resident was found at the side of his bed on his buttocks with no brief. His bed was in low position which the benefits out way the risk for injury. No injury was noted. When resident was asked what happened he stated he had slipped out of the wheelchair however no chair was in his room.Orders obtained for labs and UA (urine analysis) Resident would not give specimen. Residents bed was refreshed and incontinence cares provided. Bed was put back in lowest position; daughter was called and came to speak to resident. Will continue to monitor. The surveyor noted the incident report does not address the last time that R58 had been checked for incontinence. The surveyor noted no interventions were immediately put into place to prevent R58 from having future falls. The next day on 1/4/2018 at 6:50 am R58 fell . The incident report documents Writer entered room to do neuro check for previous fall, res was sitting on buttocks on floor, back against bed. Immediate action taken on the incident report is documented as RN supervisor assessed. Assisted back to bed with full body lift and several staff. NO noted injures, mat placed on floor next to bed, bed remains in low position. Predisposing physiological factors on the incident report include incontinence. The notes section of the incident report states 1/9/2018 IDT (interdisciplinary team) met to further discuss resident's incident where he was found sitting on the floor with his back against the bed. When resident was asked what happened he stated I know I slipped out of bed Resident was found due to nurse coming in to do follow up cran checks. Resident was assisted off the floor with the use of mechanical lift. Incontinence cares provided. Resident still would not give specimen per conversation with nurse. Resident was put back into bed. Bed put in lowest position mat placed on side of bed to help further prevent injury. The surveyor noted the incident report does not address the last time R58 was checked for incontinence. The surveyor noted R58's plan of care was not updated to include mat to floor until 3/1/2018. On 1/6/18 at 2:10 PM R58 fell . The incident report documents Resident was sitting on the floor next to his bed. The resident description is documented as Res stated 'I sat on the floor to piss you off.' Incontinence is documented as a predisposing physiological factor on the incident report. The notes section of the incident report documents 1/11/2018 Resident was found on the floor next to his bed and when he was asked what happened he said he did it just to piss you off meaning the nurse. Resident was assessed and no injuries were identified. He was lifted off of floor using full body mechanical lift. Resident is already seen by psych and will be seen again. No recent medication changes identified. Resident continues to refuse nurse to capture a urine. Resident is frequently incontinent and he did not wish to use the bathroom when writer asked nurse. We will continue with the use of mat next to bed and bed in lowest position as the benefits out way the risks for injury. Care conference set up for 1-12-18 at 9:00. The surveyor noted the facility did not put interventions in place to prevent future falls after R58 fell on [DATE] at 2:10pm. On 1/6/18 at 7:45 pm R58 fell for a second time on 1/6/2018. The incident report documents Writer was called to Resident's room, Resident found on the floor. Nurse stated resident was on the floor earlier during shift (2nd for for the day) (sic). Resident son .called and stated he was on the phone with resident and then he said to him (son) 'hold on let me sit up' and then he could not come to the phone again. (The son) called facility asking to check on his Dad at the same time that Nurse was asking for help. Resident stated he was trying to sit up and he rolled out of bed. Immediate action taken on the incident report is documented as Resident was Assessed and re-started on neuro checks. Complained of soreness to butt. However, when transferred to bed, denied pain. Moved all extremities. Considering putting a thicker mattress to floor in view of frequency of falls. The notes section on the incident report documents 1/11/2018 Resident was again found on the floor however it was the same time that his son .was on the phone talking with resident. When resident was asked what happened he stated he was talking with his son on the phone and he was trying to sit up he rolled out of bed. The son said he was talking to (R58) and (R58) said hold on I am going to sit up. Nurse assessed resident reinitiated cran checks. No injury identified. mat removed and replaced with mattress at this time to further prevent against injury. Spoke with MDS coordinator and noted resident to be declining in overall ADLs (activities of daily living). Resident will not allow therapy to work with him. Writer will reapproach resident to encourage therapy evaluation. A post fall assessment documents that R58 was barefoot/no footwear at the time of the fall. The facility's analysis of the fall does not address why R58 does not have footwear on at the time of the fall. On 1/6/18 at 10:30 pm R58 fell a third time. The facility's incident report documents RN supervisor went to res room to check VS (vital signs), res was lying face down on floor next to bed, near to bathroom door Immediate action on the incident report is documented as ADON (assistant director of nursing) aware, res's mattress was placed on floor, res rolled over onto mattress. No evidence of injury. VSS (vital signs stable). Predisposing physiological factors on the incident report include incontinence. The notes section of the incident report documents 1/7/2018 Optum Nurse spoke with (physician), new order to send to St Luke's ER (emergency room ) .1/11/2018 Resident again was found on floor however he did not stated what happened. Vitals were within normal limits. NP (nurse practitioner) was notified and spoke with physician. Physician sent resident out AMS (altered mental status). Hospital performed an urine (sic) which was negative they also captured. No acute findings noted and resident was sent back to facility. Will continue to monitor resident for any further changes. Will discuss incident and findings further at care conference. Will look at the possibility of wider bed and trapeze. Will look at going back to mat on floor for better footing for resident if he were to want to sit at side of bed. Call light re-education performed. 2/5/2018 IDT further discussed incident. The mattress from resident bed was placed on floor and another mattress put next to that. A care conference had taken placed and it was decided that resident may benefit from a trapeze and that the mattress next to the mattress was ineffective as resident had rolled over onto the other mattress and then rolled off onto the floor. Currently the benefits of using a lower bed and the use of mattress still out ways the risk of resident getting hurt. R58's care plan had no updated interventions from 1/1/18-1/16/2018 R58's care plan had no updated interventions despite R58 having 6 falls from 1/3/18-1/6/18. On 1/16/18 R58's care plan was updated to include Encourage resident to use the trapeze in helping him sit up and for exercise. On 1/19/2018 at 9:15 am R58 sustained a fall with injury requiring being sent to the emergency room and having his hip re-aligned. The facility's incident report documents RN was notified that resident had fallen. Writer went to assess resident and observed resident lying on bathroom floor, w/c facing toilet, with upper body near side/base of toilet outward, and lower extremities close up against wall. 'What do you think I did? I slid off the toilet.' Immediate action taken on the incident report documents Resident assessed for injury and initially resident had complained of generalized pain which become concentrated in the right hip/leg area. Sent to SLMC ER for evaluation and it was determined that resident had a femoral component of right hip Arthroplasty dislodged or dislocated. Hospital re-aligned right hip and resident sent back to facility. Additional [MEDICATION NAME] ordered for comfort. Resident returned with right left A frame. Issued new w/c with drop seat. Resident also has a trapeze on bed to aide in bed mobility. Added to 24 hour report for monitoring. The incident report documents incontinence as a predisposing physiological factor. The facility's incident report does not address the last time R58 was checked for incontinence prior to his fall. The notes section on the incident report on 1/22/2018 document IDT met to further discuss incident where resident was found on floor in bathroom by nurse .as resident was calling out for help. He had been observed approximately 5 minutes earlier where he had been in bed. He had transferred self from bed to chair and had a failed transfer per his own admission from chair to toilet. Floor was wet with urine. Resident was assessed and resident was then with the use of a mattress pad and a sheet under resident brought him out of bathroom where he was then transferred into bed with 3 assist. Through assessment resident who complained of generalized pain started to complain more of right hip pain. Called placed to (physician) who gave the order to have resident sent to SLMC. Resident was found to have a dislocated/dislodged right femoral component of his right hip arthroplasty. The hospital put hip back in placed and returned resident with A frame to use. Optum gave new pain medication orders. Drop seat wheelchair obtained. Trapeze removed the next day as resident unable to understand use and not helpful in repositioning resident. Will obtain therapy to eval for positioning in bed and chair and possible use of enabler bars for resident to assist with repositioning self. The surveyor reviewed R58's care plan and noted on 1/19/18 R58's plan of care was updated to include Follow Therapy recommendations for transfers, mobility and ambulation and W/C with drop seat. On 1/22/18 Encourage resident to use the trapeze in helping him sit up and for exercise and Obtain PT (physical therapy) order for positioning in bed and w/c with A-Frame leg immobilizer and A Frame leg immobilizer at all times. On 1/25/18 at 6:30 pm R58 fell . The facility's incident report documents Notified by CNA that resident was on the floor. Upon entering room, observed resident laying on the floor, on his right side. His wheelchair had been facing the wall across from his room, resident was on the floor next to wall across from his bathroom door. Shoes were on. Urine on floor underneath resident. He stated 'I was trying to leave.' Denied pain. AROM (active range of motion) WNL (within normal limits) for this resident. No deformities observed or palpated. Legs of equal length, no rotation noted. Immediate action taken is documented on the incident report as Assisted into bed with three staff and Hoyer Lift. Neuro checks initiated and have been WNL (within normal limits). Resident had not eaten supper meal, so that was reheated and fresh liquids provided. Resident did consumer 100% of meal. Blood sugar was 319 mg/dl prior to meal and fall but he did not when first served meal. (sic) Incontinence is documented as a predisposing physiological factor of the fall on the incident report. The fall incident report does not address when R58 was last checked for incontinence. The notes section of the incident report documents 1/25/2018 (R58) was admitted to Sunrise Health Services on 1/24/2017, with [DIAGNOSES REDACTED]. (R58) presents with behaviors, resistance, falls and challenges difficult to maintain. To address these conditions, the following devices (not all-inclusive) have been utilized with minimal effectiveness. Trapeze refused to be used, call light refused used, toileting schedule ignored and resident continues to void in bed on floor. Resident refuses the use of incontinence products. Therapy offered at regular and out of schedule hours, but resident adamantly refuses to participate. Resident provided a larger bed and reposition bar for easier repositioning. Medication review and treatment performed. Resident Family Care Case Management team consulted for care planning techniques. Resident wheelchair seat positioned for comfort and self propelling. Sunrise Health Services will continue to offer and encourage the use of the interventions and treatment tools noted. The surveyor noted the facility did not address the last time R58 was checked for incontinence prior to the fall. On 1/28/2018 at 9:11 AM R58 fell . The facility's incident report documents Call to patient room by staff nurse. Patient sitting on buttock on floor in front of bed. Bed noted to be in lowest position. Sheet was half off mattress. Patient was incontinent of urine. Incontinence product at the end of bed. 'I was sitting on the bed and slid off.' Immediate action on the incident report taken is documented Assessed for injury Hoyer lift off floor with assist of 3. Incontinent care provided. Predisposing physiological factors is documented to include incontinence. Notes on 1/30/2018 document Resident was found on floor. He had all his linen shoved to the end of the bed and he was incontinent. He stated he slid off the bed. It is not conclusive but highly likely resident while rearranging his bedding slid off bed. Resident prefers to sleep without clothes at times. Team agrees to see if resident would like to use an oscillating fan to keep cooler when in room. The surveyor reviewed R58's plan of care and noted that the intervention to Offer oscillating fan if too warm was not initiated until 3/1/2018. A Post Fall Assessment evaluation documents that R58 was barefoot/no footwear on at the time of the fall. The incident report does not address why R58 had no footwear on at the time of the fall. The incident report does not address the last time R58 was checked for incontinence. On 1/28/2018 at 12:07 PM R58 fell a second time. The facility's incident report documents Call to residents room. Patient Sitting on buttock in front of bed fully clothed. No incontinence at this time. Able to move all extremities. No complaint of pain or discomfort. Denies hitting head. No HA (headache) or dizziness. I was sitting on the side of the bed. Don't know what happened. Immediate action taken on the incident report documents Assessed for Injury Resident was assisted back to bed with full body mechanical lift. The notes section of the incident report documents No Notes Found. The incident report does not address a root cause analysis of the fall or future actions taken to prevent R58 from having future falls. On 1/28/2018 at 1:13 pm R58 fell a third time for the day on the bathroom floor, requiring being sent out to the emergency room . The facility's incident report documents Call to 2nd floor by staff nurse report patient with another fall. Patient in bathroom on floor with head lifted stating get me up. Patient able to move all extremities except right hip. Pain report severe right hip pain with touch. Inner rotation noted. Refused vital signs. Denies hitting head. No protrusion or breaks in skin noted. Immediate action taken is documented as MD/Optum updated. New order St Luke's ER. The notes section of the incident report documents 1/28/2018 Resident was found on bathroom floor. Resident was not interested in explaining what occurred leading to him being on the bathroom floor. Resident was immediately assessed for injuries. Upon assessment, it was clear resident had limited movement in the R-lower extremity. Nurse practitioner consulted and order received to send resident to SLMC for evaluation and treatment. The incident report does not document that last time R58 was checked for incontinence. The incident report does not address future actions taken to prevent R58 from having future falls. On 1/28/2018 at 8:12 pm R58 fell a fourth time that day in his bathroom. The facility's incident report documents witness fall. Immediate action taken is documented as Resident assessed by RN and was put in bed using hoyer lift. The notes section on the incident report documents No Notes found. The incident report does not address a root cause of the fall or interventions to prevent future falls from occurring based on the root cause analysis of the fall. On 1/28/2018 at 9:27 pm R58 fell a fifth time that day. The facility's incident report documents Resident was found on the floor next to his bed by writer while doing 15 minute checks. Bed was in low position. Immediate action taken is documented as Resident was assessed by RN supervisor and resident was placed in wheelchair and put at the nurse's station. The notes section of the incident report documents No Notes found. The incident report does not address a root cause of the fall, or interventions to prevent future falls from occurring based on the root cause analysis of the fall. On 2/11/2018 at 4:15 pm R58 fell . The facility's incident report documents Unit nurse reported that resident was on the floor in his room. Nurse stated that saw (sic) him falling, but couldn't get to him in time to prevent fall. He was observed lying on his right side. 'I was picking up my stuff' referring to a picture frame and electronic device that had fallen on the floor. Immediate action taken is documented as Resident assessed for injury. Able to move all extremities without difficulty. Denied pain. Resident transferred into bed using a mechanical lift and 3 assist. Improper footwear is documented as a predisposing situational factor on the incident report. Other info on the incident report documents Resident was sitting in stationary chair in his room which is unusual for resident. Resident also wearing 'croc' type shoes. The notes section on the incident report documents No Notes found. The incident report does not address why R58 had on improper footwear. The incident report has no notes containing a root cause analysis of the fall, or interventions to prevent future falls based on the root cause analysis. The Post Fall Assessment, signed by Director of Nurses (DON)-B on 2/13/2018, states Care plan updated? with options of no or yes. Neither option is checked. On 2/12/2018 at 10:30 pm R58 fell . The facility's incident report documents Writer called for another staff member to get RN supervisor. Writer obtained vitals, initial vitals were BP (blood pressure)-148/62 P (pulse)80, R(respirations)-18, T (temperature)-97.1. Resident was alert and answering questions appropriately. Equal hand grasp strength and movement as well as LE (lower extremity). RN supervisor arrived and assessed and told staff it was clear to hoyer into bed. Staff used Hoyer and Resident was helped back into bed. Writer then initiated neuro checks which were WNL. Writer put bed in low.(sic) Resident stated he was reaching for his phone. Immediate action taken is documented as Writer had RN assess Resident, began neuro checks and insured Resident was safe when leaving room The notes section on the incident report on 2/12/2018 document On (MONTH) 12,2018, resident was found on floor next to bed. Resident was immediately assessed. No apparent injuries noted. Resident was assisted back to bed. Resident interviewed and stated that he was reaching for his phone resulting in a roll out of bed. Resident phone placed on bedside and moved closer to resident reach. Resident able to grab phone without difficulty. From 1/22/18-2/23/18 R58's plan of care was not updated to prevent future falls despite R58 having 8 falls from 1/25/18-2/12/18, including a fall on 1/28/18 that required R58 being sent to the emergency room and having 5 falls on 1/28/18. On 2/23/18 R58's plan of care was updated to include Pharmacy consultant to review medications and inform nursing staff of recommendations if any noted. On 2/24/2018 at 8:30 pm R58 fell , requiring having to go to the emergency room requiring to be sedated to have his hip put back into place. The facility's incident report documents Nursing staff alerted to sound of resident yelling in room 'Help' This nurse observed resident lying on floor upon approaching room resident yelling loudly my right left hurt right leg inward and shortened unable to straighten leg without pain resident kept comfortable pillow under head comfort and reassurance given this writer paged nursing sup (supervisor) and updated on above called Optum nurse with NOR (new order received) to send to ER (emergency room ) for eval and tx (treatment) bell ambulance called and arrived in 10 minutes transported resident onto stretched (sic) and board resident reassured daughter would be meeting at hospital resident continued to be yelling out loud my leg hurts as ambulance was leaving facility ER nurse updated. Resident stated 'I was going to bathroom' encouraged to call for assistance to maintain safety. Notes on 2/24/2018 document Right hip dislocation resident was reportedly sedated with propofol and hip put back in place. Transported back to facility by bell ambulance. Resident appeared calm. Bed was low, resident appeared comfortable. The additional wheelchair removed from room. The incident report does not address the last time that R58 was offered to be toileted or checked for incontinence. The facility's post fall assessment documents new immediate interventions as reminded to call for assistance, reoriented to call system The surveyor noted that R58's plan of care already included an intervention from 11/20/2017 to Anticipate and meet the resident's needs. Encourage the resident to always call for assistance. The incident report documents no under the question asking if the care plan was updated. On 2/25/18 R58's plan of care was updated to include Encourage resident to allow staff to assist him with care needs, Attempt to redirect resident when he becomes agitated and verbally abusive to staff, and neurological checks per facility protocol. R58's plan of care was updated to include Therapy screen on 2/25/2018. On 3/2/2018 at 9:10 am R58 fell . The facility's incident report documents Writer was situated just outside to the resident's door with the med cart, passing morning medications. Writer preparing administered (sic) resident medications and peeked around the door and saw resident sitting on the floor in front of his bed, eating his breakfast. Resident wearing gown, and brief with no socks. Bed was in low position and fall mat on the floor. Room light adequate. Call light not active. Resident stated he was sitting along the side of the bed to eat his breakfast. He attempted to readjust himself when he slid off of the bed onto the floor. Immediate action take is documented as Resident assessed for injuries. No open areas, bleeding discoloration noted. Resident PROM WNL. Resident assisted back to bed with a full body mechanical lift. MD notified. POAHC (power of attorney health care) notified. The notes section on the incident report on 3/2/2018 document On (MONTH) 2, (YEAR) resident was found sitting on the floor mat next to bed eating breakfast. Resident refused to get out of bed for breakfast choosing to eat in his room. Resident has had multiple falls with real (TRUNCATED)

Based on observation, interview, and record review the facility did not ensure that 2 (R58 and R57) of 2 residents reviewed received the necessary care and services to promote healing and prevention of the development of pressure injuries. -R58 was admitted to the facility with a suspected deep tissue injury to his right heel on 4/6/18. The facility failed to provide daily diabetic foot checks and provide treatment as recommended by the nurse practitioner. The facility also failed to assess the wound from 4/6/18-4/26/18 and to immediately put interventions in place to reduce pressure on R58's heel. The facility also failed to develop a care plan to provide interventions to promote the healing of a pressure injury. R58's pressure injury worsened and R58 was hospitalized from [DATE]-5/8/18. R58's pressure injury became infected requiring IV antibiotics during the hospitalization and upon return to the facility. At the time of readmission from the hospital R58's pressure injury to his right heel remained. The facility again failed to develop a care plan to provide interventions to promote healing of R58's stage 4 pressure injury. The facility did not transfer interventions to offload R58's heels from his (MONTH) Treatment Administration Record to the Treatment Administration Records of subsequent months. The facility did not have a registered nurse assess R58's wound at least weekly, and did not notify a physician of the deterioration of the wound. On 8/16/18 and 8/20/18 R58 was observed in bed with his heels not offloaded of pressure, of staff not offering to offload his heels, and not offered to be repositioned in bed despite being at risk for additional pressure injuries. The facility's failure to provide necessary treatment and care to prevent R58's pressure injury from worsening and developing into a stage 4 pressure injury created a finding of Immediate Jeopardy for R58 beginning on 5/8/18. Administrator-A and DON (Director of Nursing)-B were informed of the Immediate Jeopardy on 8/21/18 at 2:52 PM. The Immediate Jeopardy was removed on 8/23/18 when the facility implemented an action plan. However, the deficient practice continues at a scope and severity level of G (actual harm/isolated) for the example involving R57. ~ R57 developed multiple, facility acquired pressure injuries. The facility did not ensure weekly assessments were completed of R57's pressure injuries that included consistent staging of the wounds. The facility did not ensure R57's pressure injuries were assessed by an RN when discovered or observed with changes. The facility did not establish a plan of care to help prevent pressure injuries from developing or deteriorating once developed. R57 developed unstageable (with eschar or slough) and /or deep tissue injury (DTI) pressure injuries on her calf, gluteal fold, right and left buttocks, calf and dorsal foot. Findings include: The facility's pressure injury policy and procedure, undated, defines a stage III (3) pressure injury as Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. Further description: The depth varies by anatomical location. Some locations do not have subcutaneous tissue and these stage III ulcers can be shallow. Bone/tendon is not visible or directly palpable. The policy describes a Stage IV (4) pressure injury as Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Further description: The depth varies by anatomical location. Some locations do not have subcutaneous tissue and these stage IV ulcers can be shallow. The policy defines an unstageable pressure injury as Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, or black) in the wound bed. Further description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed. The facility's Skin Management System policy and procedure, dated 1/2/17, states Pressure Ulcers, Venous ulcers and Arterial Ulcers and surgical sites will be documented on the 'Ulcer, Surgical Site Treatment and Progress Record: form or EMR (electronic medical record). Use one form per wound. Wound progress is to be documented each week with measurements and wound descriptions. Daily treatments are also documented on the same form .Progress of the identified area, will be documented on the back of the Ulcer Surgical Site Treatment and Progress Record form at least every 7 days, or less if the wound shows a decline or is healed. The Physician is to be contacted after 14 days if the area has not shown improvement or immediately if it shows a decline. Documentation of the physician notification is to be in the Nurses Notes in the chart or EMR. The policies provided to the surveyor do not address deep tissue injuries. 1.) R58 has [DIAGNOSES REDACTED]. R58's Minimum Data Set assessment, with an assessment reference date of (MONTH) 11, (YEAR) documents R58 is at risk for the development of pressure injuries, requires extensive assistance of one person's physical assistance for bed mobility, and requires extensive assistance of two persons physical assistance for transferring. R58's care area analysis for pressure injuries, signed as completed on 1/24/18, documents Resident is long term care resident with [DIAGNOSES REDACTED]. (history) of right hip dislocation, abd (abdominal) hernia, anal fissure, gout, depression, [MEDICAL CONDITION] [MEDICAL CONDITIONS],[MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease),[MEDICAL CONDITION](hypertension), and [MEDICAL CONDITION]. Resident is cognitively impaired and is on scheduled check and change every 2 hours and prn (as needed) with toileting/inc (incontinent) care. Resident is assist of one with transfers and toileting. Resident is on medication for [MEDICAL CONDITION]. Resident's intake is 75-100%. [MEDICATION NAME] power is applied twice daily to yeasty areas as needed. Will proceed to care plan. On 4/6/18 at 11:05 am Licensed Practical Nurse (LPN)-F documents in R58's nurse's notes .right heel o/a (open area) measured 0.5 cm x 0.9 cm LPN-F also documented R58 had an o/a (open area) 0.5 x 0.9 on a skin assessment sheet on his right heel. On 4/6/18 a Nurse Practitioner's progress note documents .He has a new deep tissue injury to R (right) heel .Nursing interviewed and reports that he hasn't had behaviors since returning to facility. Nursing reports compliance with medication .PHYSICAL EXAM .SKIN: Warm, dry, pinkish-white skin. Fair skin turgor. No open areas. The note later documents Pressure ulcer of right heel, unstageable .treatment plan: [REDACTED]. Skin prep to wound and cover. Off load pressure by elevating legs while in bed. R58's Treatment Administration Record documents No Sting Barrier Film Spray APPLY TOPICALLY TO RIGHT HEEL AFTER NSW (normal saline wash) TWICE DAILY AND AS NEEDED with a start date of 1/25/18 and a discontinue date of 4/9/18. The surveyor noted the Treatment Administration Record does not document the new intervention to cover the wound that the nurse practitioner had described. The surveyor noted there was no documentation of offloading pressure by elevating legs while in bed that the nurse practitioner had described. On 8/21/18 at 09:43 AM the surveyor interviewed Director of Nursing (DON)-B. The surveyor informed DON-B of no documentation related to the recommendation documented from the nurse practitioner on 4/6/18 to apply skin prep and cover. DON-B reviewed the residents (MONTH) Treatment Administration Record and stated she would look into it. No additional information was provided to the surveyor. Nurses notes on 4/9/18 document (Nurse Practitioner) made rounds today, NOR (new order received CMP (complete metabolic panel) on 4/10/18, right hip incision, NSW (normal saline wash), PAT dry, f/b (followed by) [MEDICATION NAME], change daily and PRN (as needed), also SOAP and water to right heel, pat dry, apply wound gel to wound bed f/b (followed by )Allevyn drsg (dressing) change daily and prn, resident and POA (power of attorney) made aware. On 4/10/18 physician progress notes [REDACTED]. Off load pressure. On 4/25/18 progress notes document .Optum NP and (physician) updated on lab results and right heel wound, NOR .d/c (discontinue) current right heel tx (treatment), tx change to clean right heel with NSW f/b foam drsg, change daily, and prn, apply prevalon boot to right foot on at all times except for wound care treatment, resident and POA updated. On 4/26/18 the Nurse Practitioner progress notes document .Upon return to the facility he had a small deep tissue injury to his right heel. We were asked to see him today because the area is now open and draining. His chart, labs, and medications are reviewed. Nursing interviewed reports that an open area on the right heel was noticed after finding drainage on his bedding .Current Status: Previous DTI (deep tissue injury) noted upon discharge from hospital on [DATE]. Today, DTI extends entire area of heel and an ulceration of approx (approximately) 2 cm x 2 cm x 0.2 cm is present. Small amount of serosanguineous drainage .treatment plan: [REDACTED]. Plan: Irrigate wound with NS (normal saline), skin prep to peri-wound, cover with foam dressing. Prevalon offloading boot to right foot at all times except for wound care. Nurse Practitioner family communication on 4/25/18 documents Spoke with daughter .regarding new wound to right heel, updated her on new wound orders and Prevalon boot. In (MONTH) (YEAR) staff monitored R58's behavior of resisting cares. R58 was documented as resisting cares 4 days in the month of April. There is no documented behavior/intervention monthly flow record for resisting cares documented after 4/2018. R58 was hospitalized from [DATE]-5/8/18. There is no documentation of assessment of the wound from 4/6/18-4/26/18. On 8/21/18 at 9:43 AM the surveyor interviewed DON- B. The surveyor asked DON-B if there was any documentation of assessment of the wound from 4/6/18-4/26/18. DON-B looked through the facility wound binder that had residents wound measurements in it. DON-B was unable to find R58's wound measurements or assessments in the binder. DON-B exited the room stating she was going to look in one other spot. On 8/21/18 at 10:10 AM DON-B returned to the room and stated she had been unable to find anything. No additional information was provided to the surveyor related to R58 having no documented wound assessment from 4/6/18-4/26/18. R58's hospital history and physical notes on 4/27/18 document Right heel and bilateral buttock pressure ulcer present on admission. Hospital notes document the wound was present at the time of the hospital admission with an initial pressure injury stage of Unstageable/necrotic tissue. R58's Treatment Administration Record for (MONTH) (YEAR) documents FLOAT HEELS WHEN IN BED with a start date of 1/25/18. There is no documentation signing out that this was completed. Upon R58's return from the hospital on [DATE], this intervention is not documented as being carried over onto the (MONTH) (YEAR) Treatment Administration Record and subsequent months Treatment Administration Records. R58's (MONTH) Treatment Administration Record documents Apply Prevalon boot to R foot-on at all times starting 4/25/18. The (MONTH) Treatment Administration Record and subsequent months Treatment Administration Records did not contain documentation related to the use of prevalon boots. There are no documented interventions to offload R58's heels of pressure noted in his care plan, Medication Administration Record, [REDACTED]. Nurses notes on 5/8/18 document .Resident's right heel has an open area that measures 3.0 x 4.0 . physician progress notes [REDACTED].He has Rt heel pressure ulcer without OM (osteo[DIAGNOSES REDACTED]) but superficial infection .right heel quite painful. On 7/18/18 LPN-L documented wound data collection on the wound evaluation tracker in R58's electronic medical record for 5/10/18. The wound is documented as being 5 cm x 5.6 cm x 0 cm, unstageable, 100% slough and the wound color documented as yellow. There is no documentation of an RN assessment on 5/10/18. Heel Protectors is not checked as a current preventative intervention. On 7/18/2018 LPN-L documented wound data collection on the wound evaluation tracker in R58's electronic medical record for 5/17/18. The wound is documented as being 5.5 cm x 4.5 cm x 0 cm, unstageable, 75% slough, and 25% granulation. There is no description of the color of the wound bed. Heel boots are not checked on the form as a current preventative intervention. There is no documentation of an RN assessment on 5/17/18. Nurse Practitioner notes on 5/18/18 document .During the most recent hospitalization earlier this month, he was placed on IV antibiotics for [MEDICAL CONDITION] that developed in his right lower extremity due to an ulcer on his right heel. The heel was debrided and a VAC was used while he was inpatient. Today a Vac continues to be used to the right heel in addition to Santyl and he continues with Vanco and [MEDICATION NAME] IV . The nurse practitioner documents Pressure ulcer of right heel, stage 3 .treatment plan: [REDACTED]@ 125mmHG continuous suction change M,W, F (Monday, Wednesday, Friday). Offload foot. Monitor for additional skin breakdown. On 7/18/18 LPN-L documented wound data collection on the wound evaluation tracker in R58's electronic medical record for 5/24/18. The wound is documented as being 5.5 cm x 4.3 cm x 0 cm, unstageable with 50% granulation and 50% slough. There is no description of the color of the wound bed. Heel boots are not checked on the form as being a current preventative intervention. There is no documentation of an RN assessment on 5/24/18. On 5/30/18 Infectious disease consult notes document: R (right) heel nonhealing ulcer. Bone felt (positive). Wound mostly granulating. Replace wound vac at facility. f/u (follow up wound care clinic at St. Luke's. On 7/18/18 LPN-L documented wound data collection on the wound evaluation tracker in R58's electronic medical record for 5/31/18. The wound is documented as being 5.5 cm x 4.6 cm x 0.3 cm, unstageable with 85% granulation and 15% slough. There is no description of the color of the wound bed. The form lists current preventative interventions and does not include interventions to offload R58's heels of pressure. There is no documentation of an RN assessment on 5/31/18. On 7/18/18 LPN-L documented wound data collection on the wound evaluation tracker in R58's electronic medical record for 6/7/18. The wound is documented as being 5.5 cm x 4.4 cm x 0.4 cm, unstageable, with 75% granulation and 25% slough. There is no description of the wound bed color. The surveyor noted an increase in slough and depth from the previous week. The form lists current preventative interventions and does not include interventions to offload R58's heels of pressure. There is no documentation of an RN assessment on 6/7/18. There is no documentation that a physician was notified of the increase in depth and slough. Inpatient wound care physician progress notes [REDACTED].History of Present Illness: This is a [AGE] year old male seen regarding a right heel wound. Patient states he has had this wound for several months, but is unable to provide a specific time frame. He states he does not like wearing Prevalon boots .Patient underwent right heel debridement with calcaneal biopsy .on 5/4/18. Culture of calcaneal biopsy: Positive for Actinomyces. Tissue Right Heel Ulcer: + for Proteus Mirabilis [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant staphylococcus aureus) .Physical Exam: .R (right) posterior heel with large open wound. Base mostly pink and granular. Superior aspect with globular necrotic tissue, which was debrided. No bone or ligament exposed after debridement .Offloading: Encouraged patient to use Prevalon boots to offload heels. Report of consultation notes from the 6/13/18 consult documents Prevalon boots (or equivalent) on right heel when in bed. The surveyor reviewed R58's medical record and noted no documentation related to refusals of the use of prevalon boots The surveyor reviewed R58's care plan and noted no updated interventions to encourage use of prevalon boots based on the physician recommendations documented on 6/13/18. R58's medical record did not contain documentation related to risks and benefits of refusing interventions to offload his heels of pressure being discussed with R58. R58's plan of care did include a focus area of Places self on floor/slides off chair/bed-resident attempts to self transfer and puts self on floor r/t (related to): attention seeking/manipulative behavior, 4/6/18; Swears at staff, refuses cares, cognitive impairment Date Initiated: 02/19/2018 Revision on 04/09/2018. Interventions include Give positive attention/praise Date Initiated: 02/19/2018 If resident refuses cares, leave and return a second time or ask another staff person to approach him Date Initiated: 04/09/2018 If sitting or laying on floor, attempt to redirect back to appropriate resting place. If unsuccessful, assure is not in a place where poses hazard to self or others Date Initiated: 02/19/2018 Provide mat or covering on floor for patient to sit on Date Initiated: 02/19/2018 Provide pillow and/or covering if indicated for comfort. Date Initiated: 02/19/2018. The plan of care does not address refusals to offload heels of pressure or refusals to use prevalon boots. On 7/18/18 LPN-L documented wound data collection on the wound evaluation tracker in R58's electronic medical record for 6/14/18. The wound is documented as being 6 cm x 4.5 cm x 0.5 cm, unstageable, with 80% granulation tissue and 20% slough. The wound color is documented as pink. Heel protectors are not checked as a current preventative intervention. There is no documentation of an RN assessment on 6/14/18. The surveyor was provided with hand written wound notes on notebook paper that were unsigned by who had completed them and had R58's room number on it, but no name. LPN-L confirmed the hand written wound notes were completed by her. The surveyor noted the handwritten wound notes from 6/14/18 did not contain documentation that the wound color was pink. The surveyor noted the handwritten wound notes did not provide the current stage of the wound. On 7/18/18 LPN-L documented wound data collection on the wound evaluation tracker in R58's electronic medical record for 6/21/18. The wound is documented as being 6 cm x 4.5 cm x 0.4 cm, unstageable, with 90% granulation tissue and 10% slough tissue. The wound bed color is not documented. Heel boots is not checked as a current preventative intervention. There is no documentation of an RN assessment on 6/21/18 On 7/18/18 LPN-L documented wound data collection on the wound evaluation tracker in R58's electronic medical record for 6/28/18. The wound is documented being 4.5 cm x 3.5 cm x 0.2 cm, unstageable, with 90% granulation tissue and 10% slough. The wound bed color is not documented. There is no documentation of an RN assessment on 6/28/18. Heel boots are not checked as a current preventative intervention. On 7/18/18 LPN-L documented wound data collection on the wound evaluation tracker in R58's medical record for 7/5/18. The wound is documented as being 4 cm x 3 cm x 0.1 cm, unstageable, with 90% granulation tissue and 10% slough. There is no documentation of the color of the wound bed. There is no documentation of an RN assessment on 7/5/18. The surveyor was provided with a handwritten wound note on notebook paper for 7/12/18. The note is not part of R58's medical record, it did not document R58's name (only his room number), and is not signed with the name of who completed the assessment. LPN-L confirmed that it was her handwriting and that she had completed the assessment. The note documents the wound as 4 x 2.8 100% granulation. The note does not stage the wound despite the wound being documented as 100% granulation. The surveyor noted no documentation of an RN assessment on 7/12/18. The surveyor was provided with a handwritten wound note on notebook paper for 7/19/18. The note is not part of R58's medical record, it did not document R58's name (only his room number) and is not signed with the name of who completed the assessment. LPN-L confirmed that it was her handwriting and that she had completed the assessment. The note documents the wound as 3.4 x 3.0, 100% granulation. The note does not stage the wound despite the wound being documented as 100% granulation. The surveyor noted no documentation of an RN assessment on 7/19/18. On 7/27/18 an American Medical Technologies patient order sheet documents R58's wound to his right heel as being a full thickness, pressure ulcer stage IV, 3.4 cm x 3.0 cm < (less than) 0.2 cm. The surveyor was provided with a handwritten wound note on notebook paper for 8/2/18. The note was not part of R58's medical record, it did not document R58's name (only his room number) and is not signed with the name of who completed the assessment. LPN-L confirmed that it was her handwriting and that she had completed the assessment. The wound is documented as 2.7 x 2, 50% slough 50% granulation with scant yellow drainage. There is no documentation of an RN assessment on 8/2/18. The surveyor noted no documentation that a physician was notified of the presence of slough. There is no stage documented of the wound. The surveyor was provided with a handwritten wound note on notebook paper for 8/9/18. The note was not part of R58's medical record, it did not document R58's name (only his room number) and is not signed with the name of who completed the assessment. LPN-L confirmed that it was her handwriting and she had completed the assessment. The wound is documented as 2.5 x 1.9, 100% granulation. There is no stage documented of the wound. There is no documentation of an RN assessment on 8/9/18. The surveyor was provided with a handwritten wound note on notebook paper for 8/16/18. The note was not part of R58's medical record, it did not document R58's name (only his room number) and is not signed with the name of who completed the assessment. LPN-L confirmed that it was her handwriting and she had completed the assessment. The wound is documented as 1.4 x 1.4 x 0 cm, 100% granulation. There is no documented wound stage. There is no documentation of an RN assessment of the wound on 8/16/18. On 8/20/18 at 1:39 PM the surveyor interviewed LPN-L, who serves as the unit manager. LPN-L informed the surveyor that she does wound rounds every Thursday. LPN-L confirmed the handwritten wound measurement notes were hers. LPN-L stated prior to ADON (Assistant Director of Nursing)-G starting last week she would generally do wound rounds alone. LPN-L stated that if there was something new or a change she would call DON (Director of Nursing)-B to look at it, otherwise DON-B would only come up once a month along with an outside wound care supply company to do wound rounds. The surveyor asked LPN-L if she had documented the wound documentation provided on notebook paper anywhere else. LPN-L informed the surveyor that she had started entering them into residents' electronic health records, but was so far behind that she hadn't caught up yet. The surveyor asked LPN-L if she was staging the wounds. LPN-L stated a RN does that. The surveyor asked if that was documented anywhere. LPN-L stated in the wound tracker or charting. The surveyor asked LPN-L how she was staging wounds when she had entered wound documentation into the electronic health record on 7/18/18 for observations from previous months if it had not been written down on the provided wound documentation on notebook paper. LPN-L stated from her notes and her memory. LPN-L informed the surveyor that she was always taught if there is any slough in a wound to categorize the wound as unstageable. The surveyor noted that this was not in accordance to the facility policy which states in the description of a stage III pressure injury Slough may be present but does not obscure the depth of tissue loss and in the description of a stage IV pressure injury Slough or eschar may be present on some parts of the wound bed. The surveyor asked LPN-L how she ensured that an RN assessment of the wound is completed. LPN-L stated DON-B does once a month wound round, and ADON-G will also now be involved weekly with wound rounds. On 8/21/18 at 9:43 AM the surveyor interviewed DON-B. The surveyor informed DON-B of the concern that an RN assessment of R58's stage 4 pressure injury to his heel was not completed weekly. On 8/21/18 ADON (Assistant Director of Nursing)-G documented wound data collection on the wound evaluation tracker in R58's medical record for 8/21/18. The wound is documented as being 1.2 cm x 1.5 cm, unstageable, with 100% granulation tissue. Current preventative interventions includes float heels when in bed The surveyor noted this is the first time floating heels is documented in the wound evaluation tracker as an intervention. Current Wound Status/Additional Comments is documented as WCC (wound care certified) RN assessed wound on this date. Resident resting in bed at time of assessment, reports pain 5/10 to area prior to treatment. Scheduled Tylenol administered and resident reports no need to wait to do treatment. Area noted as healing unstageable area to right heel, presents 100% moist granulation tissue with no noted bleeding, drainage odor or s/s infection noted. Wound edges defined and intact, surrounding skin dry with minimal flakiness noted, resolved with cleaning. Resident does have air mattress, float heels and repositioning in place for pressure off loading, prostat supplement in place for wound healing. Per staff reports, resident does often decline repositioning. Staff aware to continue to offer and educate on importance of offloading pressure. The surveyor noted ADON-G staged the wound as unstageable despite the wound bed being described as 100% granulation tissue. The surveyor reviewed R58's care plan. R58's care plan documents Resident is at risk for skin integrity condition, or pressure sores r/t (related to): diabetes, [MEDICAL CONDITIONS], end-stage renal, impaired mobility, incontinence, obesity/admitted [DATE]-revision rt (right) total his replacement with an initiation date of 12/19/17 and a revision date of 4/9/18. Interventions documented are Apply pressure reduction chair cushion on wheelchair and pressure reduction mattress on the bed. Ensure cushion is properly placed, clean and dry Date Initiated: 12/19/2017 Assess skin for redness or pressure related changes with each care encounter. Report any changes immediately Date Initiated 12/19/2017 Enc (encourage) res (resident) to reposition self in wc (wheelchair) Date Initiated 04/09/2018 Re-approach resident if he refuses to allow peri-care provided. Date Initiated: 12/19/2017. R58's care plan did not include interventions to offload heels of pressure, and was not updated to include that R58 has a stage 4 pressure injury. R58's care plan does not include interventions to promote healing and to prevent worsening to his stage 4 pressure injury to his right heel. R58's care plan was not revised as R58's pressure injury worsened. On 8/20/18 at 1:39 PM the surveyor interviewed LPN-L, who serves as the unit manager. The surveyor asked LPN-L if she was involved in care planning of residents. LPN-L stated no, DON-B is. LPN-L stated previously it had been the previous ADON who no longer works at the facility. On 8/20/18 at 2:48 PM the surveyor interviewed DON-B. The surveyor asked DON-B who develops the care plan. DON-B stated that currently it would be LPN-L, and that in the past it would have been her. The surveyor asked who is ensuring that that it is done. DON-B stated it should be done in morning report. The surveyor informed DON-B she had been unable to find care planned interventions related to R58's stage 4 pressure injury to his right heel. The surveyor asked for any additional information related to the lack of care plan to promote healing of R58's stage 4 pressure injury. No additional information was provided. On 8/21/18 at 9:43 AM the surveyor again informed DON-B of the concern related to R58 having no care planned interventions to promote healing to his stage 4 pressure injury. No additional information was provided. Surveyor shared concern related to care plan not being updated when wound developed or changed. On 8/15/18 at 10:50 AM the surveyor observed LPN-F wrapping R58's right heel with a gauze wrap. The surveyor observed LPN-F place R58's right foot and heel on the pillow, not offloaded of pressure. The surveyor observed no attempts to position the pillow so R58's foot was floating or offloaded of pressure. R58's left foot was on the mattress with no attempts observed to offload pressure. The surveyor observed R58's left heel on the mattress with the balls of his bilateral feet against the foot board. No prevalon boots were observed in R58's room. On 8/15/18 at 10:57 AM the surveyor interviewed R58. R58 stated he stays in bed related to a sore on his foot and does not attend activities because of the sore. On 8/16/18 at 07:36 AM the surveyor observed R58 in bed on his back. The surveyor observed R58's bilateral heels on the mattress, not relieved of pressure. The surveyor observed the ball of R58's left foot noted to be on the footboard of his bed. The surveyor asked R58 if he minded a pillow under his legs or boots on his feet. R58 replied that he didn't mind. The surveyor asked if staff offer a pillow to put under his legs. R58 replied if it happens it happens. On 8/16/18 at 8:33 AM the surveyor observed R58 in bed on his back, eating breakfast, with his heels on the mattress not offloaded of pressure. On 8/16/18 at 2:19 PM and 3:59 PM the surveyor observed R58 in bed on his back with his heels on the mattress not offloaded of pressure. On 8/20/18 at 7:40 AM the surveyor observed R58 in bed on his back. The surveyor observed a white pillow under R58's calves, however, both heels were observed to be on the mattress, not relieved of pressure. The surveyor observed the bilateral balls of R58's feet to be resting against the foot of the bed. The surveyor made continuous observations on R58 from 7:40 AM-9:25 AM. At 9:25 AM the surveyor observed CNA (certified nursing assistant)-M and CNA-S enter R58's room. The surveyor observed CNA-M ask R58 if he would like to get up in his chair. The surveyor observed R58 decline. The surveyor observed R58's heels remained not offloaded of pressure. The surveyor noted CNA-M and CNA-S did not attempt to offload R58's heels of pressure. The surveyor observed CNA-M and CNA-S did not attempt to reposition R58 in bed when he declined to get up in his chair. The surveyor observed R58's toes and bilateral balls of feet to be touching the footboard. The surveyor observed R58 remained on his back. On 8/20/18 at 09:33 AM LPN-F entered R58's room and repositioned the pillow under R58's legs. The surveyor observed the left heel was now offloaded of pressure; however, the right heel was resting on the black raised bolster part at the foot of R58's mattress, not offloaded of pressure. The surveyor observed R58 had

Based upon observation, interview and record review, the facility did not ensure proper care and treatment for 1 (R57) of 1 resident reviewed with a change in condition and 2 (R57 and R31) of 2 residents reviewed with non-pressure wounds and 1 (R234) of 1 Residents reviewed receiving [MEDICATION NAME] for possible constipation without a bowel assessment. This affected Residents R57, R31, and R234 from reaching their highest practicable well-being. ~ R57 is a long term resident of the facility with a frequent history of urinary tract infections (UTIs) with specific physician recommendations to have her catheter changed on a monthly basis to prevent recurring UTIs. On 7/2/18, R57 experienced a change in condition where stat labs were ordered and IV fluids were initiated by the Nurse Practitioner. On 7/2/18, at approximately 2:09pm, the lab results indicated R57 had elevated white blood cell counts and a procalcitonin level of 15.46 with a reference range of < (less than) or equal to 0.08; this lab value indicates R57 was likely [MEDICAL CONDITION] at that time. On 7/2/18 at 3:00 pm, the Nurse Practitioner ordered to place a PICC line STAT (immediately), Vanco ([MEDICATION NAME]/antibiotic) via IV x 10 days with pharmacy to dose and [MEDICATION NAME] (antibiotic) IV x 10 days and to start both antibiotics STAT. Review of the orders indicates the facility Assistant Director of Nursing (ADON) at the time received the stat orders and the Director of Nursing (DON) processed the orders. Interviews with the pharmacy indicate the initial orders were faxed on 7/2/18 to the pharmacy at 3:30 pm; the pharmacy processed the orders at approximately 5 pm and delivered both the antibiotics to the facility at 8:26 pm. There is no indication the facility contacted the physician/nurse practitioner to inform them R57 still had not received the antibiotics despite the order being a stat order. R57 did not receive either antibiotic until approximately 12:01 am on 7/3/18. There is no indication R57 was assessed by an RN on second shift on 7/2/18 despite the change of condition. At 1:10 am on 7/3/17 R57's temperature was 103.1 degrees axillary, at this time orders were received to send R57 to the hospital where R57 was admitted to the intensive care unit (ICU) with a [DIAGNOSES REDACTED]. Review of the facility processes indicate the facility did not have a policy at the time that provided procedures for STAT orders. During the Surveyor's investigation, it was determined the two antibiotics ([MEDICATION NAME] and [MEDICATION NAME]) that were ordered by R57's nurse practitioner are to be included in the facility contingency. During interviews with facility nursing staff including the Director of Nurses it was indicated, despite having IV materials in contingency, the facility would still send out to the pharmacy to prepare the IVs. During interview the Director of Nursing also reported if the medication is in contingency the nurses should go to contingency and reconstitute the medications for IVs. The Director of Nursing and Surveyors observation of the contingency on 8/23/18 determined the vials for [MEDICATION NAME] and [MEDICATION NAME] were not available in contingency. The facility had no record of when they were last used or if replacements were requested. Interviews with pharmacy indicate the last restock of the IV contingency medications was 3/29/18. The facility's failure to ensure facility staff responded appropriately to meet R57's change in condition and implement treatment orders as written created a situation of immediate jeopardy for R57 that started on 7/2/18. The facility administration was informed of the immediate jeopardy on 8/23/18 at 2:17 pm. The immediate jeopardy was removed on 8/24/18 when the facility implemented an action plan. The deficient practice continues at a scope/severity (s/s) of a G (actual harm/isolated) related to the following additional example involving R57's wound care. ~ According to interviews with facility staff R57 has an extensive history of developing diabetic wounds on her feet. In (MONTH) (YEAR) R57 was noted to have multiple wounds on her toes with slough and requiring treatment with an oral antibiotic. The wounds were facility acquired. During the survey, R57 was noted to have wounds on her toes that were covered with eschar. Review of the facility's monitoring and assessment of R57's toe wounds identified the facility did not ensure assessments and monitoring occurred on a weekly basis. There is no indication R57's plan of care was updated to address the specific diabetic wounds R57 was experiencing and specific steps to prevent the development of additional wounds. ~ R31 was hospitalized from [DATE]-5/25/18. The hospital discharge paperwork dated 5/25/18, documents: left leg venous ulcer, left posterior with slough and eschar. R31's left calf venous ulcer was not monitored by an Registered Nurse (RN) weekly with measurements and description of the wound and the care plan was not updated to reflect changes in the wound and treatment plan. ~ The facility administered and attempted to administer laxatives to R234 for constipation after she informed the facility that she does not have concerns with constipation. No assessments were completed related to bowel and bladder prior to the administration of any laxatives. Findings include: 1) R57 is a long term resident of the facility with [DIAGNOSES REDACTED]. R57's significant change Minimum Data Set ((MDS) dated [DATE] indicates for appliances R57 does not have an appliance however the MDS also indicates R57's continence is not rated due to the resident either having a catheter or no urine output for the entire 7 day look back period. The Care Area Assessment (CAA) for urinary incontinence signed as complete on 7/17/18 indicates: 62 y/o (year old) lady readmitted to center after hospitalization for recurrent UTI. A-fib, MS [MEDICAL CONDITIONS] bladder (foley catheter), DM II (diabetes type 2) [MEDICAL CONDITION] disorder. Other dx (diagnoses) include Dementia with paranoid delusions, [MEDICAL CONDITION] disorder, [MEDICAL CONDITIONS] Depression w/anxiety and [MEDICAL CONDITION]. Resident has foley catheter due to [MEDICAL CONDITION] bladder possibly related to MS. Has recurrent UTI's, currently treated with ABT's (antibiotics). She requires 2 assist for toilet hygiene. Utilizes incontinence products, staff provides catheter care, empties foley bag q shift and prn (as needed). Resident is alert, unaware of toileting needs. Monitored for UTI's, adequate fluid intake is encouraged. Proceed to care plan interventions to minimize comolications (sic) related to altered elimination. Review of R57's medical record indicated R57 was admitted to the hospital on [DATE] until 6/2/18. Review of the hospital discharge summary dated 6/2/18 indicates: (R57) has [MEDICAL CONDITION] with [MEDICAL CONDITION] bladder and chronic foley and lower extremity weakness: She absolutely needs her Foley changed every month. I changed her [MEDICATION NAME] to a syrup form as the extended release should not be crushed. Surveyor noted the written statement was noted by facility staff as it was circled and notations were made regarding the [MEDICATION NAME]. Surveyor reviewed R57's care plan, physician orders [REDACTED]. Review of an Optum Nurse Practitioner (NP- X) Note dated 7/2/18 indicates .(Resident) is being seen today for a monthly exam and a c/o (complaint of) not feeling well .Today, she was not feeling well, pale and slightly diaphoretic. She had no fever; VS (vital signs) were stable, except BP of 80/62. A stat CBC, CMP, procalcitonin, lactic acid and a UA C&S (urinalysis with culture & sensitivity) were ordered. She was started on 0.9% NS via PIV @ (at) 75cc/hr. A few hours later in the day she spiked an oral temp of 103 degrees and BS (blood sugar) hovered around 400+. Labs were back with WBC 22.5 and procalcitonin 15.46; however pt stated she felt better. In collaboration with covering PCP (primary care physician) for (Physician-V) (Physician-W), PICC line was ordered as well as [MEDICATION NAME] 1 G IV every 12 hours and Vanco with pharmacy to dose, Repeat CBC, BMP and Procalcitonin were ordered for the am to monitor kidney function as well as progression of infection .Additional notes: Foley catheter not changed since put in during hospital admission 5/29/18 and this is to be changed monthly per Urology recommendations. This was changed today prior to getting UA. Nurse Practitioner's A&P details dated 7/2/18. Acute,[MEDICAL CONDITION].[MEDICAL CONDITION] with bacterial etiology highly likely r/t (related to) procalcitonin level of 15.46 in conjunction with symptoms consistent with UTI, temp 103 and WBC of 22.5. Plan PICC line as soon as able, continue IV fluids via PIV and start IV [MEDICATION NAME] 1G every 12 hours x 10 days and Vanco per pharmacy dosing x 10 days. OK to use PIV for Vanco until PICC is able to be placed on 7/3 am. Repeat CBC, BMP and procalcitonin in AM 7/3. Finish liter of 0.9% NS, then change to 0.45% NS @ 75cc/hr for 10 days. Continue to monitor VS Q (each) shift and for mental status changes. Updated on P[NAME] (plan of care) (POA-Power of Attorney) is comfortable with treatment in place as long as we are able, if condition worsens, she would want (R57) sent to the hospital. Review of the notes for Physician-V's Nurse Practitioner (NP)-R indicates on 7/2/18: Nurse reports that she appears pale at breakfast and isn't eating very much this morning. She also reports that she had a blood sugar > (greater than) 400 this morning (but was drinking cranberry juice earlier.) (R57) is a poor historian due to her MS and delusions but tells me she feels tired this morning. Recently was hospitalized for [REDACTED]. Was also treated for [REDACTED]. Has chronic foley with follow up appointment with urology at the end of July. POA states she would like to explore option of a suprapubic catheter to decrease infections. Physical exam: She appears lethargic. She is cooperative. No distress .[MEDICAL CONDITION] comments: Foley with amber urine in bag .Oriented to person only. 1. [MEDICAL CONDITION], unspecified [MEDICAL CONDITION] type 2. Lethargy 3. History of UTI. STAT CBC, BMP, procalcitonin level, lactic acid. Obtain UA, C&S if indicated. IVF (NS0.9% at 75cc/hr x 1 liter then re-evaluate [MEDICAL CONDITION]) .Spoke with HCPOA (healthcare POA) about current condition and treatment NH vs hospital. She prefers treatment in place but would like her transferred to hospital if declines further. She is agreeable to plan of care and requests updates later. On 8/23/18 at approximately 7:29 am, Surveyor interviewed NP-R. NP-R stated she was in the building on 7/2/18 and staff came to her to look at R57 because she was sleepy and not eating. NP-R indicated she could see she (R57) was not her usual self and something was wrong. Noted resident was hypotensive. NP-R indicated she contacted R57's POA (Power of Attorney) who wanted resident treated in house but sent out if she got worse. Surveyor asked NP-R if R57 would have typically been sent out at this point. NP-R stated not necessarily, still defer to POA wishes but was aggressive with treatment even at this point by offering fluids via IV and even starting it for the facility. NP-R indicated she ordered STAT labs and consulted with NP-X and handed off. NP-R indicated she was not surprised to see next day that R57 was in the hospital stating when she goes, she goes fast. NP-R indicated she is familiar with R57 over last few years and that the last few months have been very difficult with repeated UTIs she can see the decline. Surveyor asked NP-R about the term STAT and what it means in this facility. NP-R indicated that STAT is often defined in the contracts with the labs & pharmacy but not sure what facility policy is. NP-R indicated she knows that the LPN's cannot start IVs here and this is a very LPN heavy building; which makes treating complicated. Surveyor asked about contingency. NP-R indicated that she understood that contingency often is without IV supplies & fluids. Review of R57's progress notes indicate: Effective Date: 7/2/2018 at 07:36: Type: SBAR (Situation Background Assessment Recommendation) - Change of Condition SPN Situation: SBAR form completed for a change in condition signs or symptoms: Other change in condition low b/p, elevated blood sugar, irregular HR, skin pale. This started 07/02/2018 Morning. Background: The resident is in the facility for Long Term Care. [DIAGNOSES REDACTED]. Functional Status Evaluation: General weakness Decreased mobility General weakness without fever, change in level of consciousness, or other acute symptoms Recent onset not resolving spontaneously not able to feed self. Behavioral Evaluation: No changes observed. Respiratory Evaluation: No changes observed. Cardiovascular Evaluation: New irregular pulse [MEDICAL CONDITION] Abdominal/GI Evaluation: No changes observed. [MEDICAL CONDITION] Evaluation: Other urine cloudy with foul odor and pinkish hematuria. Skin Evaluation: Not clinically applicable to the change in condition being reported. Pain Evaluation: No. Neurological Evaluation: Weakness or [MEDICAL CONDITION] Weakness, arm or leg: Abrupt onset of noticeable change in strength or use not able to feed self. Laboratory Tests/Diagnostic Procedures: Assessment: Since the change of condition the symptoms or signs gotten: Stayed the same. This condition, symptom or sign has occurred before: Unknown. Summary of observations and evaluation: Recommendations: Primary clinician's recommendations: STAT CBC, BMP, lactic acid, procalcitonin level, obtain UA C+S if indicated today, IV fluids NS 0.9% @75cc/hr. x1 liter recheck blood sugar and blood pressure in one hour Blood Tests Urinalysis or culture IV or subcutaneous fluids Response: Primary care clinician (NP-R) APNP updated 07/02/2018 7:31 AM. Family/healthcare agent notified: POA 07/08/2018 8:00 AM. Progress notes indicate: Effective Date: 7/2/2018 at 07:49. Type: General Note (NP-R) inserted PIV (peripheral IV) 24 gauge to left wrist and started IV fluids. Effective Date: 7/2/2018 at 12:00: Type: Order Note: (NP-X) made aware of BS (blood sugar) 440 mg/dl, NOR (new order received) to give additional 2 units now, resident made aware and POA. Effective Date: 7/2/2018 at 13:40 (1:40 pm) Type: Health Status Note: Note Text: rechecked resident blood sugar and observed resident shivering, skin cold and clamy (sic), blood sugar 444 mg/dl, temp 103.1 oral, resident denies pain and able to respond, (NP-X) updated on resident status, (NP-X) assessed resident and contacting on-call MD-W to make aware, writer gave resident Tylenol 650 mg, and placed cool compress across forehead. Effective Date: 7/2/2018 at 13:50 (1:50 pm): Type: Health Status Note, Note Text: writer unable to obtain blood pressure with manual cuff, (NP-X) obtained blood pressure with manual cuff reading 122/78, right arm, (NP-X) noted left wrist infiltrate as well, IV immediately stopped and PIV pulled, tip noted in place, gauze placed on site, Bell ambulance called for reinsertion. Review of R57's record indicates Bell ambulance arrived at the facility at 15:00 (3:00 pm) and inserted a peripheral IV with a catheter size of 20g in R57's right wrist. On 7/2/18 at 2:09:35 pm the facility received the results of R57's STAT labs indicating values: WBC 22.4 reference range: 3.9-11.2; RBC 5.4 reference range 3.7-5.2; Glucose 464 reference range 65-99; creatinine 1.73 reference range 0.50-1.10; Procalcitonin 15.46 reference range: <=0.08. Included in the lab results was an infectious diseases sheet indicating procalcitonin levels less than 0.25, .25 and 0.5 and greater than 0.5 indicate presence [MEDICAL CONDITION]. Baseline concentrations > (greater than) 2.0 ng/mL on the first day of ICU admission and concentrations that do not decline by more than 80% are associated with a higher risk of mortality in patients diagnosed with [REDACTED]. R57's lactic acid was 6.0 with a reference range of 0.5-2.0. UA indicated positive for leukocyte esterase and/or [MEDICATION NAME]. Urine culture was ordered. Labs were noted by NP-X. Review of R57's medical record indicates treatment orders dated 7/2/18 at 1500 (3:00 pm) stating: Place PICC line STAT. Vanco via PICC line x 10 days, pharmacy to dose. [MEDICATION NAME] 1 gram IV Q (every) 12 hrs x 10 days. Start Abx (antibiotics) STAT ok to give Vanco via peripheral IV until PICC placed. CBC, BMP on 7/3 am. Procalcitonin on 7/3 am. Pharmacy to dose Vanco to trough 10-20. Surveyor observed the orders had a starred note stating **IV DEPT** and the orders were received by the facility Assistant Director of Nursing (ADON)-Y at the time and processed by Director of Nursing (DON)-B. On 7/2/18 at 16:30 (4:30 pm) NP-X wrote additional orders stating after 0.9% NS is completed infusing change to 0.45% NS Q 75cc/ for 10 days. VS (vital signs) every shift, acidophilus PO BID (twice a day) x 20 days. Review of R57's medical record indicates the facility received an IV medication recommendation form from the pharmacy with a pharmacist recommendation to dose [MEDICATION NAME] 750 mg IV q 24 hrs to trough on 7/6/18. Surveyor observed this note was processed by DON-B. Review of an Optum Nurse Practitioner note dated 7/9/18 details the change in condition R57 was experiencing on 7/2/18 and reference to treatment as above with additional documentation indicating: .Of note, her STAT antibiotics were ordered at 3:30 pm on 7/2 and not hung until after midnight. Around 2 am she was found with altered mental status and transferred to SLRMC (St Luke's Medical Center). Per the hospital discharge summary, she received 3 liters of fluid and was admitted to the ICU for [MEDICAL CONDITION]/septic shock from urine source and [MEDICAL CONDITION] fib with RVR (rapid ventricular rate) . She received 4 days of IC (interstitial [MEDICATION NAME]) antibiotics and then was transitioned to PO (by mouth) Bactrim . Review of R57's medical record only includes one entry for the second shift on 7/2/18 written at 22:54 (10:54 pm) by Licensed Practical Nurse (LPN)-J indicating: Effective Date: 7/2/2018 at 22:54: Type: General Note: Note Text: Resident up in bed ate 25% of supper with assistance, alert and responsive, skin warm to touch, no s/s of SOB. Call out to Optum care and talk with (on call NP) at 2130 about Lactic Acid lab, she stated to start IV ABT stat, also to continue orders and if pulse rate is greater than 120 and SBP less then (sic) 120 to call back, informed supervisor of above information also report to on coming Staff Nurse. t 98.4 b\p 128/68 p (pulse) 114, r (respirations) 22. Surveyor noted there is no indication of an RN assessment for R57 on second shift despite R57 having a change of condition indicating R57 is [MEDICAL CONDITION]. There is no documentation to indicate the status of the facility processing the STAT orders for antibiotics. On 8/22/18 at 8:46 pm Surveyor interviewed LPN-J via telephone. LPN-J indicated she does not work in facility very often but remembered that night. LPN-J indicated she recalls when she came on her shift the nurse practitioner was there, supervisor, DON etc. all dealing with (R57). LPN-J indicated she was aware of R57's elevated blood sugar levels and recalls checking her through the shift & collecting vitals & calling Optum when the IV was still not running and she had critical lab values. LPN-J indicated she shared the results of her conversation with Optum with her supervisor LPN-Z. Surveyor asked LPN-J if it was her or LPN-Z that hung the IV's. LPN-J indicated no, neither could do it because they are both LPN's and not certified. LPN-J indicated she believes there was an RN but does not recall who or if/when they hung just knows when she contacted Optum there was no antibiotic running. LPN-J indicated the Optum NP gave STAT orders again for antibiotic and remembers reporting off about R57 to the next shift. Review of R57's record indicates on 7/2/18 on pm shift (time not specified) R57 had a blood sugar result of 417. Surveyor noted R57 has orders to contact the physician with blood sugar results greater than 400 unless otherwise specified by MD. Surveyor noted there are no orders to specify that the physician should not have been contacted. Surveyor noted that this would have possibly have been an opportunity to consult with R57's physician/NP on her condition and to update the status on the STAT IV's that still were not administered. Review of R57's medical record includes an infusion administration record indicating [MEDICATION NAME] 750 mg q 24 hrs x 10 days with a dose time of 0001. [MEDICATION NAME] is also listed on this form to administer 1 gram q 12 hrs x 10 days the dose time is listed as 2100 (9:00 pm) and initialed by a staff. Surveyor noted the dose time listed for the [MEDICATION NAME] was not consistent with the information provided by NP-X and LPN-J indicating the medications were not administered on the pm shift. Surveyor noted there was an additional infusion Medication Administration Record [REDACTED]. Surveyor noted there was no initials on this infusion record. When Surveyor asked multiple staff to help identify initial of staff no staff were able to identify what nurse may have initialed the infusion sheet, who started R57's IV antibiotics and what time they were administered. During the investigation Surveyor was told perhaps it was RN-BB and the [MEDICATION NAME] was possibly started at 9:00 pm as the one infusion sheet indicates. However, when the facility pulled time sheets attempting to help identify possible staff that worked the evening of 7/2/18 and 3rd shift on 7/3/18, RB-BB did not clock into her shift until 9:38 pm. During the survey Surveyor attempted to interview RN-BB however phone calls were not returned. R57's progress notes indicate: Effective Date: 7/3/2018 at 01:10 Type: Health Status Note: Note Text: Res in bed, opens eyes, but non verbal at this time. Skin very warm, dry, no cough or congestion. Abdomen large, non-tender, BS (bowel sounds) x4 quads. No [MEDICAL CONDITION]. Foley in place, urine merky, yellowish with sediment. Res has PIV in right hand, IV fluids running. First dose of Vanco started by RN supervisor. Temp elevated at 103.1 axillary. Call out to Optum, (name of on call NP) updated. Optum nurse updated (Physician-W) new order to send to Hospital to eval and treat. Surveyor noted there still is no indication of an RN assessment of R57 as this note is written by an LPN as is the SBAR. The record includes an SBAR dated 7/3/18 indicating: Effective Date: 7/3/2018 01:30 Type: SBAR - Change of Condition SPN: Situation: SBAR form completed for a change in condition signs or symptoms: Fever. This started 07/03/2018 Night. Background: The resident is in the facility for Long Term Care. Assessment (RN)/Appearance (LPN): Mental Status Evaluation: Decreased level of consciousness (sleepy, lethargic) Gradual change in level of consciousness not associated with other criteria for immediate notification. Functional Status Evaluation: No changes observed. Behavioral Evaluation: No changes observed. Respiratory Evaluation: No changes observed. Cardiovascular valuation: Resting pulse >100 or <50 pulse 107. Abdominal/GI Evaluation: No changes observed. [MEDICAL CONDITION] Evaluation: No changes observed. Skin Evaluation: No changes observed. Pain Evaluation: No. Neurological Evaluation: Decreased level of consciousness Gradual change in level of consciousness not associated with other criteria for immediate notification opens eyes. Laboratory Tests/Diagnostic Procedures: Assessment: Since the change of condition the symptoms or signs gotten: Worse. This condition, symptom or sign has occurred before: Yes hospital Summary of observations and evaluation: Recommendations: Primary clinician's recommendations: Send to ER to eval and treat. Blood Tests New or Change in Medications IV or subcutaneous fluids Response: Primary care clinician Optum on call (name of on call NP) and Physician-W updated 07/03/2018 1:15 AM. Family/healthcare agent notified: Per Optum RN - (name of POA) 07/03/2018 12:00 AM. The next progress note indicates: Effective Date: 7/3/2018 at 02:10. Type: General Note: Bell ambulance here to transport res to St Luke's Hospital. Surveyor noted Bell Ambulance is a private ambulance company and that despite R57 having clinical symptoms [MEDICAL CONDITION] and a temperature of 103.1 axillary she was not transported with emergent services. Review of the hospital admission record dated 7/3/18 indicates: 2:38 am . female with a h/o (history of) UTI, DM, MS, and hydro[DIAGNOSES REDACTED] who presents to the ED form (sic) NH via EMS with complaints of fevers and concerns [MEDICAL CONDITION] noted earlier by her NP. Per facility staff, the pt has had reported fevers of 102-103 F and her BP has been low with systolic readings in the 80's. Her new onset fever and h/o UTI's that have turned septic very quickly prompted her arrival to the ED. The pt recently had a positive UA and was to be treated for [REDACTED]. Se (sic) has a chronic indwelling foley. PT is AOx2 and has been reported to be more lethargic . ED triage vitals: temp 103.1, pulse 175, Resp 20, BP 122/79, SP02 94%. Cardiovascular: An irregularly irregular rhythm present. [MEDICAL CONDITION]. Review of R57's ED summary shows low BP's continued. Clinical [MEDICAL CONDITION] due to unspecified organism. A [DIAGNOSES REDACTED]. R57 was transferred to the ICU. The physician/hospital discharge summary dated 7/6/18 indicates R57 .presents with [MEDICAL CONDITION]/septic shock from urine source and [MEDICAL CONDITION] with RVR. Received 3 L fluids. Started on [MEDICATION NAME] due to [MEDICAL CONDITION] and [MEDICAL CONDITION] IV [MEDICATION NAME] given with improvement in AF. Pressors weaned off following volume resuscitation . Received 4 days of IV antibiotics, transitioned to PO Bactrim per sensitivities and ID recommendation. On 8/22/18 at approximately 10:47 am, Surveyor interviewed DON-B regarding R57. Surveyor asked DON-B about the facility's STAT medication/order process. DON-B indicated once written, the nurse takes the order and processes it; if STAT antibiotic IV would expect nurse to look and see if it is in contingency. Surveyor asked if [MEDICATION NAME] and [MEDICATION NAME] are in contingency. DON-B said to Surveyor let's go look. Surveyor and DON-B went to the medication room to look and DON-B pulled a contingency list and told Surveyor [MEDICATION NAME] is in contingency as is Vanco. DON-B indicated the nurse would have to reconstitute it the old fashion way but they have it. DON-B indicated policy is that IV's cannot be delegated to an LPN to start and if there is difficulty with a resident's veins nurses can call pharmacy to bring in team to start an IV or may use ambulance service. Surveyor asked about hospital discharge orders and the processing of orders and recommendations. DON-B indicated she expects nurses to review and implement/consult with NP or physician to determine what should be ordered. Surveyor shared that it appeared nursing staff noted the recommended change in R57's [MEDICATION NAME] but not the need to have a plan of care for changing R57's catheter on a monthly basis. DON-B indicated she would have to look into that. Surveyor requested a copy of the facility's policies and procedures for IV's and STAT orders and DON-B indicated she would have to look into those for Surveyor. On 8/23/18 at 9:40 am, Surveyors observed the facility contingency medication boxes located on the first floor of the facility. Assistant Director of Nurses (ADON)-G pulled the box with antibiotics and noted [MEDICATION NAME] & [MEDICATION NAME] were both missing from the box. Surveyors and ADON-G noted there was a date in the box of 7/18 however ADON-G did not know if date was delivery or what it may be. Surveyors asked if a request had been sent to refill and what the facility's process is. ADON-G indicated that the slip is filled out and faxed to the pharmacy requesting replacement. Surveyors asked where the slip is requesting refill or had it been requested. ADON-G did not know and would have to look into it. On 8/23/18 at approximately 10:30 am, Surveyor interviewed DON-B via telephone to discuss R57's STAT antibiotic orders on 7/2/18. DON-B indicated to Surveyor she processes so many orders. DON-B indicated she may have faxed the orders to pharmacy etc. Surveyor asked DON-B did she recall going to contingency and seeing about administering the antibiotics from contingency? DON-B indicated she doesn't recall, it would be policy, but she usually sends out to pharmacy and would have to send if pharmacy dosing. Surveyor asked DON-B once dosed, would they have been able to administer the antibiotics from contingency rather than waiting for delivery from pharmacy. DON-B stated they should be able to. Surveyor asked if DON-B recalled going to contingency and observing that the doses were not there. DON-B indicated no, she does not recall. DON-B stated maybe it was because of a shortage in fluid bags but not sure, does not recall anyone discussing whether they did or did not have supplies available. On 08/22/18 at approximately 2:21 PM, Surveyor interviewed LPN-L regarding R57. LPN-L shared with Surveyor that she thought that the antibiotics may have been delivered to the building maybe around 8:30 pm because she was the one that signed for 3 bags. LPN-L shared with Surveyor that both antibiotic bags were cold so they needed to warm up for about half an hour and then could hang. LPN-L indicated she signed for them, dropped them off on the unit, set them on the counter to warm up and then left the facility. LPN-L told Surveyor that she heard the next day that the IVs were not hung until after midnight. Surveyor asked what LPN-L's involvement in caring for R57 was on 7/2/18. LPN-L indicated she was assisting on the floor down a different hall and shared that the facility's former ADON-Y took the STAT orders and the person who transcribed/processed was DON-B. Surveyor asked LPN-L if it was ever discussed about sending R57 out earlier to the hospital? LPN-L shared LPN-F felt R57 was too ill and should be sent and she talked to NP-X. Surveyor shared with LPN-L what DON-B shared regarding IV antibiotics and contingency. LPN-L indicated she was not aware, in her time here, of a nurse reconstituting. LPN-L stated with not being IV certified she would not feel comfortable. LPN-L told Surveyor they always send out to pharmacy for IVs. LPN-L told Surveyor she believes if you look at contingency they do not have a big IV supply. LPN-L told Surveyor that she believed LPN-Z is IV certified but did not know if she actually hangs IVs here. On 8/22/18 at approximately 2:55 pm, Surveyor met with Nursing Home Administrator-A and Corporate Consultant RN-U to discuss R57's change in condition. Corporate Consultant RN-U verified to Surveyor that LPNs are not IV certified in the facility. Surveyor asked for any additional information to review regarding R57's change in condition and facility policies. Surveyor interviewed Pharmacist-AA on 8/23/18 at 9:23 am via telephone. Pharmacist-AA indicated once the fax is received from the facility by the pharmacy, they would process both antibiotics at same time. Pharmacist-AA checked his logs and shared with Surveyor the following times regarding R57's antibiotic orders: On 7/2/18, the pharmacy received the fax at 3:29 pm, at 4 pm the pharmacy received a call from facility to say it was STAT. At 4:45 pm the orders were entered into system, at 5:10 pm the orders were processed and filled shortly after, the IVs were picked up at 7:30 by delivery and arrived at the facility at approximately 8:26 pm. Pharmacist-AA indicated the pharmacy contracts out for delivery so could not explain the hour time between pick up from pharmacy and delivery. Surveyor asked if requesting dosing by pharmacy can that a (TRUNCATED)

Based on a complaint received at the Southeastern Region office, review of Facility self report, observations, interviews, and record reviews the Facility did not ensure that 4 (Resident #1, #6, #3, & #5) of 5 sampled Residents who required a Hoyer lift for transfer were transferred appropriately to prevent injury. During a transfer on 6/15/16 the legs of the Reliant 600 Hoyer lift were not opened, the lift started to tilt and Resident #1 slid out of the sling hitting her head on the leg of the Hoyer lift. Resident #1 received a laceration to her forehead requiring three staples. Example 1 involving Resident #1 is determined to be an example at the scope and severity of G actual harm/isolated. The remaining examples are determined to be severity 2, potential for more than minimal harm. Resident #6, #3, & #5 were observed to be transferred with a Hoyer lift without the legs being open to prevent the Hoyer lift from tipping over. Findings include: The Invacare Reliant 450 RPL450-2, Invacare Reliant 600 RPL600-2 user manual provided to the Survey team on 7/19/16 at 3:36 p.m. by Administrator-A documents on page 24 for Lifting the Patient WARNING The legs of the lift must be in the maximum open position for optimum stability and safety. If it is necessary to close the legs of the lift to maneuver the lift under a bed, close the legs of the lift only as long as it takes to position the lift over the patient and lift the patient off the surface of the bed. When the legs of the lift are no longer under the bed, return the legs of the lift to the maximum open position and lock the shifter handle immediately. 1.) A complaint and a Facility self report was received at the Southeastern Regional office regarding Resident #1's fall from the Hoyer lift on 6/15/16. Surveyor # reviewed Resident #1's medical record on 7/18/16 & 7/19/16. Resident #1 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's power of attorney was activated on 5/23/11. The quarterly MDS (minimum data set) with an assessment reference date of 4/17/16 and signed as complete on 4/19/16 documents that Resident #1 has unclear speech, sometimes makes self understood & sometimes understands other. Resident #1 has short & long term memory problems and is severely impaired for cognitive skills for daily decision making. Resident #1 requires extensive assistance with one person physical assist for bed mobility & dressing, is dependent with two plus person physical assist for transfers, does not ambulate, and is always incontinent of bowel & bladder. The nurses note dated 6/15/16 at 2200 (10:00 p.m.) documents Pt. (patient) had witnessed fall with laceration to head, bleeding at site, pt. calm, crying upon movement on floor of resident room. Paramedics (911) was called to assist resident. Writer stayed with resident and applied pressure to laceration on head. Physician-L called, ADON (Assistant Director of Nursing) called DON (Director of Nursing) called Administrator called. The nurses note dated 6/15/16 at 2015 (10:15 p.m.) documents 911 paramedics arrived to assess pt. place dressing to laceration on head and get resident on gurney to send out to St. Luke's for evaluation and treatment. The nurses note dated 6/16/16 at 0135 (1:35 a.m.) documents Res. (Resident) returned to facility via Curtis Ambulance. Transferred to bed by 2 attendants. 97.9 74 18 188/92 92% on room air. Neuro check (check mark) neg. (negative) Usual ROM (range of motion), blood in hair 3 staples in Rt. (right) upper scalp small red drng. (drainage) on pillowcase. Res. alert per usual. Per hosp. (hospital) head and cervical spine CT's (computed tomography) were neg. (negative). The hospital emergency services dated 6/15/16 documents under diagnosis Scalp laceration, initial encounter. The physician progress notes [REDACTED]. Reviewed her CT (computed tomography) head and cervical spine. Unable to provide any hx (history) d/t (due to) dementia. Pt. (patient) aphasic. Pt fell out of the Hoyer lift last night and sent to SLMC ED (St. Luke's Medical Center Emergency Department). Happened yesterday. Under assessment/Plan documents Head Injury CT negative for intracranial bleed. Large area of ____ 3 Staples monitor wound for inf. (infection) Remove in 10 days D/W (discussed with) staff regarding plan of care. Laceration of scalp. The IDT (interdisciplinary team) note post fall dated 6/16/16 documents Resident was being transferred to bed with hoyer with 2 staff assist. Resident fell during transfer and suffered laceration. Hoyer was locked out, put out of service, maintenance repair, education done with staff on proper transferring. Resident transferred to St Luke's. Returned with 3 staple. F/u (follow up) call placed to family. The nurses note dated 6/18/16 documents Bruises noted to Resident lateral chest area and right shoulder. Had recently fallen from a hoyer with laceration to back of head. Bruise old was reportedly lst noted on day of fall. Surveyor # reviewed the Facility's self report. Included in the self report is a statement from RN (Registered Nurse) Supervisor-F which documents Writer was asked by Agency CNA (Certified Nursing Assistant)-M to spot/assist hoyer transfer in room (room number) for (Resident #1). Pt. (patient) was secured in hoyer sling to hoyer lift in correct size sling and was being lifted out of her wheelchair. She (Agency CNA-M) was turning patient to move her towards the bed and the hoyer lift seem to start tilting down and (Resident #1) was falling forward from hoyer sling. Writer tried to correct the hoyer lift/sling but (Resident #1) had fallen to floor and hit her head on the metal bar of the hoyer lift. Resident (#1) had been lowered the rest of the way to the floor, pillows to support head and pressure was applied to head to stop bleeding from laceration to right side of head. 911 was called, (Physician-L) was called L/M (left message) for DON (Director of Nursing), L/M for ADON (Assistant Director of Nursing), talked to Administrator and patient was sent to St. Luke's for evaluation and treatment. Included in the self report is the misconduct incident report for date of occurrence 6/15/16 under the section describe below or attach a copy of the entity's investigative records concerning the incident documents (Resident #1) was admitted to (facility name) on June 7, 2011. (Resident #1) has a [DIAGNOSES REDACTED]. (Resident #1) requires assist of two and mechanical lift for transfers. On 6/15/16 (Resident #1) was being transferred back to bed by two staff members (CNA and RN Supervisor) via mechanical lift. Per RN supervisor legs on mechanical lift were not out during transfer and mechanical lift started to lean to the right. The RN Supervisor was able to steady the mechanical lift but (Resident #1) was already leaning forward and fell out of mechanical lift sling and hit her head on the leg of the mechanical lift. (Resident #1) sustained a laceration to her head. RN Supervisor applied pressure to laceration and 911 was called to assist (Resident #1). (Resident #1) returned early the next morning with 3 staples to laceration. Immediate education completed with nursing staff regarding how to use mechanical lifts. The mechanical lift in question was removed from service until Maintenance Director was able to assess for proper function. Maintenance Director assess mechanical lift in question and found it to be functioning properly. Maintenance Director completed through assessment of lift and determined it was functioning properly but could use adjustment in the tension which Maintenance Director completed. Maintenance Director audited all lifts in building and determined all lifts were functioning properly. The facility identified all other resident utilizing a mechanical lift as potentially could be affected. All care delivery guides were audited to ensure correct sizing for sling was listed and all were noted to be correctly reported. (Resident #1's) care delivery guide was audited with proper sling size reported on care delivery guide. The two staff members who assisted (Resident #1) during the fall will need to complete return demonstration of proper use of mechanical lift before transferring any further patients who require a mechanical lift transfer. Following completion of all nursing staff education spot check audits to be completed regarding assessing staff's usage of mechanical lift for transfers. These spot check audits will be reviewed at monthly QAPI (Quality Assurance Performance Improvement) meeting. On 7/19/16 at 12:30 p.m. Surveyor # spoke with RN Supervisor-F via the telephone. Surveyor # asked RN Supervisor-F to explain what happened the evening Resident #1 fell out of the Hoyer lift sustaining a laceration. RN Supervisor-F explained that she was helping one of the CNA's transfer Resident #1 from the wheelchair to bed. Surveyor # inquired who was operating the Hoyer lift. RN Supervisor-F replied that was me. RN Supervisor-F explained that Resident #1 was lifted off the wheelchair, the CNA turned the sling and she noticed that the Hoyer lift started to tip and Resident #1 was coming forward in the sling. RN Supervisor-F explained that she tried to correct it by putting her weight on the side that the hoyer was tipping but Resident #1 was coming out of the sling and that's when Resident #1 fell . Surveyor # inquired if the legs of the Hoyer lift were in the open position. RN Supervisor-F informed Surveyor # that they were not and that it is hard to keep the legs open at all times because they are working with limited space. Surveyor # asked RN Supervisor-F prior to Resident #1's fall from the hoyer when she was trained on using the hoyer lift. RN Supervisor-F replied a long time ago. Surveyor # inquired if she received training after the incident. RN Supervisor-F replied yes. Surveyor # asked during the training what was she told about the legs on the hoyer lift. RN Supervisor-F replied, They should remain open but explained that sometimes it's not possible. On 7/19/16 at 2:58 p.m. Administrator-A and DON (Director of Nursing)-B were informed that Resident #1's fall from the Hoyer lift in which Resident #1 sustained a laceration requiring 3 staples is not past non compliance as there is current examples of deficient practice. 2.) Surveyor # reviewed Resident #6's medical record on 7/18/16 and 7/19/16. Resident #6 has [DIAGNOSES REDACTED]. The ADL (activities daily living)/Mobility care plan rewritten 1/3/16 includes an intervention note dated of Assist 2 with hoyer -lrg (large) sling/full body. The quarterly MDS (minimum data set) with an assessment reference date of 6/13/16 documents that Resident #6 has short & long term memory problems and is severely impaired for cognitive skills for daily decision making. Resident #6 requires extensive assistance with two plus person physical assist for transfers. Resident #6 is at risk for falls but has not had any falls since the prior assessment period. On 7/18/16 at 10:22 a.m. Surveyor # observed RN (Registered Nurse)-I wheel Resident #6 into his room. Surveyor # asked RN-I what she was going to do. RN-I informed Surveyor # that she needs to apply cream. At 10:26 a.m. LPN (Licensed Practical Nurse)-J entered Resident #6's room with a Reliant 600 Hoyer lift. RN-I and LPN-J looked at the sling in Resident #6's room, discussed whether it was the correct size, and then left Resident #6's room. On 7/18/16 at 10:31 a.m. CNA (Certified Nursing Assistant)-E entered Resident #6's room and a minute later CNA-D entered Resident #6's room. CNA-E removed the amputee pad from Resident #6's wheelchair and then CNA-D & CNA-E placed a sling under Resident #6. CNA-E wheeled the Hoyer lift over to Resident #6's wheelchair and staff attached the sling to the hoyer lift. Surveyor # observed that the legs of the Hoyer lift were in the open position. CNA-D told Resident #6 that he was going up. Resident #6 was raised off the wheelchair, CNA-E backed up the hoyer lift and then the legs of the Hoyer lift were brought in so they were straight and not in the open position. Resident #6 was wheeled over to his bed and lowered onto the bed. Surveyor # observed while Resident #6 was being transferred over to his bed the legs of the Hoyer lift were narrow and were not in the open position. On 7/19/16 at 7:47 a.m. Surveyor # asked CNA-H how should the legs of the Hoyer lift be positioned when they are transferring a Resident. CNA-H replied latest information given is to open legs when moving the lift. On 7/19/16 at 2:10 p.m. Surveyor # asked CNA-E when transferring a Resident who requires a Hoyer lift how should the legs of the Hoyer lift be positioned. CNA-E replied they want them open but with some rooms can't be open so much. Suppose to be open for balance. Surveyor # asked if there is enough room in Resident #6's to open the legs of the Hoyer lift. CNA-E replied yes. Surveyor # informed CNA-E that the legs were narrow on the Hoyer lift when he and CNA-D were transferring Resident #6 yesterday. CNA-E replied they should have been open. On 7/19/16 at 2:22 p.m. Surveyor # asked RN (Registered Nurse) Manager-C what position should the legs of the Hoyer lift be when staff is transferring a Resident. RN Manager-C informed Surveyor # that when the Hoyer lift is moving the legs need to be open and that they have inserviced the staff. Surveyor # informed RN Manager-C of the observation during Resident #6's transfer that the legs were narrow and not opened. On 7/19/16 at 2:58 p.m. during the daily exit conference Administrator-A and DON (Director of Nursing)-B were informed of the above. 3.) Surveyor # reviewed Resident #3's medical record from 7/18/16 to 7/19/16. Resident #3 was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #3's quarterly MDS (Minimum Data Set) dated 06/15/16 documents under Section G that transferring for Resident #3 did not occur during the assessment period. Resident #3's ADL (Activities of Daily Living) Functional/Rehabilitation Potential CAA (Care Area Assessment) signed as completed on 1/6/15 documents under the Analysis of Findings section Res. (Resident) is assist of 2 with Hoyer lift in Transfers. Resident #3's CNA (Certified Nursing Assistant) Care Card dated as updated on 7/18/16 documents under the Mobility section Assist 2 Hoyer with Lg (Large) sling. Broda Chair. On 7/19/16 at 1:48 p.m., Surveyor # observed CNA-D and CNA-E assist Resident #3 from her bed to her Broda chair. Surveyor # noted that CNA-D and CNA-E were using a Invacare Reliant 600 Hoyer lift. Surveyor # observed CNA-E position the Hoyer sling under Resident #3 and prepare Resident #3 to be lifted up by the Hoyer lift. Surveyor # observed the two metallic legs of the Hoyer lift to be in the closed parallel position as the Hoyer legs were placed below Resident #3's bed. On 7/19/16 at 1:49 p.m., Surveyor # observed CNA-E lift up Resident #3 off of her bed with the Hoyer lift. Surveyor # observed that Resident #3 remained suspended in the air in a sling and observed CNA-D come into Resident #3's room and close the door. Surveyor # observed the two metallic legs of the Hoyer lift to be in the closed parallel position as the Hoyer legs were placed below Resident #3's bed. On 7/19/16 at 1:50 p.m., Surveyor # observed CNA-E maneuver the Hoyer lift towards Resident #3's Broda chair and transfer Resident #3 into her Broda chair. Surveyor # observed the two metallic legs of the Hoyer lift to remain in the closed parallel position as Resident #3 was maneuvered from her bed to her Broda Chair. On 7/19/16 at 1:51 p.m., Surveyor # observed CNA-E open the two metallic legs of the Hoyer lift around Resident #3's Broda chair and then set Resident #3 down into her Broda chair. Surveyor # noted that CNA-E did not open the two metallic legs of the Hoyer lift to prevent the Hoyer lift from tipping while maneuvering Resident #3 from her bed to her Broda chair. On 7/19/16 at 2:31 p.m., Surveyor # informed RN (Registered Nurse) Manager-C of the above findings. Surveyor # asked RN Manager-C if facility staff should open the Hoyer lift legs to prevent the Hoyer lift from tipping when maneuvering a resident during transfers. RN Manager-C informed Surveyor # that facility staff should open the Hoyer lift legs to prevent the Hoyer lift from tipping when maneuvering a resident during transfers. On 7/19/16 at 2:46 p.m., during the daily exit conference, Surveyor # informed Administrator-A and DON (Director of Nursing)-B of the above findings. No further information was provided as to why the facility did not ensure Resident #3 was transferred with a Hoyer lift without the legs being open to prevent the Hoyer lift from tipping over. On 7/19/16 at 3:36 p.m., Administrator-A provided Surveyor # with the user manual for the Invacare Reliant 600 Hoyer lift used in the transfer. 4.) Surveyor # reviewed Resident #5's medical record from 7/18/16 to 7/19/16. Resident #5 was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5's quarterly MDS (Minimum Data Set) dated 5/15/16 documents under Section G that Resident #4 requires a two persons physical assist and has total dependence for transferring. Resident #5's ADL (Activities of Daily Living) Functional/Rehabilitation Potential CAA (Care Area Assessment) signed as completed on 9/1/15 documents under the Care Plan Considerations section Resident is assist of 2 with Hoyer lift in transfers. Resident #5's CNA (Certified Nursing Assistant) Care Card dated as updated on 7/18/16 documents under the Mobility section Assist 2 Hoyer transfer med (medium) sling. On 7/19/16 at 3:08 p.m., Surveyor # observed CNA-P and CNA-Q transfer Resident #5 from her Broda chair into bed with the use of a Hoyer lift. Surveyor # noted that CNA-P and CNA-Q were using a Invacare Reliant 450 Hoyer lift. Surveyor # observed CNA-P and CNA-Q position a sling underneath Resident #5 and raise her up into the air with the use of the Hoyer lift. Surveyor #3616 observed the two metallic legs of the Hoyer left to be spread and in the open position around Resident #5's Broda chair as Resident #5 was lifted into the air. On 7/19/16 at 3:11 p.m., Surveyor # observed CNA-P close the two metallic legs of the Hoyer and maneuver Resident #5 over and down into her bed. Surveyor # noted that CNA-E did not open the two metallic legs of the Hoyer lift to prevent the Hoyer lift from tipping while maneuvering Resident #5 from her Broda chair to her bed. On 7/19/16 at 3:15 p.m., CNA-P asked Surveyor # if she was supposed to close the legs of the Hoyer lift while maneuvering a resident. CNA-P informed Surveyor # that she was taught to close the legs of the Hoyer lift during transfers and if Surveyor # could inform her of what was the correct procedure for opening or closing the legs of the Hoyer lift during transferring. Surveyor # informed CNA-P that she needed to ask her supervisor or check the facility's policy on the Hoyer lift use. On 7/19/16 at 2:01 p.m., Surveyor # informed LPN (Licensed Practical Nurse) Supervisor-N of the above findings. Surveyor # asked LPN Supervisor-N if facility should open the Hoyer lift legs to prevent the Hoyer lift from tipping when maneuvering a resident during transfers. LPN Supervisor-N informed Surveyor # that facility staff should open the Hoyer lift legs to prevent the Hoyer lift from tipping when maneuvering a resident during transfers. On 7/19/16 at 2:46 p.m., during the daily exit conference, Surveyor # informed Administrator-A and DON (Director of Nursing)-B of the above findings. No further information was provided as to why the facility did not ensure Resident #5 was transferred with a Hoyer lift without the legs being open to prevent the Hoyer lift from tipping over. On 7/19/16 at 3:36 p.m., Administrator-A provided Surveyor # with the user manual for the Invacare Reliant 450 Hoyer lift used in the transfer.

Based on interview and record review, facility staff did not provide services based on the Resident's plan of care to prevent injury and accidents for 1 of 3 Residents. A CNA (certified nursing assistant) provided incontinence care for Resident #1 by herself while Resident #1 was in bed on 4/12/16. Resident #1 requires two staff for bed mobility. Resident #1 rolled off of the bed, and sustained a fractured femur that required surgery. Findings include: The Southeastern Regional Office of the Bureau of Nursing Home Resident Care received two complaints and a facility self-report regarding Resident #1 falling from her bed resulting in a femur fracture. Surveyor # reviewed Resident #1's medical record which reveals the following: Resident #1 was admitted to the facility in the fall of 2015 after suffering a CVA (cardiovascular accident/ stroke). Resident #1 has [DIAGNOSES REDACTED]. Resident #1's Admission MDS (Minimum Data Set) dated 10/1/15 notes Resident #1 has short and long term memory problems, and has severely impaired cognitive skills for daily decision making. The MDS reflects Resident #1 requires extensive assistance of two staff for bed mobility, and has ROM (range of motion) limits on one side of upper and lower extremities. Resident #1's CAA (Care Area Assessment) completed on 10/5/15 in conjunction with the Admission MDS states, Resident is at risk for falls r/t (related to) physical decline with recent stroke which resulted in right side weakness and expressive aphasia. Resident also requires assist of two with Hoyer lift for transfers and assist of two for bed mobility. Resident is assessed for side effects of antidepressant. Resident's needs must be anticipated. Resident is incontinent of bladder and bowel and is on scheduled check and change every two hours and prn (as needed). The CAA notes Resident #1 is at risk for fall due to difficulty maintaining sitting balance, impaired balance during transitions, receives antidepressant, cardiovascular and diuretic medications, has cardiac dysrhythmias, loss of arm or leg movement, incontinence, [DIAGNOSES REDACTED]/hemiparesis, arthritis, cognitive impairment, and depression. Resident #1's Care Plan originally dated 9/24/15 and most recently updated 12/27/15 and 4/18/16 for ADL (Activities of Daily Living) /Mobility Care Plan includes under Interventions indicates: 10/29/15 Provide assist device as needed for bed mobility: assist of two and half side rails. The Problem states, Potential or Actual ADL/Mobility deficit, poor oral hygiene, oral infection related to: arthritis, CVA with right [DIAGNOSES REDACTED], seizure-like activity 11/22/15, depression, obesity, aphasia, generalized weakness, decreased ability to understand others, cannot remember step by step instructions, functional limitations of right arm and leg, and side effects of antidepressant medication. Surveyor # reviewed Resident #1's Fall/Injury Assessment: Prevention and Management Care Plan originally dated 12/27/15 and updated 4/18/16. It states Resident #1 is at risk for falls related to: History of falls, unsteady, osteoarthritis, poor weight bearing ability, exhaustion/weakness, high/low blood sugars, cardiovascular diagnosis, bowel and bladder incontinence, CVA, visual and hearing sensory impairments, receives cardiovascular and antidepressant medications. The Goal is Resident #1 Will be free of a serious injury if a fall would occur. Interventions include: 10/19/15: A (assist) of 2 with bed mobility. Nurses' Notes dated 4/12/16 indicate Resident #1 fell from her bed to the floor at 1:10 a.m. A LPN (Licensed Practical Nurse) took vital signs, the LPN and RN (Registered Nurse) assessed for injury and assisted Resident #1 back to bed using a Hoyer lift. Resident #1's physician was contacted who gave orders to send Resident #1 to the hospital for evaluation. Additional notes indicate Resident #1 was admitted to the hospital with [REDACTED]. Follow-up documentation from the hospital dated 4/18/16 states Resident #1 was treated for [REDACTED]. Surveyor # reviewed the facility's investigation into Resident #1's fall on 4/12/16. The investigation includes a statement from CNA-C, who stated she was in Resident #1's room changing her. She asked Resident #1 to turn and when Resident #1 turned herself to the right side, she fell out of bed. The statement indicates NHA (Nursing Home Administrator)-A asked CNA-C what type of assistance Resident #1 requires for bed mobility. CNA-C stated Resident #1 needs assist of one. NHA-A informed CNA-C that under the mobility section of the care card it stated assist of 2 with bed mobility; CNA-C did not follow Resident #1's care card/care plan. The investigation includes a statement from RN Supervisor-D, who stated she was called to Resident #1's room for a fall. Upon arrival, RN-D observed Resident #1 lying on the floor on her right side. (LPN-E) took Resident #1's vitals. They used the Hoyer lift to get Resident #1 back to bed. RN-D had LPN-E call the MD. Resident #1's RLE (right lower extremity) was swollen and painful when moved. They received an order to send Resident #1 to the hospital. When asked what happened, Resident #1 said, I don't know. RN-D talked with the CNA who told her she was in the bathroom getting washcloths and turning her to put a draw sheet under her. The bed was in the high position. CNA-C was sent home after RN-D obtained her statement and pending the results of the investigation. The facility self-report notes the RN supervisor checked all other residents for discrepancies with their plan of care and no other discrepancies were found. Staff interviewed other Residents who stated they were satisfied with their care. NHA-A provided Surveyor # with documentation stating after Resident #1's fall on 4/12/16, facility staff took the following action: - Staff analyzed the fall investigation, and training was provided to all nursing staff (nurses and CNAs) regarding following care plans/care delivery guides. 66 staff signed the attendance forms as either receiving the education in person or on the phone. - Weekly Care Card Audits were performed by NHA-A: 5 CNAs from day shift, 5 CNAs from p.m. shift and 2 CNAs from night shift regarding following the Care Delivery Guides, results will be reviewed at the monthly Quality Assurance/ Process Improvement meeting. -Staff reviewed the transfer/mobility status on care plans and care delivery guides for all residents to ensure residents requiring assist of 2 are care planned and this is reflected on the care delivery guide correctly. - An ad hoc QA meeting was held 4/14/16 with the facility's medical director, DON (Director of Nursing)-B, and the Regional Director of Clinical Services via phone to elicit medical director input and approval of the above plan.

Based upon observations and record reviews the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. This is evidenced by the number and seriousness of the citations issued at this survey and at surveys in 2011. Three deficiencies F157, F281 and F309 (other than F490) identified immediate jeopardy at this survey. F309 includes two distinct examples of immediate jeopardy regarding Resident #1 and Resident #19. * The facility administration failed to ensure that systems were in place so that nursing staff (licensed and direct care nursing staff) was aware of a resident's changing condition. This resulted in staff eventually finding the resident unresponsive. Nursing staff did not complete assessments nor did they monitor the resident's condition. * The facility administration failed to ensure that systems were in place whereby nursing would monitor and assess resident vital signs as ordered by the physician. The facility failed to ensure that resident output was monitored for 30 shifts while the resident was residing in the nursing home. The facility failed to provide care based upon recognized standards of practice for nursing care. * The facility failed to ensure that systems were in place such that facility nursing staff promptly and effectively communicated the results of a critical lab value to the physician and oncoming shifts to ensure proper treatment. * The facility failed to ensure that systems were in place such that nurses promptly consulted with the physician regarding significant condition changes and the need to significantly alter treatment. Noncompliance at the immediate jeopardy level was also identified and cited at F323 (supervision to prevent accidents), F224 (residents have right to be free from neglect) and F309 (services to promote highest practicable level of well-being) at complaint surveys in June and [DATE]. In addition to the citations at the level of immediate jeopardy at this survey, one deficiency, F314, was cited at the actual harm/isolated level (G). This deficient practice led to a resident developing a stage 3, facility acquired, avoidable pressure ulcer. In total 24 federal deficiencies were issued as a result of this survey. This deficiency, at F490, has the potential to affect all 93 residents residing at the facility. The failure to ensure that the facility was administered in a manner that enabled it to use its resources in a manner that promoted the health and well-being of residents created a finding of immediate jeopardy, which began on [DATE]. The facility Administrator, Director of Nursing and Regional Director of Operations were notified of the immediate jeopardy on [DATE] at approximately 2:20 pm. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope and severity of an F (potential for more than minimal harm that is not immediate jeopardy/widespread) as the facility needs to establish effective implementation of the policies and procedures that lead to the immediate jeopardy citations, provide continued monitoring for effectiveness of the immediate jeopardy removal plans, and to achieve regulatory compliance with current deficiencies. Findings include: Facility administration - which includes nursing administration - is responsible for ensuring that systems are in place so that all residents receive appropriate care in accordance with accepted standards of practice and enables each resident to reach his/her highest practicable level of physical, mental, and psychosocial well-being. Systems were not in place and implemented as follows: 1. The facility failed to ensure the appropriate monitoring and assessment of a resident throughout the evening of [DATE] and the morning of [DATE]. According to facility procedures, nursing assistants (CNAs) are responsible for doing all catheter care and are supposed to notify the charge nurse if there are any changes. The facility has nine residents with Foley catheters. Among them was Resident #1 who is a [AGE] year-old man who was first admitted in [DATE] and had been last readmitted on [DATE]. He was alert and oriented. Prior to his discharge to the hospital on [DATE], the last nursing note for Resident #1 was dated [DATE]. It indicated that the resident did not have any complaints of pain and had no shortness of breath. On the evening of [DATE], Resident #1 wasn't feeling well and had refused to eat dinner. This was a change for the resident since he had eaten 100% of his dinner the previous 12 days. Additionally, Resident #1 was not joking around as he usually did. The nursing assistant relayed this information to the charge nurse. Between 6:30 and 7:00 PM, two nursing assistants put this resident back to bed; a third nursing assistant washed him up. The CNA who washed the resident did not do catheter care because this was not an assigned resident. The assigned nursing assistant, however, assumed that the third CNA had done catheter care so she did not. No staff, therefore, checked Resident #1's catheter at that time; additionally, the assigned CNA admitted to not doing her last rounds so she did not check the catheter prior to the end of her shift. The evening nurse, despite having been told, allegedly, that the resident had not eaten dinner and was not joking around as usual, did not go in and assess Resident #1 and did not put the resident on the 24-hour board. Nor did the evening nurse check Resident #1's urine output herself when the nursing assistants did not report a urine output for the resident. The evening supervisor did not check Resident #1 because she did not see his name on the 24-hour board and because no one, allegedly, had told her of any problems. Between 10 and 10:30 PM, the night CNA stated that the resident was snoring and she repositioned his head. Resident #1 did not respond and she assumed it was only because the resident was sound asleep. Throughout the night shift, the night CNA failed to check Resident #1's catheter or to check his brief to determine if he had had a bowel movement. The night CNA stated she did not check because she would have been able to smell if the resident had been incontinent of bowel. Consequently, she did not look at the resident's bottom or at his catheter. The night nursing assistant stated that Resident #1 would grab the grab bar when repositioned at the beginning of the shift but did not do so later on when repositioned. The CNA told the night supervisor that he didn't look good and was snoring but the supervisor allegedly said, "He's got MS - he was probably outside and is tired." At some point, Resident #1's roommate told the CNA that Resident #1 wasn't doing well. The CNA reported this to the night supervisor, who allegedly stated, "He doesn't know what he's talking about." Both the night nurse and supervisor denied being told anything about the resident's condition. Unless someone brings something to her attention, the night nurse stated that she would check only residents whom staff had mentioned in report. Otherwise, she would only look into rooms to see if residents were in bed and breathing. Likewise, the night supervisor stated that unless someone brings something to her attention she does not check residents except on rounds at midnight to ensure that there is a body in the bed. At 6:00 AM, the night CNA and the day CNA checked the resident together after the night CNA had stated that Resident #1 hadn't been looking well and that she hadn't gotten him up and dressed. Resident #1 was unresponsive and they reported this to a nurse, who got no response when she did a sternal rub. Vital signs were taken - ,[DATE], 98.6, P88. Blood sugar 146. Oxygen sat 96% on room air. Nursing called the ambulance, which arrived at approximately 7 AM and transported the resident to the emergency room . Vital signs at the ER were 100.1 (R), P117, R32, ,[DATE]; oxygen sat 93% on 5 liters oxygen. Pus covered the resident's genitalia. Medical staff diagnosed the resident with urosepsis and pneumonia, treated and then transferred him to intensive care, where the family subsequently placed the resident on hospice. This created a finding of immediate jeopardy (Cross reference F309, scope/severity (s/s) - J, immediate jeopardy/isolated). 2. The facility failed to monitor and assess a resident's vital signs (as ordered by the physician and dictated by professional standards of practice), failed to monitor and record urinary output for all 30 shifts in which the resident was in the nursing home, and failed to communicate the resident's critical lab values to the oncoming shift. Additionally, the facility failed to promptly consult with the physician regarding significant condition changes and the need to alter treatment significantly (critical lab values and temperatures above 102 degrees that were not relieved by Tylenol). Resident #19 was a [AGE] year-old woman who had suffered a stroke that left her in an unresponsive state. She was admitted to the facility [DATE]. Since admission, Resident #19 experienced elevated temperatures of 100.2, 103.2, 100.8, 102 degrees Fahrenheit on ,[DATE], ,[DATE], ,[DATE], and [DATE] respectively, but these temperatures were brought down (99.9, 99.4, 97.6, 99.8 degrees Fahrenheit) with the administration of Tylenol. Resident #19 was admitted with a catheter. There is no documentation that staff ever measured, assessed, or recorded the amount of urinary output to ensure patency of the catheter. On [DATE], Resident #19 had a temperature of 101.2, which went down to 99 after the administration of Tylenol. The temperature later went to 100.7. Staff called the MD, who gave orders for a chest x-ray, urinalysis, and blood work. The physician also ordered [MEDICATION NAME] every 12 hours and vital signs every shift. On [DATE] at 10:11 PM, RN-O received critical lab values from the blood culture that had been done (critical labs for gram positive cocci and for gram negative bacilli, which secrete a toxin that elevates temperature). RN-O did not contact the physician concerning these lab values and did not pass this information on to the night nurse. At 1:00 AM on [DATE], Resident #19 had a temperature of 102.5 degrees Fahrenheit. Facility policy is to immediately contact the physician if the temperature is over 101 with symptoms or 102 without symptoms. The nurse did not immediately consult with the physician or take a complete set of vital signs but did give Tylenol. At 2:00 AM Resident #19's temperature was higher (102.7) despite the administration of Tylenol, which, in the past, had been effective in bringing down her temperature. The nurse did not immediately consult with the physician and did not take a complete set of vital signs. At 3:00 AM Resident #19's temperature had risen to 103 degrees. Nursing, while continuing to apply a cool compress to the resident's forehead, did not immediately consult with the physician or take a complete set of vital signs. Resident #19's temperature was 101.9 degrees at 4:15 AM. At 5:45 AM, staff contacted the physician and received orders to send the resident to the emergency room . There is no nursing documentation of when the ambulance was called, but ambulance records show they received the call at 6:25 AM and arrived at 6:35 AM. Resident #19 was in septic shock and respiratory distress when she arrived at the emergency room . Temperature was 103.1 and blood pressure was ,[DATE]. Her blood pressure continued dropping, even after administration of IV fluids. Resident #19 eventually expired after being placed on hospice. 3. Facility nursing staff failed to provide nursing services based upon current standards of practice and standards established by the Nurse Standards of Practice Act for Registered Nurses and Licensed Practical Nurses. Regarding Resident #19: Registered Nurse (RN)-O did not contact Resident #19's physician regarding critical lab values indicating [MEDICAL CONDITION], nor were the critical lab values communicated to staff. Resident #19 was not assessed by a Registered Nurse on the evening shift of [DATE]. Resident #19's physician was not contacted throughout the night shift on [DATE] of Resident #19's elevated temperatures greater than 102 degrees, nor was Resident #19 assessed by Registered Nurse-P. On [DATE], the night shift Registered Nurse-P did not follow standards of practice in regards to the delegation of nursing acts. Registered Nurse-P did not provide the supervision and direction necessary to ensure Licensed Practical Nurse-N performed delegated tasks, such as taking Resident's 19's vital signs. Resident was admitted into the hospital on [DATE] with a [DIAGNOSES REDACTED]. This created a finding of immediate jeopardy (Cross reference F157, s/s - J, immediate jeopardy/isolated) (Cross reference F281, s/s - J, immediate jeopardy/isolated) (Cross reference F309 example #2, s/s-J, immediate jeopardy/isolated). 4. Administrative staff did not ensure that systems were in place to make certain that residents received appropriate care and services as demonstrated by the following additional deficiencies: * F156 - s/s C. The facility did not ensure that the pertinent state and federal resource agencies and contact information was posted. (Cross-reference F156). * F167 - s/s C. The facility did not ensure that all of the recent survey results were posted and available for review. (Cross-reference F167). * F176 - s/s D. The facility did not ensure that all residents administering their medications were appropriately assessed to self-administer the medication. (Cross-reference F176). * F225 - s/s E. The facility did not ensure that potential allegations of neglect and misappropriation were reported to the state agency and that allegations were thoroughly investigated. (Cross-reference F225). * F250 - s/s D. The facility did not ensure that residents received medically necessary social services related to psychological needs. (Cross-reference F250). * F271 - s/s D. The facility did not ensure that admission physician orders [REDACTED]. (Cross-reference F271). * F279 - s/s D. The facility did not ensure that resident care plans were individualized and based upon an assessment for a resident receiving [MEDICAL CONDITION] medication. (Cross-reference F279). * F282 - s/s D. The facility did not ensure that staff carried out the procedures identified in individual resident's plans of care. (Cross-reference F282). * F312- s/s D. The facility did not ensure that activities of daily living, related to oral cares were provided to a resident who required assistance with oral cares. (Cross-reference F312). * F314 - s/s G. The facility did not ensure that a resident did not develop an avoidable stage 3 pressure ulcer, as well as ensuring that treatments to prevent the development of a pressure ulcer were carried out. (Cross-reference F314). * F329 - s/s D. The facility did not ensure that residents only received antibiotics to treat symptomatic infections. The facility also did not ensure that medically necessary criteria were developed to indicate when as needed medications for sleep and anxiety should be administered. (Cross-reference F329). * F364 - s/s E. The facility did not ensure that foods were provided to residents at the appropriate temperatures and that were palatable to the residents. (Cross-reference F364). * F386 - s/s E. The facility did not ensure that the physician's plans of care were reviewed and signed as reviewed in a timely fashion. (Cross-reference F386). * F387 - s/s D. The facility did not ensure that a newly admitted resident received physician visits at least every 30 days for the first 90 days following admission to the facility. (Cross-reference F387). * F425 - s/s D. The facility did not ensure that individual resident medications were not commingled in the medication carts. (Cross-reference F425). * F431 - s/s D. The facility did not ensure that resident medications and treatments were properly labeled. (Cross-reference F431). * F441 - s/s E. The facility did not ensure that glucometers were properly sanitized and that proper hand washing was carried out with nursing cares and treatments as indicated. (Cross-reference F441). * F465 - s/s D. The facility did not ensure that resident wheelchairs were maintained in a sanitary manner. (Cross-reference F465). * F502 - s/s D. The facility did not ensure that a physician ordered lab was obtained. (Cross-reference F502). * F514 - s/s E. The facility did not ensure that resident medical records were maintained with documentation that is complete and accurate in accordance with acceptable standards of practice. (Cross-reference F514). 5. Administrative staff have failed to ensure systems are in place to prevent ongoing serious citations. Serious regulatory noncompliance was also identified as an issue in 2011. The facility was cited at the immediate jeopardy level in [DATE] at F323 and F224 when staff left a resident outside in the sun in 97 degree weather and failed to communicate that he was outside, failed to check on his whereabouts, and failed to bring him back inside. Staff found the resident 3 hours and 15 minutes later to be nonresponsive. Staff called 911 but before they arrived the facility doctor pronounced his death. One hour and 20 minutes after he had been brought inside, the resident's temperature was 101.4 degrees. In [DATE], the facility was cited at F309 when nursing failed to communicate the seriousness of a resident's changed condition to the charge RN, who did not check the resident until ten minutes later. At that time the resident was pulseless and non-breathing. Staff did not check the resident's advance directives and did not provide CPR as had been requested by the resident. The failure to administer the facility in a manner that enabled it to use its resources effectively and efficiently in order to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident created a finding of immediate jeopardy. The immediate jeopardy was removed on [DATE] at which time the facility: 1. Enhanced the regional administration support for the facility with Licensed Nursing Home Administrator -KK assisting acting Nursing Home Administrator-A in assuring that systems identified in the removal of the Immediate Jeopardy as F157, F281 and F309 are implemented and effectively in place. 2. Regional Director of Clinical Operations-LL will increase facility visits to at least 2 days per week with focus to include the implementation, maintenance, and progress on the plan of correction. 3. Regional Director of Operations-MM will provide visits at least 3 times per month with the focus to include the implementation, maintenance and progress on the plan of correction. 4. Area Director of Clinical Operations-NN will conduct visits at least 1 time per month, review of system implementation plan and progress on the plan of correction each week with the Regional Director of Clinical Operations-LL 5. Provide enhanced training materials for the facility as of [DATE]. 6. Involvement of the Medical Director-Q in the approval of the facility's plan in regards to the system enhancement and that systems are effectively in place. 7. Removed the immediate jeopardy at F157, F281 and F309. (Cross reference F157, F281 and F309)

Based on staff interview, resident record review, hospital record review, and review of the Facility's polices, the Facility did not consult with the resident's physician when there was a significant change for 1 of 19 residents reviewed On 9/5/12, Resident #19 had a significant change in condition. The resident's physician was not promptly consulted in regards to Resident #19's change in physical status and a need to alter treatment. * On 9/5/12 at 10:11 p.m., Registered Nurse (RN)-O received a critical lab values pertaining to Resident #19. RN-O did not contact the physician concerning these lab values and did not pass this information on to the night nurse. Facility policy is to immediately contact the physician if the temperature is over 101 degrees with symptoms or 102 without symptoms. On 9/6/12 at 1:00 a.m., Resident #19 had a temperature of 102.5 degrees Fahrenheit. The nurse did not immediately consult with the physician. On 9/6/12 at 2:00 a.m., Resident #19's temperature was 102.7 despite the administration of Tylenol. The nurse did not immediately consult with the physician. On 9/6/12 at 3:00 a.m., Resident #19's temperature had risen to 103 degrees and the nurse did not immediately consult with the physician. On 9/6/12 at 4:15 a.m., Resident #19's temperature was 101.9 degrees and the nurse did not immediately consult with the physician. On 9/6/12 at 5:45 a.m., staff contacted the physician and received orders to send resident to the emergency room . The failure of nursing staff to promptly consult with the physician regarding significant condition changes and the need to alter treatment significantly (critical lab values and temperatures above 102 degrees not relieved by Tylenol) resulted in Resident #19's condition deteriorating to the point that Resident #19 was in septic shock upon admission into the emergency room . This created a finding of immediate jeopardy beginning on 9/5/12. The Nursing Home Administrator, Director of Nursing, and Regional Director of Operations were informed of the Immediate Jeopardy on 9/18/12 at 2:20 p.m. The Immediate Jeopardy was removed on 9/19/2012. However, the deficient practice continues at a scope and severity of D (potential for harm/isolated), as the Facility has not implemented all the components of their plan of correction. Findings include: Surveyor # reviewed Resident #19's closed medical record from 9/6/12-9/19/12. Resident #19 was discharged from the facility a few hours prior to surveyors entering the building on 9/6/12. Resident #19's medical record indicated Resident #19 was admitted on [DATE] following heart surgery ([MEDICAL CONDITION] revascularization X5-coronary artery bypass graft (CABG) surgery). Resident #19 also had suffered a stroke after surgery, which left her unresponsive. The hospital discharge summary dated 8/27/12 notes upon physical exam, neurologic response- minimal spontaneous movements and to painful stimuli; T (temperature) 96, BP (blood pressure) 98/43, pulse 74, respiratory rate 21, and pulse oximetry (POx) 100% on room air. BUN (lab test blood urea nitrogen) was 34. Resident #19's medical [DIAGNOSES REDACTED]. A family meeting was held at the hospital where it was determine to continue present care for Resident #19. Subsequently, a [DEVICE] was placed for feeding and nursing home placement arranged. Surveyor # reviewed Resident #19's Nurses' Notes. The notes show that Resident #19 routinely spiked temperatures from 9/3 - 9/5/12 but these were relieved with Tylenol. 9/3/12 3:30 a.m. T 102.1 Tylenol grain X (10) given at 1:30 a.m. Temp at this time is 99.8 P98 R20 BP 110/60. POx 95%... 11:50 a.m. T98.7 8:00 p.m. F/U (follow up) increased temp. Resident unresponsive, total cares for ADLS, fed per [DEVICE], tolerating well...Tylenol given at 6:00 p.m. for temp 99.0, no SOB noted. Continue to monitor temp... 9/4/12 4:10 a.m. Temp at 10:45 p.m. 101.2. Tylenol 650 mg. given via PEG site. Rechecked at 11:00 p.m. T 99.0... 7:00 a.m. F/U temp: T100.7 P90 R24 BP120/70 POx 91% RA. 650 mg. APAP (Tylenol) given in [DEVICE]. Call out to MD...7:05 a.m. MD returned call- new orders received for STAT CXR, CBC, BMP, blood cultures x 2, UA with C&S (culture and sensitivity) if needed. 8:30 a.m. T99.2 P93 R24 POX 92%. MD updated on labs. New orders for Echo 2D to rule out I.E. ([DIAGNOSES REDACTED]) and antibiotic ([MEDICATION NAME] IV) to start after lab draws. ([MEDICATION NAME] 1 gm, every 12 hours through IV.) 1:45 p.m. MD updated on labs. New Orders Received for increasing [MEDICATION NAME] to 10 mg. Labs: PT/INR (monitors [MEDICATION NAME]), CBC and BMP. 11:00 p.m. T98.1 UA pending. 9/5/12 1:30 a.m. T99.8 P74 R18 BP 98/64. Unresponsive. No congestion noted...IV intact L (left) arm. (The documentation looks like staff first wrote an "R" for right, then heavily wrote "L" over it.)...Foley patent. Urine amber color. ABT (antibiotic) UTI- urinary tract infection)...Tylenol given for slight temp. 6:00 a.m. T100.3 P78 R16 BP 102/64. POX 96%. PRN Tylenol given. 8:15 a.m. Family Care aware of all new orders 8/31-9/4. 12:30 p.m. IV ABT continues, T99.9 PRN Tylenol given... 3:35 p.m. MD aware of Echo, CXR and UA results. New orders. (A telephone order states "[MEDICATION NAME] 1 gram IV daily-UTI".) At 10:11 p.m., critical lab values report was received. Failure to consult with MD regarding critical lab findings: Surveyor # noted "Critical/Alert Values" lab reports from blood cultures on the front of Resident #19's chart, indicating the critical lab results were called to facility RN (Registered Nurse)-O on 9/5/12 at 10:11 p.m. Surveyor # did not note any documentation indicating Resident #19's doctor, MD-Q, was informed of the results. Further investigation reveals no other facility staff was aware of the labs until after Resident #19 was sent to the ED (Emergency Department) on the morning of 9/6/12. The lab results note: *Results on 9/5/12 for blood culture collected on 9/4/12 at 9:42 a.m. -"preliminary-source: blood-antecubital right: gram positive cocci in clusters detected from aerobic bottle after 36 hours (critical/alert value). Called to, read back and confirmed with (RN-O) at 2211 (10:11 p.m.) on 9/5/12." On 9/11/12 at 4:07 p.m., Surveyor # interviewed DON-B and ADON-I, and asked what was done with the critical/alert lab results called to RN-O on 9/5/12 at 10:11 p.m. ADON-I stated she arrived at the facility around 5:30 a.m., and LPN-N was getting Resident #19 ready to send out. ADON-I stated she helped LPN-N get the necessary paperwork ready, and did not see or assess Resident #19. ADON-I stated she was unaware of the critical/alert lab called to RN-O the evening of 9/5/12. DON-B stated no one at the facility, other than RN-O, was aware of the lab until after Resident #19 was at the hospital. DON-B stated she called RN-O, asking about the critical/alert lab, after Surveyor # asked about it. RN-O told DON-B after he received the call he asked the laboratory staff to fax the results to the facility. The fax did not arrive by the time RN-O's shift ended on 9/5/12 at 10:30 p.m. RN-O went home and did not tell anyone about the critical/alert lab reported via phone call received on 9/5/12 at 10:11 p.m. Surveyor # noted RN-O did not contact or consult with Resident #19's physician regarding the critical lab report on 9/5/12. On 9/11/12 at 8:57 p.m., Surveyor # interviewed LPN-N by phone, who had worked the night shift on 9/5 - 9/6/12. LPN-N stated RN-O did not report anything regarding lab results for Resident #19 at shift change. LPN-N stated there were no faxes on the fax machine, nor did any faxes come in that night. Surveyor #1627 interviewed RN MGR-F who stated RN-O should have documented an assessment of Resident #19 on evening shift on 9/5/12 and the receipt of critical labs. RN -F stated RN-O should have also called MD-Q with the lab results. RN-F stated she was not aware of the critical/alert lab result called to RN-O until after Resident #19 had left the facility. On 9/13/12 at 10:30 a.m., Surveyor # interviewed MD-Q, who stated he was not aware of the blood culture lab results showing the critical/alert values. Facility staff did not call him to report the results. Failure to promptly consult with MD regarding temperature above 102 degrees F. Nursing notes continue: 9/6/12 3:30 a.m. ABT/UTI (antibiotic for urinary tract infection) continues. V/S (vital signs) T102.5 at 1:00 a.m. (note: no other vital signs listed- only temperature.) Tylenol 650 mg. given rechecked at 2:00 a.m. T102.7 Cool compress applied. BS (blood sugar) 467 with 10 units given. Rechecked at 3:00 a.m. T103.0 continuing with cool compresses. Will continue to monitor. 4:15 a.m. T 101.9 5:45 a.m. Call placed to MD....MD returned call, updated on current condition, new orders given to send to ER... Family updated, requested Resident be sent to Froedtert. Bell Ambulance called, awaiting arrival. (This is the last entry documented in the nurses' notes.) Resident #19 had temperatures of 102.5, 102.7 and 103.0 starting at 1:00 a.m. on 9/6, but MD-Q was not contacted until almost 6:00 a.m. No vital signs or nursing assessment were documented for the evening shift on 9/5/12, despite physician orders [REDACTED]. Surveyor # asked for facility policies regarding when nurses should call the physician, and what they should do if a resident has an elevated temperature. DON-B provided Surveyor # with the INTERACT tool which assists staff to determine when to immediately call an MD, what does not require immediate notification, and what can wait for the next regular contact. The INTERACT Tool for Signs and Symptoms states the MD should be informed immediately for: New onset T>102 regardless of any other symptoms, OR T>101 with other symptoms (unless under treatment already or physician already aware.) DON-B stated MD-Q had previously been informed of Resident #19's fever- that is why she was on the IV antibiotics. Surveyor # noted in all the previous notes, Resident #19's elevated temperature responded well to just Tylenol; but on 9/6/12 from 1:00 a.m. through 3:00 a.m., Resident #19's temperature continued to climb up to 103, despite the Tylenol, and after receiving 4 doses of a powerful IV antibiotic, and cool compresses and Resident #19's physician had not been consulted. Surveyor # reviewed the Care Path: Fever, (part of the INTERACT tool). The Care Path shows if a resident exhibits one temperature >100 degrees, or 2 or more temps >99 oral, or >99.5 rectal, or an increase of 2 degrees over baseline, the nurse is to take the resident's vital signs, including BP, pulse, respirations, oxygen saturation, and finger stick glucose for diabetic residents. The Care Path further directs staff to notify the MD/NP/PA immediately for a fever over 102 for consideration of lab tests and transfer to acute care facility as indicated. Surveyor # noted that the facility did not notify Resident #19's physician on 9/6 at 2:00 a.m. (temp 102.7) and at 3:00 a.m. (103.0). On 9/11/12 at 8:57 p.m., Surveyor # interviewed LPN-N, who was working at the facility, by phone. LPN-N stated when Resident #19 continued to have an elevated temperature, she informed supervisor RN-P, who, at around 6:00 a.m., instructed her to call MD-Q. LPN-N stated first she spoke with MD-Q, then RN-P spoke to him, and at the end of the call, RN-P just said to get Resident #19 ready to send out. Surveyor # noted Resident #19's blood sugar of 468. LPN-N stated she called MD-Q shortly after getting that reading, but she forgot to document the call. LPN-N stated she does not think she informed MD-Q of Resident #19's temperature at that time, as she might not have taken temperature at that time. LPN-N stated when Resident #19's temperature was not coming down, she informed supervisor RN-P. LPN-N thought RN-P did go assess Resident #19, though it is not documented. RN-P instructed LPN-N to call the MD a little before 6:00 a.m. Then they sent Resident #19 out. Outcome: On 9/18/12 at 11:00 a.m., Surveyor # reviewed a report from Bell Ambulance indicating they received a call from the facility on 9/6/12 at 6:25 a.m., arrived at the facility at 6:32 a.m., arrived at the patient at 6:40 a.m., left the facility with the patient at 6:53 a.m., and arrived at the hospital and 7:12 a.m. The ambulance report states Resident #19's temperature was 102.8, skin hot to touch, unable to gain IV access due to poor venous access...blood glucose 428. When Resident #19 arrived at the Emergency Department (ED), she was diagnosed with [REDACTED]. Despite receiving 4 liters of intravenous fluids in the ED, Resident #19's blood pressure did not improve. "Sepsis is a medical condition in which the immune system goes into overdrive, releasing chemicals into the blood to combat infection (microbes in the blood, urine, lungs, skin, or other tissues) that trigger widespread inflammation (cellular injury in body tissues). If the body is not able to regulate this immune response, it then overwhelms normal blood processes ...Sepsis is more common and more dangerous in elderly persons, individuals with a compromised immune system, and persons who are already critically ill. Patients [MEDICAL CONDITION] require prompt medical attention and are usually treated in the intensive care unit with intravenous fluids and antibiotics ... Mortality rates are high, with 20% [MEDICAL CONDITION], 40% for [MEDICAL CONDITION], and more than 60% for septic shock. " JAMA, February 24, 2010-Vol 303, No. 8 Documentation from the ED reveals Resident #19 arrived at 7:17 a.m. on 9/6/12, BP 77/47 Temperature 103.1 oral, respirations 32 pulse 72... large sacral decubiti healing but dressing removal emits foul odor...2 IV's removed, one with very foul odor. Patient given IVF (Intravenous fluids) 2 liters with no response in BP. Liter 3 same or decreasing BP. Will begin norepi (norepinepherine) drip...admitted with septic shock...Problem List-[MEDICAL CONDITION] of unknown source. Had RN-O contacted MD-Q with the critical lab results, or passed along the information for the next shift to follow-up with, the critical/alert results from Resident #19's blood cultures could have been sent along to the hospital with Resident #19, providing the hospital with the source of [MEDICAL CONDITION]. That information was not provided, and the decision was made at the hospital to forgo any more tests and/or lab work, noting a complete exam was deferred at present time given the patient's condition, "comfort care measures are in place with a goal of minimizing physician intervention as (Resident #19) was actively passing." (Resident #19 was discharged from the hospital on [DATE] to a hospice.) A cursory hospital physical exam noted Resident #19 had jugular vein distention observable from a distance, respiratory distress with paradoxical chest/ abdominal wall motion, ventricular heave, diffuse rhonchi (chest sounds), and dropped beats suggestive of heart block. On 9/18/12 at 11:45 a.m., Surveyor # reviewed concerns with DON-B, including RN-O not properly responding to receipt of a critical/alert lab report- causing ED staff to report "sepsis of unknown source" and "septic shock of unknown source" -when the source could have been provided to them; and the facility not calling MD-Q sooner when Resident #19 had a temperature of 102.5 at 1:00 a.m. on 9/6, which rose to 102.7 by 2:00 a.m. after Tylenol and cool compresses were administered, and continued to rise to 103.0 by 3:00 a.m. No further information was provided. Surveyor # was unable to interview RN-O as he is no longer employed at the facility. Cross reference F309. The failure to promptly communicate Resident #19's critical lab values to the MD and oncoming shift, and to promptly consult with Resident #19's physician regarding increasing temperatures that were no longer responding to the administration of Tylenol resulted in Resident #19 deteriorating to the point that Resident #19 was in septic shock upon emergency room admission. This created a finding of immediate jeopardy. The immediate jeopardy was removed on 9/19/12 at which time the facility: 1. Completed a basic nursing assessment to include cognitive status, vital signs, breath sounds, bowel sounds, pain status and resident specific health concerns on all in house residents, including documentation of assessment in the resident's medical record. Any noted change in condition identified will be communicated to the physician. 2. Inserviced staff on assuring proper documentation in the medical records utilizing the Interact II (SBAR and Interact II Tools which includes change in condition and when to report to MD/NP/PA) guidelines and Extendicare's episodic charting procedures. 3. Reviewed the 24 hour board to ensure appropriate items are outlined as collected through the resident assessment, nursing note review, doctor order and lab review. 4. Nursing leadership including nursing supervisors will daily review the lab book to assure physician notification is completed as appropriate. 5. Nursing leadership including nurse supervisor will be auditing at least 1 shift daily to ensure items such as the 24 hour board and lab book are properly utilized to ensure clear communication. 6. The Interdisciplinary team will review the medical records of all return-to-hospital residents through the clinical meeting process to identify any opportunities for clinical improvement. 7. Nursing leadership including nursing supervisors will randomly audit daily SBAR documentation to ensure it is completed for acute changes of condition physician notifications. 8. Validated 100 percent of the Registered Nurses skills in regards to completing the nursing assessments. 9. Re-educated 100 percent of the nursing leadership on the above systems to assure complete understanding of facility processes. The facility systems include the use of the Interact II (SBAR and Interact II tools, review of the procedures for Laboratory/Diagnostic Test /Values-Monitoring, 24 Hour Report of Resident Condition, Episodic Documentation.) 10. Re-educated all licensed nurses with the exception of 4 licensed staff who work on an as needed basis, on the above systems to assure complete understanding of facility processes. The 4 remaining licensed staff not yet re-educated will receive training prior to working. 11. The above will be reviewed at monthly QPI meetings to determine the need for any further education and continued for monitoring for 3 months. 12. The Medical Director has been involved and has approved of the above plan.

Based on interviews and record reviews, facility staff did not provide services which met professional standards of quality for 1 of 19 residents reviewed. The facility did not follow the Wisconsin Nurse Practice Act for Resident #19: * Registered Nurse (RN)-O did not contact Resident #19's physician regarding critical lab values indicating [MEDICAL CONDITION], nor were the critical lab values communicated to staff. Resident #19 was not assessed by a Registered Nurse on the evening shift of [DATE]. * Resident #19's physician was not contacted throughout the night shift on [DATE] of Resident #19's elevated temperatures greater than 102 degrees, nor was Resident #19 assessed by Registered Nurse-P. * On [DATE], the night shift RN-P did not follow standards of practice in regards to the delegation of nursing acts. RN-P did not provide the supervision and direction necessary to ensure LPN-N performed delegated tasks, such as taking Resident's 19's vital signs. Resident was admitted into the hospital on [DATE] with a [DIAGNOSES REDACTED]. The failure to provide services that met professional standards of practice - the failure of Registered Nurse -O to communicate Resident #19's critical lab values to the MD and oncoming shift, the failure of Registered Nurse-O to assess Resident #19 on [DATE], the failure to consult with the physician regarding increased temperatures greater than 102 degrees, the failure of Registered Nurse-P to assess Resident #19 on the night shift of [DATE], and the failure of Registered Nurse-P to provide supervision and direction necesary to ensure LPN- N performed delegated tasks - resulted in Resident #19 deteriorating to the point that Resident #19 was in septic shock when Resident #19 reached the emergency room . This created a finding of immediate jeopardy beginning on [DATE]. The Director of Nursing was informed of the Immediate Jeopardy on [DATE] at 10:50 a.m. The Immediate Jeopardy was removed on [DATE]. However, the deficient practice continues at a scope and severity of E (potential for harm that is not immediate jeopardy/pattern) because the Facility has not implemented all the components of their plan of correction, and as evidenced by the following examples where staff had failed to meet professional standards of practice for Resident #19. * Staff did not follow accepted standards when removing Resident #19's PICC line (peripherally inserted catheter) when inserting and re-inserting a peripheral IV and monitoring the PICC line. * Staff did not follow current standards of practice in regards to documentation, such as LPN-N not documenting a physician contact regarding Resident #19's blood sugar, LPN-N indicating Resident #19 was receiving total [MEDICATION NAME] nutrition when Resident #19 was actually had a gastrostomy tube, not documenting on Resident #19's PICC line and no further documentation on [DATE] after 5:45 a.m. regarding Resident's transfer to the hospital. Resident #19 left the faciity on [DATE] at approximately 6:50 a.m. Findings include: The Wisconsin Nurse Practice Act N6.02 (Register [DATE], No 606) Definitions states: A complex patient situation, as determined by a R.N., physician, ...means any one or more of the following conditions exist in a given situation: The patient's clinical condition is not predictable; medical or nursing orders are likely to involve frequent changes or complex modifications; or the patient's clinical condition indicates care that is likely to require modification of nursing procedures in which the responses of the patient to the nursing care are not predictable. " " A delegated nursing act means acts delegated to an LPN or less-skilled assistant by a RN. "Direct Supervision" means immediate availability to continually coordinate, direct and inspect at first hand the practice of another. N6.03 Standards of practice for Registered Nurses states: 1. General Nursing Procedures: A RN shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process: a. Assessment- is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. b. Planning-is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. c. Intervention-is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to LPN's or less skilled assistants. d. Evaluation- is the determination of a patient's progress toward goal achievement which may lead to modification of the nursing diagnosis. 3. Supervision and Direction of Delegated Nursing Acts. In the supervision and direction of delegated nursing acts a RN shall: a) Delegated tasks commensurate with educational preparation and demonstrated abilities of the person supervised; b) Provide direction and assistance to those supervised; c) Observe and monitor the activities of those supervised; and d.) Evaluate the effectiveness of acts performed under supervision. N6.04 Standards of practice for licensed practical nurses states: 1. Performance of acts in basic patient situations. In the performance of acts in basic patient situations, the LPN shall, under the general supervision of a RN, b. Provide basic nursing care; c. Record nursing care given and report to the appropriate person changes in condition of patient; e. 1. Assist with the collection of data ... 2. Performance of acts in complex patient situations, the LPN shall: a. meet standards of (1.); and b. Perform delegated nursing or medical acts beyond basic nursing care under the direct supervision of a RN. Surveyor # reviewed Resident #19's closed medical record from ,[DATE] -[DATE]. Resident #19 was admitted to the facility on [DATE] following heart surgery ([MEDICAL CONDITION] revascularization X5-coronary artery bypass graft (CABG) surgery). Resident #19 also suffered a stroke after surgery, which left her unresponsive. The hospital discharge summary dated [DATE] notes upon physical exam, neurologic response- minimal spontaneous movements and to painful stimuli; T (temperature) 96, BP (blood pressure) ,[DATE], pulse 74, respiratory rate 21, and pulse oximetry (POx) 100% on room air. 1. Failure to communicate critical lab values to oncoming staff or to the physician: Resident #19 was discharged from the facility a few hours prior to surveyors entering the building on [DATE]. Surveyor # noted "Critical/Alert Values" lab reports from blood cultures (indicating [MEDICAL CONDITION]) on the front of Resident #19's chart, indicating the critical lab results were called to facility RN (Registered Nurse)-O on [DATE] at 10:11 p.m. The results were dated [DATE] for blood culture collected on [DATE] at 9:42 a.m. -"preliminary-source: blood-antecubital right: gram positive cocci in clusters detected from aerobic bottle after 36 hours (critical/alert value). Called to, read back and confirmed with (RN-O) at 2211 (10:11 p.m.) on [DATE]." Surveyor # did not note any documentation indicating Resident #19's doctor, MD-Q, was informed of the results. Further investigation reveals RN-O did not notify MD-Q or anyone else about the labs; no other facility staff was aware of the labs until after Resident #19 was sent to the ED (Emergency Department) on the morning of [DATE]. Surveyor # interviewed MD-Q on [DATE] at 10:30 a.m., who stated he was not aware of and had not been informed of Resident #19's blood culture lab results showing the critical/ alert blood culture results indicating [MEDICAL CONDITION]. Surveyor # reviewed Resident #19's hospital record which revealed when Resident #19 arrived at the ED, she was diagnosed with [REDACTED]. Despite receiving 4 liters of intravenous fluids in the ED, Resident #19's blood pressure did not improve. Documentation from the ED reveals she arrived at 7:17 a.m. on [DATE], BP ,[DATE] Temperature 103.1 oral, respirations 32 pulse 72., large sacral decubiti healing but dressing removal emits foul odor...2 IV's removed, one with very foul odor. Patient given IVF (Intravenous fluids) 2 liters with no response in BP. Liter 3 same or decreasing BP. Will begin norepi (norepinepherine) drip...admitted with septic shock...Problem List-[MEDICAL CONDITION] of unknown source. A cursory hospital physical exam on arrival at the ED noted Resident #19 had jugular vein distention observable from a distance, respiratory distress with paradoxical chest/ abdominal wall motion, ventricular heave, diffuse rhonchi (chest sounds), and dropped beats suggestive of heart block. "Sepsis is a medical condition in which the immune system goes into overdrive, releasing chemicals into the blood to combat infection (microbes in the blood, urine, lungs, skin, or other tissues) that trigger widespread inflammation (cellular injury in body tissues). If the body is not able to regulate this immune response, it then overwhelms normal blood processes ...Sepsis is more common and more dangerous in elderly persons, individuals with a compromised immune system, and persons who are already critically ill. Patients [MEDICAL CONDITION] require prompt medical attention and are usually treated in the intensive care unit with intravenous fluids and antibiotics ... Mortality rates are high, with 20% [MEDICAL CONDITION], 40% for [MEDICAL CONDITION], and more than 60% for septic shock. " JAMA, February 24, 2010-Vol 303, No. 8. Had RN-O contacted MD-Q with the critical lab results, or passed along the information for the next shift to follow-up with, the critical/alert results from Resident #19's blood cultures could have been sent along to the hospital, providing the hospital with the source of [MEDICAL CONDITION]. The critical/alert lab results was not provided, and the decision was made at the hospital to forgo any more tests and/or lab work, noting a complete exam was deferred at present time given the patient's condition, "comfort care measures are in place with a goal of minimizing physician intervention as (Resident #19) was actively passing." (Resident #19 was discharged from the hospital on [DATE] to a hospice.) Cross Reference F157 2. Failure to monitor vital signs as ordered, conduct assessments, delegation and documentation: According to the AMDA (American Medical Directors' Association) Common Infections in Long-Term Care (2011) Guideline, staff are to " assess whether the patient' s condition warrants transfer to a hospital. " The guideline notes it is often preferable to treat the resident in familiar surroundings, but a " Transfer to a hospital may be appropriate (if consistent with the patient's directives) when any of the following exist: the patient's vital signs are unstable and the patient or family desires aggressive intervention ... For example, in patients with UTI (urinary tract infection), complications such [MEDICAL CONDITION], renal obstruction, unstable pulse or blood pressure, serious illness, combined with uncertain diagnosis, may warrant a hospital transfer ... Facility staff should provide relevant patient information, including pertinent lab tests, on a standard transfer sheet or by telephone. " Per Barbara Acello, RN, MSN., in The Long-Term Care Nursing Desk Reference (HCPro. Inc: ? 2005): " In healthcare, there is a maxim ' If it's not charted, it wasn't done. ' ... In the absence of nursing documentation, a reader may assume that no care was provided ... Documentation is a critical part of nursing practice not an afterthought. ANA standards of practice require that documentation be based on the nursing process and that it be ongoing and accessible to all members of the healthcare team. The purpose of documentation is to communicate the care given. Documentation is a true, complete, objective record of the care given and the residents ' response. It is the first line of defense in proving accountability for care. " (pages ,[DATE]) Surveyor # reviewed Resident #19's Nurses' Notes which indicate Resident #19 had temperatures of 102.5, 102.7 and 103.0 from 1:00 a.m. to 3:00 a.m. on ,[DATE], but MD-Q was not contacted until almost 6:00 a.m. The last recorded temperature for Resident #19 was 101.9 at 4:15 a.m. (Cross reference F157.) Further review of Resident #19's medical record reveals no vital signs, including temperature, or nursing assessments were conducted for the evening shift on [DATE], and only Resident #19's temperature (no nursing assessment or other vital signs) was documented on night shift [DATE]. Surveyor # reviewed a Vitals Signs-Individual Resident Flow sheet for Resident #19 which included just three entries: [DATE] PM shift, [DATE] NOC (night) shift, and [DATE] NOC shift, all prior to the MD order for vital signs every four hours. Surveyor # also reviewed Nurses' Notes, the 24 hour reports, the MARS and TARS (Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. (Cross reference F309.) Resident #19 was not provided with an assessment even though there were physician's telephone orders dated [DATE] to take Resident #19's vital signs every four hours. Resident #19 was not assessed even though the the facility's INTERACT Care Path for Fever (? Florida [MEDICATION NAME] University) protocol requires the nurse to take the resident's vital signs (BP blood pressure, pulse, respirations, oxygen saturation, and finger stick glucose for diabetics) if a resident's temperature is >100 degrees on one reading, or 2 or more temperatures >99 degrees orally. Resident #19 was not assessed even though Resident #19 was on the 24 hour report since admission on [DATE]. Resident #19 was not assessed after receiving four doses of IV (intravenous) [MEDICATION NAME] since [DATE] for a urinary tract infection. Typically, a positive response (lower temperature or improvement in symptoms) is seen within ,[DATE] hours of starting an antibiotic. Resident #19's temperature rose after four doses of the [MEDICATION NAME], indicating a new or worsening problem. When questioned on [DATE] at 9:57 a.m, regarding the absence of a nursing assessment for Resident #19 on the evening shift on [DATE] and on night shift on [DATE], RN Manager- F informed Surveyor # , RN-O should have documented an assessment on [DATE] PM shift as he was the floor nurse assigned to Resident #19, and RN-P should have completed and documented an assessment on night shift on [DATE] as the house supervisor, overseeing LPN-N. Surveyor # was not able to interview RN-O as RN-O is no longer employed by the facility. On [DATE] at 4:10 p.m., Surveyor # interviewed RN-P, asking if he assessed Resident #19 on night shift on [DATE], and if so, where the assessment was documented. RN-P stated he did speak with Licensed Practical Nurse (LPN)-N regarding Resident #19's temperatures, but he did not assess Resident #19 because LPN-N stated she was a strong nurse and could handle it. RN-P stated he had only worked at the facility since [DATE], and was not that familiar with LPN-N, but she told him she could take care of it. On [DATE] at 7:03 a.m., Surveyor # interviewed LPN-N, who was the nurse caring for Resident #19 on night shift on [DATE]. Surveyor # showed LPN-N the facility's usage of the INTERACT Care Path for Fever tool, and noted where it states vital signs should be taken. In addition, the INTERACT Tool for Signs and Symptoms states the MD should be informed immediately for new onset of temperature of > 102 regardless of any other symptoms, or a temperature > 101 with other symptoms (unless under treatment already or physician already aware). Surveyor noted MD-Q was not aware of the critical /alert labs from Resident #19's blood cultures that frequently [MEDICAL CONDITION], nor was MD-Q aware of Resident #19's continually increasing temperature despite four doses of IV [MEDICATION NAME] and receiving Tylenol. LPN-N first stated she did not take Resident #19's vital signs, and then stated she may have taken them but did not write them down. LPN-N stated if a Resident is on the 24 hour report for a UTI, as was Resident #19, she would monitor their urine and Foley catheter, if they had one, but not take vital signs. LPN-N acknowledged she did not document anything regarding Resident #19's urinary status. LPN-N stated she received training on the INTERACT Tools, but when Surveyor # asked how she knows which residents need to have their vital signs taken, LPN-N stated, " That's a good question, I don't know" and "If I'm monitoring for a temperature, I don't monitor vital signs." Surveyor # reviewed an "SBAR" Physician/NP/PA Communication and Progress Note completed for Resident #19. This stands for "Situation," Background, Assessment, and Request." It was completed by ADON (Assistant Director of Nursing)-I on [DATE] at 5:45 a.m. The Situation/problem was a fever that started at 1:00 a.m., the problem/ongoing elevated temperature has gotten worse despite Tylenol and cold compresses. The Background included Resident #19's VS: Temperature was 103, P80 R20, BP ,[DATE], pulse ox 96% on room air, and includes [DIAGNOSES REDACTED]." The "Request" is checked for: Monitor vital signs (Frequency____) and observe; and IV or SC (subcutaneous) fluids. (Note: on [DATE] MD-Q already ordered monitoring vital signs every 4 hours.) ADON-I signed the form and indicated it was communicated to MD-Q at 5:45 a.m. Surveyor # interviewed ADON-I, asking when she obtained the vital signs for Resident #19. ADON-I stated she never saw or assessed Resident #19, but those VS were given to her from someone on night shift, possibly LPN-N, and she filled them in on the SBAR sheet. She does not know who took them or when they were taken. Surveyor # reviewed the rest of Resident #19's Nurses' Notes, which consisted of: [DATE] 5:45 a.m. Call placed to MD....MD returned call, updated on current condition, new orders given to send to ER... Family updated, requested Resident is sent to Froedtert. Bell Ambulance called, awaiting arrival. This is the last entry documented in the nurses' notes. Surveyor # interviewed night shift LPN-N, asking why there was no documentation indicating when the ambulance arrived, when Resident #19 left the facility, and what condition she was in when she left. LPN-N stated her shift had ended and she left the floor prior to the ambulance arriving. Surveyor # noted LPN-N only documented Resident #19's elevated temperatures, but no vital signs or reference about Resident #19's catheter or urine, even though LPN-N notes Resident #19 was receiving antibiotics for a UTI. Surveyor # also noted LPN-N's note indicates Resident #19 had a blood sugar at midnight of 468. Resident #19 has physician's orders [REDACTED]. LPN-N stated she did call MD-Q shortly after the blood sugar was obtained, but did not know about Resident #19's temperature at the time. Surveyor # interviewed day shift nurse RN-X, who stated night shift staff handled Resident #19's discharge and she was not involved with her discharge. Surveyor # interviewed night shift supervisor RN-P who stated he was not on the floor when the ambulance arrived and did not see or assess Resident #19. Surveyor # interviewed ADON-I who also stated she was not present when the ambulance arrived, and does not know when Resident #19 left the facility or what condition she was in when she left. Resident #19 was sent to the hospital on [DATE] at 6:50 a.m. The failure to provide services that met professional standards of practice created a finding of immediate jeopardy beginning on [DATE]. The Immediate Jeopardy was removed on [DATE], based off of the removal of the Immediate Jeopary at F157 and F309 at which time the facility: 1. The facility provided education to all licensed nurses regarding the need to document every shift on residents with indwelling Foley or suprapubic catheters. This documentation includes characteristics of urine, and catheter site observations. 2. Facility provided education to the nurses to enhance their supervisor skills to promote better communication between the nurses and the certified nursing assistants. To improve communication, the nurses will provide report to the CNA's and state the expectations on what needs to be communicated throughout the shift. During the shift the nurse will ask for updates, reviews and any changes with CNAs. The CNAs educated to inform the supervisor of changes if they do not see any response from their nurse. The nurses will sign and date roster sheets verifying report has been given to the CNAs. This will be monitored by the Director of Nursing/designee. The observation of reporting will be randomly audited daily by the nurse managers/designee. This form will be turned into the Director of Nursing. Any nurse not educated will be contacted by phone and given education. A certified letter will also be sent to them with education and they will not be allowed to return to work until the 1:1 education was completed. 3. The facility completed a basic nursing assessment to include cognitive status, vital signs, breath sounds, bowel sounds, pain status and resident specific health concerns on all in house residents, including documentation of assessment in the resident's medical record. Any noted change in condition identified will be communicated to the physician. 4. The facility inserviced staff on assuring proper documentation in the medical records utilizing the Interact II (SBAR and Interact II Tools which includes change in condition and when to report to MD/NP/PA) guidelines and Extendicare's episodic charting procedures. 5. Facility staff reviewed the 24 hour board to ensure appropriate items are outlined as collected through the resident assessment, nursing note review, doctor order and lab review. 6. The facility set up procedures such that nursing leadership, including nursing supervisors, will daily review the lab book to assure physician notification is completed as appropriate. 7. The facility set up procedures such that nursing leadership including nurse supervisor will audit at least 1 shift daily to ensure items such as the 24 hour board and lab book are properly utilized to ensure clear communication. 8. The Interdisciplinary team will review all return to hospital resident medical record through the clinical meeting process to identify any opportunities for clinical improvement. 9. Nursing leadership including nursing supervisors will randomly audit daily SBAR documentation to ensure it is completed for acute changes of condition physician notifications. 10. The facility validated 100 percent of the Registered Nurses skills in regards to completing the nursing assessments. 11. The facility re-educated 100 percent of the nursing leadership on the above systems to assure complete understanding of facility processes. The facility systems include the use of the Interact II (SBAR and Interact II tools, review of the procedures for Laboratory/Diagnostic Test /Values-Monitoring, 24 Hour Report of Resident Condition, Episodic Documentation.) 10. The facility re-educated all licensed nurses with the exception of 4 licensed staff who work on an as needed basis, on the above systems to assure complete understanding of facility processes. The 4 remaining licensed staff not yet re-educated will receive training prior to working. 11. The above will be reviewed at monthly QPI meetings to determine the need for any further education and continued for monitoring for 3 months. Then it will be re-evaluated. 12. The Medical Director has been involved and has approved of the above plan. The deficient practice continues at a scope/severity of E (potential for harm that is not immediate jeopardy/pattern) as evidenced by the following: Failure to accurately convey gastrostomy tube feeding versus TPN (total [MEDICATION NAME] nutrition) information on transfer form to hospital: According to MedLine, an on-line resource from National Institutes of Health, "TPN will drip through a needle or catheter placed in your vein for 10 to 12 hours, once a day or five times a week. TPN is a method of feeding that bypasses the gastrointestinal tract." Surveyor # reviewed a Resident Transfer Form dated [DATE] completed by LPN-N, the nurse who took care of Resident #19 on night shift ,[DATE]-into early morning [DATE]. LPN-N indicated Resident #19 had an IV, and in two places, LPN-N documented Resident #19 was receiving TPN, or total [MEDICATION NAME] nutrition. Surveyor # noted Resident #19 was receiving feeding through a gastrostomy tube and not TPN as indicated per LPN-N. Surveyor # interviewed LPN-N on [DATE] at 7:03 a.m. LPN-N acknowledged Resident #19 had a gastrostomy tube for feeding, not TPN. Failure to monitor the PICC/IV site and documentation : Current standards of practice from PICCLINENURSING.COM states: " Only clinicians or nurses who have been trained to manage potential complications should remove a PICC ...While removing, it is vital to exert slow, intermittent traction without applying any direct pressure at the insertion site. During the removal process, there is possibility that resistance may be present. This could be caused by a venous spasm. Warmth often relieves the spasm and after a brief period of time may easily be removed. But the catheter must never be forcefully tugged as this could break it. If still unable to remove it easily, the physician should be notified. After it is completely removed, the actual catheter length should be measured and compared with the documented insertion length. The documented and actual length must be equal as this is the only way to confirm that the catheter has not broken and has been removed intact. If the length of the removed catheter is less than the documented insertion length, it indicates that part of the catheter is retained inside the vein and the physician must be notified immediately. In addition, the catheter tip should also be examined to insure there is no breakage at the end. Again, if the tip is not intact, immediately notify the physician. If infection is suspected, then the tip of the catheter is sent for culture. After removing the catheter, gentle pressure is applied at the insertion site with sterile gauze to prevent bleeding which is typically minimal, if at all. When the bleeding stops, the gauze is removed and a sterile dressing is applied. The dressing should remain for approximately 24 hours. After this time, the site should be assessed and a new dressing applied if needed." According to PICCLINENURSING.COM, the following are some of the complications that can be associated with PICC lines: " Air Embolism: Air bubbles may enter the blood vessel during insertion of a PICC. This may produce symptoms such as decreased blood pressure; lightheadedness; confusion; increased heart rate; anxiety; chest pain; or shortness of breath. Infection: It is possible for an infection to develop either inside the vessel or surrounding the insertion site where the catheter enters the vein. The symptoms include fever; chills; [MEDICAL CONDITION] fatigue; muscle aches; weakness; decreased blood pressure; redness, swelling or purulent drainage at site; or elevated white blood cell count. Phlebitis: This is inflammation of the vein where the catheter is inserted. The symptoms include redness; pain at access site; streak formation; palpable venous cord; or purulent drainage. Catheter Malposition: Malposition can occur during PICC insertion or later due to changes in pressure inside the chest or from catheter migration. Thrombus Formation: Any catheter inserted into the vascular system increases the risk of thrombus formation, either in the vessel or in the catheter." The Nursing Comprehensive Admission Data Collection and Assessment completed on admission on [DATE] for Resident #19 indicates: T97.5, BP,[DATE], R20, P 85; level of consciousness- comatose, pupils not responsive; neck veins not distended; has suprapubic catheter; IV's (intravenous)-PICC (peripheral inserted central catheter) left arm. Surveyor # reviewed Resident #19's Nurses' Notes. There was no documentation, other than one note on [DATE], regarding nurses assessing and monitoring of Resident #19's PICC line (peripherally inserted central catheter), which was present on admission. (Cross reference F309) The [DATE] 10:30 p.m. note states: T98.4 P88 R20 BP,[DATE] ...Foley catheter patent draining yellow urine, output 350 cc this shift. PICC line patent and flushed as ordered. Nurses' Notes on [DATE] at10:45 p.m. state: MD updated on increased WBC's (white blood cells). Orders obtained 1.) Obtained to repeat CBC in a.m.; 2.) Blood cultures x 2, STAT -1 from PICC & 1 stick. 3.) Culture tip of PICC 4.) D/c PICC. Surveyor noted a culture from the tip of the PICC line was sent to the lab, consequently, the PICC line must have been removed in order to obtain the culture however; there is no documentation indicating who removed it, when, how Resident #19 tolerated the procedure, if there was bleeding, etc. Per current standards of practice, Nurses are to measure the catheter after removal to ensure none of it broke off and was left in the resident. Surveyor # reviewed Resident #19's medical record for documentation regarding peripherally inserted IV's, since the hospital Emergency Department record on [DATE] states, Resident #19 had two peripheral IVs present when she arrived there, and one was foul smelling. The ambulance record indicates they attempted to start an IV but were unsuccessful. Surveyor # did not observe any Nurses' Notes indicating who started Resident #19's IV, or when, or where (left or right side, hand, antecubital, etc.) however, an IV must have been started since the [MEDICATION NAME] was administered via IV. Surveyor # reviewed a physician progress notes [REDACTED].) Hypertension, increase free water to 250 ccs four times a day; 7.) fever-Repeat blood cultures today. Start Vanco 1 gram BID... The only Nurses Note that mentions an IV states: [DATE] 1:30 a.m. T99.8 P74 R18 BP ,[DATE]. Unresponsive. No congestion noted...IV intact L (left) arm. (The documentation looks like staff first wrote an "R" for right, then heavily wrote "L" over it.)...Foley patent. Urine amber color. ABT (antibiotic) UTI- urinary tract infection)...Tylenol given for slight temp. Surveyor # noted the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED].) Presumably, the nurse checked the site at 8:00 p.m. on ,[DATE] when they administered the antibiotic, but there is nothing to indicate a nurse observed the IV site following the [DATE] 8:00 p.m. administration of the antibiotic. The page of the MAR indicated [REDACTED]. Per Director of Nursing (DON)-B, this page of the MAR indicated [REDACTED]. The facility only found the MAR indicated [REDACTED]

Based on staff interview, resident record review, hospital record review, and review of the Facility's polices, the Facility did not provide the necessary care and services to each resident to attain or maintain their highest practicable well being for 2 of 18 sampled Residents (Resident #1 and #19) who experienced a change in condition. * Resident #1 is alert & oriented, required repositioning every 2 hours, has a Foley catheter, and is incontinent of bowel. On the evening of 8/24/12, Resident #1 refused supper which was a change as the previous 12 dinners were documented as eating 100%. In addition evening staff reported that Resident #1 was not joking with them as he usually did. The evening CNA admitted that she did not do her final rounds, check the catheter or inform the nurse of the output. The CNA informed the evening nurse that Resident #1 had not eaten and was not himself. The evening nurse did not check Resident #1's urine output, did not assess Resident #1, and did not place him on the 24 hour board. There was no report passed on to the next shift regarding Resident #1. The night CNA stated that Resident #1 was snoring and she assumed Resident #1 was sleeping. This was unusual as Resident #1 was usually awake when the 3rd shift started. The CNA stated that she did not get any response from Resident #1 when she moved his head. The night CNA admitted that she only repositioned Resident #1 and did not check the incontinence product the entire shift. The night CNA reported to the night supervisor and the floor nurse that Resident #1 didn't look good, he was not his usual self and was snoring. The night nurse and supervisor did not assess Resident #1. On 8/25/12 during change of shift the night and day CNA went into Resident #1's room together. Resident #1 was unresponsive and they reported this to the nurse. The nurse did a sternal rub with no response; the physician was contacted, and Resident #1 was transported to the hospital where Resident #1 was diagnosed with [REDACTED]. Complications of urosepsis can be life-threatening and require immediate medical attention. The failure of nursing staff to monitor and assess Resident #1 throughout the evening of 8/24/12 and the night of 8/25/12 resulted in Resident #1 being hospitalized for [REDACTED]. The Nursing Home Administrator and Director of Nursing were informed of the Immediate Jeopardy on 9/13/12 at 11:02 a.m. * Resident #19 experienced a change in condition. No vital signs or nursing assessment were documented for the evening shift on 9/5/12, despite physician orders [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The last blood pressure documented in the nurses' notes was on 9/5/12 at 6:00 a.m. As of 9/4/12, Resident #19 was being treated for [REDACTED]. The facility was not monitoring resident's urinary output nor characteristics, with the exception of a few notes from 8/28-8/30/12. On 9/5/12 at 10:11 p.m., RN-O received critical lab results indicating positive blood cultures which often [MEDICAL CONDITION]. RN-O did not consult the MD regarding the critical lab results nor did RN communicate the critical lab results to on-coming staff to follow up on. Resident #19 was not assessed by an RN on 9/5/12, p.m. shift. On 9/6/12 from 1:00 a.m.-3:00 a.m., Resident #19 had temperatures of 102.5, 102.7 and 103.0, however MD-Q was not contacted until almost 6:00 a.m. There was no RN assessment on night shift. Resident #19 was not assessed by an RN on day shift on 9/6/12 prior to Resident #19 going to the hospital. The failure to monitor and assess Resident #19's vital signs as ordered by the physician and dictated by professional standards of practice, for failing to monitor and record urinary output and urine characteristics and for failing to communicate Resident #19's critical lab values to the MD and oncoming shift resulted in Resident #19 deteriorating to the point that Resident #19 was in septic shock when Resident #19 reached the emergency room . This created a finding of immediate jeopardy beginning on 9/5/12. The Nursing Home Administrator, Director of Nursing and Regional Director of Operations were informed of the Immediate Jeopardy on 9/18/12 at 2:20 p.m. The Immediate Jeopardy was removed on 9/19/2012. However, the deficient practice continued at a scope and severity of E (potential for harm/pattern), as the Facility has not implemented all their components of their plan of correction. Findings include: EXAMPLE 1 Surveyor # reviewed Resident #1's closed medical record to investigate an online complaint that Resident #1 was hospitalized following an infection and injury from an improperly inserted catheter. Resident #1 was originally admitted to the facility on [DATE] with a readmitted following hospitalization on [DATE]. Resident #1 was discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. Resident #1 had an activated power of attorney for health care. According to the CNA (Certified Nursing Assistant) care plan updated 8/24/12, Resident #1 was alert & orientated, liked to socialize with peers, required repositioning every 2 hours, transferred with Hoyer lift with 2 assist, was independent in mobility in his electric wheelchair, was incontinent of bowel and had a Foley catheter. The nurses note 8/15/12 documents, "without c/o's (complaints of) pain - without SOB (short of breath)." There is no further nurses documentation regarding Resident #1 until 8/25/12, 10 days later, when the SBAR (Situation, Background, Assessment, Request) progress note is written on 8/25/12. The SBAR Physician/NP/PA Communication and progress note dated 8/25/12 at 0600 a.m. documents under progress note "Pt. (patient) found unresponsive on rounds, writer alerted of condition. In to assess pt. Sternum rub ineffective, unable to get response. Initial vitals taken 110/64, 98.6, 88, BS (blood sugar) 146 POX 93% RA (room air). HOB (head of bed) elevated Resp. (respirations) 20-22 unlabored. MD paged immediately. Floor nurse instructed to recheck vitals. Vitals unchanged. MD called back with n.o. (new order) to send out to hospital. Writer called for report to hosp. nurse. Bell called. Ambulance on way. Writer back with resident. Slouched over to side, straightened up. Skin cool to touch without change to skin color. Bell here for p/u (pick up). Family called with update." On 9/6/12, Surveyor # reviewed the first floor C wing 24 hour status report from 8/19/12 to 8/25/12. Resident #1 was not listed on this report until 8/25/12 which documents, "Sent to St. Francis ER (emergency room )" and "admitted ." On 9/6/12, Surveyor # reviewed the hospital records at St. Francis Hospital which included the ambulance records. Bell ambulance patient care report for date of service 8/25/12 documents for narrative located on page 4 of the 6 page document, "Arrived on scene to find 67 y/o (year old) male pt. (patient) unresponsive lying in bed in care of facility staff. Pt. would occasionally respond to painful stimuli but would only open his eyes for a short time and moan and then would become unresponsive again a short time later. Pt. noted to be congested in all fields and very warm to touch. Strong radial pulses noted on assessment. Pt. had minimal urine output but urine was very dark and potent in his Foley catheter. Per staff, pt was noted to have a change in mental status last evening at an unknown time. When first shift arrived at work today they were unable to get pt. to respond. Per staff, pt normally A/O (alert/oriented)X (times)4 and verbal with staff members and other residents. Pt. also noted have bilateral [MEDICAL CONDITION] to both lower extremities. Pt transferred to cot and secured. Vitals, BGM (blood glucose monitoring), and Hx (history) obtained as noted. 12-lead obtained and pt placed on 15 LPM (liters per minute) via NRB (non rebreather) due to decreased SPO2 (pulse oximeter oxygen saturation). Pt's RA SPO2 was noted to be 89% with 2LPM (liters per minute). Pt SPO2 increased to 90-92% with 15 LPM of O2 (oxygen) via NRB. 20 g (gauge) IV established in L (left) hand with no complications. Approx. (approximately) 200 ml (milliliter) of NS (normal saline) infused during care. Pt. transported to ER (emergency room ) and monitored en route with no acute changes. Pt continues to remain unresponsive during transport. Pt care and paperwork transferred to RN (Registered Nurse) without incident." Emergency department chart for arrival date 8/25/2012 07:21 (7:21 a.m.) and visit date 8/25/12 07:25 (7:25 a.m.) is a 9 page document. On page 2 under triage documents, "Patient has purulent drainage coming out around catheter tubing with urine draining around catheter. Very foul smelling with copious amounts of purulent drainage. Scant amount of urine in catheter, large urine draining around the catheter." "Patient comes to ED unresponsive and hypoxic. Per Bell report, patient was found by day shift unresponsive." On page 3 under nursing assessment documents under [MEDICAL CONDITION], "Has localized abnormality on [MEDICAL CONDITION] auscultation. Has diminished breath sounds over the posterior left upper lunch fields. Has diminished breath sounds over the left lower lung fields. Good air exchange heard in the posterior right upper lung fields. Good air exchange heard in the right lower lung fields." Under cardiac documents, "[MEDICAL CONDITION]. Normal S1S2 heart sounds. The right and left radial pulse is easily palpable with good quality. Blood pressure is normal. There is right and left lower extremity [MEDICAL CONDITION] noted." On page 4 under nursing continuation notes at 0800 (8:00 a.m.) documents, "Called Sunrise Care Center. Spoke with RN-GG (RN-GG is a LPN/Licensed Practical Nurse). Per RN-GG, "I don't know the patient. This was my first day with this resident. I know that during last night the patient was unresponsive to staff." I asked to speak to their supervisor. I spoke with RN-U. Per RN-U patient had clear urine output yesterday into his Foley bag. Per RN-U patient was also alert and oriented X 4 yesterday." On page 5 under progress notes documents, "Pt. (patient) unresponsive, septic, ? urosepsis vs pneumonia. Pt with Pox 92, audible rales, pus coming from penis....Abt's (antibiotics), cultures ordered. Pt is a DNR (do not resituate), Pt. with wbc (white blood cell) ct. (count) 30,000, left shift. [MEDICATION NAME], and Vanco given for possible NH (nursing home) acquired pneumonia and urosepsis. Pt's BP (blood pressure) stable. He remains unresponsive... Foley was removed here as there was no urine in the bag, pus covered external genitalia. CT abdomen ordered to see if there is abscess in pelvis from improper Foley placement....Pt's sister who is his healthcare POA (power of attorney) contacted and says he would not want anything done Pt has wanted to die for a long time. He has MS ([MEDICAL CONDITION]) and can't do anything but lay in bed. She wants him made care and comfort, no ICU bed, no antibiotics...Daughter here at bedside. She is comfortable with hospice care, no further antibiotics, treatment." On page 6 documents primary [DIAGNOSES REDACTED]." On page 9 under disposition documents, "Condition at disposition - critical." According to www.livestrong.com "Urosepsis is a bacterial infection of the blood that arises as a complication of an untreated urinary tract infection. Bacteria from the bladder can travel up into a patient's kidneys where it can enter the bloodstream, causing urosepsis--also known [MEDICAL CONDITION]. Patients who develop urosepsis can experience symptoms such as body temperature changes, skin rash, chills, confusion, or dizziness. Complications of urosepsis are life-threatening and require immediate medical attention." Evening shift 8/24/12 On 9/7/12 at 2:29 p.m., Surveyor # interviewed CNA-DD who worked the evening shift on 8/24/12. Surveyor # asked CNA-DD if Resident #1 was on her assignment. CNA-DD informed Surveyor # that Resident #1 was one of her Residents that evening. Surveyor # asked CNA-DD to explain what she did for Resident #1. CNA-DD informed Surveyor # that when she came in Resident #1 was sitting in his chair like usual but he was not joking like he usually did. CNA-DD stated that she checked him before dinner. CNA-DD stated that Resident #1 refused to eat and that she told him him she would hold his plate but he said no. CNA-DD then asked Resident #1 if he wanted to lay down. Resident #1 said yes and she told him after dinner she would lay him down. Surveyor # asked if she noticed urine in the Foley bag. CNA-DD informed Surveyor # that the bag wasn't full and it was beer colored. CNA-DD informed Surveyor # that she could tell that something was wrong with him. CNA-DD informed Surveyor # that she came back after dinner and another CNA assisted her with laying him down. CNA-DD stated that Resident #1 still wasn't himself and that he was quiet which was very unusual for him. CNA-DD stated that she told Resident #1 that she would be back to clean him up. CNA-DD stated that she came back 15 to 20 minutes later and that another CNA, CNA-EE had done his cares. Surveyor # asked CNA-DD if she said anything to the nurse about Resident #1. CNA-DD informed Surveyor # that she told LPN-FF that Resident #1 was refusing to eat, that he didn't look like his usual self, he wasn't talking, and wanted to go to bed. Surveyor # asked CNA-DD if she emptied Resident #1's Foley bag. CNA-DD replied "no" and explained that there was probably less than 100 cc of urine in the bag. Surveyor # asked after CNA-EE did cares for Resident #1 did she do any cares for Resident #1. CNA-DD informed Surveyor # that she didn't go into Resident #1's room after CNA-EE did the cares and that she was supposed to do last rounds. CNA-DD explained that she usually checks on Resident #1 but that night she was busy and didn't. Surveyor # asked CNA-DD if LPN-FF asked her about the amount of urine in Resident #1's Foley bag. CNA-DD informed Surveyor # that she told LPN-FF she didn't have anything and that CNA-EE did Resident #1's cares so he may have something. On 9/7/12 at 6:23 a.m., Surveyor # interviewed CNA (Certified Nursing Assistant)-EE, who worked the evening shift on 8/24/12. Surveyor # asked CNA-EE if he had any contact with Resident #1 on the evening of 8/24/12. CNA-EE explained to Surveyor # that he was not assigned to Resident #1 but another CNA asked if he would help with transferring Resident #1 as he was a 2 person transfer. CNA-EE explained that he had another Resident on the toilet so he would help after he was finished. CNA-EE stated that when he was done with his Resident he went to Resident #1's room to help with the transfer but Resident #1 was already in bed. CNA-EE informed Surveyor # that Resident #1 wanted to sleep and hadn't eaten any supper that evening so he removed his gown, washed him up, and put on a clean brief. Surveyor # asked what time this was. CNA-EE informed Surveyor # that he didn't know the exact time but thought it was around 6:30 p.m. to 6:45 p.m. Surveyor # asked if CNA-EE noted any discharge around Resident #1 penis. CNA-EE informed Surveyor # that he didn't notice anything. Surveyor # asked if he noted the urine in the Foley bag or if he emptied the Foley bag. CNA-EE informed Surveyor # that he was not assigned to Resident #1 and that CNA-DD had Resident #1 that evening. CNA-EE informed Surveyor # that CNA-DD would have emptied the Foley bag. Surveyor # asked CNA-EE if Resident #1 usually refused to eat dinner. CNA-EE informed Surveyor # that sometimes if Resident #1 didn't like what was being served he wouldn't want to eat but if they spoke to him then he would eat. CNA-EE informed Surveyor # that on that evening (8/24/12) Resident #1 [MEDICATION NAME] refused to eat. Surveyor # asked after CNA-EE completed cares around 6:30 p.m. to 6:45 p.m. did he have any other contact with Resident #1. CNA-EE informed Surveyor # that did not have any further contact with Resident #1. On 9/11/12 at 3:53 p.m., Surveyor # interviewed LPN-FF, who worked the evening of 8/24/12. Surveyor # asked LPN-FF if she had any contact with Resident #1 on the evening of 8/24/12. LPN-FF informed Surveyor # that she gave Resident #1 his medication but he didn't tell her he wasn't feeling well. LPN-FF stated that maybe Resident #1 wasn't feeling good and just didn't tell her. Surveyor # asked if the CNA's reported to her the amount of urine in the Foley bag. LPN-FF stated "I want to say yes, but not sure" and then explained that she can't go back that far. LPN-FF informed Surveyor # that the staff throw stuff at her when they are going out the door or sometimes they write the information on a piece of paper for her. LPN-FF informed Surveyor # that she thought the output for Resident #1 may have been 100 cc. Surveyor # asked if the output was only 100 cc did you do anything. LPN-FF informed Surveyor # that she didn't remember. Surveyor asked LPN-FF if she reported anything to the night shift about Resident #1. LPN-FF replied "no" and explained that Resident #1 was not on the board. Surveyor # asked LPN-FF if anyone reported to her that Resident #1 wasn't himself and that he didn't look good. LPN-FF replied "no." On 9/6/12 at 5:20 p.m., Surveyor # interviewed RN (Registered Nurse)-II, who was the evening supervisor on 8/24/12, to inquire if she was contacted regarding Resident #1 on 8/24/12. RN-II informed Surveyor # that she did not recall being called for Resident #1. On 9/7/12 at 8:10 a.m., Surveyor # reviewed the Resident I/O (intake/output) by day shift for Resident #1. Surveyor # noted from 8/12/12 to 8/23/12 the dinner intake % (percent) is documented as "100"% each day. On 8/24/12 "0"% is documented, which is the evening prior to discharge. On 9/7/12 at approximately 11:15 a.m., Surveyor # reviewed Resident #1's output that was documented on the Meals and Fluids detailed entry report. Surveyor # noted the urine output (in cc's/cubic centimeters) on 8/24/12 for day shift is documented as "700." There is no characteristic of the urine documented. The urine output for the evening shift on 8/24/12 is not documented nor is there any documentation for the night shift on 8/24/12 into 8/25/12. Night shift 8/24 - 8/25/12 On 9/7/12 at 6:35 a.m., Surveyor # interviewed CNA-AA, who worked the night shift on 8/24/12 into 8/25/12. Surveyor # asked CNA-AA if she was assigned to Resident #1 on the night shift prior to Resident #1 being transferred to the hospital. CNA-AA informed Surveyor # that she was assigned to Resident #1. Surveyor # asked CNA-AA if she could explain to Surveyor # what she did for Resident #1. CNA-AA informed Surveyor # that Resident #1 was usually awake when she came in but that night she assumed he was sleeping because he was snoring loud. Surveyor # asked if snoring was usual for Resident #1. CNA-AA replied no. CNA-AA informed Surveyor # that at the beginning of the shift she fixed his head on the pillow and there was no response. CNA-AA reported she said Resident #1's name but there was no response. Surveyor # asked if that was usual for Resident #1 not to respond. CNA-AA replied that it was unusual for him not saying anything. CNA-AA informed Surveyor # that Resident #1 would usually joke with staff. CNA-AA informed Surveyor # that she told RN (Registered Nurse)-J, who was the supervisor, that Resident #1 didn't seem himself, he's out of it, and he's snoring. CNA-AA informed Surveyor # that RN-J told her that Resident #1 has MS ([MEDICAL CONDITION]), was probably outside during the day, and is tired. CNA-AA informed that she went back into Resident #1's room and Resident #1's roommate told her that Resident #1 hadn't eaten or drank anything and that he had been in bed. CNA-AA informed Surveyor # that she went back to RN-J and told her what the roommate told her. CNA-AA informed Surveyor # that RN-J told her that Resident #1's roommate didn't know what he was talking about. Surveyor # asked CNA-AA if she spoke to any other nurse about Resident #1. CNA-AA replied that she told the floor nurse LPN (Licensed Practical Nurse)-CC that Resident #1 didn't seem right. Surveyor # asked if LPN-CC went in Resident #1's room. CNA-AA informed Surveyor # that she didn't know because LPN-CC was dealing with another Resident. CNA-AA informed Surveyor # that " if you say something and nobody gets alarmed what should I do." CNA-AA informed Surveyor # that she kept on "peeking in" on Resident #1. Surveyor # asked CNA-AA what cares she did for Resident #1 during the night. CNA-AA informed Surveyor # that she repositioned Resident #1 every two hours and at the beginning of the shift he (Resident #1) was able to hold onto the bar but later in the shift he wasn't able to. Surveyor # asked if she did any other cares for Resident #1. CNA-AA replied that he had a Foley and "to be honest checked and turned him." Surveyor # asked CNA-AA if she removed Resident #1's brief. CNA-AA replied, "no I didn't" and explained that she received a written warning. CNA-AA explained to Surveyor # she didn't check Resident #1's incontinence product because he had a Foley catheter and she would be able to smell if he had a bowel movement. Surveyor # asked if CNA-AA looked at the Foley bag and if she could remember what the urine looked like. CNA-AA informed Surveyor # that Resident #1's urine had been thick & smelly, mucus like and had been like that for awhile. Surveyor # asked CNA-AA if she documents a Resident's urine CNA-AA informed Surveyor # that they aren't allowed to chart anymore and that the nurse enters the intake and output. Surveyor # asked about Resident #1's output. CNA-AA informed Surveyor # that there was about 25 cc's. CNA-AA informed Surveyor # that around 6:00 a.m. or 6:15 a.m. she was doing rounds with the day CNA and told the day CNA that Resident #1 didn't look right so she did not get him dressed. CNA-AA indicated that she went in to Resident #1's room with the day shift CNA and then she went out to get the nurse and that's when they got the ball rolling. On 9/11/12 at 8:26 p.m., Surveyor # interviewed CNA-BB, who worked on the night shift, via the telephone. Surveyor # asked CNA-BB if he had any contact with Resident #1 on the night of 8/24/12 into 8/25/12. CNA-BB informed Surveyor # that he was not assigned to Resident #1 and no one asked for his assistance that night. Surveyor # asked CNA-BB if he heard CNA-AA tell the nurse anything about Resident #1. CNA-BB informed Surveyor # that he heard CNA-AA say at the nurses station between 2:00 a.m. & 3:00 a.m. that Resident #1 didn't look right, something was not right and that LPN-CC was at the nurses station. CNA-BB informed Surveyor # that he didn't know if CNA-AA got a response from LPN-CC. CNA-BB informed Surveyor # 3 that CNA-AA wasn't saying it to him because we aren't in charge. CNA-BB also stated that CNA-AA told him that she had told RN-J about Resident #1 but he did not hear that conversation. On 9/11/12 at 7:10 a.m., Surveyor # interviewed LPN-CC, who worked the night shift on 8/24/12 into 8/25/12. Surveyor # asked on the treatment records what does catheter care mean. LPN-CC informed Surveyor # that catheter care is delegated to the CNA's and that the CNA's do the catheter care. Surveyor # asked if LPN-CC was in Resident #1's room. LPN-CC explained that she does rounds to make sure the Residents are in their bed and that they are breathing. LPN-CC informed Surveyor # that Resident #1 appeared to be sleeping. Surveyor # asked if the evening shift reported anything to her about Resident #1. LPN-CC replied that she did not get a report from the 2nd shift nurse, CNA, supervisor or the night supervisor about Resident #1. LPN-CC indicated if there were any concerns they should have been brought up at report and should have been on the board. Surveyor # asked LPN-CC if any CNA's came and told her that Resident #1 didn't look himself and that he didn't look good. LPN-CC replied, "absolutely not." LPN-CC informed Surveyor # that the first time she heard about any problem with Resident #1 was when she overhead CNA-AA telling LPN-GG that something wasn't right with Resident #1. LPN-CC informed Surveyor # if there is a change in condition that needs to be addressed right away. Surveyor # asked LPN-CC if CNA-AA told her that Resident #1 didn't seem right. LPN-CC informed Surveyor # that she doesn't know who CNA-AA did or did not tell but she knows it wasn't her. LPN-CC informed Surveyor # that she does intake & output and that the CNA's give her the information LPN-CC informed Surveyor # that she would only check if the output is less than a certain amount or if the CNA's tell her there is something abnormal with the urine. Surveyor # asked what would be considered less than a certain amount. LPN-CC replied that she wasn't sure that everyone has a different fluid intake but would be concerned if there was a couple hundred or no urine output. Surveyor # asked LPN-CC if she checked Resident #1's Foley bag that night. LPN-CC replied no that she didn't have any reason to. LPN-CC indicated that the task that she is required to do is to make sure Resident is in the room, alive, & breathing. LPN-CC informed Surveyor # that she is the only nurse on the first floor and sometimes she doesn't get to take a break. On 9/7/12 at approximately 11:15 a.m., Surveyor # reviewed Resident #1's output that was documented on the Meals and Fluids detailed entry report. Surveyor # noted there was no documentation for the night shift on 8/24/12 into 8/25/12. Surveyor # noted that on 8/25/12, the evening shift documents a urine output of 250 cc for Resident #1 when in actuality Resident #1 was in the hospital during this time. On 9/12/12 at 9:19 a.m., Surveyor # interviewed RN-J, who was the night supervisor on 8/24/12 into 8/25/12. Surveyor # asked RN-J how often she supervises. RN-J explained to Surveyor # she is responsible for education and training at the Facility but they work a four week rotation. RN-J indicated that if an RN calls in and they are on call then they have to come into the Facility to Supervise. Surveyor # asked RN-J if anyone reported anything to her about Resident #1. RN-J replied "no." Surveyor # asked RN-J if she went into Resident #1's room at all during the night. RN-J replied no and then explained at midnight she has to go in every room to check to see if a Resident is in their bed for the census. On 9/13/12 at 7:50 a.m., Surveyor # met with the Administrator and Director of Nursing. The Administrator informed Surveyor # that after the Hospital had contacted them regarding Resident #1 being doubled briefed they spoke to the CNA's but they are said they didn't do it. The Facility had self reported this allegation about Resident #1 being double briefed to the State Agency. Surveyor # spoke with the Administrator and Director of Nursing about the lack of documentation in the record and during interviews with the CNA's they reported to the nurses that Resident #1 was not himself, didn't eat dinner, and he wasn't himself. The Director of Nursing informed Surveyor # that the CNA's could have filled out a Stop Watch Tool. On this tool the CNA's could have circled the change or changes a Resident has and then this form is given to the nurse with a carbon copy going to the Director of Nurses. Surveyor # asked if staff filled out this tool. The Director of Nursing informed Surveyor # that staff did not. The Director of Nursing informed Surveyor # that when staff was sending Resident #1 out to the hospital they obtained his vital signs but they didn't do a thorough assessment. The failure of nursing staff to monitor and assess Resident #1 throughout the evening of 8/24/12 and the night of 8/25/12 resulted in Resident #1 being hospitalized for [REDACTED]. EXAMPLE 2 Surveyor # reviewed Resident #19's closed medical record from 9/6/12-9/19/12. Resident #19 was discharged from the facility a few hours prior to surveyors entering the building on 9/6/12. Resident #19's medical record indicated Resident #19 was admitted on [DATE] following heart surgery ([MEDICAL CONDITION] revascularization X5-coronary artery bypass graft (CABG) surgery). Resident #19 also had suffered a stroke after surgery, which left her unresponsive. The hospital discharge summary dated 8/27/12 notes upon physical exam, neurologic response- minimal spontaneous movements and to painful stimuli; T (temperature) 96, BP (blood pressure) 98/43, pulse 74, respiratory rate 21, and pulse oximetry (POx) 100% on room air. BUN (lab test blood urea nitrogen) was 34. Resident #19's medical [DIAGNOSES REDACTED]. Resident #19 was admitted with a Stage III pressure ulcer on her sacrum, measuring 5.0 cm. (centimeters) x 2.7 cm. with no depth, per the Admission Skin grid dated 8/27/12. Resident #19 also had a [DEVICE] and urinary catheter on admission. Resident #19 receives Glucerna at 70 ccs/ hour. The Nursing Comprehensive Admission Data Collection and Assessment completed on 8/27/12 for Resident #19 indicates: T97.5, BP168/88, R20, P 85; level of consciousness- comatose, pupils not responsive; neck veins not distended; has suprapubic catheter; IV's (intravenous)-PICC (peripheral inserted central catheter) left arm. The first documentation of a fever is on 8/30/12, documented at 3:30 a.m. that Resident #19 had a T of 100.2, Tylenol given, at 12:30 a.m. for elevated temperature. Rechecked temperature at 1:00 a.m., temperature was 98.9...eyes open with verbal stimuli... Nurses Notes continue: 8/30/12 11:00 p.m. T99.1 earlier, prn Tylenol given, recheck T was 97.3, BP 102/73. Resident opens eyes at times...Foley catheter patent draining yellow urine, output 1250 ccs. 8/31/12 2:00 a.m. T97.4 P88 R20 BP120/64. BS (blood sugar) at 12:30 a.m. was 361, given ordered regular insulin. Call placed to MD, no return call. Call placed at 1:30 a.m. to MD, awaiting call back, no signs of hypo/[MEDICAL CONDITION]." 8/31/12 1:25 p.m. Resident in bed unable to respond per norm...Foley catheter patent with cloudy color urine. Respirations 18, no SOB noted. Bilateral lungs diminished slight congestion no cough. Increased mucus secretions from mouth cleared with toothette. T98.6 BP 110/60 P78... 8/31/12 2:00 p.m. Resident has been running a temp at 103.2 Prn Tylenol given, T99.4. Call made to MD, new order for STAT CXR (chest xray). CXR done. UA (urinalysis) obtained. CBC and CMP (blood work) to be done by lab. P104 BP 105/65 R24. Foley catheter changed. Foley catheter patent and draining clear yellow urine. 8/31/12 10:45 p.m. MD updated on increased WBC's (white blood cells). Orders obtained 1.) Obtained to repeat CBC in a.m.; 2.) blood cultures x 2, STAT -1 from PICC & 1 stick. 3.) Culture tip of PICC 4.) D/c PICC. 9/1/12 4:15 a.m. T100.8 P92 R22 BP 90/54, Tylenol given for elevated temp

Based upon observation, interview and record review, the facility did not ensure that 4 (Resident's #6, #10, #3, and #7) of 6 Residents reviewed who are at risk for the development of a pressure received the appropriate care and treatment by the facility to prevent the development of pressure ulcers. ~ Resident #6 developed an avoidable Stage 3 pressure ulcer after Resident #6 was admitted to the facility on [DATE] with documented discoloration under the left ankle brace that Resident #6 wears. Resident #6 was assessed to be at risk for the development of pressure ulcers. Following admission, the facility did not establish measures to ensure that the skin under Resident #6's left ankle brace was observed consistently by nursing staff. On 7/31/12, staff noted on Resident #6's bath sheet that there was an area on Resident #6's left ankle. There is no indication that this was assessed or followed up on by nursing staff. On 8/4/12, a facility incident report indicates that Resident #6 has a Stage 2 pressure ulcer on the left ankle under his brace. On 8/14/12, Resident #6's ankle wound is described to be yellow in color with minimal yellow drainage indications of a Stage 3 pressure ulcer however; this wound is continuously staged as a Stage 2 pressure ulcer despite presence of slough (reflective of a stage 3 pressure ulcer). On 9/18/12, Resident #6 received an incorrect treatment to his pressure ulcer. ~ Resident #10 has been identified as being at risk for pressure ulcers and was observed on a specialty mattress that was not set at the proper setting. ~ Resident #3 was observed to not receive the correct treatment to an existing wound and was not positioned in bed with his heel floating. ~ Resident#7 was observed in bed to not have his heels floated and without out pressure reduction boots on. Findings Include: 1. Resident #6's medical record was reviewed by Surveyor # on 9/17/12-9/19/12. Resident #6 is a [AGE] year old individual who was admitted to the facility on [DATE] for rehabilitation and strengthening. Resident #6's [DIAGNOSES REDACTED]. Resident #6 wears a left knee brace, left hand splint and left ankle splint. Resident #6's Admission Skin assessment dated [DATE] indicates Resident #6 has small reddened spots on his upper chest, a bruise on his right upper/inner arm and right lower/inner arm, a [MEDICATION NAME] pump on his right waist area, a bruise on his left wrist, a bruise of his left upper back arm, a reddened area on his coccyx and an area of discoloration on his left outer ankle. Braden assessments completed on 7/12/12, 7/19/12, 7/26/12, 8/2/12, 8/16/12, 8/23/12 and 8/30/12 score Resident #6 as a total risk value of an 18 indicating minimal risk. Resident #6's admission Minimum Data Set ((MDS) dated [DATE] indicates Resident #6 has no pressure ulcers and that there are skin tears present. Identified treatments on the MDS include pressure reducing device for chair, pressure reducing device for bed, turning/repositioning program, nutrition or hydration intervention to manage skin problems, application of nonsurgical dressings, and application of ointments/medications. The Care Assessment Area (CAA) indicates that the resident is at risk for breakdown related to being bed/chair bound, incontinent of bladder and bowel, inability to reposition self, Braden risk of 18 and physical decline. Resident has skin assessments done twice weekly on shower days by nursing along with daily cares by CNAs (certified nursing assistants). Any skin changes are reported to nursing. Resident currently has a skin tear to his right hand and laceration on left head (s/p (status [REDACTED]. Treatments are done as ordered by MD and sites are monitored for healing or s/s (signs/symptoms) of infection. Res. (Resident) also has scattered bruises from fall. Resident attends therapy for gait, strengthening, mobility, dysphagia, and ADLs (activities of daily living). Splint is worn on left lower extremity and skin underneath is monitored for changes. Will proceed to care plan. Resident #6's care plan titled Skin Integrity Assessment: Prevention and Treatment Plan of Care dated 7/12/2012 with a due date of 10/12 indicates a Braden Risk assessment score of at risk (15-18) checked is frequent turning, maximal remobilization, protect heels, manage moisture, nutrition, friction and shear and pressure reduction support surface if bed or chair bound. At risk related to: [MEDICAL CONDITION] disease, bowel incontinence, bladder incontinence, skin: healthy skin: clean well hydrated, normal colored skin, warm. Areas of impairment: redness buttocks/coccyx, bruises, scattered purpura neck, laceration left head 7/17/12, ST (skin tear) right hand 7/17/12. Braces: LLE (left lower extremity) when up, splints: left hand on 23 hours per day, wash hand and splint daily 7/26/12. Goals include: will remain free of open areas, will be cooperative with position changes, will verbalize understanding re: refusal of care outcome, will demonstrate healing without s/s of infection, will be free of pain. Interventions include: complete Braden upon admission and weekly times 4 wks, quarterly, and with change of condition, use commercial moisture barrier, use absorbent pads or diapers that wick & hold moisture, address cause if possible, see nutritional risk plan of care, monitor weight, monitor meal intake, obtain dietary consult, use lift sheet to move resident, protect elbows and heels if being exposed to friction, maintain good hydration, avoid dry skin. Bathe with mild soap, rinse & dry thoroughly, moisturize skin with lotion ...especially over bony prominences, keep skin clean, dry, and free of body wastes, perspiration and wound drainage, inspect the skin for s/s of breakdown, encourage ambulation and mobility as tolerated, implement an individual turning schedule as applicable "yellow dot," position body with pillows and or other support device, avoid positioning on trochanter, keep linen dry & wrinkle free, pressure reduction or pressure relief support surface, involve therapy where indicated, See ADL/mobility plan of care, see appropriate mood and behavior symptom plan of care, see plan of care pain management. Monitor wound weekly and PRN (as needed), see skin grid, and provide treatment per physician order [REDACTED]. Surveyor # noted upon review of Resident #6's care plans that the plans of care do not contain specific instructions for nursing staff to observe the skin under Resident #6's lower left extremity (LLE) ankle brace. The Certified Nursing Assistant (CNA) care plan updated on 9/17/12 indicates that Resident #6 gets a shower two times per week, that Resident #6's heels are to be floated. He is on the "yellow dot" program, splint LLE when up, knee brace off Q (every) HS (night time). Resident to wear left hand splint 23 hours per day. Hand splint only. Check skin integrity of hand for splint tolerance daily. Wash hand and splint daily. Surveyor # noted that there are no specific directions regarding monitoring Resident #6's skin integrity under his left ankle brace included on this care plan. Review of Resident #6's Treatment Administration Records (TARS) for July 2012 include notation for nurses to do Tuesday and Thursday pm bath body check starting 7/17/12, Braden skin assessment x 4 weeks, barrier cream to buttocks BID (two times a day) and PRN, FYI/yellow dot, nurse to remove left knee brace QHS (every night), left hand splint on 23 hours per day remove at HS wash hand and splint and check skin. Surveyor # noted that there are no specific directions on Resident #6's TAR regarding skin inspection under Resident #6's left ankle brace. A physician visit note dated 8/2/12 indicates that Resident #2 has +(plus) 2 ankle [MEDICAL CONDITION] on the left side (immobile). Review of Resident #6's nurses notes indicate: 8/3/12 NOC (night shift) ....Brace to ankle off for a couple of days per daughter when back from MD appointment. Slept well. 8/3/12 9:00am: Spoke with res. and wife re: MD suggestion to leave ankle brace off. Wife reports was r/t (related to) dry skin under brace and MD suggested to "leave off for a day and put lotion on." Brace to be on today ...Surveyor # noted that with both nurse's notes entries that there is no indication that a nurse assessed Resident #6's ankle or that revisions were initiated to Resident #6's plan of care. Review of a facility Resident Incident report dated 8/4/12 at 11:32 am indicates, "Pt (patient) c/o (complaint of) discomfort to ankle. Skin integrity checked under LLE brace and a stage 2 o/a (open area) to left lateral malleolus. Resident #6 identified that there is pain and that it hurts a little bit. Is there a known or suspected injury? Yes. Type of injury: Ulcer-pressure. Size of injury in centimeters: 1. Description of the injury: O/A lateral malleolus. Does the injury require medical attention? Yes. Describe: treatment applied. Environmental circumstances indicate that equipment factors were present. Immediate nursing actions include: documentation - 72 hour follow up, dressing. Solosite f/b (followed by) allevyn, nurse to check skin integrity under brace q (each) shift. Interview summaries indicate: Resident c/o pain to left ankle. Nurse checked skin integrity and found a stage 2 o/a caused by brace rubbing against skin. Summary of correction action taken: Tx (treatment) orders in place, brace not to be worn until area is healed. Skin check q shift. On 9/17/12, Surveyor # reviewed the bath sheets for Resident #6 and noted that the bath sheet dated 7/31/12 indicates an area was noted on Resident #6's left ankle. Surveyor # noted upon reviewing bath sheet that the sheet was signed by both a CNA and a nurse however; there is no description or documentation in Resident #6's medical record as what this area was on 7/31/12 or if there communication with Resident #6's physician regarding this area. Review of Resident #6's wound sheets indicate: 8/5/12: Wound not present on admission. Left Lateral ankle/ Stage 2, 1cm (centimeter) x (by) 1.2 cm x < (less than) 0.1 depth. No drainage, pink color, no tunneling, Physician notified. 8/14/12: Stage 2, .6cm X .6cm x 0.2. Yellow drainage, yellow color, no odor, no tunneling. Area noted yellow in color with minimal yellow drainage. Peri skin remains intact. MD updated tx (treatment) changed to Santyl BID (two times daily). 8/21/12: Stage 2, .8cm x .6 cm x <0.1cm. Yellow drainage, yellow color, no tunneling. Center of wound approximately 40% yellow slough surrounding wound base, pink/moist. Scant yellow drainage noted to old dressing. Surrounding skin c-d-I (clean, dry, intact) no s/s (signs/symptoms) of infection. Denies pain. 8/28/12: Stage 2, 1.1cm x 0.5cm x <0.1cm. Yellow drainage, yellow color, no odor, no tunneling. Wound bed pale white/pink in color with noted slough. Scant yellow drainage noted to old dressing. Surrounding skin moist. Skin prep wound edges added to treatment. 9/4/12: Stage 2, 0.4cm x 0.3cm x <0.1 cm. No drainage, yellow/pink color - odor and tunneling are blank on the form. Area remains c-d (clean-dry) minimal yellow slough noted to center of wound remaining area pink granulation (10-90%). 9/13/12: Stage 2, .3cm x .3cm x <0.1cm. No drainage, yellow/pink color, no odor, no tunneling. Area with 10% yellow/90% pink, wound bed moist. Surrounding skin c-d-i. No s/s infection noted. Surveyor # noted that the facility skin sheets define Stage 2 as: partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Stage 3 is defines as: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. On 9/18/12 at approximately 9:15 am, Surveyor # interviewed physical therapist (PT)-HH regarding Resident #6's ankle brace and wound. PT-HH indicated that the therapy department does not typically apply braces or check under the braces unless the resident comes to therapy without the brace or the resident complains about pain to the area under a brace. PT-HH indicated that she was not aware of Resident #6's wound until after the wound was present. On 9/18/12 at approximately 9:45 am, Surveyor # interviewed Resident #6 and Family Member (FM)-W regarding the pressure ulcer that Resident #6 developed while residing at the facility. Resident #6 and FM-W indicated to Surveyor # that Resident #6 always wears an ankle brace but that Resident #6 takes it off at night. Surveyor # asked if they knew how Resident #6 developed the wound on his ankle. FM-W indicated and Resident #6 confirmed that after Resident #6 was admitted to the facility (FM-W did not recall specific date) Resident #6 slept all night, for two nights with his ankle brace on. FM-W indicated she became aware this had happened and she spoke to Resident #6 to make sure Resident #6 tells staff to take the ankle brace off at bedtime. FM-W stated, "but of course, it was already too late, the damage had been done." On 9-18-12 at 9:50 AM, Surveyor # observed RN- D, change the dressing to Resident #6's left outer ankle: Resident #6 was observed seated in his wheelchair during the procedure. RN-D was observed to remove the soiled dressing from the resident's ankle with gloved hands. RN-D was then observed to place Santyl ointment on a 2 X 2 piece of gauze; RN-D then placed the gauze on the pressure ulcer on the resident's ankle. RN-D then taped the dressing in place. Surveyor # observed the wound to be yellow in color with an extended red peri-wound area. On 9/18/12 at approximately 10:50 am, Surveyors # and Surveyor # interviewed the facility wound care nurse/nurse manager (NM)-C regarding Resident #6's wound and treatment. Surveyor # asked NM-C to explain how Resident #6 developed an avoidable pressure ulcer on his ankle. NM-C indicated she thought the wound was unavoidable because it was caused by Resident #6's brace. Surveyor # asked NM-C if there were care plans in place to ensure that the skin under Resident #6's ankle brace were consistently looked at in order to monitor for any skin issues. NM-C stated staff should have looked at it. Surveyor # asked NM-C about the allegation that Resident #6 was put to bed on multiple nights without staff removing his ankle brace. NM-C reported she was made aware of this allegation by Resident #6 and FM-W. Surveyor # asked NM-C if this allegation had been looked into. NM-C indicated she did not look into it as she "went into fix mode." Surveyor # asked NM-C if she was aware that Resident #6's physician documented in a visit note that Resident #6 was experiencing + (plus) 2 [MEDICAL CONDITION] on his left ankle. NM-C reviewed the nurses' notes and physician orders [REDACTED]. Surveyor # asked NM-C about the facility bath sheets regarding how they are used and if she was aware of any area on the ankle prior to 8/5/12. NM-C indicated that CNA staff and a nurse are supposed to review a resident's skin on bath day. Surveyor # asked NM-C if she had seen the bath sheet for Resident #6 dated 7/31/12 indicating an area of concern on Resident #6's ankle. NM-C indicated she had not seen the form. Surveyor # pointed out that bath sheets for Resident #6 after 7/31/12 do not identify an area of concern on Resident #6's ankle. NM-C indicated that the forms should only identify a new area of concern and should not carry over old areas. Surveyor # noted that the form states, "All abnormalities must be carried over week to week until resolved." Surveyor # asked NM-C to explain the staging of Resident #6's ankle wound as a stage 2 wound despite documented presence of slough. NM-C indicated that there was slough but that it wasn't thick so she staged the wound as a stage 2. Surveyor # asked NM-C if the facility had developed any care plans to reduce the pressure on Resident #6's ankle. NM-C reported that Resident #6 needs to wear his brace at all times except when in bed even with the pressure ulcer on the ankle. Surveyor # asked RN-C about the current treatment to the pressure ulcer. RN-C indicated the area should be washed with normal saline followed by Santyl ointment. Surveyor # then described the above observation that was conducted without the normal saline wash. Surveyor # asked NM-C given the concerns identified regarding staging, treatment and preventable care planning if she could see that this appears to be an avoidable pressure ulcer. NM-C indicated that she could see where the question was coming from. Upon reviewing Resident #6's clinical record, an order dated 8/20/12 directs the nursing staff to apply "skin prep" to the peri wound (the area surrounding the area of skin breakdown); during the above observation, RN-D also did not apply "skin prep" to the peri wound, during the treatment. On 9/18/12 at approximately 3:00pm, Surveyor # shared concerns regarding Resident #6's avoidable pressure ulcer with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. DON-B indicated she reviewed NM-C's documentation regarding Resident #6's wounds and she told NM-C that with the presence of slough Resident #6's wounds would be a stage 3 not a stage 2 pressure ulcer. On 9/19/12, DON-B provided Surveyor # with a nurse's note written on 9/18/12 at 11:00 am. The note indicates: L (left) ankle OA (open area) observed by writer this am - wound bed noted yellow - able to cleanse with ns (normal saline) to observe pale pink wound bed. Peri wound pink in color - measures 0.4 x 0.3 x with <0.1 cm depth. MD called - updated on wound nor'd (new order) to changed treatment: nsw (normal saline wash) f/b (followed by) Santyl to wound bed cover with [MEDICATION NAME] to protect from pressure r/t (related to) brace. Change q (ever) am and PRN (as needed) for soilage. Wife and resident updated with changes. On 9/19/12 at approximately 11:30 am, Surveyor # spoke to DON-B regarding the written note from 9/18/12. DON-B stated she again spoke to NM-C about the documentation of Resident #6's wound. DON-B indicated she told NM-C that her notes needed to be more descriptive and needed to include the stage of the wound. Surveyor # noted that the measurement also does not appear to include a measurement of the peri wound area that is receiving a treatment. Following exit from the facility, no additional information was submitted to review regarding Resident #6's avoidable stage 3 pressure ulcer. 2. On 9/10/12 at 11:05 a.m., Surveyor # observed Resident #10 lying in bed. Resident #10 had a Airflo mattress running, which was set to '9' on the display panel On 9/10/12 at 1:20 p.m., Surveyor # observed Resident #10 in bed. Resident #10 had a Airflo mattress running, which was set to '9' on the display panel. Surveyor # was waiting to observe Resident #10's wound vac treatment for [REDACTED]. On 9/11/12 at 9:00 a.m., Surveyor # observed Resident #10 in bed. Resident #10 had a Airflo mattress running, which was set to '9' on the display panel. On 9/11/12 at 9:18 a.m., Surveyor # spoke with RN Manager-F (Registered Nurse). RN-F indicated that Resident #10's Airflo setting should be at a '3' and sometime with positioning they set it at '9.' RN-F indicated staff could have forgot to set it back to '3.' RN-F stated this number is calculated by Resident #10's weight and should be at a '3.' RN-F reported that this setting information is on the plan of care and on the display panel itself and would follow up. Resident #10 is a newer admission and did not show a decline in the pressure ulcer itself. On 9/13/12 at 3:15 p.m. at the facility exit meeting, Surveyor # shared Resident #10 mattress setting concerns. 3. Surveyor # reviewed Resident #3's medical record on 9/10/12 through 9/13/12. Resident #3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #3 receives his nutrition via the G (gastronomy)-tube, suprapubic catheter, is incontinent of bowel, and is dependent upon staff for all his ADL's (activities of daily living). Resident #3 developed an unavoidable Stage 4 pressure ulcer on his right ischium on 2/17/12 and unavoidable Stage 2 pressure ulcer on his right heel on 4/30/12. The skin integrity assessment prevention and treatment plan of care dated 6/18/2012 identifies Resident #3 as being high risk. Interventions include "use commercial moisture barrier" and "Position calves on pillows to elevate heels off of the bed." Handwritten next to this intervention is "float." The CNA (Certified Nursing Assistant) care plans updated 9/5/2012 for Resident #3 under skin includes, "Float heels at all times." On 9/6/12 at 10:17 a.m., Surveyor # observed Resident #3 in bed on his back. Resident #3 has a pillow under his calves but his heels are resting on the pillow and are not floating. On 9/6/12 at 11:03, Surveyor # observed CNA (Certified Nursing Assistant)-S provide morning cares for Resident #3. Resident #3 was observed in bed on his back. CNA-S washed her hands, placed gloves on and filled a wash basin. CNA-S washed Resident #3's face, removed the gown, and washed Resident #3's upper body. CNA-S placed Resident's #3 sweatshirt on, removed her gloves, changed water in the basin and washed her hands. CNA-S placed gloves on and removed the bedding from Resident #3. Surveyor # observed Resident #3's right heel with a dressing is resting on the pillow and the left heel is resting on the mattress. Resident #3's heels were not being floated. CNA-S washed around the suprapubic catheter, inner thighs, and frontal perineal area. CNA-S removed her gloves, washed her hands, and placed new gloves on. CNA-S positioned Resident #3 on his left side, wiped the bowel movement with the incontinence product and then washed Resident #3's buttocks and rectal area. Surveyor # observed there was a dressing on the right ischium and noted that Resident #3's coccyx was reddened/excoriated. Surveyor # asked CNA-S if this area is usually reddened/excoriated. CNA-S informed Surveyor # that it has improved. CNA-S removed her gloves, washed her hands, and placed new gloves on. CNA-S placed an incontinence product and pants on Resident #3 by positioning him from side to side. CNA-S placed a Hoyer sling under Resident #3, informed Resident #3 she needed to get the lift, and lowered the bed to the lowest position. CNA-S removed her gloves, washed her hands, and left Resident #3's room. CNA-S did not place any barrier cream on the reddened/excoriated area. On 9/6/12 at 11:27 a.m., Surveyor # asked CNA-S if they use barrier cream at the Facility. CNA-S replied, "yes." Surveyor # asked CNA-S if barrier cream is to be placed on Resident #3. CNA-S replied, "yes." On 9/6/12 at 11:46 a.m., Surveyor # asked CNA-S why she didn't apply any barrier cream on Resident #3 during morning cares. CNA-S informed Surveyor # that she didn't see any. On 9/7/12 at 9:13 a.m., Surveyor # observed CNA-S enter Resident #3's room with a Hoyer lift. CNA-S washed her hands, placed gloves on, removed the matt from the floor, and removed the bedding from Resident #3. Surveyor # observed that Resident #3's right heel was floating but his left heel was resting on the pillow and not floating. At 9:17 a.m., RN (Registered Nurse)-U entered Resident #3's room and assisted CNA-S with transferring Resident #3 onto the shower gurney. On 9/10/12 at 10:54 a.m., Surveyor # observed Resident #3 in bed on his back. Surveyor # observed that Resident #3's heels were resting on the mattress and were not being floated. On 9/11/12 at 8:37 a.m., Surveyor # observed Resident #3 in bed on his back. Surveyor # observed there was a pillow under Resident #3's calves. Resident #3's right heel was being floated but the left heel was resting on the pillow. On 9/11/12 at 9:38 a.m., Surveyor # observed Resident #3 continues to be in bed on his back. Surveyor # observed the right heel is floating but the left heel continues to be resting on the pillow. On 9/12/12 at 10:23 a.m., Surveyor # met with RN/Unit Manager-C and the Director of Nursing to discuss Resident #3's pressure ulcers. RN-/Unit Manager-C informed Surveyor # that Resident #3 had a number of admissions to the Facility so when he was admitted the last time, she put a number of preventative interventions in place which included an air mattress and applying barrier cream. Surveyor # informed RN/Unit Manager-C and the Director of Nursing of the observation during morning care of barrier cream not being applied. On 9/17/12 at 2:13 p.m., Surveyor # asked RN/Unit Manager-C when Resident #3 is in bed should his heels be floating. RN/Unit Manager-C replied, "yes." Surveyor # informed RN-C of Resident #3's heels not being floated. On 9/18/12 at 3:05 p.m., Surveyor # informed the Administrator and Director of Nursing of the above observations. 4. Resident #7 was admitted to the facility on [DATE] with an unstageable pressure ulcer to the left heel; the ulcer measured 6.0 X 6.3 cm and is unstageable due to necrotic (non-viable) tissue covering the wound bed. Resident #7 has a [DIAGNOSES REDACTED]. The 8-4-12 significant change of condition MDS (Minimum Data Set) assessment indicates the resident is cognitively intact, requires extensive assistance of one or two staff members for his bed mobility and transfer needs. The altered skin integrity plan of care dated 3-21-12 directs the nursing staff to "float" the resident's heels over a pillow, when Resident #7 is in bed and place a protective boot on the left foot when the resident is in his wheelchair. On 9-11-12 at 8:20 AM, 8:55 AM, 9:37 AM and 10:37 AM, Surveyor # observed Resident #7 in bed, without his heels being "floated." At 10:37 AM, Certified Nursing Assisant (CNA)-E assisted Resident #7 with his activities of daily living, i.e., washing and dressing for the day. At 11:40 AM, LPN-T was observed to conduct the treatment to Resident #7's left heel; the resident was sitting in his wheelchair at the time. After LPN-T finished the treatment, CNA-E took the resident to the dining area for the lunch meal, there was no protective boot on the resident's left foot. At 1:05 PM, 1:17 PM, and 1:27 PM, Resident #7 was observed in his wheelchair, without the protective boot on his left foot. At 1:30 PM, Surveyor # conducted an interview with Resident #7, the interview lasted approximately 40 minutes; Resident #7 did not have the protective boot on. On 9-13-12 at 12:05 PM, Resident #7 was observed in bed, again without his heels being "floated." At 12:35 PM, Surveyor # asked CNA-E what is the expectation for Resident #7's feet while in bed. CNA-E indicated the resident's feet should be placed over a pillow. Surveyor # asked CNA-E if the resident was resistive to allow his heels being floated, CNA-E indicated he was not. CNA-E also indicated the licensed nurses should be placing the protective boot on the left heel. On 9-13-12, Surveyor # related the above observation and interview with CNA-E to the administrator and director of nursing services during the daily exit conference at approximately 3:00 PM. On 9-17-12, Resident #7 was observed in the dining room during the breakfast meal, while wearing the protective boot on his left foot.

Based on interview and record review, facility staff did not ensure timely acquisition of pain medication for 1 of 4 Residents reviewed for pain management. Resident #1 was admitted with pelvic and thigh pain on 6/1/12, having been diagnosed with [REDACTED]. Resident #1's physician had examined him in the facility on 6/1/12, and ordered PRN (as needed) Vicodin. The MD Progress Note states his pain is well controlled with PRN Vicodin. The facility did not acquire the Vicodin until 9:30 p.m. on 6/2/12. The medication was not available when Resident #1 reported increasing pain and requested Vicodin before supper on 6/2/12. According to the complainant on 6/2/12 at approximately 6:40 p.m., LPN-G asked Resident to rate his pain; Resident #1 responded by asking if there was anything higher than a 10. Pharmacy had not delivered Resident #1's PRN Vicodin yet. Vicodin was not available throughout the evening of 6/2/12, during which time Resident #1 continued to experience pain. On 6/3/12 at 12:50 a.m., Resident #1 was sent to the ED (Emergency Department) without ever receiving the Vicodin, even after third shift staff noted severe pain, left knee swelling and a "knot" on the side of his left knee. Resident's hospital record included a radiology report that states: Comminuted (broken into several pieces), impacted (bone pieces imbedded into other bone pieces) fracture of distal left metadiaphysis (wide part of bone) of femur, just proximal to the knee replacement. Findings include: Resident #1's physician, MD-K, who is also the facility Medical Director, signed an admission progress note for Resident #1 dated 6/1/12 that states, "CC/HPI (Chief complaint/ history and physical) [AGE] year old gentleman was admitted to SLMC (hospital) with severe Rt (right) thigh pain and UTI (Urinary tract infection). He is transitioned to SNF (skilled nursing facility) for functional decline. Patient states they found a small fracture at Rt ramus of pubic bone. Pain is well controlled. He has LE (lower extremity) weakness for some time..." A&P (Assessment and Plan): Right hip pain- possible fracture, Xrays revealed lucency at lesser trochanteric area, pain well controlled with Vicodin PRN (as needed)..." MD-K examined Resident #1 at the facility on 6/1/12. MD-K signed admission orders [REDACTED]. tablets- two tablets every 4 hours as needed for pain or elevated temperature. Resident #1 was not receiving any scheduled pain medication. Resident #1 was admitted to the facility for strengthening and was expected to return to his assisted living apartment. Resident #1's Admission Pain Data Collection and assessment dated [DATE] indicates at that time, Resident #1 rated his pain as a "3" at rest on a scale of 0-10; his pain level was "6" when moving around, going to the bathroom, etc.; his expected level of pain is "2"; the pain comes and goes; rest relieves the pain; it is "very important" to completely eliminate the pain; his functional goals for pain management are to participate in ADLS (Activities of Daily Living), attend recreational activities and to participate in therapy. A hand-written Nurses' Notes dated 6/1/12 at 9:45 a.m. states "New Admit: Meds verified with (MD-K)..." Other notes on 6/1/12 state Resident #1 is alert and oriented x 3, able to make needs known. None of the notes dated 6/1/12 indicate any complaint of pain. According to a complaint received by the Department, Resident #1 suffered an injury to his knee around 1:30 p.m. on 6/2/12. At 3:45 p.m., Resident #1 spoke to a family member on the phone, and was crying due to the pain in his left knee. The family member went to the facility. Upon arrival at about 4:00 p.m., she observed Resident #1 to be in great pain. The complainant reports LPN (Licensed Practical Nurse)-G did come in to see what Resident #1 needed at about 4:30 p.m., and Resident #1 asked for ice and Vicodin for pain in his left leg. LPN-G stated she would check with RN (Registered Nurse) Supervisor-I to get the ice pack and Vicodin. The complainant states as time went on, and Resident #1 did not receive the ice or Vicodin, she started taking notes, jotting down the times events occurred. The complainant states she turned the call light on several times, in an effort to get the ice and pain pills, but she states she was at the facility until 7:15 p.m., and Resident #1 did not get either the ice pack or the Vicodin by that time. The complainant states at 6:40 p.m., LPN-G returned to Resident #1's room, and he told LPN-G when he takes pain medication, he also needs a laxative so he doesn't get constipated. The complainant states she has written down that at 6:40 p.m. LPN-G gave Resident #1 Milk of Magnesia, but no pain pill. LPN-G reportedly asked Resident #1 to rate his pain on a scale of 0-10, with 10 being the worst pain imaginable. Resident #1 replied- "Is there anything higher than a 10?" The complainant stated to Surveyor # that as time went on and he received neither the ice pack nor the Vicodin, Resident #1 asked the complainant to go to his apartment and get two of his Vicodin from home for him. The complainant told Resident #1 the medicine had to come from the nursing home. The complainant said Resident #1 was sent to the hospital around midnight where a left fractured femur was diagnosed . Resident #1 told her he never did receive the Vicodin or anything else for pain before being sent to the hospital, but he did get an ice pack at some point. Director of Nursing (DON)-B informed Surveyor # they conducted an investigation and submitted a self-report regarding Resident #1's injury of unknown source. DON-B provided the investigation to Surveyor # . Surveyor # reviewed the facility's investigation regarding Resident #1's left knee injury of unknown source. The investigation indicates two aides helped him into bed, and around 1:30 p.m. the nurse straight-catheterized him for urinary retention. At that time, Resident #1 said his leg hurt. The nurse looked at his leg and there was no swelling or knots in his left or right leg. He was offered Vicodin, but refused, and accepted Tylenol. He was actively moving his legs while in bed. Later in the evening the resident had an increase in his pain and a decreased in range of motion with his left leg and it was also noted he had a knot on the lateral side of his left knee. The MD was contacted and orders were received to send the resident to the ER for evaluation. The Resident was admitted to the hospital for a left femur fracture. Second shift LPN-G's statement regarding Resident #1's injury of unknown source is dated 6/3/12 states: "I was notified by Resident's (family member) that resident reported a pain in the back of left knee described as a "knot." Resident and family member told me about an incident that occurred earlier that day when the pain started...First shift nurse told me she gave Resident Tylenol Extra Strength as he did not want Vicodin. I assessed both legs. Resident reported pain upon palpation of back of knee. Left leg/knee appeared slightly swollen compared to right knee. Resident asked for PRN Vicodin and ice to put on knee. I advised the family that I would follow up with my supervisor. I paged supervisor (RN-I). When I did not get a response I found RN-I on the second floor and reported the incident, what Resident and (family member) reported, and asked him to assist. (RN-I) advised that I should call pharmacy to get authorization for Vicodin from contingency -Vicodin was not in cart- and get ice pack for resident. I called the pharmacy and was told that they would call the MD to get a written order, then fax the authorization number. When I returned to the unit, CNA (H) stated that Resident and (family member) wanted to talk to me. I told them that I had called pharmacy to get Vicodin and they are contacting MD for order. I told them I informed supervisor of the situation, and I could get resident an ice pack. Resident's (family member) stated she was leaving at that time. I got Resident an ice pack, wrapped it in a towel and placed it on his knee where he reported it was most painful." Surveyor # reviewed second shift CNA (Certified Nursing Assistant)-H's statement which states when she started her shift, she didn't know much about Resident (#1), but was told he fell or his legs gave out on him, and she kept checking on him. CNA-H took his order for dinner. CNA-H stated "I knew he was in pain with his leg so I repositioned him because he kept sliding down in his bed. His (family member) was also in his room kept asking for (RN-I) and every time I told the nurse that they wanted him. Me or the nurse came in there, I knew (RN-I) was busy upstairs. I did my job, kept checking on him and doing what he asked..." On 7/10/12, at 2:15 p.m., Surveyor # interviewed CNA-H, who stated every time Resident #1 "would move or they would reposition him, he would shout out a bit in pain. After a few minutes he would relax. I knew he was hurting. I got the nurse (LPN-G). (LPN-G) did come in with me a while before supper, but after that they wanted to talk to (RN-I)...I can't begin to tell you how many times they put the call light on- it was always the same thing- he was hurting, they wanted the supervisor. I would reposition him with a co-worker because I knew he was hurting so bad, but he'd scoot down in bed. He complained of his knees hurting. This continued until the end of her shift, then she went home and she did not know what happened after that. CNA-H stated she thought RN-I did go in to see Resident #1. Surveyor # reviewed 2nd shift supervisor RN-I's statement dated 6/3/12 stating "Nurse came to me and complained about resident c/o pain. I told her to give him pain pill. She called pharmacy to get from contingency and I will give her Vicodin from contingency and I told her to apply ice pack to pain area." On 7/10/12 at 3:22 p.m., Surveyor # interviewed RN-I who stated that evening (6/2/12, time unknown), LPN-G came to him and asked where she could get an ice pack from (she was a newer nurse), and how she could get a pain pill for Resident #1. RN-I stated he told LPN-G where to get the ice packs, and to call pharmacy to get an authorization number to get the pills from contingency and when she has the authorization number, he would get them for her. RN-I stated LPN-G never told him how much pain Resident #1 was in, or that his leg /knee looked injured, or that Resident #1 and his family member wanted to talk to him. On 7/10/12 at 5:46 p.m., Surveyor # interviewed third shift supervisor RN-J, by phone. RN-J stated 2nd and 3rd shift overlap from 10:00-10:30 p.m. and she thought towards the beginning of her shift, a CNA informed her Resident #1 was in pain and needed her. RN-J stated 2nd shift RN supervisor -I was still there. RN-J stated as she went in to assess Resident #1, she thought RN-I was exiting Resident #1's room, saying he would check to see what the Resident had ordered for pain. RN-J assessed Resident #1, noting he was complaining of pain in his left leg. RN-J stated she felt Resident #1 needed to be sent out to the hospital, so she went to call the doctor, ambulance company and family. RN-J stated she did not give Resident #1 any medication, but just concentrated on making the arrangements to get Resident #1 to the hospital. On 7/11/12, Surveyor # reviewed Resident #1's hospital medical record which indicates he arrived at the hospital at 1:13 a.m. The P.E. (physical exam) states Musculoskeletal: pain in left upper leg-exhibits swelling. Left distal femur is significantly more swollen than the right. Muscle spasms in left upper leg. Positive for myalgia (muscle pain), joint swelling, arthralgia (joint pain). Radiology reports state: 1. Comminuted (broken into several pieces), impacted (bone pieces imbedded into other bone pieces) fracture of distal left metadiaphysis (wide part of bone) of femur, just proximal to the knee replacement. Resident #1 had revision of total knee replacement surgery on 6/6/12. Surveyor # reviewed Resident #1's MAR (Medication Administration Record) for June 2012 which indicates Resident #1 was given two Tylenol 325 mg. tablets at 2:20 p.m. (corresponding with the Nurses' Notes). No documentation was located on the back side of the MAR indicated PRN Analgesic Record/ Pain Flow Sheet" indicating the level of Resident #1's pain before and after receiving the Tylenol, but he did decline the Vicodin at that point. According to the MAR, that was the only time Tylenol was given to Resident #1. The only other PRN medication documented as given to Resident #1 was MOM (Milk of Magnesia) on 6/2/12 at 1950 (7:50 p.m.). The MAR indicated [REDACTED]. Surveyor # asked the DON on 7/9/12 why Resident #1's Vicodin was not delivered by the pharmacy by Saturday evening, 36 hours after Resident #1 was admitted to the facility. This caused Resident #1 to not receive any Vicodin during his nursing home stay even though he requested it around 4:30 p.m. on 6/2/12, and was sent to the hospital just before 1:00 a.m. on 6/3/12, almost 9 hours later. DON-B stated she would look into it. On 7/10/12 at 9:50 a.m., DON-B informed Surveyor # Resident #1's Physician Medication Orders were faxed to the pharmacy Friday morning, but the pharmacy didn't get the authorization to dispense the narcotic from the physician until Saturday night around 9:30 p.m. DON-B stated pharmacy dropped the ball; they should have gotten the authorization sooner. Surveyor # asked if facility staff monitor or track which resident medications have been delivered and which have not been delivered. DON-B stated pharmacy staff should be tracking that. Surveyor # asked if Resident #1 ever received any Vicodin before going out to the hospital, noting his pain increased when he was being moved, and he would be moved and jostled from bed to the ambulance cart/gurney, then placed into the ambulance, moved again into the hospital, etc. DON-B checked the contingency logs and later reported to Surveyor # that Resident #1 did not receive any Vicodin while at the facility. DON-B provided Surveyor # with a document from the pharmacy indicating they received Resident #1's new admission orders [REDACTED]. On the evening of 6/2/12 they paged MD-K. MD-K returned the call at 9:54 p.m. The pharmacy issued the authorization to remove the Vicodin from contingency shortly after 10:30 p.m. On 7/10/12 at 2:35 p.m., DON-B stated to Surveyor # they had no written policy and procedure to obtain narcotics, but they fax the orders to the pharmacy, then the pharmacy faxes something to the physician for them to sign- including the quantity to be dispensed, DEA number, etc. Once the MD returns that to the pharmacy, they fill the order and deliver it. If the resident brings a script (prescription) from their doctor, they can just fax that and the pharmacy doesn't have to further contact the MD. Surveyor # noted MD-K was in the facility the morning of 6/1/12, and they could have faxed the necessary information/prescription to the pharmacy at that time. DON-B stated that isn't how MD-K usually does it. DON-B stated it appears after the initial fax to MD-K, pharmacy staff didn't attempt to contact MD-K again until after LPN-G called them sometime on the evening of Saturday, June 2. DON-B stated Resident #1 declined the Vicodin earlier on 6/2/12. Surveyor # noted that was true, but facility staff working with pharmacy staff need to be aware that the Vicodin prescription was not filled, and make efforts to have the Vicodin available when the Resident needs it; not starting to call a physician on a Saturday night while the Resident is waiting in pain. On 7/11/12 at 12:05 p.m., DON-B provided Surveyor # with requested documentation indicating Resident #1 ate less than half of his dinner on 6/2/12; and the ambulance crew arrived at 12:31 a.m. on 6/3/12, vital signs were taken at 12:51 a.m. and included a pain scale rating of 6/10 (would have met criteria for two Vicodin tablets per MD orders), and they left for the hospital at 1:06 a.m. On 7/11/12 at 9:50 a.m. Surveyor # interviewed the Pharmacy Technician who stated for new admissions, at the end of the first day, they try page the MD to get the needed information to dispense the medication, but due to volume, it is not always possible, and it is helpful if nursing home staff also monitor what medications the resident has not yet received. They can also work to contact the physician for a script or to have him call the pharmacist directly. On 7/12/12 at 10:25 a.m. Surveyor # interviewed Pharmacist-M by phone who stated nursing home staff share the responsibility in monitoring receipt of the narcotic medications as they have a high volume of prescriptions they process, and the nursing home staff are more familiar with the urgency of the need for that particular medication. Facility staff identified the deficient practice regarding assessing Resident #1's pain management on the evening of 6/2/12 and inserviced nursing staff on proper pain management standards. However, the issue of the delay in Resident #1 receiving his Vicodin was not identified by the facility and corrected. No follow-up or changes were made to the issue of Resident #1's Vicodin not being available when he needed and requested it. Surveyor # asked DON-B if any follow-up was done regarding the delay in Resident #1 in getting the Vicodin. DON-B stated no, the pharmacy should have stayed on top of it and they dropped the ball. Surveyor # reviewed the facility's Policy and Procedure 9.3.1 Medication Administration, provided by Corporate RN Consultant-N, revised April 2012. It states "Procedure: Licensed Staff: 1. Order Schedule II through V drugs from the pharmacy provider in accordance with federal and state regulations and pharmacy procedures. 2. Obtain a written prescription for Schedule II drugs prior to dispensing, except in an emergency situation. The prescriber may phone the pharmacists for a limited quantity emergency dispensing. Note: DEA regulations require this." As of 7/12/12, no further information was provided. On 7/18/12, the regional office received additional faxed "Fact finding" information from Corporate Consultant -O. The "Fact finding" information included the following information: "... At ~2:30 p.m., resident complained of left leg pain. The nurse assessed his legs and found no abnormalities. The nurse then offered Vicodin, resident declined. The nurse then offered Tylenol and resident accepted. At ~3:45 p.m., resident started to complain of increased pain. The nurse assess the resident and observed increased swelling on the left knee and then applied an ice pack to the left knee. The nurse identified that she would need to obtain Vicodin from the contingency box and updated the family and the resident regarding obtaining the authorization for the Vicodin. During the afternoon/evening resident had eaten dinner and daughter was in his room until around 7:00 p.m. Nursing assistant assisted resident with repositioning for comfort throughout the evening. The nurse called the pharmacy at 9:30 p.m. for the Vicodin authorization. The oncoming night nurse followed up with the doctor regarding the pain and the resident was sent out to the hospital. According to the paramedic report the resident's pain rating was a 6 out of 10 and his vital signs were stable. The root cause identified was that if the nurse had notified the MD at the time of identifying the swollen knee and applying the ice pack, the MD could have contacted the pharmacy to give authorization to release the Vicodin from the narcotic contingency box. When the MD was contacted by the pharmacy it only took 15 minutes for the authorization for the Vicodin. Staff were re-educated on physician notification if a resident has a new onset of pain or a marked changed in pain then the MD must be contacted immediately, at the time this process breakdown was identified." Surveyor # noted that although the staff were re-educated on 6/3/12, regarding physician notification if a resident has a new onset of pain or a marked change in pain, the MD must be contacted immediately; the facility did not address and develop policy's and procedures to specify how the facility will ensure the timely acquisition of pain medication for residents.

UNCORRECTED AT VERIFICATION VISIT EVENT ID: 8KMN12 Based on interview and record review, the facility did not ensure that 2 (#11 and # 18) of 15 sampled Residents at risk for falls received the supervision necessary to prevent falls. Resident #11 and Resident #18 were both left on the toilet alone and were not supposed to be. As a result both Resident #11 and #18 fell . Resident #11 suffered a right hip fracture; Resident #18 was not injured. Findings include: 1.) Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/20/11 Surveyor # reviewed an investigation provided by the facility regarding a fall Resident #3 had on 7/4/11 when she was left on the toilet and attempted to self transfer. The results of the investigation summarized on the 7/11/11 investigation report read: Resident #11 was taken to the bathroom by Certified Nursing Assistant (CNA)-K. CNA-K left Resident #11 on the toilet and went across the hall to get linen. While CNA-K was out of the room Resident #11 attempted to self transfer off the toilet and fell . Resident #11 was found on her right side on the floor complaining of right hip pain. 911 were called and Resident #11 was transferred to the emergency room where an x-ray revealed Resident #11 had a right hip fracture. On 7/20/11 Surveyor # reviewed the statement provided by CNA-K dated 7/4/11 after the fall of Resident #11 that read: "I put Resident #11 on the toilet, left out the room just to get some towels and linen. I came back down the hall and just that fast she got up and fell ." On 7/20/11 Surveyor # reviewed Resident #11's fall care plan which read: bed and chair alarm. The care plan contained several dates so on 7/21/11 at 1:50 p.m. Surveyor # interviewed DON-B. DON-B stated the bed and chair alarms were started for Resident #11 on 9/17/10. DON-B stated that Resident #11 should not have been left alone on the toilet on 7/4/11. On 7/20/11 Surveyor # reviewed Resident #11's history and physical from the hospital dated 7/4/11 which read: Resident #11 had a fall that resulted in a right hip fracture. Fortunately it was non-displaced. Resident #11 is stable. On 7/21/11 Surveyor # reviewed Resident #11's therapy notes which indicated she was progressing and expected to be back to her previous functioning by 9/18/11. The above findings were shared with the Administrator and DON at the daily exit meeting on 7/21/11. Further information was requested if available and none was provided. 2.) Surveyor # reviewed Resident #18's closed medical record on 07/19-07/20/11. Resident #18 was admitted to the facility on [DATE]. Resident #18 is [AGE] years of age and has [DIAGNOSES REDACTED]. Resident #18 was admitted for rehabilitation after fracturing a hip after falling while at home. Review of a Minimum (MDS) data set [DATE], indicated Resident #18 is severely cognitively impaired and had had 1 fall while residing at the facility. Review of Resident #18's plan of care dated 04/16/11, indicated a problem of potential or actual ADL (activities of daily living)/mobility deficit, related to fracture of left hip, dementia, metastatic cancer, fall history and generalized weakness. The plan of care also indicated Resident #18 is forgetful and non compliant with transfer status. An intervention is to transfer Resident #18 with an assist of 2 with a sit to stand lift. On 07/19/11, Surveyor # reviewed a facility self-report investigation regarding Resident #18 falling from the toilet on 06/29/11. Review of the investigation summary statement indicated Resident #18 fell self transferring from the toilet. The summary also indicated, "During the investigation of the fall entity learned that employee (Certified Nursing Assistant (CNA)-F), did a one person transfer when the care plan-effective indicated resident is a sit to stand transfer.....Resident #18 has fallen 2 previous times in the facility self-transferring." A statement provided by CNA-F dated 07/04/11, indicated she transferred Resident #18 to the toilet by herself. CNA-F indicated she then went to another resident's room to assist them in the bathroom, and when she returned to Resident #18's room, he was on the floor and a nurse was present. Surveyor # spoke with the facility Director of Nursing (DON), on 07/19/11 at approximately 10:00a.m. The DON was asked what her expectation would be with regard to the level of supervision provided during toileting for a resident requiring the use of a chair alarm. The DON stated that if a resident utilizes a chair alarm she would expect nursing staff to stay in the resident's room during toileting due to the fact a chair alarm can not be attached to a toilet.

Based upon record review, and interview, the facility did not ensure each resident was prevented from neglect for 1 of 7 Residents (Resident #1 ) reviewed. Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. - On [DATE] at approximately 2:55 p.m., Licensed Practical Nurse (LPN) M- placed Resident #1 outside in the enclosed patio off the first floor T.V. room. On [DATE] from 2:55 p.m. until 5:55 p.m., Resident #1 remained outside in the enclosed patio. During this time period, facility staff did not supervise Resident #1 even though he was outside in 97 degree temperature with no shade or fluids. Facility staff did not physically check on Resident #1 from 2:55 p.m. until finding Resident #1 at 5:55 p.m. Staff did not check to see if Resident #1 should come in from the heat. Staff did not check the health status of Resident #1 while sitting out on the patio during a heat advisory condition. Staff did not ensure Resident #1 was provided with fluids, shade from the sun, and to check as to whether Resident #1 was dressed appropriately for the weather. Staff did not provide Resident #1 with prompted toileting before supper/meal, did not provide encouragement for adequate hydration, and did not monitor for shortness of breath, change in level of consciousness, or position change as indicated in Resident #1's plan of care. During this time frame, the second shift staff on the first floor were not aware Resident #1 was outside on the patio. Leaving Resident #1 unmonitored in 97 degree weather without checking on the resident's care needs created a finding of immediate jeopardy for Resident #1 which began on [DATE]. On [DATE] at 3:05 p.m., the Administrator-A, Director of Nursing (DON)-B, RN Regional Clinical Services-C, RN-D and Corporate Representative-Z were notified of the Immediate Jeopardy (IJ). The Immediate Jeopardy was removed on [DATE] at 4:30 p.m. The deficient practice continues at a scope and severity of an E (potential for harm that is not immediate jeopardy/pattern) as the facility must continue to ensure all staff consistently implement measures of Resident accountability during shift change, monitor staff implementation of the "outdoor monitoring guidelines" established on [DATE] as part of the IJ removal. The facility must continue to ensure each new Resident is assessed for their ability to be outdoors supervised or unsupervised. Findings include: 1. From [DATE] through [DATE], Surveyor # reviewed Resident #1's medical record. Resident #1's medical record indicates Resident #1 was [AGE] years old and originally admitted into the facility from the hospital on [DATE]. Resident #1's [DIAGNOSES REDACTED]. The hospital summary report dated [DATE] sent with Resident #1 to the facility indicated Resident #1 had been residing in an Assisted Living facility prior to hospitalization . Resident #1 was admitted via the emergency roiagnom on [DATE] with increased confusion and was subsequently admitted into the hospital for further evaluation. While hospitalized Resident #1 underwent cataract surgery. The hospital transfer form dated [DATE], indicates Resident #1 is forgetful, uses a walker, needs assistance with walking and toileting and is independent with dressing and feeding self. The hospital transfer form also indicates Resident #1 is legally blind, right eye surgery on [DATE] and requires moderate assistance for hygiene. Resident #1's condition was stable for discharge and was discharged to the facility on [DATE]. The facility completed an admission Minimum Date Set (MDS) on [DATE] and an MDS on [DATE]. The MDSs indicate, " It was very important for Resident to go outside to get fresh air when the weather is good. " The MDSs indicate Resident #1 usually understands and is understood. Resident #1's vision is highly impaired. Resident #1's cognitive patterns were noted as moderately impaired. These assessments indicate that Resident #1 transfers and ambulates with extensive assistance with one person physical assist. Resident #1's locomotion on the unit was limited assistance with one and off the unit was extensive assistance with one. Resident #1 used a wheeled walker or wheelchair to get around. Resident #1's balance during transitions and walking was noted as not steady, only able to stabilize with human assistance. Resident #1 was noted to have upper extremity range of motion limitations. Resident requires supervision with one staff for eating. Resident was occasionally incontinent of bowel and frequently incontinent of bladder. The MDSs indicate Resident #1 did not have a condition or chronic disease that may result in a life expectancy of less than 6 months. As part of the [DATE] MDS, the facility completed Resident Care Area Assessments. The Resident Care Area Assessments indicate Resident is able to drink independently and fluids are kept within reach and encouraged. Resident is monitored for signs and symptoms of dehydration. Per dietician 2610 cc fluid intake. The [DATE] plan of care identifies an alteration in urinary continence with an intervention of prompted voiding upon rising, before and after meals, at bedtime and per request. The Respiratory plan of care says to monitor for cyanosis, shortness of breath, and level of consciousness. The plan of care for Skin Integrity ([DATE]) says to monitor hydration status. The [DATE] MDS indicates Resident #1 has shortness of breath or trouble breathing when sitting at rest and when lying flat. Physician orders [REDACTED]. daily, [MEDICATION NAME] (Hypertension/HTN) 50 mg. 3 times a day, [MEDICATION NAME] (HTN) 0.1 mg. every 8 hours, and [MEDICATION NAME] ([MEDICAL CONDITION]) 300 mg three times a day. According to Drugs.com, http://www.drugs.com/[MEDICATION NAME].html, [MEDICATION NAME]/[MEDICATION NAME] is a diuretic which treats fluid retention in people with [MEDICAL CONDITION], liver disease, or a kidney disorder, and high blood pressure (hypertension). [MEDICATION NAME] will make you urinate more often and you may get dehydrated easily. Avoid becoming dehydrated. Avoid exposure to sunlight. Side effects may include dry mouth, thirst, feeling weak, drowsy. According to Drugs.com, [MEDICATION NAME] is used for treating high blood pressure. [MEDICATION NAME] may cause dizziness, lightheadedness, or [MEDICAL CONDITION]; alcohol, hot weather, exercise, or fever may increase these effects. Drugs.com indicates, [MEDICATION NAME] lowers blood pressure. Side effects may include, feeling dizzy, tired, and dry skin. According to Medline Plus, http://www.nlm.nih.gov/medlineplus/druginfo/meds/a 7.html, [MEDICATION NAME] is used to relieve pain of diabetic [MEDICAL CONDITION]. Side effects may include drowsiness, tiredness or weakness, dry mouth. On [DATE] at 12:30 p.m., Surveyor # interviewed Registered Nurse (RN)-G who stated she worked first shift on [DATE]. (First shift is from 6:00 a.m. to 2:30 p.m. and second shift starts at 2:00 p.m. until 10:30 p.m.) RN-G stated on [DATE], Resident was his usual self, a little tired in the morning, rested after breakfast, elevated legs/[MEDICATION NAME], up for lunch, propels self in wheelchair, ambulates with 2 wheeled walker, was able to communicate needs, alert, oriented, confused at times. Was not aware of Resident going out on the patio before this. Usually staff stay with the resident when out on the patio, doesn't know where resident was found. If you go out to the patio the door alarm goes off, never tried getting in from the patio. Resident was on 1 hour checks but this was discontinued yesterday [DATE]. LPN-M was the second shift nurse yesterday. On [DATE] at 12:55 p.m., Surveyor # interviewed Occupational Therapist (OT)-H and Rehab Coordinator- I. OT-H stated she saw Resident yesterday ([DATE]) at 2:10 p.m. and Resident wanted to go outside. OT-H went outside to the front entrance of the building patio area with Resident. Five minutes later, we discussed it was too warm outside. We tried a few exercises but it was warm so we told him it was time to come in and the session was almost over. We wheeled him back in. He was resistive to coming back in, putting his feet on the ground. Eventually he was brought in about 2:30 p.m. Sunscreen had been applied on his face and arms. Once in the building, he insisted he wanted to go back outside. We couldn't sit with him, so I told him we would talk to the nurse. OT student told nurse he wanted to stay outside and we couldn't stay with him. So nurse went and got him from therapy hallway. Nurse wheeled him away and that was it. I didn't see him again. The nurse was LPN-M. He was insistent on going outside and enjoyed warm weather. Rehab Coordinator-I indicated she also saw Resident yesterday on [DATE]. Rehab Coordinator- I stated Resident wanted to go outside and Resident stated that no one will let him go outside. Resident stated, "I pay the bills, I can go out if I want." Rehab Coordinator-I stated she checked with the nurse, sunscreen applied...was outside from approximately 2:15 p.m. to 2:30 p.m., not more than 15 minutes, underneath a table with an umbrella. A Physical Therapy Daily/Weekly Summary dated [DATE] indicates that on [DATE], Patient requested to be outdoors...Patient refused to come back into building. Physical Therapy Assistant was involved to assist return patient to building. Weather was very hot/sunny. Physical Therapist concerns of heat and sunburn. Patient was safely brought in. On [DATE] at 12:15 p.m., Surveyor # interviewed Social Work Assistant (SS)-F regarding Resident #1. SS-F stated Resident had previously lived in an assisted living facility and was placed at the facility after a hospitalization . SS-F stated Resident was legally blind in both eyes. SS-F stated, I was at the nurse' s desk and heard her (Licensed Practical Nurse/LPN-M) say she was going to take him out and that she would check on him in 15 minutes; LPN-M needed the code to exit out the door. I did not physically see LPN-M take him out. At close to 3:00 p.m., when I was going to my office I saw him outside sitting on the patio. It was the first time I saw him outside. I was walking towards the office and saw him through the glass (patio windows). The door to the patio is alarmed and it will alarm if anyone goes out. He was observed not sitting under the covered (awning) and not at a table with an umbrella. SS-F stated Resident would have to ask to go out out due to the alarm. With Resident's recent return from the hospital ([DATE]), he appeared more confused. Initially Resident was on 15 minute checks for suicide precautions. Then it went to 1 hour checks and on [DATE] at 1:00 p.m., the 1 hour checks were discontinued. On [DATE] at around 2:30 p.m., I was in his room with him. I left work at 4:50 p.m. and did not see him after the 3:00 p.m. observation. On [DATE] at 10:00 a.m., Surveyor # interviewed LPN-M over the phone. LPN-M stated that on [DATE], Resident would not return to the unit and so occupational therapy came to get me. LPN-M talked to Resident to calm him down. LPN-M stated Resident wanted to go outside. Agreed to go out in the enclosed area. Took to patio and put Resident in clear view of the patio door at approximately 2:55 p.m. I later asked the CNA assigned to him if she accounted for her residents and she said she had. The CNA was late; the routine is that when a CNA is late, the other staff help out until the CNA gets here. The CNA arrived at about 3:,[DATE]:25 p.m. Once the CNA stated she had accounted for the Residents, I began passing medications and attending to other Residents. I returned to the nurse desk area around 3:,[DATE]:45 p.m. and observed Resident sitting outside in front of the doors. He wasn't one who did a lot of moving. That was the last time I viewed him. The physician came in and wanted to see Resident. I directed the physician to Resident's room and the physician stated Resident was not in his room, and not in dining room and again not in his room. I went to patio door and didn't see Resident because he was behind the door which is covered by the window curtain inside. I do not know who actually found Resident. I left the patio door propped open by placing magazines between the door and the door jam. Was thinking when CNA got to work, he would be accounted for and would be brought back in. The door alarm was turned off and reactivated once they found Resident. I helped bring him in and the physician saw him. RN Supervisor-O took over. CNA-R knew he was out there as well, she knew about it, she was right there after putting him out there. When asked if LPN-M provided fluids to Resident while Resident was out on the patio LPN-M stated, "No." Surveyor # questioned LPN-M as to why her facility written statement stated, "offered fluids." LPN-M stated, "If I wrote it, it was a mistake, at the time of the written statement I was told Resident had eaten and drank." According to the facility's time sheet on [DATE], LPN-M punched in at 2:16 p.m. and punched out at 9:18 p.m. On [DATE] at 10:46 a.m., Surveyor # interviewed CNA-R over the phone. CNA-R stated that on [DATE] at around 2:35 to 2:40 p.m., she saw LPN-M with (Resident #1). CNA-R indicated that prior to finding Resident at 6:00, no one mentioned he was outside. " I did not check on him or provide him with fluids." On [DATE] at 1:35 p.m., Surveyor # interviewed CNA-Q. CNA-Q stated, we are supposed to check Residents every 2 hours...that day ([DATE]) I was asking where Resident was, did he go out with family? No one answered. If someone would have told us he went out but no one did it that day. On [DATE] at 7:05 a.m., Surveyor # interviewed Assistant Director of Nursing (ADON)-E who stated on [DATE] she asked CNA-P if she had seen Resident when she first came on duty at approximately 3:00 p.m. and she (CNA-P) said no and made excuses. I asked CNA-P, did LPN-M ask you to check on Resident and did she know where Resident was? CNA-P said, "No, (LPN-M) did not and I thought Resident was in therapy." ADON-E stated, "I asked (LPN-M) did you go out and check up on him? (LPN-M) said, "No, I didn't, I did see him from the nurses station at approximately 1545 (3:45 p.m.), he was on the other side of the patio door." ADON-E stated that on [DATE] she got statements from all staff working on the unit that night. ADON-E stated she asked all of the staff on duty if anyone checked on (Resident #1.) ADON-E stated all of their answers indicated no. Their answers were, "No one saw him or checked on him." ADON-E also asked if anyone gave Resident his tray and all of the staff interviewed said, "No." ADON-E stated she obtained one statement from Dietary Aide-N who reported Resident was not in the dining room so she put a tray in the refrigerator for him. ADON-E stated, LPN-M's written original statement included she gave Resident fluids however; she (LPN-M) told me she did not offer fluids, I think she was so shook up. No one checked on Resident 1 while he was outside on [DATE] from 2:55 PM to 6:00 PM. On [DATE] at 3:55 p.m., RN Regional Clinical Services (RN) -C informed Surveyor # that the facility did not have a written policy for when Residents go outside. On [DATE] at 4:15 p.m., Surveyor # met with Administrator- A, RN-C, Director of Nursing (B), and RN-D. Surveyor # was informed that the facility does not have a written policy regarding Resident's being outside. Surveyor # asked if the facility has a verbal policy regarding Resident's being outside? Surveyor # was informed the facility verbally instructs staff to provide water to residents who go outside, and to monitor residents. The monitoring of the resident depends on the individual Resident and is on the Resident's care card. On [DATE] at 3:50 p.m., Surveyor # interviewed Dietary Manager (DM)-K who stated Resident did not receive dinner on [DATE]. Dining room doors open 15 minutes before meals. They start at 4:30 p.m. and DM-K left the facility at 5:00 p.m. while the staff were still serving. The process is that dietary staff make up trays and after everyone is served any tray left should be communicated to a certified nursing assistant (CNA) or preferably a nurse to see where the resident is. They would not be able to identify what trays are left until about 5:00 to 5:15 p.m. The aide should have said something, DM-K was uncertain if the dietary aide said anything to the Certified Nursing Assistant (CNA) or the Nurse at the time of this interview. According to the facility's investigation, Dietary Aide-N documented that on [DATE] between 5:30 and 5:45 p.m., Dietary Aide -N placed Resident #1's tray into the refrigerator when Resident #1 did not come to supper. There is no evidence Dietary Aide-N alerted staff that Resident #1 did not show up in the dining room. This was contrary to facility policy on Resident Supervision/General Supervision effective [DATE]. The policy states, general supervision will be maintained at all times. Residents on general supervision are able to move around the center at will...during night shift, Residents will be checked every two hours. Staff should be aware of which Residents fail to attend scheduled activities such as meals, etc. Staff should check on Residents who do not arrive for scheduled activities and inform the nurse on charge or shift supervisor when Resident can not be found. On [DATE] at 10:46 a.m., Surveyor # interviewed CNA-R over the phone. CNA-R stated around supper time she started pushing Residents into the dining room and assisted with the meal. CNA-R stated Resident #1 sits at the same table with 2 other male Residents and noticed Resident was not at the table. At around 5:30 p.m., LPN-T and RN-O asked if she had seen (Resident #1). CNA-R stated, "I went to check the patio, opened the door, and saw him (Resident #1) in the corner. I couldn't see him until I got to the door. The window curtain had been in the way and I couldn't see him. The door to the patio was closed and a deck of cards was on the cement outside. I had to push the door open and the door alarms did not go off. I went to touch him and called his name. He did not look good, I though he passed away, the MD was here and checked him with a stethoscope. Once in the building, I helped place him in bed. Prior to finding Resident, no one mentioned he was outside. I did not check on him or provide him with fluids." On [DATE] at 1:35 p.m., Surveyor # interviewed CNA-Q. We put up a tray for him, we were not sure where he was at. I didn't know where he was, I was busy with own assignment. I saw him at 2:00 p.m. with therapy out in front of the building, later that day, didn't recall seeing him. Around 6:00 p.m., I was asked if I saw him. I had to bring him in. I felt on him. He had a foam substance on his forehead and mustache, tongue was white, blisters on arms. He was wearing a short sleeve red top. He was really hot, on fire when touched. He was in the wheelchair, brought in and placed in room. I left when the nurse and the paramedics came into the room. Resident had been out on the patio a lot of times. Surveyor # asked CNA-Q as to whether Resident was able to get in from the patio by himself. CNA-Q stated, "I feel like not, I think by standing and opening the door would not be easy, would be hard to open, he was very weak and not doing well." An Accident/Incident Report was provided to Surveyor # on [DATE]. The Accident/Incident Report dated [DATE] at 1800 indicates, Resident found on patio at corner of the building unresponsive by CNA (Certified Nursing Assistant)- Help summoned-MD came, 911 called. Resident pronounced dead by MD. The Accident/Incident Report indicates Resident was alert and oriented times 3, expressed wishes to be outside. Vital signs: Pulseless, no respiration. Blood Sugar results at 3:00 p.m., 110. Education given to all staff regarding the monitoring of fluids when temperatures outside elevated. Two staff suspended. A physician's progress note dated [DATE] at around 6:00 p.m. states, "Patient found on porch. Patient had obvious sign of prolonged death. Patient was pronounced dead at this time. CPR (Cardiopulmonary Resuscitation) would not be appropriate." Surveyor # reviewed the Police report dated [DATE], which references RN-O's contact with the medical examiners office. The Police report indicates Resident was wheeled outside in his wheelchair at approximately 2:45 p.m. At 6:00 p.m., an employee went outside and found Resident unresponsive...911 was called...RN-O was unable to tell if anyone had checked on Resident while outside. The medical examiner advised to take Resident's temperature and it was taken at 7:52 p.m. and found to be 101.4. Surveyor # reviewed the medical examiners Demographic Report dated [DATE] indicates (Resident #1) was last seen on [DATE] at 6:00 p.m. and was last seen alive on [DATE] at 2:45 p.m. The medical examiners Demographic Report states (Resident #1) was in full rigor with lividity posterior, purplish and partially blanching. He was dressed in shoes, socks, Ted stocking to right leg, sweat pants and T-shirt. He was warm to touch. He had skin slippage to the arms, chest and legs. There was a large amount of foam at the mouth. There was no trauma noted. The deceased was conveyed to this office for autopsy...the outdoor temperature reached a high of 97 degrees at about 3:00 p.m. as listed in J.S. online. Apparently the Health Department also issued weather related advisories as to the heat index and warning residents of the condition..." On [DATE] at 10:56 a.m., Surveyor # interviewed MD-U who was on-call for Resident #1's primary physician. MD-U stated he arrived at the facility on [DATE] at 5:30 p.m. and left at 6:30 p.m. MD-U stated he came to the facility to see several Residents. MD-U stated, " when I asked where (Resident #1) was, the nurse insisted (Resident #1) was in his room. I told the nurse he was not in his room. I told the nurse several times to find out where Resident was. I went to (Resident #1's) room and he was not there. I went to another Resident's room and returned to (Resident #1's) room and he still was not there. MD-U stated, I told the nurse he was not in his room and the nurse insisted he was. I saw another Resident and when walking out of that Resident's room, staff stated they found (Resident #1). This process of trying to find (Resident #1) was at least 20 to 30 minutes. They came and found me and needed me immediately, 911 was already called. It was obvious Resident was deceased , he was extremely hot when I examined him for a pulse check. It was very hot that day. The metal parts on his wheelchair was very hot. Resident's head all the way down was pale, blood pooling at the ankles, If I were to guess the time, Resident was deceased at least greater then 30 minutes, early rigor mortis set in. Resident was outside on the back patio. If you look out the door, he was right behind the door, by the wall corner. If you look out the door fast, you couldn't see him. Resident was moved to a bed but it took about 10 to 15 minutes in order to move the other Residents out of the T.V. area. The Resident's temperature taken 2 hours later at 101.4 would mean Resident was hotter outside when found. The temperature would have been over 101 degrees. Most people's temperatures drop when they pass away. Without a doubt, the heat affected Resident. He had diarrhea and [MEDICAL CONDITION]. His [MEDICATION NAME] was increased due to leg swelling and at the same time worsening of [MEDICAL CONDITION]. If the heat did not cause Resident #1's death, without a doubt, it played a role in contributing to his death. If Resident was young and healthy, being out there for 2 to 3 hours without fluids, would make him extremely ill." The Milwaukee Journal Sentinel dated [DATE] indicated on [DATE], "a heat advisory was in effect for all southern Wisconsin, including the city of Milwaukee, in other words hot and humid. Slow down a bit today and keep cool. Temperatures will be in the low to mid 90's...it will be very uncomfortable at times, especially in the afternoon." The Milwaukee Journal Sentinel (JS) dated [DATE] indicated the high temperature in Milwaukee on [DATE] reached 97 degrees. On [DATE], Surveyor # asked DON-B to clarify as to which CNA was specifically assigned to Resident #1 on [DATE] from 2:00 to 3:00 p.m. On [DATE], DON-B stated that Resident #1 was not physically assigned to any CNA specifically as he was in therapy until 2:30 p.m. and all staff on the unit answer call lights. On [DATE] at 4:30 p.m., Surveyor # received the facility's self report investigation. Based off of review of the facility's investigation, information reviewed remained consistent with the above findings. Surveyor # observed the first floor T.V. area, the exit door to the patio and the enclosed patio on [DATE], [DATE], [DATE], and [DATE]. Surveyor # observed the T.V. area has 2 walls primarily made of windows that look out into the enclosed court yard. The windows have curtains which are pulled back to the corner of each window. These curtains cover some parts of the windows so that some parts of the court yard could not be viewed. There is also a glass exit door that opens directly into the courtyard. This exit door is equipped with a Code Alert Freedom Series Model 70 alarm. This door dually activates when ever anyone exits the door and when a Resident with a wander-guard tries to exit. The alarm for this door can be turned off manually at the nurses desk. Upon exiting the door into the court yard, the facility has a large outside temperature gauge attached to the outside wall. The patio is enclosed by a fence with a gate and is partially covered by an awning and 5 tables with umbrellas. The patio also has areas that are not covered by either the awning or the tables/umbrellas. Once out onto the patio and the exit door is closed, Surveyor noted that the door locks. The only way to get back into the facility is to press a door bell located on a speaker box which alerts the staff of the need to release the doors locking device in order to open the door. The door bell is 47 to 48 inches from the ground. Surveyor # noted it may be difficult for a Resident in a wheelchair to reach the doorbell to get back into the facility. Surveyor # also noted that the door bell may also be difficult to see for a Resident who has visual impairment or who is legally blind. On [DATE], Surveyor # and RN-G went outside to view the patio. Surveyor # asked RN-G if she thought Resident #1 could independently get back into the facility. RN-G stated she was not sure. RN-G stated Resident would have had to push the button for reentry and was not sure if Resident #1 could do so due to being blind. According to interviews with LPN-M, Resident #1 was initially placed right outside of the exit door. During conversation with the Assistant Director of Nursing -E on [DATE] at 7:44 a.m., Resident #1 was found further back in the corner behind the door, which is an area blocked from viewing due to the inside window curtain. On [DATE], facility staff neglected Resident #1's care needs. Staff did not provide Resident #1 with prompted voiding, did not provide encouragement with hydration, did not monitor for shortness of breath, change in level of consciousness, or position change, as indicated in his plan of care dated [DATE]. Staff did not physically check on Resident #1, nor did staff know of Resident #1's whereabouts with the exception of a visual observation made of Resident #1 from the nurse's desk by LPN-M at 3:30 to 3:45 p.m. There is no indication Resident #1 was physically checked on to ensure Resident #1's safety and was provided with fluids even though a "heat advisory" was in effect. On [DATE], the temperature reached 97 degrees. Resident was wearing sweat pants and a T-shirt along with a Tubi grips and socks. No one checked Resident #1 to ensure his clothing remained appropriate after sitting outside for an extended period of time and to check on his condition. On [DATE], Dietary staff did not notify the nurse when Resident #1 did not come for supper. On [DATE] at 5:55 p.m., Resident #1 was found outside in the enclosed patio dead. On [DATE] at 7:50 p.m., Resident #1's temperature was 101.4 degrees (temporal/taken by ear). Leaving Resident #1 unmonitored in 97 degree weather with no shade, fluids or the provision of care plan interventions, resulted in a finding of immediate jeopardy for Resident #1. The facility removed the immediate jeopardy on [DATE] at 4:30 p.m. by which time it had: 1. Provided education to 80% of their staff on hydration and knowledge of resident where- about's. All remaining staff will be educated prior to shift duty. 2. Developed and instituted "Outdoor Monitoring guidelines" to ensure Residents for safety. The patio will be for supervised activities. All residents have been assessed for safety regarding outdoor activities and all care plans and Nursing Assistant Care Cards have been updated. 3. Upon arrival to the units, Certified Nursing Assistants will complete unit rounds with the previous shift nursing assistants documenting visual observation of each resident under their care and supervision. If any Resident can not be accounted for, the nurse will be immediately informed and a missing resident will be initiated. 4. Staff will monitor Residents throughout their shift based off of individual needs. 5. Dietary staff will inform the nurse of any Resident not receiving a tray in writing by the end of meal service and the nurse will sign written notification. This will be monitored by the Dietary Services Manager. 6. Any staff scheduled to start a shift at a time other than normal start of shift will be replaced by a staff member. This will be monitored by the Director of Nursing. 7. Weather advisory radios are in place at each nurses station. 8. The above will be reviewed at the QPI meetings to determine need for any further educations and continued monitoring. Cross Reference F323

Based upon observation, record review, and interview, the facility did not ensure the residents ' environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents in 2 of 7 Residents (Resident #1 and #2) reviewed. - On [DATE] at approximately 2:55 p.m., Licensed Practical Nurse (LPN) M- placed Resident #1 outside in the enclosed patio off the first floor T.V. room. On [DATE] from 2:55 p.m. until 5:55 p.m., Resident #1 remained outside in the enclosed patio. During this time period, facility staff did not supervise Resident #1 even though he was outside in 97 degree temperature with no shade or fluids. Facility staff did not physically check on Resident #1 from 2:55 p.m. until finding Resident #1 at 5:55 p.m. Staff did not check to see if Resident #1 should come in from the heat. Staff did not check the health status of Resident #1 while sitting out on the patio during a heat advisory condition. Staff did not ensure Resident #1 was provided with fluids, shade from the sun, and to check as to whether Resident #1 was dressed appropriately for the weather. During this time frame, the second shift staff on the first floor were not aware Resident #1 was outside on the patio. Leaving Resident #1 unmonitored in 97 degree weather without supervision resulted in a finding of immediate jeopardy for Resident #1 which began on [DATE]. On [DATE] at 3:05 p.m., the Administrator-A, Director of Nursing (DON)-B, RN Regional Clinical Services-C, RN-D and Corporate Representative-Z were notified of the Immediate Jeopardy (IJ). The Immediate Jeopardy was removed on [DATE] at 4:30 p.m. The deficient practice continues at a scope and severity of an E (potential for harm that is not immediate jeopardy/pattern) as the facility must continue to ensure all staff consistently implement measures of Resident accountability during shift change, monitor staff implementation of the "outdoor monitoring guidelines" established on [DATE] as part of the IJ removal. The facility must continue to ensure each new Resident is assessed for their ability to be outdoors supervised or unsupervised. Further evidence of continued deficient practice at severity level 2 is evidenced by the following. - According to a facility self report investigation dated [DATE] while completing an investigation into an allegation regarding staff behaving inappropriately, the facility discovered that on [DATE] Certified Nursing Assistant (CNA)-Y transferred Resident #2 without having two staff present and without using the proper lift. CNA-Y transferred Resident #2 by herself using a stand lift instead of a Hoyer lift. Findings include: 1. From [DATE] through [DATE], Surveyor # reviewed Resident #1's medical record. Resident #1's medical record indicates Resident #1 was [AGE] years old and originally admitted into the facility from the hospital on [DATE]. Resident #1's [DIAGNOSES REDACTED]. The hospital summary report dated [DATE] sent with Resident #1 to the facility indicated Resident #1 had been residing in an Assisted Living facility prior to hospitalization . Resident #1 was admitted via the emergency roiagnom on [DATE] with increased confusion and was subsequently admitted into the hospital for further evaluation. While hospitalized Resident #1 underwent cataract surgery. The hospital transfer form dated [DATE], indicates Resident #1 is forgetful, uses a walker, needs assistance with walking and toileting and is independent with dressing and feeding self. The hospital transfer form also indicates Resident #1 is legally blind, right eye surgery on [DATE] and requires moderate assistance for hygiene. Resident #1's condition was stable for discharge and was discharged to the facility on [DATE]. The facility completed an admission Minimum Date Set (MDS) on [DATE] and an MDS on [DATE]. The MDSs indicate, " It was very important for Resident to go outside to get fresh air when the weather is good. " The MDSs indicate Resident #1 usually understands and is understood. Resident #1's vision is highly impaired. Resident #1's cognitive patterns were noted as moderately impaired. These assessments indicate that Resident #1 transfers and ambulates with extensive assistance with one person physical assist. Resident #1's locomotion on the unit was limited assistance with one and off the unit was extensive assistance with one. Resident #1 used a wheeled walker or wheelchair to get around. Resident #1's balance during transitions and walking was noted as not steady, only able to stabilize with human assistance. Resident #1 was noted to have upper extremity range of motion limitations. Resident requires supervision with one staff for eating. Resident was occasionally incontinent of bowel and frequently incontinent of bladder. The MDSs indicate Resident #1 did not have a condition or chronic disease that may result in a life expectancy of less than 6 months. As part of the [DATE] MDS, the facility completed Resident Care Area Assessments. The Resident Care Area Assessments indicate Resident is able to drink independently and fluids are kept within reach and encouraged. Resident is monitored for signs and symptoms of dehydration. Per dietician 2610 cc fluid intake. Physician orders [REDACTED].#1 was receiving Lasix (for edema) 40 mg. daily, Hydralazine (Hypertension/HTN) 50 mg. 3 times a day, Clonidine (HTN) 0.1 mg. every 8 hours, and Gabapentin (neuropathy) 300 mg three times a day. According to Drugs.com, http://www.drugs.com/lasix.html, Lasix/Furosemide is a diuretic which treats fluid retention in people with congestive heart failure, liver disease, or a kidney disorder, and high blood pressure (hypertension). Lasix will make you urinate more often and you may get dehydrated easily. Avoid becoming dehydrated. Avoid exposure to sunlight. Side effects may include dry mouth, thirst, feeling weak, drowsy. According to Drugs.com, Hydralazine is used for treating high blood pressure. Hydralazine may cause dizziness, lightheadedness, or fainting; alcohol, hot weather, exercise, or fever may increase these effects. Drugs.com indicates, Clonidine lowers blood pressure. Side effects may include, feeling dizzy, tired, and dry skin. According to Medline Plus, http://www.nlm.nih.gov/medlineplus/druginfo/meds/a 7.html, Gabapentin is used to relieve pain of diabetic neuropathy. Side effects may include drowsiness, tiredness or weakness, dry mouth. On [DATE] at 12:30 p.m., Surveyor # interviewed Registered Nurse (RN)-G who stated she worked first shift on [DATE]. (First shift is from 6:00 a.m. to 2:30 p.m. and second shift starts at 2:00 p.m. until 10:30 p.m.) RN-G stated on [DATE], Resident was his usual self, a little tired in the morning, rested after breakfast, elevated legs/tubigrips, up for lunch, propels self in wheelchair, ambulates with 2 wheeled walker, was able to communicate needs, alert, oriented, confused at times. Was not aware of Resident going out on the patio before this. Usually staff stay with the resident when out on the patio, doesn't know where resident was found. If you go out to the patio the door alarm goes off, never tried getting in from the patio. Resident was on 1 hour checks but this was discontinued yesterday [DATE]. LPN-M was the second shift nurse yesterday. On [DATE] at 12:55 p.m., Surveyor # interviewed Occupational Therapist (OT)-H and Rehab Coordinator- I. OT-H stated she saw Resident yesterday ([DATE]) at 2:10 p.m. and Resident wanted to go outside. OT-H went outside to the front entrance of the building patio area with Resident. Five minutes later, we discussed it was too warm outside. We tried a few exercises but it was warm so we told him it was time to come in and the session was almost over. We wheeled him back in. He was resistive to coming back in, putting his feet on the ground. Eventually he was brought in about 2:30 p.m. Sunscreen had been applied on his face and arms. Once in the building, he insisted he wanted to go back outside. We couldn't sit with him, so I told him we would talk to the nurse. OT student told nurse he wanted to stay outside and we couldn't stay with him. So nurse went and got him from therapy hallway. Nurse wheeled him away and that was it. I didn't see him again. The nurse was LPN-M. He was insistent on going outside and enjoyed warm weather. Rehab Coordinator-I indicated she also saw Resident yesterday on [DATE]. Rehab Coordinator- I stated Resident wanted to go outside and Resident stated that no one will let him go outside. Resident stated, "I pay the bills, I can go out if I want." Rehab Coordinator-I stated she checked with the nurse, sunscreen applied...was outside from approximately 2:15 p.m. to 2:30 p.m., not more than 15 minutes, underneath a table with an umbrella. A Physical Therapy Daily/Weekly Summary dated [DATE] indicates that on [DATE], Patient requested to be outdoors...Patient refused to come back into building. Physical Therapy Assistant was involved to assist return patient to building. Weather was very hot/sunny. Physical Therapist concerns of heat and sunburn. Patient was safely brought in. On [DATE] at 12:15 p.m., Surveyor # interviewed Social Work Assistant (SS)-F regarding Resident #1. SS-F stated Resident had previously lived in an assisted living facility and was placed at the facility after a hospitalization . SS-F stated Resident was legally blind in both eyes. SS-F stated, I was at the nurse's desk and heard her (Licensed Practical Nurse/LPN-M) say she was going to take him out and that she would check on him in 15 minutes; LPN-M needed the code to exit out the door. I did not physically see LPN-M take him out. At close to 3:00 p.m., when I was going to my office I saw him outside sitting on the patio. It was the first time I saw him outside. I was walking towards the office and saw him through the glass (patio windows). The door to the patio is alarmed and it will alarm if anyone goes out. He was observed not sitting under the covered (awning) and not at a table with an umbrella. SS-F stated Resident would have to ask to go out out due to the alarm. With Resident's recent return from the hospital ([DATE]), he appeared more confused. Initially Resident was on 15 minute checks for suicide precautions. Then it went to 1 hour checks and on [DATE] at 1:00 p.m., the 1 hour checks were discontinued. On [DATE] at around 2:30 p.m., I was in his room with him. I left work at 4:50 p.m. and did not see him after the 3:00 p.m. observation. On [DATE] at 10:00 a.m., Surveyor # interviewed LPN-M over the phone. LPN-M stated that on [DATE], Resident would not return to the unit and so occupational therapy came to get me. LPN-M talked to Resident to calm him down. LPN-M stated Resident wanted to go outside. Agreed to go out in the enclosed area. Took to patio and put Resident in clear view of the patio door at approximately 2:55 p.m. I later asked the CNA assigned to him if she accounted for her residents and she said she had. The CNA was late; the routine is that when a CNA is late, the other staff help out until the CNA gets here. The CNA arrived at about 3:,[DATE]:25 p.m. Once the CNA stated she had accounted for the Residents, I began passing medications and attending to other Residents. I returned to the nurse desk area around 3:,[DATE]:45 p.m. and observed Resident sitting outside in front of the doors. He wasn't one who did a lot of moving. That was the last time I viewed him. The physician came in and wanted to see Resident. I directed the physician to Resident's room and the physician stated Resident was not in his room, and not in dining room and again not in his room. I went to patio door and didn't see Resident because he was behind the door which is covered by the window curtain inside. I do not know who actually found Resident. I left the patio door propped open by placing magazines between the door and the door jam. Was thinking when CNA got to work, he would be accounted for and would be brought back in. The door alarm was turned off and reactivated once they found Resident. I helped bring him in and the physician saw him. RN Supervisor-O took over. CNA-R knew he was out there as well, she knew about it, she was right there after putting him out there. When asked if LPN-M provided fluids to Resident while Resident was out on the patio LPN-M stated, "No." Surveyor # questioned LPN-M as to why her facility written statement stated, "offered fluids." LPN-M stated, "If I wrote it, it was a mistake, at the time of the written statement I was told Resident had eaten and drank." According to the facility's time sheet on [DATE], LPN-M punched in at 2:16 p.m. and punched out at 9:18 p.m. On [DATE] at 10:46 a.m., Surveyor # interviewed CNA-R over the phone. CNA-R stated that on [DATE] at around 2:35 to 2:40 p.m., she saw LPN-M with (Resident #1). CNA-R indicated that prior to finding Resident at 6:00, no one mentioned he was outside. "I did not check on him or provide him with fluids." On [DATE] at 1:35 p.m., Surveyor # interviewed CNA-Q. CNA-Q stated, we are supposed to check Residents every 2 hours...that day ([DATE]) I was asking where Resident was, did he go out with family? No one answered. If someone would have told us he went out but no one did it that day. On [DATE] at 7:05 a.m., Surveyor # interviewed Assistant Director of Nursing (ADON)-E who stated on [DATE] she asked CNA-P if she had seen Resident when she first came on duty at approximately 3:00 p.m. and she (CNA-P) said no and made excuses. I asked CNA-P, did LPN-M ask you to check on Resident and did she know where Resident was? CNA-P said, "No, (LPN-M) did not and I thought Resident was in therapy." ADON-E stated, "I asked (LPN-M) did you go out and check up on him? (LPN-M) said, "No, I didn't, I did see him from the nurses station at approximately 1545 (3:45 p.m.), he was on the other side of the patio door." ADON-E stated that on [DATE] she got statements from all staff working on the unit that night. ADON-E stated she asked all of the staff on duty if anyone checked on (Resident #1.) ADON-E stated all of their answers indicated no. Their answers were, "No one saw him or checked on him." ADON-E also asked if anyone gave Resident his tray and all of the staff interviewed said, "No." ADON-E stated she obtained one statement from Dietary Aide-N who reported Resident was not in the dining room so she put a tray in the refrigerator for him. ADON-E stated, LPN-M's written original statement included she gave Resident fluids however; she (LPN-M) told me she did not offer fluids, I think she was so shook up. No one checked on Resident 1 while he was outside on [DATE] from 2:55 PM to 6:00 PM. On [DATE] at 3:55 p.m., RN Regional Clinical Services (RN) -C informed Surveyor # that the facility did not have a written policy for when Residents go outside. On [DATE] at 4:15 p.m., Surveyor # met with Administrator- A, RN-C, Director of Nursing (B), and RN-D. Surveyor # was informed that the facility does not have a written policy regarding Resident's being outside. Surveyor # asked if the facility has a verbal policy regarding Resident's being outside? Surveyor # was informed the facility verbally instructs staff to provide water to residents who go outside, and to monitor residents. The monitoring of the resident depends on the individual Resident and is on the Resident's care card. On [DATE] at 3:50 p.m., Surveyor # interviewed Dietary Manager (DM)-K who stated Resident did not receive dinner on [DATE]. Dining room doors open 15 minutes before meals. They start at 4:30 p.m. and DM-K left the facility at 5:00 p.m. while the staff were still serving. The process is that dietary staff make up trays and after everyone is served any tray left should be communicated to a certified nursing assistant (CNA) or preferably a nurse to see where the resident is. They would not be able to identify what trays are left until about 5:00 to 5:15 p.m. The aide should have said something, DM-K was uncertain if the dietary aide said anything to the Certified Nursing Assistant (CNA) or the Nurse at the time of this interview. According to the facility's investigation, Dietary Aide-N documented that on [DATE] between 5:30 and 5:45 p.m., Dietary Aide -N placed Resident #1's tray into the refrigerator when Resident #1 did not come to supper. There is no evidence Dietary Aide-N alerted staff that Resident #1 did not show up in the dining room. This was contrary to facility policy on Resident Supervision/General Supervision effective [DATE]. The policy states, general supervision will be maintained at all times. Residents on general supervision are able to move around the center at will...during night shift, Residents will be checked every two hours. Staff should be aware of which Residents fail to attend scheduled activities such as meals, etc. Staff should check on Residents who do not arrive for scheduled activities and inform the nurse on charge or shift supervisor when Resident can not be found. On [DATE] at 10:46 a.m., Surveyor # interviewed CNA-R over the phone. CNA-R stated around supper time she started pushing Residents into the dining room and assisted with the meal. CNA-R stated Resident #1 sits at the same table with 2 other male Residents and noticed Resident was not at the table. At around 5:30 p.m., LPN-T and RN-O asked if she had seen (Resident #1). CNA-R stated, "I went to check the patio, opened the door, and saw him (Resident #1) in the corner. I couldn't see him until I got to the door. The window curtain had been in the way and I couldn't see him. The door to the patio was closed and a deck of cards was on the cement outside. I had to push the door open and the door alarms did not go off. I went to touch him and called his name. He did not look good, I thought he passed away, the MD was here and checked him with a stethoscope. Once in the building, I helped place him in bed. Prior to finding Resident, no one mentioned he was outside. I did not check on him or provide him with fluids." On [DATE] at 1:35 p.m., Surveyor # interviewed CNA-Q. We put up a tray for him, we were not sure where he was at. I didn't know where he was, I was busy with my own assignment. I saw him at 2:00 p.m. with therapy out in front of the building, later that day, didn't recall seeing him. Around 6:00 p.m., I was asked if I saw him. I had to bring him in. I felt on him. He had a foam substance on his forehead and mustache, tongue was white, blisters on arms. He was wearing a short sleeve red top. He was really hot, on fire when touched. He was in the wheelchair, brought in and placed in room. I left when the nurse and the paramedics came into the room. Resident had been out on the patio a lot of times. Surveyor # asked CNA-Q as to whether Resident was able to get in from the patio by himself. CNA-Q stated, "I feel like not, I think by standing and opening the door would not be easy, would be hard to open, he was very weak and not doing well." An Accident/Incident Report was provided to Surveyor # on [DATE]. The Accident/Incident Report dated [DATE] at 1800 indicates, Resident found on patio at corner of the building unresponsive by CNA (Certified Nursing Assistant)- Help summoned-MD came, 911 called. Resident pronounced dead by MD. The Accident/Incident Report indicates Resident was alert and oriented times 3, expressed wishes to be outside. Vital signs: Pulseless, no respiration. Blood Sugar results at 3:00 p.m., 110. Education given to all staff regarding the monitoring of fluids when temperatures outside elevated. Two staff suspended. A physician's progress note dated [DATE] at around 6:00 p.m. states, "Patient found on porch. Patient had obvious sign of prolonged death. Patient was pronounced dead at this time. CPR (Cardiopulmonary Resuscitation) would not be appropriate. Surveyor # reviewed the Police report dated [DATE], which references RN-O's contact with the medical examiners office. The Police report indicates Resident was wheeled outside in his wheelchair at approximately 2:45 p.m. At 6:00 p.m., an employee went outside and found Resident unresponsive...911 was called...RN-O was unable to tell if anyone had checked on Resident while outside. The medical examiner advised to take Resident's temperature and it was taken at 7:52 p.m. and found to be 101.4. Surveyor # reviewed the medical examiners Demographic Report dated [DATE] indicates (Resident #1) was last seen on [DATE] at 6:00 p.m. and was last seen alive on [DATE] at 2:45 p.m. The medical examiners Demographic Report states (Resident #1) was in full rigor with lividity posterior, purplish and partially blanching. He was dressed in shoes, socks, Ted stocking to right leg, sweat pants and T-shirt. He was warm to touch. He had skin slippage to the arms, chest and legs. There was a large amount of foam at the mouth. There was no trauma noted. The deceased was conveyed to this office for autopsy...the outdoor temperature reached a high of 97 degrees at about 3:00 p.m. as listed in J.S. online. Apparently the Health Department also issued weather related advisories as to the heat index and warning residents of the condition..." On [DATE] at 10:56 a.m., Surveyor # interviewed MD-U who was on-call for Resident #1's primary physician. MD-U stated he arrived at the facility on [DATE] at 5:30 p.m. and left at 6:30 p.m. MD-U stated he came to the facility to see several Residents. MD-U stated, " when I asked where (Resident #1) was, the nurse insisted (Resident #1) was in his room. I told the nurse he was not in his room. I told the nurse several times to find out where Resident was. I went to (Resident #1's) room and he was not there. I went to another Resident's room and returned to (Resident #1's) room and he still was not there. MD-U stated, I told the nurse he was not in his room and the nurse insisted he was. I saw another Resident and when walking out of that Resident's room, staff stated they found (Resident #1). This process of trying to find (Resident #1) was at least 20 to 30 minutes. They came and found me and needed me immediately, 911 was already called. It was obvious Resident was deceased , he was extremely hot when I examined him for a pulse check. It was very hot that day. The metal parts on his wheelchair was very hot. Resident's head all the way down was pale, blood pooling at the ankles, If I were to guess the time, Resident was deceased at least greater then 30 minutes, early rigor mortis set in. Resident was outside on the back patio. If you look out the door, he was right behind the door, by the wall corner. If you look out the door fast, you couldn't see him. Resident was moved to a bed but it took about 10 to 15 minutes in order to move the other Residents out of the T.V. area. The Resident's temperature taken 2 hours later at 101.4 would mean Resident was hotter outside when found. The temperature would have been over 101 degrees. Most people's temperatures drop when they pass away. Without a doubt, the heat affected Resident. He had diarrhea and renal failure. His Lasix was increased due to leg swelling and at the same time worsening of renal failure. If the heat did not cause Resident #1's death, without a doubt, it played a role in contributing to his death. If Resident was young and healthy, being out there for 2 to 3 hours without fluids, would make him extremely ill." The Milwaukee Journal Sentinel dated [DATE] indicated on [DATE], "a heat advisory was in effect for all southern Wisconsin, including the city of Milwaukee, in other words hot and humid. Slow down a bit today and keep cool. Temperatures will be in the low to mid 90's...it will be very uncomfortable at times, especially in the afternoon." The Milwaukee Journal Sentinel (JS) dated [DATE] indicated the high temperature in Milwaukee on [DATE] reached 97 degrees. On [DATE], Surveyor # asked DON-B to clarify as to which CNA was specifically assigned to Resident #1 on [DATE] from 2:00 to 3:00 p.m. On [DATE], DON-B stated that Resident #1 was not physically assigned to any CNA specifically as he was in therapy until 2:30 p.m. and all staff on the unit answer call lights. On [DATE] at 4:30 p.m., Surveyor # received the facility's self report investigation. Based off of review of the facility's investigation, information reviewed remained consistent with the above findings. Surveyor # observed the first floor T.V. area, the exit door to the patio and the enclosed patio on [DATE], [DATE], [DATE], and [DATE]. Surveyor # observed the T.V. area has 2 walls primarily made of windows that look out into the enclosed court yard. The windows have curtains which are pulled back to the corner of each window. These curtains cover some parts of the windows so that some parts of the court yard could not be viewed. There is also a glass exit door that opens directly into the courtyard. This exit door is equipped with a Code Alert Freedom Series Model 70 alarm. This door dually activates when ever anyone exits the door and when a Resident with a wander-guard tries to exit. The alarm for this door can be turned off manually at the nurses desk. Upon exiting the door into the court yard, the facility has a large outside temperature gauge attached to the outside wall. The patio is enclosed by a fence with a gate and is partially covered by an awning and 5 tables with umbrellas. The patio also has areas that are not covered by either the awning or the tables/umbrellas. Once out onto the patio and the exit door is closed, Surveyor noted that the door locks. The only way to get back into the facility is to press a door bell located on a speaker box which alerts the staff of the need to release the doors locking device in order to open the door. The door bell is 47 to 48 inches from the ground. Surveyor # noted it may be difficult for a Resident in a wheelchair to reach the doorbell to get back into the facility. Surveyor # also noted that the door bell may also be difficult to see for a Resident who has visual impairment or who is legally blind. On [DATE], Surveyor # and RN-G went outside to view the patio. Surveyor # asked RN-G if she thought Resident #1 could independently get back into the facility. RN-G stated she was not sure. RN-G stated Resident would have had to push the button for reentry and was not sure if Resident #1 could do so due to being blind. According to interviews with LPN-M, Resident #1 was initially placed right outside of the exit door. During conversation with the Assistant Director of Nursing -E on [DATE] at 7:44 a.m., Resident #1 was found further back in the corner behind the door, which is an area blocked from viewing due to the inside window curtain. On [DATE], facility staff did not provide Resident #1 with the supervision necessary to prevent an accident. On [DATE], Resident #1 who was medically compromised due to his diagnosis, medications, and physical limitations, was placed outside and left unattended from approximately 2:55 p.m. until 5:55 p.m. Staff did not physically check on Resident #1, nor did staff know of Resident #1's whereabouts with the exception of a visual observation made of Resident #1 from the nurses desk by LPN-M at 3:30 to 3:45 p.m. There is no indication Resident #1 was physically checked on to ensure Resident #1's safety and was provided with fluids even though a "heat advisory" was in effect. On [DATE], the temperature reached 97 degrees. Resident was wearing sweat pants and a T-shirt along with a Tubi grips and socks. No one checked Resident #1 to ensure his clothing remained appropriate after sitting outside for an extended period of time and to check on his condition. On [DATE], Dietary staff did not notify the nurse when Resident #1 did not come for supper. On [DATE] from 2:55 p.m. to 5:55 p.m., Resident #1 was not provided with prompted toileting before supper/meal, was not provided with encouragement for adequate hydration, monitoring for shortness of breath, change in level of consciousness, or position change as indicated in Resident #1's plan of care dated [DATE]. On [DATE] at 5:55 p.m., Resident #1 was found outside in the enclosed patio dead. On [DATE] at 7:50 p.m., Resident #1's temperature was 101.4 degrees (temporal/taken by ear). Leaving Resident #1 unmonitored in 97 degree weather with no shade, fluids or the provision of care plan interventions, resulted in a finding of immediate jeopardy for Resident #1. The facility removed the immediate jeopardy on [DATE] at 4:30 p.m. by which time it had: 1. Provided education to 80% of their staff on hydration and knowledge of resident where- about's. All remaining staff will be educated prior to shift duty. 2. Developed and instituted "Outdoor Monitoring guidelines" to ensure Residents for safety. The patio will be for supervised activities. All residents have been assessed for safety regarding outdoor activities and all care plans and Nursing Assistant Care Cards have been updated. 3. Upon arrival to the units, Certified Nursing Assistants will complete unit rounds with the previous shift nursing assistants documenting visual observation of each resident under their care and supervision. If any Resident can not be accounted for, the nurse will be immediately informed and a missing resident will be initiated. 4. Staff will monitor Residents throughout their shift based off of individual needs. 5. Dietary staff will inform the nurse of any Resident not receiving a tray in writing by the end of meal service and the nurse will sign written notification. This will be monitored by the Dietary Services Manager. 6. Any staff scheduled to start a shift at a time other than normal start of shift will be replaced by a staff member. This will be monitored by the Director of Nursing. 7. Weather advisory radios are in place at each nurses station. 8. The above will be reviewed at the QPI meetings to determine need for any further educations and continued monitoring. The deficient practice continues at a scope/severity of E as evidenced by the ongoing threat to residents who are left outside unattended (which continues until all inservicing is completed) and by the following example. 2. On [DATE]-[DATE], Surveyor # reviewed the facility self report dated [DATE] & medical record regarding Resident #2. The facility self report indicates that during an investigation into an allegation that staff were being loud, laughing, obnoxious and unprofessional etc. it was discovered that on [DATE] Certified Nursing Assistant (CNA)-Y transferred Resident #2 without the assistance of a second staff person and an improper lift was used. Resident #2 is [AGE] years old with [DIAGNOSES REDACTED]. Resident #2's annual Minimum Data Set ((MDS) dated [DATE] indicates that Resident #2 requires extensive assistance for transfers with two plus staff for assistance. The Resident Assessment Protocol (RAPs) dated [DATE] indicates under the problem area for falls: Resident is assist of two with transfers and Hoyer lift. Review of Resident #2's care plans for ADL/Mobility (Activities of daily living/mobility) and Fall/Injury Assessment: Prevention and management plan of care that were rewritten on [DATE] with a current due date of ,[DATE] indicate that Resident #2 has a goal and intervention to transfer with the assistance of two with the use of a Hoyer. The CNA Care Plan dated [DATE] indicates for Resident #2 under mobility: Transfer: assist 2 w/Hoyer (with Hoyer). On [DATE] Surveyor # reviewed the personnel file and competency information regarding CNA-Y. Included in this documentation is a training record indicating that CNA-Y received training on [DATE] regarding customer care service, safe transfer, and the use of the assist of 2 with a mechanical lift. On [DATE] at approximately 3:20 pm Surveyor # observed CNA-Y preparing to transfer Resident #2 to bed. Surveyor asked CNA-Y about transferring Resident #2. CNA-Y indicated that she needed to go get the other lift and another CNA before she could transfer Re

Based on observations, record review and interviews, the facility did not ensure that 1 (Resident #1) of 9 residents sampled with urinary incontinence, received the appropriate treatment and services to restore as much normal bladder function as possible. Resident #1 experienced a decline in urinary continence from being frequently incontinent in December 2009, to total incontinence in June 2010. The facility had not completed a comprehensive assessment, including a voiding diary, and had not developed a plan of care that reflected modified interventions related to mobility changes experienced by Resident #1. Between December 2009, and June 2010, Resident #1 went from requiring 2 persons to assist with transfers, to requiring the use of a mechanical lift for safe transfers. Findings include: Surveyor # reviewed Resident #1's record on 8/19 - 8/24/10. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's quarterly Minimum Data Set Assessment (MDS), dated [DATE], revealed Resident #1 is totally incontinent of bladder. This is a decline in bladder continence since the annual MDS completed on 12/22/09, when Resident #1 was occasionally incontinent. A Bladder Data Collection and Assessment form dated 12/16/09, indicates Resident #1 is alert and oriented x 3 and is able to make needs known. She is a 2 person assist and needs to be toileted at regular intervals. A Bladder Data Collection and Assessment form dated 6/10/10, indicated Resident #1 was apparently unaware of toileting needs, is incontinent of bowel and bladder. Resident is to be checked and toileted before and after meals, at bedtime and at 2:00a.m., and 4:00a.m. Review of Resident #1's Care Tracker Bowel and Bladder elimination information indicates the facility monitored Resident #1's bladder continence from 05/28/10-06/11/10. Bladder data on the Resident Bowel and Bladder Sheet, indicates incontinence episodes were recorded 1 time per shift for most of the shifts during the time frame of 05/28-06/11/10. Resident #1's bladder elimination data indicates she was continent of bladder during 5 shifts and incontinent of bladder during 34 shifts of the monitoring period. The Resident Bowel and Bladder Sheet does not indicate at what time during each shift of the monitoring period, Resident #1 was either continent or incontinent of bladder, to identify a bladder elimination pattern to enable the facility to complete a thorough assessment of Resident #1's bladder elimination status. Review of Resident #1's plan of care-Alteration In Urinary Continence Plan Of Care dated 06/10, indicates a problem of incontinence. Interventions relating to Resident #1's incontinence include complete Care Tracker 3-day elimination tracking to determine a voiding/incontinence pattern and to toilet Resident #1 upon rising, before and after meals, at bedtime and at 2:00a.m. and 4:00a.m. Resident #1's Certified Nursing Assistant (CNA), Care Card instructs staff to offer a bedpan every two even hours during the night, and check every 2 hours as needed, before and after meals, at bedtime and at 2:00a.m. and 4:00a.m. On 8/23/10 at 8:30a.m., Surveyor # asked RN-Q about Resident #1's toileting needs. RN-Q stated Resident #1 used to be able to say when she needed to use the toilet, but no longer seems to know when she needs to have a bowel movement or urinate. On 8/19/10 at 1:15p.m., Surveyor # observed CNA-P complete incontinence care for Resident #1. Resident #1 was transferred to bed using a mechanical lift. Once in bed, CNA-P removed Resident #1's soiled (urine only) incontinence brief. CNA-P cleansed Resident #1, applied barrier cream and a clean brief. On 8/24/10 at 8:00a.m., Surveyor # observed RN-R provide incontinence care for Resident #1 prior to completing a treatment to Resident #1's pressure ulcer. Resident #1's soiled brief (urine only) was removed, the perineal area was cleansed and a clean brief was provided. As RN-R was leaving the room, Resident #1 stated she was urinating. Surveyor # asked Resident #1 if she could feel when she needed to urinate. Resident #1 stated "yes". Surveyor # asked Resident #1 if she ever used the bedpan. Resident #1 stated she has used the bedpan, but it was too small and she didn't like the bedpan because it was too small. When interviewed by Surveyor # on 8/24/10 at 1:20p.m., Certified Nursing Assistant (CNA) - P, stated that Resident #1 can at times feel she is urinating and will tell staff so they can change her. CNA-P stated Resident #1 can no longer use the toilet due to the need to utilize a mechanical lift for transfers. CNA-P also stated that Resident #1 does not care for the mechanical lift, but it was required for safe transfers. CNA-P stated Resident #1 sometimes uses the bedpan. CNA-P stated Resident #1 uses a fracture bedpan (smaller that a regular bedpan), and CNA-P was not aware that Resident #1 did not like the small bedpan. CNA-P stated that during the dayshift Resident #1 is usually checked and changed, but the second and third shifts reportedly use the bedpan. On 8/23/10 at 8:30a.m., Surveyor # interviewed RN-Q regarding the facility's process of obtaining urinary incontinence data. RN-Q stated that the CNA's document in the Care Tracker when the resident urinates, and RN-Q uses that information for the assessment. When asked if the CNA's check the resident every hour during the bladder diary time frame, RN-Q stated no, the CNA's do the usual check and change routine, and document if the resident is incontinent. On 8/23/10, Surveyor # received a copy of the facility's procedure for addressing urinary incontinence. According to the procedure, factors to be included in assessment for incontinence include patterns of incontinence episodes, and daily voiding patterns. The procedure also stated that for residents on a scheduled check and change program the schedule should be based on the resident's voiding pattern and accepted standards of practice.