Every finding on record at Three Oaks Health Services

Based on observation, interview, and record review, the facility did not ensure proper disposal of garbage and refuse.-Grease dumpster was open.-Cigarette butts all over the ground outside the back door.-Cardboard box with plastic and other garbage materials frozen to the ground outside the dumpster.Findings include:Facility Policy titled, Dispose of Garbage and Refuse, last revised 02/2025, reads in part: All garbage and refuse will be collected and disposed of in a safe and efficient manner .The Dining Services Director coordinates with the Director of Maintenance to ensure that the area surrounding the exterior of the dumpster is maintained in a manner free of rubbish or other debris .All trash will be properly disposed of in external receptacles (dumpsters) with lids covered when not in use.On 03/02/26 at 9:06 AM, Surveyor completed the initial kitchen tour with Dietary Manager (DM) N. DM N showed Surveyor the location of the dumpsters outside a back door. Upon exiting the building, Surveyor observed a large amount of cigarette butts scattered across the ground outside the back door. Surveyor observed the grease dumpster door on top was open. DM N closed it. Surveyor observed a large cardboard box which contained plastic and other debris behind the dumpster. DM N stated DM N was going to pick it up immediately but was unable to as it was frozen to the ground. DM N stated if staff ever have concerns with pests or rodents, there are people that come and take care of it.On 03/03/26, Surveyor observed the cigarette butts were still present on the ground, and the box behind the dumpster was still frozen to the ground.On 03/04/26 at 11:15 AM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A acknowledged the garbage should not be on the ground and around the dumpster and the dumpsters should be closed.

Based on observation, interview, and record review, the facility did not provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections which had the potential to affect all 65 residents (R).-Residents were not offered hand hygiene prior to meals.-Improper use of Personal Protective Equipment (PPE) by kitchen staff.-Staff did not wear gloves and/or gown during observation of wound care for resident R10.Findings include: Example 1 Facility policy titled, Hand Hygiene, last revised 11/02/22, reads in part, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors.Hand hygiene is indicated and will be performed.Before and after eating.before performing invasive procedures.before and after performing care to residents in isolation. On 03/02/26 at 12:35 PM, Surveyor observed no hand hygiene offered to residents prior to receiving meal. On 03/03/26 at 8:04 AM, Surveyor observed residents entering the dining room for breakfast were not offered hand hygiene prior to being served their meals. On 03/03/26 at 8:36 AM, Surveyor interviewed Certified Nursing Assistant (CNA) G. CNA G stated they usually wash the residents' hands prior to bringing them out of their rooms. CNA G stated she was unsure about the residents that go to the dining room independently after touching walkers and wheelchair wheels. Example 2 On 03/03/26 at 10:58 AM, Surveyor entered the kitchen to watch temping. Surveyor observed [NAME] Q and Dietary Manager (DM) N with their face masks down. Masks were pulled up into place once [NAME] Q and DM N were aware that Surveyor was present. DM N acknowledged the masks should have been on properly. On 03/04/26 at 10:20 AM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A stated it would be the expectation if utilizing a universal masking for staff, all staff should have their masks on. NHA A also stated the kitchen staff should definitely have their masks on. Surveyor updated NHA A that upon walking into the kitchen for follow up, staff present had their masks down. Example 3 R10 was admitted to the facility on [DATE] with a diagnosis including peripheral vascular disease. R10 had wounds that developed from a bunion on second left toe and second right toe. On 10/11/24, R10 was placed on Enhanced Barrier Precautions (EBP) for her indwelling Foley catheter. On 12/29/25, progress note indicated a skin assessment post fall included, open areas to knuckle on the 2nd and 3rd toe of the left foot and on 1/16/26 noted wound to right foot open area of bunion of 2nd toe on right foot. Most recent wound care order on 2/21/26 includes, wound of the left 2nd toe & right bunion: cleanse with normal saline, apply iodosorb, apply calcium alginate, cover with dry dressing daily, one time a day for wound healing. On 3/04/2026 at 6:31 AM, Surveyor observed Registered Nurse (RN) J provide wound care to R10. RN J obtained a bin of R10's wound supplies from the nurse's station. Prior to entering R10's room, RN J put on a gown. RN J did not put on gloves before taking off R10's socks, touching R10's feet that were bandaged, and positioning R10's feet over a disposable gown on the floor. RN J then put on gloves. During wound care, Surveyor observed RN J remove her gloves, leave R10's room to get bandage scissors out of her lab coat pocket left in the hallway, return to resident's room, handle contents of wound care tub without gloves and cut a piece of dressing to apply to R10's wound. During wound cares, R10 expressed discomfort while cleansing her 2nd wound. RN J stopped to give R10 her Tylenol. RN J stated she doesn't typically do R10's dressing change so she is uncertain for the need to pre-medicate R10 before doing wound care. On 3/04/2026 at 6:40 AM, Surveyor observed RN J reenter R10's room without putting on gloves or a gown and bent over top of R10's legs with R10's wound exposed. RN J put R10's sock on her left bandaged foot. RN J, with ungloved hands and no gown, then took a towel placed under R10's right foot with exposed, uncovered wound, lifting up R10's right leg, and gathered old dressing off the floor to dispose of. Immediately after this observation, Surveyor interviewed RN J regarding EBP with wound care. RN J stated she should have worn a gown and gloves when providing direct care such as dressing R10 and repositioning R10's legs, during R10's wound care and with R10's exposed wound. On 3/4/26 at 7:45 AM, Surveyor interviewed Director of Nursing (DON) B, who reported her expectations would be that staff wear gowns and gloves when performing wound care and when dressing resident on EBP.

Based on interview and record review, the facility did not ensure that a resident who requires dialysis receives such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 1 sampled resident (R52) reviewed for dialysis.The facility failed to provide ongoing assessments of R52's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. This is evidenced by:Facility's policy titled Hemodialysis with revised date of 09/10/23 documented in part, The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatment received at a certified dialysis facility.4. The licensed nurse will communicate to the dialysis facility by utilizing the Pre-dialysis Communication UDA, that will include, but not limit itself to:.b. Physician/treatment orders, laboratory values, and vital signs; On 2/21/26 at 12:04 PM, post dialysis assessment documented the weight that was obtained prior to dialysis of 169.2 at 5:24 AM. The facility staff did not obtain a weight when R52 returned from dialysis. On 02/24/26 at 7:53 PM, post dialysis assessment documented the blood pressure, pulse and respirations that were obtained prior to dialysis at 4:37 AM. The facility staff did not obtain blood pressure, pulse and respirations when R52 returned from dialysis.On 02/26/26 at 1:34 PM, post dialysis assessment documented the weight that was obtained prior to dialysis at 5:24 AM of 183.6 pounds. The facility staff did not obtain a weight when R52 returned from dialysis.On 02/28/26 at 5:44 AM, pre dialysis assessment, that is sent to the dialysis center, documented vitals of blood pressure, temperature, pulse, and respirations that were obtained on 02/26/26 at 1:35 PM. Oxygen saturations were documented from 02/26/26 at 5:22 AM. Weight was documented from 02/27/26 at 1:12 PM of 182.4 pounds. The facility staff did not complete a current assessment of R52's condition prior to dialysis.On 02/28/26 at 12:49 PM, post dialysis assessment documented blood pressure, temperature, pulse, and respirations from 02/27/26 at 5:38 PM.On 03/03/26, no pre dialysis assessment was documented prior to R52 going to dialysis.On 03/03/26 at 12:00 PM, post dialysis assessment documented the weight that was obtained on 03/01/26 at 10:14 AM of 178.3 pounds.On 03/03/26 at 2:00 PM, Surveyor interviewed Director of Nursing (DON) B to ask if assessments are to be completed pre and post dialysis. DON B stated assessments are completed and entered on the pre and post dialysis forms. Reviewed with DON B the documented assessments did not have completed current assessments. DON B stated will look for additional information. No further information was providedOn 03/04/26 at 10:43 AM, Surveyor interviewed Registered Nurse (RN) O and RN P asking if pre and post dialysis assessments of R52 are to be completed. RN O and RN P stated R52 leaves before 6 AM and is completed from the prior shift. We would do weight and vitals and everything that pre dialysis form requires. The form is given to dialysis. When R52 returns we would get all the vitals and enter in the computer and on the post dialysis form. If there are new orders from dialysis will be written on the pre dialysis form or call.

Based on observation and interview, the facility did not ensure care and services were in accordance with professional standards of practice that will meet a resident's (R) physical, mental, and psychosocial needs for 1 of 8 residents. (R2)R2's call light was not kept within reach.R2 was admitted to the facility on [DATE], with diagnoses including Parkinson's disease, aspiration pneumonia, weakness, dementia, stroke, larynx cancer, and gastrostomy. R2 is on palliative care. R2's care plan, with a revision date of 10/01/25, states R2 has a self-care deficit due to impaired vision, physical limitations, weakness, fatigue, Parkinson's disease, and pain. R2 requires assistance of one for toileting, transfers, and bed mobility. R2's care plan also notes R2 is fed via tube, at risk for falls, has episodes of pain, has periods of incontinence, and is at risk for complications of tube feedings and high-risk meds.On 12/17/25 at 8:50 AM, Surveyor entered R2's room and found R2 lying in bed with pad call light attached to bed approximately four inches lateral to R2's right upper arm. Surveyor asked R2 if they can reach the call light. R2 lifted up arms, tried to move about but could not find or reach the call light. Certified Nursing Assistant (CNA) C entered the room, checked R2's blood pressure and did not move call light within reach. At 9:15 AM, Registered Nurse (RN) D entered R2's room, completed medication administration, tube feeding dressing change, and began a tube feeding. RN D left the room without ensuring R2 had the call light within reach.On 12/17/25 at 9:56 AM, Surveyor pressed the call light which was answered by Licensed Practical Nurse (LPN) E. Surveyor informed LPN E that Surveyor activated the call light with a concern that R2 was not able to reach it. LPN E agreed that R2 cannot reach the call light where it is currently placed and moved it onto R2's lap. LPN E also elevated the head of the bed until R2's body was approximately at an appropriate 45-degree angle. Important to note at this time R2 was receiving a tube feeding infusion. R2's body was previously at an approximate 20-degree angle which placed R2 at very high risk for complications such as vomiting, reflux, and/or aspiration and no means of using the call light for help.At 10:12 AM, Surveyor informed Director of Nursing (DON) B of the finding noted above. DON B asked how that could be possible, since R2 can sometimes get up enough to self-transfer. Surveyor informed DON B that R2 is at end of life and continues to decline. R2 could not find or reach the call light when asked and needs to be able to reach it at all times, especially on bad and weaker moments/days. DON B acknowledged and voiced understanding.

Based on observation, interview and record review, the facility failed to ensure staff providing care and services to residents (R) who have a feeding tube are competent in and utilize facility protocols/meeting professional standards regarding feeding tube care for 1 of 2 residents reviewed.Staff did not check placement prior to administering medications.Staff auscultated air to check placement prior to beginning tube feeding.R2's body was at a 20-degree angle while tube feeding was being administered. Facility policy dated 08/10/22, titled, Verifying Placement of Tube Feeding, states, in part, 1. Before beginning a feeding, flushing the tube, or administering a medication via the feeding tube, proper placement and functioning will be verified. 2. Resident's head-of-bed (HOB) should be kept elevated at a minimum 30 degrees at all times during the administration of feedings or medications to prevent aspiration and pneumonia.According to https://www.ismp.org/tools/articles/ASPEN.pdf, auscultation is no longer recommended for checking placement of the feeding tube. Movement of air would likely be heard whether the tube was in the correct or incorrect location. R2's care plan, dated 09/19/25, notes, Elevate head of bed 30-45 degrees.R2 was admitted to the facility on [DATE], with diagnoses including Parkinson's disease, stroke, and pneumonia due to inhaling food and vomit, dysphagia, malnutrition, larynx cancer, reflux, and gastrostomy. R2 requires full staff assistance to complete all tube feeding management and care.On 12/17/25 at 9:15 AM, Surveyor observed Registered Nurse (RN) D administer medications to R2 via gastrostomy tube. RN D washed hands, donned personal protective equipment (PPE), placed cloth under tube, flushed tube, administered medication through the tube, and flushed again as ordered. Surveyor asked RN D how s/he checks for placement. RN D replied, I listen with a stethoscope and put air in. I failed to do that this morning.On 12/17/25 at 9:42 AM, Surveyor observed R2 lying at a 20-degree angle. RN D washed hands, donned PPE, checked placement by injection air into the gastrostomy tube while listening with a stethoscope, then administered requested pain medications. RN D flushed tube with water, placed 1 1/2 container of feeding in gravity bag, primed tube, connected the feeding tubing to R2's gastrostomy tube, slowly opened the line, and counted 45 drips per minute. On 12/17/25 at 9:56 AM, Surveyor pressed R2's call light. At 10:02, LPN E answered the call light and Surveyor asked about the elevation of R2's bed. LPN E elevated R2's head of bed up until R2's body was at a 45-degree angle.On 12/17/25 at 10:12 AM, Surveyor interviewed Director of Nursing (DON) B. DON B provided Surveyor with the facility policy regarding tube feeding and stated the expectation would be to have the resident's body at a minimum of 30 degrees, placement should always be checked prior to administration of flushes, medications, or feedings, and it is not advised to inject air to check for placement.

Based on observation, record review, and interview, the facility did not provide a resident the needed supervision and assistance to eat safely per speech therapy recommendations. The facility practice affected 1 of 3 residents reviewed (R1). R1 has cancer of the larynx (throat) and a history of dysphagia (difficulty swallowing) and aspiration pneumonia. On 02/06/25, R1's speech therapy guidelines were not followed when R1 was not given assistance and supervision at mealtime. R1 choked on sweet potatoes. R1's POA, who had just come to visit, found R1 red in the face. No staff were present. R1's POA performed the Heimlich maneuver. The approach to be supervised while eating or drinking was not followed again as observed on survey 02/24/25. The facility's failure to provide the necessary supervision and assistance for R1 to eat safely during meals created a finding of immediate jeopardy that began on 02/06/25. The State Agency (SA) notified Nursing Home Administrator (NHA) A of the immediate jeopardy on 02/27/25 at 2:45 PM. The immediate jeopardy was removed on 02/27/25; however, the deficient practice continues at a scope/severity level D (potential for harm/isolated) as the facility continues to implement their interventions for residents requiring supervision with meals. This is evidenced by: The facility policy titled NSG Accidents and Supervision dated 7/14/2022, reads in part: Policy: The resident environment will remain free of accidents hazards as is possible. Each resident will receive adequate supervision .to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 'Accident' refers to any unexpected or unintentional incident, which results in injury or illness to a resident. 'Environment' refers to any environment or area in the facility that is frequented by or accessible to residents, including (but not limited to) .activity areas. Policy Explanation and Compliance Guidelines: 1. Identification of Hazards and Risks-the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. a. All staff .are to be involved in observing and identifying potential hazards in the resident environment, while taking into consideration the unique characteristics and abilities of the resident. b. The facility should make a reasonable effort in identifying hazards and risk factors for each resident. 2. Evaluation and Analysis-the process of examining data to identify specific hazards and risks and develop targeted interventions to reduce potential accidents . i. Implementing specific interventions as part of the care plan. ii. Supervising staff and residents etc. 4. Monitoring and Modification-Monitoring is the process of evaluating the effectiveness of care plan interventions . a. Ensuring that interventions are implemented correctly and consistently. 5. Supervision-Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: a. Defined by type and frequency. b. Based on individual resident's assessed needs and identified hazards in the resident's environment. Surveyor reviewed R1's record and noted the following: R1's most recent quarterly Minimum Data Set (MDS) completed 1/26/25 noted R1 eats with supervision. R1's Speech Therapy SLP (Speech Language Pathology) Discharge Summary, dates of service 11/08/24-11/26/24, reads Dysphagia Therapy: Diagnosis of dysphagia, oropharyngeal (mouth to throat) phase. Current level of function: thin liquids and mechanical soft/ground textures, minced and moist. R1's nutritional assessment dated [DATE] specifies: Specify other swallowing disorder: H/O (history of) dysphagia, need for altered diet per SLP/MD. H/O radiation to throat. H/O aspiration pneumonia. High risk for aspiration per MD. Recommended to eat with supervision. Diet Order: Regular diet, L2 Mech. Alt texture. Regular/Thin consistency liquids-Regular textured breads, pastries, desserts, and tater tots .Add moisture, gravies and sauces. R1's care plan noted: Focus: I'm at risk for altered nutrition status r/t (related to) dysphagia (difficulty swallowing) and need altered texture diet. I also have a PMH (past medical history) of malignant neoplasm of larynx (throat cancer) s/p (status post) chemoradiation, Parkinson's disease, malnutrition, GERD (gastroesophageal reflux disease), h/o (history of) weight loss. Date Initiated: 5/19/2022. Goal: I will show no signs/symptoms of chewing/swallowing difficulty . Date Initiated: 8/22/23 Revised on: 10/08/24 Target Date: 7/21/2025 Interventions/Tasks: Instructions per Speech Therapy: Small bites and sips. Slow rate with dabble swallow after food as needed. Multiple swallows, give extra time to clear. Frequent and thorough mouth cares. Supervision with eating. R1's Certified Nursing Assistant (CNA) care card included: Instructions per Speech Therapy: Small bites and sips. Slow rate with dabble swallow after food as needed. Multiple swallows, give extra time to clear. Frequent and thorough mouth cares. Supervision with eating. R1's nurses notes included: 2/7/2025 00:08 (12:08 AM) Health Status Note Note Text: When writer approached sight [sic] where resident was her son was putting her back into her wheelchair. ADON (Assistant Director of Nursing) .was there and some other staff members. ADON and son stated that resident was choking on sweet potatoes from supper. The son stated that resident was not able to breathe when he approached her, so he took her to just outside the dining room for help. Writer was in STR (short term rehab) heard To the dining room over the walkie talkie x 2. Then writer was paged to come to area. Resident was noted with coughing up pieces of sweet potatoes into a tissue several times. Unclear to everything that was done or happened, please see ADON assessment and charting. Resident food needs to be the right consistency, easy to chew, with no large or hard pieces that she could choke on. Oak Medical called and updated .with order to continue to monitor and to take vitals q shift for 24 hours. Surveyor reviewed Assistant Director of Nursing (ADON) D's assessment of the incident above. The assessment noted vital signs as stable and lung sounds clear. Recommending a trial period of pureed foods. On 2/24/25 at 9:20 AM, Surveyor interviewed Power of Attorney (POA) F (R1's son) regarding R1's incident on 2/06/25. POA F indicated he came to visit R1 a few weeks ago. R1 was seated in the activity area across from the dining room with her meal and no staff were present. R1 was red in the face and nodded her head Yes when POA F asked her if she was choking. POA F wheeled R1 across the hallway to the dining room and told staff R1 was choking. R1 was stood from wheelchair by POA F and a Certified Nursing Assistant (CNA) who called for help and started patting R1 on the back. POA F attempted the Heimlich, and R1 started coughing and spitting out sweet potato for 2-3 minutes before a nurse arrived. By the time the nurse arrived R1 was able to talk and was no longer choking. R1 has history of throat cancer and dysphagia. R1 is supposed to be supervised by staff when eating and no staff were in the area where R1 was eating in the lounge/activity room. On 2/24/25 at 12:27 PM, Surveyor observed R1 seated in the small dining room, which is a separate room adjoined to the large dining room. R1 was observed with 2 small regular consistency glasses of orange juice in front of her on the table. Surveyor saw no staff present in the dining room. At 12:32 PM, Surveyor observed staff in and out of the small dining room, the adjoined kitchen and the large dining room. R1 continued with the 2 glasses of orange juice at table. At 12:45 PM, R1 was served her pureed meal with gravy on foods and ice cream. Surveyor observed staff serve R1's peer at table and sit down at table across from R1. On 2/25/25 at 10:10 AM, Surveyor spoke with Director of Nursing (DON) B about R1's incident on 2/06/25 and her swallowing guidelines that were in place per her care plan at the time of the incident. DON B verified the swallowing guidelines were in R1's care plan at the time of the incident. The approaches are also on the Kardex (care card) staff use. At the time of the incident R1's approaches based on the guidelines were not followed as staff were not present with her. R1's diet was downgraded after the incident. DON B expressed there was no reeducation of staff or audits done to ensure staff are implementing R1's guidelines post incident. On 2/25/25 at 11:15 AM, Surveyor interviewed Speech Language Pathologist (SLP) E regarding R1's diet and recommendations for safe eating. SLP E explained R1 had a choking episode late last fall. SLP E picked R1 up for services at that time and determined R1 was safe with a mechanical soft diet with foods cut up and gravy on top with regular breads/pastries and regular liquids. R1 had guidelines developed that included staff in proximity encouraging small bites and sips. R1 was recommended to use a Provale (sippy) cup which she would not use. R1 is at high risk for swallowing issues without the use of the cup. R1 had a subsequent choking episode recently and her diet was downgraded to pureed foods and she was moved to the assisted dining room to ensure staff supervise her while eating. SLP E expressed she would expect staff to be present when R1 is eating and/or drinking. Surveyor asked SLP E if she has reeducated staff on R1's guidelines post incident on 2/06/25. SLP E responded the guidelines are unchanged and she has not reeducated staff on the guideline expectations. Surveyor shared observation of R1 being in the dining room with beverages with no staff present. SLP E expressed she is concerned about lack of supervision due to R1's potential risk of choking; she would expect someone be present. On 2/25/25 at 12:18 PM, Surveyor interviewed CNA C regarding R1's incident on 2/06/25 and R1's swallowing guidelines at the time of the incident. CNA C stated on 02/06/25, R1 was set up for supper meal in the lounge across from the dining room with no direct staff supervision. Staff were in dining room across the hall. POA F brought R1 across the hallway to the dining room and said Help, help. CNA C and POA F assisted R1 to stand and started patting her on the back. POA F attempted the Heimlich, and R1 started coughing up sweet potatoes which were partially chewed up. ADON D came to the dining room about 2 minutes later. R1 was coughing up food by then and was talking. ADON D instructed R1 to cough and spit out the food and R1 began laughing. R1 is now on pureed foods and sits in the assisted dining room to eat. Surveyor asked CNA C if R1 required supervision or if R1 had any swallowing guidelines in place at the time of the incident. CNA C responded R1 has always sat by herself with her meal set up in the lounge across the hallway from the dining room. CNA C further expressed she was unaware of any swallowing guidelines at the time of the incident. CNA C said she was unaware R1 required supervision with eating, and R1 was never supervised prior to moving to the assisted dining room. On 2/25/25 at 12:47 PM, Surveyor interviewed ADON D regarding R1's incident and swallowing guidelines at the time of the incident. ADON D stated she heard a page for an RN (Registered Nurse) to the dining room. ADON D responded and found R1 standing up with CNA C and POA F. POA F was saying, Mom, cough. R1 responded, No. POA F reported R1 had choked, was not breathing or speaking. ADON D observed R1 to be talking and coughing. R1 was coughing up a couple of pieces of sweet potato. R1's nurse from her unit then came on site and by then R1 was no longer coughing, was breathing per baseline, and was spitting up phlegm. ADON explained she did not know if staff were present with R1 after she was served dinner. The facility's failure to provide the necessary supervision and assistance during meals for a resident at risk for difficulty swallowing/choking created a reasonable likelihood for serious harm, which created a finding of immediate jeopardy. The immediate jeopardy was removed 03/11/25 when the facility implemented the following: 1. Reeducation with nursing staff (CNAs and Licensed Nurses) on following physician orders or Speech Therapy recommendations to include but not limited to, level of required supervision or cueing needed, and ensuring those residents requiring supervision while eating or drinking snacks or meals, have nursing staff at the dining table or bedside table when food/fluids are in front of the resident. 2. DON/designees completed an audit of current residents to validate: a. Speech therapy recommendations pertaining to swallowing precautions are reflected in the care plan and Kardex. b. Physician orders pertaining to swallowing precautions are reflected in the care plan and Kardex. c. Level of supervision during meals and snacks for residents with swallowing precautions are reflected in the care plan and Kardex. 3. DON/designee completed random observations (audits) of dining room service or snack pass daily for 7 days to verify that residents in need of supervision related to swallowing precautions receive assistance as per plan of care. 4. DON/designee will continue these observations on varying meals or snacks 3 times per week for 4 additional weeks, then 2 times per week for 4 additional weeks. 5. Results of audits will be presented to facility QAPI (Quality Assurance Performance Improvement) committee for review and any recommendations. 6. Ad hoc QAPI meeting held on 02/27/25 to review this plan.

Based on observation, interview, and record review, the facility did not prepare, store, and distribute foods under sanitary conditions. The facility practice had the potential to affect all 61 residents. Floors in the kitchen, dish room and walk-in refrigerator/freezer had dirt and debris present during the initial tour of the kitchen. Carts used to transport foods and beverages to residents were discolored and had visible debris. Refrigerators in the ACU (Alzheimer's Care Unit) and East dining room, where resident foods are stored, had dried beverages and discolored ice pooled on the bottom. This is evidenced by: Example 1 The facility policy titled Food Preparation dated 9/2017. The policy in part read: Policy Statement All Foods are prepared in accordance with FDA (Food and Drug Administration) food code. Procedures 2. Dining Services staff will be responsible for food procedures that avoid contamination by potentially harmful physical, biological and chemical contamination. 3. All utensils, food contact equipment and food contact surfaces will be cleaned and sanitized after each use. The facility policy titled, Food Storage dated 4/2028. The policy, in part, read: Policy Statement All time/Temperature for Safety foods, frozen and refrigerated, will be appropriately stored with guidelines of the FDA food code. Procedures 5. All foods will be stored .and arranged in a manner to prevent cross contamination. The facility policy titled Food Storage: Dry Goods dated 9/2017. The policy in part read: Policy Statement All dry goods will be appropriately stored in accordance with the FDA food code. Procedures 6. Storage areas will be neat . On 2/24/25 at 8:45 AM, Surveyor conducted an initial tour of the facility's kitchen. Surveyor noted the floors in the kitchen, dish room, and walk-in refrigerator/freezer with dirt, debris, and food particles throughout. On 2/24/25 at 12:12 PM, Surveyor spoke with Dietary Manager (DM) H about the dirty floors. DM H agreed the floors were visibly dirty and indicated the floors are supposed to be swept and mopped daily per the dietary staff daily cleaning logs to ensure sanitation in the kitchen. Surveyor requested the daily cleaning logs since the facility's last recertification survey on 12/12/24. Surveyor reviewed the daily cleaning logs and noted the logs titled, Nightly Closing Checklist included Floors in dining room and kitchen are swept and mopped. Surveyor noted the sheets were missing or not initialed as swept or mopped on 24 days. Example 2 The facility policy regarding resident storage of foods brought in by visitor including clean storage of the food items. The policy titled Food Storage dated 4/2028 was provided and read in part: Policy Statement All time/Temperature for Safety foods, frozen and refrigerated, will be appropriately stored with guidelines of the FDA food code. Procedures 5. All foods will be stored .and arranged in a manner to prevent cross contamination. On 2/24/25 at 8:45 AM, as part of the initial tour, Surveyor observed the refrigerator in the east dining room kitchenette with discolored water that had frozen to the bottom of the refrigerator. The refrigerator contained resident food items brought in and snacks provided by the kitchen. Surveyor observed dried red fluid that was sticky to the touch across the bottom of the refrigerator on the Alzheimer's Care Unit (ACU). The refrigerator contained snacks provided by the kitchen and foods brought in for residents. On 2/24/25 at 12:12 PM, Surveyor spoke with DM H about the observation. DM H accompanied Surveyor to the refrigerators and observed the refrigerators as Surveyor had during the initial tour. DM H commented, Not at all clean, with observation of the east refrigerator and expressed the refrigerator is supposed to be cleaned daily. DM H expressed the ACU refrigerator is supposed to be cleaned daily and is obviously not. DM H expressed the refrigerators pose a risk of cross contamination. Surveyor requested the daily cleaning logs and noted the logs do not include cleaning of the refrigerators. DM H indicated the Dietary Aide tasks lists include cleaning the refrigerators. Surveyor reviewed the task list and noted: If fridge is dirty wash it out immediately. Example 3 The facility policy titled, Food Preparation dated 9/2017. The policy, in part, read: Policy Statement All Foods are prepared in accordance with FDA (Food and Drug Administration) food code. Procedures 2. Dining Services staff will be responsible for food procedures that avoid contamination by potentially harmful physical, biological and chemical contamination. 3. All utensils, food contact equipment and food contact surfaces will be cleaned and sanitized after each use. On 2/24/25 at 12:12 PM, during observation of food service for lunch in the kitchen, Surveyor observed dietary staff placing resident beverages and foods on 3-tiered carts for distribution. Surveyor observed the carts to be dirty, discolored and containing dried food matter on the surfaces. Surveyor brought the dirty carts to the attention of DM H who stated the carts were not clean, less than cleanly for service. DM H used a wet rag to wipe one of the carts and the rag was visibly dirty after wiping the surface of the top tier of the cart. DM H had staff move the beverages from the cart which were then placed on another cart that was visibly dirty. Surveyor noted seven 3-tiered carts in the kitchen for food service which were visibly dirty. On 2/25/25 at 7:44 AM, Surveyor interviewed DM H about the sanitation concerns in the kitchen and the refrigerators on the east and ACU units. DM H expressed her expectation is for floors to swept and mopped daily including the kitchen, dish room and walk-in refrigerator to maintain sanitation and prevent rodents. DM H's expectation is the refrigerators on the ACU and East wings to be checked daily and cleaned immediately if dirty to prevent cross contamination. Her expectation is for cleaning to be done daily. The current system is failing for cleaning and does not hold staff responsible or accountable for the cleaning. Going forward a new checklist for cleaning will be developed and follow through will be done with staff who are not meeting the expectations.

Based on record review and interview, the facility did not inform R1's power of attorney (POA) for health care when medication was initiated and dosage was changed. The facility practice affected 1 of 3 residents reviewed. R1 was started on Tramadol as needed and scheduled Tramadol was added without informing R1's power of attorney for health care of the risks and benefits of the medication. This is evidenced by: Surveyor requested and reviewed the facility policy titled Pain Management dated 8/09/2022. The policy in part read: Policy: This facility must ensure that pain management is provided to residents who require such services. consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents goals and preferences. Pain Management and Treatment: The facility in collaboration with the attending physician/prescriber, other health care professionals .and the resident and or the residents representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual residents pain . Surveyor reviewed R1's record and noted the following: R1's most recent quarterly Minimum Data Set (MDS) completed 1/26/25, noted R1 has frequent pain rated at a 5 with both scheduled and as needed pain medications. R1's care plan noted: Focus: I have pain or the potential for pain . Intervention: Educate me and my family about pain. R1's physician orders included: 11/01/24: Tramadol HCI oral tablet 50 MG (milligrams): give one tablet by mouth every 8 hours as needed for pain. 2/18/25: Tramadol HCI oral tablet 50 MG (milligrams): give one tablet by mouth every 8 hours as needed for pain 2/18/25: Tramadol HCI oral tablet 50 MG (milligrams): give one tablet by mouth at bedtime for pain. R1's record showed POA F was the activated power of attorney (POA) for health care. R1's medication administration record showed: November 2024: Tramadol administered 5 times prn December 2024: Tramadol administered 10 times prn January 2025: Tramadol administered 6 times prn February 2025: Tramadol administered 9 times prn and daily at bedtime from 2/18/25 to 2/24/25. R1's record showed no evidence POA F was informed when R1's as needed Tramadol was ordered as needed on 11/01/14 or when the scheduled Tramadol was added on 2/18/25. On 2/24/25 at 9:20 AM, Surveyor spoke with POA F regarding R1's Tramadol. POA F indicated he took R1 out for an overnight stay at home a few weeks ago. The nurse provided POA F Tramadol to administer to R1 when she was home. POA F informed the facility he had not been informed R1 was prescribed the Tramadol. The facility did not inform POA F that R1 had started taking Tramadol for pain. On 2/25/25 at 9:55 AM, Surveyor spoke with Director of Nursing (DON) B about R1's prescriptions for Tramadol and whether the facility informed POA F when the Tramadol was initiated as needed on 11/01/24, or when the scheduled Tramadol was added on 2/18/25. DON B explained when an order is put in the system by a prescriber the nurse who removes the new order is expected to notify the resident and/or power of attorney of the medication change. POA F was not informed of the Tramadol prescriptions on either occasion and should have been. The facility did not recognize the error and did not put a process improvement plan in place to address the concern.

Based on record review and interview, the facility continued administration of a psychotropic medication after the medication was no longer necessary and recommended to be discontinued. The facility practice affected 1 of 3 residents (R) R2, reviewed. This is evidenced by: Surveyor requested and reviewed the facility policy titled, Psychotropic Medications dated 10/24/2022. The policy, in part, read: Policy: Residents should not receive psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the residents response to the medication. Policy Explanation and Compliance Guidelines: 3. The attending physician will assume leadership in medication management by developing, monitoring and modifying medication regimen in collaboration with the residents, their families and/or representatives . Surveyor reviewed R2's record and noted the following: R2's power of attorney (POA) for health care was her spouse (POA) G. R2's diagnoses included dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, Parkinson's disease and depressive disorder. R2's minimum data set (MDS) dated [DATE] notes R2 had no hallucinations or delusions. R2's care plan included: Focus: Exhibits changes in mood and/or behavior related to dementia, major depressive disorder and mild cognitive impairment of uncertain etiology. Goal: Will accept care and medications as prescribed. Date Initiated; 7/16/24 Interventions/Tasks: Administer medications as ordered. Behavior 1: Hallucinations Interventions included: Psych referral as needed. R2's physician orders included: ~Duloxetine HCL DR 20 MG cap, give 1 cap by mouth daily for hallucinations. Start 10/26/23. Discontinued 12/02/24. R2's Behavioral Care Solutions/Psychiatry Follow up for medication review visits noted: ~10/30/24: Admission: 11/24/23 R2 seen today with husband .discussed stopping duloxetine 20 mg. Indicated use in the chart for hallucinations which she has not had any since our initial visit. Thought content: No delusions, no paranoia, no hallucinations, no perceptual disturbances, no delusional or bizarre material expressed. Assessment and Plan: discussed with husband and [R2] about stopping duloxetine. Monitor for mood and pain. No hallucinations for several years as indicated it is used for hallucinations. Husband in agreement with plan . ~11/24/24: Discussed stopping duloxetine 20 mg. Indicated use in chart is hallucinations which she has not had any since initial visit. We asked duloxetine be stopped .It was not stopped . Patient seen with husband today .Plan: discussed with husband and [R2] about stopping duloxetine .no hallucinations in several years .husband in agreement with plan .duloxetine was not discontinued after last visit. Husband appeared as it had been stopped, email sent to .Director of Nurses to follow up. ~12/23/24: Duloxetine was not discontinued in October .Husband expressed his concern for the duloxetine not being stopped when it was discussed . Surveyor reviewed R2's Medication Administration Record (MAR) and noted R2 was administered duloxetine from 10/30/24 to 12/02/24 after the provider and power of attorney agreed on the discontinuation of the medication. Surveyor reviewed R2's documentation for behaviors of hallucinations from February 2024 through October 2024 and noted no hallucinations as noted by R2's provider. On 2/24/25 at 10:18 AM, Surveyor interviewed POA G who indicated he is R2's power of attorney for health care. POA G indicated his only concern at the facility was Director of Nursing (DON) B missed a medication change. DON B did not discontinue the use of duloxetine when R2 had not experienced hallucinations and the duloxetine was recommended to be discontinued by R2's psychiatry provider. On 2/25/25 at 12:35 PM, Surveyor interviewed DON B about R2's psychiatry provider's recommendation for discontinuation of R2's duloxetine on 10/30/24. DON B indicated she receives the psychiatry provider notes via email. DON B further expressed she does not know how she did not catch the recommendation for discontinuing the duloxetine as recommended by the provider in the October and November notes. DON B further expressed she did not read the notes and did not act on the recommendation to discontinue the medication until 12/02/24 which is unacceptable. DON B indicated R2 continued to receive the medication after it was deemed unnecessary.

Based on observation, policy review and interview, the facility did not store foods brought in for residents and snacks for residents in a manner to prevent contamination in 2 refrigerators with the potential to affect 47 of 66 residents. This is evidenced by: Surveyor requested and received the facility policy titled Food From Approved Source most recently dated 9/2017. The policy in part read: ~Food may be brought into the facility by family, visitors or other outside sources. The facility staff will assist with proper food storage and handling as appropriate. Surveyor requested and received the facility policy titled Food Storage most recently dated 4/2018. The policy in part read: ~All foods will be stored wrapped or in covered containers, labeled, dated and arranged in a manner to prevent cross contamination. On 12/09/24 at 8:34 AM, Surveyor conducted an initial tour with Account Manager (AM) G, who is responsible for food service operations at the facility. Surveyor observed refrigerators in the east and in the west kitchenettes with water pooled in the bottom of the refrigerators which was dripping from the freezers over snacks and beverages. Surveyor asked AM G about the dripping pooled water. AM G indicated the west kitchenette's freezer has been dripping into the refrigerator for several weeks and the east refrigerator has been dripping for 1-2 weeks. AM G expressed the refrigerators/freezer are used for resident snacks and foods brought in by visitors. Surveyor asked AM G what has been done for repairs of the freezers/refrigerators. AM G expressed she does not know what has been done. Surveyor asked AM G if foods continued to be stored in the freezers/refrigerators and if the dripping water posed a potential risk for contamination. AM G responded the facility has not had anyone look at the freezers/refrigerators for repairs, foods and beverages continued to be stored in the freezer/refrigerator and the dripping water poses a risk for contamination of residents' foods and beverages. On 12/09/24 at 1:14 PM, AM G reported to Surveyor the refrigerators had been wiped of water and foods removed from refrigerators/freezers. On 12/11/24 at 7:14 AM, AM G informed Surveyor the water that was dripping over food/beverages in east and west refrigerators was due to the freezer temperatures being set at too high of a temperature. The high temperature caused the freezers to defrost and drip water over the foods/beverages. Maintenance has adjusted the temperatures and AM G will monitor the temperatures to ensure they are maintaining a proper temperature for 2 days before placing any foods/beverages back in the units. On 12/12/24 at 1:20 PM, Surveyor asked Director of Nursing (DON) B how many residents reside on the east and west wings that had the potential to be affected by storage of foods stored in the east and west wing's refrigerators/freezers. DON B responded 47 of 66 residents had the potential of being affected.

Based on interview and policy review, the facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare and Medicaid Services (CMS). The facility failed to enter accurate data in their Payroll Based Journal (PBJ) system which triggered that they have excessively low weekend staffing. This has the potential to affect all 66 residents residing in the facility. This is evidenced by: Centers for Medicare & Medicaid Services (CMS) Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, states in part: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.1.2 Submission Timelines and Accuracy. Direct care staffing and census data will be collected quarterly and is required to be timely and accurate . Report Quarter: staffing and census data will be collected for each fiscal quarter. Staffing data includes the number of hours paid to work by each staff member each day within a quarter. Census data includes the facility's census on the last day of each of the three months in a quarter. The fiscal quarters are as follows: Fiscal Quarter, Date range: 1 October 1 - December 31, (quarter 1) 2 January 1 - March 31, (quarter 2) 3 April 1 - June 30, (quarter 3) 4 July 1 - September 30 (quarter 4) . PBJ Staffing Data Report, CASPER Report (Certification and Survey Provider Enhanced Reports) 1705D for Fiscal year Quarter 2 2024 (January 1 - March 31), ran on 12/04/24, indicates the following: Submitted Weekend Staffing data is excessively low. PBJ Staffing Data Report, CASPER Report (Certification and Survey Provider Enhanced Reports) 1705D for Fiscal year Quarter 4 2024 (July 1 - September 30), ran on 12/04/24, indicates the following: Submitted Weekend Staffing data is excessively low. On 12/11/24 at 10:00 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and Scheduler H in relation to facility staffing. Scheduler H reported the facility schedules the same number of RNs LPNs and CNAs on the weekends as they do during the weekdays. Scheduler H stated that at times they have a Nurse manager who is in a salaried position on duty on the weekend who may actually work the floor for a while depending on needs. Scheduler H also reported that agency staff works on weekends also. Surveyor asked about the low weekend staffing data that triggered on the PBJ reports. NHA A responded that a while back they discovered that agency staff were not punching in on the facility's time clock. They also discovered that on weekends, if a nurse manager covered the floor, they were not clocking in. This would lead to an under reporting of hours as the PBJ data was reported from their time clock system. The NHA stated she feels the PBJ data triggered for low weekend staffing, due to agency staff not clocking in to the time system. NHA A stated this problem was discovered in mid-September and they implemented a change that now all agency staff and nurse manager/weekend supervisors' hours are clocking into the system here. On 12/11/24 at 3:20 PM, NHA A reported Elite staffing agency is not in their system - and was not reporting hours worked via their payroll system. On 12/12/24 at 8:00 AM, NHA A reported she has reviewed past schedules and staffing data and does not see any significant changes in staffing on weekends. She stated she saw occasional call in's and the like, but no other changes. The facility currently is budgeted for a PPD of 3.0 for nursing staff. On 12/12/24 at 12:34 PM, NHA A provided this Surveyor with a document titled PBJ Action Plan, dated 03/05/24, which states in part, A discrepancy was identified as agency hours were not pulling when the PBJ hours were submitted. The document goes on to state, in part; that if excessively low weekend staffing occurs, an investigation into why this occurs, root cause analysis and systemic changes as applicable will be implemented. Excessively low weekend staffing triggered after the 03/05/24 date, but no further evidence of the root cause analysis or systemic changes was provided.

Based on interview and record review, the facility did not notify the resident and/or the resident's representative of resident transfer in writing including the reasons for the transfer. The facility did not give written notice of transfer or send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. The facility practice affected 5 of 5 residents reviewed (R49, R52, R6, R3 and R22). Findings include: Surveyor requested and received the facility policy titled Transfer and discharge date d as most recently revised on 7/15/22. The policy in part read: Policy Explanation and Compliance Guidelines: Emergency Transfers/Discharges- Complete and send with the resident (or provide as soon as practicable) a transfer form which documents: ~Resident status, including baseline and current mental, behavioral and functional status and recent vital signs. ~Current diagnosis, allergies and reason for transfer. ~Contact information for the practitioner responsible for the care of the resident. ~Resident representative information including contact information. ~Current medications (including when last received), treatments, most recent relevant lab and/or radiological findings and recent immunizations. ~Special instructions or precautions for ongoing care to include precautions such as isolation or contact. ~Special risks such as risk for falls, elopement, bleeding or pressure injury and/or aspiration precautions. ~Any other documentation as applicable to ensure a safe and effective transition of care. ~Provide transfer notice as soon as practicable to resident and representative. Example 1 Surveyor reviewed R49's record and noted the following: R49's discharge return anticipated minimum data set (MDS) noted R49 discharged to the hospital on 11/23/24. R49's entry MDS noted she returned to the facility on [DATE]. R49's nurses notes were reviewed. Surveyor noted the following: ~11/23/2024 9:37 AM General Note: Note Text: unwitnessed fall, hit head c/o (complaint of) R (right) hip and knee pain, vitals taken and recorded called 911 transferred resident to ED (emergency department) at 930 for low 02 (oxygen) . ~11/23/2024 1:43 PM General Note: Note Text: Called ED for update, being admitted for hypoxia. ~11/25/2024 8:25 PM Clinical Follow Up: Note Text: Resident is on follow up for: Resident was readmitted to facility from hospital after being treated for, acute hypoxic, respiratory failure, submassive PE (pulmonary embolism) with right heart strain thrombectomy, generalized weakness and fall . Surveyor reviewed R49's record and found no written notice of transfer given to R49 when sent to the hospital. On 12/11/24 at 1:28 PM, Surveyor interviewed R49. R49 indicated she is her own legal decision maker. Surveyor asked R49 if she was provided a written notice of her transfer to the hospital when she was transferred on 11/23/24. R49 expressed she knew why she was being transferred and was in agreement with the decision to transfer to the hospital but was not provided a written notice of her transfer. Example 2 R52's record shows discharge return anticipated to hospital on 1/17/24 and entry from hospital on 1/25/24. R52's nurses notes indicated: ~1/17/2024 2:44 AM General Note: Note Text: Resident complaining of not feeling well, states it burns when takes a sip of water. Resident was given a suppository and MOM per his request with a large bowel movement noted, complained of nausea on the evening shift, bowel sounds active times Resident requesting to go to the ER, call placed to on call Dr, order obtained to send to ER (emergency room ) for evaluation and treatment. ~1/18/2024 9:17 AM General Note: Note Text: Writer called MMC this am to check on status of resident, resident has been admitted to MMC for altered mental status and complications of UTI (urinary tract infection). Surveyor reviewed R52's record and could not locate a written notice for transfer or notification to State Ombudsman of R52's transfer. On 12/11/24 at 1:39 PM, Surveyor interviewed R52 about his transfer to the hospital and whether he was provided information in writing of his transfer. R52 indicated he did not recall being provided written notice of his transfer when he went to the hospital. Surveyor requested evidence of reporting R52's transfer to the hospital and notification to State Ombudsman. On 12/10/24 at 1:31 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and Director of Nursing (DON) B about R49 and R52's notice of transfer to the hospital. NHA A and Director DON B expressed the floor nurses are responsible for completing the notice of transfer when residents are transferred to the hospital. The facility identified an issue with incomplete transfer information being done when residents are transferred to the hospital. In October the facility developed a Process Improvement Plan to re-educate nurses on the process. The facility is conducting audits to ensure compliance and continues to have concerns with the information being completed. NHA A expressed R49's transfer was after the PIP was put into place and was not done. NHA A expressed she understands that past non-compliance cannot be considered as the facility is not in current compliance. 47657 Example 3 R6 was admitted to facility on 05/25/18 and has diagnoses that include chronic obstructive pulmonary disease, hypertensive heart, and chronic kidney disease with heart failure. R6 has a BIMS of 14, indicating cognitively intact. On 09/22/24, R6 was transferred to hospital via ambulance for myoclonic jerking movements that were increasing in frequency. R6 returned back to facility on same day. A review of MDS record documented on 05/06/24, R6 was discharged with return anticipated and returned to the facility on [DATE]. Surveyor reviewed R6's medical record and was unable to locate documentation to support R6 received a notice of transfer or notification was sent to State Ombudsman of transfer. On 12/11/24 at 1:36 PM, Surveyor interviewed R6 about transfers to hospital and not receiving notice of rights for transfers on the two transfers to hospital. Surveyor asked how would R6 feel if not aware of rights to return to facility and financial responsibility. R6 indicated, That would be bad, that would not be good. Example 4 R3 was admitted to facility on 09/22/22 and has diagnoses that include paraplegia, Spina Bifida, hypertension, and neurogenic bladder. A review of MDS records, documented on 02/13/24, 09/04/24 and 11/24/24, R3 was discharged with return anticipated. On 02/12/24, R3 was transferred to hospital for abnormal labs, fever, and chills. R3 returned to facility on 02/15/24. On 09/04/24, R3 was transferred to hospital for chills and not feeling well. R3 returned to facility on 09/06/24. On 11/24/24, R3 was transferred to hospital due to change in condition of feet. R3 returned to facility on 11/25/24. Surveyor reviewed R3's medical records and was unable to locate documentation to support R3 received a notice of transfer for all 3 hospitalization s and 2 of 3 notifications of transfer to state Ombudsman (02/12/24 and 09/04/24). On 12/11/24 at 12:42 PM, Surveyor interviewed R3 regarding not receiving notice of transfer on 3 hospitalization s and asked how would R3 feel if not aware of rights to return to facility and financial responsibility. R3 indicated R3 would be mad. On 12/11/24 1at 2:47 PM, Surveyor interviewed Registered Nurse (RN) E regarding responsibility when sending a resident to hospital for change in condition. RN E stated that they would provide documentation to resident to sign if able or receive verbal consent. If they are not their own person, the resident's representative would be contacted and provide information and receive verbal consent to transfer out of building. 49353 Example 5 R22 was admitted to the facility on [DATE] with pertinent diagnoses of obstructive and reflux uropathy, dementia, congestive heart failure, and chronic ulcer of the foot. Review of R22's Minimum Data Set (MDS) record shows discharge return anticipated on 01/05/24, 03/01/24, 03/16/24, and 03/25/24. Surveyor reviewed R22's record and noted the following: On 01/05/24, R22 was transferred to the hospital with left sided weakness and facial drooping. R22 returned to the facility on [DATE]. Nursing notes indicated: -1/5/2024 06:24 Resident had increased left sided weakness and shakes at 0400. Resident unable to transfer increased confusion and emotional. Resident had slurred speech. 0530 resident had facial drooping. Called Provider, POA, and DON. On 03/01/24, R22 was transferred to the hospital with increased weakness and impaired speech. R22 returned to the facility on [DATE]. Nursing notes indicated: -3/1/2024 14:02 Resident was sent out at 0700 for increased weakness and impaired speech. Resident was in visible pain. Resident was hypotensive, crying and was diagnosed with an acute kidney injury and a UTI on 2-29-24. Resident was sent nonemergency to the ER due to being out of parameters with vitals as her blood pressure was 96/56, her temperature was 98.3, pulse of 74 and respirations of 18. The POA was called and agreed to have resident sent out. Resident was sent out at 0700. Nurse called the ER at 1200 for an update and the resident was admitted with an acute kidney injury and cellulitis. On 03/16/24, R22 was transferred to the hospital with increased fluid. R22 returned to the facility on [DATE]. Nursing notes indicated: -3/14/2024 14:04 Resident seen by MD today- Restart furosemide 20mg BID. BMP next lab day. Follow up with heart failure clinic. -3/15/2024 14:28 Voiding trial was unsuccessful. NP placed foley catheter. Since catheter has been placed, resident has had 800cc of urine output. Resident is not complaining of pain or discomfort. Resident has been resting in bed comfortably. -3/16/2024 20:41 Spoke with medical center. Updated that R22 has been admitted with diagnosis of CHF exacerbation. Will be diuresed. On 03/25/24, R22 was transferred to the hospital with increased weakness. R22 returned to the facility on [DATE]. Nursing notes indicated: -3/24/2024 14:00 Resident refused lunch this afternoon, ate breakfast. Slept through most of shift. Required increased assistance with transfers and ADL's this AM. Resident denies increased pain or discomfort. VS stable. Continues to be able to make needs known, speech appropriate. -3/25/2024 10:51 Resident was unable to sit up or stand this AM, resident was unable to tell staff her name or respond at all. MD gave VO to send resident to ER for evaluation. Resident's POA was contacted and approved resident to be sent out. Surveyor reviewed R22's medical record and was unable to locate documentation to support R22 received a notice of transfer for any of the discharges. On 12/11/24 at 12:14 PM, Surveyor requested information of notification to the State Long Term Care Ombudsman for R22's discharges to the hospital and written notice of transfer. NHA A stated the facility did not have documentation for notice of transfer or ombudsman notification for any of these discharges.

Based on interview and record review, the facility did not provide notification of bedhold, including the resident right to appeal, to 4 of 5 residents and/or their representatives reviewed for hospital transfer (R52, R6, R3 and R22). Findings include: Surveyor requested and received the facility policy titled Transfer and discharge date d as most recently revised on 7/15/22. The policy in part read: Policy Explanation and Compliance Guidelines: Emergency Transfers/Discharges .(nursing responsibilities unless other wise specified) Provide a notice of the resident bedhold policy to the resident and representative at the time of transfer, as possible, but no later than 24 hours of the transfer. Example 1 R52's record shows discharge return anticipated Minimum Data Set to hospital on 1/17/24 and entry from hospital on 1/25/24. R52's nurses notes indicated: ~1/17/2024 2:44 AM General Note: Note Text: Resident complaining of not feeling well, states it burns when takes a sip of water. Resident was given a suppository and MOM per his request with a large bowel movement noted, complained of nausea on the evening shift, bowel sounds active times Resident requesting to go to the ER, call placed to on call Dr, order obtained to send to ER (emergency room ) for evaluation and treatment. ~1/18/2024 9:17 AM General Note: Note Text: Writer called MMC this am to check on status of resident, resident has been admitted to MMC for altered mental status and complications of UTI (urinary tract infection). Surveyor reviewed R52's record and a notice of R52's bedhold, including right to appeal, was not located when he transferred to the hospital on 1/17/24. On 12/11/24 at 1:39 PM, Surveyor interviewed R52 about his transfer to the hospital and whether he was provided information about a bedhold and his right to appeal when he transferred to the hospital. R52 indicated he was able to return to his room/bed when he returned. R52 expressed he would not be a happy camper and would not be happy if he was not accepted back to facility or have a bed when he returned. Surveyor requested evidence of reporting R52's bedhold when he transferred to the hospital. On 12/10/24 at 1:31 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and Director of Nursing (DON) B about R49 and R52's notice of bedhold when he transferred to the hospital. Nursing Home Administrator (NHA) A and Director of Nursing (DON) B expressed the floor nurses are responsible for completing the notice of bedhold when residents are transferred to the hospital. The facility identified an issue with incomplete transfer information, including notice of bedhold being done when residents are transferred to the hospital. In October the facility developed a Process Improvement Plan to re-educate nurses on the process. The facility is conducting audits to ensure compliance and continues to have concerns with the information being completed. 47657 Example 2 R6 was admitted to facility on 05/25/18 and has diagnoses that include chronic obstructive pulmonary disease, hypertensive heart, and chronic kidney disease with heart failure. R6 has a BIMS of 14, indicating cognitively intact. On 09/22/24, R6 was transferred to hospital via ambulance for myoclonic jerking movements that were increasing in frequency. R6 returned back to facility on same day. A review of MDS record documented on 05/06/24, R6 was discharged with return anticipated and returned to the facility on [DATE]. Surveyor reviewed R6's medical record and was unable to locate documentation to support R6 received Notice of bed hold for transfers to hospital. On 12/11/24 at 1:36 PM, Surveyor interviewed R6 about transfers to hospital and not receiving notice of rights for bed hold on the two transfers to hospital. Surveyor asked how would R6 feel if not aware of rights to hold bed. R6 indicated, That would be bad, that would not be good. Example 3 R3 was admitted to facility on 09/22/22 and has diagnoses that include paraplegia, Spina Bifida, hypertension, and neurogenic bladder. A review of MDS records, documented on 02/13/24, 09/04/24 and 11/24/24, R3 was discharged with return anticipated. On 02/12/24, R3 was transferred to hospital for abnormal labs, fever, and chills. R3 returned to facility on 02/15/24. On 09/04/24, R3 was transferred to hospital for chills and not feeling well. R3 returned to facility on 09/06/24. On 11/24/24, R3 was transferred to hospital due to change in condition of feet. R3 returned to facility on 11/25/24. Surveyor reviewed R3's medical record and was unable to locate documentation to support R3 received a notice of bed hold. On 12/11/24 at 12:42 PM, Surveyor interviewed R3 regarding not receiving notice of bed hold on 3 hospitalization s and asked how would R3 feel if not aware of rights to hold bed return to facility. R3 indicated R3 would be mad. 49353 Example 4 R22 was admitted to the facility on [DATE] with pertinent diagnoses of obstructive and reflux uropathy, dementia, congestive heart failure, and chronic ulcer of the foot. Review of R22's Minimum Data Set (MDS) record shows discharge return anticipated on 01/05/24, entry to facility on 01/06/24, discharge return anticipated on 03/01/24, entry to facility on 03/11/24, discharge return anticipated on 03/16/24, entry to facility on 03/19/24, discharge return anticipated on 03/25/24, and entry to facility on 03/27/24. Surveyor reviewed R22's record and noted the following: On 01/05/24, R22 was transferred to the hospital with left sided weakness and facial drooping. R22 returned to the facility on [DATE]. Nursing notes indicated: -1/5/2024 06:24 Resident had increased left sided weakness and shakes at 0400. Resident unable to transfer increased confusion and emotional. Resident had slurred speech. 0530 resident had facial drooping. Called Provider, POA, and DON. On 03/01/24, R22 was transferred to the hospital with increased weakness and impaired speech. R22 returned to the facility on [DATE]. Nursing notes indicated: -3/1/2024 14:02 Resident was sent out at 0700 for increased weakness and impaired speech. Resident was in visible pain. Resident was hypotensive, crying and was diagnosed with an acute kidney injury and a UTI on 2-29-24. Resident was sent nonemergency to the ER due to being out of parameters with vitals as her blood pressure was 96/56, her temperature was 98.3, pulse of 74 and respirations of 18. The POA was called and agreed to have resident sent out. Resident was sent out at 0700. Nurse called the ER at 1200 for an update and the resident was admitted with an acute kidney injury and cellulitis. On 03/16/24, R22 was transferred to the hospital with increased fluid. R22 returned to the facility on [DATE]. Nursing notes indicated: -3/14/2024 14:04 Resident seen by MD today- Restart furosemide 20mg BID. BMP next lab day. Follow up with heart failure clinic. -3/15/2024 14:28 Voiding trial was unsuccessful. NP placed foley catheter. Since catheter has been placed, resident has had 800cc of urine output. Resident is not complaining of pain or discomfort. Resident has been resting in bed comfortably. -3/16/2024 20:41 Spoke with medical center. Updated that R22 has been admitted with diagnosis of CHF exacerbation. Will be diuressed. On 03/25/24, R22 was transferred to the hospital with increased weakness. R22 returned to the facility on [DATE]. Nursing notes indicated: -3/24/2024 14:00 Resident refused lunch this afternoon, ate breakfast. Slept through most of shift. Required increased assistance with transfers and ADL's this AM. Resident denies increased pain or discomfort. VS stable. Continues to be able to make needs known, speech appropriate. -3/25/2024 10:51 Resident was unable to sit up or stand this AM, resident was unable to tell staff her name or respond at all. MD gave VO to send resident to ER for evaluation. Resident's POA was contacted and approved resident to be sent out. Surveyor reviewed R22's medical record and was unable to locate documentation to support R6 received notice of bed hold for transfers to hospital. On 12/11/24 at 12:14 PM, Surveyor requested documentation of notice for bed hold for R22's transfers on 01/05/24, 03/01/24, 03/16/24, and 03/25/24. NHA A was unable to find or provide documentation for any of the bed hold notices given.

Based on interviews and record reviews, the facility did not consult with a physician as indicated by ordered parameters with a significant weight increase for 1 of 17 residents (R) R6. This is evidenced by: The facility policy titled Change in Condition of the Resident, dated September 2022, states in part, A facility should immediately consult with the resident's physician when there is the potential for requiring physician intervention; 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. R6 was admitted to facility on 05/25/18 and has diagnoses that include chronic obstructive pulmonary disease, hypertensive heart and chronic kidney disease with congestive heart failure (CHF). R6 has a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating cognitively intact. R6's Quarterly Minimum Data Set (MDS) with target date of 10/23/24, Section K: weight 150#. R6's care plan initiated 04/19/24, with a target date of 01/08/25, states, Edema/excess fluid volume as evidenced by CHF. Goal: Will be free of complications r/t edema/excess fluid volume. R26's physician orders dated 04/26/24 states: Daily weight - call the Heart Failure Clinic (HFC), if the patient has a weight gain of greater than or equal to 3 lbs overnight, or a weight gain greater than or equal to 5 lbs in a week. Also, if resident shows worsening signs of heart failure such as weight gain. On 12/10/24 at 12:57 PM, Surveyor reviewed R6's daily weight record which showed on 12/02/24, R6 weighed 148.2 lbs and on 12/08/2024, the R6 weighed 153.4 lbs, indicating R6 had a weight gain of 5.2 lbs in a 5-day period. On 12/11/24, the facility record indicated that R6's daily weight was 156.9 lbs. On 12/17/24 at 12:57 PM, Surveyor reviewed R6's medical record and was unable to locate documentation to support the HFC or primary physician was updated of weight results. On 12/12/24 at 10:05 AM, Surveyor interviewed Registered Nurse (RN) E, regarding process of monitoring and contacting a provider if a resident with CHF has increased weight or signs and symptoms of heart failure. RN E stated after checking R6's physician orders, Per orders would need to contact the HFC if R6 gains 3 lbs in 1 day or 5 lbs in 5 days. RN E confirmed that R6 had a weight gain of 5+lbs from 12/03/24 to 12/08/24. RN E was unable to locate any notification to HFC or primary physician in progress notes of weight gain. On 12/12/24 at 10:18 AM, Surveyor interviewed Director of Nursing (DON) B and Licensed Practical Nurse (LPN) D regarding increase of R6's daily weight and following physician orders. LPN D reviewed R6's medical record and confirmed was not able to find any assessments conducted of R6's current health status related to CHF, or contact to HFC or primary physician per physician orders. On 12/12/24 at 10:25 AM, Surveyor interviewed DON B, who stated that expectation would be for the nurse to contact the HFC per physician orders. On 12/12/24 at 12:19 PM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding facility policy for following physician orders. NHA A stated the facility does not have a policy for following physician orders, as it would be a standard of practice for staff to follow physician orders.

Based on record review and interview, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when an allegation of verbal abuse was not reported immediately but not later than 2 hours after the allegation is made to local law enforcement in accordance with state law through established procedures. The facility practice affected 1 of 3 residents (R) reviewed. (R47). This is evidenced by: Surveyor requested and reviewed the facility policy titled, Reporting Reasonable Suspicion of a Crime which was last revised on 08/16/2022, which indicated the following: Policy: It is the policy of this center, pursuant to Section 1150B of the Social Security Act, to report any reasonable suspicion of a crime committed against a resident of this facility. Crime is defined by law of the applicable political subdivision where the facility is located. Law enforcement is the full range of potential responders to elder abuse, neglect and exploitation including: police, sheriffs, detectives, public safety officers, corrections personnel, prosecutors . Guidelines: The facility will coordinate with state and local law enforcement entities to determine what actions are considered crimes in the facility's political subdivision and will work with law enforcement to determine which crimes are reported. Examples of situations that would be considered crimes in all subdivisions include, but are not limited, to: murder, manslaughter, rape, assault and battery, sexual abuse, theft/robbery, drug diversion for personal use or gain, fraud and/or forgery, certain cases of abuse, neglect, and exploitation, others as required by local jurisdiction and/or specific circumstances of the incident(s). Surveyor reviewed the Facility Reported Incident (FRI) and noted: On 11/09/24 at 10:15 AM, R47 was in the dining room in his wheelchair sitting at the dining table with another resident. R16 attempted to manually wheel himself through the dining room behind the table where R47 was sitting and came too close to R47's wheelchair where the two wheelchair wheels came into contact. R16 was unable to maneuver his wheelchair to get around R47. R47 could not move his wheelchair as he was blocked by R16's wheelchair. R16 became angry when he could not get his wheelchair around R47 and hit R47 on the back of his head. Licensed Practical Nurse (LPN) C had witnessed the incident and immediately intervened. Both residents were separated and R47 was assessed. No physical injury or bruising was observed. R47 denied pain. LPN C notified hospice provider, R47's Activated Power of Attorney (APOA), and Director of Nursing (DON). Law enforcement was not notified. On 12/10/24 at 12:12 PM, Surveyor attempted to interview R47 about the incident. R47 was unable to recall any details of the incident or it even occurring. On 12/12/24 at 10:32 AM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding the reported incident. Surveyor asked NHA A why this incident was not reported to local law enforcement. NHA A stated that she had been on the fence about whether to call the police because no major injury was sustained. Surveyor asked NHA A if their policy for reporting a suspicion of a crime would include what had happened in this incident. NHA A stated that after reviewing the policy, which included physical abuse, that this incident should have been reported to the local police at the time of the incident.

Based on observation, policy review and interview, the facility did not ensure a medication error rate of 5% or less. During the medication administration task, Surveyor observed 2 errors out of 30 medication opportunities, resulting in an error rate of 6.67%. Surveyor had to intervene to stop Licensed Practical Nurse (LPN) C from administering eye drop to the wrong resident. This had the potential to affect 1 of 1 resident (R14) observed for medication administration. This is evidenced by: Facility policy titled, Medication Administration, stated in part, Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record (MAR). Compare the medication and dosage schedule on the resident's MAR with the medication label .verify medication is correct three (3) times before administering .medications supplied for one resident are never administered to another resident. On 12/10/24 at 10:37 AM, Surveyor observed Licensed Practical Nurse (LPN) C prepare two ophthalmologic solutions (eye drops) for administration by removing them from the medication cart. Surveyor asked LPN C who the eye drops would be administered to. LPN C stated they were for R14. Surveyor observed LPN C compare the eye drops to the MAR for correct medication, resident, time, route, dosage. LPN C then handed the two eye drop bottles to Surveyor for review. Surveyor noted the medication label was prescribed for R43. LPN C then went and brought R14 into the nurse's station for administration of the eye drops. Surveyor handed the two eye drop bottles back to LPN C and asked who they were going to be administered to. LPN C stated again R14. Surveyor asked LPN C to verify the medications again. LPN C opened the MAR and stated out loud the medication, dose ordered, resident name as R14, and the order documented in the MAR while comparing to the two eye drop bottles for R43. LPN C then completed hand hygiene, donned gloves, and opened one of the eye drop bottles to administer to R14. Surveyor stopped LPN C prior to administering eye drops to R14 and asked LPN C to look at the bottle's prescription label. LPN C then stated, Oh my goodness! This isn't R14's eye drops. Somebody put them in the wrong slot. LPN C then replaced the two eye drops into the correct resident's slot and removed R14's correct eye drops from the medication cart and administered the correct medications ordered. Immediately following the incident, Surveyor asked LPN C what the expected procedure is for safely administering medications. LPN C stated to verify the resident name matches the label and order before administration. LPN C stated that she thought she had looked at the label and saw R14's name but must have just focused on the medication matching the MAR. LPN C stated recognition of almost administering the wrong medication to the wrong resident. On 12/12/24 at 11:43 AM, Surveyor interviewed Director of Nursing (DON) B and asked the facility policy for administering medications. DON B stated the nurses should verify the correct medication with the order in the MAR prior to administration.

Based on observation, record review and interview, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 (R) resident observed for wound care while on Enhanced Barrier Precautions (R47), staff did not change gloves or perform hand hygiene during 1 of 5 observations (R6) of incontinence cares. This is evidenced by: Facility policy titled, Enhanced Barrier Precautions, with a most recent revised date of 08/08/24, stated in part: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high-contact resident care activities .high-contact resident care activities include: .wound care: any chronic skin opening requiring a dressing. R47 was admitted to the facility on [DATE] with pertinent diagnoses of diabetes and chronic obstructive pulmonary disease. R47's most recent Minimum Data Set (MDS) completed 08/29/24 indicated no current pressure injuries or other skin/wound concerns. R47's care plan dated 11/15/24 and target date of 12/26/24 stated, At risk for alteration in skin integrity related to: impaired mobility. Skin will remain intact, free from erythema, breakdown, excoriation, or bruising until next review. Wound nurse to assess weekly. Enhanced Barrier Precautions will be maintained. On 12/10/24 at 9:44 AM, Surveyor observed an EBP sign on R47's door and a PPE bin located just outside of R47's room containing disposable gowns and gloves. Surveyor observed Licensed Practical Nurse (LPN) C don gown and gloves after completing hand hygiene outside of R47's room prior to entering to provide wound care for R47's pressure injury on left ear. LPN C placed a barrier on bed linens to set down wound care supplies. LPN C removed the dressing from R47's ear and cleansed the area. LPN C then removed gloves and donned new gloves without completing hand hygiene. LPN C dried area with sterile dressing gauze and then disposed gauze. LPN C removed gloves and donned new gloves without completing hand hygiene. LPN C then applied a new dressing to R47's ear. LPN C then disposed of used supplies in garbage, removed gloves, and washed hands in sink. LPN C then returned to R47 to assess ear again and touched R47's ear and head without gloves on. LPN C then removed gown, donned gloves, gathered garbage to remove from R47's room, and placed in soiled linen utility closet for disposable. LPN C then completed hand hygiene. Immediately following observation, Surveyor asked LPN C about the care provided. Surveyor asked LPN C about EBP and use of gloves. LPN C stated that she realized afterward that she didn't complete hand hygiene in-between glove changes and should have. Surveyor asked LPN C when gloves should be used. LPN C stated while completing all contact care for residents on EBP. Surveyor asked if LPN C had followed this policy. LPN C stated no, that gloves should be warn all the time while providing cares and hand hygiene should be completed whenever they are removed. On 12/12/24 at 11:43 AM, Surveyor interviewed Director of Nursing (DON) B regarding observation of wound care and EBP. Surveyor asked DON B what the expectation is for providing wound care for residents on EBP. DON B stated that staff are to wear gown and gloves when providing high-contact care, like wound care, and complete hand hygiene whenever gloves are removed. DON B stated that staff are educated regularly regarding EBP and are audited on this practice due to the high-risk of transmission of infections. DON B stated disappoint in this observation as all staff are aware of the importance of hand hygiene and use of PPE to protect all residents and will complete additional training with staff. 47657 The facility policy titled Hand Hygiene dated 11/02/22 states, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. Policy explanation and compliance guidelines .2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. The attached Hand Hygiene Table per facility policy indicates hand hygiene should be conducted . when, during resident care, moving from a contaminated with .body fluids, secretions or excretions. On 12/11/24 at 7:31 AM, Surveyor observed Certified Nursing Assistant (CNA) F complete AM cares on R6. After completing upper body cleansing, CNA F cleansed R6's frontal peri care with a washcloth and dried with a towel. Without removing gloves and conducting hand hygiene, CNA F proceeded to dress R6's upper body with a bra and shirt, rolled R6 onto right side and fastened bra and pulled down back of shirt, removed wet incontinent product, washed and dried R6's buttocks and proceeded to position a clean incontinent product under R6. CNA F then fastened the incontinent product and pulled up R6's pants with contaminated gloves. On 12/11/24 at 7:40 AM, Surveyor interviewed CNA F, regarding observation of removing and/or conducting hand hygiene when moving from a dirty to clean area. CNA F confirmed removal of gloves and hand hygiene should have been conducted after conducting peri care and continuing cares. On 12/11/24 at 9:18 AM, Surveyor interviewed DON B regarding observation of CNA F not removing gloves and conducting hand hygiene following completion of R6's peri care. DON B stated expectation would be to remove gloves and conduct hand hygiene before continuing cares after going from a dirty to clean area.

Based on observations, interviews, and record review, the facility failed to protect the residents' right to be free from sexual abuse. The facility did not implement interventions to protect other residents (R) from sexual abuse. This affected 2 of 6 residents reviewed for sexual abuse. (R1 and R6) On 02/19/24, R2 sexually abused R1 by groping R1 under the shirt and over the bra, touching R1's breast, while in a common area. After the incident, R2 was left unsupervised and 7 minutes later sexually abused R6, groping R6's breast over her shirt. After the first incident, appropriate interventions were not implemented to prevent the second occurrence of sexual abuse from happening. R1 and R6 were found to have severe cognitive impairment. This type of inappropriate, unwanted sexual contact would reasonably cause anyone to have psychosocial harm. It can be determined that a reasonable person in the resident's position would not want someone to come into their home and touch them in a sexual manner unless they are in a relationship and able to consent. A reasonable person would likely experience severe psychosocial harm, dehumanization, and humiliation because of the sexual abuse and would not feel safe. The facility's failure to keep residents free from sexual abuse and initiate immediate safety measures to prevent further sexual abuse created a finding of immediate jeopardy that began on 02/19/24. The State Agency (SA) notified Nursing Home Administrator (NHA) A and Director of Nursing (DON) B of the immediate jeopardy on 2/27/24 at 3:00 PM. On 02/19/24, the facility identified the failure to protect residents from sexual abuse when R2 was allowed to sexually abuse two residents. The facility took steps to correct the deficient practice immediately after the incident and ensure compliance. Based on this determination, the immediate jeopardy was removed and corrected on 02/19/24. This is being cited as past non-compliance. Findings include: The facility's Abuse, Neglect, and Exploitation policy, with a revision date of 07/15/22, indicates: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to responding immediately to protect the alleged victim and integrity of the investigation. On 02/27/24, Surveyor requested and reviewed a facility reported incident that addressed and verified the allegations of sexual abuse that occurred to R1 and R6 by R2. The investigation included a plan to educate staff and update the policy to improve the facility practice. Staff signatures were noted that they received education on 02/19/24. Surveyor reviewed R2's medical records. R2 is a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that include a stroke and speech deficits. R2's most recent Minimum Data Set (MDS) dated [DATE] identifies a Brief Interview for Mental Status (BIMS) score of 6 that indicates severe cognitive impairment. The MDS documents R2 has physical and verbal behaviors toward others on occasion which was new from the previous MDS. MDS also documents that R2 uses a manual wheelchair with supervision or touching assistance. Helper provides verbal cues or touching/steadying assistance while resident performs the activity and R2 does not wander. R2's medical record made no mention of inappropriate sexual behaviors prior to 02/19/24. Surveyor did not locate a sexual history assessment for R2. R2's admission care plan did not identify behaviors of entering others personal space, approaching or touching others prior to this incident. The facility incident report documented an interview with R2's family stating R2 had an inappropriate sexual behavior in the past, and the facility was not made aware of this when R2 was admitted to the facility. Documentation on the facility reported incident noted that RN C indicated the priority was to keep R1 safe and do an assessment. RN C took R1 to evaluate for injury and left R2 in the common area. R2 wheeled self to the dining room across from the common area where he was sexually inappropriate with R6. On 02/27/24 at 11:30 AM, Surveyor interviewed Registered Nurse (RN) C, who witnessed the sexual abuse occur to R1. RN C stated, As I was walking down the hall on 02/19/24 at 11:53 AM I noticed [R2] reach over and inappropriately grab [R1's] breast. I informed [R2] the behavior was not appropriate. I then pulled [R2] away and took [R2] to the dining room. I ensured [R1] was safe by separating [R1] and [R2]. I reported the incident to [Assistant Director of Nursing (ADON) E] and then had to start my noon medication pass. RN C stated that RN C did not tell anyone to watch R2 because RN C didn't think of it at the time. Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with current diagnoses that include sepsis and diabetes mellitus. R1's MDS, dated [DATE], documents R1's cognitive status as being severely impaired. R1 is dependent on staff for mobility and activities. Surveyor noted R1's most recent MDS dated [DATE] notes she is rarely understood and has severely impaired cognition. R1 is dependent on a wheelchair and staff for mobility. R1 has an activated power of attorney for health care and does not have the capacity to consent to sexual activity. The facility revised R1's care plan following the incident regarding her vulnerability as follows: I am a vulnerable adult and is at risk for potential abuse due to advanced dementia, dependence for cares, mobility issues and residing in a long-term care facility. Approaches include explaining the environment and surroundings, staff will be educated on reporting allegations of abuse, Facility staff will follow policy and procedure, facility staff will observe for changes in mood and behavior, psychological needs, and cognition. I will be free from retaliation if alleged abuse is reported, my family will be encouraged to verbalize concerns or problems, my family will be educated on resident bill of rights, redirect from potentially dangerous situations, redirect me from others who disturb me or that I disturb. R1's nurses notes show daily monitoring of mood and behavior since the incident with no changes noted. On 02/27/24 at 11:45 AM, Surveyor interviewed Activity Director (AD) D who observed R2 inappropriately touching R6. Surveyor asked AD D to review events of 2/19/24 with R6. AD D stated, I was coming out of the kitchen and into the dining room and saw [R2] grab [R6] outside of the shirt over [R6's] breast. I immediately took [R6] to the lounge and asked if [R2] has done this to [R6] before, which [R6] stated [R2] had not. I then left [R6] in the west lounge to report to the social worker. The social worker educated me on the need to stay with the abuser. The social worker took over supervision of [R2]. [R2] was then placed on 1:1 and continues to be on 1:1 since this event. Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE]. R6's current diagnoses include traumatic brain dysfunction, dementia with anxiety, depression, agoraphobia, restlessness, and agitation. R6's MDS, dated [DATE], documents R6's BIMS score is 6, indicating R6 has severe cognitive impairment. R6 is dependent on staff for mobility and activities of daily living (ADLs). R6 has a legal guardian and does not have the capacity to consent to sexual activity. R6's nurses notes show daily monitoring of mood and behavior since the incident with no changes noted. The facility revised R6's care plan regarding her vulnerability after the incident as follows: I am a vulnerable adult and at risk for potential abuse due to dementia and mental health issues. I also do not like the dark I prefer my TV left on. Approaches include allow TV to be left on, explain cares, staff will be educated on reporting allegations of abuse, Facility staff will follow policy and procedure, facility staff will observe for changes in mood and behavior, psychological needs and cognition. I will be free from retaliation if alleged abuse is reported, encourage to verbalize concerns or problems, my family will be educated on resident bill of rights, redirect from potentially dangerous situations, redirect me from others who disturb me or that I disturb. On 02/27/24 at 12:20 PM, Surveyor interviewed Nursing Home Administrator (NHA) A, and asked what would be expected of staff that discovered the sexual abuse on 2/19/24. NHA A reported the expectation is that staff should stay with the accused and place accused on 1:1. The social worker offered materials to meet the sexual needs of R2 and educated R2 on appropriate places for sexual activity. Director of Nursing (DON) B checked all residents for possible abuse, and it was determined there were no other residents involved and no long-standing ill effects to R1 or R6. NHA added that the situation was brought to the QAPI meeting, the policy was reviewed, and they are revising it to address the abuser interventions. On 02/27/24 from 9:31 a.m. - 9:42 a.m., Surveyor interviewed R3, R4, and R5 asking if they felt safe in the facility or had any concerns with inappropriate touching. All three residents stated they felt safe in the facility. Surveyor spoke with RN C and 2 Certified Nursing Assistants who demonstrated knowledge of R2's incident with female peer and touching inappropriately. Staff reported an incident that occurred about a week ago on 2/19/24 when R2 touched female peers inappropriately near the dining room. Staff separated the residents and R2 has been on 1:1 since incident. Staff were unaware of any incidents prior to 2/19/24 and none since. Surveyor observed R2 throughout the survey. R2 was 1:1 with staff in various settings at all times, including the dining room for breakfast and lunch and in his room. A reasonable person who has been sexually assaulted could feel Recurrent (i.e., more than isolated or fleeting) debilitating fear/anxiety that may be manifested as panic, immobilization, screaming, and/or extremely aggressive or agitated behavior(s) (e.g., trembling, cowering) in response to an identifiable situation (e.g., approach of a specific staff member). A person who has been sexually assaulted could also experience Ongoing, persistent expression of dehumanization or humiliation in response to an identifiable situation . According to the article written by a member of the [NAME] University Law School, Grandparent Molesting: Sexual Abuse of Elderly Nursing Home Residents and its Prevention, Emotional signs and symptoms [of sexual assault in a nursing home] include denial, humiliation, flashbacks, intense fear, guilt, anxiety, depression, feelings of hopelessness and helplessness, phobias, and rage. These conditions are symptomatic of post-traumatic stress disorder or rape trauma syndrome. Because victims of sexual abuse are likely to be cognitively impaired, practitioners must consider additional effects of abuse. Often cognitively impaired individuals are unable to describe the assault event, the fears, or the feelings of helplessness. This makes it more difficult to provide these victims with necessary services because they are unable to express their needs. In addition, victims suffering from dementia, including Alzheimer's disease, often display post-rape emotional distress, including disorganized or agitated behaviors, sleep disturbance, and extreme avoidance of certain staff members. Research shows that sexual abuse may increase the victim's mortality. Injuries, but more significantly stress, from the assault may exacerbate other health conditions of the victim, such as hypertension and diabetes. http://scholarship.law.[NAME].edu/cgi/viewcontent.cgi?article=1066&context=elders The facility's failure to keep residents free from sexual abuse created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy that began on 02/19/24. On 02/19/24, the facility identified the deficient practice that occurred when R2 sexually abused R1 and R6. The facility took steps to correct the deficient practice and ensure compliance immediately after the incident. Based on this determination, the immediate jeopardy was removed on 02/19/24 and corrected on 02/19/24 when the facility implemented the following: 1. Immediately placed R2 on 1:1 supervision at all times. 2. Revised the facility abuse policy interventions to address staff to stay with the accused to protect others. 3. Educated staff on abuse and protecting other residents, by always staying with the accused. 4. R2's care plan was revised with sexual behaviors and 1:1 intervention. 5. Obtained a neuro psych evaluation for R2 6. Physician review of medications for R2

Based on interview and record review, the facility did not ensure 1 of 15 residents (R) R36, reviewed for comprehensive care plans had a developed care plan specific to the resident. R36 did not have a care plan to include falls when R36 was at risk for falls and fell while in the facility. This was evidenced by: R36 was admitted to the facility on [DATE] and has diagnoses that include in part acute osteomyelitis to the left ankle, pressure ulcer of the left heel stage 4 (healed), unsteadiness on feet, congestive heart failure, anxiety, and dementia. R36's Minimum Data Set (MDS) assessment, dated 8/03/23, indicated that the Brief Interview for Mental Status (BIMS) score was 11 indicating moderate cognitive impairment. R36's transfer ability was extensive assist with 1-person physical assist. R36's balance for moving from seated to standing was not steady, only able to stabilize with staff assist. R36's surface to surface transfer was not steady, only able to stabilize with staff assist. R36's fall risk assessment, completed on 7/28/23, showed a score of 16, which indicated at risk for falls. On 10/29/23, the fall risk assessment for R36 showed a score of 17, which indicated at risk for falls. On 10/30/23 at 12:11 PM, Surveyor interviewed R36 who stated she had a fall while at the facility. R36 denied any injury from the fall. On 10/31/23, Surveyor reviewed R36's record to find the care plan did not include falls. R36's record contained on 9/22/23 an unwitnessed fall note with assessment completed. The note indicated .[R36] was found on the floor next to her bed and wheelchair in front of her. [R36] stated she had transferred from her wheelchair to the bed and slid out of bed onto the floor . R36's record contained on 9/25/23 an Interdisciplinary Team (IDT) note concerning R36's fall to include root cause and interventions. On 11/01/23 at 7:54 AM, Surveyor asked Director of Nursing (DON) B if R36 had a care plan to include falls. DON B said she would look into this. On 11/01/23 at 8:51 AM, DON B and Nursing Home Administrator (NHA) A said they did not have a fall care plan for R36, so they created one today. R36's care plan, dated 11/01/23, states: At risk for falls due to impaired balance/poor coordination and lack of safety awareness related to unrealistic physical expectations. Goal: minimize risk for falls. Interventions: ensure appropriate footwear as I allow, grip strips on left side of bed to aide in traction, reinforce need to call for assistance.

Based on observation, interview and record review, the facility staff did not perform hand hygiene when warranted while providing care to one (R42) of three residents observed for care. Certified Nursing Assistant (CNA) C did not perform hand hygiene when warranted while providing morning cares to R42. This is evidenced by: On 10/31/23 at 7:23 AM, upon entering room, CNA C completed hand hygiene with soap and water. CNA C completed hand hygiene and donned gloves. CNA C wet washcloth and soap and gave to R42 to wash face. CNA C grabbed another washcloth, wet it, applied soap and began cares on upper body. Washcloth rinsed in basin and cleaned same areas. CNA C dried R42's face and upper body with clean towel and placed soiled washcloths in disposable garbage bags. CNA C removed gloves, did not complete hand hygiene and donned new gloves. CNA C then removed the soiled incontinence brief and cleansed R42's peri-area. After completing this task, CNA C removed dirty gloves and again, did not complete hand hygiene and donned new gloves. CNA C used a clean towel to dry R42, then removed the dirty gloves, did not complete hand hygiene, and donned new gloves. CNA C then placed dirty linens in the garbage bag. CNA C removed the dirty gloves, did not complete hand hygiene and donned new gloves. CNA C continued with cares on R42's peri-cares on backside with washcloth. Once completed, CNA C did not remove soiled gloves and dried peri-area with clean towel. CNA C then placed soiled linens in garbage bag, removed dirty gloves, did not complete hand hygiene, and donned new gloves. CNA C then proceeded to apply a clean incontinence brief and then applied lotion to R42's extremities. CNA C discarded dirty water from the basin in R42's bathroom sink and put away toiletries. CNA C then removed dirty gloves, did not complete hand hygiene, and donned new gloves to place all remaining dirty linens in garbage bag and disposed of the bag in the dirty laundry bin in R42's room. CNA C removed dirty gloves and completed hand hygiene with soap and water after all cares were performed. On 10/31/23 at 7:58 AM, Surveyor interviewed CNA C regarding policy/procedure for hand hygiene. CNA C stated that she should have performed hand hygiene every time gloves were removed and before new gloves were donned. Surveyor asked CNA C why hand hygiene had not been completed. CNA C stated, It's just my routine. I'm sorry. I messed up. I should have cleaned my hands whenever I took off my gloves. On 10/31/23 at 8:25 AM, Surveyor interviewed Registered Nurse (RN) Assistant Director of Nursing (ADON) D regarding hand hygiene policy/procedure. RN/ADON D reported that hand hygiene is expected to be completed per policy - before donning gloves, after removing gloves, and whenever indicated. RN/ADON D reported being the nursing staff educator and reported repeated education for all staff on importance of hand hygiene. Surveyor requested hand hygiene policy from RN/ADON D. Surveyor received policy titled, Hand Hygiene with most recent revision 11/02/22, in part states: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.

Based on observation, record review and interview the facility did not provide appropriate assistive devices and supervision to prevent accidents when it did not comprehensively assess for individual safe and appropriate mechanical lift slings, did not care plan the individual sling required for safe transfer and did not ensure staff followed the care plan to ensure safe transfers, affecting 13 of 78 residents requiring mechanical/ Hoyer lift transfer (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12 and R13). On [DATE] R1 was transferred by 1 staff (instead of 2) using a divided leg sling that was not properly crossed. R1 slid from the sling, fell to the floor, and was transferred to the hospital. R1 fractured his ribs and obtained a pneumothorax (collapsed lung), was placed on comfort measures and expired in the hospital on [DATE]. Additionally, surveyor noted that the facility did not have an individualized assessment for the type and size of sling to use for R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12 and R13. The failure to transfer R1 with the assist of 2, the failure to properly cross R1's sling, and the failure to assess residents for the appropriate size and type of sling created a finding of immediate jeopardy. The Regional Field Operations Director notified the NHA (Nursing Home Administrator), of the immediate jeopardy on [DATE] at 2:15p.m. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope/severity of E (potential for more than minimal harm/pattern) as the facility continues to implement its action plan. Findings include: Example #1: The surveyor reviewed R1's medical record. R1's [DIAGNOSES REDACTED]. R1's most recent significant change Minimum Data Set ((MDS) dated [DATE] noted a mild cognitive impairment, he was dependent on 2 staff for transfers and he had not sustained any falls. R1's previous MDS dated [DATE] noted cognitively intact, he required extensive assistance of 2 staff for transfers and he had not sustained any falls. The surveyor requested R1's care card that was in effect on [DATE]. The care card noted Hoyer lift and 2 for transfer. The care card did not indicate a particular sling to use for R1's transfers. The surveyor requested and reviewed R1's care plan that was in effect on [DATE]. The care plan noted Focus: ADL (Activities of daily living) deficit as evidenced by: weakness, right above-knee amputation and cognitive decline related to physical limitations. Goal: will receive assistance necessary to meet ADL needs, Will not develop any complications related to decreased mobility. Revised date: [DATE]. Target date: [DATE]. Intervention initiated [DATE] with revision on [DATE]: Transfers: please use Hoyer lift and 2 for transfer until further notice. On [DATE] at 1:20 p.m. the surveyor spoke with CNA-C regarding the incident involving R1 on [DATE]. CNA-C indicated she has been a certified nursing assistant for almost 3 years. She worked at the facility for the summer the previous year and was recently rehired on [DATE]. CNA-C indicated she received a one day orientation with her return along with 2 days of job shadowing. The surveyor asked CNA-C if the training involved following resident plans of care. CNA-C responded she could not remember if the training covered following resident plans of care but she knows it is important to follow care plans for resident best outcome. The surveyor asked CNA-C if resident care plans are accessible to staff to direct resident care. CNA-C responded resident care plans are located in each resident closet. The surveyor asked CNA-C if she had checked R1's care plan prior to transferring him on [DATE]. CNA-C responded she had not. She further explained that when she previously worked at the facility R1 was an EZ stand lift. The surveyor asked CNA-C if she had assisted other CNA's with Hoyer lift transfers. CNA-C indicated she had. The surveyor asked if the transfers were done with 1 or 2 staff. CNA-C indicated 2 staff were used for the transfers she assisted with. The surveyor asked CNA-C if she had transferred R1 by herself and to explain why she had. CNA-C responded she had transferred R1 by herself. She was under the impression she had to be 18 to transfer with one staff and she now meets that requirement. The surveyor asked CNA-C to explain what had occurred. CNA-C explained she had responded to R1's call light. R1 wanted to go to bed. He was sitting on a sling. The sling was blue. She thought the sling to be a full body sling and had not been taught the difference in slings. The sling was a divided leg sling. R1 has a right leg amputation. CNA-C hooked the straps to the lift and pressed the button to lift R1. CNA-C moved R1's wheelchair aside. His right stump slipped out and he continued to slip to his right side. R1 hit the floor. The Hoyer did not tip over. The nurse was called. Nurse told to get resident up to bed and CNA did so with assistance of another staff. R1 complained of pain and an ambulance was called. The nurse called the DON and provided education to CNA-C. CNA-C indicated the education consisted of the requirement to use 2 staff for all lifts. CNA-C indicated she asked the floor nurse (RN-D) if there are different types of slings and how you know what slings you should use. RN-D said she did not know. CNA-C expressed I still don't know if it was the right sling. CNA-C said she received further training which showed use of 2 staff for Hoyer transfers however she still does not know sling types and resident slings needed. The surveyor reviewed R1's hospital records and noted History of present Illness: patient complaining of right sided chest pain. CT was diagnostic for multiple displaced rib fractures of the third, fifth, eighth, ninth and tenth ribs. Evidence of right apical pneumothorax from trauma. Very diminished breath sound bilateral. Patient is do not resuscitate. Assessment/Plan: status [REDACTED]. Given extensive for fractured ribs and high risk of [MEDICAL CONDITION] I would strongly recommend palliative care team to be involved to discuss further goals of care with the power of attorney. Progress notes further state patient poor candidate for ORIF (open reduction internal fixation) due to age and comorbidities. Patient is only on conservative management and pain control. Resident moving to comfort based approach to his ongoing management. Talked with poa, want resident to be kept as comfortable as possible. Notes showed resident pain management until he expired on [DATE]. The surveyor reviewed CNA-C's employee record and confirmed current CNA registry. The record showed the disciplinary action as noted in the FRI, along with a Certified Nursing Assistant Job description signed by CNA-C on [DATE]. The job description notes CNA's essential job functions in part as lifting, turning and transporting residents and demonstrates proper use of equipment. The employee record did not contain record of employee orientation. On [DATE] at 2:15 p.m. the surveyor spoke with RN-D. RN-D indicated she has worked at the facility on and off since 2005. She was familiar with R1. RN-D explained she was called to R1's room and found R1 on the floor complaining of pain to his right side. R1 was lifted via Hoyer to bed and RN-D conducted an assessment. R1 was found to have a skin tear to his right arm and R1 continued to complain of right sided pain. RN-D called the doctor and family. An order was obtained to transfer to the emergency room via ambulance. RN-D called the DON who directed RN-D to begin paper work and re-educate CNA-C on the need for 2 staff for Hoyer transfers and types of slings. RN-D further expressed she is not clear on slings, some cross, some don't cross, not sure who determines the right sling, not sure if therapy evaluates, not sure what assessment is done or who does them. RN-D expressed R1 needed the big sling and it was not used. The sling should have been crossed but it was not. RN-D further stated she was certain the right sling was not used. The wrong sling and not using 2 staff was the reason for the accident. On [DATE] at 2:40 p.m. the surveyor spoke with the DON regarding the facility-related incident (FRI) report and follow up completed after the incident. The DON explained the accident as reported by CNA-C. The facility determined the cause of the fall to be CNA- C did not follow R1's care plan and use 2 staff for the transfer. Additionally CNA-C did not cross the legs of the divided leg sling that was used during the transfer causing R1 to fall. The facility addressed the root causes by immediately training CNA-C and retraining all staff on the same including competency checks, conducting audits of care plans, updating care plans to read 2 staff with Hoyer lift transfers, having maintenance check the Hoyer's to ensure no mechanical issues. CNA-C received disciplinary action and will be required to have a nurse supervise all transfers for the next 12 weeks. The surveyor asked the DON if CNA-C was provided training on following resident care plans and facility policy related to using 2 staff with Hoyer transfers during her orientation when she was re-hired [DATE]. The DON responded the facility does not currently have an orientation checklist with listed required training. The DON expressed CNA-C was provided training on day one of her rehire on the facility transfer policy. The surveyor asked the DON if the facility considered correct sling usage as part of the root cause of R1's fall. The DON indicated they had not. The surveyor asked if the facility policy addresses Hoyer sling selection and whether this was considered when auditing and updating resident plans of care. The DON indicated plans of care were audited and updated to include Hoyer lift and assist of 2 staff for all Hoyer transfers. Staff were trained related to his expectation along with the expectation of following resident plans of care. The surveyor requested and received the facility policy related to safe mechanical lift transfer. The surveyor reviewed the facility policy titled Safe use of Mechanical Lifts. The policy is not dated. The policy states in part: Purpose: The purpose is to bear the load .and allow to maneuver the individual safely and efficiently. There are different types of lifts. Be sure to always consider partnering with a coworker when using mechanical lifts according to both the manufacturers and organizations recommendations. A sling is used with the mechanical lift to cradle and support the individual's body during transfer. Some medical conditions will determine sling choice; such as: orthopedic conditions, .amputations .Stroke which may affect individuals ability .The sling used should also be determined by the manufacturers recommendation for type of transfer required, size and weight of the individual, back and head support need, padding that may be required, and preferred or medically necessary positioning of the individual. Summary: It is important to recognize when to use lifts and the different types of lifts and slings available. There are many things that influence the type of lift and sling you should use, ranging from the individuals physical and mental condition to the type of transfer required. On [DATE] at 9:20 a.m. the surveyor conducted an interview with R1's power of attorney (POA)-J, who is R1's daughter. The POA described the accident with her father as reported in the FRI. The POA further indicated the family had on-going concerns during her father's stay related to staff not following his plan of care. The concerns were reported to the facility but continued. The family was informed by the facility staff again failed to follow her father's care plan by not using 2 staff to transfer him and he fell causing the accident. The surveyor reviewed the manufacturer's information for the 2 types of Hoyer lifts used by the facility. Both guides included a color coded chart of slings needed for resident by weight. The guide for the Invacare brand notes specifications of 2 staff preferred for transfer and other sizing requirements. On [DATE] at 11:00 a.m. the surveyor called and spoke with an Invacare Representative (IR)-H regarding sling selection and sizing. IR-H indicated each individual resident needs to be measured for proper sling fitting to include weight, height, girth/middle and shoulders. Additionally other medical conditions need to be considered to determine best sling to be used. This assessment needs to be conducted by a therapist of other medical professional. The Invacare sling with divided legs was the sling used for R1 when he slid to the floor. There was no evidence in the record such an assessment was conducted. The surveyor reviewed the Arjo brand manufacturer's information. Similar to the Invacare brand the guide contains information for sling fitting beyond resident weight. On [DATE] at 12:38 p.m. the surveyor spoke with Arjo Representative (AR)-I regarding sling selection and sling sizing. AR-I indicated each individual needs to be assessed for best sling fitting. This assessment needs to consider resident height, weight, shape and measurements as well as other physical unique needs of the resident such as amputations both a single and a double amputation. The representative further indicated the slings are not interchangeable between manufacturers and the facility needs a clear system in place to identify which Hoyer lift and sling is best for the individual based on each person's needs. Review of R1's medical record showed no comprehensive assessment of appropriate sling needed to safely transfer R1. R1's care plan did not direct staff in the safe and appropriate sling to use to safely transfer R1. Example #2: The surveyor reviewed R2's medical record and noted an admission MDS completed [DATE]. The MDS noted R2 was cognitively intact, was dependent on 2 staff for transfers and had not experienced any falls. The surveyor reviewed R2's care card provided by the facility on [DATE]. The card indicated Hoyer lift with 2 assist and do not pull sling too tight into groin. The surveyor reviewed R2's care plan provided to the surveyor on [DATE]. The care plan notes: Focus: Resident has impaired functional mobility as evidenced by chronic condition, communication deficit and recent left [MEDICAL CONDITION]. Goal: Resident will have ADL needs met with staff assistance. Intervention: Resident requires 2 staff assist to transfer with Hoyer. Date initiated: [DATE]. Revised on: [DATE]: Hoyer lift with 2 staff assist, do not pull sling too tight into groin. The surveyor reviewed R2's care card provided to the surveyor on [DATE]. The card indicated Hoyer lift with 2 assist and do not pull sling too tight into groin. Utilize red sling, size small. The surveyor reviewed R2's care plan provided to the surveyor on [DATE]. The care plan revised on [DATE] indicated Hoyer lift with 2 assist and do not pull sling too tight into groin. Utilize red sling, size small. The surveyor reviewed R2's medical record and found no assessment for determining the safe and appropriate Hoyer sling to use to safely transfer R2. Example #3: The surveyor reviewed R3's care card provided by the facility on [DATE]. The card indicated nursing will provide assistance as needed for transfer via the Hoyer lift, may leave for the Hoyer under resident. The surveyor reviewed R3's care plan provided to the surveyor on [DATE]. The care plan notes: Focus: Resident has impaired functional mobility as evidenced by altered gait or balance, cognitive deficit, communication deficit and decreased range of motion. Goal: Resident will have ADL needs met with staff assistance. Intervention: Nursing -hands on transfer of assistance of 2. On [DATE] at 1:05 p.m. the surveyor observed CNA-E and F transfer R3 via Hoyer lift with a green sling which was crossed between resident legs prior to transfer from wheel chair to her bed. The surveyor asked CNA-E and F about the appropriate sling to use for R3's transfers. CNA-E and F indicated they use the green sling. The sling is not indicated in the resident care plan or care card. Staff use a color coded chart in the utility room to determine the appropriate sling to use, which goes by resident weight. CNA-E and F indicated they always use the particular Hoyer (Arjo) and the sling can either be crossed or not crossed. The surveyor reviewed R3's care card provided to the surveyor on [DATE]. The card was updated to include use green sling for transfers. The surveyor reviewed R3's care plan provided to the surveyor on [DATE]. The care plan revised on [DATE] indicated use green Hoyer sling with transfers. The surveyor reviewed R3's medical record and found no assessment for determining the safe and appropriate Hoyer sling to use to safely transfer R3. Example #4: The surveyor reviewed R4's care card provided by the facility on [DATE]. The card indicated Nursing will provide assistance as needed for transfer via 2 person Hoyer lift. Utilize purple sling with transfers. The surveyor reviewed R4's care plan provided to the surveyor on [DATE]. The care plan notes: Focus: Resident self-care deficit as evidence by: disease process, diabetes, spinal stenosis, [MEDICAL CONDITION], physical limitations. Goal: will not develop any complications related to decreased mobility. Intervention: Transfer Hoyer lift 2 assist, utilize purple sling with transfer. On [DATE] at 9:48 a.m. the surveyor spoke with R4 regarding her transfers. R4 expressed staff use a Hoyer lift to transfer with usually 2 staff. R4 indicated the sling is crossed between her legs. R4 was not certain of the color of the sling used to transfer her. On [DATE] at 9:57 a.m. the surveyor spoke with CNA-G. CNA-G indicated she was familiar with R4 and cares for her often. The surveyor asked CNA-G about R4's Hoyer transfers. CNA-G indicated R4 is a 2 staff Hoyer transfer using the large blue sling that is crossed at her legs. R4's care plan did not contain an individualized assessment for type and size of sling required to safely transfer R4. Example #5 The surveyor reviewed R5's care card provided to the surveyor on [DATE]. The card read 2 assist with Hoyer for transfers, toileting. Use green Hoyer sling when transferring. The surveyor reviewed R5's care plan provided to the surveyor on [DATE]. The care plan revised on [DATE] indicated Focus: ADL self-care deficit related to post-[MEDICAL CONDITIONS], Left upper and left lower extremity with minimal movement, pain, impaired mood, and cardiac. Goal: Will receive assistance necessary to meet ADL needs. Intervention: 2 assist with Hoyer transfers, toileting. Use green Hoyer sling when transferring. R5's care plan did not contain an individualized assessment for type and size of sling required to safely transfer R5. Example #6: The surveyor reviewed R6's care card provided to the surveyor on [DATE]. The card read, nursing will provide assistance for transfers via Hoyer lift. There is no mention of 2 staff needed or color of sling to use for the transfer. The surveyor reviewed R6's care plan provided to the surveyor on [DATE]. The care plan revised on [DATE] indicated Focus: Resident has impaired functional mobility as evidenced by chronic condition [MEDICAL CONDITION]. Goal: Resident will have needs met with staff assistance. Intervention: Nursing will provide assistance with Hoyer lift, resident requires 2 staff assist to transfer, use green sling. R6's care plan did not contain an individualized assessment for type and size of sling required to safely transfer R6. Example #7: The surveyor reviewed R7's care card provided to the surveyor on [DATE]. The card read Transferring: 2 person assist from chair to wheelchair, EZ stand for toileting, utilize the yellow stand assist sling. Hoyer lift if she does not stand up, utilize yellow sling for EZ stand. The surveyor reviewed R7's care plan provided to the surveyor on [DATE]. The care plan revised on [DATE] indicated Focus: At risk for falls related to use of medication history of falls, fell in the past ,[DATE] days, [MEDICAL CONDITION] with frequent falls, deconditioning, history of self-transferring and 2 falls in past 3 months without injury. Goal: decreased falls in 3 months. Date Initiated: [DATE], Revised on: [DATE], target date: [DATE]. Intervention: @ person assist from chair to wheelchair, utilize the yellow stand assist sling. Although R7 is listed on the facility list of requiring both EZ stand and Hoyer lift, that varies, there is no direction to staff on when to use the Hoyer or what Hoyer sling is required to transfer R7 safely. Example #8: The surveyor reviewed R8's care card provided to the surveyor on [DATE]. The card read 2 staff assist to transfer with EZ stand for toileting and shower. EZ stand from wheelchair to shower chair, if she does not tolerate use the Hoyer. Nursing will provide assistance with transfers via ez stand from bed to chair and chair to bed. Hoyer lift if she does not stand up. Utilize the yellow sling for EZ stand and full body sling for Hoyer. The surveyor reviewed R8's care plan provided to the surveyor on [DATE]. The care plan indicated Focus: Resident has impaired functional mobility as evidenced by cognitive deficit, communication deficit, decreased range of motion. Goal: Resident will have needs met with staff assistance. Date initiated: [DATE], Target date: [DATE]. Interventions: 2 staff assist to transfer with EZ stand for toileting and shower, EZ stand from wheelchair to shower chair. If she does not tolerate use Hoyer. Revision: [DATE]: nursing will provide assistance with transfers via EZ stand from bed to chair and chair to bed, Hoyer lift if she does not stand up. There is no further direction to staff regarding safe Hoyer transfer. R8's care plan did not contain an individualized assessment for type and size of sling required to safely transfer R8. Example #9: The surveyor reviewed R9's care card provided to the surveyor on [DATE]. The card read transfer: bed to wheelchair and wheelchair to bed: slideboard 1 assist may use 2 if fatigued. Toileting: Hoyer for toileting, utilize yellow sling with transfers. The surveyor reviewed R9's care plan provided to the surveyor on [DATE]. The care plan indicated: Focus: ADL self-care deficit as evidenced by: orthostatic [MEDICAL CONDITION], chronic back pain, cognitive dysfunction related to physical Limitations. Goal: will receive assistance necessary to meet ADL needs. Interventions: Revised: [DATE]: Hoyer for toileting, utilize yellow sling with transfers. R9's care plan did not contain an individualized assessment for type and size of sling required to safely transfer R9. Example #10: The surveyor reviewed R10's care card provided to the surveyor on [DATE]. The card read Transferring: bed at height for safe transfers into and out of bed with 2 assist and gait belt, pad between leg and Hoyer sling between bilateral thighs, pad Hoyer strap between neck and strap, transfer with 2 assist with 2 assist with gait belt from bed to wheelchair. The surveyor reviewed R10's care plan provided to the surveyor on [DATE]. The care plan indicated: Focus: ADL self-care deficit as evidenced by: need for assistance. Goal: will receive assistance necessary to meet ADL needs. Interventions: pad Hoyer between neck and strap: date initiated: [DATE], toilet use Hoyer and 2 assist, use green sling: revised on [DATE], Transfer with 2 assist with gait belt from bed to wheelchair. Revised on [DATE]. R10's care plan did not contain an individualized assessment for type and size of sling required to safely transfer R10. Example #11: The surveyor reviewed R11's care card provided to the surveyor on [DATE]. The card read Transferring: Hoyer transfer 2 assist, total dependence, and use yellow sling with transfer. The surveyor reviewed R11's care plan provided to the surveyor on [DATE]. The care plan indicated: Focus: ADL self-care deficit as evidenced by: inability to complete self-cares independently related to weakness, potential pain, cognitive impairment, and [MEDICAL CONDITION]. Goal: will maintain existing ADL self-performance, Will be clean, dressed and well-groomed daily to promote dignity and psychosocial well-being. Interventions: Transfers: Hoyer transfer 2 assist total dependence, use yellow sling with transfers. Revised: [DATE]. R11's care plan did not contain an individualized assessment for type and size of sling required to safely transfer R11. Example #12: The surveyor reviewed R12's care card provided to the surveyor on [DATE]. The card read: Transfer: 2 assist with Hoyer for all transfers use the green Hoyer sling. The surveyor reviewed R12's care plan provided to the surveyor on [DATE]. The care plan indicated: Focus: ADL self-care deficit as evidenced by: physical limitations related to history of [MEDICAL CONDITION]. Goal: will receive assistance necessary to meet ADL needs. Interventions: Transfer: 2 assist with Hoyer for all transfers, use the green Hoyer sling. Revised: [DATE]. R12's care plan did not contain an individualized assessment for type and size of sling required to safely transfer R12. Example #13: The surveyor reviewed R13's care card provided to the surveyor on [DATE]. The card read: Nursing will provide assistance as need for transfers via Hoyer lift with 2 assist and toileting sling when available, please use ( .) resident last name. The surveyor reviewed R13's care plan provided to the surveyor on [DATE]. The care plan indicated: Focus: Resident has impaired functional mobility as evidenced by: Altered gait or balance, communication deficit. Goal: Resident will have ADL needs met with staff assistance: Interventions: Nursing will provide assistance as need for transfer via Hoyer lift with 2 assist and toileting sling when available please use ( .) resident last name. Revised: [DATE]. R13's care plan did not contain an individualized assessment for type and size of sling required to safely transfer R13. On [DATE] at 9:00 a.m. the surveyor spoke with the DON regarding Hoyer sling selection for safe resident transfers. The DON indicated all residents who require Hoyer lift transfers care plans were updated over the weekend to include the color of sling required. The Arjo brand slings are color coded. The Arjo charts were used that indicate a color of sling to use. The sling used for each resident is based solely on resident weight. The DON further stated the Invacare brand slings (the type used for R1) both the full body and divided leg slings are universal for all residents. There are no size differences. On [DATE] at 9:30 a.m. the DON expressed she had misspoke. The Invacare brand slings are also colored by a size guide/chart. The color sling used is based on resident weight. She further explained R1 had a large blue divided leg sling during his incident. The sling was appropriate to his weight. Large slings are for resident weighing of 200 to 400 pounds and R1 weighed approximately 202 pounds at the time. The surveyor asked if staff use any other information for sling selection. The DON Indicated the color size chart is used which is based on resident weight. The facility removed the immediate jeopardy on [DATE] when it had completed the following To assure the most current training resources, Arjo and Invacare contacted and detailed manufacturer's instructions on sling sizing obtained. Facility residents that utilize hoyer lift to have therapy reassessments and documentation completed for recommendations as to appropriate sling size and specifications. Facility resident care plans and Kardex's reviewed and updated, as necessary, to assure correct sling type, size and specifications upon completion of therapy recommendation by Director of Nursing or designee. Facility Nursing Staff were reeducated. Reeducation including where to find transfer status and sling type, size and information on care plan and Kardex, which slings to use for each lift (Arjo and Invacare) and difference between each type of sling available.

Based on interview and record review, the facility did not ensure 2 of 4 residents reviewed (R78, R31) were free of significant medication errors. R78 had an order for [REDACTED]. There is no evidence this lab had been drawn and therefore, did not have an order for [REDACTED]. R78 also had instructions upon discharge from the hospital to take [MEDICATION NAME] 6 mg daily until next INR on 10/04/19. There is no evidence upon review of hospital Medication Administration Record [REDACTED]. R31 received 2 doses of [MEDICATION NAME] due to an error in transcription. Ordered lab work to check R31's [MEDICATION NAME] trough levels was not completed on 08/09/19 R31 was hospitalized for [REDACTED]. Facility failure to ensure nursing staff double-check lab orders created a finding of immediate jeopardy that began on 08/09/19. Regional Director notified the NHA (Nursing Home Administrator) and DON (Director of Nursing) of the immediate jeopardy on 10/17/19 at 12:45 p.m. The immediate jeopardy was removed on 10/19/19 and continues at a scope/severity level D (potential for more than minimal harm/isolated) while the facility continues to implement their removal plan. This is evidenced by: Example 1: On 10/17/19 at 11:53 AM, Surveyor interviewed RN-N (Registered Nurse) about the facility's procedure to obtain a laboratory specimen for an INR. RN-N stated first a fax is received from the [MEDICATION NAME] Clinic to redraw a lab on a certain date. The nurse who gets the fax is responsible to refax that to the pharmacy, sign off the order and put it in the computer. This order is double checked by another nurse as the order is first put in the queue and the second nurse has to take it out of the queue and check it. RN-N stated the nurse receiving the order is then to fill out a lab slip and enter the [DIAGNOSES REDACTED]. In addition, there is another slip that is kept in the lab book (a large binder at the nurses' station) especially for [MEDICATION NAME] labs. This secondary form is filled out by the night nurse. RN-N stated the order in the computer is time dated to pop up for the day nurse to draw the specimen as it is put in the computer to be drawn at 6:00 AM. This order ends at 11:59 AM that same day. RN-N stated that the nurses try to align the day these labs are drawn to the days that the laboratory personnel are here but that all the nurses can draw the lab if needed. R78 was admitted to the facility 04/21/17. [DIAGNOSES REDACTED]. R78 takes [MEDICATION NAME] sodium and is followed by the [MEDICATION NAME] Clinic for regular labs and dosing of the [MEDICATION NAME]. [MEDICATION NAME] is a blood-thinning medication intended to reduce the risk for blood clots, which can reduce the risk for stroke, [MEDICAL CONDITION], or other serious conditions. Review of R78's medical record found communication from the [MEDICATION NAME] Clinic on 9/13/19. [MEDICATION NAME] Clinic communication form, dated 09/13/19, states R78's primary [DIAGNOSES REDACTED]. Desired therapeutic range is indicated as: 2.00 - 3.00. There is an INR re-check date of 09/18/19. The 09/13/19 communication form from the [MEDICATION NAME] Clinic was signed off by RN-Q and RN-R (Registered Nurse) on the night shift. The 09/18/19 INR lab was entered into facility's electronic health record to be completed on 09/17/19 (the date the lab was to be drawn was changed to match the dates laboratory staff are in the facility). The required lab popped up in the electronic health record to draw the lab on 9/17/19, but when the lab popped up in the system to draw on 9/17/19, it was signed off as completed by RN-[NAME] There was no check to ensure the lab had indeed been drawn before being signed off. The omission was not identified until 9/23/19 when a lab order for R78's INR came up to be completed on that date. According to a nurses note on 09/23/19, R78 was in the lab book to have an INR drawn on 09/23/19. There was no order for the lab in the computer. This was confirmed by on-call nurse line that R78 had not had an INR drawn since 09/13/19. Since no INR had been drawn on 09/18/19, no new [MEDICATION NAME] orders had been received from the [MEDICATION NAME] Clinic. Therefore, R78 had not received [MEDICATION NAME] since 09/17/19 at bedtime. Assessment of R78 in nurses note, dated 09/23/19, of R78 states, Resident been confused over last 2+ days which was thought to be related to recent d/c (discontinuation of) O2 order with parameters .residents lungs remain diminished throughout, O2 drops to low 80's or even high 70's when resident is asleep and without oxygen, only sating about 85 (achiving an oxygen saturation level) with O2 on .DON (Director of Nursint) and on-call MD (Medical Doctor) updated of situation, new orders from MD to obtain PT/INR today. Nurses note, dated 09/24/19, states that a verbal order was received from APNP (Advanced Practice Nurse Practitioner) to send R78 to ER for changes in cognition, shaking, low O2 sats 80-82 %, fatigue and pallor. emergency room report, dated 09/24/19, states that R78's chief complaint is [MEDICAL CONDITION]. Lab values show a low red blood cell count, low hemoglobin, and low hematocrit percentage, and sub-therapeutic INR of 1.3 (therapeutic range for R78 is 2.00 - 3.00). R78 required a [MEDICATION NAME] injection in order to increase the INR. R78 was admitted to the hospital and remained there until 9/30/19. R78 was discharged from the hospital on [DATE] and returned to the facility with instructions to take [MEDICATION NAME] 6 mg daily until next INR on 10/04/19. There is no evidence that this order was transcribed onto R78's Medication Administration Record [REDACTED]. R78 did not receive any [MEDICATION NAME] on 9/30/19. Example 2: R31 was admitted to the facility for rehabilitation on 03/07/17. R31 had the following, but not all inclusive, Diagnoses: [REDACTED]. In the last year, R31 was hospitalized 9 times for infections or complications from infections. On 07/27/19 through 08/04/19, R31 was hospitalized and treated for [REDACTED].[MEDICAL CONDITION] is a life threatening condition where the infection is wide spread throughout the body. Upon R31's return to the nursing facility on 08/04/19, R31 was to receive [MEDICATION NAME] 1.25 grams daily and [MEDICATION NAME] 2 grams every 12 hours. Both medications were intravenously administered. [MEDICATION NAME] and [MEDICATION NAME] are strong antibiotics that are toxic and processed through the kidneys. [MEDICATION NAME] requires frequent blood sampling to evaluate kidney function and proper dosing. Review of the physician orders [REDACTED]. A [MEDICATION NAME] trough test is used to monitor levels of [MEDICATION NAME] in the blood. After one takes [MEDICATION NAME], the amount in the blood rises, peaks, and then begins to fall, usually reaching its lowest level, or trough, just before the next dose. A [MEDICATION NAME] trough is drawn prior to the next dose and displays the lowest level of [MEDICATION NAME] that remains in the body. The trough gives the physician an opportunity to adjust the dose based on the value or level of medication remaining. For treatment of [REDACTED]. The normal values for creatinine were 0.6-1.2. An increase in the creatinine level indicates poor kidney function and eventually failure. On 08/05/19, the physician reviewed the blood values. The [MEDICATION NAME] trough level was 25.3 and the creatinine level was 2.0, both levels are above the therapeutic range. The physician ordered to hold [MEDICATION NAME] on 08/06/19 and also changed the dose of [MEDICATION NAME] to 750 milligrams daily beginning on 08/07/19. The physician ordered to check blood values on 08/09/19 instead of 08/08/19. On 08/09/19, R31's [MEDICATION NAME] level was still elevated at 24.3 and creatinine was deteriorating at 2.6. The physician ordered to hold [MEDICATION NAME] and recheck blood values on Monday 08/12/19. These orders were never transcribed and R31 received doses of [MEDICATION NAME] on 08/09/19 and 08/10/19. On 08/11/19, the facility identified the transcription error and notified the on call physician who ordered to hold [MEDICATION NAME] and obtain blood values on 08/12/19 as well as update the ID (Infectious Disease) physician who was monitoring the treatment of [REDACTED]. On 08/12/19 the [MEDICATION NAME] level was 26.6 and the creatinine was 3.7. The ID physician changed the dose of [MEDICATION NAME] to 1 gram daily and to recheck blood values for R31 on 08/13/19 and 08/14/19. On 08/14/19 the [MEDICATION NAME] level was 21.1 and the creatinine was 4.5. Although the [MEDICATION NAME] trough had decreased, the creatinine levels increased. The ID physician ordered R31 to be hospitalized . According to the hospital admission data, R31 was admitted to treat acute kidney injury. The hospital physician ordered to stop all antibiotics and slowly infuse intravenous fluids. On 08/16/19, R31 was transferred to the UW (University of Wisconsin) Hospital in[NAME] WI due to progressive kidney injury with the creatinine level as high as 5.4. Review of the UW Hospital discharge summary indicated R31 had acute kidney injury due to [MEDICATION NAME] toxicity. R31 returned to the facility on [DATE] no longer on [MEDICATION NAME] or [MEDICATION NAME]. Review of the MAR (Medication Administration Record) confirmed R31 received the following doses of [MEDICATION NAME]: ~08/05/19 1.25 grams. ~08/07/19 750 milligrams. ~08/08/19 750 milligrams. ~08/09/19 750 milligrams. ~08/10/19 750 milligrams. On 10/15/19 and again on 10/16/19, Surveyor interviewed the DON regarding R31's medication error. The DON stated the physician orders [REDACTED]. The DON stated R31's orders arrived approximately at 3:00 p.m. on 08/09/19 but were never transcribed. The DON stated on 08/11/19 a nurse discovered R31's physician orders [REDACTED]. The failure to ensure residents were free from significant medication errors created a finding on immediate jeopardy. The facility removed the immediate jeopardy on 10/19/19 when it had completed the following: 1. Audit of all residents taking high risk medications requiring lab monitoring were audited for accuracy of dosing and lab orders; 2. Education of all licensed nurses on medication errors, laboratory monitoring, and lab procedures before the start of their next scheduled shift; 3. Implemented a plan for daily monitoring of lab orders; 4. Review by the facility Quality Assurance/Process Improvement committee.

Based on interview and record review, the facility did not ensure 1 of 8 residents reviewed (R1) was free of significant medication error. On 07/12/19 RN-C transcribed a physician's order from another resident into R1's (MAR) electronic medication administration record. There is no evidence that this order had been double-checked by another licensed nurse. R1 was administered 4 doses of [MEDICATION NAME] sodium (blood thinner) 5 mg daily without a physician's order. R1 was sent to the emergency department on 07/18/19 for increased confusion, sleepiness, lethargy, and new onset irregular heart rate. R1 was admitted to the hospital on [DATE] for GI (Gastro-Intestinal) bleed. The failure to transcribe a physician's order to the correct resident created a finding of immediate jeopardy that began on 07/13/19. The NHA (Nursing Home Administrator), DON (Director of Nursing), and RNC (Regional Nurse Consultant) were notified of the immediate jeopardy on 08/28/19 at 11:30 a.m. The immediate jeopardy was removed and corrected on 07/25/19, prior to the date of the survey and was therefore Past Non-compliance. This is evidenced by: R1 was admitted to the facility on [DATE] for short term rehab following hospitalization for altered mental status and high ammonia level. [DIAGNOSES REDACTED]. Review of R1's MAR finds an entry for [MEDICATION NAME] ([MEDICATION NAME] sodium) 5 mg in the evening for [MEDICAL CONDITION] embolism. (R1 does not have a [DIAGNOSES REDACTED]. The MAR indicated [REDACTED]. On 7/18/19, R1 was assessed by the NP (Nurse Practitioner) due to increased confusion, sleepiness, lethargy, and new onset of irregular heartbeat. The NP wrote an order for [REDACTED]. Hospital history and physical report states upon arrival to emergency department R1 had a heart rate of 77 beats per minute and a blood pressure of 100/54. R1's lab results showed a red blood cell count of 2.38 (low), hemoglobin of 8.5 (low), hematocrit of 25% (low), a platelet count of 71 (low), and blood in urine. At the hospital, R1 developed nausea, had a large emesis of blood and had a bloody, foul smelling bowel movement. R1's INR (International Ratio/blood draw to detect therapeutic drug level) was noted at 9.3 (normal INR is 1.1 and therapeutic range is 2.0-3.0). The observations by the hospital staff and the lab results are indicative of internal bleeding. R1 received 2 units of packed red blood cells in emergency room . R1 received Kcentra (Vitamin K/for blood clotting), IV (Intravenous) proton pump inhibitor (acid reducer in stomach), [MEDICATION NAME] (for stomach/intestinal bleed), and [MEDICATION NAME] (Antibiotic) 1 gram every twenty-four hours. These treatments were started in order to thicken the blood. R1's lab results on the morning of 07/19/19 showed critical lab values of red blood cells at 1.87, hemoglobin of 6.7, hematocrit of 19.6%, and platelet count of 83 (low). R1 was also noted as guarding upper abdomen region and had notable blood in urine. Hospital physician summary states that R1 had multiple episodes of bloody vomit and bloody bowel movements since admission and is status [REDACTED]. Physician order states to draw hemoglobin every 12 hours with a threshold of less than 7 to transfuse (give blood) and every 24 hour INR's. R1 was placed on cardiac monitoring due to observed episodes on telemetry (heart monitor) of rapid ventricular rate (lower chambers of heart), [MEDICAL CONDITION] (erratic rhythm of upper chamber of heart) , and [MEDICAL CONDITIONS](rapid rate of upper chamber of heart). R1's blood pressure medication, [MEDICATION NAME] 12.5 mg twice a day, was discontinued due to observed episodes of [MEDICAL CONDITION] (slow heart rate) to 40's (beats per minute) on telemetry. On 07/19/19, R1 had a GI consult and an EGD (esophagogastroduodenoscopy/scope through mouth into esophagus, stomach and upper small intestine) was done. The EGD findings on showed a normal esophagus, coffee ground (blood) staining of entire stomach, no ulceration, no gastric varices (abnormal enlarged veins in stomach), and no [MEDICAL CONDITION] varices (abnormal large veins in esophagus). R1's hospital progress notes state, est. (estimated) blood loss [PHONE NUMBER] ml (not measured, covered floor and bed .). 1 pint is equivalent to 473 ml. R1 lost between 1 and 3 pints of blood. Hospital physician orders on 07/21/19 states to continue Vitamin K 10 mg daily by way of Intravenous Piggy Back (small bag connected to fluid bag run into vein). R1's lab results on 07/22/19 showed a drop in white blood cell count to 3.0 (low), red blood cell count of 2.31 (low), hemoglobin of 7.7 (low), hematocrit of 22.8% (low), and drop in platelet count to 52 (low). On 07/23/19, the facility received a call from hospital physician inquiring about the order for R1's [MEDICATION NAME]. This prompted the facility to review R1's medical record, which showed an order was entered in electronic system on 07/12/19 at 11:59 PM by RN-C for [MEDICATION NAME] 5 mg. There was no physician order for [REDACTED]. Facility interviews with staff who passed medications were initiated on 07/24/19. On 07/25/19 Med Tech-D (Medication Technician) was interviewed by the facility. Med Tech-D reported remembering giving a dose of [MEDICATION NAME] to R1 and that an RN had to retrieve the medication from the EKIT (contingency). This prompted the facility to run the EKIT dispense report with parameters to include the entire facility. The dispense report showed that [MEDICATION NAME] doses had been retrieved for R1 on 07/13/19, 07/15/19, 07/16/19, and 07/17/19. On 08/26/2019 at 1:45 PM, Surveyor interviewed RC-E (Regional Consultant) who stated that the order had been transcribed twice and that there was no [MEDICATION NAME] error for R9. RC-E also stated RN-C did not remember transcribing this order twice and has no explanation for this. The immediate jeopardy was removed and the deficient practice corrected by 7/25/19 after the facility implemented a systemic plan that included the following actions: ~Facility immediately initiated education with licensed staff and medication aides on 07/24/19 prior to their next shift on medication transcription, policy on double checking orders, medication administration and 72 hour monitoring of new medications. ~Audits were also initiated on 07/24/19 for medication aides, [MEDICATION NAME] orders, and all MEDICATION ORDERS FOR [REDACTED]. ~Education was provided on contingency medications, transcription of physician orders, double-checks on orders, signing off medications, [MEDICATION NAME]/PT/INR orders, dangerous medications, understanding adverse drug events, and medication administration: avoiding common errors. ~Audits were done on PT/INR orders, physician orders, and medication passes. ~The facility also held a QAPI (Quality Assurance Performance Improvement) meeting and initiated a PIP (Performance Improvement Plan). ~The facility also called Point Click Care (electronic charting system) consultant and had a safety control initiated on the electronic MAR indicated [REDACTED].

Based on observation, record review, and interview the facility did not ensure that each resident was cared for in a manner to prevent skin breakdown for 1 of 3 residents at risk for pressure injury (R1). R1 (Resident) developed an erosion of the skin and tissue of his penis from the pressure and manipulation of his indwelling catheter. Staff first noted the area when the erosion had already extended all the way through the glans of his penis. Facility staff did not consistently ensure the latex tubing was secure to his thigh in order to minimize the movement and rubbing of the tubing against the tissue of his urinary meatus. This was even though the staff was aware the usual device used to secure his tubing was insufficient to do so. Staff did not begin consistently using an appropriate device only after staff discovered the impaired skin and tissue under his foreskin. In addition, Surveyor observed R1 not assisted with any repositioning off of his scrotum and penis area for 5 hours and 20 minutes. Direct care staff indicate the routine is to reposition him off his perineal area when his is first cared for in the morning and then again at the end of the shift unless R1 indicates he has to use the bathroom. Staff indicates this is due to his refusal of cares and aggressive behaviors even though behavior monitoring shows his outbursts are an exception. On 5/24/19 R1 had a surgical procedure to have a suprapubic catheter placed in his bladder. A suprapubic catheter is a catheter that is surgically implanted into the bladder and drains into tubing that runs to the outside of the body though the bladder wall, through the tissue and skin, and comes out above the suprapubic bone. This is evidenced by: R1 was first admitted to the facility in (MONTH) of (YEAR) and readmitted in (MONTH) of (YEAR). His [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment dated [DATE] and virtually unchanged prior to that shows that he needs the extensive physical assistance of 2 staff members to move about in bed, to transfer from his bed to his wheelchair, to reposition himself and dress himself. He also needs a full body mechanical lift for position changes. This MDS also indicates that he has a pressure reducing device for his bed and wheelchair and a turning and repositioning program. The assessment indicated that he had no other skin issues except for a surgical wound and had not had any pressure injuries since (MONTH) of 2019. On 6/10/19 at 8:40 a.m. until 1:50 p.m. Surveyor continuously observed the care and treatment of [REDACTED]. At 8:40 a.m. CNA-B and CNA-C (Certified Nursing Assistants) had just finished assisting R1 with his shower, had helped him dress, and lifted him into his wheelchair. Over the course of the day R1 was observed to eat breakfast, sit and dose at the hall at the nursing station, attend a music program, eat lunch and then again sit and dose in the hall at the nurses' station. This observation continued until 1:50 p.m. when CNA-B and CNA-C assisted him into bed to check his brief. It was at this time Surveyor noted a 2 cm (centimeter) long (the length of his glans penis) by 0.3 cm wide open slit that was a deep as his ureter. The area was only visible when R1's foreskin was retracted. Of note is that at no time did staff ask him to reposition or go to the bathroom and R1 had a ready smile for the surveyor. At no time did he present with a negative demeanor to any staff or peer. At 1:55 p.m. while R1 was in bed that Surveyor interviewed the 2 aides about the usual repositioning schedule for R1. The CNAs stated they normally help him to reposition when he first gets up and dressed and when they empty his catheter at the end of the shift. They stated R1 usually gets up late at around 10:00 a.m. but today he was up earlier as he had a shower. Both CNAs stated it is done at these times as he will sometimes refuse and become combative. They stated he is taken to the toilet when he indicates he has to go to the bathroom for a bowel movement and he will run his wheelchair into them to tell them that. CNA-B stated she was working the day the slit was noticed and she recalled being quite surprised by how big it was. CNA-B stated now staff were using a Velcro catheter strap that would stick to his upper thigh. At 2:15 p.m. Surveyor interviewed RN-D (Registered Nurse) about the cause of the open area on R1's penis. RN-D stated she was told the area was due to caked on powder to the foreskin. RN-D stated R1 liked to play with his catheter and multiple times staff would have to remove it from his hands. She stated there was a CNA that would put copious amount of talcum powder on his penis and no matter how many time you told her not to do so she would continue to do so. The RN was asked to look at the area with Surveyor. When asked to retract R1's foreskin and look underneath, RN-D stated she had never seen the erosion slit before. The RN was asked if such an injury would be from irritation from powder and RN-D stated it was from tension. RN-D stated R1 would pull on his catheter and there would be days when you could not get him to stop and staff would know those days as his eyes twitch. RN-D stated that in the past the staff would use whatever catheter strap they could find in the supply closet and it was usually an elastic one with a Velcro tab that would not stay in place and R1 would take it off. RN-D stated staff should be assisting R1 to reposition but that R1 was dangerous and gave one staff member a concussion in the past. (Review of the behavior documentation found that he hit a staff member and a peer in (MONTH) of 2019.) When asked how this instance was the first time RN-D had seen the slit when she had been noted to sign off on the treatment record that she had assessed the skin of R1's penis 3 times a day, RN-D stated she must have not understood the order and not looked as close as she should have. Review of care plan both current and in the past found: Resolved: Secure catheter with securement device. Initiated on 8/14/17. The use of this device was to address the security of the catheter and therefore reduce the rubbing of the tubing at the tip of his penis. This was only on his care plan from 8/14/17 to 10/13/17 but the need to secure the catheter was not outlined as an intervention in 2019. The plan of care has never indicated what type of device was to be used. In addition the plan pf care instructs the aides that R1 is incontinent of his bowels and is to be offered the toilet when getting up, around mealtimes, and at bedtime. Surveyor reviewed an incident report dated 5/5/19 and revised on 5/6/19 by RN-A documenting that in addition to a 2 cm (centimeter) by 1 cm sore on R1's foreskin there was an erosion of the glans from under his urethra to the bottom of the glans and along the left side of the glans. This had been brought to her attention by a CNA. The report goes on to document other info. POA states, cath hasn't always been secured in the past. There have been several times that there has been a loop in the cath or it has been just flying in the breeze. It has only been secured with a leg strap in the last few weeks. CNA stated there was copious amounts of smegma and caked on powder under the foreskin. On 5/6/19 the DON (Director of Nursing) noted that the IDT met and reviewed this incident and determined that powder on the foreskin was the root cause of the breakdown. On 6/10/19 at 5:09 p.m. Surveyor interviewed the DON and she stated she has not seen the area. When asked what measure could be put in place to prevent such an erosion the DON stated the only measure is the placement of a SP (suprapubic) cath. Medical Doctor (MD)-E saw R1 and made a notation to discuss options such as a SP catheter as he has discomfort with his catheter. MD-E determined the erosion was due to continued pressure on his glans penis. R1's urologist saw him right after the discovery of the long and deep erosion on 5/6/19. The urologist's examination found, On exam, he also has some glans penis erosion and also some early [MEDICAL CONDITION] of the ventral (underside) penile skin. I started him on keflex 250 mg three times a day and he will come back in a week for a wound check of penis and I instructed the nursing home personnel to check on his penile skin every shift. His daughters are interested in potentially changing his urinary drainage to a suprapubic location and I told them this eliminates the discomfort of sitting on the catheter and the continued pressure on his glans penis and prevent further erosion of the glans. For now we will use [MEDICATION NAME] jelly (pain relieving gel) on this until we switch to a suprapubic tube, which I think would be a good idea under the circumstances. On 6/10/19 at 3:20 p.m. Surveyor interviewed an office personnel in charge of ordering some medical supplies for the residents. OS-F (Office Staff) stated that the adhesive catheter strap secures had been ordered in the past for 2 other residents through their supplier and the adhesive ones for R1 had been personally ordered by her since R1's NP (Nurse Practitioner) had ordered these pricier ones. OS-F indicated she did not know how long she had had to order this type of strap. Of note is that the NP saw him on 5/13/19 one week after the penile wound was discovered and on 5/31/19 there was an order to ensure the catheter was properly secured with the leg strap, nursing was to check this 3 times a day to ensure R1 was not sitting on the catheter and this was after the SP catheter was implanted. Review of the documentation of his behaviors found that the nursing staff document when and how often he is combative with staff in their attempts to care for him. The LNs (Licensed Nurses) record in the TAR (Treatment Administration Record) and the in the narrative nursing notes when he is having episodes of isolation, restlessness, mood swings, and striking out at staff. The CNAs record in the computer kiosks what shift and if he had exhibited various behaviors such as frequent crying, repetitive movements, yelling and screaming, sexually inappropriate behavior, threatening behavior, and any rejection of care. In addition the CNAs record if he has done any kicking and hitting, pushing, and grabbing, pinching, scratching, and spitting, biting toward themselves or others. None of these has any elaboration of the severity of the reaction and what happened both before or after the episode. Review by the surveyor found the record to show more often than not he did not have such behaviors or negative reactions to staff trying to assist him. Notations note that a therapeutic cat or to be left alone was effective in deterring negative behaviors. LN documentation 6/1/19 to 6/10/19: The evening of 6/5/19 he had 2 episodes of restlessness, 5 of mood swings, and 10 of striking out. This was also noted in the narrative notes as he hit the nurse trying to administer his medications. There were no other negative behaviors noted. CNA documentation 6/1/19 to 6/10/19: Evening shift of 6/6/19 he had grabbing behavior. Day shift of 6/8/19 he had repetitive movements and 6/10/19 he was noted to have mood swings but no aggressive behaviors. LN (MONTH) 2019: One episode of restlessness on the evening shift of 5/1/19 and on 5/15/19 he hit a nurse when she tried to test his blood sugars with a finger prick and swung at her when she tried to give him his evening medications. On 5/23/19 he was agitated and scolding his peers and a walk outside was effective to calm him. CNA (MONTH) 2019: There were 11 shifts of all 93 shift with any record of behaviors with 1 of being threatening, 3 kicking, 1 grabbing, 2 of wandering, and 3 with repetitive movements LN (MONTH) 2019: 8 of the 90 shifts that month had any record of the behaviors and only 1 episode on one shift was when he was striking out when staff again attempted to check his blood sugar and give him medications. CNA (MONTH) 2019: 16 of the 90 shifts was he observed wandering and only 1 time did he show repetitive movements and there was no recorded episode of his having any outbursts either physically or verbally.

Based on observations, interviews and record reviews the facility did not ensure 1 of 18 residents (R60) received treatment and care in accordance with professional standards of practice. R60 had a facility acquired unstageable necrotic covered wound on her slight outer left calf of undetermined cause. The facility did not ensure this area was offloaded in order to prevent worsening and allow healing of the wound to occur. This is evidenced by: R60 was admitted to the facility on [DATE] with Medical [DIAGNOSES REDACTED]. She has generalized [MEDICAL CONDITION], predominantly of the lower extremities and hands. The MDS (Minimum Data Set Assessment) with an assessment reference date of 9/4/18 indicates R60 required extensive assistance of staff for bed mobility, transfers, toileting and personal hygiene. She is non-ambulatory and was scored a BIMS (Basic Interview of Mental Status) of 12/15, indicating mild cognitive decline. This MDS indicates R60 did not have any skin integrity concerns. The facility completed a 14 day MDS dated [DATE]. This MDS indicates 1 DTI (Deep Tissue Injury) noted. The facility provided Surveyor with an Injury of Unknown document dated 9/10/18. According to this form, staff noticed a new breakdown area on R60's calf while doing cares. This form described the wound as a quarter-sized discolored blister on the left lower calf. Staff noted the area of blistering matches up with the plastic lip of the leg rest from R60's wheelchair. A towel was then placed over the wheelchair leg rest to prevent the plastic lip from hitting the area. A follow-up review was then conducted on this report, dated 9/16/18. This documentation states IDT (Interdisciplinary Team) reviewed incident of blister on left lower calf .Root cause was leg rubbing and resting on newly place (sic) un-padded leg rest. Immediate intervention was to pad the leg rest. IDT agrees with intervention and pad the other leg rest and/or replace leg rest for padded ones .care plan updated. R60 was seen by the Nurse Practitioner (NP-D) on 9/10/18. According to the documentation, R60 has chronic venous stasis changes with this assessment. The NP notes the blood blister as being 4 x 2.5 cm. Surrounding skin extremely red and warm. The Dx at that time was [MEDICAL CONDITION]. R60's Care Plan indicated a problem of Skin integrity alteration risk related to impaired mobility, nutritional deficit, bullous area to left calf and lower extremities. This care plan was dated 9/1/18 and last revised on 9/23/18. Interventions include: - float heels as able (9/1/18) - use pillows/positioning devices as needed. The Care Plan was not updated with the new intervention to pad the leg rests of the wheelchair. R60 was then treated for [REDACTED]. According to the discharge summary dated 9/18/18, while R60 was being treated at the hospital, they discovered the blister to the left calf, which drained and developed a shallow crater. The summary indicated the area of breakdown was consistent with a pressure point while resident was up in the wheelchair, as the area of the calf that the wound was located was consistent with the location of the wheelchair leg rest/brace. A different wheelchair was ordered and the wound team was consulted. The wound team at the hospital ordered [MEDICATION NAME] 4 times daily as well as [MEDICATION NAME]. A venous Doppler was conducted while hospitalized and was negative for [MEDICAL CONDITION] ([MEDICAL CONDITION].) The facility's Wound Evaluation Tracker included the following documentation: Week 1: - 9/12/18: 5.0 cm x 3.5 cm. Wound type is described as a Pressure Ulcer There is no description of the wound bed, surrounding tissue or wound color on this assessment. The wound was described as having defined margins. In-house acquired Pressure Ulcer, blood filled, no redness or drainage, no pain. treatment of [REDACTED]. Week 2: -9/19/18: 4.5 cm x 3.5 cm unstageable with small amount of [MEDICAL CONDITION] drainage, no odor, 100% necrotic. The treatment was changed to [MEDICATION NAME] twice daily, cover with an ABD pad and wrap with Kerlix. Week 3: - 9/26/18: 4.9 x 4.6 x 0.3, unstageable, with a thin, watery [MEDICAL CONDITION] drainage, 100% necrotic. The treatment remained the same. On 9/24/18, NP-D again saw R60 and identified a new smaller area to the left of the larger wound on the left calf, stating it looked like it was caused by irritation from the compression stockings. On 9/27/18 NP-D saw R60 once again and documented in the progress note the blistered area on the left calf has increased in size. She recommended an evaluation by dermatology for a vasculitis. R60 was observed several times throughout the survey to be positioned in such a manner, that direct pressure was being forced onto the wound: 10/01/18: - At 1:18 PM: R60 was in bed with her legs resting on a heels-up device on the bed, floating the heels but also causing direct pressure to the current wound of the left leg. - At 3:46 PM: R60 was asleep in bed as previously stated. 10/02/18: - At 6:36 AM: R60 was in bed on her back with a heels-up device under her calves, floating the heels. Her calves were against the cushion itself, causing pressure to an already existing wound. - At 7:28 AM, 8:28 AM,9:33 AM, 10:10 AM, and 11:18 AM; R60 was positioned as noted above. - At 11:48 PM staff assisted R60 into her wheelchair. There was no additional padding placed on the leg rests of the chair. The continued pressure to the area created the potential for the wound to worsen and does not allow healing, as blood supply to the area is hindered. On 10/02/18 at 2:19 PM, Surveyor observed RN- A (Registered Nurse) complete R60's treatment to the left calf wound. RN-A and Surveyor noted the old dressing contained a large area of dark brown to black drainage a little larger than a half-dollar coin. The wound itself was also slightly larger than the size of a half-dollar coin, necrotic and dry with a dark pink to red area surrounding the wound. There was a small scabbed area just below the wound, approximately the size of a dime. No other blisters or wounds in the area were noted on the entire lower leg. RN-A stated that it was originally thought to be [DIAGNOSES REDACTED], then R60 developed [MEDICAL CONDITION] to the area. Surveyor asked R60 if she had any pain to the area. R60 stated that she did not have pain now but has a throbbing pain at night when she goes to bed. She stated that she didn't really have any pain to her leg until the blister popped open. Surveyor asked R60 if she generally has padding on the footrests of her wheelchair. Resident shook her head and stated No they don't put any padding there. On 10/02/18 at 3:39 PM, Surveyor interviewed NP-D (Nurse Practitioner) regarding her latest assessment of R60's wound. NP-D stated she assessed the area the previous week and noticed that it was about the same size. She stated it was a dark red area with an approximate size of a quarter coin in the center that was black. There was no notable redness or warmth surrounding the area at that time. Surveyor then described the wound. NP-D stated it sounds like it has worsened . On 10/2/18 NP-D saw R60 to reassess the left calf ulceration. She noted in her progress note that the area is covered in eschar and recommended wound clinic for sharps debridement. She noted that the cause remains doubtful and stated that after further evaluation, the staff felt it was not pressure related as R60's calf is not against the leg rest of the wheelchair. She then questioned whether the heels-up pad was at fault and determined that it would not cause a localized pressure as the pad is flat against the calf On 10/02/18 at 4:06 PM, Surveyor asked RN-A if she recalled additional padding of the leg rests for R60 when she is up in the wheelchair. RN-A stated, Yes, I remember prior to hospitalization we had pillows under her calves. I know because I was the one who put it on her careplan. The Surveyor asked RN-A if she felt R60 should have padding under her legs now. RN-A replied,Yes she should. On 10/02/18, at 4:13 PM, Surveyor interviewed RN-E regarding R60's wound. RN-E is Director of Clinical Services. RN-E stated she doesn't feel the area is pressure related as it does not have a pressure component. She stated that she believes the wound is Bullous [DIAGNOSES REDACTED] or Vasculitis. [DIAGNOSES REDACTED] is an [DIAGNOSES REDACTED] disorder that occurs when the immune system attacks the skin and causes blistering. The affected individuals develop small to large, itchy blisters with areas of inflamed skin. These blisters are generally located throughout the body surface. The blisters are painful, bleed easily and heal slowly. There is also a characteristic odor that emanates with the draining of the serum from the blisters. None of these symptoms have been documented in R60's Medical Record. Surveyor then asked RN-E to accompany her to R60's room to show her that R60 was without any padding to the footrest. Upon entering, the Surveyor and RN-E noted the heels-up device from her bed, was now on the wheelchair footrests so that her calves were resting on same. This again created pressure to the area as the device has a lipped area on each side in which the outer calf was resting upon. RN-A stated that she had directed staff to place the cushion under R60's legs in the chair following the Surveyor's questions of padding. 10/03/18: - At 7:30 AM: R60 lying in bed on her back. The heels-up device was under her legs causing the heels to float but the left calf was resting against the device. - At 7:46 AM, the Surveyor observed morning cares provided to R60. Upon staff removing the covers in order to bathe R60, the Surveyor noted there was a pillow on top of the device, under R60's calves. The lip of the heels-up device was resting against the lateral left calf, imposing direct pressure to her wound. When cares were completed, staff positioned R60 slightly on her left side with the heels-up device under her calves. This posed direct pressure to the wound. - At 09:41 AM, R60 remained in the same position. - At 10:01 AM, R60 remained as noted above. Even though the wound is no longer considered a pressure injury, pressure exerted on to the wound can cause additional damage and slow the healing process. At 10:46 AM, RN-F entered R60's room to complete the dressing change to her left calf wound. RN-F stated she is the facility's wound care nurse and was treating the wound when it first presented itself. RN-F stated originally the wound was an intact blood-filled blister. She stated upon R60's return from the hospital, she noted that the fluid had drained out, and initially, she thought it was pressure, but with everything going on with her medically, they considered another cause. They do not really know what it is. RN-F stated the area does not follow the normal pattern of a pressure injury. RN-F stated R60 has an appointment set up for a dermatology consult. RN-F measured the wound to be 5.5 cm x 4.0 cm. The wound was necrotic, black, dry and scaly. RN-F identified the wound to also have an area of yellowing from 7 o'clock to 11 o' clock and dark pink tissue on the very edge of the wound from 7 o'clock to 10 o'clock. This measurement was nearly twice the size of it's original assessment. RN-F stated that the tissue is indeed eschar, dead tissue. The newer area to the lower left of the major wound that measured 1.5 cm x 1.2 cm was also dry, flat and covered in eschar. RN-F stated, That was not there the last time I saw the wound about a week ago. Surveyor asked RN-F if she thought the cushion may be causing the wound to worsen. RN-F stated Yes but she also needs a cushion for the previous breakdown on her heels and for her [MEDICAL CONDITION]. I am curious to hear what Dermatology has to say.

Based on record review and interview, the facility did not ensure that 1 of 6 sampled residents were transferred appropriately to prevent injury. CNA-A (Certified Nursing Assistant) transferred Resident #6 alone when the plan of care stated 2 staff members were needed. Resident #6 fell and was later diagnosed with [REDACTED]. This is evidenced by: Surveyor # reviewed the comprehensive plan of care for Resident #6 printed 3/2/14, the day before the fall. The care plan states: "At risk for falls related to: Use of medication, fell in the past 31-180 days, unable to transfer/ambulate without assistance, assist with toileting needs, locomotion, weakness to left side, use of antidepressants. Uses w/c (wheelchair) for main source of mobility." The list of interventions included: "Use hoyer lift with 2 assist for all transfers PRN (as needed). Date initiated 11/22/2013. Revision on 1/3/2014." "Has worked with therapy to transfer with 2 staff stand and pivot (both feet remain on the floor and the person turns only). Date Initiated: 1/3/14." The nursing notes indicated Resident #6 had an upper endoscopy on 2/26/14, the Wednesday before the weekend. The procedure was done under general anesthetic. On Thursday, 2/27/14, LPN-B documented Resident #6 was not up to his baseline cognitive status, complained of being tired, and was eating less than 25%. On Friday, 2/28/14, there were no nursing notes with the exception that he slept at night. On Saturday, 3/1/14, the nursing notes indicated he was still having poor meal intakes, but drinking his supplements. On Sunday, 3/2/14, Resident #6 reported frequent and severe pain, had a large emesis after supper, and was lethargic the rest of the evening shift. On Monday, 3/3/14, after midnight, Residents #6 had a low grade fever of 100.0 degrees F (Fahrenheit) and was given Tylenol. The nursing notes indicated he had pain, fever, was not eating well, and had vomited over the weekend. Surveyor # reviewed the nursing notes and post fall paperwork and discovered that on 3/3/14 at 9:45 a.m., Resident #6 was "lowered to the ground" during a transfer from his bed to a shower chair by CNA-A. Over the course of the next few days, Resident #6 had increased complaints of pain. Resident was subsequently diagnosed with [REDACTED]. There is a handwritten order by LPN-B (Licensed Practical Nurse) on 3/3/14 (the date of the fall) that states, "Orders for PT (physical therapy), OT (occupational therapy) for (increased) strength, gait/transfer training." On 3/20/14 at 7:23 a.m., Surveyor # asked LPN-G what Resident #6's transfer assistance needs were prior to the incident when he was lowered to the floor. LPN-G stated she did not remember. On 3/20/14 at 7:34 a.m., Surveyor # interviewed CNA-A. CNA-A stated Resident #6's transfer status was "one or two depending on what we (CNAs) felt comfortable with." CNA-A stated on the day of the fall, she was assisting him to a shower chair. She stated in order to get to the shower chair, Resident #6 had to take a step and his knee gave out. She then had to hang on tight to the belt in order to lower him to the floor and stop him from falling. CNA-A stated she had been transferring Resident #6 by herself for 2 months prior to the fall and had no fear of him not being able to do so. CNA-A stated Resident #6 had improved greatly since he was last hospitalized before and was even trying to walk in the hall with two people and a wheelchair following. CNA-A stated in thinking back, she should not have done so because "Resident #6 had just had the esophageal procedure and when he came back he wasn't as clear and sharp mentally. His throat hurt him and he didn't want to eat and drink. He was dehydrated and had kidney failure." On 3/20/14 at 7:40 a.m., Surveyor # interviewed CNA-E. CNA-E works full time on the ACU (accute care unit). CNA-E stated she didn't work very often with Resident #6 prior to the fall but she thought he needed 2 staff to assist him and a gait belt. CNA-E stated the aides are "never, never, never" to transfer a resident alone that needed 2 people. On 3/20/14 at 7:45 a.m., Surveyor # interviewed CNA-F. CNA-F had been working on the unit for 2 months. CNA-F also stated she did not work very often with Resident #6 but she also thought he needed 2 staff to assist him. CNA-F stated therapy staff would sometimes walk him in the hall and that she would sometimes assist. CNA-F stated, "Resident #6 was doing pretty good with 2 people before and that he was was not hard to get up and it went pretty good." CNA-F stated that if the care card said for 2 people then 2 people had to be used. On 3/20/14 at 9:30 a.m., Surveyor # interviewed LPN-B. LPN-B was the nurse on duty at the time of the fall and had filled out the "Post Fall Investigation/Plan" dated 3/3/14. The report stated at the time of the fall, Resident #6 needed the assistance of 1 or 2 persons to transfer. LPN-B was asked if she verified that the care card stated that one person could transfer Resident #6. LPN-B stated she did not look at the care card. LPN-B indicated she was told by CNA-A that Resident #6 was getting pretty good at transfers over the weekend, was improving, and was "now a 1 person." She recalled that therapies had assessed that Resident #6 needed 2 staff persons to transfer and she had been off for the weekend. Surveyor # reviewed the nursing notes for 6 days prior to the fall and over the weekend. There are no notations in the nursing notes about Resident #6 improving in his transfer abilities. On 3/20/14 at 9:50 a.m., the ACD (Alzheimer's Care Director) submitted to Surveyor # a photo copy of the CNA care cards dated 2/28/14 (3 days before Resident #6 fell ). The care card states Resident #6 is to be helped with "assist of 2 CGA (contact guard assistance) with transfers; Hoyer (mechanical lift) as needed." CGA is defined as using one or two hands to guide or help with balance. The ACD stated the card on 3/1/14 could have been changed by therapy staff as he was being seen by them at the time. On 3/20/14 at 8:26 a.m., Surveyor # interviewed PT-C (Physical Therapist). PT-C stated when Resident #6 was on his caseload previously, that he was able to help Resident #6 stand with minimal assistance and he had devised a program for Resident #6 to walk to the dining room. Resident #6 had been discharged from his caseload on 1/3/14, but was now back on his caseload after the recent fall. PT-C stated he had not changed the CNA care card. PT-C stated the comprehensive plan of care and the CNA care card should be a mirror image of each other. PT-C stated Resident #6's transfer skills were inconsistent with the staff and that Resident #6 did better mid-day when he was more awake. PT-C stated that was why he changed the care plan on 1/3/14 to have staff use a Hoyer lift if they needed it in the morning and at night. On 3/20/14 at 9:10 a.m., Surveyor # interviewed OT-D (Occupational Therapist). OT-D stated he was able to transfer Resident #6 by himself as Resident #6 was able to do 75% of the work of standing by himself however, that would mean that Resident #6 would need 2 staff to transfer as they did not have the higher skills in that area to safely do so with only one person. OT-D stated that he had not changed the care card. OT-D stated that after therapy the nurses can modify care cards too. On 3/20/14 at approximately 10:15 a.m., the ACD stated she was unable to find a copy of the care card on the day of the fall in order to verify if Resident #6 could be transferred with only one person. She stated staff are to sign them and hand them in each day to verify they did the cares as directed. The ACD stated she had found only the ones CNA-F had signed and the rest of the staff must be throwing them away. The ACD stated when she checked the care card as part of the post injury investigation, she may have misread it as saying 1 person could transfer Resident #6. The ACD stated had she realized it, the investigation would have taken another more serious turn. The dates of therapy services were confirmed. He was discharged in January 2014 by both OT and PT. There was no indication that therapy had changed the CNA care card to reflect Resident #6 could be transferred by 1 person. On 3/20/14 at 10:45 a.m., Surveyor # met with the NHA and DON. The DON stated that they would question the nurse manager on the unit and continue to look for the old care cards. No additional information was received.

Uncorrected at Verification Visit. Based on staff interviews and record reviews, the facility did not consult with a physician when there was a significant change in a resident's physical health status and the need to alter medical treatment for 1 of 5 sampled residents. Resident #34 had a [DIAGNOSES REDACTED]. Resident #34 had significant daily weight increases totaling 8 pounds in 5 days with a 1 day gain of nearly 5 pounds. The facility contacted a nurse practitioner regarding the 1 day weight gain of almost 5 pounds. There was no physician consultation. From 2/16/12 through 2/19/12, Resident #34 had a decline in lung status including wheezing on inspiration and expiration, rhonchi, decreased lung sounds to the bases and occasional course rales. There was no physician consultation. This is evidenced by: On 03/20/12, Surveyor # received a copy of the facility policy and procedure from the facility Interim Administrator entitled "Notification of Change in Resident Health Status" which states, "Notification: Within 24 hours from the time an assessment has been made indicating there may be a potential for physician intervention." It includes the following: "The Center will consult the resident's physician, nurse practitioner or physician assistant, and if known notify the resident's legal representative or an interested family member when there is: ....(B) acute illness or a significant change in the resident's physical, mental, or psychosocial status ( ie. deterioration in health, mental, psychosocial status in either life-threatening conditions or clinical complications...." Surveyor # 's review of Resident #34's closed medical record on 03/20/12, reveals the following discharge [DIAGNOSES REDACTED]." Further review of Resident #34's record reveals the following discharge order dated 02/10/12: "Report any of the following conditions to the patient's provider: a). Weight gain: Greater than 2 pounds in one day; Greater than 5 pounds in one week; One pound daily for 3 days in a row. B) If the patient shows worsening signs of heart failure such as weight gain, worsening shortness of breath, dizziness/lightheadedness, increased [MEDICAL CONDITION]." Review of Resident #34's admission weight from the weight monitoring sheet reveals an admission weight of 130.6 pounds on 02/10/12. On 02/14/12, Resident #34's weight was noted to be 128.4 pounds. On 02/15/12, Resident #34's weight was noted to be 133.2 pounds (+4.6 pound), on 02/16/12 the weight was 133 pounds. This was an increase of greater than 2 pounds in a day and nearly 5 pounds in a week. There was no indication that Resident #34's physician was consulted. Review of Resident #34's progress notes reveals the following entry on 02/16/12 at 12:15 a.m.: "Resident had bilateral inspiration and expiration of wheezing and rhonchi throughout lungs; still present after asking her to cough. Resident denies SOB (shortness of breath) and was able to follow simple commands. Affect: smiling and pleasant. Currently safe, and sleeping with call-light in reach. Will continue to monitor throughout shift." Review of Resident #34's progress notes reveals the following entry made by RN-F (registered nurse) dated 02/16/12 at 16:53 (4:53 p.m.): "Updated NP (Nurse Practitioner) of weight gain of 5 pounds over a day. No new orders." Resident #34's physician was not consulted regarding the weight gain or the decline in Resident #34's lung status. On 03/20/12 at 2:10 p.m., Surveyor # spoke with RN-F. RN-F indicated that she had called and updated NP-A (Nurse Practitioner) about the 5-pound weight increase that Resident #34 had between 02/14/12 and 02/15 and 02/16/12. RN-F said NP-A did not see Resident #34. RN-F said NP did not have any new orders. On 03/20/12 at 4:10 p.m., Surveyor # spoke with NP-A. This was witnessed by Surveyor # . Surveyor # showed NP-A Resident #34's progress note dated 02/16/12 regarding the update on Resident #34's weight gain of 5 pounds. NP-A said she did not recall this event but that was because she receives a lot of calls. NP-A was asked if she recalled consulting with the physician about the weight gain. NP-A said she did not know of calling the physician on this. NP-A then went on to indicate that she would have asked for a reweigh the next day and then she would have contacted the physician. NP-A went on to indicate that she did not recall being informed of the wheezing and rhonchi either. Further review of Resident #34's weight monitoring record reveals a weight of 135.6 pounds on 02/17/12. This is a 2-pound increase in one day. By 02/18/12, Resident #34's weight was up to 136.4 pounds. Again, there was no evidence that the physician was consulted. Progress notes continue: 02/17/12 at 11:42 p.m.: "...LS (lung sounds) decreased to the bases, occ. (occasional) coarse rales, resp. even and unlabored..." On 02/19/12 at 3:53 p.m., the following progress note was made in Resident #34's record: "...Resident's oxygen level was at 89% RA (room air) and on recheck was 90% RA. Resident has scattered occasional crackles throughout. Weight is increasing each day. HFC (Heart Failure Clinic aware...HFC wanted her initial visit with HFC to be rescheduled from Wednesday February 22 to Monday February 20 but family isn't available at that time to take her to the appointment. Denies SOB (shortness of breath), pain, dizziness, nausea, or [MEDICAL CONDITION]. Continue to monitor." Review of the record reveals that Resident #34's physician did a chart review on 02/20/12 and ordered Furosimide ([MEDICATION NAME]) 20 milligrams every day for fluids and blood pressure control and discontinued the Hydrocholorothiazide. Progress notes continue: 2/22/12 at 8:53 a.m., "...RN was called to resident's room about back and chest pain. RN said B/P was a little high 185/89 (Resident #34's blood pressure had been running in the 131-146/40-66)...O2SAT (oxygen saturation) 89% put oxygen on. RN assessed heart sounds which were irregular and 79..." There is no indication that the physician was consulted. Review of Resident #34's record reveals a HFC note dated 02/22/12. This progress note indicates Resident #34's BNP was 711. A level of greater than 400 is indicative of severe [MEDICAL CONDITION]. Crackles were noted in the left lung base and trace [MEDICAL CONDITION] was noted. [MEDICATION NAME] was discontinued and an order for [REDACTED]. Progress notes continue: 2/23/12 at 4:11 a.m., "...continues to complain of congestion with intermittent productive cough or clear phlegm, noted expiratory wheezes bilaterally..." 2/23/12 at 3:22 p.m., indicates the HFC was contacted and informed of Resident #34's weight gain of 2 pounds between 2/22/12 and 2/23/12. There is no indication that the HFC was informed of the congestion and wheezes at that time. There is no indication that the physician was consulted regarding Resident #34's condition. Progress notes continue: 2/23/12 at 3:58 p.m., "...Lungs are diminished throughout...Continue to monitor." 2/23/12 at 8:00 p.m., "...Called to resident's room by family, they report resident doesn't seem to be herself this evening. They voice concerns that resident appears more SOB (short of breath), and seems to be having difficulty verbalizing her thoughts...LS (lung sounds) clear..." 2/24/12 at 1:54 a.m., "...resident reports intermittent cough, she has a loose sounding cough-non productive at time I was present, lungs were clear to auscultation with diminished bases. She has mild dyspnea (shortness of breath) on exertion which resolves with few minutes of rest..." 2/24/12 at 8:07 a.m., "...lungs have expiratory wheezes more audible in the upper lobes, right greater than left..." 2/24/12 at 3:24 p.m., "It was reported by CNA that resident was feeling SOB (short of breath). Upon assessment, resident was perspiring and was breathing rapidly. Resident was given supplemental oxygen at 2L (liters) and a nebulizer treatment...BP 161/88, P (pulse) 110-130, R (respirations) 24-30 and labored O2 85%...MD called immediately and resident sent to ER via ambulance...for SOB..." Resident #34 was admitted to the hospital on [DATE] and passed away there on 2/27/12.

Based on observation, interview, and record review, the facility did not ensure that 1 of 7 residents sampled for limited range of motion had interventions in place to improve or prevent further decline in function. Resident #9 had avoidable contractures in both knees. While Resident #9's care plan directed staff generally to complete range of motion (ROM), the facility had not identified, assessed nor implemented a plan of care with regards to Resident #9's knee contractures. Additionally, staff were not completing ROM as there was no directive for them to do ROM on the nursing assistant care card. On 1/25/12, Physical Therapy assessed Resident #9 as having a 55 degree contracture in both of her knees that had not been previously identified. This is evidenced by: Surveyor # completed a review of Resident #9's clinical record and noted the following: Resident #9 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Resident #9's current Minimum Data Set ((MDS) dated [DATE], indicated Resident #9: ~Had both short and long-term memory problems; ~Cognition was severely impaired; ~Required extensive assistance of 2 staff persons for transfers, dressing, bathing, and toileting; ~Did not walk; ~Balance was not steady moving from a seated to standing position, when moving on and off the toilet, and during surface to surface transfers; and, ~Had no Range of Motion (ROM) limitations that interfered with daily function or put Resident #9 at risk for injury. Resident #9's MDSs dating back to 1/26/11 indicated Resident #9 had no ROM limitations that interfered with daily function or put Resident #9 at risk for injury. On 1/24/12 at 5:30 p.m., Surveyor # spoke with RN-T (Registered Nurse). RN-T indicated she was 1 of the RNs who completed MDS assessments including the section regarding ROM. Surveyor # asked RN-T about Resident #9's MDS indicating Resident #9 had no ROM limitations. RN-T indicated she wanted to consult with another RN prior to answering the question. On 1/25/12 at 10:00 a.m., Surveyor # spoke with RN-S and RN-T. RN-S indicated she also completes MDS assessments. Surveyor # again asked about Resident #9's MDS indicating that Resident #9 had no ROM limitations. RN-S indicated Resident #9's limitation did not interfere with her daily functioning or put her at risk for injury therefore it was coded as no impairment. According to the RAI (Resident Assessment Instrument) manual, Section G0400B, Lower Extremity Range of Motion, staff are to Code 0 or No Impairment, "If resident has full functional range of motion on the right and left side of upper/lower extremities." According to Resident #9's clinical record, Resident #9 had a history of [REDACTED]. Resident #9's care plan dated 2/10/11, indicated Resident #9 had impaired mobility and directed staff to monitor and report any changes to Resident #9's ROM as well as provide ROM. Resident #9's care plan did not address Resident #9's knee contractures. There were no specific interventions on how staff were to maintain or improve Resident #9's function. Resident #9's CNA care plan did not direct staff to complete ROM. On 1/23/12 at 9:20 a.m., Surveyor # observed CNA-R and CNA-H assist Resident #9 with morning cares. Surveyor # noted Resident #9 had approximately a 45 degree contracture in both knees. There was no ROM done on Resident #9's legs. On 1/23/12 at 3:30 p.m., Surveyor # observed CNA-P and CNA-Q assist Resident #9 with cares. Surveyor # asked CNA-P and CNA-Q who did ROM for the residents. CNA-Q indicated CNAs do not do ROM. CNA-P indicated this was completed by the therapy staff. On 1/23/12 at 3:45 p.m., Surveyor # spoke with CNA-P. Surveyor # asked CNA-P who does ROM for residents who require it. CNA-P indicated ROM was only done if the resident's care card or care plan indicated that it needed to be done. CNA-P indicated ROM was not part of Resident #9's cares. On 1/24/12 at 10:05 a.m., Surveyor # spoke with CNA-R. Surveyor # asked CNA-R what the facility's practice was for completing ROM. CNA-R stated therapy staff complete ROM. CNA-R also stated that if CNAs were supposed to complete ROM, it would be on their care cards. On 1/24/12 at 10:50 a.m., Surveyor # spoke with CNA-U about the contractures to Resident #9's knees. CNA-U stated Resident #9's knees were becoming more contracted and "more stiff." On 1/25/12 at 11:40 a.m., Surveyor # spoke with the Director of the Therapy Department and requested to have the range of Resident #9's knees measured. On 1/25/12 at 12:25 p.m., the Director of the Therapy Department indicated they noted a 55 degree contracture in both of Resident #9's knees. On 1/25/12 at 12:00 p.m., Surveyor # spoke with the Director of Nursing (DON). The DON indicated Resident #9 should have been on a ROM program.

Based on interview and record review, the facility did not ensure that 1 of 11 sampled incontinent residents received the necessary care and treatment to maintain or restore bladder function. Resident #8 had a decline in bladder function. There was no bladder reassessment completed to determine the potential cause and to determine if the current interventions were still appropriate. This is evidenced by: According to WOCN (Wound Ostomy and Continence Nurses Society), the outcome of incontinence services can be determined by recognition of the problem, nursing assessment, and referral for diagnostic evaluation and treatment. All residents with incontinence should be evaluated for causative factors, as treatment is dependent on these factors. However, before successful treatments can be initiated, the problem needs to be identified. The identifying of the type of incontinence is essential in a multidisciplinary collaboration for both the assessment of the individual and the treatment of [REDACTED]. The goal should be to restore as much normal bladder function as possible for each resident by decreasing or eliminating the incontinent episodes. This promotes dignity, reduces risk factors for skin breakdown, and reduces the incidents of urinary tract infections. Resident #8 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Surveyor # completed a review of Resident #8's most current bladder assessment dated [DATE] and indicated, "...Three day...bladder assessment completed. Resident was noted to have one bladder incontinence noted on three day tracking tool..." Resident #8's most current Minimum Data Set ((MDS) dated [DATE], and indicated Resident #8 was frequently incontinent of bladder. Resident #8's previous MDS dated [DATE], indicated Resident #8 was occasionally incontinent of bladder. This indicates a decline in bladder function. There were no bladder assessments completed after the decline was noted on 10/20/11. On 1/24/12 at 5:30 p.m., Surveyor # spoke with RN-T (Registered Nurse). RN-T indicated she was 1 of 2 nurses who completed MDS assessments. Surveyor # reviewed the decline in Resident #8's bladder function. Surveyor # requested from RN-T a bladder assessment which corresponded to the MDS dated [DATE]. On 1/25/12 at 9:05 a.m., Surveyor # spoke with RN-T and RN-S. RN-S indicated the bladder assessment dated [DATE] was the most current bladder assessment for Resident #8. On 1/25/12 at 12:00 p.m., Surveyor # spoke with the Director of Nursing (DON) regarding Resident #8's decline in bladder function. The DON indicated bladder assessments should be completed routinely with MDS assessments.