Every finding on record at Tomah Nursing and Rehab

Based on interviews and record review, the facility failed to ensure each resident is free from sexual abuse for 1 of 8 resident's (R8) out of a total sample of 9 residents.R7 had a diagnosis of Sexual Behavior Disorder upon admission. The facility failed to create a baseline care plan with interventions and goals related to this diagnosis. 25 days after admission, staff observed R7 with his hand under R8's lap blanket. Staff did not separate the residents and left them alone to go inform a nurse. No interventions or increased monitoring implemented. The next day, staff observed R7 with his hand under R8's gown and sheet. The facility's failure to ensure residents were free from sexual abuse, created a finding of Immediate Jeopardy (IJ) that began on 7/26/26. Surveyor notified NHA A (Nursing Home Administrator) of the immediate jeopardy on 7/29/26 at 4:15 PM. The immediate jeopardy was removed on 7/29/26; however, the deficient practice continues at a severity/scope level of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Evidenced by: The facility's policy titled Abuse Prevention Program Policy and Procedure, includes: Each resident has the right to be free from abuse . Sexual abuse is defined as nonconsensual sexual contact of any type with a resident. Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, or others but has not been investigated. Sexually aggressive behavior includes but is not limited to behavior such as saying sexual things, inappropriate touching or grabbing. Facility staff will report to their supervisor of potential characteristics or inappropriate behaviors by staff/resident or anyone that could potentially increase risk for abusive behavior.Sexual abuse includes but is not limited to unwanted intimate touching especially of breasts or perineal area. Situations where a resident. cannot give consent. Capacity and Consent-Residents have the right to engage in consensual sexual activity. However, anytime the facility has reason to suspect that a resident may not have the capacity to consent to sexual activity; the facility will assess for capacity to consent by utilizing resources to assist in this determination. Resources may include but not limited to: Ombudsman, resident representative, resident's physician, facility Medical Director, Ethics Committee and Legal Counsel. Prevention: The facility has written programs, practices, policies, and procedures to prevent and prohibit all types of abuse. These include: . sexual abuse, identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's rights to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship.R7 admitted to the facility on [DATE] with the following diagnoses: Unspecified lack of expected normal physiological development in childhood, personal history of benign neoplasm of the brain, developmental delay, and sexual behavior disorder.R7's most recent Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 7/4/26, indicates R7 is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15.R7's Hospital discharge date d 6/30/26, includes: . Active Problems-Sexual behavior disorder. On 7/29/26 at 1:50 PM, NHA A and Surveyor reviewed R7's admission paperwork noting his diagnoses. NHA A indicated she was not aware R7 had a diagnosis of Sexual Behavior disorder. NHA A indicated she never saw this in his referral documentation.Neither R7's Baseline Care Plan, initiated on 7/2/26 nor Comprehensive Care Plan dated 7/2/26, contain goals or interventions related to R7's diagnosis of sexual behavior disorder.R8 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis, cerebral infarction affecting left non dominant side, and dysphagia.R8's most recent MDS, with ARD 5/24/26, indicates R8's cognition is severely impaired with a BIMS score of 3 out of 15. R8's MDS also indicates R8 has impairments on both sides of her bilateral upper and lower extremities.R8's Comprehensive Care Plan includes: 1/10/25 Resident requires a Broda chair for postural support/positioning/comfort/body alignment related to hemiplegia/hemiparesis following CVA (Cerebrovascular Accident/stroke.) She is currently dependent for most ADLs and requires a full body lift for transfers. On 7/29/26 at 8:57 AM, during an interview, LPN J (Licensed Practical Nurse) stated she observed R7 sitting by R8 on 7/13/26. R7 reached out and put his hand on R8's hand. LPN J stated, R7 was very interested in R8. I reported that to ADON K (Assistant Director of Nursing). ADON K didn't know what to do about it and told me not to document anything until they talked about it in a meeting the next day. We took R8 away right away and put her in her bedroom. She is not her own person. LPN J indicated the next time she worked was Monday, 7/27/26. LPN J stated, There was nothing in report. No changes in care plan. ADON K never got back to me about if I should chart about that incident. I thought it was odd.R8's Nurse Notes, dated 7/23/26, include: R7 was observed with R8 stroking her hand. When asked if she was okay R8 said yes. She was asked if it bothered her, she replied, No.On 7/29/26 at 10:22 AM, during an interview, CNA O (Certified Nursing Assistant) indicated on Sunday, 7/26/26, she observed R7 to have his hand under R8's lap blanket up to his elbow. CNA O indicated she left the area and went to report this to RN P (Registered Nurse.) CNA O indicated she has observed other interactions between R7 and R8 but this is the first time witnessing full contact. CNA O stated, I didn't remove either resident because I was unsure if it was normal but when I went back, I separated them.On 7/29/26 at 10:40 AM, during an interview, RN P indicated on 7/26/26, CNA O reported to her that R7 had his hand under R8's blanket that was draped over her lap. RN P indicated she asked CNA O to see what R7 was doing with his hand. RN P indicated CNA O went to look and R7 wasn't doing it anymore. RN P indicated when she went to look, R7 was no longer in the room. RN P indicated she did not report the incident to management, including NHA A but stated she did pass it along to the 2nd shift group. RN P stated, I thought that it had been decided that if she was not upset, that R8's Power of Attorney was ok with this. I asked R8 if she was ok, and she said yes, but he wasn't there any longer.Review of R7's and R8's medical record found no documentation of the incident observed by staff on 7/26/26.On 7/27/26 at 5:00 PM, R8's record includes a nurse's note written by LPN J that states, Resident was in dining room when writer noticed a male resident with his left hand under resident sheet and gown by upper left thigh area. When approaching incident writer removed left hand where now a watch was noted. Raised eyes were noted at this time from female. Writer moved male resident who was sitting in a wheelchair and asked female resident if she was ready to go up front and she replied, yes. Writer reached under sheet to pull down gown that had been higher on left side compared to right and straightened/replaced sheet. female resident was then taken to front of building . Writer notified resident nurse as to what was witnessed and was asked if she knew anything about inappropriateness or what she knew if anything. Writer notified Administrator (NHA A).R7's Nurse Note written by LPN J, dated 7/27/26 at 5:00 PM includes: Resident was found by writer at this time in dining room with left hand under the white sheet and gown of a female resident and on her upper left thigh area. Just before approaching resident, R7 removed his hand completely where watch is now visible. Writer moved resident wheelchair away from R8 and was told that was inappropriate. R7 did not state anything and continued to sit in wheelchair as writer talked to R8. Writer removed her to front of building. NHA A was notified. R7 now on 15-minute checks per Administrator. 15 min checks sheet was given to night shift nurse to continue until R7 discharges from facility at a later date.On 7/29/26 at 8:57 AM during an interview, LPN J stated R8 has an activated Power of Attorney and is not her own person. LPN J stated, On 7/27/26, I saw through the window. R8 was in her Broda chair facing R7. He had his hand up under a folded sheet that sat over her from waist to feet, like a lap blanket. His hand was underneath the white sheet above the thigh area. As I approached R7, he pulls his hand out. I saw he had a watch; that is how high his hand was up (under the sheet). I told him it was inappropriate. R8 had a gown and brief on, no pants. I pulled R7 away and said this is not appropriate. I asked R8 if she wanted to go up front. She said yes. Then I moved the sheet and noticed the gown was higher on the left side than the right side. I pulled the gown down and straightened it out. From my experience 2 weeks before, I was upset that this is still happening and nothing was being done about it. (LPN J observed the hand holding on 7/13/26.) Having been reported and there was nothing in report, no change in care plan, nothing noting to watch for behaviors. I was upset. Here we are a couple weeks later and they are together. I asked, myself, 'Why is nothing being done?'On 7/29/26 at 10:13 AM, SSD F (Social Services Director) indicated R7 and R8 have been spending time together. SSD F indicated she is unsure if R8 has the ability to consent, but NHA A did contact R8's Power of Attorney about it. SSD F stated, I don't think there has been any harm.On 7/29/26 at 11:00 AM, NHA A (Nursing Home Administrator) indicated she was unaware of the incident that occurred on 7/26/26. NHA A indicated R8 can consent even with a low BIMS score. NHA A indicated she can answer simple questions and say yes or no. NHA A indicated she has never heard of an assessment for residents to decide if they can consent or not. NHA A indicated all staff should be aware that R7 is on 15-minute checks as his room is in the back of the building, but he spends most of his time in the front of the building.Neither R7 nor R8 had been assessed by the facility for their ability to consent to sexual activity.On 7/29/26 at 2:20 PM, ADON K indicated she was unaware of R7's diagnosis of sexual behavior disorder and she would expect that the admission nurse would find out if he has behaviors related to this disorder or where it came from. ADON K indicated staff could have called R7's case manager from his Medical Care Organization or the Assisted Living Facility he used to live at for more information regarding this diagnosis, but they didn't. ADON K indicated R7's Baseline Care Plan and Comprehensive Care Plan should contain goals and interventions related to this diagnosis and associated behaviors. ADON K indicated if she was aware of this diagnosis she would have looked at the hand holding differently and put in a more robust plan to keep all residents safe.The facility's failure to protect R8, a vulnerable resident, from sexual abuse by R7 and failure to assess residents for their ability to consent to sexual activity created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The facility removed the Immediate jeopardy on 7/29/26; however, the deficient practice continues at a severity/scope level of D (potential for more than minimal harm/isolated) as the facility continues to implement the following action plan: Administrator, Clinical management, and social services will be educated on ethics: sexuality and the older adult.Education of staff on aging and sexuality for healthcare professionals in LTC Administrator, Clinical managers will be reeducated on referral reading prior to admission.Staff have been educated to company abuse policy which includes identification and definitions of verbal, emotional, sexual, physical abuse and neglect. Education includes but not limited to the following: protection of residents, reporting to necessary authorities, notification, interventions, documentation and follow up by 7/29/2026 or prior to next working shift.Staff will be educated on appropriate interventions to protect residents immediately with any additional incidents within the facility by 7/29/2026 or prior to next working shift.Staff have been interviewed regarding any other resident who had physical contact with male resident. Residents were interviewed asking if they had any issue with other residents with no concerns noted.Facility will audit 3-5 residents weekly regarding abuse.Facility will audit 3-5 employees weekly to ensure understanding of abuse.Current residents will be assessed for ability to consent. Moving forward all newly admitted residents will be assessed and care plans will be updated as necessary.Director of Nursing/designee will audit all new admissions for need for assessment and completed assessment with necessary care plan updates 3x a week for 4 weeks, twice weekly for 8 weeks, and weekly for 3 months. Results of audits will be reported to QAPI.

Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 62 residents who reside in the facility.Surveyor observed 2 coolers in the main dining room of the facility with scoops lying in direct contact with ice cubes used for resident beverages.Evidenced by:Facility Policy titled, Dietary Manual-Storage Procedures Chapter 6.3 Revised 1/25, pages 1-3 does not include a procedure for scoop storage. On 7/28/26 at 8:05 AM, Surveyor observed 2 coolers in the main dining room of the facility with scoops stored in the cooler, lying in direct contact with ice cubes.On 7/28/26 at approximately 8:10 AM, during an interview MDS (Minimum Data Set) Coordinator/RN G indicated scoops should not be left in direct contact with ice cubes for infection control reasons.On 7/28/26 at 8:14 AM, during an interview, Dietary Manager H indicated the ice cubes are for resident beverages and the scoops should not be left in contact with the ice because it can cause cross contamination.On 7/28/26 at 9:28 AM, LPN I (Licensed Practical Nurse) indicated that the two scoops should not be stored in the ice coolers, in direct contact with the ice cubes, due to the potential for contamination. LPN I indicated the scoops should be stored in scoop holders with covers that are attached to the side of the coolers.On 7/28/26 at 3:30 PM, NHA A (Nursing Home Administrator) indicated scoops should not be stored inside of the coolers, in direct contact with the ice cubes due to the potential for cross contamination. NHA A indicated the ice is used for residents' beverages.(It is important to note the facility's scoops were being stored inside of the coolers, lying in direct contact with ice cubes used for resident beverages.)

Based on interview and record review, the facility did not make prompt efforts to document, investigate, and resolve grievances a resident may have for 1 of 2 residents reviewed for grievances (R2). R2 voiced grievances to the facility. Staff did not write their concerns up as a grievance, complete an investigation, or follow-up with the complainant. Evidenced by:The facility's policy titled Grievances/Concerns reviewed on 1/2025 states in part .2. The Social Services Director will coordinate the facility system for collecting grievances and tracking those grievances for timely and appropriate response. 3. Administrator and Social Service Director will lead investigation; maintaining confidentiality of all information associated with grievances and ensure residents are protected from discrimination or reprisal. 4. Upon receipt of grievance, an immediate action will be implemented to prevent further potential violation of any resident right while the alleged violation is being investigated. 5. If an alleged violation involving neglect, abuse, including injuries of unknown source, and or misappropriation of resident property is reported the facility will reference and follow Abuse & Neglect Procedures, Standards of Care Volume. The facility has implemented Ambassador Rounds. The instructions on the form states in part .3. Administrator to personally follow up on any grievance/concerns regarding care or services. 4.Any concerns will be documented on a grievance form and reviewed with the administrator for further follow up. R2 was admitted to the facility on [DATE] with diagnoses that include fibromyalgia, depression, anxiety, mood disorder, chronic pain syndrome, and Chronic Obstructive Pulmonary Disease (COPD). R2's most recent Minimum Data Set (MDS) dated [DATE] states that r2 has a Brief Interview of Mental Status (BIMS) of 15 out of 15, indicating that R2 is cognitively intact. R2's concerns documented on Ambassador Rounds forms include: 4/14/26: Portions are too big. (breakfast). 4/15/26: [R2's name] rcvd (received) new bed, not working right. Bed gets hot. 4/21/26: She would like a trapeze to help w (with)/mobility, needs the correct foot pedals for her wheelchair. Staff need to help get her teeth in every day. She also wants her feet elevated. 4/23/26: Would like [Maintenance Director's name] to put new pillow cover on her mattress. 4/27/26: Girls put her back to bed on wrinkled sheets and O2 (oxygen) under her- told [R2's name] they're not trained in that.Is still upset about foam mattress. 4/28/26: .Still complaining about mattress on her bed. Conformed with maintenance she cannot have foam mattress on her bed. 4/30/26: Would like to see [NHA's (Nursing Home Administrator) name]- re (regarding)- foam mattress. 6/15/26: [CNA (Certified Nursing Assistant) name] - Rude- in a rush and rough doing cares. 6/18/26: .Knob on fan. Missing top of coffee cup. Surveyor requested R2's grievances from February 2026 to present. Surveyor received 1 grievance dated 6/16/26 which states in part .Summary of Grievance/Complaint: Resident states [CNA's initials] is rude and rough- She states this CNA always seems to act like resident is a burden or inconvenience. Also, not completing peri care adequately. Always in a rush.Findings of Investigation: [CNAs name] states she didn't perform any cares on [R2's name] and only filled her coffee and emptied the urinal. [R2's name] asked for the wipe to do the peri care herself. On 7/27/26 at 1:52 PM, Surveyor interviewed R2. Surveyor asked R2 if they were receiving their showers when they were supposed to, R2 stated no and that they are supposed to have a shower twice a week. R2 reported to Surveyor they had discussed their concerns regarding showers with NHA A and they haven't heard anything back. R2 reported to Surveyor that if they get upset with staff, staff will say they are being disrespectful and will not complete cares. R2 also reported to Surveyor that they have requested small portions of food at meals and are still receiving big portions. On 7/29/26 at 8:29 AM, Surveyor interviewed SSD F (Social Services Director). Surveyor asked SSD F what the process was for Ambassador Rounds, SSD F stated that they meet with R2 every day to see how things are going and if they have any concerns, they write it down, talk to NHA A and if it can't be resolved right away, it gets put on a grievance form. Surveyor reviewed R2's Ambassador Rounds forms with SSD and asked if the concerns listed on the forms were written up as grievances, SSD F stated they should have been. SSD F reported that R2 stated that they have to be [NAME] and tell staff when they want a shower. Surveyor asked SSD F if concerns aren't written up as grievances, how are they being tracked and resolved, SSD F stated they were unsure. The facility did not ensure that all resident concerns were following their grievance policy.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 of 3 residents (R2 and R8) reviewed for abuse. R2 reported to SSD F (Social Services Director) that a CNA was rough when performing cares and the facility failed to report the incident to the State Agency (SA). Staff did not report an allegation of sexual abuse affecting R8 to NHA A. The facility did not report the allegation of sexual abuse to the state agency. The facility did not report an allegation of verbal or mental abuse when residents witnessed/overheard staff cussing and screaming about not having staff to care for the current population of residents. Evidenced by: The facility's policy titled Abuse Prevention Program 7 Components last reviewed on 1/2026, states in part .VII. Reporting/Response: All alleged or suspected violations are to be reported immediately to the Administrator or Director of Nursing, which are responsible to notify required officials, including the State Survey Agency, Adult Protective Services, Local Public Safety.and any other agencies in accordance with State Law through established procedures. All alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made if the events of that allegation involve abuse or result in serious bodily injury.Response to Alleged Violations of Sexual Abuse: If an allegation of sexual abuse has been reported, the facility must immediately: g. Protect the alleged victim(s) involved h. Report the alleged violations to the Administrator and appropriate State and local authorities. Example 1: R2 was admitted to the facility on [DATE] with diagnoses that include fibromyalgia, depression, anxiety, mood disorder, chronic pain syndrome, and COPD (Chronic Obstructive Pulmonary Disease). R2's most recent Minimum Data Set (MDS) dated [DATE] states that R2 has a Brief Interview of Mental Status (BIMS) of 15 out of 15, indicating that R2 is cognitively intact. On 6/15/26, R2 reported to SSD F (Social Services Director) during Ambassador Rounds that [CNA name] – Rude, in a rush, and rough doing cares. On 6/16/26 SSD F filled out a grievance form which states in part .Summary of Grievance/Complaint: Resident states [CNA's initials] is rude and rough- She states this CNA always seems to act like resident is a burden or inconvenience. Also, not completing peri care adequately. Always in a rush.Findings of Investigation: [CNAs name] states she didn't perform any cares on [R2's name] and only filled her coffee and emptied the urinal. [R2's name] asked for the wipe to do the peri care herself. It is important to note that facility staff did not interview R2 regarding this incident. On 7/29/26 at 8:21 AM, Surveyor interviewed SSD F. Surveyor asked SSD F about R2's report on 6/15 that a CNA was rough with care, SSD F reported that resident reported the incident during their morning Ambassador Rounds. Surveyor asked SSD F if a resident states that a staff member is rough with cares, could that be an allegation of abuse, SSD F stated yes. Surveyor asked SSD F if an allegation of abuse should be reported to the State Agency, SSD F stated yes. On 7/29/26 at 8:38 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor and DON B reviewed R2's 6/16/26 grievance. Surveyor asked DON B what actions or interventions they took regarding this incident, DON B stated that they interviewed the accused CNA and had a conversation with the CNA about avoiding R2's room as much as possible. Surveyor asked DON B if a resident reports that a CNA is rough with cares, could that be considered an allegation of abuse, DON B stated that it could be but they would need to do an investigation to find out what rough means. Surveyor asked DON B if they interviewed R2 about this incident, DON B stated no. Surveyor asked DON B if this allegation should have been reported to the State Agency, DON B stated yes. On 7/29/26 at 8:45 AM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor and NHA A reviewed R2's grievance dated 6/16/26. Surveyor asked NHA A if a resident reports a staff member is rough with cares, could that be an allegation of abuse, NHA A stated yes. Surveyor asked NHA A if that should have been reported to the State Agency, NHA A stated yes. Example 2 R7 admitted to the facility on [DATE] with the following diagnoses: Unspecified lack of expected normal physiological development in childhood, Personal history of benign neoplasm of the brain, Developmental Delay, and Sexual Behavior Disorder. R7's most recent Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 7/4/26, indicates R7 is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. R8 was admitted to the facility on [DATE] with diagnoses, including hemiplegia and hemiparesis, cerebral infarction affecting left non dominant side, dysphagia. R8's most recent MDS with ARD of 5/24/26, indicates R8's cognition is severely impaired with a BIMS score of 3 out of 15. R8's MDS also indicates R8 has impairments on both sides of her bilateral upper and lower extremities. On 7/29/26 at 8:57 AM during an interview LPN J (Licensed Practical Nurse) stated she observed R7 sitting by R8 on 7/13/26. R7 reached out and put his hand on R8's hand. LPN J stated, R7 was very interested in R8. I reported that to ADON K (Assistant Director of Nursing). ADON K didn't know what to do about it and told me not to document anything until they talked about it in a meeting the next day. We took R8 away right away and put her in her bedroom. She is not her own person. LPN J indicated the next time she worked was Monday, 7/27/26. LPN J stated, There was nothing in report. No changes in care plan. ADON K never got back to me about if I should chart about that incident. I thought it was odd. R8's Nurse Notes, dated 7/23/26, include: R7 was observed with R8 stroking her hand. When asked if she was okay R8 said yes. She was asked if it bothered her, she replied, No. On 7/29/26 at 10:22 AM, during an interview CNA O (Certified Nursing Assistant) indicated on Sunday, 7/26/26, she observed R7 to have his hand under R8's lap blanket up to his elbow. CNA O indicated she went to report this to RN P (Registered Nurse). CNA O indicated she has observed other interactions between R7 and R8 but this is the first time witnessing full contact. CNA O stated, I didn't remove either resident because I was unsure if it was normal but when I went back I separated them. On 7/29/26 at 10:40 AM, during an interview RN P indicated on 7/26/26 CNA O reported to her that R7 had his hand under R8's blanket that was draped over her lap.RN P indicated she asked CNA O to see what R7 was doing with his hand. RN P indicated CNA O went to look and R7 wasn't doing it anymore. RN P indicated when she went to look R7 was no longer in the room. RN P indicated she did not tell management, including NHA A (Nursing Home Administrator) about this incident, but she did pass it along to the 2nd shift group. RN P stated, I thought that it had been decided that if she was not upset, that R8's Power of Attorney was ok with this. I asked R8 if she was ok, and she said yes, but he wasn't there any longer. RN P indicated she did not know if R7 was on 15-minute checks right now. On 7/29/26 at 8:57 AM, during an interview LPN J stated R8 has an activated Power of Attorney and is not her own person. LPN J stated, On 7/27/26, I saw through the window. R8 was in her Broda chair facing R7. He had his hand up under a folded sheet that sat over her from waist to feet like a lap blanket. His hand was underneath the white sheet above the thigh area. As I approached R7, he pulls his hand out. I saw he had a watch that is how high his hand was up. I told him it was inappropriate. She had a gown and brief on, no pants. I pulled him away and said this is not appropriate. I asked her if she wanted to go up front. She said yes. Then I moved the sheet and noticed the gown was higher on the left side than the right side. I pulled the gown down and straightened it out. From my experience from 2 weeks before. I was upset that this is still happening and nothing was being done about it. Having been reported and there was nothing in report, no change in care plan, nothing noting to watch for behaviors. I was upset. Here we are a couple weeks later and they are together. I asked, myself, why is nothing being done? On 7/29/26 at 11:00 AM, NHA A (Nursing Home Administrator) indicated she was unaware of the incident that occurred on 7/26/26. NHA A indicated if she had been aware of his diagnosis and the incident, she would have reported it to the state agency. NHA A indicated staff are to report all allegations of abuse to her immediately. NHA A indicated another incident occurred on 7/27/26 where staff reported R7 having his hand under the sheet and under R8's gown. On 7/29/26 at 2:20 PM, ADON K (Assistant Director of Nursing) indicated the incident should have been reported to NHA A right away and then to the state agency within 2 hours. Example 3 Facility policy, titled Abuse Prevention Program Policy and Procedure, reviewed 1/2026, includes: . Mental and Verbal Abuse- Mental abuse is the use of verbal or nonverbal actions, which cause or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Possible indicators of Mental or Verbal Abuse include- . use of oral, written, or gestured communication, or sounds, to residents within hearing distance. On 7/27/26 at 10:28 AM, NHA A brought in LPN N's personnel file that was requested by the Survey Team. NHA A indicated LPN N had been terminated because she was basically going to tell residents we could not care for them; to me, that's abuse. On 7/28/26 at 7:33 AM, LPN N indicated on 2/12/26 there was 1 nurse (LPN N) and 3 CNAs (Certified Nursing Assistants), and 1 training CNA. LPN N indicated at 10:00 AM the management team had sent 1 CNA home and told the training CNA to work on computer training, leaving only 2 CNA on the floor. LPN N indicated both CNAs left on the floor had restrictions or injuries preventing them from performing their full duties. LPN N indicated she asked ADON K (Assistant Director of Nursing) if the training CNA was able to come assist with some non- CNA duties to which ADON K replied no and told LPN N to figure it out. LPN N indicated she may have raised her voice in or near the gathering area of residents as they were gathering in the dining room and near the nurse station, but she was advocating for them. LPN N indicated when she was fired ADON K told her she caused an incident. On 7/28/26 at 10:19 AM, ADON K indicated LPN N was outspoken in the hallway and became heated. ADON K indicated LPN N said that she would answer call lights and tell the residents we didn't have staff to take care of them and was going on and on. ADON K indicated BOM L (Business Office Manager) also heard LPN N carrying on in a loud manner. ADON K indicated there were residents gathering at the time near the nurse station due to a construction project going on in the front of the building when all of the heaters were being changed out. ADON K indicated LPN N's actions could have made the residents who heard and saw her feel scared. ADON K stated, I don't recall who the residents were but there were residents around. We checked in with them. They were ok. ADON K indicated LPN N was terminated immediately and asked to turn in her keys. Surveyor asked why LPN N was terminated immediately. ADON K indicated LPN N's actions and threats were allegations of abuse. Surveyor asked ADON K if she followed the facility's abuse policy. ADON K indicated the facility did not follow the abuse policy, they just terminated LPN N and removed her. ADON K indicated the facility did not report the allegation to the state agency and in hindsight it should have been reported. On 7/28/26 at 11:03 AM, BOM L indicated LPN N was terrible and rude. BOM L indicated residents sit at the nurses' station and could hear and see LPN N as she was raising her voice. BOM L indicated LPN N's actions could have caused residents distress and that is why ADON K and BOM L removed her right away. Surveyor asked BOM L if this allegation of abuse was reported to NHA A or to the state agency. BOM L indicated she filled out a written statement that day so she is pretty sure the incident was reported and investigated. On 7/28/26 at 11:36 AM, NHA A indicated she was unaware how to report an allegation of abuse if she is unaware of which resident it affected. Surveyor and NHA A reviewed the facility's policy noting the definitions of verbal abuse and emotional abuse. NHA A indicated the facility is to report all allegations of abuse, neglect, misappropriation of property, and exploitation to the state agency. NHA A indicated a thorough investigation was not completed so she does not know who was affected by LPN N's actions. On 7/28/26 at 1:34 PM, LPN M indicated he was working in the front of the building on 2/12/26 when LPN N was yelling in SSD F's (Social Services Director) located near the dining room. LPN M indicated LPN N was yelling something about the facility abusing residents. LPN M indicated residents filled the dining room at this time and they could most likely hear the exchange. LPN M stated, She was on a roll. I thought to myself, you better take this somewhere else. LPN M indicated when LPN N came out of the office he met her in the hallway and asked her if she was going on break. LPN N replied, No they [explicit word beginning with F] fired me. LPN M indicated LPN N's actions could have caused residents to worry, stating, It would make myself worried. It was important to remove her from the situation. LPN M indicated this could be an allegation of abuse and the facility should follow their abuse policy. On 7/28/26 at 3:30 PM, NHA A stated, It is concerning that my management staff did nothing with this information except take it to the Human Resources Department (HR). NHA A indicated she never saw the statements until HR reached out to her. NHA A indicated staff are to report all allegations of abuse to her immediately. It is important to note that staff removed LPN N due to her actions and raised voice possibly causing nearby residents distress and because she was threatening to tell residents there were not staff to care for them creating an allegation of abuse. The facility did not report this allegation to the state agency.

Based on interview and record review, the facility did not ensure a thorough investigation of abuse/exploitation was completed for 2 of 3 Residents (R2 and R8) reviewed for abuse. R2 reported an allegation of abuse to SSD F (Social Services Director) that a CNA was rough when performing cares and the facility failed to investigate the incident. Staff did not investigate an allegation of sexual abuse affecting R8. The facility did not investigate an allegation of verbal or mental abuse when residents witnessed/overheard staff cussing and screaming about not having staff to care for the current population of residents. Evidenced by: The facility's policy titled Abuse Prevention Program 7 Components last reviewed 1/2026 states in part .V. Investigation 1. The Administrator or Director of Nursing are to initiate and coordinate completion of a thorough investigation. Investigations must be initiated immediately and conclude as soon as possible not to exceed (5) days.The investigation must include but not limited to: Identify alleged perpetrator, remove from resident care area immediately, suspend pending investigation conclusion, obtain statement.Identify and interview (witness statements) all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s) such as roommate.Determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause. Body assessment and psychological status of the resident.State and local agencies notified facility reported incident, (FRI). Example 1 R2 was admitted to the facility on [DATE] with diagnoses that include fibromyalgia, depression, anxiety, mood disorder, chronic pain syndrome, and Chronic Obstructive Pulmonary Disease (COPD). R2's most recent Minimum Data Set (MDS) dated [DATE] states that R2 has a Brief Interview of Mental Status (BIMS) of 15 out of 15, indicating that R2 is cognitively intact. On 6/15/26, R2 reported to SSD F (Social Services Director) during Ambassador Rounds that [CNA name] – Rude, in a rush, and rough doing cares. On 6/16/26 SSD F filled out a grievance form which states in part .Summary of Grievance/Complaint: Resident states [CNA's initials] is rude and rough- She states this CNA always seems to act like resident is a burden or inconvenience. Also, not completing peri care adequately. Always in a rush.Findings of Investigation: [CNAs name] states she didn't perform any cares on [R2's name] and only filled her coffee and emptied the urinal. [R2's name] asked for the wipe to do the peri care herself. It is important to note that facility staff did not interview R2 regarding this incident. On 7/29/26 at 8:21 AM, Surveyor interviewed SSD F. Surveyor asked SSD F about R2's report on 6/15 that a CNA was rough with care, SSD F reported that resident reported the incident during their morning Ambassador Rounds. Surveyor asked SSD F if a resident states that a staff member is rough with cares, could that be an allegation of abuse, SSD F stated yes. On 7/29/26 at 8:38 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor and DON B reviewed R2's 6/16/26 grievance. Surveyor asked DON B what actions or interventions they took regarding this incident, DON B stated that they interviewed the accused CNA and had a conversation with the CNA about avoiding R2's room as much as possible. Surveyor asked DON B if a resident reports that a CNA is rough with cares, could that be considered an allegation of abuse, DON B stated that it could be but they would need to do an investigation to find out what rough means. Surveyor asked DON B if they interviewed R2 about this incident, DON B stated no. Surveyor asked DON B if this allegation should have been reported to the State Agency and investigated, DON B stated yes. On 7/29/26 at 8:45 AM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor and NHA A reviewed R2's grievance dated 6/16/26. Surveyor asked NHA A if a resident reports a staff member is rough with cares, could that be an allegation of abuse, NHA A stated yes. Surveyor asked NHA A if that should have been reported to the State Agency and investigated, NHA A stated yes. The facility did not ensure that all allegations of abuse were investigated. Example 2 The facility's policy titled Abuse Prevention Program 7 Components last reviewed 1/2026 states in part .V. Investigation 1. The Administrator or Director of Nursing are to initiate and coordinate completion of a thorough investigation. Investigations must be initiated immediately and conclude as soon as possible not to exceed (5) days.The investigation must include but not limited to: Identify alleged perpetrator, remove from resident care area immediately, suspend pending investigation conclusion, obtain statement.Identify and interview (witness statements) all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s) such as roommate.Determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause. Body assessment and psychological status of the resident.State and local agencies notified facility reported incident, (FRI). R7 admitted to the facility on [DATE] with the following diagnoses: Unspecified lack of expected normal physiological development in childhood, Personal history of benign neoplasm of the brain, Developmental Delay, and Sexual Behavior Disorder. R7's most recent Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 7/4/26, indicates R7 is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. R8 was admitted to the facility on [DATE] with diagnoses, including hemiplegia and hemiparesis, cerebral infarction affecting left non dominant side, dysphagia. R8's most recent MDS, with ARD of 5/24/26, indicates R8's cognition is severely impaired with a BIMS score of 3 out of 15. R8's MDS also indicates R8 has impairments on both sides of her bilateral upper and lower extremities On 7/29/26 at 8:57 AM during an interview LPN J (Licensed Practical Nurse) stated she observed R7 sitting by R8 on 7/13/26. R7 reached out and put his hand on R8's hand. LPN J stated, R7 was very interested in R8. I reported that to ADON K (Assistant Director of Nursing). ADON K didn't know what to do about it and told me not to document anything until they talked about it in a meeting the next day. We took R8 away right away and put her in her bedroom. She is not her own person. LPN J indicated the next time she worked was Monday, 7/27/26. LPN J stated, There was nothing in report. No changes in care plan. ADON K never got back to me about if I should chart about that incident. I thought it was odd. R8's Nurse Notes, dated 7/23/26, include: R7 was observed with R8 stroking her hand. When asked if she was okay R8 said yes. She was asked if it bothered her, she replied, No. On 7/29/26 at 10:22 AM, during an interview CNA O (Certified Nursing Assistant) indicated on Sunday, 7/26/26, she observed R7 to have his hand under R8's lap blanket up to his elbow. CNA O indicated she went to report this to RN P (Registered Nurse). CNA O indicated she has observed other interactions between R7 and R8, but this is the first time witnessing full contact. CNA O stated, I didn't remove either resident because I was unsure if it was normal but when I went back I separated them. On 7/29/26 at 10:40 AM, during an interview RN P indicated on 7/26/26 CNA O reported to her that R7 had his hand under R8's blanket that was draped over her lap.RN P indicated she asked CNA O to see what R7 was doing with his hand. RN P indicated CNA O went to look and R7 wasn't doing it anymore. RN P indicated when she went to look R7 was no longer in the room. RN P indicated she did not tell management, including NHA A (Nursing Home Administrator) about this incident, but she did pass it along to the 2nd shift group. RN P stated, I thought that it had been decided that if she was not upset, that R8's Power of Attorney was ok with this. I asked R8 if she was ok, and she said yes, but he wasn't there any longer. RN P indicated she did not know if R7 was on 15-minute checks right now. On 7/29/26 at 8:57 AM, during an interview LPN J stated R8 has an activated Power of Attorney and is not her own person. LPN J stated, On 7/27/26, I saw through the window. R8 was in her Broda chair facing R7. He had his hand up under a folded sheet that sat over her from waist to feet like a lap blanket. His hand was underneath the white sheet above the thigh area. As I approached R7, he pulls his hand out. I saw he had a watch that is how high his hand was up. I told him it was inappropriate. She had a gown and brief on, no pants. I pulled him away and said this is not appropriate. I asked her if she wanted to go up front. She said yes. Then I moved the sheet and noticed the gown was higher on the left side than the right side. I pulled the gown down and straightened it out. From my experience from 2 weeks before. I was upset that this is still happening and nothing was being done about it. Having been reported and there was nothing in report, no change in care plan, nothing noting to watch for behaviors. I was upset. Here we are a couple weeks later and they are together. I asked, myself, why is nothing being done? On 7/29/26 at 11:00 AM, NHA A (Nursing Home Administrator) indicated she was unaware of the incident that occurred on 7/26/26. NHA A indicated if she had been aware of his diagnosis and the incident, she would have initiated an investigation. NHA A indicated another incident occurred on 7/27/26 where staff reported R7 having his hand under the sheet and under R8's gown. On 7/29/26 at 2:20 PM, ADON K indicated the incident should have been investigated but wasn't. Example 3 On 7/27/26 at 10:28 AM, NHA A (Nursing Home Administrator) brought in LPN N's (Licensed Practical Nurse) personnel file that was requested by the Survey Team. NHA A indicated LPN N had been terminated because she was basically going to tell residents we could not care for them. To me, that's abuse. On 7/28/26 at 7:33 AM, LPN N indicated on 2/12/26 there was 1 nurse (LPN N) and 3 CNAs (Certified Nursing Assistants), and 1 training CNA. LPN N indicated at 10:00 AM the management team had sent 1 CNA home and told the training CNA to work on computer training, leaving only 2 CNA on the floor. LPN N indicated both CNAs left on the floor had restrictions or injuries preventing them from performing their full duties. LPN N indicated she asked ADON K if the training CNA was able to come assist with some non- CNA duties to which ADON K replied no and told LPN N to figure it out. LPN N indicated she may have raised her voice in or near the gathering area of residents as they were gathering in the dining room and near the nurse station, but she was advocating for them. LPN N indicated when she was fired ADON K told her she caused an incident. On 7/28/26 at 10:19 AM, ADON K indicated LPN N was outspoken in the hallway and became heated. ADON K indicated LPN N said that she would answer call lights and tell the residents we didn't have staff to take care of them and was going on and on. ADON K indicated BOM L (Business Office Manager) also heard LPN N carrying on in a loud manner. ADON K indicated there were residents gathering at the time near the nurse station due to a construction project going on in the front of the building when all of the heaters were being changed out. ADON K indicated LPN N's actions could have made the residents who heard and saw her feel scared. ADON K stated, I don't recall who the residents were but there were residents around. We checked in with them. They were ok. ADON K indicated LPN N was terminated immediately and asked to turn in her keys. Surveyor asked why LPN N was terminated immediately. ADON K indicated LPN N's actions and threats were allegations of abuse. Surveyor asked ADON K if she followed the facility's abuse policy. ADON K indicated the facility did not follow the abuse policy, they just terminated LPN N and removed her. ADON K indicated the facility did not conduct a thorough investigation regarding the allegation and ADON K could not identify residents who may have been affected by the interaction. On 7/28/26 at 11:03 AM, BOM L (Business office Manager) indicated residents sit at the nurses' station and could hear and see LPN N as she was raising her voice. BOM L indicated LPN N's actions could have caused residents distress and that is why ADON K and BOM L removed her right away. Surveyor asked BOM L if this allegation of abuse was reported to NHA A or to the state agency. BOM L indicated she filled out a written statement that day so she is pretty sure the incident was reported and investigated. On 7/28/26 at 11:36 AM, NHA A indicated she was unaware how to report an allegation of abuse if she is unaware of which resident it affected. Surveyor and NHA A reviewed the facility's policy noting the definitions of verbal abuse and emotional abuse. NHA A indicated the facility is to report all allegations of abuse, neglect, misappropriation of property, and exploitation to the state agency. NHA A indicated a thorough investigation was not completed so she does not know who was affected by LPN N's actions. NHA A indicated the facility did not conduct skin assessments on the non-interviewable residents and did not interview residents who may have information that could be used in a thorough investigation. On 7/28/26 at 3:30 PM, NHA A stated, It is concerning that my management staff did nothing with this information except take it to the Human Resources Department (HR). NHA A indicated she never saw the statements until HR reached out to her. NHA A indicated staff should have followed the abuse requirements of reporting and investigating and did not. It is important to note that staff removed LPN N due to her actions and raised voice possibly causing nearby residents distress and because she was threatening to tell residents there were not staff to care for them creating an allegation of abuse. The facility did not conduct a thorough investigation into the allegation. Cross reference F600 and F609.

Based on interview and record review, the facility did not accurately complete required Preadmission Screen and Resident Review (PASRR) Level I and/or Level II screens to determine appropriate placement to the facility, or need for specialized services for 1 of 1 resident reviewed (R7).R7 was admitted with unspecified lack of expected normal physiological development in childhood and Developmental Delay. The facility failed to appropriately complete a PASRR Level 1 screen with a short-term exemption from a Level 2 screen as R7 planned to reside less than 30 days in the facility.This is Evidenced by:R7 was admitted to the facility on [DATE] with a diagnosis of R62.50 Unspecified lack of expected normal physiological development in childhood and Developmental Delay.The facility's policy, titled Social Service Pre-admission admission Process, revised 10/2017, reviewed 01/2025, states: . Social Services will review each potential resident's psychosocial and behavioral needs and Pre-admission Assessment and Annual Resident Review as available from the referral source prior to determining appropriateness of placement.The admission coordinator will provide the Social Service Director with all information related to each potential resident's psychosocial and behavioral status. Social Services will ensure that the referring party obtains a Level 2 PASARR screening, when indicated.R7's Level 1 PASRR Screen Summary, undated, indicates: . Is there a history of intellectual disabilities? yes. Is there a diagnosis of cerebral palsy, epilepsy, autism, brain injury or intellectual/developmental condition other than mental illness that results in impairment of general intellectual function or adaptive behavior similar to that of the intellectual disabled persons, and requires treatment or services similar to those required for these persons and was manifested before the person was age [AGE]: yes. Screening result: Resident is suspected of having a serious intellectual/developmental disability: agree. Screening result: Resident is suspected of having a serious mental illness: agree. Hospital discharge exemption-30 day Maximum: no. Emergency Placement-7 day Maximum: no. Respite Care-7 days per Stay Maximum; 30 Days Per Year Maximum: no(It is important to note the facility did not have evidence of the form being submitted and did not have a response by the county with approval to admit R7.)On 7/29/26 at 1:15 PM, Surveyor requested R7's PASARR level 2 screen from Social Services Director F. SSD F (Social Services Director) indicated she only has the one form. SSD F indicated that because the facility anticipated that R7 was expected to discharge within 30 days of admission, no PASRR II was needed. SSD F and NHA A (Nursing Home Administrator) indicated the facility completed R7's PASRR level 1 screen inaccurately by not indicating yes on the 30-day exemption question. NHA A and SSD F indicated form F-20822 should have been submitted for County approval, but it wasn't. NHA A indicated it is her expectation SSD F follows the facility's PASRR policy and procedure.(It is important to note SSD F indicated she marked no in the Hospital discharge exemption-30 day Maximum box when it should have been yes. Despite error, SSD F and NHA A did not provide evidence of County approval for admission, for a Hospital Short Term Exemption (STE), or a PASRR level 2 screen. The facility was unaware if R7 needed specialized services while residing at the facility.)

Based on interviews and record review the facility did not ensure that a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 3 residents (R2) reviewed for ADLs.R2 reported to Surveyor that they have not been receiving showers as scheduled.Evidenced by:The facility's policy titled Activities of Daily Living (ADLs)/Maintain Abilities last reviewed 1/2025, states in part .2. The facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. 3. The facility will provide care and services for the following activities of daily living: a. Hygiene- bathing, dressing, grooming, and oral care. 4. A resident that is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.R2 was admitted to the facility on [DATE] with diagnoses that include fibromyalgia, depression, anxiety, mood disorder, chronic pain syndrome, and Chronic Obstructive Pulmonary Disease (COPD). R2's most recent Minimum Data Set (MDS) dated [DATE] states that R2 has a Brief Interview of Mental Status (BIMS) of 15 out of 15, indicating that R2 is cognitively intact. R2's care plan dated 10/12/21 states in part: .Problem: Resident requires assistance for ADLs r/t (related to) weakness and severe morbid obesity.Approach: .Bathing: Assist of 1.The facility's shower schedule states that R2 is to receive a shower on Tuesday and Friday on the PM (evening) shift.R2's shower documentation states the following missed showers:February 2026: showers missed on 2/10, 2/24, and 2/27.March 2026: showers missed on 3/6, 3/13, and 3/27.April 2026: showers missed on 4/3, 4/21, 4/24, 4/28.May 2026: showers missed on 5/8 and 5/26.June 2026: showers missed on 6/26.July 2026: showers missed on 7/3, 7/10, and 7/21.On 7/27/26 at 1:52 PM, Surveyor interviewed R2. Surveyor asked R2 if they were receiving their showers when they were supposed to. R2 stated no and that they are supposed to have a shower twice a week. R2 reported to Surveyor they had discussed their concerns regarding showers with NHA A (nursing Home Administrator) and they haven't heard anything back. R2 reported that one of the CNAs said that they were told to wait until R2 asked for a shower before offering it. On 7/28/26 at 9:35 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what the expectation was for resident's showers, DON B stated that residents are typically scheduled for one shower a week, if they want more then they figure out a schedule for that. DON B stated that the CNAs have a schedule but sometimes the CNAs give the showers the next day if a resident refuses, is at an appointment, or if the CNA isn't able to provide the shower at the time the resident requests it at. Surveyor asked DON B if a shower is missed, does the nurse document it, DON B stated sometimes but not always. Surveyor asked DON B what the process was if a resident misses a shower, DON B stated that they will ask the CNAs and figure out why it was missed and see if there is a way to switch the day and/or time. Surveyor asked DON B who was responsible for ensuring that showers are being completed, DON B stated that the unit clerk audits showers weekly. DON B stated that they have QAPI (Quality Assurance and Performance Improvement) project they are working on regarding showers.On 7/28/26 at 12:55 PM, Surveyor interviewed NHA A. Surveyor asked NHA A what steps are in place to ensure that showers are getting done, NHA A stated that they reapproach the resident. NHA A reported they have a QA project for determining the percentage of showers being completed and they have implemented Ambassador Rounds for R2.The facility did not ensure that R2 was receiving all scheduled showers, with the exception of showers refused by R2.

Based on interview and record review, the facility did not ensure that a resident with skin integrity concerns receives the necessary treatment and services, consistent with professional standards of practice, for 1 of 3 Residents (R3) reviewed for wounds.Staff identified a wound on R3 and did not complete an assessment.Evidenced by:The facility's Skin Care policy, dated 1/26, states, in part: .Purpose: To promote and facilitate skin integrity with appropriate interventions and treatment of skin impairments to promote resolution of impaired areas.4. Non-pressure related skin impairment will be assessed and documented upon admission, readmission, upon discovery, and weekly thereafter. Assessment may include include the size, location, type of wound, odor, drainage, per-wound condition, wound edges, exudate, pain, symptoms of infection, and current treatment order.R3 admitted to the facility on [DATE] with diagnoses that included: unspecified dementia; type 2 diabetes mellitus with diabetic nephropathyR3's Resident Progress Note, dated 4/4/26 at 5:33 PM, states in part: Resident has an open pressure wound on his buttocks discovered at 3:45 PM by aides during brief change.*Important to note: there is no assessment of this wound in R3's chart.R3's Specialty Physician Wound Evaluation and Management Summary, dated 4/15/26, states, in part: .Non-Pressure Wound Buttocks Partial Thickness. Etiology: Moisture Associated Skin Damage.*Important to note: There was no assessment of this wound for the 11 days between the 4/4/26 discovery by the facility and the 4/15/26 provider documented assessment.On 7/28/26 at 2:10 PM, Surveyor interviewed LPN C (Licensed Practical Nurse) who stated they do observations of resident wounds with the wound doctor on weekly rounds. Surveyor asked about protocol when a wound is noted. LPN C stated the nurse will measure, contact the provider to update and get orders and update the family. LPN C stated an assessment, including size, type of wound, surrounding skin, wound bed, drainage should be documented in a skin event form. Surveyor asked about assessment when R3's wound was noted. LPN C stated I don't know why there wouldn't be an assessment of the wound.On 7/29/26 at 12:33 PM, Surveyor interviewed DON B (Director of Nursing) and asked about assessment of R3's buttocks wound. DON B stated I don' t see an assessment until 4/15/26. DON B stated that an assessment, including type of wound, dimensions, appearance of wound bed and periwound/edges, drainage, pain, signs of infection, is expected when a wound is found.

Based on interview and record review, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 3 (R3) residents reviewed for pressure injuries.Staff identified new wounds on R3's heels and did not complete an assessment.Evidenced by:The facility's Pressure Injury Prevention and Care policy, dated 1/26, states, in part: .Purpose: To promote and facilitate pressure injury prevention and implement appropriate interventions and treatment of pressure injuries to promote and facilitate resolution of pressure injuries.6. Pressure injuries will be assessed and documented upon admission, readmission, upon discovery, and weekly thereafter. Assessment may include the size, location, category/stage, odor (if any), drainage (if any), peri-wound condition, wound edges, undermining, tunneling, exudate, pain, and current treatment order.R3 admitted to the facility on [DATE] with diagnoses that included: unspecified dementia; type 2 diabetes mellitus with diabetic nephropathyR3's Resident Progress Note, dated 4/4/26 at 10:23 PM, states in part: Resident has pressure wounds on both heels.*Important to note: there was no assessment of these wounds until 4 days later when a provider documented an assessment on 4/8/26.On 7/28/26 at 2:10 PM, Surveyor interviewed LPN C (Licensed Practical Nurse) who stated that LPN C completes observations of resident wounds with the wound doctor on weekly rounds. Surveyor asked about protocol when a wound is noted. LPN C stated the nurse will measure, contact the provider to update and get orders and update the family. LPN C stated an assessment, including size, type of wound, surrounding skin, wound bed, drainage should be documented in a skin event form. Surveyor asked about assessment when R3's wounds were noted. LPN C stated I don't know why there wouldn't be an assessment of the wounds.On 7/29/26 at 12:33 PM, Surveyor interviewed DON B (Director of Nursing) and asked about assessment of R3's heel wounds. DON B stated I don't see an assessment until 4/8/26. DON B stated that an assessment, including type of wound, dimensions, appearance of wound bed and periwound/edges, drainage, pain, signs of infection, is expected when a wound is found.

Based on interview and record review, the facility did not ensure that residents were assisted in obtaining dental services to meet the needs of each resident for 1 of 1 resident reviewed for dental services (R4) out of a sample of 9.R4's lower denture is broken, and the facility did not assist with scheduling an appointment.Evidenced by:The facility's Dental Services policy, dated as reviewed 01/25, states, in part: Our facility shall provide or obtain an outside resource for routine and 24-hour emergency dental and oral care to meet the needs of each resident and provide prompt referrals, as necessary.Prompt Referral: Within reason, as soon as the dentures are lost or damaged. Referral does not mean that the resident must see the dentist at the time but does mean that an appointment (referral) is made, or that the facility is aggressively working at replacing the dentures. Procedure: . 5. Social Service will promptly refer, within 3 days, residents with lost or damaged dentures dental services.R4 admitted to the facility on [DATE]. R4's Minimum Data Set (MDS), dated [DATE], indicates a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating the resident is cognitively intact.On 7/27/26 at 11:03 AM, Surveyor interviewed R4 who stated my lower denture is broken. I don't have a dental appointment; they just put me on a soft diet. It is very upsetting because now when I talk, I drool; that didn't happen with my denture.On 7/28/26 at 8:06 AM, Surveyor interviewed CNA D (Certified Nursing Assistant) who stated that R4's denture has been broken; R4 told me about it when I came here in April. I told the nurse.R4's Dental visit note, dated 7/22/25, states, in part: .I was told that patient had a broken bridge .The lower denture is retained by four implants. There is an external facial pin on the buccal of the lower right side of the lower full denture that when pushed in, engages with the implants to lock in place. There is a similar situation on the lower left side, except the facial metal pin is missing. As a result, the left side of the lower full denture does not stay in place and moves. It looks like the receptors on the inside of both dentures should be replaced, as the part that engages with the bar does not look to be in working condition and the O-rings on the upper denture are either worn out or missing. She should also have the external facial pin on the left side of her lower denture replaced.I recommended she find an implant specialist or prosthodontist who might be able to replace the needed items.R4's Resident Progress Note, dated 9/29/25, states in part: Resident's lower dentures were broke in half, in the cup, when his (sic) writer arrived on shift. Resident stated that staff from last night dropped them on the floor. Management made aware of resident's dentures being broken.On 7/28/26 at 8:11 AM, Surveyor interviewed UC E (Unit Clerk) who stated when there is a concern with dentures, I try to get them in, but dentists are hard to get into. Surveyor asked about R4. UC E stated the facility's dental provider told me there was an issue when they were here for a dental appointment. Surveyor asked if an appointment was made. UC E stated we let the POA (Power of Attorney) know so that they could set up the appointment. UC E stated there is no appointment yet made. Surveyor asked when the POA was contacted. UC E provided an email to POA/guardian, dated 10/28/26, which states, in part: .please make these appointments. Dental Please see the attached document from previous visit. It looks like Dr (provider name) referred to see a prosthodontist.*Important to note: dental provider recommended an appointment 3 months prior, and the dentures were broken in half one month prior to this email.On 7/28/26 at 8:28 AM, Surveyor interviewed SSD F (Social Services Director) who stated that R4's guardian was contacted about the denture. Surveyor asked if an appointment was made. SSD F stated I'm not sure, I believe that UC E would work with guardian on that.On 7/28/26 at 9:30 AM, SSD F stated, I called the guardian and an appointment has now been made.On 7/28/26 at 10:01 AM, Surveyor interviewed NHA A who stated that an appointment should have been pursued timely.

Based on observation, interview, and record review, 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 infection for 1 of 1 Residents (R1) observed for blood sugar check.LPN C (Licensed Practical Nurse) had a breech in infection control when they placed a glucometer in their uniform pocket after use.Evidenced by:The facility's Standard Precautions policy, dated as reviewed 1/25, states, in part: Policy Standard Precautions will be used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents.Resident care equipment and instruments/devices: handle used resident-care equipment soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of microorganisms to other residents and environments.On 7/27/26 at 12:03 PM, Surveyor observed LPN C perform a blood sugar check for R1. After the test, LPN C removed the test strip from the glucometer and placed the glucometer in their pocket. Surveyor asked LPN C if a glucometer is contaminated after use. LPN C stated yes, it could be because there was blood on the test strip. Surveyor asked LPN C if the glucometer touched LPN C's uniform after it was used. LPN C stated yes, I should not have placed it in my pocket.On 7/29/26 at 12:33 PM, Surveyor interviewed DON B (Director of Nursing) and asked about infection control with blood sugar testing. DON B stated that glucometers are contaminated after use and should not be placed into a staff member's pocket.

Based on interview and record review the facility failed to thoroughly investigate an allegation of misappropriation for 1 of 2 abuse allegations (R1). On 1/16/26 R1 reported to CNA C (Certified Nursing Assistant) that she was having pain after CNA C assisted her with cares. CNA C reported R1's concern to RN D (Registered Nurse). R1 told RN D, That CNA was rough and She didn't mean to hurt me. R1 was sent to the ED (emergency department). The ED physician indicated, I suspect that R1 likely has a right elbow sprain. The facility failed to interview other residents to determine the scope of the concern. Therefore, this incident has not been thoroughly investigated. This is evidenced by:Facility policy, titled Abuse Prevention Program Policy and Procedure, includes: Each resident has the right to be free from abuse, neglect, and corporal punishment of any type by staff or anyone. The facility will provide a safe resident environment and protect residents from abuse. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Abuse also includes the deprivation of an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well being. Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, or others but has not yet been investigated and if verified could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Investigation: Identify alleged perpetrator, remove from resident care area immediately, suspending investigation conclusion, obtain statement. Identify and interview all involved-witness statements- including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. Interview coworkers or other supervisors in regards to the alleged perpetrator's work performance. Review alleged perpetrator's employee file to confirm background checks, reference checks, and to review any possible past performance issues. Determine if abuse, neglect, . occurred, the extent, and the cause. Providing complete/thorough documentation of the investigation findings. time line of events. summary or conclusion. Follow-up actions to correct and prevent potential recurrence. All information must be gathered and reviewed with a final summary analysis with an action plan to prevent reoccurrence. R1 was admitted to the facility on [DATE] with diagnoses including: dementia with behavioral disturbance (memory impairment with a variety of behaviors), cerebral infarction-multiple (strokes), and weakness. R1's Comprehensive Care Plan, initiated 8/31/25, indicates R1 requires 1 staff for bed mobility. Toileting: R1 can be incontinent and does need assist of 1. The facility's Self-ReportOn 1/16/26 CNA C (Certified Nursing Assistant) reported to the RN D (Registered Nurse) that R1 was complaining of pain after performing care. When RN D went to assess R1, R1 stated that CNA C was rough. CNA C was suspended pending investigation, R1 sent to ED (emergency department) for evaluation and law enforcement has been notified. R1's statement: CNA C pulled resident to left with her arm. R1 heard a snap and it hurt. RN D came in and moved R1's arm and it hurt real bad. 10/10 pain CNA C's statement: CNA C documents, I went to clean R1 up and she was complaining of her legs that was hurting. I ask if she was having cramps but she said no. I then proceed to clean her up. At some point, I needed her to roll so I could get the other side of the brief to tape. R1 gave me her hand so I hold [sic] her hand and her hip to roll her. That is when she said I hurt her arm, because I pull it. [sic] I try [sic] to look at her arm but I was surprise [sic] she was hurt. RN D's statement: CNA C came to get me to let me know that R1 was complaining of pain in her right arm after she had turned her to provide cares. RN D assessed R1's pain and she was tearful when RN D tried to touch her elbow. CNA C said that she used R1's right arm to pull her towards the window to complete cares. R1 said that she heard a pop when she was being turned and that was when the pain started. R1 said that aide and was crying. R1 stated, I don't want her to lose her job. RN D tried to do range of motion as part of her assessment but R1 was still sobbing. LPN E (Licensed Practical Nurse) went into [sic] talk to R1 to get more information about what exactly happened. R1 is confused and can be hard to understand. The other nurse confirmed to RN D that R1 said CNA C was rough. CNA C was suspended and did not additional cares. Management was notified. LPN E's statement: R1 said that CNA C went to roll her to the left by pulling her arm. R1 heard a snap, she felt pain. RN D came in to check on R1 and R1 tried to lift her arm and it hurt really bad. 10/10 pain. CNA C came to RN D and myself, LPN E, and reported that when she went to roll R1, R1 started screaming at her that her arm hurt. CNA C asked what was wrong, R1 replied that CNA C hurt her. When EMS (Emergency Medical Services) arrived, R1 wasn't sure what happened. R1's pain was 3/10. The ED report documents as follows: R1 presenting to the emergency department by ambulance from nursing facility due to concern for right elbow pain after being repositioned in bed. Upon evaluation, patient is clinically well appearing, vital signs are stable. Physical exam reveals tenderness to palpation of the radial head of the right arm. Radiograph obtained and negative for acute fracture. The physician further documents, I suspect that patient likely has a right elbow sprain. Recommend she use a sling as needed for comfort, take OTC (over the counter) pain meds (medications) as needed. No further documentation was provided related to this incident On 1/26/26 at 3:15 PM, Surveyor spoke with NHA A (Nursing Home Administrator). Surveyor asked NHA A if the facility interviewed other staff regarding this incident. NHA A stated, no. Surveyor asked NHA A if the facility should have interviewed other residents during their investigation. NHA A stated, yes. The facility failed to interview other residents to determine the scope of R1's concern. This is not a thorough investigation.

Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 48 residents who reside in the facility.Surveyor observed dishwashing process. Dietary Aide failed to ensure proper hand washing was complete before going from dirty items to clean items in the kitchen.Evidence by:The facility policy, Machine Dishwashing Racking Procedure, Reviewed 1/25, states, in part;.To prevent cross-contamination when one employee is operating the dish machine, strict hand washing procedures must be adhered to between the soiled dish and clean dish handling.The facility policy, Hand washing/Hand Hygiene, Reviewed 1/25, states, in part;.Procedure:.3. Scrub your hands for at least 20 seconds. Need a timer? Hum the Happy Birthday song from beginning to end twice.On 1/12/26 at 8:54 AM, Surveyor observed dishwashing. Surveyor observed two staff assisting with dishwashing, one was assigned to the dirty dishes and the other staff assigned to clean dishes. Dietary Aide M (DA) indicated he was assigned to the dirty dishes and began cleaning off plates. [NAME] L indicated since he was the cook he was assigned putting away the clean dishes. DA M did not have on gloves and was directly touching the left-over food and dirty napkins. DA M went from the dirty area to other areas of the kitchen without washing hands. DA M was observed to go from dirty dishes to emptying the garbage can and then touching two clean coffee pots and multiple clean cups. Multiple times DA M would go from dirty dishes and wash hands for less than 20 seconds and then touch clean dishes. Surveyor met with DA M and [NAME] L and both indicated understanding of the above concern.On 1/12/26 at 5:00 PM, Dietary Manager K (DM) indicated staff should always wash their hands when going from dirty dishes to clean. DM K indicated staff should wash their hands at least 20 seconds. DM K indicated understanding of the above concern.The facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 48 residents who reside in the facility.

Based on observation, interview, and record review, the facility did not ensure that garbage and refuse was disposed of properly. This has the potential to affect all 48 residents who reside at the facility.Surveyor observed the facility's main dumpster lid open and garbage outside of the dumpster. Surveyor observed a garbage bag, multiple disposable gloves, a hairnet, food wrappers, and cardboard outside of the dumpster.Evidenced by:The facility policy, Sanitizing Garbage Cans and Dumpsters, Revised 1/25, states, in part;.8. Dumpsters provided by the local refuge vender will be maintained by the facility and kept covered at all times. 9. Area around the dumpster will be kept clean, free of debris, foul odors, and free of harboring/feeding of pests.On 1/7/26 at 10:06 AM, During the initial walk through of the kitchen, Surveyor observed the facility dumpsters. Surveyor and Dietary Manager K (DM) observed the dumpster lid open and a garbage bag, multiple disposable gloves, a hairnet, food wrappers, and cardboard outside of the dumpster. DM K indicated it is everyone's responsibility to keep the area around the dumpster clean, and all garbage should be inside the dumpster with the lid down. DM K indicated they would clean up the area.The facility did not ensure that garbage and refuse was disposed of properly. This has the potential to affect all 48 residents who reside at the facility.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse, to the administrator of the facility and to other officials including the State Survey Agency for 2 of 2 incidents (R10 & R5) reviewed. R10 voiced an allegation of neglect to CNA O (Certified Nursing Assistant) of being left in her wheelchair for around 6 hours, left in a wet brief, left without colostomy care, and left without a call light or a way to summons assistance. The facility failed to follow the facility's abuse policy and failed to report allegation to NHA A and to state agency. R5 reported an allegation of abuse via a grievance form. The facility failed to report the allegation of abuse to the State Agency. Evidenced by: Facility policy, titled Abuse Prevention Program Policy and Procedure, includes: Each resident has the right to be free from abuse, neglect, and corporal punishment of any type by staff or anyone. The facility will provide a safe resident environment and protect residents from abuse. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Willful is defined as used in the definition of abuse means the individual acted deliberately, not that the individual must have intended to inflict injury or harm. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation of an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well being. Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, or others but has not yet been investigated and if verified could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Immediately means as soon as possible, in the absence of a shorter state time frame requirement, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Reporting/Response: All alleged or suspected violations are to be reported immediately to NHA A (Nursing Home Administrator) or DON B (Director of Nursing), which are responsible to notify required officials, including the State Survey Agency, Adult Protective Services, Local Public Safety, Licensure Boards, Regional Director of Operations or Regional Clinical Directors, and any other agencies in accordance with State law through established procedures. All alleged violations involving abuse, neglect, . are reported immediately, but not later than 2 hours after allegation is made if the events that cause the allegation involve abuse. Not later than 24 hours after the allegation is made if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Example 1 R10 admitted to the facility on [DATE] with diagnoses including: weakness, diabetes mellitus with diabetic neuropathy (never damage) R10's Comprehensive Care Plan, initiated 4/11/25, indicates R10 requires 2 staff and a hoyer lift (full body) for transfers. On 1/7/26 at 11:06 AM, during the screening process, Surveyor introduced self and asked R10 to complete a short interview. R10 stated, It won't do a damn bit of good to talk to you. Surveyor observed R10 use her hands to shield her face. R10 indicated staff leave her in her wheelchair for long periods of time even when she is asking them to lay down in her bed. R10 indicated staff tell her there is only one staff working and they are too busy to assist her. R10 indicated one time she was left in her chair for 12 hours. R10 indicated she has reported this event and others to staff and has asked to file a report, but nothing ever happens about it. Surveyor observed R10 to have tears rolling down her face as she spoke. R10's Grievance Form, dated 12/24/25, includes: Summary of Grievance- at 12:00 AM when I did my rounds R10 was still in her chair in her day clothes. She needed her colostomy bag changed due to leaking. I feel like the PM aide/Activity Director/CNA P (certified nursing assistant) who was assigned did not take care of her. Receipt of grievance: 12/25/25 at 12:30 AM. Who received: DON B (Director of Nursing) via phone. Summary of Findings: grievance confirmed. R10 was still in her wheelchair at 12:00 AM. CNA that was assigned stated that R10 refused to go to bed or allow cares. R10 agrees that she may have told CNA she did not want to lay down when approached. R10 feels as though they should have come back again later to put her to bed. Corrective action: Education with CNA to reapproach resident after refusal of cares. R10's Nurse Notes, dated 12/25/25 at 2:24 AM, includes: . R10 is alert and cooperative. R10 was found awake, still in her wheelchair during rounds at midnight. R10 was very tearful and upset with the evening staff, whom she stated left her alone, in her wheelchair, since supper. R10 requested a report to be filed, which was documented with DON B. R10 was toileted, changed and helped into her bed. (It is important to note the facility's supper meal is served between 5:00 PM and 6:00 PM). On 1/12/26 at 4:15 PM, DON B (Director of Nursing) indicated CNA O called her in the middle of the night around 12:30 AM on 12/25/25 to inform her of R10's concern that CNA P did not provide care and that R10 was left in her chair since before supper, was not assisted into her night clothes, and was assisted into bed. DON B indicated she talked to R10 the next day and she also talked to some of the staff that worked on the PM shift of 12/24/25 and the night shift of 12/24/25 to 12/25/25. DON B indicated she did not document the interviews, she did not interview other residents, and she did not interview all staff that were working during this period of time. DON B indicated a concern of a staff member not taking care of a resident or a resident being left in her wheelchair for 6 hours could be an allegation of neglect. DON B indicated the facility policy is that the facility reports all allegations of abuse/neglect to the state agency within 2 hours. DON B indicated she did not report this allegation to the state agency. On 1/13/26 at 7:20 AM, LPN Q(Licensed Practical Nurse) indicated during the night shift of 12/24/25 to 12/25/25, CNA O reported to her around 12:00 AM that R10 was never put to bed. LPN Q indicated R10 was found in her wheelchair wearing her day clothes, her call light was not in reach, and R10 could not get to her call light. LPN Q indicated R10 is very soft spoken and she doesn't know if R10 tried to yell for help. LPN Q indicated she went to talk to R10 and R10 was sad, tearful, mad, and at first did not want to talk. LPN Q indicated R10 requires a hoyer lift for transfer assistance. LPN Q indicated a concern of a staff member not providing cares and/or leaving a resident without a call light for 6 hours could be an allegation of abuse/neglect and that is why she told CNA O to call DON B right away to report it. LPN Q indicated she is not aware of R10 having a behavior of crying or being tearful. On 1/13/26 at 7:44 AM, during an interview CNA O (Certified Nursing Assistant) indicated on the night shift between 12/24/25-12/25/25 she found R10 in her wheelchair at around midnight. CNA O indicated R10 was crying and really upset, she was incontinent and had soaked through her clothing , her colostomy bag had exploded and was on her clothing, and she did not have her call light nearby nor was she able to get to it. CNA O indicated R10's supper tray was still in her room and she removed it at midnight rounds. CNA O indicated R10 likes to go to bed early and she would stay in bed all of the time if she could. CNA O indicated R10 wanted to file a report that CNA P neglected to provide cares for her. CNA O indicated she filled out the grievance form for R10, reported the allegation of neglect to LPN Q and DON B right away. CNA O stated, I told DON B that this was an allegation of neglect against CNA P. On 1/13/26 at 7:55 AM, Activity Director/CNA P indicated she works as a CNA on the floor every once in awhile when the facility needs her to. CNA P indicated she worked on 12/24/25 from 6PM to 10PM. CNA P indicated her and 2 other CNAs covered the hallway sharing the workload. CNA P indicated at around 8:00 PM she went in and asked R10 if she wanted to go to bed and R10 indicated she was fine. CNA P indicated she was unsure if R10 had her call light in reach at this time. CNA P indicated R10 is soft spoken and she has never heard her call out or yell. CNA P indicated DON B never interviewed her about R10 or asked her to fill out a statement regarding 12/24/25 PM shift until Surveyor brought it to her attention. On 1/13/26 at 8:26 AM NHA A (Nursing Home Administrator) indicated the facility needs to work on reporting allegations of abuse timely and investigating them thoroughly. NHA A indicated DON B told her the following day that there was a concern, but that the concern was a concern that third shift had issues with second shift. NHA A indicated DON B should have interviewed residents and all staff who worked that shift, should have documented her interviews, should have told NHA A the concern from the resident's perspective as it was reported initially, and should have informed NHA A immediately so that she could report to the state agency timely. NHA A indicated R10's allegation was not reported to the state agency. Example 2 R5 was admitted to the facility on [DATE] with diagnoses that include PTSD (Post -traumatic stress disorder), borderline personality disorder, chronic kidney disease stage 5 (kidney failure), and dependence on dialysis (a life sustaining treatment that filters waste, toxins, and extra fluid from the blood when the kidneys fail). R5's most recent MDS (Minimum Data Set) dated 1/12/26 states that R5 has a BIMS (Brief Interview of Mental Status of 14/15, indicating that R5 is cognitively intact. Nurse's note on 1/11/26 states in part, the following: Resident talked to the Aide about her treatment the day she didn't go to dialysis. Aide gave resident the grievance form to fill out. R5's grievance form dated 1/12/26 states in part .Date received 1/12 Time: 9AM Who Received: SW C (Social Worker) .Findings of Investigation (R5 inadvertently wrote their grievance in this section): on 1-6-26 I woke up with severe pain in my right leg. Couldn't lift it, etc. I had PT (Physical Therapy) from [PTA (physical Therapy Aide) name] the day B4 (before). When trying into[sic] get into medical van for dialysis, I couldn't lift my right leg. [PTA Name, RN (Registered Nurse name)] and blonde CNA (Certified Nursing Assistant)- came out and try to shove me in and I was in more pain. I screamed in pain and cried. I didn't make it to dialysis that day. On 1/13/26 at 8:28 AM, Surveyor interviewed R5. Surveyor asked R5 to explain the events of 1/6/26, R5 stated that the 3 staff were trying to shove her into the van to go to dialysis. R5 reported that their actions caused increased pain and was upset. Surveyor asked R5 if anyone from the facility discussed the grievance with her, R5 stated not really. On 1/13/26 at 11:02 AM, Surveyor interviewed DON B (Director of Nursing) and SW C. Surveyor asked DON B when they were made aware of R5's grievance, DON B stated yesterday afternoon (1/12/26). Surveyor asked DON B if R5's report of staff members tried to shove me in and I was in more pain be considered an allegation of abuse, DON B stated yes. Surveyor asked DON B and SW C when an allegation of abuse should be reported to the State Agency, SW C stated within 2 hours. Surveyor asked if the allegation was reported to the State Agency, DON B stated no. On 1/13/26 at 12:21 PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor reviewed R5's grievance form with NHA A. Surveyor asked NHA A if R5's allegation of abuse should have been reported to the State Agency, NHA A stated yes and reported that since she became aware, they have submitted the allegation.

Based on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation or mistreatment, that all alleged violations are thoroughly investigated for 1 of 2 sampled Residents (R10). R10 voiced an allegation of neglect to CNA O (Certified Nursing Assistant). The facility failed to investigate the allegation thoroughly, including gathering staff interviews, gathering resident interviews, and recording an interview with R10. Evidenced by: Facility policy, titled Abuse Prevention Program Policy and Procedure, includes: Each resident has the right to be free from abuse, neglect, and corporal punishment of any type by staff or anyone. The facility will provide a safe resident environment and protect residents from abuse. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Abuse also includes the deprivation of an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well being. Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, or others but has not yet been investigated and if verified could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Investigation: Identify alleged perpetrator, remove from resident care area immediately, suspending investigation conclusion, obtain statement. Identify and interview all involved-witness statements- including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. Interview coworkers or other supervisors in regards to the alleged perpetrator's work performance. Review alleged perpetrator's employee file to confirm background checks, reference checks, and to review any possible past performance issues. Determine if abuse, neglect, . occurred, the extent, and the cause. Providing complete/thorough documentation of the investigation findings. time line of events. summary or conclusion. Follow-up actions to correct and prevent potential recurrence. All information must be gathered and reviewed with a final summary analysis with an action plan to prevent reoccurrence. R10 admitted to the facility on [DATE] with diagnoses including: weakness, and diabetes mellitus with diabetic neuropathy (nerve damage)R10's Comprehensive Care Plan, initiated 4/11/25, indicates R10 requires 2 staff and a Hoyer lift (full body lift) for transfers.On 1/7/26 at 11:06 AM, during the screening process, Surveyor introduced self and asked R10 to complete a short interview. R10 stated, It won't do a damn bit of good to talk to you. Surveyor observed R10 use her hands to shield her face. R10 indicated staff leave her in her wheelchair for long periods of time even when she is asking them to lay down in her bed. R10 indicated staff tell her there is only one staff working and they are too busy to assist her. R10 indicated one time she was left in her chair for 12 hours. R10 indicated she has reported this event and others to staff and has asked to file a report, but nothing ever happens about it. Surveyor observed R10 to have tears rolling down her face as she spoke.R10's Grievance Form, dated 12/24/25, includes: Summary of Grievance- at 12:00 AM when I did my rounds R10 was still in her chair in her day clothes. She needed her colostomy bag changed due to leaking. I feel like the PM aide/Activity Director/ CNA P who was assigned did not take care of her. Receipt of grievance: 12/25/25 at 12:30 AM. Who received: DON B (Director of Nursing) via phone. Summary of Findings: grievance confirmed. R10 was still in her wheelchair at 12:00 AM. CNA that was assigned stated that R10 refused to go to bed or allow cares. R10 agrees that she may have told CNA she did not want to lay down when approached. R10 feels as though they should have come back again later to put her to bed. Corrective action: Education with CNA to reapproach resident after refusal of cares.R10's Nurse Notes, dated 12/25/25 at 2:24 AM, includes: . R10 is alert and cooperative. R10 was found awake, still in her wheelchair during rounds at midnight. R10 was very tearful and upset with the evening staff, whom she stated left her alone, in her wheelchair, since supper. R10 requested a report to be filed, which was documented with DON B (Director of Nursing). R10 was toileted, changed and helped into her bed.(It is important to note the facility's supper meal is served between 5:00 PM and 6:00 PM).On 1/12/26 at 4:15 PM, DON B (Director of Nursing) indicated CNA O called her in the middle of the night around 12:30 AM on 12/25/25 to inform her of R10's concern that CNA P did not provide care and that R10 was left in her chair since before supper, was not assisted into her night clothes, and was assisted into bed. DON B indicated she talked to R10 the next day and she also talked to some of the staff that worked on the PM shift of 12/24/25 and the night shift of 12/24/25 to 12/25/25. DON B indicated she did not document the interviews, she did not interview other residents, and she did not interview all staff that were working during this period of time. DON B indicated a concern of a staff member not taking care of a resident or a resident being left in her wheelchair for 6 hours could be an allegation of neglect.On 1/13/26 at 7:20 AM, LPN Q (Licensed Practical Nurse) indicated during the night shift of 12/24/25 to 12/25/25, CNA O reported to her around 12:00 AM that R10 was never put to bed. LPN Q indicated R10 was found in her wheelchair wearing her day clothes, her call light was not in reach, and R10 could not get to her call light. LPN Q indicated R10 is very soft spoken and she doesn't know if R10 tried to yell for help. LPN Q indicated she went to talk to R10 and R10 was sad, tearful, mad, and at first did not want to talk. LPN Q indicated R10 requires a hoyer lift for transfer assistance. LPN Q indicated a concern of a staff member not providing cares and/or leaving a resident without a call light for 6 hours could be an allegation of abuse/neglect and that is why she told CNA O to call DON B right away to report it. LPN Q indicated she is not aware of R10 having a behavior of crying or being tearful.On 1/13/26 at 7:44 AM, during an interview CNA O (Certified Nursing Assistant) indicated on the night shift between 12/24/25-12/25/25 she found R10 in her wheelchair at around midnight. CNA O indicated R10 was crying and really upset, she was incontinent and had soaked through her clothing, her colostomy bag had exploded and was on her clothing, and she did not have her call light nearby nor was she able to get to it. CNA O indicated R10's supper tray was still in her room and she removed it at midnight rounds. CNA O indicated R10 likes to go to bed early and she would stay in bed all the time if she could. CNA O indicated R10 wanted to file a report that CNA P neglected to provide cares for her. CNA O indicated she filled out the grievance form for R10, reported the allegation of neglect to LPN Q and DON B right away. CNA O stated, I told DON B that this was an allegation of neglect against CNA P.On 1/13/26 at 7:55 AM, Activity Director/CNA P indicated she works as a CNA on the floor every once in a while, when the facility needs her to. CNA P indicated she worked on 12/24/25 from 6PM to 10PM. CNA P indicated her and 2 other CNAs covered the hallway sharing the workload. CNA P indicated at around 8:00 PM she went in and asked R10 if she wanted to go to bed and R10 indicated she was fine. CNA P indicated she was unsure if R10 had her call light in reach at this time. CNA P indicated R10 is soft spoken and she has never heard her call out or yell. CNA P indicated DON B never interviewed her about R10 or asked her to fill out a statement regarding 12/24/25 PM shift until Surveyor brought it to her attention. On 1/13/26 at 8:26 AM, NHA A (Nursing Home Administrator) indicated the facility needs to work on reporting allegations of abuse timely and investigating them thoroughly. NHA A indicated DON B told her the following day that there was a concern, but that the concern was a concern that third shift had issues with second shift. NHA A indicated DON B should have interviewed residents and all staff who worked that shift, should have documented her interviews, should have told NHA A the concern from the resident's perspective as it was reported initially, and should have informed NHA A immediately so that she could report to the state agency timely. NHA A indicated R10's allegation was not investigated thoroughly, and it should have been.

Based on interview and record review the facility did not ensure that each resident had a baseline care plan developed and implemented, within 48 hours, with needed instructions to provide effective and person-centered care for 1 of 6 residents (R5) reviewed. R5's baseline care plan did not include R5's diagnosis of PTSD (Post- traumatic stress disorder), triggers, or interventions.Evidenced by:The facility's policy titled Resident Baseline Care Plan Development updated on 1/17/18 states in part .Policy: The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person- centered care of the resident that meet professional standards of quality care. The baseline care plan must-.ii. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to- .e. Social Services.R5 was admitted to the facility on [DATE] with diagnoses that include PTSD (Post -traumatic stress disorder), borderline personality disorder, chronic kidney disease stage 5 (kidney failure), and dependence on dialysis (a life sustaining treatment that filters waste, toxins, and extra fluid from the blood when the kidneys fail).R5's most recent MDS (Minimum Data Set) dated 1/12/26 states that R5 has a BIMS (Brief Interview of Mental Status) of 14 out of15, indicating that R5 is cognitively intact.R5's baseline care plan dated 12/15/25, signed by R5 on 12/17/25 does not list any pertinent diagnoses, including PTSD, nor does it list triggers or interventions.The portion of the baseline care plan pertaining to Social Services is blank.The portion of the form titled additional comments/Needs/ Preferences is blank.On 1/12/26 at 10:30 AM, Surveyor interviewed SW C (Social Worker). Surveyor asked SW C if R5 should have a care plan for PTSD, SW C stated yes, and that nursing is responsible for the care plans.On 1/12/26 at 10:41 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if R5's PTSD, triggers and interventions should be on their baseline care plan, DON B stated yes.

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 (R5) reviewed for dialysis. Facility staff were not fluent in the emergency plan for a resident bleeding from their dialysis access site. This is evidenced by:The facility's policy titled Dialysis Services last reviewed on 1/2025 does not include an emergency plan. According to Clinical Journal of the American Society of Nephrology article titled Diagnosis, Treatment, and Prevention of Hemodialysis Emergencies dated February 2017, .Vascular Access Hemorrhage: Hemorrhage from an AV access is an uncommon but potentially fatal complication if it is not recognized promptly and acted on with an appropriate intervention. Most fatal vascular access hemorrhages occur outside of the dialysis facility, but occasionally, they rupture at the dialysis unit (120). Patients and their families should be educated about the recognition and emergent management of a bleeding AV access. In the event of bleeding from vascular access site, direct continuous pressure with a finger for 15-20 minutes is the most effective method of controlling the bleeding. In the event of rupture of a PSA or aneurysm away from dialysis unit or hospital, direct pressure with a finger at the site of bleeding is the best method of controlling bleeding. Patients should be advised to continue holding direct pressure until emergency medical help arrives and avoid applying a tourniquet, towel, or BP cuff to the extremity. Diagnosis, Treatment, and Prevention of Hemodialysis Emergen . : Clinical Journal of the American Society of Nephrology R5 was admitted to the facility on [DATE] with diagnoses that include PTSD (Post -traumatic stress disorder), borderline personality disorder, chronic kidney disease stage 5 (kidney failure), and dependence on dialysis (a life sustaining treatment that filters waste, toxins, and extra fluid from the blood when the kidneys fail).R5's most recent MDS (Minimum Data Set) dated 1/12/26 states that R5 has a BIMS (Brief Interview of Mental Status) of 14 out of 15, indicating that R5 is cognitively intact. R5's care plan initiated on 12/16/25 does not include steps for staff to take if R5 is bleeding out of their dialysis catheter. R5's CNA (Certified Nursing Assistant) Kardex does not include steps for staff to take if R5 is bleeding out of their dialysis catheter. 01/07/2026 10:48 AM Surveyor observed R5's room. Surveyor noted that there was no signage indicating that R5 has a dialysis catheter or what to do in an emergent situation if R5 starts bleeding from their dialysis catheter. Additionally, Surveyor did not observe any emergency equipment or supplies in R5's room. On 1/8/26 at 10:06 AM, Surveyor interviewed CNA D. Surveyor asked CNA D what steps they would take if they saw R5 bleeding from their dialysis catheter, CNA D stated they would immediately get the nurse, put on their PPE (Personal Protective Equipment), and then follow the nurse's instruction. Surveyor asked CNA D if their care sheet or Kardex had any emergency instructions on it, CNA D stated no. Surveyor asked CNA D if they have received any education from the facility on how to care for a resident on dialysis, CNA D stated no. On 1/8/26 at 10:14 AM, Surveyor interviewed CNA E. Surveyor asked CNA E what steps they would take if they saw R5 bleeding from their dialysis catheter, CNA E stated that they would yell for the nurse, not leave the resident alone, make sure they are in a safe and comfortable position. Surveyor asked CNA E if they have received any education from the facility on how to care for a resident on dialysis, CNA E stated no. On 1/8/26 at 10:23 AM, Surveyor interviewed LPN F (Licensed Practical Nurse). Surveyor asked LPN F what they would do if they saw R5 bleeding from their dialysis catheter, LPN F stated that they would apply pressure, call for help, call they dialysis center, and send the resident to the ER (Emergency Room). Surveyor asked LPN F what steps they would expect the CNAs to take, LPN F stated that they should call for the nurse immediately or call the ADON/DON (Assistant Director of Nursing/ Director of Nursing). On 1/8/26 at 10:27 AM, Surveyor interviewed CNA G. Surveyor asked CNA G what steps they would take if they saw R5 bleeding from their dialysis catheter, CNA G stated that they would get the nurse, hurry back, put on gloves and grab some rags and stuff to apply pressure. Surveyor asked CNA G if they have received any education from the facility on how to care for a resident on dialysis, CNA G stated no. On 1/8/26 at 11:27 AM, Surveyor interviewed DON B and RN H (Regional Nurse). Surveyor asked what steps they would expect staff to take find a dialysis resident is bleeding from their dialysis catheter, DON B stated they would expect staff to make sure the site is bleeding, apply pressure and update the MD (Medical Doctor). Surveyor asked what steps they would expect the CNAs to take, RN H stated they would expect the CNAs to get the nurse. Surveyor asked if they would expect the CNAs to apply pressure, RN H stated they should get nursing assistance. Surveyor asked what steps the facility has in place to ensure that their staff knows what to do in an emergent bleeding situation, RN H stated that there is site monitoring on every shift. Surveyor asked if there was any education provided to staff on what to do if a dialysis resident was bleeding from their access site, RN H stated they would have to look.Of note, no education was provided to Surveyor.

Based on record review and interview, the facility did not ensure 1 of 1 resident (R5) who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. R5 has a diagnosis of PTSD (Post Traumatic Stress Disorder) and does not have a complete trauma assessment or a care plan addressing triggers, resident specific approaches, or interventions.Evidenced by:The facility's policy titled Trauma Informed Care revised 9/2022 states in part, .Policy Explanation and Compliance Guidelines: .2. The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), admission Assessment, the history and physical, the social history/assessment, and others.6. The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the resident's care plan.R5 was admitted to the facility on [DATE] with diagnoses that include PTSD (Post -traumatic stress disorder), borderline personality disorder, chronic kidney disease stage 5 (kidney failure), and dependence on dialysis (a life sustaining treatment that filters waste, toxins, and extra fluid from the blood when the kidneys fail).R5's most recent MDS (Minimum Data Set) dated [DATE] states that R5 has a BIMS (Brief Interview of Mental Status) of 14 out of 15, indicating that R5 is cognitively intact.R5's Trauma Informed Care Observation dated [DATE] states in part .Have you ever experienced, witnessed, learned about a natural disaster (e.g. flood, tornado, hurricane, earthquake, etc.)? Answer: Personally witnessed.Have you ever experienced, witnessed, learned about a life-threatening illness or injury (e.g. cancer, heart attack, AIDS, leukemia, multiple sclerosis, etc.)? Answer: Personally experienced. Have you ever experienced, witnessed, learned about a physical assault (e.g. attacked, hit, beaten up, etc.)? Answer: Personally experienced. Have you ever experienced, witnessed, learned about a sexual assault (e.g. rape, attempted rape, made to perform sexual act via force or threat of harm, etc.)? Answer: Personally experienced.R5's care plan dated [DATE] does not have PTSD listed as a problem, and there are no goals, triggers, or interventions.On [DATE] at 10:48 AM, Surveyor interviewed R5. Surveyor asked R5 if they were comfortable talking about their PTSD, R5 stated yes and then proceeded to tell Surveyor that they have had a lot of traumas in their life that included an assault in 1990 that resulted in a broken neck and near-death situation, their brother, mother, father, and cat all died. R5 reported that their brother died from sarcoidosis (an inflammatory disease where immune cells form tiny lumps in organs, potentially disrupting organ function) and had to be med flighted to a hospital. Surveyor asked R5 what their triggers are, R5 stated that loss of special people, their diagnosis of kidney failure, and hearing helicopters.On [DATE] at 10:05 AM, Surveyor interviewed CNA G (Certified Nursing Assistant). Surveyor asked CNA G how they are made aware that a resident has a diagnosis of PTSD, CNA G stated that when the resident is admitted , they get an overview. Surveyor asked CNA G how they know what the triggers and interventions are, CNA G stated they are on the care plan. Surveyor asked CNA G if they were aware of what R5's triggers and interventions are, CNA G stated that they have not had the opportunity to review the care plan. Surveyor and CNA G reviewed R5's care plan. Surveyor asked CNA G if R5's care plan contained any triggers or interventions for PTSD, CNA G stated no.On [DATE] at 10:11 AM, Surveyor interviewed LPN F (Licensed Practical Nurse). Surveyor asked LPN F how they are made aware that a resident has a diagnosis of PTSD, LPN F stated that the information would get passed along during report. Surveyor asked LPN F if they were aware that R5 has a diagnosis of PTSD, LPN F stated yes. Surveyor asked LPN F what R5's triggers and interventions are, LPN F reviewed R5's care plan and reported to Surveyor that they were unable to find triggers or interventions in R5's care plan.On [DATE] at 10:30 AM, Surveyor interviewed SW C (Social Worker). Surveyor asked SW C what the process is when a resident is admitted with a diagnosis of PTSD, SW C stated they set the resident up with psych services. Surveyor asked SW C if a trauma assessment is completed as part of the admission assessment, SW C stated yes. Surveyor asked SW C if they completed R5's trauma assessment, SW C stated yes. Surveyor asked SW C if they asked R5 about their trauma, triggers, and interventions, SW C stated that for the assessment, the resident answers yes or no to the questions and that she did not ask any additional questions about R5's trauma, triggers, or interventions. Surveyor asked SW C if a resident with PTSD should have a care plan addressing the diagnosis, SW C stated yes and that they believe nursing staff makes the care plans.On [DATE] at 10:41 AM, Surveyor interviewed DON B (Director of Nursing), NHA A (Nursing Home Administrator), and RN H (Regional Nurse). Surveyor asked what the expectation is when a resident is admitted with a diagnosis of PTSD, DON B and RN H stated they should complete a trauma informed care assessment and a PTSD care plan. Surveyor asked if R5 should have a care plan for PTSD, given their diagnosis, DON B stated yes.

Based on interview, and record review, the facility did not provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (R13) of 5 residents reviewed for medications.R13 was prescribed Buspirone for anxiety and failed to receive the medication.This is evidenced by:The facility's policy Care Standards, Standards of Nursing Practices, dated 1/25, includes: Responsibility with Medications and Physicians Orders 1. The licensed nurse that receives an order and notes the order is responsible to carry the order through by placing in achieve [Electronic Health Record], on the MAR (Medication Administration Record), TAR (Treatment Administration Record), ordering the medication from pharmacy, communicating order specifics to appropriate departments.R13 admitted to the facility on [DATE] with diagnoses including other symptoms and signs involving cognitive functions and awareness, anxiety disorder and depression.R13's BIMS (Brief Interview for Mental Status) dated 11/6/25 has a score of 11, indicating R13 has moderate cognitive impairment.R13's Psych Initial Evaluation, dated 11/17/25, provided by NP I (Nurse Practitioner) includes: .a past medical history significant for anxiety disorder, cognitive impairment. She reports her current mood has been up-and-down with symptoms of anxiety described as on and off being restless. Medications Buspar (buspirone) 5 mg tablet - NEW Take 1 tablet by mouth three times a day for anxiety. Assessment and Plan F41.9 Anxiety disorder, unspecified: Patient reports anxiety symptoms described as on and off being restless with mood fluctuations. Denies symptoms of depression, hallucinations, delusions, or thoughts of self-harm. Starting buspirone (Buspar) 5 mg three times daily for anxiety management. Follow-up Start buspirone Follow-up in 2 weeks or sooner if changes in mood or behaviors.R13's physician orders for November 2025 do not include Buspar 5 mg three times daily.R13's November 2025 MAR does not include Buspar 5 mg three times daily.On 1/12/26 at 1:50 PM, Surveyor interviewed NP I regarding R13's buspirone order. NP I indicated she is not sure why the faxed order was not processed. NP I indicated if a fax fails she receives a notice and would resend the order. NP I indicated she did not have any fax failed notifications.On 1/12/26 at 1:42 PM, Surveyor interviewed ADON J (Assistant Director of Nursing) regarding R13's buspirone order. ADON J indicated when NP I completes her assessment on a resident, NP I will verbally discuss any changes she recommends with the ADON J or DON B (Director of Nursing). ADON J indicated NP I will fax over the order changes and ADON J will put the order in. ADON J stated NP I will fax the orders over almost instantly. ADON J indicated she is not sure why R13's buspirone order was not entered into R13's physician orders or MAR. ADON J indicated she remembered talking about R13's buspirone order with NP I but the faxed order never came through.R13's Psych Follow Up note, dated 12/1/25, provided by NP I includes: At her last evaluation, the patient reported her mood as up-and-down with symptoms of anxiety. Buspirone was initiated at her last visit to address her anxiety symptoms and racing thoughts. The order was never entered or administered resend buspirone 5 mg 3 times daily for anxiety. Assessment and Plan Start buspirone 5 mg by mouth three times daily.R13's Physician Order Form, dated 12/1/25, signed by NP I, states buspirone 5 mg by mouth three times a day for anxiety. The order has a received faxed date and time stamp of 12/25/25 9:37 AM.R13's physician orders for December 2025 do not include Buspar 5 mg three times daily.R13's December MAR does not include Buspar 5 mg three times daily.R13's Informed Consent for Medication for Buspirone was presented to R13 by ADON J and signed by R13 on 12/2/25.On 1/12/26 at 1:50 PM, Surveyor interviewed NP I regarding R13's buspirone order. NP I indicated she is not clear about what happened with R13's buspirone order. NP I indicated she did not receive a fax failed notification and since she did not hear from the facility she though R13's buspirone order had been entered and R13 was receiving the buspirone. NP I indicated she would expect the facility to call her if the fax was not received since they had discussed the change to R13's medication. On 1/12/26 at 1:42 PM, Surveyor interviewed ADON J regarding R13's buspirone order. ADON J indicated she talked with NP I about the buspirone. ADON J indicated she obtained consent for buspirone on 12/2/25 from R13 based on the conversation with NP I. ADON J indicated she never received the faxed order for R13's buspirone so she did not enter it into R13's electronic physician orders or MAR. ADON J indicated she found the faxed order was uploaded into R13's documents but never entered into R13's physician orders or MAR.R13's Progress Note, dated 1/5/26, provided by NP I, includes: Assessment and Plan F41.9 Anxiety disorder, unspecified Buspirone order was never initiated.On 1/12/26 at 1:50 PM, Surveyor interviewed NP I regarding R13's buspirone order. NP I indicated since R13's anxiety had decreased on the 1/5/26 visit, NP I felt the anxiety was situational. NP I indicated R13 did have complaints of feeling more depressed and NP I decided to increase a different medication R13 was already receiving. NP I indicated she put the order through the facility's messaging app to ensure they would receive the order.On 1/12/26 at 3:40 PM, Surveyor interviewed DON B regarding R13's buspirone order. DON B indicated the facility should follow provider orders. DON B indicated the facility should have sent a message to NP I regarding the facility not receiving the faxed order after the verbal conversation of NP I wanting to initiate a new medication. DON B indicated R13 did not receive buspirone NP I had ordered but should have received buspirone as NP I had ordered.

Based on observation, interview, and record review, the facility did not ensure a resident's environment remained as free of accident hazards as possible for 5 of 8 residents (R3, R7, R9, R10, and R11) by failing to have a system in place for monitoring the surface temperature of baseboard heaters to prevent burns. R3 is a resident with impaired mobility and cognition. On 10/29/25, R3 fell out of bed onto the baseboard heater. R3 was stuck between the wall and the bed. R3 sustained partial thickness (2nd Degree) burns. R7 is a resident with impaired mobility, who was observed by Surveyors to have her bed next to the baseboard heater, with the foot of the bed touching the baseboard heater, and the head of the bed less than 6 inches away from the baseboard heater. R7's base board heater temperature was 130.6. R7 has had a prior fall out of bed. The facility's failure to have a system in place for monitoring the surface temperature of baseboard heaters to prevent burns created a reasonable likelihood for serious harm or injury, thus resulting in a finding of Immediate Jeopardy that began on 10/29/25. Surveyor notified NHA A (Nursing Home Administrator) and RCD D (Regional Clinical Director) of the Immediate Jeopardy on 12/10/25 at 4:00 PM. The immediate jeopardy was removed on 12/10/25; however, the deficient practice continues at a severity/scope level of E (potential for harm/isolated) as the facility implements its action plan, and due to the following examples: R9 is a resident with cognitive impairment who is at risk for falls. Surveyors observed R9's bed touching the baseboard heater. On 12/10/25, the temperature of R9's baseboard heater was 127.2 F. R10 is a resident with impaired mobility who is at risk for falls. Surveyors observed R10's bed to be an estimated six inches from the baseboard heater. On 12/10/25, the temperature of R10's baseboard heater was 156 F. R11 is a resident with impaired mobility who is at risk for falls. Surveyors observed R11's bed to be touching the baseboard heater. On 12/10/25, the temperature of R11's baseboard heater was 169.1 F. Findings include: The facility provided Surveyor with the Owner's Guide and additional technical documentation from the manufacturer relating to the facility's baseboard heaters. In the Owner's Guide, there is a section titled, High-temperature safety shutoff that states, All baseboard heaters come with a built-in high-temperature safety shutoff that stops electricity flowing to the heater if it gets too hot inside. This automatically resets after cooling. (Of note: The specific temperature in which shut-off occurs is not listed.) The additional documentation contains a section titled, Technical Information that states, in part: Baseboard heaters work best when placed under a window and at least 12 inches away from furniture or other objects. Keep at least 12 inches minimum from objects hanging above (i.e. drapes) . The section titled, Important Instructions states . 4. This Linear Convector Baseboard is hot when in use. To avoid burns, do not let bare skin touch hot surfaces. Keep combustible material such as: furniture, pillows, bedding, papers, clothes and curtains away from Linear Convector Baseboard. 5. To prevent a possible fire, do not block air intakes or exhaust in any manner. The section titled Installation Instructions with subsection Placement of the Linear Convector Baseboard states in part: .Due to the higher outlet temperature, the wall surface can reach temperatures of 160 F (71 C) or above, and some materials may discolor or deform at these temperatures, e.g. vinyl or plastic. According to the State of Michigan, Department of Licensing and Regulatory Affairs, . Based on research by our Health Facilities Engineering Section, it has been determined that a temperature of 125 degrees Fahrenheit is normally acceptable on the surface of a heating unit in a nursing home or long-term care facility. This memo continues by noting, This temperature was determined from information found in ASTM International Standard C1055-03, titled Standard Guide for Heated System Surface Conditions that Produce Contact Burn Injuries. American Society for Testing and Materials (ASTM) Standard C 1055 -03 is largely based on the work of [NAME] and [NAME]. This maximum acceptable temperature is based on a maximum acceptable injury level of a first-degree burn, which is reversible, and causes no permanent tissue damage, and a maximum contact time with the heated surface of 60 seconds, to reflect the slower reaction times of the elderly or the infirm (not physically or mentally strong, especially through age or illness). At this temperature, one must recognize that there is some risk. While those who can react should have sufficient time to remove themselves from contact with the heated surface without sustaining permanent damage, it is incumbent upon the facilities to identify those residents who may be unable to recognize the danger or pull away from the heat source and provide extra protective measures for those residents as needed.(Source: https://www.michigan.gov/-/media/Project/Websites/[NAME]/bchs/Folder2/BHS_NHM_Heating_Unit_Temperature1.pdf?rev=0c6e67303a1746349f096eaf0c3ba0d3) 1. R3 was admitted to the facility on [DATE], with diagnoses including cerebral infarction due to embolism of right cerebellar artery (stroke caused by a blockage of the artery supplying blood to the right cerebellum responsible for coordinating movement, balance, motor learning, and cognitive functions), muscle weakness (generalized), type 2 diabetes with diabetic neuropathy (nerve damage caused by diabetes causing symptoms such as weakness, dumbness, and pain), mild cognitive impairment of uncertain or unknown etiology, aphasia (impairment of communication abilities due to brain damage), overactive bladder (sudden urges to urinate that are hard to control), and hemiplegia (unilateral paralysis) and hemiparesis (unilateral weakness) following cerebral infarction affecting the left non-dominant side.(Of note: R3 has several diagnoses limiting mobility and sensation including left-sided paralysis and weakness, diabetic neuropathy, and generalized muscle weakness) R3's admission Minimum Data Set (MDS), with Assessment Reference Date 10/13/25, states R3 has a Brief Interview for Mental Status (BIMS) of 7 out of 15, indicating severe cognitive impairment. Section GG indicates R3 has impairments on both of her upper extremities and on one lower extremity. R3 utilizes a walker and wheelchair for mobility. R3's functional abilities indicate she is independent with rolling left and right and requires partial/moderate assistance for moving from sitting to lying and lying to sitting on the side of the bed. On 10/13/25, a Critical admission Assessment (vs 8) was performed for R3. The section titled Functional Status indicates R3 is a 1 person assist for transfers and ambulation, utilizes a walker, and utilizes a wheelchair with an assist. The section titled Fall Risk Assessment indicates R3 is a high fall risk with a score of 18. The assessment used by the facility indicates a score of 5 or greater indicates high risk. On 10/19/25 at 17:30 (5:30 PM), R3 experienced an unwitnessed fall without injury. R3 was found in her bathroom and stated that after toileting she got up to get a new brief and lost her balance. The fall documentation indicates R3 did not have access to the briefs at the time of the falls as they were in the corner of her bathroom. Contributing factors are indicated to be a balance problem and non-compliance. The immediate measures taken are indicated to be a reminder to ask for assistance and R3's briefs were moved within reach. The Post Fall Risk Assessment indicates R3 is a high fall risk with a score of 10. On 10/20/25, an IDT progress note was written that indicated R3 was walking in her room without her walker, leaned over to pick up a brief and fell. The note also indicated therapy was to determine if R3 is able to use reacher (tool to pick up things without bending or leaning) and walker to be kept within reach. On 10/20/25, R3's Comprehensive Care Plan was updated to include the fall risk approach: Keep walker within reach. On 10/26/25, R3's Skin Body Assessment indicates she had no areas of skin impairment. On 10/29/25 at 1:45 AM, R3 experienced a second unwitnessed fall. According to the progress note written on 10/29/25 at 1:45 AM by LPN C (Licensed Practical Nurse), R3 was found on the floor between her bed and mattress with her left upper outer thigh against the baseboard heater. R3 stated she rolled off the bed when turning. Ice was placed on the area with redness. The note also indicated R3's bed was moved to the opposite wall, away from the baseboard heater. Finally, it notes that the DON (Director of Nursing) and physician were notified of the fall. The fall event documentation indicated R3 was found to have two burns that were 1 cm (centimeters) x (by) 7cm and 5 cm x 9 cm. The immediate interventions were indicated to be reposition/rearrange items in room and bed side against wall. The Post Fall Risk Assessment indicates R3 is at high risk for falls with a score of 5. (Of note: This assessment was completed after the 2nd fall in two weeks.). On 10/29/25 at 5:54 AM, a progress note was written by LPN C: New order apply Aloe Vera Gel to left upper outer thigh burn every AM (morning) until healed. On 10/29/25 at 10:39 AM, a progress note was written by RN E (Registered Nurse): RN assessment of burn on left thigh by [Name], ADON (Assistant Director of Nursing.) Wound management updated with initial measurements and referral sent to wound provider to be followed on rounds. On 10/29/25 at 11:52 AM, a progress note was written by RCD D (Regional Clinical Director), who is a registered nurse: Left Thigh: There is linear redness to the upper lateral site. Measures 1.4 cm (centimeters) x 9 cm no noted blistering or open areas or drainage. She does have area on the more dorsal lower thigh that measures 6.3 cm x 9 cm with a blister that is intact measures 1.2 cm x 1.5 cm that is on the right side of the redness. She does rate her pain at 2/10 and did decline to have any medications related to pain. She is wearing light cotton pants at this time that are loose fitting. Reminded to be careful to keep incontinence product away from area. She will be seen by the wound MD (Medical Doctor) today on rounds. She does deny any other injuries related to fall at this time. On 10/29/25, R3's Comprehensive Care Plan was updated with the fall risk approach Post Fall Intervention: Bed was moved and [sic] the room rearranged immediately.On 10/28/25, a document titled Huddle 10/28/25 contains a written-in statement on the second page that states, Registers (Baseboard heaters) need to be cleared, residents pulled away- . This huddle sheet contains an associated sign-in sheet with 20 nursing staff signatures. At the date of survey, 12/9/25, the staff list provided by the facility contains 51 staff members in the department titled Nursing. (Of note: the event related to this note did not occur until 10/29/25, this document is dated erroneously.)On 10/30/25 at 9:00 AM, a Daily Meeting Report document was completed with a sign-in sheet containing ten signatures from leadership staff, including NHA A, RCD D, and MDR E (Maintenance Director). Under the section labeled Housekeeping there is the statement: All beds moved away from heaters. A supplemental document provided by the facility labeled, Daily Census Report is a list of residents with marks next to each resident's name along with two staff signatures on the bottom of the second page. RCD D indicates these marks indicate each resident room was checked to ensure the bed was not near the baseboard heaters. On 10/30/25 at 8:15 AM, an email was written from RCD D to NHA A, along with other recipients. The email indicated RCD D brought an infrared temperature device to the facility to test the baseboard heaters. The top of R3's baseboard heater was tested to be 106.6 F on top and 96.6 F on the side. RCD D indicated the rest of the facility's baseboard heaters are a newer style and run about 10 degrees over what the room temperature is set. RCD D stated, This is the root cause of the burn. RCD D also stated, I could not leave my hand on it for more than 30 seconds as this was that hot. RCD also indicated in the email that the outside temperature was about what the temperature was during the night of the fall and the room temperature was set the same as the time of testing. (Of note: the temperature outside on the date of the fall was approximately 28 F.)The facility also provided surveyors with an associated document titled, Daily Census Report dated 10/30/25, with written-in text indicating the baseboard heaters or Registers were checked by RCD D. Seven residents have a written-in Checked next to their name, which RCD confirmed indicated those rooms were checked with her infrared thermometer. R3's room is listed to have been checked according to this document. On 10/30/25 at 9:42 AM, an IDT progress note was written that states, IDT Fall Note: She did have a fall and did have skin impairment related to fall. She did roll out of bed as she did have a queen bed at home. Root Cause: she did state that she rolled over and fell as she did have her larger bed at home. IDT Intervention: She will be getting a wider bed for fall prevention. On 10/30/25, R3's Comprehensive Care Plan was updated with the fall risk approach IDT Intervention Fall: She will have a bed that is 42 for prevention of falls. On 12/9/25 at 10:00 AM, Surveyor interviewed R3. Surveyor asked R3 if she had any recent falls. R3 indicated no; however, she had a fall a few weeks ago in which she burned her leg. R3 indicated she fell between the wall and bed onto the baseboard heater. Surveyor asked R3 what happened after R3 burned her leg. R3 indicated staff replaced the baseboard heater and moved her bed to the other side of the room. Surveyor asked R3 if she went to the hospital for her burn. R3 indicated no, a doctor came to the facility to check the burn. On 12/10/25 at 12:48 PM, Surveyor interviewed DON B (Director of Nursing) who has been employed at the facility for about a month. Surveyor asked DON B if the facility has a policy or procedure related to how close beds should be to baseboard heaters. DON B indicated she found out yesterday (12/9/25) that the facility wants beds to be 12 inches away from the baseboard heater. DON B indicated she also heard beds are not supposed to be near the baseboard heaters at all. DON B indicated facility staff moved all residents' beds away from the baseboard heaters last night. Surveyor asked DON B why is it important to keep resident beds away from the baseboard heaters. DON B indicated, to prevent burns or injuries. Surveyor asked DON B if she was familiar with R3. DON B indicated, no. Surveyor stated she could refer to R3's chart to assist and asked if R3 is independent with her bed mobility. DON B indicated, R3's care plan states she is 1 assist for turning and repositioning as of 10/14/25. Surveyor asked DON B if R3 is a fall risk. DON B indicated, yes. On 12/9/25 at 4:50 PM, Surveyor interviewed LPN C. LPN C indicated she was working the night R3 fell and was burned. Surveyor asked LPN C if she was the only nurse working that night. LPN C indicated she was the only nurse and had one CNA (Certified Nursing Assistant) for the front two halls and one CNA for the back two halls. LPN C indicated the CNA in front heard the fall and went to check on the resident. LPN C indicated the CNA told her that R3 fell onto the baseboard heater on her left side. The CNA also indicated to LPN C that she slid R3 away from the baseboard heater for safety as the CNA was concerned about the possibility for further injury if R3 was left in that position. The CNA then immediately reported the fall to LPN C. Surveyor asked LPN C what she saw when she entered R3's room. LPN C indicated she found R3 lying at the end of the bed, where the CNA indicated she had dragged her to for safety. On a diagram drawn by the Surveyor, LPN C indicated R3 was stuck in between the bed and the wall closer to the foot of the bed, with her left side against the baseboard heater. LPN C then indicated when she entered the room R3 was lying on the floor near the foot of the bed. Surveyor asked LPN C if she performed an assessment prior to moving R3. LPN C indicated she did and observed slight redness to R3's upper left thigh. LPN C also indicated no blistering or open areas were present upon her assessment and R3 denied having pain. Surveyor asked LPN C how she moved R3's bed after the fall. LPN C drew the bed to now be perpendicular to the baseboard heater, against the wall to the right of the door. Surveyor asked LPN C what she did after assessing R3. LPN C indicated she assisted resident back to bed and placed ice on the burn. LPN C also indicated she notified the physician, and the physician ordered Aloe Vera Gel and to remove the ice. (Of note: Surveyor attempted to contact the involved CNA for an interview, however the phone number provided by the facility indicated the caller was unavailable and Surveyor was unable to leave a voice message.) On 12/10/25, a document titled, Resident Area Baseboard Temp Log was completed by MDR E (Maintenance Director). The column dated 12/10 indicates R3's baseboard heater temperature was 121.2 F. The Wound Management Detail Report indicated R3 sustained a partial thickness burn (2nd Degree burn, penetrates the top two layers of skin) in two locations: Back of Left Thigh and Left Posterior Lateral Thigh. The initial back of left thigh burn measurement occurred on 10/29/25 at 10:38 AM and was 7.5 cm x 5.5 cm. This burn was determined by the Wound Physician to have healed on 11/5/25 at 18:14 (6:14 PM). The initial left posterior lateral thigh burn measurement occurred on 10/29/25 at 16:22 (4:22 PM) and was 1 cm x 1.2 cm. This burn was determined by wound physicians to have healed on 11/26/25 at 15:35 (3:35 PM).2. R7 was admitted to the facility on [DATE] with diagnoses that include history of falling, weakness, adult failure to thrive, body mass index [BMI] 60.0-69.9 (severe obesity), limitation of activities due to disability, and spondylosis of the lumbosacral region (degenerative condition of the spine causing back pain, stiffness, or nerve compression) R7's most recent Minimum Data Set with Assessment Reference Date of 10/1/25 indicates R7 has a BIMS of 13 out of 15 indicating R7 is cognitively intact. Section GG indicates R7 has impairment in both upper extremities and utilizes a walker and wheelchair for mobility. Section GG also indicates R7 is independent with rolling left and right along with requiring substantial/maximal assistance with moving from sitting to lying and lying to sitting on the side of the bed. Additionally, R7 is dependent on staff for moving from sitting to standing, chair/bed-to-chair transfers, and toilet transfers. Walking 10 feet was not attempted due to a medical condition or safety concerns. On 10/13/25 at 5:00 AM, R7 experienced an unwitnessed fall without injury. R7 was found in her room lying on her floor mat. The progress note dated 10/13/25 at 5:36 AM indicated R7 crawled out of bed and had been incontinent at the time of the fall. The note also stated R7 did not have her call light and was heard hollering. The immediate measures put in place were listed as: reposition for comfort, fall mat next to bed, and 15-minute checks. Root cause is determined to be resident crawled from bed. R7's Post Fall Risk Assessment indicates R7 is a high fall risk with a score of 9. On 10/13/25 R7's Comprehensive Care Plan was updated with the fall risk approach Post Fall Intervention: Bolster mattress for edge of bed awareness. R7 also sustained falls on 10/18/25 and 11/12/25, both without injury. Following R7's fall on 11/12/25, her Post Fal Risk Assessment indicates she is a high fall risk with a score of 9. On 12/9/25 at 3:47 PM, two Surveyors observed R7's room and found the foot of her bed to be touching the baseboard heater and the head of the bed less than 6 inches away from the baseboard heater. Residents at this facility can set the temperatures in their rooms and Surveyors observed R7's room to be set to 75 F. After observing how close the bed was to the baseboard heater, Surveyors touched the baseboard heater with their hands and immediately had to pull their hand away due to the heat. R7 came into the room as Surveyors were observing her baseboard heater and asked if the Surveyors were checking on it. Surveyors confirmed they were, and R7 indicated that her bedspread falls on the baseboard heater at night and when she pulls it up it's very hot. Surveyor asked R7 if she has ever burned herself on the baseboard heater and R7 stated, No, but almost. It's hot. On 12/9/25 at 4:45 PM, LPN C went to R7's room with Surveyor. Surveyor asked LPN C what she thought of the distance between R7's bed and the baseboard heater. LPN C indicated the bed and the baseboard heater were too close together but does note R7's bed is usually not touching the baseboard heater. On 12/10/25, a document titled, Resident Area Baseboard Temp Log was completed by MDR E (Maintenance Director) and provided to surveyors. The column dated 12/10 indicated R3's baseboard heater temperature was 130.6 F.On 12/9/25 at 3:52 PM, Surveyor interviewed RCD D. Surveyor asked RCD D if the facility had an infrared thermometer in the facility to test the baseboard heaters. RCD indicated, no, but one would be brought in tomorrow. Surveyor asked RCD D if the facility has any temperature logs for the baseboard heaters. RCD D indicated she does not know. On 12/9/25 at 3:54 PM, Surveyor interviewed MDR E. Surveyor asked if MDR E or anyone at the facility maintains surface temperature logs from the baseboard heaters in the resident rooms. MDR E stated, no. MDR E also indicated the baseboard heaters do have a built-in resistor inside to only heat to a certain temperature. Surveyor noted that per facility records, some of the baseboard heaters in the facility have been replaced and asked MDR E if both the old and new baseboard heaters had the built-in resistor installed. MDR E stated, yes. MDR E also made the statement that these devices have to have a limit otherwise they could overheat and become an actual fire hazard. On 12/10/25 at 9:00 AM, Surveyor interviewed MDR E again, following the completion of the Resident Area Baseboard Temp Log. MDR E indicated he brought in an infrared thermometer and assessed the temperature of the baseboard heaters in all resident rooms that are currently occupied. Temperatures indicated on this document indicate a range from 56.6 F to 187.4 F and MDR E indicated he assessed the temperatures at the top center of each device. MDR E explained that these baseboard heaters have the heating element in the center of the device and the heat radiates out, this is why the baseboard heaters are hottest at the top center. MDR E also noted none of the baseboard heaters were outside the manufacturer's rating and none of the baseboard heaters have cut off yet. Surveyor asked MDR E how he knows that no baseboard heaters have been tripped or automatically shut off yet. MDR E indicated each baseboard heater in the facility is on its breaker, and if a baseboard heater would automatically shut off he would need to flip the breaker to restart the baseboard heater. Surveyor asked MDR E when the last time was he completed one of these temperature logs for the resident baseboard heaters. MDR E stated, never. Surveyor asked MDR E how far away objects need to be from the baseboard heater. MDR E indicated per manufacturer recommendations, objects need to be 12 inches away from the baseboard heater. On 12/9/25 at 4:08 PM, Surveyor interviewed CNA F. Surveyor asked CNA F if she has ever touched the baseboard heaters. CNA F indicated she knows it is hot because if you drop fabric on the baseboard heater the fabric will change color. Surveyor asked CNA F if she knows how close the resident beds can be to the baseboard heaters. CNA F indicated, 4-6 inches away and most beds don't go against the wall with the baseboard heater. On 12/9/25 at 4:14 PM, Surveyor interviewed HSK G (Housekeeper). Surveyor asked HSK G if she has ever noticed if the baseboard heaters were hot to the touch. HSK G indicated, she has never noticed the baseboard heaters to be hot. Surveyor asked HSK G how far beds should be kept away from the baseboard heaters. HSK G indicated she did not know. On 12/9/25 at 4:15 PM, Surveyor interviewed LPN H. Surveyor asked LPN H if she has ever noticed if the baseboard heaters were hot to the touch. LPN H indicated, yes, sometimes they can be hot. Surveyor asked LPN H how far beds should be kept away from the baseboard heaters. LPN H indicated staff are supposed to keep the beds two feet away from the baseboard heaters. On 12/10/25 at 12:48 PM, Surveyor interviewed DON B (Director of Nursing) Surveyor asked DON B if she was familiar with R7. DON B indicated, no. Surveyor asked DON B about R7's bed mobility. DON B indicated per R7's medical record, she is working with therapy, switched to stand and pivot transfers then switched back the next day, and is currently a Hoyer transfer with two person assist. Surveyor asked DON B about R7's transfer status. DON B indicated, R7 is a Hoyer transfer. Surveyor asked DON B if R7 is a fall risk. DON B indicated, yes. Surveyor asked DON B if R7 has a risk of rolling out of bed. DON B indicated, potentially, R7 is fairly cognitively intact, but she does not know R7 very well. Surveyor asked DON B, if a resident were to fall today and sustain a burn from the baseboard heater, what would she do to prevent further similar incidents. DON B indicated, auditing every day and ensuring beds are moved to their designated, safe location. Surveyor asked DON B if she would provide education related to the beds and baseboard heaters. DON B indicated, yes, along with counseling if repeated education is needed for the same staff members. The facility's failure to have a system in place to monitor surface temperatures of baseboard heaters in resident rooms and failure to ensure resident beds were an appropriate, safe distance from the heaters according to manufacturer's recommendations created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The immediate jeopardy was removed on 12/10/25 when the facility implemented the following: On 10/28/25, (R3) had a fall and did have burn to left posterior thigh. Immediate intervention: bed was moved away from the heat register. The next day she had a larger 42 bed to replace her bed as she did have standard bed in place and was used to a queen size bed. She did have change to the heat register to a newer style to be proactive for precautionary measures. (R3) did had no negative outcome. Denied pain to burn, no psychological harm, or negative outcome. and skin is healed at this time. (R7)-noted to have bed that was close to the heat register she could have had a fall from bed and had potential for injury related to risk level. She did have her bed moved to the other side of the room on 12/9/25. Care plan updated to include keep bed away from register. She did have a fall from bed but not onto the register. Re-education of staff was provided to staff to keep residents and bed away from heaters was started on 12/9/25, all staff educated prior to start of next working shift. All residents had ambassador rounds completed to make sure that beds were moved away the registers. Audit of rooms that on that end of the facility had tempteraure of the registers checked with infared thermometer. Staff education was done at the time with Huddle with staff. On 12/9/25, all resident rooms were checked and any beds that were closer than 1-2 foot from the registers. All rooms were rechecked and any beds next to the heat registers were adjusted away from heaters. Care profiles are updated for staff to check bed/personal items placement in relation to the registers. All room heat registers had temperature checked and all are within manufacturer specificiations. 12/10/25 rooms were again checked for bed placement in designated place away from registers. 12/9/25 - (R7) was one of the 3 residents identified and bed was moved to the opposite side of the room away from the heat register. Facility did complete education with all staff that resident beds need to be away from the heat registers. All residents rooms were checked and some rooms were rearranged to move beds away from the heat registers. One room was not able to be rearranged and she was moved to another room. 3 other identified rooms were rearranged back to have the beds away from the heat registers ((R7) was one of these residents). Audit of rooms was completed on 12/9/25 and 12/10/25. Audits created to monitor heat registers temperature, room temperature, and any corrections for the heat registers. Audit created for the placement of bed away from the registers. Protocol was created for plan with follow on the registers. Submitted with IJ plan Will complete random temperatures for 5x/wk x 30 days, and 3x/wk x 2x/wk x 2 weeks then all audits will go to QAPI. NHA or designee will complete bed positioning audits to be completed 5x/wk x 30 days, 3x/wk x 2 weeks, 2x/wk x 2 weeks, and review all audits at QAPI. QAPI meeting held 12/10/25 for plan with auditing, root cause of concern, and plan for ensure complaince with F689. Baseboard Heat Registry Protocol Intent: Residents will maintain a safe distance away from the baseboard heat registries to ensure they are not at risk for burns. Resident beds will maintain a safe distance away from the baseboard heat registries. Resident recliners will be positioned in a way that does not put them at risk to come in contact with a baseboard heat registry. Concerns with any baseboard heat registry will be brought to the Maintenance Lead or Administrator's attention and receive prompt follow-up. Effective Date: 12/10/25The deficient practice continues at a scope and severity of E (potential for harm/pattern) related to the examples of R9, R10, and R11 and as the facility continues to implement its action plan:3. R9 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, muscle weakness (generalized), contracture of muscle (permanent shortening and tightening of muscle fibers leading to reduced flexibility and difficulty moving), multiple sites, low back pain, history of falling, tremor, dementia, and osteolysis (bone degeneration). R9's most recent Minimum Data Set with Assessment Reference Date of 11/10/25 indicated R9 has a BIMS score of 00 out of 15 indicating severe cognitive impairment. Section GG indicated R9 utilizes a wheelchair for mobility and is independent with rolling left and right including all other mobility except for tub/shower transfers, which he is dependent on staff, and walking 10 feet which was not attempted due to R9's current illness, exacerbation, or injury. R9's Comprehensive Care Plan indicated in part:Problem: Resident requires assistance for ADLs (Activities of Daily Living) r/t (related to) weakness and diagnosis of dementia. Approaches include, in part: .Mobility: Independent wheelchair. Start Date: 8/22/23. Bed Mobility: Independent. Start Date: 8/22/23. Transfers: Assist of 1. He does self-transfer at times. Start Date: 5/27/24.On 12/9/25 at 3:40, Surveyors observed R9's room and noted he has his room temperature set to 75 F. Two Surveyors both touched R9's baseboard heater and both had to pull their hands away immediately due to the baseboard heater being so hot. Surveyors also noted that the bed was touching the baseboard heater at the time of observation and R9 was laying in the bed. R9, who gave permission for Surveyors to observe his baseboard heater, stated that the wall is hotter than hell. R9, who had his bed in the low position, also indicates his fingers have accidentally touched the baseboard heater while he was sleeping and it makes him jump because the baseboard heater is so hot. On 12/9/25 at 4:35 PM, LPN C (Licensed Practical Nurse) went to R9's room with Surveyor. Surveyor asked LPN C what she thought of the distance between R9's bed and the baseboard heater. LPN C indicated the bed and the baseboard heater were too close together. On 12/10/2

Based on interview and record review, the facility failed to ensure Residents (R) receive treatment and care in accordance with professional standards of practice for residents experiencing changes in condition and failed to assess non-pressure wounds weekly for 1 of 1 Residents (R7) reviewed for changes in condition. The facility did not properly assess R7's response to interventions for a urinary tract infection (UTI). This resulted in actual harm when R7 was found unresponsive with hypoxia and admitted to the hospital with a diagnosis of acute on chronic respiratory failure with hypoxia and associated severe sepsis. This example, regarding R7's change of condition, is being cited at a scope and severity of a G (actual harm/isolated). The facility did not properly assess and document skin weekly of R7's Moisture Associated Skin Damage (MASD), such as how the edges and wound bed appear, location, shape, condition of surrounding tissues. This is evidenced by: The facility policy, entitled Standards of Nursing Practices, dated ,d+[DATE], states: .Documentation when providing skilled level of care includes: monitoring of the resident's progress when skilled services are provided is essential to evaluate the ongoing benefits as well as need to make changes in the resident's plan of care. It is important to monitor the effectiveness of treatments, medications or rehab services provided. Resident vital signs (temperature, pulse, respirations, blood pressure and pulse oximetry) will be required daily as a minimum nurse's responsibility to document a more detailed assessment when particular issues arise for a resident. Documentation should contribute to the identification and communication of the resident's problems, needs and strength, providing a tracking of their condition on an ongoing basis, recording resident's response to services provided is a matter of good clinical practice and is an expectation of trained and licensed healthcare professionals .Ongoing monitoring may be required of the resident's condition by the licensed nurse to identify the resident's response to clinical interventions and if resolution is achieved .Monitoring a change in condition requires a licensed nurse to include an entry in the progress notes. Monitoring a resident condition may have multiple entries in the resident's medical record that include progress notes, observations, and assessment tools . On [DATE] and [DATE], Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE], and had diagnoses that included but were not limited to chronic obstructive pulmonary disease with acute on chronic exacerbation, urinary tract infection, pulmonary hypertension, pulmonary fibrosis, bronchiectasis, morbid obesity, diabetes type 2, asthma, chronic congestive heart failure, obstructive sleep apnea, mild cognitive impairment of uncertain or unknown etiology, hypertensive heart disease with heart failure, and chronic respiratory failure with hypoxia. R7's Minimum Data Set (MDS) assessment significant change was completed on [DATE]. Prior quarterly MDS was completed on [DATE]. [DATE] R7's MDS Brief Interview for Mental Status (BIMS) = 12, [DATE] BIMS = 7. BIMS score ranges from ,d+[DATE]. Scores with the range of ,d+[DATE] = severe cognitive impairment, ,d+[DATE] = cognition is moderately impaired, and ,d+[DATE] = cognitively intact. Functional Status: [DATE] MDS stated bed mobility, transfer, and toilet use was supervision with one person assist. Walk in room supervision with setup help. Dressing extensive assist with one person. Eating independent with setup help. Personal hygiene was limited assist with one person. [DATE] MDS stated bed mobility, transfer, and toilet use was extensive assist with 2 + people. Walk in room did not occur. Dressing and Personal hygiene was extensive assist with one person. Eating supervision with set up. Review of R7's Physician Orders: Cefpodoxime tablet; 100 mg; amt: 1; oral Special Instructions: dx: (diagnosis): UTI Twice a Day [DATE] (Start Date) [DATE] (End Date) Levofloxacin tablet; 750 mg; amt: 1 tablet; oral Special Instructions: dx: UTI Once a Day Every Other Day [DATE] (Start Date) [DATE] (End Date) Levofloxacin tablet; 750 mg; amt: 1 tablet; oral Special Instructions: dx: UTI Once a Day Every Other Day [DATE] (Start Date) [DATE] (End Date) CODE STATUS: Full Code/Give CPR [DATE] (Start Date) [DATE] (End Date) CODE STATUS: DNR/Do Not Give CPR, DNI (Do not intubate) [DATE] (Start Date) Open Ended. Review of progress notes, document in part: [DATE] 7:17 AM, R7 was sent out at 445am after talking to POA O about R7's behaviors and changes. R7 did sound like she was no all there, talking to self - my grandson is spending the night in my bed and I need a ride out of here. He keeps making that noise. I would whoop his a** if I could get up. R7 was slumping in the recliner and could not sit up by herself, staff to scoot her back in her chair. R7 had also been moaning most of the night on and off and still up / have not slept. Pulse was a bit elevated and oxygen would go from 92% to 86% and she did take her oxygen on and off but between the moaning she was not taking in oxygen well. POA O agreed that R7 would be sent in. Doctor gave order. Director of Nursing (DON) notified/ Admin, and Inclusa. R7 did get some labs done and also a urinalysis. Found R7 does have a UTI. She will return to facility. [DATE] 8:48 AM, R7 returned from ER at 0845, new diagnosis of UTI, new order for cefpodoxime 100mg by mouth, twice a day for 7 days. [DATE] 10:34 AM, R7 return from [NAME] Healthcare ER at 0830, Vitals: Oxygen sat 91% with 2 Liters of oxygen, Respirations 20, Temp 97.4, Pulse 90, Blood Pressure ,d+[DATE], alert and oriented to self, feeling tired, refused breathing treatment and breakfast, stated she is tired and wanted to rest, not hungry, took all morning medications, cooperative with cares, skin check reveal fungal rash to right and left under breast, areas cleansed with soap and water, pat dry nystatin powder applied and vivid towel under [NAME] both breasts, resident tolerated well, resident has no c/o pain, burning and discomfort during urination, incontinent this morning, wears brief, urine is yellow with strong odor, fluids encouraged and resident accepted, drank 240 milliliters, oral mucosa moist and pink, no c/o abdominal pain, continues with new antibiotic which will start tonight, pharmacy will deliver this afternoon, will continues to monitor. [DATE] 6:38 AM, R7 has been waking up on and off in the night. Night aid stated R7 woke up shouting into the hallway confused about furniture being switched around in her room and what was it there for. Interestingly this am she remembered the strange situation she was in during the night by stating I thought all this furniture was in my room and I was shouting. I didn't mean too. I must have had a bad dream. Resident tolerating antibiotic with no adverse effects. Still has yeasty skin rash. Continues to need staff assist of 1 for cares. Urinating and drinking fluids well. Vitals: blood pressure ,d+[DATE] supine, 103 pulse, 97.7 temp, 22Respiratory Rate, 93% on 3Liters oxygen. The facility staff did not recognize and reassess the abnormal vital signs or consult with a phsysican for further treatment. [DATE] 8:50 PM, R7 with no complaints of (c/o) pain while urinating or frequency. [DATE] 4:57 AM, R7 continues with antibiotic for UTI with no adverse effects. Resting well all shift. Vital signs stable. [DATE] 1:52 PM, R7 yelled at staff this am stating: I've got to get out of here and go to the crazy house. I need to go to the ER. Nobody around here will do anything. I can't walk and I want to know what is wrong. R7 was redirected by staff, repositioned for comfort and assured she would receive help from staff if she requires it. Resident did become calm and decided she wanted to take a nap. No further episodes of yelling noted during shift. Surveyor did not find facility documentation of assessment, vital signs, continued monitoring or physician consultation. No nursing assessment notes for change in condition were completed between [DATE] - [DATE] prior to R7 being transferred and hospitalized with chronic respiratory failure with hypoxia and associated severe sepsis with lactic acidosis, elevated lactate. Pneumonitis. Acute on chronic diastolic congestive heart failure, Chronic Obstructive Pulmonary Disease (COPD), and UTI. [DATE] 8:45 AM, R7 noted to be groaning and hyperventilating at 0830 this am. Oxygen saturation found to be 63%. Heart Rate 113. Resident would not respond to verbal or physical stimuli. Resident transferred to bed by staff. Oxygen via nasal cannula titrated up to 5liters (machine max). Oxygen saturation increased to 73%. Resident is full code. 911 called. Emergency Medical Technicians (EMT)s arrived and applied oxygen via facemask. Saturation did not rise above 74% while in building. POA notified. Report called to ER. Resident left facility via stretcher at 0845. Transported to ER via ambulance. Review of the hospital admission note on [DATE], read in part: .R7 was diagnosed with acute on chronic respiratory failure with hypoxia and associated severe sepsis with lactic acidosis, elevated lactate. Pneumonitis. Acute on chronic diastolic congestive heart failure. Chronic Obstructive Pulmonary Disease (COPD). UTI. R7 was found down and significantly hypoxic at the nursing home and admitted on [DATE] with acute hypoxic respiratory failure, elevated lactate, acute kidney injury, elevated liver function tests, diagnosed with severe sepsis and was meeting systemic inflammatory response system (SIRS) criteria, had elevated lactate and hypoxia/lab results indicating organ dysfunction. CT chest at time of admission showed ground glass opacities consistent with chronic fibrosis with superimposed pneumonitis. Patient sepsis was thought to be secondary to pneumonia versus inadequately treated UTI. Patient was admitted to inpatient and treated with broad spectrum antibiotics and fluid resuscitation. By morning after admission patient was no longer meeting sepsis criteria and was back to baseline oxygen needs. Patient continued to clinically improve and was discharged back to the skilled nursing facility on [DATE] R7 was continued on Levaquin 750 milligrams with every other day to dose due to increased creatinine clearance for a total of 7-day course . Review of nursing progress notes after return from hospital: [DATE] 12:35 AM, R7 readmission from [NAME] Health by van at 1600. Diagnosis Acute on chronic respiratory failure with hypoxia. Alert and oriented X3 with confusion at times. Moist mucus membranes. Lungs clear. Cardiovascular regular rate and rhythm. Abdomen soft non distended. Scheduled Tramadol effective for pain. Able to make needs known and demonstrates use of call light. Vitals stable with Oxygen 96% 2Liters Nasal Cannula. [DATE] 3:39 AM, R7 is alert with no respiratory or gastrointestinal (GI) distress. R7 has periods of confusion. R7 has been 2 assist with transfers this shift. R7 is in bed resting at this time. Vital signs stable. [DATE] 9:45 AM, Vitals:,d+[DATE], 94%@2Liter Oxygen, 98Heart Rate, 97.5 Temperature, 20 Respirations. R7 with increased confusion noted this am. R7 unsure of location and situation. Resident called 911 in attempt to report a dead baby in a pillowcase behind my bed. She also stated, They left me at the gas station, and I don't know how to get back. Resident was transferred from bed to chair and redirected to television and snacks on table. Resident became calm and started watching tv. One hour later, R7 began screaming for help. Upon entering room, staff discovered resident on edge of lift chair which was in full up position. R7 was assisted to bedside toilet per request. Resident then scratched and hit this writer stating: I hate you with a passion. You all just want to leave me at the gas station. After R7 was seated on toilet, she became calm and allowed staff to carry out peri care. After resident was cleaned, she was transferred back to recliner where she is currently sitting quietly with call bell within reach. [DATE] 10:58 AM, R7 was being treated with antibiotics for UTI and pneumonia. R7 was recently hospitalized and returned to the facility with orders for a palliative care consult. R7 is having increased confusion and continues with auditory and visual hallucinations. The pharmacy is reviewing medication regime at Power of Attorney (POA) O request to ensure that increase in behaviors is not related to medications. [DATE] 3:27 PM, R7 was unable to stand without max staff assist during the morning shift. 3 staff members assisted resident at all times during transfers and routine cares. Staff will attempt transfers with easy stand lift for safety and per therapy recommendations. [DATE] 9:28 PM, R7's family here visiting. R7 is confused. She has her oxygen on at 2 liters and oxygen saturations have remained above 90%. R7 requires sit stand with transfers and assist with activities of daily living (ADLs). Vital signs stable. [DATE] 7:53 AM, Quarterly MDS changed to significant change MDS due to R7's decline. Now more confused and needing multiple staff members for assist for activities of daily living (ADL). [DATE] 11:02 PM, R7 is in bed resting well at this time with no signs or symptoms of distress. Vital signs stable. [DATE] 5:17 PM, R7 is sit to stand for transfers this shift. R7 is now 1 assist and soft diet for meals and is encouraged to go to dining room. Resident 93% Oxygen on 2Liter NC. [DATE] 11:33 PM, R7 is in bed resting well at this time. Her vitals are within normal limits. R7 is alert and with no shortness of breath. [DATE] 21:46 R7 is sit to stand for transfers this shift. Resident is 1 assist and soft diet for meals and ate in dining room. Assist with all cares. Resident 95% oxygen on 2Liter Nasal Cannula (NC). [DATE] 8:42 PM, Palliative care has consulted and will be working with facility to collaborate on plan of care. R7 has had a decline in transfer status and is using a sit to stand lift for transfers. Code status has changed to DNR. R7 has skin issues under breasts and pannus which are improving with current treatments. Written by Nursing Home Administrator (NHA) A. No nursing assessment notes from [DATE] until [DATE] when R7 was sent back to the hospital. [DATE] 7:32 AM, R7 have troubles with her oxygen saturation this morning. Low 70's upon start of shift. Registered Nurse (RN) gave nebulizer and both inhalers. Increased oxygen to 3Liters of oxygen, not much change with her saturation numbers. 82 was the highest reading the oxygen machine gave regardless of interventions from nursing staff. POA/HC and emergency contacts were called, no answer. [NAME] Palliative care called (R7 is on the referral list yet, she is set to be evaluated on ,d+[DATE]) Doctor called, and stated R7 should be transferred out for treatment at local ER. (EMS) Emergency Medical Services called and R7 was transferred out at 0800. On [DATE] at 3:00 PM, Surveyor asked DON B if there was any other facility documentation for R7's assessment/progress notes from [DATE] until [DATE], when the resident was recently back from the ER with new diagnosis of UTI and placed on an antibiotic, then found unresponsive on [DATE]. Surveyor also requested nursing assessments from [DATE] - [DATE] after R7's return from the hospital, and prior to being sent to the ER again. DON B said she would look for information on this. Surveyor asked DON B if it was the facility's policy to document regular assessments on a resident who was recently back from the ER with a new diagnosis of UTI and placed on an antibiotic. DON B said yes, the nurses should have assessed more than what they did. On [DATE] at 3:30 PM, DON B said there was no documentation of nursing assessments for R7 during that time. On [DATE] at 4:50 PM, Surveyor interviewed DON B who said no education or training was provided to staff concerning nursing assessments when a resident returned from the hospital with new orders. SKIN: The facility policy, entitled Skin Care, dated ,d+[DATE], states: .non-pressure related skin impairment will be assessed and documented upon admission, readmission, upon discovery, and weekly thereafter. Assessment may include the size, location, type of wound, odor, drainage, peri wound condition, wound edges, exudate, pain, symptoms of infection, and current treatment order . R7's Care Plan: [DATE] Problem: Resident experiences occasional bladder incontinence related to pain and decreased ability to transfer and move. Approach: Report signs/symptoms of UTI (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain, difficulty urinating, low back/flank pain, malaise, nausea/vomiting, chills, fever, foul odor, concentrated urine, blood in urine). Report any signs of skin breakdown (sore, tender, red, or broken areas). Apply moisture barrier to skin. Provide incontinence care for each incontinent episode. Assess possible reversible problems (conditions, environment, diagnosis, medications, abnormal labs, etc.). Use facility incontinence product. [DATE]: Problem: Resident has a yeast infection in pannus/under breasts related to resident declining cares. Resident displays cognitive impairment and is dependent on nursing for cares. Approach: Treatment per Medication Administration Record (MAR). Ensure that skin is cleaned well with cares. Dry thoroughly. [DATE] Problem: Resident is at risk for skin breakdown R/T weakness, pain and history of incontinence, rubs feet on shin and does have scratches, reoccurring MASD under breasts. Approach: Encourage resident to lay in bed for one hour after lunch to help decrease risk of skin breakdown. Nystatin and Viva paper towel under breast per orders. Eval for different incontinence product. Report any signs of skin breakdown (sore, tender, red or broken areas). Use moisture barrier product to perineal area. Provided incontinence care after each incontinent episode. Use facility mattress for pressure reduction when resident is in bed. Avoid shearing resident skin during positioning transferring and turning. Turn and reposition every 2 hours and more frequently as requested. Use wheelchair cushion for pressure reduction and when resident is in chair. Encourage physical activity mobility and range of motion to maximal potential. Conduct a systemic skin inspection weekly. Pay particular attention to bony prominences. Keep linen clean dry and wrinkle free. Keep clean and dry as possible. Minimize skin exposure to moisture. Assess resident for possible of risk factors. Treat, reduce and eliminate risk factors to extent possible. Review of R7's Physician Orders: Nystatin powder; 100,000 unit/gram; amt: application 1; topical Special Instructions: Standing Order: may apply up to 5 days as needed for yeasty skin folds, if no improvement then update physician As Needed [DATE] (Start Date) [DATE] (End Date) Nystatin powder; 100,000 unit/gram; amt: application 1; topical Special Instructions: Standing Order: may apply up to 5 days as needed for fungal rash to skin folds/groin, if no improvement then update physician Twice a Day Upon rising in AM, upon retiring in PM [DATE] (Start Date) [DATE] (End Date) Nystatin powder; 100,000 unit/gram; amt: application 1; topical Twice a Day Upon rising in AM, upon retiring in PM [DATE] (Start Date) open ended. Apply skin protectant after each incontinent episode / toileting assistance / brief change. Every Shift [DATE] (Start Date) [DATE] (End Date) Apply skin protectant after each incontinent episode / toileting assistance / brief change. Every Shift [DATE] (Start Date) Open Ended Apply zinc ointment to redness/fissure under abdominal fold. Place viva towels to help with remove moisture from area. Twice A Day [DATE] (Start Date) Open Ended Weekly Skin Assessment Once a Day on Mon [DATE] (Start Date) [DATE] End Date) Weekly Skin Assessment Once a Day on Mon [DATE] (Start Date) Open Ended Review of MDS: Skin: [DATE] MDS stated no skin issues. [DATE] MDS stated no skin issues. R7 noted to be at risk for skin issues for both assessments. Functional Status: [DATE] MDS stated bed mobility, transfer, and toilet use was supervision with one person assist. Walk in room supervision with setup help. Dressing extensive assist with one person. Eating independent with setup help. Personal hygiene was limited assist with one person. [DATE] MDS stated bed mobility, transfer, and toilet use was extensive assist with 2 + people. Walk in room did not occur. Dressing and Personal hygiene was extensive assist with one person. Eating supervision with set up. R7's Progress Notes: [DATE] 5:36 PM, R7 continues yeast and redness in abdominal folds. Nystatin applied as ordered. R7 carrying on about needing nystatin powder under folds and that nobody put any when in fact when looking under folds there was bits of powder under there and folds were dry (not sweaty as expected). R7 is a bit yeasty under breast and pannus fold, redness noted. [DATE] 10:34 AM, R7 return from [NAME] Healthcare ER at 0830, .refused breathing treatment and breakfast, stated she is tired and wanted to rest, not hungry, took all morning medications, cooperative with cares, skin check reveal fungal rash to right and left under breast, areas cleansed with soap and water, pat dry nystatin powder applied and vivid towel under [NAME] both breasts, resident tolerated well . [DATE] 6:38 AM, .Resident tolerating antibiotic with no adverse effects. Still has yeasty skin rash. Continues to need staff assist of 1 for cares . [DATE] 7:53 AM, Quarterly MDS changed to significant change MDS due to R7's decline. Now more confused and needing multiple staff members for assist for activities of daily living (ADL). No nursing assessment notes from [DATE] until [DATE] when R7 was sent back to the hospital. [DATE] 8:42 PM, Palliative care has consulted and will be working with facility to collaborate on plan of care. R7 has had a decline in transfer status and is using a sit to stand lift for transfers. Code status has changed to DNR. R7 has skin issues under breasts and pannus which are improving with current treatments. Written by Nursing Home Administrator (NHA) A. Review of R7's weekly skin assessments dated [DATE] stated Yeasty abdomen (gets nystatin for it), [DATE] stated Red areas under breast. Treatment in place, [DATE] stated Red areas under breast. Treatment in place, [DATE] stated Fissure to abdomen fold. The weekly skin assessments did not further document if improvement or decline to the areas with redness or yeast after it was initially reported. Interviews: On [DATE] at 10:00 AM, Surveyor interviewed Licensed Practical Nurse (LPN) G concerning R7's skin. LPN G stated R7 had a bad yeast infection to the pannus that was red and did smell. Nystatin powder and Viva towels to the area for treatment. On [DATE] at 10:30 AM, Surveyor interviewed Certified Nursing Assistant (CNA) J concerning R7's skin. The yeast infection for R7 care included washing in the AM drying and Nystatin powder with Viva towels. On [DATE] at 10:50 AM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A and DON discussed with family about the decline in R7 and possible palliative care. Staff nurses would discuss with family also about the resident's decline. Palliative consult was placed. R7 was discharged to the Serenity Hospice House. R7's refusal of care is what had led to increased yeast infection. The treatment for the yeast infection was nystatin, Viva and, keep clean and dry. On [DATE] at 11:55 AM, Surveyor interviewed the Interim Director of Nursing (DON) B concerning R7's weekly skin assessments received that discussed yeast infection/red skin issue assessments from February 2023 until resident discharge. Only four assessments completed on [DATE], [DATE], [DATE] and [DATE] noted these skin issues. DON B said these four assessments were the only assessments that contained information about yeast infection/ red skin issue assessments.

Based on interview and record review, the facility did not provide behavioral health services to ensure the highest practicable mental and psychosocial well-being for 1 Resident (R) (R3) of 8 sampled residents. R3 had a court order for administration of [CONDITION(S)] medication (used to affect a person's mental state) and treatment related to R3's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .) The facility did not enforce the court order. R3's psychotic symptoms escalated. R3 required an emergency room (ER) visit on 9/8/22 related to R3's expression of wanting to end R3's life. Findings include: On 10/3/22, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Minimum Data Set (MDS) assessment, dated 7/1/22, stated R3's Brief Interview for Mental Status (BIMS) score was 15 out of 15 which indicated R3 had no cognitive impairment. R3's medical record contained a Power of Attorney for Healthcare (POAH) document, dated 11/19/19 and activated on 9/14/22, indicating R3's POAH agent was responsible for R3's medical decisions. R3's medical record contained an Order of Extension of Commitment from (named) County Circuit Court, dated 9/7/21, that stated, A hearing was held on 09/07/2021. The court finds: Grounds for extension of commitment have been established. The subject is mentally ill, a substantial probability of physical impairment or injury to himself or herself or other individuals due to impaired judgment. As manifested or shown by a substantial likelihood, based on the subject's individual's treatment record, that the individual would be a proper subject for commitment if treatment were withdrawn .The dangerousness of the subject is likely to be controlled with appropriate medication administered on an outpatient basis . Additionally, R3's medical record contained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .Due to mental illness the subject is not competent to refuse [CONDITION(S)] medication or treatment because the subject is substantially incapable of applying an understanding of the advantages, disadvantages and alternatives to his or her condition in order to make an informed choice as to whether to accept or refuse [CONDITION(S)] medications. The court orders: Medication and treatment may be administered to the subject, regardless of his or her consent during the period of commitment, or until further order of the court. On 10/3/22, Surveyor reviewed ER notes, dated 9/8/22, that stated, .Patient states 'I need to be put down'. States 'I am tired of the society' .Patient is refusing to get on the ED (emergency department) bed. Continuously mumbling statements and talking to [R3's] self. Staff from care center states that [R3] has been refusing [R3's] medications for several months including [R3's] court ordered [MEDICATION(S)] (used for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff states that patient is on hospice and that they (hospice) are aware [R3] is here. Patient states that [R3] is Evil and needs to be destroyed .Patient sitting in wheelchair, rocking back and forth. Continues mumbling and occas (occasionally) states the world is evil and [R3] wants to be put down. States other people are talking to [R3] besides writer .patient is saying [R3] will hurt staff .The encounter diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] (used to treat severe agitation associated with certain mental/mood conditions) 10mg (milligrams) IM (intramuscular) injection was ordered. Request was for inpatient psychiatric hospitalization and stabilization .2049 (8:49 PM) Patient was reassessed after [MEDICATION(S)] 10mg IM. [R3] had very little change in [R3's] agitation. For this reason [MEDICATION(S)] (used to treat severe anxiety) 10mg IM is ordered .Since the patient's arrival [R3] has been doing little other than shouting insults at staff and myself. [R3] seems to have some religious themes to [R3's] insults repeatedly stating things such as 'the devil is going to take you all' or 'God will kill you all'. All history is obtained through nursing supervisor (RN-F). Nursing supervisor relays to me that the patient was making statements that [R3] wanted to end [R3's] life today. [R3] was stating that [R3] was going to go outside and hit [R3's] head against a rock. The patient is interrupting stating 'just end me, take my life now'. Nursing supervisor states [R3] has become more final it (sic) (violent) with other residents and with staff .I have asked why the patient was not given [MEDICATION(S)] as this was court ordered and I was told that '(named) county signed off on [R3]' .Patient has had similar behavior in the past when [R3] has refused medications .Patient will not comply with formal neurological examination .Patient appears very angry and agitated. [R3] is shouting insults at staff. [R3] is not able to answer questions appropriately. Thought content is abnormal. Patient has poor insight to [R3's] condition and poor judgment exhibited by asking to come to the emergency room then refusing all help .Pt able to answer all questions appropriately and denies any thoughts of self harm (sic) to the police officer. Pt states that [R3] feels better after the medication that pt was given in this department .2055 (8:55 PM) . Patient has not yet been cooperative during [R3's] stay. May need to be chaptered. 2140 (9:40 PM) .Patient is less agitated than [R3's] arrival based on medications that were received an hour earlier .nursing home employee states that the patient had made some comments about wanting to end [R3's] life .The patient states [R3] has not been getting [R3's] medications .The nursing home employee states that for the last several months the patient has been refusing a majority of [R3's] medications. [R3] was court-appointed by (named) county to receive [MEDICATION(S)] but has also not been receiving that for the last several months. It is unclear as to whether the nursing home was aware of that or not. The patient at this point states [R3] would just like to go back to the nursing home . It was also mention (sic) that it would seem unusual the nursing home would let this go on for several months and not have a court hearing to determine the patient's competency. [NAME] police is coming to talk with the patient about potential need to chapter the patient. 2225 (10:25 PM) Police have spoken with patient. They do not feel [R3] is chapterable (sic) at this point .Discharge Instructions: It is important you take your medications on a regular basis as prescribed. The nursing home needs to have a court hearing to decide if you are still able to make decisions for your self (sic). Hospice needs to continue to be involved in your care. Please clarify with (named) county if they are going to be giving you your [MEDICATION(S)] injections . On 10/3/22 at 9:56 AM, Surveyor interviewed R3. R3 verified R3 was receiving Hospice services and stated, They do whatever they can in regards to R3's pain. When Surveyor asked if R3 had been to the ER recently, R3 stated, Go away! Surveyor questioned, Do you want me to leave? R3 stated, Yes. Surveyor left R3's room. On 10/3/22, Surveyor reviewed R3's nursing progress notes which included the following: ~ 1/10/22 at 4:49 PM: Chart Review: .R3] does continue to see psychiatry in (named) County. [R3] does have [MEDICATION(S)] ordered but [R3] does refuse this at times . ~ 1/18/22 at 9:20 AM: Resident continue to complain of pain all over and SOB (shortness of breath) but refuses Tylenol/[MEDICATION(S)]/[MEDICATION(S)] (used to treat mild pain/moderate to severe pain/anxiety). Reluctantly allowed Nursing to apply O2 (oxygen). Resident stated Dr. [named physician] is a quack, they are giving me rat poison. Nobody is helping me. Also stated that [R3] hears voices from the TV whether the TV is on or off . When asked what we can do to help [R3] feel better [R3] say nothing and yells at staff . ~ 1/25/22 at 5:14 PM: DON (Director of Nursing)/SW met with [R3] and [family member]. Explained that [R3] is declining and that this is a rapid progression at this time. [R3] is having changes and is declining treatment at the facility. [R3] has been calling 911 for help to go to the hospital. Explained there is not treatment that they could do for [R3] that we are not able to do but [R3] does refuse meds, treatments, nebs (nebulizers), inhalers, oxygen, and [MEDICATION(S)]/[MEDICATION(S)] (used for pain/anxiety) .[R3] did state that [R3] is hearing voices and [R3] is not taking [R3's] [MEDICATION(S)] at this time. [R3] does state that they say mean things. Did update [family member] that [R3] has been both verbal and physical with staff. [R3] is angry, scared, and in denial of disease progression. Family is also in a state of denial of the progression and outcome of [R3's] disease process. Hospice was also made aware of the behavior changes being seen. ~ 1/28/22 at 11:00 AM: Staff/Team meeting was held on 01/27/2022. In attendance: Resident, resident's [named family member], and family friend [named friend], [another named family member], [two named members of R3's managed care team] Team, [County Crisis Worker (CCW)-H] CCS (County Crisis Services) Case Manager .[named former NHA] - Administrator (Nursing Home Administrator/NHA), [Quality Manager (QM)-C] - (former) DON, and [SW-G] - Social Worker. Reviewed and updated Care Plan. This writer will audit chart and scan Court Documents into Matrix. Please see Observation for details. ~ Observation dated 1/27/22 .The team had a lengthily (sic) discussion regarding a Court Order in affect since 2006 requiring resident to continue taking specific medications. Professional/family opinions differed suggesting the medication may not be necessary for the resident with [R3's] decline in health. Other concerns were mentioned for the health, and safety of resident, other residents, and staff. End result: Resident agrees to attempt to continue taking medications. A meeting with Psychiatric Doctor and resident's doctor (Dr. [named physician]) at this facility will be scheduled to discuss how to move forward . ~ 2/3/22 at 1:34 PM: [R3] is being administered IM injection from the (named) County per court order. [R3] does continue to call 911 at times . ~ 2/8/22 at 8:43 PM: .Hospice was here at the beginning of the shift. Hospice nurse stated that resident has a court order for [R3's] psych meds and cannot refuse them. Writer was unable to get resident to take [R3's] PM (evening) medications. Resident refused fluids/food as well . ~ 2/24/22 at 1:58 PM: [R3] does continue to have court order for [CONDITION(S)]. [R3] does continue to have county coming to administer this medication . ~ 2/25/22 at 11:18 AM: .[R3] does have court ordered antipsychotics that [R3] does refuse so [R3] does have IM replacement done by county . ~ 4/21/22 at 1:21 PM: [R3] continues to have [MEDICATION(S)] ordered and does refuse most of the time. The county does monitor for need of IM replacements. ~ 5/24/22 at 2:26 PM: Resident received DHS (Department of Health Services) County Crisis Plan from [CCW-H] at (named) County to sign. This writer assisted resident in sending back to [CCW-H] after resident signed. ~ 6/23/22 1:39 PM: Does continue to trigger for [MEDICATION(S)]. Does currently refuse to take medication. Does have appropriate diagnosis, care plan and orders in place. Resident is showing increased hallucinations, delusions and behaviors lately . ~ 8/18/22 at 10:51 PM: Very behavioral tonight . [R3] then called 911 and cops on wanting to get out of here. NN (Nurses Note) indicates resident psychotic, delusional and with support of POAHC refused ER visit due to resident being on hospice care. ~ 8/24/22 at 12:21 AM: Resident up at 1222am and 2 aids in to assist with cares. Incontinent bowel and bladder, dried but [R3] declined cares. [R3] told aid don't use the electrics would 'discombobulate me.' . NN indicates resident continues with psychotic behaviors, [NAME] 911 and then refusing to go to ER. POAHC contacted and agreed to be seen by hospice nurse and no ER. ~ 8/30/22 at 1:37 PM: Resident began yelling at staff immediately upon rising. Resident stated: 'I don't belong here! I have to get out!' Resident called 911 on personal cell phone and requested law enforcement be sent to facility. When law enforcement arrived, resident told officer staff in facility were not taking care of [R3] properly. Officer attempted to deescalate. Resident became angry with officer and told [officer] to 'Get the [OBSCENITY] out of here. Leave me alone.' [named] hospice was called. Nurse from hospice came to facility and was able to deescalate the situation. Resident became calm and no longer yelled at staff after meeting with hospice nurse. Currently resident is propelling self about facility ad lib (on own as able) with no behaviors noted. ~ 9/1/22 at 1:40 PM: Continues to trigger due to order for [MEDICATION(S)]. At this time, resident is on hospice/end of life (care) and has continued to refuse this med for several months. Behaviors and [CONDITION(S)] continue to decline. Does continue to have support from staff and hospice staff. ~ 9/7/22 at 11:49 PM: Resident rang for incontinence changes while cursing. Ability to move all extremities. Lifting hips in bed while pericares (sic) (perineal cares) and new bed pad placed. [R3] did agree to vitals and neuros (neurological assessment) at this time but agitated .[R3] continues to have delusions and cursing/disruptive behaviors- says yes to cares then says get the [OBSCENITY] out . ~ 9/8/22 at 3:09 AM: Hospice nurse came and just left after an hour. Was not able to do much for [R3] as [R3] also declined anything the hospice nurse offered and also told [hospice nurse] the same repertoire of comments such as 'youre (sic) not a nurse' 'Youre (sic) stupid.' etc. [Hospice nurse] stated [hospice nurse] sat by [R3] as [R3] laid in bed. ~ 9/8/22 at 5:18 PM: [R3] approached writer by entering office. [R3] is making statements which include, 'I need to be put down, I am dismembered, we are dead and have no souls'. [R3] is exhibiting behaviors of rocking and pushing at temples, and appears to be hearing voices and responding at this time. [R3] is talking about last rites, and when writer asked about wanting a rosary brought in tomorrow [R3] stated, 'I will not be here tomorrow even if I have to kill myself.' . Staff has called [family member] at [R3]'s request and is collaborating with hospice and [named managed care team] to assist [R3] in dealing with current issue. ~ 9/8/22 at 9:06 PM: Was updated by administrator that resident had express (sic) [CONDITION(S)], this nurse did speak with resident and [R3] stated that [R3] had to 'get out of here', [R3] also stated that [R3] was agreeable with going to have an eval at the ER to get help with [R3's] mental health .Awaiting update on admission/transfer at this time. On 10/3/22 at 11:24 AM, Surveyor interviewed SW-G who verified R3 did have a court order through (named) County to receive medications. SW-G stated, [R3] would refuse meds here including the court ordered IM medication. We can't force [R3]. (named) said we could but we can't .(named) County said they were going to come to give it (court ordered medication) but they never did. SW-G indicated SW-G would provide Surveyor with documentation of (named) County signing-off on R3's case management. On 10/3/22 at 11:28 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-I who indicated R3 made a statement to NHA-A that R3 had to get of here even if it meant killing R3's self. ADON-I indicated RN-F went with R3 to theER on [DATE]. ADON-I verified R3 had been refusing [CONDITION(S)] medications for quite some time. ADON-I indicated R3 was going to psychiatry appointments at (named) County routinely, but did not know if R3 was given medications at those appointments. ADON-I indicated R3 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . ADON-I was unsure how long R3 allowed patches to remain on R3's body. R3's medical record contained the following physician orders: ~ [MEDICATION(S)] ([MEDICATION(S)]) tablet; 20 mg; amt: 1; oral At Bedtime ~ [MEDICATION(S)] ([MEDICATION(S)]) (used to treat depression) tablet; 20 mg; amt: 1 tablet; oral Special Instructions: take 1 tablet by mouth daily ~ [MEDICATION(S)] Patch ([MEDICATION(S)]) patch 24 hour; 4.6 mg/24 hour; amt: 1; transdermal Once A Day ~ [MEDICATION(S)] - Schedule II patch 72 hour; 12 mcg/hr (micrograms per hour); amt: 12 mcg-1 patch; transdermal Once A Day Every 3 Days In addition, the following was noted to be ordered on 7/21/21 and discontinued on 8/10/21: ~ [MEDICATION(S)] ([MEDICATION(S)] lauroxil) (injectable [MEDICATION(S)]) suspension, extended [NAME] (extended release syringe); 882 mg/3.2 mL (milliliters); amt: 1 Injection; intramuscular Once A Day Every 28 Days On 10/3/22, Surveyor reviewed facility provided Medication Administration Records (MARs) for R3's [CONDITION(S)] medications for the months of April, May, June, July, August and September 2022. R3's order for [MEDICATION(S)] 20mg orally at bedtime was documented as refused most nights. In the month of April 2022, R3 accepted [MEDICATION(S)] eight times. In the month of May 2022, R3 accepted [MEDICATION(S)] eight times. In the month of June 2022, R3 accepted [MEDICATION(S)] twice. In the month of July 2022, R3 accepted [MEDICATION(S)] four times. In the month of August 2022, R3 accepted [MEDICATION(S)] twice. One [MEDICATION(S)] dose on 9/3/22 was documented as taken by R3 in September 2022 prior to R3's ER visit on 9/8/22. R3's Care Plan contained the following: Alteration in mood status related to mental health disorders manifested by behaviors and the need for [CONDITION(S)] medications. Resident has several psychiatric diagnosis (sic) and is on an antipsychotic and antidepressant with interventions to include: ~ AIMS (assessment for drug induced movement disorders) assessment quarterly and prn (as needed). ~ Reduce and/or discontinue medication(s) if S/S (signs and symptoms) of adverse side effects emerge. ~ Review functional status quarterly and prn to determine if status has been maintained or improved with use of drug. Notify physician of decline in functional status. ~ Refer to behavioral health services as needed. ~ Monitor behavior and document. ~ Administer medications as ordered. R3's Care Plan also contained the following: Resident is [R3's] own decision maker and has made choices against plan of care. Resident refuses meds at times with one intervention of Nursing staff to continue to educate resident and accept residents (sic) choice for self determination (sic). R3's Care Plan did not contain mention of [CONDITION(S)] medications being court ordered. On 10/3/22, Surveyor reviewed a facility provided (named) County Crisis plan which was emailed to the facility on [DATE] and stated, .(named) County no longer handles [R3]'s medications. Despite [R3] being under a medication order, [R3's] compliance is minimal as [R3] does refuse medications often at [R3's] current placement . This document was signed by R3 and SW-G on 5/24/22. On 10/3/22, Surveyor reviewed a facility provided Email from NHA-A to (named) County, dated 9/2/22, that stated, .I wanted to follow up regarding [R3]'s orders for ariprizole and [MEDICATION(S)]. [R3's] primary physician in conjunction with Hospice have discontinued these medications. [R3] has refused to take them for well over a year. When the county ends their monitoring of [R3], the facility feels confident that we are able to manage [R3's] behaviors using the resources we have available to us. On 10/3/22 at 2:14 PM, Surveyor interviewed NHA-A who indicated NHA-A had started employment at facility in May of 2022. When questioned if NHA-A had any knowledge of why R3's injectable [MEDICATION(S)] was discontinued shortly after R3's admission to the facility, NHA-A indicated it was NHA-A's understanding that (named) County obtained the court order prior to R3's admission to the facility and stated, We can't do that IM (injection) here. NHA-A indicated R3 had a right to refuse treatment in the facility. NHA-A stated, The county told me they no longer wanted to be involved in [R3's] care and wanted our MD (physician) to order meds (medications). NHA-A indicated a county worker told NHA-A that information after [R3's] final visit with a county worker at the facility. NHA-A could not recall the date of that final visit. On 10/4/22 at 10:03 AM, Surveyor interviewed CCW-H. Also on the call via speaker phone with CCW-H was County Corporation Council (CCC)-J. CCC-J stated, We've tried to get them to force [R3] to take the meds under the court order but to no avail so we closed [R3's] case. CCW-H indicated R3 received IM injections at the county building prior to R3's admission to the facility. CCW-H indicated R3 did not receive IM injections from (named) County staff at the facility. CCW-H indicated IM injections were discontinued by the county psychiatrist because R3 was in a healthcare facility and oral medications were ordered. CCW-H indicated CCW-H attended a meeting a while back with facility staff where CCW-H suggested facility staff crush oral medication and put it in applesauce for administration then CCW-H stated, I was told (by facility staff) that was not ethical. CCW-H verified discussing safety in the community with facility staff and recalled questioning during meeting, Was [R3] really safe going out into the community without receiving [R3's] meds? CCW-H stated, The current administrator (NHA-A) brought up to us ((named) County staff) [R3] was becoming more and more psychotic and what were we ((named) County staff) going to do about it. I reminded them again about the court ordered meds. CCC-J stated, We are very concerned (about R3's situation). On 10/5/22 at 1:37 PM, Surveyor interviewed CCW-H again via phone. CCW-H indicated R3 was seen four times a year by a county psychiatrist and verified the county case managers, who saw R3 in the facility, CCW-H being one of them, were not nurses and not trained to administer IM injections. CCW-H indicated the date R3 was formally released from county services was 9/14/22 because R3 was in a facility that said they could manage R3 without county services. On 10/5/22 at 2:02pm, Surveyor interviewed QM-C via phone. QM-C verified NHA-A was not the NHA at the time of the 1/27/22 meeting. QM-C indicated QM-C was the DON at the time of the 1/27/22 meeting and attended that meeting. QM-C indicated R3's medication refusals were discussed at the meeting and stated, [R3] did state [R3] was hearing voices but they (the voices) were not mean, harassing or telling [R3] to do things. QM-C indicated the facility was under the understanding R3 would receive IM injections when R3 saw the county psychologist or at monthly meetings with R3's case workers. When questioned if the facility could provide documentation from (named) County indicating they would provide, were providing or did provide IM injections to R3, QM-C stated, I will look. (Of Note: Surveyor did not receive such documentation from the facility.) On 10/10/22, Surveyor reviewed Service Entry documentation, dated 1/27/22, provided by (named) County Department of Human Services that stated, .This worker sent an email with the med order and commitment extension attached to [SW-G] .This worker asks in the email for immediate reporting of new behaviors .This worker spoke to Dr (doctor) [Medical Doctor (MD)-K/County Psychiatrist] and discussed the reported behaviors and symptoms. [MD-K] ordered [R3's] [MEDICATION(S)] to be taken in the morning rather than at night so that the staff at the facility could offer the meds during morning rounds and if [R3] refuses, they can continue to offer the meds throughout the day with hopes that [R3] would take them eventually. [MD-K] also reordered the injection and informed this worker that the facility should give the injection to [R3] as soon as they are able to. [MD-K] reported that they (the facility) need to get [R3] psych ([CONDITION(S)]) meds in [R3] immediately. Later that day, this worker attended the teleconference for [R3] at request of the facility .(list of attendees match list in facility note dated 1/28/22 regarding 1/27/22 Staff/Team meeting) .This worker gave background on [R3]'s mental health and struggle to take [R3's] [CONDITION(S)] medication as prescribed. Discussed the non-compliance with the current medication order. This worker explained that [R3] was hospitalized at one point and then as part of [R3's] being released there was an agreement to extend [R3's] mental health commitment and that this means that [R3]'s enrollment in the CSP (Community Support Program) program is mandatory and that [R3] does not have a choice in having our services. This worker explained the medication order .This worker also explained [R3]'s history with blaming [R3's] [CONDITION(S)] medications for every negative thing including [R3's] [CONDITION(S)] .[SW-G] the social worker at the facility reported that [R3] is not a danger to [R3's] self or others. [Managed Care Worker (MCW)-L] interrupted and stated, 'you (facility staff) are the ones that reported that [R3] choked one of your staff members'. The response to [MCW-L]'s comment was, 'that's nothing, we deal with patients who get physical all the time, it's part of the job. The staff member is fine and has no injuries' .This worker explained that because [R3] is under a commitment order and med order, we are responsible for [R3] and making sure [R3] follows [R3's] med order and is safe to [R3's] self and others. This worker also explained that there has been a disconnect with communication regarding [R3]'s physical health. [R3] has been on hospice since before the last time [R3] was admitted to [R3's] facility and that was over 7 months ago. Just because [R3] is on hospice does not mean that [R3] is truly at end of life and what happens if [R3] lives another year or years on hospice, does this mean that [R3] should be without [CONDITION(S)] medications the entire time because this is [R3's] wishes? The staff continues to express that they believe that they can manage [R3] there . On 10/10/22, Surveyor reviewed Email documentation, dated 1/27/22, sent by CCW-H to SW-G and others, provided to Surveyor by (named) County, which stated, Good Morning, Please find the commitment and medication order attached. I was wanting to have a conversation with you today [SW-G] and I did leave you a voicemail, regarding [R3]'s refusal to take [R3's] medications. It has been discussed and staffed on our end and it was determined that since [R3] is under a medication order, [R3] cannot refuse [R3's] [CONDITION(S)] medications. We would suggest that the staff that administer the medication at your facility please crush [R3]'s medications and put them in [R3's] food or drink and do not tell [R3] that the meds are in there. We believe that [R3]'s [CONDITION(S)] and behaviors are only going to get worse the more time [R3] is off of [R3's] medications. I am not sure it would be safe to take [R3] out into the community if [R3] is not taking [R3's] medications. I also wanted to let you know that [R3] has blamed [R3's] [CONDITION(S)] medication for every negative thing that happens to [R3] including [R3's] [CONDITION(S)]. [R3] has tried many tactics to stop [R3's] medications and I believe that the reporting of the metallic taste in (sic) another such tactic. I would ask that all parties please inform us as the case managers, whenever there are new developments or behaviors such as this so that we can help support [R3] and [R3's] care team in managing [R3's] mental health symptoms .

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents with dining for 4 of 40 residents (R28, R38, R17, R290) who require dysphagia diets. Surveyor observed DC I (Dietary Cook) pour ready to serve honey-thickened, lemon flavored, water into pre-poured thin liquids in an attempt thicken the liquids. These liquids were served to R28 and R17. DC I indicated he prepared a total of four residents' (R28, R38, R17 and R290) drinks this way as this is how he was taught. Failure to ensure fluids were served to residents in the appropriate consistency created a finding of Immediate Jeopardy (IJ), which started on 5/18/22. Surveyor notified Nursing Home Administrator A (NHA) of the immediate jeopardy on 5/19/22 at 2:49 PM. The deficiency continues at a scope/severity of E (potential for more than minimal harm that is not IJ/pattern) as the facility continues to implement its removal plan. Evidenced by: The International Dysphagia Diet Standardization Initiative (IDDSI) is a global texture modified diet standard for all languages, all people and for all settings. As of October 2021, IDDSI is the only diet described by the Academy of Nutrition & Dietetic with the support of the American Speech-Language Hearing Association, the National Foundation of Swallowing Disorders, & the Dysphagia Research Society According to Dysphagia in the Elderly, .dysphagia in the elderly is increasingly recognized as an important national healthcare concern with enormous cost. Aging may adversely affect all components of swallowing function. The elderly is at increased risk for development of dysphagia, as illnesses affecting the swallowing mechanism are more common in their population group. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 93/pdf/GH-09-784.pdf Facility policy, entitled Dietary Manual, dated 4/21, includes, in part: Food and beverages are prepared, seasoned, and tasted by Food and Nutrition Services Associate . for proper flavor, seasoning, and texture. ~R28 was admitted on [DATE] with diagnoses including Dysphagia oral pharyngeal phase R28's Physician Orders include: start date: 12/9/22 Mechanical soft diet . start date: 10/17/21 Honey thick liquids. R28's Comprehensive Care Plan, initiated 1/18/22, revised 5/19/22, includes, in part: Resident is her own decision maker and has made choices against her plan of care. Resident refuses meds and continues to drink thin liquids despite order for thickened liquids. Nursing staff will continue to educate and accept residents' choice for self-determination . ~R17 was admitted on [DATE] with diagnoses including Dysphagia following a cerebral infarction. R17's physician Diet orders: start date: 6/29/20 mechanical soft diet Start date: 6/29/20 Nectar thick liquids R17's Comprehensive Care Plan, initiated 7/18/18, includes, in part: Diet: Mechanical soft with Nectar thickened liquids . provide supplements as ordered: Nectar thickened . ~R290 was admitted to the facility on [DATE] with diagnoses, including swallowing difficulty and [CONDITION(S)] without bleeding. R290's Physician orders, start date 5/13/22: regular diet . Nectar thick liquids R290's Comprehensive Care Plan, initiated 5/4/22, includes in part: R290 is at nutritional/hydration risk due to her need for thick liquids . approach: diet per doctor's orders ~R38 was admitted to the facility on [DATE] with diagnoses including Dysphagia. R38's Physician orders, start date 4/6/22: pureed diet with nectar thick liquids R38's meal card, dated 5/20/22: mechanical soft diet . Nectar thick liquids (It is important to note this diet does not reflect the current Physician orders.) R38's Comprehensive Care Plan, initiated 3/11/22, updated 5/19/22, includes, in part: R38 generally refuses to sit up for meals . Remind R38 to eat and drink slowly, small, single sips of nectar thickened liquids . Observe for signs and symptoms of possible complications; pneumonia . dehydration . Diet- regular mechanical soft 3/16/22, nectar thick liquids 3/16/22 (It is important to note R38's Comprehensive Care plan diet and R38's current Physician orders do not match.) On 5/18/22 between 7:38 AM and 8:38 AM Surveyor observed DC I prepare thickened liquids for 2 residents on dysphagia diets. The milk, juice and water were pre-poured in cups three fourths full. DC I then took honey-thickened lemon water (which is a ready-to-serve thickened liquid) and added it to the pre-poured liquids. Surveyor observed the liquids still looked thin. DC I indicated he is a dietary aide who began working here 4/26/22 and is one of the longest-tenured employees in the dietary department. DC I indicated he had one day of training from the corporate clinical consultant who worked at the facility from 2/22 - 3/29/22 and from 4/6 - 4/27/22 after the facility's Dietary Manager quit in January 2022. On 5/18/22 at 8:45 AM Surveyor observed staff serving the meal trays to the residents. Although the meal tickets for the 2 residents indicated they were to receive either honey-thickened or nectar-thickened liquids, none of the staff noticed that the liquids being served were not of the consistency ordered. (It is important to note this is the second line of defense in assuring residents receive food and liquids consistent to their diets). Before R17 and R28 could drink the liquids, Surveyor asked DON B (Director of Nurses) if the liquids were at the proper consistency. When Surveyor explained how the drinks had been prepared, DON B stated, I don't know how they could be. I will take care of this. On 5/18/22 at 9:15 AM Surveyor interviewed DM D (Dietary Manager), DC I, and DC F. None of these staff knew what standard of practice the facility uses for preparing mechanically altered diets, and no one was aware of the International Dysphagia Diet Standardization Initiative (IDDSI). (It is important to note IDDSI is a global texture modified diet standard for all languages, all people and for all settings and, as of October 2021, is the only diet described by the Academy of Nutrition & Dietetic with the support of the American Speech-Language Hearing Association, the National Foundation of Swallowing Disorders, & the Dysphagia Research Society.) DC I indicated he had prepared thickened liquids for two more residents that morning. Surveyor asked DON B for a list of residents who receive thickened liquids. The list consisted of R28, R17, R290, and R38. DON B indicated, during an interview, that she was calling the MD for these four residents and has already began monitoring them for signs and symptoms of aspiration or pneumonia. On 5/18/22 at 10:47 AM DON B (Director of Nursing) indicated they could give R28 thin liquids since she signed a form with risks and benefits of not consuming the thickened liquids. DON B indicated she did not provide education with return demonstration when giving the risks and benefits. DON B indicated she only provided the form and education to R28 at the time. DON B indicated the thickened liquids she was offered were not honey thick and they were not thin. On 5/18/22 at 11:37 AM NHA A indicated the facility did not have unflavored thickener and she was going to Walmart to buy some. On 5/19/22 at 9:27 AM DC I indicated he does not have any long-term care experience but does have [AGE] years cooking experience. DC I indicated a Corporate Clinical Consultant taught him how to mix thickened liquids when he first started, and he only met him the one day. DM D indicated he did not have any long-term care experience either but has over [AGE] years of cooking experience. DM D indicated the facility must have run out of thickener and no one told him. On 5/19/22 at 1:44 PM SLP J (Speech Language Pathologist) indicated she has been trying to get the facility to follow the international dyshaphia diet standard of practice vs. national dysphagia diet standards of practice where you can use a fork or a spoon and tilt it with the liquid running off to decide what consistency it is. SLP J indicated adding ready to serve honey thickened lemon water to thin milk just sounds gross and this would thin the consistency so it would no longer be honey thick. It would be the same with water or juice. SLP J indicated adding honey thickened lemon water to a cup ¾ full of thin liquid would not necessarily make the consistency nectar thick. SLP J indicated it does not work that way. According to Swallowing Problems Increase Risk of Death, Nursing Home Admissions, If untreated, dysphagia can cause patients to aspirate food and liquid into the lungs, leading to infections, aspiration pneumonia, inadequate oral intake leading to unintended weight loss and dehydration and ultimately death. https://www.med.wisc.edu/news-and-events/2017/november/swallowing-problems-following-stroke/ Similarly, an article in Nutrition Journal notes, Complications of dysphagia include chest infection, and in some cases death due to choking on food, or as a result of aspiration pneumonia. In order to reduce the likelihood of aspiration, liquid thickness is often altered .Individuals with dysphagia .find the turbulent and fast flow of liquids difficult to control during passage through the pharynx, resulting in impaired airway protection. One of the methods of managing this challenge is to thicken liquids in order that they flow more slowly, allowing the individual time to coordinate safe swallowing. Thickened liquids are not a diet of choice, but one of safety. (Emphasis added.) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 77/ 8 Signs of Dying from Aspiration Pneumonia notes that Mortality estimates for aspiration pneumonia vary. At least 5 percent of people who are hospitalized for aspiration will die .Among geriatric populations, mortality skyrockets. A 2013 study of elderly patients put 30-day mortality at 21 percent. First responders, doctors, nurses, and other healthcare providers must always treat aspiration pneumonia as a medical emergency with a high mortality risk .In the immediate aftermath of aspiration, a patient may be unable to breathe or swallow, presenting a medical emergency. After the risk of [CONDITION(S)] has passed, the dangers of aspiration pneumonia have not. Aspiration pneumonia can cause numerous complications, including: [CONDITION(S)], Respiratory failure, Acute respiratory distress syndrome (ARDS), and Bacterial pneumonia https://blog.sscor.com/8-signs-of-dying-from-aspiration-pneumonia Serving liquids that were not the appropriate consistency for 4 residents who had orders for thickened liquids because of their risk of aspirating created a reasonable likelihood for serious harm, and thus led to a finding of immediate jeopardy. The Facility removed the jeopardy on 5/19/22 when it had completed the following: * Tray cards have been reviewed against physician orders to ensure that liquid consistency is appropriate. * Dietary staff have been educated to standard of practice for thickened liquids. * All staff to be educated to standard of practice for thickened liquids and reading tray cards prior to providing fluids to residents * IDT review of dietary policies and procedures including thickened liquids * Facility will use pre-thickened product moving forward with the exception of availability issues * Speech therapy will audit proficiency with current staff and all new hires after department specific training. * The facility has developed a plan to easily identify residents requiring thickened liquids on tray cards and in resident rooms. A colored dot by name outside room and highlighted on tray card. * Trays of residents with thickened liquids will be audited 3x's weekly for 4 weeks, and then weekly for accuracy of liquid consistency. Dietary staff will be skill checked for proficiency of thickening liquids weekly for 4 weeks and monthly thereafter. Results will be report to QAPI committee for review.

Based on observation, interview and record review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety to prevent foodborne illness, as the facility served non-pasteurized, runny yolk eggs, to 2 of 3 (R14, R15) supplemental Residents out of a total of 40 residents residing at the facility. Failure to ensure that eggs served were pasteurized or fully cooked placed these residents at risk for becoming infected by Salmonella and created a finding of Immediate Jeopardy (IJ) that started on [DATE]. The facility administrator was made aware of the findings of IJ on [DATE] at 9:54 AM, which was removed on [DATE]. The deficiency continues at a scope/severity of F (potential for more than minimal harm that is not IJ/widespread) as the facility continues to implement its removal plan. Findings include: According to the 2017 FDA (Food and Drug Administration) Food Code: ,d+[DATE].13 Pasteurized Eggs, Substitute for Raw Shell Eggs for Certain Recipes. Raw or undercooked eggs that are used in certain dressings or sauces are particularly hazardous because the virulent organism Salmonella Enteritidis may be present in raw shell eggs. Pasteurized eggs provide an egg product that is free of pathogens and is a ready-to-eat food. The pasteurized product should be substituted in a recipe that requires raw or undercooked eggs. Highly susceptible population means PERSONS who are more likely than other people in the general population to experience foodborne disease because they are: (1) Immunocompromised; preschool age children, or older adults; and (2) Obtaining food at a facility that provides services such as custodial care, health care, or assisted living, such as a child or adult day care center, kidney [CONDITION(S)] center, hospital, or nursing home, or nutritional or socialization services such as a senior center. ,d+[DATE].11 Pasteurized Foods, Prohibited Re-Service, and Prohibited Food. In a FOOD ESTABLISHMENT that serves a HIGHLY SUSCEPTIBLE POPULATION: (B) Pasteurized EGGS or EGG PRODUCTS shall be substituted for raw EGGS in the preparation of . (2) A partially cooked animal FOOD such as lightly cooked FISH, rare MEAT, soft-cooked EGGS that are made from EGGS, and meringue; The facility policy, entitled Safe Food Handling, with a revision date of ,d+[DATE], states, in part: . POLICY: All food purchased, stored, and distributed is handled with accepted food-handling practices and per federal, state and local regulations. PROCEDURE: .9. Unpasteurized eggs and undercooked meat are not served to any resident. Only pasteurized liquid and shell eggs will be used. Only liquid eggs are used to make scrambled eggs to eliminate pooling . The facility policy, entitled Resident Interviewing/Obtaining Nutritional History, with a revision date of ,d+[DATE], states, in part: . POLICY: A representative from the Food and Nutrition Services department visits all residents upon admission and routinely thereafter. Food preferences, nutritional history and a visual assessment are documented . PROCEDURE: . 3. The Director of Food and Nutrition Services communicates: Regulation prohibiting the service of unpasteurized eggs and under cooked meat . The facility policy, entitled Food Production Guideline, with a revision date of ,d+[DATE], states, in part: . POLICY: Safe and sanitary handling of food will be employed during food production. PROCEDURE: . 20. Raw eggs are not to be served unless make a recipe calling for same where the egg is cooked into that item for example: meatloaf, cake. Pasteurized eggs marked with a P on the shell are the only egg to be used when serving them with the yoke [sic] intact. (over easy, sunny side up) .27. Wholesome, non-adulterated foods are purchased . On [DATE] at 9:51 AM, during the initial tour of the facility's main kitchen with DC E (Dietary Cook), Surveyor observed unpasteurized hard-shell eggs and liquid eggs in cartons in the kitchen's main refrigerator. DC E indicated the facility uses the unpasteurized eggs for breakfast. DC E indicated the residents can have specially made eggs, but DC E was not sure what residents order them. On [DATE] at 3:07 PM, Surveyor interviewed DM D (Dietary Manager). DM D indicated R14 orders eggs fried easy with runny yolks and R15 orders fried eggs every morning for breakfast. Example 1 R14 was admitted to the facility on [DATE] and has diagnoses that include Mild Cognitive Impairment, Chronic Congestive Heart Failure, and Type II Diabetes Mellitus. R14's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], shows that R14 has a Brief Interview of Mental Status (BIMS) Score of 15 indicating R14 is cognitively intact. On [DATE] at 7:38 AM, Surveyor observed DC F frying 2 eggs. DC F indicated there are ,d+[DATE] special orders for over easy eggs this morning. Surveyor observed R14's meal ticket indicating runny eggs. On [DATE] at 7:43 AM, Surveyor followed R14's breakfast tray, which included the runny eggs down to R14's room. R14 indicated to Surveyor breakfast usually consists of 2 eggs over easy. On [DATE] at 8:06 AM, Surveyor informed LPN G (Licensed Practical Nurse) that R14 was served runny, unpasteurized eggs. Example 2 R15 was admitted to the facility on [DATE] and has diagnoses that include Chronic Kidney Disease Stage 3, Chronic Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, and Chronic Respiratory Failure. R15's Admission MDS Assessment, dated [DATE], shows that R15 has a BIMS Score of 15 indicating R15 is cognitively intact. On [DATE] at 8:03 AM, Surveyor entered R15's room and observed R15 eating breakfast. Surveyor asked R15 how breakfast was. R15 stated she prefers scrambled eggs. Surveyor asked R15 how are your eggs cooked. R15 stated, Over easy. Surveyor asked resident how many eggs did she receive for breakfast. R15 stated she received two eggs. Surveyor observed that R15 had eaten 1 egg and ,d+[DATE] a biscuit and had started eating the second egg. Surveyor observed the egg yolk to be runny. Surveyor exited R15's room and observed DON B (Director of Nursing) standing nearby. On [DATE] at 8:05 AM, Surveyor asked DON B to come to R15's room. Surveyor stated to DON B that R15 prefers scrambled eggs. Surveyor asked DON B, if the facility is cooking unpasteurized eggs, is it acceptable for the egg to be served over easy. DON B immediately entered R15's room and stated to R15, Honey, that's not a pasteurized egg so it should be cooked hard. DON B removed R15's plate and returned with scrambled eggs for R15. Of note, the menu for [DATE] indicated scrambled eggs. On [DATE] at 8:10AM, Surveyor, NHA A, DON B (Director of Nursing), DM D, and CC H (Cooperate Nurse Consultant) observed the box of unpasteurized eggs in the refrigerator in the kitchen. Surveyor and NHA A reviewed the food invoice dated [DATE] noting the food service company had substituted pasteurized eggs with unpasteurized eggs. NHA A, DM D, DON B, and CC H were unaware of the substitution. According to the Centers for Disease Control and Prevention (CDC) Eggs, like meat, poultry, milk, and other foods, are safe when handled properly. Shell eggs are safest when stored in the refrigerator, individually and thoroughly cooked, and promptly consumed. The larger the number of Salmonella present in the egg, the more likely it is to cause illness. Keeping eggs adequately refrigerated prevents any Salmonella present in the eggs from growing to higher numbers, so eggs should be held refrigerated until they are needed. Cooking reduces the number of bacteria present in an egg; however, an egg with a runny yolk still poses a greater risk than a completely cooked egg. Undercooked egg whites and yolks have been associated with outbreaks of Salmonella enteritidis infections. The CDC notes that Salmonella causes 1.2 million cases of illness each year in the United States and 450 deaths. According to Salmonella enteritidis Infection, A bacterium, Salmonella enteritidis, can be inside perfectly normal-appearing eggs, and if the eggs are eaten raw or undercooked, the bacterium can cause illness .A person infected with the Salmonella enteritidis bacterium usually has fever, abdominal cramps, and diarrhea beginning 12 to 72 hours after consuming a contaminated food or beverage. The illness usually lasts 4 to 7 days, and most persons recover without antibiotic treatment. However, the diarrhea can be severe, and the person may be ill enough to require hospitalization . The elderly, infants, and those with impaired immune systems may have a more severe illness. In these patients, the infection may spread from the intestines to the blood stream, and then to other body sites and can cause death unless the person is treated promptly with antibiotics. https://wonder.cdc.gov/wonder/prevguid/p 03/p 03.asp#:~:text=A%20person%20infected%20with%20the,persons%20recover%20without%20antibiotic%20treatment Serving unpasteurized eggs that were not fully cooked created the potential that residents could contract Salmonella and created a reasonable likelihood for serious harm, thus leading to a finding of Immediate Jeopardy (IJ). The IJ was removed, on [DATE], when the facility began implementing the following: *R14 and R15 will be monitored for signs and symptoms of foodborne illness: including fever, abdominal pain, nausea, and vomiting. Assessments every 4 hours times for 4 hours then daily for additional 48 hours. MD [medical director] will be contacted for any change in condition. Public health was contacted and reviewed plan. *Dietary staff were educated on how to identify pasteurized vs. [versus] non-pasteurized eggs. *Dietary staff have reviewed company policies and procedures for food sanitation which include only use of pasteurized eggs. *On [DATE] policies and procedures were reviewed by cooperate dietician and dietary manager to ensure that they meet standards of practice. Dietary manager to review and sign off on all deliveries with egg product to ensure that no substitutes have been made. All unpasteurized eggs were discarded immediately. Pasteurized eggs obtained and put into fridge for use. *NHA [Nursing Home Administrator] to verify purchase of pasteurized eggs through food vendor. Unpasteurized eggs removed/blocked from order system. Dietary Manager to update NHA immediately if product is unavailable. If substitution is needed, education to be completed at that time. NHA will observe food delivery weekly X 90 days to ensure eggs are delivered. NHA/Dietary manager to complete audit 2xs weekly to ensure pasteurized eggs are being used X 30 days, then weekly X 60 days. The deficient practice continues at a scope/severity of F (potential for more than minimal harm/widespread) as evidenced by: Example 3: On [DATE] at 6:10 PM Surveyor observed 3 dented cans in circulation. DC E indicated it was not his job to remove dented cans, so he left them on the shelf with all the undented cans. On [DATE] at 3:07 PM during an interview, DM D (Dietary Manager) indicated dented cans should be removed from the shelf and placed in a holding area so the facility can let the company know and get a credit. Example 4: Facility policy, entitled Dietary Manual, dated ,d+[DATE], includes, in part: Leftovers must be dated, labeled, and covered . If refrigerated, they will be used within 48 hours or follow State Food Code guidelines by use by date. Dry Storage area On [DATE] at 6:10 PM Surveyor observed Cheerios and Bran Flakes in plastic containers. These were removed from their original boxes/bags and did not have an expiration date or an opened date. During an interview DC E (Dietary Cook) indicate he was unsure when these were opened. On [DATE] at 3:07 PM during an interview, DM D indicated staff need to put an open date and/or expiration date on food when it is removed from the original packaging. Facility Walk in Refrigerator On [DATE] at 6:10 PM Surveyor observed flat bread with expiration date of [DATE]. DC E indicated this should not be in the refrigerator past the expiration date. Surveyor also observed an opened gallon of 1% milk with no open date. DC E indicated he was unsure when this was opened. On [DATE] at 3:07 PM during an interview, DM D indicated milk should be marked with an open date when it is opened, and it should be used within 7 days of opening. DM D also indicated expired food should not be left in circulation. Resident Refrigerator On [DATE] at 6:10 PM during the initial walk through of the kitchen, Surveyor observed the following in the resident refrigerator. DON B indicated the following items should be tossed in the garbage as they have pass their expiration dates or are not labeled with a name and date. Coleslaw . resident name . date: ,d+[DATE] Chicken . resident name . ,d+[DATE] crackers barbequed meat . no name . date: ,d+[DATE] Culvers to go . no name . no date Arby's to go . resident name . no date cheese sausage in sandwich bag . no name . no date pickle chips . no name . best by [DATE] fried chicken . resident name . no dated to go container unknown food . resident name . no date soft shell tacos . resident name . best by [DATE] [NAME] Vanilla ice cream . no name . no date On [DATE] at 3:07 PM during an interview, DM D indicated the facility lacks a system for maintaining the resident refrigerator and all staff are responsible for the upkeep.

Based on interview and record review, the facility did not ensure each resident received the necessary care and services in accordance with professional standards of practice (N6 Wisconsin Nurse Practice Act) to meet each resident's physical needs for 2 of 3 residents reviewed (R1 and R3) out of a total sample of 3 residents. The facility failed to take immediate action to assess, monitor, and evaluate R1's condition and to seek prompt medical intervention to prevent R1's underlying condition from worsening. According to interviews, ED (Emergency Department) and EMS (Emergency Medical Services) notes, this resident had been less responsive in the three-four (,d+[DATE]) days before transfer to the emergency room . Staff did not monitor the resident's condition and did not thoroughly assess him, did not develop plans and interventions for caring for him, and did not routinely evaluate R1 or his response to treatment. When staff left a message for the Physician, staff did not follow up when there was no response. R1 was transferred to the ED where he was diagnosed with acute [CONDITION(S)], septic shock, [CONDITION(S)] and [CONDITION(S)]. In addition, the ED Physician indicated he suspects R1 likely has pneumonia and may have potentially aspirated at some point and that a urine culture is suspicious for a [CONDITION(S)] (urinary tract infection). The facility did not recognize or address their systemic problems with assessment and intervention so that other residents experiencing a change in condition receive care consistent with professional standards of practice. R3 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was prescribed two diuretics. R3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When R3 had a significant weight loss (e.g., on [DATE] R3 had a 24.2 lb. weight loss in 8 days and on [DATE] R3 had a 9 lb. weight loss in one day) the facility failed to recognize this loss, failed to monitor R3's intake and output in the presence of 2 diuretics, and a fluid restriction and failed to consult with a physician. When R3's labs indicated R3 had dehydration, the facility failed to revise R3's care plan to prevent further fluid loss. The facility did not have a systematic process in place to monitor to assess R3's daily fluid intake or output, complete, monitor and assess daily weights in the presence of 2 diuretics and a fluid restriction, notify the physician per physician orders, and take corrective action to prevent further fluid volume deficit. The facility failed to have a system for R3 including the failure to: * Consistently gather data, record, and assess fluid intake * Accurately assess and complete cardiac and respiratory assessments in the presence of diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] * Develop individualized care plan approaches * Notify Physician and follow Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE] R3 admitted to the Hospital Critical Unit for Urinary Tract Infection, low blood pressure, Hypovolemia, and IV therapy to include [MEDICATION(S)] for Urinary Tract Infection. The facility's failure to assess R1 and R3 when they were experiencing significant changes in condition created a finding of IJ (Immediate Jeopardy) beginning on [DATE]. NHA A (Nursing Home Administrator), DON B (Director of Nursing). and RCN H (Regional Clinical Nurse) were informed of the IJ on [DATE] at 2:57 PM. The IJ was removed on [DATE]; however, the deficient practice continues at a severity and scope of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Evidenced by: According to N6, Wisconsin Nurse Practice Act, An R.N. shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.'s or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. Example 1 R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Admission MDS (Minimum Data Set) indicated R1's BIMS (Brief Interview for Mental Status) as severely cognitively impaired. R1 requires extensive two+ (2+) staff assist extensive assist for bed mobility, transferring, toileting and 1 assist for dressing, eating, and hygiene. R1 did not have any pressure injuries upon admission and is at risk for pressure injuries. R1 is a DNR (do not resuscitate if respirations or heartbeat cease) and has an APOAHC (Activated Power of Attorney for Health Care). R1's Care plan for ADL (Activities of Daily Living) Functional / Rehabilitation Potential: Problem start date [DATE]; Goal: Goal Target Date: [DATE] Resident will continue to be able to eat with as much independence as he can safely maintain. Approach: Position resident upright in broda wheelchair. Assist with all meals. Place cups and straws in hand. R1's current Physician Orders, signed [DATE], including, in part, the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] *[MEDICATION(S)] (Benzodiazepine - Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] *[MEDICATION(S)] (Anticonvulsant - Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] *[MEDICATION(S)] (Anticonvulsant - Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] *[MEDICATION(S)] (A supplement - Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] *[MEDICATION(S)] (A Selective Serotonin Reuptake - Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] *[MEDICATION(S)] (An antipsychotic - Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] It should be noted [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] all have significant side effects of sedation the combination of these medications in an elderly individual can greatly increase these side effects. On [DATE] at 9:57 PM, RN C (Registered Nurse) documented the following progress note in R1's medical record: Med A: Resident has been sleeping this evening with no complaints of pain or discomfort. Resident is alert and oriented x,d+[DATE]. Requires maximal assistance from two people with completing ADLs. Requires continual stimulation to be cooperative with a conversation or answering questions. Heart rate and rhythm is within normal limits. Bowel sounds are active in all 4 quadrants. Lung sounds are coarse in bilateral lower lobes and patient does have a cough at times. Note, RN C documented Lung sounds are coarse in bilateral lower lobes and patient does have a cough a times. There is no indication that RN C obtained a full set of vitals, or consulted with the Physician. It is important to note, coarse crackles are often a sign of adult respiratory distress (ARDS), early congestive heart failure, asthma, and pulmonary [CONDITION(S)]. R1's intakes indicate R1 would typically consume ,d+[DATE]% or ,d+[DATE]% of meals. R1's intake fluctuations are as follows: [DATE]: Breakfast: No documentation, Lunch: No documentation, Dinner: ,d+[DATE]%, Fluids 360 ml [DATE]: No intakes documented [DATE]: No intakes documented [DATE]: No intakes documented [DATE]: No intakes documented [DATE]: No intakes documented It is important to note, there is no additional documentation of R1's fluid or food intakes. The facility did not consult with R1's Physician regarding R1's decreased fluid and food intakes. On [DATE] at 5:09 PM, DON B documented the following progress note: Change of Cond (Condition): He (R1) started waxing and waning the last few days. He does have blister to the right heel. Applied skin prep to area. SBAR completed. MD (Medical Doctor) also updated he is sleepier as of recent. He did start to take meds tonight, then spit them out and slapped at nurse. Medications were wasted. On [DATE] at 8:07 AM, DON B completed an SBAR (Situation, Background, Assessment, Recommendation): Schedule Details: Unscheduled Section 1: Before calling MD/NP/PA -Evaluate the Resident: Complete relevant aspects of the SBAR form below -Check Vital Signs: BP, pulse and/or apical heart rate, temperature, respiratory rate, oximetry and finger stick glucose, if indicated - Review Record: Recent progress notes, labs, orders - Review a care path The change in condition, symptoms, or signs I am calling about is/are: Decreased mentation and new pressure area DTI to right heel *This started on: [DATE] Since then, it has gotten: Stayed the same Things that make the condition or symptoms worse are: With increased medications This condition, symptoms, or signs has occurred before: No Other relevant information: He did start of [MEDICATION(S)] and this has increased the sedation of the resident Primary Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] *Vital Signs: BP: ,d+[DATE] Pulse: 76 Respirations: 16 Temperature: 98.1 Oximetry: 97% room air *1. Mental Status Changes: Altered level of consciousness *Describe the symptom of signs: He is hard to rouse and is not eating or drinking as well. *Functional Status Changes: Needs more assistance with ADLs (Activities of Daily Living), Decreased mobility Behavioral Changes: No changes observed Respiratory: N/A Cardiovascular Evaluation: No changes observed GI/Abdomen: N/A GU/Urine Changes: N/A Does this resident have pain: No *Neurological Evaluation: Altered level of consciousness Review and notify: Monitor vital signs and New or change in medication(s) Nursing Notes: Please review recent changes as he is more sedated. *Date/Time Called: [DATE] at 4:00 PM and [DATE] at 8:15 AM - It is important to note, DON B did not consult with the Physician, she only sent an email. Per interview (below), Physician G arrived to the facility on [DATE] at approximately 3:00 PM. On [DATE] Physician G documented the following Physician's Progress Notes: Acute Care: SOAP (Subjective, Objective, Assessment, Plan) Note: S: Asked to see resident as resident Director I am told when he started on [MEDICATION(S)], he became increasingly sedated. Has had low grade fever-99, PMH (Past medical history) of OSA (Obstructive Sleep Apnea), DM2 (Diabetes Mellitus Type 2) O: Currently resident appears asleep and I could not arouse him. S1 (first heart sound), S2 (second heart sound) ok, lungs clear, (illegible), abdomen soft non-tender, P (Pulse): 62, R20, BP ,d+[DATE] A: Appears over sedated P: Will obtain CBC (Complete Blood Count), BMP (Basic Metabolic Panel) and [MEDICATION(S)] (an anticonvulsant) level and order reduction in medication dosages On [DATE] Physician G wrote the following orders: Please get CBC (Complete Blood Count) and BMP (Basic Metabolic Panel), [MEDICATION(S)] level as soon as possible. U/A (Urinalysis) if able - lethargy, fever, [CONDITION(S)]. Decrease [MEDICATION(S)] ([MEDICATION(S)]) to 0.5 mg (milligrams) daily hold if sedated, decrease [MEDICATION(S)] 250 mg daily and decrease [MEDICATION(S)] to 200 mg BID (twice daily), d/c [MEDICATION(S)], decrease [MEDICATION(S)] to 20 mg daily, decrease [MEDICATION(S)] to 35 mg BID hold if over sedated. Seen for acute care visit today. On [DATE] at approximately 5:00 PM, DON B transported R1's lab samples to the hospital. On [DATE] at 12:15 AM, RCN H documented the following progress note: Seen by Physician G today. New orders for stat labs. Labs obtained on first attempt. Labs transported to hospital at approximately 5:30 PM. Resident with occasional non-productive cough. COVID 19 test completed and negative. Staff nurse updated wife on current plan of care. Emotional support provided via phone-Wife reporting/sounding ill. Remains on AP (Alternating Pressure) mattress and resting. On [DATE] at approximately 6:00 PM, the hospital notified the facility of R1's critical lab results. The facility notified Physician G. On [DATE] at 6:01 PM, the facility called 911 to have R1 transported to the ED (Emergency Department). On [DATE] at 6:02 PM, LPN F documented an SBAR (Situation, Background, Assessment, Recommendation): S (Situation): Critical Labs; This started on: [DATE] at 6:00 PM; Since then, it has gotten: Stayed the same; This condition, symptoms, or signs has occurred before: No; This resident is in the NH (nursing home) for: Long-term care; Primary Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician G notified at 6:15 PM, R1's APOAHC notified [DATE] at 6:15 PM. Situation: The change in condition, symptoms or signs I am calling about is: Decreased mentation and new pressure area DTI (Deep Tissue Injury) to right heel. This started on: [DATE]. Things that make the condition or symptom worse are: With increased medications; Other relevant information: He did have start of [MEDICATION(S)] and this has increased the sedation of the resident. Vital Signs: ,d+[DATE], Pulse 76, Respirations 16, Temperature: 99.1, Oximetry 97% room air. EMS (Emergency Medical Services) report indicates the facility's call was received on [DATE] at 6:01 PM, Enroute at 6:02 PM, At Scene at 6:10 PM, At Patient at 6:12 PM, Depart for hospital at 6:34 PM. The EMS Narrative Med 1 was dispatched for a male that has high Creatin. (Creatinine). Med 1 responded to the scene. Med 1 arrived on location without incident. The crew entered the facility via the front door. The crew was escorted to the pt.'s (patient's) room by the facility staff. The patient was found sitting in a powered reclining chair. The facility staff were putting the pt.'s feet into slip on shoes. The pt. was found to be only responsive to painful stimuli and had snoring respirations. The nursing staff stated that the pt. had been this way for three days and that they had done blood work on the pt. and found that his Creatin. was high and the facility physician wanted the pt. taken to the hospital for evaluation. The pt.'s vital signs were reassessed as charted. The pt.'s BG (blood glucose) was obtained as 126 via finger stick. An 18g (gram) IV (intravenous) was established in the right AC (antecubital). NS (normal saline) was initiated at a bolus rate. The pt.'s temperature was obtained as 99.9 axillary. Began transport to the hospital. Verbal report was given by the crew to the receiving hospital via cell phone. Continued to monitor the pt. with no significant changed noted . Vitals obtained by EMS 6:20 PM: BP ,d+[DATE], P 96, Rhythm [MEDICATION(S)] [CONDITION(S)], Rhythm Regular, R 22, SpO2 85, No motor response to pain/no verbal response 6:21 PM: BP ,d+[DATE], P 91, Rhythm [MEDICATION(S)] [CONDITION(S)], Rhythm Regular, R22, SpO2 83, No motor response to pain/no verbal response 6:23 PM: BP ,d+[DATE], P 96, Rhythm [MEDICATION(S)] [CONDITION(S)], Rhythm Regular, R22, SpO2 85, No motor response to pain/no verbal response 6:34 PM: BP ,d+[DATE], P 95, Rhythm [MEDICATION(S)] [CONDITION(S)], Rhythm Regular, R22, SpO2 93, No motor response to pain/no verbal response 6:38 PM: BP ,d+[DATE], P 94, Rhythm [MEDICATION(S)] [CONDITION(S)], Rhythm Regular, 22, SpO2 89, No motor response to pain/no verbal response The ED documented the following: R1 is a [AGE] year-old male who is being admitted through the emergency room with a complaint of Unresponsive. We have been consulted to evaluate this patient for admission. He is a [AGE] year old male from the care center who is a DNR who has reportedly over the last 3 days been unresponsive. This evening the care center contacted EMS and transferred him to our facility for evaluation. On EMS arrival at the care center he was found to be hypoxic (Absence of enough oxygen in the tissues to sustain bodily functions) and hypotensive (Abnormally low blood pressure). An IV was established and he was transferred to our emergency room for evaluation On arrival to the emergency room he is found to be febrile with a temperature of 101.8, pulse of 92, respirations 20, blood pressure low ,d+[DATE], SpO2 84%. In the emergency room laboratory testing this evening shows an elevated white count of 19 (Normal range is 3.,d+[DATE].5) Chemistry shows an elevated glucose 141 (Normal range ,d+[DATE]), elevated BUN 181 (Normal Range ,d+[DATE]), elevated creatinine 10.4 (0.,d+[DATE].3), elevated potassium 5.4 (Normal Range 3.,d+[DATE].0). His GFR calculates to 5 (Normal Range is greater than 60), Repeat lab work in the emergency room at 7:00 PM shows an elevated white count at that time of 17.23 (Normal range is 3.,d+[DATE].5), electrolytes show glucose elevated 144 (Normal range ,d+[DATE]), BUN elevated 176 (Normal Range: ,d+[DATE]), creatinine elevated 10.5 (Normal Range: 0.,d+[DATE].3), potassium remains elevated unchanged at 5.4 (Normal Range 3.,d+[DATE].0). Liver enzymes show an elevated at alk-phos 160 (Normal Range ,d+[DATE]), GFR then calculated to 5 again (Normal is greater than 60). One urinalysis in the emergency room demonstrates 100 glucose moderate amount of bilirubin, trace ketones specific gravity greater than 1.030, pH 5 protein 30 uro bilirubin 11, leukocyte esterase negative, positive for bacteria, moderate amount white cells, ,d+[DATE] epithelial cells trace, nitrates are positive. The ED Physician indicated, these findings are suspicious for [CONDITION(S)] (urinary tract infection). Finding chest x-ray shows atelectasis versus a faint infiltrate in the left lung. .Realizing that his condition is quite serious the discussion with his family was that removing even oxygen could hasten his death. They understand would like him kept comfortable but appreciate that his condition is grave they would like minimal care other than comfort. At this point oxygen was removed terminated all of his regular medications. We have instituted are [SIC] comfort care protocol. The hospice service has been notified. He does appear to be imminent for death and because of this we will allow family to visit with him in the emergency room for as long as possible. R1's Physical Findings are, in part, as follows: Physical Exam Appearance: He is obese. He is ill-appearing. Eyes: Scleral icterus present (Yellowish pigmentation of the sclera, which is normally white area of the eye. This yellowish pigmentation arises due to the buildup of bilirubin in blood.) Pulmonary: Effort: Respiratory distress present Breath sounds: Decreased air movement present. Examination of the right-middle field reveals decreased breath sounds. Examination of the right-lower field reveals decreased breath sounds. Decreased breath sounds and rhonchi present. No wheezing or rales. Neurological: Mental Status: Unresponsive Abdominal: GCS (Glasgow Coma Scale) eye sub score is 1 (no response), GCS verbal sub score is 1 (no response), GCS motor sub score is 1 (no response) Reason for admission: Comfort care in the presence of a patient who is a DNR with acute kidney injury, failing vital signs, [CONDITION(S)], respiratory failure with associated [CONDITION(S)]. Functional Status Prior to This hospitalization : Significantly diminished Treatment Plan and Goals of Admission: Comfort care Current Discharge Plan: Failing vital signs with assumption that death is imminent is admitted , should he continue to record [SIC] treatment to the morning the hospice service will be contacted. Clinical Impression: 1. Acute [CONDITION(S)], unspecified acute [CONDITION(S)] type (HCC) (A condition in which the kidneys suddenly can't filter waste from the blood. Acute [CONDITION(S)] develops rapidly over a few hours or days. It may be fatal. Symptoms include decreased urinary output, swelling due to fluid retention, nausea, fatigue, and shortness of breath.) 2. Septic shock (HCC) - Note, [CONDITION(S)] may progress to septic shock. This is a dramatic drop in blood pressure that can lead to severe organ problems and death. 3. [CONDITION(S)] (A high level of the electrolyte potassium in the blood) 4. [CONDITION(S)] (The absence of enough oxygen in the tissues to sustain bodily functions) R1's x-ray final result is as follows: Atelectasis versus faint infiltrates in the left lung. The Physician also documented that R1's chest x-ray shows, Atelectasis versus infiltrate on the left. Based on patient's presentation and [CONDITION(S)] I suspect he most likely does have pneumonia. Patient has potentially aspirated at some point. Note, aspiration occurs when foreign material is inhaled into the airway. Causes of death include asphyxiation due to a blocked airway and irritation or infection of the respiratory tract due to inhaled material, or aspiration pneumonia. On [DATE] at 8:51 PM, an ED Registered Nurse documented the following progress note: Patient comfort measures, family members at the bedside. Patient O2 (oxygen) removed and monitor turned to comfort mode. IV (intravenous) fluids stopped. On [DATE] at 1:35 AM, R1 expired in the hospital ED. The facility failed to identify R1's change in condition and notify the physician timely of this change of condition. R1 was not transferred to the ED until his condition was grave and R1 later passed in the ED. On [DATE] at 12:50 PM, Surveyor spoke with NA K (Nursing Assistant). Surveyor asked NA K to tell me about R1 prior to being sent to the ED on [DATE]. NA K stated, my partner, CNA D, and I, Couldn't get him to wake up. NA K stated a couple days prior to that R1 was up in the chair by the Nurses station and he was, Out, out. No matter what we did he would not wake up. Over the next few days R1 would crack his eyes open and then go back to sleep. NA K stated on [DATE] when they were going to lay R1 in bed, they noticed R1 was turning blue and not breathing. NA K and CNA D got LPN F who did a sternal rub. (LPN F indicated to Surveyor that R1 did not turn blue or stop breathing at any time while in the facility.) NA K stated in the days prior to going to the ED, R1 was Quieter and slept more. On [DATE] at approximately 2:00 PM, Surveyor spoke with CNA J (Certified Nursing Assistant). Surveyor asked CNA J how long she has worked at the facility. CNA J stated, 3 years on and off. Surveyor asked CNA J if she is familiar with R1. CNA J stated, yes. Surveyor asked CNA J if she noticed any change in R1's abilities or overall condition prior to him being sent to the ED on [DATE]. CNA J stated she was working with R1 the day he was sent out and assisted EMT (Emergency Medical Technicians) to get R1 onto the stretcher. CNA J stated R1 didn't eat on [DATE] and staff did not get him up as he was not well. CNA J added he would not eat at all unless somebody fed him. He wouldn't even take a bite for us, however, he would drink fluids. CNA J stated that R1 declined super, super, fast. CNA J stated, R1 normally loved to walk, was very antsy, and talkative. CNA J stated R1 stopped getting out of bed, eating, and wouldn't stay awake. Surveyor asked CNA J when did these changes start. CNA J stated, 4 days prior to being sent to the ED on [DATE]. CNA J stated, He wasn't alert at all. CNA J stated, he wouldn't get up, was sleepy, and when he would open his eyes he would not respond to me. CNA J stated, this was 100% different for R1 and she was used to R1 always talking to her whenever she walked by him. CNA J stated she heard about R1's decline in report and assumed that everybody knew. CNA J stated that prior to this change in condition R1 was a stand pivot transfer. Over the last 4 days, R1 would not get out of bed so we would roll him and change him in bed. It is important to note, CNA J is indicating R1 was no longer eating, ambulating, toileting or talking or responding to staff and he slept continually. CNA J indicates that R1 was in this condition for four (4) days prior to being discharged to the ED. CNA J stated she did not notify staff as she assumed they were aware of R1's change in condition based on information shared in report. On [DATE] at 10:37 AM, Surveyors spoke with CNA D (Certified Nursing Assistant). Surveyor asked CNA D how long she has worked at the facility. CNA D stated she has worked at the facility for 3 months. Surveyor asked CNA D if she is familiar with R1. CNA D stated, yes, R1 was my favorite person at the facility. CNA D stated on Friday [DATE] she cared for R1 and had concerns regarding his condition. CNA D stated on [DATE] she worked from 6:00 AM - 2:00 PM. CNA D stated, on this date any time she touched R1 he would wince, squint (grimace) his face and cry out in pain. CNA D stated during this time R1 did not void and there was only a dime size spot of urine in his brief the entire shift. CNA D stated she told RN E (Registered Nurse). CNA D stated she declined to give R1 a shower due to his pain level and not wanting to increase his pain and discomfort. CNA D stated she told RN E (Registered Nurse) something is not right and R1 is having a change in condition. CNA D stated she did not see RN E go in to assess R1 and obtain vitals. (Note: there was no documented assessment of R1 on this date.) CNA D stated if R1 would have been sent out that day (Friday) the hospital could have helped him more and he may still be here. CNA D stated R1 only ate about 25% on this date. CNA D added, R1 would open his eyes, look at me, and go back to sleep. CNA D stated that R1 was non-verbal and unable to answer yes and no questions. CNA D stated previously R1 was alert and oriented to get out of bed, get dressed, and eat meals every day. On [DATE] R1 was falling asleep and CNA D stated she didn't think it was normal because he was sleeping all the time. On [DATE] at 1:13 PM, Surveyor spoke with PA I (Physician Assistant). Surveyor asked PA I if he recalls R1. PA I stated, yes. PA I stated he had concerns regarding R1 as did the other two (2) ED Physicians. PA I stated he was called to complete R1's admission H&P (History and Physical). PA I stated it was clear that R1's death was imminent. PA I stated facility staff told the hospital that R1 had been in this condition (unresponsive) for 3 days prior to being transferred to the hospital. PA I stated what he was not clear on was if R1 was on comfort cares. PA I stated if so, why was he transferred to the hospital and if he's not on comfort care, why was he not transferred to the hospital sooner. PA I stated maybe a new nurse saw him at the facility and recognized his critical condition. PA I stated, R1's, Condition was grave upon arrival to the ED. PA I stated, he does not understand why R1 was left in this state without being brought in sooner. PA I stated R1 had pneumonitis and could have aspirated. PA I stated R1 was admitted to the hospital, but remained in the ED during his 7 hour stay due to COVID precautions. PA I stated R1 had a beautiful family and if they transferred him to the unit, COVID Precautions would take effect limiting R1's visitors. R1 remained in the ED with all of his family members present until he expired. PA I stated, R1's outcome could have been different if the resident had been brought in sooner. He could have had a fighting chance if staff had recognized the change of condition sooner and allowed for earlier medical intervention. As a point of reference, PA I stated he saw R1 in August of 2021 and R1 was talkative, interactive, had confusion at times and could be combative; however, he was very easily redirected by hospital PT (Physical Therapy) and OT (Occupation Therapy) staff. On [DATE] at 10:55 AM, Surveyor spoke with LPN F. Surveyor asked LPN F how long she has worked at the facility. LPN F stated she has worked at the facility for 1 year and 9 months. Surveyor asked LPN F if she is familiar with R1. LPN F stated, yes. LPN F stated she worked that Friday ([DATE]), Saturday ([DATE]), Sunday ([DATE]), was off Monday ([DATE]), and back on Tuesday ([DATE]). LPN F stated she sent R1 out on [DATE] due to stat labs. LPN F stated, over the prior weekend we were pushing fluids; the more fluids we would push the more alert R1 would become. LPN F stated R1 did not want to eat. LPN F stated R1 was able to communicate, but not how he normally communicates, particularly since his medication change ([MEDICATION(S)]). LPN F stated she contacted R1's APOAHC (Activated Power of Attorney for Health Care) on Monday, [DATE], regarding R1 not eating. LPN F stated that R1 was bouncing back and forth. Surveyor asked LPN F to clarify what she means by that. LPN F stated R1 would be fine one day then groggy the next day. LPN F stated on Tuesday morning ([DATE]) R1 had a temperature of 99.1 degrees F (Fahrenheit) she could hear expiratory wheezing. LPN F stated that DON B called R1's Physician on [DATE], however, she was unable to reach him. (It is important to note, DON B faxed R1's Physician, she did not consult with the Physician.) LPN F stated she spoke with DON B the morning of [DATE] and stated that Physician G will be doing rounds at the facility today and asked DON B regarding having Physician G see R1. LPN F stated that DON B was agreeable so they contacted Physician G and asked him to see R1. LPN F stated Physician G arrived at the facility around 3:00 PM. LPN F stated that Physician G ordered labs. LPN F stated she received the critical Creatinine lab result at 6:00 PM and immediately called 911 to transport R1 to the ED. On [DATE] at 12:04 PM, Surveyor spoke with DON B. Surveyor read the [DATE] progress note (above) that documented Lung sounds are coarse in bilateral lower loves and patient does have a cough a times. Surveyor asked DON B was the Physician contacted. DON B stated, It doesn't look like it. Surveyor asked DON B, should the Physician have been notified. DON B stated, If he was unable to clear I would have, yes. Surveyor asked DON B is there documentation that the lung sounds cleared with coughing. DON B stated, no. Surveyor asked DON B, would you expect the RN (Registered Nurse) to complete the appropriate assessments and obtain a complete set of vitals. DON B stated, With any change I would expect that. DON B stated that staff obtain a temperature and respirations BID (twice daily) with COVID. Surveyor reviewed documentation and noted a lack of complete vitals, including blood pressures. Surveyor asked DON B when do staff monitor and record blood pressure and pulse. DON B stated staff check puls

Based on interview and record review the facility failed to ensure the physician was immediately consulted with regarding a significant change of condition for 1 out of 15 total sampled Residents (R7) R7 had a change in condition. The facility failed to complete a RN (Registered Nurse) assessment and failed to notify the physician as R7's condition continued to deteriorate. R7 was hospitalized with dehydration and an infected parotid gland. The facility's failure to timely consult with the physician created a finding of Immediate Jeopardy that began on 12/14/20. The NHA A (Nursing Home Administrator) was informed of the IJ finding on 1/12/21 at 11:00 AM. On 12/16/20, the facility recognized the deficient practice by the facility nursing staff and took steps to correct the deficient practice and ensure compliance at the time of the complaint survey. Based upon this determination, the IJ was removed and corrected on 12/17/20. This is being cited as past noncompliance. This is evidenced by: R7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R7's Admission MDS (Minimum Data Set) dated 10/15/20 indicates R7 has a BIMS (Brief Interview of Mental Status) of 14 out of 15 indicating R7 is cognitively intact. R7 needs one person physical assist with supervision for transfers and bed mobility. R7 is indicated as being able to eat independently after set up. Section K indicates R7 weighs 170 pounds and R7 has no difficulties with swallowing or chewing. R7 fell and fractured her hip on 10/27/20 and was hospitalized through 10/30/20 when R7 was readmitted to the facility. R7's MDS dated [DATE] indicates R7 is now moderately cognitively impaired. R7 needs an extensive two person physical assist with bed mobility and needs extensive assist of one for transfers. R7 is indicated as needing supervision with eating after setup. Section K indicates that R7 weighs 170 pounds and has no problems with swallowing or chewing indicated. On 12/13/20 at 8:21 PM, R7's Nurses Note, written by an LPN (Licensed Practical Nurse), states in part: writer notes swollen hardness to right upper jaw approximately 4.5 inch x 4.5 inch in size. MD notified N.N.O. (no new orders) at this time. However requests to be called in AM to set up Telehealth visit for 12/14/2020 for possible antibiotic dosing. Vitals remain stable afebrile (fever free). Denies pain/discomfort to site of swelling.Resident took all medication as ordered one at a time with moderate fluids. Appetite noted poor with 25% intake. (There is no evidence that an RN went down to assess R7 at this time or that an RN was notified of R7's change in condition.) On 12/14/20 at 11:29 AM, R7's Nurses Note, written by DON B (Director of Nursing) states: Teledoc visit with (physician name) today for swelling in jaw. The above is an inaccurate statement as R7 did not receive a teledoc (telehealth) visit from any type of provider on 12/14/20 despite the physician's request to see the resident on this date. On 12/15/20 at 4:25 AM R7's Nurses Note, written by a Licensed Practical Nurse, states in part: .Resident noted with muscle guarding and facial grimacing prior to scheduled Tylenol dose as scheduled with positive effectiveness noted. Writer notes resident requires assist with meals and oral intake at this time. Medications were given crushed for comfort in applesauce resident tolerated well. Sips of water encouraged throughout night with total oral intake of 240 cc (cubic centimeters). Repositioning recommended r/t (related to) resident increase in staff assistance. Extensive assist of one utilized for ADL's. Resident continues to be monitored closely r/t swelling to right upper jaw MD is aware writer notes no clinical change today. Oral care provided by writer x2 (times two).will continue to monitor closely. (R7 is now experiencing pain, when previously on 12/13/20, when a Physician was notified, R7 was not experiencing pain to the area. R7 is requiring assist with meals and oral intake at this time and there is no indication that R7's MD was notified or updated. There is no evidence of the area being measured since 12/13/20 to ensure the area is not getting larger, or whether there is any type of redness to the area.) On 12/15/20 at 8:20 AM, R7's Nurses Note, written by DON B, states in part: Family notification: Call placed with update that she did have the swelling and that MD seen her yesterday and did not make any changes. Asked to return a call as this needed to be left in a message. R7 was not seen on 12/14/20 by an MD or any type of Medical Provider. On 12/15/20 at 6:06 PM, R7's Nurses Note, written by RN N (Registered Nurse), states in part: Resident vitals within normal limits this PM shift. Lung sounds diminished. Resident has had one medium void throughout AM shift and thus far none on PM shift.Resident's intake has been poor unless strongly encouraged and assisted by staff. Residents sister in law did come see her via window visit this early afternoon and brought chocolate ice cream which resident ate 75% of. Resident drank med pass (supplement) with early morning medication pass but declined the majority of this at lunch time and only had 25%. This PM shift resident is responding when addressed but quiet and minimal response. Is alert and orientated to person and time but attempt x 2 for correct place. Will continue to monitor resident frequently and reposition frequently.spoke with (MD M's name) nurse this afternoon in regards to resident condition and skin check. No new orders at this time and will plan to have meeting with (MD M) and resident tomorrow morning. There is no indication that MD M received the message regarding R7's condition or if RN N received a call back regarding R7 after speaking with MD M's nurse. On 12/15/20 at 7:05 PM, R7's Nurses Note written by RN N states in part: Resident vital signs within normal limits but breathing is shallow. She is alert and orientated to self but states (hospital name) when asked of location and unable to determine time or date. Resident has facial grimacing present with any repositioning but unable to state where pain is. Responds very minimally to assessment questions by writer and unable to speak above a whisper. Called MD (name) to update on condition and MD ordered resident to be sent to ER (emergency room ) and evaluated further . (The Physician contacted at this time is not R7's primary care physician. There is no evidence that the facility called to notify R7's primary care provider of R7's change in condition resulting in R7 being sent to the ER) On 12/15/20 at 7:30 PM, R7's Emergency Department Notes, state in part: Physical Exam: .(Temp) (99 degrees Fahrenheit) (respirations) 36, (blood pressure) 182/97, (oxygen) 99% on room air . weight (138 lb. (pounds) 3.7 oz. (ounces)). Physical exam: .she is in acute distress. Appearance: she is ill-appearing. She is not toxic-appearing. Comments: Confused, delirious appearing. HENT (Head, Ears, Nose, and Throat): .mouth: mucous membranes are dry.comments: dried blood on teeth and oral mucosa. Dry mucous membranes. Swollen, tender and [DIAGNOSES REDACTED]tous (red) right parotid area.patient given IV (intravenous fluids) and 3 g (grams) of [MEDICATION NAME] (antibiotic) for suppurative parotitis.clinical impression: 1. Suppurative parotitis. (Infection of the salivary gland) 2. Altered mental status. 3. Dehydration. On 12/15/20 at 10:14 PM, R7's Nurses notes indicate that R7 was transferred to another Hospital. On 12/16/20 at 9:13 AM R7's Hospital General Medicine Progress Note, states in part: she's been confused for the past 2.5 days, difficulty to swallow liquids and solids for 2 days. Swelling on her face was noted starting on 12/13. [MEDICAL CONDITION] due to suppurative parotitis, leading to [MEDICAL CONDITION], dysphagia, some grunting . On 12/16/20 at 1:47 PM, R7's Nurses Note states: Resident admitted to (Hospital name) with Dx. (diagnosis) of Dehydration and infection in right side of face. On 12/16/20 at 3:03 PM, R7's Physician Note, by MD M states in part: S: Scheduled nursing home visit via video conference under COVID quarantine. On Sunday 12/13/20, I was called by (Name of facility) nursing to report pt (patient) had swelling on the right side of her face. No fever or abnormal vitals. She was still able to speak, eat and drink. I instructed them to call the clinic first thing Monday morning to arrange a video conference so I could evaluate her face and determine if she needed antibiotics for possible dental or other infection. This was not done. On Wednesday I called at the time scheduled for our video visit, at which time I was informed the patient had been sent to the hospital last night, then transferred from (name of hospital) to (name of hospital). The charge nurse at (name of hospital) would not disclose much information . but I was able to ascertain that the patient was admitted with dehydration, [MEDICAL CONDITION] and parotitis that required IV Abx (Intravenous antibiotics); she is not able to take PO's (by mouth). I then called patients POA (power of attorney), (name) who confirmed all of the above and also mentioned that the patients [MEDICATION NAME] was being held because she was actively bleeding with even gentle touching of the gums and oral mucosa . On 12/17/20 at 11:03 AM, Email regarding Resident Care Concern, states in part: (Physician name) connected with me regarding a care concern for one of his patients. On Sunday nursing home staff called (physician name) to report a patient had swelling of the right face/cheek. He determined b/c (because) no fever so (sic) didn't think she needed to go to the ER. He instructed nursing home staff he couldn't make a [DIAGNOSES REDACTED]. (appointment) they didn't. Tuesday night she was taken to (hospital name) and transferred to (hospital name) for a nasty infection of the parotid gland in her right cheek. She's dehydrated, delirious, and may end up needing surgery. (Physician name) feels we are dependent on nursing home staff for arranging video visits. Nursing home staff called (physician name) on Sunday to ask for advice then didn't follow through on his request to get a video visit scheduled. He feels if we had started Abx (antibiotics) early it wouldn't have gotten to this point . On 12/17/20 at 4:09 PM, R7's Nurses Note, states in part: .Call placed to (hospital name) spoke with (name) RN. She does remain stable with improvement of less swelling. She does continue to have antibiotics for infection in parotid gland. Today did have a NG (nasogastric) tube placed as she is not taking in adequate nutrition . R7's Facility Investigation provided to Surveyor on 12/28/20 states in part: 12/14/20 .06:00 (6:00 AM) - staff statement by (Licensed Practical Nurses name). Notified DON and day shift RN (RN H) of telehealth visit requested by MD for 12/14/2020. Staff statements by (RN H) states she didn't know the visit was not set up and needed to be.investigation steps: .12/17/2020 11:03 (11:03 AM) Administrator and DON received email from (name, title, physician name) regarding concern for patient (R7's name) and no telehealth visit done/set up on 12/14/2020. (Regional Nurse Consultant's name), DON B, and writer (NHA A) reviewed charting again. (DON B), DON interviewed. Progress note documented on 12/14/20 at 11:29. Writer asked (DON B) is (sic) she did the teledoc visit with (Physician name) and resident. (DON B) indicated she did not, but she was aware it was supposed to happen and so she documented that it was to happen today and she thought (RN H) did the telehealth visit. On 12/29/20 at 10:43 AM, Surveyor interviewed RN N (Registered Nurse) regarding R7. RN N indicated she sent R7 to the ER due to the right side of her cheek being swollen. RN N indicated R7 was never seen by the (Physician name) due to a lack in communication. RN N indicated it was relayed to her that R7 had been seen by a Physician. RN N indicated that R7 was at first taking sips of fluid and that R7 had ice cream brought in for her. RN N indicate after that R7 could not drink without gurgling. RN N indicated R7 was sent to the ER due to changes in swallowing, change in mental status as R7 was not able to talk above a whisper and was not able to say where she was or what was going on. RN N indicated that R7 was assisted with meals due to having a decrease in appetite and was accepting of assistance with meals. On 12/29/20 at 12:45 PM. Surveyor interviewed MD M (Medical Doctor) who is R7's Primary Care Provider (PCP). MD M indicated on 12/13 he was on call that day and had received a call from the Nursing Home. MD M indicated he was told R7 had swelling in her face. MD M indicated he told the nurse to call him first thing Monday (12/14/20) in order to see her. MD M indicated he was working 12/14 and did not receive a call and did not receive a video call. MD M indicated he was working Tuesday (12/15/20) and also did not receive a call from the NH (Nursing Home). MD M indicated on Wednesday (12/16/20) he called the NH and found out that R7 went to the Hospital. MD M indicated that R7 was in the hospital for a parotid gland infection to the right side of her face. MD M indicated that this can happen if it's blocked or due to dehydration. MD M indicated a parotid infection itself is not a problem if caught right away. MD M indicated that R7 had a significant infection and that R7 was not with it, was unable to swallow and unable to be orientated. MD M indicated that R7 passed away yesterday (12/28/20). MD M indicated it was unexpected for R7 to pass away from a parotid gland infection. MD M stated I'm sure she was dehydrated due to probably not eating or drinking from the infection. MD M and Surveyor reviewed R7's meal and fluid intakes. MD M indicated he was not notified of R7's decrease in meals or fluid intakes. MD M indicated he expects to be notified with a decrease in meal of fluid intake over three days. MD M indicated that a provider should have been contacted after three days maximum with a change in intakes. MD M indicated that a parotid gland infection would decrease the amount of moisture, but R7 would still have the other glands (other side of mouth and under tongue) to moisten her mouth. MD M indicated R7 had dry membranes due to dehydration. MD M reviewed R7's labs from the hospital and indicated her labs are better than expected, but at R7's baseline she is completely with it but a little fuzzy at times. MD M indicated that R7's outcome could have been different, if he had been able to see her two days sooner and had been started on antibiotics sooner. MD M indicated he would expect to be notified with any changes from baseline. MD M indicated he gave an order to have them call on Monday and they did not call, which delayed R7's treatment. MD M indicated he never received a call with an update on R7's status or that she went to the hospital until he called the NH on 12/16/20. On 12/29/20 at 6:00 PM, Surveyor interviewed DON B regarding assessments for R7. DON B indicates they have a statement from RN H in their investigation indicating an RN looked at it and indicated there wasn't a change. DON B indicated there is no further documentation in R7's record between 12/13 and 12/15 of an assessment of the area that would include a measurement or description of the area. DON B indicated she would prefer nursing staff to assess the area at least daily. DON B indicated that R7's physician needed to be updated if there was a change or a change in condition with R7. DON B indicated based on R7's documentation in her record, you would not know if R7's swollen jaw had a change. The facility's failure to timely consult with the physician regarding a change of condition created a finding of IJ on 12/14/20 when R7 should have received a telehealth MD visit. The facility recognized the deficient practice and took the following corrective steps to ensure that deficient practice does not occur again: (12/16-12/17/20.) 1) The facility completed an audit to ensure no other residents are affected. a. Audits will be completed daily x (times) 30 days and then weekly x 3 months and then as recommended by QAPI Committee. b. Educated licensed nursing staff on facility change in condition policy and procedure 12/16/20 - 12/17/20. c. On 12/16/20- 12/17/20 education was provided on change in condition & family/MD notification. Education to be provided for all licensed staff on SBAR, POA notification, MD Notification, Recognizing a Change in condition, documentation of a change in condition, notification of RN on call/ duty, and timely writing of physician orders [REDACTED]. d. Administrator and DON are reviewing Facility Activity Report Daily to ensure proper completion of: SBAR, POA notification, MD Notification, Recognizing/ documenting a change in condition, notification of RN on call/ duty, and timely writing of physician orders [REDACTED]. e. Education included how to document family/MD notification, recognizing change in condition - including vital signs, weight loss, and new orders - including medications. Review of what a change in condition would be and documentation requirements. f. Discrepancies will be followed up on and documentation will be verified for completion. g. The Director of Nursing is reviewing the facility progress notes via facility activity report. Records will be reviewed for proper procedure. h. The Nursing Home Administrator and Clinical team will review change in conditions daily. i. Education of license staff of recognizing change in condition and documentation j. Education of staff to update DON or RN designee with all change in condition. 2) The facility will monitor its actions through: a. Audits will be conducted by the DON or designee on the facility activity report, 24 hour nurse board, and facility activity reports. Nursing progress notes for change in condition procedure. Daily on-going. b. Audits will be conducted of change in conditions have been identified timely and notifications have been completed with family/MD. c. Audits will be conducted by DON or designees for change in conditions along with proper notification timely. Daily x's 30 days then weekly x's (times) 3 months and then reviewed at next QAPI meeting for recommendations. 3) Any negative findings will be corrected immediately and referred to QAPI for follow-up. 4) Administrator will monitor to ensure compliance.

Based on interview and record review the facility failed to ensure that each resident receives treatment and care in accordance with professional standards of practice for 1 out of 15 total sampled Residents (R1) R1 is COVID-19 Positive and staff failed to recognize a change of condition in R1, until the NP (Nurse Practitioner) assessed the patient. Facility staff did not assess and monitor R1's condition. R1 was not sent to the ER (emergency room ) per the NP's directive until 8 hours later, by which time R1's condition had worsened, resulting in R1 being admitted to Hospital and passing away. Facility failure to recognize an acute change in condition, failure to closely monitor and assess a Resident with an acute change in condition, and failure to clarify verbal orders with the Nurse Practitioner, which resulted in a delay of treatment and alternative interventions at the hospital created a finding of Immediate Jeopardy that began on 12/4/20. Surveyor notified NHA A (Nursing Home Administrator), DON B (Director of Nursing) and RNC C(Regional Nurse Consultant) of the Immediate Jeopardy on 12/15/20 at 4:05 PM. The Immediate Jeopardy was removed on 12/15/20, however the deficient practice continues at a scope/severity of an E (potential for more than minimal harm/pattern) as the facility continues to implement its action/corrective plan. This is evidenced by: Example 1 Facility policy entitled 'Notification of Change' states in part: .The resident's physician and responsible party must be notified when an event involving the resident occurs or when the resident experiences a change in condition, potential discharge, room transfer or death .adopted the current INTERACT Tools change of condition. When to report to the MD/NP/PA (Medical Doctor/Nurse Practitioner/Physician Assistant) .Assessment: 1. When made aware of a change in condition of a resident the licensed nurse will perform an assessment based on their professional judgement that may include: vital signs; mental status; major diagnosis (i.e. blood glucose check); allergies [REDACTED].Planning: .D . speaks to the Physician/PA/NP utilizing SBAR (Situation, Background, Assessment, Recommendation) communication. Reference and follow INTERACT Care Paths and or change in condition reference tools as applicable . Notify the Physician immediately if the resident requires immediate action. Call 911 in emergency situations: such as unconsciousness .respiratory arrest, unresponsiveness . Notification: 1. Call the Physician and document using the SBAR communication form and/or progress note.5. Notify the Director of Nursing of the residents condition change. 6. The licensed nurse is to provide frequent checks on the residents condition while waiting for a call back from the physician and or NP. Alert the direct care givers of residents condition change and signs and symptoms to be watching for. 6. Once the physician calls back, describe residents condition . Document physician's orders [REDACTED]. Document the residents condition change and new orders on the 24 hr (hour) report log. Outcome evaluation: Monitor and reassess the residents status and response to interventions. The physician should develop a working [DIAGNOSES REDACTED]. Facility Policy entitled '2019 Novel Coronavirus (COVID-19)' states in part: Increase monitoring of ill residents, including assessment of symptoms, vital signs and respiratory status to at least 3 times daily to identify and quickly manage serious infection and consider increasing monitoring of asymptomatic residents to at least every shift to more rapidly detect any with new symptoms.definitions: .moderate illness: residents who have evidence of lower respiratory disease by clinical assessment or imaging, and a saturation of oxygen less than or equal to 94% on room air. Severe illness: residents who have respiratory frequency greater than 30 breaths per minute oxygen saturation of less than 94% on room air (or, for patients with chronic hypoxemia, a decrease from baseline of greater than 3%) . On 12/15/20 at 10:00 AM Surveyor asked NHA A for the facility's INTERACT tools for respiratory changes and temperature changes, Surveyor was not provided any type of INTERACT tools or policy. R1 was admitted on [DATE] and has [DIAGNOSES REDACTED]. R1's Annual MDS (Minimum Data Set) dated 11/9/20 indicates R1 has a BIMS (Brief Interview of Mental Status) of 10 out of 15 which indicates moderate cognitive impairment. R1 requires extensive physical assist of one for bed mobility and limited assist of one for transfers. R1 is indicated as being able to eat independently after setup. R1 is able to understand others and make herself understood. R1's PRN (as needed) Standing Order Form, signed on 11/26/19 by NP D (Nurse Practitioner), states in part: 18. O2 via nasal cannula as needed at 2-4L (liters) for O2 sats less than 90% Notify PCP (primary care provider) within 24 hours of decreased O2 sats . 20 .Notify provider for fever greater than 100 (degrees) or if symptoms not relieved in 3 days . There are no other Standing Order Forms signed by the NP or MD for R1 since 10/6/20 in R1's chart. Surveyor asked for R1's most current signed Monthly Physician order [REDACTED]. R1's Care Plan, dated 12/1/20, states in part: Resident is positive or exhibiting signs and symptoms of COVID-19 infection.Approach: . (12/1/20) administrator respiratory treatments as ordered (sic) . Assess for any shortness of breath, apply oxygen per physicians orders, encourage resident to take deep breaths. Position resident to allow ease of breathing Assess vital signs every 4 hours. Record all vitals and report any changes to the physician.monitor for cough, frequency, changes .record and report any changes in mental status to physician . On 12/1/20, R1's Nurse Practitioner virtual visit note, states in part: .recently diagnosed with [REDACTED]. She denies any acute concerns for me today. She denies cough, fever, chills, (shortness of breath), or chest pain, (nausea/vomiting), diarrhea. Staff do report poor appetite last day. She is more quiet/sleepy and lying in bed, which is outside her norm. Vitals reviewed and noted low grade temp of 99.1.Plan . 2. COVID-19 positive. She appears to be doing well today. Mild low grade temp per NH chart. Will obtain baseline labs for monitoring. Repeat labs is decline (sic), worsening symptoms. Encouraged staff to push fluids . On 12/1/20 at 12:37 PM, R1's vital signs indicate a temperature of 99.1 degrees Fahrenheit with a 02 sat (oxygen saturation) of 95% without the use of oxygen. On 12/1/20 at 6:20 PM, R1's vital signs indicate a temperature of 99.6 degrees Fahrenheit with a 02 sat of 95% without the use of oxygen. On 12/1/20 at 11:59 PM, R1's vital signs indicate a temperature of 99.0 degrees Fahrenheit with a 02 sat of 95% without oxygen. On 12/2/20 at 4:15 PM, R1 had a temperature of 100.2 degrees Fahrenheit. Contrary to standing orders, there is no indication of R1's NP or Physician being updated on R1 having a temp. of 100.2 degrees at this time. On 12/2/20 at 8:53 PM, R1's vital signs indicate a temperature of 99.3 degrees with an 02 sat of 99% without the use of oxygen. On 12/3/20 at 11:41 AM, R1's vital signs indicate a temperature of 99.7 degrees Fahrenheit with an oxygen level of 95% without oxygen use. On 12/4/20 at 9:49 AM, R1's vital signs indicate a temperature of 98.3 degrees and 02 sat. of 92% without using oxygen. Per R1's care Plan R1's vitals are to be monitored every 4 hours, indicating R1's vitals would of needed to be checked at or around 1:49 PM, based on last vitals on day shift. There is no evidence R1 had her vital signs rechecked at or around 1:49 PM. On 12/4/20 at 1:35 PM, R1's Nurses Note, states in part: Conts (continues) with isolation with proper PPE (personal protective equipment) in use. She has had no c/o (complaints of) pain, cough or SOB (shortness of breath). VSS (vital signs stable). On 12/4/20 at 3:21 PM, R1's vital signs indicate a 02 sat. of 84% without using oxygen, a respiratory rate of 18, pulse/heart rate of 110 and a temperature of 98.4 degrees. R1's vital sign documentation indicates an acceptable pulse/heart rate of 50-100 beats per minute and an acceptable oxygen level of 90-100%. The facility did not notify NP or MD of change in R1's vital signs including a significant change in R1's increased heart rate and decreased oxygen saturation. On 12/4/20, R1's NP Visit Note, states in part: Patient was recently seen via virtual visit on Monday. At that time, she was alert sitting up in wheelchair, she denied any acute concerns at that visit. Today, she is much more lethargic. She is not responsive to my presence. Staff are unaware this is a change. Nursing home notes reviewed: previous charted vitals today were WNL (within normal limits) was noted to have a temperature of a 100.2 yesterday. Today on rounds, I find her HR (heart rate) is 110, BP (blood pressure) 146/80, 84% on RA (room air). She is afebrile at 98.4 during rounds.general: the patient appears comfortable and in no acute distress. Resp: non-labored RRR (regular respiratory rate), no rales, rhonchi, wheezing, on room air, O2 sat 84% on RA. CV: (cardiovascular) HR [MEDICAL CONDITION] (high pulse), regular rhythm. Neuro: lethargic, unresponsive . Plan when I came on rounds today, patient does not appear well. This is a change from visit I did virtually 3 days ago. She is quite lethargic, unresponsive, HR [MEDICAL CONDITION], low oxygen sats at 84-86%, RN (Registered Nurse) unaware of change, but states it is a change. Staff are unable to tell me how long she has been like this. Both son and daughter tell me they were unaware she has COVID. RN updated that family would like patient sent to ER for further work up . Electronically signed by (NP D) at 12/04/2020 at 4:36 PM CST. On 12/14/20 at 10:50 AM, Surveyor interviewed CNA G (Certified Nursing Assistant) regarding R1 on 12/4/20. CNA G indicated R1 would look at you and wouldn't talk or respond to you. CNA G indicated they repositioned R1 a lot that day and she would smile but wouldn't look at you. CNA G indicated that R1 was not eating well or drinking. CNA G indicated she worked the AM shift into the PM shift (6 AM to 6 PM) that day and R1 sounded like she was not having an easy time breathing. CNA G indicated they were told if O2 sats were low could go out, CNA G indicated R1's O2 sats were low, and the Nurse on the wing didn't seem to know what to do. CNA G indicated that R1 looked like she was trying harder to breathe than normal the whole 12 hours she was there and R1 did not have oxygen on. CNA G indicated the nurse told her to keep R1 sitting up to increase her oxygen. CNA G indicated that she could not get R1 to eat breakfast or lunch that day and that by supper time R1 couldn't handle anything. CNA G indicated R1 was sleeping all day, and would look at you but no response. CNA G indicated this was different for R1, as R1 was always talking. CNA G indicated she reported it to the AM nurse and to the PM Nurse as R1 was not doing well. CNA G indicated it was like R1 was looking through you. On 12/4/20 at 8:57 PM, R1's Nurses Note, states in part: At start of shift resident was very lethargic. Vital signs were: Temp 98.4 Pulse 110 Resp 18 Oxygen 84%. (sic) Through out the shift fluids were given. 3 containers of apple juice 120 cc (cubic centimeters) each along with ½ (half) bottle of coke, a bottle of Gatorade and 120 cc of nutritional shake. Total intake of fluids this shift is over 600 cc. at this time of 2100 (9:00 PM) residents vitals are as follows: temp 98.0 Resp 18 Pulse 82 Oxygen 90%. Resident is also able to respond when spoken to and resident also gave herself fluid and appeared to be very thirsty. BP 140/80. Resident is resting comfortable with no complaints of pain or shortness of breath. Resident's breathing is deep and quiet, no crackles or wheezes. It should be noted the Nurses Note indicates resident was very lethargic at the beginning of the shift. R1 had just received a visit from the NP with verbal orders given to send R1 to the hospital for further evaluation. Although the nurse documents the lethargy at the beginning of the shift there is no follow-up assessment with a RN, or contact with the NP or MD on this noted lethargy. R1's vitals were not re-checked until 9:00 PM according to R1's Nurses Note. There is no indication of continued assessment or monitoring despite R1 noted to be lethargic at the beginning of the shift. On 12/14/20 at 1:50 PM, Surveyor interviewed CNA L regarding R1. CNA L indicated she worked 4:00 PM to 10:00 PM on 12/4/20 with R1. CNA L indicated that R1 had COVID-19 and was declining. CNA L indicated they were monitoring her O2 sats, but no interventions were put in place that she was aware of. CNA L indicated that R1 would go in and out of it, as sometimes she'd acknowledge us and respond at times and other times tired and not wanting to drink. CNA L indicated that this was not normal for R1. CNA L indicated that R1 was like that the whole shift. CNA L indicated she saw R1 on 12/1/20 and she didn't feel good that day, but wasn't lethargic and was responding, eating and drinking more than she was on the 4th, but was still out of it as she didn't feel good. CNA L indicated she cannot recall R1 having oxygen on. CNA L indicated that the NP did rounds on the hall on 12/4/20. On 12/4/20 at 11:50 PM, R1's vital signs indicate a 02 sat of 75% while resting and no use of oxygen. Respiratory rate of 16 breaths per minute, temperature of 98.1 and a blood pressure of 128/78. On 12/5/20 at 12:31 AM, R1's Nurses Note, states in part: Upon assessment resident was delirious, non-verbal and non-responsive. Resident would open eyes, but did not maintain eye contact or acknowledge presence. Mental status change noted. VS taken BP: 134/44, P: 110 R 10, O2 75% on room air. LS (lung sounds) diminished in lower lobes. Resident is using accessory muscles to breath at this time, SOB noted, MD contacted as resident has had a change in mental status and is having [MEDICAL CONDITION] at this time. New order received from Medical Director to send to ER for further eval and tx (evaluation and treatment), family notified unable to reach POA stated number is disconnected. Son (name) contacted and agreed with transfer to hospital. Ambulance arrived and departed facility at 0035 (12:35 AM). Report called to ER. Awaiting new orders at this time. On 12/14/20 at 11:40 AM, Surveyor interviewed RN H regarding R1. RN H indicated it was reported to her in report that R1 did not have a good afternoon and an aide came to RN H and reported around 11:00 or 11:30 PM on R1's condition and R1 was sent out around midnight. RN H indicated that R1 normally responds and wouldn't even talk to me. RN H indicated she tried a sternal rub and R1 opened her eyes and wouldn't say anything, wouldn't squeeze my hands. RN H indicated she'd never seen R1 like that. RN H indicated that R1 did not have oxygen on. RN H indicated she was unable to put on oxygen on R1 as there was no concentrators available as they were all broken and no portable oxygen tanks available. RN H indicated she did not see anything they could use for R1. RN G indicated there was no order from the Nurse Practitioner, so RN H called the Medical Director and received an order to send to ER. RN H indicated she was told R1 was fatigued and didn't seem herself and that fluids were pushed during PM shift. RN H indicated her assessment wasn't anything like what she was told in report. On 12/5/20 at 12:04 AM, R1's Physician order [REDACTED]. On 12/5/20 at 12:41 AM, R1's Hospital Note, states in part: .brought by EMS (emergency medical services) from (Facility name) for evaluation. Report is that patient recently tested positive for COVID-19. Today, she has had altered mental status, and has not been as responsive as usual, as usually she is very talkative. She has also been hypoxic. It is unclear when exactly symptoms started . there is a note from earlier today by (NP D), Nurse Practitioner, that confirmed that she had been hypoxic with decreased level of alertness throughout the day.Patient did test positive for COVID-19 on 12/01. The note does state that the family would like the patient sent to ER for further workup. That note was signed at 4:30 in the afternoon. It is unclear why the care center waited until 12:30 in the morning to send her to the ER. EMS reports that she was hypoxic on room air when they arrived.ED course: .patient brought in by EMS. Placed on oxygen via non-rebreather to maintain O2 sats. greater than 92%.during ED course, she did say (sic) more awake and alert with oxygen in place. She is given IV fluids judiciously given her respiratory [MEDICAL CONDITION] with COVID-19. Clinical impression: 1. COVID-19 2. Acute [MEDICAL CONDITION] with [MEDICAL CONDITION] .3. [MEDICAL CONDITION] (high blood sugar). (A non-rebreather mask is a medical device that helps deliver oxygen in emergency situations. It consists of a face mask connected to a reservoir bag that is filled with a high concentration of oxygen.) On 12/9/20 at 4:08 PM, R1's Hospitalist Death Summary, states in part: Admission Diagnoses: [REDACTED].positive COVID-19 test on 11/30/20 (exposed to roommate with positive test) had routine nursing home follow-up with (NP D's name) on 12/1/20 initially unlabored breathing in . mood pleasant - speech clear and intact had repeat visit on 12/4/20 with significant change in status, very lethargic, not responsive to presence of NP (NP D) at virtual visit had temperature of 100.2 on 12/3/20. She was noted to be hypoxic and per NP (NP D's) note at 4:36 PM, recommended evaluation in ED (emergency department).(Ambulance Service) called to (Facility Name) and brought patient to ED at 0032 (12:32 AM) on 12/5/20 with significant [MEDICAL CONDITION] on RA (room air) and non-communicative, altered mental status. Patient unable to provide any history. Hospital Course She was hypoxic in the ER and required 12 L of oxygen on non-rebreather to maintain appropriate oxygenation. She was also [MEDICAL CONDITION] with new onset [MEDICAL CONDITION].poor prognosis immediately from her admission. Facility investigation on R1 signed by RNC C on 12/7/20 notes the following: RN F's statement states in part: statement regarding interactions with (NP D's name) on 12/04/2020. This writer had been assisting (NP D) with her visit that afternoon. At around 4:30 PM, this writer and (NP D) were discussing (R1's) health status. At the time, NP D was attempting to contact the resident's family regarding their wishes for the resident in regards to hospitalization . Shortly afterwards, (NP D) related to me that the family would wish for the resident to be sent in if the residents oxygen saturations were still in the 80's and she wasn't doing well. I relayed this to the nurse on the COVID unit (LPN E's name). She informed me that she would go and check on (R1) at that moment. I left the facility shortly after that time. (signed by RN F on 12/9/20) Interview with (LPN E) completed. (LPN E) was keeping resident stabilized. This was a directive she received from (RN F). (RN F) reporting NP told her if residents condition worsened family wanted her to be sent to the ER. Multiple checks and interventions provided to the resident. Resident was able to consume (greater) 600 cc (cubic centimeters) of fluid. During her shift she attempted to contact POA (name) without success. Phone number disconnected. At the end of her shift, she was comfortable with resident's status. Condition improved. Report was given to the oncoming nurse (RN H). RN H's statement, states in part: Statement regarding (R1), I received report from Nurse (LPN E) about resident being lethargic on PM's, also that her pulse was 140 and that O2 sat was 84%. (LPN E) claimed she was dehydrated and had been pushing fluids. After asking (LPN E) if she called and notified the DR (Doctor) about the resident's current status she told me that the resident was stable and there was no need to wake the Dr. up. (LPN E) stated we had an order from (NP D) to send resident out if needed, however there was no order or progress note noted. Upon assessment of Resident I called (Physician name) our medical director for an order to send resident to the ER for further eval and tx (treatment) as she was critical. I never had any contact with (NP D). Ambulance came and took resident to hospital and resident was admitted to (hospital name). NHA A's statement, states in part: 12/9/20 (NHA A's name) Friday 12/4/20. About 5 PM, approached by (RN F) (MDS) that (NP D) was hot to trot. I talked to (NP D) as she was upset to fix it. NP D stated found patient unresponsive and [MEDICAL CONDITION] and sats 84%, proceeded to ask nurse (LPN E) how long she had been this way. Nurse replied she didn't know. Then said nurse had an attitude with her. NP D advised another resident looked rough, Nurse response looked better than 3 days ago. NP D asked why she was not updated 3 days ago. (No) response given. NHA A's typed investigation time line for R1's events on 12/4/20, states in part: On December 4, 2020 at approx. 5 PM, I was approached by (RN F), MDS informing me that (NP D), NP was hot to trot regarding her rounds today. Writer went down to see her to see what was going on. Writer introduced herself as the new administrator and asked what was going on? (NP D) asked for clarification and writer stated, I heard you were upset with some things and I wanted to touch base. (NP D) informed writer that during her rounds today she found (R1) unresponsive, [MEDICAL CONDITION] and her O2 sats at 84%. She stated she asked the nurse how long she had been like this and the nurse didn't know and unable to give her an answer. She stated she was sending her into the hospital for [MEDICAL CONDITION] . December 7, 2020 ~ 11:30 am - writer stopped to check schedule on her way in and (RN H) was at the desk as well. (RN H) informed writer that (R1) was not sent out until after 10 PM on Friday due to decline in condition. December 8, 2020 .2:26 PM - writer retrieved NP note from (hospital name) (computer system) dated 12/4/2020 (NHA A's typed investigation indicates she was aware that R1 was to be sent to the emergency roiagnom on [DATE]. R1 was not sent until after 12:30 AM the next morning.) On 12/9/20 at 11:16 AM, R1's Internal Clinic Message, states in part: she states (NP D) saw the patient on 12/4. In the note, she recommended that patient be seen in ER. The note was signed at 4:30, and patient didn't present to ER until midnight. The patient is expected to pass away. They need to know why there was a delay in sending patient to the ER, and if this needs to be reported. NP D's reply at 11:41 PM, states in part: .the delay was on the behalf of the care center. I saw the patient on rounds and requested transfer right away due to [MEDICAL CONDITION], unresponsive. The family was notified per my note and requested transfer, I am not sure why there was such a delay in transfer and I was not made aware of the delay until this time . (Signed by NP D). On 12/14/20 at 1:10 PM, Surveyor interviewed NP D regarding R1. NP D indicated she saw R1 on 12/1/20 and R1 was looking fine. NP D indicated on the 4th, she came in to do rounds and did her own vitals and R1's oxygen was 84% and she was sleepy, lethargic and then was told she had a temperature of 100.2 the day before and I was not notified of this. NP D indicated she spoke with RN F, who indicated it was a change for R1. NP D indicated after she saw R1 she requested R1 be sent to the ER. NP D indicated she verbally gave an order and did not write an order. NP D indicated she told RN F that R1 needed to be sent out. NP D indicated she is aware that staff had a hard time getting a hold of R1's power of attorney. NP D indicated that R1's family requested she be sent in. NP D indicated she did not write any order for oxygen and has no idea if they started oxygen on R1, as it was her assumption the facility would transfer R1 right away. NP D indicated she left the COVID-19 unit and talked to a nurse, who said it was a change. NP D indicated she requested another set of vitals be completed and is unsure if those vitals were taken as they were not reported to NP D. NP D indicated she was told that R1 woke up and was eating. NP D indicated that staff should have called with R1's change of condition, as R1 had normal vitals documented and on her rounds she R1 had a O@ sat of 84%, unsure of facility staff's accuracy with taking vitals as they never know their patients conditions. NP D indicated that RN F told her she'd check on R1 herself and look at R1, and RN F never updated NP D. NP D indicated that R1 was to be sent out via 911 due to being hypoxic. NP D indicated that if she was notified when R1's change of condition occurred, it could have changed the outcome due to providing COVID-19 treatment sooner, but cannot say for sure. NP D indicated she did not receive a call indicating R1 was COVID-19 positive, didn't find out until doing a visit with R1. NP D indicated she was not notified of R1 having a temperature the day before either, NP D indicated if notifications would have occurred R1's treatment course could have been changed and treatment could have been more timely if staff would of notified with change of condition. On 12/14/20 at 2:04 PM, Surveyor interviewed RN F regarding R1. RN F indicated she was not the nurse on the unit, so she did not physically see R1 but heard she wasn't doing well and was assisting the NP with questions. RN F indicated she tried to help the NP get a hold of R1's family and only able to go off of R1's condition based on what's in their electronic health record. RN F indicated that NP D was on the unit to see Residents. RN F indicated it was her understanding that NP D came to her and said if (R1) is till not doing well and her sats are low in the 80's, to send out. RN F indicated she went to the Nurse on the unit at the time and passed on the message verbally. RN F indicated she told the nurse face to face, through the barrier. RN F indicated she thinks NP D's communication should have been written as an order, and that it was not. RN F indicated they get written orders from providers and don't typically take orders. RN F indicated the nurse on the unit was told and she indicated she was going to check on her. RN F indicated she has no knowledge of an RN assessment being done. RN F indicated an RN assessment is to be done with a change of condition. RN F indicated that a change in mental status and decrease in oxygen saturation would be considered a change in condition and an RN assessment is to be completed. On 12/14/20 at 1:40 PM, Surveyor interviewed LPN E, who was R1's nurse on 12/4/20 regarding R1. LPN E indicated that R1 improved after receiving 600 ml (milliliters) of fluids and her oxygen saturation went up to 90%. LPN E indicated the last time she checked on R1 was around 9:45 PM and provided R1 with a few juices as she was completely dehydrated. LPN E indicated that R1 did not eat any food but R1 was improved as when she came onto her shift, R1's O2 sat was 84%. LPN E indicated the communication skills in the facility are lacking as they used to get shift report and now they no longer get a shift report due to a big plastic sheet barrier being up. LPN E indicated she did not know who was talking to her through the COVID-19 unit plastic barrier. LPN E indicated that she was told by someone through the COVID-19 barrier that if O2 sats (saturations) are down the NP authorized to send to ER. LPN E indicated she has no clue who she was speaking to through the barrier, who spoke with the NP or who provided the information to her. LPN E indicated she had no order to go by. LPN E indicated she is unable to say if R1 was to go in as she was told if the O2 saturation is down and does not improve to send in. LPN E indicated she did not clarify anything with NP D as R1 was improving and that LPN E's understanding was if she got worse to send her in. LPN E indicated she did not know they had an order to send her into the ER now. LPN E indicated that R1's oxygen saturation was at 84% when she got to the facility. LPN E indicated by having R1 at 30 degrees and having her drink fluids otherwise R1 was laying there and out of it. LPN E indicated this was not R1's normal behavior, LPN E indicated R1 is usually in her wheelchair asking when she can go out to smoke and is an active person. LPN E indicated that R1's condition was a change from the last time she saw R1 a week prior. LPN E indicated they are limited on RN's and has no idea if an RN assessed R1 as there was no communication of an RN assessment or who would of done the RN assessment. LPN E indicated she did not see anyone on the unit. LPN E indicated she had no clue the NP was in the building as she never saw her. LPN E indicated she did not see any oxygen started on R1 and has no idea if anyone was notified of R1's 84% oxygen saturation. On 12/14/20 at 3:45 PM, Surveyor interviewed NHA A and DON B regarding R1. DON B indicated they follow standards of practice (SOP) (did not specify what SOP when asked) . DON B indicated that if NP or MD is in house they are expected to write their own orders and sign them. DON B indicated that R1 was positive for COVID-19 on 11/30 and was updated on 12/1 during telehealth visit. DON B indicated that R1's POA was not updated due to number was not working, and attempted. DON B and NHA A did not reply when asked if NP was to be updated on 12/2 with R1's signs and symptoms with having a Temperature above 99.0 twice. DON B indicated it was not understood to be a verbal order that if she gets worse to send her in, viewed it as a communication and not an order. DON B indicated that staff are to call the DON or have an RN come down to assess to determine an improvement or decrease in status or with a change in condition. DON B indicated that the NP was in the facility and should have written the order herself, when asked if staff needed to write a verbal order. DON B indicated that all other MD's that come in write their own orders and enter them into the computer. DON B Indicated they are not able to get ahold of LPN E to interview her about what happened. Facility failure to recognize an acute change in condition, failure to closely monitor and assess a Resident with an acute change in condition, and failure to clarify verbal orders with the Nurse Practitioner resulted in a delay of treatment and alternative interventions created a finding of immediate Jeopardy. The Facility removed the jeopardy on 12/15/20 when it had completed the following: 1) The affected resident no longer resides at the facility. 2) The facility will complete an audit to ensure no other residents are affected. 3) F684 audit notification of changes to ensure changes in condition have been identified & placed on the 24 hour report tool have been instituted. a. Audits will be completed daily x (times) 30 days and then weekly x 3 months and then as recommended by QAPI Committee. b. Educate licensed nursing staff on facility change in condition policy and procedure prior to next working shift. c. On 12/14/20 education being provided prior to next (TRUNCATED)

Based on interview and record review the facility did not ensure Residents maintained acceptable parameters of nutritional and hydration status for 1 of 3 Residents (R) out of a total sample of 15 Residents (R7). R7's nutritional needs were not monitored to ensure she was meeting her estimated daily fluid needs, when she had a change of condition that resulted in hospitalization . This is evidenced by: Facility Policy entitled 'Weight Monitoring,' dated 01/2019, states in part: 4. Procedure: Residents will be weighed monthly in a timely manner (at least by the 10th of each month).Nursing Services is responsible to obtain monthly weights on each resident.The results are given to the DON (Director of Nursing), designee or RD/CDM/RDT (Registered Dietitian/Certified Dietary Manager) for input into the computer. Facility Policy entitled 'Monthly and Weekly Weights,' states in part: .8.3.1 Monthly and weekly weights. Monthly weights: conducted on residents whose weight has been stable from the time of admission to current. Weekly weights conducted on residents that: a. have experienced a significant weight loss\gain as indicated by the weight variance report. b. are newly admitted to the facility regardless of payer. c. are readmitted to the facility. d. Have a gradual weight loss over a period of time.All monthly weights will be transcribed on the weight and vital sign form in the residents medical record . R7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R7's Admission MDS (Minimum Data Set) dated 10/15/20 indicates R7 has a BIMS (Brief Interview of Mental Status) of 14 out of 15 indicating R7 is cognitively intact. R7 needs one person physical assist with supervision for transfers and bed mobility. R7 is indicated as being able to eat independently after set up. Section K indicates R7 weighs 170 pounds and R7 has no difficulties with swallowing or chewing. R7 fell and fractured her hip on 10/27/20 and was hospitalized through 10/30/20 when R7 was readmitted to the facility. R7's MDS dated [DATE] indicates R7 is now moderately cognitively impaired. R7 needs extensive two person physical assist with bed mobility and needs extensive assist of one for transfers. R7 is indicated as needing supervision with eating after setup. Section K indicates that R7 weighs 170 pounds and has no problems with swallowing or chewing indicated. There is no further documentation of R7's weight other than in R7's MDS assessments. There is no evidence that R7's weights are being monitored. R7's Nutrition Care Plan, edited on 11/10/20, states in part: . (at) Nutritional/hydration risk d/t (due to): DM (diabetes mellitus), Chronic back pain,[MEDICAL CONDITION](gastro-[MEDICAL CONDITION] regurgitation disorder) [MEDICAL CONDITION] 1+ bilat. LE (1 plus [MEDICAL CONDITION] to bilateral lower extremities), recent nailing of R (right) hip 11/2020, poor po (oral) intake upon return. Goal: (R7) will receive adequate nutrition/hydration. No s/s (signs/symptoms) signif (significant) wt (weight) loss, no s/s fluid imbalance, surgical wound will show improvement, [MEDICAL CONDITION] to resolve by next review . Approach: .10/12/2020 Assist with meals as needed . diet per doctors order: Regular w/sugar sub (with sugar substitute).10/12/2020 Diet provides > 1920 cc's (greater than 1920 cubic centimeters) of fluids per day.10/12/2020 encourage fluids @ bedside and with activities.honor likes/dislikes . 10/12/20 monitor for signs & symptoms of fluid imbalance (i.e. swelling, shortness of breath, dry mucous membranes, dry skin, poor skin turgor).10/12/20 Monitor meal intake/record.10/12/20 offer substitutes if consumes <50% (less than 50 percent) of meals.10/12/20 weight every month and/or prn (as needed) notify MD of significant change . R7's care plan is not being followed as R7 has not been weighed monthly or as needed. On 11/17/20 at 4:24 PM, R7's Nutritional Assessment Note states in part: Dietitian follow-up for skin. Surgical wound on hip and coccyx wound noted to show improvement. Meal acceptance is unpredictable with variable intakes of zero to 100% of meals without an evident pattern. Diet has been supplemented with mighty shakes TID (three times a day) with meals, .she also is provided with the ordered house supplement 90 ml QID (four times a day) . estimated needs .fluid need -1925 cc. no further additions recommended as needs are readily provided. On 11/21/20 at 5:20 PM, R7's Nurses Note states in part: .Skin is warm, dry, pale, appetite good . R7's December 2020 Physician order [REDACTED]. R7's December 2020 MAR/TAR (Medication Administration Record/Treatment Administration Record) provided to Surveyor has no documentation of R7 receiving any supplements or how much of the supplement R7 consumed. There is no documentation to show R7 even received the supplements per her Physician orders. On 12/1/20 R7's total fluid intake is indicated as 210 milliliters (ml). On 12/1/20 R7's meal intakes indicate R7 ate 26 -50% of breakfast and dinner. There is no documentation for lunch intake. On 12/2/20 R7's total fluid intake is indicated as 60 ml On 12/2/20 R7's meal intakes indicate R7 ate 51-75% of breakfast and 1-25% of lunch. There is no documentation for dinner intake. On 12/2/20 at 12:11 PM, R7's Nurses Note, states in part: .Resident encouraged to drink fluids throughout shift due to no urine output on shift prior. Resident has been drinking adequate fluids today . Of note, per documentation R7 only had 60 ml of fluid intake. On 12/3/20 R7's total fluid intake is indicated as 120 ml. On 12/3/20 R7's meal intakes indicate R7 ate 1-25 % of breakfast. There is no documentation for lunch or dinner intake. On 12/4/20 R7's total fluid intake is indicated as 240 ml. On 12/4/20 R7's meal intakes indicate R7 ate 51 -75% of breakfast. There is no documentation for lunch or dinner intakes. On 12/5/20 R7's total fluid intake is indicated as 120 ml. On 12/5/20 R7's meal intakes indicate R7 ate 51-75% of breakfast and lunch. There is no documentation for dinner intake. On 12/6/20 R7 has no documentation of fluid intakes. On 12/6/20 R7's meal intakes have no documentation for breakfast, lunch or dinner. On 12/7/20 R7's total fluid intake is indicated as 360 ml. On 12/7/20 R7's meal intakes indicate R7 ate 26-50% of breakfast and lunch and 51-75% of dinner. On 12/8/20 and 12/9/20 R7 has no documentation of fluid intakes. On 12/8/20 R7's meal intakes indicate R7 ate 51-75% of breakfast, 76-100% of lunch, and there is no documentation of R7's dinner intake. On 12/9/20 R7 has no documentation of meal intakes for breakfast, lunch or dinner. On 12/9/20 at 9:00 AM, R7's Nurses Note, states in part: MD (medical Doctor) update of positive COVID test from Monday. She is having mild confusion no other symptoms. R7 is indicated as having an infection due to COVID-19, which would increase R7's nutritional and fluid needs. R7 has had multiple days of decreased fluid intake and not meeting estimated needs. The facility did not update the MD of R7's decrease oral intake. On 12/10/20 R7's total fluid intake is indicated as 720 ml. On 12/10/20 R7's meal intakes indicate R7 ate 26-50% of breakfast, 1-25% of lunch and no documentation of dinner intake. On 12/11/20 at 9:49 PM, R7's Nurses Note states in part: Resident remains in bed, decreased appetite, difficult to swallow medication, re-positioned every 2 (two) hours and prn (as needed) to increase comfort. VS WNL (vital signs within normal limits). On 12/11/20 R7's total fluid intake is indicated as 360 ml. On 12/11/20 R7's meal intakes indicate R7 refused dinner. There is no documentation for breakfast or lunch intakes. On 12/12/20 R7 has no documentation of fluid intakes or documentation of meal intakes for breakfast, lunch or dinner. On 12/13/20 at 8:21 PM, R7's Nurses Note, written by an LPN (Licensed Practical Nurse), states in part: writer notes swollen hardness to right upper jaw approximately 4.5 inch x 4.5 inch in size. MD notified N.N.O. (no new orders) at this time. However requests to be called in AM to set up Telehealth visit for 12/14/2020 for possible antibiotic dosing. Vitals remain stable afebrile (fever free). Denies pain/discomfort to site of swelling.Resident took all medication as ordered one at a time with moderate fluids. Appetite noted poor with 25% intake. (R7 has a potential site of infection to her right jaw area, which would increase R7's fluid and nutritional needs in order to fight off an infection R7 already has a COVID-19 infection.) On 12/13/20 R7's total fluid intake is indicated as 120 ml. On 12/13/20 R7's meal intakes indicate R7 refused dinner. No documentation of meal intakes for breakfast or lunch. On 12/14/20, R7's total Fluid intake is indicated as 250 ml. On 12/14/20, R7's meal intakes indicate R7 ate 1-25% of dinner. No documentation of meal intakes for lunch or breakfast. (There is no indication that a Medical Professional such as a Physician or a Registered Dietitian was updated on R7's change in intakes over the past few days.) On 12/15/20 at 4:25 AM R7's Nurses Note, written by a Licensed Practical Nurse, states in part: .Resident noted with muscle guarding and facial grimacing prior to scheduled Tylenol dose as scheduled with positive effectiveness noted. Writer notes resident requires assist with meals and oral intake at this time. Medications were given crushed for comfort in applesauce resident tolerated well. Sips of water encouraged throughout night with total oral intake of 240 cc (cubic centimeters). Repositioning recommended r/t (related to) resident increase in staff assistance.will continue to monitor closely. (R7 is now experiencing pain, is requiring assist with meals and oral intake. There is no indication R7's MD was notified or updated.) On 12/15/20 at 8:20 AM, R7's Nurses Note, written by DON B, states in part: Family notification: Call placed with update that she did have the swelling and that MD seen her yesterday and did not make any changes. Asked to return a call as this needed to be left in a message. R7 was not seen on 12/14/20 by a MD or any type of Medical Provider. On 12/15/20, R7's total fluid intake is indicated as 480 ml. On 12/15/20 R7's meal intakes indicate R7 ate 1-25% of breakfast, lunch and a morning snack. On 12/15/20 at 6:06 PM, R7's Nurses Note, written by RN N (Registered Nurse), states in part: Resident vitals within normal limits this PM shift. Lung sounds diminished. Resident has had one medium void throughout AM shift and thus far none on PM shift.Resident's intake has been poor unless strongly encouraged and assisted by staff. Residents sister in law did come see her via window visit this early afternoon and brought chocolate ice cream which resident ate 75% of. Resident drank med pass (supplement) with early morning medication pass but declined the majority of this at lunch time and only had 25%. This PM shift resident is responding when addressed but quiet and minimal response. Is alert and orientated to person and time but attempt x 2 for correct place. Will continue to monitor resident frequently and reposition frequently.spoke with (MD M's name) nurse this afternoon in regards to resident condition and skin check. No new orders at this time and will plan to have meeting with (MD M) and resident tomorrow morning. There is no indication that MD M received this message regarding R7 from RN N. On 12/15/20 at 7:05 PM, R7's Nurses Note, written by RN N states in part: Resident vital signs within normal limits but breathing is shallow. She is alert and orientated to self but states (hospital name) when asked of location and unable to determine time or date. Resident has facial grimacing present with any repositioning but unable to state where pain is. Responds very minimally to assessment questions by writer and unable to speak above a whisper. Called MD (name) to update on condition and MD ordered resident to be sent to ER (emergency room ) and evaluated further . On 12/15/20 at 7:30 PM, R7's Emergency Department Notes, state in part: Physical Exam: .(Temp) (99 degrees Fahrenheit) (respirations) 36, (blood pressure) 182/97, (oxygen) 99% on room air . weight (138 lb (pounds) 3.7 oz (ounces)). Physical exam: .she is in acute distress. Appearance: she is ill-appearing. She is not toxic-appearing. Comments: Confused, delirious appearing. HENT (Head, Ears, Nose, and Throat): .mouth: mucous membranes are dry.comments: dried blood on teeth and oral mucosa. Dry mucous membranes. Swollen, tender and [DIAGNOSES REDACTED]tous (red) right parotid area.patient given IV (intravenous fluids) and 3 g (grams) of [MEDICATION NAME] (antibiotic) for suppurative parotitis.clinical impression: 1. Suppurative parotitis. (Infection of the salivary gland) 2. Altered mental status. 3. Dehydration. R7 is indicated as weighing 138 lbs on 11/4/20. The facility indicates in R7's MDS that R7 had weighed 170 lbs. This represents a 31.6 lb weight loss between 11/4/20's MDS information and being hospitalized which would indicate a 18.58% weight loss.) On 12/15/20 at 10:14 PM, R7's Nurses notes indicate that R7 was transferred to another Hospital. On 12/16/20 at 9:13 AM R7's Hospital General Medicine Progress Note, states in part: she's been confused for the past 2.5 days, difficulty to swallow liquid and solid for 2 days. Swelling on her face was noted starting on 12/13. [MEDICAL CONDITION] due to suppurative parotitis, leading to [MEDICAL CONDITION], dysphagia, some grunting . On 12/16/20 at 1:47 PM, R7's Nurses Note states: Resident admitted to (Hospital name) with Dx (diagnosis) of Dehydration and infection in right side of face. On 12/16/20 at 3:03 PM, R7's Physician Note, by MD M, states in part: S: Scheduled nursing home visit via video conference under COVID quarantine. On Sunday 12/13/20, I was called by (Name of facility) nursing to report pt (patient) had swelling on the right side of her face. No fever or abnormal vitals. She was still able to speak, eat and drink. I instructed them to call the clinic first thing Monday morning to arrange a video conference so I could evaluate her face and determine if she needed antibiotics for possible dental or other infection. This was not done. On Wednesday I called at the time scheduled for our video visit, at which time I was informed the patient had been sent to the hospital last night, then transferred from (name of hospital) to (name of hospital). The charge nurse at (name of hospital) would not disclose much information . but I was able to ascertain that the patient was admitted with dehydration, [MEDICAL CONDITION] and parotitis that required IV Abx (Intravenous antibiotics); she is not able to take PO's (by mouth). I then called patients POA (power of attorney), (name) who confirmed all of the above and also mentioned that the patients [MEDICATION NAME] was being held because she was actively bleeding with even gentle touching of the gums and oral mucosa . On 12/17/20 at 11:03 AM, Email regarding Resident Care Concern states in part: (Physician name) connected with me regarding a care concern for one of his patients. On Sunday nursing home staff called (physician name) to report a patient had swelling of the right face/cheek. He determined b/c (because) no fever so (sic) didn't think she needed to go to the ER. He instructed nursing home staff he couldn't make a [DIAGNOSES REDACTED]. (appointment) they didn't. Tuesday night she was taken to (hospital name) and transferred to (hospital name) for a nasty infection of the parotid gland in her right cheek. She's dehydrated, delirious, and may end up needing surgery . On 12/17/20 at 4:09 PM, R7's Nurses Note, states in part: .Call placed to (hospital name) spoke with (name) RN. She does remain stable with improvement and less swelling. She does continue to have antibiotics for infection in parotid gland. Today did have a NG (nasogastric) tube placed as she is not taking in adequate nutrition . On 12/29/20 at 7:39 AM, Surveyor interviewed RN H regarding R7. RN H indicated that R7 had no signs and symptoms of infection. RN H indicated that R7 was assisted with meals especially when she was confused. RN H indicated a lot of the time R7 would not want to eat but would drink cold items when she had COVID. On 12/29/20 at 10:43 AM, Surveyor interviewed RN N (Registered Nurse) regarding R7. RN N indicated that R7 was at first taking sips of fluid and R7 had ice cream brought in for her. RN N indicated after that R7 could not drink without gurgling. RN N indicated R7 was sent to the ER due to changes in swallowing, change in mental status as R7 was not able to talk above a whisper and was not able to say where she was or what was going on. RN N indicated R7 was assisted with meals due to having a decrease in appetite and was accepting of assistance with meals. On 12/29/20 at 12:45 PM. Surveyor interviewed MD M (Medical Doctor) who is R7's Primary Care Provider (PCP). MD M indicated on 12/13 he was on call that day and had received a call from the Nursing Home. MD M indicated he was told R7 had swelling in her face. MD M indicated he told the nurse to call him first thing Monday (12/14/20) in order to see her. MD M indicated he was working 12/14 and did not receive a call and did not receive a video call. MD M indicated he was working Tuesday (12/15/20) and also did not receive a call from the NH (Nursing Home). MD M indicated on Wednesday (12/16/20) he called the NH and found out that R7 went to the Hospital. MD M indicated that R7 was in the hospital for a parotid gland infection to the right side of her face. MD M indicated that this can happen if it's blocked or due to dehydration. MD M indicated a parotid infection itself is not a problem if caught right away. MD M indicated that R7 had a significant infection and that R7 was not with it, was unable to swallow and unable to be orientated. MD M indicated that R7 passed away yesterday (12/28/20). MD M indicated it's was unexpected for R7 to pass away from a parotid gland infection. MD M stated I'm sure she was dehydrated due to probably not eating or drinking from the infection. MD M and Surveyor reviewed R7's meal and fluid intakes. MD M indicated he was not notified of R7's decrease in meals or fluid intakes. MD M indicated he expects to be notified with a decrease in meal or fluid intake over three days. MD M indicated that a provider should have been contacted after three days maximum with a change in intakes. MD M indicated that a parotid gland infection would decrease the amount of moisture, but R7 would still have the other glands (other side of mouth and under tongue) to moisten her mouth. MD M indicated R7 had dry membranes at the hospital due to dehydration. MD M reviewed R7's labs from the hospital and indicated her labs are better than expected, but at R7's baseline she's completely with it but a little fuzzy at times. MD M indicated that R7's outcome could have been different, if he had been able to see her two days sooner and R7 had been started on antibiotics sooner. MD M indicated he would expect to be notified with any changes from baseline. MD M indicated he gave an order to have them call on Monday and they did not call, which delayed R7's treatment. MD M indicated he never received a call with an update on R7's status or that she went to the hospital until he called the NH on 12/16/20. On 12/29/20 at 3:00 PM, Surveyor interviewed DON B regarding supplement and fluid intake documentation. DON B indicated that mighty shakes are documented in the meal intakes. On 12/29/20 at 3:10 PM, Surveyor interviewed DM R (Dietary Manager) regarding R7. DM R indicated in order to know if R7 was meeting her needs would be by looking at food and fluid intakes. DM R indicated that RD S is the Registered Dietician for R7. DM R looked at R7's fluid intakes and indicated based on the documentation you would not know if R7 is meeting her estimated fluid needs or not as DM R does not know if the fluid documentation includes daily room water or just meals. DM R indicated that all supplement intakes are added into the fluid intake each shift. DM R indicated she's unaware of the location for staff documentation for supplement intakes or mighty shake intakes. DM R indicated that CNA's document resident fluid and food intakes. DM R indicated there is nowhere for the intakes to flag, if there is a concern or change. DM R indicated the mighty shakes are provided from dietary. On 12/29/20 at 4:10 PM, Surveyor interviewed LPN O regarding R7. LPN O indicated CNA's would chart fluid intakes and that Nurses would chart what was given to them if they were under a push fluid order. LPN O indicated otherwise she does not chart water intake for medication pass unless they're on intake and output. LPN O indicated dietary keeps track of meal and fluid intakes. On 12/29/20 at 4:12 PM, Surveyor interviewed CNA P and CNA Q regarding R7 and fluid intake. CNA P and CNA Q both indicated they document fluids in their electronic computer system. CNA P and CNA Q both indicated there's an option to mark refusal/not taken, did not occur, not here as well as they amount received. CNA Q indicated water is passed on each shift. CNA Q indicated that all water pass and meal intake fluids are added up and charted together per shift. On 12/29/20 at 4:35 PM, Surveyor interviewed RD S regarding intakes and fluids for R7. RD S indicated fluids and calorie needs are estimated upon admission based on admitting [DIAGNOSES REDACTED]. RD S indicated based on his progress note for R7, that R7's needs would like up with 25 ml (milliliters) per kilogram due to R7 having [MEDICAL CONDITIONS]. RD S indicated that R7's estimated fluid needs are 1925 ml, which 80% would come from fluids and 20% would come from food intake. RD S indicated R7 would get approximately 400 ml from her food and would still need 1525 ml through fluid intake itself. RD S indicated that R7 gets med pass supplement of 120 ml three times a day (360 ml), and scheduled water pass of 120 ml three times a day (360 ml) resulting in 780 ml needed from all other fluids. RD S indicated he assumes R7 is being given her supplements and water, unless it's not documented. RD S indicated if fluids are to be given with medication pass it would be on the MAR (Medication Administration Record). RD S indicated that on 12/15 R7 had 480 ml of fluids, on 12/14 250 ml, on 12/13 120 ml, on 12/12 no fluid intake documented, on 12/11 360 ml and 12/10 600 ml of fluid, RD S indicated those amounts are not meeting R7's estimated fluid needs. RD S indicated meal and fluid intakes are used as a tool as there is little value to recoding all intakes unless using it to notice a change of condition. RD S indicated that if a CNA notices a decrease or change in urine it needs to be reported. RD S indicated that signs of dehydration would be dry mucous membranes, poor skin turgor, and a change in consciousness which can all determine inadequate fluids. RD S indicated he should have been notified as soon as staff noticed a change in intake habits. RD S indicated the RD is not responsible for monitoring accuracy of meal and fluid intake documentation. RD S indicated residents are to be weighed monthly unless there is a change in condition or decrease in intakes. RD S indicated that R7 does not have any weights recorded and is not aware of what the facility policy states.

Based on interview and record review, the facility did not ensure that its residents were free from significant medication errors for 1 of 3 residents (R1) reviewed for medication errors as R1 did not receive his scheduled [MEDICATION NAME], a beta blocker (heart medication), for three days. R1 was sent to the ER (emergency room ) and admitted to the hospital for [MEDICAL CONDITION] on 8/12/2020. In the ER and hospital, R1 had a very rapid pulse. R1 was treated with intravenous (IV) medications and transitioned back to the previous oral medications he was on prior to returning to the facility. R1's Medication Administration Record [REDACTED]. This is evidenced by: According to Web MD [MEDICAL CONDITION] with rapid ventricular response is a another term for an irregular heartbeat. When your heart's electrical signals aren't working right, it can lead to a heartbeat that's too fast. This abnormal heart rhythm is what doctors call [MEDICAL CONDITION], or AFib for short. For most people, the faulty signals start in the heart's two upper chambers, called the atria.During [MEDICAL CONDITION], the heart's two upper chambers (the atria) beat chaotically and irregularly - out of coordination with the two lower chambers (the ventricles) of the heart. Sometimes the misfiring signals can also make your heart's two bottom chambers, called ventricles, beat too quickly. That's a specific type of [MEDICAL CONDITION] called AFib with rapid ventricular response. Symptoms of AFib With RVR: Feel like your heart is beating too fast, chest pain, dizzy, faint, short of breath, tired or weak. What Causes AFib With RVR? Electrical signals make your heart beat in a coordinated way. First, the atria squeeze, or contract. Then the signal travels to the lower chambers, or ventricles. They squeeze and pump out blood to your lungs and body. In AFib, these signals don't go out correctly. Instead of contracting, the atria quiver. The flutters are too weak to send enough blood into the ventricles. In AFib with rapid ventricular response, the ventricles also beat too fast. These beats are too weak to push enough blood out of the heart to your lungs and body. What Does AFib With RVR Feel Like? A normal heartbeat is 60 to 100 beats per minute (BPM). In AFib with RVR, your heart rate can reach more than 100 BPM. What Are the Complications? Any type of AFib can lead to a stroke or heart failure. If you don't get treated, over time the condition can damage your heart muscle and lead to heart failure. But the right treatment will bring your symptoms under control and get you back into a healthy rhythm. The facility policy titled, General Dose Preparation and Medication Administration, dated 2017, which states, in part . After medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: Document necessary medication administration/treatment information (e.g., when medications are opened, when medications are given, injection site of a medication, if medications are refused, PRN medications, application sight) on appropriate forms; . R1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's most recent readmission to the facility was on 8/5/20 after a hospitalization for pneumonia. According R1's MAR, R1 had an order for [REDACTED]. R1 also had an order for [REDACTED]. Record review of R1's MAR indicated [REDACTED]. On 8/12/2020, at 12:45 PM, Nurse's notes indicate R1 had a fall and was noted to be confused and SOB (short of breath), Pulse is 140-150. MD notified, new orders received to transfer to ER for further eval and tx. At 7:27 PM, facility Nurse's Notes read, Resident is admitted to (hospital) for [MEDICAL CONDITION] Fibulation (sic) and Mental Status Changes. On 8/12/20, at 3:13 PM, emergency room Provider Progress Notes state that the chief complaint is patient presents with fall. The patient is a [AGE] year-old gentleman with history of [MEDICAL CONDITIONS], type 2 diabetes, [MEDICAL CONDITION], and hypertension. He is on chronic anticoagulation with Eliquis. He presents to the emergency department from (facility) for evaluation. I am given no report from (facility) nor did they call nursing staff. EMS (Emergency Medical Services) gave report that the patient fell more frequently and seems confused and this is all the report they have. The patient cannot provide history in (sic) this severely limits history of present illness. Under physical examination notes, comments state, Heart rate is [MEDICAL CONDITION] and irregular. On 8/12/20, at 3:20 PM, Emergency Department Course notes state, Upon arrival to the emergency department is recommends the patient is in [MEDICAL CONDITION] with rapid ventricular response (RVR) with rate in the 160-170 range. Twelve lead EKG was obtained this demonstrated [MEDICAL CONDITION] with rapid ventricular response at a rate of 156 without acute ST or T-wave changes. IV access established . He is placed on [MEDICATION NAME] (medication to lower heart rate) drip with 15 mg bolus followed by 5 milligram/hour drip . At 4:57 PM, Emergency notes state, Frequent reassessments were made of the patient. He has improvement overall of his rate down to the 110-120 range. Patient remains very somnolent and unresponsive but is protecting airway and has stable vital signs at this time. I feel patient needs admission for observation, further workup, and continued rate control. On 8/13/2020, Physician's Progress Notes during hospital stay read, Subjective: Pt was interviewed in his room alone. He is coming in for [MEDICAL CONDITION] with RVR. Some concern that he is not getting his [MEDICATION NAME] in the nursing home setting over the last 4 days. Patient is not aware whether he is taking it or not. Regardless, responded to [MEDICATION NAME] drip and is in the 80s to 90s now. He denies shortness of breath, chest pain, or palpitations . On 8/14/2020, at 2:32 PM, R1's Discharge Summary signed by the provider indicates R1's admission [DIAGNOSES REDACTED]. R1's Hospital Course Summary states, Patient was brought in with A Fib with RVR. He was started on [MEDICATION NAME] drip and tolerated this well with improvement in his rates. He eventually was switched back to his oral [MEDICATION NAME] which he also tolerated. He was watched for an additional day on oral medications and remained rate controlled. He will return to the nursing home for continued strengthening with no changes in his medications. Physical exam on discharge indicated R1's heart is irregularly irregular with a normal rate. (Of note, R1 was discharged with the same dose of [MEDICATION NAME] as he had been ordered prior to hospitalization , and the medication administration time was changed starting on 8/15/2020 to be given once a morning at 8:00 AM.) On 9/11/2020, Surveyor reviewed the Facility Misconduct Incident Report and Investigation, which indicates the concern regarding R1's medications was reported to MDS/RN L (Minimum Data Set Registered Nurse) on 8/13/2020 by (hospital staff). MDS/RN L then reported it to the interim Nursing Home Administrator, who is no longer at the facility, and the facility began investigating. According to the facility investigation, MDS/RN L retrieved statements from the three Registered Nurses responsible for administering R1's PM shift medications from 8/9/20 to 8/11/20. Statements documented in the facility's investigation summary include the following: On 8/9/20, RN K was assigned to R1: Statement from (RN K) regarding meds for (R1) 8/9/20: RN K stated that he believes to the best of his knowledge that he would have given the HS meds unless the heart rate or blood pressure were out of parameters. (Of note, RN K did not document any vital signs or Nurse's Notes for R1 on 8/9/20. The only Nurse's Note documented for R1 on 8/9/20 was done at 2:18 AM stating R1 rested well all shift with no signs or symptoms of distress. At 1:18 PM, on 8/9/20, R1's pulse was charted as 86/per minute.) On 8/10/20, RN J was assigned to R1 Statement from (RN J) regarding (R1) 8/10/20: Yes, I did give (R1's) HS meds. I didn't sign them out? She stated that she was impressed that he didn't get nauseous afterwards because she was told that he does that. 8/11: (RN J) stated that she was not down that hall 8/13/2020 at 1621 (4:21 PM) 8/19/20 (Handwritten note added to sheet) 11:22 AM T. C. (telephone call) (RN J) re: incident above. No answer. Left message for her to call writer back. On 8/11/20, RN I was assigned to R1: (RN I's) statement regarding (R1) 8/11: Resident had an emesis right before she had arrived. Assisted with cleaning up and then held meds. She was not sure if she gave them later. 8/13/20 at 1500 (3:00 PM) Hand written statement from RN I reads: I (RN I) held (R1's) meds on 8/11/20 on the PM shift due to having GI symptoms and an emesis. I do not remember if I gave them later in the shift. (Of note, there is no documentation in the Nurse's Notes regarding R1 having an emesis or held medications.) According to the facility investigation summary, RN I was interviewed on 8/13/20 and stated she was not sure if she gave the medications or not and when RN I was interviewed again on 8/19/20, RN I stated that she did give him the medications ([MEDICATION NAME] and Atorvastatin) on 8/11/20. On 9/9/20, at 2:30 PM, Surveyor spoke with RN I regarding R1 and the medications in question for 8/11/20. RN I stated that R1 had been back and forth from the hospital and said that, (MDS/RN L) had called me, and I said I don't really remember any specifics. I wish I could. Surveyor asked RN I about the facility's policy on medication administration documentation and what it meant if a blank was left on the MAR, and she stated there aren't supposed to be any blanks ever. RN I indicated that all actions for an ordered medication have a mark for if it is held, refused, etc. not blank. RN I could not specifically recall what type of education was provided by the facility after R1's medication concerns, but stated probably had something about refusals and maybe talked about it at the nurse's station. On 9/9/20, at 3:05 PM, Surveyor spoke with NHA A (Nursing Home Administrator), who began her role at the facility on 8/19/20. Surveyor asked NHA A what she knew of R1's hospitalization on [DATE] and why R1 was sent out, and she stated, What I know is he went in (to ER, then hospital) and they found the MAR indicated [REDACTED]. NHA A did not complete this self-report, but states she did review it along with the related documentation. The facility's investigation summary indicates that During the investigation, we obtained statements from the nurses that were responsible on the days the medications should have been provided. Regardless of their response as to have administered medication or not, it should have been documented in the MAR. Nurses did not document giving the medication in the MAR indicated [REDACTED]. The facility concluded that the concern was substantiated and that all medication provided needs to be documented in the MAR. Of note, not all nurses were educated on the above. R1 did not receive his [MEDICATION NAME], a beta blocker medication which controls heart rate, for 3 days. R1 was sent to the ER with elevated heart rate and was diagnosed with [REDACTED]. Uncontrolled Afib can lead to stroke and/or heart failure.

Based on interview, and record review, the facility failed to ensure that a resident does not develop a pressure ulcer/injury (PU/PI) unless clinically unavoidable and that the facility provides care and services consistent with professional standards of practice for 3 of 7 Residents out of a total sample of 14 Residents (R2, R3, & R1) R2 developed a new pressure injury (PI) that worsened. Staff failed to measure and assess R2's wounds weekly, to contact an MD timely, or implement preventative measures timely to prevent R2's PI from deteriorating /worsening. Facility failure to recognize that R2 was at risk for PI development and failure to implement appropriate proactive interventions led to R2 developing a pressure injury that worsened into a Stage IV. This created a finding of immediate jeopardy that began on 4/3/20. Surveyor notified NHA A (Nursing Home Administrator) of the immediate jeopardy on 8/5/20 at 2:50 PM. The immediate jeopardy was removed on 8/17/20. However the deficient practice continues at a scope/severity of a G (Isolated/Actual Harm) as the facility continues to implement its action plan and as evidenced by the following: R3 developed a PI. Staff did not obtain a treatment order, properly assess or measure R3's PI and failed to provide preventative measures timely. R1 developed a facility acquired Stage II pressure injury (PI) the facility failed to assess and measure the PI. This is evidenced by: Facility policy entitled 'Pressure Ulcer Prevention/Risk assessment, dated 6/2019, states in part: Pressure Ulcer Prevention/Risk Assessment: Purpose: (Name) has established a standardized policy with guidelines that assigns responsibility and provides procedures for identifying residents at risk for pressure ulcers; to provide guidelines for the prediction, prevention and treatment of [REDACTED].identifying residents level of risk for pressure ulcer development. b. implementing preventative/supportive approaches appropriate for the residents identified level of risk. c. preventative measures will be reviewed monthly and with resident change in condition to identify need for change in devices.Residents will have a Braden Scale . performed monthly to determine their risk level. The Braden Scale Score reflects the level of Pressure Ulcer Risk as follows: a. Score of 15-18 reflects Low risk. b. Score of 13-14 reflects Moderate risk. c. Score of 0-12 reflects High risk. Pressure ulcer preventative/supportive approaches will be implemented appropriate to the residents' level of risk and the residents care plan updated to reflect the approaches. Facility Policy entitled 'Pressure Ulcer Prevention/Supportive Approaches,' dated 4/2018, states in part: Establish a 1 or 2 hour repositioning schedule as appropriate to meet the resident's needs. Continue to turn and reposition regardless of the support surface in use as no support surface provides complete pressure relief. Facility Policy entitled 'Certified Nursing Assistant Bath/Shower Audit,' dated 4/2018, states, in part: This facility will routinely monitor the skin condition of all residents during bathing activities which will be provided a minimum of twice a week (unless otherwise requested by the resident/resident representative).The residents skin will be inspected to determine if any skin irregularities are present (place greatest emphasis on bony prominences such as heels, buttocks, head, hips, elbows, coccyx, knees and shoulders). The Certified Nursing Assistant will report to the licensed nurse . At the time of discovery the licensed nurse will: 1. Notify the resident, resident representative, and physician of the skin irregularity. 2. At the time of discovery, a treatment will be initiated in accordance with facility protocols, standing orders or physician directions. 3. At the time of discovery, pressure relieving approaches will be implement as appropriate. 4. Take appropriate action to assure that, as appropriate, the skin irregularity is measured and staged. 5. Implement pressure relieving interventions as appropriate. 6. Document findings and notifications in the medical record . Facility Policy entitled 'Licensed Nurse - Skin condition Discovery and Documentation,' dated 4/2018, states, in part: A complete wound assessment and documentation will be conducted on all skin conditions upon discovery and weekly thereafter until they are healed. Weekly assessments of skin conditions will be documented in the residents electronic medical record . Documentation may include: location, category/stage, size, tissue type(s), color, peri-wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, odor and pain . Notification of Change in Skin condition will be made to the Physician/NP/PA utilizing the INTERACT SBAR communication tool . Facility Policy entitled 'Staging Classification per National Pressure Ulcer Advisory Panel,' dated 4/2018, states, in part: Stage II: Partial Thickness Skin Loss. Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.Category/Stage III: Full Thickness Skin Loss. Full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss . Category/Stage IV: Full Thickness Tissue Loss. Full Thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often including undermining and tunneling . Unstageable: Depth unknown. Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed . Due to multiple management changes staff are unable to answer questions regarding R2 and R3's pressure injuries including interventions, measurements, treatments and root cause analysis. (Pressure Ulcer (PU) and Pressure Injury (PI) will be used interchangeably throughout.) Example 1 R2 was admitted on [DATE] with [DIAGNOSES REDACTED]. R2's Care Plan indicates that R2 requires assist of 2 for transfers (12/09/19) and to provide 2 person assist for toileting (12/13/19). R2's significant change MDS (minimum data set), dated 1/8/20, indicates R2 is at risk for pressure injuries and currently does not have any unhealed pressure injuries. Despite this risk, there was no skin care plan with approaches to reduce the risk of pressure injury development. On 3/12/20 R2's Braden Scale for prediction of Pressure Sore Risk indicates that R2 is at moderate risk with a score of 13. On 3/12/20, R2's Shower Sheet indicates Hole on tailbone. There is no indication that R2's Physician or Resident Representative were notified of R2 having a Hole on tailbone. There is no assessment for R2's skin impairment at this time or treatment orders received. On 3/18/20, R2's Skin Body Assessment indicates weekly wound rounds. R2 has areas of skin impairment to her sacrum/coccyx. Sacral dimple noted to be 0.3cm (centimeters) x (by) 0.3cm x 0.3cm, skin intact to (sic) drainage or redness noted. Order requested for [MEDICATION NAME] BID (twice daily) for bacteria collection prevention. On 3/23/20, R2's Skin Body Assessment, form indicates no areas of skin impairment. On 3/30/20 at 7:18 AM, R2's Nurses Note states in part: .assessed resident sacrococcygeal wound at bedside after CNA completed ADLs. Area is a crater wound, not yet measured but approximately size of a pencil eraser, with dark drainage . slight redness also noted left upper inner buttock distal to current wound. Telephone call to (Name) PA (Physician Assistant) and requested cleanse with NSS (normal saline solution), skin prep periwound area (around the wound), loosely pack [MEDICATION NAME] into wound bed, cover with dry dressing daily and PRN (as needed). No documentation indicating R2's Representative/POA (Power of Attorney) was updated on R2 having a wound. R2's wound size is approximated, and has not been measured since 3/18/20. On 4/2/20, R2's Physician Visit Note states in part: (R2) has been discovered to have a small pressure ulcer sore on her sacrum, about an eraser-head-size lesion with some depth to it. It is soft tissue and it looked like it had been a previous wound that healed with a scar, per the nurse's description.now there is a new skin sore on her bottom. Orders to get [MEDICATION NAME] gauze application for about a week and then perhaps switching over to hydrogel next week and keeping pressure off the area and getting a new cushion for her chair is important to relieve pressure off this area . R2's Physician indicated that R2's wound is a Stage 2 pressure injury. There is no indication that a care plan was developed at this time to address R2's pressure injury or to prevent it from progressing/worsening. Current DON B (Director of Nursing) and ADON L (Assistant Director of Nursing) are unable to provide information to show if R2 received a new cushion. On 4/3/20 at 10:08 AM, R2's Nurses Note states, in part: Wound Care: wound care completed to open area on resident's coccyx. Area is approximately the size of the head of a pencil eraser. Yellow slough noted at wound edges and on old dressing . No documentation indicating that the POA or Physician was updated on having slough in the wound bed. R2's wound per the National Pressure Ulcer/Injury Advisory Panel (NPUAP/NPIAP) would be considered a Stage 3 PI. There is no documentation indicating the wound has actually been measured since 3/18/20. Despite now being a stage 3, there were no changes to the care plan. On 4/8/20 at 12:39 PM, R2's Nurses Note states, in part: Wound Care: writer spoke with DON/Wound certified RN who states to continue current treatment x 1 more week and she will re-assess next week for new treatment. There are no measurements indicated for R2's wound at this time. On 4/9/20, R2's Braden Scale for Prediction of Pressure Sore Risk indicates that R2 is moderately at risk with a score of 13. Braden indicates R2 is chairfast- ability to walk severely limited or nonexistent. Can't bear own weight and/or must be assisted into chair or wheelchair. On 4/13/20 at 2:23 PM, R2's Nurses Note states, in part: Wound Care: .measures approximately 0.7cm x 0.8cm and is approximately 0.6cm in depth. Peri-wound is pink and intact without signs of maceration. At approximately 12 o'clock to 3 o'clock .adherent yellow slough is noted in wound bed. No odor is noted, and serosanguineous (clear blood tinged fluid) drainage was noted on old dressing . Facility DON/WCC RN (Wound Care Certified Registered Nurse) to assess wound this week for new/further treatment orders. There is no documentation to indicate that the Physician or Responsible Party were updated on R2's wound having slough present in the wound bed on 4/3 or 4/13. There is no indication of what stage R2's PI is at this time. Last measurement was on 3/18/20. On 4/13/20 at 3:26 PM, R2's Nurses Note states, in part: IDT present to discuss care. Therapy continues to work with resident. Continues to work on transfers. Varies from max to min (minimum) assist. Therapy is working on range of motion in legs. Resident is not appropriate for the (stand lift). Therapy does not believe that resident will be appropriate for discharge . R2's Quarterly MDS dated [DATE] indicates that R2 is severely cognitively impaired, requires extensive two person assistance with bed mobility, transfers and toileting. R2 is at risk for pressure injuries and currently has one Stage II pressure injury. On 4/17/20 at 4:43 AM, R2's Nurses Note states, in part: Wound Care: .area noted to be getting smaller and is filling in. New open area noted just above current area. New area presents as slit and measures approximately 0.6cm in length. Barrier cream applied to this area for protection . No documentation to indicate that R2's Physician or Responsible Party was updated on R2 having a new open area or that a treatment order was obtained. On 4/21/20 at 4:50 AM, R2's Nurses Note states, in part: Wound Care: Area to Sacrum/coccyx continues to show signs of improvement. Area measures approximately 0.6cm x 0.8cm x 0.4cm. Small amount of adherent yellow slough noted from 12 o'clock to 1 o'clock in wound bed. No odor or other signs of infection noted.small slit above current open area remains, but is showing signs of improvement . On 4/24/20, a fax was sent to R2's Physician, stating We have treatment orders currently for lightly packing [MEDICATION NAME] gauze into a sacrococcygeal wound. Area is significantly improving and no longer requires packing. Area does have some slough. Can we change treatment to medi-honey to wound bed, cover with border foam dressing change daily and PRN? Nurse Practitioner responded on 4/27/20 with Yes. This fax/order was not noted or started by staff until 4/29/20. There is no documentation of R2's pressure injury being assessed or measured for 14 days between 4/21 and 5/6/20, in which R2's wound worsened. There is no indication R2's Physician or POA/Representative was updated. R2's wound was not assessed or measured during this time. On 5/6/20 at 6:27 PM, R2's Nurses Note states, in part: This RN called to residents room. CNA's at bedside performing incontinence care found wound previously noted with healing evident now deteriorated. Complete wound area 5.4 x 3.2cm and primary wound 3.0 x 3.2cm black firm eschar covered with unknown depth. Slightly distal to main wound is resident's dimple which is 1.0 x1.0 x 0.6 with redness noted within punch-hole type wound. Total 13 x 6.8cm surrounding redness, inflammation. Resident is incontinent of B&B (bowel and bladder). Requires total cares with her ADL's (Activities of Daily Living) and positioning. Has had slight weight loss noted. Order received 5/5/20 for OT d/t possible decline in ADL abilities. Telephone call to (Physician Assistant) and orders for low airless (sic) mattress, Prosight BID (twice daily) during wound healing duration, [MEDICATION NAME] 1 packet QD (daily) and house supplement 60cc BID along with Santyl to clear/debride eschar . Telephone call to POA-HC (Power of Attorney for Healthcare) . Instruction, education with CNA staff to position resident on her back only during meals or to be on her left/right side when not eating. On 5/6/20, R2's 'Skin Integrity Event - *New or worsened Pressure Ulcer' form states: What new interventions will be implemented to promote healing and prevention of further wound development? The following interventions are marked: Dietary Supplements and/or vitamins and minerals ordered, fortified food in diet, turning/repositioning schedule, wound treatment as ordered by physician, pillows to position resident, other - low air loss. Evaluation Notes section states, in part: .resident with DX (diagnoses) to include left femur fx (fracture), weakness, anxiety, hemorrhagic [MEDICAL CONDITION], Alzheimers, [MEDICAL CONDITION], h/o (history of) open wound with healing. Requires total care with all ADLs and positioning/transfers. Appetite diminishing, weight loss noted. Open wound worsened in short amount of time including development of eschar covering, requires debride/removal to fully assess wound and determine most effective treatment. RD (Registered Dietitian) involved. Wound care nurse involved. POA-HC updated. Interventions: added [MEDICATION NAME], low air low, Rojo, (sic) avoid sitting up in chair except for meals. (Prosight, [MEDICATION NAME], and house supplement are different types of nutritional supplements. Rojo is intended to be Roho. A Roho cushion, is an inflatable cushion for wheelchairs. Low air loss is a mattress composed of multiple inflatable air tubes that alternately inflate and deflate.) There is no indication a Care Plan has been initiated or updated at this time. On 5/6/20, R2's 'Braden Scale for Prediction of Pressure Sore Risk' indicates R2 is very high risk with a score of 8. Indicates R2 is now bedfast (confined to bed most or all of the time). On 5/7/20 at 4:03 PM, R2's Dietary Manager's Progress Note states, in part: (R2) has lost 5#s/11.3% (5 pounds or 11.3 percent) in 30 days. She had remained pretty stable and had a sudden drop. Nursing to notify MD of change of condition will review upon next visit. Will continue to monitor. On 5/7/20, R2's Physician Visit Note, states, in part: .They did send me some requests for OT to help with getting patients position better to take the pressure off her sacral sore.Assessment/Plan: #1 Pressure Injury, sacral Ulcer, unspecified stage . On 5/12/20, R2's Weekly Pressure Ulcer Progress Report states, in part: In house acquired.Stage Unstageable. Size - length cm x width cm x depth cm: 8cm x 6cm x undetermined depth. R2's wound is indicated as having a moderate amount of green, foul exudate (drainage), with foul wound odor. R2's periwound redness is 16cm x 15cm, previously separate fistula area is not encompassed within base of wound at 6:00. Continue with current Santyl to debride necrotic tissue daily and as needed. Progress section indicates softer necrotic eschar removal can lead to healthy tissue and possible healing. Notification section indicates that R2's Physician and Representative were last updated on 5/6/20. R2 has no evidence of having a fistula: R2 had evidence of an area presenting as a slit previously. On 5/16/20, R2's 'Weekly Pressure Ulcer Progress Report' indicates R2's sacrum wound measures 6.2cm x 5.4cm x 4.2cm depth with 3cm of undermining from 11 o'clock to 6 o'clock. R2 has copious amounts of purulent drainage/exudate with a foul wound odor. R2 is indicated as losing weight. Treatment order is Santyl and the wound progress is indicated as other. Turning every 2 hours is indicated along with low air loss mattress and Roho cushion. R2's Physician and Representative were last updated on 5/15/20. On 5/16/20 R2's Care Plan states in part: Problem Start Date: 05/16/2020, Category: Pressure Ulcer. Impaired skin integrity related to limited mobility, incontinence, poor appetite, weight loss and pressure injury wound to sacral-bilat buttocks with evidence of purulence.Approach: .05/16/2020 Turn and reposition at least every 2 hours as tolerated. R2's wound has been present since 3/12/20 and her Care Plan was not initiated until 5/16/20. On 5/17/20 at 2:14 PM, R2's Nurses Note, states, in part: Wound care. Large amount of lite yellow drainage, drained out of wound, while patient was assisted in dressing this AM. Wound with necrotic tissue, odorous, redness around wound edges and pain noted to patient . On 5/19/20, R2's Shower sheet indicates Large open sore. On 5/20/20, R2's Weekly Pressure Ulcer Progress Report indicates a Stage 4 in house acquired pressure injury to sacrum/buttock area. Area measures 6.5cm x 4cm x 3.4cm with undermining of 3.4cm. Moderate decreased purulent drainage/exudate, with slightly foul wound odor. Peri-wound slightly red. On 5/20/20 R2's Care Plan states in part: Problem start date: 05/20/2020, Resident is at risk for skin breakdown R/T (related to) current pressure ulcer, weight loss, cognitive impairment, urinary and bowel incontinence, use of medications, advanced age, anxiety, [MEDICAL CONDITION], poor safety awareness.Approach: Approach Start Date 05/20/20 . Use air mattress for pressure reduction when resident is in bed.use Broda for pressure reduction when resident is in chair. On 5/22/20, fax sent to R2's Physician requesting wound vac orders. Orders: 1) wound vac to sacral/buttock wound. 2) Cleanse wound with normal saline or wound cleanser. 3) Apply xeroform to wound bed. 4) Apply skin prep to periwound. 5) Use black [MEDICATION NAME] dressing on top of xeroform. 6) Change dressing 2-3 times per week at discretion of facility wound certified treatment nurse. (A wound vac is a dressing that uses negative pressure therapy to help with wound closure.) On 5/27/20, R2's Weekly Pressure Ulcer Progress Note indicates Stage 4 in house acquired pressure injury to sacrum/buttock area. Measurement of 7.1cm x 5.0cm x 3.0 cm with undermining from 11 o'clock to 2 o'clock measuring 3.0 cm and 2.7cm's at 3 o'clock. R2's wound has moderate liquid brown- red drainage with a fecal odor to wound. Treatment ordered is wound vac 3 times per week, with nutritional supplements, low air loss mattress, roho cushion in wheelchair and R2 is fed by staff. On 5/29/20, R2 receives orders from the wound clinic as follows: 1. Discontinue wound vac, 2.apply santyl to areas of slough. 3. 0.9 % normal saline and 4x4 gauze in wet to dry fashion daily for 2 weeks. Return in 2 weeks' time. On 6/3/20, R2's Weekly Pressure Ulcer Progress Report indicates Stage 4 in house acquired PI (pressure injury) measuring 8.8cm x 5.7cm x 3.4cm with undermining at 10 o'clock of 2.4cm, at 11 o'clock 2.8cm and from 3 o'clock to 5 o'clock 3.2cm. R2 has moderate purulent drainage with foul odor to wound. Turn and reposition every 1-2 hours. On 6/4/20, R2's Physician Visit note for a Telemedicine visit states, in part: Stage 4 sacral decubitus . She has been getting a wound vac which quickly changed over a course of a week with increased necrosis, drainage and malodorous discharge. There is a 6.4 x 6.5 x 2.4cm size ulcer with undermining that exists from 10:00 to 2:00 position which measures 2 to 1.5cm. There is [DIAGNOSES REDACTED] (redness) around the periphery. Necrotic tissue slough is exposed down to bone with invasion of the periosteum.Cultures are obtained . (Periosteum is a dense layer of vascular connective tissue covering the bones except at the surfaces of the joints.) On 6/10/20 R2's Weekly Pressure Ulcer Progress Report indicates Stage 4 pressure injury to sacrum that measures 8.5cm x 6cm x 3.2cm with moderate purulent drainage. Redness to the periwound, with maceration around wound edges. Foul wound odor, with darkness scattered throughout wound bed, bone evident in wound bed, foul odor, recent sharp debridement at wound clinic. Indicates turning every 1 to 2 hours and a Roho cushion and low air loss mattress. On 6/12/20, a Fax sent to R2's Physician, indicates that R2 has lost 19 pounds or 14.8% in 155 days and has had a loss of 28 pounds or 20.5% in 86 days. R2 is receiving Plus 2, [MEDICATION NAME], Magic Cup and Med Pass nutritional supplements. On 6/12/20, R2's Wound Clinic note states, in part: Wound with exposed bone. Less necrotic tissue than when initially seen some purulent drainage which was irrigated out. On 6/12/20 R2's Braden Scale for Prediction of Pressure Sore Risk indicates that R2 is incontinent and bed bound and that she is very high risk with a score of a 9. On 6/15/20 at 10:11 AM, R2's Nurses Note, states, in part: Dressing change to coccyx completed. Outside edges of wound now with black coloration, continues to have slough and purulent drainage with odor. DON notified. Resident moans when wound is being cleaned . On 6/18/20, R2's Weekly Pressure Ulcer Progress Report indicates Stage 4 in house acquired pressure injury to sacrum. Measuring 7cm x 7.2cm x 2.5cm with undermining of 4.2cm from 9 o'clock to 4 o'clock. R2's wound has moderate amounts or purulent drainage with a foul odor. R2's wound is noted to have darkness scattered throughout wound bed, bone evident in wound bed, foul odor, dark rim edge from 6 o'clock to 10 o'clock, with peri-wound having redness. Reposition on to sides every 1 -2 hours and on back/buttocks for meals. On 6/19/20 at 5:11 AM, R2's Nurses Note, indicates that on routine rounds R2 was found not breathing and no heart sounds. On 8/4/20 at 12:07 PM, Surveyor interviewed ADON (Assistant Director of Nursing) L regarding R2. ADON L indicated that moisture associated skin damage cannot have slough present. ADON L indicated that open wounds are to be measured once a week, staged and assessed by an RN (Registered Nurse). ADON L indicated that R2's wound on 4/3/20 would be a Stage 3 pressure injury due to slough. ADON L indicated the DON (Director of Nursing) at the time did wound rounds. ADON L indicated on 4/13/20, R2's wound would be considered a Stage 3 due to slough being present. ADON L indicated that R2's wound on 5/6/20 would have been an Unstageable pressure injury. ADON L indicated she was unable to say if the facility's standard mattress is appropriate for a Stage 3 or Unstageable pressure injury. ADON L indicated she is unable to say what the root cause is for R2's Pressure Injury. ADON L indicated she is unable to say when R2's mattress was changed to a low air loss mattress (air mattress) as she's unable to find documentation. ADON L indicated she is unable to provide wheel chair cushion information as she is unable to find documentation of R2's cushion being changed. ADON L indicated wounds are to be measured and assessed at least every 7 days. ADON L indicated they're unable to get R2's cause of death or death certificate from R2's Physician. On 8/4/20 at 1:57 PM and 8/5/20 at 11:14 AM, Surveyor placed a call to R2's Primary Physician to reach out about R2's wounds and cause of death. Surveyor left a message with Clinic staff and R2's Primary Physician has not returned the Surveyor's call. On 8/4/20 at 6:00 PM, Surveyor interviewed DON B regarding R2. DON B indicated that staff were to notify if wound odor is present. DON B indicated she questioned herself after reviewing R2's charting why staff didn't update the Physician with odor or with the change in wound status. The failure to recognize that R2 was at risk for PI development and failure to implement appropriate proactive interventions led to R2 developing a pressure injury that worsened into a Stage IV created a finding of Immediate Jeopardy. The facility removed the jeopardy on 8/17/20, when it had completed the following: * Affected resident no longer resides at the facility. * The facility will complete a skin sweep all current residents to ensure no other residents are affected. * On 8/4/2020 the Nursing Staff did a full house skin sweep to identify residents at risk for skin breakdown and with skin breakdown. * Policy and procedure will be reviewed and revised as needed wound care and skin care. * On 8/4/2020 RN assessed Residents with wounds and documented findings. * On 8/4/2020 Residents at Risk for PI and with PI had care plans updated with revision dates. Interventions reviewed and implemented for PI prevention and healing. *On 8/4/20 education being provided to all nursing staff prior to next shift worked on wound care and skin care policy and procedures, wound staging and assessment, immediate notification of MD if wound deteriorates or id (sic) failing to progress toward healing, interventions for prevention and promote healing, interventions are in place. Educate on care plan updating/revision date with any skin changes, weekly skin observation, use of shower sheets, notification of MD and POA, identification of skin concerns, when to notify the RN, how to get a treatment order, education on follow up on wounds, residents who develop wounds will be assessed by IDT to ensure interventions are in place immediately. Call with change in condition no faxing. The following will commence immediately on 8/4/2020 and all dates forward: * The director of nursing will review shower sheets daily to follow up on any concerns not reported. The Director of Nursing with (sic) do RN assessment weekly of wounds and document in medical record, including measurements and description. * Notification in change of condition will be phone to the MD immediately per recognized standard of practice. Standard of practice AMDA/interact. The facility will monitor its actions through: * Audits will be conducted by the DON or designee daily of shower sheets for skin concerns daily. * Audits will be conducted on MD/POA notification daily during clinical meeting. * Audits will be conducted during guardian angel rounds to ensure interventions are in place. * DON or Designee RN will audit actual PI's/wounds daily x 7 days then weekly. * Audits will be conducted of RN assessment including measurements, description and documentation is done at least every 7 days weekly for all wounds/PI per NPUAP and reviewed by QAPI. * Care Plans will be audited daily x2 weeks then weekly x's 4 weeks or as directed by the QAPI committee to ensure care plan interventions for prevention and healing are in place with dates. Any negative findings will be corrected immediately and referred to QAPI for follow-up. Administrator will monitor to ensure compliance. The deficient practice continues at a scope/severity of G based on the following example: Example 2 R3 was admitted on [DATE] with [DIAGNOSES REDACTED]. R3's ADL Functional/Rehabilitation Potential Care Plan indicates a start date of 10/29/19, with approach of Resident prefers to sleep in her wooden chair versus bed (10/29/19). Resident will complete pivot transfers from wheelchair to and from chair in room with front wheeled walker, with caregiver assist of 1 and gait belt. Pressure Ulcer Care Plan indicates start date of 10/29/19, with approaches that include ensure resident is repositioned every two hours, position with pads/cushions to prevent pressure as needed, pressure-reduction wheel chair cushion, and provide pressure-reducing mattress. On 4/9/20, R3's 'Braden Scale for Prediction of Pressure Sore Risk' indicates that R3 is at risk with a score of 16. R3's Quarterly MDS (minimum data set) dated 5/5/20 indicates R3 has a BIMS (Brief interview of mental status) of a 3 out of 15, indicating R3 is severely cognitively impaired. R3 requires one person physical assist with bed mobility, toileting and transfers. R3's weight is indicated as being 115 pounds with weight loss while not on a physician prescribed weight loss regimen. Section M indicates that R3 is at risk for Pressure injuries (PI) and currently does not have a PI. On 6/15/20, R3's 'Braden Scale for Prediction of Pressure Sore Risk' indicates that R3 is at risk with a score of 18. On 6/15/20, R3's 'Skin Condition Report (non-pressure sore)' indicates right lower buttock shearing. Measuring 1.8cm x 0.4cm x 0.1cm, described as shallow, shearing, deep pink base, grey thin frail ruffled skin edges to wound. On 6/19/20 at 12:58AM, R3's Nurses Note states, in part: Resident has an approx. (approximate) 1/4 (quarter inch) diameter open area on R (right) buttock, cleansed and (brand name) drsg (dressing) applied. R3 was identified as having skin impairment on 6/15 described as shearing which is now an open area on 6/19, and there is no indication of a treatment order, Physician notification or Resident Representative being notified of R3's skin impairment. A dressing was applied on 6/19/20 without a Physician order. There are no other interventions added to R3's Care Plan since 10/29/19 for preventing/reducing R3's Pressure Injury risk since noting R3's skin impairment on 6/15/20. On 6/22/20 at 6:54 AM, R3's Nurses Note states, in part: Resident continues to c/o (complain of) discomfort due to open area of .5 (0.5) on right buttock. Open area noted on 6/19/20 by night nurse. No treatment noted for open area. MD faxed treatment requested. On 6/22/20, R3's APNP (Advanced Practice Nurse Practitioner) response fax to facility states, in part: 1. Please offer nutritional supplement Boost or Ensure TID (three times a day) with meals for weight loss concerns. 2. Update if further weight loss and will consider adding [MEDICATION NAME]. Any depression concerns? 3. for right buttock: any measurements you can provide? Any slough present? For treatment: Cleanse daily with wound cleanser, pat dry. Apply collagen and cover with foam dressing, change daily and prn (as needed) if soiled. Update in 1 week o (TRUNCATED)

Based on interview and record review the facility failed to ensure each Resident has the right to be free from abuse and neglect for 1 of 5 Residents out of a total sample of 14 residents (R4). R4 was left for several hours sitting in her own BM (bowel movement) due to staff not assisting R4 with her personal hygiene. This is evidenced by: Facility Policy entitled 'Abuse Prevention Program,' states, in part: Definitions: Abuse,' is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation of an individual, including care taker, of goods or services that are necessary to attain or maintain physical, mental and psycho-social well-being . Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.willful, defined as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Type of abuse & indicators . Neglect/deprivation of goods and services by staff. Abuse also includes the deprivation by staff of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Caregiver have been determined to have knowledge and ability to provide care and services, but choose not, or acknowledge the request for assistance from a resident(s) and intentional or willfully fail to provide goods or services, that result in care deficits to a resident(s). R4 was admitted on [DATE] with [DIAGNOSES REDACTED]. R4's Quarterly MDS dated [DATE] indicates R4 is severely cognitively impaired but is independent with bed mobility, transfers, walking and toileting. R4's Care Plan, states, in part: Approach start date: 09/12/2018 Staff to assist with toileting and cleaning after incontinence. Approach start date: 09/04/2019 Provide assistance for toileting upon rising, before and after bed and every two hours as resident will allow.provide incontinence care after each incontinent episode. Document refusal of cares. R4's Care Plan, indicates that she needs help toileting and with incontinence episodes, which the staff failed to provide to R4 when she needed it on 3/19/20. On 3/19/20 at 10:19 PM, R4's Nurses Note, recorded as late entry on 3/20/20 at 8:38 AM, states: Reported to writer by NOC (night) CNA (certified nursing assistant) the previous shift had reported off resident had dried BM (bowel movement) on her clothing, floor, room walls, sink and bathroom. Writer immediately had two CNA's come with to check on resident in her room. Writer found the resident's clothes and socks were covered in dried BM, it was in her hair and under her nails. Writer also observed dried BM on resident's bedding, floor, sink, bathroom toilet and floor. Writer had CNA's take resident into the shower and writer cleaned resident room, swept and mopped the BM off the floor along with cleaning the residents bathroom and wipe down the bed and changed the sheets. Resident was cooperative with the cares and shower, two night CNA's and writer spent an hour cleaning resident up. Resident had lotion applied to skin, her hair and body cleaned of dried BM. Resident's walker was also cleaned of BM. Per AM CNA's it was reported to management, around supper time and they were advised per DON to give resident a tub bath in AM on 3-20-20. There is no indication in R4's record R4 refused to have staff assist her or refused to take a shower on 3/19/20. Staff were not following R4's care plan, as she did not receive cares for several hours. On 5/7/20, R4 was discharged to another facility. On 8/4/20 at 10:09 AM, Surveyor interviewed CNA N regarding R4 having dried BM on her person. CNA N indicated she came in on the night shift at 10:00 PM and a PM shift CNA (CNA O) told her the PM girls refused to clean her (R4) up due to it being the end of shift. CNA N indicated she talked to CNA P the next morning who stated to her Yeah, I have to clean up (R4), she's a mess. CNA N indicated she informed CNA P R4 was cleaned up on night shift. CNA N indicated she was told by CNA P the DON (former DON) told them to leave R4, because she doesn't like to bathe. CNA N indicated the BM was dried on R4, when staff had found her like that at supper time. CNA N indicated R4 was left covered in her own feces until at least 12:00 or 1:00 in the morning, when night shift showered her. CNA N indicated it was about 11:30 PM when it was reported to her R4 was covered in BM. CNA N indicated no one from the facility questioned her regarding this incident. CNA N stated, This was neglect. (The night shift nurse and the DON whom CNA N is referring to no longer work at the facility thus were not interviewed.) On 8/4/20 at 10:23 AM, Surveyor interviewed NHA A regarding R4. NHA A indicated she was aware of the situation as she had been notified by the Night nurse in the morning on 3/20/20. NHA A indicated on the afternoon of 3/19/20 the DM (Dietary Manager) came and notified her of an issue with R4. NHA A indicated she reported to the former DON R4's room was a mess, with BM on the floor and R4 needed care and the room needed to be cleaned. NHA A indicated she passed this on to the former DON to take care of on 3/19/20. NHA A indicated the next day (3/20/20) the night shift nurse came into my office first thing when I got here, She was livid about the condition of (R4). NHA A indicated the night nurse did talk about dried BM and the state of her room. NHA A indicated she again talked to the former DON on 3/20/20, who indicated she would take care of it. NHA A indicated she personally did not investigate this situation as she turned it over to the former DON. NHA A indicated after the fact, looking back it could be a potential incident of neglect. NHA A indicated if a resident keeps refusing, she doesn't look at it as neglectful. NHA A stated Of course not, when asked if a reasonable person would want to sit in or have BM all over their room. NHA A stated No, indicating it is not appropriate to leave a resident sitting in BM. On 8/4/20 at 12:25 PM, Surveyor interviewed CNA O regarding R4. CNA O indicated she worked night shift with R4, and R4 is very hard to take care of. CNA O indicated while getting report for the night shift, she was told R4 had a BM in the morning and AM shift refused to clean her. CNA O indicated PM shift said they did not clean her up either. CNA O indicated R4 was not provided care for approximately 12 to 16 hours sitting in her own BM. CNA O indicated when they went into change and shower R4, there was BM all over the floor, bed, walls and R4. CNA O indicated it looked like R4 had bathed in it. CNA O indicated staff were told not to give R4 a shower unless management is with them as R4 can be combative. CNA O stated Not an excuse to let a resident sit in stool for 12 to 16 hours. CNA O indicated this was reported to the Nurse, who wrote a note and reported it to NHA A and the former DON. CNA O indicated they informed AM shift of the situation, the staff on were the same staff who were supposed to bath her the day prior. CNA O indicated no one from the facility had followed up with her regarding the situation. CNA O indicated night shift is the only shift giving her showers because days and PMs won't do it. CNA O indicated once R4 was in the shower she calmed down and R4 loves showers. CNA O indicated the night R4 was covered in BM they went in around 12:00 AM and were not done until after 1:00 AM. On 8/4/20 at 2:09 PM, Surveyor interviewed CNA P regarding R4. CNA P indicated R4 has had a few occurrences with feces on her person. CNA P indicated it's hard to get her in the shower. CNA P indicated she went to the DON (at the time). CNA P indicated she found out R4 needed to be showered when taking in meal tray, on day shift. CNA P indicated the BM could have been from nights or am shift. CNA P indicated R4's room needed to be cleaned of BM often and takes more than one aide to give her a shower. CNA P indicated she came in (3/20/20) and the Night shift staff were mad about the directions, I got from the DON. CNA P indicated she can't remember exactly what the DON told her. CNA P indicated she knows she was supposed to give her (R4) a bath the next day (3/20/20). CNA P indicated she worked day shift into PM shift on 3/19/20. On 3/19/20 multiple staff members had knowledge R4 required personal hygiene assistance including AM and PM Shift staff, NHA A and the former DON. However multiple staff failed to provide this care leaving R4 to sit in her own feces for several hours. Using the reasonable person concept a reasonable person would feel pyschosocially dehumanized to be left in their feces for hours. On 8/4/20 11:42 AM, NHA A reported this incident to the state agency and began an investigation into this allegation of neglect.

Based on staff interview and record review, the facility did not ensure that pain management was provided consistent with standards of practice for 1 of 4 sampled residents (R6) out of a total sample of 14. The facility did not thoroughly assess R6's pain according to standards of practice; R6 did not receive pain medications as ordered; R6 left the facility AMA (Against Medical Advice) due to uncontrolled pain. Evidenced by: The facility's Pain Management policy, dated 11/16, states, in part: Policy: The facility believes pain is a personal experience that, if left undertreated or mismanaged, can radically change a residents quality of life and impact their overall well-being. A resident's pain is best treated and managed by an interdisciplinary team that actively engages the resident in the development of an effective treatment plan. Our pain management program will utilize a combination of methods, encompassing a holistic, person-centered approach. At the time of admission the resident will be interviewed regarding pain during the initial Critical Admission Assessment. Period interviewing, observations will also be conducted throughout the residents day to identify any new onset of pain or effectiveness from implemented pain interventions. Findings will be documented on the resident MAR (Medication Administration Record), utilizing pain scales numerical descriptors prior to interventions and post interventions to determine effectiveness. Licensed staff will conduct assessments just prior to administering medications or alternative methods and then again following to determine effectiveness. (It is important to note that this policy does not address resident comprehensive pain goals and preferences.) R6 was admitted to the facility, on 6/18/20, with [DIAGNOSES REDACTED]. R6's Admission MDS (Minimum Data Set) assessment was not started at time of discharge on 6/19/20 at 11:55 PM, this included a BIMS (Brief Interview of Mental Status). R6's Admission Pain Assessment was requested by Surveyor and not received from facility prior to exit. R6's Physician order [REDACTED]. On 6/18/20 - [MEDICATION NAME] tablet 325 MG (Milligrams) Give 2 tablets by mouth every 6 hours as needed for pain On 6/18/20 - [MEDICATION NAME] 10 MG give 1 tab every 4 hours as needed for pain On 6/18/20 - [MEDICATION NAME] Gel 1%, administer 2 GMS (Grams) topical QID (four times a day). On 6/18/20 - Pregabalin ([MEDICATION NAME]) capsule 300 MG give 300 MG oral at bedtime. Review of R6's MAR pain rating are as follows . On 6/18/20, Evenings, pain rating of 8 On 6/18/20, Nights, pain rating of 9 On 6/19/20, Days, pain rating of 4 On 6/19/20, Evenings, pain rating 8 On 6/19/20, Nights, pain rating 5 (It is documented that R6 received as-neededTylenol 650 MG on 6/18/20 at 8:00 PM, at 12:00 AM, 6:00 AM AND 6:00 PM but there is no documentation of follow up pain assessments in R6's record indicating the effectiveness of the medication. There also is no indication that R6 received any other ordered pain medications including scheduled [MEDICATION NAME] Gel 1%, administer 2 GMS (Grams) topical QID and [MEDICATION NAME] capsule 300 MG give 300 MG oral at bedtime. R6 also had an order for [REDACTED]. (Note: There are no nurse's notes or pain notes documenting resident complaints of pain.) On 6/24/20 complaint intake indicates R6 did not receive pain medication while in the facility. R6 rated her pain at a 9 or 10. On 6/19/20, R6 was crying because she was in so much pain. R6 called 911 to be transported to the hospital due to uncontrolled pain. EMS (Emergency Medical Services refused to transport R6. R6 discharged from the facility AMA (Against Medical Advise). On 8/04/20 at 9:35 AM, Surveyor interviewed RN J (Registered Nurse). Surveyor asked RN J the facility process for medications on new admissions. RN J stated that on admission the medications are put into the system, at times medications are brought from home or the hospital and those will be used. Medications are put into Matrix (Facility computer system) then orders are faxed to the pharmacy. Medication deliveries come 1 time a day usually between 12:00 PM and 1:00 AM. If we have the orders to the pharmacy by 4:00 PM we get that night. Surveyor asked RN J what happens if the medications don't get to the pharmacy in time. RN J stated, if we are unable to get them we can use contingency medications including narcotics. We have to call and get a code from the pharmacy to be able to get the narcotics from contingency. On 8/04/20 at 11:08 AM, Surveyor interviewed LPN K (Licensed Practical Nurse). Surveyor asked LPN K what the process is from giving and getting medications for new admissions. LPN K stated, For new admissions the day Nurse orders medications. If those medications are unavailable, call the pharmacy and find out when the medications will be coming. If they don't come from the pharmacy then we use contingency. Surveyor asked LPN K if she could explain to surveyor the reason medications were not given to R6 as ordered on [DATE] and 6/19/20. LPN K stated, I am done answering your questions. R6 was a difficult patient. She yelled out constantly. On 8/04/20 at 11:21 AM, Surveyor interviewed DON B (Director of Nursing) and ADON L (Assistant Director of Nursing). Surveyor asked what the process was for receiving medications from the pharmacy on a new admission. ADON L stated, As soon as we get the discharge summary we immediately fax it to the pharmacy. The nurse on duty is in charge of doing this. If the pharmacy receives the discharge summary by 4:00 PM they will be delivered between 11:00 PM and 1:30 AM. Surveyor asked if discharge summary does not get to pharmacy in time what the protocol for medications is. DON B states, We have a 4 hour stat regardless of time. A back up pharmacy in LaCrosse or Milwaukee will deliver those medications. Also, we can use any CVS Pharmacy 24 hours a day. Surveyor reviewed R6's MAR (Medication Administration Record) with DON B and ADON L. Surveyor asked what a Nurse's initials circled on the MAR indicated [REDACTED]. Surveyor asked if the facility had these medications available to them in contingency. ADON L stated, Yes. Surveyor asked if it was the facility expectations that residents receive ordered medications. DON B stated, Yes. Surveyor reviewed R6's pain ratings noted on the MAR. Surveyor asked DON B and ADON L if the rating would be considered severe pain. ADON L stated, According to the pain scale, yes. If a resident has complaints of pain at an 8 or 9 I would expect the nurse to place a call to the pharmacy to be able to pull pain medication from contingency and get something for pain. On 8/04/20 at 6:06 PM, Surveyor interviewed R6. Surveyor asked R6 about her time in the facility. R6 stated, I wasn't given pain medication for the entire time in the facility. Surveyor asked R6 if she ever remembered being given Tylenol. R6 stated, I'm not sure. R6 stated, she had surgery on her back, spinal stenosis and perirectal abscess with [DIAGNOSES REDACTED], the pain was constant. Surveyor asked R6 if she could describe her pain. R6 stated, I can't describe it but it was very painful. I had medication that I was supposed to get for pain and never received it. They kept telling me they didn't have it but when I went to leave they all of the sudden they were able to get me something stronger. My pain was over a 10. I cried the whole time I was there and begged my husband to come to get me. That last day I called 911 on 2 to 3 occasions. When 911 came they told me couldn't take me that it had to be an emergency. I told them I had uncontrolled pain and they still would not take me. That is when I called my husband to come get me and I left the facility. On 8/06/20 at 11:10 AM, Surveyor received EMS dispatch reports for R1. Dispatch reports indicate the following concerns on the following dates and times. - 6/19/20 at 9:44 PM: Caller states that she does not have her medications and her back is bleeding. - 6/19/20 at 10:12 PM: Caller states that she is not happy with her care. Has not received her medications and is upset that she was told there was no need for an ambulance. She said, She needed help and she thought she was going to get it. R6 had complaints of severe pain with pain ratings of 8-9. The facility failed to administer scheduled or as needed pain medication to control R6's pain. R6's pain was so severe she called 911 and left the facility against medical advice due to untreated pain.

Based on observation, interview, and record review, the facility did not provide an environment in which residents were free from neglect (failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress) and/or verbal, mental and physical abuse. This prevented residents from reaching their highest practicable level of physical, mental, and psychosocial well-being for 4 of 13 sampled residents and 1 supplemental resident (R8, R30, R40, R15, R11). This resulted in psychosocial harm (embarrassment, humiliation, degradation). R8 reported to Surveyor she was in need of assistance to go to the bathroom and had her call light on four times in about an hour time frame and CNA C kept turning it off. R8 and CNA C indicated that CNA C told R8 she needed to wait until after breakfast to go to the bathroom. R30 reported to the facility a staff member told her to urinate in her brief when she asked for assistance. The facility made staff members line up in front of R30 and asked R30 to identify who said it. R40 filed a grievance about staff not answering her call light, staff getting angry with her, making her get up, making her go to bed, making her stay in a chair until a certain time, and voicing they don't have time to answer her call light 12 times a night. R40 stated she sometimes wishes she never even came to the facility to live. R15 complained of a nurse yelling and cursing at R15; the facility failed to assure R15 was free from verbal abuse. R11 reported staff come in and turn her call light off and then exit room without meeting R11's needs. R11 does not always get her showers when she is supposed to and has to scream and cry to get them. Evidenced by: Facility policy entitled Abuse Prevention Program, revision date of 11/2018, includes, in part: . Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . Staff to Resident Abuse: All staff are expected to be in control of their own behavior, are to behave professionally, and should appropriately understand how to work with nursing home population. Retaliation by staff is abuse, regardless of whether harm was intended, is unacceptable and must be cited . Characteristics- . unsympathetic or negative attitude towards residents, voicing disgruntled comments about facility, company, supervisors, co-workers, work assignments . verbally aggressive behavior such as screaming, cursing, bossing around/demanding, insulting . intimidating ., resistive to cares and services . Neglect/Deprivation of goods and services by staff: Abuse also includes deprivation of services and goods by staff that are necessary to attain or maintain physical, mental, and psychosocial well-being of the resident(s). Possible indicators of neglect: failure to provide sufficient, qualified, competent staff to meet the residents' needs . failure to provide supervision and/or monitoring of the delivery of care . Possible indicators of Mental or Verbal Abuse: Use of oral, written, or gestured communication, or sounds, to resident within hearing distance . Example 1 R40 was admitted to the facility on [DATE]. R40's [DIAGNOSES REDACTED]. R40's Physician Orders, 5/1/19-5/31/19, include, in part: [MEDICATION NAME] (diuretic) twice daily, [MEDICATION NAME] for fluid retention, [MEDICAL CONDITION] once daily, [MEDICATION NAME] (diuretic) as needed, if weight increases 3 lbs (pounds) administer at noon and notify cardiology. (It is important to note the medications that are prescribed R40 increase urination.) R40's most recent MDS (Minimum Data Set), with ARD (Assessment Reference Date) of 2/25/19, indicates R40 is cognitively intact with a BIMS (Brief Interview of Mental Status) score of 15 out of 15. R40 requires the extensive physical assist of two staff to meet her needs in bed mobility, toileting, and transferring, and R40 received diuretics 7 out of the 7 look back days. On 4/29/19 at 10:20 AM, during an interview, R40 indicated at night they have trouble answering her call light. The longest she has had to wait for staff to answer her call light was three hours. R40 stated, An overnight nurse counts how many times I put my light on. She says you have been on the light 11 times. I went to the Social Worker and told her about it and she says I have the right to put light on whenever I need something. R40 also indicated she puts her call light on because she has been incontinent or is in need of the bathroom and then dozes off waiting for help, staff come in and just shut call light off. R40 indicated at other times, staff come to the activated call light and ask what she needs, shut off the call light, and say they will be back in a minute, but they do not return to assist her in meeting her need. R40 indicated she pees her pants when she just can't get help and she has a history of skin breakdown; she constantly worries about urinating in her brief will cause more skin issues for her. R40 shared the name of the overnight nurse with Surveyor and stated, It makes me feel terrible really. Surveyor observed R40 to be tearful and use a tissue to dry her face. R40's Grievance Form, dated 3/14/19, includes, in part: Name: (R40) self . Night shift nurse (LPN P (Licensed Practical Nurse)) and (CNA Q (Certified Nursing Assistant)) are not answering call lights. If call light is answered, they are angry it was turned on. They also get angry with patient for wetting the bed because they weren't answering call light. When patient is restless at 4 AM, instead of helping to calm her down, they make her get up when she doesn't want to get up yet. They also have a very bad attitude with patient when she uses her call light at night. Staff is refusing to let patient go to bed when she wants. They make her stay in her chair until at least 8 PM. When call light is answered, CNA says she needs to go get another CNA to help her, then never comes back. We're too busy to be answering your light 12 times a night. Summary of findings/Conclusion: Call lights not answered in a timely fashion per audit. Corrective Action taken: Staff member given final written notice. On 5/6/19 at 9:41 AM, during an interview, R40 indicated she woke up in a wet bed again; LPN P was working with her last night. R40 stated, She used to count how many times I put my light on. It makes me feel bad. I don't do it to cause trouble. It makes me feel bad, like other people are important and like I am not liked here. R40 also indicated staff have said mean things to her here and one incident was last night when one staff member told another staff member to just give R40 what she wants, because the first staff member who doesn't will get written up. R40 stated, I am not scared, but I feel like I shouldn't have come here. Makes me uncomfortable. On 5/6/19 at 9:57 AM, Surveyor and R40 went into NHA A's (Nursing Home Administrator) office to report together the allegation of last night's incident. R40 explained she called the NHA A's phone two times over the weekend with concerns of her skin breaking down due to staff not cleaning her well after incontinent episodes and just dressing her, I worry about laying in a wet bed and yeast. It makes me feel bad, like other people are important and like I am not liked here. R40 reported the incident of a staff member saying to just give R40 what she wants so she doesn't get written up. NHA A assured R40 he would be looking into this incident, speaking with the staff member who made the comment, and he would make adjustments on her care plan as needed to meet her preferences and needs. Example 2 R30 was admitted to the facility, on 3/22/19, with [DIAGNOSES REDACTED]. R30's most recent MDS, ARD of 3/29/19, indicates R30 is cognitively intact with a BIMS score of 15 out of 15. R30's MDS also indicates R30 took diuretics 7 of the 7 look back days and is dependent on the extensive physical assistance by two or more staff members to meet her needs in bed mobility, transferring, and toileting. On 4/29/19 at 10:06 AM, during initial screening, R30's husband was at her bedside. R30 indicated she [MEDICAL CONDITION] and is on [MEDICATION NAME]. Surveyor observed R30 to be slow to respond to questions and her eyes were opening and closing. R30 indicated she wanted to move to a different nursing home in a neighboring town and that there was not enough staff working in this home. R30's Grievance Form, dated 4/3/19, includes, in part: staff member filled out for (R30) . Patient stated that after receiving her [MEDICATION NAME], she asked to go to the bathroom and was told she should just go in her brief. She described the person who said it as bigger with puffy hair. She sat in a wet bed from around 7:00 to 9:45 because CNA asked if she needed anything and didn't check to see that she was wet . Conclusion: All staff were questioned and reported they wouldn't have told her to just go in her brief. It was confirmed she was wet for some time and that during rounds she was not checked to see if she needed to be toileted or was wet. Resident wasn't able to tell us who the person was that told her to do this. The BOM H (Business Office Manager) and SW F (Social Worker) brought in staff members that were working during this time of allegation one by one. The resident was unable to identify any of the staff members working during the time the allegation occurred. A CNA checked on this resident 3 separate times between 6:00 AM and 9:45 AM, each time it was asked if the resident needed assistance to when she stated, No. As soon as it was communicated around 9:45 AM that she needed assistance with her brief, it was changed. On 5/2/19 at 2:59 PM, during an interview, BOM H indicated, We took in every staff member, including the nurses, into the residents' room and she couldn't identify anybody. On 5/2/19 at 3:51 PM, during an interview, NHA A indicated it is not appropriate to make a line-up of the accused for the victim to identify when a resident voices an allegation of neglect or abuse. On 5/6/19 at 10:07 AM, during an interview, R30 indicated she barely had the energy to keep her eyes open and stated, I do recall that incident. Surveyor asked R30 how that made her feel. R30 replied, Well, going in my brief isn't something I ever did. I don't like to have to do that. It embarrassed me. I think I could make it if I didn't have to wait so long for help. Some days I am just too weak and can't get out of bed, I need help. Example 3 R8 was admitted to the facility on [DATE]. She has [DIAGNOSES REDACTED]. Her most recent MDS, with an ARD of 2/14/19, indicates R8's cognition is moderately impaired with a BIMS score of 9 out of 15. R8's MDS also indicates she requires the extensive physical assistance by 2 staff for bed mobility, toileting, hygiene, transfer, and R8 has an impairment on one of her upper and one of her lower extremities. On 4/30/19 at 7:46 AM, R8 waved Surveyor into her room. R8 was rocking back and forth in her wheelchair and had her hands over her groin area when Surveyor entered room. R8's call light was not activated. R8 stated, I put my call light on at 6:50 AM and she turned it off at 7. I am still waiting. CNA C and CNA D entered room at 7:50 AM. CNA C stated, You ready for breakfast? R8 replied, I have to go to the bathroom. CNA C continued, Ok. Both CNA C and CNA D walked out of room without explanation. CNA C returned to room with easy lift, but no sling. Surveyor asked CNA C if she assisted R8 with morning cares, CNA C stated, (R8) got up at 6:30 AM with (CNA D) and myself (CNA C). Surveyor asked if R8 had her call light on after she was assisted with morning care. CNA C stated, She had her call light on after that and I am not sure what she wanted. R8 raised her voice and pointed at CNA C, I had to go to the bathroom. I told you and you said, 'Can't you wait until after you eat?' CNA C replied to R8, Yup and then I said I would be right back. R8, still with a raised voice and rapid speech, You knew I had to go. I told you. Surveyor asked CNA C how long R8 was waiting, Maybe 15 minutes she was waiting. DON B entered room at 7:55 AM and states to R8, We are trying to find the right sheet. R8 replied, Yeah and you won't come back until next year. DON B walked out of room, laughing, and calls back, I hope it's not 2020. During an interview, Surveyor asked CNA C, What were you coming in (R8)'s room for? CNA C answered, To take her to breakfast. Surveyor asked, Did (R8) have her call light on because she had to go to the bathroom? CNA C replied, Yes. Surveyor asked, Why didn't you come prepared to assist resident to the restroom? CNA C stated, I don't know. Surveyor asked, Why didn't you bring the lift with you? CNA C replied, I don't know. I should have. We need two staff members to assist her. At 8:01 AM, R8 was assisted by CNA C and CNA D to the restroom. On 4/30/19 at 8:11 AM, R8 waved her arm at Surveyor, motioning to come over to her in the dining room at her assigned place at the table. R8 stated, I made it to the bathroom. I had my light on four times and she shut it off every time. R8 pointed at CNA C who was assisting with the breakfast meal, across the dining room, by the kitchen door. On 4/30/19 at 8:48 AM, during an interview, DON B indicated the facility had a policy that call lights should be answered within 10 minutes and an hour wait time is not a reasonable wait time for a resident. DON B indicated staff should not turn a resident call light off until the need is met and CNA C should not have turned R8's call light off four times. On 4/30/19 at 2:12 PM, during an interview, CNA C indicated she did shut off R8's call light more than one time after morning cares and before Surveyor observed CNA C and CNA D assisting R8 to the bathroom, because she didn't have anyone to assist her with R8 at the time. On 5/6/19 at 10:23 AM, Surveyor observed an odor of stool in R8's room and R8's call light to be activated. During an interview, R8 told Surveyor she had her light on to poop and not too long ago a staff member came in, shut her light off, and told her they had to get a partner. R8 indicated she then put her call light on again, because too many times it has happened that they don't come back in. R8 stated, When they come in and turn my light off and don't come back it makes me feel kind of bad. Example 4 On 3/18/19, R15 filed a grievance with DON B regarding an incident that happened on 3/17/19. The grievance states, Tonight I peeked out my door and asked RN L if she'd remember [MEDICATION NAME] and [MEDICATION NAME]. RN L said, 'Leave me alone! I'm trying to figure out things!' After last night, I went back to my room and mumbled, 'I've had it!' RN L came in and yelled at me to not 'lip off at her' and 'don't interrupt me!' When I take [MEDICATION NAME], I'm supposed to rinse my mouth. I usually swallow the water, sip a little, and then rinse my mouth out. RN L refused to let me do that. On 5/6/19 at 11:38 AM, Surveyor interviewed R15. Surveyor asked R15 about the incident, on 3/17/19, with RN [MI] R15 stated RN L was rude to her. Surveyor asked if the incident bothered R15. R15 stated, Yes, it bothered me and it has happened again since then. Surveyor asked if R15 reported the new incident to anyone. R15 stated, Yes, I told the NHA A and Social Worker (SW) F. R15 also stated she did not want to have RN L as a nurse, she will go to anyone but RN L if she needs anything, and if RN L sees her, she walks the other way. R15 states, I am not scared of RN L, just feel like I could smack her sometimes, but know I can't. R15 also states RN L talks down to her. RN L was passing medications one night and did not give R15 her medications. R15 had to find another nurse to give her medications. R15 states, I feel neglected when RN L is working, as she won't help me with anything and ignores me. She is just plain rude. On 5/6/19 at 12:47 PM, Surveyor again spoke with R15. Surveyor asked if RN L continues to provide care and medications for her. R15 stated, Sometimes. If she brings in my medications, she puts them on the bedside table and leaves. R15 again states that if she needs something, I go to someone else. Surveyor asked if the facility had followed up with her. R15 states, No! If I have concerns I tell them and they state, 'okay, we will take care of it!' DON B met with R15 and completed Grievance Form. Findings of DON B's investigation were as follows . Nurse made note on what happened at time of complaint. No witnesses to any wrong doing by nurse. Nurse denied allegation. Corrective action taken by DON B . Spoke with nurse to have witness available if resident is visibly upset. On 3/18/19, DON B met with R15 and wrote the following statement. Interview with R15 regarding incident with nurse, RN [MI] Resident repeated story that is on her Grievance Form. She states she does not feel she was neglected, demeaned, or scared. She stated she felt that their personalities just didn't go well together. She stated she did not care if RN L continued to be her nurse. R15 has a history of yelling and cursing at staff and refusal of care or assistance. R15 has anxiety and major [MEDICAL CONDITION], and socially disruptive behaviors. Individualized care plan is in place. Example 5 R11 was admitted to the facility, on 7/7/17, with [DIAGNOSES REDACTED]. R11 most current MDS, dated [DATE], indicates R11 is cognitively intact with a BIMS score of 15 out of 15. On 4/30/19 at 11:06 AM, R11 indicated she used to work as a CNA and her facility had rules about call light wait times and here they don't. R11 indicated the facility does not have enough staff to meet the needs of residents residing in the home and staff are unable to complete tasks, such as giving showers and answering call lights timely. R11 stated, They come in and turn call light off and then I turn it back on. R11 also indicated she had to wait two hours one day for staff to assist her to the bathroom. R11 indicated Mondays and Thursdays are her shower days and she prefers to take her showers in the afternoon. R11 stated, This is a sore subject with me. They say they are too busy or short staffed. I do everything myself, I am in and out, but they don't come back after they tell me they can't. Then days later, I scream and cry and then they do it (give R11 a shower).

Based on observation, interview, and record review, the facility did not ensure there was always sufficient staff in the facility to meet resident needs and related services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 4 of 13 sampled and 2 supplemental residents (R). R30, R40, R14, R8, R21, R11 voiced concerns about staffing, call light response times, and needs not being met or not being met timely. Residents reported being embarrassed because they wet themselves, wishing they were in a different nursing home, and feeling devalued and unimportant. Resident Council minutes for four months include concerns brought up each month about call light wait times and fresh water not being passed, Evidenced by: Example 1 R30 was admitted to the facility, on 3/22/19, with [DIAGNOSES REDACTED]. R30's most recent MDS (Minimum Data Set), ARD (Assessment Reference Date) of 3/29/19, indicates R30 is cognitively intact with a BIMS (Brief Interview of Mental Status) score of 15 out of 15. R30's MDS also indicates R30 took diuretics 7 of the 7 look back days and is dependent on the extensive physical assistance by two or more staff members to meet her needs in bed mobility, transferring, and toileting. R30's Grievance Form, dated 4/3/19, includes, in part: staff member filled out for (R30) . Patient stated that after receiving her [MEDICATION NAME], she asked to go to the bathroom and was told that she should just go in her brief. She described the person who said it as bigger with puffy hair. She sat in a wet bed from around 7:00 to 9:45 because CNA (Certified Nursing Assistant) asked if she needed anything and didn't check to see that she was wet . On 4/29/19 at 10:06 AM, during initial screening, R30's husband was at her bedside. R30 indicated she [MEDICAL CONDITION] and is on [MEDICATION NAME]. Surveyor observed R30 to be slow to respond to questions and her eyes were opening and closing. R30 indicated she wanted to move to a different nursing home in a neighboring town and that there was not enough staff working in this home. On 5/6/19 at 10:07 AM, during an interview, R30 indicated she barely had the energy to keep her eyes open and stated, I do recall that incident. Surveyor asked R30 how that made her feel. R30 replied, Well, going in my brief isn't something I ever did. I don't like to have to do that. It embarrassed me. I think I could make it if I didn't have to wait so long for help. Some days I am just too weak and can't get out of bed, I need help. Example 2 R40 was admitted to the facility on [DATE]. R40's [DIAGNOSES REDACTED]. R40's most recent MDS, with ARD of 2/25/19, indicates R40 is cognitively intact, with a BIMS score of 15 out of 15, that R40 requires the extensive physical assist of two staff to meet her needs in bed mobility, toileting, and transferring, and that R40 received diuretics 7 out of the 7 look back days. On 4/29/19 at 10:20 AM, during an interview, R40 indicated at night they have trouble answering her call light. The longest she has had to wait for staff to answer her call light was three hours. R40 stated, An overnight nurse counts how many times I put my light on. She says you have been on the light 11 times. I went to social worker (SW) and told her about it and she says I have right to put light on whenever I need something. R40 also indicated she puts her call light on because she has been incontinent or is in need of the bathroom and then dozes off waiting for help, staff come in and just shut call light off. R40 indicated, at other times, staff come to the activated call light and ask what she needs, shut off the call light, and say they will be back in a minute, but they do not return to assist her in meeting her need. R40 indicated she pees her pants when she just can't get help and that she has a history of skin breakdown that she constantly worries about, urinating in her brief will cause more skin issues for her. R40 shared the name of the overnight nurse with Surveyor and stated, It makes me feel terrible really. Surveyor observed R40 to be tearful and use a tissue to dry her face. On 5/6/19 at 9:41 AM, during an interview, R40 indicated she woke up in a wet bed again; LPN P (Licensed Practical Nurse) was working with her last night. R40 stated, She used to count how many times I put my light on. It makes me feel bad. I don't do it to cause trouble. It makes me feel bad, like other people are important and like I am not liked here. On 5/6/19 at 9:57 AM, Surveyor and R40 went into NHA A's (Nursing Home Administrator) office to report together the allegation of last night's incident. R40 explained she called the NHA A's phone two times over the weekend with concerns of her skin breaking down due to staff not cleaning her well after incontinent episodes and just dressing her, I worry about laying in a wet bed and yeast. It makes me feel bad, like other people are important and like I am not liked here. Example 3 R14 was admitted to the facility on [DATE]. R14's most recent MDS, with ARD of 2/26/19, indicates R14's cognition is mildly impaired, with a BIMS score of 11 out of 15. R14's MDS also indicates she requires the extensive physical assistance of two or more staff members to meet her needs in bed mobility, transferring, toileting, dressing, and ambulating in her room. On 4/29/19 at 10:48 AM, during an interview, R14 indicated she doesn't always get help when she needs it and sometimes she has to wait too long for assistance. R14 was unable to give Surveyor an example of what too long meant to her. Example 4 R8 was admitted to the facility on [DATE]. R8 has [DIAGNOSES REDACTED]. Her most recent MDS, with an ARD of 2/14/19, indicates R8's cognition is moderately impaired, with a BIMS score of 9 out of 15. R8's MDS also indicates she requires the extensive physical assistance by 2 staff for bed mobility, toileting, hygiene, transfer, and that R8 has an impairment on one of her upper and one of her lower extremities. On 4/30/19 at 7:46 AM, R8 waved Surveyor into her room. R8 was rocking up and back in her wheel chair and had her hands over her groin area when Surveyor entered room. R8's call light was not activated. R8 stated, I put my call light on at 6:50 AM and she turned it off at 7. I am still waiting. CNA C and CNA D entered room at 7:50 AM. CNA C stated, You ready for breakfast? R8 replied, I have to go to the bathroom. CNA C continued, Ok. Both CNA C and CNA D walked out of room without explanation. CNA C returned to room with easy lift, but no sling. Surveyor asked CNA C if she assisted R8 with morning cares, CNA C stated, (R8) got up at 6:30 AM with (CNA D) and myself (CNA C). Surveyor asked if R8 had her call light on after she was assisted with morning care. CNA C stated, She had her call light on after that and I am not sure what she wanted. R8 raised her voice and pointed at CNA C, I had to go to the bathroom. I told you and you said, 'Can't you wait until after you eat?' CNA C replied to R8, Yup and then I said I would be right back. R8 still, with a raised voice and rapid speech, You knew I had to go. I told you. Surveyor asked CNA C how long R8 was waiting, Maybe 15 min she was waiting. DON B (Director of Nursing) entered room at 7:55 AM and states to R8, We are trying to find the right sheet. R8 replied, Yeah and you won't come back until next year. DON B walked out of room, laughing, and calls back, I hope it's not 2020. During an interview, Surveyor asked CNA C, What were you coming in (R8)'s room for? CNA C answered, To take her to breakfast. Surveyor asked, Did (R8) have her call light on because she had to go to the bathroom? CNA C replied, Yes. Surveyor asked, Why didn't you come prepared to assist resident to the restroom? CNA C stated, I don't know. Surveyor asked, Why didn't you bring the lift with you? CNA C replied, I don't know. I should have. We need two staff members to assist her. At 8:01 AM, R8 was assisted by CNA C and CNA D to the restroom. On 4/30/19 at 8:11 AM, R8 waved Surveyor over to her in the dining room at her assigned place at the table. R8 stated, I made it to bathroom. I had my light on four times and she shut it off every time. R8 pointed at CNA C who was assisting with the breakfast meal, across the dining room, by the kitchen door. On 5/6/19 at 10:23 M, Surveyor observed an odor of stool in R8's room and R8's call light to be activated. During an interview, R8 told Surveyor she had her light on to poop and not too long ago, a staff member came in, shut her light off, and told her they had to get a partner. R8 indicated she then put her call light on again, because too many times it has happened that they don't come back in. R8 stated, When they come in and turn my light off and don't come back it makes me feel kind of bad. Example 5 R21 was admitted to the facility, on 3/27/15, and her most recent MDS, with an ARD of 3/8/19, indicates R21 is cognitively intact, with a BIMS score of 15 out of 15. R21's MDS also indicates R21 requires the physical assistance by two or more staff to meet her needs in bed mobility, transferring, dressing, and toileting. On 4/30/19 at 9:37 AM, during Resident Council Group Meeting with Surveyors, R21 voiced a concern about call light wait times due to a staffing shortage. R21 stated, I waited 2.5 hours to get put to bed last night and my call light was on the whole time. My roommate's husband was here the whole 2.5 hours and I even asked him to go out the door to see if my light was working and it was. R21 also voiced she does not get fresh water daily. When asked if R21 has told anyone in the facility about her concerns, R21 indicated she has told facility staff members about her concerns and, it doesn't do any good. Example 6 R11 was admitted to the facility, on 7/7/17, with [DIAGNOSES REDACTED]. R11 most current MDS, dated [DATE], indicates R11 is cognitively intact, with a BIMS score of 15 out of 15. On 4/30/19 at 11:06 AM, during an interview, R11 indicated she used to work as a CNA and her facility had rules about call light wait times and here they don't. R11 indicated the facility does not have enough staff to meet the needs of residents residing in the home and staff are unable to complete tasks, such as giving showers and answering call lights timely. R11 stated, They come in and turn call light off and then I turn it back on and they say, 'I forgot.''' R11 also indicated she had to wait two hours one day for staff to assist her to the bathroom. R11 indicated Mondays and Thursdays are her shower days and she prefers to take her showers in the afternoon. R11 stated, This is a sore subject with me. They say they are too busy or short staffed. I do everything myself, I am in and out, but they don't come back after they tell me they can't. Then days later, I scream and cry and then they do it (give R11 a shower). Example 7 Resident Council Minutes, dated 1/14/19, include, in part: . Call lights improved but not on night shift . water/ice second shift is not reliable . Resident Council Minutes, dated 2/11/19, include, in part: . call lights-timely answered? Good . Bad . Depends on who is working for both first and second (shifts) . Resident Council Minutes, dated 3/11/19, include, in part: . call lights - Administration List . Resident Council Minutes, dated 4/8/19, include, in part: . call lights still not very fast . Water distribution is still not happening every shift. On 5/6/19 at 10:57 AM, during an interview, AD M (Activity Director) indicated he records all of the minutes for the monthly Resident Council meetings. AD M indicated he does not write names down of who said what, as a rule of thumb, during Resident Council meetings and he doesn't know anymore who made the comments about long call light wait times in December, January, February, March, or (MONTH) meetings. Example 8 On 5/2/19 at 9:33 AM, during an interview, AD M indicated he just took over the activity department 10 months ago and he is the only employee in the Activity Therapy Department and has had several very short term Activity Therapy Aides in the past 10 months and that he alone can't meet the activity needs of all of the residents. Example 9 On 5/6/19 at 12:17 PM, during an interview, CNA J indicated sometimes the facility has enough staff to meet the needs of the residents and sometimes they don't. CNA J stated, Today we do not have enough of us. There should be four of us. We had a partial shift person and three full shift people. It is hard to answer call lights timely. CNA J explained some staff have to be in the dining room during meal times and then call lights on the floor take longer to get to. Example 10 R20 developed a stage 2 PI (pressure injury), on 3/29/19, which progressed to a stage Unstageable PI on 5/2/19. R20's PI was not assessed by a RN upon discovery and weekly measurements and assessments were not completed. On 5/2/19 at 9:40 AM, Surveyor interviewed DON B regarding no skin assessment between 4/3/19 and 4/17/19. DON B stated, I didn't have anyone to do one! Surveyor asked if a skin assessment should have been done during that time period. DON B stated, Yes, they are supposed to be done weekly. Example 11 R35 had a fall with fracture, on 1/19/19, when his w/c (wheelchair) rolled away from him when trying to transfer. R35's w/c's anti-rollback brakes were observed not properly functioning. Staff did not recognize the antiroll backs were not functioning. On 5/1/19 at 2:00 PM, Surveyor observed R35's w/c in his room with anti-rollbacks in place. Surveyor moved w/c backwards to see if anti-rollbacks worked. The right side moved back while left side stayed in place, indicating R35's anti-rollback brakes are not currently functioning properly. On 5/1/19 at 2:05 PM, Surveyor interviewed RN K (Registered Nurse) and RN [NAME] about R35 and transfer ability. RN [NAME] stated R35 has a history of transferring himself even though he was supposed to be assisted with transfers. R35 was impulsive and thought he could do those things. RN K agreed with this. On 5/1/19 at 2:18 PM, Surveyor had RN K go to R35's room and further discussed R35's anti-rollbacks. Surveyor asked RN K to move R35's w/c backwards to check anti-rollbacks. RN K did this and noted the right side moved while the left side stayed in place. RN K stated that the right side shouldn't move. On 5/2/19 at 8:15 AM, Surveyor observed R35's w/c anti-rollbacks still not working on right side of w/c. Surveyor had LPN S come into R35's room and she confirmed the right side anti-rollback wasn't working. LPN S indicated the right side of w/c should not move when backed up. Even after the Surveyor pointed out R35's antiroll backs were not functioning properly, staff still did not assure they were repaired to prevent a fall.

Based on observation, interview, and record review, the facility did not implement professional standards of practice to prevent PIs (pressure injury) from worsening for 1 of 1 resident reviewed for PIs, out of a sample of 13 residents (R20). R20 developed a Stage 2 PI, on 3/29/19, which progressed to an Unstageable PI on 5/2/19. The facility did not ensure interventions were in place and did not implement additional approaches to prevent the PI from reoccurring or worsening. R20's PI was not assessed by a RN (Registered Nurse) upon discovery and weekly measurements and assessments were not completed. R20's physician was not updated when the PI deteriorated. This is evidenced by: The facility's policy, Pressure Ulcer Prevention / Risk Assessment, dated 4/2018, states, in part: Resident's will 'automatically be HIGH risk' when admitted with: e) The use of a medical device that is a potential source of pressure. Examples of such devices are catheter tubing, anti-embolism stockings, bedpans and orthopedic appliances such as braces, cast, splints, etc. When using the Braden Scale (scale for predicting pressure sore risk), once the resident scores at a 'HIGH' risk, the resident will be considered at 'HIGH' risk for the entire length of their stay in the facility; therefore, the Braden Scale will not have to be completed again for that resident. Inspect the skin under and around medical devices at least twice daily for signs of pressure related injury. Note this may need to be increased in the presence of localized or generalized [MEDICAL CONDITION]. Avoid positioning the resident directly onto medical devices, such as tubes, drains and other foreign objects. A complete wound assessment and documentation will be conducted on all skin conditions upon discovery and weekly thereafter, until they are healed. Weekly assessments of skin conditions will be documented in the resident's electronic medical record using the following observations: - Weekly Pressure Ulcer Progress Report - Skin Condition Report (Non-Pressure Sore) - If the wound/skin condition does not show signs of improvements in fourteen (14) days, the physician will be notified for further recommendations and/or treatment changes. R20 was admitted to the facility, on 12/16/98, with diagnosed including: [DIAGNOSES REDACTED]. (Note there is no [DIAGNOSES REDACTED].) R20's most recent MDS (Minimum Data Set), dated 3/6/19, indicates a BIMS (Brief Interview of Mental Status) of 7, indicating R20's cognition is moderately impaired. R20's record indicates they have an activated POA (Power of Attorney). R20's most recent MDS indicates extensive assist is needed with bed mobility, personal hygiene, toileting and transfers. R20's Comprehensive Care Plan, dated 4/3/19, indicates R20 has a Stage 2 PI to right inner thigh and Indwelling Catheter. R20's Comprehensive Care Plan states, in part . The resident has 2 Stage 2 pressure ulcers to right inner thigh with potential for infection and discomfort to the area. Associated factors: MS, catheter, history of PIs to this area. Goal: The resident's ulcer will heal without complications (created 4/4/19). Interventions with start date of 4/4/19: Assess and record the condition of the skin surrounding the pressure ulcer. Assess the pressure ulcer for location, Stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization with treatments and weekly. Avoid friction or shearing forces during transfers or position changes. Keep resident off affected area as much as possible. Pressure reduction mattress OR Specialty Air Mattress. Pressure reduction cushion to wheelchair. Provide incontinence care after each incontinent episode. Treatment as ordered. Turn and reposition q (every) 2 hours and PRN (as needed) as resident will allow. Indwelling Catheter: R20 requires an indwelling urinary catheter r/t (related to) advanced MS, [MEDICAL CONDITION], and [MEDICAL CONDITION] bladder; history of UTI. Long Term Goal Target Date: 6/14/19 to prevent and reduce the occurrence of UTIs via indwelling catheter. Approach: Position catheter tubing in front leg (sic) to avoid skin injury. Use catheter strap and alternate site to prevent skin breakdown. R20's most current Physician Orders, dated 2/5/19, indicate the following order: Check inner thigh area BID (twice a day), continue with Duoderm to inner thighs to protect from catheter tubing. Skin Assessment weekly. These orders are effective for 60 days. (It is important to note this order is not listed on the TAR (Treatment Administration Record) or MAR (Medication Administration Record). R20's most recent Braden Score, completed on 2/26/19, shows a score of 13, indicating R20 is at moderate risk for PI development. (Note: A new Braden was not completed on development of R20's PI and according to the policy; R20 entered at 'HIGH' risk due to having a catheter in place and with entering the facility at 'HIGH' risk, would not require another Braden, as R20 would be considered 'HIGH' risk for entire stay. R20's Progress Note, on 3/21/19, indicates protective dressing on left thigh. Note: Current PI is located on the right thigh. R20's Skin-Skin Body Assessments state, in part . 3/29/19, area of skin impairment to right inner thigh upper area. Two areas noted on the right upper inner thigh, areas are red and sore. No drainage noted. One area closest to the peri area is 1.0 cm (centimeter) x (by) 0.25 and below the area is measured at 0.5 cm x 0.25 cm. (Note: There are no new orders for treatment until 4/5/19.) 4/5/19, area of skin impairment, described below. Right inner thigh; open area. See RN skin documentation. Left inner thigh not open but slightly reddened/irritated. Daily treatments/cath (catheter) care in place per orders. Progress Note, from 4/5/19, states: Area on inner right thigh cleansed and Hydrogel applied with boardered (sic) patch covering. Zinc oxide on inner left thigh per order, without foam patch at this time. Left inner thigh is slightly irritated and slightly red. No drainage from these areas noted. No area is open on left side. Areas are tender to touch, according to resident. Cath strap on right leg. Tubing appropriately placed to prevent pressure. Will continue to monitor this area. Foley bag changed. (Note: No measurements or description of open areas was done.) R20's TAR, for 4/1/19 to 4/30/19, states, in part . Order entered and started on 2/27/19 - open ended for: Apply Zinc Oxide to macerated tissue on bilateral thighs. Apply foam dressing over, if area is too moist, apply Zinc only until healed. R20's TAR, for 4/5/19 to 5/31/19, states, in part . Order entered and started on 4/5/19 - open ended for: Apply Hydrogel to wound beds of open areas to right inner thigh and cover with foam boarder (sic) dressing until resolved. Once a day. R20's weekly skin assessments titled Skin Integrity Events -- *New or Worsened Pressure Ulcer were documented, as follows . Date and Time of discovery: 4/3/19 at 21:00 (9:00 PM), In House Acquired. Location: Other - Right inner thigh #1. Stage 2, measuring 3.2 cm x 0.3 cm x 0.1 cm. During routine skin assessment resident noted to have open area to right inner thigh, documented by LPN (Licensed Practical Nurse), with MD/RP (Medical Director/Resident Physician) notification, treatment order received. Upon weekly wound rounding, by RN, area noted to be larger in measurement, MD notified/RP notified. Wound presents as 100% granulation, resident has increased moisture between thighs r/t (related to) body habitus, Peri wound intact, no redness, no drainage, and resident denies pain at this time. Treatment: Zinc ointment, cover with bordered foam gauze. .4/4/19. Location: Other - Right inner thigh #2. Stage 2, measuring 3.2 cm x 0.1 cm x 0.1 cm. During routine skin assessment resident noted to have open area to right inner thigh, documented by LPN, with MD/RP notification, treatment order received. Upon weekly wound rounding, by RN, area noted to be larger in measurement, MD notified/RP notified. Wound presents as 100% granulation, resident has increased moisture between thighs r/t body habitus, Peri wound intact, no redness, no drainage, resident denies pain at this time. Treatment: Zinc ointment cover with bordered foam gauze, which was discontinued on 4/4/19 and new orders received for Hydrogel. (It is important to note that PIs were initially discovered, on 3/29/19, by an LPN and a RN did not assess these areas until 4/3/19, at which time they were bigger in size.) .4/17/19. Location: Right inner thigh, Stage 2, measuring 3 cm x 0.7 cm. No drainage and no odor. Progress: Improved. Note: Length is smaller in size from previous measurement but width is 0.6 cm larger than previous assessment. (Of note, these PI's were not assessed, skin sheet was not completed and measurements were not done between 4/3/19 and 4/17/19.) .4/24/19. Location: Right inner thigh, Stage 2, upper area measuring 1 cm x 2 cm; lower area measuring 1 cm x 1 cm; directly across 0.1 cm x 4 cm; next to this 0.1 cm x 3.8 cm. No drainage and no odor. Progress: Deteriorated. (Note: Progress Notes from 4/24/19 do not indicate that the PCP (Primary Care Provider) was updated on wound deterioration.) .5/1/19. Location: Right inner thigh, Stage 2, upper inner thigh (outside): 3.8 cm x 0.8 cm x less than 0.1 cm; directly below: 6.7 cm 0.7 cm x less than 0.1 cm; the other two areas are 100% epithelized. Treatment: Hydrogel to wound beds and covered with a foam border dressing; skin prep applied as protectant. Progress: Deteriorated. (Note: There is not an order for [REDACTED].) On 5/2/19 at 7:32 AM, Surveyor observed treatment to R20's PI being completed by RN [NAME] and DON B (Director of Nursing). RN [NAME] removed dressing to PI. Surveyor asked if RN [NAME] could Stage the PI. RN [NAME] stated that both PIs were a Stage 3, from R20's catheter tubing. DON B then assessed and measured both areas. DON B stated the lower PI was Unstageable with 95% slough and 5% scabbed, with this area measuring 7.6 cm x 0.3 cm x 0.2 cm, surrounding skin was WPD (warm, pink and dry). DON B stated the upper PI was a Stage 3, with 5% eschar and 95% granulation tissue. Upper PI was measured to be 3.8 cm x 0.5 cm x 0.2 cm, surrounding skin WPD. Surveyor asked DON B what preventative measures are in place to promote healing to R20's PI's. DON B stated R20 should have a catheter strap in place at all times. Surveyor asked if DON B could locate R20's catheter strap at this time. DON B stated, Maybe they took it off for wound care. Surveyor asked if R20 should have a catheter strap, DON B stated, Yes. Surveyor asked DON B if she could locate R20's catheter strap on R20 or in R20's room, DON B was unable to locate. DON B then left R20's room to get a new catheter strap, which was applied by RN E. On 5/2/19 at 9:40 AM, Surveyor interviewed DON B regarding no skin assessment between 4/3/19 and 4/17/19. DON B stated, I didn't have anyone to do one! Surveyor asked if a skin assessment should have been done during that time period. DON B stated, Yes, they are supposed to be done weekly. On 5/6/19 at 9:46 AM, Surveyor interviewed LPN R. Surveyor asked if R20 should have a catheter strap on. LPN R stated, Yes, she should. Surveyor asked who ensures that catheter strap is in place. LPN R stated, The CNAs (Certified Nursing Assistant) would. On 5/6/19 at 9:59 AM, Surveyor asked CNA N if aware of open area. CNA N stated, Yes, it has been there for a while. Surveyor then asked CNA N if R20 was to have a catheter strap. CNA N stated, Yes, every person with a catheter should have one. On 5/6/19 at 10:03 AM, Surveyor interviewed CNA D and CNA O. Surveyor asked if R20 should have a catheter strap on. CNA D stated, Yes and if not in place, I would go to the Nurse. CNA O stated, Yes, definitely and if not I would put one on. R20 was admitted without a PI. The facility did not ensure that a PI did not develop, monitor current treatments, update the physician on changes, or assure interventions were in place to ensure that R20's PI did not deteriorate. The facility did not ensure that weekly skin assessments, including accurate measurements, and treatments were completed for R20's PI.

Based on observation, interview, and record review, the facility did not ensure that the resident remains as free of accident hazards as is possible and receives adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (R35) reviewed for falls and 1 of 1 residents (R11) reviewed for smoking, out of 13 total sampled residents. R35 had a fall with fracture, on 1/19/19, when his w/c (wheelchair) rolled away from him when trying to transfer. R35's w/c's anti-rollback brakes were observed not properly functioning. R11 does not have a current smoking assessment to identify risks and to ensure facility has appropriate interventions in place to keep R11 safe while smoking. R11's most current MDS (Minimum Data Set) indicates R11 is cognitively intact with a BIMS (Brief Interview of Mental Status) score of 15 out of 15. This is evidenced by: The facility's policy entitled Fall Prevention and Management Program Policy, dated 1/2018, includes, in part: .Three Components of Fall Prevention Program: 1. Long Term Management: The Interdisciplinary Care Team (IDT) must begin the process of falls prevention before the first fall occurs by identifying an individual's risk factors and history of falls .Residents will be assessed for their fall risk upon admission/re-admission, change of condition, and with MDS 3.0 assessments (quarterly and annually). This multifactorial risk assessment is essential, as many potential falls may be related to medications, medical conditions in addition to balance and strength .Once a comprehensive fall risk assessment is completed, the team will plan care interventions to address each risk identified on the falls assessment instrument .Residents will be scored following an assessment to determine if they are either high risk or low risk for potentially falling .All residents will be considered a potential for falling (low risk) upon admission to the facility. Each resident will have a care plan that is specific to their risk level and individualized preventive approaches specific to identified contributing factors to reduce and attempt to eliminate their risk for fall incidents .2. Post Fall Event Investigation and Action Plan: .Procedure: .7. The post Fall Assessment and Initial Investigation Form will be completed by the responsible nurse of the first responding nurse prior to the end of her shift. Upon conclusion of investigation the nurse(s) will have identified contributing factors and potential root cause(s) to the resident's fall event. Immediate preventive measures will be implemented to prevent fall reoccurrence . R35 was admitted to facility on 1/3/17. R35's [DIAGNOSES REDACTED]. R35's annual Fall Risk Assessment, done on 1/8/19, was a 16, which indicates R35 is high risk for falls (any score 5 or greater is high risk). R35's care plan, on 1/19/19, at time of fall, includes, in part: Problem: Fall; Goal: Resident will have no injury from falls by target date; Approaches: Resident fell on [DATE]. As a result, anti-roll backs will be applied to w/c. (Start date: 11/2/18); Assure w/c is within reach when resident is in bed. (Start date: 7/9/18); Call light to be within reach. (Start date: 1/3/17); lock wheel chair brakes when transferring. (Start date 1/3/17); Provide assistance with all transfers and ADLs (Activities of Daily Living) as needed per therapy recommendations. (Start date: 1/3/17). Fall Event Report, for 1/19/19, includes, in part: .Fall occurred at 21:25 (9:15 PM) .R35 had been calm and watching television prior to fall .fall occurred in R35's room .R35 told staff he was trying to go to the bathroom .R35 was observed on floor of room hollering in pain .There were no witnesses to the fall .Pain was rated at a 7 - severe pain - horrible, intense .Did the fall result in an injury? Fracture - left hip was marked .Range of Motion (ROM) findings: Unable to complete ROM .Positioning of Extremities: Rotation/Deformity/Shortening of left lower extremity .Interventions - immediate measures taken: Other was checked: Explained - contact MD (medical doctor), ambulance service, guardian, family unavailable. Describe measures, if necessary: wheelchair evaluation for safe transfers by physical therapy; anti-roll back breaks on wheelchair . Facility's fall investigation for R35's 1/19/19 fall included the above Fall Event Report. On the last page of the facility's Fall Event Report investigation, there is a hand written note stating, Resident self transfers and mobility on unit independent. Self transfers from w/c to toileting, missed surface and fell to floor. (It is important to note that R35 is supposed to receive assist with transfers per care plan.) There is also another hand written note stating, Resident fell while self transferring from his wheelchair. He has a very cluttered room. He becomes very upset if his room is cleaned. While out of facility, we moved a dresser into closet and mounted TV on wall. Resident was upset when he returned about cleaning of room. DON (Director of Nursing) spoke with him and he is now OK with it. Facility investigation continued: Root Cause and Summary Section of fall investigation includes, in part: .Fall with negative outcomes marked for reportable event/root cause analysis .Briefly describe the incident that occurred: Resident attempted to self-transfer to w/c to go to the restroom as per his usual activity. The resident states that he missed the w/c and sat on the floor. The resident c/o (complained of) left hip pain. Resident sent to ER (emergency room ) for evaluation and treatment. Dx (diagnosis) with left [MEDICAL CONDITION]. Resident was admitted to the hospital for surgical intervention.After a thorough review of this incident, investigation and or incident explain the root cause that led to this incident? Room close with furniture arrangement, WC (wheelchair) rolled away from resident. (This is important to note since anti-roll back brakes were supposed to be in place, from 11/1/18, as a fall intervention, w/c should not have rolled away, indicating the anti-rollback brakes were either not in place or not functioning properly.) Explain what your intervention is going to be to prevent similar incidents from occurring to other residents in your facility. Room rearranged to give more space to transfer safely-resident in agreement to change, refer to therapy for safe transfers, anti-rollbacks to WC. Follow the four point plan of correction for this event. 1. What did you do to prevent further occurrence with the involved resident? Resident room rearranged to provide more space for safe transfers, anti-rollbacks added to WC (Please note this says they were added, which would indicate they were not on), refer to therapy for safe transfers. CNA (Certified Nursing Assistant) Care Card, included in the investigation, which was not dated, indicated R35 was assist of 1/assist of 2 to transfer from bed to w/c or from w/c to toilet or assist of 2 with sit-to-stand lift if resident is difficult to stand. Anti-rollbacks to w/c is hand written on this CNA Care Card.) On 5/1/19 at 10:54 AM, Surveyor reviewed Maintenance Log Book at Nurse's Station. Surveyor could not find any documentation for when R35's anti-rollbacks were requested to be placed on w/c in (MONTH) (YEAR) or (MONTH) 2019. Surveyor requested from DON B to find when they were placed. On 5/1/19 at 1:01 PM, Surveyor had interview with DON B about R35's anti-rollback brakes. DON B stated she couldn't find any maintenance slip/documentation indicating when anti-rollbacks were applied to w/c. DON B stated she spoke with MDS RN G (MDS Registered Nurse) about this. MDS RN G told DON B it was on the care plan, on 11/1/18, so it was done, but no evidence could be found to support that. On 5/1/19 at 1:30 PM, Surveyor had conversation with NHA A (Nursing Home Administrator) about concern for R35's fall, on 11/1/18, where anti-rollbacks being applied to w/c was the intervention, but then anti-rollbacks was the intervention again on R35's 1/19/19 fall with fracture. NHA A did not provide any documentation on when anti-rollbacks were applied. On 5/1/19 at 2:00 PM, Surveyor observed 35's w/c in his room with anti-rollbacks in place. Surveyor moved w/c backwards to see if anti-rollbacks worked. The right side moved back while left side stayed in place indicating R35's anti-rollback brakes are not currently functioning properly. On 5/1/19 at 2:05 PM, Surveyor interviewed RN K and RN [NAME] about R35 and transfer ability. RN [NAME] stated R35 has a history of transferring himself even though he was supposed to be assisted with transfers. R35 was impulsive and thought he could do those things. RN K agreed with this. On 5/1/19 at 2:18 PM, Surveyor had RN K go to R35's room and further discussed R35's anti-rollbacks. Surveyor asked RN K to move R35's w/c backwards to check anti-rollbacks. RN K did this and noted the right side moved while the left side stayed in place. RN K stated that the right side shouldn't move. On 5/2/19 at 8:15 AM, Surveyor observed R35's w/c anti-rollbacks still not working on right side of w/c. Surveyor had LPN S (Licensed Practical Nurse) come into R35's room and she confirmed the right side anti-rollback wasn't working. LPN S indicated that the right side of w/c should not move when backed up. The facility failed to ensure that adequate assistive devices (anti-rollback brakes) to prevent accidents were in place or functioning properly. Current non-compliance was observed with R35's anti-rollback brakes not properly functioning. Example 2 R11 was admitted to the facility, on 7/7/17, with [DIAGNOSES REDACTED]. R11 most current MDS, dated [DATE], indicates R11 is cognitively intact with a BIMS score of 15 out of 15. R11's Comprehensive Care Plan, initiated 7/7/17, includes, in part: 7/7/17 Problem: Risk for injury related to smoking Goal: Resident will comply with smoking policies. Resident will safely smoke in designated area with staff supervision . Approach: .Resident will be evaluated upon admission, quarterly, and as needed. Resident will be provided with a smoking apron if necessary. Resident will obtain smoking material. Staff will assist upon request and as needed. R11's Admission Smoking Assessment, dated 8/20/17, includes, in part: Observation date: 7/11/17 . The resident is determined to be a safe smoker . R11's Smoking Assessment, dated 11/17/17, includes, in part: Observation date: 11/17/17 . The resident is determined to be a safe smoker . R11 does not have a current smoking assessment to identify risks and to ensure facility has appropriate interventions in place to keep R11 safe while smoking. On 5/1/19, from 1:15 PM - 1:30 PM, Surveyor made an observation of R11 waiting in the dining room for staff member to supervise her smoking. R11 had her cigarettes and lighter in her pocket and stated, I keep these all of the time. CNA C brought a lighter with her but she lit one other resident's cigarette with it. R11 lit her own cigarette with lighter she had in her pocket. CNA C put smoking vest on R11 and R11 indicated she doesn't wear one of those and hasn't for over a year. R11 stated, No, I don't wear that! I haven't worn that for a year and a half. What is this? I don't want that. I don't need that. I didn't wear it yesterday. R11 stated to Surveyor, I really never wear this. R11 did allow CNA C to fold the vest and lay it over her knees/lap. (Of note, R11's care plan indicates R11 will comply with smoking policies and obtain smoking materials and a smoking assessment will be completed annually. R11 indicated she keeps her smoking materials and a smoking assessment has not been completed since (YEAR).) On 5/1/19 at 4:23 PM, during an interview, DON B stated, There is no current smoking assessment. It should be done at least annually.

Based on observation, interview and record review, the facility did not ensure each resident receives care, consistent with professional standards of practice (SOP), to prevent pressure injuries (PI) and to promote healing of existing pressure injuries for 3 of 4 residents reviewed (R1, R3 and R4). R1 developed a Stage 4 PI to his penis related to a medical device (indwelling Foley catheter). The facility failed to assess the Stage 4 PI and did not assure interventions were in place to prevent progression of the Stage 4 PI. Due to the development and progression of R1's Stage 4 penile PI, which was flayed open from the tip of the penis to the base of the scrotum on 2/21/19, R1 had to have a surgical procedure to place a suprapubic (SP) catheter. Facility failure to provide care, consistent with current SOP to prevent the development and progression of a pressure ulcer created a finding of Immediate Jeopardy (IJ) that began on 1/14/19. The INHA A (Interim Nursing Home Administrator) was notified of the IJ on 2/22/19 at 10:00 AM. The IJ was removed on 2/21/19; however, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as evidenced by examples R4 and R3. R4 was observed not having leg strap for catheter in place and sitting directly on catheter tubing, resulting in a stage 2 PI to the left inner thigh. The facility did not follow R3's physician's orders [REDACTED]. This is evidenced by: The facility's Pressure Ulcer Prevention/Risk Assessment policy, dated 4/2018, includes, in part: (Organization Name) has established a standardized policy with guidelines that assigns responsibility and provides procedures for identifying residents at risk for pressure ulcers; to provide guidelines for the prediction, prevention and treatment of [REDACTED]. level of risk. Procedure: Resident's level of risk for pressure ulcer development will initially be determined within 8 hours after admission or readmission taking into consideration the nature of risk to include underlying causes. (Emphasis included in the policy.) Resident's will automatically be HIGH risk when admitted with: a) Any pressure ulcers b) Any history of pressure ulcers c) Any pressure ulcer wounds which the resident has physician order(s) addressing treatments . Pressure Ulcer Preventative/ Supportive approaches will be implement appropriate to the resident's level of risk and the residents care plan updated to reflect the approaches. Facility policy entitled Urinary Catheters, dated 6/2016, includes, in part: positioning devices must be used to prevent unnecessary pulling on catheter and potential dislodging from the bladder . The facility's Pressure Ulcer Prevention/Supportive Approaches policy, dated 4/2018, includes, in part: . Avoid positioning the resident directly onto medical devices, such as tubes, drains and other foreign objects . The facility's Licensed Nurse Skin Discovery and Documentation policy, dated 4/2018, includes, in part: . A complete wound assessment and documentation will be conducted on all skin conditions upon discovery and weekly thereafter until they are healed . Documentation may include: Location, Category/Stage, Size, Tissue Type, Color, Peri-wound Condition, Wound Edges . All dressing changes . will be completed and documented in a manner compliant with accepted standards of clinical practice . c) Once completed, dressing changes will be documented on the treatment administrations record (TAR) and in nursing notes, as appropriate . The Plan of Care will be updated as appropriate, to address the resident's skin condition and any approaches initiated . Facility competency checklist, entitled (Facility name) Catheter Care Competency, undated, includes, in part: Secure tubing to resident's leg with leg strap . adjust catheter leg strap to ensure no tension on the catheter tubing. This should be positioned above the knee mid-thigh .straps should be loose enough not to have skin irritation . Example 1 R1 was admitted to the facility, on 3/17/17, with [DIAGNOSES REDACTED]. R1 has a court appointed guardian. R1's re-admission MDS (Minimum Data Set) assessment, on 1/14/19, notes a BIMS (Brief Interview for Mental Status) score of 7, indicating severe cognitive impairment. MDS also notes that R1 is at risk for PIs and has 2 Stage 2 PI's. R1's Comprehensive Care Plan notes, in part: -Problem start date 11/14/18: Pressure Ulcer Resident has 2 PIs . Approach: (dated 11/14/18) Assess and record the condition of the skin surrounding the pressure ulcers. Assess the pressure ulcers for location, stage, size (length, width and depth), presence/absence of granulation tissue and epithelization with treatments and weekly Conduct a systematic skin inspections weekly and prn (as needed). Report any signs of further breakdown . Keep resident off affected area as much as possible . -Problem start date 3/17/17 Indwelling Catheter. Risk for complications and infection related to indwelling catheter. Dx. (Diagnosis) [MEDICAL CONDITION] and [MEDICAL CONDITION]. Goal: Resident will not have complications related to the use of indwelling urinary catheter including infections or erosion. Approach: (dated 7/19/17) Resident refuses to have drainage bag at times and refuses to have a leg strap at times. Attempt and encourage daily . (dated 3/17/17) Provide catheter care each shift . (It is important to note that R1's Comprehensive Care Plan does not address what to do when R1 refuses the leg strap. There is no documentation in the record that staff explained to the resident and guardian the risks and benefits of refusals.) R1's Braden Scale for Predication of Pressure Sore Risk: On 10/30/18 notes a score of 14, Moderate Risk On 1/7/19 notes a score of 16, At Risk Review of the facility's documentation of R1's weekly Skin Body Assessment includes: On 12/26/18- No Areas of Skin Impairment On 1/3/19- No Areas of Skin Impairment R1's facility Progress Notes include, in part: On 1/3/19 at 4:00 PM, R1 was observed to not being able to sit up in wheelchair without staff assistance. Vital signs were taken and the facility notified the hospital and guardian that R1 was being sent to the emergency room . R1 was admitted to the hospital with [REDACTED]. R1 was in the hospital from 1/3/19-1/7/19. The hospital's Discharge Summary, dated 1/7/19, notes: Discharge Diagnosis: [REDACTED]. [MEDICAL CONDITION]- It is noted that the patient's indwelling Foley has continued to erode through his penile shaft and is now eroded completely to the base of penis. R1's After Visit Summary, dated 1/7/19, includes instructions: Home care . Use a leg band to secure the drainage tube, so it does not pull on the catheter . (It is important to note there is no documentation that this was being done.) Facility Progress Note, on 1/7/19, states: R1 returned from the hospital. Discharge instructions: Keep peri area clean and dry. Apply Zinc to peri area TID (three times a day) and apply split gauze dressing around the Foley . R1's weekly Skin Body Assessment includes: On 1/7/19 (R1 returned from hospital) - Base of penis is red. (It is important to note there are no measurements for this area and there is no assessment of R1's penis.) This assessment also notes: Area on right heel open area 0.8 CM (Centimeters) x (by) 1 CM . Buttocks are intact, skin is fragile. R1's care plan was updated to include: 1/7/19 Return from hosp. (hospital) R (right) heel area, R buttocks area, and (Handwritten entry) on 1/9/19 Area to penis. Goal: Resident's ulcer will heal without complications. Approach: (dated 1/7/19) Encourage resident to be compliant with ordered treatments. Resident's care plan was updated to include: (dated 1/7/19) Air mattress. R1's Physician Orders, signed on 1/8/19, include: 16 French urinary catheter with 10 cc (cubic centimeter) balloon, change as needed, Catheter care every shift, Diaper rash product (Zinc) . 2 oz. (ounces) to affected area three times daily . Apply thick layer to buttocks and scrotum under Foley catheter. On 1/9/19, R1 was sent to hospital for evaluation, presenting with blood in catheter and large clots from penis. R1 returned with order to make urology appointment. (There is no evidence the facility completed an assessment to R1's penis.) R1's care plan was updated, on 1/9/19, to include: Uro (Urology) Consult for Supra Pubic Cath (Catheter). MD (Medical Doctor) order on 1/10/19-Apply Zinc Oxide TID to open areas on right buttocks and scrotum under Foley (catheter). After application, apply a split gauze sponge dressing around Foley catheter TID. The Wound Clinic Note, on 1/14/19, indicates: There is significant penile shaft erosion into the base of the penis with subcutaneous and muscle tissue visible . Assessment: . Penis/scrotum Stage IV PI secondary to urinary indwelling catheter. Facility Progress Note on 1/14/19 states: Returned from wound clinic with orders: . 3) Penis ulceration: Apply zinc oxide TID and keep catheter tube away from wound. Comprehensive Care Plan was updated to include: (Handwritten entry) on 1/14/19 New tx. (treatment) orders for R buttocks and R heel-per Wound Care Clinic. Weekly Skin Body Assessment, on 1/16/19, indicates - (Document notes skin impairment to R sacrum/coccyx, R heel with measurements) and penis Zinc oxide as ordered to tip of penis. There are no measurements for this area. Wound Clinic Note, on 1/22/19, states: There is significant penile shaft erosion into the base of the penis with subcutaneous and muscle tissue visible . Assessment: . Penis/scrotum Stage IV PI secondary to urinary indwelling catheter . In addition to wound care instructions were given to keep the urinary catheter off loaded off of the patients skin . be seen by Urology . for evaluation. Weekly Skin Body Assessment, on 1/23/19, notes skin impairment to heel, buttocks and penis. Description of Skin impairment: Current treatments. Wound Clinic Note on 1/29/19: Penis/scrotum Stage 4 pressure ulcer: . peri care daily was with soap and water and apply [MEDICATION NAME] and fluffs. Keep catheter away from penile wound. The weekly Skin Body Assessment, on 1/30/19, notes skin impairment to penis, foot. Description of Skin impairment: specialty clinic treatment to foot wound. Daily treatment to penis. (It is important to note that the facility has no documentation or complete assessment for R1's skin impairment to penis.) On 2/7/19, the Nurse Practitioner (NP) at the wound clinic noted: There is significant penile shaft erosion and ulceration that is full-thickness and extends from the external urethral office (sic) through the shaft of penis right into the top of the scrotum. The full thickness ulcer extends through all of this penial tissue layers .The indwelling catheter is visible going into the base of the penis just above the scrotum . Plan: to remove . indwelling catheter and replace to a suprapubic urinary cath. NP further notes that based on assessment it did not appear as if R1 was receiving adequate care at the nursing home and the physician agreed. NP contacted R1's guardian who also agreed that R1 was not receiving adequate care and is seeking alternative placement for R1. On 2/11/19, a facility Progress Note indicates: Returned to facility suprapubic catheter in place. The Comprehensive Care Plan was updated to reflect this. Review of R1's monthly TAR's (treatment administrations record), orders for treatments include: Assessments and measurements were documented for R1's areas to R buttocks and R heel. -On 12/1/18-12/31/18: Catheter Care every shift- Treatment was not documented as being completed 56/93 shifts, documentation was left blank. -On 1/1/19 -1/31/19: Catheter Care every shift- Treatment not documented as being completed 49/81 shifts. (Of note: R1 was in hospital 1/3/19-1/7/19. There is an indication that R1 refused this treatment on 1/9/19 and 1/23/19 as a circled R was noted on the TAR, but there is no other documentation related to these entries.) -On 1/7/19-1/9/19: Diaper rash product (Zinc) apply 2 ounces to affected areas three times daily .Apply thick layer to buttocks and scrotum under Foley catheter - this treatment was documented as completed 2/9 shifts. Treatment was not documented as being completed 7/9 shifts. -On 1/10/19-1/13/19: Apply Zinc oxide TID to open areas on right buttocks and scrotum under Foley (catheter). After application apply a split gauze sponge dressing around Foley catheter TID - this treatment was documented as completed 2/12 times. Treatment was not documented being completed 10/12 times. -On 1/14/19- 1/30/19: Penis Ulceration: Apply Zinc oxide TID. Keep catheter tube away from wound. This treatment was documented as completed 29/51 times. Treatment was not documented being completed 22/51 times when it should have been. On 2/21/19 at 9:35 AM, Surveyor observed R1 sitting in wheelchair with a covered urinary drainage bag hanging below R1's wheelchair. Surveyor asked R1 if he had any sores, R1 indicated that he had sores on his buttocks, penis and foot. R1 was unable to explain when or how these areas occurred. R1 indicated that he had a new suprapubic catheter that was recently placed. R1 denied having pain. On 2/21/19 at 9:55 AM, Surveyor observed RN G (Registered Nurse) complete R1's treatment to Stage 4 penile PI. Surveyor observed that a catheter leg band was in place to support R1 suprapubic catheter tubing. Surveyor noted the posterior aspect of R1's penis was flayed open, from below the head of the penis to R1's scrotum, the open area was approximately 5.0 CM in length and 2.0 CM wide, the exposed tissue was red granulation tissue. Surveyor observed RN G complete R1's treatment as ordered and completed suprapubic catheter care. On 2/21/19 at 10:15 AM, Surveyor interviewed CNA J (Certified Nursing Assistant) and CNA I about R1's daily routine. CNA J stated that R1 likes to get up about 6:00 AM and goes to bed at 9:30 or 10:00 PM, and that R1 goes outside for a cigarette 3 times each day. Surveyor asked CNA J if R1 is laid down during this time, CNA J stated that R1 is offered and refuses. CNA I stated that R1 doesn't like to be washed or messed with. CNA I stated that R1 will let staff know if he needs to use the bathroom. Surveyor asked CNA I how staff completes peri care for R1. CNA stated we usually complete peri care over the toilet with R1 standing in the stand lift. Surveyor asked CNA J if R1 was using a catheter leg band in (MONTH) or January. CNA J stated R1 sometimes refuses; CNA J indicated that this is not documented. CNA J was not sure when R1 developed an open area to his penis. CNA J stated that staff works on different Units. On 2/21/19 at 10:30 AM, Surveyor interviewed IDON B (Interim Director of Nursing), who also is the facility's Wound Care Nurse, about R1's open area to his penis. IDON B stated that she was not aware that R1 had any open areas to his skin when he left the faciity on [DATE]. IDON B stated she first knew of the open area when R1 had a urology consult, but she did not recall the exact date. IDON B stated that the wound clinic was following R1's open area to his penis. When Surveyor asked IDON B her expectation of weekly skin assessments, IDON B stated that the Floor Nurses should complete a head-to-toe assessment and observe and document any skin concerns, including measurements. IDON stated that she completed weekly measurements to PIs on Wednesdays. Surveyor requested facility documentation of R1's open area to his penis. No further documentation was provided. On 2/21/19 at 2:20 PM, Surveyor interviewed RN G about completing R1's readmission skin assessment on 1/7/19. RN G had opened R1's assessment in the electronic health record but RN G thought the next shift (RN H) completed it when they came in. On 2/21/19 at 4:00 PM, when Surveyor asked INHA A (Nursing Home Administrator) what she would expect, INHA A stated that she would expect a complete head-to-toe skin assessment with any skin impairment documented and measured. Surveyor asked INHA A about R1's care plan entry refuses to have drainage bag at times and refuses to have a leg strap at times. INHA A explained that R1 refused the catheter drainage bag cover for privacy at times. When Surveyor requested documentation of R1's refusal of catheter leg band or cares, no further information was provided. On 2/21/19 at 7:00 PM, Surveyor interviewed RN H on the phone. Surveyor asked if RN H completed the skin assessment for R1 on 1/7/19 noting Base of penis is red. RN H could not recall if they were the person who completed this or not and could not describe the condition of the area on R1's penis. On 2/21/19 at 7:10 PM, IDON B reported to Surveyor that R1's open area to his penis measured 5.2 CM by 2.1 CM and the tissue was red and beefy. Surveyor asked IDON if this was the first time R1's open area on his penis had been measured in the facility. IDON B stated yes. Surveyor asked if wound measurements should have been completed since his return from the hospital on [DATE], IDON stated yes. While there is no evidence that R1 developed an open area to his penis before his hospitalization , on 1/3/19, the facility was aware that there was a red area on the base of R1's penis upon his return to the facility on [DATE]. Despite knowing this, the area was not fully assessed. When R1 returned from the wound clinic, on 1/14/19, noting a Stage 4 open area to his penis, the facility did not update R1's care plan to reflect this area, did not complete weekly skin measurements or implement new approaches, such as trying to have R1 offload this area by repositioning or lying down. There is no evidence that the facility explained the risk or benefits to R1 or R1's guardian of his refusals of cares or repositioning every 2 hours. R1's weekly skin assessments, after 1/7/19, do not reflect any loss of skin integrity to R1's penis. Additionally, the facility does not have documentation that treatments to R1's penis were completed as ordered, between 1/7/19 and 1/30/19, when R1's penile wound progressed to a Stage 4 PI. Facility failure to provide care, consistent with current SOP to prevent the development and progression of a pressure ulcer, and failure to ensure a resident with a pressure ulcer receives treatment and services to promote the healing of a pressure ulcer, created a finding of IJ that began on 1/14/19. The facility removed the IJ, on 2/21/19, when it developed and began implementing a removal plan after being told that an IJ Call would be held the next day. The facility's plan indicated it would: -Conduct a sweep of all residents with a supra-pubic or indwelling Foley catheter with a date of completion of 2/21/19. - Skin assessments will be completed on all residents with a supra-pubic or indwelling Foley catheter with a date of completion of 2/21/19. -Beginning on 2/21/19, education will be provided to nursing staff. No nursing staff will work without having completed the educations. Education as follows: -All Nursing Staff: wearing leg straps for those residents with a catheter. Documenting in real time a review of risks and benefits to resident or responsible party, if a resident with a catheter refuses the leg strap. Monitoring of skin integrity on residents with catheters during cares with immediate report to nurse regarding any skin impairment. The nurse will then immediately report to the DON or RN designee. -Licensed Nurses: Documentation of any skin impairment. Wound documentation to include complete measurements of all wounds. Documentation of treatments being done and signing out on the TAR as ordered. - The DON or designee will audit that residents with a catheter are using a leg strap every shift for three days, then three times weekly for twelve weeks. The results will be reported to the QAPI (Quality Assurance Process Improvement) Committee. -The DON or designee will audit five resident treatment records weekly for twelve weeks to ensure that treatments are being signed by the licensed nurse. The results will be reported to the QAPI Committee. The deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as evidenced by: Example 2 R4 was admitted to the facility, on 10/13/2008, with [DIAGNOSES REDACTED]. R4's Care Area Assessment (CAA), associated with most recent Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/13/2018, includes, in part: Urinary Incontinence and Indwelling Catheter: CAA triggered related to the use of an indwelling urinary catheter and the need for extensive assistance with toileting . is unable to complete any of own catheter cares. When asked about catheter (resident) appears to forget sometimes that it is in place or why it is there. Staff report other times (resident) will approach them to say that (resident) thinks bag is full. R4 requires the use of an indwelling catheter related to [MEDICAL CONDITION] bladder secondary to MS ([MEDICAL CONDITION]) and a history of urine retention. (R4) requires the use of a silicone catheter because of a latex allergy. Catheter cares are performed at least once per shift. Catheter does place (R4) at a higher risk for UTI's and dignity issues . Pressure Ulcers: CAA triggered related to the indication that (R4) has risk factors present for pressure ulcer development. (R4) presents with limited mobility, presence of urinary catheter . does not have any pressure ulcers currently . can reposition self in wheelchair somewhat independently, but requires staff assistance for large position changes . always requires cues for repositioning . Problem: Pressure Ulcer: Potential for alteration in skin integrity related to immobility secondary to advancing MS, poor safety awareness and indwelling catheter . Goal: Prevent loss of skin integrity . Approach start date: 7/18/19 Alternate catheter secure strap sites to prevent skin breakdown . catheter tubing needs to be positioned in front of resident's body versus behind . R4's Comprehensive Care Plan, includes, in part: Problem (R4) requires an indwelling urinary catheter related to advanced MS, [MEDICAL CONDITION], and [MEDICAL CONDITION] bladder . Goal: To prevent and reduce the occurrence of urinary tract infections via indwelling catheter . Approach start date: 7/18/18 Position catheter tubing in front of body versus behind . use a catheter strap and alternate site to prevent skin breakdown . Approach start date: 10/15/2007 avoid lying on top of tubing . Provide total assistance for catheter care every shift . R4's Physician Orders, for 2/1/19-2/28/19, include, in part: start date 12/28/17: Silicone Foley Catheter size 22 F with 10 ml (milliliter) balloon change as needed if malfunction or infection; dx: [MEDICAL CONDITION] bladder, retention . start date 1/31/19: Check inner thigh area daily two times continue with Duoderm to inner thighs to protect from catheter tubing . R4's Braden Assessment, dated 2/3/19, indicates R4 is at risk for PI development with a score of 15. R4's most recent Quarterly MDS with an ARD of 2/4/2019 indicates R4's cognitive status to be severely impaired with a BIMS score of 7. R4's MDS also indicates R4 has used a catheter for 7 of the 7 look back days, is at risk for PI development, and has no unhealed PIs. R4's Nurse Notes, dated 2/4/19, include, in part: Resident has open areas between legs from catheter. Lotion to skin by staff. Skin turgor is good. No issues at this time. On 2/21/19 at 5:00 PM, during an interview, CNA C indicated that if a resident refuses leg strap, CNA C does not document this, but the nurse would. On 2/21/19 at 6:35 PM, during an interview, CNA D indicated that some residents who have catheters do not use leg straps, due to having skin sores on their inner legs and if a resident refused to use leg strap CNA D would report this to the nurse and mark it on the clipboard at Nurse Station. (It is important to note, the facility did not provide any documentation of R4 refusing the use of the leg strap by the nurses or CNAs). On 2/21/19 at 6:40 PM, during an interview, CNA E indicated that R4 uses a leg strap, but not every resident who has a catheter uses one. On 2/21/19 at 6:50 PM, during an interview, CNA F makes sure to strap the tube to the resident's leg while providing catheter care if the nurse provides straps or butterfly stickers. CNA F also indicated that if the nurse does not provide a strap or butterfly stickers, CNA F assumes the resident does not need them. On 2/21/19 at 7:30 PM, Surveyor observed R4 sitting in wheelchair on top of catheter tubing. Surveyor asked R4 if they had a strap around R4's leg to secure the catheter tubing. R4 indicated that R4 is supposed to but did not have it on now. During an interview, IDON B sighed heavily and stated, She should have a leg strap on. On 2/21/19 at 7:48 PM, Surveyor observed R4 still sitting on catheter tubing with no leg band in place. IDON B indicated that she did not know why R4 did not have a leg band on and that she is supposed to have a leg band and not supposed to be sitting on catheter tubing. IDON B also indicated that R4 should have Duoderm in place between thighs for protection. Surveyor observed CNA E and IDON B transfer R4 from wheelchair to bed and then observed R4's inner thigh to not have any Duoderm placed and to have a red impression and open area on left inner thigh. IDON B again indicated that R4 should have Duoderm placed on inner thighs and she doesn't know why it is not there. Surveyor asked IDON B, What do you see? IDON B stated, An open area from R4 sitting on catheter. DON B handed Surveyor a hand written notepad paper indicating that these notes were from today (2/21/19). Note includes, in part: .(R4) . at 8:05 PM left inner thigh . 3.9 x .5 . beefy red . peri wound pink . blanchable .2 CM around wound . stage 2 . Provider notified at 8:30 PM. Example 3 R3 was admitted to the facility, on 6/21/2016, with [DIAGNOSES REDACTED]. R3's Comprehensive Care Plan includes, in part: start date: 12/01/16 Category: Pressure Ulcer . Approach: start date 12/01/16 Pressure reduction/air flow mattress. Pressure reduction cushion to wheelchair . R3's Braden Scale Assessment, dated 9/26/18, indicates R3 is at moderate risk for PI development. R3's Situation Background Assessment Recommendation (skin event), dated 10/18/18, includes, in part: . open pressure wound to right outer thigh .What appears to be going on with the resident? Summarize your observations and evaluation: resident sits in wheelchair all day, is resistant to laying down and has history of pressure areas in same areas . Other pertinent history: old pressure ulcers to bilateral thighs R3's Weekly Wound Charting includes: 10/18/18 6 x 4 CM 10/24/18 3.3 x 5.1 CM 10/31/18 4.3 x 6.2 x 0.1 CM 11/7/18 4.3 x 6.2 x 0.1 CM 11/14/18 3.0 x 2.5 x 0.1 CM 11/21/18 3.5 x 2.0 x 0.1 CM 11/28/18 1.9 x 1.8 CM 12/5/28 2.2 x 1.6 CM 12/12/18 2.6 x 2.5 CM 12/19/18 1.1 x 0.8 CM 12/26/18 0.8 x 0.3 CM 1/2/19 2.4 x1.4 CM 1/9/19 3.2 x 2.1 CM 1/16/19 3.2 x 2.1 CM 1/23/19 2.4 x 1.6 CM 1/30/19 2.4 x 1.4 CM 2/6/19 2.2 x 1.3 CM 2/13/19 0.9 x 0.6 CM 2/20/19 0.9 x 0.4 CM R3's Physician order [REDACTED]. Start date: 10/26/16 . open ended . air flow mattress to bed . Start date 10/28/16 . open ended . gel cushion to wheelchair . Start date: 10/23/18 . open ended . cleanse wound with wound cleanser, pat dry, apply barrier to healthy skin around wound, apply collagen matrix to wound bed, cover with foam dressing once a day . R3's physician progress notes [REDACTED]. Currently has one wound to upper right posterior thigh near buttock crease. Area is shallow without drainage or pain. Nursing report the wound measures 2.4 CM x 1.6 CM with no depth. Wound is beefy red in appearance. Surrounding tissue is not inflamed . is receiving daily dressings with barrier to healthy skin followed by collagen matrix to wound bed and covered with foam bordered dressing . Diagnoses: [REDACTED]. Left now healing. Right almost healed: 8/10/2017 On 2/21/19 at 11:20 AM, Surveyor observed R3's bed to have a Panacea foam mattress on it. Surveyor also observed R3 sitting in wheelchair on a blue foam cushion. R3 gave Surveyor permission to feel wheelchair cushion. On 2/21/19 at 2:10 PM, Surveyor and PTA K (Physical Therapy Assistant) observed R3's wheelchair cushion. PTA K indicated cushion is not a gel cushion, it is a foam Panacea cushion. PTA K was unaware of R3's Physician order [REDACTED]. On 2/21/19 at 2:20 PM, during an interview, DOPT L (Director of Occupational and Physical Therapy Department) was unaware of R3's order for a gel cushion and an air flow mattress and that the facility was getting a referral for R3 to be re-assessed by therapy.

Surveyor: Kleist, Stephanie R. Based on observation, interview, and record review, the facility did not provide an environment in which residents were free from neglect (failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress) and/or verbal, mental and physical abuse for 8 of 27 sampled residents (R44, R48, R41, R43, R24, R15, R52, and R17). This prevented residents from reaching their highest practicable level of physical, mental, and psychosocial well-being and resulted in psychosocial harm (embarrassment, humiliation, degradation) and pain for 4 sampled residents (R44, R48, R41, and R52). R44 indicated that she has had to wait for 45 minutes to one hour to be assisted to the bathroom, causing her to be incontinent. R44 indicated that she has reported allegations of abuse and neglect to management and other staff and now is afraid of retribution if she brings up concerns. R44 states, It made me feel like crap, like I wasn't worth anything. It bothers the hell out of me and other people It is like they are degrading us . R44 indicated she has wet her pants waiting for assistance and stated this used to embarrass her. R48 indicated staff made her sleep in her easy chair after soiling her bed. R48 also indicated that she has had to wait for long periods of time for assistance, resulting in incontinent episodes and feeling dirty, unimportant, and neglected. R48 pointed at a staff member, indicating she had a problem with the staff member and management was aware, but conducted no immediate investigation. R48 indicated she has voiced concerns to the facility and that she is afraid of retaliation. R41 voiced she felt hurt due to staff making her feel bad regarding her size. R43's call light was placed out of reach and out of sight by staff, because he was on it constantly. R43 was noted to have a history of falling. R24 was not assisted with a shower, because the staff member was too tired. Staff signed out that she did receive a shower. R24 stated, I didn't have a choice. R15 reported that her bed was not made and she slept on the bare mattress all night. A thorough investigation was not completed of R15's allegation of neglect. R15 indicated that people are afraid to speak up, because of fear of retaliation. R24 voiced a verbal allegation regarding a staff member and is afraid of retaliation. R52 voiced a verbal allegation regarding a staff member and is afraid of retaliation. Surveyor observed R52 in significant pain, while waiting over an hour for a staff member to bring her medication for pain and to reposition her R17's family member indicates neglectful cares and R17 getting yelled at by staff. Evidenced by: According to the interpretive guidelines to the federal nursing home regulations, Each resident has the right to be treated with dignity and respect. All activities and interactions with residents by any staff, temporary agency staff or volunteers must focus on assisting the resident in maintaining and enhancing his or her self-esteem and self-worth and incorporating the resident's, goals, preferences, and choices. When providing care and services, staff must respect each resident's individuality, as well as honor and value their input. (F550) Facility abuse policy, chapter 6.2, Purpose, dated 11/2016, states, in part: Purpose: The facility will establish an environment that is as homelike as possible and includes a culture and environment that treats each Resident with (SIC) Resident and dignity. Treating Resident in any manner that does not uphold a Residents sense of self-worth and individuality dehumanizes the Resident and creates an environment that perpetuates a disrespectful and/or potentially abusive attitude towards the Resident. The facility requires services and care provided by staff in a person-centered environment in which all individuals are treated as human beings. Staff providing care and services will include: employees, consultants, contractors, volunteers and other caregivers providing services on behalf of the facility The facility will-not use verbal, mental, sexual or physical abuse, corporal punishment or involuntary seclusion . Example 1 R44 is a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. R44 has a BIMS (Brief Interview for Mental Status) score of 7/15 (a score of 0-7 indicates severe cognitive impairment), but is able to understand and be understood. R44's MDS section 0700/Makes Self Understood indicates R44 is understood. Section 0800/Ability to Understand Others indicates R44 is understood- clear comprehension. On 2/5/18 at 11:12 AM, during Group/Resident Council interview, R44 voiced her call light gets turned on and staff doesn't answer it. R44 indicated she had to wait 45 minutes and she soiled herself. R44 indicated this incident occurred less than a month ago. When asked how often this occurs, R44 indicated it depends on the CNAs who are coming in, some are better at answering lights. R44 indicated that staff come in, shut off the call light, and say I'll be back and never come back. R44 indicated this occurs mostly with CNA L who works the evening shift. R44 indicated filing a grievance on CNA L, the same day as other residents, and that a nurse made them write a statement. R44 stated, They got sassy with me and say they'll be right back and leave and don't come back. R44 indicated that a CNA told her to Quit being a baby, and R44 indicated she reported it to DON B. R44 indicated that the SW told us not to say anything to anyone. R44 indicated a CNA came up to her and said, So I heard you don't like the job I'm doing for you. R44 also indicated she received a rough pat on the back by a CNA as she stated, I heard you are talking about me. R44 indicated to CNA that it hurt and that CNA stated to her, Oh sorry, didn't mean to do it. R44 indicated she voiced wanting that CNA to stay out of her room, and that the CNA's been coming in her room more often, and when she comes in her room, R44 won't let her help her, because she's down right rude. (Please note R44 refused to give names due to fear of retaliation regarding above situations/grievances/concerns.) 2/8/18 at 7:53 AM, during an interview, R44 stated, The staff here get crabby. They say things to me like, 'Oh, You do it yourself. You don't belong here.' I had two nasty ones yesterday morning. I won't name names, because we get retribution if they find out you say something about them. They get nasty and treat you differently. I went to SW awhile back with complaints and they (CNA's) found out it was me. After that, one aide was rough on me with transferring in the bathroom. She was pushing really hard on my braces on my feet and causing me a lot of pain. The CNA told me, 'Oh quit your crying, I didn't do anything wrong.' She was working with CNA P when it happened and I like CNA P. Another time, a CNA came up behind me and gave me a hard slap on the back. She said, 'I hear you're complaining about me.' She acted like it was no big deal. It is a big deal to me. It made me feel like crap, like I wasn't worth anything. It bothers the hell out of me and other people. I am not going to put up with it. It is like they are degrading us . R44 indicated that she has to wait 45 minutes to 1 hour for assistance to go to the bathroom; that she has wet her pants waiting for assistance. She stated, I was embarrassed at first, now I am like screw it, they can clean it up. R44 indicated to Surveyors that she's afraid of retaliation and does not voice concerns because of this. R44 indicated she gets the silent treatment from some CNAs when she voices a concern. Example 2 R48 was admitted on [DATE]. R48's MDS BIMS score of 14 indicates R48 is cognitively intact. A Grievance/Complaint Form, dated 1/15/18, initiated by R48's family member, includes, in part: Summary of Grievance/Complaint: 'I turned on my light at 10:00 PM and no one answered it or changed me until 2:00 AM. I was soaking wet' Steps Taken to Investigate Grievance/Complaint: (section is blank) . Summary of Findings/Conclusion: (section is blank) . Corrective Action Taken: staff was reminded to answer lights in prompt and timely manner . Signature of who copy review was offered and provided to: (section is blank). On 2/5/18 at 10:51 AM, during initial tour, R48 stated, I put my call light on and no one comes. I was so wet two nights ago that staff made me sleep in my easy chair. It makes me feel not dignified. I have to make extra noise when I put my call light on because no one comes. I bang whatever I can reach, sometimes my call light. R48 indicated that she had talked to RN W and DON B about the incident that happened two nights ago and about her having to make extra noise in the night. On 2/7/18 at 2:45 PM, during an interview, R48 indicated that 2 or 3 nights prior, she had to wait 2 or 3 hours for assistance and she had to bang on something with her call light, because no one was coming. R48 indicated that CNA LL and CNA NN came into her room at 3:00 AM and that she was very wet. She also indicated that CNA LL and CNA NN made her sleep in her easy chair for the rest of the night, because her bed was wet. R48 stated, I don't want them to know I said their name. I am afraid they will retaliate. Maybe that is why they won't help me and make me wait so long. R48 indicated that when she is incontinent, she feels dirty. On 2/8/18 at 11:25 AM, during an interview, R48 indicated that she tries to hold her urine and does not want to wet her bed. She also indicated that when she waits a long time and can't hold it, that she feels dirty, unimportant, and neglected. She indicated that she was afraid to complain, stating, I will be the most complaining person. They will transfer me to another home. Example 3 R41 was admitted to the facility on [DATE] and readmitted [DATE], with [DIAGNOSES REDACTED]. R41's quarterly MDS, dated 11/ 22/17, indicates R41 as being totally dependent on staff for bed mobility, transfers and toileting. Section C indicates R41 cognitive skills, for daily decision making, is severely impaired (rarely/never makes decisions). Section E indicates R41 has 1 to 3 days of verbal behaviors and no other behaviors are marked; in addition, it indicates R41 did not have hallucinations/delusions. 2/5/18 at 11:08 AM, Surveyors conducted the Resident Council/Group meeting interview. During this interview, R41 indicated that staff makes her feel bad for her size. R41 indicated it happens often. R41 was visibly tearful, and then began crying while stating, It hurts me a lot. R44 indicated she witnessed the situation occur in the dining room and that staff stated, You are so big, we can't lift you to R41 in front of others. Example 4 R43 is an [AGE] year old male, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R43's care plan, initiated 6/3/2009, identified R43 as a fall risk. Approaches include: pressure pad call light to edge of bed, initiated 12/28/17. On 2/5/18 at 9:32 AM, Surveyor observed a sign on resident's wall that stated: Please attach call light to sheet in such a way that he will trigger if attempts to get out of bed. Surveyor also observed R43 sleeping in bed. One call light was noted to be hanging over the footboard of the bed, unattached to anything, hanging on outside of footboard. A second call light was coiled up under a chair, on the other side of the divider curtain. On 2/5/18 at 10:25 AM, Surveyor observed call light positioned in the same place, over bottom foot board, unattached to bedding or bed, hanging on inside of footboard. R43 was asleep in bed. A second call light was coiled up under a chair, on the other side of the divider curtain. On 2/5/18 at 12:43 PM, Surveyor observed R43 sleeping in bed and observed his call light draped over foot board of bed, unattached to anything, hanging on outside of footboard. A second call light was coiled up, under a chair, on the other side of the divider curtain. On 2/5/18 at 4:25 PM, Surveyor observed R43 sleeping in his bed. Two call lights were observed. One call light draped over the chair on the other side of the divider curtain and the other one is on the floor, in a coil, under the chair on the other side of the divider curtain. On 2/5/18 at 4:35 PM, Surveyor observed R43 calling out. CNA O walked into room and talked with resident. R43 indicated that he did not want to get out of bed at this time. CNA O walked out of R43's room and call lights remained in place: one call light draped over the chair on the other side of the divider curtain and the other one is on the floor, in a coil under the chair, on the other side of the divider curtain. On 2/5/18 at 4:38 PM, Surveyor observed R43 calling out. CNA L walked into room where R43 is sitting up on the edge of his bed. CNA L assisted him in lying down again. CNA L leaves the room. Call lights remain in place: one call light draped over the chair on the other side of the divider curtain. The other one is on floor in a coil under the chair on the other side of the divider curtain. On 2/5/18 at 4:40 PM, during an interview, CNA L stated, That is where the call light always is placed. It is supposed to be there; otherwise, he is on it constantly. CNA L indicated that R43 can get up to get to the call lights, as they are draped over the chair on the other side of the divider curtain and on the floor, in a coil, under the chair, on the other side of the divider curtain. CNA L indicated that the sign was placed on the wall, because R43 gets confused. On 2/5/18 at 4:45 PM, during an interview, RN Q stated R43's call light is not ok to be placed on the other side of curtain, on chair, or under chair. She stated, I expect staff to place call light on his (R43's) bed, in his reach. This resident is always on the call light. RN Q positioned call light by attaching to R43's sheets, within his reach. On 2/6/18 at 8:09 AM, during an interview, RN J states that she expects staff to place R43's call light in his reach. On 2/6/18 at 8:14 AM, during an interview, UM/LPN H states that she expects staff to place R43's call light on his bed, in his reach. She removed the sign off of R43's wall. On 2/6/18 at 2:48 PM, Surveyor observed R43 sleeping in his bed. Surveyor also observed two call lights draped over the footboard of bed, towards resident. On 2/7/18 at 7:35 AM, Surveyor observed R43 sleeping in bed. One call light is on chair seat, on other side of curtain. The other call light is under the chair, on other side of curtain. On 2/7/18 at 8:00 AM, during an interview, MDS/RN K (Minimum Data Set Coordinator / Registered Nurse) indicated that she was unsure if R43's call light should be placed on the chair or under the chair on the other side of the divider curtain. She indicated that she was also unsure if R43 was able to call for assistance with his call lights on and under the chair, on the other side of divider curtain. MDS/RN K left room and did not reposition call lights. On 2/7/18 at 8:06 AM, Surveyor, along with DON B and MDS/RN K, observed R43 sleeping in his bed. Also observed, were two call lights: one on seat of chair, one underneath chair, both behind divider curtain. DON B indicated that R43's call light should not be on other side of divider curtain, on chair or under chair. She indicated that R43 cannot call for assistance when call light is placed on chair or under chair, behind divider curtain. DON B positioned call light on edge of bed, attached to sheet. On 2/7/18 at 8:12 AM, during an interview, RN V indicated that she was last in R43's room between 6 -7 AM. She also indicated that she was unsure where the call light was placed at that time, but it should be placed in R43's reach. On 2/7/18 at 8:13 AM, during an interview, CNA M stated that she had not been in R43's room yet and his call light should be placed on his bed, where he can reach it. Example 5 R24 is a [AGE] year old woman, admitted to facility on 10/21/16, with [DIAGNOSES REDACTED]. R24's MDS BIMS, with an ARD of 11/22/17, indicates cognitively intact with a score of 15. On 2/6/18 at 8:03 AM, Surveyor observed R24 indicate to RN J that she did not get a shower the previous night, because the CNA was too tired. RN J asked, Are you ok with that? R24 replied, I didn't have a choice. RN J indicated to R24 that it was alright as long as she received her bath that day. On 2/7/18 at 8:00 AM, Surveyor observed R24's hair to be wet and asked her if she just gotten out of the shower. R24 rolled her eyes, sighed, and stated, No, I just got a good head washing. I never got a shower this week. R24 refused to name the staff member who was too tired to assist her in the shower on 2/5/18, but did indicate that staff work long hours and she doesn't blame them for being tired. R24's Nursing Assistant Flow Record, for (MONTH) (YEAR), indicated R24 had received a shower SH on 2/5/18, on the PM shift. Example 6 R15 is a [AGE] year old female, admitted to facility on 1/17/16. R15's MDS, with an ARD of 11/8/17, indicates cognition to be moderately impaired and that she requires extensive, physical assistance of one staff in performing these ADLs: bed mobility, toileting, transferring, dressing, and personal hygiene. A Grievance/Complaint Form, dated (not legible), signed by DON B on 1/26/18, includes, in part: Summary of Grievance/Complaint: Had shower, bed was stripped, bed never remade. Slept all night on bare mattress and covered up with her quilt . Findings of Investigation: R15 took sheets off own bed. Did not inform staff. CNA L gave shower. CNA LL toileted at 4:00 AM. Corrective Action Taken: skin check . A copy of this review was offered and provided to: (section blank). A copy of this review was offered and provided to: (section blank). CNA LL interview, undated, for the above mentioned complaint/grievance, includes, in part: .Did you give (R15) her shower on 1/18/18? Unknown (handwritten response). Did you strip (R15)'s bedding on 1/18/18? Unknown (handwritten response). Did you complete rounds on R15 on the N[NAME] (night) shift on 1/18/18-1/19/18? Yes (handwritten response). On 2/5/18 at 11:15 AM, during Resident Council Group interview, R15 indicated that when she has a shower, her bedding does not get changed. R15 stated, I have told the aides. If you complain they pick on us. People are afraid to speak up because of retaliation. Another resident from Resident Council group replied to R15's concern, stating, You know what you have to do. You have to throw the bedding on the floor. That way they have to change it. It works. R15 agreed. Example 7 2/5/18 at 11:12 AM, during Group/Resident Council interview, R24 indicated filing a grievance on a CNA, the same day as other residents, and that a nurse made them write a statement. R24 indicated a CNA insisted she could get up on an EZ stand, and was put on it by the CNA, who then got mad and stated, You're the reason nobody wants to take care of you. (Please note Surveyor has a written facility statement from R24 regarding this situation.) There is no Grievance Form completed for this incident reported by R24 that was provided to Surveyor. One on One Teachable Moment Form for CNA AA, not dated, states, in part: Explanation of required education: per 3 residents (CNA AA's name) came into room, turned off call light, said she would be back and did not come back. Additional interventions for employee: Call lights must be answered timely. If can't right at the moment, must get back as soon as possible to provide good care and customer service. If problems with residents, get the nurse or supervisor. (No employee comments) Signed on 1/5/18 by CNA AA. Attached statement, signed on 1/4/18 by R24, states: Staff CNA AA said to me, 'It is people like you that make other aides not want to come back here & take care of you.' Those were her exact words. I'm sorry, but I am not able to stand & get changed with just something holding me up under my arms. She told me she hit a wall with her hand earlier & had Band-Aids under her glove. She took off her gloves and left the room as she said, 'I give up.' R24 also indicated she gets the silent treatment from CNAs when she voices a concern. R24 voiced, during group/resident council interview on 2/5/18, that she is afraid of retaliation from staff. Example 8 2/5/18 at 11:12 AM, during Group/Resident Council interview, R52 indicated filing a grievance on a CNA, the same day as other residents, and that a nurse made them write a statement. A One on One Teachable Moment Form for CNA AA, not dated, states, in part: Explanation of required education: per 3 Residents (CNA AA's name) came into room, turned off call light, said she would be back and did not come back. Additional interventions for employee: Call lights must be answered timely. If can't right at the moment, must get back as soon as possible to provide good care and customer service. If problems with residents, get the nurse or supervisor. (No employee comments) Signed on 1/5/18 by CNA AA. Attached statement, signed on 1/4/18 by R52, states: Between 10:00 AM and noon I had to go to bathroom. When I got done, I turned my light on for help and (CNA AA) came in asked me what I wanted, told her I need to be cleaned up. She turned off light, said she would get someone, but never came back or told anyone, the nurse told (CNA Name). She has done this in the past. R52 voiced during Group/Resident Council interview on 2/5/18 that he is afraid of retaliation from staff; staff give him the silent treatment when he voices concerns. R52 was observed with verbal and non-verbal signs and symptoms of pain on 2/7/18, from 10:05 AM to 11:12 AM, until his pain began to be relieved. On 2/7/18 at 10:50 AM, Surveyor asked R52 to rate his pain. R52 stated to Surveyor, over a 10, and I'm sitting on my wounds without a pad, I keep hearing the nurse is coming. R52 indicated to Surveyor that he gets this all the time. R52 is still visibly sitting in his w/c with his pants down to mid-thigh, his bottom appears uncovered, sitting on soaker pad. R52 stated to Surveyor, It's been over a half hour already, this is how slow things are. R52 stated, I'm going to start screaming. (Cross reference F697) Example 8 On 2/7/18 at 2:10 PM, Surveyor interviewed FM CC, the daughter of R17. FM CC stated that she visits R17 almost daily, during the daytime. Explained that she felt she had to be there to take care of R17 herself. She explained that CNA NN often told the nurse that she took care of R17, when FM CC said that the care had not been completed or she had done it herself. FM CC stated that a Clergy Member had reported to her that CNA NN had yelled at R17 during a visit. She explained that she had found a bag of poopy linen in R17's closet that stank up the room one time. She described some staff at the facility as having no [MEDICATION NAME] and that her Mother (R17) endured a lot of torture, due to the lack of care/assistance.

Based on Resident Council group interview, resident interview, and family interview, the facility did not provide an environment that encouraged residents to voice grievances without discrimination or fear of reprisal for 10 of 27 sampled residents (R44, R48, R41, R53, R24, R15, R11, R52, R39, and R17). One resident described experiences of actual retaliation for having voiced a grievance (R44). Five residents in the group interview (R44, R41, R24, R15, and R11) indicated they do not feel comfortable bringing forward any problems/concerns, because they are afraid of reprisal and that their care will be hindered and there was no follow up by management with resolution to their concerns. Residents and or family members outside of Resident Council Group interview, filed grievances or reported concerns to staff members that were not passed on to the Grievance Official, investigated thoroughly, or followed back up with, when a resolution was reached. Residents and family members indicated that they fear retribution if they would express concern. Example 1 rose to a level of actual harm. Evidenced by: The facility's policy, Grievances/Concerns, dated 10/17, includes, in part: Purpose: .to support each resident's right to voice grievances and to ensure that a policy is in place to process grievances . Policy: Residents have the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or fear of reprisal and without fear or discrimination or reprisal . The Administrator is the Grievance Officer . Procedure: Upon admission, Social Services or designee will inform residents and resident representative of their right to voice grievances with respect to treatment received, as well as a lack of treatment received, as well as a lack of treatment received during their stay in the facility, and how to file or submit a complaint/grievance . Social Services Director will coordinate the facility system for collecting grievances and tracking those grievances for timely and appropriate response .Administrator will lead investigation and ensure residents are protected from discrimination or reprisal . an immediate action will be implemented to prevent further potential violation of any resident right while the alleged violation is being investigated .involving neglect, abuse, including injuries of unknown source, and or misappropriation .reported the facility will reference and follow Abuse and Neglect Procedures .will be investigated within 72 hours following receipt of the complaint .Social Services Director will report to facility Administrator during . the status of all grievances . Social Services will analyze the grievance tracking system for trends or patterns .Identifiable trends will be addressed through the facility Continuous Quality Performance Improvement Committee (a QAPI (Quality Assurance and Performance Improvement) program) . will train staff upon hire how to receive grievances voiced by residents and/or family members . training will include .: Listening without becoming defensive, Diffusing an emotionally charged resident or family member, The need to take all voiced grievances seriously, what to do with grievances voiced, when to put a grievance in writing. Example 1 R44 is a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. R44 has a BIMS (Brief Interview for Mental Status) score of 7 of 15. (A score of 0-7 indicates severe cognitive impairment.) R44's MDS section 0700/Makes Self Understood indicates R44 is understood. Section 0800/Ability to Understand Others indicates R44 is understood- clear comprehension. A Grievance/Complaint Form, dated 12/8/17, initiated by R44's family member, includes, in part: Summary of Grievance/Complaint: every day this week I have heard horror stories from her (R44) regarding her care, having to wait for hours before being taken to the bathroom or being put to bed . Steps Taken to Investigate Grievance/Complaint: (section is blank) . Summary of Findings/Conclusion: DON checked with staff. DON was aware that resident was left in bed for breakfast and was in main dining room for lunch and up to smoke. At 2 PM (family member) approached DON stating that resident needed assistance. DON spoke with staff and 2 CNAs (Certified Nursing Assistant) went immediately . to assist. Corrective Action Taken: (section is blank). Signature of who copy review was offered and provided to: (section is blank). (It is important to note that the Grievance/Complaint Form indicated there was no follow through with R44 or her family member regarding a resolution to the concerns expressed in this grievance.) 2/5/18 at 11:12 AM, during Group/Resident Council interview, R44 voiced that her call light gets turned on and staff doesn't answer it. R44 indicated she had to wait 45 minutes and she soiled herself. R44 indicated this incident occurred less than a month ago. When asked how often this occurs, R44 indicated it depends on the CNAs who are coming in, some are better at answering lights. R44 indicated that staff comes in, shuts off the call light, and say I'll be back and never come back. R44 indicated this occurs mostly with CNA L, who works the evening shift. R44 indicated she filed a grievance on CNA L, the same day as other residents, and that a nurse made them write a statement. R44 stated, They got sassy with me and say they'll be right back and leave and don't come back. R44 indicated that a CNA told her to Quit being a baby, and R44 indicated she reported it to DON B. (Please note that R44 identified DON B by her first name.) R44 indicated that the Social Worker (SW) told us not to say anything to anyone. R44 indicated a CNA came up to her and said, So I heard you don't like the job I'm doing for you. R44 also indicated she received a rough pat on the back by a CNA as she stated, I heard you are talking about me. R44 indicated to CNA that it hurt and that CNA stated to her, Oh sorry, didn't mean to do it. R44 indicated she voiced for that CNA to stay out of her room, and that the CNA has been coming in her room more often, and when she comes in her room, R44 won't let her help her, because she's down right rude. On 2/8/18 at 7:53 AM, during an interview, R44 stated, The staff here get crabby. They say things to me like, 'Oh, You do it yourself. You don't belong here.' I had two nasty ones yesterday morning. I won't name names, because we get retribution if they find out you say something about them. They get nasty and treat you differently. I went to SW awhile back with complaints and they (CNA's) found out it was me. After that, one aide was rough on me with transferring in the bathroom. She was pushing really hard on my braces on my feet and causing me a lot of pain. The CNA told me, 'Oh quit your crying, I didn't do anything wrong.' She was working with CNA P when it happened and I like CNA P. Another time, a CNA came up behind me and gave me a hard slap on the back. She said, 'I hear you're complaining about me.' She acted like it was no big deal. It is a big deal to me. It made me feel like crap, like I wasn't worth anything. It bothers the hell out of me and other people. I am not going to put up with it. It is like they are degrading us . R44 indicated that she has to wait 45 minutes to 1 hour for assistance to go to the bathroom and that she has wet her pants waiting for assistance. She indicated that this happens almost every day. She stated, I was embarrassed at first, now I am like screw it they can clean it up. (Important to note R44 refused to give names, due to fear of retaliation regarding above situations/grievances/concerns.) R44 indicated to Surveyors that she's afraid of retaliation and does not voice concerns because of this. R44 indicated she gets the silent treatment from some CNAs when she voices a concern. On 2/8/18 at 8:50 AM, during an interview, DON B indicated that R44 is not cognitively intact and has named the wrong CNAs names at other times when voicing concerns about her care. DON B indicated that if Surveyor has questions, she should direct them to R44's family member. (It is important to note that facility provided no further evidence of above mentioned concerns/grievances/allegations being addressed/investigated.) Example 2 R48 was admitted on [DATE]. R48's MDS BIMS score is 14, indicating cognitively intact. A Grievance/Complaint Form, dated 1/15/18, initiated by R48's FM, includes, in part: Summary of Grievance/Complaint: 'I turned on my light at 10:00 PM and no one answered it or changed me until 2:00 AM. I was soaking wet' Steps Taken to Investigate Grievance/Complaint: (section is blank) . Summary of Findings/Conclusion: (section is blank) . Corrective Action Taken: staff was reminded to answer lights in prompt and timely manner . Signature of who copy review was offered and provided to: (section is blank). (It is important to note that no further evidence was provided regarding an investigation of R48's alleged wait time. There was also no evidence that the facility followed up with R48 or her family with a resolution for this grievance.) On 2/5/18 at 10:51 AM, during initial tour, R48 stated, I put my call light on and no one comes. I was so wet two nights ago that staff made me sleep in my (easy) chair. It makes me feel not dignified. I have to make extra noise when I put my call light on, because no one comes. I bang whatever I can reach, sometimes my call light. R48 indicated that she had talked to RN W and DON B about the incident that happened two nights ago and about her having to make extra noise in the night. On 2/5/18 at 4:25 PM, R48 called Surveyor over. CNA L and CNA N were with R48. R48 pointed at CNA L and stated, This is the one I have a problem with. Surveyor asked R48 if she wanted to talk further and R48 declined. On 2/5/18 at 5:15 PM, during an interview, Surveyor reported this incident immediately to NHA A (Nursing Home Administrator). NHA A stated that he was unaware of any interaction/incident between CNA L and R48, until Surveyor reported this incident to NHA A. Additional information received from NHA A, dated 2/16/18 (no time indicated), includes, in part: .Meeting was held between NHA A, DON B, and CNA L. Questioned CNA L on the exchange between herself and R48 the afternoon of 2/5 . No caregiver misconduct noted. (It is important to note that the facility provided no evidence of R48, other residents, or other staff being interviewed regarding this incident.) On 2/7/18 at 5:30 PM, during an interview, NHA A indicated that he did not start an investigation regarding the interaction between R48 and CNA L immediately on 2/5/18. He stated that he started the investigation on 2/6/18 and he did not interview R48, other residents, or other staff members regarding the interaction between R48 and CNA L. NHA A stated that he should have interviewed R48. He also indicated that it is hard to rule out abuse without interviewing others that may have information regarding this interaction. NHA A confirmed that CNA L worked her regular scheduled shifts on 2/5/17 and 2/6/17 with R48; therefore, the facility failed to protect R48 while conducting a thorough investigation. Example 3 R41 was admitted to the facility on [DATE] and readmitted [DATE], with [DIAGNOSES REDACTED]. R41's quarterly MDS, dated 11/ 22/17, indicates R41 as being totally dependent on staff for bed mobility, transfers and toileting. Section C indicates R41 cognitive skills, for daily decision making, is severely impaired (rarely/never makes decisions). Section E indicates R41 has 1 to 3 days of verbal behaviors and no other behaviors are marked, in addition, it indicates R41 did not have hallucinations/delusions. 2/5/18 at 11:08 AM, Surveyors conducted the Resident Council/Group meeting interview. During this interview, R41 indicated that staff make her feel bad for her size. R41 indicated it happens often. R41 was visibly tearful, and then began crying while stating, It hurts me a lot. R44 indicated she witnessed the situation occur in the dining room and that staff stated, You are so big, we can't lift you, to R41 in front of others. (Please note that R41 and R44 were individuals during group that indicated being afraid of retaliation from the staff related to voicing concerns, there is no indication that this was not emotional/verbal abuse.) 2/5/18 at 12:28 PM, Surveyor reported R41's staff treatment concerns voiced during group to the NHA A. NHA A indicated he was unaware of the incident and will be starting an investigation. 2/5/18 - Investigation by facility, states, in part: State Surveyors informed NHA A that R41 stated that staff tease her about her weight during their Resident Meeting. DON B and RN H spoke with R41 on 2/5/18 at 2:45 PM. DON B asked R41, Do staff tease you about your weight? R41 answered, Yes. I asked the resident which staff was saying that. R41 answered, I don't know. I asked her what time of day or shift was it happening on and she answered, I don't know. Do you know on what day this happened? Resident answered, No. I asked the resident to let me know the next time it happens, to come and find me, or have the Charge Nurse call me so R41 can tell who it was. Spoke with Unit Manager and she stated she had not seen anyone say anything to that effect to the resident. She did state that resident very sensitive and if she hears people laughing, she assumes it's about her even if it's not. Talked to first shift CNAs and they state they have never heard anyone say anything about her weight. No indication that the facility thoroughly investigated or reported the situation. Example 4 R53 is a [AGE] year old male, admitted to facility on 9/21/05, with [DIAGNOSES REDACTED]. R53's MDS, with an ARD of 12/12/17, indicates R53's cognition is severely impaired. R53's wife is his legal guardian. A Grievance/Complaint Form, dated 12/07/17, includes, in part: Summary of Grievance/Complaint: R53's wife was not pleased with the number of staff members available to assist with cares, not pleased she was not given the proper notice when resident was transferred to his new room, and was not given reason why he was placed in a different room, unhappy that some CNA's use EZ stand to transfer the resident, she feels resident's w/c is too wide, unhappy that therapy was not able to tell her today what therapy goals are (sic) ., upset resident had fall 2 years ago and she was not allowed to see the report about the fall .What immediate action was taken to prevent further potential alleged violations: (section not legible) . Findings of Investigation: All of the grievances were previously made and addressed. The investigation revealed staff is working hard to meet the resident needs and have been able to do so. Both SW and BOM (Business Office Manager) had contact with the wife before the room change/documentation is in the chart to demonstrate notification. CNAs are being diligent and using care when transferring resident. CNAs do not feel comfortable using transfer pole and are using (sic) easy stand. Only therapy can order a new w/c; first therapy must be allowed to eval (evaluate). Wife either refuses or wants to argue when therapy attempts to eval resident. Any reports on falls are (not legal) documents, root causes are QAPI'd. Any corrective action was already done . Identify method used to notify the resident and/or representative of resolution: (section left blank) . A copy of this review was provided to: (section left blank). (It is important to note that no evidence was provided regarding the six above named concerns/grievances and there was no indication that this grievance was followed up on with R53's guardian/wife.) On 2/5/18 at 1:03 PM, during an interview, R53's wife indicated that she had asked to see R53's medical record that is kept behind the nurses' desk. While sitting in the dining room one night looking at it, NHA A asked what she was looking for. According to R53's guardian, NHA A stated, Why are you even here, because you are not happy with anything? R53's guardian indicated that at another time, UM/LPN H came to R53's room and R52's guardian asked about the therapy he was receiving as she had received a bill at her residence. R53's guardian indicated that UM/LPN H stated, This is not a communist country. We don't give things equally to everyone in this country. R53's guardian indicated that she asked UM/LPN H why her husband was being moved to a different room; UM/LPN H stated, It isn't like he is falling out of bed anymore. Who is paying for the room anyway, not you? Surveyor observed R53's guardian to be tearful during the interview. She stated, I feel like I can't bring up concerns, because I am afraid of repercussion. On 2/5/18 at 1:23 PM, Surveyor observed HSKPR EE (Housekeeper) enter R53's room. R53's guardian asked him, Why do I have to hunt down the chair from this room every day? Where does it go? Who takes it out? HSKPR EE replied, We need to figure this out. On 2/7/18 at 6:00 PM, during an interview, R53's guardian indicated that the chair was not in R53's room again and she feels like no one cares. R53's guardian indicated that she still has a concern with the number of staff members there are to take care of the residents and doesn't recall facility following up with her on concerns she has expressed. Example 5 R24 is a [AGE] year old woman, admitted to facility on 10/21/16, with [DIAGNOSES REDACTED]. R24's MDS BIMS, with an ARD of 11/22/17, indicates cognitively intact with a score of 15. 2/5/18 at 11:12 AM, during Group/Resident Council interview, R24 indicated that she feared retaliation for voicing concerns/filing grievances. On 2/6/18 at 8:03 AM, Surveyor observed R24 indicate to RN J that she did not get a shower the previous night, because the CNA was too tired. RN J asked, Are you ok with that? R24 replied, I didn't have a choice. RN J indicated to R24 that it was alright as long as she received her bath that day. On 2/7/18 at 8:00 AM, Surveyor observed R24's hair to be wet and asked her if she just got out of the shower. R24 rolled her eyes, sighed, and stated, No, I just got a good head washing. I never got a shower this week. R24 refused to name the staff member who was too tired to assist her in the shower on 2/5/18, but did indicate that staff work long hours and she doesn't blame them for being tired. (It is important to note that the facility provided no evidence that R24's care concern was reported to the Grievance Official or followed up on.) Example 6 R15 is a [AGE] year old female, admitted to facility on 1/17/16. R15's MDS, with an ARD of 11/8/17, indicates cognition to be moderately impaired and that she requires extensive, physical assistance of one staff in performing these ADLs (Activities of Daily Living: bed mobility, toileting, transferring, dressing, and personal hygiene. A Grievance/Complaint Form, dated (not legible), signed by DON B on 1/26/18, includes, in part: Summary of Grievance/Complaint: Had shower, bed was stripped, bed never remade. Slept all night on bare mattress and covered up with her quilt . Findings of Investigation: Nancy took sheets off own bed. Did not inform staff. CNA L gave shower. CNA LL toileted at 4:00 AM. Corrective Action Taken: skin check . A copy of this review was offered and provided to: (section blank). A copy of this review was offered and provided to: (section blank). (It is important to note there is no indication the facility followed up with R15.) On 2/5/18 at 11:15 AM, during Resident Council Group interview, R15 indicated that when she has a shower, her bedding does not get changed. R15 stated, I have told the aides. If you complain, they pick on us. People are afraid to speak up, because of retaliation. Example 7 R11 was admitted to the facility on [DATE]. R11's MDS BIMS, with an ARD of 10/26/17, scored 14 indicating cognitively intact. On 2/5/18 at 11:12 AM, during Group/Resident Council interview, R11 indicated that she was afraid of staff retaliation if she voiced concerns/filed a grievance. Example 8 2/5/18 at 11:12 AM, during Group/Resident Council interview, R52 indicated filing a grievance on CNA L, the same day as other residents, and that a nurse made them write a statement. No grievance was provided related to CNA L. Surveyor did receive a One on One Teachable Moment Form, not dated, regarding CNA AA, but not a Grievance Form, which states, in part: Explanation of required education: per 3 residents (CNA AA's name) came into room, turned off call light, said she would be back and did not come back. Additional interventions for employee: Call lights must be answered timely. If can't right at the moment, must get back as soon as possible to provide good care and customer service. If problem with resident, get the nurse or supervisor. (No employee comments) Was signed on 1/5/18 by CNA AA. Attached statement, signed on 1/4/18 by R52, states: Between 10:00 AM and noon I had to go to bathroom. When I got done, I turned my light on for help and (CNA AA) came in, asked me what I wanted, told her I needed to clean up. She turned off light, said she would get someone, but never came back or told anyone, the nurse told (CNA Name). She has done this in the past. There is no resident follow-up indicated on the One on One Form for CNA AA, there is no indication of a resolution of this concern that R52 voiced. 2/5/18 at 11:12 AM, interview continued with R52 indicating he receives the silent treatment from CNAs when he voices a concern. (Please note R52 was not willing to give specific staff names other than CNA L and CNA AA). R52 also voiced that he tried to call the State once and indicated staff said I'm trouble for threatening to call the State of Wisconsin. 10/15/17 - Grievance/Complaint Report indicates R52 voiced a grievance, on 10/15/2017, to the facility regarding: Yesterday, 10/14/17, I waited at least 1 hour for someone to answer my call light and today (10/15/17) I've waited nearly 45 minutes. Section for facility follow-up indicates date to be resolved by: (10/16/17) indicated a group meeting was held and indicates, AM clinical meeting IDT review discussion. Resolution: was grievance/complaint resolved, the box for No is checked and states Continue to monitor call light answer. (Please note there is no further information provided on grievance, no call light log/audit attached to grievance.) Example 9 2/5/18 at 11:12 AM, during Group/Resident Council interview, R24 indicated filing a grievance on CNA L, the same day as other residents, and that a nurse made them write a statement. R24 indicated a CNA insisted she could get up on an EZ stand, and was put on it by the CNA, who then got mad and stated, You're the reason nobody wants to take care of you. (Please note Surveyor has a written facility statement from R24 regarding this situation). There is no Grievance Form completed for this incident, reported by R24 that was provided to Surveyor. One on One Teachable Moment Form for CNA AA, not dated, states, in part: Explanation of required education: per 3 Residents (CNA AA's name) came into room, turned off call light, said she would be back and did not come back . Additional interventions for employee: Call lights must be answered timely. If can't right at the moment, must get back as soon as possible to provide good care and customer service. If problem with residents, get the nurse or supervisor. (No employee comments). Signed on 1/5/18 by CNA AA. Attached statement, signed on 1/4/18 by R24, states: Staff CNA AA said to me, 'It is people like you that make other aides not want to come back here & take care of you.' Those were her exact words. I'm sorry, but I am not able to stand & get changed with just something holding me up under my arms. She told me she hit a wall with her hand earlier & had Band-Aids under her glove. She took off her gloves and left the room as she said, 'I give up.' There is no indication on this form that anyone at the facility followed up with R24 regarding her concern or what the resolution was other than a one-on-one with the staff member. R24 also indicated she gets the silent treatment from CNAs when she voices a concern. R24 indicated during group that she is afraid of retaliation. Example 10 10/31/17 - R39 voiced a grievance as indicated by the facility's Grievance/Complaint Report. This report indicates the following: Documentation of Grievance/Complaint: describe concern using factual terms: She is treated like[***] once moved back to back hall. Was promised an electric bed, hasn't received, requesting a chair told she has to be measured, hasn't received yet, air mattress not working right, can feel bed frame, not getting fresh water passed to her. Document follow up: 10/31/17, resolved by 11/3/17, group meeting was not held .Resolution of Grievance/Complaint: was grievance/complaint resolved? Yes was checked and indicates R39 is satisfied with the chair, bed, and ROHO cushion. Grievance does not address or have a resolution related to how R39 was being treated. R39 filled out a Grievance/Complaint Form on 12/9/17, which indicates: It is 7:30 PM and I have been asking for something for breakthrough pain since before 2 o'clock and haven't gotten anything from the nurse yet! This happens all the time. I will write down if and when I get anything for breakthrough pain. It is 9 PM and I haven't gotten it yet. Concern was reported to Administrator. Immediate actions taken to prevent further potential alleged violations, Resident, and nurses to communicate the need for a PRN medication when requested per orders. Grievance Form indicated grievance was confirmed and Findings of Investigation: Resident was not given PRN pain med (medication) when requested. The Grievance Form states: Identify method(s) used to notify the resident and/or Resident Representative of resolution: this entire area is blank. Therefore, there is no indication on this form that R39 was provided resolution to this concern. Example 11 R17's care plan, started 11/15/17, included the following problem areas: Impaired cognition with her BIMS, score of 8, moderately impaired (Important to note, a score of 7 shows severe cognitive impairment). Her Power of Attorney (POA) is activated. The facility Grievance / Complaint Form, with received date 12/7/17, states the summary of R17's daughter's concern. 1) Resident has not been feeling well and wants to eat in her room. 2) Resident has not received drinks on her tray with meals. R17's daughter's note is attached and also includes that R17 prefers to eat in her room, you can continue to ask her to go (to the dining room), but if she refuses, please do no force her to go . She has not been receiving drinks on her tray, could you please offer her juice or coffee? The form notes that the Immediate Action Taken was: staff was in-serviced on having drinks on every tray and to offer to take her to DR (dining room) if resident feels like going. Attached to the form was an In-Service Sheet that 3 CNAs, 1 LPN, and 1 RN has signed, as completing the in-service, dated 12/8/17. The form has a place that states: Identify method(s) used to notify the resident and / or Resident Representative of resolution: with several options of a copy of the form, phone conversation, and in-person discussion. This entire section is blank and the facility provided no evidence that they followed up with R17's daughter. 2/8/18 at 11:59 AM, interview with DON B & NHA A regarding R17's grievance process and concerns, dated 12/7/17. NHA A identified that the previous DON was the person who completed the form mentioned above for R17. Surveyor asked how many staff work with R17 in a day. DON B and NHA A responded: a nurse, 2 CNA, 1 housekeeper, 2nd 1 nurse, 2 more CNAs, N[NAME] (nighttime) nurse, 2 more CNAs - totaling 9 staff. Surveyor stated that 5 staff were educated as the solution to educate staff that R17 doesn't have to go to meals and make sure she gets a drink. Surveyor asked if this was an adequate solution. NHA A responded, No. Surveyor stated that the portion of the form indicating follow-up with the family was blank. No evidence was provided as to family notification or if they were satisfied with the resolution.

Based on observation, interview, medical record review and facility policy and procedure review, the facility did not implement professional standards of practice to prevent PIs (pressure injuries) from developing, worsening, or to promote healing of PIs and assessments of PIs are not being completed by a RN, for 3 of 7 residents reviewed for PIs out of a sample to 27 residents (R33, R21 and R17). R33 developed an unstageable PI on his L heel on 10/31/17 and an unstageable PI on his R heel on 1/22/18. The facility had not implemented approaches to prevent these PIs from developing, they were not consistently implementing approaches to promote healing, and they did not have a RN assess these areas. R17 acquired an avoidable unstageable PI at the facility. R17 was identified by the facility assessment to be a low risk for PIs. The facility did not ensure her physician was notified and a treatment put in place the same day the PI was observed. The facility did not have an assessment of the wound documented until 2 days after it was open and did not document a Root Cause of the PI. The facility did not ensure R17 had interventions recommended to be put in place for her, such as an air mattress. R 21 developed an avoidable unstageable pressure ulcer to his L heel at the facility. This is evidenced by: Facility policy entitled Pressure Ulcer Prevention Protocols/Risk Assessment, dated 1/2008, states, in part: 9.1.2 Pressure Ulcer Prevention/Supportive Precautions for Moderate Risk. Utilize support surfaces. Place pressure reduction overlay or mattress on bed and utilize pressure reduction cushion when resident is in chair If Resident is unable to spontaneously change position in bed, establish a turning and repositioning schedule appropriate to meet the Resident's needs there is no scientific data which reflects heel protectors prevent pressure ulcer development. Therefore, do not use heel protectors as pressure ulcer prevention or supportive device. As appropriate, take measures to assure the Resident's feet do not come into contact with the foot board by placing foam/foam wedge cushion at foot of bed Example 1 On 2/5/18 at 10:20 AM, Surveyor observed R33 seated in his wheelchair in his room. R33 was wearing gripper socks on both feet. R33's feet were resting on the metal foot pedals of his wheelchair. R33 did not have shoes on, nor heel protectors on either foot. R33 was admitted to the facility on [DATE]. A Nursing Progress Note, dated 10/27/17, identified R33 had complaints of left lower extremity swelling and pain with dorsiflexion. An ultrasound was obtained and no [MEDICAL CONDITION] was noted. Surveyor read R33's Nursing Progress Notes from date of admission, 10/21/17 to 10/30/17. There was no mention of R33's heels being floated or heel protector boots being used during that time. R33's 5 day MDS assessment, with the target date of 10/28/17, identified R33 was dependent on two staff for bed mobility and transfers. R33 did not walk in his room or the corridor. R33 had functional limitation in range of motion (ROM) of one of his lower extremities (hip, knee, ankle, foot). This MDS identified R33 was assessed as being at risk of developing PIs, but did not have any PIs at that time. This MDS identified R33 had pressure reducing devices for his chair and his bed. No turning and repositioning program was checked as being part of R33's skin care. Left heel PI: Surveyor reviewed R33's medical record and read a Physician Telephone Order, dated 10/31/17. R33 was evaluated for swelling and pain in his L ankle. R33 had x-rays taken of his L ankle and lab work. On that date, a blister was found on R33's L heel. Orders were written to elevate his heels off the bed and to use a heel protector to the L heel to prevent skin breakdown. Surveyor requested a copy of R33's care plan that was in place, prior to the onset of R33's L heel blister (PI) that was found on 10/31/17. Surveyor was provided with a care plan page for R33 that read: Problem Start Date: 10/31/17; Category: Pressure Ulcer; Impaired skin integrity related to: (This was blank). Written below this read: L heel blister and R heel (someone's initials) 1/2018. The goal read: Long Term Goal Target Date: 1/31/18; Heal skin and prevent infection. 4/31/18. Approaches under this care plan problem for R33 were all hand written dates of 10/31/17, the date R33's L heel blister/PI was found. One of these approaches read Pressure-reduction mattress. It does not identify the specific type of mattress R33 was to use. (Surveyor later learned it was a standard pressure reduction mattress). R33 did not have an alternating air type of mattress. Another approach, wrote in and dated 10/31/17, read Heel protectors. No specific type of heel protectors were identified. This care plan problem for R33 for pressure ulcers did not include the approach to float R33's heel or heels off of surfaces, to provide pressure relief. It did include to turn and reposition at least every two hours. R33's 14 day MDS, with the target date of 11/2/18, identified R33 required extensive assistance of two or more staff for bed mobility and transfers. R33 was not walking. This MDS identified R33 had no impairment in his lower extremities. This MDS assessed R33 as being at risk for PIs. This MDS reflected R33 had no PIs, despite the L heel blister being discovered on 10/31/17. The treatment section identified the use of pressure reducing devices for R33's chair and bed, no turning and repositioning program was identified. R33's 30 day MDS, with the target date of 11/16/17, identified R33 has one unhealed, stage 2 pressure ulcer, with the date of the ulcer being 11/10/17, and one unstageable PI with suspected deep tissue injury (DTI) in evolution. The skin and ulcer treatment section does not identify R33 is on a turning and repositioning program or that pressure ulcer care is being performed. R33's 60 day MDS, with the target date of 12/20/17, identified R33 remained at risk for developing PI's and had one stage I unhealed PI and no unstageable or deep tissue injury PI's. This MDS does now identify R33 is on a turning and repositioning program and that pressure ulcer care is being provided. R33's 90 day MDS, with the target date of 1/16/18, identified R33 had one unhealed stage I PI. R33 was not assessed as having any unstageable or deep tissue PI's on this MDS. This MDS identified R33 was on a turning and repositioning program and is receiving pressure ulcer care. R33's Weekly Pressure Ulcer Progress Sheet for the L heel PI identified the following: 10/31/17-Unstageable 3.2.x 4 cm blister to L heel. No description as to color of the area, if the blister was fluid filled, or description of the surrounding skin. Interventions listed were heel protectors, feet to be elevated, ACE wrap toe to calf. 11/7/17-Unstageable 3.2 x 4.0 cm intact blister to L heel. No further description documented. 11/14/17-Unstageable 3.0 x 3.5 cm area of purple non-blanchable skin on L heel. No blister noted. Interventions continue the heel protectors and feet to be elevated, ACE wrap toe to calf. 11/21/17-Unstageable 3.0 x 3.5 cm area of purple, non-blanchable area. 11/28/17-Unstageable 3.0 x 3.5 cm area. Area is purple on the R side of heel, with brown and black eschar on the left. Interventions continued to use heel protectors and feet to be elevated and float heels. 12/6/17-Unstageable 0.0 x 0.0. Soft smooth [MEDICATION NAME] tissue present, dry skin around area. Interventions for heel protectors, feet to be elevated/floated, ACE wrap toe to calf. Requested orders for [MEDICATION NAME] to heel BID (two times per day). All of the above entries were made by a LPN, who is also the UM, LPN H. There was no Nursing Progress Note identifying R33's L heel PI was healed. A Nursing Progress Note by LPN H, dated 12/16/17, read, in part: .Skin intact. Surveyor cross referenced Nursing Progress Notes to look for assessments by a RN, of R33's PI. No assessments by a RN were located or provided. The only RN documentation regarding R33's L heel PI was by RN C, as follows: 11/24/17- . Heel booty on the L heel. It is also elevated when he lays down. 12/12/17- .Lotion was applied to his bilateral heels. Surveyor reviewed Skin Body Assessment documents for R33 that contained the following information. 11/3/17-Weekly Skin Condition Skin Turgor < (less than) 3 seconds. Mucous Membranes Moist and See Nursing Documentation. There was one Nursing Progress Note written for R33 on 11/3/17. This entry read: Sleeping all shift. Calls for assist and able to make needs known. Voiced no complaints. It did not address R33's L heel PI. 11/10/17-Weekly skin. Skin Condition Areas of Skin Impairment, describe below. Skin Turgor < 3 seconds. Mucous Membranes Moist. Describe Skin Impairment, if necessary. Heel buttock. No further information was documented regarding R33's L heel PI. 11/18/17-No areas of Skin Impairment. No further information regarding R33's L heel addressed on this body assessment document or in the Nursing Progress Notes. 11/24/17-Weekly skin assessment. Areas of Skim Impairment, describe below. Skin Turgor < 3 seconds. Mucous Membranes Moist. Describe Skin Impairment, if necessary. Refer to skin sheet. No documentation related to R33's L heel PI was on the weekly pressure ulcer progress note nor in Nursing Progress Notes for 11/24/17. 12/1/17-Weekly. Skin Turgor < 3 seconds. Mucous Membranes Moist. See Nursing Documentation. No documentation related to R33's L heel PI was on the weekly pressure ulcer progress note, nor in Nursing Progress Notes for 12/1/17. 12/8/17-Weekly skin. No Areas of Skin Impairment R33's L heel ulcer is not mentioned again on weekly skin assessments until 1/19/18. This read in part: No Areas of Skin Impairment . left heel intact and has old scabbing present, cleaned and booties on in bed. On 2/8/18 at 3:43 PM, Surveyor asked RN C if they were using heel protectors and elevating R33's off the bed prior to the L heel PI developing on 10/31/17. RN C said it doesn't stand out to me that we were. Right Heel PI: On 2/5/18 at 10:20 AM, during an interview with R33, Surveyor asked R33 if he had any sores on his skin. R33 said he had a sore on his heel and pointed to his R foot. A Nursing Progress Note for R33, dated 1/22/18, reads, in part: .Open area on R heel, dressing applied and guaze (sic) wrap, heel protector. No measurements or other description of the area was documented. A Nursing Progress Note for R33 on 1/29/18 reads, in part: .Resident's heel tx (treatment) completed, dry no drainage noted . R33's 2/2/18 Weekly skin assessment identified No Areas of Skin Impairment. Though R33 had the PI to his R heel at that time. On 2/6/18 at 1:07 PM, Surveyor observed R33's R heel and saw that R33 had an unstageable PI on his R heel, approximately 2 cm x 1 cm in size. Surveyor asked CNA D if she knew how R33 got the area on his R heel. CNA D said it has been there for a while. RN C said it was healed, but then this happened. (The L heel PI had healed, the R heel PI was new as of 1/22/18). Surveyor looked at the heel protectors being used for R33. The type in use do not have a cut out inside to provide a heel float capability. Surveyor asked CNA D and CNA U if they knew what brand of heel protectors R33 was using. CNA D read a tag on them that said Patterson. Surveyor observed staff apply the Patterson heel protectors to R33's R and L heel and position a pillow under his lower legs to float his heel at that time. On 2/7/18, Surveyor reviewed the manufacturers' information provided by DON B, for the type of heel protectors R33 was using. The information provided for R33's Patterson Medical Extra Soft Heel Protector identified this type of heel protector is used to help protect the heel area from shear friction and to provide extra padding to area when in bed. This type of boot is used to prevent heel pressure injuries. Surveyor asked DON B if this type of heel protector had any heel float ability. DON B said, That's all I know about them, pointing to the print out about the heel boot. Surveyor asked if they have any other type of heel protectors/boots that they use. DON B said no. The type of heel protector R33 was using was not for use with an existing unstageable PI. On 2/8/18, Surveyor requested R33's care plan that was in place just prior to the discovery of R33's unstageable R heel PI, found on 1/22/18. Surveyor was provided with a care plan problem with the computer generated start date of 11/10/17, for pressure ulcer, impaired skin integrity, risk for related to decreased mobility . All of the approaches were computer generated dates of 11/10/17 and did not include R33 was to be wearing heel protectors, though this was an approach on R33's care plan problem hand written in, for his L heel ulcer found on 10/31/17. At the time of the 11/10/17 care plan, R33 still had the unstageable L heel PI. Surveyor was provided with a care plan for R33 that had hand written dates of 1/22/18 for the problem start date and the approaches. This care plan identified R33 had impaired skin integrity related to an unstageable PI on his R heel. Approaches are all dated 1/22/18. One approach reads Keep boney prominences from direct contact with one another with using pillows, blankets, pads and cushion. Another approach read Heel protectors on @ (at) all times - unless ambulating. It did not direct staff to float R33's heels. It included the approach to turn and reposition at least every two hours. On 2/8/18 at 5:58 PM, Surveyor observed R33 with his shoes on both feet, not a heel protector on his R heel. Surveyor pointed this out to the DON. Surveyor spoke with LPN X who helped get R33 up. LPN X said we put his shoes on for the transfer. LPN X was not sure what time that was. LPN X said then she got pulled away. Surveyor interviewed CNA Y who also helped with the transfer, she started work at 4:00 PM. CNA Y said she had to run out of the room to answer a call light. They had not taken R33's shoe off his R foot and apply the heel protector. On the afternoon of 2/8/18, Surveyor asked UM/LPN H for additional information regarding R33's PIs and why they occurred. No further information was provided. On 2/13/18, Surveyor was provided with R33's Weekly Pressure Ulcer Progress Sheets for the R heel PI. 1/24/18-Unstageable PI on R heel. 1.8 x 1.2 cm. Intervention Heel protectors to be on at all times unless ambulating. Brown and purple eschar to R heel. Request for [MEDICATION NAME] from NP BID. No redness noted around periwound, no odor, no drainage. (R33's R heel PI was discovered on 1/22/18. Measurements and description of area were not documented on until 1/24/18). 1/30/18-Unstageable 1.4 x 1.2 cm PI to R heel. Brown eschar noted on R heel. [MEDICATION NAME] to R heel BID. 2/6/18-Unstageable 1.0 x 0.8 unstageable PI to R heel. Heel protectors to be on at all times, unless ambulating. Brown eschar, no odor, no drainage. The information documented for R33's R heel PI was done by LPN H. No RN assessments were documented as being completed in R33's Weekly Pressure Ulcer Progress Notes, the Weekly Skin Check Sheets or in Nursing Progress Notes until RN C did an assessment of R33's heel on 2/6/18. RN C's Nursing Progress Note of 2/6/18 reads, in part: .R heel also has a purple eschar area on his heel and area measures 2 cm x 1.2 cm. Dr. (Name) here are (sic) evaluated areas. Orders received for simple bandage over abrasion (on left hip) and alleviate the pressure from the R heel . Example 2 R17s care plan, started 11/15/17, included the following problem areas: Impaired cognition with her BIMS, score of 8, moderately impaired (Important to note, a score of 7 shows severe cognitive impairment); Communication related to her [DIAGNOSES REDACTED]. It includes intervention, added on 11/15/17, assess resident for risk factors. Treat, reduce, eliminate risk factors to extent possible; Avoid shearing resident's skin during positioning, transferring, and turning; weekly skin assessment; Report any signs of skin breakdown (sore, tender, red, or broken areas); use pressure reduction cushion when resident is in chair as needed; and use moisture barrier product to perineal area. (It is important to note that no new interventions were added to her skin care plan after 11/15/17, nor was it updated to include that she had a PI.) R17's 11/7/17 Braden, completed by the facility, score -22 or a low risk. R17's Skin Check Sheet, completed 11/23/17, has a circle around the buttocks with a #2, which the key provides is a Red area. It has a nurse signature, but does not have other documentation if any further action/intervention was done. R17's Skin Check Sheet, completed 12/7/17, has a circle over the crease in the butt, written next to it is, Red sore. R17's Progress Notes: 12/7/17 .Resident had a shower this afternoon and silicone edged dressing applied to day shift reported open area at the lower end of coccyx crease; benson's bottom paint applied to area prior to dressing application. (sic) 12/9/17 - Resident noted to have an open area that measures 5.8 cm. x 2.7 cm. on the lower end of coccyx crease, midline buttocks. Resident denies pain regarding the area. The wound bed has yellow slough. Periwound is pink in color. A comfort foam dressing was applied to the area. She also has red excoriated areas on bilateral sides and lower than the open area. Skin barrier is applied to that area. She has had a recent bout of loose stools. MD and daughter . updated. Fax sent to MD with orders clarification on the comfort foam dressing. (It is important to note that a fax dated 12/9/17 was not found during the investigation.) Fax to physician regarding R17, dated 12/10/17, to notify physician, states: A stage II ulcer is noted on lower end of coccyx crease. Area measures 5.8 cm x 2.7 cm. Wound bed has yellow slough. Periwound is pink. She has red excoriation on bilateral buttocks sub-open area. Can we please have order clarification for comfort foam border dressing? How many times weekly do you want it changed? Do you want anything else ordered in addition to pad? The physician's response is dated the next day, 12/11/17: Needs air bed, change position every 2 hours, Duoderm on change every 3 days to sacrum, needs w/c pad. (It is important to note that this is the 1st physician response and treatment order documented after R17's identified open area after 12/7/17. R17's care plan was not updated with the orders and the facility provided no evidence that the interventions were put in place when this order was received.) R17's TAR states that comfort foam pad dressing change when soiled was started on 12/10/17 and done through 12/15/17, with a note fax to MD for direction. R17's Progress Notes: 12/11/17 .Comfort foam border dressing replaced this AM. It had fallen off. Barrier Cream applied to excoriated areas on the bilateral buttocks . Excoriated slightly less irritated after barrier cream was applied. The first documented Weekly Pressure Ulcer Progress completed for R17, 12/12/17, states, as follows: risk factors: not present on admission, diabetes, incontinence Stage: unstageable; Measurement: 5.4 x 2.3; Site: L Gluteal Fold; Intervention: request for calcium alginate covered by foam border; pink periwound area with a center of slough 1.2 cm x 1 cm, no odor, no drainage. R17's Progress Notes: 12/12/17 - Wound to lower coccyx is healing. It still has slough in the wound bed. Fax sent to MD to request [MEDICATION NAME] agent and Calcium Alginate Silver . Fax to physician regarding a treatment, dated 12/12/17, to notify physician, states: (MONTH) please have an order for [REDACTED]. She has open area on her lower coccyx. 12/12/17- MD responded, Yes, but who is this for? Facility reply by fax, Sorry - for R17. We don't use Duoderm, may we please have order for [MEDICATION NAME]? 12/21/17 the physician responded, [MEDICATION NAME] apply every 3 days. R17's 12/14/17 Braden, completed by the facility, score = 18 or at risk. R17's Progress Notes: 12/14/17 - Resident seen by PA (Physician Assistant) . today. Orders clarified regarding the treatment. The wound was evaluated . (Later the same date) Resident received shower and had new coccyx treatment completed, which includes washing with normal saline, pat dry area, Silver Alginate to open area, foam boarder dressing applied . 12/14/17 - Physician order [REDACTED]. Request for Pro-Stat protein drink 30 ml (milliliters) BID (twice daily) as well as Calcium Alginate Silver covered by foam border clean area and apply alginate BID and foam border every three days or as needed if soiled or covered with 70% drainage. On the same date is another order that states, Wound care cleanse upper Gluteal cleft saline, pat dry, skin prep to periwound, apply Silver Alginate to wound bed and cover with border foam dressing daily and PRN. The 2nd treatment order is what was completed per the TAR, completed 12/15/17 to 12/30/17. R17's Progress Notes: 12/15/17 .Duoderm was applied to the buttocks, continue wound care as ordered yesterday. (Family) aware of the orders. New treatment applied to the buttocks when she returned. Duoderm was removed and comfort foam border dressing applied. Barrier cream to the red excoriated areas. Crease of buttocks more reddened today, ? Duoderm irritation. The Weekly Pressure Ulcer Progress completed for R17, 12/19/17, states, as follows: Stage: unstageable; Measurement: 3.7 x 2.3; Site: L Gluteal Fold; Intervention: request for Calcium Alginate Silver covered by foam border; pink periwound with 98% slough yellow white, no odor, no drainage. R17's Progress Notes: 12/21/17 - R17 received a physician's telephone order for the following: egg create cushion for w/c, consult wound clinic for wound care . 12/22/17 - TAR indicates an egg crate cushion was put in place. R17's Care Guide for CNAs to follow, dated 12/24/17, includes: she is independent in her room, to remind to off load while in w/c, cushion in w/c, and to ambulate her two x a day with her walker. The Weekly Pressure Ulcer Progress completed for R17, 12/26/17, states, as follows: Stage: unstageable; Measurement: 3.8 x 1.6; Site: L Gluteal Fold; Intervention: request for Calcium Alginate Silver covered by foam border; 50% slough, no odor, no drainage. The Hospital Palliative Care Summary/Initial Consult, dated 12/27/17, includes under Assessment/Plan: Sacral decubitus with reported slough. Explained to family this may never heal, even with extensive intervention. Twice daily dressing changes with enzymatic powder, Santyl, calcium alginate with silver and [MEDICATION NAME], and has a wound care consult this next week. Recommend pressure-relieving air mattress for bed, and having her first lie down, propped with pillows when she reports of wound pain for relief, before offering opioid. Ensure frequent position changes. Has cut-out foam cushion for w/c. Protein-rich nutritional supplement. The Weekly Pressure Ulcer Progress completed for R17, 1/2/18, states, as follows: Stage: unstageable; Measurement: 4.0 x 2.0; Site: L Gluteal Fold; Relief Device: Air Mattress & w/c cushion; Intervention: prism matrix, Pro-Heal, 4 cm x 2 cm x 0.5 cm with undermining of 1 cm at 2:00 and 6:00 slough inside and peripherally. 1/2/18 - R17 received a new physician's orders [REDACTED]. Progress Note: Patient with stage 3 decubitus ulcer with measurements: 4 cm x 2 cm x 5 mm with undermining of 1 cm at 2:00 and 2 mm (millimeter) at 6:00. There is slough both inside and peripherally. Dressing Plan 1) Santyl cream to slough and 2) [MEDICATION NAME] matrix to wound change every 3 days. R17 left the faciity on [DATE] after a fall and did not return to the facility. On 2/8/18 at 8:07 AM ,Surveyor interviewed UM/LPN H. UM/LPN H stated that she and another nurse monitor the wounds, but do not always do the assessments, but rather encourage the floor nurses to complete them. She explained the skin monitoring procedure is that nurses do weekly skin checks and CNAs let nurses know if they see any issue with skin such as redness or bruising. Once an open area is identified for a resident, a skin assessment is done and documented in the EMR and the resident's physician and family are notified. A treatment should be received the same day the physician is notified. UM/LPN H stated that she would look into R17's PI to find evidence of what interventions were put in place and when. She did agree the physician should have been notified on 12/7/17 when R17's open area was 1st identified and a treatment should have been received and put in place. No further evidence was provided regarding R17 during this survey. Example 3 R21 was admitted to the facility on [DATE], with readmission date of [DATE] and 1/4/18 with [DIAGNOSES REDACTED]. R21's Admission MDS, dated [DATE], indicates R21 has a BIMS of 12 out of 15, which indicates R21 is not cognitively impaired. This assessment also indicates R21 as being at risk for PI development and as not having any PIs at the time of the assessment. Section G indicates R21 is an extensive 2 person physical assist with bed mobility and is dependent on physical assist from staff for transfers along with total dependence for dressing, to toilet and bathing. R21's MDS, dated [DATE], is indicated as an entry MDS. R21's PPS (Prospective Payment System) 5 day Assessment, dated 1/11/18, indicates R21 is at risk for PIs, and that he currently does not have any PIs. Section G of this assessment shows R21 as being an extensive assist of 2 with bed mobility, transfers, dressing, to toilet, and bathing. (R21 did not have skin impairment from returning from the hospital to the facility on [DATE] as noted by no skin issues indicated on 1/11/18's 5 day PPS Assessment.) R21's PI Care Plan, with problem start date of 2/28/17, indicates the following: Resident is at risk for pressure ulcer due to moisture. Approaches include: Consider low air loss bed, skin assessment and inspection every shift with close attention to heels. R21's other care plan, with goal date of 5/6/18, started on 2/28/17, indicates: Resident is at risk for pressure ulcer due to activity and chairfast. Approaches include: Consider postural alignment, weight distribution, balance stability, and pressure relief when positioning in chair or w/c. Consider specialty chair pad. Instruct resident to reposition every 30 minutes when in chair. Pad bony prominences with foam wedges, rolled blankets, or towels. Skin assessment and inspection every shift with close attention to heels. Stand every 2 hour/s (SIC). Teach or do frequent small shifts of body weight. (Please note full skin care plan provided does not address positioning while in bed or offloading R21's heels.) CNA Care Guide, dated 2/6/18, indicates R21 transfers SPT (staff pivot transfer) Assist of 1, Assist 2 of 2 and EZ stand as needed. Skin indicates reposition as tolerated every 2 hours, must have heel protector on L heel at all times. Equipment indicates heel protectors and float. Care guide also indicates to encourage resident to be up for all meals. 1/8/18 - Skin assessment indicated no areas of skin impairments. R21's nursing note, dated 1/16/18, indicates: Resident seen by PA during rounds. Order: paint L heel wound with [MEDICATION NAME] daily. Will continue to monitor. 1/16/18 - Left heel unstageable measures (Length) 4.3 cm x (Width) 4.3cm, purple brown area no redness noted on border of wound, no odor, and no drainage. Relief: heel protector on at all times, float heels while in bed. Intervention: [MEDICATION NAME] to heel daily at bedtime. (R21's full care plan does not indicate to float his heels while in bed.) 1/23/18 - Left heel unstageable measures 3.8 cm x 4.3cm, purple, brown dry no odor, and no drainage. Relief: heel protector on at all times, float heels while in bed. Intervention: [MEDICATION NAME] to heel daily at bedtime. 1/30/18 - Left heel unstageable measures 3.8 cm x 4.0 cm, brown eschar, dry no odor, no drainage, and periwound is free from redness. Relief: heel protector on at all times, float heels while in bed. Intervention: [MEDICATION NAME] to heel daily at bedtime. 2/5/18 - Left heel unstageable measures 3.2 cm x 3.8 cm, brown eschar no area of redness around periwound. Relief: heel protector on at all times, float heels while in bed. Intervention: [MEDICATION NAME] to heel daily at bedtime. 2/7/18 at 3:40 PM, Surveyor observed R21 lying in bed on a regular mattress with head of bed up, (appears more than 30 degrees) with CNA O. CNA O indicated that R21 is to wear a teal plush booty. Surveyor observed R21's toes on his R foot touching the foot of the bed with his R heel flat on the bed. CNA O indicated that R21's R heel was touching the bed and his toes were touching the foot board. CNA O indicated to Surveyor that R21 needed to be scooted. L heel in teal boot, heel of boot resting flat on bed. 2/8/18 at 9:24 AM, Surveyor interviewed UM/UM/LPN H who indicated that R21's unstageable PI started on 1/16/18. UM/LPN H stated R21's Braden score was a 14 on 1/4/18, which indicated he was at moderate risk for skin break down. UM/LPN H indicated by stating Yes that R21's mattress is the same mattress he was on when the PI was developed. UM/LPN H was not able to tell Surveyor what PI stage R21's current mattress was good for. UM/LPN H indicated that R21 went to the hospital, l came back, tried to do dose reductions of medications, then R21 went into a catatonic state, ([MEDICAL CONDITION] motor immobility and behavioral abnormality manifested by stupor), and has been sent to the hospital multiple times since then. UM/LPN H indicated after last hospitalization is when heel PI was found. UM/LPN H indicated that R21 had been refusing to get out of bed. UM/LPN H indicated the Root Cause for R21's PI was most likely due to bed mobility. UM/LPN H indicated heel protector boot was put in place as soon as noticed yellowing of R21's heel. UM/LPN H indicated that R21's heel protector only keeps it protected, and is unaware if its pressure relieving. UM/LPN H indicated R21 kicks things out, and will have to care plan that for him, when informing UM/LPN H of observation above. UM/LPN H was unable to indicate if PI was avoidable or unavoidable. 2/8/18 at 6:13 PM, Surveyor interviewed DON B regarding R21's mattress being used for an unstageable PI. DON B indicated she would put an unstageable PI, on an air mattress. PrevaMatt Series mattress indicates under Clinical indications that are recommended for prevention and treatment of [REDACTED]. (R21 does not have an air mattress on his bed; R21 has a standard mattress the facility uses.)

Based on interview and record review, the facility did not ensure that it provided each resident with sufficient fluid intake to maintain proper hydration and health for 1 of 27 records reviewed (R56) and maintains acceptable parameters of nutritional status, such as body weight unless the resident's clinical condition demonstrates this is not possible for 2 of 27 records reviewed (R4 and R54). R56 had a change of condition and documented findings of poor oral intake of fluid. The facility did not assess R56's fluid intake to determine if interventions were needed to prevent dehydration. R56 was admitted to the hospital on [DATE] for dehydration. R4 experienced a 38.2 lb weight loss over a 6 month period (July (YEAR)-January (YEAR)), which calculates out to a 21.36 percent loss. Once the weight loss was discovered, the facility failed to implement interventions, update the physician and family, and update her care plan. R54 experienced a severe unexplained weight loss. The facility failed to identify the loss, update R54's Medical Doctor (MD), or take aggressive measures to prevent further unexplained weight loss. This is evidenced by: The facility policy entitled Dehydration Fluid Maintenance, dated 1/2008, states, in part: Purpose: To determine the risk status of residents to develop dehydration and to implement measures to assure adequate fluid/maintenance hydration. Procedure: At the time of each resident's admission, readmission, quarterly review, or significant change in condition, a Nutritional Assessment will be completed by the Registered Dietician with input from the Interdisciplinary Team. The attending physician will be notified of the results and of the assessment of the resident is found to be at risk for dehydration and the appropriate recommendations will be written and protocols will be implemented to promote hydration. Risk factors include: b. elevated temperatures and/or infection, c. dependence on staff for the provision of fluid intake, d. use of medications that cause fluid loss, f. dysphasia, g. limited fluid intake h. refusal of fluids. The facility policy entitled Intake and Output, dated 1/2011, states, in part: Policy: Monitoring intake and output may be implemented for many reasons to ensure that the resident receives adequate hydration and maintains adequate kidney function. (Corporation Name) believes that documentation and monitoring of the residents fluid intake and output may be performed for the following reasons: 1. Physician Order, 2. Resident on fluid restriction. Example 1 R56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R56 MDS, with an ARD of 12/22/17, indicates R56 had a BIMS completed indicating moderately impaired cognition. Section GO110 indicates R56 required extensive assistance with all areas of activities for daily living, except required supervision and set up for eating. Section J1550 C indicates R56 was not dehydrated. Section K0300 indicates R56 had no weight loss and Section K0510 indicates R56 was on a mechanically altered diet. R56's Physician order [REDACTED]. * 5.3.16 - House supplement 4 oz daily. * 6.16.17 - Mechanical Soft diet; nectar thick liquids * 2.8.16 - [MEDICATION NAME]-[MEDICATION NAME] (medication for blood pressure and promotes fluid/water loss) 10-12.5 mg administer 0.5 mg tablet by mouth (po) daily in morning for hypertension/[MEDICAL CONDITION]. R56's Comprehensive Plan of Care, dated 2/20/16, states, in part: Problem: Nutritional Status - resident at nutritional/hydration risk due to status/post fracture of L hip, hypertension, [MEDICAL CONDITION] .Goal: Resident will receive adequate nutrition/hydration .Approach: 5/31/16 - Receives house supplement 4 oz daily, 2/20/16 - encourage fluids at bedside and with activities, 2/20/16 - Monitor for signs and symptoms of fluid imbalance (i.e. swelling, shortness of breath, dry mucous membranes, dry skin, poor skin turgor), 2/20/16 - Monitor meal intake/record, 1/4/17 - Mechanical soft diet, 2/20/16 - Assist with meals as needed, eats all meals in main dining room independently with cueing at times. Nutritional Risk Assessment, dated 4/27/17, states, in part: resident daily fluid needs 2160 cubic centimeters (cc's) daily. By mouth intake 50-74 % of meals. Dietician Assessment, dated 12/20/17, states, in part: diet order is mechanical soft, pureed meats with nectar thick liquids. R56 has eaten 75-100% of most meals. House supplement 4 ounces daily. Calculated fluid need 2160 cc's. On 2/8/18 at 10:00 AM, Surveyor interviewed RD E regarding R56. Surveyor asked RD E how he determines a resident's estimated fluid needs. RD E stated the assessment is made on a resident's, diagnoses, weight and medications. Surveyor read R56's Dietician Assessment and asked RD E, based on your assessment, R56 required 2160 cc's of fluid daily, is this the minimal amount of fluid R56 needs to maintain adequate hydration needs. RD E stated, Yes, R56, based on his assessment, would need 2160 cc's daily to meet his hydration needs. RD E stated a resident should receive 80% of their hydration through fluids - R56 was on thickened liquids and this would be about 1600-1900 cc's a day. RD E stated the other 20% comes from food. Surveyor asked RD E if he would expect to be notified if a resident was not meeting their recommended calculated fluid needs. RD E stated as per standard of practice (SOP) he would expect to be notified. RD E stated if this was an anomaly, i.e. one day, it may not be necessary, but if several days pass and resident is not consuming their calculated fluid needs, he would expect he and DM F would be notified. Surveyor asked if he had been notified R56 was not meeting his daily calculated fluid needs. RD E stated he did not recall being notified and if he had he would have noted the concern in R56's medical record and made recommendations. Surveyor asked RD E if he would expect nursing to monitor a resident's intake and output or to notify the physician if the resident was not meeting calculated hydration needs. RD E stated I would expect a nurse to use clinical judgement and if a resident was turning the corner toward dehydration to alert the physician. Skin Assessments for (MONTH) (YEAR) and (MONTH) (YEAR) state the following: 12/6/17 - Skin turgor less than 3 seconds (sign of hydrated skin), Mucous membranes moist 12/13/17 - Skin turgor less than 3 seconds, moist mucous membranes 12/20/17 - Skin turgor less than 3 seconds - (Of note the box for moist mucous membranes was left unchecked.) 12/27/17 - Skin turgor less than 3 seconds, moist mucous membranes 1/3/18 - Skin turgor less than 3 seconds - (Of note the box for moist mucous membranes was left on checked.) Nursing Assistant Flow Record for (MONTH) (YEAR) state the following fluid/meal intake: Fluid: 1/1/18 - Breakfast 360 cc - Lunch 240 cc - Dinner 240 cc 1/2/18 - Breakfast 120 cc - Lunch 120 cc - Dinner 120 cc 1/3/18 - Breakfast 240 cc - Lunch 240 cc - Dinner 240 cc 1/4/18 - Breakfast 240 cc - Lunch 200 cc - Dinner 120 cc 1/5/18 - Breakfast 0 cc Meal: 1/1/18 - Breakfast: 26-50% - Lunch: 51-75% - Dinner: 26-50% 1/2/18 - Breakfast: 76-100% - Lunch: 51-75% - Dinner: 51-75% 1/3/18 - Breakfast: 51-75% - Lunch: 26-50% - Dinner: 51-75% 1/4/18 - Breakfast: 51-75% - Lunch: 26-50% - Dinner: 1-25% 1/5/18 - Breakfast 0 cc Of note, the facility was unable to locate R56's (MONTH) (YEAR) Nursing Assistance Flow Record. R56's General Flowsheet for (MONTH) (YEAR) indicates House supplement 4 oz daily - Of note this converts to 120 cc daily. 1/1/18 - 120 cc 1/2/18 - 120 cc 1/3/18 - 120 cc 1/4/18 - 120 cc 1/5/18 - 120 cc Of note the facility completed no formal intake or output for R56. R56's daily fluid needs per RD E's assessment, dated 12/20/17, indicated R56 requires 2160 cc's of fluid daily. Adding liquid fluid intake, only based on limited recorded data, indicates R56 had the following liquid fluid intake, which was well below the calculated daily fluid needs of 2160 cc's daily. 1/1/18 - 960 cc 1/2/18 - 480 cc 1/3/18 - 840 cc 1/4/18 - 680 cc 1/5/18 - 120 cc On 2/8/18 at 12:10 PM, Surveyor interviewed CNA D regarding R56. Surveyor asked CNA D if she had cared for R56 prior to his hospitalization ; CNA D stated she had. CNA D stated prior to his hospitalization , R56 had a big change in condition. CNA D stated, several weeks prior to hospitalization , R56 just was no longer himself. CNA D described R56 as being agitated; frequently awake, even in the night hours, and moving around frequently in bed. CNA D stated that had all changed, and R56 was more sleepy, difficult to arouse and no longer moved around as he did prior. CNA D stated she and other staff had reported this change in condition to the nurses. Surveyor asked CNA D if R56 was able to feed himself or if he needed assistance. CNA D also indicated this had changed in the recent past. CNA D stated R56 had difficulties feeding himself and had recently been moved to a table in the dining room where he was provided more assistance. Surveyor asked about R56's appetite and fluid intake. CNA D stated R56 ate fair, but was on thickened liquids and did not drink well. Surveyor asked CNA D if R56 had always drank poorly or if this was new. CNA D stated R56 was never a big drinker, but that this had worsened recently. Surveyor asked CNA D when a resident has a change in appetite and drinking do staff complete intake and output records. CNA D stated she told the nurses R56 was not eating or drinking well. CNA D stated the staff records the intake at meals only on the Nursing Assistant Flow Record. Surveyor asked CNA D if they track resident's bedside intake or fluids the resident may get throughout the day in activities or medication pass. CNA D stated to her knowledge the only thing that is recorded is fluids consumed at meal time. Surveyor asked CNA D when she reported R56's decrease oral intake to the nurses if she was given any instruction from the nurses to try to increase R56's intake. CNA D stated she was not. Surveyor asked did anyone tell you to offer fluids more frequently, or if R56 continued to drink poorly to report back to nursing. CNA D stated she was not provided with any instructions. Surveyor asked CNA D did you attempt to give R56 more fluids. CNA D stated she would offer R56 fluids and he would either take sips or refuse. On 2/7/18 at 4:40 PM, Surveyor spoke with DM F regarding R56. (It should be noted DM F has only worked at the facility for 5 weeks.) Surveyor asked DM F how he or his staff knows how much fluid to offer a resident at meal time. DM F stated that unless contraindicated all residents receive a minimum of 1900 cc's on the meal trays over the course of the day. Surveyor asked DM F if he monitors resident's intake. DM F stated he does not monitor resident's intake, this is completed by nursing. Surveyor asked what the DM's role is in assuring residents receives adequate nutrition and hydration. DM F stated he monitors residents who are nutritionally at risk. DM F stated this is determined by completing a Nutrition Assessment or nursing will notify him if a resident has a change in eating/drinking habits. Surveyor asked DM F if R56 was considered nutritionally at risk. DM F stated R56 was nutritionally at risk. Surveyor asked DM F if he knew why R56 was considered nutritionally at risk. DM F stated he was not sure, but he knew nursing was monitoring him. Surveyor asked DM F if he would be notified if a resident had a change in food or fluid intake. DM F stated he would be notified and this is discussed in morning meeting. DM F stated if there is a concern with intakes he also notifies RD E. RD E will then complete an assessment on the resident during monthly rounds. Surveyor asked DM F if he was notified about R56 recently or if it had been reported to dietary R56 was drinking poorly. DM F stated he recalled R56's name coming up in the morning meeting. Surveyor asked DM F if he was consulted to assess or make changes for R56 due to poor oral intake. DM F stated if R56 needed more fluids they would discuss this at morning meeting with nursing. Vital Signs, dated 1/2/18 at 5:58 AM, Temperature - 98.4, Pulse - 108, Respirations: 20, Blood Pressure 112/55, Oxygen Saturations 95%. Progress Notes, dated 1/2/18 at 2:08 PM, state, in part: continues to have dry non-productive cough. The facility completed a Situation, Background, Assessment and Recommendation (SBAR - form to communicate change of condition), dated 1/5/18 at 9:37 AM, which states, in part: Description: change in condition, poor skin turgor. Situation: poor skin turgor, he looks like he is deteriorating, clear lung sounds. This started on 1/2/18 (Of note: this indicates change of condition was noted 3 days prior.) Since then, it has gotten: worse. Vital signs: Blood Pressure: 157/49, Pulse: 96, Respirations: 24, Temperature: 98.4 Oximetry (blood oxygen) 80% on room air. Mental Status Changes: decreased consciousness (sleepy, lethargic). Functional Status: weakness. Respiratory: Abdominal breathing, lung sounds clear. Urine Changes: decreased urine output, minimal urine output throughout the night. At this time the drainage bag is empty. Assessment: Deteriorating condition. He is very dehydrated. NP notified 1/5/18 at 9:15 AM. Request: ER (emergency room ). On 2/8/18 at 12:22 PM, Surveyor interviewed RN C regarding R56. (It should be noted RN C was the nurse caring for R56 and who wrote the SBAR on 1/5/18.) Surveyor asked RN C regarding R56's condition on 1/5/18. RN C stated R56 was not feeling well for a few days prior. Surveyor asked RN C to describe R56's condition. RN C stated R56 had been sleepier, had a cough and just appeared different. RN C stated on 1/5/18 he looked like he was dying when I went in to check on him. RN C stated he looked gaunt and dehydrated, using his accessory muscles to breath, was not responding. RN C stated she thought he maybe had pneumonia [MEDICAL CONDITION] as he had a urinary catheter. RN C stated she called the family and they choose to send R56 to the ER. Surveyor asked RN C if she was aware R56 was not drinking well. RN C stated I know he did not seem to like his thickened liquids and I am sure he was not drinking well the last few days when he was not feeling well. Surveyor asked RN C if the facility completes an intake or output (I&O) record routinely for residents. RN C stated we do not complete I&O's. Surveyor asked how nursing determines the amount of fluid a resident consumes especially at a time when a resident may not be feeling well or has a change in condition that may impact desire to eat or drink. RN C stated in a perfect world I guess we should be monitoring I&O's, but we just don't have time. Surveyor asked RN C if she reviews the Nursing Assistant Flow Record to review resident's intake. RN C stated she does not look at the Flow Record. Surveyor asked RN C if she knew who would be responsible for reviewing the Flow Record to assure residents are receiving adequate nutrition/hydration. RN C stated she was not educated on this; I guess that would be nice to know, so that we would be aware if someone had hydration concerns or weight loss. If nursing was aware, then we could be certain a resident is eating and drinking. Surveyor asked RN C if you do not monitor a resident's nutrition or fluid intake, how would you know a resident may be at risk for dehydration. RN C stated she would not be aware, unless a resident presented with signs of dehydration like R56. Hospital Admission History and Physical, dated 1/5/18, states, in part: presents as transfer for complicated UTI [MEDICAL CONDITION]. Presents with altered mental status, noted to have a decline in mental status over the last 2-3 days, resulting in him not being as responsive today, with minimal to no po intake. In the emergency department was noted to be initially hypotensive, initially responsive to IV, but eventually [MEDICATION NAME] (drug to raise blood pressure) was started. This was after about 2 liters of normal saline was given. White blood cell count 22,000 (notes infection normal is 10,000), creatinine 1.7 (normal 0.6-1.1), Blood Urea Nitrogen (BUN) 89 (normal level 7-20) and sodium of 160 (normal 135 -145). (It should be noted R56 had a creatinine of 0.9 and a sodium level 130 on 10/4/17.) He received about 6 liters of normal saline. Diagnoses: [REDACTED]. [MEDICAL CONDITION] presumably from decreased/no po intake over the last several days. On 2/8/18 at 4:00 PM, Surveyor interviewed RD/RN G regarding the facility's policy for monitoring resident intake. Surveyor asked RD/RN G if the facility completes I&O on residents. RD/RN G stated the facility does not routinely complete I&O on residents. RD/RN G stated residents receive 1920 cc of fluid on their meal trays daily; in addition, they receive fluids at bedside and with medication pass. Surveyor asked RD/RN G who reviews the Nursing Assistant Flow Record to assure residents are receiving adequate nutrition and hydration. RD/RN G stated DM F, RD E and nurse managers periodically review the flowsheet. Surveyor asked RD/RN G if the total intake of fluids on the flowsheet only represent meal intake; RD/RN G stated yes. Surveyor asked if intake is totaled at the end of the day to assure resident have consumed adequate hydration. RD/RN G stated it is not totaled. Surveyor asked RD/RN G how staff assures residents are receiving adequate hydration. RD/RN G stated the staff complete weekly skin assessments and monitor skin, and if there are concerns with the skin assessment that may trigger a hydration concern, the staff complete a Hydration Assessment. Surveyor asked RD/RN G if you are not assessing a resident's intake how are you assuring a resident is meeting their hydration needs, especially when a resident presents with a change of condition or decreased oral intake. RD/RN G stated I understand. Facility staff was aware R56 had a change of condition and had decreased oral intake. The facility documented very poor fluid intakes from 1/1/18 to 1/5/18. There was no dietary or nursing assessment completed to evaluate the need for interventions to attempt to prevent R56 from becoming dehydrated. Example 2 R4 is a long term resident of the facility with the following diagnoses; [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION], malnutrition and anxiety. Additional [DIAGNOSES REDACTED]. The facilities care standards for monthly and weekly weights, dated 7/2012, states, in part; .Monthly weights: conducted on residents whose weight has been stable from the time of admission to current. Weekly weights conducted on residents that: a) Have experienced a significant weight loss/gain as indicated by the weight variance report . d) Have a gradual weight loss over a period of time. Weekly weights will be monitored for 30 days or more. The IDT determines if the resident is at high risk for further weight loss. Reweighs: conducted on residents that: a) Have experienced a 5 lb weight loss or 5% weight gain from the previous month if current weight is over 100 lbs .If a reweigh is required it should be conducted in the presence of a licensed nurse and the weight recorded with the nurse's initials in the medical record, reweight should be done within 48 hours of request . R4's weights over past 6 months: 7/14/17 = 178.8 entered by DM KK 8/9/17 = 171.8 entered by DM KK (loss of 7 lbs) 8/21/17 = 165.6 entered by DM KK (loss of 6 lbs) 9/1/17 = 157.4 entered by DM KK (loss of 8 lbs) 9/14/17 = 158.7 entered by DM KK (gain of 1 lb) 9/21/17 = 160.4 entered by DM KK (gain of 2 lbs) 9/28/17 = 157.2 entered by DM KK (loss of 3 lbs) 10/13/17 = 156.4 entered by DM KK (loss of 3 lbs) 11/2017 = held, no weight obtained 12/7/17 = 151.1 entered by LPN MM (loss of 5 lbs) 1/2/18 = 145.8 in book at Nurse's station, not entered into computer (loss of 6 lbs) 1/9/18 = 140.6 reweigh from 1/2/18 entered by LPN H (loss of 5 lbs) R4's Quarterly MDS dated [DATE], records a weight of 178 lbs and marks that she receives a mechanically altered diet (require change in texture of food or liquids i.e. pureed food, thickened liquids). R4's Quarterly MDS, dated [DATE], records a weight of 157 lbs and marks that she receives a mechanically altered diet. Question of Loss of 5% or more in the last month or loss of 10% or more in last 6 months is answered yes, not on physician-prescribed-weight-loss regimen. R4's Annual MDS, dated [DATE], records a weight of 151 lbs and marks that she receives a mechanically altered diet. Question of Loss of 5% or more in the last month or loss of 10% or more in last 6 months is answered no or unknown. R4's CAA that accompanies Annual MDS, dated [DATE], states, in part; Resident was admitted to facility 12/13/13. Current weight 195.30 lbs .Diet order is regular. Resident eats all meals in the main dining room independently with tray set up assist. Has no chewing or swallowing issues on current diet. Resident has own teeth. Resident likes to have soup spoon and bread with all meals R4's Care Plan for Nutritional Status has a goal of: She will not have significant changes in weight. Approaches documented are in part: Diet: puree with nectar thick liquids, soup spoon, white lipped plate, was receiving Magic Cups with all meals and now is switched to only yogurt with breakfast meals or upon request . assist of 1 with extensive assist . receives a 2 oz nectar thick house supplement 4 x per day to help with caloric intake. Progress Note made by DM KK on 8/10/17, states, in part; .Resident was hospitalized from [DATE] to 4/6/17 .NPO with feedings .Resident recently took tube out and SLP has placed order for resident to receive a pureed diet with nectar liquids and to receive supplements .Physician put in an order for [REDACTED]. Progress Note made by DM KK on 8/23/17, states, in part: .upgrade diet to mechanical soft with ground meats and gravy/sauce as of 8/22/17 .max assist with each meal . Progress Note made by RD E on 9/9/17, states, in part; .Weight 157.4 lbs on 9/1/17; weight history includes- 30d 171.8 lbs; 90d 175.9 lbs; 180d 192 lbs. IBW 135 lbs. Diet- mechanical soft with ground meat, nectar thick liquids .Weight is down additional supplementation isn't necessary as she spits out foods. Progress Note made by DM KK on 9/29/17, states, in part: Recently resident has had a 15.9% weight loss in 6 months, but weights have stabilized after 9/1/17 .Resident was receiving Magic Cups with all meals and now has discontinued, due to resident not wanting them and instead wanting yogurt with all meals . Progress Note made by RD E on 10/4/17, states, in part: .Weight 157.2 lbs on 9/28/17; weight history includes 30d 165.6 lbs; 90d 177.1 lbs; 180d 192 lbs .Additional supplementation isn't needed as she spits out foods. Progress Note made by DM KK on 10/20/17, states, in part; Resident has had a 12.5% weight loss in 6 months, but weights have stabilized after 9/1/17 . Progress Note made by RD E on 11/2/17, states, in part: .Weight 156.4 lbs on 10/13/17; weight history includes - 30d 158.7 lbs; 90d 178.8 lbs; 180d 180.5 lbs .Additional supplementation isn't needed as she spits out foods. Physician order [REDACTED]. Progress Note made by RD E on 1/12/18, states, in part: .Weight 140.6 lbs on 1/9/18; weight history includes - 30d 151.1 lbs; 90d 156.4 lbs; 180d 178.8 lbs .She did have an order for [REDACTED]. Weight Variance Report ran from 6/7/17-12/7/17 has R4 identified on it with handwritten notes that document trending down. Weights are listed from 6/14/17 (177.1 lbs) through 10/13/17 as noted above. Circled on this report is 12.5% significant weight change of 22 lbs on 7/14/17 and a 5% weight change of 8 lbs on 9/1/17. Quality Assurance Action Plan for Weight Program, reviewed 12/20/17, states: 1. Review Weight Program Policy with DM and clinical. 2. DM to track monthly and weekly weights per policy. 3. DM to bring weight changes to IDT morning meeting and weekly standards of care. 4. DM to notify RD of changes in weight, skin concerns. 5. Education to nursing staff of monthly weights to be completed within the first 10 days of the month, resident on weekly weights, and documentation requirements. 6. Identify current residents with weight loss, verify MD, RD, Family notifications, and care plans with appropriate interventions. Physician order [REDACTED]. On 2/8/18 at 8:37 AM, Surveyor interviewed MDS/RN K with DON B present. Surveyor asked where the weight information comes from that is used for the MDS; MDS/RN K replied from the computer system. Surveyor asked who was in charge of entering the weights into the computer system; MDS/RN K explained that DM KK put weights in the computer and no one else. Surveyor asked MDS/RN K if she could explain to me the process with weights from when DM KK was employed. MDS/RN K explained that the CNA's obtained the weights and gave them to the nurse, DM KK then took the weights from the Vital Sign Sheet, reviewed them and entered them into the computer. Surveyor asked MDS/RN K where someone would look to compare weights from current to previous; MDS/RN K said in the computer. Surveyor asked MDS/RN K to view R4's Quarterly MDS from 9/14/17 and tell me what weight was entered and if R4 triggered for weight loss on that MDS. MDS/RN K read 157 lbs for the weight and yes - not on physician-prescribed-weight-loss regimen. Surveyor asked MDS/RN K with R4's weight triggering a weight loss that is unplanned, what happens next; RN said it depends how the resident is weighed. DON B stated that the scales were re-calibrated on 1/16/18 prior to her start of employment; she stated she was told that the weight program had been updated. On 2/8/18 at 8:58 AM, Surveyor interviewed UM/LPN H. Surveyor asked UM/LPN H to explain the weight program; UM/LPN H explained that the policy is for all residents to be weighed monthly, unless they have orders for weekly or daily weights. UM/LPN H showed Surveyor a sheet that had each room broken down to a day of the week and explained that is how the weights were done. Surveyor asked UM/LPN H who was in charge of reviewing the weights and entering them into the computer; UM/LPN H stated previously DM KK and no one else. UM/LPN H stated that the weight program had been taken to QA meeting in (MONTH) or (MONTH) and they revised the program. Surveyor asked UM/LPN H to explain the new process. UM/LPN H explained that all weights were to be obtained between the 1st-5th of the month, the weights are to be put into the Weight Books. DM F and UM/LPN H go to the Weight Book and review weights; if a reweigh is needed, UM/LPN H relays that to the nursing staff and they put it in the Weight Book. UM/LPN H explained the goal is to have all the weights in the computer by the 10th of the month. Surveyor asked UM/LPN H what happens if a weight loss is identified. UM/LPN H stated that she would get staff involved that needs to be, they would discuss as a team and at S[NAME]; the physician would be updated and the RD would be consulted for recommendations. On 2/8/18 at 9:53 AM, Surveyor interviewed DON B. Surveyor asked DON B what her expectation would be for the weight program. DON B stated her expectation would be to follow their plan developed in QA. Surveyor asked DON B what her expectation would be if a weight loss is seen. DON B said for the resident to be reweighed, consult the RD for recommendations, and update the MD. On 2/8/18 at 10:05 AM, Surveyor interviewed DM F. Surveyor asked DM F what he does when he sees a weight loss. DM F explained that he reaches out to the RD for him to make a note and a nutrition plan, and he reports to nursing, either UM/LPN H or DON B. Surveyor asked how he knows who is a weight loss concern. DM F stated IDT discusses in stand up meeting every day and weekly S[NAME]. Surveyor asked DM F at what point of a resident losing weight is he concerned. DM F said once a resident triggers for a 5% change is when he takes action. Surveyor asked DM F if he was familiar with R4; DM F replied yes. Surveyor asked DM F if he is concerned with her weight loss. DM F stated that she does trigger for weight loss and that she has interventions in place. Surveyor asked DM F if he could tell me what those interventions are. DM F replied white lipped plate, soup spoon, mechanical soft diet, ground meat, nectar thick liquids, yogurt with meals, slurried desserts (nectar), eating all meals in main dining room and that she has partial dentures. Surveyor asked DM F if he saw a change in R4's eating since going into dining room for meals. DM F said she's eating better in dining room than in her room. On 2/8/18 at 10:38 AM, Surveyor interviewed RD/RN G. Surveyor asked RD/RN G if the facility had identified specific people with weight changes when they took weight program to QA. RD/RN G stated yes, that she had run the weight variance report and that is how they identified the weight program concerns. On 2/8/18 at 12:24 PM, Surveyor interviewed RD/RN G. Surveyor asked RD/RN G if the physician should have been updated about R4's weight loss; RD/RN G stated yes. Surveyor asked RD/RN G if she had any insight as to why the physician was not updated. RD/RN G stated the Interim DON didn't follow through with the action plan. Example 3 R54 was admitted to the facility on [DATE]. R54's [DIAGNOSES REDACTED]. R54 is not her own decision maker. R54's MDS, with an ARD of 9/12/17, indicated cognition to be severely impaired. It also indicates that R54 eats independently, weighs 133 lbs, and has no weight loss. R54's MDS, with an ARD of 12/13/17, indicated cognition to be severely impaired. It also indicates that R54 eats independently, weighs 133 lbs, and has no weight loss. R54's Nutritional Care Plan, initiated 4/13/16, included the following problem: R54 is at nutritional/hydration risk due to [MEDICAL CONDITION], hypertension, and stroke - initiated 4/13/16. R54's Nutritional Care Plan, initiated 4/13/16, included the following approaches: Diet per doctor order: regular - initiated 4/13/16 Encourage fluids at bedside and with activities - initiated 4/13/16 Honor likes/dislikes. Dislikes: cold (sic), salmon, shrimp, fish, biscuits and gravy, cereals, and white bread - initiated 4/13/16 R54 eats meals mostly in main dining room independently with tray setup assist - initiated 4/13/16 Medications as ordered - initiated 4/13/16 Monitor for signs and symptoms of fluid imbalance - initiated 4/13/16 Monitor labs as needed - initiated 4/13/16 Monitor meal intake/ record - initiated 4/13/16 Monitor tolerance to diet texture, make adjustments as needed - initiated 4/13/16 Offer substitutes if consumes less than 50% of meals - Initiated 4/13/16 Therapy/Restorative screen and treat as needed - initiated 4/13/16 Weigh every month and/or as needed, notify MD of significant change - initiated 4/13/16 (It is important to note that the Nutritional Care Plan approaches were initiated on 4/13/16, upon R54's admission and have not been updated since.) R54's medical record included th (TRUNCATED)

Based on observation, interview and record review, the facility did not ensure that residents receive appropriate treatment and care related to pain management for 1 of 6 residents investigated for pain (R52), out of a total sample of 27. R52 was observed in pain, from 10:05 AM until 11:29 AM, without having his pain relieved prior to wound dressing change, by medication or repositioning. This is evidenced by: Facility policy entitled Pain Management, dated 11/2016, states, in part: Policy: Atrium Centers believes pain is a personal experience that, if left under treated or mismanaged can radically change a Residents quality of life and impact their overall well-being.each member of the IDT has the responsibility to advocate for the Resident's comfort and to take in account their benefits, preferences, burdens of treatment, risks of potential adverse effects, while providing the Resident with options to all appropriate interventions, including; medications, non-pharmacological approaches, and complementary therapies in the development of the Residents individualized pain management plan. Procedures: Assessment and Monitoring: 1. It is the responsibility of all direct care staff to be vigilant for signs and symptoms suggesting pain during the Residents daily activities .3. Licensed staff will conduct assessments just prior to administering medications or alternative methods and then again following to determine effectiveness 6. Tools to be utilized during the recognition and assessment of pain include a numerical and verbal descriptive scales and FLACC. Each scale use scoring results from zero to ten . Example 1 R52 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. R52's Quarterly MDS, dated [DATE], indicates R52 has a BIMS of 14 out of 15, indicating he's cognitively intact. Section J indicates R52 occasionally has pain, with a pain intensity of a 4 on a 0 to 10 scale, and has not limited R52's day to day activities. R52's MDS also indicates that he was independent for transfers but needs extensive assist for toileting and limited assistance for dressing. R52's - Pressure Ulcer Care Plan, dated 11/7/16, indicates an approach of Prevent or treat pain prior to wound care, dressing changes or debridement. Pain Care Plan, dated 8/27/16, does not indicate R52's pain tolerance level on a 0 - 10 scale. Pain Care Plan indicates to assess characteristics of pain; location, severity on a scale of 1 to 10, type, frequency, precipitating factors, relief factors, observe for non-verbal signs of pain: grimacing, moaning, increased vital signs, guarding areas of body, diaphoresis, dilated pupils, and Offer comfort measures such as: distraction, backrubs, re-adjusting position, application of heat or cold, slow breathing. R52's MAR indicated [REDACTED] 2/4/18 at 3:50 AM -[MEDICATION NAME] 25 mg given by mouth (po), for pain in groin with results of effective. There is no numeric pain rating for R52 at this time. 2/4/18 at 3:50 AM - Tylenol 325 mg times 2 (650 mg) given po for pain to groin and indicates effective. No numerical pain rating indicated. 2/7/18 at 2:15 AM - [MEDICATION NAME] 25 mg and Tylenol 650 mg given po for pain to groin, and indicated as effective, again there is no numerical pain rating. 2/7/18 at 1100 AM - [MEDICATION NAME] 25 mg po for Pain 10/10 results indicated as effective 0/10. 2/8/18 at 11:50 AM - [MEDICATION NAME] 25 mg po for leg/knee pain 5/10 results indicated as effective. 2/7/18 at 10:05 AM, Surveyor observed R52 propelling self down the hall to his room, R52 indicated he was hurting. R52 placed his light on around 10:10 AM, two CNAs came and assisted R52 at 10:19 AM until 10:25 AM, one CNA told R52 that the nurse is coming. 2/7/18 at 10:38 AM, R52 propelled himself to the doorway and voiced to Surveyor, I'm in a lot of pain. Surveyor could hear and see R52, from the lounge across the hall, moaning and rocking back and forth in his w/c. R52 continued moaning and groaning out loud in his chair, in doorway of his room, while waiting for the nurse, verbalizing, Oh god, and they better get here. 2/7/18 at 10:40 AM, Surveyor heard R52 stating, Come on nurse, and moaning ooh and mm, while in his room, rocking back and forth still in his w/c. R52 continued voicing oh god and observed to be grimacing from across hallway from Harvest Lounge. Surveyor has a direct sight into doorway of resident's room and foot/side of resident's bed, where he has moved to in his w/c and is moaning. 2/7/18 at 10:44 AM, Resident brought himself back to door stating, Jesus Christ, while looking up the hallway towards the Nurse's station, still verbally moaning, They're killing me. (Call light has not been on, but CNA verbalized to resident after assisting him that the nurse is coming.) 2/7/18 at 10:48 AM, R52 is still in his w/c, stating, Jesus F***ing Christ, and come on, indicating to Surveyor, this is getting aggravating. R52 continues to exhibit moaning/groaning at this time. A CNA went by and stated (nurse's name) is coming, then went into another resident's room across the hall. 2/7/18 at 10:50 AM, R52 moved over by his bed still in his w/c moaning, and stating, damn, while visibly holding on to the bed. He proceeded to state, oh f**k, while continuing to moan. Surveyor asked R52 to rate his pain? R52 stated to Surveyor, over a 10, and I'm sitting on my wounds without a pad, I keep hearing the nurse is coming. R52 indicated to Surveyor that he gets this all the time. R52 is still visibly sitting in his w/c with his pants down to mid-thigh, his bottom appears uncovered, sitting on soaker pad. R52 stated to Surveyor, It's been over a half hour already, this is how slow things are. R52 stated, I'm going to start screaming. 2/7/18 at 10:55 AM, Surveyor observed RN Q come down to R52's room, and asked, Would you like a pain pill? R52 replied, yeah, but it's not going to help, I need to get off of these. RN Q replied, I know you do, then proceeded to sign out a prn order of [MEDICATION NAME] at this time. RN Q asked R52 to rate his pain on a scale of 1 to 10? R52 stated, Higher than a 10 right now, I'm ready to go through the roof. (Resident verbally moaning Ooh and visible grimacing noted at this time.) 2/7/18 at 10:58 AM, RN Q gave R52 pain medication ([MEDICATION NAME]) at this time. RN Q left R52's room, and left him sitting in his chair. RN Q voiced she was going to gather stuff and would be right down. (Please note RN Q never suggested to R52 to lie down or reposition self in order to relieve pressure/pain off of wounds, which were causing R52 pain.) 2/7/18 at 10:59 AM, R52 is still in his chair, wounds on soaker pad, pants partially down, door open, able to see his skin top thighs and abdomen. R52 continues to verbally moan and grimacing still visibly noted. Appears uncomfortable, as he's grasping tightly on to footboard with his left hand and bedding with his right hand. 2/7/18 at 11:01 AM, R52 voiced to Surveyor, This is what I mean, it shouldn't be taking this long to get stuff, meanwhile, the sores get worse, because they're not covered. R52 continues to exhibit moaning such as loud mm being vocalized. R52's fidgety with his feet, verbalizing, Come on. Surveyor asked R52 how often is your pain like this? R52 replied, Every time I have to sit and wait constantly, if I lay down it'll start to go away, because I have the pressure evened out. Surveyor also observed R52 hitting his bed with his right fist at 11:04 AM, while moaning in pain and visibly grimacing vocalizing, mm and god damn it. (Please note R52's face appears red in cheek area and ears are also red in color.) 2/7/18 at 11:05 AM, R52 verbalized, Come on someone. R52 appears as if about to cry, rocking in chair, while bent over with pain, stating, oh god, ugh, and ooh. 2/7/18 at 11:06 AM, Surveyor observed R52 still sitting up in w/c, clenching his fists. Then proceeded to be holding onto the footboard, grimacing, groaning mm. R52 stated, I want to hit something so bad, while clenching teeth while talking. R52 asked Surveyor, Are they coming? (Surveyor can visually see nurse at a cart in hallway at the Nurse's station at the top of the hall.) 2/7/18 at 11:09 AM, a CNA walked by R52 and went into the room across hall with a lift, never stopped for R52 when heard moaning. R52 stating, come on, someone, while grimacing, then continuing moaning, in w/c, leaning back, face is reddened, clenching eyes shut, stating, oh god. 2/7/18 at 11:10 AM, R52 observed bent over in his chair, with clenched fists stating, Come on. 2/7/18 at 11:11 AM, R52 stated, It's getting close to the screaming point, I'm going to start screaming. 2/7/18 at 11:12 AM, RN V and RN Q entered R52's room at this time. RN Q stated to R52 get positioned for me and instructed R52 to stand up, to do wound dressings. Blood visible on soaker pad and R52's wounds on ischial area were bleeding. Resident standing and leaning over bed moaning mm. R52 stated, My knees about to go, while breathing hard, and moaning ooh. R52 also verbalized to RN V and RN Q, My knee is starting to buckle. RN V stated, Bear with us, with R52 replying, Left leg is starting to buckle. Once dressing change completed, R52 moaning ooh and mm then voiced, oh my knee, RN Q assisted R52 to sit back down in his w/c. 2/7/18 at 11:29 AM, R52 stated, now I'm starting to feel a little better, I can feel the difference. R52 in w/c at this time smiling, interacting with RN V and his face is still red in appearance on cheek areas and ears reddened. 2/7/18 at 11:30 AM, R52 stated to Surveyor, It's dropping rapidly, now it's down to a 5 since there's padding and I'm not sitting directly on the wounds. 2/8/18 at 12:46 PM, Surveyor interviewed DON B, who indicated she wouldn't expect residents to have to wait an hour for pain medication or for pain to be relieved. DON B indicated that CNA's told the nurse and that RD/RN G and DON B were at the desk at the time of notification. DON B stated, So they did tell the nurse. RD/RN G and DON B unable to indicate to Surveyor what time the nurse was notified. 2/8/18 at 2:29 PM, Surveyor interviewed UM/LPN H, who indicated staff should be putting a numerical indication for pain, not just groaning. UM/LPN H indicated the facility just changed PRN medication on the MAR indicated [REDACTED]. UM/LPN H indicated there should be follow-up pain scores.

Based on medical record reviews, policy review, observation and interview, the facility did not ensure that based upon current standards of practice, a resident receives the necessary treatment to promote healing, prevent infection, and prevent new pressure injuries from developing for 2 of 3 residents reviewed with pressure injuries (R2, R10). R2 developed an unstageable pressure injury on her left heel in the facility. R2 was not provided interventions for offloading pressure on her heels prior to the development of the pressure injury or during the survey. R2's dressing change had not been completed timely as ordered by the physician. R10 has a history of pressure injuries to her buttocks. R10's dressing change was not done as ordered. R10 was not offered offloading every 15 minutes as ordered. This is evidenced by: Review of the facility policy identifies the National Pressure Ulcer Advisory Panel (NPUAP) as the standard of practice utilized by the facility. R2 was admitted [DATE] and has [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documents R2 has a brief interview for mental status score (BIMS) of 13, meaning she can answer most questions accurately. The MDS documents R2 needs physical assistance of one person for transfers and mobility. The care plan, Pressure ulcer impaired skin integrity related to: friction from self propelling, ulcer on both heels. R (right) w x 2.2 hard blue calus (sic) healed. L (left) 5 x 3.8 cm purple blister. 01/31/17 Goal: Heal skin and prevent infection Approaches in part: keep bony prominences from direct contact with one another with using pillows, blankets, pad and cushions. The Certified Nursing Assistant (CNA) care guide: Heel protectors on when up. physician progress notes [REDACTED]. This is an extra visit in nursing home setting to check patient's heels. She developed heel blisters presumptively from pushing too hard moving her wheelchair extremities: .I unwrapped the left leg showing her bruising on the heel but the skin is intact .Plan: Nursing will continue protective boots when in the wheelchair. If areas open up we will have to treat as ulcers . The National Pressure Ulcer Advisory Panel (NPUAP) definition of a suspected deep tissue injury, Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear .evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. The nurses' notes in part: 01/31/17, It's been noted that resident has a black area on bilateral heels. Left measures length 5 cm width 3.8 cm. Right is 2 cm length and 2.2 width. Foam booties placed on her feet. Encouraged her not to propel herself in the w/c . Wound measurements in part: 02/07/17, right heel, 5 x 3 cm callous, hard bruise .likely the result of propelling self independently in w/c This ulcer is documented as healed on 04/11/17. 02/07/17, left heel, 10 cm x 7 cm depth 0 cm, description callous, area is a purple/bruised hard callous to the left heel. The area is measured weekly and gets smaller in size as of 04/11/17, with a measurement of 2 x 2 cm with a depth of 0.8 cm. Physician orders in part: Hydrogel to left heel after cleansing. Wrap with kerlix Once a day. 05/08/17. Weekly measurements in the nursing notes continue, showing an increase in size on 05/16/17, with a measurement of 3 cm x 2.6 cm depth of 0.7 cm. On this date it is documented there is now minimal drainage. All other notes until this date state there is no drainage. 06/06/17, The left heel injury area increases in size to 4.2 cm x 2.9 cm with a depth of 0.6 cm., minimal drainage. On 06/13/17 at 12:55 p.m., Surveyor observed the wound care for the left heel with the Director of Nursing (DON) and Registered Nurse (RN) L. RN L sat on the floor to unwrap the old dressing. Surveyor noted the date on the dressing was 06/11/17. RN L verified the date of the dressing. RN L removed the dressing that had a moderate amount of brown/tan drainage. Surveyor could smell a foul odor. RN L cleansed the wound with wound cleanser. R2 yelled out, Ow as the area was cleansed. Surveyor could observe the open area on the bottom of the left heel; it was circular in shape, located on a bony prominence that has been observed having direct pressure. Surveyor was unable to visualize the wound base, due to exudate in the wound. The pressure injury is unstageable at this time. Surveyor asked RN L what stage the wound was. RN L replied that this was not a pressure injury but a venous stasis ulcer. RN L then applied hydrogel on a gauze, applied it to the heel and wrapped it with kerlix. Surveyor asked if an odor was noted. The DON said she did not notice an odor. RN L acknowledged there was a definite odor from the wound. Observations 06/13/17 at 11:00 a.m., R2 is up in her wheelchair wearing gripper socks. There are no heel boots on. 06/13/17 at 3:40 p.m., R2 is up in her wheelchair wearing blue gripper socks, there are no heel boots, R2's heels are in direct contact with the floor. On 06/14/17 at 8:10 a.m., R2 was at the dining room table wearing gripper socks, with her heels directly on the floor. On 06/13/17 at 11:50 a.m., Surveyor observed R2 being assisted by CNAs M and K. CNAs M and K assisted R2 onto the toilet from her wheelchair. R2 was observed to have gripper socks on her feet. Once completed with toileting, R2 was assisted back into her wheelchair. Gripper socks remained on her feet which were directly on the floor. At 3:25 p.m., R2 was observed in the dining room in her wheelchair eating chips and drinking a drink. R2 was observed to have blue gripper socks on her feet which were observed directly on the floor. On 06/14/17 at 6:15 a.m., CNA G pulled the covers off R2 legs and feet as she was lying in bed. R2 was observed to have her feet, heels and legs directly on the mattress. R2 had blue gripper socks on her feet. The NPUAP recommendation for treating existing heel pressure injuries, For category/Stage III, IV and unstageable pressure ulcers, place the leg in a device that elevates the heel from the surface of the bed, completely offloading the pressure ulcer . On 06/14/17 at 12:30 p.m., Surveyor interviewed the DON about the above pressure injury. Surveyor asked if the facility has a wound care certified nurse on staff. The DON replied, No. Surveyor shared the observations above. The DON acknowledged that R2 had been pushing too hard with her feet into the floor while propelling her wheelchair and stated they were getting a wound culture of the wound. The DON went on to say a physician said it could be from venous stasis issues, so the facility went with that description. The review of R2's medical record does not include [MEDICAL CONDITION], or venous stasis ulcer diagnoses. Example 2 R10 has [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], documents a BIMS score of 15, meaning R10 is alert and oriented and able to answer questions accurately. The MDS indicates R10 needs extensive assistance of two persons for transfers and mobility. The MDS states R10 has one existing pressure ulcer that is unstageable. The MDS does not indicate a turning and repositioning schedule for R10. The care plan, Pressure ulcer, risk for impaired skin integrity .08/27/15 .often refuses position changes and states she does not want to lay down throughout the day .Approaches in part: 03/13/17 Order for repo (reposition) 15 minutes . Physician orders in part: Change dressing three times daily. Cleanse with safclens. Blot dry, apply [MEDICATION NAME] powder around skin around wound and buttock. Place [MEDICATION NAME] Ag in the gluteal cleft and wound. Place sacrum dressing, continue repositioning in wheelchair every 15 minutes in bed every 1 hour. 05/27/17. The wound measurements on the weekly pressure ulcer progress report: 06/06/17 Stage II 4 x 3 mm depth 0.2 mm, sero sang drainage 06/13/17 Stage II 4 x 3 mm, sero sang drainage On the initial tour, Surveyor interviewed R10 about wound care. R10 stated that the dressing changes do not get done as ordered. R10 stated it is to be done three times a day and most days it gets done once. R10 stated that sometimes the CNAs do the dressing change and not the nurses. Surveyor asked about R10's repositioning schedule. R10 stated she sits in her chair most days from 9:30 a.m. until 9:00 p.m. without repositioning. Surveyor asked if R10 refuses to be repositioned. R10 stated that she does not want to lie down for long periods because she likes to work on her crafts but she would not refuse to be lifted up and repositioned in her chair. R10 stated that her doctor would be here today and that he has also noted the dressing changes not being done the way they should. Nurses' note 06/11/17 : Resident encouraged to change position as as often as tolerated and to shift weight in chair every 15 minutes per PA rounding . Observations On 06/13/17, Surveyor observed R10 sitting in her wheelchair from 9:30 a.m. until 11:40 a.m. The staff did not offer offloading or repositioning to R10. On 06/14/17, Surveyor observed R10 in bed, lying on her back at 6:08 a.m., the head of the bed was elevated 45 degrees. The observation continued until 7:20 a.m. The staff did not go in the room and offer repositioning to R10. On 06/14/17 from 7:00 a.m. to 7:06 a.m. and from 7:20 a.m. through 7:46 a.m., Surveyor observed R10 lying in her bed on her back with her head elevated approximately 45 degrees. No staff were observed to enter the room to offer R10 repositioning. On 06/13/17 at 1:20 p.m. the Physician Assistant (PA) H performed the wound care for R10. Surveyor observed as R10 was lifted up with the EZ stand at this time. PA H removed a very small dressing from the buttock and redressed the wound, with a large [MEDICATION NAME] foam dressing. Interviews At 1:30 p.m., Surveyor interviewed PA H about the dressing changes. PA H stated that the frequency of the dressing changes is an issue. Many times he comes to do the wound care and the dressing is dated with an older date. The PA went on to say that the dressing he removed today was not what was ordered. PA H stated that R10 was to have a large [MEDICATION NAME] dressing that would help absorb moisture and add some protection. Surveyor asked about the repositioning of R10. PA H stated he had written very specific orders for R10 to be offloaded every 15 minutes, that was not being followed. Surveyor asked if R10 could lift herself up in the chair to offload. PA H stated R10 cannot do that. PA H stated he has spoken with the DON about these concerns. PA H stated he would like to decrease his frequency of visits from the 2 x each week, but cannot do so because the pressure injury has declined any time he has decreased his visits. On 06/14/17 at 11:00 a.m., Surveyor interviewed CNA M to ask if CNAs have been asked to perform dressing changes on R10. CNA M acknowledged that this has happened when certain nurses work. Surveyor asked CNA M about R10's repositioning schedule. CNA M stated that R10 is to offload in her chair. Surveyor asked if staff go in and offer to help her. CNA M stated that they do not. On 06/14/17, Surveyor interviewed the DON about the repositioning orders, and concerns with dressing changes The DON stated she was not aware of problems with the dressing changes. The DON indicated that R10 does not like to lie down. Surveyor asked if alternative options to offloading were provided, such as using the EZ stand to offload a few minutes. The DON acknowledged other interventions to offload had not been tried.

Based on observations, interviews and record reviews, the facility did not ensure 3 of 4 sampled residents (R11, R17, R10) reviewed with catheters received appropriate treatment and services for catheter care, and 1 of 3 (R18) sampled residents observed for personal cares was provided care to prevent urinary tract infections. R11 has a urinary catheter. R11 was observed to have no securing device in place with a history of penile erosion. This increased the likelihood of undue tension on the catheter and continued erosion of the tissue. R11's catheter was washed in the wrong direction during personal cares, and the foley bag was emptied without using an alcohol wipe to prevent infection. R17 has a urinary catheter that was not secured causing undue tension on the catheter and has documented urinary erosion from the wrong size catheter. R10 has a foley catheter that is ordered to be changed monthly. The facility has not provided this catheter care. The order in place does not follow the standard of practice for changing catheters as needed. R18 has a history of urinary tract infections. The Certified Nursing Assistant (CNA) washed in the wrong direction while providing cares, potentially introducing bacteria into the bladder. This is evidenced by: Example 1 R11 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. R11's Minimum Data Set (MDS) assessment dated [DATE], indicated that R11 is severely cognitively impaired, needs extensive assist of two staff for transfers, bed mobility, dressing, hygiene and toilet use and has an indwelling catheter. R11's Care Plan, dated 12/06/16 stated: .Indwelling catheter, risk for infection related to the presence of an indwelling urinary catheter; history of postprocedural bulbous urethral stricture .approaches in part: change catheter bag per facility policy, change catheter on schedule ordered by MD. Catheter should be changed once per month unless contraindicated .provide catheter care every shift. The care plan, dated 05/30/17 stated, Impaired skin integrity related to penis shaft r/t (related to) catheter. NP (nurse practitioner) assessed 05/30/17, appt June 6th w (with) urology . The CNA care card instructs: cath care every shift The physician orders [REDACTED].>Change foley catheter once a month on the 9th of the month Catheter leg bag on am off hs (hour of sleep) Strap catheter to leg at all times and alternate sides daily to help prevent further erosion 06/06/17 Nurses' notes in part: 05/28/17 Observed resident's indwelling urinary catheter this AM during cares. The underside of the resident's penis has separated from the urethra to the base of the shaft by the scrotum. The site is not bleeding .will request MD/NP review the resident's condition . 05/30/17 .NP (nurse practitioner) here to see resident due to catheter separating his penis He has an apt. June 6th at Urology . 06/06/17 .returned from urology apt with new orders and progress note as follows: strap catheter to leg at all times and alternate sides daily to help prevent further erosion. Erosion through urethra . Nurse practitioner note 05/30/17, in part: .increased erosion of urethra that has been progressing over past 6 months .Physical exam: .Urethra of penis erosion from tip to scrotum .Plan: .this is not an acute issue as has been noted to be progressing over past few months . Urology note 06/06/17, in part: .has erosion of his urethra that has been present for over 6 months .Objective: .the catheter was not secured in any way and was pulling down which is contributing to the erosion .Assessment and Plan: .would recommend better securing of the catheter to the leg to help prevent further erosion and alternating sides daily . Surveyor reviewed the treatment adminstration record (TAR) and noted the leg bag use and securing the catheter were signed out daily as having been done. On 06/13/17 at 9:00 a.m., Surveyor observed R11 sitting in his wheelchair with a foley catheter bag under his chair. R11 did not have a leg bag on. On 06/13/17 at 1:30 p.m., Surveyor observed R11 sitting in his wheelchair with a foley catheter bag under his chair. R11 did not have leg bag on. On 06/14/17 at 7:15 a.m., Surveyor observed CNA G and CNA K (who routinely care for R11) assist R11 with morning cares. Surveyor observed the foley catheter tubing was not secured to R11's leg. The catheter bag contained about 900 cc of urine, which caused added weight to pull down on the catheter tubing. CNA G emptied the catheter without placing a barrier on the floor. CNA G opened the catheter and emptied urine into the graduate without using an alcohol wipe. CNA G measured 700 ccs, then came back, opened the spigot again without using alcohol and drained an additional 200 cc of urine. CNA G kept the same gloves on as she proceeded with cares. Surveyor could observe a red area on R11's inner left thigh. CNA G washed the catheter tubing in a downward motion, then upward towards the urinary meatus. The catheter tubing was covered in a brown colored substance. CNA G lifted up the penis to wash the underside. Surveyor could observe the erosion of tissue, so that the catheter tubing was visible on the underside of the penis. CNA G indicated that R11 had a problem with his skin because of the catheter. Surveyor asked what was being done to prevent it. CNA G stated she did not know, that would be a question for a nurse. Surveyor asked if R11 has ever used a leg bag. (A leg bag would lessen the length of tubing and weight that would be pulling downward). CNA G and CNA K stated they have never been aware of using a leg bag. CNA G and CNA K assisted R11 to sit up on the edge of the bed. R11 was sitting on the catheter tubing as they started to wash his upper body. CNA G proceeded to pull the foley catheter bag through R11's pant leg and was going to pull up his pants. Surveyor asked if there was anything else that needed to be done for the catheter. CNA G stated to be sure the tubing was not kinked. Surveyor then asked if R11 uses a leg strap to secure the catheter to prevent pulling. Foley catheters are often subject to inadvertent pulling forces that can lead to discomfort. A catheter stabilization device is designed to minimize catheter movement and accidental dislodgement, thereby maximizing comfort. CNA K stated she has never seen one. CNA G stated that R11 probably should have one. The CNAs were going to transfer R11 when Surveyor stopped the CNAs and informed them the orders state R11 is to be using a leg bag, and to have the catheter secured. CNA G then went to get a leg bag and a strap to secure the catheter tubing. Facility Procedure for emptying a drainage bag: 2. Place a paper towel on the floor. Place graduate on top of it. 6. Clean the end of the drain with an antiseptic wipe . Facility Procedure for giving catheter care: 9. Hold the catheter at the meatus. 10. Clean the catheter from the meatus down the catheter at least 4 inches. Clean downward, away from the meatus with one stroke. Do not tug or pull on the catheter. 15. Secure the catheter . On 06/14/17 at 11:00 a.m., Surveyor interviewed CNA M to ask if a leg bag or a securing device was used for R11. CNA M stated she has not seen a leg bag or catheter securing strap used for R11. On 06/14/17 at 12:30 p.m., Surveyor interviewed the Director of Nursing (DON) about the observations of the catheter not being secured and the resulting erosion for R11. Example 2 R17 was admitted [DATE] and has [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] documents R17 has a brief interview mental status (BIMS) score of 13, meaning he is alert and oriented and able to answer most questions accurately. The MDS documents R17 has an indwelling catheter. The physician orders [REDACTED].>16 Fr urinary catheter with only 10 cc balloon; change monthly and PRN (as needed) Special instructions: Need smaller catheter because 22 fr was causing urethral sores/erosion inside. 06/11/17 The care plan, Indwelling catheter, risk for infection related to indwelling urinary catheter. Size 16 fr with 30 cc balloon. Approaches in part: Change catheter as needed per MD order .provide catheter care every shift. 03/30/17. Impaired skin integrity, .cath (catheter) rubbing on left thigh 1 x 1 cm. (This is undated). The approaches listed do not address securing the catheter in the care plans. The balloon size is inaccurate on the care plan. Nurses' notes in part: 05/11/17 Resident returned from urology appointment with following data on referral form: changed catheter to 18 fr and only 10 cc in balloon; change catheter once a month use 16 fr, 10 cc in balloon; the 22 fr was causing urethral sores/erosion inside so need smaller catheter. 05/28/17 Staff reported to this nurse that with HS cares resident's foreskin was pulled back to cleanse. Foreskin did not want to return forward. PM supervisor reported she returned the foreskin with A&D ointment. Will monitor for pain or s/sx (symptoms) of infection . 06/08/17 .is alert and oriented makes his needs known . On 06/14/17 at 9:45 a.m., Surveyor interviewed R17 to ask if he had any current problems with his catheter. R17 replied, It hurts on my penis, it is a sharp pain, it is hurting now and it is just irritating. R17 went on to say he tries to move the catheter tubing on his own to decrease the discomfort. R17 stated, It is not very comfortable most of the time. Surveyor asked if it would be alright to inspect the catheter. R17 agreed. Surveyor called CNA K to the room to assist in looking at the catheter. Surveyor noted the catheter tubing was not secured, and R17 is using a foley catheter bag. Surveyor could observe sores on the head of the penis by the urethral opening. The sores have a yellow slough on them, the surrounding tissue is very red in color. CNA K indicated that the penis had been like this for a while. Surveyor asked if the nurses have any treatment for [REDACTED]. CNA K stated she has asked about it and was told to put on A & D ointment. At this time R17 requested Tylenol for the discomfort. On 06/14/17 at 11:00 a.m., Surveyor interviewed CNA M about the above concerns. CNA M indicated R17 has complained of pain for awhile and comments that the catheter bothers him. CNA M was aware of the sores on the penis and stated they have been there for some time. CNA M recalled that about six weeks ago she went to the nurse and was told by the nurse that the CNA was to put [MEDICATION NAME] powder on it. Surveyor asked if the nurse assessed the area or if any treatments had been started since then. CNA M stated, No. Surveyor asked if R17 routinely uses a securing device for the catheter tubing. CNA M stated they do not use a strap to secure the tubing. The urology noted dated 05/11/17: Change catheter once a month use 16F, 10 cc balloon. The 22 Fr was causing urethral sores/erosion inside so need smaller catheter. On 06/14/17 at 12:30 p.m., Surveyor interviewed the DON to ask if R17 had been assessed or had any treatments for the sores on his penis. The DON acknowledged there was no current treatment and that she would contact the physician today. Example 3 R10 has [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], documents a BIMS score of 15, meaning R10 is alert and oriented and able to answer questions accurately. The MDS indicates R10 has an indwelling catheter. The physician orders [REDACTED].>Change foley catheter 20 or 22 fr with 10 cc balloon once a day on the 6th of the month. The care plan, The care plan, Indwelling catheter, risk for infection related to indwelling urinary catheter due to [MEDICAL CONDITION] . Approaches in part: Change catheter as needed per MD order .provide catheter care every shift. Wipe down tube with alcohol wipes after emptying. 03/30/17. On 06/13/17, during the initial tour at 8:45 a.m., Surveyor interviewed R10 about her care at the facility. R10 had concerns that her catheter did not get changed like it should. R10 indicated it should be changed monthly but has not been done for a long time. Surveyor reviewed the Treatment Administration Record (TAR) and noted the catheter change had not been signed out as completed for March and May 2017. The changing of the foley bag every two weeks was not completed. Surveyor reviewed the nurses' notes to look for any information that the catheter was changed the above months. The medical record contains no indication the catheter was changed as ordered. The nurses' note 05/11/17, Resident and CNA noted small amount of blood in the tubing of residents catheter, resident complained that she felt it was from the bag not being emptied until 1300 mls was drained. bag holds 2000 ml, resident was concerned something was wrong.at HS cares CNA and writer noticed the urine appeared to be a little more reddish than amber, drained another 1000 ml. Explained to writer that staff would check to see if bag had been changed in last month . On 06/19/17, Surveyor called the DON to ask if R10 had seen a urologist to determine the need for monthly catheter changes. The current standard of practice to prevent healthcare acquired infections instructs to not change catheters routinely, but only as needed. Surveyor asked for a policy related to the need for catheter changes. The DON responded that R10 had not seen a urologist, and that the facility has no policy to guide them in determining the need for catheter changes. Example 4 R18 was admitted [DATE], and has a history of urinary tract infections. The MDS, dated [DATE], documents R18 needs extensive assistance with transfers and personal hygiene. R18 is incontinent of bowel and bladder. On 06/13/17 at 9:05 a.m., Surveyor observed CNA I assist R18 with personal cares. R18 had been incontinent of urine. CNA I washed the frontal area starting downward, but then washing in a circular motion upward from the rectal area. CNA I dried R18 in the same manner. CNA I kept the same gloves on after doing the perineal care to apply the barrier cream, and then apply the clean incontinent product. The above has the potential to introduce bacteria into the bladder, causing a urinary tract infection. The above observation was shared with the DON on 06/14/17 at 12:30 p.m

Based on medical record review and interview, the facility did not ensure that 1 of 6 sampled residents (R1) received the care and services to maintain ambulation abilities. R1 was admitted to the facility on [DATE], able to walk independently. R1 was seen by therapy initially, and was set up on a functional maintenance program (FMP) to be walked 100-200 feet daily. The FMP was not carried out and R1's ability to walk declined. This is evidenced by: R1's medical record states he is cognitively intact and has [DIAGNOSES REDACTED]. Surveyor interviewed R1's wife by telephone on 05/11/17 at 8:25 a.m. as R1 was unavailable. R1's wife stated she was R1's caregiver at home, and R1 came to live at the facility when she had to undergo treatments [MEDICAL CONDITION]. R1's wife stated that before R1 was admitted to the facility, he could walk around in their apartment independently with a cane. She and R1 also walked around a walking path together with his wheeled walker, which was 1/4 mile, when the weather was nice. R1 was seen by the therapy department initially for strengthening and to maintain his abilities, in hopes of returning home with his wife after [MEDICAL CONDITION] treatments were completed. On 01/23/17, an FMP was set up, instructing staff to Ambulate with 4WW (wheeled walker) 100 - 200 feet depending on how tired patient is with SBA (stand-by assistance). A copy of this FMP was obtained from R1's medical record. Surveyor interviewed Restorative Aide (RA) D on 05/10/17 at 1:10 p.m., who stated that she initially discussed therapy's FMP for R1 with the Director of Nursing (DON). RA D stated her caseload was too full to take the time to walk R1, so it was set up for the Certified Nursing Assistants (CNAs) to carry out, perhaps in a walk-to-dine program. Surveyor asked RA D if she had seen the CNAs walking R1 in the hall, and she stated, Maybe two times (since 01/23/17). RA D stated she thought R1 was walking independently from his bed to his bathroom while he was in his room. Surveyor asked RA D if she would have had room on her caseload, would R1 have been walked by her. RA D stated, I'm not sure, because it's the DON who oversees who gets put onto the program. I can't physically add someone myself, because she has to get the computer stuff set up, and get all that done first. In the above interview, RA D stated that on Sunday, 04/30/17, she gave R1 a shower, but he could only take a couple of steps because he said he had fallen and that his butt was sore. RA D stated that she notified the nurse. Surveyor interviewed Registered Nurse (RN) B on 05/10/17 at 1:35 p.m. RN B stated she was not aware that R1 had an FMP for walking. Surveyor asked how often she saw R1 walking in the hall with the CNAs and RN B stated, I never saw him walk in the hallway. RN B also stated, Looking back, he probably wasn't moving around a lot. He might have been compromised by his history and moving less. Surveyor interviewed Physical Therapy Assistant (PTA) F on 05/10/17 at 3:20 p.m., who confirmed she had worked with R1, and she had set up the FMP for R1 to walk with staff, 100 - 200 feet daily. PTA F also confirmed she initially wanted the RA to carry out this FMP, but RA D's caseload was full, so the CNAs were to walk with him. There is no documentation that this FMP was carried out. In the above interview with R1's wife, she confirmed that R1 told her that he seldom walked in the hall with the CNAs. Surveyor interviewed the Nursing Home Administrator (NHA) and LPN A on 05/10/17 at 3:50 p.m. Licensed Practical Nurse (LPN) A confirmed there was no documentation that R1 had been walked in the hall by staff, and there has been no follow-up to ensure that this FMP was carried out. LPN A stated that the FMP could not be found in the communication binder. (Surveyor located the FMP in R1's chart.) LPN A confirmed R1 was not walked as ordered, and he did have a decline in his walking abilities. Surveyor interviewed CNA C on 05/10/17 at 2:35 p.m. CNA C stated R1 initially walked in his room to the bathroom, but after moving to a different room, he transferred himself to his wheelchair, wheeled to the bathroom, stood up at the grab bar and transferred himself to the toilet. CNA C stated at times, when R1 would try to walk to the shower room, he would get 1/2 the way there and would need to sit down because his legs hurt him, and he didn't have as much energy. Surveyor asked CNA C if R1 walked daily in the hallway with the CNAs. CNA C stated there is a communication book which tells you who is supposed to walk when they're done with therapy, but he did not get walked daily in the hallway. CNA C stated, We just completely spaced it. You can't hide that. We didn't know he was supposed to walk. At first he walked to his bathroom, and then he just used his wheelchair. Surveyor interviewed LPN E on 05/11/17 at 10:00 a.m., who stated that she had not seen R1 walk in the hall recently. LPN E stated after R1 was no longer receiving therapy, she saw him walking to a meal independently with his walker which had a bench seat, and sometimes she would walk back with him. LPN E stated that she did not know anything about therapy setting up a walking program, but that typically the CNAs do not have time to walk residents, unless they are assigned to the Restorative Aide. LPN E stated that RA D is in charge of certain people (residents) so those people get walked.

Based on interview and record review, the facility did not ensure nutritional care and services were provided to each resident, and that each resident with weight loss was promptly identified, evaluated and each resident's nutritional needs were assessed and met. This occurred for one of four residents reviewed for nutrition and weight loss. Resident #2 had an 18% weight loss in 25 days. The facility did not promptly identify the weight loss, conduct a comprehensive nutritional assessment by a Registered Dietician (RD), and did not update the care plan or implement individualized interventions to promote nutritional intake and prevent additional weight loss. This is evidenced by: On 06/22/16, Surveyor received and reviewed a facility policy entitled, Weight Monitoring. The policy, dated July 2012, states the following, in part: .All residents' height and weight will be determined by the appropriate method and recorded within 24 hours of admission. Weight will be measured monthly. The Weight changes of all residents will be monitored monthly . Procedure: 1. Dietitian will obtain resident's height from nursing. 2. Dietician will calculate acceptable body weight range (AWR) .Review resident's weight history .Establish individual acceptable body weight range for each resident. Range will not exceed 10 pounds .The acceptable weight range is documented on the Nutritional Assessment form in the resident's clinical record . On 06/22/16, Surveyor reviewed Resident #2's medical record. Resident #2 was initially admitted to the facility on [DATE] for short term rehabilitation. Resident #2 has [DIAGNOSES REDACTED]. On 05/03/16, Resident #2 was diagnosed with [REDACTED]. There is no documentation or testing to determine if the mass was a terminal illness for Resident #2. Resident #2's Brief Interview for Mental Status (BIMS) score, dated 05/13/16, was a 14 out of 15 possible points, indicating intact cognitive function. Resident #2 had the following scheduled medications ordered, in part, upon admission: -[MEDICATION NAME] (used to treat high blood pressure) 5 milligrams (mg), every day -Atorvastatin (used to treat high cholesterol) 20 mg, at bedtime -[MEDICATION NAME] (used to treat high blood pressure) 25 mg, three times a day -[MEDICATION NAME] (used to treat high blood pressure) 25 mg, twice a day -[MEDICATION NAME] (an antibiotic) 500 mg, three times a day from 05/07/16 to 05/18/16 -[MEDICATION NAME] (an antidepressant) 15 mg, at bedtime -[MEDICATION NAME] (used to treat [MEDICAL CONDITION] reflux disease) 20 mg, once a morning before a meal -[MEDICATION NAME] (a steroid used to treat inflammation) 2.5 mg, once a day -Quetiapine (an antipsychotic medication) 37.5 mg, at bedtime An Occupational Therapy evaluation, dated 05/09/16, states Resident #2 is independent with eating, and requires supervision from staff for grooming. Resident #2 requires moderate assistance for transfers and uses a wheelchair for mobility throughout the facility. Resident #2's weight, on 05/09/16, was 187.2 pounds. Surveyor reviewed Resident #2's comprehensive care plan. The care plan states the following, in part: Problem Start Date: 05/07/2016 .Return to Community Referral. Resident is to be discharged from the facility .Goal .Resident will be discharged to _his group home . Problem Start Date: 05/13/2016 .Nutritional Status. Resident is @ (at) Nutritional/Hydration risk d/t (due to):[MEDICAL CONDITION](Hypertension), CKD ([MEDICAL CONDITION]) and depression/anxiety .Goal .Resident will receive adequate nutrition/hydration . Approach Start Date: 05/13/2016. Assist with meals as needed. Eats all meals in own room independently with tray setup assist .Diet per doctors (sic) order regular (consistency) NAS (No Added Salt) .Honor likes/dislikes. Dislikes: wheat bread .Medications as ordered .Monitor for signs & symptoms of fluid imbalance .Monitor meal intake/record .Monitor tolerance to diet texture, make adjustments as needed .Offer substitutes if consumes < (less than) 50% of meals Weigh every month and/or prn (as needed) notify MD of significant change . Resident #2's nurses' notes, from 05/07/16 to 05/17/16, state the following, in part: -05/07/16: Alert, oriented .Resident and daughter both stated resident 'like(s) soup' and snacks . -05/09/16: Alert, he can self feed . Surveyor reviewed Resident #2's initial nutritional assessment, dated 05/12/16, and completed by Dietary Manager (DM) A. The assessment states the following, in part: .History .Admission Weight-187.2 (pounds) .Body Mass Index (BMI)-28.46 .% PO (Oral) Intake (approximate):Diet .50-74% .% PO Intake (approximate): Supplements/Snacks NA (Not Applicable) .Resident Daily Needs: Calories-1846 .Resident Daily Needs: Protein-85 (grams) .Meal Location: Room .Assessment/Summary (left blank) . Resident #2's Nutritional History, dated 05/13/16 and completed by DM A, states the following, in part: .Have you recently gain or lost weight? No .What is your usual weight? (left blank) .How has your appetite been? Good. What is your best consumed meal? Dinner. Do you consume a night snack? No. Other snacks? No .Food Dislikes (left blank) .List favorite foods (left blank) Obtained information from: Resident A dietary note, written by DM A, on 05/13/16, states the following, in part: Admission Assessment .Current weight 187.2 lbs (pounds) and height is 68 inches .Resident eats all meals in own room. Has no chewing or swallowing issues on current diet . Resident #2's nurses' notes continue, in part: -05/17/16: .Refused supper tray and did verbally agree to eat supper if nurse would get it for him. Resident refused salad, biscuit and cookie . -05/18/16: .He has refused to get out of bed this shift .Refused all meals today as well. When asked why he refuses to give a reason at all. -05/21/16: The medical record identifies the resident frequently refuses medications. .'No I don't want any of that medicine, it all makes me sick .' -05/22/16: .Ate poorly. Did remind him that he needs to eat and take his medications as food is for energy and medications help with his blood pressure. He acknowledged it but stated 'I don't have (an)appetite. I'm not working.' . -05/26/16: .Independent with bed mobility .No behavior problems. Wt (weight) is stable. A dietary note, dated 05/25/16 and written by DM A, states the following in part: 14 Day Assessment .Resident eats all meals in room room independently with tray setup assist. Resident consumes 25-50% of all meals when doesn't refuse them .no chewing or swallowing issues on current diet ordered .weight is #187.2. Resident has not had a 5% weight gain/loss since admission. Will have nursing contact MD about poor nutritional intake . Resident #2 was last weighed on 05/09/16. Surveyor reviewed Resident #2's meal intakes, from 05/07/16 to 06/01/16. The documentation states the following, in part: -05/07/16: No intake documented for the supper meal. -05/08/16: Breakfast 26-50% consumed; no intake for lunch or supper -05/16/16: No supper intake -05/17/16: No breakfast or supper intake-05/18/16: Resident #2 had no intake for breakfast, lunch and supper -05/19/16: No breakfast or lunch intake. No supper intake documented. -05/20/16: No breakfast intake documented. No lunch was consumed, and the resident ate 26-50% of the supper meal. -05/21/16: Breakfast and lunch were consumed at 1-25%, no supper intake. -05/24/16: No breakfast and lunch intake documented. Supper intake was 1-25%. -05/27/16: Breakfast consumed was 1-25%, no lunch or supper was consumed. -05/28/16: No intake for breakfast, lunch and supper. -05/30/16: No intake for breakfast and supper. No intake documented for supper. From 05/08/16 to 05/25/16, Resident #2 consumed the following: -No intake for 15 meals -1-25% was consumed for 16 meals -26-50% intake for seven meals -51-75% intake for five meals -76-100% intake for two meals From 05/26/16 to 06/01/16, Resident #2 consumed the following: -No intake for 12 meals -1-25% consumed for 6 meals -26-50% intake for one meal -Nothing was consumed over 50% No interventions were identified in Resident #2's medical record to increase his appetite or intake. There is no documentation alternative meal choices or snacks between meals were offered or the percentage of the snack consumed or refused. The medical record identifies Resident #2's weight on 06/01/16 was 151.8 pounds. Based on Surveyor 's calculation, Resident #2 lost a total of 35.4 pounds, or 18.9% of weight, within 25 days, considered to be a severe weight loss. A fax, dated 06/01/16, was sent to Resident #2's physician, and states the following, in part, .CONCERN: Patient eats very poorly. May we please have an order for [REDACTED]. This is the first nutritional intervention identified in Resident #2's medical record. On 06/22/16, Surveyor received and reviewed a hand-written note, written by Physician's Assistant (PA) B. The note, provided by the Director of Nursing (DON), states the following, in part: (DON's first name)-Correspondence but no notes .Clinic message (Friday) 5/27 (2016) (at 4:00 p.m.) FYI (For Your Information) .Pt (Patient) not eating lg (large) stools requested .to fax (resident's) record .(Registered Nurse (RN) C's first name) Calling 6/2 (2016) refusing to eat loosing (sic) wt, wanting terminal dx (diagnosis) . There is no documentation in Resident #2's medical record, a physician received and followed up from the message, on 05/27/16, regarding the resident not eating. Cross reference F 157. A note, written by DM A on 06/01/16, states the following, in part, Resident has had an 18% weight loss since admission. Resident is consuming 25-50% of meals when he doesn't refuse them which is daily. Resident refuses to get out of bed, meds and cares daily as well. MD was notified of weight loss and nursing is requesting a supplement to help with caloric intake. RD was also notified of weight loss. Will continue to monitor weights and meal intake. On 06/02/16, the facility obtained orders for Speech Therapy to evaluate and treat Resident #2 for attention and swallowing, due to low consumption and low hydration. On 06/02/16, PA B visited Resident #2 in the facility. PA B's progress note, from this date, states the following, in part: .Chief Complaint/Reason for Visit: Special visit today to follow up on declining health and dehydration. History of Present Illness .(Resident #2's name) has a history of progressive dementia. He has had recent problems with 3 hospitalization (sic) in a very short window of time .(Resident #2's name) was admitted to this facility for rehabilitation and strengthening from his hospitalization (from 05/03/16 to 05/07/16) .His bowels have been somewhat of a problem with being soft to loose anywhere from 1 to 2 times daily . Patient was admitted to this facility at a weight of 187.2 on 05/07 (2016), yesterday's weight is 151.8 a significant weight loss .occupational therapy have recommended that he come out of his room for meals, however, he has been refusing this .He has has certain personnel that he does better with with his meals and when he does eat his meals he eats without difficulty 100% .has significant [MEDICAL CONDITION] arthritic changes in his hands that he is really unable to reach for a cup by himself making him very dependent for fluids. Patient is seen today for evaluation of dehydration. His legal guardian .is in the room as is the resident's wife .They are concerned about (Resident #2's name) general well-being and significant decline in the past 3 weeks that he has been at the facility. They would like him sent into an emergency department for evaluation and treatment .He has attempted therapy, however, he becomes quite ornery with therapy and does not want to participate . Past Medical History .Recent frequent hospitalization s for increasing debility and dehydration. Most recent hospitalization ,[DATE] to 05/07 (2016) with acute on (sic) chronic kidney failure secondary to dehydration with [DIAGNOSES REDACTED]. Physical Examination .Grip strength is weak bilaterally .The nursing staff present concern of possible sundowning in the evening as he tends to fall asleep and wants to stay asleep all evening long . The medical record indicates Resident #2 was sent to an emergency roiagnom on [DATE], and returned to the facility on [DATE]. On 06/03/16, RD F wrote a note on Resident #2. This is the first note written by a Registered Dietician for the resident. The RD's note states in part, (Resident #2's name) has lost 35# since admission on 5/7/2016. Resident has had very poor nutritional intake consuming 25-50% of meals or refusing entirely. Full assessment to follow. On 06/04/16, Resident #2 was sent to an emergency room for face and mouth swelling. A hospital note, dated 06/04/16, states Resident #2 will be enrolled in hospice due to [MEDICAL CONDITION] and failure to thrive. Resident #2 was readmitted to the facility on [DATE]. Resident #2's nurses' notes, from 06/04/16 to 06/09/16, state the following, in part: -06/05/16 at 10:42 a.m.: .Resident responds to name by opening eyes and moved arm to wave at staff .Resident accepted medication and water/fluids, using 2-cc doses with syringe into side of mouth . The notes identify Resident #2 now requires the use of oxygen. -06/08/16: The note identifies the resident requires extensive assistance from staff for cares. On 06/06/16, the facility down-graded Resident #2's diet from regular to pureed textures. This was done to see if Resident #2's meal intake improved. On 06/08/16, RD F completed a nutritional assessment. The RD assessment states the following, in part: .Hospice status .Weight-147# 6/7/16; 5/9/16 187.2#. Diet-Pureed. Eating 25-50% or less of most meals. 4 oz (house supplement) BID added 6/1/16 .Currently fed (the resident now required assistance from staff with eating) .Protein need-85 grams, fluid need-2550 cc (cubic centimeters). Weight loss appears unavoidable. The RD does not identify or document how Resident #2's weight loss is unavoidable. On 06/09/16, Resident #2 was transferred to another facility for hospice care. On 06/22/16 at 11:50 a.m., Surveyor interviewed the DON. The DON indicates PA B comes to the facility every week. The DON further stated, anything regarding a resident's acute condition is written in a notebook for PA B to review, upon the PA's facility visit. Surveyor asked for a copies of any notebook entries related to Resident #2. The DON responded the facility does not keep this notebook. At 1:24 p.m., Surveyor interviewed Certified Nursing Assistant (CNA) E. CNA E stated Resident #2 was independent with eating, was friendly, joked with staff and was more mobile upon admission to the facility. CNA E stated later in Resident #2's stay, he became more combative, resistive to cares and seemed sicker. CNA E indicated staff would leave food, such as cookies and milk, and meal trays in Resident #2's room, but he frequently refused to eat. CNA E stated she informed the charge nurse when Resident #2 refused to eat. At 1:32 p.m., Surveyor interviewed the DON. The DON indicated the facility has alternative food choices, and residents are offered snacks after lunch and supper. Surveyor asked if there is any documentation when residents are offered snacks, what is offered, what percentage of the snack is consumed or if the snack is refused. The DON replied there is no documentation of resident snacks, or what is offered and consumed by the residents. The DON indicated Resident #2 had behaviors towards staff, such as kicking, hitting and refusing to have others in the room. Surveyor asked if the facility interdisciplinary team monitors residents' weights and implements interventions for intakes and/or weight loss. The DON indicated a resident's weight has to flag when weight loss or a weight variance is identified. The DON stated the facility was monitoring Resident #2's weight monthly. At 1:40 p.m., Surveyor interviewed DM A. DM A stated she obtained Resident #2's weight upon admission, and monitored the weight one time a month. DM A stated she attempted to obtain Resident #2's weight, approximately four to five days before 06/01/16, but he refused. This information is not documented in Resident #2's medical record. During the continued interview, DM A stated she sent an email to RD F, notifying the RD of the resident's poor intake. DM A no longer has the email correspondence. DM A stated RD F may have been on vacation, since it took awhile for RD F to respond. DM A though the email was sent on or around 05/25/16. DM A stated RD F comes to the facility on ce a month. Surveyor asked if DM A spoke to Resident #2 and discussed the poor intakes, and/or food preferences. DM A indicated nursing staff talk to the residents when they are not eating. Surveyor asked what normally occurs when a resident is not eating well, to which DM A replied the RD and physician are both contacted, the resident's diet may be altered and the resident's food preferences may be updated. DM A indicated a care conference with Resident #2's family was held on 06/01/16. DM A indicated the family noticed a change in Resident #2's weight at this time. Surveyor reviewed Resident #2's care conference note, dated 06/01/16 and completed by the Social Worker. The care conference note states the following, in part, .Attendees .RN D .DM A .Review of meal preferences: Reviewed with no changes .Resident has a regular diet, eats most or all meals in his room .Rationale for resident remaining in this facility: Resident is here for short term rehabilitation, but is looking to be returning into long term nursing home are due to him not wanting to participate in therapy . The documentation does not identify Resident #2's severe weight loss, poor meal intakes, declining health or any interventions implemented for weight loss or to increase appetite. At 3:15 p.m., Surveyor interviewed PA B. PA B stated she was not notified on Resident #2's nutritional status or weight loss until 06/02/16. PA B stated she was at the facility on 05/12/16, 05/19/16 and 05/26/16, but was not notified or consulted by the facility regarding Resident #2's declining condition and poor intakes. PA B stated Resident #2 had normal vital signs, and it is difficult to determine why Resident #2 lost the severe amount of weight within a short period of time. PA B stated she provided Resident #2 with a terminal [DIAGNOSES REDACTED]. On 06/23/16 at 9:02 a.m., Surveyor interviewed RN D. The DON was present at this time. RN D stated she believes she attempted to obtain Resident #2's weight on 05/17/16, but he refused. RN D stated she would offer Resident #2 alternative foods, such as ice cream or mashed potatoes, but he refused these options. RN D stated the alternatives and Resident #2's refusals to obtain weights were not documented, and are not identified on the care plan. During the continued interview, RN D stated the Activity Director interviewed Resident #2, and identified Resident #2 liked drinking beer. However, the next time beer was offered, Resident #2 was sleeping. RN D stated she believes this occurred on 05/17/16. This is not documented in the medical record or in Resident #2's care plan. The DON stated Resident #2 was able to drink independently, until the last two weeks of his stay in the facility. Surveyor asked why the facility attempted to obtain Resident #2's weight, prior to 06/01/16, if his weight was to be monitored monthly. The DON replied the facility attempted to obtain the weight due to Resident #2 not eating well. No additional information was provided to the surveyor.

Based on observation, interview and record review the facility did not ensure that each resident received, and the facility provided, the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 14 sampled residents. Resident #8 acquired an ulcer to the foot and ankle and multiple skin breakdowns to the coccyx, buttocks and leg. The facility determined the foot ulcer to be a venous diabetic ulcer, coccyx to be a pressure ulcer and the rest of the areas to be non-pressure sores. The facility did not care plan consistently based on information from the assessment, did not evaluate the results of the interventions and did not revise the interventions as necessary. This is evidenced by: Resident #8 was admitted to the facility on [DATE] with current [DIAGNOSES REDACTED]. On 01/02/2013 at 3:15 p.m. Surveyor observed wound care provided for Resident #8. Surveyor observed multiple areas of skin breakdown on Resident #8. ~Coccyx has a 1.4 centimeter (cm) by (x) 0.6 cm intact blood blister, origination date of 01/02/2013 ~Right buttocks has a 7.0 cm x 8.0 red area, with an origination date of 01/02/2013 ~Right gluteal fold has 2.5 cm x 1.1 pink granulation with yellow slough and a 3 cm x .5 cm pink tissue, with an origination date of 12/11/2012 ~Back area of the right leg above the knee amputation has three areas with pink granulation with yellow slough: 2.5 cm x 0.3 cm with 0.3 cm slough, 2.7 cm x 0.5 cm with 1.6 cm x 0.4 cm slough, and 0.9 cm x 0.4 cm with 0.3 cm x 0.3 cm eschar with an origination date of 12/19/2012 ~Right hip area has two areas with an [MEDICATION NAME] appearance: 0.7 cm x 0.7 cm and 1.2 cm x 0.3 cm, no documentation of origination dates. ~Left outer aspect ankle has an area 2.8 cm x 1.7 cm with dark eschar with the top right edge has 0.3 cm area with slough and near the bottom edge has a 0.2 cm area with slough, with an origination date of 11/06/2012. ~Left outer foot has a distinct odor and the area is 7.2 cm x 5.3 with dark eschar with the top right edge having 0.3 cm of pink granulation tissue. Origination date of 11/06/2012 with the size of 2.7 cm x 2.0 cm with scant amount of serosanguineous drainage. On 01/02/2013 Surveyor reviewed Resident #8's medical record. Review of the care plan of alteration in skin integrity related to diabetes, [MEDICAL TREATMENT], and decline in Activities of Daily Living (ADL) with problem start date of 02/09/2010. The care plan approaches dated 12/21/2012 indicate to continue to attempt to reposition resident every two hours despite frequent refusals of care. Ensure resident can repeat the risks associated with refusal of care. The care plan approaches did not address pressure relieving interventions or the use of a pressure relieving device in wheelchair or recliner. Review of the Certified Nursing Assistant (CNA) care guide sheet did not address pressure relieving interventions or the use of a pressure relieving device in wheelchair or recliner. The Minimum Data Set (MDS), assessment reference date 11/12/2012, Section M indicates that Resident #8 is at risk for developing pressure ulcers but has no current pressure ulcers. The MDS indicates that Resident #8 has 2 venous or arterial ulcers present. Section M1200 skin and ulcer treatments, section A is marked indicating use of a pressure reducing device for chair. On 01/07/2013 Surveyor reviewed Resident #8's weekly pressure wound report dated 11/10/2012, related to left foot, indicate on 11/06/2012 Resident #8 intervention is to encourage to elevate on pillows. Surveyor reviewed care plans, no update for this intervention was found. Review of weekly pressure ulcer progress report related to ball of left foot stage II venous diabetic ulcer: ~11/06/2012 size was 2.7 centimeter (cm) by (x) 2.0 cm with scant serosanguineous drainage, intervention to encourage elevation of left lower extremity. ~11/13/2012 size was 2.7 cm x 2.0 cm with scant serosanguineous drainage, intervention to encourage elevation of left lower extremity. ~11/20/2012 size was 2.5 cm x 2.8 cm with scant serosanguineous drainage, intervention to encourage elevation of left lower extremity. ~11/27/2012 size was 2.8 cm x 3.0 cm with serosanguineous drainage, intervention to encourage elevation of left lower extremity. ~12/4/2012 size was 3.2 cm x 3.4 cm with foul strong odor, serosanguineous drainage, no interventions listed. ~12/11/2012 size 6.0 cm x 6.0 cm with odor, necrotic tissue, no interventions listed. ~12/18/2012 size 6.0 cm x 6.0 cm with odor, necrotic tissue, no interventions listed. ~12/25/2012 size 5.8 cm x 5.0 cm with odor, necrotic tissue, and interventions of - turned every 2 hours - often refuses and pressure relieving pads Roho in chair. ~01/02/2013 size 7.2 cm x 5.3 cm with odor, necrotic tissue with pink granulation at top right edge, intervention of: turned every 2 hours - often refuse and pressure relieving pads Roho in chair. Review of Resident #8's care plan did not indicate the above listed interventions and did not indicate an evaluation of the results of the interventions and revising the interventions as necessary. Report of consultation dated 12/11/2012 states in part: a diabetic ulceration of plantar surface of left lower extremity 6 cm x 6 cm in size with necrotic tissue with associated discharge and odor. There is a dry eschar of posterior calf left lower extremity is 3 cm x 2 cm in size. Anteriorly (2) ruptured blisters upper 1/3 of left lower extremity is 1 cm x 1 cm in size. Ulceration at right gluteal fold of right above the knee amputation is 2.5 cm x 0.7 cm with exudate. Recommendations: Patient needs medical clearance for surgical debridement of plantar surface and posterior calf left lower extremity. In meantime application of [MEDICATION NAME] to both areas and 4 x 4 and kling every third day. Hydrogel every day with kling and 4 x 4 to both blister sites of anterior left leg. [MEDICATION NAME] to right gluteal fold 2 x 2 [MEDICATION NAME] every other day. Offload right gluteal region at rest. Ace wrap leg daily and elevate. Review of Resident #8's care plans did not indicate treatments as recommended and does not indicate to offload right gluteal region at rest and elevate leg. Review of weekly skin condition report dated 12/11/2012 indicating skin breakdown to the right gluteal fold, and no interventions listed. Reviewed the impaired skin integrity care plan date 12/11/2012, the approaches did not address interventions or the use of a pressure relieving devices in wheelchair or recliner. Review of the composite weekly skin report dated 12/22/12 indicate on 12/11/2012 Resident #8 intervention is a cushion in recliner and cushion in wheelchair. Surveyor reviewed care plans, no update to the care plans for this intervention. On 01/07/2013 at 1:30 p.m. Surveyor interviewed Nursing Home Administrator (NHA), Director of Nursing (DON) and Register Nurse (RN) H about Resident #8's impaired skin integrity. DON and RN H indicate Resident #8 is noncompliant with cares, treatments and interventions. Resident #8 forms blisters to legs often and when he comes back from [MEDICAL TREATMENT]. Surveyor asked when the blisters form and when formed after [MEDICAL TREATMENT] are the blisters investigated and is his skin assessed daily. RN H indicated that the blisters are not investigated and his skin is not assessed daily. Surveyor asked if the blood blister on the coccyx that was observed on 01/02/2013 was investigated. RN H indicated the blood blister on the coccyx was not investigated, Resident #8 is noncompliant of repositioning and he sleeps in his recliner and he had an inflatable tire in his chair and on 12/25/2012 a Roho cushion was placed in his wheelchair and recliner. On 12/26/2012 he started to lie in bed and on 01/02/2013 he was offered to try an air mattress for his bed, and he agreed. Surveyor asked is the air mattress on his bed now. DON indicated it came in late on Friday and Maintenance is looking at it today. Surveyor asked if any resident has a skin issue is there a care plan. RN H indicated there is care plans for each area. Surveyor asked where these care plans are and are they available for all staff to review. RN H indicated the care plans are in the skin treatment books and staff would have to ask the nurses to look at the care plans. Surveyor ask to review the skin treatment book and care plans for Resident #8. On 01/08/2013 at 2:45 p.m. Surveyor reviewed findings of skin treatment book and care plans with NHA and DON. ? Coccyx, origination date of 01/02/2013, care planned on 01/02/2013 for an air mattress on bed and was not on bed as of 01/07/2013 ? Right buttocks, origination date of 01/02/2013, care planned on 01/02/2013 for an air mattress on bed and was not on bed as of 01/07/2013 ? Right gluteal fold, origination date of 12/11/2012, has no care plan interventions ? Right hip area has two areas, no documentation of origination dates, has no care plan interventions ? Back area of the right leg above the knee amputation has three areas, origination date of 12/19/2012, has no care plan interventions ? Left outer aspect ankle, origination date of 11/06/2012, has no care plan interventions ? Left outer foot, Origination date of 11/06/2012, has no care plan interventions ? The facility did not evaluate and revise the care plan approaches dated 12/21/2012, that indicates to continue to attempt to reposition resident every two hours despite frequent refusals of care. Ensure resident can repeat the risks associated with refusal of care. The facility did not care plan consistently based on information from the assessment and evaluate the results of the interventions and revising the interventions as necessary.

Based on closed record review and interview, the facility did not ensure that services provided by a Registered Nurse (RN) met professional standards of quality for 2 of 24 sampled residents. Resident #14 had a large dark reddish-brown emesis (vomited) on [DATE] and was listless. The Registered Nurse (RN) stated that the emesis was "disgusting" in front of the resident. The nurse did not assess her vital signs or other physical symptoms and did not inform the next shift so that Resident #14 could be more closely monitored. The nurse did not consult with the physician regarding the emesis so that the physician could be aware and treat Resident #14 if necessary, and the nurse did not inform the family. The nurse told the Certified Nursing Assistants to not tell anyone about the emesis. Resident #14 had 2 more emeses on the following night shift, was transferred to ED (Emergency Department), returned to the facility with a [DIAGNOSES REDACTED]. Failure to provide Resident #14 care which conformed to the standards of the Nurse Practice Act (N6), created the potential that the resident could go into shock (which can happen rapidly) and die. This failure created an immediate jeopardy situation which was identified on [DATE]. The immediate jeopardy began on [DATE] when the facility nurse failed to take appropriate action by not immediately assessing Resident #14 and not immediately consulting with her physician. The facility's Nursing Home Administrator was notified on [DATE]. The immediate jeopardy was determined to be removed, but not corrected on [DATE] when the new Director of Nursing recognized the necessity to train all nursing staff on appropriate response for residents' changes of condition. The deficient practice continues at a scope/severity of D, (potential for more than minimal harm/isolated) as evidenced by the following example. Resident #8 had a physician's orders [REDACTED]. During surveyor observation on three of three days of survey the dressing was not applied as ordered by the physician. This is evidenced by: According to N 6.03(1), Standards of practice for registered nurses, "An R.N. shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.'s or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis." N 7.03(1) of the Nurse Practice Act defines "negligence" as "a substantial departure from the standard of care ordinarily exercised by a competent licensee. " Negligence" includes but is not limited to the following conduct; ... (c) Failing to observe the conditions, signs and symptoms of a patient, record them, or report significant changes to the appropriate person ..." Facility nurse RN G did not provide care to Resident #14 in a manner that was consistent with the standards of the Nurse Practice Act. 1. Resident #14's closed record states that she had resided at the facility since [DATE], and had [DIAGNOSES REDACTED]." On [DATE], the nurses' notes state that there was a new order for Resident #14 to receive [MEDICATION NAME] as needed, prior to bathing and/or PT/OT (physical therapy/occupational therapy). On [DATE], at 4:15 p.m., Surveyor interviewed CNAH, asking her standard questions pertaining to abuse prevention. Surveyor asked CNA H if she had ever reported anyone for abuse or neglect, and CNA H stated that she had told the previous DON, Registered Nurse (RN) K about an incident regarding neglect of Resident #14. CNA H stated that last month, she could not remember exactly when, Resident #14 had a large dark reddish-brown emesis. The nurse on duty, RN G, did not assess the resident, did not take vital signs, and that CNA H found out 2 days later that Resident #14 had died of a GI (gastrointestinal) bleed. Surveyor reviewed Resident #14's chart on [DATE]. There was no mention of the emesis on [DATE] on the p.m. shift when RN G worked. Surveyor interviewed CNA H on [DATE] at 1:05 p.m. by telephone. CNA H stated that on the evening of [DATE] Family Member I told her and CNA J, "There's a resident covered in vomit." Surveyor interviewed Family Member I on [DATE] at 1:28 p.m. Family Member I stated, "I was going out that evening (after visiting her husband) and saw the resident, sitting near the nurses' station. She was in a wheelchair, and had vomited, a dark color, all over the floor. I stood there for a minute or so and didn't see any staff, so I went to the front wing to find someone. (CNA H) and another CNA (CNA J) were coming back from their break and told them what I saw." CNA H stated in the above interview that she and CNA J then saw Resident #14 in the hall in her wheelchair with her lap buddy on. CNA H stated that Resident #14 had vomited a large amount, which was dark reddish-brown, and was down the front of her clothing, on her lap buddy, in her contracted hands, and on the floor. CNA H stated that she told RN G about the emesis, who stated, in front of the resident, "You need to clean her up - that's disgusting." CNA H stated that Resident #14 could not speak, but she could hear and understand. CNA H stated that usually Resident #14 needs a medication to help her relax before her shower, as she usually screamed during her showers because she didn't like water. CNA H stated that on this night, it was difficult to undress Resident #14 in the shower because of all of the vomit, but Resident #14 did not seem to have the strength to fight the CNAs like she normally did. CNA H stated that the shower was given at approximately 8:00 p.m. In the above interview, CNA H also stated that she told RN G that Resident #14 just did not look right, her face was red and she "seemed miserable." CNA H stated that RN G did not go and assess Resident #14, did not take a set of vitals, and did not call the physician. RN G told them that the color of the emesis was probably because of Resident #14's [MEDICATION NAME], (even though this is a white pill). CNA H stated that she thought about what Resident #14 ate for supper, and nothing she ate would have made the vomit that color. CNA H stated that RN G told the CNAs to not say anything about the emesis, because Resident #14's roommate's daughters would get upset and think their mother was going to catch the flu. The night nurse was not told of the emesis. Surveyor interviewed ADON (Assistant Director of Nursing) RN F on [DATE] at 11:10 a.m., and asked if there could be anything written about the emesis on the 24-hour report, which would indicate that RN G may have informed the night nurse. RN F stated at 11:20 a.m. that she had reviewed the 24-hour report sheet, and there was nothing written about the emesis by RN G on the p.m. shift. CNA H stated that she was off for a couple of days after [DATE], and a colleague from work called her and told her that Resident #14 had died , and that she should go to RN K and tell her of her concerns of neglect. CNA H stated that she thought, "You just can't treat people like that." CNA H stated that she then did tell RN K about RN G's not assessing Resident #14, and stated that RN K stated that it was not necessary to follow up, because you can't really stop a GI bleed once it starts. CNA H stated that RN K minimized RN G's neglect of Resident #14. CNA H stated that RN K and RN G had worked at another facility together, were friends, and there had been other things about RN G that were reported to RN K, but RN K would not do anything about it and covered up for her friend. The facility sent a fax to the Western Regional Office on [DATE], which stated that RN G had been interviewed and she told the new DON, RN AA, that she was unaware of the above emesis on [DATE]. Also, that the former DON, RN K told the new DON, RN AA, that she did not recall that anyone came to her to inform her about Resident #14's emesis, and that she could not recall that she was told that RN G had not properly cared for the resident on [DATE]. Surveyor again interviewed CNA H on [DATE] at 11:39 a.m., who reiterated that she, as well as CNA J, and the above family member, had indeed witnessed the emesis as stated above, and that RN G knew fully well about the emesis and did not assess the resident, nor call the physician. CNA H also reiterated that she went to the former DON on Monday, [DATE] to discuss her concerns with the lack of care that Resident #14 received from RN G. CNA H also told Surveyor that she was interviewed by the Interim DON, who was told the same information as stated above, but this interview was not included in the fax that the facility sent the WRO on [DATE]. Surveyor interviewed CNA J on [DATE] by telephone at 10:53 a.m., who stated that she could not remember the exact date, but she confirmed that Resident #14 did have the above mentioned emesis, and that RN G did not assess the resident. She also confirmed that RN G stated that Resident #14 looked "disgusting" and told her and CNA H to take her to the shower and clean her up. CNA J stated that she is in nursing school, and that she could not believe that RN G did not assess Resident #14 after the emesis. She stated that even as a CNA, she could tell that Resident #14 needed to be assessed. Prompt, appropriate assessment and physician notification was needed following Resident #14's significant condition change on [DATE]. According to The Merck Manual, "Hematemesis (vomiting blood), melena, (black, tarry stool or vomit) or hematochezia (bright red blood in stool) should be considered an emergency until proven otherwise." Another source also notes that "...hematemesis ... indicates bleeding that is a potential emergency and should be handled as such until the situation can be assessed ... Mortality from acute upper gastrointestinal hemorrhage is between 8 and 10%, but varies widely with age and with the presence or absence of serious associated diseases such as [MEDICAL CONDITION], malignancy, [MEDICAL CONDITION], or [MEDICAL CONDITION]. The majority of deaths occur in patients over age 60. Older patients are less able to withstand massive hemorrhage and surgical intervention." http://www.ncbi.nlm.nih.gov/books/NBK411/. According to the Mayo Clinic's website, "It's important to quickly identify the underlying cause of the bleeding and prevent more severe blood loss and other complications." <http://www.mayoclinic.com/health/vomiting-blood>. Resident #14 had a second emesis; the night nurse charted on [DATE] at 3:57 a.m., "Resident noted to have vomited moderate amount (8 inch circle) of black emesis. (The blackness of the emesis would indicate the presence of blood.) T (temperature) 99 P (pulse) 85 R (respirations)18 BP (blood pressure) ,[DATE]. Abdomen soft. Call placed to (physician's name). He stated to keep resident in house and to contine (continue) to monitor condition. Call placed to POA (power of attorney) daughter to update. No answer. Message left on cell and house phone. DON (RN K) updated." Nurses' notes on [DATE] written at 5:35 a.m. state, "Resident noted to have large coffee-brown colored emesis. (Again indicating the presence of blood.) Resident was lying on side with head of bed elevated. Emesis was on side of bed and floor. BP ,[DATE] P 84. Resident is alert. Abdomen is soft. Resident is having soft BM (bowel movement) at this time and had extra large BM yesterday. Call again placed to daughter, Granddaughter states that daughter POA is out of town. Call placed to (name of physician) and he stated to send to ER (emergency room ) for evaluation." The nurses' note states that Resident #14 left for the hospital via ambulance around 6:10 a.m. "DON (RN K) made aware of transfer." The former DON, RN K, was notified of Resident #14's health concerns for a second time. Surveyor interviewed Resident #14's physician by telephone on [DATE] at 10:15 a.m., who stated that he was unaware that when he was called on the night shift, this was actually Resident #14's second emesis. He stated that any coffee ground emesis, or one containing blood "is something we need to know about" and that an acute GI bleed can certainly be a situation requiring emergency attention. The physician stated that he would expect a nurse to assess the resident and monitor vital signs, to determine if the resident is tachy (fast heart beat) or hypoxic (low oxygen saturation). He stated that he depends on the nurses to "report to us any important information." He stated that he discussed with the night nurse the fact that she had been unable to get hold of Resident #14's Power of Attorney (daughter). When he was notified that there was a "second" emesis (actually the resident's third), he sent Resident #14 to the emergency department. Resident #14's physician stated that he was aware that later in the day, Resident #14 declined, and that the daughter just wanted her mother to be kept comfortable before she died , versus [MEDICAL CONDITION] lavaging (placing a tube down the resident to wash out the stomach) or scoping her or performing surgery. Resident #14 returned from the ED around 10:00 AM on [DATE] with a [DIAGNOSES REDACTED]. Recheck Hgb (hemoglobin) in 3 - 5 days. Resident #14's daughter returned to town early that afternoon, and at suppertime, Resident #14 was described in nurses' notes as having "very poor color and lethargic. Resident laid down in bed in order to obtain VS (vital signs). B/P ,[DATE] (decreased from above readings) HR (heart rate - pulse) 121 (increased from above readings, indicating that the heart rate was compensating for the lowering of the blood pressure), R 28 (respirations above normal indicating trouble breathing) Sats 76% (normal oxygen saturations are at or near 100%, again indicating trouble breathing and a lack of hemoglobin, which can result from blood loss). Temp 98.4. Oxygen applied at 2 liters. Sats remain low. By 2100 (9:00 p.m.) temp at 100.2. Cool compresses applied and Tylenol 650 mg PO (milligrams by mouth) administered." The facility called Resident #14's daughter and her physician. The daughter wanted Resident #14 to remain at the facility, and she came to the facility to sit with her mother. She requested that her mother be kept comfortable. Resident #14 passed away on [DATE] at 2:40 a.m. Failure to take appropriate action according to standards of practice for Resident #14, created a finding of immediate jeopardy. The facility removed the immediate jeopardy on [DATE] by which time the new Director of Nursing recognized the necessity to train all nursing staff on appropriate response residents change of condition. The deficient practice continues at a D level, (potential for harm/isolated) as evidenced by the following example: 2. On [DATE] at 2:50 p.m. Surveyor observed staff assist Resident #8 to the bathroom. During this observation Surveyor noted Resident #8 had a dressing approximately five inches wide around her right lower leg just above her ankle. On [DATE] beginning at 9:33 a.m. Surveyor observed Licensed Practical Nurse (LPN) E assisted by Registered Nurse/Assistant Director of Nursing (RN/ADON) F complete a dressing change to Resident #8's right lower leg. After applying the [MEDICATION NAME] to the ulcer sites, LPN E covered the wounds/ulcers with an ABD (abdominal) pad and used another ABD pad to wrap around the ankle and secured the ABD pads with tape. Review of Resident #8's medical record on [DATE] by Surveyor identified the physician's orders [REDACTED]." An additional physician order [REDACTED]." During the dressing change observation on [DATE] Surveyor did not observe LPN E or RN F apply any [MEDICATION NAME] or other non-adherent type dressing. Nor did they wrap the dressing with Kling, or wrap the dressing starting below the ankle as directed by the physician order. Surveyor did identify Resident #8 had a small amount of swelling in her right foot below the dressing and in her right lower leg above the dressing. Surveyor observed Resident #8 had the ABD pads wrapped around her right lower leg on [DATE], [DATE] and [DATE]. No Kling was in place any of these three days, nor was the dressing applied starting below Resident #8's ankle as directed by the physician's orders [REDACTED]. Review of Resident #8's ,[DATE] treatment flow sheet by Surveyor on [DATE] at 2:25 p.m. identified the treatment was written to match the physician orders. The nurses were signing their initials that they were completing the treatment as identified on the treatment flow sheet. Surveyor 's observations identified they were not doing the treatment according to the treatment flow sheet and the physician orders.

Based on record review and interview, the facility did not ensure that appropriate care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the residents' comprehensive assessment and plan of care were provided for 4 of 24 sampled residents. Resident #14 had a large dark reddish-brown emesis (vomited) on [DATE] and was listless. The nurse stated that the emesis was "disgusting" in front of the resident. The nurse did not assess the resident's vital signs or other physical symptoms, and did not inform the next shift so that Resident #14 could be more closely monitored. The nurse did not promptly consult with the physician regarding the emesis so that the physician could be aware and treat Resident #14 if necessary, and the nurse did not inform the family. The nurse told the Certified Nursing Assistants to not tell anyone about the emesis. Resident #14 had 2 more emesis on the following night shift, was transferred to ED (Emergency Department), returned to the facility with a [DIAGNOSES REDACTED]. Failure to take appropriate action for Resident #14, created the potential that the resident could go into shock (which can happen rapidly) and die. This failure created an immediate jeopardy situation which began on [DATE] when the facility nurse failed to take appropriate action by not immediately assessing Resident #14 and not immediately consulting with her physician. The facility's Nursing Home Administrator was notified of the immediate jeopardy on [DATE]. The immediate jeopardy was determined to have been removed, but not corrected on [DATE] when the new Director of Nursing recognized the necessity to train all nursing staff on appropriate response residents ' changes of condition. The deficient practice continues at a E, (potential for harm/isolated) as evidenced by the following 4 examples. Resident #1 stated his pain during wound vac dressing changes was not controlled with his current [MEDICATION NAME]. Facility records identified Resident #1 had a history of [REDACTED]. Resident #1's physician had ordered prn pain medication be administered 1 hour prior to the dressing change. Upon re-admission to the facility on [DATE] no orders were obtained for pain medication prior to the wound vac dressing change. The re-admission pain assessment identified Resident #1 stated he had stump pain which he rated as 8 out of 10 (10 being intolerable). Resident #2 received 2 wound vac dressing changes prior to the physician being notified and orders received to pre-medicate 1 hour before the dressing change. Resident #8 had ulcers/wounds to her right lower extremity. The facility policy identified the ulcers/wounds were to be measured on a weekly basis. Review of Resident #8's skin condition report identified no weekly measurements were done between [DATE] and [DATE], and not done since [DATE]. Resident #8 had a decline in her condition and was started on oxygen (O2). On [DATE] a facility LPN put Resident #8 on a oxygen mask at 2 liters due to her mouth breathing. An oxygen mask is not to be used for a liter flow of less than ,[DATE] liters per the facility policy. The LPN did not document that she notified an RN or Resident #8's physician with the low O2 saturation levels. Resident #24 had two large loose stools that were black in color during the night shift of [DATE], early morning of [DATE]. The Registered Nurse (RN) that was on duty was interviewed and stated she had not learned of the color of the stools until the end of her shift, when she heard a Certified Nursing Assistant (CNA) tell the oncoming Licensed Practical Nurse (LPN), the day shift nurse, about the color of the stools. The CNA interviewed stated she had reported the color of the stools to the RN earlier in the shift. On the afternoon of [DATE] Resident #24 had a large loose bright red stool and was admitted to the hospital for a gastrointestinal (GI) bleed. Resident #24 was not on iron medication, which is known to cause the stool to be black. In the absence of a medication that colors the stool black, a black stool is usually an indicator of a GI bleed. The oncoming LPN did not document that she had done any type of assessment or notify Resident #24's physician until [DATE] at approximately 1:25 p.m. after Resident #24 had the large loose bright red stool. This is evidenced by: 1. Resident #14's closed record states that she had resided at the facility since [DATE], and had [DIAGNOSES REDACTED]." On [DATE], the nurses' notes state that there was a new order for Resident #14 to receive [MEDICATION NAME] as needed, prior to bathing and/or PT/OT (physical therapy/occupational therapy). On [DATE], at 4:15 p.m., Surveyor interviewed CNA H, asking her standard questions pertaining to abuse prevention. Surveyor asked CNA H if she had ever reported anyone for abuse or neglect, and CNA H stated that she had told the previous DON, Registered Nurse (RN) K about an incident regarding neglect of Resident #14. CNA H stated that last month, she could not remember exactly when, Resident #14 had a large dark reddish-brown emesis. The nurse on duty, RN G, did not assess the resident, did not take vital signs, and that CNA H found out 2 days later that Resident #14 had died of a GI (gastrointestinal) bleed. Surveyor reviewed Resident #14's chart on [DATE]. There was no mention of the emesis on [DATE] on the p.m. shift when RN G worked. Surveyor interviewed CNA H on [DATE] at 1:05 p.m. by telephone. CNA H stated that on the evening of [DATE] Family Member I told her and CNA J, "There's a resident covered in vomit." Surveyor interviewed Family Member I on [DATE] at 1:28 p.m. Family Member I stated, "I was going out that evening (after visiting her husband) and saw the resident, sitting near the nurses' station. She was in a wheelchair, and had vomited, a dark color, all over the floor. I stood there for a minute or so and didn't see any staff, so I went to the front wing to find someone. (CNA H) and another CNA (CNA J) were coming back from their break and told them what I saw." CNA H stated in the above interview that she and CNA J then saw Resident #14 in the hall in her wheelchair with her lap buddy on. CNA H stated that Resident #14 had vomited a large amount, which was dark reddish-brown, and was down the front of her clothing, on her lap buddy, in her contracted hands, and on the floor. CNA H stated that she told RN G about the emesis, who stated, in front of the resident, "You need to clean her up - that's disgusting." CNA H stated that Resident #14 could not speak, but she could hear and understand. CNA H stated that usually Resident #14 needs a medication to help her relax before her shower, as she usually screamed during her showers because she didn't like water. CNA H stated that on this night, it was difficult to undress Resident #14 in the shower because of all of the vomit, but Resident #14 did not seem to have the strength to fight the CNAs like she normally did. CNA H stated that the shower was given at approximately 8:00 p.m. In the above interview, CNA H also stated that she told RN G that Resident #14 just did not look right, her face was red and she "seemed miserable." CNA H stated that RN G did not go and assess Resident #14, did not take a set of vitals, and did not call the physician. RN G told them that the color of the emesis was probably because of Resident #14's [MEDICATION NAME], (even though this is a white pill). CNA H stated that she thought about what Resident #14 ate for supper, and nothing she ate would have made the vomit that color. CNA H stated that RN G told the CNAs to not say anything about the emesis, because Resident #14's roommate's daughters would get upset and think their mother was going to catch the flu. The night nurse was not told of the emesis. Surveyor interviewed ADON (Assistant Director of Nursing) RN F on [DATE] at 11:10 a.m., and asked if there could be anything written about the emesis on the 24-hour report, which would indicate that RN G may have informed the night nurse. RN F stated at 11:20 a.m. that she had reviewed the 24-hour report sheet, and there was nothing written about the emesis by RN G on the p.m. shift. CNA H stated that she was off for a couple of days after [DATE], and a colleague from work called her and told her that Resident #14 had died , and that she should go to RN K and tell her of her concerns of neglect. CNA H stated that she thought, "You just can't treat people like that." CNA H stated that she then did tell RN K about RN G's not assessing Resident #14, and stated that RN K stated that it was not necessary to follow up, because you can't really stop a GI bleed once it starts. CNA H stated that RN K minimized RN G's neglect of Resident #14. CNA H stated that RN K and RN G had worked at another facility together, were friends, and there had been other things about RN G that were reported to RN K, but RN K would not do anything about it and covered up for her friend. The facility sent a fax to the Western Regional Office on [DATE], which stated that RN G had been interviewed and she told the new DON, RN AA, that she was unaware of the above emesis on [DATE]. Also, that the former DON, RN K told the new DON, RN AA, that she did not recall that anyone came to her to inform her about Resident #14's emesis, and that she could not recall that she was told that RN G had not properly cared for the resident on [DATE]. Surveyor again interviewed CNA H on [DATE] at 11:39 a.m., who reiterated that she, as well as CNA J, and the above family member, had indeed witnessed the emesis as stated above, and that RN G knew fully well about the emesis and did not assess the resident, nor call the physician. CNA H also reiterated that she went to the former DON on Monday, [DATE] to discuss her concerns with the lack of care that Resident #14 received from RN G. CNA H also told Surveyor that she was interviewed by the Interim DON, who was told the same information as stated above, but this interview was not included in the fax that the facility sent the WRO on [DATE]. Surveyor interviewed CNA J on [DATE] by telephone at 10:53 a.m., who stated that she could not remember the exact date, but she confirmed that Resident #14 did have the above mentioned emesis, and that RN G did not assess the resident. She also confirmed that RN G stated that Resident #14 looked "disgusting" and told her and CNA H to take her to the shower and clean her up. CNA J stated that she is in nursing school, and that she could not believe that RN G did not assess Resident #14 after the emesis. She stated that even as a CNA, she could tell that Resident #14 needed to be assessed. Prompt, appropriate assessment and physician notification was needed following Resident #14's significant condition change on [DATE]. According to The Merck Manual, "Hematemesis (vomiting blood), melena, (black, tarry stool or vomit) or hematochezia (bright red blood in stool) should be considered an emergency until proven otherwise." Another source also notes that "...hematemesis ... indicates bleeding that is a potential emergency and should be handled as such until the situation can be assessed ... Mortality from acute upper gastrointestinal hemorrhage is between 8 and 10%, but varies widely with age and with the presence or absence of serious associated diseases such as [MEDICAL CONDITION], malignancy, [MEDICAL CONDITION], or [MEDICAL CONDITION]. The majority of deaths occur in patients over age 60. Older patients are less able to withstand massive hemorrhage and surgical intervention." http://www.ncbi.nlm.nih.gov/books/NBK411/. According to the Mayo Clinic's website, "It's important to quickly identify the underlying cause of the bleeding and prevent more severe blood loss and other complications." <http://www.mayoclinic.com/health/vomiting-blood>. Resident #14 had a second emesis; the night nurse charted on [DATE] at 3:57 a.m., "Resident noted to have vomited moderate amount (8 inch circle) of black emesis. (The blackness of the emesis would indicate the presence of blood.) T (temperature) 99 P (pulse) 85 R (respirations)18 BP (blood pressure) ,[DATE]. Abdomen soft. Call placed to (physician's name). He stated to keep resident in house and to contine (continue) to monitor condition. Call placed to POA (power of attorney) daughter to update. No answer. Message left on cell and house phone. DON (RN K) updated." Nurses' notes on [DATE] written at 5:35 a.m. state, "Resident noted to have large coffee-brown colored emesis. (Again indicating the presence of blood.) Resident was lying on side with head of bed elevated. Emesis was on side of bed and floor. BP ,[DATE] P 84. Resident is alert. Abdomen is soft. Resident is having soft BM (bowel movement) at this time and had extra large BM yesterday. Call again placed to daughter, Granddaughter states that daughter POA is out of town. Call placed to (name of physician) and he stated to send to ER (emergency room ) for evaluation." The nurses' note states that Resident #14 left for the hospital via ambulance around 6:10 a.m. "DON (RN K) made aware of transfer." The former DON, RN K, was notified of Resident #14's health concerns for a second time. Surveyor interviewed Resident #14's physician by telephone on [DATE] at 10:15 a.m., who stated that he was unaware that when he was called on the night shift, this was actually Resident #14's second emesis. He stated that any coffee ground emesis, or one containing blood "is something we need to know about" and that an acute GI bleed can certainly be a situation requiring emergency attention. The physician stated that he would expect a nurse to assess the resident and monitor vital signs, to determine if the resident is tachy (fast heart beat) or hypoxic (low oxygen saturation). He stated that he depends on the nurses to "report to us any important information." He stated that he discussed with the night nurse the fact that she had been unable to get hold of Resident #14's Power of Attorney (daughter). When he was notified that there was a "second" emesis (actually the resident's third), he sent Resident #14 to the emergency department. Resident #14's physician stated that he was aware that later in the day, Resident #14 declined, and that the daughter just wanted her mother to be kept comfortable before she died , versus [MEDICAL CONDITION] lavaging (placing a tube down the resident to wash out the stomach) or scoping her or performing surgery. Resident #14 returned from the ED around 10:00 AM on [DATE] with a [DIAGNOSES REDACTED]. Recheck Hgb (hemoglobin) in 3 - 5 days. Resident #14's daughter returned to town early that afternoon, and at suppertime, Resident #14 was described in nurses' notes as having "very poor color and lethargic. Resident laid down in bed in order to obtain VS (vital signs). B/P ,[DATE] (decreased from above readings) HR (heart rate - pulse) 121 (increased from above readings, indicating that the heart rate was compensating for the lowering of the blood pressure), R 28 (respirations above normal indicating trouble breathing) Sats 76% (normal oxygen saturations are at or near 100%, again indicating trouble breathing and a lack of hemoglobin, which can result from blood loss). Temp 98.4. Oxygen applied at 2 liters. Sats remain low. By 2100 (9:00 p.m.) temp at 100.2. Cool compresses applied and Tylenol 650 mg PO (milligrams by mouth) administered." The facility called Resident #14's daughter and her physician. The daughter wanted Resident #14 to remain at the facility, and she came to the facility to sit with her mother. She requested that her mother be kept comfortable. Resident #14 passed away on [DATE] at 2:40 a.m. Failure to take appropriate action for Resident #14, created a finding of immediate jeopardy. The facility removed the immediate jeopardy on [DATE] by which time the new Director of Nursing had trained all nursing staff on appropriate response to residents' changes of condition. The deficient practice continues at an E level scope/severity (potential for harm/isolated) as evidenced by the following 4 examples. 2. Resident #1 was admitted to the facility on [DATE]. The latest re-admitted was on [DATE]. [DIAGNOSES REDACTED].. Resident #1 was re-admitted to the facility on [DATE]. Pain medications ordered on re-admission were [MEDICATION NAME] mg BID, [MEDICATION NAME] 2 mg every 4 hours as needed and Tylenol ,[DATE] mg every 4 hours as needed. The wound vac to the left stump incision was to be changed on Monday, Wednesday, Friday and as needed. Resident #1's prn medication record identified Resident #1 received [MEDICATION NAME] 2 mg and [MEDICATION NAME] mg prior to dressing changes on [DATE], [DATE], and [DATE]. Resident #1 received no prn pain medications prior to dressing changes on [DATE] and [DATE]. On [DATE] the physician ordered [MEDICATION NAME] 2 mg before wound vac dressing change. Review of the [DATE] prn medication sheets identified Resident #1 received [MEDICATION NAME] 2 mg before dressing changes on [DATE], [DATE], [DATE], [DATE] and [DATE]. Resident #1 was hospitalized and readmitted on [DATE]. Physician orders [REDACTED]. There was no order for pre-medicating Resident #1 prior to wound vac dressing changes and nursing did not follow up with the physician upon receipt of the resident ' s medication orders. The pain assessment completed on [DATE] identified Resident #1 had stump pain with a severity level of 8 of 10 (with 10 being intolerable). Resident #1 received wound vac dressing changes on [DATE] and [DATE]. No prn pain medication was administered prior to the dressing changes. Resident #1's nurses notes on [DATE] at 11:37 a.m. written by RN F stated, "This writer took off old wound vac, resident did have some pain but was pre medicated with [MEDICATION NAME] mg two hours prior to dressing change." (The scheduled dose of [MEDICATION NAME] administered at 8:00 a.m.). On [DATE] at 2:40 p.m. Surveyor interviewed Resident #1. During the interview Resident #1 brought up the wound vac dressing change is completed 3 times weekly (Monday, Wednesday and Friday). Resident #1 stated he only receives scheduled pain medications 2 times daily. Resident #1 stated he receives no prn pain medication prior to the dressing changes. Resident #1 stated during the dressing changes it hurts like "hell" and is pure torture. Resident #1 said the dressing changes are to be done on the day shift but the nurses do them at different times each time. Resident #1 stated he had told the nurses about the terrible pain during the dressing changes but all they say is, "Sorry, Sorry." Resident #1 stated he used to get pain medication before some of the dressing changes. Resident #1 stated even with the prn pain medication before the dressing change it still hurt but not as bad. Resident #1 stated Surveyor could observe his treatment the following day to see the amount of pain he had. On [DATE] at 10:40 a.m. Surveyor interviewed LPN (licensed practical nurse) U related to Resident #1's pain with the wound vac dressing changes. LPN U verified Resident #1 is not pre medicated for pain and has pain during the dressing changes. LPN U stated she heard on Monday ([DATE]) Resident #1 had more pain during the dressing change. LPN U stated she had a call out to Resident #1's physician to get orders for pain medicating prior to the dressing changes. LPN U stated she did not know why the orders for pain medication 1 hour prior to the dressing change was not ordered on re-admission on [DATE]. On [DATE] at 10:45 a.m. Surveyor interviewed Registered Nurse (RN) F who verified that Resident #1 had complaints of pain with the wound vac dressing changes especially when removing the black sponge. RN F stated when she completed the dressing change on [DATE] Resident #1 had complained of pain. RN F stated currently Resident #1 did not have any orders for break through pain or prior to the dressing changes. RN F stated she had a call out to the doctor and would not be doing the dressing change until she spoke with the doctor. On [DATE] at 1:08 p.m. RN F informed Surveyor she had received a call back from the physician. The physician said that since Resident #1 was seeing the doctor in the morning related to the wound vac and he was changing the order to wet-dry dressings. RN F stated the physician said there was no reason to continue the wound vac dressing if they were so painful. RN F stated on re-admission on [DATE] the orders did not include administering a pain medication 1 hour prior to the dressing change. RN F stated obtaining an order for [REDACTED]. On [DATE] Resident #1's physician ordered [MEDICATION NAME] 10 mg 1 hour before dressing changes. Resident #1 was administered [MEDICATION NAME] 10 mg at 2:45 p.m. On [DATE] at 3:48 p.m. Surveyor observed RN F and LPN U remove the wound vac dressing. Resident #1 was observed to lay back on his bed and close his eyes at times during the dressing change. RN F prior to remove the black foam from the wound bed informed Resident #1, "Now this is the tough part, this is what hurts." At the end of the treatment RN F asked Resident #1 how the pain was now. Resident #1 stated the pain was "mediocre" and that receiving the extra pain pill helped. RN F stated that even with ,[DATE] pain medications on board Resident #1's pain is not controlled entirely. 3. The facility policy titled "Licensed Nurse-Skin Condition Documentation" dated ,[DATE] read in part as follows: Procedure: A complete wound assessment and documentation will be conducted on all skin conditions upon discovery and weekly thereafter until they are healed. Documentation may include: a. Site/location b. Identification of type of skin condition. This may include but not limited to: 1. Ulcer 2. Skin tear 3. Abrasion 4. Bruise 5. Redness 6. Swelling c. Size-length, width, and depth in centimeters (cm). Review of Resident #8's medical record was conducted on [DATE] by Surveyor . During this review Surveyor read Resident #8's skin condition report. On [DATE] Resident #8 was diagnosed with [REDACTED]. She developed arterial ulcers as identified by the facility. The facility policy directed measurements were to be taken of the ulcers on a weekly basis. The measurements were completed weekly [DATE]-[DATE] as documented on the skin condition report. The next measurements were completed on [DATE]. There were no weekly measurements obtained [DATE] through [DATE]. Measurements were completed weekly [DATE]-[DATE] but have not been completed since [DATE]. An entry on the "Head to Toe Weekly Skin Body Assessment" for Resident #8 contained an entry dated [DATE] by Registered Nurse (RN) N, where the "See Skin grid" was checked. (Per interview with Licensed Practical Nurse (LPN) M on [DATE] the skin grid is the same as the skin condition report), there were no measurements on the skin condition report since those of [DATE]. Surveyor also checked Resident #8's nurses' notes from [DATE]-[DATE] and [DATE]-[DATE] but did not locate any measurements in the nurses' notes for those time frames. 4. The undated facility policy titled "Oxygen Delivery Systems" reads in part: 1. Low Flow a. Nasal Cannula IV. Appropriate flow note: ,[DATE] L/ min (liters per minute) according to physician's orders. b. Simple Mask 1. Risks A. Aspiration B. Subcutaneous [MEDICAL CONDITION] into ocular tissue at very high flow rates. C. Pressure necrosis. D. CO2 (carbon [MEDICATION NAME]) accumulation at low flows. II. Appropriate Flow Rate: ,[DATE] L/min (liters per minute). On [DATE] Surveyor reviewed Resident #8's medical record and identified a nurses' note written by LPN CC on [DATE] with a time of 5:46 p.m. that read ... "Sats below 90%, therefore oxygen admin (administered) per mask at 2 liters. Resident does not appear in distress." On [DATE] at 1:25 p.m. Surveyor interviewed LPN CC regarding Resident #8. LPN CC confirmed she had changed Resident #8 from a nasal cannula to a mask for her oxygen on [DATE] and the liter flow was at 2 liters. LPN CC stated she did that because Resident #8 was mouth breathing and she thought it would be more beneficial to her to have a mask. Surveyor asked LPN CC what were Resident #8's O2 sats (saturations) as the nurses' notes just said they were below 90%. LPN CC stated her sats were around ,[DATE]%. LPN CC told Surveyor Resident #8 had an order for [REDACTED]. Surveyor asked LPN CC when she had put the oxygen mask on Resident #8. LPN CC said she switched her to the mask just before she charted on her. Her charting entry was at 5:46 p.m. on [DATE]. LPN CC told Surveyor she worked until 6:00 p.m. that day. Surveyor asked LPN CC if she had told RN N, the nurse relieving her that she had started Resident #8 on an oxygen mask. LPN CC didn't recall. Surveyor told LPN CC a common standard of practice is not to use a mask with a liter flow of less than 5 or 6 liters of O2. Surveyor explained the CO2 can build up and this can depress the respiratory center of the brain and can cause very serious consequences. The nurse that worked [DATE] 6:00 p.m. - 6:00 a.m. [DATE] was interviewed by Surveyor on [DATE] beginning at approximately 2:50 p.m. Surveyor asked RN N if LPN CC had told her in report that Resident #8 was on an oxygen mask at 2 liters. RN N said "No." RN N was asked if Resident #3 continued to use the oxygen mask at 2 liters the remainder of the pm and through out the night shift. RN N said, "Yes, I believe so but she was taking it off continuously. Surveyor shared the concern with RN N about Resident #8 using an oxygen mask with the oxygen at 2 liters. RN N stated "I never thought of that, never dawned on me, can't be on that mask." Surveyor reviewed the nurses' note written by RN N [DATE] with the time of 4:42 a.m. that read ..."O2 sats 97% with o2 on at times as she continues to take this off. No SOB." In the above-referenced interview, Surveyor asked RN N if she had worked the night of [DATE] and RN N confirmed she had, she came in at 10:00 p.m. that night. Surveyor asked if Resident #8 was using the oxygen mask or the cannula. RN N confirmed Resident #8 was using the oxygen cannula that night. Surveyor was unable to determine exactly when the mask was switched back to a cannula as the nurse that worked the day shift [DATE] was on vacation and was unable to be reached. On [DATE] Surveyor was able to speak with RN DD, the nurse that worked the evening shift on [DATE]. An interview was conducted by phone [DATE] beginning at 4:56 p.m. RN DD was asked if Resident #8 had O2 on that shift. RN DD stated she was pretty sure she did. Surveyor asked if Resident #8 was using the oxygen cannula or the mask. RN DD said I think she had both. The mask was sitting there in her room, but she was using the cannula. RN DD told Surveyor "I think (LPN E) switched her over probably. Surveyor explained the concern with using the O2 at 2 liters with a mask and RN DD was aware that 2 liters was to low of a liter flow to use with a mask. An interview was conducted by Surveyor with the DON on the afternoon of [DATE]. Surveyor asked the DON if it is all right to use an oxygen mask at 2 liters of O2. The DON stated no mask with less than 4 liters. 5. The facility policy titled "Care Standards, Notification Of Change" dated ,[DATE] read: Introduction: The Residents physician and responsible party must be notified when an event involving the resident occurs or when the resident experiences a change in condition, potential discharge, room transfer or death. Notification Parameters: Condition: Immediate (within 1 hour of condition to allow time for resident assessment) Bleeding Prolonged nosebleed; bloody emesis; Frank blood found in stools not from hemorrhoids. Medicine.Net.com's medical dictionary notes that " black, smelly and tarry stool is called melena. Melena occurs when the blood is in the colon long enough for the bacteria in the colon to break down into chemicals (hematin) that are black. Therefore, melena usually signifies bleeding is from the upper gastrointestinal tract (for example: bleeding from ulcers in the stomach or the duodenum or from the small intestine) because the blood is usually in the GI tract for a longer period of time before it exits the body. " During the extended survey on [DATE] Surveyor reviewed Resident #24's medical record and read the following nurses' notes: [DATE] 3:15 a.m. ..."Did have a large incontinent stool this shift. ...Is alert but forgetful. VSS (vital signs stable)." [DATE] 1:25 p.m. "Call to resident room at 1320 (1:20 p.m.) found to have had a massive loose stool that wad (sic) bright red in color with several small to med. (medium) size clots. He is alert and oriented x 4 and is aware that he is being transferred to TMH (Tomah Memorial Hospital). DON (Director of Nursing) made aware and also saw resident. Call to clinic and obtained order to send to TMH ER (emergency room ) to be Eval (evaluated) and treated. ...Vitals at this time are T (temperature) 98.9, P (pulse) 97, R (respirations) 20 O2 (oxygen) 98% R.A. (room air), B/P (blood pressure) ,[DATE]." [DATE] 1:41 p.m. "Resident left by ambulance at this time. ..." [DATE] 5:43 p.m. "Resident transferred to Gunderson Lutheran Hospital from TMH DX (diagnosis) GI Bleed. On [DATE] Surveyor reviewed the bowel movement (BM) flow record for Resident #24 for the night shift of [DATE]-[DATE]. The BM flow record contained an entry of LL and LS for that night. At 12:02 p.m. on [DATE] Surveyor spoke with the DON who is also the Regional Clinical Nurse (RCN) in the presence of the New DON AA,and asked what LL and LS stood for. The DON/RCN told Surveyor she thought the LL LS stood for large loose stool with an extra L. Review of the 24 hour nurses' report sheet from the night of [DATE]-[DATE] contained an entry written by RN N that read LE (lower extremity) dressings changed 0330 (3:30 a.m.) soiled with stool. The 24 hours report sheet did not include information as to the color of the stool or that it was loose. Resident #24's [DATE] 3:15 a.m. nurses' note did not identify the color of the stool or that it was loose only that it was a large incontinent stool. Review of the vital sign record showed Resident #24's vital signs were charted [DATE] at 3:13 a.m. as BP ,[DATE], O2 saturation 96%, P 90, R 22 per minute, T 98.1 degrees Fahrenheit. During the interview below, on [DATE] CNA BB told Surveyor that Resident #24 had two large loose black stools that night, the second one being around 3:30 a.m. The time of the above vital signs reflect they were taken prior to the second loose black stool that occurred. On [DATE] at approximately 2:20: p.m. a phone interview was conducted by Surveyor with CNA BB in the presence of the Nursing Home Administrator (NHA) by speaker phone. Surveyor asked CNA BB if she recalled Resident #24 having a large loose stool the night of [DATE], early morning of [DATE]. CNA BB said she did recall this. CNA BB told Surveyor that the stool looked pure black, really, really loose. He went two times and the nurse had to change his bandages. He went large down the bed twice, extra large two times, very liquidy and pure black. Surveyor asked CNA BB if R

Based on facility and hospital record review, policy review, and staff, physician and family interviews, the facility did not provide the necessary care and services to 1 of 4 residents reviewed to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with a comprehensive assessment and care plan. The facility did not assess the resident for injury prior to being moved following a fall and did not adequately assess and monitor a bruise and pain level from 10/2-10/4/10. On 10/2/10, Resident #16 was lowered to the floor. Nurse aides moved the resident from the floor to bed and then to her wheelchair prior to notifying the nurse to allow for proper assessment of possible injuries. By 9:53 p.m. on 10/2/10, Resident #16 had swelling, pain and discoloration of her left lower extremity. There was inadequate assessment and monitoring of the bruise and inadequate assessment and monitoring of pain. On 10/4/10, at 8:22 a.m. Resident #16 was transferred to the emergency room via ambulance and found to have both a left tibia and left fibula fracture. This is evidenced by: Surveyor reviewed the medical record of Resident #16 on 10/6-10/7/10. Resident #16 is diagnosed with [REDACTED]. She receives aspirin (81 mg.) daily as an anticoagulant. Surveyor reviewed Resident #16's full care plan dated 6/18/09, under the "risk for falls" problem. The care plan shows no changes from 6/18/09 until 10/2/10, when the date of the fall (10/2/10) was the only thing added. The care plan read Resident #16 requires "Two assist with transfer with GB (gait belt)-pivot." Marissa lift and EZ stand were written below the mode of transfer, but were crossed out with no date, signature or explanation. Review of the Care Sheets, used and carried by the Certified Nursing Assistants (CNAs) show that on 10/2/10 the sheet read Resident #16 was to be transferred by the assist of two, a pivot transfer with gait belt. Surveyor interviewed Physical Therapy Assistant (PTA) L on 10/7/10 at 8:55 a.m. PTA L stated both Occupational therapy and Physical therapy had been seeing Resident #16 for approximately one month prior to 10/2/10 to address changing needs. PTA L stated Resident #16 was transferred with moderate assist of two, doing a pivot transfer, with a gait belt. PTA L stated Resident #16 had instability in her left ankle due to her past stroke. She stated if Resident #16 was "hard to get up," staff were to use the EZ stand lift. PTA L stated prior to 10/2/10, Resident #16 was able to bear full weight on both lower extremities. Review of a nursing note dated 10/4/10 at 11:29 a.m. as a late entry for 10/2/10 read, "Staff member informed this writer (Licensed Practical Nurse E) that they lowered resident to the floor when transferring her from shower chair to bed to finish dressing her for the day." Surveyor reviewed the facility's investigation of Resident #16's "lowering to the floor." It showed that the DON wrote on 10/4/10, "They stood her back up after they had adjusted their positioning with her and put her to bed...Once they completed getting (Resident #16) dressed and into her wheelchair they took her to the dining room for breakfast and then they told the nurse what had happened." The facility's investigation also included a statement by Assistant Director of Nursing (ADON) D stating she completed a Registered Nurse (RN) assessment of Resident #16 at approximately 2100 (9:00 p.m.) on 10/2/10. The RN assessment is not documented in Resident #16's medical record. Further review of the investigation showed an incident report was written by Licensed Practical Nurse (LPN) E for the 10/2/10 incident, but the signature/incident report had no date to show when it was written. Surveyor interviewed LPN E on 10/7/10 at 10:10 a.m. regarding when she wrote the incident report. LPN E stated she wrote the report on 10/4/10, two days after the incident. LPN E stated she had not notified a physician as she did not consider the lowering a fall as Resident #16 had "no mark" and "no injury" from the incident. LPN E stated the facility considers a lowering to the floor a fall and she generally would have done an incident report, but it was a "very busy morning." LPN E stated on 10/3/10 she got a note from the PM nurse that she was to call the family about a bruise, but it "didn't click" it may be related to the lowering to the floor the day before until she was at home on 10/4/10 and then thought of it. She stated she then notified the Director of Nursing. Review of the 10/2/10 24-hour report only stated, "Left shin bruise elevate leg, cold compress. It did not say how Resident #16 received the bruise or anything about being lowered to the floor. Surveyor reviewed other statements as part of the facility's investigation into Resident #16's fall. A statement by CNA P read that on 10/2/10 at 9:00 p.m. (after the "lowering to the floor " incident had already occurred) she was transferring Resident #16 and Resident #16 "sounded out in pain." A statement by CNA M reviewed as part of the facility's investigation into Resident #16's fall noted that at 9:00 p.m. on 10/2/10 (after the "lowering to the floor" incident had already occurred) "she (Resident #16) was complaining of pain when I tried to put her shoes on her." Another statement written by CNA S on 10/2/10 read, "CNA P and I were putting Resident #16 to bed Saturday night-about 7:45 p.m. She kept telling us that her leg was hurting her. I reported to the PM nurse right away...when she lay down she pointed to her leg-that it hurt... (that was her left leg)." There was no R.N. assessment of Resident #16 after the noted the complaints of pain on 10/2/10. A nursing note dated 10/2/10 at 9:53 p.m. read, "CNA notified writer (LPN F) that resident was having increased pain with movement/transfers in left lower leg. Writer found a new bruise forming on left shin, below knee posterior side of the leg. Bruise very light purple in coloration...Writer administered Tylenol 1000 mg. and is encouraging resident to elevate leg. Cold compress as needed. Will continue to monitor." There was no RN assessment of the increased pain or bruising at this time. Review of Resident #16's nursing note dated 10/3/10 at 10:00 a.m. by LPN E read, "Left shin bruise: POA called this morning at 0952 to update on bruise, no one home so left message for her to call on her return. Resident did have complaints of left leg discomfort this morning when getting her up in w/c (wheelchair), Tylenol 650 mg. was given...Monitor as needed." Again, there was no RN assessment of the continued complaints of left leg discomfort. The 10/3/10 nursing note at 3:32 p.m. read, "POA called back and was informed of current bruise on left leg." There are no other nursing notes for 10/3/10. There is no physician consultation documented. A note dated 10/4 at 8:14 a.m. by Registered Nurse (RN) D read, "Resident's left lower extremity noted to be very warm to the touch, [MEDICAL CONDITION], red/bruised and resident complains of pain with movement of both lower extremities. Call placed to on-call MD (MD O) and informed of resident's condition and ordered for resident to be sent to ...ER (emergency room ) for evaluation. Call placed to dtr. (daughter)...Ambulance called. ER notified." Nursing note on 10/4/10 at 8:22 a.m. read, "Ambulance here...Ambulance left with resident at this time." Resident #16's discharge [DIAGNOSES REDACTED]." Findings by MD T read, "Minimally displaced [MEDICATION NAME] oriented fractures seen through the proximal tibial shaft as well as the proximal fibular shaft at a similar level compatible with trauma to this region." Review of Resident #16's care plan shows a problem for back pain dated 6/18/09. There were no additions made following the 10/2/10 incident to address leg pain until after her 10/4/10 hospitalization . On 10/7/10, Surveyor requested the DON provide any pain assessments completed on Resident #16 in the recent past. The last pain assessment on Resident #16 was completed by RN D on 9/23/10. The investigation dated 10/4/10 for Resident #16 written by the DON read, "Resident did continue to receive prn Tylenol throughout the weekend for discomfort." Surveyor reviewed the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There were no entries for prn Tylenol use until 10/6/10 which was after Resident #16's return from the hospital. The statement written by ADON D states she gave LPN F instructions on 10/2/10 to give Tylenol. A review of all nursing notes from 10/2/10-10/4/10 show that on 10/2/10 at 9:53 p.m. Resident #16 received 1000 mg. of Tylenol for increased pain with movement/transfers in left lower leg . Review of another nursing note on 10/3/10 at 10:00 a.m., shows Resident #16 received 650 mg. of Tylenol for complaints of left leg discomfort. The DON showed Surveyor that Resident #16 had a [MEDICATION NAME] order dated 5/1/2010 for 25 mcg/hr; [MEDICATION NAME], for [MEDICAL CONDITION]. The patch was to be changed every three days. Resident #16 received a patch on 10/1/10, prior to the 10/2/10 incident. She did not receive another before her transfer to the hospital. Review of Physician orders [REDACTED].#16 every shift as of 6/29/10. This was not on Resident #16's MAR indicated [REDACTED]. Review of the facility's policy titled, "Resident Incident/Accident Reporting Protocol" dated revised on 1/08, read at 9 d) "Mark the resident's chart in order to alert nursing that documentation related to the resident's status following the incident/accident is required every shift for 72 hours..." The nursing notes show this monitoring was not completed as there are only six nursing notes from 10/2-10/4/10 when Resident #16 was transferred to the ER, with three of the notes dated 10/4/10. Surveyor interviewed the DON on 10/7/10 at 4:55 p.m. as to where the 72 hour monitoring for a bruise and pain following a fall would be found. The DON stated she would expect it be on the resident's MAR. On 10/7/10, Surveyor reviewed the facility's policy titled, "Pain Management" last revised on 6/08. The policy read the facility will "respect and support the resident's rights to optimal pain management." The purpose read, "Effective pain management can remove the adverse psychological and physiological effects of unrelieved pain." Under procedure it read, "It is the responsibility of all clinical staff to assess and periodically reassess the resident for pain and relief from pain." It reads an assessment will be done and pain control mechanisms will be employed. It also says that for any mechanism employed, the mechanism will be reassessed with [REDACTED]. The policy lists medications as a pain control mechanism, but the MAR indicated [REDACTED]. The DON also provided Surveyor with a form titled "Pain Assessment Form." She stated on 10/7/10 at 4:55 p.m. it is to be attached to the incident /accident report. She stated the facility did not have one for Resident #16's fall on 10/2/10. Surveyor interviewed emergency room (ER) physician (MD) J on 10/7/10 at 8:50 a.m. MD J stated Resident #16's bruise was "a couple days old" when she saw it on 10/4/10 as it was a "yellow/brown bruise." When asked about swelling, MD J stated the swelling was "significant." When asked about pain, MD J stated it was uncomfortable to touch Resident #16 where the bruise was. MD J stated, "Definitely painful for her." She added (Resident #16 ' s) ankle also seemed painful when touched. Resident #16's discharge [DIAGNOSES REDACTED]." Findings by MD T read, "Minimally displaced [MEDICATION NAME] oriented fractures seen through the proximal tibial shaft as well as the proximal fibular shaft at a similar level compatible with trauma to this region." Surveyor interviewed Medical Doctor O on 10/7/10 at 1:33 p.m. MD O stated Resident #16's fractures were "impact fractures." Surveyor interviewed MD K on 10/7/10 at 8:12 a.m. While she believes Resident #16's [MEDICAL CONDITION] played a lot into Resident #16's fractures, she did state while being transferred, (her leg) "shouldn't have broken."