Every finding on record at Watertown Health Care Center

Based on observation, interview, and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 3 of 3 residents (R6, R2 & R11) reviewed for supervision.R6, who is cognitively impaired, was at risk for elopement, exited the facility unsupervised, and was found 2.5 hours later about 2 miles from the facility.The facility's failure to provide adequate supervision for a resident who is at risk for elopement, created a finding of immediate jeopardy that began on 8/9/26. Surveyor notified NHA A (Nursing Home Administrator) and DON B (Director of Nursing) of the immediate jeopardy on 8/18/26 at 3:30 PM. The immediate jeopardy was removed on 8/17/26.However, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as evidenced by the following examples:R2 and R11 were assessed as needing supervision with smoking. Surveyor observed R2 and R11 smoking without supervision in a non-designated smoking area. Evidenced by:It is important to note this facility sits prominently on a hillside medical campus, directly adjacent to the regional hospital. The closest major highway runs directly past the medical campus and serves as the main northern bypass for the city.Facility policy, titled Unsafe Wandering and Elopement Prevention, initiated 12/21/25, includes: The facility will identify residents who are at risk for unsafe wandering or elopement and strive to prevent harm while maintaining the least restrictive environment and respecting resident rights. The facility will utilize screening, care planning, and controlled access procedures to ensure residents can safely leave and return to the facility when appropriate. Elopement- A resident leaving the facility or secured area without authorization or supervision when supervision is required. Procedure: Identification and screening of risk. Care Planning and Least Restrictive Interventions. Residents identified at risk will have individualized, least restrictive interventions incorporated into their care plan. Any restriction on a resident's ability to exit the facility must be clinically justified, care=planned, and consistent with resident rights and regulations. Residents wishing to leave the facility independently must be assessed for safety. Residents not cleared must be supervised when leaving the facility. Staff responsible for monitoring exits must verify authorization to leave, consult with High-Risk Elopement Log when uncertain, and ensure residents return safely. Staff Response to Exit Attempts- If staff member observes a resident attempting to leave and the resident is not authorized to exit independently, the staff member shall courteously attempt to redirect the resident, seek assistance as needed, and immediately notify the Charge Nurse or Director of Nursing Services. Missing Resident/Elopement Procedure- . If a resident is missing. If unauthorized a search of the building and grounds will be initiated immediately. If the resident is not promptly located the Administrator, Director of Nursing Services, legal representative, attending Physician, and law enforcement will be notified.1. R6 admitted to the facility on [DATE] with diagnoses including Wernicke's Encephalopathy (a serious brain disorder caused by a lack of vitamin B1/thiamine. It can lead to long term memory problems or permanent brain damage), dysphagia, general Anxiety, and acute respiratory failure.R6's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 8/12/26 indicates R6's cognition is moderately impaired with a BIMS (Brief Interview for Mental Status) score of 11 out of 15.R6's Fall Risk Assessment, dated 8/5/26, includes: . Disoriented times three at all times.R6's Elopement Risk Assessment, dated 8/5/26, includes: Is resident independent with mobility- yes. Does resident wander: unknown. Does the resident have a cognitive impairment or diagnosis associated with impaired judgement or wayfinding: yes. Does the resident have a history of elopement or an attempted elopement while at home: no. Does the resident have a history of elopement or attempting to leave the facility without informing staff: no. Has family or responsible party expressed concern that the resident may attempt to leave the facility unsafely: no. Has resident verbally expressed the desire to go home, packed belongings to go home, or stayed near exit door? No. Score value of 1 or higher indicates risk of elopement. Elopement Evaluation: The resident is independently mobile, with or without an assistive device (including wheelchair). It is unknown if the resident exhibits wandering behavior. The resident has a cognitive impairment or diagnosis with impaired judgement or wayfinding. No history of elopement at home. No history of/attempts to leave unsafely. Resident has not verbally expressed the desire to go home, packed belongings to go home, or stayed near an exit door. The resident has been admitted or readmitted within last 30 days and has responded positively to the current care setting. Elopement score:1.0.R6's Nurse Notes, dated 8/5/26 at 8:26 PM, include: .He is alert and oriented times one, able to verbalize simple needs. He is confused and disoriented most of the time and requires constant re-direction.(It is important to note R6 requires constant re-direction.)R6's Elopement Evaluation, dated 8/7/26 at 11:16 AM, includes: The resident is independently mobile with or without an assistive device. The resident exhibits wandering behavior. Wandering behavior is goal-directed. It is unknown if resident's wandering is likely to affect the safety or well-being of self/others. Wandering behavior is not likely to affect the privacy of others. The resident has a cognitive impairment or diagnosis with impaired judgement or wayfinding. History of elopement at home. No history of/attempts to leave facility without informing staff. The family or responsible party expressed concern that the resident may attempt to leave the facility unsafely. Resident verbally expressed the desire to go home, packed belongings to go home, or stayed near an exit door. Elopement score: 06. Resident is at risk for elopement. R6's Comprehensive Care Plan, includes: Focus: Date initiated: 8/7/26 at risk for elopement related to wandering, walking the halls. I am easily re-directed. Date Initiated: 8/7/26. Goal: Patient will have no incidents of elopement. Date Initiated: 8/7/26, Target Date: 11/10/26. Will remain safe during placement. Date Initiated: 08/07/2026 Target Date: 11/10/26 . Interventions: Assess for risk of elopement per living center policy. Date Initiated: 8/7/26. Involve patient in preferred activities. Date Initiated: 08/07/2026. Redirect patients from doors Date Initiated: 8/7/26. Take picture of patient upon admission for identification for updating elopement book. Date Initiated: 8/7/26.R6's Nurse Note, dated 8/7/26 at 9:05 PM, includes: . remains alert with baseline confusion. Wandering throughout the unit this evening.R6's Nurse Notes, dated 8/9/26 at 12:19 AM, include: At this time resident at nurse's station wanting to leave. Resident insists that he needs to go home to fix the problems that are going on. Resident attempted to go out the door in the . TV room. Resident very hard to re-direct. Writer asked resident to walk with her towards room to discuss the issues. Resident continued to state that he was going home, that he could walk because it is only 5 minutes away. Writer asked resident if he would like to talk with his sister. Resident stated she already knows because he just talked with her. Resident stated that his sister was just down the hallway. Reassurance given to resident. Writer did get resident into his room to talk. Resident agreed to stay at the facility at this time. Will continue to monitor.(It is important to note R6 is attempting to go out the door, verbalizing the need to leave, is hard to re-direct, and the facility did not increase supervision.)R6's Elopement Timeline, includes: Date and Time of incident: 8/9/26 at approximately 4:05 AM. Brief Summary: At approximately 4:00 AM, R6 was observed by staff in another resident's room. CNA reported that she attempted to redirect R6 after observing him touching the resident's belongings and informed R6 that he was in another resident's room and should not be in there due to resident privacy. R6 stated that he was leaving and began walking towards the back exit door (location). CNA reported that she attempted to block the door and redirect R6, at which time R6 began pushing, pulling, and hitting CNA. After the final push R6 was able to get past her and exit through the back door. CNA immediately ran for assistance. CNA DON reported that at approximately 4:05 AM CNA came running down the hall stating that R6 had hit her and ran out the door, CNA DON immediately began searching the perimeter in an effort to locate R6. Staff searched the hospital, wooded areas, and surrounding perimeter. Staff then contacted 911. Police report information provided indicates that R6 was located by police at approximately 6:35 AM and returned to the facility at approximately 6:41 AM.Police Report Log, dated 8/9/26, includes: 4:16 AM missing adult priority 1. 4:18 AM R6 was wearing Packers coat at one point, possibly jeans, unable to provide descriptors. 4:20 AM bald, does have photo available. He told staff he wanted to walk to (nearby town). At 4:23 AM, he went out the North door and left wearing jeans and a Packers zip up hoodie. 4:24 AM emergency room staff have not seen him. 4:40 AM mutual aid request with (neighboring county). 4:53 AM (Neighboring County) on scene. 5:00 AM (Neighboring County) k-9 has started his track. 5:16 AM Officer checked with (nearby gas station). They have not seen him but will call if they do. 6:01 AM Officer's drone is up. 6:17 AM Officer from (nearby town) to attempt to contact R6's prior address. 6:31 AM Officer, I believe I have contact with R6 on Main Street/College Avenue. 6:35 AM Officer, R6 is secured in the back of my squad. 6:35 AM Officer enroute to (facility name)/beginning miles: 12297.8. 6:41 AM . at (facility name) with R6/ending miles 12299.8.R6's Comprehensive Care Plan, updated 8/9/26, includes Please call my sister when I am wanting to leave. Date Initiated: 8/9/26.R6's Nurse Note, dated 8/9/26 at 5:38 AM, includes Change in condition evaluation: . Writer was alerted that resident went out . door. CNA attempted to redirect. Resident became aggressive and was striking out. CNA yelled for another CNA to help. Both CNA and housekeeping out looking for resident. Writer was also looking for resident. Resident could not be located. 911 called at 4:12 AM. Police Officer here. Information was given that was requested.R6's Nurse Notes, dated 8/9/26 at 6:45 AM, include Resident returned to the facility accompanied by a police officer. Resident's sister was present upon arrival. Writer provided education regarding the importance of remaining in the facility for resident safety. 15-minute safety checks were initiated.On 8/18/26 at 8:27 AM CNA O indicated on 8/9/26 she was on her hallway sitting in the hall when CNA P came running and told her R6 had gotten out. CNA O indicated she entered the nurse's office and heard the alarm. CNA O indicated her and CNA P went to back door, then went outside and looked in back parking lot. CNA O indicated CNA P saw someone by hospital so she went that way while CNA O looked around the medical building parking lot and they did not find him. The two then went down to the woods and along perimeter of the grounds. They looked at the facility's parking lot and even in the cars. Then came back inside the facility. CNA O stated, At this time the nurse said we need to call the police. CNA P knew he left the building, so we never scanned the rooms. They brought in the dog and started their search. He was not on any extra supervision. He was not on 15-minute checks until after police returned him. R6's Nurse Notes, dated 8/9/26 at 9:59 PM, include Resident remains stable but a bit restless which was managed by redirection and engagement. He made no further attempts to abscond.R6's Nurse Notes, dated 8/10/26 at 1:19 AM, includes at 12:30 AM resident up in hallway stating he wanted to stretch his legs. Resident walking up .wing then down (the next) wing. CNA was following resident. Resident told CNA he wanted to leave. CNA walked with resident back down . wing and updated writer. Writer asked resident to follow her to nurse station and asked what resident wanted. Resident first said a drink then stated he wanted to leave facility. Writer called resident's sister. Resident talked with his sister for a while. When resident was done talking with sister, resident stated he was hungry. Writer provided resident with a peanut butter and jelly sandwich along with cookies and resident got a bottle of water to drink out of his refrigerator.R6's Nurse Notes, dated 8/10/26 at 9:45 PM, include: . Resident remains alert and oriented x1-2 with baseline confusion noted. Resident continues to be exit seeking not actively attempting to exit throughout the evening. Increased confusion noted. No aggressive behaviors. Redirection provided.R6's Health Note, dated 8/11/26 at 8:21 AM, includes: . male resident with Wernicke's encephalopathy and status post CVA (stroke) eloped last night and has been returned to the facility by police. His escape was witnessed - an aide attempted to prevent the elopement, but resident was pushing/pulling and striking out and got away. 911 was activated and police eventually found him and brought him back. He is also a Hospice patient, and Hospice staff are coming out today to assess and adjust his medications. Noted he is on high doses of lorazepam (1 mg 5X per day) as well as olanzapine and still has periods of agitation and elopement behaviors. Ability to understand and retain the importance of not eloping from the facility is limited. Escape was witnessed but resident was combative to the point that staff could not prevent him from leaving.R6's Nurse Note, dated 8/12/26 at 12:18 AM, includes Resident continues to be monitored for elopement risk and behavioral concerns, with one-on-one supervision maintained at all times as ordered. No behavioral concerns were reported by CNA staff during this shift. Resident accepted care and medications without difficulty and remained cooperative with staff. No exit-seeking behaviors or elopement attempts were observed by writer thus far this shift. Will continue one on one supervision and ongoing monitoring for any changes in behavior or safety status.R6's Nurse Note, dated 8/12/26 at 1:00 PM, includes CNA informed writer R6 was missing. All staff searching grounds. Non- Emergency police notified and DON B notified.R6's Elopement Evaluation, dated 8/12/26 at 1:44 AM, includes: The resident is independently mobile, with or without an assistive device (including wheelchair). The resident exhibits wandering behavior. It is unknown if wandering behavior is goal-directed or non-goal-directed. Wandering behavior is not likely to affect the safety or well-being of self/others. Wandering behavior is not likely to affect the privacy of others. The resident has a cognitive impairment or diagnosis with impaired judgement or wayfinding (e.g., dementia, Alzheimer's disease, delirium, psychosis, severe mood disorder). History of elopement at home. History of / attempted leaving the facility without informing staff. The family or responsible party expressed concern that the resident may attempt to leave the facility unsafely. Resident verbally expressed the desire to go home, packed belongings to go home, or stayed near an exit door. The resident has been admitted or readmitted within the last 30 days and demonstrates difficulty accepting the current care setting. Elopement Score: 7.0.Facility Self-Reported Incident, dated 8/12/26 at 1:39 AM, includes: . R6 exited the facility through an exterior door, activating the door alarm. Law enforcement was notified and located R6. Upon return, pain and skin assessments were completed. One on one initiated.R6's Elopement Timeline, includes date of incident- 8/12/26. 12:30 AM CNA N (Certified Nursing Assistant) completed a 15-minute check. R6 was in bed. CNA N moved on to care for another resident. 12:40 AM The same CNA (CNA N) saw R6 walking past a room while providing care. He was wearing a gray t-shirt, blue jeans, sneakers, and carrying a bag and a cup. CNA N assumed he was going to get ice as was his usual routine. No immediate concerns noted. 12:45 AM After finishing care, CNA N did not see R6 in the hall. She went to his room and he was not there. CNA N notified the nurse who also had not seen R6. At about the same time, a door alarm was heard, but the specific door was unknown. Staff assumed the alarm was likely R6's exit. 12:46 AM Staff began searching inside of the facility, focusing on exit doors and areas R6 typically walked by. Around 12:47 AM The nurse instructed CNA N to get additional staff. CNA N ran to the other side of the facility, notified other CNAs and asked if anyone had seen R6. No one had seen him. Around 12:48 AM Staff expanded the search to outside areas through front and side exit doors. Around 12:49 AM -12:50 AM The nurse called law enforcement and notified NHA A and DON B to report the situation. 1:03 AM According to police report, R6 was located walking on the side of the road at 1076 [NAME] St., across the street from a cemetery.Police Report Log, dated 8/12/26, includes: 12:59 AM missing adult priority 1. 1:03 AM Officer out with R6 on [NAME] Street. At 1:04 AM Officer in front of 1076 [NAME] Street. 1:07 AM Officer in route to the Health Care Center with R6. 1:11 AM R6 had a small abrasion on his left elbow. He fell. That appeared to be his only injury. Officer took picture. R6 was turned over to nursing staff. R6's Comprehensive Care Plan, updated 8/12/26 to include: one on one at all times.On 8/17/26 at 2:47 PM CNA N indicated on 8/12/26 R6 was a 15- minute watch and at 12:30 AM she went into R6's room. CNA N indicated R6 was asleep in his room, so she went to assist another resident with cares. CNA N stated, I had the curtain pulled and I saw R6's feet go by. I looked out and he had a bag and a cup. I thought nothing of it, because he does go to get ice from the nurse station a lot. When I was done assisting, I went to check on him. He was not there. I asked the nurse if she saw him. She told me about the door alarm that was going off. Then she told me and another CNA to go look for him. We separated to look. The nurse called police. They found him a block away and brought him back. His arm was scratched up from the bushes or maybe a fall. R6's Nurse Notes, dated 8/13/26 at 1:37 PM, include Resident continues to require continuous one on one supervision for safety related to elopement risk and history of behavioral concerns. Resident has been pleasant and redirectable throughout the shift, with no behavioral episodes reported by CNA staff. Medications and routine care were accepted without resistance. No wandering, exit-seeking, or attempts to leave the facility have been noted by writer. Safety precautions remain in place as ordered. Will maintain one on one observation and continue to assess for changes in behavior or safety needs.On 8/17/26 at 11:23 AM CNA N indicated R6 is very outgoing, busy, and determined. CNA N indicated R6 requires redirection a lot as he is talking about the need to get home or leave the facility. CNA N indicates she uses distractions like talking about sports, R6's sister, or R6's friends. CNA N indicated the schedule reflects who is assigned to be one on one each shift.R6's Nurse Notes, dated 8/16/26, include: 6:44 AM Resident slept through the night. Remains on one-on-one. 10:58 PM Remains on one-on-one. No attempts to elope, no concerns. R6's Nurse Note dated 8/17/26, includes: 11:53 AM Resident remains on continuous one on one supervision for ongoing safety concerns related to elopement risk. Resident has been calm and cooperative throughout the shift, interacting appropriately with staff and accepting scheduled medications and routine care without resistance. CNA staff reported no behavioral concerns. No wandering, exit seeking, or attempts to leave the facility were noted. Current safety interventions remain in place. Will maintain continuous observation and continue to assess resident for changes in behavior, elopement risk, or overall safety status.R6's Nurse Note dated 8/17/26, includes 4:35 PM Writer took the taste testing activity to resident today in his room. He enjoyed getting to try the different pretzels and getting to rate them. When he was done, he did go in and out of activity room (across the hall from his room) the remaining time but kept to himself and his one-on-one. On 8/18/26 at 10:01 AM CNA M indicated she was assigned to be one on one with R6 on 8/17/26 and he wanted to leave a bunch of times. CNA M stated, He did make an exit at around 2:30 PM and 3:00 PM. He went out the door by the shower room. He wanted to leave. Did not want to be here. I followed him out and I told him if he didn't come back in, I would have to call the police. I would have been walking with him to wherever if he wouldn't come back in. He came back in. CNA M also indicated the therapy department saw R6 go out. They called NHA A right away. When he started pushing on the door, CNA M called out for help. Another resident witnessed this and told the therapy staff CNA M needed help. CNA M indicated the facility does not have walkie talkies or phones, so staff need to keep their personal cell phones on them all shift to communicate. CNA M indicated she does not chart in R1's medical record that he got out the door or he talks about leaving, but she does report to her nurse who should be charting these incidents. CNA M indicated there was another time R6 wanted to walk the hallway and they did. This time, CNA M stated, He didn't try to exit. CNA M indicated R6 did fall asleep around 7:00 PM and then at 8:30 PM the nurse came in with meds and woke him up. CNA M stated, He woke up and thought his call light was a headlight, and he needed to turn it on. Around 9:00 PM R6 wanted to exit again. We redirected him before he got out. CNA M indicated when she takes breaks the nurse takes over for her as one on one with R6. CNA M stated, His sister talked to us on the phone and said he likes horses, racing cars/Nascar, and watching fishing on TV.(It is important to note R6's medical record does not reflect this incident when R6 got out of the door but was able to be redirected back into the building. It is also important to note R6's medical record does not accurately reflect R6's exit seeking behaviors.) On 8/18/26 at 8:27 AM CNA O stated, He is adamant. When I worked with R6, on Sunday, he kept coming to the door with different clothes on and asking if his clothes were ok to weld in. I kept saying yes but we need to wait to hear from the boss. He stated he needed to get to his job in the morning. He believes he needs to go out to weld. I told the next shift he will try something and he did. On 8/17/26, he got out the door while CNA M was one on one with him. He got out but came back. CNA O also stated, The nurse needs to chart when he says he is waiting to get to job or needing to leave. They don't chart it, but they need to. CNA O stated, I did report exactly what happened Sunday night to the nurse and she is supposed to chart that.(It is important to note R6's medical record did not reflect his behaviors of getting dressed for work, his verbalizations of needing to leave, his actions of coming and staying by exit doors or when he got out of the exit door and was redirected back inside of the building.) On 8/18/26 at 7:30 AM Activity Director C indicated there is zero activity attendance charted on R6. Activity Director C indicated the facility does not track refusals of group activities or attempts made to invite R6 to group activities. Also, Activity Director C indicated she did not know she could chart individual activities that CNA staff do with R6. Surveyor asked how Activity Director C knows her plan of care is appropriate for R6. Activity Director was unsure. Surveyor asked what data Activity Director C was collecting to measure the care planned goals for R6. Activity Director C was unsure. Surveyor discussed with Activity Director C the importance of measuring effectiveness of personalized interventions and using collected data to decide if R6's goals are being met. Activity Director C agreed that activity therapy plays an important role in the facility's IDT when it comes to reducing falls, reducing elopements, reducing unnecessary medication use, and personalizing staff/resident interactions.On 8/18/26 at 10:41 AM NHA A and DON B indicated if R6 gets out the door staff have to follow him outside. DON B stated, I don't expect staff to document if he is talking about leaving to his sisters or gets outside but not off of the premises. Staff should not document when he talks about eloping. It is not an elopement when we have a staff member with him, and he is still on the premises. Staff just tell me. Surveyor asked DON B how she tracks and trends R6's behaviors and elopement attempt to know if the plan of care is appropriate. DON B was unsure. DON B indicated she would consider tracking R6's behaviors to share with the IDT (Interdisciplinary Team) for tracking and trending. DON B indicated activity staff try to keep him involved in activities. Surveyor asked if she expects activity staff to document activity attendance, attempts, interventions, and their effectiveness. DON B indicated she does expect activities staff to chart R6's participation including refusals and attempts at inviting R6 to activities. DON B and Surveyor reviewed R6's activity attendance noting his medical record did not have any activity tracking. NHA A indicated he identified some deficient practice with his staff in response to R6's elopements. NHA A indicated staff did not initiate the code green as they were supposed to and some did not know how to tell which door alarmed so they had to go door to door looking for the one that was activated. NHA A indicated CNA P should have kept an eye on R6 instead of running back into the building, but he felt she was disoriented from R6 hitting her. NHA A also indicated CNA P should not have blocked the doors in a confrontational stance, but rather communicated with R6 on a solution, accompanied him, or followed from a distance and had more of a dementia care response/interaction. NHA A stated a staff member from the Activity Department talked with his sister to find out what activities he likes. NHA A indicated staff should be tracking what approaches they are trying and if they are effective or not. NHA A indicated R6's medical record should contain documentation of how many times R6 is attempting to go outside, talking about leaving, and it should reflect each time R6 gets out a door. NHA A indicated this documentation would show trends and track if interventions were successful or if the plan of care needed adjustments. NHA A indicated staff need to chart when they see a resident staying near an exit door, see them with their belongings packed up, or are verbalizing that they are leaving or need to leave. Then NHA A indicated staff should increase supervision when a resident starts to talk about leaving, is seen with his belongings, or is staying near an exit door. NHA A indicated he started education on 8/12/26 regarding these identified concerns. When discussing R6's elopement on 8/12/26, NHA A indicated R6 was able to exit through a malfunctioning door. The door was not locked/latched fully. The lock appeared to be broken. The alarm feature did sound when R6 went through the door. NHA A indicated staff did not call a code green on 8/9/26 or 8/12/26. NHA A stated, We started education on elopements right away. We did audits and drills. NHA A indicated some of the drills have been unsuccessful and he has been re-educating after each one. NHA A indicated the facility still needs to work on how staff can follow a resident outside and call for help. NHA A indicated walkie talkies have been considered, but the facility has some reservations regarding the use of them. NHA A indicated for now staff are using their personal cellphones for communicating.The facility's failure to supervise a resident who is at risk for elopement created a reasonable likelihood for serious harm, which created a finding of immediate jeopardy. The facility removed the jeopardy on 8/17/26 when it completed the following:On August 12th Facility-wide elopement drills began, the elopement policy was reviewed, staff education began on Elopement/Door alarms.On August 13 Staff supervision education beganOn August 14 Elopement risk assessments were completed for all residents with care plan updates, activity assessments were revised, and unannounced drills, quizzes, and audits were conducted to validate understanding and compliance.On August 15-17 Education continued. When drills failed, more education was given on missing residents/elopement procedures. Audits are ongoing. Drills are ongoing. All collected data will be reviewed by QAPI team. The facility's deficient practice continues at a scope/severity of D and includes the following examples:2.) Facility did not provide a policy related to Safe Smoking upon Surveyor request.R2 admitted to the facility on [DATE] with diagnoses of muscle wasting and atrophy, fracture of neck of right femur, contusion of right hip, alcohol abuse, alcoholic fatty liver and tobacco use.R2's care plan, initiated 5/20/26, includes Focus: Resident is an active smoker. Goal: Resident will adhere to smoking policies of the facility . Interventions: Educate resident on risks/health effects of tobacco use, educate resident/responsible party on the facility's smoking policy, Orient resident to smoking times and procedures, Smoking assessments to be completed per facility policy.R2's MDS (Minimum Data Set) with ARD of 5/27/26, indicates R2's cognition is intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15.R2's Smoking Safety Screen with Effective Date of 8/6/26 indicates question 8. Clinical considerations (as applicable): a. Requires supervision during smoking.On 8/18/26 at 7:22 AM Surveyor observed R2 smoking outside on facility grounds, behind a dumpster. Surveyor observed no staff to be present.On 8/18/26 at 7:24 AM Activity Director C and Surveyor observed R2 smoking outside the facility and outside of the facility's designated smoking area. Activity Director C indicated they were safe to smoke independently. Activity Director C and Surveyor entered the building.On 8/18/26 at 2:46 PM NHA A (Nursing Home Administrator) and DON B (Director of Nursing) indicated residents who are assessed and care planned to need staff supervision should not be smoking without staff supervision. 3.) R11 was admitted to the facility on [DATE] with diagnoses of Muscle Wasting and Atrophy, Type II Diabetes, Essential Hypertension, Peripheral Vascular Disease.R11's care plan, initiated 4/20/26, includes Focus: I am an active smoker. I have been educated on the detriments of smoking to my health and have been offered smoking cessation which I have declined. Goals: Resident will adhere to smoking policies of the facility. Resident will be able to smoke independently with staff assistance. Interventions: Educate resident on risks/health effects of tobacco use, educate resident on risks/health effects of tobacco use, ensure eyeglasses are being used, orient resident to smoking times and procedures.R11's MDS with ARD of 7/28/26, indicates R11's cognition is intact with a BIMS score of 15 out of 15.R11's Smoking Safety Screen with Effective Date of 4/20/26 indicates on question 9. IDT Determination a. Safe to smoke independently and b. Safe to smoke with supervision.On 8/18/26 at 7:22 AM Surveyor observed R11 smoking outside on facility grounds, behind a dumpster. Surveyor observed no staff to be present.On 8/18/26 at 7:24 AM Activity Director C and Surveyor observed R11 smoking outside the facility and outside of the facility's designated smoking ar

Based on interview and record review, the facility failed to protect a resident's (R2) right to be free from physical abuse from another Resident (R3) for 1 of 11 sampled residents. R3 had 5 verbal and physical altercations with other residents, including entering R2's room while he was sleeping and punching him 7-8 times in the jaw. The facility's failure to provide adequate supervision and protect residents from physical abuse created a reasonable likelihood for psychosocial harm, thus resulting in the finding of immediate jeopardy (IJ) that began on 8/4/26. Surveyor notified NHA A (Nursing Home Administrator) of immediate jeopardy on 8/18/26 at 4:07 PM. The immediate jeopardy was removed on 8/13/26). However, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Evidenced by: The facility policy, Abuse/Neglect/Exploitation, undated, states, in part: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident. and prevent abuse. Policy Explanation and Compliance Guidelines: . III. Prevention of Abuse, Neglect and Exploitation: The facility will implement policies and procedures to prevent and prohibit all types of abuse. B. Identifying, correcting and intervening in situations in which abuse. is more likely to occur with the deployment of trained. staff on each shift. and assure that the staff assigned have knowledge of the individual residents' care and behavioral symptoms. D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict. IV. Identification of Abuse, Neglect and Exploitation. A. The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal. physical abuse. B. Possible indicators of abuse include but are not limited to: . 5. Verbal abuse of a resident overheard. 6. Physical abuse of a resident overheard. VI. Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to. B. Examining the alleged victim for any sign of injury, including a physical examination. C. Increased supervision of the alleged victim and residents. D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. VII. Reporting/Response. 4. Taking all necessary actions as a result of the investigation, which may include, but are not limited to, the following: a. Analyzing the occurrence(s) to determine why abuse. occurred, and what changes may be needed to prevent further occurrences; b. Defining whether care provision should be changed and/or improved to protect residents receiving services. d. Identification of staff responsible for implementation of corrective actions.f. Identification of staff responsible for monitoring the implementation of the plan. R3 was admitted to the facility on [DATE] with diagnoses that include, in part: unspecified dementia, unspecified severity with agitation, Epilepsy, unspecified, altered mental status, unspecified, anxiety disorder unspecified, depression unspecified, personal history of traumatic brain injury, alcohol abuse uncomplicated, restlessness, and agitation, irritability and anger. R3 was admitted to the facility from the hospital. R3's hospital referral to the facility stated, Hx (history) of behaviors; currently manageable with medications. R3 has an activated Power of Attorney. R3's most recent Minimum Data Set (MDS), dated [DATE], indicates R3 has a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating R3 is severely cognitively impaired. Section E of R3's MDS states, in part: physical behaviors of hitting, kicking, grabbing etc. directed towards others 1 to 3 days. verbal behaviors of threatening, cursing etc. directed towards others 4 to 6 days. It was marked no for being a threat to others and no for wandering behaviors. R3's Social Services Initial Evaluation, dated 4/28/26, states, in part: Mood/Behaviors symptoms that include: Verbal behavior towards others, disruptive to others, impulsive, physical behavior towards others, argumentative, agitated. Mood/behavior symptoms have deteriorated over the past 6 months. R3's Comprehensive Care Plan, dated 4/20/26, states, in part: Focus: I sometimes have behaviors which include disruptive behaviors, Physical aggression (hitting, kicking, spitting), Verbal aggression (swearing). I will enter other residents' rooms.Interventions: Administer meds as ordered. Monitor and document for side effects and effectiveness. Assess and address for contributing sensory deficits. Discuss resident's behavior, explain/reinforce/ educate why behavior is inappropriate/unacceptable. Encourage resident to express feelings appropriately. Explain all procedures to the resident before starting and allow resident time to adjust to changes. Give resident personal space. Intervene as necessary to maintain safety of resident or others. Make sure I am not in pain or uncomfortable. Minimize potential for behavior by offering diversionary tasks. Modify environment to decrease sensory load, as much as possible. Monitor/document/report any s/sx (signs/symptoms) of resident posing danger to self or others. When resident becomes agitated: Intervene before escalation, engage calmly in conversation, if response is aggressive walk away and reapproach later. R3's physician orders upon admission include the following:-- Lorazepam Oral Tablet 0.5 MG *Controlled Drug*. Give 1 tablet by mouth as needed for Anxiety or agitation related to anxiety disorder unspecified. Take 0.5mg, two times daily, as needed. Start Date: 4/15/26-- Quetiapine Fumarate Oral Tablet 50 MG. Give 1 tablet by mouth three times a day for Depression adjunct, dementia related agitation related to Unspecified Dementia, Unspecified severity, with Agitation; Depression unspecified. Take 50mg TID (three times a day). Start Date: 4/15/26-- Lacosamide Oral Tablet 200 MG *Controlled Drug*. Give 1 tablet by mouth two times a day related to Epilepsy unspecified. Start Date: 4/15/26--Perampanel Oral Tablet 6 MG *Controlled Drug*. Give 1 tablet by mouth at bedtime related to Epilepsy unspecified. Start Date: 4/15/26-- Clobazam Oral Tablet 10 MG *Controlled Drug*. Give 1 tablet by mouth two times a day related to Epilepsy unspecified. Start Date: 4/15/26 A review of R3's EHR (Electronic Health Record) includes the following progress notes:On 4/15/26 at 8:04 PM, .Resident arrived to facility. scant amount of agitation noted. refused to allow writer and supervisor to perform skin check d/t (due to) aggressive behavior.On 4/17/26 at 1:08 PM, . Res(resident) remains to have verbal outbursts.On 4/18/26 at 2:47 PM, . restless, agitated, combative, attempting to stand despite attempts at safety teaching, distraction and redirection. he is repeatedly attempting to hit at staff, punch, swearing. DON (Director of Nursing) request for send out d/t (due to) his agitated behaviors and risk of safety to self and staff.On 4/22/26 at 1:15 AM, Resident constantly trying to stand. Yelling profanity. Lorazepam given but ineffective. Magazines, snack, and drink provided. Will monitor closely.On 4/22/26 at 10:01 PM, Patient on report for Behaviors. Patient had one episode of yelling out this shift.On 4/24/26 at 1:18 PM (physiatry progress note), . History of present illness. Patient with worsening behaviors and confusion. experienced progressive cognitive and behavioral decline over the past year marked by increasing episodes of anger, combativeness, and violent behavior. The facility completed a self-report/incident investigation which states that on 6/8/26 at approximately 9:02 AM, staff observed a resident-to-resident altercation involving R3 and R10. CNA (Certified Nursing Assistant) observed R3 standing at R10's bedside while R10 was lying in bed. Both residents were observed striking each other with open hands. Staff immediately intervened and separated the residents. Assessments were completed. Law enforcement was contacted. R10 was noted to have an abrasion to his cheek. No injuries noted on R3. R3 was relocated to another room and placed on 1:1 supervision pending further evaluation. Care plans reviewed and updated. R3 unable to recall the incident d/t (due to) cognitive impairment. The IDT (Interdisciplinary Team) reviewed R3's history of dementia with agitation and physically aggressive behaviors, evaluated existing interventions and implemented additional monitoring and supervision measures to reduce the risk of future resident-to-resident altercations. Staff continue to monitor both residents and evaluate intervention effectiveness. On 8/18/26 at 9:28 AM, Surveyor interviewed CNA H (Certified Nursing Assistant) about the incident between R3 and R10 on 6/8/26. CNA H indicated that R3 and R10 were roommates at the time of the incident. CNA H stated that she was working that day, and she heard a commotion while coming up the hallway. CNA H stated she went into their room to see what was happening, and she saw that R3 had gone through the barrier curtain that was separating the two sides of the room. CNA H indicated that she saw that R3 was leaning over R10 who was in bed, and that R3 was slapping R10, and that R10 was slapping R3 back in attempt to defend himself. CNA H stated that she immediately tried to separate R3 and R10 and that she yelled for assistance. CNA H indicated that her and her co-worker were able to get R3 into his wheelchair and redirect him away from R10. (Of note, R10 no longer resides at the facility.). R3's Progress Notes indicate the following:On 6/8/26 at 1:47 PM, Resident was placed on 1:1 supervision following a resident-to-resident altercation due to exhibiting aggressive behaviors. Resident was closely monitored throughout the observation period. Resident demonstrated a calm demeanor, and no further aggressive behaviors were observed prior to discontinuation of the 1:1 supervision. Resident remained in his room for the remainder of the day and was cooperative with staff. Staff will continue to monitor resident behaviors and assess for any changes in condition. IDT reviewed and in agreement.On 6/10/26 at 6:26 AM, .resident continues with behaviors yelling abusive language refusing cares wandering walking without assistive devices and on his own not easy to redirect .On 6/10/26 at 10:31 PM, Resident exhibited occasional verbal outbursts during the shift but was easily redirected by staff. Resident was noted wandering in hallways and entering other residents' rooms throughout the shift. Redirection and supervision provided as needed. Will cont(continue) to monitor. On 6/23/26, R3's Comprehensive Care Plan was updated to include the following interventions:Provide frequent orientation and reminders regarding resident's current room location.Reinforce positive behaviors when resident independently locates and enters the correct room. R2 was admitted to the facility on [DATE], with diagnoses that include, in part: Muscle wasting and atrophy, fracture of unspecified part of neck of right femur, and alcohol abuse. R2's MDS dated [DATE] indicates that R2 has a BIMS score of 15 out of 15, indicating that R2 is cognitively intact. The facility completed a self-report/incident investigation that stated on 7/1/26 at 10:45 AM, staff heard yelling from the area of room [Resident Room Number] and responded. The concern involved a resident-to-resident interaction between R3 and R2. Staff observed R2 standing with his wheelchair and moving it toward R3 however staff did not observe the wheelchair make contact with R3. Staff also observed R3 swing towards R2 and attempted to grab at R2 however staff did not observe physical contact. Staff immediately separated both residents. R3 was assisted back to his room, was easily redirected and remained calm following this interaction. Law enforcement contacted. Pain and skin assessments completed on both residents. R3 unable to recall the incident and stated he did not remember entering another resident's room. R2 stated R3 entered his room and did not leave when asked. R2 stated that he felt as though he had to be on guard but that he is currently doing fine. R3 was placed on 15-minute checks for monitoring and safety. R2 was provided a stop sign for his door. Residents educated on what to do if a disoriented resident enters their room, and residents signed an attestation related to how to speak to an uninvited guest/resident. Staff educated and care plans updated related to incident. Education was signed by 10 CNA's (Certified Nursing Assistants) and 4 nurses. R2's Trauma Informed Care Assessments indicate the following:On 7/1/26: A. PTSD Screen. 1. Have you experienced this kind of event? Yes was marked. B. PTSD Interview: In the past month have you. 3. Been constantly on guard, watchful, or easily startled? Yes was marked.(Of note, R2's previous assessment, dated 5/22/26 was marked No to having experienced a PTSD event.) R3's Progress Notes indicate the following:On 7/1/26 at 2:26 PM (social service note), Writer talked with resident about incident withother resident. Resident could not remember what occurred. Resident stated he did not remember going into another resident's room.On 7/1/26 at 8:48 PM (eMAR: electronic Medication Administration Record note), . Resident was yelling toward staff and pt (patient) who was walking by or close by, repeating his usual phrase while swearing.On 7/3/26 at 10:30 AM (late entry IDT note), : IDT met to review 15 min(minute) checks, no other incidents observed. Resident cooperative and easily redirectable. Education to residents in facility on steps to take when resident (any) enters rooms mistakenly to prevent confrontation. 15 min checks discontinued. Plan of care reviewed with MD (Medical Director) and POA (Power of Attorney) . On 8/18/26 at 10:10 AM, Surveyor interviewed DON B (Director of Nursing) about what interventions were put in place to keep residents safe after this incident. DON B indicated that R3 was placed on 15-minute checks for 3 days and R3's behaviors were fine, so they took R3 off 15-minute checks, which ended on 7/3/26. DON B stated that they did education with residents about what to do if another resident comes into their room, that they should call for help and not yell at them. DON B stated that R2 was offered a stop sign to place on his door. On 7/8/26, R3's Comprehensive Care Plan was updated to include the following interventions:Approach the resident with a calm, smiling, and reassuring demeanor during periods of agitation, as the resident is likely to mirror staff emotions and behavior. Use a soft tone of voice and non-threatening body language to help de-escalate the situation.When I seem agitated bring me by puzzles to complete.Attempt to re-direct resident prior to entering other residents' room. R3's Progress Notes indicate the following:On 7/9/26 at 8:09 PM, Resident's on 24 hour board for increased Seroquel; pt (patient) exhibited a few episodes of yelling this evening, consistent with baseline behavior.On 7/30/26 at 3:31 PM, SWEARING AND YELLING AT STAFF. HE REFUSED ANY FURTHER BATHING.On 7/30/26 at 4:33 PM (eMAR note), SCREAMING AND SWEARING AT STAFF. DIFFICULT TO REDIRECT. PRN GIVEN AND FAIRLY EFFECTIVE FOR A BRIEF TIME. HAS BEEN GOING INTO OTHERS ROOMS AND LYING IN THEIR BEDS. WILL CONTINUE TO MONITOR CLOSELY AND PUT EYES ON HIM OFTEN.On 7/31/26 at 7:42 PM (eMAR note), resident being combative. On 7/31/26, R3's Comprehensive Care Plan was updated to include the following interventions:I am HOH (Hard of Hearing), I get frustrated when I don't understand what is being said to me. Talk slowly while facing me.Offer me a snack when I am agitated.Offer to rub my back when I am agitated.Offer to walk with me when I am agitated.When approaching me come alone, more than one person increases my agitation.Initiate 1:1 when resident is displaying behaviors that put him or others at risk such as unredirectable (sic) aggression. The facility completed a self-report/incident investigation that stated that on August 2, 2026, at approximately 10:00 AM, R3 entered room [Resident Room Number] occupied by R2 and R4. R3 entered in his wheelchair and stood next to R4's bed (by the door) while R2 and R4 remained in their wheelchairs. R2 and R4 yelled for R3 to leave. A CNA attempted to redirect R3 to his wheelchair, but he became combative and difficult to redirect. Additional staff responded and assisted R3 out of the room. R3 became increasingly agitated and attempted to re-enter the room and attempted to strike staff. R3 was returned to his room and calmed without further incident. The facility provided targeted education on de-escalation, including avoiding group approaches when possible, reducing environmental stimulation, redirecting other residents from the area, using calm therapeutic communication and avoiding confrontational statements. Education also addressed timely reporting of events to the NHA/DON (Nursing Home Administrator/Director of Nursing). Education was provided for 28 staff members. Stop signs were offered to 28 residents throughout the facility. Supervisory observation and ongoing education will continue. On 8/18/26 at 9:32 AM, Surveyor interviewed MT K (Medication Technician) about the incident between R2 and R3 on 8/2/26. MT K indicated that she was working that day and she was passing medications when she heard yelling coming from [Room Number]. MT K stated that she went to investigate and as she entered the room she heard R3 yell f*** you. MT K indicated that she tried to get R3 out of the room, but he was resistant and became combative. MT K yelled for assistance, and her and her co-worker were able to remove R3 from the room, although he remained aggressive, trying to hit her and her co-worker. MT K indicated that after they got R3 back to his own room he calmed down, and she went back to passing medications. On 8/18/26 at 10:10 AM, Surveyor interviewed DON B (Director of Nursing) about what interventions were put in place to keep residents safe after this incident. DON B indicated that R3 was removed from the room and placed on 1:1 monitoring immediately. R3's Progress Notes indicate the following:On 8/4/26 at 2:27 AM, Resident laid down with roommate in his bed. Staff attempted to redirect. Resident kicking, hitting, yelling, and swearing. Staff eventually got him up and into his own bed.On 8/4/26 at 5:32 AM, While 1:1 CNA was on break; writer was covering. Resident got past writer and entered [Resident Room Number]. He was trying to hit resident [R2]. Writer and other CNAs took [R3] out of room. Other resident (R2) denied being injured. Writer did not see resident [R3] strike [R2]. [R2] stated he is calling police. DON notified. The facility completed a self-report/incident investigation that stated that on August 4, 2026, at approximately 5:30 AM, the NHA and DON were notified that R3 entered [Resident Room Number] occupied by R2 and R4. The initial report stated a verbal altercation occurred, staff responded, residents were separated and R3 was removed. Responding staff did not observe a strike make contact. During follow-up, R2 reported R3 approached him and struck him on the left jaw 7-8 times while R2 attempted to block the strikes and yelled for help. R4 [R2's roommate] reported observing R3 move toward R2 and strike him. Review identified R3 had been assigned to 1:1 supervision, however the assigned RN (Registered Nurse) looked away for approximately three minutes while charting, during which R3 stood from his wheelchair and entered [Resident Room Number]. R2 reported that when R3 approached him, he positioned himself behind his wheelchair and used it as a barrier because he didn't want R3 to come close to him. R2 tried to block the strikes and stated he did not strike back. R4 observed the interaction and stated that R3 never approached or make contact with him, only with R2. Staff responded after hearing R2 yell for help and removed R3 from the room. Staff immediately separated the residents and resumed 1:1 supervision. R3 was relocated to a private room on the opposite side of the building and remained on 1:1 supervision. Skin, pain, and trauma assessments were completed for R2, R3 and R4 with no abnormalities noted. Psych services were offered and declined. Law enforcement and R3's POA was notified. Residents with a BIMS score below 12 received skin checks and residents with a BIMS score of 12 and above were interviewed. Staff were interviewed. Care plans were updated. Facility wide education was initiated regarding 1:1 supervision, care plans, stop signs and redirection including quizzes and competency review. Education was completed by 27 staff members. Daily audits were initiated with review by the NHA or designee. R2's Trauma Informed Care Assessments indicate the following:On 8/4/26: A. PTSD Screen. 1. Have you experienced this kind of event? Yes was marked. B. PTSD Interview: In the past month have you. 3. Been constantly on guard, watchful, or easily startled? Yes was marked. On 8/17/26 at 10:42 AM, Surveyor interviewed R2 and R4 about the incident with R3. R2 stated that R3 had come into their room several times before this happened, and was loud and screaming obscenities, but that he hadn't gotten physical before. However, R2 stated that this time R3 entered the room in the middle of the night while he was asleep and the room door was closed. R2 indicated that R3 just started punching him in the face. R2 indicated that he didn't fight back because R3 is an older man and he didn't want to hurt him. R4 recalled that it was very early in the morning and the door to their room was closed. R4 stated that his bed faces the door, and that R3 entered their room and didn't say or do anything to him but walked in and started attacking R2. R4 stated that he saw R3 punch R2 several times without R2 hitting back. On 8/17/26 at 1:16 PM, Surveyor interviewed CNA G (Certified Nursing Assistant) about the incident between R2 and R3 on 8/4/26. CNA G stated she was working that NOC (overnight) shift and was assigned to be 1:1 with R3 but that she had gone on break when the incident happened. CNA G stated that when she came back from break, staff were already in the room separating R2 and R3, but that she heard that R3 was punching R2 in the face, and that earlier in the shift R3 had punched her in the face when she was trying to assist him back to bed. CNA G indicated that R3 was frequently aggressive with staff, hitting and kicking them when they were helping him. CNA G indicated that even when the schedule indicated that R3 was to have 1:1 supervision, she was told that on the NOC shift the staff could leave the room if he was sleeping and only perform 15-minute checks on R3 instead. CNA G indicated that R2 was mostly independent and minded his own business.On 8/17/26 at 11:39 AM, Surveyor interviewed LPN E (Licensed Practical Nurse) about the incident between R2 and R3 on 8/4/26. LPN E stated that she was working that night when CNA G went on break. LPN E stated that it was between 4:00 and 5:00 AM, and she had R3 in the common area in front of the nurse's station, and that she gave him a snack and a drink. LPN E indicated that R3 was calm and respectful at that time, so she sat down approximately 20 feet away in the nurse's station to complete some charting. LPN E indicated that R3 was within eyesight of her while she was sitting in the nurse's station, but that she looked away for about 2 or 3 minutes, and the next thing she knew she heard a noise coming from down the hall and R3 was no longer sitting at the table. LPN E stated that she ran down to R2's room and that she saw R3 trying to attack R2. LPN E stated that she didn't see any physical connection, and that R2 had his wheelchair between himself and R3 to act as a barrier. LPN E indicated that R2 was saying, he's punching me, get him out of here, and that R3 wasn't saying anything, just swinging out at R2. LPN E stated that R3 was attempting to strike R2, so she went over and held R3 by the arms and attempted to steer him away from R2. LPN E indicated that by that time the other aides were in the room helping, so she went back to the nurse's station to notify the DON. LPN E stated that she had never seen R3 go into R2's room prior to this incident, but that he had gone into other resident's rooms and one time it took 4 staff members to remove R3 from another resident's bed. LPN E stated that R3 could be pretty ferocious, and that he swears at staff and tries to hit and kick them. LPN E indicated that R2 was very pleasant to staff and residents and that she never had an issue with him at all. On 8/17/26 at 11:51 AM, Surveyor interviewed CNA F about the incident that happened between R2 and R3 on 8/4/26. CNA F stated that she was working that night but that she really didn't witness much, as she was working [NAME] different hallway. CNA F stated that she saw R3 walking down the hallway and go into a room that wasn't his, and then she heard yelling. CNA F indicated that by the time she entered R2's room, the nurse was already in there, and so she assisted in getting R3 off R2, but she didn't see R3 hit anybody. CNA F stated that as far as she knew, R2 normally gets along well with all the other residents. On 8/18/26 at 8:05 AM, Surveyor interviewed CNA L about the incident that happened between R2 and R3 on 8/4/26. CNA L stated that she was working that night but did not witness the actual altercation. CNA L stated that she heard R3 yelling fuck you and saw other staff entering [Room Number], so she figured everything was under control. CNA L indicated that there had been another incident with R3 where he had gotten into another resident's bed and was incontinent of stool. CNA L stated that when her and the nurse attempted to remove R3 from the other resident's bed, he was yelling fuck you at them and swinging out at them, as well as kicking his legs and hitting the other resident who was asleep in the bed. CNA L stated that R3 was often aggressive with staff, especially during cares or redirection, and that night of 8/4/26, R3 had hit CNA G in the nose when she was attempting to help him. CNA L stated that R2 mostly stays in his room and minds his own business. On 8/18/26 at 11:20 AM, Surveyor interviewed R2 and R4 again about the incident with R3. R2 indicated that generally he does feel safe at the facility, but that he is angry about the situation because management did not do anything to prevent R3 from coming into their room multiple times. R2 stated that the stop banner over the door was only put up after he had been assaulted, and that it really is not effective as a deterrent if someone can't read it. R2 stated that they also did not move R3 to a different part of the building until after this incident. R2 stated that he was woken from a dead sleep with a shadowy goblin looking creature coming at him, and that nobody should have to deal with that. R2 stated that when he jumped out of bed to defend himself, he jarred his leg that is healing from a fracture, and he had some pain from that for a few days. R2 stated that his face was red and swollen from being repeatedly punched, and that the police officer took a picture of his face. R4 stated that he feels like he has to watch the door all the time now to make sure that no one comes in. R4 indicated that he does not feel safe in the facility, as he can't get up and protect or defend himself. R4 stated that he feels like anyone could come into his room in the middle of the night and beat him with a stick if they wanted to, and that the facility didn't seem to do anything about R2 being assaulted. R4 stated that the stop signs over the door don't mean much if other residents just come in anyway, even with the door closed. It would be reasonable that R2 experienced psychosocial harm from the altercation with R3 as evidenced by R2's trauma screen: Have you experienced this kind of event? Yes . B. PTSD Interview: In the past month have you. 3. Been constantly on guard, watchful, or easily startled? Yes, stating he feels he has to be on guard at all times and does not feel safe. A resident should feel safe in their own home and not feel as if they need to be on constant guard or fear of being physically abused. On 8/18/26 at 12:37 PM, Surveyor interviewed LPN H about the incident that happened between R2 and R3 on 8/4/26. LPN H stated that she was working that night and while she was at the nurse's station she heard R3's voice yelling down the hallway, which is normal, but then she heard another voice yelling too so she ran down the hall to investigate. LPN H indicated that she entered R2's room and saw R2 standing behind his wheelchair, and R3 was attempting to lean over the wheelchair and hit R2. LPN H stated that R2 and R3 were both yelling at each other, and that she asked R2 to calm down because R3 was not with it. LPN H indicated that, with the help of one of the CNAs she was able to get R3 in the wheelchair, but when they got to the doorway, R3 stuck out his arms on the door frame and was fighting them to stay in the room. LPN H stated that they were finally able to calm R3 down and get him back to his own room. LPN H stated that she was aware of a prior incident with R3 and his roommate, but that R2 had never had a prior incident with any of the other residents. On 8/18/26 at 12:40 PM, Surveyor interviewed LPN/UM I (Licensed Practical Nurse/Unit Manager) about the incident that happened between R2 and R3 on 8/4/26. LPN/UM I stated that she did work that day, but that she did not witness the altercation. LPN/UM I indicated that R3 was supposed to be on 1:1 monitoring at the time of the altercation. LPN/UM I stated that on that day there was also another resident who was 1:1 and she was monitoring the other resident. LPN/UM I stated that she had not worked much with R3, as he had moved off her hallway after a short time, but that R2 was always very pleasant and friendly. LPN/UM I stated that R2 told her he had increased pain in his leg after the incident, and that they were addressing that with pain medication. A police report, provided to surveyor by the facility, states that on 8/4/26 at 5:32 AM, [Police Department] was contacted by R2 with a complaint of disorderly conduct. The police report states, in part: . physically attacked by another resident / states staff would not call 911 to make a report. [Police Department] responded to the call and was on scene at the facility at 5:44 AM. On 8/18/26 at 11:43 AM, Surveyor left a voicemail message with [Police Department] but did not receive a call back or any additional documentation. R3's Progress Notes indicate the following:On 8/5/26 at 2:02 AM, Res(ident) continues to be 1 on 1. At the beginning of shift (resident) yelling out and swearing. On 8/6/26 R3's physician orders were updated to include:--Citalopram Hydrobromide Oral Tablet 10 MG. Give 1 tablet by mouth one time a day for Anxiety and agitation related to anxiety disorder unspecified, Restlessness and agitation. Take 10mg daily. On 8/7/26, R2's Comprehensive Care Plan was updated to include the following:Focus: I sometimes have behaviors which include screaming and cursing when my peers enter my room uninvited. I choose not to see psych services to assist with my mood Interventions: Discuss resident's behavior, explain/reinforce/ educate why behavior is inappropriate/unacceptable. Encourage resident to express feelings appropriately. Give resident personal space. Psychology/psychiatry consult as ordered. R2's Trauma Informed Care Assessments indicate the following:On 8/7/26: A. PTSD Screen. 1. Have you experienced this kind of event? Yes was marked. B. PTSD Interview: In the past month have you. 3. Been constantly on guard, watchful

Based on interview and record review, the facility did not complete a thorough investigation in response to an allegation of neglect for 1 of 5 residents (R5) reviewed for abuse out of a total sample of 15.On 7/21/26, the facility became aware of an allegation of neglect for R5. The facility did not interview staff as part of their investigation.Evidenced by:The facility's Abuse/Neglect/Exploitation policy, dated 11/25, states, in part: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: . Neglect means 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. V. Investigation of Alleged Abuse, Neglect and Exploitation .4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; .R5 was admitted to the facility on [DATE] and has diagnoses that include: Chronic Obstructive Pulmonary Disease; Muscle wasting and atrophy; depression; obesity.R5's MDS (Minimum Data Set) dated, 6/4/26, indicates a BIMS (Brief Interview for Mental Status) score of 11, which indicates the resident has moderate cognitive impairment.A facility self-report indicates that on 7/21/26 the facility learned of an allegation that R5 had a wound that wasn't being addressed, had odor and long toenails, and did not have an appropriate place to sleep. On 8/17/26 at 2:25 PM, Surveyor interviewed NHA A (Nursing Home Administrator) regarding the self-report and asked if this was an allegation of neglect. NHA A stated yes. Surveyor asked what is done when there is an allegation of neglect. NHA A stated we start an investigation; interview the resident, get a statement from the reporter, contact law enforcement, and self-report. Surveyor asked if staff are interviewed as part of the investigation. NHA A stated yes. Surveyor asked if staff were interviewed. NHA A stated I'd need to look.On 8/18/26 at 8:50 AM, Surveyor interviewed NHA A who stated that staff were not interviewed as part of the investigation and should have been.

Based on interview, and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, for 1 of 3 Residents (R12) reviewed out of total sample to 15 residents. R12 sustained a fall, R12 was not assessed by an RN (Registered Nurse) and neuro checks were not completed following the fall. 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. The facility's policy, Fall Management Process, undated, documents in part as follows: In the event a resident has fallen and/or is found on the ground, a complete head-to-toe assessment must be performed prior to moving the resident unless life-threatening safety concerns are present (fire, highway etc.). Remain with the resident while calling for assistance, if at all possible. Upon arrival of the nurse, a quick head-to-toe scan will be performed without unnecessary movement, palpating and examining all areas for breaks in the skin and/or other abnormal findings. Obtain neurological checks (neuro-checks) per policy for unwitnessed fall or any fall with evidence of injury to head. R12 was admitted to the facility on [DATE] with diagnoses including, but not limited to, as follows: cerebral infarction, acute respiratory failure with hypoxemia, diabetes mellitus, diabetic neuropathy, dissection of descending thoracic aorta, and traumatic ischemia of muscle.R12 has an APOAHC (Activated Power of Attorney for Health Care). R12 resided at the facility on 8/3/26 from approximately 1:45 PM to approximately 10:00 PM. R12's comprehensive care plan documents as follows: (Date Initiated: 8/3/26) Focus: At risk for falls related to left side deficit r/t (related to) CVA (Cerebrovascular Accident/stroke), other weakness with staff assistance required. Goal: No serious fall related injuries. Interventions: Call light at personal items available and in easy reach; Encourage participation in activities to improve strength or balance; Encourage rest periods if feeling fatigued; Keep bed locked; Keep environment well-lit and free of clutter. R12's comprehensive care plan documents as follows: (Date Initiated: 8/3/26) Focus: I have a physical functioning deficit related to: Mobility impairment, Self care impairment due to weakness, left side deficit r/t CVA (Cerebrovascular Accident/stroke), and need for staff assistance. Goal: I will improve my current level of physical functioning. Interventions: Assistive device wheelchair; Bed mobility assistance of 1; Call bell within reach; Dressing assistance of 1; Easting assistance of 1 dependent with tube feedings (NPO) (nothing by mouth); Oral care assistance extensive 1; Personal hygiene assistance of extensive 1; Rehab therapy services as ordered; Transfer assistance of 2 full body lift. On 8/3/26 LPN Q (Licensed Practical Nurse) documented the following Fall.8/3/26 9:15 PM - Description: writer entered resident's room to answer call light, resident noted on floor sitting on buttocks. Incontinence pads dry, gripper socks noted to bilateral feet. Resident last seen by CNA (Certified Nursing Assistant) around 9:00 PM, incontinent cares provided at that time. No complaints of pain or discomfort noted at this time. ROM (range of motion) is WNL (within normal limits). Resident assisted into bed via hoyer and two staff, all commonly used items within reach. Neuro checks started.Was this incident witnessed: N (No)Resident Taken to Hospital: NoInjury: No injuries observed at time of incidentLevel of Consciousness: AlertMobility: Transfer with assistMental Status: Oriented to Person and PlacePredisposing Environmental Factors: None selectedPredisposing Physiological Factors: Gait imbalance; Impaired Memory, ConfusedPredisposing Physiological Factors: None selectedPredisposing Situation Factors: admitted within last 72 hoursPeople Notified: DON B (Director of Nursing) and APOAHC (Activated Power of Attorney for Health Care)Notes: Resident was newly admitted to the facility approximately 5 hours prior to the fall. Resident is primarily Spanish speaking and requires a Hoyer lift for transfers and assistance of one staff member with bed mobility. Resident has diagnoses including cerebral infarction, dysphagia, diabetes mellitus, and hypertension. Resident was found sitting on the floor next to the bed. Residents (family member) had recently left the facility prior to the incident. Resident was just checked on 15 minutes prior to fall. Resident stated that she was attempting to get out of bed to follow her (family member) when the fall occurred. Resident was assessed following the incident, and the provider was notified. Resident was sent to the emergency room for further evaluation. Current fall interventions remain in place. New interventions include a room change for increased safety and placement of a fall mattress on the floor next to the right side of the bed. On 8/26/26 at 1:55 PM, Surveyor spoke with LPN Q (Licensed Practical Nurse). Surveyor asked LPN Q if she recalls R12. LPN Q stated, yes. LPN Q stated that staff were in and out of R12's room constantly as she was pushing her call light frequently. LPN Q stated, when R12 fell she discovered R12 on the floor. LPN Q stated that she notified LPN Spv R (LPN Supervisor). LPN Q stated, she observed R12 sitting straight up while seated on the floor. Surveyor asked LPN Q, how soon did EMS (emergency medical services) arrive after R12 fell. LPN Q stated, approximately 15-20 minutes. LPN Q stated that she did not observe any bruises, bumps, abrasions and checked R12's head. LPN Q stated that there was no sign of injury. Surveyor asked LPN Q, did the facility start neuro checks. LPN Q stated, as far as she knows, yes. On 8/27/26 at 10:20 AM, Surveyor spoke with LPN Spv R. Surveyor asked LPN Spv R if she recalls R12. LPN Spv R stated, yes. Surveyor asked LPN Spv R if R12 had any falls during her stay at the facility. LPN Spv R stated, yes, one (1) fall. LPN Spv R stated, LPN Q (Licensed Practical Nurse) came and got her as she was supervisor that night. LPN Spv R stated that she observed R12 lying on the floor on her right side. LPN Spv R stated, R12 fell from bed. Surveyor stated to LPN Spv R, R12's fall is documented as occurring at 9:15 PM, is that correct. LPN Spv R stated that sounds accurate. LPN Spv R stated that we were not aware R12 contacted her APOAHC (Activated Power of Attorney for Health Care) who called 911 following the fall, until EMS (emergency medical services) walked through the door. Surveyor asked LPN Spv R, was there an RN working in the facility at the time of R12's fall. LPN Spv R, stated, I don't think so not that shift. Surveyor asked LPN Spv R, who assessed R12 following the fall. LPN Spv R stated, We (Licensed Practical Nurses) did our little make sure everything is movable, used the Hoyer to get her off the floor. LPN Spv R added that we called DON B (Director of Nursing). Surveyor asked LPN Spv R, did you contact DON B before or after R12 was moved via Hoyer back into bed. LPN Spv R stated, I'm not sure if it was before. LPN Spv R stated that she is unsure if anybody called an RN (Registered Nurse) for instructions before moving R12 off the floor. Surveyor asked LPN Spv R what is the facility policy regarding moving residents off the floor following a fall. LPN Spv R stated, I'm not for sure. Surveyor asked LPN Spv R were neuro checks started. LPN Spv R stated, no, we did not have time because the ambulance came right away. Surveyor asked LPN Spv R, did the facility investigate or educate staff regarding falls and procedures following R12's fall. LPN Spv R stated, no, there was no education regarding R12's fall. It is important to note; there is not an RN (Registered Nurse) working on the PM shift.On 8/27/26 at 11:40 AM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B if she identified any areas of concern regarding R12's fall. DON B stated, no she did not identify any areas of concern nor provide any education to staff. On 8/27/26 at 12:25 PM, Surveyor spoke with DON B (Director of Nursing) and Corporate Consultant D. Surveyor asked DON B, when a resident falls what do you expect staff to do. DON B stated, assess for injuries, notify the provider, notify the POA (Power of Attorney), and obtain vital signs. Surveyor asked DON B, should an RN (Registered Nurse) assess a resident that has fallen prior to moving them off the floor. DON B stated, yes. DON B stated, in the evening the facility utilizes a contracted video provider that can assess the resident if there is no RN in house. Surveyor asked DON B if it is acceptable to move a resident off the floor prior to being assessed by an RN. DON B stated, no. Surveyor asked DON B, did staff notify you when R12 was on the floor or after they moved R12. DON B stated that she was notified by staff after R12's APOAHC (Activated Power of Attorney for Health Care) called 911 and EMS was at the facility. Surveyor shared with DON B, based on Surveyor's interviews, LPN Q and LPN Spv R transferred R12 off the floor with a Hoyer and back into bed with no documented RN assessment and no documented neuro checks. Surveyor stated to DON B that R12 is receiving a blood thinner. Surveyor asked DON B what should staff have done following the fall. DON B stated usually we leave it at the provider's discretion. Corporate Consultant D stated that we encourage the provider to send resident out of testing when they are receiving a blood thinner. DON B stated an RN, or video provider should have assessed R12 before staff moved her off the floor and back into bed and neuro checks should have been started.

Based on observation, interview, and record review, the facility did not ensure that snacks were provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care for 1 of 1 resident (R12) reviewed for snacks out of a sample of 19. R12 did not receive a snack at 2:00 PM as ordered. This is evidenced by: The facility's policy, titled Therapeutic Diets, undated, states the following, in part: Policy Statement: Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. Policy Interpretation and Implementation: 1. Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. Diagnosis alone will not determine whether a resident is prescribed a therapeutic diet.9. Snacks will be compatible with the therapeutic diet. R12 was admitted to the facility on [DATE] with diagnoses that include the following, in part: unspecified protein-calorie malnutrition. R12's most recent Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 4/23/26 states that R12 has a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating she is cognitively intact. On 7/7/26 at 11:27 AM, Surveyor interviewed R12. R12 indicated she is supposed to get a snack at 2:00 PM but did not remember the last time she received one. R12 indicated that she prefers to have yogurt for this snack. Surveyor reviewed R12's physician orders and noted the following snack order: Offer 2pm snack (resident likes yogurt); record amount consumed in the afternoon for supplement - Order start date: 2/1/24. On 7/7/26 at 2:25 PM, Surveyor followed up with R12 to see if she received her 2:00 PM snack. R12 said no. On 7/7/26 at 2:31 PM, Surveyor observed CNA R (Certified Nursing Assistant) taking a tray of snacks to the wing where R12's room is. Each snack was labeled with a resident's name. The snacks come from the kitchen and are labeled based on resident preference and if the resident is ordered to have a snack at that time. Surveyor asked CNA R to look through the snacks for the residents on R12's hallway. R12 did not have a labeled snack on the tray. On 7/8/26 at 10:15 AM, Surveyor spoke with DM S (Dietary Manager) and asked to review the sheet the kitchen keeps on file with the list of residents who receive snacks. The sheet lists resident preferences and the time of the day that residents get snacks. Surveyor did not see R12's name on any of the snack lists. Surveyor asked DM S if R12 should be on the snack list if she has an order for a 2:00 PM snack. DM S indicated R12 should be on the snack list if she has an order. DM S indicated this was her first time hearing about R12 not receiving a snack at that time. DM S indicated she recently started in this position and R12 may have been missed if she hadn't been on the snack list when DM S took over the position, as DM S meets with newly admitted residents to review their choices. DMS S indicated that she would look into this issue. On 7/8/26 at 2:41 PM, Surveyor notified INHA W (Interim Nursing Home Administrator) and CNO N (Chief Nursing Officer) about the issue with R12's scheduled snack not being given.

Based on observation, interview, and record review, the facility did not provide a clean, comfortable, homelike environment for 3 residents of 19 sampled Residents (R14, R10, & R13). R14's room walls and privacy curtains had visible stains/marks on them. R10 was observed with a gown saturated with colostomy leakage, flies were on R10's blankets. R13's room was not clean. Findings Include: The facility 's Homelike Environment Policy, effective date July 2026, states: The facility is committed to maintaining a home-like environment that supports resident dignity, privacy, independence, choice, and quality of life. *Keep resident rooms and common areas clean, safe, comfortable, and welcoming. Example 1: On 7/7/26 at 11:20 AM, Surveyor observed numerous dark brown colored marks scattered on the wall along the side of R14's bed between bed and wall light. Area affected was approximately 2.5 feet in length by 3.5 feet in width. Bedspread on bed had scattered dark areas of discoloration present toward head of bed. Privacy curtain had scattered dark areas of discoloration at the mid to lower end of curtain. R14 admitted to the facility on [DATE] with multiple wounds due to peripheral vascular disease including areas to fingers and hands that require daily dressing changes. R14 is known to remove dressings from fingers independently. On 7/8/26 at 9:00 AM, Surveyor observed same areas of discoloration on the wall and privacy curtain as previous day. R14 was sleeping in bed with clean sheet on and no bedspread in use. On 7/8/26 at 9:15 AM, Surveyor interviewed Hskp V (Housekeeper) who was shown privacy curtain with dark stains, and wall beside R14's bed with dark colored scattered stains. Hskp V states housekeeping cleans the floors, tables, and bathroom and not areas like walls. Hskp V was not sure who was responsible for changing out privacy curtains or when they are cleaned or changed. On 7/8/26 at 9:30 AM, Surveyor interviewed HD H (Housekeeping Director) who was shown privacy curtain with dark stains by surveyor and asked who is responsible for cleaning and changing privacy curtains. HD H stated that privacy curtain should have been changed. When asked who is responsible for changing out privacy curtains HD H stated that housekeeping staff is responsible for this task. Surveyor then showed HD H the dark colored scattered stains on wall next to R14's bed. HD H stated housekeeping should be cleaning this area. Surveyor informed HD H that Hskp V was not aware this is a housekeeping responsibility. HD H stated they started as HD 6 days ago and will work on education with housekeeping staff. HD H also has plans to start a deep cleaning of 3 per day each month. HD H is working on the process of starting room audits. Example 2: R10 was admitted to the facility on [DATE] and had diagnoses including fistula of intestine. R10's Minimum Data Set (MDS) assessment, dated 5/21/26, stated R10 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. On 7/7/26 at 11:28 AM, Surveyor observed R10 resting in bed with blanket pulled over head. On 7/7/26 at 2:18 PM, Surveyor interviewed R10 who indicated that staff leave R10 soiled for long periods of time, staff don't like to take off my ostomy bag and if it is not emptied frequently, it causes it to leak more and overflows. On 7/8/26 at 9:35 AM, Surveyor interviewed and observed R10 lying in bed with a strong odor and flies on top of the blankets. Surveyor lifted blanket, gown was saturated with colostomy drainage. R10 indicated that keeps blankets up above head to keep the flies off self and feels having to lay like this for hours was cold, cruel, and callous treatment. R10 indicated that staff had not changed bed or linens yet that day only repositioned R10 earlier. On 7/8/26 at 9:45 AM, Surveyor interviewed CNA X (Certified Nursing Assistant) who indicated that they had bathed, changed gown, and changed bed linen at 7:40 AM and noted that flies were present at that time. CNA X verified that gown was saturated. On 7/8/26 at 1:57 PM, Surveyor interviewed CNO N (Chief Nursing Officer) who indicated they were unaware of the flies in R10's room until today. Example 3 R13's room was not clean. On 7/7/26 at 11:40 AM, Surveyor observed R13's room and bathroom and noted standing water on the floor of the bathroom between the right side of the toilet and the wall of the bathroom. FM O (Family Member) was also in R13's room at the time and noted that the water had been observed on the floor of R13's bathroom for several days. On 7/8/26 at 11:05 AM, Surveyor observed standing water on the floor of R13's bathroom in the same place as the previous day. Surveyor spoke with R13 about the water on the bathroom floor. R13 indicated the water is not healthy or clean and said she does not like it. LPN I (Licensed Practical Nurse) entered the room, and Surveyor had her observe the water on the floor next to R13's toilet. LPN N indicated she did not know if the toilet was leaking or why the water was there, but she would follow up on it. On 7/8/26 at 11:25 AM, AA H (Assistant Administrator) entered R13's room and looked at the toilet and the standing water next to it. AA H indicated he did not know what was wrong with the toilet, but he submitted a work order so MD P (Maintenance Director) could look at it. On 7/8/26 at 2:41 PM, Surveyor spoke with Hskp Q (Housekeeper). Hskp Q had recently cleaned R13's room and indicated the water next to the toilet was a maintenance issue. On 7/8/26 at 2:45 PM, Surveyor followed up with AA H to find out if MD P had determined what was causing the standing water next to the toilet. AA H indicated this was still on their list to look at but they had not gotten to it yet. On 7/8/26 at 2:41 PM, Surveyor notified INHA W (Interim Nursing Home Administrator) and CNO N (Chief Nursing Officer) about R13's environmental concern with her toilet.

Based on interview and record review, the facility did not ensure written bed holds were completed for 1 of 1 resident (R5) reviewed for bed holds out of a sample of 19.R5 was transferred to the hospital. The facility did not provide a written bed hold notice to R5 and/or R5's resident representative. This is evidenced by:The facility's policy, titled Bedhold Notice Upon Transfer, implemented 3/1/26, states in part: Policy: At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed.Policy Explanation and Compliance Guidelines: .1. Before a resident is transferred to a hospital or goes on therapeutic leave, the facility will provide to the resident and/or the resident representative written information that specifies: a. The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; b. The reserve bed payment policy in the state plan policy, if any. C. The facility policies regarding bed-hold periods to include allowing a resident to return to the next available bed. d. Conditions upon which the resident would return to the facility. 2. In the event of an emergency transfers [sic] of a resident, the facility will provide within 24 hours written notice of the facility's bed-hold policies, as stipulated in the State's plan.5. The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file. R5's medical record indicated R5 was sent to the hospital on 6/15/26. R5's medical record did not contain a written bed hold notice. On 7/8/26 at 3:15 PM, ADON M (Assistant Director of Nursing) informed Surveyor that the facility did not have a bed hold for R5's hospital admission on [DATE] but should have had one. On 7/8/26 at 3:25 PM, Surveyor notified INHA W (Interim Nursing Home Administrator) and CNO N (Chief Nursing Officer) about R5's missing bed hold form.

Based on interview and record review, the facility did not ensure that the comprehensive care plan was being followed for 1 (R9) of 19 care plans reviewed out of a total sample of 19 residents.R9's care plan indicates staff assistance of 2 for all cares. Staff are consistently assisting R9 using only one staff member.Evidenced by:The facility policy, titled, Care Planning - Interdisciplinary Team, dated March 2026, states, in part, Policy Statement: The interdisciplinary team is responsible for the development of resident care plans. Policy Interpretation and Implementation: 1. Resident care plans are developed according to the timeframes and criteria established . 2. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT).R9 was admitted to the facility on [DATE] with diagnoses that include, in part, Type 2 Diabetes Mellitus, Morbid Obesity, Pain in right leg, and Weakness. R9's most recent Minimum Data Set (MDS) Assessment, dated 5/26/26, indicates R9's Brief Interview for Mental Status (BIMS) score was 15 out of 15, indicating that R9 is cognitively intact.R9's Comprehensive Care Plan includes, in part: Focus: I have a physical functioning deficit related to: Mobility impairment, Self-care impairment due to weakness, physical limitations, choosing to stay in bed and need for staff assistance. I prefer to not have my thighs touch when assisting in turning and repositioning me. Date Initiated: 5/22/26.Interventions: . Bed mobility assistance of 2 r/t (related to) possible behaviors. Date Initiated: 5/22/26. Dressing assistance of 2 r/t possible behaviors. Date Initiated: 5/22/26. Oral care assistance set up with 2 r/t possible behaviors. Date Initiated: 5/22/26. Personal Hygiene assistance of 2 r/t possible behaviors. Date Initiated: 5/22/26. Toileting assistance of 2 r/t possible behaviors. Date Initiated: 5/22/26. Transfer assistance of 2 with full body lift. Date Initiated: 5/22/26.R9's Certified Nursing Assistant (CNA) Kardex Report indicates, in part:*Dressing assistance of 2 r/t possible behaviors*Oral care assistance set up with 2 r/t possible behaviors*Personal Hygiene assistance of 2 r/t possible behaviors*Transfer assistance of 2 with full body lift*Provide 2 assistance to toilet*Bed mobility assistance of 2 r/t possible behaviorsOn 7/7/26 at 11:49 AM, Surveyor interviewed R9 who stated that sometimes two staff will come to assist her with dressing, toileting, and hygiene, but that most of the time it is just one staff member.On 7/8/26 at 11:38 AM, Surveyor interviewed CNA C (Certified Nursing Assistant) and asked her about providing cares for R9. CNA C stated that there was an incident last month where she went into R9's room to change them and R9 became combative with her, swinging her arm and trying to hit her. CNA C stated that she then went to get the nurse to assist her in providing cares to R9. CNA C indicated that she had never had a problem with R9 before this incident.Surveyor reviewed CNA C's staff statement of the incident, which was provided by the facility. CNA C's statement included the following, in part: . I answered [Resident Name]'s call light. and asked how she preferred to be turned. As I attempted to begin care [Resident Name] would not allow me to touch her. I attempted to provide incontinent care. [Resident Name]. swung her arm backward. I called for Nurse.On 7/8/26 at 1:34 PM, Surveyor interviewed CNA D about providing cares for R9. CNA D stated she wasn't sure if R9 was supposed to be assisted with one staff member or two.On 7/8/26 at 1:37 PM, Surveyor interviewed CNA E about providing cares for R9. CNA E stated that R9 was a one assist of staff for cares and a two-assist transfer using the Hoyer lift.On 7/8/26 at 1:38 PM, Surveyor interviewed CNA F about providing cares for R9. CNA F stated that R9 is a one assist of staff for cares, but that they are hard to roll over so other people sometimes provide cares using two staff members. CNA F stated she has a good rapport with R9 and can provide cares for them by herself.On 7/8/26 at 1:51 PM, Surveyor interviewed RN G (Registered Nurse) who stated that R9 was a one-assist for cares and that the CNAs don't call her to the room for assistance with R9.On 7/8/26 at 3:50 PM, Surveyor interviewed INHA W (Interim Nursing Home Administrator) and asked if he would expect R9's care plan to be followed for staff assistance of two for all care needs. INHA W stated yes, that if it was in R9's care plan, he would expect it to be followed.The facility did not ensure that R9's comprehensive care plan was being followed.

Based on observation, interview, and record review, the facility did not provide elimination (incontinence) care and repositioning for 1 of 3 Residents (R18) reviewed for ADL care for dependent residents out of 19 sampled residents.R18 was not provided with incontinence care or repositioning for 3 hours and 40 minutes.Findings include:The facility's Activities of Daily Living (ADL), Supporting policy with a revision date of April 2026, indicates: Residents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. 5. Appropriate care and services are provided to residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care); c. elimination (toileting).On 7/7/26 at 3:05 PM, Surveyor heard moaning and grunting noises from room where R18 was assigned. Surveyor observed R18 rocking back and forth in a Broda chair (a reclining wheelchair). Under the Broda chair was a large puddle of clear liquid with a rolled-up blanket lying in it. R18 admitted to the facility on [DATE] with diagnoses that include traumatic brain injury, quadriplegia (a symptom of paralysis that affects all person's limbs from the neck down), and aphasia (the inability to speak). R18's admission Minimum Data Set (MDS) dated [DATE] was in progress with the Brief Interview for Mental Status (BIMS) in progress status. R18 had an activated Power of Attorney for Healthcare to assist with medical decisions. R18 was dependent on staff for all ADLs including incontinence care, personal hygiene, and repositioning. R18 has a feeding tube in place for nutrition and hydration needs. Food and fluids are not given orally and would not be in R18's room.On 7/7/26 at 3:20 PM Surveyor interviewed RN K (Registered Nurse) who was working with R18 during the day shift. Surveyor asked RN K to observe R18 in the Broda chair in the room and RN K verified there was a puddle of clear liquid on the floor under the Broda chair that R18 was sitting in. Surveyor asked RN K when R18 was last repositioned or assisted with toileting, RN K stated they would verify with the Certified Nursing Assistant (CNA) working on unit.On 7/7/26 at 3:25 PM Surveyor conducted an interview with CNA L who worked with R18 during the day shift. Surveyor asked CNA L how often residents who need assistance with toileting or incontinence care should be changed or toileted and repositioned. CNA L stated residents are to be changed and repositioned every 2 hours. Surveyor asked when R18 was last repositioned or had incontinent care provided. CNA L stated R18 was last changed and repositioned at 11:50 AM. Surveyor asked CNA L about clear puddle of liquid under R18's Broda chair and was observed by CNA L. CNA L stated R18 sometimes rips incontinence brief off. On 7/7/26 at 3:30 PM Surveyor observed incontinence care of R18 by CNA L. CNA L, RN K, and an additional unidentified staff assisted with transferring R18 from Broda chair to bed with a Hoyer lift (mechanical device to transfer dependent residents who cannot stand). A wet brief was removed from R18 by CNA L, and RN K stated sling that was under R18 in Broda chair and R18's shorts were wet. CNA L previously stated R18 was last changed at 11:50 AM. R18 did not have incontinence care or repositioning for 3 hours and 40 minutes. CNA L placed a clean brief on R18 without peri care performed or barrier cream applied to skin. CNA L put clean dry shorts on R18. A clean dry sling was being brought to room by other staff.Surveyor reviewed R18's current plans of care 7/7/26-7/8/26. The following interventions were not followed:Assist to reposition every 2-3 hoursProvide thorough skin care after incontinent episodes and apply barrier creamOn 7/8/26 at 10:30 AM Surveyor interviewed ADON M (Assistant Director of Nursing). Surveyor asked ADON M when repositioning and incontinence care would be performed for a dependent resident by staff. ADON M stated residents should be repositioned and have incontinence care or toileting every 2-3 hours. Surveyor indicated R18 had not had incontinence care or repositioning for 3 hours and 40 minutes and there was a large puddle of clear fluid under the Broda chair R18 was sitting in. CNO N (Chief Nursing Officer) was also present at time of interview.

Based on observation, interview, and record review, the facility did not provide appropriate colostomy care for 1 of 1 Residents out of a total sample of 19 Residents (R10). R10 has an open abdominal wound leaking bowel contents. This was a recognized complication after intestinal fistula repair with anticipated future surgical repair. R10's leaking colostomy was not care planned or identified on the Kardex treatment record resulting in staff not providing timely colostomy cares. Findings include:The facility's Colostomy/Ileostomy Care Policy, revised 10/2025, indicates: the purpose of this procedure is to provide guidelines that will aid in preventing expose of the resident's skin to fecal matter. Preparation 1. Review the resident's care plan to assess for any special needs of the resident.The facility's Care Planning - Interdisciplinary Team Policy, revised 02/2026, indicates: . Policy Statement: The interdisciplinary team is responsible for the development of resident care plans. Policy Interpretation and Implementation: 1. Resident care plans are developed according to the timeframes and criteria established . 2. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT).R10 was admitted to the facility on [DATE] and had diagnoses including fistula of intestine. R10's Minimum Data Set (MDS) assessment, dated 5/21/26, stated R10 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. On 7/7/26, Surveyor reviewed R10's medical admission records, dated 2/18/26, indicating R10 was admitted for rehabilitation following a recent intestinal fistula and laceration of the sigmoid colon, which necessitated colostomy placement and drainage of abdominal incision.Medical orders:~Midline abdominal fistula care change wound Friday and immediately after leaking colostomy appliance change to be performed prior to wound change every 8 hours as needed for wound care. Apply skin barrier, utilize replica and ostomy ring to help facilitate seal. May reinforce with tape if needed. Dated 5/9/26~Fistula wound care: Cleanse with warm water and washcloths. If there's skin breakdown: sprinkle a thin layer of stoma powder over the area and spray with 3M cavilon barrier film to seal the powder. If no skin breakdown just spray the barrier spray. Use ostomy rings to build up edges of wound to help with leaking issues at lower abdomen. Place cut out wound manager firmly to fistula. Use replica to line edge of pouch to aid with seal. Every Friday and as needed, dated 5/9/26.On 7/8/26, Surveyor reviewed R10's Care Plan and Kardex Care Card, there were no goals or interventions documented regarding R10's colostomy, frequency of cares, and/or monitoring for a leaking colostomy.On 7/7/26 at 11:28 AM, Surveyor observed R10 resting in bed with blanket pulled over head.On 7/7/26 at 2:18 PM, Surveyor interviewed R10 who indicated that staff leave R10 soiled for long periods of time, staff don't like to take off my ostomy bag and if it is not emptied frequently, it causes it to leak more and overflows.On 7/8/26 at 9:35 AM, Surveyor interviewed and observed R10 lying in bed with a strong odor and flies on top of the blankets. Surveyor lifted blanket, gown was saturated with colostomy drainage. R10 indicated that keeps blankets up above head to keep the flies off self and feels having to lay like this for hours was cold, cruel, and callous treatment. R10 indicated that staff had not changed bed or linens yet that day only repositioned R10 earlier.On 7/8/26 at 9:45 AM, Surveyor interviewed CNA X (Certified Nursing Assistant) who indicated that they had bathed, changed gown, and changed bed linen at 7:40 AM and noted that flies were present at that time. CNA X verified that gown was saturated and indicated that R10 often picks at the colostomy site. CNA X indicated that they review cares from the Kardex and was not aware of who updates the Kardex. CNA X informs the nurse when the colostomy was leaking which happens frequently.On 7/8/26 at 9:58 AM and 12:16 pm, Surveyor interviewed UM Z (Unit Manager) who indicated that R10's colostomy does not seal well and has to be changed constantly, staff should refer to the Care Plan and Kardex for care instructions. UM Z denied awareness that colostomy odor was attracting flies. UM Z reviewed the Care Plan and Kardex and verified that the colostomy cares were not documented on the Care Plan/Kardex and had entered goals/interventions for colostomy cares. On 7/8/26 at 10:56 AM, Surveyor interviewed CNA F who indicated that they follow the Kardex for all resident cares and Kardex should be updated whenever there is a change but was unsure who updates the Kardex, maybe nursing. On 7/8/26 at 11:45 AM, Surveyor interviewed FM AA (Family Member) who indicated they had spoken with SS Y (Social [NAME]) on 6/4/26 regarding concerns with fistula leaking and required more frequent changes. FM AA indicated that you could smell the odor of the colostomy leakage from the hallway; it was pungent. FM AA does not expect the facility to provide immaculate cares but expects R10 to be comfortable and clean.On 7/8/26 at 1:57 PM, Surveyor interviewed CNO N (Chief Nursing Officer) who indicated that staff were expected to follow Kardex and Care Plans when providing cares and would expect a colostomy to be care planned. The clinical management team was responsible for updating Care Plans and Kardex.

Based on interview and record review, the facility did not ensure they maintained complete medical records on each resident in accordance with professional standards of practice. This has the potential to affect 2 residents (R6 and R12) out of 19 residents reviewed for medical records out of a total sample of 19 residents. R6's medical record was incomplete. R12's medical record was incomplete. Findings include: The facility policy, titled Documentation in the Medical Record, dated 3/2026, includes, in part: Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the residents progress through complete, accurate, and timely documentation. Policy Explanation and Compliance Guidelines: 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. 3. Principles of documentation include, but are not limited to: . b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. R6 was admitted to the facility on [DATE]. On 6/9/26 at 11:54 AM, a progress note in R6's medical record indicates, Change in Condition report. Abnormal vital signs, seems different than usual, tired, weak, confused or drowsy. Nursing observations, evaluation, and recommendations are: Informed by assigned CNA that resident appears different than usual. Res (resident) appears more tired today but easy to arouse. VSS (vital signs stable) obtained. Tylenol given. NP (Nurse Practitioner) notified, NOR (new order received) for UA (urinalysis) and labs. [Family Name] notified, no concerns at this time. POC (plan of care) ongoing. On 6/9/26 at 6:56 PM, an emergency room (ER) report provided by the facility indicates that R6 was transferred to the hospital via ambulance. The ER report indicates the following, in part: Pt (patient) here for AMS (altered mental status). is SOB (short of breath). has a fever. Pt (patient) is normally A and O (alert and oriented) x4 per staff, but today is x1 so a non-emergent ambulance was called, per staff Pt (patient) has been this way all day. Of note, there is no other documentation in R6's medical record indicating that R6 was sent to the hospital, or what occurred in the hours prior to being sent to the ER. On 6/12/26 at 11:02 AM a progress note in R6's medical indicates, Patient is at [Hospital Name] concerns for stroke. On 7/8/26 at 11:19 AM, Surveyor interviewed LPN H (Licensed Practical Nurse) about R6's change in condition. LPN H indicated that usually R6 is alert and oriented but that day R6 was more sleepy and their blood pressure was elevated. LPN H stated that they reached out to the provider to get orders to send R6 out to the hospital. LPN H stated that the situation with R6 was brought to her attention by the nurse working on R6's floor, and that she just assisted her. On 7/8/26 at 2:49 PM, Surveyor interviewed LPN I about R6's change in condition. LPN I stated that R6 just seemed lethargic that day, that normally they converse but that day R6 wasn't talkative. LPN I indicated that R6 didn't look like their normal self so she had DON B come to assess R6, and at that time they reached out to the NP (Nurse Practitioner) to have R6 sent out to the hospital. LPN I stated that at first the NP requested that a urine sample be tested for R6, but as the day went on they weren't turning around. LPN I stated that they reached out again to the NP and it was determined at that time to send R6 to the ER. On 7/8/26 at 3:31 PM, Surveyor interviewed DON B (Director of Nursing) about R6's change of condition. DON B stated that the staff came and got her around noon because R6 wasn't acting like their normal self, so they got an order for UA (urinalysis) and lab work. DON B stated that staff came and got her later and that R6 wasn't appearing themselves and wasn't moving like they normally did. DON B stated she called the NP, sometime after 3:00 PM, and asked if they could send R6 out because they weren't better or worse, but they weren't able to get the UA. DON B indicated that R6's vital signs weren't way off, and their assessment wasn't too crazy but something was definitely off with R6. DON B indicated that the NP was okay with sending R6 to the hospital via non-emergency transport. On 7/8/26 at 3:50 PM, Surveyor interviewed INHA W (Interim Nursing Home Administrator) about the events that happened with R6 on 6/9/26, and the lack of documentation of these events in R6's medical record. INHA W stated that yes, these events should have been documented for a complete medical record. The facility did not maintain medical records on each resident that were accurate and complete. Example 2: R12 was admitted to the facility on [DATE] with diagnoses that include the following, in part: unspecified protein-calorie malnutrition. R12's most recent Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 4/23/26 states that R12 has a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating she is cognitively intact. On 7/7/26 at 11:27 AM, Surveyor interviewed R12. R12 indicated she is supposed to get a snack at 2:00 PM but does not remember the last time she received one. R12 indicated that she prefers to have yogurt for this snack. Surveyor reviewed R12's physician orders and noted the following snack order: Offer 2pm snack (resident likes yogurt); record amount consumed in the afternoon for supplement – Order start date: 2/1/24. Surveyor reviewed R12's Medication Administration Record (MAR) for July 2026 and noted RN G (Registered Nurse) had charted that R12 had received her snack at 2:00 PM on 7/7/26 and had consumed 100% of it. On 7/7/26 at 2:25 PM, Surveyor followed up with R12 to see if she received her 2:00 PM snack. R12 said no. On 7/7/26 at 2:31 PM, Surveyor observed CNA R (Certified Nursing Assistant) taking a tray of snacks to the wing where R12's room is. Each snack was labeled with a resident's name. The snacks come from the kitchen and are labeled based on resident preference and if the resident is ordered to have a snack at that time. Surveyor asked CNA R to look through the snacks for the residents on R12's hallway. R12 did not have a labeled snack on the tray. On 7/7/26 at 2:35 PM, Surveyor interviewed RN G (Registered Nurse) about the facility's snack process and how nursing staff knows to chart if a resident receives a snack or not. RN G indicated a tray comes up from the kitchen and nursing staff knows the resident gets the snack because they can see CNAs taking them down the hallway. RN G indicated the snacks are usually for the same people each time. Surveyor asked RN G why she had charted that R12 had received her snack at 2:00 PM when Surveyor had not observed a snack for R12 on the snack tray and R12 had indicated that she had not received one. RN G indicated she was not sure why R12 had not received a snack that day and suggested maybe her snack order fell through the cracks somehow. RN G indicated she had assumed R12 had received a snack but should have checked to see if R12 had actually received the snack before completing documentation on it. On 7/8/26 at 2:41 PM, Surveyor notified INHA W (Interim Nursing Home Administrator) and CNO N (Chief Nursing Officer) about the nursing documentation for R12's snack administration not being accurate.

Based on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe and sanitary environment to prevent the transmission of communicable disease and infection for 1 of 19 sampled Residents (R15).LPN BB (Licensed Practical Nurse) did not follow Enhanced Barrier Precautions (EBP) or complete hand hygiene between glove changes while providing tracheostomy care for R15.Findings include:Facility policy titled Infection Prevention and Control Program with a revised date of 7/2025 indicated: 7. Enhanced Barrier Cautions (EBP) a. EBP use gowns and gloves during high contact care to prevent the spread of resistant germs b. EBP is recommended for residents with.medical devices, regardless of MDRO status. c. High contact resident care vii. Device care or use (.tracheostomy.)Facility policy titled Handwashing / Hand Hygiene with a revision date of December 2025 indicated: Indications for gloves: 2. The use of gloves does not substitute for hand hygiene. Always perform hand hygiene after gloves are removed. Applying and Removing Gloves. 1. Perform hand hygiene before applying non-sterile gloves. 3. When removing gloves, pinch the glove at the wrist and peel away from the hand, turning the glove inside out. [NAME] he removed glove in the gloved hand and remove the otehr glove by rolling it down the hand and folding it into the first glove. 4. Perform hand hygiene.R15 was admitted to the facility on [DATE] and had diagnoses that included tracheostomy status. R15 had a quarterly Minimum Data Set (MDS) dated [DATE] at section O indicated R15 required tracheostomy care. On 7/7/26 at 4:02 PM, Surveyor observed LPN BB provide tracheostomy care to R15. Surveyor noted that R15 had a sign outside of R15's door that indicated Enhanced Barrier Precautions. LPN BB pulled the tracheostomy kit out of R15's drawer. Surveyor observed LPN BB wash hands and put gloves on. LPN BB did not don (put on) a gown.During this observation, Surveyor noted the following moments when LPN-BB changed gloves but did not complete hand hygiene between glove changes.~LPN BB removed R15's inner cannula, LPN BB realized the garbage was across the room. LPN BB picked up the garbage can with gloved hands and then moved it next to LPN BB. LPN BB then removed gloves and put a new pair of gloves on. LPN BB did not complete hand hygiene. ~LPN BB removed R15's old dressing, LPN BB changed gloves but did not complete hand hygiene prior to donning new gloves. ~LPN BB was attempting to suction R15, the suctioning did not work. LPN BB was adjusting the suctioning machine with gloved hands, then a piece of the trach kit fell on the floor. LPN-BB got out a new trach kit and opened it with the gloved hand that was adjusting suctioning machine. LPN-BB doffed gloves and set up the new kit. LPN BB did not complete hand hygiene prior to donning new gloves. Near the end of this observation, Surveyor asked LPN BB if LPN BB should be wearing a gown. LPN BB indicated they would wear a gown if an individual had something contagious or was on some kind of contact precaution. We exited the room. Surveyor pointed to the sign outside of R15's door which indicated a gown should be worn. LPN BB acknowledged this sign. Surveyor informed LPN BB of not completing hand hygiene when changing gloves. On 7/8/26 at 11:30 AM, Surveyor interviewed Director of Nursing (DON-B) and Chief Nursing Officer (CNO-N) who confirmed a gown should have been worn, and hand hygiene should have been completed when changing gloves.

Based on interview and record review, facility personnel failed to provide basic life support to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 7 residents (R) reviewed (R4.)R4's chosen code status was full code. R4 was found pulseless and nonbreathing; facility staff delayed notifying 911 and delayed initiating cardio pulmonary resuscitation (CPR.) Facility staff failed to utilize life support equipment such as an AED (Automatic External Defibrillator) while providing CPR to R4.The facility's failure to provide proper basic life support to a resident who wished to be a full code, including immediately starting CPR, utilizing the AED, and promptly calling 911, created a finding of immediate jeopardy that began on [DATE].Surveyor notified CNO D (Chief Nursing Officer) and DON B (Director of Nursing) of the immediate jeopardy on [DATE] at 3:19 PM. The immediate jeopardy was removed on [DATE]. 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.This is evidenced by:The facility's policy titled Emergency Procedure - Cardiopulmonary Resuscitation and Basic Life Support, undated, includes: Personnel are certified in cardiopulmonary resuscitation (CPR) for healthcare providers and basic life support (BLS,) including defibrillation for victims of sudden cardiac arrest. 1. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a staff member who is certified in CPR for healthcare providers/BLS will administer CPR. General Sequence for Adult Basic Life Support 5. Ensure scene safety. 6. Check for response. 7. Shout for nearby help/activate the resuscitation team. 8. Check for no breathing or only gasping and check for pulse (ideally simultaneously.) 9. Retrieve and activate the AED/emergency equipment immediately after the check for no normal breathing and no pulse identifies cardiac arrest. 10. Immediately begin CPR and use the AED/defibrillator when available. 11. When the second rescuer arrives, provide 2-rescuer CPR and use the AED/defibrillator.The facility's policy, Automatic External Defibrillator, Use and Care of, dated 2001, includes: 4. In general, SCA (Sudden Cardiac Arrest) should be suspected if: a. the victim's symptoms appeared very suddenly; he or she is unresponsive; and c. his or her breathing has stopped. 5. If an individual is found unconscious and SCA (Sudden Cardiac Arrest) is suspected, begin the AED Protocol below. 1. Verify code status by looking [sic] facility CPR/DNR form found in [Electronic Health Record.] 2. Call (or direct someone to call) 911. 3. Apply personal protective equipment. 4. Assess the victim: a. Responsiveness - if unresponsive, retrieve (or direct someone to retrieve) the AED from its location and bring it to the victim. b. Breathing - open airway and look, listen, feel for breathing. If breathing is absent, deliver two rescue breaths. c. Circulation - if signs of circulation are absent, begin CPR until the AED is available. EMS (Emergency Medical Services) Arrival 1. Communicate the following information to the EMS personnel: a. Name of the victim; b. Any known medical history, allergies or conditions; c. The condition in which the victim was found; d. Time the victim was found; e. Number of shocks delivered; and f. Approximate length of CPR administration. Documentation 2. If the victim is a resident of the facility, document details of the event in the resident's medical record.R4 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (a progressive, irreversible lung disease that restricts airflow, making it difficult to breathe,) acute respiratory failure with hypoxia (where the lungs cannot adequately oxygenate the blood,) tracheostomy (a surgically created opening through the front of the neck and directly into the windpipe (trachea). A breathing tube is placed into this hole to bypass the nose and mouth, providing an alternative airway for the patient to breathe,) dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life,) seizures, and quadriplegia (a form of paralysis that affects all four limbs and the torso.)R4's CPR form, signed [DATE], states: Full Code. I understand that [Facility Name] performs onsite resuscitation. It is my desire to have a FULL CODE, which means that our facility will call 911 ([City Name] EMTs (Emergency Medical Technicians)) in the event of a cardiac or respiratory arrest and begin resuscitation measures including Cardiopulmonary Resuscitation. I am aware of the risks involved.R4's physician orders include Full Code. Order start date [DATE].R4's comprehensive care plan, printed [DATE], includes: Focus: Patient has an advance directive as evidenced by: Full Code. Date initiated [DATE]. Goal: Patient's wishes will be honored. Date initiated [DATE]. Interventions: CPR will be performed as ordered. Dated initiated [DATE].R4's nurse progress notes, dated [DATE], written by LPN F (Licensed Practical Nurse) state: Resident noted lying in bed unresponsive. Writer entered room and assessed resident; no pulse and no respirations noted. CPR initiated and 911 called. EMS arrived and assumed resuscitative efforts. EMS discontinued CPR at 1737 (5:37 PM) and resident was pronounced deceased . ME (Medical Examiner) notified. Resident's daughter notified and made aware of resident's passing. [County Name] was contacted and advised case would be referred to the [City Name] Medical Examiner.On [DATE] at 11:00 AM, Surveyor interviewed RN E regarding the code event for R4. RN E indicated that [DATE] was her first day of training and she was training with LPN F. RN E indicated she was not sure of the time everything took place but knew it was around dinner time because she was preparing for the evening medication administration. RN E indicated she entered R4's room to obtain vital signs for his medications. RN E stated she used the machine and was not able to get any vital sign results. RN E indicated she attempted to feel for a pulse but was unable to determine if she could feel a pulse. RN E stated she went across the hall to get LPN F. RN E indicated because it was her first day, she was not sure how a code worked at the facility. RN E stated LPN F came to R4's room and checked for a pulse. RN E stated LPN F indicated there was no pulse and LPN F left the room to see what R4's code status was. RN E stated LPN F returned to R4's room and started CPR. RN E stated she is unaware of how long it took for LPN F to return to the room after verifying R4's code status. RN E indicated there was a CNA and LPN F told the CNA to get the nurse supervisor. RN E stated LPN F started CPR after telling the CNA to get the nurse supervisor. RN E indicated she took over performing CPR and LPN F called 911. RN E indicated the nurse supervisor came and took over performing CPR.On [DATE] at 5:10 AM, Surveyor interviewed LPN F (Licensed Practical Nurse) regarding the code event for R4. LPN F indicated she was training RN E (Registered Nurse) on [DATE] for the evening shift. LPN F indicated sometime around 5:00 PM, she was in a room across the hall from R4. LPN F stated RN E went into R4's room to obtain vital signs prior to passing medications. LPN F stated RN E came across the hall, into the room LPN F was in, and notified LPN F that RN E was unable to obtain vital signs on R4. LPN F stated she left the room and went across the hall to R4's room. LPN F stated she checked R4's carotid artery (an artery in the neck) to feel for a pulse and was unable to obtain a pulse. LPN F stated R4 had no pulse. LPN F stated she left the room and went up the hall to the nurses' station to access R4's electronic medical record to verify his code status. LPN F indicated that once she obtained R4's code status and noted R4 was a full code, she instructed the two CNAs (Certified Nursing Assistants) who were in the nurses' station to get the nurse supervisor. LPN F indicated the nurse supervisor was across the building on a different unit. LPN F stated she returned to R4's room and instructed RN E to start CPR. LPN F stated she called 911 at 5:11 PM from her cell phone while in the resident's room. LPN F indicated CNA H came into the room and deflated the mattress and laid the bed flat. LPN F indicated once she was off the phone with 911, she assisted with performing CPR. LPN F stated once EMS (Emergency Medical Services) arrived, they took over performing CPR. LPN F stated she could not recall the times or timeframes the different actions took place but knew it started around 5:00 PM. LPN F stated the facility staff did not use the AED when providing CPR.On [DATE] at 2:10 PM, Surveyor interviewed CNA H regarding the code event for R4. CNA H indicated he was in the room with LPN F assisting a resident across the hall from R4. CNA H indicated RN E entered the room and told LPN F that RN E was unable to get vital signs on R4. CNA H indicated LPN F left the room. CNA H indicated he stayed in the room to finish assisting the resident he had been working with. CNA H indicated after he finished across the hall, which took about two minutes or so, he walked past R4's room. CNA H stated he saw LPN F starting CPR on R4. CNA H indicated he heard LPN F yell to get the nurse supervisor. CNA H indicated he was going to get the nurse supervisor when he saw another CNA going to notify the nurse supervisor, so CNA H stated he went back down to R4's room. CNA H indicated when he got to the room, he adjusted the mattress and bed. CNA H stated RN E took over CPR and LPN F called 911. CNA H stated he was trying to keep track of the times but it all was happening so fast. CNA H did not recall the times the different events took place but did recall that EMS arrived at 5:19 PM.Of note, there were two nurses in R4's room when CNA H walked past. CNA H walked past R4's room at least 2 minutes after R4 was noted to have no vital signs. LPN F had just started CPR and 911 had not yet been called for emergency services. Of note, taking into consideration the observations of the staff interviewed, there was a delay in starting CPR for R4 once he was found to have no vital signs. RN E was unable to obtain R4's vital signs through the vital sign machine. RN E then attempted to feel R4's pulse. RN E walked across the hall to inform LPN F of the situation. LPN F had to walk across the hall to R4's room. LPN F attempted to feel a pulse. LPN F had to go up the hall to the nurses' station and access the electronic health record to verify R4's code status. LPN F then went back down the hall to R4's room. CNA H indicated it was two minutes before he left the other resident's room. LPN F indicated she instructed the CNA to get the nurse supervisor prior to starting CPR. LPN F started performing CPR prior to calling 911 when RN E was in the room. On [DATE] at 12:39 PM, Surveyor interviewed LPN G regarding the code event for R4. LPN G indicated she is the nurse supervisor. LPN G stated a CNA came and told her to go to R4's room. LPN G indicated she could not recall which CNA came to get her. LPN G indicated when she arrived at R4's room, LPN F was on the phone with 911 and RN E was performing CPR. LPN G indicated she took over performing CPR for RN E. LPN G indicated she performed 2 rounds of CPR, for approximately 4 minutes, before LPN F took over performing CPR. LPN G indicated while LPN F was performing CPR, EMS arrived. LPN G indicated once EMS took over, she left the room.On [DATE] at 11:28 AM, Surveyor interviewed RN J regarding the code event for R4. RN J indicated she was working the evening shift on [DATE] but was not notified there was a code event until after EMS arrived. RN J stated she was working on the unit nearest to R4's unit. RN J indicated the AED is located at the beginning of the hall near the nurses' station on her unit. RN J indicated the AED was not removed until after EMS arrived.R4's EMS report, dated [DATE], includes:Unit Notified: [DATE] 17:12:17 (5:12 PM)Primary Symptom: Cardiac arrest, cause unspecifiedArrest Date/Time: [DATE] 17:06 (5:06 PM)At Patient: [DATE] 17:20 (5:20 PM)Who First Applied the AED: EMS ResponderNarrative: .dispatched for a male in cardiac arrest. went enroute with use of lights and sirens without delay. On arrival.found the.in cardiac arrest. Nurses at the healthcare facility were actively performing CPR, nurse stated that had been doing CPR for roughly 10 minutes prior to EMS arrival.Police incident report, dated [DATE], written by PO K (Police Officer), includes:Reported Date/Time: [DATE] 17:35:18 (5:35 PM)Arrival Date/Time: [DATE] 17:43:29 (5:43 PM)Initial Information: On [DATE] at around 1735pm (5:35 PM) I, PO K of the [City Name] Police Department, responded to [Facility Address, R4's Room] for a report of a sudden death. My body worn camera was active and the video later entered into evidence.Scene: Upon arrival, I first spoke with fire department personnel. They stated when they arrived on scene, there was [sic] no signs of life from the patient. I spoke with 2 nurses on scene. R4 was last checked at 16:40pm (4:40 PM). He had been fine at that time. While the nurses doing their rounds of administering medication, RN E observed that R4 was not breathing. RN E asked LPN F for assistance. This was around 1703pm (5:03 PM). LPN F noticed he did not have a pulse and was not breathing. LPN F checked to make sure that R4 did not have a DNR order (do not resuscitate.) They then began CPR at about 1711pm (5:11 PM) and called 911. EMS arrived on scene at around 1720pm (5:20 PM).On [DATE] at 8:45 AM, Surveyor contacted the police department and spoke with DT I (Detective.) DT I provided surveyors with the body camera footage from PO K. The following is from PO K's body camera footage dated [DATE]: At 5:43 PM, PO K entered R4's room. At 5:45 PM, LPN F entered R4's room. The following conversation occurred:PO K: What's going on?LPN F: Unexpected death.PO K: Who was the last person to see him?LPN F: I was.PO K: What time did you do your last check?LPN F: It was 1640 that last time he was last known well. She came in here while I was with another patient. She found him unresponsive with no pulse. Code status was verified.PO K: inaudible question askedLPN F: It was 1700 (5:00 PM). Code status verified. Initiated CPR at 17 like 1703 (5:03 PM,) 1704 (5:04 PM.) EMS was called at 1711 (5:11 PM.) They arrived at 1720 (5:20 PM.)PO K: How do you know all these times off the top of your head? Inaudible question.LPN F: No because I have them written down and I just told everyone else them three times.Of note, CPR was not initiated until 3 minutes after R4 was found pulseless and nonbreathing. EMS was not called until 7 or 8 minutes after CPR was initiated.On [DATE] at 10:54 AM, Surveyor interviewed DON B (Director of Nursing) regarding R4's code event. DON B indicated CPR needs to be started immediately. DON B indicated the AED should be utilized during CPR. DON B indicated the time frame of 3 to 4 minutes after finding R4 pulseless and nonbreathing to initiate CPR is not timely. DON B indicated 911 should be called immediately. DON B stated waiting 7 to 8 minutes to call 911 after starting CPR is not timely. According to the American Red Cross CPR Facts and Statistics: Survival chances decrease by 10% for every minute that immediate CPR and use of an AED is delayed.Immediate CPR can triple the chance of survival.https://www.redcross.org/take-a-class/resources/articles/cpr-facts-and-statistics?srsltid=AfmBOoomUtjb_zr9YtUD42NsDoqabnIcPMxub7b5eaHfALNKVrrU5mmh#:~:text=Survival%20chances%20decrease%20by%2010%25,triple%20the%20chance%20of%20survival.The failure to provide proper basic life support, including immediately starting cardiopulmonary resuscitation, utilizing the AED, and promptly calling 911, created a reasonable likelihood of serious harm for R4, which created a finding of Immediate Jeopardy. The facility removed the immediate jeopardy on [DATE], 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.On [DATE], DON began educating licensed staff on emergency response procedure for CPR including ensuring emergency medical supplies are used appropriately, 911 is called promptly, starting CPR immediately.Education included proper and prompt use of AED.Education reviewed on perform CPR per AHA (American Heart Association) guidelines.All licensed staff will be educated prior to their next tour of duty.On [DATE], facility reviewed the policy and procedure on CPR in coordination with the medical director and AHA guidelines.Nursing managers will conduct random audits four times weekly, then weekly for four weeks, followed by QAPI process for ongoing monitoring and compliance. Audits will consist of a complete review of a code event to ensure adherence to facility policy, documentation requirements, and staff response expectations. In addition, random mock code drills will be conducted to evaluate staff preparedness, response times, communication, and adherence to emergency procedures. The mock drills will be conducted randomly weekly for 4 weeks.An audit was conducted on [DATE] for the past 30 days to review any codes that has occurred. The audit included reviewing how the code was conducted and performed.

Based on observation, interview, and record review, the facility did not ensure 1 resident (R) of 3 residents reviewed for pressure injuries received the necessary care and services to promote healing and/or prevent pressure injuries from developing (R7.) R7 was admitted to the facility on [DATE] with a Stage 3 pressure injury (PI) to his sacrum and inability to turn and reposition himself. The facility failed to implement a turning and repositioning schedule until 5/5/26 (8 days later.) On 5/5/26, R7 was discovered with an avoidable Stage 2 PI to his left buttock. Subsequently, on 5/12/26, the PI to R7's left buttock worsened to an Unstageable PI. On 5/12/26, Physician T (a wound physician) documented Bed rest please following a PI assessment. Per DON B (Director of Nursing) this was likely the day Physician T discussed offloading pressure with R7's Guardian, who liked R7 to be up in his Broda chair. DON B indicates the root cause analysis for R7's PI to his left buttock is friction, shear and a little bit of moisture and R7's Guardian demanding he be up in the chair for a long time. The facility did not provide R7 with a cushion for his Broda chair per Physician T's order and R7's Care Plan. The facility did not identify the deficient practices associated with R7's facility acquired PI nor educate staff. Evidenced by:The facility's policy, Pressure Injuries Overview, revised March 2020, documents in part, as follows: Purpose: The purpose of this procedure is to provide information regarding definitions and clinical features of pressure injuries. General definitions are derived from the State Operations Manual, Appendix PP (F686.) Pressure injuries for purposes of staging reference the National Pressure Injury Advisory Panel Classification System.General Definitions (State Operations Manual, Appendix PP): Pressure Ulcer/Injury (PU/PI) refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful. Pressure ulcers/injuries occur as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities and condition of the soft tissue.Avoidable/Unavoidable Avoidable means that the resident developed a pressure ulcer/injury and that one or more of the following was not completed:Evaluation of the resident's clinical condition and risk factors;Definition or implementation of interventions that are consistent with resident needs, resident goals, and professional standards of practice;Monitoring or evaluation of the impact of the interventions; orRevision of the interventions as appropriate Friction/Shearing Friction is the mechanical force exerted on skin that is dragged across any surface. Shearing occurs when layers of skin rub against each other or when the skin remains stationary and the underlying tissue moves and stretches and angulates or tears the underlying capillaries and blood vessels causing tissue damage. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermisPartial-thickness loss of skin with exposed dermis.The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-intact blister.Adipose (fat) is not visible and deeper tissues are not visible.Granulation tissue, slough and eschar are not present.Commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Stage 3 Pressure Injury: Full-thickness skin lossFull-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present.Slough and/or eschar may be visible.The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds.Undermining and tunneling may occur.Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed.If slough or eschar obscures the wound bed, this is an Unstageable PI. Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue lossFull-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. R7 was admitted to the facility 4/27/26 with diagnoses including, but not limited to, the following: Stage 2 PI sacrum (Partial-thickness skin loss with exposed dermis,) nontraumatic intracranial hemorrhage (a blood vessel leaks or ruptures inside the skull-a life-threatening emergency,) muscle wasting and atrophy (loss of muscle mass which leads to weakness,) somnolence (excessive sleepiness,) diabetes mellitus type 2 (the body resists the effects of insulin or does not produce enough to maintain normal blood sugar,) and trach status (a surgically created opening in the neck leading to the windpipe to help the person breathe.) R7's admission Minimum Data Set (MDS) dated [DATE] documents R7 is at risk for PIs; R7 is admitted with one (1) Stage 2 PI; R7 has no Stage 3 or 4 PIs.Of note, according to Physician T, R7 has a Stage 3 PI (physician assessment completed the day after R7's admission to the facility) to his sacrum (at the base of the lumbar spine and between the hip bones.) R7's family member is his legal Guardian. It is important to note, R7 does not have a care plan for turning and repositioning until 5/5/26, eight days after admission and the same day the second PI was discovered. R7's care plan indicates the following Focus area: (Date Initiated 4/27/26): At risk for/actual altered skin integrity related to CVA (cerebrovascular accident-stroke) with mobility problems, weakness, and need for staff assist.Active: PI Left Buttock 5/5/26Pressure to thoracic spinePressure to coccyx (admit)Goal: Affected area will heal without complicationsInterventions:(Date Initiated: 4/28/26) Air mattress setting at 7(Date Initiated: 4/27/26) Assist to elevate bilateral heels *(Date Initiated: 5/5/26) Assist to reposition every 1-2 hr (hours)(Date Initiated: 4/27/26) Complete Braden scale per facility policy(Date Initiated: 4/27/26) Complete weekly skin inspection*(Date Initiated: 5/12/26) Encourage me to remain in bed and assist me with repositioning every hour(Date Initiated: 5/5/26) Heel boots in bed(Date Initiated: 4/27/26) Monitor for signs and symptoms of infection such as swelling, redness, warm, discharge, odor notify physician of significant findings(Date Initiated: 4/27/26) Notify practitioner if symptoms worsen or do not resolve(Date Initiated: 4/27/26) Nutritional and Hydration support(Date Initiated: 5/19/26) Offer me assistance out of bed for 1 hr per day(Date Initiated: 4/27/26) Provide pressure reducing wheelchair cushion(Date Initiated: 4/27/26) Provide pressure reduction/relieving mattress(Date Initiated: 4/27/26) Provide thorough skin care after incontinent episodes and apply barrier cream(Date Initiated: 4/27/26) Skin assessment to be completed as per facility protocol(Date Initiated: 4/27/26) Treatments as ordered(Date Initiated: 4/27/26) Weekly wound evaluation R7's Braden Assessment on 4/27/26 is 13 (Moderate Risk of PIs.) On 4/28/26 at 12:45 PM, Physician T documented the following: Sacrum (Note, this was present on admission) 1.21 cm (centimeters) x 0.25 cm x 0.00 Color: Yellow 0.05 cm (centimeters) squaredObservations: Etiology: Pressure Ulcer - Stage 3 Margin Detail: Attached edgesWound bed Assessment: Fully granulatedDrainage Amount: SmallDrainage Description: SerousOdor: Normal odorPeriwound: Clean, dry, intactCurrent Formularies:Cleanser: Cleanse wound with salineCreams/Ointments: Zinc barrier cream TID (three times a day)/PRN (as needed)Nutrition: Discussed nutrition and its impact on wound healingCurrent Formularies: Pressure Relief/Offloading: Follow Facility Pressure Ulcer Prevention Policy/Protocol, Pressure Redistribution Mattress per Facility Policy/Protocol, Wheelchair Pressure Redistribution Cushion per Facility Policy/Protocol, Offload heels per Facility Policy/ProtocolPlan of Care: Plan of Care discussed with Facility Staff Note, R7's Stage 3 to his sacrum healed. However, on 5/5/26, a new PI is discovered. On 5/5/26 at 11:15 AM, Physician T documented the following:Left ButtockMeasurements: 0.85 cm (centimeters) x 0.47 cm x 0.10 cmObservations:Etiology: Pressure Ulcer - Stage 2Margin Detail: Attached edgesWound bed Assessment: Clean, non-granulatingDrainage Amount: ModerateDrainage Description: SerousOdor: Normal odorPeriwound: Clean, dry, intactCurrent Formularies:Cleanser: Protect periwound with Skin Prep; Cleanse with salineSecondary dressings: Cover wound with superabsorbent dressingDressing frequency: Change daily and PRN (as needed) soiling/saturation of dressingNutrition: Discussed nutrition and its impact on wound healingPressure Relief/Offloading: Follow Facility Pressure Ulcer Prevention Policy/Protocol, Pressure Redistribution Mattress per facility Policy/Protocol, Wheelchair Pressure Redistribution Cushion per Facility Policy/Protocol/Offload heels per Facility Policy/ProtocolPlan of Care: Plan of Care discussed with Facility Staff On 5/12/26 Physician T documented the following:Left ButtockMeasurements: 4.83 x 4.62 x 0.10Observations:*Etiology: Pressure Ulcer - UnstageableMargin Detail: Attached edgesWound bed Assessment: Granulation 26-50%, Slough 26-50%Drainage Amount: SmallDrainage Description: SerousOdor: Normal odorPeriwound: Clean, dry, intactCurrent FormulariesCleanser: Protect periwound with Skin Prep, Cleanse with 1/2 strength Dakin's solutionPrimary dressing: Apply nickel thick Santyl to wound bedSecondary dressing: Cover wound with Bordered GauzeDressing frequency: Change daily and PRN (as needed) soiling/saturation of dressingNutrition: Discussed nutrition and its impact on wound healingCurrent Formularies: Pressure Relief/Offloading: Follow Facility Pressure Ulcer Prevention Policy/Protocol, Pressure Redistribution Mattress per facility Policy/Protocol, Wheelchair Pressure Redistribution Cushion per Facility Policy/Protocol/Offload heels per Facility Policy/ProtocolPlan of Care: Plan of Care discussed with facility staff Wound Notes: 5/12/25 at 11:15 AM: Bed rest please On 5/19/26 at 11:47 AM, Physician T documented the following:Left ButtockMeasurements: 4.13 cm x 2.67 cm x 0.10 cmObservations:Etiology: Pressure Ulcer - UnstageableMargin Detail: Attached edgesWound bed Assessment: Granulation 26-50%, Slough 26-50%Drainage Amount: SmallDrainage Description: SerousOdor: Normal odorPeriwound: Clean, dry, intactCurrent Formularies:Current Formularies: Pressure Relief/Offloading: Follow Facility Pressure Ulcer Prevention Policy/Protocol, Pressure Redistribution Mattress per facility Policy/Protocol, Wheelchair Pressure Redistribution Cushion per Facility Policy/Protocol/Offload heels per Facility Policy/ProtocolPlan of Care: Plan of Care discussed with facility staff Wound Notes: 5/12/25 at 11:15 AM: Bed rest please On 5/26/26 at 11:00 AM, Physician T documented the following:Measurements: 2.93 cm x 1.83 cm x 0.20 cmObservations:Etiology: Pressure Ulcer - UnstageableMargin Detail: Attached edgesWound bed Assessment: Granulation 1-25%, Slough 51-75%Drainage Amount: SmallDrainage Description: SerousOdor: Normal odorPeriwound: Clean, dry, intactCurrent FormulariesCurrent FormulariesCleanser: Protect periwound with Skin Prep, Cleanse with 1/2 strength Dakin's solutionPrimary dressing: Apply nickel thick Santyl to wound bedSecondary dressing: Cover wound with Bordered GauzeDressing frequency: Change daily and PRN (as needed) soiling/saturation of dressingNutrition: Discussed nutrition and its impact on wound healingCurrent Formularies: Pressure Relief/Offloading: Follow Facility Pressure Ulcer Prevention Policy/Protocol, Pressure Redistribution Mattress per facility Policy/Protocol, Wheelchair Pressure Redistribution Cushion per Facility Policy/Protocol/Offload heels per Facility Policy/ProtocolPlan of Care: Plan of Care discussed with facility staff Wound Notes: 5/12/25 at 11:15 AM: Bed rest please On 5/27/26 at 3:00 PM, Surveyor spoke with LPN U (Licensed Practical Nurse.) Surveyor asked LPN U what skin interventions are in place for R7. LPN U stated, reposition every 2 hours, and R7 has a wound to his coccyx, boots to bilateral feet in bed, and an air mattress. Surveyor asked LPN U, has R7 been turned and repositioned every 2 hours since admission. LPN U stated repositioning is something we established to prevent further skin breakdown. LPN U added, turning and repositioning was not in place upon admission and was started at a later date. Surveyor asked LPN U, should turning and repositioning be in place upon admission. LPN U stated, yes, especially when R7 is unable to make his needs known and reposition himself independently. LPN U stated, R7 does not have a cushion in his Broda chair. LPN U stated, she overheard Physician T recommending that R7 have a cushion in his Broda chair. LPN U stated, R7's Guardian was very insistent on having R7 up in the chair very often. LPN U added, it wasn't until skin breakdown started occurring that Physician T indicated that R7 needs to lay in bed with repositioning. LPN U stated, it's understandable that R7's Guardian has no knowledge of what is going on and the importance of turning and repositioning side to side (to offload pressure.) Surveyor asked LPN U if R7 refuses care or has behaviors. LPN U stated, no, he's very cooperative. 5/27/26 at 3:10 PM, Surveyor observed ADON Q (Assistant Director of Nursing) pull back R7's dressing to his left buttock. Surveyor asked ADON Q what she observed. ADON Q stated, there is 50% slough and 50% granulation in the wound bed. ADON Q stated, R7's PI to his left buttock is drastically improved. Surveyor asked ADON Q if R7 has a cushion in his Broda chair. ADON Q stated, no. Surveyor asked ADON Q if R7 should have a cushion in his Broda chair. ADON Q stated, the facility does not normally put cushions in Broda chairs. ADON Q stated, currently Physician T wants R7 in bed to offload pressure. ADON Q stated, we will discuss the appropriateness of a cushion in R7's Broda when he is back up in his chair. Note, the Care Plan indicates R7 is to have a cushion in his wheelchair and Physician T ordered a wheelchair cushion. On 5/27/26 at 3:54 PM, Surveyor spoke with DON B (Director of Nursing.) Surveyor asked DON B what is the root cause analysis for R7's PI to his left buttock. DON B stated, it is originally from friction and shear, a little bit of moisture, and R7's Guardian demanding that R7 be in the chair (Broda) for a long time. Surveyor asked DON B, between 5/5-5/12/26 did the facility educate staff regarding the root cause analysis and how to prevent the PI from worsening and prevent new PIs. DON B stated, No. Surveyor stated to DON B, R7's Care Plan documents that turning and repositioning was not put in place until 5/5/26. DON B checked the EHR (Electronic Health Record.) DON B stated, that is correct, repositioning was not put in place until 5/5/26. Surveyor asked DON B what her expectation was for turning and repositioning. DON B stated she expects turning and repositioning to be in place upon admission due to R7's existing PI and inability to turn and reposition. Surveyor asked DON B, should R7 have a wheelchair (Broda) cushion in place per his Care Plan and order from Physician T. DON B stated yes, it is an order. DON B added, R7's Broda chair can also be reclined to help relieve pressure. DON B stated, the facility ordered a cushion for R7's Broda chair on 5/20/26. DON B stated there has been a delay in shipment and the cushion should arrive sometime this week.

Based on observation, interview, and record review, the facility did not ensure that each resident received food and drinks that are safe and appetizing temperature. This has the potential to affect all 92 residents who reside at the facility. Surveyor received a test tray with cold foods that were not cold enough. Surveyor received a test tray with hot foods that were not hot enough. R2 voiced concerns about food quality and temperature. This is evidenced by: The facility policy, titled Preventing Foodborne Illness – Food Handling, reviewed 1/25, states in part: Policy Statement: Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. Policy Interpretation and Implementation: 1. The facility recognizes that the critical factors implicated in foodborne illness are: .b. Inadequate cooking and improper holding temperatures. The Food and Drug Administration (FDA) Food Code 2022, includes in part: 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. Time/Temperature control for safety - food shall be maintained: (1) At 57 degrees C (135 degrees F) or above.(2) At 5 degrees C (41 degrees F) or less. Example 1 R2 was admitted on [DATE]. R2's admission MDS (Minimum Data Set) with a target date of 5/7/26, indicates in part: Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating R2 is cognitively intact. On 5/26/26 at 9:34 AM, Surveyor interviewed R2 who stated she eats most of her meals in her room. R2 indicated the food at the facility is awful and very bad quality. R2 stated they don't get the minimum amount of protein required for healing, and that many times for breakfast there is no protein in the meal. R2 stated the food is always cold, and they have run out of milk and coffee a lot lately. R2 showed Surveyor a dietary form that stated there are no alternatives offered for breakfast. A review of R2's EHR (Electronic Health Record) include the following progress notes: On 5/24/26: NHA received complaint from Regional Ombudsman. regarding resident [Resident Name]. Complaint included concerns regarding food services. Plan to coordinate care conference with resident to discuss concerns and follow up accordingly. Example 2: On 5/26/26 at 12:04 PM, Surveyor received a lunch test tray from the kitchen with cold foods on it. The test tray was served directly from the kitchen's cold food holding area after staff had taken trays to resident rooms and served lunch to the last resident eating in the dining room. The temperature of the chicken salad (served on white bread) was 57.2 degrees F. The temperature of the potato salad was 42.3 degrees F. The temperature of the chocolate milk was 48.4 degrees F. Example 3: On 5/27/26 at 12:30 PM, Surveyor received a lunch test tray from the kitchen with hot foods on it. The test tray was served directly from the kitchen's hot food holding area after staff had taken trays to resident rooms and served lunch to the last resident eating in the dining room. The temperature of the sloppy joe meat (served on a bun) was 125.6 degrees F. The temperature of the tater tots was 121.6 degrees F. The temperature of the peas was 122.5 degrees F. On 5/27/26 at 1:55 PM, Surveyor followed up on the meal trays with [NAME] N. (Of note: the facility's new dietary manager started on 5/26/26 and was not in the building on 5/27/26.) [NAME] N indicated cold foods should be served around 40 degrees F. Surveyor discussed the temperatures of the chicken salad, potato salad, and milk on 5/26/26. [NAME] N indicated the recorded temperatures were too high. [NAME] N indicated hot food temperatures are typically between 165-175 degrees F when food is coming out of the oven and should be served hot to residents. Surveyor discussed the temperatures of the sloppy joe meat, tater tots, and peas with [NAME] N. [NAME] N indicated those temperatures were not high enough. [NAME] N indicated they would work on the temperatures. On 5/27/26 at 2:00 PM, Surveyor discussed the food temperature issues with NHA A (Nursing Home Administrator) and DON B (Director of Nursing.) On 5/27/26 at 2:45 PM, Surveyor discussed the food temperature issues with RD L (Registered Dietician.)

Based on interview and record review, the facility failed to maintain acceptable parameters of nutritional status and consult with the residents' Physician on this for 1 of 3 residents (R7) reviewed for nutrition. R7 did not have a nutrition care plan. R7 experienced a significant weight loss of 4.29% in one week (13.5# loss) and the facility did not notify the physician. Evidenced by: Facility policy: Weight Monitoring states in part: . Process. Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status. 1. The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes: a. Identifying and assessing each resident's nutritional status and risk factors. b. Evaluating and analyzing the assessment information. c. Developing and consistently implementing pertinent approaches. d. Monitoring the effectiveness of interventions and revising them as necessary. 2. A comprehensive nutritional assessment will be completed upon admission on residents to identify those at risk for unplanned weight loss/gain or compromised nutritional status. 3. Information gathered from nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident's specific nutritional concerns and preferences. The care plan should address the following, to the extent possible: a. Identified causes of impaired nutritional status. b. Reflect the residents personal goals and preferences. c. Identify resident specific interventions. d. Time frame and parameters for monitoring. e. Updated as needed such as when the residents condition changes, goals are met, interventions are determined to be ineffective or a new causes of nutrition related problems are identified. g. The resident and/or resident representative will be involved int he development of the care plan to ensure it is individualized and meets persal goals and preferences. 6. A weight monitoring schedule will be developed upon admission or all residents. b. Newly admitted residents-monitor weight weekly x 4 weeks. c. residents with weight loss-monitor weight weekly d. if clinically indicated-monitor weight daily. e. All other monitor weight monthly. 6. Weight analysis: A significant weight is defined as: a. 5% change of weight in a month (30 days). 7. Documentation: a. The physician should be informed of a significant change in weight and may order nutritional interventions. e. The Registered Dietician should be consulted to assist with interventions, actions are recorded int he nutrition progress notes. R7 was admitted to the facility on [DATE] with diagnoses of: Non traumatic intercranial hemorrhage (bleeding in the brain), Chronic respiratory failure (lungs can't move oxygen into blood and carbon monoxide out causing ongoing fatigue and shortness of breath), Type II Diabetes Mellitus (body stops making enough insulin or not responding properly to insulin), Tracheostomy (small hole in front of neck directly into windpipe to place a breathing tube allowing the person to breathe without using their nose or mouth), Gastrostomy tube (soft, flexible tube placed directly into the stomach through a small hole in the belly; acts as a direct tunnel for liquifood, water, and medications when eating or drinking by mouth isn't safe (dysphagia)). As of 5/27/26 R7 did not have a nutrition care plan with specific interventions and goals for weight loss/gain. R7's admission Nutritional assessment dated [DATE] at 13:20 PM states R7's weight at 321.6# Goal: resident will have no significant weight changes per MDS criteria, however gradual weight loss desired due to high BMI. Of note R7 had a significant weight loss of 4% or 13.5# since 5/12/26 R7's physician order: 4/27/26 Enteral Feed Order-every shift Jevity 1.5 at rate of 70 mL/hr (milliliters/hour) with 150 free water flush Q4 (every four) hours. Weekly weight x (times) 4 weeks every day shift every Tue for 4 Weeks. Current Weights: 4/28 336.04/29 332.9 4/30 337.95/2 335.75/3 335.75/5 335.75/12 335.15/19 321.6 (this is a 3% change from the last weight, decrease of 13.5 lbs.) 5/27 316.4 (note: this is another 5.2 pounds lost, or a 5.58% loss in 15 days) No documentation was provided to show that a provider was updated on R7's weight loss. On 5/27/27 at 3:22 PM, Surveyor interviewed LPN F (Licensed Practical Nurse) Surveyor asked LPN F where she would find a significant weight loss in the chart. LPN F stated that a significant weight loss will turn red on banner where it says weight. Surveyor asked LPN F what would you do if you saw this weight loss. LPN F stated she would try to find out why, assess the resident, check for trends, and call the MD. Surveyor asked who else would you notify. LPN F stated DON, and immediate floor manager. Surveyor asked if a significant weight loss would be considered a COC (change of condition). LPN F stated yes, she would do a COC note and paste it into the progress note. On 5/27/26 at 3:45 PM, Surveyor interviewed RD L (Registered Dietician). Surveyor asked how do you get notified of a weight loss. RD L stated that they talk about it at our resident at risk meetings. Surveyor asked RD L how often do the resident as risk meetings happen. RD L states pretty much weekly. Surveyor asked if you didn't have a meeting how would you get notified. RD L stated ADON Q (Assistant Director of Nursing) tells me. I couldn't do anything because you (state surveyors) have been here the last two weeks, so we haven't had a meeting. Surveyor asked RD L should the physician be notified of a significant weight loss? RD L stated we determine that in resident at risk meeting. I don't get notified until there is a 5% weight loss so that is why we talk about it at the meeting. Surveyor asked RD L should a significant weight loss be considered a change of condition. RD L reported that he (R7) is meeting his required intake, he was obese when he came to us. Surveyor asked RD L if the resident has not had a change in his tube feed order, would you be concerned about a significant weight loss. RD L indicated yes. Surveyor asked RD L what would you do then. RD L stated I would talk with the NP (Nurse Practitioner), RD L indicate she hasn't yet, but would request labs possibly a pre albumin, and check kidney function, keep NP on the same page. On 5/27/26 at 4:45 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B would you consider a significant weight loss in a week a change of condition. DON B stated yes. Surveyor asked DON B would you expect staff to notify the physician with a significant weight loss in one week. DON B stated yes.

Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision for 1 of 3 residents (R5) reviewed for elopement. On 5/18/26, R5 attempted to exit the building, setting off the door alarm. There was a 3-minute delay in the door alarm resetting. During this delay, the staff failed to adequately supervise R5, who was then able to exit the building and was found in the ER (Emergency Room) waiting room next door to the facility. This is evidenced by: Facility policy titled Elopement, undated, states in part: Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care. Policy Explanation and Compliance Guidelines: . 3. The facility is equipped with door locks/alarms to help avoid elopements. 4. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 5. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering. implementing interventions to reduce hazards and risks. 6. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering: . d. Adequate supervision will be provided to help prevent accidents or elopements. R5 was admitted on [DATE] with diagnoses that include Vascular Dementia, Severe, With Agitation, Repeated Falls, Generalized Anxiety Disorder, and Restlessness and Agitation. R5's admission Minimum Data Set (MDS) with a target date of 5/21/26, indicates a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating R5 is moderately cognitively impaired. R5's Comprehensive Care Plan states in part: Focus: At risk for elopement related to: Attempts to leave Living Center, Wandering. I had an elopement incident 5/18/26. Date Initiated: 5/18/26.Goals: Will remain safe during placement at Living Center Date Initiated: 5/18/26 Target Date: 8/19/26.Interventions: 15 minute checks to be completed to ensure resident safety. Date Initiated: 5/18/26. Assess for risk of elopement per living center policy. Date Initiated: 5/18/26 . Educate family/responsible party on talking positively about Living Center Placement. Date Initiated: 5/18/26. Encourage family to bring in personal possessions. Date Initiated: 5/18/26. Evaluate effect of cognitive impairment upon resident's ability to understand changes in surroundings.Date Initiated: 5/18/26. Involve patient in preferred activities including reading books, drawing, writing in note pad, art like activities, and puzzles. Date Initiated: 5/18/26. Revision on: 5/19/26. Provide redirection, reassurance, and diversion activities when resident demonstrates exit-seeking behaviors. Date Initiated: 5/18/26. Redirect patients from doors. Date Initiated: 5/18/26. Talk to me in a calm unhurried voice when providing redirection. Date Initiated: 5/19/26. A review of R5's Electronic Health Record (EHR) includes the following progress notes:On 5/18/26 at 1:30 AM: Late Entry: At 1:09 AM Resident attempted elopement through the back of the facility towards the tunnel. The alarm sounded, staff redirected resident away from door and staff put in code to the door for alarm to be shut off. The resident was walking alongside staff writer went past Nurse's station to Supply closet and the other staff member present at the time went down the 400 hall. Writer was away from nurse's station for roughly 5 to 7 mins while writer was getting supplies. When writer was back at the nurse's station within the 7 min timeframe writer received a call from (hospital name) ER that resident had entered their ER ambulating with his walker. Writer assisted resident back to the facility. Resident was placed on 15 minute checks with close supervision. Resident remained within line of site through the duration of shift. On 5/19/26 at 2:08 AM, Resident is up, wandering, striking out at staff, and not easily redirected. He has tried to exit 2x (two times). Will monitor closely. On 5/19/26 at 11:45 AM, Some agitation noted - cont (continue) to wander halls via w/c (wheelchair) mobility or ambulation - on q (every) 15 min (every 15 minute) checks. On 5/19/26 at 7:29 PM, . Patient continues to wander around the unit . On 5/26/26 at 5:16 PM, Resident continues on 15 minute checks, anxious and in need of redirection. confused and disoriented most of the time. Fidgeting often. No attempts of eloping at this time. On 5/26/26 at 10:11 PM, Resident continues on 15 minute checks. At risk of elopement. Has been anxious and pacing. On 5/27/27 at 2:39 AM, Late Entry: Residents continues on 15 minute checks for elopement risk. Resident had been at the nurse's station with staff all night long. He was sitting in his wheelchair and dozed off. A staff went about resident care one of the CNAS (Certified Nursing Assistant) Called into a residence room when I came back to the nurse's station other nurse on staff was bringing him back from the Northside stated that he was tempting to elope. RESIDENT CONTINUES ON 15 MIN CHECKS. The facility completed a Self-Report Summary for R5's elopement, which included the following, in part: . Incident Description: On May 18, 2026, at approximately 1:10 AM, [Resident Name] was observed exiting through the 300 Hall common area door. Staff immediately responded and redirected the resident back into the facility. LPN F (Licensed Practical Nurse) entered the alarm code to reset the door alarm system while staff escorted the resident away from the exit area. Upon re-entering the facility with staff, the resident stated, 'the alarm is going off, I can't go out that way,' indicating awareness that the alarm system had initially activated during the resident's first exit attempt. Staff reported the resident was observed walking alongside staff back into the facility. LPN F stated she was under the impression CNA (Certified Nursing Assistant) staff were continuing to escort the resident back toward his room while she returned to resident care duties. During the facility investigation, staff reported it is believed the resident turned back toward the 300 Hall exit door while staff resumed resident care duties. Due to the delay in alarm reactivation following code entry, the resident was able to re-exit the facility before the alarm system fully reset and without the alarm immediately sounding. At approximately 1:19 AM, Watertown Hospital contacted the facility and notified LPN F that [Resident Name] was present in the emergency room waiting area. Investigative Findings/Root Cause Analysis: . The investigation identified that once the code was entered, the door alarm system had an approximate three-minute delay before reactivation. During that delay period, the resident was able to re-exit the facility without the alarm immediately sounding. On 5/26/26 at 3:15 PM, Surveyor observed R5 actively attempting to exit seek the building. Surveyor observed CNA P (Certified Nursing Assistant) retrieve R5 and redirect him away from the door. On 5/27/26 at 2:17 PM, Surveyor interviewed CNA H about R5's elopement. CNA H indicated that last week R5 started wandering and tried to escape. CNA H stated that when R5 initially tried to elope, he put the code in to keep R5 away from the door and then he went back to the other side of the building where he was working for the night. CNA H stated that is when R5 went out the exit door. CNA H indicated that the door alarm didn't automatically go back on when he entered the code. Surveyor asked CNA H if R5 still attempts to exit seek. CNA H replied no because R5 remains with a staff member throughout the shift. On 5/27/26 at 2:35 PM, Surveyor interviewed LPN F (Licensed Practical Nurse) about R5's elopement. LPN F stated that R5 wanders and exit seeks, and last week he got out of the building. LPN F indicated that R5 was trying to leave when the door alarm rang. LPN F stated her and CNA H were in the nurses' station and the CNA from 400 Hall came over so all three of them were with R5 by the exit door. LPN F stated they punched in the alarm code, and they told R5 to come with them. LPN F stated she then went to get some supplies, and it was at that time that R5 must have doubled back and went out the exit door. LPN F stated that CNA H went back to the nurses' station and the CNA from 400 Hall went back to that side of the building. LPN F indicated that after she received the call from Watertown Hospital and brought R5 back to the facility, she immediately started him on 15-minute checks. Surveyor asked LPN F if R5 still attempts to exit seek. LPN F stated yes, and that last night R5 tried to elope again. LPN F stated that R5 was in the nurses' station asleep when she left him to go suction another resident and when she came back the nurse from the north side of the building was bringing R5 back. LPN F indicated she had only left R5 alone for 3-4 minutes. On 5/27/26 at 2:45 PM, Surveyor interviewed CNA P about R5's elopement. CNA P indicated that she was not working that day, but that R5 still continues to exit seek. CNA P stated that last night on 3rd shift in the middle of rounds, R5 was found on the other side of the building, and the nurse had to bring him back to this side. CNA P stated that R5 does that often. On 5/27/26 at 3:25 PM, Surveyor interviewed MD R (Maintenance Director) and NHA A (Nursing Home Administrator) about R5's elopement. NHA A indicated that R5 went out the smoker's door, down the sidewalk and through the hospital parking lot, straight ahead to the ER entrance. MD R indicated that he adjusted the door reactivation alarm so that now there is only a 15-second delay.

Based on interview and record review, the facility did not ensure that each resident's drug regimen is free from unnecessary drugs for 1 of 1 resident (R5) receiving a psychotropic medication. R5 was prescribed Quetiapine, an anti-psychotic medication, scheduled twice daily and PRN (as needed), Cymbalta, an anti-depressant, scheduled daily, Lorazepam, an anti-anxiety medication PRN, Haldol, an anti-psychotic medication PRN, and Remeron, an anti-depressant, scheduled daily. R5's care plan does not address the use of anti-psychotic medications. This is evidenced by: Please note: the survey team requested a psychotropic medication policy but did not receive one from the facility. Per the SOM (State operations manual) An unnecessary drug is any drug when used- (1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. S483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-S483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. R5 was admitted on [DATE] with diagnosis that include Vascular Dementia, Severe, With Agitation, Repeated Falls, Generalized Anxiety Disorder, and Restlessness and Agitation. R5's Physician Orders include, in part:--Cymbalta Oral Capsule Delayed Release Particles 30 MG (Duloxetine HCl) Give 1 capsule by mouth one time a day for Anxiety. Take 30mg daily. Order Date: 5/14/26.--QUEtiapine Fumarate Oral Tablet 25 MG (Seroquel) Give 3 tablets by mouth in the evening for dementia. Order Date: 5/14/26. Discontinue Date: 5/22/26.--QUEtiapine Fumarate Oral Tablet 25 MG (Seroquel) Give 1.5 tablet by mouth two times a day for dementia related agitation, restlessness. Take 1.5 tablets (=37.5mg) twice daily. Order Date: 5/23/26.--QUEtiapine Fumarate Oral Tablet 25 MG (Seroquel) Give 1 tablet by mouth every 8 hours as needed for Agitation until 6/6/26. Order Date: 5/23/26.--Haloperidol Oral Tablet 0.5 MG (Haldoll) Give 1 tablet by mouth every 4 hours as needed for Agitation, delirium, nausea for 14 Days. Order Date: 5/22/26.--LORazepam Oral Tablet 0.5 MG (Ativan) *Controlled Drug* Give 1 tablet by mouth every 4 hours as needed for Anxiety, Nausea, Restlessness until 11/23/26. Comfort Med, call Agrace prior to first dose. May crush or dissolve. Order Date: 5/23/26.--Remeron Oral Tablet (Mirtazapine) Give 7.5 mg by mouth at bedtime for Anxiety. Take 7.5 mg at bedtime. Order Date: 5/25/26.(Of note: Symptoms of dementia include memory problems, communication difficulties, mood changes, disorientation, confusion, poor judgement and difficulty with everyday tasks. This includes an increase in anxiety, depression, and/or agitation etc.,) R5's Medication Administration Record (MAR) for May indicates the following as needed (PRN) medications were administered:-Haldol PRN given on 5/22/26, 5/23/26, twice on 5/24/26, and 5/26/26-Lorazepam PRN given on 5/19/26, 5/20/26, twice on 5/21/26, twice on 5/22/26, 5/24/26, 5/25/26, and twice on 5/26/26 R5's Comprehensive Care Plan, states in part:Focus: Potential for drug related complications associated with use of psychotropic medications related to: Anti-Depressant medication. Date Initiated: 5/14/26.Goals: Will be free of psychotropic drug related complications. Date Initiated: 5/14/26. Target Date: 8/19/26.Interventions: Monitor for side effects and report to physician: Antidepressant-Sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photo sensitivity and excess weight gain. Date Initiated: 5/14/26. Provide Medications as ordered by physician and evaluate for effectiveness. Date Initiated: 5/14/26. Revision on: 5/14/26.Focus: I have diagnosis/exhibit signs of a mood disorder related to Diagnosis - Dementia, Loss of function, Such as yelling, grabbing at residents and their items, thinking that other residents belongings are his and will try to claim them as his. Date Initiated: 5/20/26. Goal: Resident will have improved mood state: Date Initiated: 5/20/26. Revision on: 5/26/26. Target Date: 8/19/26.Interventions: Administer meds as ordered. Monitor and document for side effects and effectiveness. Date Initiated: 5/20/26. Assist resident in developing program of activities that is meaningful and of interest. Date Initiated: 5/20/26. Assist resident/family/caregiver to identify strengths, positive coping skills and reinforce those. Date Initiated: 5/20/26. Encourage resident to express feelings in a productive way. Date Initiated: 5/20/26. Monitor/record mood to determine if problems seem to be related to external causes (medication, treatment, concern over diagnosis). Date Initiated: 5/20/26. Offer me food and beverages I like. Date Initiated: 5/20/26. Psychology/psychiatry consult as ordered. Date Initiated: 5/20/26. When resident appears to be looking for clothes, help assist resident in finding clothes. Date Initiated: 5/22/26.On 5/18/26 at 1:30 AM: Late Entry: At 1:09 AM Resident attempted elopement through the back of the facility towards the tunnel. The alarm sounded, staff redirected resident away from door and staff put in code to the door for alarm to be shut off. The resident was walking alongside staff writer went past Nurse's station to Supply closet and the other staff member present at the time went down the 400 hall. Writer was away from nurse's station for roughly 5 to 7 mins while writer was getting supplies. When writer was back at the nurse's station within the 7 min timeframe writer received a call from (hospital name) ER that resident had entered their ER ambulating with his walker. Writer assisted resident back to the facility. Resident was placed on 15 minute checks with close supervision. Resident remained within line of site through the duration of shift.On 5/27/26 at 2:17 PM, Surveyor interviewed CNA H (Certified Nursing Assistant) about R5's behaviors. CNA H indicated that R5 seems fine and doesn't have a lot of behaviors. CNA H stated that R5 walks around with his walker and doesn't bother others. CNA H stated that starting last week R5 began trying to exit the building and did get outside one night. CNA H indicated that since then R5 has had a change of behavior and staff are doing 15-minute checks on R5 and monitoring him closely. On 5/27/26 at 2:35 PM, Surveyor interviewed LPN F (Licensed Practical Nurse) about R5's behaviors. LPN F stated that R5 sometimes bites, kicks, screams, wanders, and is aggressive with staff. LPN F stated that R5 wanders and exit seeks, and last week he got out of the building. Surveyor asked LPN F what interventions are in place when R5 has these behaviors. LPN F stated that they started R5 on 15-minute checks and he likes to talk about his job, so she tries to redirect him. LPN F also stated that hospice just gave new orders for morphine, lorazepam, and Seroquel. LPN F stated that they have not been giving morphine, because R5 does not exhibit signs of pain, but that they are giving the lorazepam and Seroquel which are helping calm him down some, however it depends on R5's mood and the situation. On 5/27/26 at 3:02 PM, Surveyor interviewed ADON Q (Assistant Director of Nursing) about R5's behaviors. ADON Q stated that R5 wanders, has been exit seeking, and can become anxious and agitated at times. ADON Q stated that R5's behaviors are persistent but not harmful. Surveyor asked ADON Q what interventions are in place when R5 has these behaviors. ADON Q stated that currently R5 was on 15-minute checks, and they offer him his preferred activities, such as writing and drawing in a notebook. ADON Q indicated that R5 doesn't stay on task or keep his attention on anything for more than 10-15 minutes. ADON Q stated that the PRN (as needed) medications they are giving R5 have been effective. ADON Q stated that R5 had been displaying symptoms of delirium last week, but since hospice started the PRN medications, those symptoms have reduced. Surveyor asked ADON Q to explain why R5 had been prescribed so many psychotropic medications. ADON Q indicated that R5 was on the Cymbalta and quetiapine when he came in, but the psych NP (Nurse Practitioner) split the doses because he was taking it all at night and then she changed it to twice daily. ADON Q stated that Remeron was started as an appetite stimulant, and the lorazepam and morphine were started by hospice. ADON Q indicated that the Haldol was ordered by hospice when R5 was displaying signs of delirium. Please note there is no documentation in R5's Electronic Health Record (EHR) indicating that R5 had symptoms of delirium. On 5/27/26 at 5:54 PM, Surveyor interviewed DON B (Director of Nursing) about R5's behaviors and medications. DON B stated that R5 attempts to exit seek, but that now staff know him better they are better able to redirect him, however nothing keeps him sitting still for too long. Surveyor asked DON B to explain why R5 had been prescribed so many psychotropic medications. DON B indicated that R5 was originally admitted with the Cymbalta, and the Seroquel was originally 3 tablets once daily so the psych NP split the tablets to twice a day without changing the dosage. DON B stated hospice prescribed the lorazepam and morphine and also added on a PRN Haldol and Seroquel. Surveyor asked DON B if all of these psychotropic medications could be considered a chemical restraint. DON B stated no. Surveyor asked if the addition of more psychotropic medications in addition to what R5 had already been taking could be contributing to his frequent falls. DON B stated no because she talked to R5's daughter who was unable to manage his falls at home. Surveyor asked DON B if R5 had been displaying signs of delirium. DON B indicated that she was unaware of that because she had been on vacation last week. Surveyor asked DON B how she would know what's been effective or not effective when R5 has 3 scheduled and 4 PRN psychotropic medications. DON B stated that she notified the psych NP, who wants her to have a stern talk with hospice about R5's medication management.

Based on interview and record review, the facility did not make prompt efforts to document, investigate, and resolve grievances a resident may have for 2 of 3 residents (R1 & R2) reviewed for grievances. R1 reported finding a paperclip in her cereal to CNA O (Certified Nursing Assistant), who did not follow up appropriately to address this concern. R2 voiced a concern and the facility did not follow its grievance policy. This is evidenced by: The facility policy, titled Grievance Policy, dated 9/15/25, states in part: Policy Statement: The facility ensures that all residents have the right to voice grievances without discrimination, reprisal, or fear of retaliation.Residents and representatives will be informed throughout the process, and grievances will be promptly investigated and resolved. Policy Interpretation and Implementation: .Investigation and Resolution: Investigations may include interviews, medical record reviews, and consultation with staff or family members. Written resolutions will summarize the grievance, investigation steps, findings, actions taken, and the completion date.All grievances will be reviewed in collaboration with the appropriate department leadership to ensure the corrective actions address the underlying concern effectively. Grievances should be resolved as promptly as possible, with a goal of resolution within five (5) working days. If resolution cannot be achieved within this timeframe.the resident and/or representative will be notified of the reason for the delay and provided with an updated expected timeframe for completion.The facility maintains grievance logs for three (3) years. Example 1 R1 admitted to the facility on [DATE]. R1's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/8/26, lists her BIMS (Brief Interview for Mental Status) score as 15 out of 15, indicating R1 is cognitively intact. On 5/26/26 at 10:00 AM, Surveyor interviewed R1. R1 indicated she had found a paperclip in a bowl of cereal she had for breakfast on 5/12/26. The date was verified by a picture R1 had taken that morning. R1 indicated that she told CNA O (Certified Nursing Assistant) right away and CNA O followed up with the kitchen staff. R1 indicated she never heard anything back about this issue, and was concerned, as she had previously found a piece of wax paper and plastic wrap in her food as well. On 5/27/26 at 8:57 AM, Surveyor interviewed [NAME] S. [NAME] S indicated she had never been informed about items being found in a resident's food. [NAME] S indicated she was unsure who would have been told about this, but noted their previous dietary manager quit two weeks ago. On 5/27/26 at 11:30 AM, Surveyor interviewed CNA O. CNA O indicated R1 told her about the paperclip in her cereal and she had observed it. CNA O then reported this issue to kitchen staff. CNA O could not recall who she told or what staff said they would do about this issue. Surveyor reviewed the grievance log for May 2026 provided by the facility and did not see R1's food issue recorded on the log. On 5/27/26 at 4:15 PM, Surveyor spoke with DON B (Director of Nursing). DON B indicated she was not aware of any resident issues regarding finding items in food. Surveyor informed DON B of the concern and that CNA O had followed up with kitchen staff. DON B indicated the CNA should have reported this issue to management so they could follow up on it properly instead of reporting it to kitchen staff. DON B indicated she would start education on the facility's grievance process with staff and wrote down the concern and said she would follow up on it. Example 2: R2 was admitted on [DATE], with diagnoses that include Major Depressive Disorder, Recurrent, Unspecified, Generalized Anxiety Disorder, and Chronic Pain Syndrome. R2's admission MDS (Minimum Data Set) with a target date of 5/7/26, indicates, in part: Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating R2 is cognitively intact. On 5/26/26 at 9:34 AM, Surveyor interviewed R2 who voiced frustrations about her desire to be transferred to a facility closer to her daughter. R2 stated that she had asked facility management over and over to move her closer to her only living relative, which is her daughter. R2 indicated that she had spoken to the social worker and had even written a letter to management asking to be transferred. R2 stated that at the end of the day, facility management gets to go home and be with their families, and she's not being allowed to be with her family. R2 stated that she doesn't think it is too much to ask to be allowed to move to a facility closer to her daughter. R2 also indicated that the food at the facility is awful and very bad quality. R2 stated that they don't get the minimum amount of protein required for healing, and that many times for breakfast there is no protein in the meal. R2 stated that the food is always cold, and that they have run out of milk and coffee a lot lately. R2 showed Surveyor a dietary form that stated there are no alternatives offered for breakfast. A review of R2's EHR (Electronic Health Record) include the following progress notes: On 4/14/26 a Social Services Note: Baseline care plan meeting held. Unknown discharge plan at this time, resident would like to have referrals sent closer to home. On 5/5/26 a Social Services Note: Writer was informed that resident wanted to meet, writer met with resident who requested referrals be sent out. Prefer closer to home but would consider other options. On 5/24/26: NHA received complaint from Regional Ombudsman. regarding resident [Resident Name]. Complaint included concerns related to resident's requests for transfer to [County name] not being followed up on and concerns regarding food services. Plan to coordinate care conference with resident to discuss concerns and follow up accordingly. On 5/26/26 at 3:15 PM, Surveyor interviewed SSA C (Social Services Assistant) who stated that she had been in her role for only 2 weeks. Surveyor asked SSA C what the process was for residents who desired to be transferred to another facility. SSA C stated that she would go and talk with the resident to find out if they had any facilities or a particular area in mind. Surveyor asked SSA C what an acceptable time frame for making those referrals would be. SSA C stated that she would make the referrals the same day if possible. Surveyor asked SSA C where she was in the process of referrals for R2. SSA C stated that she was just on her way to talk to R2 about that today. Surveyor asked SSA C if she had sent any referrals for R2. SSA C indicated that she personally had not sent any, and that if the previous social worker had sent any, she would have entered a progress note on it. On 5/26/26 at 3:34 PM, Surveyor interviewed NHA A (Nursing Home Administrator), DON B (Director of Nursing), and CNO D (Chief Nursing Officer) about the facility's referral process. DON B indicated that if a resident had a preferred facility or one that was closer to their desired region, social services was responsible for sending out the referrals. Surveyor asked what an acceptable timeframe would be for sending out referrals. NHA A stated that the referrals are usually sent out immediately. Surveyor asked where social services were at in R2's referral process. NHA A stated that he was having the previous social worker send out referrals for R2, but he was not sure who accepted her or what facilities might be full, etc. Surveyor asked where that information would be documented. DON B indicated that there should be a progress note in R2's chart on that. Surveyor asked if a resident asked to be transferred to a facility closer to family, if 6 weeks was an acceptable timeframe to wait for referrals to be sent out. CNO D stated that would not be an acceptable timeframe, but she would check to see if they had more information about R2's referrals. On 5/27/26 a Social Service Note in R2's EHR indicated Writer faxed 4 referrals to skilled nursing facilities. Waiting to hear back. No other information or follow-up was provided by the facility.

Based on observation, interview and record review the facility did not ensure each resident has the right to privacy and confidentiality for 1 of 7 residents (R) reviewed (R7). During the survey, a camera (an electronic monitoring and recording device) was observed to be used in R7's room. Two of R7's family members have saved recordings with video and voice footage including all cares performed in the room (e.g., pericare, tube feedings, transfers, trach care, dressing, bathing, etc.). The facility does not turn off the camera or cover it up at any time to respect R7's privacy. Evidenced by:R7 was admitted on [DATE]. R7's most recent Minimum Data Set (MDS) with an assessment reference date of 5/4/26 indicates under section C that R7s Cognitive Skills for Daily Decision Making is Severely impaired-never/rarely made decisionsOn 5/5/26 at 12:21 PM, during a Care Conference, the facility documents, in part, as follows. Family would like to put a camera in his (R7's) room. R7's does not have a Care Plan for electronic monitoring and recording devices.Surveyor requested a copy of the facility's electronic monitoring and recording devices policy. On 5/27/26 at approximately 9:45 AM, Surveyor spoke with R7's family member in-person while she was at the facility. Surveyor observed a camera in R7's room pointed toward R7's bed where he was sleeping. R7's family member stated to Surveyor that she and another family member installed a camera in R7's room on 5/9/26 due to concerns regarding cares. Surveyor observed signage/notification to any resident, family, and staff who may enter R7's room that the room was under surveillance by a camera. R7's family member shared saved recordings with video and voice footage. On 5/27/26 at 4:00 PM, Surveyor interviewed NHA A (Nursing Home Administrator), CNO D (Chief Nursing Officer), and DON B (Director of Nursing). NHA A stated the facility does not have a policy and procedure for electronic monitoring and recording devices. Surveyor asked NHA A, should the camera be turned off or covered during resident care. NHA A stated, the facility reviewed this with an Ombudsman (not the facility's Ombudsman) who told them it is the Family Member/Guardian's right to have the electronic monitoring and recording device. Surveyor asked NHA A if electronic monitoring and recording devices are appropriate in resident care areas. NHA A stated, yes. Surveyor shared with NHA A, CNO D (Chief Nursing Officer), and DON B (Director of Nursing) that electronic monitoring and recording devices are not appropriate in resident care areas. Surveyor shared with the facility that the videos with voice recordings from this device are saved and R7's Guardian and close family members have access. Using the reasonable person concept, a person would want their privacy and dignity maintained during cares and while undressed. NHA A stated, That's new. Surveyor asked NHA A, did the facility complete an assessment for the electronic monitoring and recording device. NHA A stated, it was not put in (installed) by the resident so, no.

Based on staff interview and record review, the facility did not ensure care and treatment in accordance with professional standards of practice for 4 residents (R) (R4, R5, R16, and R8) of 4 sampled residents. R4 was admitted to the facility with a surgical wound to the sternum that increased in size and became infected. Registered Nurse (RN) assessments were not completed timely and staff did not document changes in the wound or notify the physician of the changes. (This example is being cited at a level G (actual harm/isolated.) R5 went 4 days without a documented bowel movement (BM). The physician was not notified and R5 was not provided with prescribed as needed (PRN) medication. Staff did not consistently document whether or not R5 had a BM. In addition, R5's Treatment Administration Record (TAR) for colostomy care and surgical wound care was not thoroughly completed. R5's weekly skin checks were also not completed. R16 went multiple days without a documented BM. The physician was not notified and R16 was not provided with prescribed PRN medication. In addition, staff did not consistently document whether or not R16 had a BM. R8's Medication Administration Record (MAR) indicated multiple prescribed treatments, medications, and monitoring were not completed on 2/27/26, 3/12/26, 3/15/26, and 3/17/26 . Findings include: The facility's Wound Care policy, revised 10/2010, states in part: .The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any change in the resident's condition. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 7. How the resident tolerated the procedure. 8. Any problems or complaints made by the resident related to the procedure. 1. R4 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, chronic kidney disease, anxiety disorder, depression, and was status post (s/p) coronary artery bypass grafting (CABG) (a procedure that creates a new path for blood to go around a blocked or partially blocked artery in the heart) (dated 3/14/26). R4's most recent Minimum Data Set (MDS) assessment, dated 5/7/26, indicated R4 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. R4's admission assessment, dated 4/8/26, stated in part: .Surgical wound to sternum 3 centimeters (cm) x 2 cm .Exudate: light, seropurulent (a mixture of purulent (pus) and serous, usually watery, yellow, green, tan, or brown) . Facility wound assessment documentation indicated the following: 4/14/26: Completed by an Licensed Practical Nurse (LPN). The assessment did not address R4's surgical wound to the sternum. The assessment only addressed R4's abdominal incisions. 4/21/26: Completed by an LPN. The assessment did not address R4's surgical wound to the sternum. The assessment only addressed R4's abdominal incisions. 4/28/26: Completed by Assistant Director of Nursing (ADON)-C. The assessment for R4's sternal wound indicated: 3.8 cm x 3.4 cm x 2.3 cm, tunneling, purulent drainage, odor, 75% slough (non-viable, dead tissue in a wound, typically yellow or white, that can impede healing and harbor bacteria). 5/5/26: Completed by ADON-C. The assessment for R4's sternal wound indicated: 3.9 cm x 3.5 cm x 2.3 cm, tunneling, purulent drainage, odor, 75% slough. Nurse Practitioner (NP) notes indicated the following: 4/16/26: .Physical examination: Inspection of the midline surgical wound shows stable condition with some drainage, no erythema (superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood capillaries) .Assessment and Plan: Post-CABG Surgical Wound with Possible Infection: (R4) has a stable midline chest wound from CABG surgery complicated by drainage but no overt signs of cellulitis. Plan includes continuation of wound care with cleansing using Dakin's solution and application of skin protectant and iodoform gauze per wound care nurse. A course of antibiotics will be initiated pending lab results . 4/17/26: (R4) reported the wound dressing falls off frequently, leading to exposure and drainage .Physical Exam Results: .Wound on the chest with notable drainage; dressing frequently falls off .Assessment: 1. Chest wound post-CABG: Wound shows significant drainage and the dressing has difficulty staying in place, increasing the risk of infection .Plan: For the chest wound, a picture will be sent to the wound care physician for expert evaluation and recommendation regarding the initiation of antibiotics. The care staff will be notified to ensure the wound dressing is properly applied and maintained to prevent further dressing displacement . 5/5/26: (R4) reported a new open wound area on the upper part of R4's chest incision with some purulent drainage. The original lower chest wound remains open but is being managed with packing .Plan: A wound culture sample has been obtained for the new upper incision wound, with results pending. Empiric antibiotics will be considered based on culture results; staff to monitor wound closely and change dressings as needed to manage drainage. The cardiothoracic surgeon will follow the wound directly. (R4) has an upcoming clinic visit in two days . 5/6/26: (R4) presents for a follow-up visit for acute care management of MRSA-infected chest wounds following recent CABG surgery .(R4) was informed about a MRSA infection discovered from wound cultures obtained during prior visit .Plan: Begin oral antibiotic treatment with Bactrim Double Strength (DS) twice daily for 10 days based on culture and sensitivity results to address MRSA wound infection .Chronic care management includes monitoring of post-CABG wound healing with an emphasis on infection control . Documentation from Provider (PR)-U indicated the following: 4/20/26: After Visit Summary: The following issues were addressed: post-operative state: S/P CABG x 2; and dehiscence of operative wound . 4/28/26: Report of consultation.Report Requested Regarding: Sternal wound .Findings: Wound was debrided. (R4) needs better wound care, wet gauze (with) puracyn or sterile saline/water, then pack and cover (with) dry gauze and tape. Change every day. (R4) should shower every day or at least every other day .(It is important to note this order was noted by facility staff on 5/1/26.) 5/5/26: Report of Consultation .Findings: Upper sternal wound with tunneling and undermining - cleanse once a day, spray with puracyn, wet to dry dressing, if possible soak in gauze and pack. Continue Bactrim, wound care referral .(Surveyor requested documentation regarding R4's wound care referral and documentation from the wound care physician's visits, however, it was not provided.) On 5/12/26 at 2:25 PM, Surveyor interviewed ADON-C who stated ADON-C first saw R4's wounds approximately 2 weeks after R4 was admitted . When Surveyor asked if R4's wounds should have been assessed by an RN prior to 4/28/26, ADON-C stated ADON-C would have to look. (Surveyor requested ADON-C provide RN assessment information, however, none was provided.) On 5/13/26 at 10:32 AM, Surveyor interviewed Director of Nursing (DON)-B. When Surveyor asked if R4's provider was updated about the wound's seropurulent drainage upon admission, DON-B stated R4's wound was icky in the hospital and DON-B would provide Surveyor with the documentation. When Surveyor asked DON B when DON-B would expect an RN assessment be completed for a newly admitted resident with wounds, DON-B stated DON-B would expect the assessment within 24 hours of admission. When Surveyor asked if the order for daily or every other day showers was transcribed, DON-B indicated DON-B talked to R4 regarding increasing showers, however, R4 stated R4 would not take additional showers. When Surveyor asked DON-B if the conversation was documented and reported to the provider, DON-B stated DON-B did not enter a progress note. When Surveyor asked who completes weekly wound rounds, DON-B stated the wound doctor comes weekly. When Surveyor asked if R4 is seen by the wound care doctor, DON-B stated yes. When Surveyor asked if DON-B had documentation of the visits, DON-B stated DON-B would provide it. (No additional information was provided to Surveyor.) It is also important to note, R4 was admitted to the hospital on [DATE] after an appointment at the clinic. Hospital documentation, dated 5/12/26, states in part: (R4) presented to the clinic today and continues to have sternal wound drainage. Decision to admit from clinic for sternal debridement and possible wound vac. (This example is being cited at a level G (actual harm/isolated.) 2. Surveyor requested the facility's bowel protocol policy and received a Colostomy/Ileostomy care policy, dated October 2010, and a Bowel (Lower Gastrointestinal Tract) Disorders - Clinical Protocol. Neither policy discussed documentation of bowel movements for residents or when to contact a physician or provide as needed medications related to constipation. Between 5/12/26 and 5/13/26, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] after a hospital stay due to a bowel obstruction while residing at home. R5 underwent surgery for a colostomy (a procedure that creates an opening, called a stoma, in the abdominal wall. A section of the large intestine (colon) is brought to the surface so that stool bypasses the anus and empties into an external pouch, commonly known as a colostomy bag.) R5 was at the facility for rehabilitation. R5 had diagnoses including Parkinson's disease, unspecified intestinal obstruction, and generalized anxiety disorder. R5's MDS assessment, dated 1/9/26, stated R5 had a BIMS score of 15 out of 15, indicating intact cognition. R5 did not have an activated healthcare decision maker. R5's care plan, initiated 1/8/26, related to gastrointestinal distress due to a large bowel obstruction. The care plan contained interventions (dated 1/8/26) to observe and document vital signs, bowel sounds, amount and consistency of stool .Notify physician of significant changes, observe for presence of nausea/vomiting or weight changes, intake and difficulty chewing. A pain management care plan, initiated 1/8/26, contained an intervention (dated 1/8/26) to evaluate the need for a bowel management regimen. An additional care plan, initiated 1/8/26, contained an intervention for bowl medication as ordered. On 2/25/26, Nurse Practitioner (NP)-R saw R5 and noted R5's colostomy bag was recently changed. R5 reported minimal output since then. R5 received daily Miralax (a laxative used to treat occasional constipation) and a mechanical soft diet. R5 actively participated in physical and occupational therapy and felt R5 was getting stronger with therapy. R5 denied any new headaches, dizziness, shortness of breath, palpitations, or other acute symptoms. Bowel movements were a concern due to minimal ostomy output, but R5 was passing some gas. R5 was encouraged to increase mobility to promote bowel activity On 2/26/26, a change in condition assessment was completed because R5 complained of nausea and constipation. NP-R was notified and prescribed zofran (used to prevent and treat moderate to severe nausea and vomiting) as needed (PRN), senna 2 tablets daily (used to treat constipation and empty the bowels), and Miralax PRN daily. On 2/27/26, NP-R saw R5 and noted R5 reported good bowel movements on (2/25/26) and (2/26/26) after a previous period of reduced output. R5 ate as best as R5 could and urinated adequately with no swelling. R5 was preparing for discharge next week. R5's medical record indicated the following: ~ R5 did not have a documented bowel movement on 3/5/26, 3/6/26, 3/7/26, or 3/8/26. On 3/9/26 at 10:24 AM, R5 received a dose of PRN Miralax. Later that day, R5 had a bowel movement. R5's medical record did not indicate the physician was notified. ~ R5's bowel documentation contained missing documentation for multiple shifts. In January 2026, 22 shifts were missed; In February 2026, 11 shifts were missed; In March 2026, 16 shifts were missed. ~ R5 was admitted to the facility with a surgical wound. The wound clinic followed R5 weekly until R5's surgical wound healed, however, weekly skin checks were only completed on the following dates for R5 since admission: [DATE], 1/21/26, 1/27/26, 1/28/26, and 2/18/26. The facility could not provide any other weekly skin checks for R5. On 5/13/26, Surveyor interviewed NP-R who indicated NP-R would want to be notified if R5 had not had a bowel movement after 72 hours. NP-R indicated R5 had concerns of constipation and NP-R was concerned with how R5's stoma looked (it had turned whitish/gray) on 3/10/26. NP-R indicated R5 had a follow-up appointment with the surgeon later that day. NP-R indicated if R5 had not had the appointment, NP-R would have sent R5 for evaluation. NP-R indicated the surgeon was not concerned with R5's stoma and did not change any of R5's orders. 3. Between 5/12/26 and 5/13/26, Surveyor reviewed R16's medical record. R16 was admitted to the facility on [DATE] and had diagnoses including schizophrenia, secondary Parkinsonism. R16's MDS assessment, dated 2/16/26, stated R16 had a BIMS score of 9 out of 15, indicating moderate cognitive impairment. R16's care plan, dated 1/13/23, indicated R16 was a limited assist of one for toileting and transfers to the bathroom and occasionally incontinent of bowel. Surveyor reviewed R16's bowel records for March, April, and May 2026 and noted the following: - Bowel documentation was not completed every shift. In March 2026, documentation was missing for 6 shifts; In April 2026, documentation was missing for 23 shifts; In May 2026, documentation was missing for 4 shifts. - From 4/25/26 through 5/3/26, R16 did not have a bowel output recorded. The facility could not provide physician notification or if a PRN bowel medication was offered. - From 5/5/26 through 5/9/26, R16 did not have a bowel output recorded. The facility could not provide physician notification or if a PRN bowel medication was offered. On 5/13/26 at 2:30 PM, Director of Nursing (DON)-B confirmed skin checks should be completed weekly and documented. DON-B also confirmed bowel movements should be documented every shift. DON-B confirmed residents should be provided PRN medication to assist with bowel movements if available after 3 days and the physician should be notified. DON-B indicated the facility does not have a bowel protocol, however, providers should be notified to determine next steps if there are no PRN medications available for the resident. 4. Between 5/12/26 and 5/13/26, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and discharged on 3/19/26. R8 was admitted with diagnoses including cerebral palsy, acute and chronic respiratory failure with hypoxia, severe protein-calorie malnutrition, quadriplegia, seizures, pneumonia, and sepsis due to enterococcus. R8's MDS assessment, dated 3/12/26, stated R8 had a BIMS score of 0 out of 15, indicating severely impaired cognition. R8 had an activated healthcare decision maker. Surveyor reviewed R8's Medication Administration Record (MAR) which indicated the following medications were not administered: ~ 2/27/26 8:00 AM doses: Benzoyl peroxide external gel 10% apply to affected area topically once daily for acne; Diprolene AF (augmented formulation) external cream 0.05% apply to scalp topically once daily for abrasion; Hydrocortisone external cream 1% apply to rash on abdomen topically two times daily ~ 2/27/26 12:00 PM doses: Gabapentin oral solution 250 milligrams (mg)/5 milliliters (ml) give 10 ml via gastrostomy tube (g-tube (a small medical device inserted directly through the abdomen into the stomach) three times daily for neuropathic pain; Non-pharmacological interventions used every shift - pain monitoring every shift; simethicone oral liquid 40 mg/0.6 ml give 1.8 ml via g-tube three time daily for gas 2/27/26 AM shift: G-Tube: Stoma care every day and evening shift; Check air mattress to ensure proper functioning, inflation, and settings. Notify maintenance if mattress is not functioning and in need of repair every shift; Check oxygen (O2) saturation every shift; Colostomy care every shift; Ensure O2 foam protectors are in place and replace every shift; Head of bed 30 degrees every shift; Monitor blanchable redness to right upper thigh, update MD if worsening, every shift for monitoring; Oral care every shift; Oxygen: 1-3 liters via nasal cannula (NC) continuous to maintain oxygenation greater than 90% every shift; Behavior monitoring due to use of antipsychotic medication every shift ~ 3/12/26 night (NOC) shift: Change graduated cylinder and syringe nightly every shift; Check air mattress to ensure proper functioning, inflation, and settings. Notify maintenance if mattress is not functioning and in need of repair every shift; Check 02 saturation every shift; Colostomy care every shift; Ensure O2 foam protectors are in place and replace as needed every shift; Head of bed at 30 degrees every shift; Oral care every shift; Oxygen: 1-3 liters via NC continuous to maintain oxygenation greater than 90% every shift; Behavior monitoring due to antipsychotic medication every shift ~ 3/15/26 PM shift: Record output every shift ~ 3/17/26 NOC shift: Record output every shift On 5/13/26 at 11:50 AM, Surveyor interviewed DON-B who stated documentation should be complete so nurses can take credit for what they administer. DON-B indicated missing documentation does not mean the order was not implemented as staff can be forgetful at times.

Based on observation, interview, and record review, the facility does not have an effective infection control program to control the spread of infectious disease, in this case COVID-19; this has the potential to affect all 71 residents residing at the facility. Staff were observed going in and out of COVID positive rooms without appropriate PPE (Personal Protective Equipment). Staff were observed exiting COVID positive room with PPE on and doffing PPE in the hallway. Staff were observed not using source control. Staff were working with COVID symptoms and not tested . Facility is not utilizing dedicated equipment in COVID positive resident rooms. Privacy curtains are not being pulled between COVID positive and COVID negative residents. Staff were observed working with a COVID positive resident and then with same PPE about to work with a resident who was COVID negative. Observations of COVID positive residents smoking outside with non-COVID positive residents and not six feet apart. Food cart was left with the door open in front of a COVID positive resident room, the resident was sitting in the doorway of the room and coughing without using cough etiquette. The facility did not offer residents the most recent COVID-19 vaccine. The facility did not offer residents antiviral (drug or treatment effective against viruses) medication. The facility's failure to ensure appropriate infection control practices are in place and followed during a COVID-19 outbreak, created a finding of immediate jeopardy that began on 11/4/24. Surveyor notified NHA A (Nursing Home Administrator) of the immediate jeopardy on 11/11/24 at 1:23 PM. The immediate jeopardy was removed on 11/11/24, however, the deficient practice continues at a scope/severity of F (potential for more than minimal harm/widespread) as evidenced by the following: The facility did not have complete water management control measure documentation. Poor hand hygiene was observed with wound care and medication administration. This is evidenced by: The facility's Policy and Procedure titled Infection Prevention and Control Program dated 10/1/22, documents in part: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines .4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use protective equipment (PPE) according to established facility policy governing the use of PPE. d. Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies .5. Isolation Protocol (Transmission-Based Precautions): a. A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC (Center for Disease Control and Prevention) guidelines. b. Residents will be placed on the least restrictive transmission-based precaution for the shortest duration possible under the circumstances. c. When a resident on transmission-based precautions must leave the resident care unit/area, the charge nurse on that unit/area shall communicate to all involved departments the nature of the isolation and shall prepare the resident for transport in accordance with current transmission-based precaution guidelines . The facility's Policy and Procedure titled Infection Outbreak and Response dated 10/1/22, documents in part: .Outbreak generally refers to the occurrence of more cases of a communicable disease than expected in a given area or among a specific group of people over a particular period of time .2. Implementation of infection control measures: a. Symptomatic employees will be screened by the Infection Preventionist, or designee, and referred to appropriate medical provider. c. Standard precautions will be emphasized. Transmission-based precautions will be implements as indicated for the particular organism . The facility's COVID-19 Outbreak timeline documents the following: On 10/25/24, there was one resident with a cough, he tested positive for COVID. The facility updated his care plan, started COVID monitoring, tested residents on south side, and staff on that side of facility to test every two days. On 10/27/24, all residents on south side of facility were tested , all were negative. On 10/28/24, R63 tested positive on the south side of the facility. On 10/29/24, R329 and R37 tested positive on the north side of the facility and R14, R36, R24, and R64 tested positive on the south side of the facility. NM H (Nurse Manager) and LPN E (Licensed Practical Nurse) tested positive on this date as well. The facility identified this as an outbreak, hung signage on front door, initiated use of well-fitting mask throughout facility, updated care plans, started COVID monitoring, dietary began utilizing disposable dishware for positive residents, Activities distanced residents as needed, Therapy saw positive resident last, housekeeping increased their cleaning of high touch areas (light switches, door knobs, door frames, and handrails), testing for all staff and residents to be done every 2 days, families and providers updated, and updated Public Health. On 10/30/24, CNA I (Certified Nursing Assistant) tested positive. On 10/31/24, R130, R330, and R49 tested positive on the north side of the facility and R67, R66, and R26 tested positive on the south side of the facility. BOM RR (Business Office Manager) and SLP SS (Speech/Language Pathologist) tested positive on this date. On 11/2/24, R56 tested positive on the north side of the facility and R2 and R18 tested positive on the south side of the facility. On 11/3/24, R48 tested positive on the south side of the facility. On 11/4/24, R34 tested positive on the south side of the facility and LPN J tested positive. On 11/6/24, all residents tested , all negative, first round of no new positives. Staff Line List documents the following: On 10/2/24, LPN J (Licensed Practical Nurse) is listed as having a headache/migraine. There is no documentation that a COVID test was completed. On 10/4/24, NM H (Nurse Manager) is listed as having a headache. There is no documentation that a COVID test was completed. On 10/29/24, NM H tested positive for COVID, line list documents that symptoms started 10/25/24. NM H's punch detail documents that she worked 10/25/24 and 10/28/24, eight hours each day with a COVID positive test result on 10/29/24. On 10/29/24, LPN E tested positive for COVID, the staff line list documents that symptoms started on 10/27/24. LPN E's punch detail documents that she worked 10/29/24 the beginning half of the shift with COVID positive result on 10/29/24. On 10/30/24, CNA I (Certified Nursing Assistant) tested positive for COVID, the staff line list documents that symptoms started 10/29/24. CNA I's punch detail documents that she worked on 10/29/24 with COVID positive result on 10/30/24. On 11/4/24 at 11:56 AM, Surveyor observed CNA K enter R64's room. On the wall outside R64's room was an infection control sign indicating COVID precautions for R64's room. The infection control sign indicated staff should wear eye protection, N95 mask, gown, and gloves when entering the room. CNA K was wearing a surgical mask, gown, and gloves. On 11/4/24 at 12:00 PM, Surveyor interviewed CNA K regarding the required PPE (Personal Protective Equipment) when entering a COVID positive room. CNA K read the infection control sign outside the door indicating she should wear eye protection, N95 mask, gown, and gloves when entering the room. Surveyor asked CNA K if she should have put on eye protection and an N95 mask prior to entering the room. CNA K indicated she should have applied the appropriate PPE but did not. On 11/4/24 at 11:56 AM, Surveyor observed CNA L enter R67's room. On the wall outside R67's room was an infection control sign indicating COVID precautions for R67's room. The infection control sign indicated staff should wear eye protection, N95 mask, gown, and gloves when entering the room. CNA L was wearing a surgical mask, gown, and gloves. On 11/4/24 at 12:00 PM, Surveyor interviewed CNA L regarding the required PPE when entering a COVID positive room. CNA L read the infection control sign outside the door indicating he should wear eye protection, N95 mask, gown, and gloves when entering the room. Surveyor asked CNA L if he should have put on eye protection and an N95 mask prior to entering the room. CNA L indicated he should have applied the appropriate PPE but did not. On 11/4/24 at 2:02 PM, Surveyor observed CNA T (Certified Nursing Assistant) don (put on) 2 surgical masks and an N95 over the top of the surgical masks, a gown, and gloves. Then CNA T entered R14's room to assist R14 who was COVID positive. (It is important to note CNA T did not don eye protection and had on a total of 3 masks.) On 11/4/24 at 12:00 PM, Surveyor observed R36 watching TV with the room curtain divider pulled back. R36 is COVID positive and R36's roommate, R30, is not. On 11/4/24 at 2:56PM, CNA T (Certified Nursing Assistant) answered the call light for R30. Surveyor observed CNA T put on gown, gloves, and a face shield. Surveyor observed CNA T wear a surgical facemask and enter R30's room. CNA T walked past R36's side of the room. R36 is R30's roommate and is COVID positive. CNA T came out of the room and still had the surgical facemask on. Surveyor asked who CNA T assisted. CNA T indicated she answered call light for R30 and R30 is not COVID positive. CNA T indicated she puts on the full PPE for precaution since R30's roommate is COVID positive. CNA T indicated if she was assisting someone who is COVID positive she will don all PPE, gown, gloves, face shield, 2 surgical face masks, and 1 N95. CNA T indicated she wears the 3 face masks for extra protection. CNA T indicated staff are constantly reminding R36 to keep his facemask above his nose when he is out in common areas. On 11/4/24 at 12:11 PM, Surveyor interviewed LPN F (Licensed Practical Nurse) regarding appropriate PPE for COVID positive rooms. LPN F indicated staff should wear eye protection, N95 mask, gown, and gloves when entering a COVID positive room. On 11/7/24 at 3:21 PM, Surveyor interviewed DON B (Director of Nursing) regarding appropriate PPE for COVID positive rooms. DON B indicated staff should wear eye protection, N95 mask, gown, and gloves when entering a COVID positive room. DON B was aware of Surveyor's observations of CNA K (Certified Nursing Assistant,) CNA L, and CNA T. DON B indicated the CNAs should have worn eye protection and an N95 mask when entering the COVID positive rooms. On 11/4/24 at 2:02 PM, Surveyors observed 5 residents smoking in a circle outside. Residents were not 6 feet apart and two of the residents were positive for COVID. On 11/07/24 05:51 PM, Surveyor interviewed DON B (Director of Nursing) regarding COVID positive residents going outside to smoke. DON B indicated COVID positive residents should go out to smoke separately but if the COVID positive residents go outside to smoke with COVID negative residents, then they should stay 6 feet apart. On 11/5/24 at 11:32 AM, Surveyor observed two staff members bring a meal tray cart onto the 200 unit. The cart was placed within six feet of the door to the right of R49's room who was COVID positive. At the time, R49 was sitting in his wheelchair in the threshold of his doorway, not wearing a mask, and actively coughing. Staff members were passing trays and leaving the tray cart door open at this time. On 11/5/24 at 11:39 AM, Surveyor observed the tray cart moved from the right to the left of R49's room. The tray cart was still within six feet of the resident, and at this time within arm's reach. R49 remained in the threshold of his doorway and was still actively coughing without a mask. On 11/5/24 at 11:41 AM, DSS W (Director of Social Services) came onto the unit and moved the tray cart down to the other end of the hall away from R49. On 11/5/24 at 11:43 AM, Surveyor observed DSS W exit R330's room, who was COVID positive, still wearing all her PPE. Surveyor observed DSS W doff all her PPE in the hallway and dispose of her PPE in the medication cart trash can. On 11/5/24 at 11:54 AM, Surveyor interviewed DSS W. Surveyor asked DSS W if she was passing trays on the 200 hall. DSS W stated yes. Surveyor asked DSS W if she passed a tray to R330's room who is on special isolation precautions for COVID. DSS W stated yes. Surveyor asked DSS W if she walked out of the room with all her PPE on. DSS W stated yes. Surveyor asked DSS W if she should have doffed her PPE prior to exiting R330's room. DSS W stated yes. On 11/6/24 at 8:05 AM, Surveyor observed LPN N (Licensed Practical Nurse) leave R56's bedside, go into the resident's bathroom, remove gloves, cleanse hands, and don new gloves. R56 is COVID positive. LPN N then walked to R56's roommate's side of the room, past the privacy curtain. Surveyor intervened as LPN N passed around the corner of R56's roommate's bed and asked LPN N to come to the doorway. Surveyor asked LPN N if she was going to see R56's roommate. LPN N stated yes. Surveyor asked why LPN N was wearing PPE in the room. LPN N stated that R56 has COVID and is on precautions. Surveyor asked if PPE worn with a COVID positive resident could be worn with another resident. LPN N stated no. LPN N removed the PPE, cleansed hands, and went to the medication cart. LPN N pushed the medication cart to the next room down the hall and opened the medication cart and began preparing medications. Surveyor asked if any PPE was required to be worn by staff while in the hallways of the building due to the COVID outbreak. LPN N stated yes, a surgical mask. Surveyor asked LPN N if she was wearing a mask at the present time. LPN N took a mask from the isolation cart in the hallway and applied the mask. On 11/7/24 at 8:24 AM, Surveyor interviewed DON B (Director of Nursing) who indicated that the preferred order to see residents sharing a room is to see the resident without COVID first, then remove PPE, cleanse hands, apply new PPE, then see the COVID positive resident. DON B stated that after seeing a COVID positive resident, PPE must be removed and hand hygiene must be performed. DON B stated that a surgical mask needs to be worn by staff in the building while there is a COVID outbreak. On 11/5/24 at 4:47 PM, Surveyor interviewed HLS Q (Housekeeping and Laundry Supervisor). Surveyor asked HLS Q if the cleaning products they use are good for COVID; HLS Q stated yes. Surveyor asked HLS Q what surfaces are they cleaning with these products; HLS Q said all high touch areas (doorknobs, light switches, doorframes, handrails). Surveyor asked HLS Q if cleaning changed once there was a COVID outbreak; HLS Q stated yes, we increased cleaning of high touch areas by one time per day (already being done three times per day regularly). On 11/6/24 at 3:08 PM, Surveyor interviewed LPN/IP G (Licensed Practical Nurse/Infection Preventionist). Surveyor asked LPN/IP G once the facility had a positive COVID resident in the building, were residents who declined the vaccine to use a mask; LPN/IP G stated all residents were encouraged to wear a mask. Surveyor asked LPN/IP G if there was consultation about beginning an antiviral medication; LPN/IP G said she had spoken to their Medical Director prior to this outbreak and the medical director didn't seem to want to go there. Surveyor asked LPN/IP G if masks are being offered to residents when the residents are out of their rooms; LPN/IP G stated yes, not all residents are compliant. Surveyor asked LPN/IP G what PPE is to be worn in COVID positive rooms, LPN/IP G replied gown, gloves, N95, and eye protection. Surveyor asked LPN/IP G what PPE is to be worn throughout the facility when not in a COVID positive room; LPN/IP G said a well-fitting mask (surgical mask). Surveyor asked LPN/IP G if it is acceptable to wear two surgical masks with an N95 over the top, LPN/IP G stated no. On 11/7/24 at 11:32 AM, Surveyor interviewed LPN/IP G again. Surveyor asked LPN/IP G if COVID boosters/vaccines have been offered, LPN/IP G explained they offer, on admission, then for the next three days if they refuse, if still refused then offered quarterly. Surveyor asked LPN/IP G if NM H had symptoms that started 10/25/24, should she have tested on [DATE]? LPN/IP G stated yes, she should have. LPN/IP G stated she was unsure if she had access to testing. Surveyor asked LPN/IP G if she didn't have access to testing 10/25/24, should she have tested on [DATE] before working; LPN/IP G said yes. On 11/7/24 at 4:36 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B when would you expect a staff member to test for COVID if they have symptoms? DON B said when the symptoms start. Surveyor asked DON B if she would expect staff to be working if they have COVID symptoms; DON B stated no, they should test before they work. The facility's failure to ensure appropriate infection control practices are in place and followed during a COVID-19 outbreak created a reasonable expectation of serious outcome resulting in a finding of immediate jeopardy. The facility removed the immediate jeopardy on 11/11/24 when the facility completed the following: ~A record review was completed on all residents to ensure no unreported signs and symptoms of infection were present. ~An audit was completed on all residents COVID-19 vaccination status with vaccines offered if appropriate. ~All staff had a competency completed on DONNing and DOFFing PPE as well as hand hygiene and will be completed prior to next shift worked. ~All staff were educated on the appropriate use of PPE on all types of precautions and COVID specific precautions to include donning gown, gloves, mask, and eye protection when entering COVID positive rooms, and removing PPE prior to leaving the resident room. ~Education also included not wearing a surgical mask under a N95 and that surgical masks are to be worn in the halls during a COVID outbreak. ~All staff were education on appropriate hand hygiene. ~All nursing staff were educated on offering Antiviral medications for residents with a positive COVID result and offering the most recent COVID vaccines. ~All staff were educated on the use of privacy curtains in positive COVID rooms as well as disinfecting equipment and doffing PPE after working with a COVID positive resident. ~All staff were educated on taking COVID positive smoking residents out separately than non-positive smoking residents. ~All staff were educated on dining carts cannot be left open during meal tray pass in the hallways. ~All staff were educated on testing for COVID prior to working if symptoms are present. Education will be completed prior to next shift worked. ~Infection Control and vaccines policy and procedures were reviewed with no updates at this time. ~DON or designee will audit 5 residents weekly x8 weeks to ensure residents are up to date with current COVID-19 vaccinations. ~DON or designee will audit 5 employees weekly x8 weeks to ensure appropriate DONNing/DOFFing PPE, privacy curtains are being closed in a COVID positive room and appropriate hand hygiene is being completed. ~Dietary Manager or designee will complete 5 observations weekly x8 weeks to ensure dining carts are being closed during meal tray pass in the hallways. ~SSD or designee will complete 5 observations weekly x8 weeks to ensure COVID positive residents are being taken out after non COVID residents have finished smoking. ~Audits will be reported and reviewed to QAPI for further direction. Example 2: The facility is lacking documentation on the water management control measures. The facility's Policy and Procedure titled Infection Prevention and Control Program dated 10/1/22, documents in part: .16. Water Management .b. Control measures and testing protocols are in place to address potential hazards associated with the facility's water systems. c. The Maintenance Director serves as the leader of the water management program . The facility's Water Management Plan has multiple control measures in it that are to be tested on a regular basis. Testing/documentation of testing of these control measures are in place until May or July. On 11/7/24 at 3:30 PM, Surveyor interviewed AIT S (Administrator in Training). Surveyor asked AIT S why the documentation for the control measures stop in either May or July? AIT S explained that the facility has been without a full-time Maintenance Director since July, they do have Maintenance from other facilities or their Corporate Office covering but the documentation has not been completed. 49436 Example 3: The facility policy Hand Hygiene not dated, states in part: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors . Staff will perform hand hygiene when indicated, using proper technique consistent with the accepted standards of practice. On 11/6/24 at 9:30 AM, Surveyor observed RN M (Registered Nurse) perform wound care for R43. During the observation, RN M removed the old dressing from R43's left lower leg. R43 has two separate wounds on her left leg, one on the posterior (back) left calf and one on the anterior (front) left leg. RN M washed and dried the posterior wound then proceeded to wash and dry the anterior wound. It is important to note, RN M did not perform hand hygiene in between caring for the two separate wounds. On 11/6/24 at 9:39 AM, Surveyor interviewed RN M regarding hand hygiene during wound care. RN M indicated since the two wounds on R43 were in different locations, she should have treated the wounds separately. RN M indicated she should have performed hand hygiene after treating the posterior left calf wound before proceeding to the anterior left leg wound. On 11/6/24 at 9:39 AM, Surveyor interviewed DON B (Director of Nursing) regarding hand hygiene during wound care. DON B indicated the two wounds on the left leg should have been treated separately. DON B indicated RN M should have performed hand hygiene after treating the posterior left calf wound before treating the anterior left leg wound. 50228 Example 4: LPN N did not remove gloves and cleanse hands following administration of insulin. LPN N contaminated a medication cup with her finger. On 11/6/24 at 9:20 AM, Surveyor observed LPN N performing medication administration. LPN N donned gloves and administered insulin to R32. Following the medication administration, LPN N touched the following with her contaminated gloves: R32's door and the medication cart. LPN N then removed and disposed of gloves. LPN N touched computer keyboard and med cart drawer following removal of gloves. Surveyor intervened and asked LPN N if there was anything that should be done following administration of insulin. LPN N stated that gloves should have been removed and hands sanitized prior to touching any items. LPN N went on to take R32's oral medications from the medication cart. LPN N picked up a medication cup and flipped it upright by placing her index finger inside the cup. LPN N then placed a medication card onto the cup and positioned the card to dispense the medication into the cup. Surveyor asked LPN N where medication cups should be touched by staff. LPN N stated on the outside near the bottom. Surveyor asked if it is ok to touch inside the cup. LPN N stated no. On 11/6/24 at 11:13 AM, Surveyor interviewed DON B (Director of Nursing) who indicated that gloves are to be removed and hand hygiene performed following insulin administration and prior to touching other things. DON B indicated that medication cups are to be handled from the outside and fingers are not to touch the inside of the cup.

Based on interview and record review, the facility did not ensure that parenteral medications were administered consistent with professional standards of nursing practice for 1 of 1 resident (R29) reviewed for parenteral medications. R29 was readmitted to the facility on [DATE] with a midline for IV (intravenous) antibiotic treatment following a diagnosis of sepsis secondary to urinary tract infection with E. coli bacteremia (bacteria in the blood). On 7/27/24, LPN P (Licensed Practical Nurse) attempted to flush the midline and was unable to, noting that some of the normal saline ran down R29's arm. LPN P reported this to RN O (Registered Nurse) around 2:20 PM on 7/27/24. RN O did not complete an immediate assessment and when he did complete an assessment, he found the line to appear infiltrated (catheter delivering fluid into tissues instead of the vein). RN O attempted to remove the catheter without a physician order, and the midline broke, retaining a piece of catheter in R29's left arm. R29 was then sent to the emergency room at 11:30 PM that night, 9 hours after the initial concern was raised by LPN P. R29 was found to have a 10 cm (centimeter) length of catheter retained in her upper arm that required a surgical procedure to remove it. After several failed attempted procedures and a long referral process, R29 finally had the catheter removed on 10/7/24. The facility's failure to monitor and document monitoring of the midline site, to measure and record the measurement of the midline, to notify the provider following LPN P's concern of the midline not flushing, to complete a timely RN assessment following notification of a problem with the midline, and conduct removal procedures according to policy and current standards of practice caused R29 to retain 10 centimeters of midline catheter within her brachial vein. This put R29 at risk for pulmonary embolism (blockage of lung vessels by the catheter), stroke, or death. This created a finding of Immediate Jeopardy beginning on 7/27/24. NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were informed of the finding of Immediate Jeopardy on 11/11/24 at 1:23 PM. The immediacy was removed on 11/13/24 and continues at a severity/scope level of D (potential for more than minimal harm/isolated) as the facility continues to implement its removal plan. This is evidenced by: The facility policy titled, Intravenous Therapy, dated 10/1/22, states in part: .Compliance Guidelines: . 8. IV sites are changed every seventy-two (72) hours unless otherwise ordered by the physician, if the site becomes infiltrated, or if the resident exhibits signs and symptoms of phlebitis. 9. In the event an IV is left in place longer than seventy-two hours, IV site care will be done every twenty-four (24) hours . 13. IV sites are checked every shift or as per facility policy and PRN (as needed) for signs and symptoms of infection or inflammation .14. The nurse will assess for associated risks due to IV fluid administration such as: a. infiltration b. bruising c. embolism (air or blood) d. phlebitis . 15. IV documentation is recorded in the nurses' notes and/or Medication Administration Record. 16. The nurse will notify the practitioner to assess the need for continuation of the catheter if not being used for IV fluids or medication and will discontinue as per the practitioner's order . The facility policy titled, Midline Catheter Flushing-Lock-Removal, dated 11/28/23, states in part: Policy: It is the policy of this facility to ensure that midline catheters are flushed, locked and removed consistent with current standards of practice . Compliance Guidelines: . 2. Midline catheters will be flushed and aspirated for blood return prior to each infusion to assess catheter and functionality and prevent complications . 5. The catheter will be locked after the final flush to prevent catheter occlusion if used intermittently. If it is a multilumen catheter, all lumens must be flushed regularly . 7. The facility will use a flush such as a heparin flush solution or preservative-free normal saline solution to lock the catheter as per facility protocol. 8. Syringes no smaller than 10 mL (milliliters) should be used when assessing patency to avoid catheter damage . 10. Midline catheter removal will be performed by the practitioner or nurse in accordance with facility policy and your state's nurse practice act. 11 . Obtain a physician's order for removal. Removal: 1. Verify the physician's orders . 6. Place resident in sitting or recumbent position. 7. Carefully remove the dressing and dispose in appropriate receptacle. 8. Remove stabilization device or sutures, if present . 10. Hold sterile gauze over insertion site and with dominant hand remove the catheter using gentle, even pressure . 11. Have the resident perform the Valsalva maneuver unless contraindicated, or exhale as the last segment of the catheter is withdrawn to prevent an air embolism. 12. Apply pressure to the site with gauze for about 30 seconds or hemostasis is achieved. 13. Apply a petroleum-based ointment to the exit site and cover with an occlusive gauze dressing or a transparent semipermeable dressing for at least 24 hours. 14. Label the dressing with date and initials. 15. Encourage resident to lie flat or reclining for at least 30 minutes to reduce risk for air embolism. 16. Inspect the catheter to ensure that the tip is intact and not damaged and entire length of catheter has been removed . 20. Document the procedure . According to the National Library of Medicine, midline peripheral catheters have a large catheter (16-18 gauge) that allows for rapid infusions. Midline catheters are typically inserted into the basilic, cephalic, or brachial veins of the upper arm with the proximal tip placed near the level of the axilla (armpit). They are much longer and inserted deeper than a peripheral IV (intravenous access), but do not extend into a central vessel, so are not considered a central line. (Source: https://www.ncbi.nlm.nih.gov/books/NBK594499/) According to the Center for Disease Control and Prevention's (CDC) recommendation for catheter education, training, and staffing, healthcare personnel should be educated regarding maintenance of intravascular catheters. Periodic assessment of knowledge of and adherence to guidelines for all personnel involved in the insertion and maintenance of intravascular catheters should be conducted. Additionally, designate only trained personnel who demonstrate competence for the insertion and maintenance of peripheral and central intravascular catheters. The CDC also recommends evaluation of the catheter insertion site daily by palpation to discern tenderness and by inspection. They also recommend removal of peripheral venous catheters if the patient develops signs of phlebitis (vein inflammation), infection, or a malfunctioning catheter, along with promptly removing any intravascular catheter that is no longer essential. The CDC's recommendations for dressings include not submerging the catheter site in water. (Source: https://www.cdc.gov/infection-control/hcp/intravascular-catheter-related-infections/summary-recommendations.html) R29 was admitted to the facility on [DATE], with diagnoses that include, in part: encounter for orthopedic aftercare, chronic obstructive pulmonary disease, type 2 diabetes mellitus, congestive heart failure, partial traumatic amputation of right foot, and acute osteomyelitis, right ankle and foot. R29's most recent Quarterly Minimum Data Set (MDS) with a target date of 9/6/24, documents a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicates the resident is cognitively intact. On 7/17/24, R29's Hospital Discharge paperwork states that she was admitted for sepsis secondary to a urinary tract infection with E. coli bacteremia. While in the hospital, the resident had a midline placed in her left upper arm for antibiotic administration. On 7/20/24, R29 was discharged from the hospital and readmitted to the facility with the midline in place for continued antibiotic administration. NP FF (Nurse Practitioner) wrote a note with a date of service of 7/21/24 with an assessment and plan for history of UTI (urinary tract infection) and sepsis is to continue meropenem (antibiotic) for a total of a five-day course and to monitor for any signs of infection recurrence or complications. R29's Physician Orders for July 2024, state in part: Ertapenem Sodium Injection Solution Reconstituted 1 GM (Gram) (Ertapenem Sodium) Use 1 vial intravenously in the morning for E. coli in blood (bacteremia) for 55 days Give intravenous via midline in LUE (Left Upper Extremity) Heparin Sod (Sodium) Lock Flush Intravenous Solution (Heparin Sodium (Porcine) Lock Flush) Use 5 cc (cubic centimeters) intravenously one time a day for Midline Left AC (antecubital space, space inside of elbow) Normal Saline Flush Intravenous Solution 0.9% (Sodium Chloride Flush) Use 10 ml intravenously every day shift for Flush Midline before and after IV ABT (Antibiotic) administration. (Of note: The Medication Administration Record (MAR) and Treatment Administration Record (TAR) from July 2024, contains no documentation or orders regarding dressing changes, midline site assessment, measurement, or monitoring.) R29's Comprehensive Care Plan states in part: Focus: Potential for infection/complication r/t (related to): IV use for ABO (antibiotic) for bacteremia. Date initiated: 7/22/24. Goal: Will be free from signs and symptoms of infection. Date initiated: 7/23/24. Target Date: 12/10/24. Interventions: Administer IV fluids/medications per MD (medical doctor) order, Change IV tubing, dressings, and caps according to line type change schedule in IV order set or more frequently as needed. Monitor for infiltration. Monitor IV site for s/s (signs and symptoms) of infection: redness, inflammation, drainage, irritation to the vein. Notify physician of any abnormalities. PICC. All interventions initiated on 7/22/24. (Of note: The care plan lists the wrong catheter type and does not include basic midline site care such as protecting the Tegaderm or bandage when showering, changing the dressing, or maintaining a measurement of how long the catheter is from the site.) NP FF wrote a note with a date of service of 7/22/24 that states R29 reported midline IV site discomfort. The assessment and plan for the IV site discomfort is to continue to use the midline as it flushes without resistance and no erythema or swelling is present, monitor the site for any signs of infection or complications, provide patient education on proper care of the midline site. R29's Medication Administration Record indicates she was administered her prescribed Ertapenem (antibiotic) as ordered from 7/21/24 to 7/25/24. On 7/25/24 at 00:30 (12:30 AM), a progress note was written by LPN CC which states: Res (resident) continues to receive IV abt (antibiotic) as ordered for bacteremia. No adverse reaction noted. (Of note: No progress notes regarding resident's midline are written on 7/26/24) On 7/27/24 at 14:24 (2:24 PM), a progress note was written by LPN P which states: Writer went in to flush res (resident) mid line. Res mentioned that it might not flush, because last flush res had had went back down arm. Writer attempted a flush with scant amount of NS (normal saline) but NS just rolled down res arm instead. Writer updated [Name] RN O to assess IV. (Of note: There are no notes written about the previous flush attempt where the midline was not working correctly and the saline ran down R29's arm.) On 11/7/24 at 1:50 PM, Surveyor interviewed LPN P. LPN P indicated she was working on 7/27/24, but no longer works at this facility. LPN P stated that she gave report to RN O about 2:20 PM, regarding the midline not flushing. LPN P stated she can't remember any additional information about the incident. On 7/27/24 at 23:34 (11:34 PM), a progress note was written by RN O which states: Writer started process of removing midline from resident. Upon removal of dressing and assessment of skin, unable to locate midline lumen insertion point. Writer determines midline has broken off into vein, coinciding with earlier reports from dayshift LPN P [Name] that midline did not flush. Area cleansed, dressed with gauze and tape. On 11/6/24 at 4:35 PM, Surveyor interviewed RN O. RN O described the standard of practice for both administering IV medication and removing a midline. Surveyor asked RN O what R29's midline site looked like when he entered the room. RN O states that it looked swollen and bruised and appeared to be infiltrated, and that he was going to remove it. As he pulled the Tegaderm off, the catheter broke and some of the catheter was still in R29's skin. Surveyor asked RN O if he received any education or training from the facility prior to caring for R29's midline. RN O stated no. Surveyor asked RN O if he completed any competency checks prior to caring for R29's midline. RN O stated no. On 11/7/24 at 3:00 PM, Surveyor interviewed RN O for the second time. Surveyor asked RN O if he had obtained an order to remove the midline. RN O indicated he would never remove a midline without an order. Surveyor asked RN O who he obtained the order from. RN O stated he doesn't remember. Surveyor asked RN O if he obtained a telephone or verbal order, should that order have been transcribed into the electronic medical record. RN O stated yes, but that he was too busy trying to transfer R29 to the emergency department. Surveyor asked RN O what he did after the Tegaderm was removed and the piece had broken off. RN O indicated he covered the site with a 4x4 sterile gauze and tape and notified the provider immediately. (Of note: LPN P reported to RN O around 2:20 PM that R29's midline was not flushing. R29 was not assessed, provider was not notified, and R29 was not sent out until around 11:30 PM, 9 hours after discovery of the problem. Additionally, there is no record of an order being given to remove the midline.) On 7/27/24 at 23:32 (11:32 PM), a triage note was written by RN DD, who is employed by an outside hospital. This note states: The patient comes from [Facility Name] after the nurse was removing her midline and part of it was missing. The patient brought the external piece of the midline and states the internal part is still in her. The patient denies any pain to that area of her arm. On 7/28/24, an x-ray was taken confirming 10 cm of a linear radiopaque density is found in R29's left upper extremity. On 7/28/24 at 01:41 (1:41 AM), a note was written by DO (Doctor of Osteopathic Medicine) EE, who is also employed by an outside hospital. This note states in part: . She had a midline catheter placed so that she could complete her course of meropenem at home for her E coli bacteremia. This was stopped however yesterday when the catheter was flushed her arm swelled up. Then today the hub of the catheter broke off without the rest of the catheter coming with it. She presented today with x-ray findings of the catheter still in her arm. This note also indicates that DO EE attempted a sterile procedure utilizing local anesthesia to numb the area and an ultrasound to visualize the catheter. DO EE made an incision down to the brachial arterial sheath but was unable to identify the catheter in the brachial vein, and due to the risk to the brachial artery had to stop the procedure. On 7/28/24 at 03:53 (3:53 AM), hospital documentation shows R29 was transferred from one hospital to another outside hospital for further care and treatment. R29's discharge paperwork from the second outside hospital indicates that she was admitted from 7/28/24 to 7/30/24. Discharge diagnosis includes in part: vascular catheter issue s/p (status post) IR (interventional radiology) attempt to retrieve, which was unsuccessful. The hospital course indicates R29 reported that her midline had been flushing ok up until Friday (7/26/24) when the flush went all over. R29 also reported her midline seemed to flush fine on Thursday (7/25/24). Additionally, R29 reported that the line was to be discontinued yesterday (7/27/24) but when the RN took the band aid off, it was broken. Under the section labeled ED Course, it states in part: . IR attempted to retrieve under sedation, but unsuccessful. Per IR, she will need upper arm brachial exposure in the event of phlebitis or infection to perform a venotomy and removal of the catheter. The catheter will be very unlikely to [sic] move due to the thrombosed vein. Plan to keep in place and monitor for phlebitis or infection. Would recommend no IVs or BPs (blood pressures) to LUE (left upper extremity) . NP FF wrote a note with a date of service of 8/13/24. This note indicates an Assessment & Plan for left upper extremity pain and PICC line remnants [sic] of scheduling an appointment for vascular surgery to remove the remaining catheter and to continue to monitor the site for any signs of infection, erythema, discharge, swelling, or discoloration. NP GG's note from 10/7/24, indicates that R29 had the catheter removed on this date. On 11/7/24 at 10:40 AM, Surveyor interviewed NP FF. Surveyor asked if NP FF assessed and flushed the midline herself. NP FF stated she assessed the site but did not flush the midline. Surveyor asked NP FF if she gave an order to remove the midline. NP FF stated, I'm 100% sure someone did. Surveyor asked NP FF if she would expect staff to conduct dressing changes. NP FF indicated once every seven days or when soiled. Surveyor asked NP FF if she would expect staff to be doing measurements of the line to ensure the line wasn't migrating, which is current standard of practice. NP FF indicated she would not expect staff to measure the external line. Surveyor asked NP FF if she expects staff to document things like dressing changes or removal of the midline. NP FF stated she doesn't speak to staff expectations at the facility. On 11/7/24 at 11:57 AM, Surveyor interviewed R29. Surveyor asked R29 what her experience was like throughout this process. R29 indicated that initially she was ok since things were getting taken care of, however after she returned from the second outside hospital, she was experiencing a lot of pain and discomfort. She also indicated that this pain was worse than her normal chronic pain due to the unpredictability of pain occurrence. R29 described not knowing what kind of action or motion caused the pain so she was always surprised when it started hurting which made it worse. Surveyors requested all training, education, and competency records for all LPNs and RNs working in the facility for the past year. LPN CC last received training on managing intravenous devices on 10/5/24. A description of this training was obtained from the facility, and it does review vascular access devices, care of vascular access devices, and risks of vascular access devices. Documentation does not list any other dates this training was completed. Also of note, the facility provided a document titled, Medication Administration Competency Test that is undated. Surveyor notes only two questions that could be applicable specifically to midlines or central venous catheters and asks about heparin locks and using the SASH flushing method (Flush Saline, administer medications, Flush Saline, Administer Heparin). LPN CC has the question regarding heparin locks marked incorrect. Surveyor also notes these questions contradict each other, as the SASH method requires a heparin lock following each infusion, whereas the correct answer indicated for the heparin lock question requires this to only be done one time per day. Additionally, several documents titled, Licensed Nurse Competency were provided to Surveyor with the most recent date 2/24/24. Under the section titled, Medication Management, there are many topics including one titled, IV Therapy; no further specifics are listed, especially pertaining to midlines. No documentation of competency checks was provided regarding care of a resident with a midline. LPN P last received training on managing intravenous devices on 4/18/24. A description of this training was obtained from the facility, and it does review vascular access devices, care of vascular access devices, and risks of vascular access devices. Also of note, the facility provided a document titled, Medication Administration Competency Test that is dated 12/3/19. Surveyor notes only two questions that could be applicable specifically to midlines or central venous catheters and asks about heparin locks and using the SASH flushing method. LPN CC has the question regarding heparin locks marked incorrect. Surveyor also notes these questions contradict each other, as the SASH method requires a heparin lock following each infusion, whereas the correct answer indicated for the heparin lock question requires this to only be done one time per day. Additionally, several documents titled Licensed Nurse Competency were provided to Surveyor with the most recent dated 12/8/23. Under the section titled Medication Management, there are many topics including one titled IV Therapy; no further specifics are listed, especially pertaining to midlines. No documentation of competency checks was provided regarding care of a resident with a midline. (Of note: According to the Wisconsin Nurse Practice Act, N6.03(1), LPNs may only accept patient care assignments which the LPN is competent to perform and perform delegated acts beyond basic nursing care under the direct supervision of an R.N. or provider.) RN O also has a document titled Licensed Nurse Competency dated 8/2 with no year listed. Under the section titled, Medication Management, there are many topics including one titled, IV Therapy. RN O's records came with an undated guideline titled IV Competency without any facility designation or markings. This document contains topics related to vascular access devices, maintenance, dressing changes, and midline removal. No names, signatures, dates, or competency checks are listed on this document. There is no indication if or when this information was provided to RN O. The facility did not provide Surveyor with any documentation of competency checks regarding care of a resident with a midline for RN O. The facility provided Surveyor with an additional 17 Licensed Nurse Competency documents with the same notation under the section titled, Medication Management, there are many topics including one titled IV Therapy. Of these 17 documents, 14 had only the month and day documented, with no year. One additional Education/Training sheet was provided to Surveyor with 6 RNs, the DON (Director of Nursing), and one LPN listed that is dated 8/1/24. The IV Therapy policy is attached that is described above. However, the Midline Catheter Flushing-Lock-Removal policy is not. On 7/7/24 at 10:10 AM, Surveyor interviewed LPN N. Surveyor asked LPN N what her responsibilities were for the care of a resident with a midline. LPN N stated she flushes the midline, observes and monitors for signs of infection and pain, and makes sure everything is intact. Surveyor asked LPN N if she does dressing changes. LPN N stated, no, only the RNs do dressing changes. Surveyor asked LPN N what she would do if she noticed anything abnormal with the midline. LPN N stated she would call for another LPN/RN immediately. Surveyor asked what LPN N would do if she noticed there was bleeding, redness, or swelling at the site. LPN N stated, notify the nurse manager as soon as possible and notify the physician. Surveyor asked LPN N if she every completed a competency check for midlines. LPN N stated yes, I believe so, it was a long time ago. Surveyor asked LPN N how she knew how much fluid to flush into the midline. LPN N stated she would check the order. Surveyor asked LPN N what she looks for as she flushes a midline. LPN N stated to make sure it's flushing, if it's not blocked, and that the cap is on securely. Surveyor asked what LPN N would do if she noticed the midline was leaking. LPN N stated she would call the Nurse Practitioner, get the nurse manager to get the dressing off and check the line. Surveyor asked LPN N how she would know how long the line should be. LPN N stated the line should be measured with some documentation of how long it's supposed to be. On 11/7/24 at 10:13 AM, Surveyor interviewed RN BB. Surveyor asked RN BB how she cares for a resident with a midline. RN BB stated she monitors the site and line for signs and symptoms of infection, keeps the site clean, conducts sterile dressing changes, and makes sure the lines and dressing stay in place. Surveyor asked RN BB how she knows when the midline needs to be flushed. RN BB stated she flushed the line before and after medications, and once a shift with a heparin lock. Surveyor asked RN BB how she conducts dressing changes. RN BB stated that this is a sterile process, so sterile gloves and masks need to be worn, the site should be cleaned, and measurements should be made of the line. Surveyor asked RN BB how she knows when to do dressing changes. RN BB stated by physician order. Surveyor asked RN BB how she knows when to remove the midline. RN BB stated by physician order. Surveyor asked what RN BB would do if she found that the midline was leaking. RN BB stated she would contact the Nurse Practitioner and [Company Name] if the midline needs to be replaced. Surveyor asked RN BB if she has ever had a competency check related specifically to midlines. RN BB stated yes. Surveyor asked RN BB, who was working on R29's unit at the time of interview, if she recalled the incident with R29's midline. RN BB stated she does, and that she took care of the midline during the week on the day shift and did not notice any issues with the midline. Surveyor asked RN BB if she recalled the measurements for R29's midline, as they were not documented. RN BB stated she does not recall, but the measurements should be charted and believes this midline had the measurement markings directly on the midline. Surveyor asked RN BB how she delegates care of midlines to LPNs. RN BB stated she does not delegate this task and prefers to care for her resident's midlines herself. On 11/7/24 at 10:31 AM, Surveyor interviewed LPN F. Surveyor asked LPN F what she can do to care for a midline. LPN F stated she can't do anything with it unless they have a grenade (small ball of medication that is attached to the midline that self-administers medication). Surveyor asked LPN F if she can flush midlines. LPN F stated that she can. Surveyor asked LPN F how she knows when she's supposed to flush the line. LPN F stated she would check the order in the medication administration record. Surveyor asked LPN F how dressing changes are completed. LPN F stated that RNs do dressing changes. Surveyor asked LPN F what she would do if she noticed something different with the midline. LPN F stated she would get the RN as soon as possible to observe the site. Surveyor asked LPN F if she received any education from the facility on IVs. LPN F stated she received training on grenades. LPN F also stated they showed her how to flush and hook up the grenade with a return demonstration. LPN F stated that she has been agency staff at this facility for two years and prior to that was regular staff. LPN F estimates her last IV training to be around four years ago and said that she has not received additional training since coming back as agency staff around two years ago. Surveyor asked LPN F what she would do if she attempted to flush a line and met resistance. LPN F stated she would talk to the RN about it. On 11/7/24 at 2:50 PM, Surveyor interviewed LPN E. Surveyor asked LPN E what she does to care for midlines. LPN E stated she can't change dressings, but she can flush them and start IV medication. LPN E noted she is in school to become an RN and has documentation to show she has completed an IV therapy class in school. Surveyor asked LPN E what she checks for when caring for a resident with a midline. LPN E stated she would look for signs and symptoms of infection and that the dressing is intact. LPN E stated she would clean the port or remove the cap cover to use the line. LPN E also notes she has seen one with clamps but it's been months since she had a resident with a midline. Surveyor asked LPN E what she would do if she met resistance while trying to flush a midline. LPN E stated she would replace the cap and get a nurse manager. Surveyor asked LPN E if she would remove the midline. LPN E stated no, she is not allowed to do that and there should be an order to remove the midline. Surveyor asked LPN E if she has completed a competency check for caring for residents with a midline. LPN E stated she cannot remember, she believes it is on the [Name] outside training and that they have come around with the steps before. Surveyor asked what LPN E would do if the midline was broken or falls apart. LPN E stated she would go get the nurse manager. Surveyor asked LPN E what she would do if the midline is leaking. LPN E stated she would stop flushing and get the nurse manager as the line is probably dislodged. Surveyor asked LPN E how she knows what to flush and how much. LPN E stated she would check the order in the electronic medical record. Surveyor asked LPN E if she had ever attended a skills fair. LPN E stated no. On 11/7/24 at 2:54 PM, Surveyor interviewed LPN LL. Surveyor asked what LPN LL does to care for midlines. LPN LL stated he does not care for them, he has the RN care for them. Surveyor asked LPN LL if he monitors anything with the midline. LPN LL stated he monitors the site and dressing and if something doesn't look right he tells the RN and informs DON B. On 11/7/24 at 4:24 PM, Surveyor interviewed DON B. Surveyor asked DON B to describe the issue that occurred in July with R29's midline. DON B stated, we had an order to remove the midline, RN O removed it and realized it wasn't intact. R29 was sent out to the hospital and eventually transferred to a second hospital. R29 returned to the facility with the catheter still in her arm due to second outside hospital being unable to remove it. The facility then made referrals to get R29 the care she needed. Surveyor asked DON B if RN O had received a telephone or verbal order to remove the midline and if the order should have been transcribed into the electronic medical record. DON B stated she would have expected it to be transcribed. DON B also added that she would expect some sort of progress note or change of condition note regarding this event. Surveyor asked DON B if a midline could ever be removed without an order. DON B stated no. Surveyor asked DON B if she was aware there was no order in the electronic medical record to remove the midline. DON B stated no. Surveyor asked DON B what she would expect staff to monitor for in residents who come to the facility with a midline in place. DON B indicated she would expect staff to monitor the insertion site for infection, redness, swelling, pain, and when the line is removed to check to make sure the catheter is intact. Surveyor asked DON B if she would expect staff to notify a provider if a midline was leaking. DON B stated yes. Surveyor asked DON B what she would expect to happen after LPN P notified RN O of the midline not flushing. DON B indicated she would expect an LPN to get an RN to assess the line immediately and to notify the Nurse Practitioner right away. Surveyor asked DON B how often she expects dressing changes to be conducted. DON B stated weekly. Surveyor asked DON B where Surveyor could find that documented. DON B stated, in the TAR (Treatment Administration Record). DON B added that this comes in as an order and an RN is expected to add this into the TAR. Surveyor asked DON B when she expects midlines to be measured. DON B stated during dressing changes. Surveyor asked DON B if she expects dressing changes to be documented. DON B stated yes. Surveyor asked DON B if any competency checks were conducted prior to staff managing R29's midline. DON B stated they do competency checks yearly, so after a year they would, but otherwise no. Surveyor ask [TRUNCATED]

Based on 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 each resident with PIs receives necessary treatment and services, consistent with professional SOP, to promote healing, prevent infection, and prevent new injuries from developing in 1 of 4 sampled residents (R1). R1 admitted with no pressure injuries and was identified to be at risk for PI development. R1 developed an unstageable pressure injury. The facility failed to put aggressive measures in place to promote healing, prevent infection, and to prevent new PI from developing. Evidenced by: Facility policy, titled Pressure Injury Prevention Guide, dated 2016, includes: . it is the policy of the facility to implement evidence based interventions for all residents who are assessed at risk or who have a pressure injury present . individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment . interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used, and for tasks the frequency for performing them . prevention devices will be utilized in accordance with manufacturer recommendations . interventions will be documented in the care plan and communicated to all relevant staff . compliance with interventions will be documented in the medical record . the effectiveness of interventions will be monitored through ongoing assessment of the resident . Repositioning: reposition all residents at risk of, or with existing pressure injuries, . every two hours, using both side lying and back positions . Reposition one in bed and out of bed . Pressure Relieving Devices: the standard mattress for all facility beds are pressure redistribution mattresses with high specification reactive foam . provide alternative support services as needed . R1 admitted to the facility on [DATE] with diagnoses including chronic kidney disease stage 3, muscle wasting and atrophy, muscle weakness, asthma, arthritis, chronic congestive heart failure, and unsteady on feet. R1's most recent Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 9/6/24, indicates R1's cognition is intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. His MDS also indicates R1 requires substantial/maximal assistance to meet his needs in the following areas: toileting hygiene, rolling left to right, lower body dressing, putting on/taking off footwear, sitting to lying, and lying to sitting. R1's MDS indicates he is totally dependent on the assistance of staff to meet his needs in the following areas: bed to chair transfer, toilet transfer, and tub/shower transfer. On 10/17/24 at 10:21 AM, RR D (Resident Representative) voiced concerns to Surveyor regarding R1 developing a PI and the facility staff not responding timely to assist R1's need for repositioning/turning, staff leaving R1 in soiled briefs for long periods of time, and R1 not being offered an air mattress. R1's Braden Scale, dated 7/30/24, indicates R1 is at moderate risk for PI development with a score of 14. R1's Comprehensive Care Plan, initiated 7/30/24, includes: Focus- 7/30/24 Potential For Skin Integrity as evidenced by Braden Scale for Predicting PI Risk: High Risk for PI . Goal- initiated 7/30/24, target date 11/16/24 Resident's skin will remain intact . Interventions/Tasks- 7/30/24 educate resident/representative about proper skin care to prevent breakdown . educate resident/representative about proper usage of pressure reducing devices . educate resident/representative on the importance of keeping skin clean and moisturized . evaluate skin integrity, monitor nutritional status, perform objective PI risk tool such as Braden . provide skin care per facility guidelines and as needed . R1's Braden Scale, dated 8/6/24, indicates R1 is at moderate risk for PI development with a score of 16. Of note despite R1 being at risk for PI the facility did not implement aggressive measures to prevent PI development. R1's Skin Assessment, dated 8/13/24, includes: left inguinal region redness noted . right inguinal region redness noted . R1's Nurse Notes, dated 8/18/24, include: Nursing observation, evaluation, and recommendations are: during morning cares resident was found to have an open area to coccyx approximately 1.2 cm (centimeters) x 0.3 cm open area to coccyx area . No bleeding. No drainage noted. No odor noted. No signs and symptoms of infection this time . Area cleaned with soap/water. Zinc applied and covered with foam dressing. Resident encouraged to offload weight when possible. Wound nurse C informed of new concern. Primary Care Provider notified and responded with the following feedback: notify wound nurse C and continue current wound treatment. R1's Braden Scare, dated 8/20/24, indicates R1 is at risk for PI development with a score of 17. R1's Specialty Physician Wound Evaluation and Management Summary, dated 8/20/24, includes: Patient present with a wound on his coccyx. At the request of the referring provider . a thorough wound care assessment and evaluation was performed today . Review of the Systems: Genitourinary- intermittent incontinence . Support surfaces: bed- group 1 . chair: pressure reduction cushion . Feet: pillow, non-skid socks . Exam: Orientation- oriented to person, oriented to place . Mood and affect- calm, appropriate, content . Focused Wound Exam: unstageable DTI (Deep Tissue Injury) . Etiology- pressure . Duration- greater than 3 days . Objective- healing/maintain healing . Wound size- 1.5 cm x 0.3 cm x 0.2 cm . Surface area- 0.45 cm squared . Exudate- light sero-sanguinous . Recommendations-off-load wound, reposition per facility protocol, group 2 mattress, upgrade offloading chair cushion . Evaluation by wound care specialist within 7 days with further intervention as indicated . R1's Grievance, dated 8/25/24, includes: R1's wife was upset that her husband had his call light on for 45 minutes and he ended up having an accident within that time. R1's Grievance, dated 8/26/24, includes: R1's wife was upset that call light was on for 45 minutes, then while investigating wife had an issue with call light wait time on 8/26/24 . R1's Weekly Skin Impairment and Wound Evaluation, dated 8/27/24, includes: unstageable DTI to the coccyx . wound identified 8/18/24 . pressure ulcer . unstageable: full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed . Visible tissue : 100 percent slough tissue present . Drainage: moderate amount of serosanguineous . Odor present: No . Measurement: 1.5 cm x 0.3 cm x 0.2 cm . Any signs of potential infection: No . Wound/Skin Impairment is unchanged . R1's Specialty Physician Wound Evaluation and Management Summary, dated 9/3/24, includes: Patient present with a wound on his coccyx. At the request of the referring provider . a thorough wound care assessment and evaluation was performed today . Review of the Systems: Genitourinary- intermittent incontinence . Support surfaces: bed- group 1 . chair: pressure reduction cushion . Feet: pillow, non-skid socks . Exam: Orientation- oriented to person, place, time, and situation . Mood and affect- calm, content. Cooperative . Focused Wound Exam: stage 3 pressure wound coccyx full thickness . Etiology- pressure . Duration- greater than 17 days . Objective- healing/maintain healing . Wound size- 1.0 cm x 0.3 cm x 0.2 cm . Surface area- 0.30 cm squared . Exudate- moderate sero-sanguinous . Recommendations-off-load wound, reposition per facility protocol, group 2 mattress, upgrade offloading chair cushion . Evaluation by wound care specialist within 7 days with further intervention as indicated . (It is important to note the recommendations made on 8/20/24 for a group 2 mattress and to upgrade offloading chair cushion. It is also important to note the physician's observation this visit, 9/3/24, of R1 having a group 1 mattress and a pressure reduction cushion and again the recommendations of a group 2 mattress and to upgrade R1's offloading chair cushion.) On 10/17/24 at 10:21 AM, during an interview, RR D (Resident Representative) indicated R1 was left for long periods of time without assistance in changing positions or with incontinence care after an incontinent episode. RR D indicated the police department has been called due to R1 not being able to get help or reach his call light to signal help. RR D indicated R1 was on the same mattress throughout his stay, even after a PI was discovered. R1's Comprehensive Care Plan, dated 10/17/24, initiated 7/30/24, includes: Focus- 7/30/24 Potential For Skin Integrity as evidenced by Braden Scale for Predicting PI Risk: High Risk for PI . Goal- initiated 7/30/24, target date 11/16/24 Resident's skin will remain intact . Interventions/Tasks- 7/30/24 educate resident/representative about proper skin care to prevent breakdown . educate resident/representative e about proper usage of pressure reducing devices . educate resident/representative on the importance of keeping skin clean and moisturized . evaluate skin integrity, monitor nutritional status, perform objective PI risk tool such as Braden . provide skin care per facility guidelines and as needed . (It is important to note the facility did not update R1's comprehensive care plan to reflect R1's open wound and aggressive measures/interventions to be implemented when R1 was found to have an unstageable PI.) On 10/17/24 at 1:30 PM, during an interview, Med Tech E indicated she recalls providing care to R1 but does not recall if the facility changed his mattress throughout his stay. Med Tech E indicated when a resident develops a PI, the care plan should be updated with new interventions and goals to promote healing, such as repositioning the resident more often. On 10/17/24 at 1:32 PM, RN F (Registered Nurse) indicated R1 spent a lot of time in his chair and not so much time in his bed. RN F indicated R1 needed the assistance of two staff for transfers and bed mobility. RN F indicated she did not recall if R1's mattress was changed during his stay. RN F indicated R1's care plan should have been updated when the PI was noted to include a new goal and interventions to promote healing and prevent infection. On 10/17/24 at 1:41 PM, during an interview, RR G indicated she was in to visit R1 daily. RR G indicated staff would be aware of R1 having had an incontinence episode but would not assist him. RR G indicated R1 requires 2 staff to transfer and many times there were not 2 staff available to assist. RR G recalled a time R1 had his call light on, due to an incontinence episode, for 45 minutes. When staff came in, they de-activated the call light and left the room to retrieve another staff member. R1 waited 10 minutes and put his call light on again. This time one staff came in with his meal tray and told him to eat and then the staff would assist him with incontinence care. RR G indicated R1 was left in a dirty brief for over an hour and expected to eat his meal with a dirty brief on. RR G indicated R1's mattress was a foam mattress and was not an air mattress and this is the mattress R1 had throughout his stay. On 10/17/24 at 1:45 PM, during an interview, R1 stated, I was given a bed when I got there and that is the one I had until I left. R1 indicated many times he called for assistance with toileting needs or repositioning needs and was left to wait for long periods of time. R1 indicated he was left in soiled briefs for long periods of time also. On 10/17/24 at 2:00 PM, DON B (Director of Nursing) indicated when staff became aware of R1's PI, his care plan should have been updated. DON B indicated she would like to see turning and repositioning frequency on care plan, air mattress added, and chair cushion updated with dates. DON B indicated R1's skin integrity care plan was created on 7/30/24 and was not updated through his stay. DON B and Surveyor reviewed R1's Physician Wound Evaluation, noting the mattress recommendations on 8/20/24 and on 9/3/24. DON B indicated usually the wound care nurse, the maintenance man, or office support changes out the mattress, but she can't recall if R1's was ever changed from the original foam mattress. DON B and Surveyor reviewed facility policy regarding PI prevention and care. DON B indicated staff should record in resident's medical record the type of devices that are being used and staff are to follow physician recommendations when it comes to devices or interventions.

Based on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice when experiencing a change of condition for 1 of 3 sampled residents (R1). On [DATE], R1 experienced a change in condition exhibiting as shortness of breath and critically low oxygenation. The facility failed to recognize the change of condition as a medical emergency, complete a comprehensive cardiorespiratory data collection, and consult with the RN which resulted in a delay of treatment. LPN E's (Licensed Practical Nurse) failure to recognize a change of condition, complete a comprehensive cardiorespiratory data collection, and consult with the RN resulted in a delay of treatment and created a finding of Immediate Jeopardy (IJ) beginning on [DATE]. On [DATE] at 2:15 PM, NHA A (Nursing Home Administrator) was informed of the IJ. The IJ was removed on [DATE] when the facility recognized the IJ and implemented an immediate action plan. The IJ was corrected on [DATE]. This is evidenced by: The facility policy titled Notification of Changes Policy dated [DATE], states in part: Policy: It is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate .Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative , and the resident's physician, to ensure best outcomes of care for the resident DEFINITIONS Significant change in status - deterioration in health, mental or psychosocial status in life threatening conditions or clinical complications Significant alteration in treatment - A need to alter treatment significantly. A significant treatment alteration includes the need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment. OBJECTIVE OF THE NOTIFICATION OF CHANGE POLICY The objective of the notification policy is to ensure that the facility staff makes appropriate notification to the physician and delegated Non-Physician Practitioner and immediate notification to the resident and/or the resident representative when there is a change in the resident's condition, or an accident that may require physician intervention. The intent of the policy is to provide appropriate and timely information about changes relevant to the resident's condition .to the parties who will make decisions about care, treatment, and preferences to address the changes. OVERVIEW OF COMPONENTS OF THE POLICY 1. Requirements for notification of resident, the resident representative, and their physician . 2) A significant change in the resident's physical, mental, or psychosocial status. (i) A significant change includes deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications . Notification is provided to the physician to facilitate continuity of care and obtain input from the physician about changes, additions to or discontinuation of treatments . PROCEDURE FOR NOTIFICATION OF CHANGES FOR RESIDENT PURPOSE The facility shall promptly notify the resident and/or the resident representative and his or her physician or delegate of changes in the resident's condition or status in order to obtain orders for appropriate treatment and monitoring and promote the resident's right to make choices about treatment and care preferences. PROCEDURE 1. The nurse will immediately notify the resident, resident's physician, and the resident representative(s) for the following (list is not all inclusive): . b. A significant change in the resident's physical, mental, or psychosocial status that is a deterioration in the health, mental or psychosocial status in either life threatening conditions or clinical complication. c. A need to alter treatment significantly a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment. d. A decision to transfer or discharge the resident from the facility . 3. Document the notification and record any new orders in the resident's medical record . 7. Communicate the changes to the rest of the care team and inform the supervisor . According to Wisconsin Statutes N 6.04 Standards of practice for licensed practical nurses. (1) Performance of acts in basic patient situations. In the performance of acts in basic patient situations, the L.P.N. shall, under the general supervision of an R.N. or the direction of a provider: (a) Accept only patient care assignments which the L.P.N. is competent to perform. (b) Provide basic nursing care. (c) Record nursing care given and report to the appropriate person changes in the condition of a patient. (d) Consult with a provider in cases where an L.P.N. knows or should know a delegated act may harm a patient. (e) Perform the following other acts when applicable: 1. Assist with the collection of data. 2. Assist with the development and revision of a nursing care plan. 3. Reinforce the teaching provided by an R.N. provider and provide basic health care instruction. 4. Participate with other health team members in meeting basic patient needs. (2) Performance of acts in complex patient situations. In the performance of acts in complex patient situations the L.P.N. shall do all of the following: (a) Meet standards under sub. (1) under the general supervision of an R.N., physician, podiatrist, dentist or optometrist. (b) Perform delegated acts beyond basic nursing care under the direct supervision of an R.N. or provider. An L.P.N. shall, upon request of the board, provide documentation of his or her nursing education, training or experience which prepares the L.P.N. to competently perform these assignments. R1 was admitted to the facility on [DATE] with diagnoses to include chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease with (acute) exacerbation (COPD) and dependence on supplemental oxygen. R1's Minimum Data Set (MDS) with an assessment date of [DATE] includes the following: Brief Interview of Mental Status (BIMS) assessment score of 14 indicating R1 is cognitively intact. Section J1100 C. Shortness of breath or trouble breathing when lying flat was marked. J1400 Prognosis. Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? 'No' was marked. O0110 Special Treatments, Procedures, and Programs C1. Oxygen therapy while a resident was marked. R1's physician orders included the following: DNR (Do Not Resuscitate) start date [DATE]. Q4 (every 4 hours) vital signs every 4 hours start date [DATE]. Continuous Oxygen via NC (Nasal Cannula) 3L (3 Liters) every shift start date [DATE]. Albuterol Sulfate Inhalation Nebulization Solution (2.5MG/3ML) 0.083%v (Albuterol Sulfate) 1 vial inhale orally via nebulizer three times a day for COPD exacerbation start date [DATE]. Mometasone Furo-Formoterol Fum Inhalation Aerosol ,d+[DATE] MCG/ACT 2 puff inhale orally at bedtime for COPD start date [DATE]. Mometasone Furo-Formoterol Fum Inhalation Aerosol ,d+[DATE] MCG/ACT 2 puff inhale orally one time a day for COPD start date [DATE]. Spiriva HandiHaler Inhalation Capsule 18MCG 1 puff inhale orally one time a day for COPD rinse mouth after use start date [DATE] R1's comprehensive care plan Alteration in Respiratory Status Due to Chronic Obstructive Pulmonary Disease, Chronic Hypoxic Respiratory failure. Oxygen Dependent. Dated [DATE] has goals of Patient will have adequate gas exchange as evidenced by no adventitious breath sounds, absence of respiratory distress, and absence of shortness of breath. Patient will remain free of exacerbation of COPD. Interventions include Observe labs, response to medication and treatments. Administer oxygen as needed per Physician order. Monitory oxygen saturations on room and and/or oxygen. Monitor oxygen flow rate and response. Elevate HOB (Head of Bed) to alleviate shortness of breath. Monitory cough and effectiveness of inhaler/nebulizer. Notify practitioner if symptoms worsen or do not resolve. R1's Progress Notes written by LPN E (Licensed Practical Nurse) include the following: [DATE] 10:56 (AM) Note Text: At 0725 (7:25AM) res (R1) was on call light requesting a boost due to SOB (Shortness of Breath) because she was to [sic] low. Writer went to get an aide to assist, and res was repositioned, and HOB (Head of Bed) was raised. After that writer went to get res nebulizer (a device for producing a fine spray of liquid for inhaling a medication) meds (medication) and ran that with mask (a face mask used to administer medication via a nebulizer). And writer also gave the res an inhaler. Res breathing was labored. Checked res POX (Pulse Oximetry, a noninvasive method for monitoring blood oxygen saturation) and it was 62% on oxygen at 3L (Liters) via NC (Nasal Cannula), writer increased oxygen to 4L. Writer came back in a little while and rechecked res POX and it had gone up to 69% but writer had CNA (Certified Nursing Assistant) get res a mask (a face mask to administer oxygen) and it was applied to the res instead of the NC. Res was responsive at that time. Writer rechecked POX and it was at 72%. Res was responsive at that time. Writer went back soon after this to recheck res POX and at that time res noted to have her eyes rolling up and not responding to verbal but did have a slight response to touch. POX was down to 54% on mask so writer went and called EMS (Emergency Medical Services) to come for resident. Writer went back into res room and stayed there with res until EMS arrived. Res was not really responsive then and was pale in color and had labored breathing but when writer went and held res hand res did respond to it. According to Lippincott Nursing 2024 King, [NAME] E. RN, C, ACNP, ANP, PhD. How do I choose a supplemental oxygen delivery device? Nursing 33(12):p 32, [DATE] states in part; perform a more complete physical assessment. Besides the patients SPO2 (blood oxygen level), note the respiratory rate, quality of breath sounds, use of intercostal muscle (muscles around ribs, if noting intercostal muscle use the patient is working hard to breath), presence of mottling (bluish color of skin), heart rate and any cardiac arrhythmias. The nasal canula is most appropriate for patients experincing minimal respiratory distress. The flow rates rate from 1 to 6 liters. Like the nasal canula the face mask mixes oygen with room air but can provide higher oxygen concentration and higher flow rates (5 to 10 Liters). To prevent carbon dioxide accumulating in the mask, maintain an oxygen flow rate of at least 5 liters/minute. Of note, despite R1's significant respiratory history and R1's presentation LPN E did not listen to R1's lungs or complete a full respiratory review of R1. At no time did LPN E consult with a RN regarding R1; instead LPN E left R1's room despite R1 showing increased respiratory distress as evidenced by low O2 sats and labored breathing. Additionally, LPN E chose to use an oxygen mask with a low oxygen delivery of 4 liters per mask which would have increased the carbon dioxide accumalation in the mask making breathing more difficult for R1 and furthering R1's respiratory distress. EMS report dated [DATE] includes the following information: Clinical Impression: Primary Impression: Acute Respiratory Distress. Onset Time: 07:00 (AM) [DATE]. Chief Complaint: Respiratory distress. Duration: 2 hours. Signs & Symptoms: Acute respiratory distress (Primary), Slowness and poor responsiveness. Initial Patient Acuity: Critical (Red) Vital Signs: Time 09:08 (AM) BP (Blood pressure) Blank. Pulse Blank. RR (Respiratory Rate) 10 R. SPO2 (Oxygen Saturation) 70 Rm. (on room air) Time 09:13 (AM) BP ,d+[DATE]. Pulse 111. RR 12 R. SPO2 93 Ox. Flow Chart: Time: 09:09 (AM). Treatment: Oxygen. Description: Device: Non-Re-breather Mask (NRB); Flow Rate; 15 lpm; Patient Response: Improved; Successful; Complications: None; Medical Control: Protocol (Standing Order) Time 09:13 (AM). Treatment: Oxygen. Description: Device: Bag Valve Mask (BVM); Flow Rate: 15 lpm; Patient Response: Improved; Successful; Complication: None; Medical Control: Protocol (Standing Order) Assessments Time 09:08 (AM) Mental Status - Slowness and poor responsiveness. Skin - Cold, Cyanotic (bluish or purplish discoloration due to deficient oxygenation). Eyes - Left: Non-Reactive, right: non-reactive. Extremities: Cyanotic extremities. Narrative: [Ambulance Number] was dispatched to a nursing home for difficulty breathing. [Ambulance Number] responded emergent and arrived on scene without incident. On arrival EMS crew was met at the front door by facility staff and escorted to pt's (R1) room. On contact pt was [age] GCS 7 (Glasgow Coma Scale indicating severe traumatic brain injury requiring immediate emergency care) laying upright in bed with an oxy (oxygen) mask on. Pt had shallow respirations and was cyanotic in the extremities. Pt's eyes were moving on initial contact. Nursing home staff state she has a history of pulmonary failure and started to have acute difficulty breathing around 0700 (7:00AM) this morning, which has not improved with their treatments of oxygen and a nebulizer. Nursing home staff state that her initial spO2 was 60% on a 2 LPM NC (liters per minute/via nasal canula), spO2 at time of EMS contact 71% on oxy mask @6 LPM. Nursing home state they obtained an automated blood pressure of ,d+[DATE] prior to EMS arrival. EMS unable to obtain with monitor, radial pulse was weak. EMS was presented with a valid DNR for the pt, as well as med list indicating the pt was on blood thinners. Unable to obtain stroke scale due to pt's GCS. Pt slide sheet transferred over to stretcher and a NRB was applied @15 LPM. Pt moved via stretcher to [Ambulance Number]. In [Ambulance Number] a 4-lead was applied showing a tachy sinus arrhythmia (an irregular and faster than normal heart rate). SpO2 remained at 69% on NRB (Non-rebreather/face mask), BVM (Bag Valve Mask-device used to deliver ventilation to patient) ventilation started due to shallow respirations, raising the spO2 to 93%. Pt began to increase ventilatory effort following BVM, however it was noted that her eyes were now fixed. [Ambulance Number] started emergent transport to hospital. Enroute BVM was continued with spO2 remaining above 90%. BP obtained enroute was ,d+[DATE]. [Ambulance Number] arrived at [ER Name] without incident and pt was moved via stretcher to ER room [ROOM NUMBER] where she was slide sheet transferred to bed. Care, report, and DNR (Do Not Resuscitate) paperwork transferred to RN. [Ambulance Number] cleared [ER name] following decon (decontamination). Level of Service: Advanced Life Support Incident Times: Call Received 09:01:04 Dispatched 09:01:13 En Route 09:01:44 On Scene 09:05:29 At Patient 09:07:00 Depart Scene 09:14:16 At Destination (Hospital ER) 09:15:45 Pt. Transferred 09:17:16 [DATE] 10:52 (AM) Note Text: Res left via EMS around 0914 (9:14AM). ER (emergency room ) updated on res going over there for evaluation at 0916 (9:16AM) and son [Name] updated that res was going to the ER due to low oxygen sats (Oxygen Saturation) at 0918 (9:18AM). [Name] NP (Nurse Practitioner) consulted regarding res low POX and low BP (Blood Pressure) and high pulse, send to ER. Hospital Emergency Department report dated [DATE] includes the following: Date of service [DATE]. Chief complaint: Difficulty breathing. Unable to obtain history r/t (related to): Other - Patient nonverbal due to critical nature presentation. Comments: .presents to the emergency room by ambulance for evaluation of respiratory distress which did not respond to a breathing treatment at the nursing home . When she was brought into the emergency department the patient was being bag (manual ventilation) and she was having agonal respirations (a distinct and abnormal pattern of breathing) she did have a palpable pulse, but she did not have any other signs of life she was not responding to needlestick or questioning . General Appearance: other - Patient is not responding to stimulation or verbal communication . Eyes: Bilateral: Other - The right pupil is blown left pupil is 6 mm but not responding Respiratory: Other - Decreased air movement only noted with bagging. Neuro/Psych: Other - On arrival patient had a blown pupil on the right. She was not responding to verbal communication she was not responding to tactile stimulation or needlestick. Medical Decision Making: Summary of care: Patient presents with agonal respirations and appeared to be at end of life. She is a DNR. I spoke to the son who has power of attorney and comfort care measures were started. Patient was given intravenous morphine Zofran and lorazepam. Shortly after arrival patient lost all signs of life. She had no palpable pulse no cardiac sounds and no respiratory effort. No neurologic function. Clinical course as noted above after speaking with the son since she is a DNR comfort measures were started the patient expired at 9:55 a.m. [DATE] 11:14 (AM) Note Text: At 1000 (10:00AM) received call from [Name] ER that res was pronounced dead at 0955 (9:55AM). [Name of practitioner] NP was consulted regarding res pronounced dead after phone call from ER. [DATE] 11:16 (AM) Note Text: [Name] DON was updated at 1045 (10:45AM) regarding res passing at [Name] ER. On [DATE] at 9:49 AM, Surveyor interviewed PO D (Police Officer - Detective). PO D indicated the facility contacted the police and reported the incident as possible neglect due to the delay in treatment. PO D indicated she spoke with the medical examiner in charge of R1's case. PO D indicated there was an autopsy which revealed preliminary cause of death as COPD, emphysema, and lung disease. PO D and medical examiner discussed the case, and it was said that being deprived of adequate oxygenation might be a contributing factor for the cause of death. On [DATE] at 10:26 AM, Surveyor interviewed NP C (Nurse Practitioner). NP C indicated she was not made aware of R1's change in condition until after R1 was sent to the ER which was almost 2 hours after the change in condition started. NP C stated she had ordered vital signs every four hours for R1 because of R1's condition. NP C indicated R1 had no reserve due to end stage COPD. NP C indicated the first oxygen saturation of 62% was a critical value and R1 should have been sent to the ER immediately. NP C indicated she does not believe the situation was handled correctly. NP C indicated staff should have called 911 then attempted other interventions like the inhaler or nebulizer as they waited for EMS to arrive. NP C agreed being deprived of adequate oxygen for that long could have been a contributing factor to R1's death. NP C indicated it is her expectation that any critical values in vital signs need an immediate phone call to the provider. On [DATE] at 4:06 PM, Surveyor interviewed DON B (Director of Nursing). DON B indicated R1 had a hospice consult on [DATE] but declined hospice services. DON B indicated she was notified of R1's death on [DATE]. DON B indicated on [DATE], LPN E did not give details of what happened that lead to R1 being sent to the hospital and passing. On [DATE], after reviewing LPN E's documentation, DON B suspended LPN E and started an investigation. DON B indicated she would have expected LPN E to call the NP and send R1 to the hospital for a pulse oximetry reading of 62%. DON B indicated LPN E did delay treatment for R1. On [DATE] at 8:40 AM, Surveyor interviewed LPN E. LPN E indicated the following: At 7:30 AM R1 had her light on and needed a boost up in bed because she was short of breath. LPN E left the room to get a CNA on a different hallway. They returned and boosted R1 up in bed. After they boosted R1, LPN E went to her cart to get a nebulizer treatment that took about 15 minutes to run. LPN E also grabbed an inhaler for R1 and brought in a pulse oximeter. LPN E checked R1's O2 sats (oxygen saturation) and it was 62% on 3L. LPN E turned the oxygen up to 4L at that time. LPN E left the room and came back a little later and rechecked R1's O2 sats. It was 69%. LPN E then had a CNA get an oxygen mask and change it out with the nasal cannula. LPN E then came back a little later and R1's O2 sats was 72%. LPN E left R1's room and returned to her medication cart. LPN E prepared another resident's medications and went to administer that resident's medications to them. Then LPN E went back to R1 to recheck O2 sats which was now at 52%. LPN E ran out of the room and called 911. LPN E returned to R1's room and waited for EMS to arrive. Upon EMS arrival, LPN E gave EMS report then left the room. LPN E then escorted EMS out of the building. LPN E then called ER to give them report on R1 being sent there and called R1's son. Surveyor asked LPN E when she first took an O2 sats reading for R1. LPN E indicated she checked R1's O2 sats for the first time after boosting R1 and administering the nebulizer and inhaler. LPN E indicated R1 was a DNR and R1's O2 sats were going up slowly. LPN E indicated in hindsight LPN E would have done things way different. LPN E indicated she would have called 911 after the first O2 reading of 62%. On [DATE] at approximately 7:30 AM, R1 complained of shortness of breath. R1's O2 sats were not obtained for approximately 20 minutes. R1's O2 sats at that time was critically low at 62% and remained low. The facility did not notify the provider. The facility called 911 at 9:01AM, approximately 1.5 hours after the facility noted the change in condition. R1 expired at 9:55AM. The facility's failure to recognize a change of condition complete a comprehensive cardiorespiratory data collection and consult with the RN resulted in a delay of treatment creating a finding and immediately notify the physician created a finding of IJ which was removed, on [DATE], when the facility implemented the following action plan: Investigation initiated. Police notified. Nurse suspended. Chart review completed. Hospital notes reviewed. Staff statements obtained. Like resident statements obtained Skin assessments completed on residents with BIMS of 12 or less. Audit completed on all change in conditions within the last week to ensure RN (Registered Nurse) assessment completed and Nurse Practitioner was updated timely. Audit completed on oxygen use orders. Audit completed on all vital signs to determine if there were any missed vital signs or abnormal vital signs. Review of all nursing competencies Review of crash carts Audit of Code status Audits daily x (for) 30 days for change in condition, appropriate assessments, vital signs completed, any new orders completed, place d on 24-hour board, and continued follow up. Respiratory assessments reviewed or completed on residents with Respiratory diagnosis. [NAME] Clinical Consulting educated the QAPI (Quality Assurance and Performance Improvement) committee on notifications/investigations that must begin off-hours for any death or unusual event. Education completed for all licensed staff and CNA's. Recognition of change in condition with post test O2 orders with post test Following MD orders and MD notification MD and RN notification Vital signs and Baseline vital signs with post test Education completed for all staff. Change in condition. Reporting to nursing any changes Abuse, Neglect, Misappropriation

Based on observation, interview, and record review, the facility did not ensure that the resident's environment remains as free of accident hazards as is possible and did not ensure resident's care plans are up to date for 1 of 3 residents (R3) reviewed for accidents. R3 fell on [DATE], sustaining a laceration under his left eye that required stitches. This is evidenced by: The facility's Policy and Procedure entitled Falls Management Process dated 1/10/24 documents the following in part: .12. The nurse will determine the most appropriate intervention, implement, and update care plan . The facility's Policy and Procedure entitled Comprehensive Care Plan dated 3/1/23 documents the following in part: .3. The comprehensive care plan will describe, at a minimum, the following .f. Resident specific interventions that reflect the resident's needs and preferences .8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. R3 is a short-term rehab resident admitted to the facility with the following diagnoses: intraspinal abscess and granuloma, MRSA (methicillin-resistant Staphylococcus aureus), type 2 diabetes mellitus, muscle wasting, cystitis, MSSA (Methicillin-Sensitive Staphylococcus aureus), cognitive communication deficit, fall in shower or empty bathtub, acute metabolic acidosis, sepsis due to MSSA, and fusion of spine-cervical region. R3's Fall Risk Evaluations document the following: 4/25/24 - score of 12 4/27/24 - score of 17 5/15/24 - score of 18 6/1/24 - score of 17 8/4/24 - score of 8 A score of 10 or higher indicates the resident is at high risk for falls. R3's Care Plan documents the following: Focus: 4/25/24 At risk for falls related to: History of falls, New environment, Use of medication; Goal: No Fall related injuries; Interventions: Keep personal items within reach, Keep environment well-lit and free of clutter, Gait belt with transfers, Encourage rest periods if feeling fatigued, Encourage participation in activities to improve strength or balance, Clear and monitor environmental obstacles (tubing, cords, etc.), Call light and personal items available and in easy reach or provide reacher, Activity Programming - exercises, TV programs 5/1/2024 Grip socks to be donned when shoes are not worn. 5/15/2024 Sign hung in room and bathroom to remind resident to call for assistance. 5/20/2024 Resident to be offered assistance with toileting Q2hrs (every 2 hours) while awake. 6/17/2024 Resident to be offered toileting after lunch daily. 8/6/2024 8/3-Resident to be offered Q2hrs toileting throughout the NOC (Night shift) R3's Certified Nursing Assistant (CNA) Care Plan documents the following: -Resident is to be offered assistance with toileting needs Q2hr while awake. -Resident is to be offered toileting assistance following lunch daily. -Resident to be offered Q2hrs toileting throughout the NOC. Of note, the following interventions were not on the CNA Care Plan - Sign hung in resident's room and bathroom to call for assistance and - Larger Dycem (non-slip material) to seat of wheelchair. R3's Fall Reports document the following: 5/9/24 - Notified by PT (Physical Therapy) that resident had a witnessed fall and did not hit his head. Per PT, safety education provided. No injury. PT witnessed resident fall in front of sink just before making it to his wheelchair. DON (Director of Nursing), MD (Medical Doctor), POA (Power of Attorney) notified. RCA (Root Cause Analysis) trying to get out of bed to go to the bathroom. Intervention - Sign hung in resident's room and bathroom to call for assistance. R3's dates of falls in correlation with when fall interventions were added to the care plan: Fall 5/9/24, Intervention - Sign hung in resident's room and bathroom to call for assistance. Sign hung in room and bathroom to remind resident to call for assistance added to Care Plan 5/15/2024. This is six (6) days after this fall. On 8/7/24 at 12:56 PM, Surveyor entered R3's room with his permission. There were no signs in R3's room or bathroom. 5/15/24 - Staff outside room heard ow! sound came from the room. Went in room and saw resident on buttocks, leaning to right side, right arm extended to floor and left arm in lap, feet on floor, knees bent up toward ceiling. Resident began to move about and stood up from floor with help from writer and social worker. Resident sat in chair. VS (Vital Signs). Neuro (Neurological) check complete. Skin assessment/assessment for injury. NP (Nurse Practitioner), DON, RR (Resident Representative) notified. RCA - R3 I lost my footing when I tried to get to the bathroom. I know I'm supposed to ask for help, but I didn't want to bother anyone. Intervention - Resident is to be offered assistance with toileting needs Q2hr while awake. R3's dates of falls in correlation with when fall interventions were added to the care plan: Fall 5/15/24, Intervention - Resident is to be offered assistance with toileting needs Q2hr while awake. Resident to be offered assistance with toileting Q2hrs while awake added to Care Plan 5/20/2024. This is five (5) days after this fall. 5/21/24 - Alerted by CNA that resident had fallen. Found on floor, resting on buttocks in front of wheelchair. Assessed for injury and pain. VS = 100.2 (dressed in multiple top layers and room is very hot in temperature). Follow-up temp = 98.8. Neuro checks assessed. Grip socks on, not incontinent. DON, MD, Family notified. RCA - I slid out of wheelchair and lowered myself onto my buttocks. Intervention - larger dycem to seat of wheelchair. R3's dates of falls in correlation with when fall interventions were added to the care plan: Fall 5/21/24, Intervention - Larger Dycem to seat of wheelchair. This intervention was not added to the Care Plan. On 8/7/24 at 12:56 PM, Surveyor entered R3's room with his permission. Surveyor asked R3 if he was sitting on a non-slip mat, R3 wasn't sure. There was no Dycem noted on top of wheelchair cushion. On 8/7/24 at 1:05 PM, Surveyor interviewed CNA/Med Tech I (Medication Technician). Surveyor asked CNA/Med Tech I what R3's fall interventions are? CNA/Med Tech I stated keeping bed low, trip hazards out of way, door open, and table away from bed. Surveyor asked CNA/Med Tech I if R3 was sitting on Dycem. CNA/Med Tech I said unsure. Surveyor asked CNA/Med Tech I if she could look with Surveyor if R3 was sitting on Dycem. CNA/Med Tech I had R3 pick up his legs so she could look and feel under his thighs and lean forward to see under his buttocks; there was not Dycem in place. 6/1/24 - Resident found on the floor in the bathroom. Resident on coccyx, back to the wall, arms at sides, feet flat on floor, knees bent toward chest. ROM WNL (Range of Motion Within Normal Limits). VSS (Vital Signs Stable). Skin assessment. Neuro check. DON, NP, family notified. RCA - R3 I did not fall on the floor. I don't know why everyone says I fell . I stood up, my knees got weak, and I sat myself on the floor. I know, but I didn't want to wait. Intervention - resident is to be offered toileting assistance following lunch daily. R3's dates of falls in correlation with when fall interventions were added to the care plan: Fall 6/1/24, Intervention - Resident is to be offered toileting assistance following lunch daily. Resident to be offered toileting after lunch daily added to Care Plan 6/17/2024. This is 16 days after this fall. 8/3/24 - Resident was sitting on toilet, naked from the waist down, no shoes or socks on feet. Resident had blood coming from small laceration to left lateral eye. There were large areas of urine in front of end table and closet. Wheelchair was at bedside with brakes locked, call light attached to bedsheets and in view accessibility. RCA - R3 stated he didn't know if he could make it to toilet without having an accident. He stated that he fell off his bed but didn't know what he hit his face on. Resident stated he was fine and didn't need to go to hospital. Neuro checks initiated. VS. MD, NM (Nurse Manager), family notified. While notifying MD, swelling under R3's left eye became more significant, and MD requested he be sent to ER (emergency room ) for evaluation. Intervention - Resident to be offered Q2hrs toileting throughout the NOC. R3's ER paperwork documents the following: -Traumatic hematoma of left orbit, laceration of face, right hip pain, fall. -Pt (Patient) presents with left periorbital hematoma and laceration. Pt was trying to get up to use the bathroom and fell hitting his left side of face on his nightstand. Pt denies LOC (Loss of Consciousness). Pt is unable to open his left eye. Pt has severe swelling to left periorbital hematoma. Pt is on warfarin (anticoagulant - medication that inhibits the coagulation (the action of a liquid changing to a solid or semi-solid state)). Pt denies nausea, vomiting, CP (Chest Pain), SOB (Shortness of Breath), cold symptoms, weakness, and dizziness. Pt C/O (complained of) of 6/10 left facial pain. Pt's speech is clear. -3 stitches to laceration below left eye. R3's dates of falls in correlation with when fall interventions were added to the care plan: Fall 8/3/24, Intervention - Resident to be offered Q2hrs toileting throughout the NOC. Resident to be offered Q2hrs toileting throughout the NOC added to Care Plan 8/6/2024. This is 3 days after this fall. On 8/7/24 at 12:58 PM, Surveyor interviewed CNA F (Certified Nursing Assistant). Surveyor asked CNA F what R3's fall interventions are. CNA F stated keep door open, nothing next to bed, and to encourage him to call for assistance. Surveyor asked CNA F if R3 was sitting on Dycem, CNA F said not sure about that. It is important to note that CNA F did not say anything about toileting R3. On 8/7/24 at 1:03 PM, Surveyor interviewed CNA J. Surveyor asked CNA J what R3's fall interventions are. CNA J stated for him to call for assist, door open, and verbal encouragement to use call light. Surveyor asked CNA J if R3 was sitting on Dycem, CNA J replied don't know for sure on that. It is important to note that CNA J did not say anything about toileting R3. On 8/7/24 at 1:22 PM, Surveyor interviewed RN/UM K (Registered Nurse/Unit Manager). Surveyor asked RN/UM K how the fall interventions get on the care plan. RN/UM K stated, I enter them daily or on Monday if over a weekend and I'm not here. Surveyor asked RN/UM K how the CNAs know the fall interventions. RN/UM K replied they are written on 24-hour board, the Nurses should be giving them verbally in report, and they are on the CNA Care Plan. Surveyor asked RN/UM K where is R3's Dycem supposed to be? RN/UM K stated between him and the wheelchair cushion. Surveyor asked RN/UM K should all the fall interventions be in place, RN/UM K said yes. Surveyor asked RN/UM K should all fall interventions be on the Care Plan and CNA Care Plan, RN/UM K replied yes. Surveyor told RN/UM K that R3 doesn't have any signs in his room or bathroom, R3 is not sitting on any Dycem, and none of the staff on R3's unit brought up toileting as part of his fall interventions. RN/UM K said R3 must have taken the signs down again. On 8/7/24 at 3:21 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B would you expect all fall interventions to be in place, DON B stated yes. Surveyor asked DON B would you expect all fall interventions to be on the Care Plan, DON B responded yes. Surveyor asked DON B would you expect all fall interventions to be on the CNA Care Plan, DON B said yes. Surveyor asked DON B if an intervention is removed by the resident what should occur? DON B replied we should come up with a different intervention. Surveyor showed DON B R3's CNA Care Plan that Surveyor viewed on computer prior to speaking with staff and compared it to the printed copy given after speaking with staff. The two documents did not match. The document pulled up on the computer did not include the Sign hung in room and bathroom to remind resident to call for assistance. Surveyor asked DON B if she had any idea why the paper copy of CNA Care Plan and computer copy of CNA Care Plan didn't match, DON B said I'm not sure.

Based on observation, interview, and record review, the facility failed to assess and provide appropriate treatment and services to achieve and maintain as much normal bowel and bladder function as possible for 2 of 4 sampled residents (R) (R4 and R2) reviewed with a bladder and bowel decline. R4 is being cited at severity level 3 (actual harm). R2 is being cited at severity level 2 (potential for more than minimal harm). R4 was continent of bowel and bladder prior to admission. R4 had a decline in bowel and bladder continence from 7/15/24 to present. R4 was assessed by the facility as continent on admission on 7/15/24 and currently is frequently incontinent of bladder and bowel. The facility failed to implement measures to improve R4's bowel and bladder continence and failed to update R4's care plan or establish a toileting program in an effort to restore R4's bowel and bladder continence. R2 had a decline in bowel and bladder continence from 6/20/24 to the present. R2 was continent of bowel and bladder on admission. R2 has had a decline in bowel and bladder continence since admission and is now incontinent of bowel and bladder. The facility failed to update R2's care plan and failed to establish a toileting program to restore R2's bowel and bladder function. This is evidenced by: The facility's policy, Incontinence, with an effective date of 3/26/23 and no revision/review dates noted states in part . The facility must ensure that residents who are continent of bladder and bowel upon admission receive appropriate treatment, services, and assistance to maintain continence . The facility's policy, Comprehensive Care Plan, with an effective date of 3/1/23 and no revision/review dates noted; states in part: .The comprehensive care plan will describe, at a minimum, the following: (3)(a) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . (6) The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed . Example 1: R4 was admitted to the facility on [DATE] with diagnoses that include, in part: Chronic Kidney Disease, Type II Diabetes with Diabetic Neuropathy, Dehydration, Major Depressive Disorder, Generalized Anxiety Disorder, Muscle Wasting and Atrophy, Unsteadiness on feet, Weakness. R4's admission Minimum Data Set (MDS) with a target date of 7/18/24, indicates in part: Brief Interview of Mental Status (BIMS) of 14, indicating cognitively intact. R4's Elimination charting indicates R4 was of continent bladder and bowel elimination on 7/15/24 and 7/16/24. R4's Elimination charting beginning on 7/17/24, indicates 3 continent voiding episodes and 54 incontinent episodes for bladder. R4's elimination charting beginning on 7/17/24 indicates all 34 bowel episodes as incontinent. There is no evidence in R4's medical record that the facility assessed R4 or implemented a plan including a bowel and bladder toileting plan to assist R4 in achieving or restoring bowel and bladder continence. There is no evidence the facility attempted to complete a bowel and bladder diary, implement interventions such as a bedside commode, frequent toileting to aid R4 in maintaining or regaining bowel and bladder continence. On 8/7/24 at 10:18 AM, Surveyor interviewed R4 who stated she had been continent before she came to the facility but has been incontinent the entire time since admission. R4 indicated that at first staff assisted her to the commode, but that was stopped, and the commode removed by therapy because she was always soiled by the time staff came to help her. R4 stated that she has to urinate approximately every 30 minutes, and that she can't wait that long for staff to come and assist her. R4 also confirmed that she was continent of bowel at home but has been incontinent of bowel since being in the facility. R4 stated she never had problems with continence before coming to the facility. On 8/6/24 at 9:34 AM, Surveyor observed R4 sitting in a wheelchair in her room, dressed in a nightgown. R4 expressed concerns to Surveyor that she had no clean clothes, that they were all in the laundry. R4 stated that she stays in her room because it makes her uncomfortable to be out in common areas with others while dressed in her nightgown. R4 indicated that staff tell her it is okay to wear her nightgown out of her room, but for her it is not okay. R4 told Surveyor that she eats in her room and won't go to activities without wearing regular clothes. R4 stated, I feel foolish sitting here in my nightgown. Surveyor observed that R4 had no clean clothes hanging in her closet except one sweater. R4 stated she has no clean clothes because she frequently soils herself. On 8/7/24 at 10:18 AM, Surveyor interviewed R4 who stated she had been at therapy earlier. Surveyor observed R4 to be dressed in clean clothes. R4 stated that she might go to activities now that she had clean clothes. R4 confirmed that not having clean clothes had been an ongoing issue since she was admitted to the facility. R4 stated that she feels much better today in her own clothes. R4 stated she doesn't feel like she has any dignity when forced to wear a nightgown. On 8/7/24 at 10:39 AM, Surveyor interviewed CNA I who stated she has never seen R4 come out of her room except to go to therapy. On 8/7/24 at 10:43 AM, Surveyor interviewed CNA F who stated that R4 stays mostly in her room but that she does come out for therapy. CNA F said that she offers to take R4 to the dining room for meals or to activities, but that R4 always refuses. CNA F stated that R4 told her that she is embarrassed to not have clothes to wear. R4's admission MDS with a target date of 7/18/24 indicates, in part: Section GG - Functional Abilities: Substantial/Maximum Assist - helper does more than half the effort for Toileting Hygiene. Toilet transfer - not attempted due to medical conditions or safety concerns. Section H - Bladder and Bowel: Urinary Toileting Program: Has a trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) been attempted on admission/entry or reentry or since urinary incontinence was noted in this facility? Code 0 is entered, meaning: No. Bowel Toileting Program: Is a toileting program currently being used to manage the resident's bowel incontinence? Code 0 is entered, meaning: No. Urinary Continence: Code 2 is entered, meaning: Frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). Bowel Continence: Code 2 is entered, meaning: Frequently incontinent (7 or more episodes of bowel incontinence, but at least one episode of continent voiding). R4's Care Plan contains no focus or goals related to toileting or incontinence. A Focus of Physical functioning deficit related to: Mobility impairment, Self-care impairment was initiated on 7/15/24. Goal: I will improve my current level of physical functioning was initiated on 7/15/24. Intervention: Toileting Extensive assistance of one with bed pan was initiated on 7/15/24. Of note: R4's Care Plan did not contain a focus, goal, or interventions related to incontinence or aims to improve or maintain bladder or bowel functioning. R4's Certified Nursing Assistant (CNA) Kardex printed 8/7/24 states in part: Elimination/Toileting. B&B Bladder Elimination . Of note: R4's CNA Kardex gives no indication of her continence status or the way in which she is to be toileted. On 8/6/24 at 9:23 AM, Surveyor interviewed R4 who stated that she is dependent upon staff for all Activities of Daily Living (ADLs). R4 stated that she cannot do things by herself. R4 stated she needs assistance with a mechanical lift and staff to get up to use the bathroom. R4 indicated that she is always incontinent, sitting in a wet brief and wet clothes because she sometimes has to wait 1-2 hours for assistance. R4 stated this happens every day. R4 stated it, Makes me feel degraded that I have to sit here an hour and half in my pee. I feel like nothing more than an animal. On 8/7/24 at 12:50 PM, Surveyor interviewed DOR L (Director of Rehabilitation) who confirmed that R4 was incontinent, and that they have encouraged her to do a two-hour toileting schedule, which would include sitting on the toilet every two hours even if she did not need to relieve herself at that moment. DOR L stated that the commode had been removed from R4's room because it was a bariatric commode and was needed for another resident who was larger. DOR L stated that R4 is able to get on and off the toilet with a mechanical lift and staff assistance and does not require a bedside commode. On 8/7/24 at 1:04 PM, Surveyor interviewed CNA J who stated that R4 has always been incontinent to her knowledge, and that R4 utilizes her call light for staff to change her, not use the commode or toilet. CNA J stated she was not aware of a toileting program for R4. On 8/7/24 at 1:22 PM, Surveyor interviewed RN/UM K (Registered Nurse/Unit Manager) who indicated that there is no bowel and bladder diary or training program for R4. On 8/7/24 at 2:38 PM, Surveyor interviewed CNA M who stated that R4 is always incontinent. CNA M stated she was unaware of a toileting program for R4. CNA M stated that she uses the CNA Kardex for information on how to care for the residents, including what their toileting needs are. CNA M indicated that there is a form in the nursing station, hanging on the wall, that states if a resident has a change in their toileting or transferring needs. On 8/7/24 at 2:43 PM, Surveyor interviewed RN N (Registered Nurse) who stated that whenever there is a change or therapy makes a new recommendation, it is indicated on a Rehab Recommendation to Nursing form and hung in the nursing station. RN N stated that therapy will also give a verbal report to nursing of any changes, who in turn gives a verbal report to the caregiver staff. RN N stated that it is his expectation that the CNAs check the forms to be apprised of any changes in resident status. RN N showed Surveyor an example of the Rehab Recommendation to Nursing form but confirmed that there was no such form in the nursing station for R4. On 8/7/24 at 2:46 PM, Surveyor interviewed DOR L, who stated that there was no written order or form completed for R4 to start a bladder training program, but that she had told R4 verbally. DOR L confirmed that the Rehab Recommendation to Nursing form is how changes in resident care are communicated to staff. Example 2: R2 was admitted to the facility on [DATE] with diagnoses that include, in part: Muscle Wasting and Atrophy, Morbid Obesity, Coronary Artery Disease, Cardiac Arrest, Retention of Urine, Unsteadiness of Feet, Need for Assistance with Personal Care. R2's admission Minimum Data Set (MDS) with a target date of 6/27/24, indicates, in part: Brief Interview of Mental Status (BIMS) of 15, indicating cognitively intact. R2's admission MDS with a target date of 6/27/24 indicates, in part: Section GG - Functional Abilities: Dependent - helper does all of the effort for Toileting Hygiene. Toilet transfer - not attempted due to medical conditions or safety concerns. Section H - Bladder and Bowel: Urinary Toileting Program: Has a trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) been attempted on admission/entry or reentry or since urinary incontinence was noted in this facility? Code 0 is entered, meaning: No. Bowel Toileting Program: Is a toileting program currently being used to manage the resident's bowel incontinence? Code 0 is entered, meaning: No. Urinary Continence: Code 9 is entered, meaning: Not rated, resident has a catheter, urinary ostomy, or no urine output for the past 7 days. Bowel Continence: Code 2 is entered, meaning: Frequently incontinent (7 or more episodes of bowel incontinence, but at least one episode of continent voiding). Of note, R2's indwelling foley catheter was discontinued on 7/2/24. R2's Care Plan contains no focus or goals related to toileting or incontinence. A Focus of Physical functioning deficit related to: Mobility impairment, Self-care impairment was initiated on 6/20/24. Goal: I will improve my current level of physical functioning was initiated on 6/20/24. Intervention: Toileting Dependent Assistance of two was initiated on 6/20/24. A Focus of Needs pain management and monitoring related to low back pain, advanced distention of urinary bladder was initiated on 6/20/24. Goal: Evaluate need for bowel management regimen was initiated on 6/20/24. A Focus of Urinary Tract Infection, potential or actual was initiated on 7/7/24. Intervention: Monitor bowel pattern and evaluate need for bowel management regimen was initiated on 7/7/24. A Focus of Alteration in elimination of bowel and bladder due to Indwelling Urinary Catheter was initiated on 6/20/24 and discontinued on 7/2/24. Goal: I will have a soft formed bowel movement at least every three days initiated on 6/20/24. Intervention: Monitor bowel status frequency initiated on 6/20/24. Of note: R2's Care Plan did not contain a focus, goal, or interventions related to incontinence or aims to improve or maintain bowel functioning. R2's CNA Kardex printed on 8/7/24 states in part: Elimination/Toileting. B&B Bladder Elimination .) Of note: R2's CNA Kardex gives no indication of his continence status or the way in which he is to be toileted. R2's elimination charting beginning on 7/9/24, indicates 60 continent voiding episodes and 24 incontinent episodes for bladder. R2's elimination charting, beginning on 7/9/24, indicates 9 continent episodes of bowel and 28 incontinent episodes for bowel. On 8/6/24 at 9:38 AM, Surveyor observed R2 in his room in his bed wearing a hospital gown, no brief, and entire groin area was exposed and covered in stool that appeared to be quite dry. R2 stated that he had pressed his call button at approximately 8:00 AM and no one had come in yet to assist him with getting cleaned up. R2 stated I've been sitting in my s**t for over an hour. At this point, R2 terminated the interview by telling Surveyor to find another resident to answer questions. R2 stated, I'm not in a good mood right now. I need to get out of this place. I will crawl home if I have to. On 8/7/24 at 1:01 PM, Surveyor interviewed CNA F who stated she didn't know if R2 was continent at admission and was not aware of any changes or decline in his continent status. On 8/7/24 at 1:22 PM, Surveyor interviewed RN/UM K who indicated that there is no bowel and bladder diary or training program for R2. On 8/7/24 at 2:38 PM, Surveyor interviewed CNA M who indicated that R2 was sometimes incontinent and sometimes continent. CNA M was unaware if this was a change of status since admission. On 8/7/24 at 3:12 PM, Surveyor interviewed DON B (Director of Nursing) who stated that bowel and bladder assessments are completed for residents upon admission, and if there is a noted change in resident continence, they will do a three-day bowel and bladder diary. DON B stated that the bowel and bladder diary will be completed for three days, then quarterly, and again with any change of condition that affects their continence status. DON B confirmed that a bowel and bladder diary had not been completed for R4 or R2. DON B stated that if a resident was incontinent, this should be indicated on their care plan with person-centered focus and interventions. DON B confirmed that R4 and R2 did not have a focus or interventions for incontinence. DON B stated that changes in continence status and toileting needs would be indicated on the CNA Kardex and communicated to staff with an alert on the POC (Point of Care) dashboard. DON B stated it was her expectation that the CNA Kardex would have detailed information on how the staff were to assist the residents with toileting. DON B confirmed that the CNA Kardex for R4 and R2 did not have any detailed information for bowel and bladder elimination. The facility failed to implement a robust care plan for residents, implement person-centered goals and interventions, and complete ongoing bowel and bladder assessments, which resulted in a failure to recognize and prevent resident's functional decline in continent status.

Based on interview and record review, the facility failed to protect a resident's right to be free from verbal/mental abuse by a Certified Nursing Assistant (CNA). This affected 1 of 4 residents (R1) reviewed for abuse. R1 had a verbal altercation with CNA C (Certified Nursing Assistant) which led CNA C to become angry and perseverate on the altercation. CNA C then wrote a letter to R1 telling him that she was going to kill him. The facility's failure to keep residents safe from verbal/mental abuse created a finding of Immediate Jeopardy that began on 5/26/24. The Administrator was informed of Immediate Jeopardy on 6/11/24 at 1:26 PM. The immediate jeopardy was removed and corrected on 5/27/24. This is being cited as past noncompliance. Evidenced by: The facility's policy titled Abuse, Neglect, and Exploitation dated 10/1/22, states in part It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Definitions: .Verbal Abuse means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability . R1 was admitted to the facility on [DATE] with diagnoses that include encephalopathy (a broad term for any brain disease that alters the brain function or structure), type 2 diabetes mellitus, hallucinations, and congestive heart failure (CHF; a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs). R1's most recent Minimum Data Set (MDS) dated [DATE] states that R1 had a Brief Interview of Mental Status (BIMS) of 10 out of 15 indicating that R1 has moderate cognitive impairment. R1's MDS also indicates that R1 is dependent on staff for transfers, toileting, and dressing. R1 is wheelchair bound. On 5/26/24, R1 had a verbal altercation with CNA C. R1 had yelled at CNA C for not closing his door. This led to CNA C becoming quite upset and repeatedly telling her co-workers about the incident. On 5/27/24, R1 found a note in his room that stated: [R1] don't f***ing swear at me about closing the door and if you ever yell and swear at me again I will f***ing kill you due to man like you who is mental retard due to causing drama for no reason and don't take order from man like you. I don't like you and I hope you drop dead someday. {sic} R1 showed the note to a CNA, who reported the note to the Licensed Practical Nurse (LPN), who then gave the note to the Director of Nursing (DON). On 5/27/24, the facility began an investigation. Witness statements are as follows: CNA D writes in part, On Sunday, May 26th, a CNA, [CNA C] approached me, very upset, stating that R1 cussed her out for not shutting his door. These are things that were said to me by CNA C throughout remainder of out PM (evening) shift. CNA C repeatedly (emphasis intended) told me the story. She said that he has ruined her happiness of the day and that she doesn't deserve it because she didn't do anything wrong. She repeatedly told me how angry she was, literally over and over. She said, no one will talk to me like that and that as long as she doesn't hit or shoot anyone, she will be ok. She said she was going to stand up for herself .I tried de-escalating her thoughts numerous times. I told her that I get cussed at sometimes too, and that it happens to everyone. She did not want to hear any of that. I could sense the anger was brewing .I said that we cannot allow ourselves to become reactive to behaviors. She then went back and literally repeated the entire story .Upon clock out time, downstairs by the time clock, CNA C was still carrying on about how R1 had ruined her night, the whole story, literally all over again .The nurse and I discussed her behaviors, and I clocked out and went to my car. Statement from LPN E was obtained by DON B via a telephone call is as follows, On Sunday night 5/6/24 CNA C got very angry and upset about R1 being mean and swearing at her. CNA C asked LPN E if she doesn't hit or swear at other residents, was there anything else she shouldn't do. LPN E told CNA C even the tone of voice can be a problem and not okay. CNA C got upset with LPN E. CNA C then went to CNA D and was talking about how R1 was swearing at her. Statement from CNA F states, On 5/26/24 when picking up supper trays, CNA C came to the nurse's station stating she didn't understand why R1 swore at her. He never swore at me before. He was swearing because I didn't close his door. She continued on about him swearing at her and was telling other staff member how he was swearing at her. She was still talking about when I left my shift at 8 PM. It is important to note that Surveyor called and left messages for CNA D and LPN E and has not received return calls. Statement from CNA G states in part, .I was walking through the hallway and resident called me over to help him and turn off the A/C (air conditioner), while I was leaving the room, he asked me who the manager was of this place and told me that someone hates me here he was in his wheelchair and pulled out the note from his dresser. So, I asked the [sic] from across the hall to help me and I handed her the note. Statement from LPN H states in part, [CNA] alerted writer that R1 had a letter in his room that was threatening resident. Writer went to resident's room and reported the letter to DON B immediately. Writer asked resident when he noticed the letter, resident stated after lunch, but it could have been before lunch. Resident stated the letter was in his chair on top of clothes next to his sink .Writer asked resident if there was any staff who he may have yelled at, or any staff who seemed upset, resident stated no, I yell at everyone to close my door and they always leave it open. Resident asked if there is any staff he does not get along with, resident stated no. Resident asked if there is any staff he does not like? Resident stated no. Resident stated, Surprisingly this weekend no one's been an issue. Resident asked if he feels scared for his safety. Resident stated No, I wish they would come see me, I have lived in scarier places in my life. It should be noted that R1 has a BIMS of 10, an activated healthcare power of attorney, and a diagnosis including encephalopathy. R1's response to the threatening letter is incongruent to how a reasonable person would respond to receiving a letter in their home that threatens to kill them and humiliates them, especially if the individual were dependent on others to provide daily care for them. A reasonable person would have extreme fear, anxiety, and feel humiliated by the threat and derogatory language used in the letter. Statement from CNA C on 5/27/24 states: 1. Not in my computer 2. Walked in hallway and went to his room to check on him and he was okay in bed. I turn around and I saw the letter on the chair and that's when I touched the paper, when I did however glance a little bit to know the first sentence was, I got scared and walk away from his room. 3. Later on, the PM shift is when other staff saw the letter on the chair and took it with them, to the nurse station to figure out who did the typing the letter about [R1] death wish. I did touch it again to see the whole story about the letter, but they saw it first in the nurse station first before I touch it again. 4. I never did type and print the letter. {sic} On 5/28/24, NHA A (Nursing Home Administrator) called the local police department. PO I (Police Officer) responded to the call. PO I's report states that he spoke with NHA A who suspected that CNA C wrote the letter, but at this time was unable to prove it and that CNA C quit when she was being questioned about leaving the note. PO I spoke with R1 who stated that he did not want a complaint and did not feel scared. R1 just wanted the information documented. NHA A reported that CNA C would not be hired back at the facility and currently lives in [city name]. On 5/29/24, NHA A requested that CNA C bring in her personal laptop so they could search it for any indication that she wrote the letter. CNA C complied and brought the computer to the facility. The Administrative Assistant looked through the computer and it appeared that it had been dry erased. Per the facility's investigation summary, the Administrative Assistant spoke with CNA C again, and eventually CNA C confessed to writing the letter. CNA C reported to the facility administration that she was having mental health issues. Statement from CNA C on 5/29/24 states: + Went to library in [city name] for typing the letter to make the point to him about him yelling at me about closing door and I got carry away with it and I'm very, very sorry about the whole situation about the incident. + I don't hate him, and we never argue either. His did yell at me by accident due to him having bad day. + I will never do that ever again. This is only incident that I dealt with only. + I wish nothing would happen to him at all. I'm so glad he is safe and sound. I don't think he is mean person. {sic} On 6/10/24 at 9:59 AM, Surveyor interviewed R1. Surveyor asked R1 about the letter he received, R1 reported that the letter said, I want to kill you and You should die. Surveyor asked R1 what he did once he found the letter, R1 stated that he gave it to someone in charge. R1 also reported to Surveyor that the police came and asked him some questions. Surveyor asked R1 how receiving the letter made him feel, R1 stated, I didn't give a s**t. I was a little worried because I'm in a wheelchair, if they wanted to kill me, they probably could. R1 reported to Surveyor that he feels safe and is not fearful of staff. On 6/10/24 at 1:28 PM, Surveyor interviewed NHA A. Surveyor asked NHA A if CNA C was terminated, NHA A stated that CNA C was suspended and required to seek treatment for her mental health issues prior to returning to work. On 6/10/24 at 3:36 PM, Surveyor interviewed PO I. Surveyor asked PO I about his investigation regarding the letter that R1 had received, PO I stated that he came to the facility and spoke with R1 and NHA A and at that point there was no proof that CNA C had written the letter, therefore there was nothing else he could do. Surveyor asked PO I what R1's response was to the letter, PO I stated that R1 reported that he was not scared, was not in fear, and was not intimidated by the letter. PO I reported that NHA A updated him that CNA C had confessed to writing the letter, but neither R1 nor the facility wanted to press charges. Surveyor asked PO I if a threat, like the one R1 had received, would be criminal in nature, PO I stated, with a victim, yes it would be. On 6/13/24 at 1:05 PM, Surveyor interviewed LPN H. Surveyor asked LPN H to recall the day she was made aware of the letter, LPN H stated that she was at the nurse's station and a CNA asked her if she had heard about the letter. LPN H stated that she had not and accompanied the CNA to R1's room, read the letter, and then immediately called DON B. LPN H stated that she questioned R1 about the note, if he felt safe, and if he knew where the note came from. Surveyor asked LPN H what time she was made aware of the note, LPN H stated that it was around 8:00 PM. Surveyor asked LPN H if she had worked with CNA C in the past, LPN H stated yes. Surveyor asked LPN H if CNA C had displayed behaviors in the past, LPN H stated never, and she was shocked when she found out that CNA C had written the letter. R1 is dependent on staff for all care. R1 received a letter threatening to kill him and used derogatory language toward R1. A reasonable person would have extreme fear and anxiety if they received a letter in their home stating a subject wanted to kill them and would be humiliated with the use of derogatory language. The facility's failure to prevent and protect residents from verbal/mental abuse created a reasonable likelihood for serious harm to occur and a finding of Immediate Jeopardy. The facility removed and corrected the immediate jeopardy on 5/27/24 when it completed the following: 1. Initiated immediate investigation. 2. Trauma assessment completed for R1 3. PHQ9 (Depression screening) assessment for R1. 4. Completed a new BIMS for R1. 5. Abuse Policy education to all staff. 6. R1's care plan was updated. 7. Placed R1 on 15-minute checks. 8. R1 was placed on the 24- hour board to monitor psychosocial well-being. 9. Interviewed residents and staff regarding abuse. 10. Complete skin checks on residents who were not able to be interviewed. 11. Suspended alleged employee. 12. Education to all staff to immediately notify management if they have a concern regarding staff burnout.

Based on observation, interview and record review, the facility did not ensure each resident receives adequate supervision to prevent accidents for 6 of 8 residents reviewed for smoking (R1, R3, R4, R8, R9, and R10) and to prevent accidents from accessing alcohol and drugs for 6 of 8 residents reviewed for substance abuse (R3, R4, R5, R6, R7, and R8). On 12/18/23, R1 was observed smoking cigarettes in his room. R1 was observed again on 12/28/23 smoking in his room while telling staff he was going to burn the building down. On 1/3/24, R1 was again observed smoking in his room with ashes and burn holes in his bedsheets observed. R8 was observed by staff to have an e-cigarette in his room on 1/3/24. R10 was observed smoking in his room on 2/10/24. Additionally, the facility was aware that Residents had history of substance use disorders (SUD) and did not put measures in place to address how they would prevent residents from obtaining drugs and alcohol related to their SUD. R8 admitted to continual use of marijuana and sold a vape pen with THC to another resident. R6 has a history of cocaine abuse and tested positive for fentanyl on 1/10/24 and THC on 1/26/24. R3 has a history of marijuana use and tested positive for Benzodiazepines. R7 has a known history of substance abuse. The facility did not put measures in place to minimize the opportunities or help prevent these Residents from using, obtaining and disseminating alcohol and illicit drugs. The facility's failure to ensure all staff follow proper safety interventions to prevent accidents created a finding of Immediate Jeopardy that began on 12/18/23. Surveyor notified the NHA A (Nursing Home Administrator) of the Immediate Jeopardy on 2/22/24 at 5:30 PM. The Immediate Jeopardy was removed on 2/23/24; however, the deficient practice continues at a scope/severity of a E (potential for more than minimal harm/pattern) as the facility continues to implement its action plan and as evidenced by R5 has a known history of alcohol abuse. The facility did not put measures in place to minimize the opportunities or help prevent R5 from using and obtaining alcohol. R4 and R9 were observed to be smoking independently with their smoking materials while smoking in an undesignated smoking area on 2/21/24. Findings include: The facility policy entitled Resident Smoking, dated 10/1/22, states, in part: . It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents. Policy Explanation and Compliance Guidelines: 1. Smoking is prohibited in all areas except the designated smoking area . 4. All residents and family members will be notified of this policy during the admission process, and as needed . 7. Electronic cigarettes (E cigarettes/vape/vapor pen) can catch on fire and/or explode if not handled and stored safely. Safety measures for the use of electronic cigarettes by residents will include, but are not limited to: a. Use of E cigarettes in designated smoking areas only. b. A safe smoking assessment will be completed on all residents using E cigarettes. c. Staff supervision of resident use if indicated . 8. Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas (weather permitting), at designated times, and in accordance with his/her care plan . 10. All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on each resident's care plan. 12. If a resident or family does not abide by the smoking policy or care plan (e.g., smoking materials are provided directly to the resident, smoking in non-smoking areas, does not wear protective gear), the plan of care may be revised to include additional safety measures. 13. Smoking materials of residents requiring supervision with smoking will be maintained by the nursing staff. 14. The interdisciplinary team, with the guidance from the physician, will help to support the resident's right to make an informed decision regarding smoking by: . d. Developing a safe smoking plan . 15. Documentation to support decision making will be included in the medical record, including but not limited to: .d. Compliance with smoking policy . The facility smoking times are 9:00 AM, 11:00 AM, 4:00 PM, 6:30 PM, and 8:00 PM and the designated smoking area is on the 300-wing patio (side of the building.) Facility policy, entitled Safety For Residents with Substance Use Disorder, dated 10/2022, includes: It is the policy of the facility to create an environment as free of accident hazards as possible for residents with a history of substance use disorder . Substance Use Disorder (SUD) defined as recurrent use of alcohol and/or drugs that causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home . Guidelines: Residents with a history of SUD will be assessed for risks including the potential to leave the facility without notification and use of illegal/prescription drugs. Care plan interventions will be implemented to include increased monitoring and supervision of the resident and their visitors. When substance use is suspected, in the facility or upon return from an absence from the facility which could lead to overdose, facility staff should implement the care plan interventions, which includes notification of the residents physician or non-physician practitioner. Care planning interventions will address risks by providing appropriate diversions for residents and encouraging residents to seek out facility staff to discuss their plan of care, including discharge planning, rather than leaving to seek out substances which could endanger the residents health and/or safety . Residents with SUD may try to continue using substances during their stay in the nursing home. Facility staff will assess the resident for the risk for substance use in the facility and have knowledge of signs and symptoms of possible substance that includes, but are not limited to: frequent leaves of absence with or without facility knowledge, odors, new needle marks, changes in resident behavior especially after interaction with visitors of absences from the facility, unexplained drowsiness, slurred speech, lack of coordination, mood changes . Example 1 R1 was admitted to the facility on [DATE] and had diagnoses that including schizophrenia and functional quadriplegia. R1's most recent Minimum Data Set (MDS), dated [DATE], includes a Brief Interview for Mental Status (BIMS) of 13, indicating R1 was cognitively intact. A Smoking and Safety assessment, dated 12/19/23, indicates R1 needs to be supervised when smoking due to: 1) Drops ashes on self, 2) Unable to hold tobacco/marijuana or vape products safely, 3) Unable to extinguish tobacco or marijuana safely and 4) Unable to use ashtray to extinguish tobacco or marijuana. R1's care plan states, Focus: .often has behaviors which include cursing, screaming and shouting .usually says he's upset about cigarettes .Interventions: Attempt interventions before my behaviors begin, Offer something I like as a diversion . R1's care plan does not indicate what interventions are or what he likes. R8 was admitted to the facility on [DATE]. His most recent MDS, dated [DATE], shows a BIMS score of 15, indicating he is cognitively intact. A Smoking and Safety assessment, dated 12/1/23, for R8 states, Follows the facility's policy on location and time of smoking and indicates R8 only uses tobacco products (not vapes). R9 was admitted to the facility on [DATE]. Her most recent MDS, dated [DATE], shows a BIMS score of 14, indicating R4 is cognitively intact. A Smoking and Safety assessment, dated 2/8/24, for R9 states, Follows the facility's policy on location and time of smoking. R10 was admitted to the facility on [DATE] and has diagnoses that include Chronic obstructive pulmonary disease (COPD). His most recent MDS, dated [DATE], shows a BIMS score of 14, indicating R10 is cognitively intact. A Smoking and Safety assessment, dated 6/13/23, for R10 states, Follows the facility's policy on location and time of smoking. Of note, R10 has a warrant from a neighboring county for Negligent handling of burning material. His care plan, dated 4/13/23, states, Smoking: .is a known smoker .has a history of hiding smoking materials in room and not telling staff .has been caught smoking in his room. The facility documented the following progress notes for R1: On 11/16/23 at 7:20 PM: Resident states he is in need of money and cigarettes. On 11/17/23 at 1:05 PM: Patient very upset this morning about wanting to smoke. Writer was told he had cigarettes but the patient does not have any cigarettes in the facility. Writer let patient know he does not have any cigarettes, Patient was yelling and very agitated and was attempting to get self up because he wants a cigarette. Writer got CNA's to assist patient with getting up safely into a wheelchair. Guardian called to see if someone is able to bring him cigarettes, voicemail left. On 11/18/23 at 1:55 PM: Resident requesting cigarettes and does not have any, resident continues to yell. On 11/20/23 at 7:20 PM: Resident is heard and seen in activity room/common area near other residents throwing side tables to the floor. The table nearly missed another resident in the room. Resident was screaming and calling out repeatedly, upsetting other residents in the area. Resident is upset that he cannot smoke cigarettes. On 11/20/2023 at 7:32 PM: Police arrived at facility and was able to deescalate resident. Resident's verbal tone has changed and voice was lowered toward officer. Officer told resident that it was inappropriate to be verbally or physically attacking staff and residents. Resident is in agreement with officer. Res states, I just want to go outside and smoke but they won't give me my cigarettes.Currently resident does not have cigarettes in the facility. On 11/22/2023 at 7:02 PM: Resident noted being belligerent with staff and other residents. Resident states that he will keep yelling until he gets a cigarette. Call out to Case-worker and Guardian. Continue to monitor. On 11/23/2023 at 8:07 PM: Resident noted screaming out. Resident states that he is going to scream until he gets a cigarette. On 11/27/2023 at 6:35 PM: Resident angry & screaming at staff because he wanted to smoke. Staff tried explaining to resident he would have to wait for special adaptive equipment to aid in smoking so that he doesn't burn himself d/t (do to) the current injuries he has on his hands. On 11/28/23 at 7:00 PM: Resident became verbally abusive during smoke break when he was notified that he had no cigarettes and peers weren't willing to share. Resident yelling and using foul language at staff and peers. On 11/28/23 at 7:11 PM: Note Text: Resident in common area. Other residents noted to be in the area, coming back in from smoke break. Resident started yelling and cussing, F*** you, give me my cigarettes. Resident was told that he did not have any cigarettes. Resident was redirected and was unsuccessful. Resident then became physically aggressive and moved the medicine cart from the area it was in. He grabbed the charging cords behind the nursing station and began to swing them around. Tipped over chair in area. He opened the refrigerator door and began to look for food. Resident is not allowed in this area and writer began to lock refrigerator door. Resident stated , Don't do that I want cheese.! Writer told him that he did not have any cheese. Resident began to hit writer in right arm, chest and back. Writer notified police who came out and assessed situation. Resident was told not be aggressive towards staff. DON (Director of Nursing), administrator aware. On 12/18/23 at 4:48 AM, the facility documented that R1 was smoking in his room, writing, Resident noted in room smoking. Resident verbally abusive to staff. Resident refused to have cares. The facility documented that they found a lighter at the time on R1's bedside table. The facility asked R1 where he got his smoking materials and who got them for him, to which R1 would not answer. R1 was then educated on the smoking policy and 6 staff members were asked if they were aware of who was passing out smoking materials, to which they all answered, No. These 6 staff members were then asked if they were familiar with the facility's smoking policy, to which they all answered, Yes. On 12/28/23 at 11:28 PM, the facility documented, Note Text: At beginning of shift, resident told CNA (Certified Nursing Assistant) that he was going to start a fire in his room. CNA took lighter and cigarette away from resident, and searched room for anymore lighters. None were found . The facility asked R1, again, where he had gotten his smoking materials to which R1 refused to answer. The facility again educated R1 on the smoking policy and then asked 4 staff members if they knew how and where R1 was getting smoking materials, to which the staff answered no. These staff members were asked if they knew the facility smoking policy, to which they replied, Yes. A summary of the incident, compiled by NHA A (Nursing Home Administrator) on 12/29/23 states, Resident is a supervised smoker. Resident is aware of facility policy. On 1/3/24 at 10:40 AM, the facility noted, CNA reports resident has ashes and cigarette in bed, with a burn hole in sheets. Per Assistant Administrator, to call police and report. Police here at 11:00 PM to speak to resident. As soon as police left. Resident stated that he didn't care if he gets a ticket and didn't care about rules and regulations within facility. The facility again confiscated R1's smoking materials and asked R1 where he got his smoking materials, to which R1 refused to answer. Facility staff asked R8, who was R1's roommate at the time, if R1 had cigarettes and R8 instructed the staff to look in R8's Bible where the staff found cigarettes and confiscated them. R8 denied supplying R1 cigarettes. The facility again educated R1 on the facility's smoking policy and asked the other smokers in the facility if they were giving R1 cigarettes or if they knew who was, to which the other residents denied knowing any information. The facility interviewed 3 staff members and asked them if they knew where R1 had gotten his cigarettes, to which they all responded, No. These 3 staff members were asked if they knew the facility smoking policy, to which they responded, Yes. R1 and R8 were separated after the event. Undated documentation indicates staff observed R8 on 1/3/24 smoking an e-cigarette in his room. Although no time is documented as to what time the incident occurred, the facility documents that R8's vape pen/e-cigarette was taken at the time it was observed and no other smoking materials were found in the room. An undated summary written by NHA A, states that R8 was educated on the smoking policy after this event. The facility conducted education on 1/10/24 with all staff regarding the facility's smoking policy, which included: *Designated smoking times and areas *Must be supervised at all times *Smoking material must be locked up in nurse's station. No resident should have any smoking material on them or in their rooms. The facility documented on 1/25/24, regarding R10, heard report from roommate and CNA that resident will smoke in room/bathroom at night. On 2/8/24, R10 was issued a behavior contract for smoking inside the building, reading, Consequences established for non-compliance with this behavioral contract will be at the discretion of the administrator. On 2/10/24, R10 was observed smoking in his bathroom. The facility contacted the police department, confiscated R10's smoking materials and questioned staff as to how R10 got the smoking materials and no staff was aware, nor did the resident have an answer. The resident was re-educated on the smoking policy. On 2/22/24 at 1:43 PM, Surveyor interviewed R10 who acknowledged that he had recently smoked in his room. R10 stated that he had kept his smoking materials on him when he had come in from smoking on a previous day and that nobody had asked for his cigarettes or lighter. Surveyors conducted the following interviews: *On 2/21/24 at 2:10 PM, CNA N (Certified Nursing Assistant) and CNA O stated that typically around 10 residents go out to smoke with 1 CNA and residents are allowed 2 cigarettes. CNA N stated that when she takes residents out, she usually gives each resident 1 or 2 cigarettes. CNA N also stated that CNAs are supposed to keep track of what they give out and retrieve any lighters and unsmoked cigarettes, but that doesn't always happen. CNA O stated that she will give 1 cigarette to a resident and if they smoke that one and want another, then she will give a second. CNA N stated that R1 would yell out all day until he was taken out to smoke and would often ask others for cigarettes, even though residents are not supposed to share cigarettes. *On 2/21/24 at 2:30 PM, CNA E stated that CNAs are supposed to light the cigarettes for residents during smoking times but some residents refuse and use their own lighters to light their cigarettes. CNA E also stated that R1 would yell throughout the entire day until he was able to go out and smoke a cigarette. *On 2/21/24 at 2:31 PM, CNA P stated that each resident is supposed to get 2 cigarettes when they go out to smoke and that CNAs are supposed to account for smoking materials when residents go out to smoke and when they come back in, but some residents refuse to give them up, including R4. *On 2/21/24 at 3:44 PM, CNA Q stated she was working on 2 occasions when R1 was smoking in his room. The first time (12/18/24), CNA Q stated she could see smoke in the room and there was a Styrofoam cup on R1's table that had some water and a cigarette butt in it. CNA Q stated the second time (1/3/24), she saw the cigarette butt smoking on the bedsheet at the foot of R1's bed and there were holes in the sheets around the cigarette. CNA Q stated that other residents keep their lighters and cigarettes in their rooms. CNA Q stated CNAs are supposed to make sure all smoking materials are returned, but she believes residents pocket their cigarettes before returning from smoke break. CNA N, CNA O, CNA E, CNA P, and CNA Q all stated that there is no guidance, method or specific form or procedure for accounting for residents' smoking materials once they have been given out, but they notify their nurse if they are aware of a resident refusing to give up their smoking materials. On 2/21/24 at 2:45 PM, Surveyor interviewed NHA A and DON B regarding the facility's smoking policy. DON B stated that only CNAs are to be lighting cigarettes. NHA A stated that he bought lighters for staff to use for residents and that residents are not to have lighters, but somehow they continue to get them. NHA A stated that staff tell him that residents are keeping their smoking supplies but he has no proof. NHA A stated it is his expectation that staff tell him every time residents are keeping their supplies but stated that is not happening. NHA A also stated that it is the facility's policy and his expectation that no residents have smoking materials in their room, smoking materials are locked up and CNAs gather whatever they give out to residents when they go out to smoke. The facility's smoking policy states that resident smoking materials will be maintained by nursing staff but does not detail how staff are supposed to account for smoking materials, how many cigarettes residents are allowed, or how smoking materials are audited to determine what has and has not been returned to safe storage. Example 2 R8 was admitted to the facility on [DATE]. His most recent Minimum Data Set (MDS), dated [DATE], shows a Brief Interview of Mental Status (BIMS) score of 15, indicating he is cognitively intact. R8 was discharged from a local hospital to the facility. Prior to his discharge to the facility, the hospital noted a recent urine drug screen to be positive for marijuana and amphetamines and noted polysubstance abuse. The facility documented the following progress notes for R8: *12/27/23 at 2:14 PM: Reports last use of amphetamines was in September. Denies cravings. *1/8/24 at 11:39 PM: CNA found a 750ml [milliliter] of [NAME] and 2 [two] 24 cans of beer near his room. *1/17/24 at 3:57 PM: Patient was positive for THC during drug screen. Also patient left the faciity on 2 separate occasions without notice and was gone for over 12 hours. *1/24/24: Patient admits to drinking alcohol to see if it would make him feel better. Patient also says he has been smoking weed. He does not disclose where he's getting it from, and does not deny that he is sharing it with other residents when asked. AS R (Anonymous Staff) and AS S stated to Surveyors on 2/22/24 at 12:26 PM that they had confiscated vapes/e-cigarettes from R8's room (exact date unknown). R8 signed a behavior contract with the facility, dated 1/16/24, stating he would follow facility rules for substance and alcohol abuse. On 1/23/24, R1 was found unresponsive in the facility's dining room. The facility sent R1 to the hospital where he tested positive for THC. The facility conducted an investigation and R8 admitted to selling R1 a Delta 8 vape. The facility was unable to provide any evidence that R8 was offered any support services to address his substance use history. In a local police report, dated 1/24/24, NHA A (Nursing Home Administrator) requested police presence at the facility and stated that he believed R8 was distributing drugs in the facility due to residents testing positive for THC, fentanyl, and Benzodiazepines. In the report, NHA A stated he did not have proof, but a feeling it was R8. On 2/21/24 at 11:20 AM, during an interview, Social Worker D (SW D) indicated R8 was not offered services related to his substance abuse history and he should have been. SW D indicated if R8 wanted services she wouldn't even know where to begin with arranging them as no one has ever instructed her regarding this. SW I indicated R8's care plan should have identified him to be at risk of substance abuse and it should have contained interventions like monitoring, how R8's impairment manifests, what triggers him, and what staff should do if they find R8 with illegal/illicit substances. Additionally, SW D stated the facility did not have a plan in place to monitor R8 to help in preventing him from obtaining drugs and alcohol. Example 3 R6 was admitted to the facility on [DATE] and has diagnoses that include anxiety, depression and quadriplegia. R6's most recent Minimum Data Set (MDS), dated [DATE], shows a Brief Interview for Mental Status (BIMS) score of 14, indicating R6 is cognitively intact. R6 was discharged from a local hospital to the facility. His discharge diagnoses include Polysubstance abuse, history of cocaine abuse and marijuana use. R6's care plan states, Focus: .has been intoxicated from alcohol and cannabis during stay here .has tested positive for fentanyl and THC on a drug screen .Interventions: Attempt interventions before my behaviors begin. R6's plan of care does not give details on what interventions may work for R6. Additionally, R6's care plan mentions that he has a history of substance use. The facility documented the following progress notes for R6: *11/15/23 at 7:45 AM: History of polysubstance abuse *11/16/23 at 3:50 AM: Resident stated that he was on oxycodone and tramadol while in the hospital and would like it back because he is going through withdrawals. *11/2423 at 2:56 PM: Cocaine abuse, in remission. Past history of cocaine use disorder. *12/28/23 at 1:37 PM: Resident had another ER visit on 12/27 related to hyperglycemia and intoxication On 1/10/24, the facility conducted a drug screen on R6, which came back positive for THC and fentanyl. On 1/22/24, R6 tested positive for THC (results returned 1/26/24). On 1/25/24, R6 signed a behavior contract with the facility in regard to sharing, giving, or selling of medication, illegal substances or alcohol in the facility or on the premises. According to facility documentation (internal email) dated 1/25/24 at 5:51 PM, right after signing the behavior contract, staff assisted resident with opening a package and inside the package were 2 vapes, 1 nicotine and the other a Delta 8. The package came from R6's brother. Additionally, the email mentions that R6 believed he tested positive for fentanyl due to a vape. On 2/21/24 at 11:20 AM during an interview SW D (Social Worker) indicated R6 was not offered services related to his substance abuse history and he should have been. SW D indicated if R6 wanted services she wouldn't even know where to begin with arranging them as no one has ever instructed her regarding this. SW I indicated R6's care plan should have identified him to be at risk of substance abuse and it should have contained interventions like monitoring, how R6's impairment manifests, what triggers him, and what staff should do if they find R6 with illegal/illicit substances. Additionally, SW D stated that the facility did not have a plan in place to help prevent any further drugs from being mailed or brought into the facility for R6. 41788 Example 4 R3 was admitted to the facility on [DATE], and has diagnoses that include alcohol abuse, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and paraplegia (paralysis of the legs and lower body, typically caused by spinal injury). R3's Admission Minimum Data Set (MDS) Assessment, dated 11/20/23, shows that R3 has a Brief Interview of Mental Status (BIMS) score of 15 indicating R3 is cognitively intact. R3's Smoking and Safety Assessment, dated 11/10/23, states, in part: AS_1. Smoking Safety Interaction 1. Smoking and Safety. 1.Supervision, designated smoking location, and smoking times are determined by facility policy. This evaluation will be utilized for the Resident's smoking care plan on admission and as indicated. 2. Which of the following products does the Resident use? Tobacco 3. Does the Resident display any of the following? Follows the facility's policy on location and time of smoking . AS_2. Care Planning 1. Care Planning 1. Smoking Care Planning- . Note: Nothing is checked under Smoking Care Planning, nor does this assessment indicate whether R3 is safe to smoke unsupervised or with supervision. R3's Care Plan initiated 11/10/23 does not include R3 smokes or smoking safety measures. R3's Certified Nursing Assistant (CNA) card, as of 2/21/24, does not include R3 smokes or smoking safety measures. On 2/21/24 at 2:35 PM, Surveyor interviewed DON B (Director of Nursing). DON B indicated smoking assessments are completed by the floor nurse admitting the resident. The assessment then gets entered into PCC (point click care) and then DON B or the MDS nurse enters the smoking care plan into the resident's medical record. Surveyor asked DON B for a resident who smokes would you expect a care plan in place regarding smoking. DON B indicated yes. Surveyor asked DON B for R3 is he care planned for smoking. DON B looked up R3's care plan and indicated no. Surveyor asked DON B if R3 should be care planned for smoking and DON B indicated yes. Example 5: R3 was admitted to the facility on [DATE], and has diagnoses that include alcohol abuse, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and paraplegia (paralysis of the legs and lower body, typically caused by spinal injury). R3's Admission Minimum Data Set (MDS) Assessment, dated 11/20/23, shows that R3 has a Brief Interview of Mental Status (BIMS) score of 15 indicating R3 is cognitively intact. R3's Care Plan initiated 12/15/23, states, in part: . Focus: Per care team, resident has a history of using marijuana and alcohol during stays at other facilities. Resident has had alcohol here per staff and tested positive for THC, and Benzos without prescription. Would not state how this occurred. Per care team, resident has history of aggression towards staff at previous placements. Signed Behavior Contract 2/2024 Date Initiated: 12/15/23. Goal: R3 will remain safe and not pose a safety risk to others during stay at (facility name). Date Initiated: 12/15/23 Revision on: 1/10/24 Target Date: 5/16/24. Interventions/Tasks: -Attempt interventions before behaviors begin. Date Initiated: 12/15/23 Revision on: 12/15/23. -Give me my medications as my doctor has ordered. Date Initiated: 12/15/23. -Make sure I am not in pain or uncomfortable. Date Initiated: 12/15/23. -Please refer me to my psychologist/psychiatrist as needed. Date Initiated: 12/15/23 . R3's NP progress note dated 1/26/24, 4:15 AM, states, in part: . Patient appeared dazed, confused, and did not make total sense. Did call nurse into the room who also felt patient was slightly off baseline. No reports of fever, chills, nausea, vomiting, diarrhea, constipation, shortness breath, chest pain. Patient eats meals fairly well but reports he does not sleep well. Reviewed facility EHR (Electronic Health Record), medication list, discussed care with facility staff. They will continue to monitor and update provider for any acute changes or concerns ***Follow-up*** Blood alcohol/drug screen . R3's progress note dated 1/27/24, at 7:15AM, states, Writer found Vape pen on Resident. NHA and DON notified. R3's Progress Note, dated 1/27/24, at 7:30 AM, states Urine sample obtained for drug screen. R3's Progress Note, dated 1/27/24, at 2:48 PM, states Lab results received positive for THC and Benzodiazepines. R3's Progress notes dated 1/27/24 through 2/20/24, when R3 discharged , there is no mention of any type of service offered to R3 for substance use. R3's Drug Screen, dated 1/27/24 shows THC- Positive and Benzodiazepines- Positive. On 2/21/24 at 11:57 AM, Surveyor interviewed SW D (Social Worker). SW D indicated services were not offered to R3. SW D indicated if she would have offered and R3 indicated wanting services SW D would not have known what to do or where to go with that. SW D indicated the facility could not provide transportation. SW D indicated she does not know the protocol if R3 did want services and in hindsight the facility did not fully address R3's SUD (substance use disorder). 38882 Example 6 R7 admitted to the facility on [DATE]. She has the following diagnoses: Major Depressive Disorder, Bipolar Disorder, Personal History of Other Mental and Behavioral Disorders, Generalized Anxiety Disorder, Sedative/Hypnotic or Anxiolytic Dependence, and substance abuse. R7's Hospital Discharge, dated 12/14/23, includes: . Diagnoses: substance abuse (CMP), history of heroin and cocaine- last use 12/5/19 . vaping use- daily . R7's Physician Ordersinclude, in part, Gabapentin for neuropathic pain, hydroxyzine for anxiety and itching, Lamotrigine for seizures, Lyrica/Pregabalin for pain (discontinued 1/16/24), Quetiapine Fumarate for Bipolar Disorder with psychotic features and Sertraline HCI for Depression. R7's Psych Consult, dated 1/19/24, includes: Patient is . being seen today for a psych follow up. She is observed sitting upright in her wheelchair in her room. She appears lethargic and asleep-she is slumped over in wheelchair with mouth hanging open. Writer said hello and knocked on door, patient seemed to startle. She is disoriented, does not know where she is or [TRUNCATED]

Based on observations, interviews, record reviews, and review of the facility's policy, the facility failed to assess the risk, advise of the risk and/or benefits, and obtain consent prior to use of bed rails with air mattresses for 8 residents (R23, R11, R16, R18, R19, R24, R25, and R28) on the skilled unit. R23's bed was equipped with an alternating air mattress as well as bed rails so she could assist with bed mobility. On [DATE], R23 was having a hard time breathing and wanted to get up. R23 was found entrapped between the bed rail and the air mattress. Facility staff were able to free her and began CPR (Cardio Pulmonary Resuscitation) which was unsuccessful. R11, R16, R18, R19, R24, R25, and R28 were also found to be using bed rails without a risk assessment, without being advised of the risks and benefits of the side rails, and without obtaining informed consent for their use. The failure to assess the risks of the side rail use with an alternating air mattress, advise the resident or their representative of the risks and benefits of the side rails as well as obtaining informed consent prior to the use created a finding of immediate jeopardy that began on [DATE]. NHA A (Nursing Home Administrator) and DON B (Director of Nursing) was notified of the immediate jeopardy on [DATE] at 9:25 a.m. The immediate jeopardy was removed on [DATE]. However, the deficient practice continues at a scope/severity of E (potential for more than minimal harm/pattern) as the facility continues to to implement its action plans. Findings include: The facility policy titled Proper Use of Bed Rails, dated [DATE], indicated: Policy: It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails. Definitions: Bed Rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. Also, some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed. Examples of bed rails include, but are not limited to side rails, bed side rails, safety rails, grab bars and assist bars. Entrapment is an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail . Policy Explanation and Compliance Guidelines: Resident Assessment 1. As part of the resident's comprehensive assessment, the following components will be considered when determining the resident's needs, and whether or not the use of bed rails meets those needs: a. Medical diagnosis, conditions, symptoms, and/or behavioral symptoms b. Size and weight c. Sleep habits d. Medication(s) e. Acute medical or surgical interventions f. Underlying medical conditions g. Existence of delirium h. Ability to toilet self safely i. Cognition j. Communication k. Mobility (in and out of bed) l. Risk of falling 2. The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs. 3. The resident assessment must also assess the resident's risk from using bed rails. Examples of the potential risks with the use of bed rails include: a. Accident hazards (e.g., falls, entrapment, and other injuries sustained from attempts to climb over, around, between, or through the rails, or over the footboard) b. Barrier to residents from safely getting out of bed c. Physical restraint (e.g., hinders residents from independently getting out of bed or performing routine activities) d. Decline in resident function, such as muscle functioning/balance e. Skin integrity issues f. Decline in other areas of activities of daily living such as using the bathroom, continence, eating, hydration, walking and mobility g. Other potential negative psychosocial outcomes such as an undignified self-image, altered self-esteem, feelings of isolation, or agitation/anxiety. 4. The resident assessment should assess the resident's risk of entrapment between the mattress and bed rail or in the bed rail itself Informed Consent 6. Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails. This information should be presented in an understandable manner, and consent given voluntarily, free from coercion. 7. The information that the facility should provide to the resident, or resident representative includes, but is not limited to: a. What assessed medical needs would be addressed by the use of bed rails; b. The resident's benefits from the use of bed rails and the likelihood of these benefits; c. The resident's risks from the use of bed rails and how these risks will be mitigated; and d. Alternatives attempted that failed to meet the resident's needs and alternatives considered but not attempted because they were considered to be inappropriate . Review of the blank Bed Rail Assessment provided by the facility revealed the assessment reviewed the following areas: 1. Information 1. Is the resident Non-Ambulatory? 2. Does the resident's level of consciousness fluctuate? 3. Does the resident have alteration in safety awareness due to cognitive decline? 4. Does the resident have history of falls? 5. Has the resident displayed poor bed mobility or difficulty moving to a sitting position on the side of the bed? 6. Does the resident have difficulty with balance or poor trunk control? 7. Does the resident have difficulty with postural hypertension? 8. Has the resident expressed a desire to have Side Rails/Assist Bar for safety and/or comfort? 9. Is the resident visually challenged? 2. Interventions . 2. Select all interventions that apply to this resident a. Lower the bed to the floor b. Provide restorative care to enhance abilities to safely stand and walk c. Provide frequent staff monitoring at night d. Provide assisted toileting for the resident at night e. Visual and verbal reminders to use the call bell f. Other 3. Side Rail Placement . 3. Side rail replacement recommendations a. None b. Left c. Right d. Bilateral 3a. Side Rail Placement: a. Side Rails/Assist Bar are indicated and serve as an enabler to promote independence b. The resident has expressed a desire to have Side Rails/Assist Bar c. Side Rails/Assist Bar are not indicated at this time This assessment did not address the risk associated with the use of side rails with an air mattress, include documentation of the advisement of the risks and benefits of having bed rails, or show that the resident or resident representative signed an informed consent for the use of bed rails. According to the US Food and Drug Administration's Recommendations for Consumers and Caregivers about Adult Portable Bed Rails, Use caution when using bed rails with a soft mattress as this may increase risk of entrapment between the mattress and bed rail. Be aware that gaps can be created by movement or compression of the mattress which may be caused by patient weight, patient movement or bed position, or by using a specialty mattress, such as an air mattress, mattress pad or waterbed. R23 was admitted to the facility on [DATE] with medical diagnoses that included cellulitis (infection of the tissues), type II diabetes, anxiety, chronic pain syndrome, muscle wasting, difficulty in walking, and unsteadiness on feet. R23 had an admission weight of 396.9 pounds and was able to transfer with a gait belt, walker, and assistance of one. Review of R23's EMR did not find a bed rail assessment in the record. Upon request, the facility provided Bed Rail Assessment, dated [DATE]. The assessment indicated R23 requested rails for positioning in bed and to assist with getting out of bed. R23 was ambulatory, did not have a fluctuating level of consciousness, no history of falls, did not display poor bed mobility or difficulty moving to a sitting position at the side of the bed, did not have difficulty with balance or poor trunk control, had no postural hypertension, and was not visually challenged. Based on this assessment a decision was made that bed rails were indicated to serve as an enabler to promote independence. This assessment did not include the risk of using bed rails with an air mattress or take into consideration the compression effect of R23's weight of 396.9 pounds causing increased size of gaps between the mattress and the bed rail. During an interview with a complainant on [DATE] at 10:48 AM, the surveyor was advised of a death in facility on [DATE] where a resident was entrapped by a side rail. R23's electronic medical record (EMR) included a Progress Note dated [DATE] at 3:39AM that stated, At approx [approximately] 0330 [3:30 AM] the body was taken by coroner [name]. [Medical Examiner name] was given all paperwork including progress notes from admission and statements . A second entry stated, Effective Date: [DATE] 02:15 [2:15 AM] Type: eMar - Shift Level Administration Note Text: At approx 0040 [12:40 AM] residents [sic] bathroom light came on. As I was going to the room; the CNA C [Certified Nursing Assistant] came to doorway requesting help. The resident had slowly slid out of bed while she was there. We got her head and arm out from between the bed and railing. She was face down and the CNA had placed pillows to protect her head. The resident was not breathing. Writer verbally called other nurse. Together we were able to roll her over and position her to begin CPR. While other nurse started compressions; writer called 911. Writer then took over compressions while other nurse retrieved the AED [automated external defibrillator] unit. Paramedics then arrived and took over. DON [Director of Nursing] notified, coroner notified, sister notified, Dr .notified. R23 was pronounced dead at the facility. During an interview on [DATE] at 1:32 PM, NP D (Nurse Practitioner) stated, I was aware of R23 expiring but did not know the circumstances. NP D continued, Last Thursday ([DATE]), NHA A (Nursing Home Administrator) requested I attend a reenactment of the death with the coroner. NP D stated the coroner did not show up; however, the reenactment was verbally walked through. NP D stated, T the CNA relayed that the resident wanted to get up due to difficulty breathing, the resident stood up and sat down 3 times; on the third sit down, the resident was put back in bed, but due to R23's weight, CNA C was unable to center her and the resident was angled in the bed. CNA C went to the bathroom to use the call light so staff knew she needed assistance now. When she returned to the bed, the resident had slid down with her lower body and abdomen on the floor and her head was lodged by the side rail. CNA C left the room to get help. When the LPN (Licensed Practical Nurse) and CNA C arrived they lifted the resident from between the rail and the mattress and laid her flat on the floor. CPR was started and EMS called. During an interview on [DATE] at 12:08 AM, CNA C stated R23 had been short of breath and unable to stand, sitting back down and doing deep breathing. During the last attempt to stand R23 sat then laid down on the bed, angled across the mattress, and CNA C was unable to straighten her. The resident was complaining she could not breathe and raised the head of the bed. CNA C had activated the room call light for assistance and went into the bathroom to use the emergency call light for assistance. As CNA C exited the bathroom, R23 slid down and rolled over as she slid out of bed, lodging her head in the rail. When asked to clarify, CNA C stated R23's head was between the mattress and rail. LPN E was interviewed on [DATE] at 12:27 AM and stated she was not the one that assisted CNA C to extricate R23 and by the time she got to the room R23 was non-responsive and blue, and CPR was started. On [DATE] at 6:00 PM, Surveyor along with NHA A and DON B measured R23's unoccupied bed with the air mattress and bed rails in place. The measurements revealed a gap at the end of the bed of 2.5 inches, at the foot of bed was a gap of 4 inches, a 2 inch gap at the left side rail, and a 2.75 inch gap at the right side rail. The air mattress on R23's bed was identified as the Protekt Aire 8000. Review of the facility provided air mattress manufacturer documentation titled, Proactive Medical Products Protekt Aire 8000 Operation Manual revealed that the manual did not address the use of bed rails with the air mattress. During an interview on [DATE] at 1:40 PM, NHA A stated an expectation that all rails would be assessed, risks and benefits advised, the rails are care planned, and an informed consent is obtained as the policy states. Observation of the skilled unit on [DATE] at 10:15 AM and review of the EMR Assessments tab for each of the following residents. Review of the bed rail assessments for these residents revealed the same assessment as described above was used. These bed rail assessments did not address the increased risk of entrapment with the use of bed rails with air mattresses. ~R11 had an air mattress with bed rails; the bed rail assessment was completed on [DATE] and [DATE]. ~R16 had an air mattress with bed rails; the bed rail assessment was completed on [DATE]. ~R18 had an air mattress with bed rails; the bed rail assessment was completed on [DATE]. ~R19 had an air mattress with bed rails; had an incomplete bed rail assessment started on [DATE]. ~R24 had an air mattress with bed rails; the bed rail assessment was completed on [DATE] and [DATE]. ~R25 had an air mattress with bed rails; the bed rail assessment was completed on [DATE]. ~R28 had an air mattress with bed rails; the bed rail assessment was completed on [DATE]. The failure to assess the risks of the side rail use with an alternating air mattress, advise the resident or their representative of the risks and benefits of the side rails as well as obtaining informed consent prior to the use created a finding of immediate jeopardy. The facility removed the jeopardy on [DATE] when it had completed the following: 1. Completed a house wide sweep to ensure all resident with siderails and air mattresses had assessments, orders, care plans, and risk/benefits in place; 2. Completed gap assessments to ensure the gap was not greater than 2.5 inches; 3. Licensed nurses and therapy staff were educated on entrapment risks for residents using air mattresses or residents with increased movement or cognitive impairment. All staff to be educated prior to beginning their next scheduled shift. 4. Educated maintenance staff on performing gap assessments. Education provided before the next scheduled shift. 5. DON or designee will audit 5 residents weekly for 6 weeks to ensure the process is following with the initiation of side rails including risk/benefits, orders, alternative interventions tried/failed, care plans, and gap assessments. Result of the audits will be reported to QAPI (Quality Assurance Program Improvement) for further direction.

Based on staff interview, family interview and record review, the facility did not ensure 1 Resident (R) of 8 sampled residents (R1) was monitored after an episode of [CONDITION(S)] (low blood sugar) in accordance with professional standards of practice. R1 had an episode of [CONDITION(S)] on [DATE] and was sent to the ED (Emergency Department) for evaluation. The ED sent R1 back to the facility at approximately 10:00 PM. Facility staff did not assess R1's blood sugar on return to the facility from the ED, facility staff did not assess need for, ensure availability of, or document/monitor R1's food consumption after return from the ED or during the course of the night. Facility staff did not assess R1's blood sugar throughout the night until R1 developed signs/symptoms again of [CONDITION(S)] the morning of [DATE]. R1 was again sent to the ED, was hospitalized and expired at the hospital on [DATE]. Facility failure to assess R1's blood sugar on return from the ED; assess need for, ensure availability of, or document/monitor R1's food consumption on return from the ED or during the night; and not determine the need to assess R1's blood sugar during the night until signs/symptoms of [CONDITION(S)] occurred created a finding of Immediate Jeopardy (IJ) that began on [DATE]. NHA (Nursing Home Administrator)-A was notified of the IJ on [DATE] at 11:55 AM. The IJ was removed on [DATE], however the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: The facility [CONDITION(S)] policy, dated [DATE], indicated it is facility policy to ensure effective management of a resident who experiences a hypoglycemic episode. [CONDITION(S)] is a condition in which a person's blood sugar (glucose) level is lower than normal. [CONDITION(S)] is a condition that is typically related to diabetes treatment. Effective management of [CONDITION(S)] is important to ensure that the resident does not have further decline in their condition. The facility will identify residents that are at risk for [CONDITION(S)] and observe them for signs and symptoms of low blood glucose. Nursing will continue to follow up and observe for any further hypoglycemic episodes post treatment and notify the practitioner of any changes. The facility change of condition policy with an implemented date of [DATE], indicated follow up documentation in Point Click Care will occur every shift for 72 hours post resolution of symptoms. Include conversation with primary care provider, orders received and resident's response. The Mayo Clinic article which can be located at https://www.mayoclinic.org/diseases-conditions/[CONDITION(S)]/symptoms-causes/syc- 685 and entitled [CONDITION(S)] stated, [CONDITION(S)] is a condition in which your blood sugar (glucose) level is lower than normal. Glucose is your body's main energy source. [CONDITION(S)] needs immediate treatment when blood sugar levels are low. For many people, a fasting blood sugar of 70 milligrams per deciliter (mg/dL), or below should serve as an alert for [CONDITION(S)]. [CONDITION(S)] usually occurs when you haven't eaten. If blood sugar levels become too low, signs and symptoms can include an irregular or fast heartbeat, fatigue, pale skin, shakiness, anxiety, sweating, hunger, irritability, and tingling or numbness of the lips, tongue or cheek. Untreated [CONDITION(S)] can lead to confusion, abnormal behaviors or both, blurred vision, seizures, loss of consciousness, and death. Treatment involves quickly getting your blood sugar back to normal either with high-sugar foods, drinks or with medications. Once your blood sugar is normal, eating a snack or meal can help stabilize it and replenish your body's glycogen stores. [CONDITION(S)] is considered severe if you need help from someone to recover. For example, if you can't eat, you might need a [MEDICATION(S)] injection or intravenous glucose. The CDC (Centers for Disease Control and Prevention) article which can be located at https://www.cdc.gov/diabetes/basics/low-blood-sugar-treatment.html and entitled How To Treat Low Blood Sugar ([CONDITION(S)]) with a page last updated date of [DATE] stated, blood sugar below 55 mg/dL is considered severely low. Injectable [MEDICATION(S)] is the best way to treat severely low blood sugar. After you have low blood sugar, your early symptoms for low blood sugar are less noticeable for 48 to 72 hours. Be sure to check your blood sugar more often to keep it from getting too low again 1. On [DATE], the Surveyor reviewed the closed medical record of R1. R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's admission MDS (Minimum Data Set), dated [DATE], indicated R1's cognition was 13 out of 15 (the higher the score, the more cognizant). R1 required extensive assistance from staff for bed mobility and eating. R1 was dependent on staff for transfer and did not ambulate. R1 received insulin seven out of seven days and went to [CONDITION(S)]. R1's plan of care with a closed date of [DATE] and print date of [DATE], indicated R1 had a plan of care for unstable blood glucose levels which was initiated on [DATE]. The goal, which was initiated on [DATE] and revised on [DATE], indicated R1's blood glucose level will be within desired range. Interventions initiated on [DATE] indicated staff would administer medications as prescribed. R1 had a plan of care for a nutrition problem related to [CONDITION(S)] on [CONDITION(S)] three times weekly, numerous medical diagnoses, pressure injury to coccyx, and elevated A1C (a blood test that measures average blood sugar levels over the past three months) initiated on [DATE]. The goal, which was initiated on [DATE] and revised on [DATE], indicated R1 would maintain adequate nutritional status by maintaining weight, no signs of malnutrition, and consuming at least 75 percent of at least three meals daily. The interventions, initiated on [DATE], indicated staff were to encourage adequate fluid and meal intake, monitor/document/report to physician as needed for refusing to eat as R1 appears concerned during meals. R1 had a plan of care for behavior management regarding new refusal of care that was initiated on [DATE]: R1 refuses cares from staff. R1 likes to only wear gown and comes out of room dressed inappropriately. R1 refuses to wear clothing as R1 prefers gown. The goals, which were initiated on [DATE] and revised on [DATE], indicated R1 will remain safe, undesirable behaviors will be monitored/managed, and R1's risk for depression will be evaluated. The interventions, initiated on [DATE], indicated staff were to attempt an alternate time to provide care refused per R1's preference, educate R1 on the necessity of care attempted to provide, encourage participation in self-calming behaviors such as breathing exercises, and to ensure the safety of R1 and others. R1's weights and vitals summary documentation, indicated R1 had a blood sugar of 149 taken on [DATE] with time documented as 8:03 AM. At 12:11 PM, R1's blood sugar was 99. At 12:12 PM, R1's blood sugar of 99 was documented again. At 4:39 PM, R1's blood sugar was 46. There were not any other blood sugars documented on the weights and vitals summary for [DATE]. R1's progress notes dated [DATE] at 5:02 PM indicated R1 had a change of condition with a low blood sugar of 46. R1 feels scared and unstable. Snacks, orange juice and candy were given. The NP (Nurse Practitioner) was notified and ordered an injection of [MEDICATION(S)]. The [MEDICATION(S)] was administered to R1 and R1's blood sugar was taken again. R1's blood sugar was 41. The Physician was notified and ordered an injection of [MEDICATION(S)]. R1's blood sugar was taken again. R1's blood sugar was 60. R1 requested to go to the ED. The facility called 911 and R1 was transferred to the hospital. An INTERACT SBAR Communication Form and Progress Notes for Nurses was completed on [DATE]. The situation indicated the change in condition was worse because blood sugars continued to be unstable; rising after [MEDICATION(S)] and dropping shortly after. R1's mental status evaluation indicated R1 had other symptoms or signs of [CONDITION(S)]. Functional status evaluation was checked other, but no signs or symptoms were described. Behavioral, respiratory, cardiovascular, abdominal, urinary, skin, pain, and neurological evaluations were all checked as not clinically applicable to the change in condition being reported. The summary of observations and evaluation indicated R1 had low blood sugar of 46. R1 felt scared and unstable. Snacks, orange juice and candy as given. NP ordered [MEDICATION(S)] injection. Administered. At 5:20 PM, blood sugars are now 41. Called physician and had another one (1) mg (milligram) of [MEDICATION(S)] ordered. At 6:35 PM, R1's blood sugar is 60. R1 is asking to go to the ED. Facility called 911 and R1 was transferred. PCP (Primary Care Physician) notified at 5:00 PM. Recommendation of PCP was blood sugars are still low. Give another 1 mg [MEDICATION(S)]. on [DATE] at 7:00 PM, the facility notified R1's FM (Family Member)-C. On [DATE] at 5:33 PM per EMS (Emergency Medical Service) final report, EMS took R1's blood sugar. R1's blood sugar was 104. R1 was transported to the hospital. At 6:34 PM, R1's blood sugar/bedside glucose was taken at the hospital and was 119. At 7:01 PM, R1's glucose level was taken at the hospital with other lab work and was 111. At 8:25 PM, R1's blood sugar/blood glucose was taken again at the hospital and was 96. R1's blood chemistry, indicated R1 had a BNP (B-type natriuretic peptide) test completed. The results of the BNP were 3082. The WNL (within normal limits) range for the BNP test is 10 to 500. According to the University of Rochester Medical Center with a date of 2021 and found at https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=167&contentid=bnp_blood, indicated the BNP test looks for the hormone in your blood to diagnose heart failure, plan treatment, see how well treatment is working, and when it is safe for you to leave the hospital. Other things besides heart failure can cause your BNP to rise including kidney failure or being on [CONDITION(S)]. R1 had a chest x-ray taken at the hospital. The findings of the x-ray reflected a mild degree of congestive heart failure or fluid overload. There is a left pleural effusion with bibasilar atelectasis or infiltrate. R1 was discharged from the ED with a primary impression of diabetes mellitus with [CONDITION(S)] and an additional impression of volume overload [CONDITION(S)] on [CONDITION(S)]. R1 was counseled regarding lab and x-ray results, treatment, diagnosis, and need for follow-up. Continue all current medications as prescribed and be sure to get to [CONDITION(S)] tomorrow as scheduled. R1 was transported back to the facility. R1's progress notes dated [DATE] at 6:55 PM, indicated the facility spoke with R1's FM-C and FM-C was able to give consent to hold R1's bed. There were not any other progress notes in R1's medical record for [DATE]. Additionally, there were not any other INTERACT SBAR Communication Form and Progress Notes for Nurses after the first communication form was filled out when R1 was sent to the ED on [DATE] for low blood sugars. R1's weight and vitals summary dated [DATE] at 10:06 PM, indicated R1's blood pressure on return from the ED was ,d+[DATE], Oxygen sat was 100 percent with oxygen via nasal cannula, pain level was zero, pulse was 58, respirations were 20, and temperature was 97.1 degrees F (Fahrenheit). A blood sugar was not documented as taken on return from the ED or during the night. There was not documentation R1 was offered or provided with food on return from the ED or during the night. There was not any documentation if R1 had signs/symptoms of [CONDITION(S)] on R1's return from the ED or during the night. The ED report from [DATE] provided to the Surveyor by the facility on [DATE] was faxed from the medical center on [DATE] to the facility. R1's progress note INTERACT SBAR summary for providers, dated [DATE] at 6:17 AM, indicated R1's blood sugar was 35. Recommendation: sent to ED via 911. Out of [MEDICATION(S)], called 911. R1's progress note, general note, dated [DATE] at 6:31 AM, indicated R1 was heard yelling out. R1 was witnessed thrashing head around the bed, legs hanging out of bed, incoherent, would not respond to verbal stimuli, and was taking off oxygen nasal cannula. R1 felt very sweaty and cold. Took blood sugar. Blood sugar was 35. Called 911. No [MEDICATION(S)] in facility to treat. Sent to hospital via ambulance. Family member notified and physician updated. A narrative from EMS with a date and time notified of 5:46 AM, indicated EMS was dispatched to the facility for R1 who was discharged earlier in the night ([DATE]) from the hospital for diabetic issues, is now having low blood sugar and is unresponsive. At 5:53 AM, upon EMS arrival to R1's room, EMS noted R1 was awake and flailing arms around. Problem with R1 was observed by the facility approximately 20 minutes prior to EMS activation. The facility reports they are out of [MEDICATION(S)] within the entire facility. In the ambulance, R1's blood sugar was taken and was 20. 6:07 AM, R1 was administered 25 grams of Dextrose 50% injectable solution with unchanged response. After administration of the Dextrose, R1 had become unresponsive. R1 had palpable pulses, however R1's breathing appeared to be shallow and less frequent. Ventilations were administered with high flow oxygen while R1 was being placed onto cardiac monitor. At 6:09 AM, R1 was administered one (1) mg of [MEDICATION(S)] with unchanged response. At 6:10 AM at the ED bay doors, R1 lost pulses and compressions were started. R1 was removed from the ambulance and moved into room [ROOM NUMBER] of the ED. The ED/hospital assessment/plan, dated [DATE] with an electronically time signed at 2:41 PM, indicated R1 had witnessed asystole cardiac arrest secondary to [CONDITION(S)] that was present on admission and received 20 - 30 minutes of advanced cardiac life support. A summary from the ED/hospital, dated [DATE] with an electronically time signed at 3:57 PM, indicated R1 arrived to the ED in asystole and had no pulse. R1 was not breathing on own. Called three hospitals to transfer R1, but none of the hospitals had an acute ICU (intensive care unit) bed open. Clinical impression was [CONDITION(S)]. Primary impression was cardiac arrest and additional impression was [CONDITION(S)]. R1 was transferred to an ICU bed at another hospital on [DATE] with impressions of status post [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 subsequently expired at the hospital on [DATE]. On [DATE] at 10:59 AM, the Surveyor interviewed R1's FM-C via telephone. FM-C stated R1 was hypoglycemic for too long and that was what caused the cardiac arrest. R1 should have been sent to the ED sooner than R1 was sent. On [DATE] at 4:01 AM, R1 texted FM-C to let FM-C know R1 was okay after being at the ED on [DATE]. On [DATE] at 5:30 AM, R1 called FM-C. FM-C had a hard time understanding R1 as R1 sounded like R1 was choking and having a hard time breathing. The only thing FM-C understood was when R1 stated R1 would call FM-C back. On [DATE] at 1:49 PM, the Surveyor interviewed DON (Director of Nursing)-B regarding R1. DON-B verified R1 was at the ED on [DATE] for an episode of [CONDITION(S)] after exhausting the supply of two [MEDICATION(S)] emergency kits the facility has to use for episodes of [CONDITION(S)]. After this incident, the supply of [MEDICATION(S)] was increased from two to three [MEDICATION(S)] emergency kits. On [DATE] at 6:16 PM, the Surveyor interviewed PS (Pharmacy Supervisor)-H regarding how many [MEDICATION(S)] emergency kits the facility has to use for episodes of [CONDITION(S)]. PS-H stated the facility has two [MEDICATION(S)] emergency kits available for use that was the same number of [MEDICATION(S)] kits available in [DATE]. On [DATE] at 4:52 PM, the Surveyor interviewed CNA (Certified Nursing Assistant)-E via telephone regarding R1. CNA-E verified CNA-E was one of three CNAs working the night shift when R1 returned from the ED on [DATE] to the end of night shift on [DATE]. CNA-E stated CNA-E was not asked to observe, offer R1 food or bring R1 food on the night shift because R1 was super busy on another wing. CNA-C confirmed CNA-C did not see R1 during the entire shift worked. On [DATE] at 4:57 PM, the Surveyor interviewed CNA-F via telephone regarding R1. CNA-F verified CNA-F was working the night shift when R1 returned from the ED on [DATE] to the end of the night shift on [DATE]. CNA-F stated R1 was, pretty much sleeping/resting all night. CNA-F peeked in on R1 every so often and while checking on R1's roommate. CNA-F stated CNA-F, doesn't think (CNA-F) brought (R1) anything to eat. Didn't see (R1) eating. This happened a long time ago. On [DATE] at 5:01 PM, the Surveyor interviewed LPN (Licensed Practical Nurse)-D via telephone regarding R1. LPN-D stated LPN-D was working the night shift when R1 returned from the ED on [DATE] until sending R1 out of the facility for a low blood sugar the morning of [DATE]. LPN-D stated R1 was in bed for the night shift watching television and on the telephone. The CNAs tried to clean R1 up, but R1 refused. LPN-D stated LPN-D did not take R1's blood sugar all night and thinks R1 was munching on things because R1 had food in R1's room. LPN-D then stated LPN-D did not offer or give R1 any food when working the night shift, but again, thinks (LPN-D) saw (R1) munching. LPN-D stated LPN-I readmitted R1 to the facility on [DATE] probably around shift change. LPN-I was working the PM shift. LPN-I advised LPN-D that R1's blood sugar was in the 90's at the ED and LPN-I told the ED that the ED, should not be sending (R1) back because they didn't have any [MEDICATION(S)] at the facility and, it made (LPN-I) nervous they were sending (R1) back to the facility. LPN-D confirmed R1 was lethargic, tired, alert, and did not have any new orders when returning from the ED at PM to night shift on [DATE]. On [DATE] at 8:07 PM, the Surveyor interviewed CNA-G regarding working with R1 on the night shift of [DATE] to the morning of [DATE]. CNA-G verified CNA-G was one of three CNAs working. CNA-G stated CNA-G did not offer R1 food, provide R1 with food, did not see R1 eating food, and had not ever worked with R1 as CNA-G worked on a different wing of the facility with CNA-E. The failure to assess R1's blood sugar on return from the ED, assess the need for, document/monitor or ensure availability/comsumption of food for R1 on return from the ED or during the night, and not assess the need to check R1's blood sugar during the night until signs/symptoms of [CONDITION(S)] occurred created a finding of Immediate Jeopardy (IJ). State Agency Note: On [DATE] the facility submitted additional information to the State Agency regarding the events noted in the citation above. Details in this additional information differed from statements that were obtained from staff during the on-site investigation. The State Agency reviewed all additional material submitted by the facility and asserts that the real-time information provided to surveyors during the on-site survey justifies the issuance of the citation at the scope/severity of J. The facility removed the jeopardy on [DATE], when it completed the following: Reviewed all residents with same/similar diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Education immediately initiated for nursing staff regarding changes of condition assessment and documentation. Assessment education included vital signs and assessment of affected system- including blood sugar checks and [CONDITION(S)] and documentation of said assessment. The [CONDITION(S)] management policy was reviewed and revised using AMDA clinical practice guidelines Diabetes Management in the Post-Acute and Long-Term Care Setting 2015. An Ad-Hoc QAPI meeting was held [DATE] to discuss removal plan A performance improvement plan was initiated with a focus on change of condition assessment and documentation related to change of condition policy. The DON will monitor compliance with the completion of the education. DON or designee will monitor all documentation (progress notes, user defined assessments, 24-hour boards and blood sugar documentation) as well as clinical rounding daily for change of condition and follow up assessments and documentation related to hypoglycemic events for 2 weeks. The DON or designee will complete chart audits for change of condition documentation and follow up documentation: 3 residents weekly for 2 weeks, two residents weekly for 2 weeks, two residents a month for 2 months and ongoing as needed or directed by QAPI. The Regional Director of Clinic Operations will visit the facility at least weekly for six weeks to provide general oversight and monitoring of the PIP. All results will be reported to QAPI team on a regular basis.

Based on interview and record review, the facility did not provide care and treatment in accordance with professional standards of practice related to assessment and monitoring for change in condition for 1 resident (R1) of 4 residents reviewed for change of condition of a total of 10 sampled residents. On [DATE] at 6:45 AM, when R1 presented with a significant change in mental and physical status. the facility failed to immediately complete a full nursing assessment of R1's condition, or consult with a physician, which delayed R1 in receiving needed emergency medical services. R1 was later transferred to the emergency room for change in mental status and subsequently died on [DATE]. The facility's failure to assess R1 when R1 was noted to be experiencing a change in condition, exhibiting symptoms of new onset of mental status changes and inability to respond, created a finding of IJ (Immediate Jeopardy) beginning on [DATE]. On [DATE] at 2:30 PM, NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were informed of the IJ. The facility removed the jeopardy on [DATE]. The deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. This is evidenced by: Upon request, the facility was not able to provide a policy for completing an RN (Registered Nurse) assessment of residents with change of condition. The facility stated they follow INTERACT 4.0 tools for change of condition. INTERACT 4.0 Care Path for symptoms of Acute Mental Status Change updated ,[DATE], states in part: New Mental Status Change . New symptoms or signs of increased confusion (e.g. disorientation, change in speech), Decreased level of consciousness (sleepy, lethargic), Inability to perform usual activities (due to mental status changes) . unresponsiveness. This Care Path includes guidance to: Take vital signs (Temperature, BP (Blood Pressure), pulse, Respirations, Oxygen saturation and to notify the MD (Medical Doctor) if any Vital Sign Criteria is met, including . Oxygen saturation below 90 percent .Resident unable to eat or drink . Findings: R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1 was reviewed as a closed record. R1's MDS (Minimum Data Set) quarterly assessment dated [DATE] noted R1 BIMS (Brief Interview for Mental Status) score of 3 of 15 indicating severe cognitive impairment. Section G of the MDS notes R1 was independent in ambulation. Review of R1's Progress Notes for [DATE] notes documented entry: Late Entry at 10:15 AM, CNA informed writer that res (resident) was not acting like her normal self. Upon assessment, res appeared sleepy, not able to respond verbally, and not able to follow commands. Vitals were obtained. MD was notified about residents change in condition and instructed writer to send res to ER. Ambulance arrived around 10:00. This entry was signed by LPN E. Of note: there is no documentation of any data gathered (e.g. vital sign, responsiveness) of R1's status change when it was reported to LPN E at 6:45 AM. Additionally, there is no documentation of an RN assessment for R1's significant change of condition on [DATE]. On [DATE] at 10:00 AM R1's vital signs were documented: Temperature- 97.3, BP: ,[DATE], Pulse: 99, Respirations: 14, Oxygen saturation: 88%. Review of EMS report for R1 dated [DATE], notes that EMS was notified at 10:11 AM and arrived at facility at 10:17 AM for R1's condition of altered mental status, duration 3 hours. R1's vital signs per EMS at 10:37 AM were BP ,[DATE], P90, R16 and oxygen sturation 90%. Review of R1's hospital record notes in part: On [DATE], R1 presented in the emergency room with altered mental status changes and unable to ambulate which was not normal for R1. R1's oxygen saturation was 73% on room air. It was noted that R1's drug screen was positive for opioids and R1 had no orders for opioids. R1 had hypoventilation and pinpoint pupils and [MEDICATION NAME] was given for possible opioid ingestion, which R1 responded to, but R1's condition continued to decline. R1 was placed on comfort care on [DATE] in the hospital and R1 expired on [DATE]. R1's hospital Discharge Summary notes includes in part, final Diagnoses: [REDACTED]. Of note it is unclear at this time, if R1 had an opioid overdose. The facility investigated and completed a self -report incident and was unable to determine how or if R1 received opioids. Subsequent lab orders were inconclusive. On [DATE] at 10:35 AM, Surveyor interviewed CNA C (Certified Nursing Assistant) about R1. CNA C stated on [DATE] at 6:45 AM, CNA C went to complete R1's morning cares noting R1 was groggy, like she was drunk, R1 would open her eyes and say yeah but did not wake up. CNA C stated R1 could not suck on a straw. CNA C explained R1 was usually was alert and after staff got R1 ready for the day R1 was able to ambulate independently. CNA C stated she notified LPN E (Licensed Practical Nurse) of R1's changes right away, and said LPN E took R1's vital signs. CNA C said LPN E stated she did not know how to send someone out and was going to check with LPN G. CNA C stated she checked on R1 about every ,[DATE] minutes that morning and R1 stayed the same not really responding much. CNA C stated RN D (Registered Nurse) came to check on R1 about 9:30 AM. On [DATE] at 11:44 AM Surveyor interviewed LPN E on the phone about R1's change in condition on [DATE]. LPN E stated CNA C had reported to her at about 6:45 AM that R1 was acting different. LPN E stated she took R1's vital signs. LPN E stated she was not 100 percent sure if R1 needed to go out to the hospital and wasn't familiar with the process of how to send residents out to the hospital. LPN E stated she went to talk to LPN G who was working on another unit. LPN G texted DON B, who said RN D was coming into the facility and to have RN D assess R1. LPN E stated she continued to check on R1, took R1's vital signs, and monitored R1. LPN E stated all R1 said was yeah which was not normal for her. LPN E stated she held R1's medication that morning as she didn't feel comfortable attempting to give her medication. Later Surveyor asked LPN E about the one set of vital signs recorded for R1 on [DATE] at 10:00 AM. LPN E could not explain why she had not documented the vital signs she had taken for R1 before 10:00 AM. Of note, an LPN by law and training cannot assess. On [DATE] at 11:20 AM, Surveyor interviewed LPN G about R1's change of condition on [DATE]. LPN G stated that LPN E came down to her unit at 7:45 AM reporting R1 was not acting herself and moving around like she was drunk. LPN G said she asked LPN E if R1 needed to be sent to the hospital, LPN E said R1 seems better, and it did not seem urgent. Surveyor ask LPN G if she had gone to see R1, she stated she did not and LPN E did not ask her to. LPN G said there wasn't an RN on duty at the time so she texted DON B who said to wait until RN D came into the facility and have her assess R1. On [DATE] at 11:00 AM, Surveyor interviewed RN D (Registered Nurse) about R1's significant change of condition on [DATE]. RN D stated she had received a text at about 8:15 AM from LPN G asking when RN D would be coming into work, because R1 was not acting herself and DON B (Director of Nursing) was off duty. RN D stated she got to the facility at 9:30 AM and went to LPN E to get updated on R1's condition, LPN E told RN D that R1 was acting like she was drunk that her blood pressure was low and her oxygen saturations were in the ,[DATE] % range. RN D said she assessed R1 noting that R1 was unable to speak, had tremors and could not squeeze RN D's hands, RN D thought R1 had a stroke. RN D stated she obtained vital signs and got oxygen started for R1. RN D said she told LPN E to call the doctor to get orders, call EMS (Emergency Medical Services), to call ER (emergency room ) with a report and to call R1's POA (Power of Attorney). Surveyor asked how long did R1 had to wait for an RN assessment, RN D stated 2 ½ hours, and stated this was unacceptable. Later, the facility provided Surveyor with a timeline document from [DATE] signed by RN D and dated [DATE] which notes in part: Received text message at 8:15 AM from (name-LPN G) asking when I was coming in because (name -DON B) was off and (initials-R1) was not acting herself and wanted me to assess her when I got into work. Replied at 8:45 AM stating I would be at work in 30 minutes (R1) was acting like she was drunk BP was low and 02 (oxygen was low). (R1) was lying in bed with her eyes closed and opened her eyes when RN D said her name, (R1) did not say anything, (R1) tried to say something, but could not get the words out . RN D obtained vitals: BP ,[DATE] R: 14 P: 99 O2 88% T: 97.3. Lung sounds were clear. (R1) would respond to verbal and touch stimuli . (R1) was unable to squeeze RN D's hands, (R1) was unable to follow any directions. (R1) had some tremors when asking to squeeze hands. CNA went and got oxygen .applied oxygen. Sat (R1) up in bed. O2 rechecked and was at 90% . Told (LPN E) . to call MD to give update. (LPN E) called MD and got order to send out to ER to be evaluated . On [DATE], Surveyor interviewed RN D about the timeline document RN D signed on [DATE] related to RN D's assessment of R1 on [DATE]. Surveyor asked RN D if she should have documented her findings into R1's medical record, RN D said she should have but forgot to do this and should have made a late entry. It is important to note that there is no documentation in R1's record of an RN assessment being completed on [DATE] when R1 presented with a significant change in condition. On [DATE] at 12:15 PM, Surveyor interviewed DON B about R1's significant change of condition on [DATE]. DON B stated she was off duty on [DATE]. DON B reported that at about 7:45 AM she received a text message from LPN G saying they noticed a change in R1, they were monitoring R1, that her oxygen saturation was in the 80 percent's but now up to 93 percent, LPN G said R1 was acting differently, DON B stated she attributed that to R1's lower oxygen level. Surveyor asked DON B what she would expect staff to do for a resident with a significant change in condition. DON B stated she would want the doctor updated that staff were monitoring R1. DON B stated she did not tell staff to update the doctor. DON B stated she did not know that LPN G had not looked at R1 on [DATE]. DON B stated she told LPN G that RN D would be in later and to have RN D assess R1. DON B stated she had been educating nurses to monitor residents more versus sending residents to the emergency room and transferring them quickly. DON B stated she had been training nurses to use their assessment skills to monitor residents. DON B stated she would expect the doctor to be notified as soon as possible with a critical change in condition. Surveyor asked what standard of practice the facility follows regarding change of condition. On [DATE] at 7:45 PM CD F (Clinical Director) reported to Surveyor the facility uses INTERACT 4.0 tools for resident change of condition which includes: Stop and Watch, SBAR (Situation, Background, Assessment and Recommendations), and Care Pathways. CD F stated, I know this is not what was followed regarding change of condition for R1. On [DATE] at 7:55 PM Surveyor interviewed R1's physician, MD H (Medical Doctor), who stated he would have expected to have been notified of R1 change in condition of unresponsiveness within 30 minutes of noting R1's change. (Cross reference F580.) The facility was aware of R1's significant change of condition including alteration in mental status, significant decrease in responsiveness and inability to swallow at 6:45 AM. The facility did not ensure R1 received a thorough RN assessment until 9:30 AM, which delayed R1 in receiving needed emergency medical services. The facility's failure to provide care consistent with current standards of practice for completing an RN assessment for a resident with a significant change in condition created a finding of IJ that began on [DATE]. The facility developed and began implementing a removal plan on [DATE]. The facility's plan indicated it would: -Immediately conduct a sweep of facility 24 hour boards and interview of nurses to ensure all changes of condition were assessed. -Revise the Change of Condition policy using AMDA (American Medical Director Association) clinical practice guidelines for Acute Change of Condition in the Long Term Setting 2003. -Immediately initiate education for nursing staff regarding change of condition documentation and assessment. All staff will be educated prior to starting their next scheduled work day. -Assessment education includes vital sign and assessment of the affected system. -Implement a Performance Improvement Project with a focus on assessment and documentation of significant change. -DON will complete chart audits for health assessment documentation and monitor all documentation daily for change of condition, SBAR INTERACT assessments for 2 weeks, and then 3 residents weekly for 4 weeks, 2 residents for 2 weeks the 2 residents a month for 2 months. -Results of all audits will be reported at least monthly to the QAPI team. -Complete competencies for all nursing on recognition and response to change of condition, Resident Assessment.

Based on record review and interview, the facility did not notify the resident representative and did not immediately notify and consult with the resident's physician when a significant change in the resident's physical, mental, or psychosocial status occurred for 1 of 4 residents reviewed (R1) of a total sample of 10 residents. On [DATE], at 6:45 AM R1 presented with a significant change in mental and physical status, the facility did not notify R1's physician until 10:00 AM, which delayed R1 in receiving EMS (Emergency Medical Services) for 3 hours. R1 was later transferred to the emergency room , for mental status changes and subsequently died on [DATE]. The facility's failure to immediately notify the physician of R1's significant change of condition on [DATE], of new onset of mental status changes and inability to respond, created a finding of IJ (Immediate Jeopardy) beginning on [DATE]. On [DATE] at 2:30 PM, NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were informed of the IJ. The facility removed the jeopardy on [DATE]. The deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. This is evidenced by: The facility's Notification of Changes Policy dated [DATE] states in part: It is the policy of this facility that changes in a resident's condition . are immediately shared with the resident and/or the resident representative . and reported to the attending physician or delegate. Nurses .are educated to identify changes in a resident's status and define changes that require notification .to ensure the best outcomes of care for the resident . 2) (i) A significant change includes deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications . Notification is provided to the physician to facilitate continuity of care and obtain input from the physician about changes . The facility stated they follow INTERACT 4.0 standard of practice for change of condition, this document guides decision making of when to report to the MD/NP/PA (Medical Doctor/ Nurse Practitioner/Physician Assistant) and notes in part: Change in Condition: Immediate Notification-Any symptoms, sign or apparent discomfort that is: Acute or Sudden in onset, and: A marked change (i.e. more severe) in relation to usual symptoms . Signs and Symptoms: Altered Mental Status: Immediate notification- Abrupt significant change in cognitive function from usual with or without altered level of consciousness .Consciousness: Immediate notification -Sudden change in level of consciousness or responsiveness . INTERACT 4.0 Care Path for symptoms of Acute Mental Status Change updated ,[DATE], states in part: New Mental Status Change . New symptoms or signs of increased confusion (e.g. disorientation, change in speech), Decreased level of consciousness (sleepy, lethargic), Inability to perform usual activities (due to mental status changes) . unresponsiveness. This Care Path includes guidance to: Take vital signs (Temperature, BP (Blood Pressure), pulse, Respirations, Oxygen saturation and to notify the MD (Medical Doctor) if any Vital Sign Criteria is met, including . Oxygen saturation below 90 percent .Resident unable to eat or drink . Findings: R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1 was reviewed as a closed record. R1 had an activated Power of Attorney for Health Care (APOAHC). R1's MDS (Minimum Data Set) quarterly assessment dated [DATE] noted R1 BIMS (Brief Interview for Mental Status) score of 3 of 15 indicating severe cognitive impairment. Section G of the MDS notes R1 was independent in ambulation. On [DATE] at 10:35 AM, Surveyor interviewed CNA C (Certified Nursing Assistant) about R1. CNA C stated on [DATE] at 6:45 AM, CNA C went to complete R1's morning care noting R1 was groggy, like she was drunk, would open her eyes and say yeah but did not wake up. CNA C stated R1 could not suck on a straw. CNA C explained R1 was usually alert and after staff got R1 ready for the day R1 was able to ambulate independently. CNA C stated she notified LPN E (Licensed Practical Nurse) of R1's changes right away, and said LPN E took R1's vital signs. CNA C said LPN E stated she did not know how to send someone out and was going to check with LPN G. On [DATE] at 11:44 AM, Surveyor interviewed LPN E on the phone about R1's change in condition on [DATE]. LPN E stated CNA C had reported to her at about 6:45 AM that R1 was acting different. LPN E stated she did an assessment took R1's vital signs. LPN E stated she was not 100 percent sure if R1 needed to go out to the hospital and wasn't familiar with the process of how to send residents out to the hospital. LPN E stated she went to talk to LPN G who was working on another unit. LPN G texted DON B, who said RN D was coming into the facility and to have RN D assess R1. LPN E stated that she continued to check on R1, took R1's vital signs, and monitored R1. LPN E stated all R1 said was yeah which was not normal for her. LPN E stated she held R1's medication that morning as she didn't feel comfortable attempting to give her medication. Of note, LPN E did not immediately notify a physician when R1 presented with a change of condition of decreased level in consciousness and inability to swallow at 6:45 AM. Review of R1's Progress Notes for [DATE] notes: On [DATE] Late Entry at 10:15 AM, CNA informed writer that res (resident) was not acting like her normal self. Upon assessment, res appeared sleepy, not able to respond verbally, and not able to follow commands. Vitals were obtained. MD was notified about residents change in condition and instructed writer to send res to ER. Ambulance arrived around 10:00. This entry was signed by LPN E (Licensed Practical Nurse). Of note there is no evidence that R1's physician was notified when R1 presented with a significant change of condition at 6:45 AM. Review of EMS report for R1 dated [DATE], notes that EMS was notified at 10:11 AM and arrived at facility at 10:17 AM for change in mental status duration: 3 hours. Review of R1 hospital record notes state in part; on [DATE], R1 presented in the emergency room with altered mental status changes and unable to ambulate which was not normal for R1. R1 oxygen saturation was 73% on room air. It was noted that R1's drug screen was positive for opioids and R1 had no orders for opioids. R1 had hypoventilation and pinpoint pupils and [MEDICATION NAME] was given for possible opioid ingestion, which R1 responded to, but R1's condition continued to decline. R1 was placed on comfort care on [DATE] in the hospital and R1 expired on [DATE]. R1 hospital Discharge Summary notes includes in part; final Diagnoses: [REDACTED]. Of note it is unclear at this time, if R1 had an opioid overdose. The facility investigated and completed a self -report incident and was unable to determine how or if R1 received opioids. Subsequent testing was performed at the hospital and was inconclusive. On [DATE] at 11:00 AM, Surveyor interviewed RN D (Registered Nurse) about R1's change of condition on [DATE]. RN D stated she had received a text at about 8:15 AM from LPN G asking when RN D would be coming into work, because R1 was not acting herself and DON B (Director of Nursing) was off duty. RN D stated she got to the facility at 9:30 AM and went to LPN E to get updated on R1's condition, LPN E told RN D that R1 was acting like she was drunk that her blood pressure was low and her oxygen saturations were in the ,[DATE] % range. RN D said she assessed R1 noting R1 was unable to speak, had tremors and could not squeeze RN D's hands, RN D thought R1 had a stroke. RN D stated she obtained vital signs and got oxygen started for R1. RN D said she told LPN E to call the doctor to get orders, call EMS (Emergency Medical Services), to call ER (emergency room ) with a report and to call R1's POA (Power of Attorney). RN D stated later that day ([DATE]) we found out LPN E did not call R1's POA. Surveyor asked how long it took the facility to notify R1's POA of R1 change of condition and transport to ER, RN D stated about 7 hours, RN D stated that was unacceptable. On [DATE] at 12:15 PM, Surveyor interview DON B and CD F (Clinical Director) about R1's change of condition on [DATE]. DON B stated she was off duty on [DATE]. DON B stated at about 7:45 AM she received a text message from LPN G saying they noticed a change in R1, they were monitoring R1, R1's oxygen saturation was in the 80 percent range but now up to 93 percent, LPN G said R1 was acting differently, DON B stated she attributed that to R1's lower oxygen level. Surveyor asked DON B what she would expect staff to do for a resident with a significant change in condition. DON B stated she would want the doctor updated staff were monitoring R1. DON B stated she did not tell staff to update the doctor. DON B stated she did not know LPN G had not looked at R1 on [DATE]. DON B stated she told LPN G that RN D would be in later and to have RN D assess R1. DON B stated she had been educating nurses to monitor resident more versus sending residents to the emergency room and transferring them quickly. DON B stated she had been training nurses to use their assessment skills to monitor residents. DON B stated she would expect the doctor to be notified as soon as possible with a critical change in condition. It is important to note, there is no evidence a doctor was notified of R1's change in condition until 10:00 AM, 3 hours and 15 minutes after R1's change in condition was first noted. R1's Progress Note continues: On [DATE] at 2:52 PM, Call placed to POA (name). Updated on transfer to hospital. Of note, R1's POA was not notified for almost ,[DATE] hours after R1 presented with a change in status. Surveyor asked about the delay in R1's POA being notified. CD F stated that on [DATE] at 2:45 PM, LPN E had come to her to report LPN E had not notified R1's POA that morning of R1's change in condition and transfer to the hospital, as LPN E was not comfortable notifying R1's POA. CD F stated that she notified R1's POA at that time with LPN E present so that LPN E could learn. On [DATE] at 3:41 PM, Surveyor interviewed R1's POA, FM I (Family Member) who stated that she had not been notified of R1's change in condition by the facility on [DATE], and had not been notified that R1 was sent to the hospital until 2:49 PM on [DATE]. FM I stated that she thought the facility did not take R1's change of condition seriously. On [DATE] at 7:55 PM Surveyor interviewed R1's physician, MD H (Medical Doctor),who stated he would have expected to have been notified of R1's, change in condition, unresponsiveness within 30 minutes of noting R1's change. The facility was aware of R1's significant change of condition including alteration in mental status, significant decrease in responsiveness and inability to swallow at 6:45 AM. The facility did not immediately notify the physician of R1's changes until 10:00 AM, 3 hours and 15 minutes after R1 change was first noted, which delayed R1 in receiving needed emergency medical services. The facility's failure to provide care consistent with current standards of practice for staff notifying a physician for a resident with a significant change in condition created a finding of IJ that began on [DATE]. The facility developed and began implementing a removal plan on [DATE]. The facility's plan indicated it would: -Immediately conduct a sweep of facility 24 boards and review all documentation to ensure all Primary Care Providers (PCP) and responsible parties were notified of changes of condition. Nurses were interviewed to ensure no changes of condition were missed. -Disciplinary action was taken with licensed nurse who was aware of significant change but did not report it to the physician timely. -Immediately revised Notification Policy to reflect INTERACT Tool used and Standard of Practice. -Immediately educated for nursing staff regarding PCP, RN, and responsible party notification of changes using the INTERACT Version 4.0 Tool as to when to notify. Staff will be educated before the start of their next scheduled work day. -A Performance Improvement Project was implemented with a focus on physician notification, RN notification, and Responsible party notification. -DON or designee will monitor all documentation daily for change of condition and PCP and responsible party notification time for 2 weeks, the 3 residents weekly for 4 weeks, the 2 residents weekly for 2 weeks the 2 residents a month for 2 months and ongoing as needed. -Immediately complete competencies for all nursing on recognition and response to change of condition, MD/family notification. -Random Competency Check for change of condition, notification of physician/responsible party, and RN completed at least weekly for 12 weeks and ongoing as need or directed by QAPI. -Results of all audits and competencies will be reported to the QAPI team at least monthly

Based on observation, interview and record review, the facility did not ensure residents have an environment free of hazards and did not provide adequate supervision and assistive devices for 3 of 7 total sampled residents (R3, R5 and R7). R3 had a witnessed fall from her bed when CNA H (Certified Nursing Assistant) left R3 unattended while the bed was in a high position. The fall resulted in a head injury that required sutures. R3's care plan stated 1-2 CNAs for personal hygiene/dressing, leaving the CNA to decide if the care required 1 or 2 staff. R5's fall interventions were not implemented per R5's care plan and the facility did not monitor or re-evaluate their effectiveness. R7 was taken by accident away from the facility and facility did not put in safety measures to ensure it did not happen again. Evidenced by: Facility policy entitled Fall Prevention and Fall Related Injury Management, dated 4/11/17, states, in part: .The Care Center will evaluate, treat, investigate and document fall incident investigation findings. Procedure: .3. At a minimum, the IDT (Interdisciplinary Team) will re-assess the patient/resident risk for falls according to the RAI (Resident Assessment Instrument) guideline on admission, quarterly, annual and significant change of condition basis. 4. The IDT will review, revise and alter the plan of care based on the patient/resident conditions and risk factors as needed. Care and Documentation: 1. When a patient/resident fall occurs, the employee making the discovery immediately notifies the licensed nurse to conduct an appropriate evaluation, provide interventions and/or emergency care as needed . Example 1 R3 was admitted to the facility, on 5/1/13 & 3/3/17, with [DIAGNOSES REDACTED]. R3 has an activated Power of Attorney (POA). R3's Quarterly MDS (Minimum Data Set), dated 2/6/19, indicates the following: R3 is severely cognitively impaired, Section B shows that R3's speech clarity is indicated as no speech or absence of spoken words. R3's ability to express ideas and wants is indicated as rarely/never understood. R3 rarely/never understands others. Section G indicates R3 requires extensive 2 person assistance with bed mobility and is dependent on staff for transfers, eating and toileting. Section J indicates R3 has not had any falls since her last full MDS. R3's care plan, indicated as being in place prior to 2/12/19, states, in part: Focus: I have a physical functioning deficit related to: mobility impairment, cognition impairment. Date initiated: 5/22/2014.Interventions: Dressing assistance 1 - 2 staff.Personal Hygiene assistance 1-2 staff. Date initiated: 10/20/2015. Revision on: 1/15/2018 . Transfer assistance - mechanical sling lift and 2 assist . (Of note, R3's care plan stated 1-2 staff for personal hygiene and dressing, leaving this for a CNA to decide the number of staff required to provide care. This is beyond a CNA's scope of practice.) Progress Note, dated 2/12/19 at 9:34 PM, states: At 1830 (6:30 PM) was called into res (resident) room by CNA because res fell out of bed. Writer entered res room, res lying on back with floor mat underneath, res with a moderate amount of blood on mat. CNA stated that she was doing cares on res, she had her on her side to put the brief under res, then I went to the counter and res then fell out of bed onto the mat that was on the floor next to the res bed. Res was alert the whole time. No pain indicators noted. Unable to determine were res was bleeding d/t (due to) not moving res if she had a potential neck injury. At 1833 (6:33 PM) called 911. Ambulance came a short time later and res was transported to hospital. POA (name) update on res fall and being sent to ER. R3's SBAR (situation, background, assessment, recommendations) Post Fall Form, dated 2/12/2019, indicates the following: R3 was doing usual activities prior to the fall and the fall occurred in R3's room. R3 was next to transfer surface and had socks on and R3 was dry and not incontinent at the time of the fall. Injury bleeding from back of head. Fall was witnessed and R3 rolled/slid out of bed. R3 is chair bound and requires assist with elimination. MD (medical doctor) notified and sent to ER and POA updated. (Please note that the CNA made the decision to use only 1 staff member instead of 2, which resulted in the CNA having to leave R3 unattended to obtain supplies, which led to R3 rolling/falling out of bed and sustaining a laceration to her head.) Emergency Department Note, dated 2/12/19, indicates: Patient comes in from the nursing home with a chief complaint of fall and head injury with laceration .apparently there (SIC) doing bed care and rolled her and she rolled off the other side of the bed and struck her head against something caused (SIC) a laceration. No [MEDICAL CONDITION] to lower extremities. Assessment and plan: fall with scalp contusion/laceration; patient rolled out of bed and hit her head causing a laceration. CT (computed tomography) scan of the head and neck was normal. INR ((International Normalized Ratio) - clotting ability of the blood) is therapeutic. Sutures were placed in the laceration could (SIC) which can be removed in 7-10 days. Progress Note, dated 2/12/19 at 10:28 PM, states: At 2200 (10 PM) res returned to facility without incident. Res received stitches to top of right side of head. New orders received and noted, to have her stitches removed in 7-10 days. Res sister was there with res at ER. Per ER nurse res CT scan and X-ray was neg (negative). R3's care plan, indicated as being in place after 2/12/19, states, in part: I have a physical functioning deficit related to: Mobility impairment, cognition impairment.Dressing assistance 2 staff. Date initiated: 2/14/2019 .Personal Hygiene assistance 2 staff. Date initiated: 2/14/2019.Transfer assistance - mechanical sling lift and 2 assist. On 7/31/19 at 2:00 PM, Surveyor interviewed RN I (Registered Nurse) regarding R3. RN I indicated R3 was a total assist with all cares and she needed 1-2 staff for rolling. RN I indicated the CNA's would determine if they needed 1-2 staff. On 7/31/19 at 2:05 PM, Surveyor interviewed CNA K regarding R3. CNA K indicated it would take two (2) staff to assist R3 with cares, due to being dependent on staff for cares. CNA K indicated R3 was always a 2 person assist for rolling, incontinent care. CNA K indicated R3 was a 2 person assist even before her fall. CNA K indicated there were no changes in her care even after R3 fell out of bed on 2/12/19. CNA K indicated the way R3 was maneuvered when rolling she needed 2 assist, because R3 would try to sit up when rolling her and would roll out of bed, and would need 2 people. CNA K indicated R3 was a larger person in a single size bed. CNA K indicated determination was made by CNA's if using 1 or 2 staff. CNA K indicated she would not want to go in by herself to roll R3 due to R3's size and would roll out of bed. CNA K indicated there was no way to prevent her from rolling out of bed when rolling R3 over, unless another person was there. CNA K indicated that R3 was a Hoyer transfer with 2 people. CNA K indicated R3 had some [MEDICAL CONDITION], but the day she left to the hospital, on 3/2/19, noticed bruising to the hip that day. CNA K indicated R3 did not have contractures, but required assist with moving and lifting extremities. CNA K indicated she let the nurse know about the bruising and swelling on 3/2/19. On 7/31/19 at 2:15 PM, Surveyor interviewed LPN G (Licensed Practical Nurse) regarding R3. LPN G indicated she was called into R3's room by the CNA, who said she was getting her washed up and she had R3 on her side and went to the counter to get something and R3 rolled out of bed. LPN G was unable to say what R3's care plan said. LPN G indicated it depended on the CNA if 1 or 2 staff were used. LPN G indicated if staff were comfortable doing R3's cares by themselves then they did R3 by themselves. Surveyor asked who determines if you need 1 or 2 staff. LPN G indicated administration does, because they update the care plan and Care Card. LPN G indicated R3 would stiffen up due to anxiety related to her Dow[DIAGNOSES REDACTED]. On 7/31/19 at 2:25 PM, Surveyor interviewed LPN J regarding R3. LPN J indicated she could not remember back to 2/12/19. LPN J indicated staff usually did a 2 assist on the day shift with R3. LPN J indicated she is unsure what R3's care plan said, but does remember she was a 2 person Hoyer lift. LPN J indicated she doesn't believe R3 moved her extremities on her own. On 7/31/19 at 3:00 PM, Surveyor interviewed DON B (Director of Nursing) and ADON C (Assistant Director of Nursing) regarding R3's fall. DON B indicated the CNA had rolled to reposition and change R3's brief, then went to the counter and got supplies and R3 rolled off the bed towards the window. R3 was laying on her right side on the mat and the CNA got the nurse and they did not move R3 due to possible injury to the neck. DON B indicated that determination of needing 1 or 2 staff depends on the care, if had a bowel movement or needing to be rolled, R3 would need 2 assist. (Please note that DON B indicated to Surveyor that R3 needed 2 people to roll her and R3 only had 1 person assisting her when she fell out of bed and sustained a laceration requiring stitches.) March 2019 'Summary Report of Meeting,' states in part: Subjects covered: falls/bed safety. Recently, a resident was left unattended in her bed, on her side, while a staff member went to the counter to obtain supplies the resident rolled out of bed, causing injury. Expectations: 1. Staff are expected to have supplies ready before beginning cares. 2. A resident's bed should be in the low position when staff are not immediately at the resident's side to provide safety. 3. When in doubt, ask another staff member for help. 4. Follow the resident's care plan regarding bed safety. On 8/1/19 at 2:46 PM, Surveyor interviewed R3's Guardian L via phone. Guardian L indicated she had seen R3 earlier that day, then received a call that (R3) was bleeding from her head and was sent to the ER. Guardian L indicated staff kept apologizing to her and told her they would be having 2 people from now on and would not say how R3 fell out of bed. Guardian L stated it's careless, should have been two. One on each side of the bed. Guardian L indicated she thought the physicians looked R3 over good on 2/12/19. Guardian L indicated they did not look at her hips or legs due to no swelling at that time. Guardian L indicated she did not notice anything prior to 3/2/19, regarding swelling. Guardian L indicated R3 did not move around, and that she'd stay where you'd put her and she couldn't have done it on her own, when asking about R3 rolling out of bed. Guardian L indicated staff didn't always use 2 people, it depended on if they were busy or the amount of staff on. Guardian L indicated she asked how her fall from the bed occurred and was told by staff that they didn't know. Guardian L indicated she asked how R3's fracture occurred and was told they didn't know. Guardian L indicated R3 was on the heavier side and if she started to slip, you wouldn't be able to hold her or help her with just 1 person. Please note that Surveyor placed a call to CNA H and left a voicemail, on 7/31/19, and has not received a return call. Example 2 R5 was admitted to the facility, on 9/21/18, and has [DIAGNOSES REDACTED]. R5's Quarterly MDS (Minimum Data Set), dated 6/14/19, indicates R5 has a BIMS (Brief Interview of Mental Status) of 5, indicating severe cognitive impairment. R5's MDS also indicates she needs extensive assistance from staff with transfers and toileting, and when moving from seated to standing she is not steady and only able to stabilize with staff assistance. R5's Fall Risk Care Plan, initiated on 9/27/18, indicates R5 is at risk for falls related [MEDICAL CONDITION], history of [MEDICAL CONDITION], use of medication; will not wait for assistance with transfers. Current care plan interventions include bed in low position, call light and personal items available and in easy reach which were all initiated 9/27/18. A soft touch call light was added to the care plan on 10/25/18, and anti-rollbacks on wheelchair were added to the care plan on 2/8/19. R5 fell in her room on 2/8/19, 4/1/19, 6/1/19, and 6/19/19. R5 also fell out of her wheelchair in the hallway, on 7/2/19, as result of a brief [MEDICAL CONDITION] episode. On 2/8/19, R5's Fall Report indicates R5's fall took place at 1:15 AM. R5 was found sitting on the floor next to her bed and stated she was going to the bathroom and the chair moved away when she attempted to sit. R5 reported hitting her left side of body and top of head and reported pain to right side of body. After the Interdisciplinary Team (IDT) reviewed the fall, anti-rollbacks were placed on the wheelchair for safety, staff was notified via Point Click Care (PCC) and CNA Care Sheet to check resident on both night shift rounds for incontinence and the need to use the bathroom. R5's care plan only indicates she should be offered toileting before supper and on first N[NAME] (night time) shift rounds. On 4/1/19, R5's Fall Report indicates R5's fall took place at 11:45 PM. R5 was found sitting upright with her legs extended in front of her, leaning against the bed. No injuries were observed at the time of the incident. Predisposing situation factors noted are responding to toileting needs and improper footwear. Report indicates IDT reviewed. Offer toilet on 1st N[NAME] shift. On 6/1/19, R5's Fall Report indicates R5's fall took place at 10:20 PM when resident was found kneeling at her bedside with wheelchair behind her and her arms on the bed. The Immediate action taken section of the Fall Report indicates the resident has poor safety awareness and was encouraged to utilize call light for assistance with transfers. Predisposing factors checked related to this incident were Impaired memory and Incontinent. The Fall Report indicates the IDT reviewed. Resident likes to go to bed around 2130 (9:30 PM); ADON spoke with resident. Resident indicated she would be OK with being offered to go to bed between 2100 and 2200 (9:00 and 10:00 PM). R5's care plan does not indicate R5's preferred bedtime. On 6/19/19, R5's Fall Report indicates fall took place in R5's room at 9:54 PM when she was found on the floor by a CNA. Minimal details listed on Fall Report. Documentation notes: No injuries observed at time of incident, although pain numerical level is listed at 6. Notes on 6/20/19 indicated IDT reviewed. PT (Physical Therapy) and OT (Occupational Therapy) to evaluate today. On 7/31/19 at 11:27 AM, Surveyor observed R5 in bed and the bed was not in low position, rather at knee high level. Surveyor spoke to R5 and observed call light was not in reach. Surveyor asked R5 how she lets staff know that she needs help. R5 stated, I push a button. She looked around and then said, I'm not sure where it is right now. Surveyor observed call light lying on floor under R5's bed. Call light cord did have a clip attached to it for securing placement, which was not in use. On 7/31/19 at 11:28 AM, Surveyor interviewed CNA D who indicated R5 has not been transferring well recently, so she said she has been using a stand lift as she was told to do if R5's knees seem to buckle. CNA D reports she did use the stand lift this morning to get R5 ready and to toilet, but CNA D states R5 put herself to bed and self-transferred after breakfast. Surveyor asked CNA D if R5 was able to reach her call light. CNA D looked for a moment and stated, Oh, it's right here, as she picked it up off the floor. Care plan indicates R5 is to transfer with assist of one and use gait belt. On 7/31/19 at 11:38 AM, Surveyor, with CNA D, spoke to LPN [NAME] who indicated she did not help R5 into bed and was unsure if another staff member had helped her or if she self-transferred. LPN [NAME] indicated speech therapist had been in the room earlier. On 7/31/19 at 12:52 PM, Surveyor observed R5 sitting in her wheelchair in her room watching television. R5 pointed to her bed, which was now in the low position and stated, I don't know why it's like that. Observed R5 to have a regular call light (not a soft touch call light) lying unsecured on R5's bed. No sign was observed in R5's room reminding her to call for help. No anti-rollback device was observed on R5's wheelchair. On 7/31/19 at 1:34 PM, Surveyor spoke to ST F (Speech Therapist) who states she worked with R5 from 10:38 AM until 11:23 AM. ST F indicates R5 was in her bed for the entire session and was lying flat in bed when she arrived. This was her first formal meeting with R5. ST F says she was in the room the entire time, with the exception of having to leave to get a cracker for part of her evaluation. Surveyor asked, Do you recall leaving her with her call light when you left the room? ST F replied, I know she had a remote or something in her hand, but I don't know what it was. On 7/31/19 at 2:00 PM, R5 was observed by Surveyor pedaling herself through the hallways in a wheelchair that was not equipped with anti-rollback wheels. On 7/31/19 at 2:30 PM, Surveyor spoke with DON B regarding interventions in place for R5 to prevent falls and how the facility ensures interventions are implemented. DON B indicates that after a fall, the IDT meets to review the care plan and update it. The Care Worksheet is then updated for staff and an alert is sent through electronic charting system or staff is informed verbally of the change and they are then expected to implement it. DON B listed interventions in place for R5 and also reviewed care plan. DON B indicated the current interventions in care plan were keeping her bed against the wall, a sign in her room, anti-rollback wheelchair, rest periods, and soft touch call light. Surveyor and DON B observed R5's room together. DON B stated, I see we're missing the soft touch call light. Also checked room and bathroom and indicated, I do not see a sign to call for help with transfers. R5 was then located up in wheelchair attending Bingo activity. DON B stated, She is actually in a different chair. I don't know. Therapy is usually the one to switch that out. On 7/31/19 at 2:59, DON B reported to Surveyor, I found the chair she (R5) is supposed to be in. It was in the hallway. DON B indicated she would be checking with physical therapy and the CNA who worked with R5 this morning regarding the different chair. DON B indicated she would feel better if she could determine how long the chair being used at this time had been in place, especially if it had only been used for a day. Example 3 R4 was admitted to the facility, on 10/8/18, with [DIAGNOSES REDACTED]. R7 was admitted to the facility, 9/12/14, with [DIAGNOSES REDACTED]. R7 speaks very little English. On 6/17/19, R7 was sitting outside on the patio. A transport person put him in their van and took him to another facility. The other facility called the Care Center and told DON B they sent the wrong resident, they were expecting R4. At that time, DON B was not aware R7 was missing. DON B called the transport company and reported the error. The transport company returned to the other facility, picked up R7 and returned him to the Care Center and picked up R4 and took him to the other facility. On 7/31/19 at 3:00 PM, Surveyor spoke to TS M (Transport Supervisor). TS M said the transport person said she approached R7 outside and asked if he was R4. R7 nodded his head and the transport person put him in the van and took him to the other facility. The transport company did not know of the error until DON B called them and said they took the wrong resident. Then the transport person returned to the other facility, picked up R7, returned him to the Care Center and took R4 to the other facility. TS M said the transport person violated the policies. The transport person was supposed to enter the facility, verify the resident and pick up the paperwork to transport. The transport person no longer works for the company. On 7/31/19 at 3:30 PM, Surveyor spoke to DON B. DON B said no one knew that R7 was gone until the other facility called them. DON B said the staff had not been educated and no safety measures had been put in place to prevent this from happening again.

Based on observation, interview and record review, the facility did not provide services and assistance to maintain bowel continence for 1 of 2 residents reviewed and identified with bowel incontinence out of a total sample of 30 residents (R36). R36 was diagnosed with [REDACTED]. Evidenced by: Facility policy entitled Incontinence Management/Bladder Function Guideline, dated 6/14/18, includes, in part: Upon admission (if resident has a history of incontinence) complete the Bowel and Bladder Evaluation. Identifying the signs and symptoms of urinary and bowel incontinence . Identification of contributing diagnosis/medical condition . Continuing evaluation that includes past medical history/lab results . R36's Hospital Discharge Summary, dated 10/23/18, includes, in part: . Final Diagnoses: [REDACTED]. Emergency Department Findings: A CT (computerized tomography) scan of the abdomen and pelvis showed . fecal impaction . Pertinent diagnostics .3. Rectal stool ball and thickening of the rectal wall with surrounding [MEDICAL CONDITION] changes may be seen in the setting of Stercoral ulceritis (an ulcer of the colon due to pressure and irritation resulting from severe, prolonged constipation due to large bowel obstruction) . Follow-up: We'll need to pay close attention to the patient's bowels as this is likely the underlying source for urinary incontinence that led to Foley catheter placement and [MEDICAL CONDITION] . R36 was admitted to the facility, on 10/23/18, with [DIAGNOSES REDACTED]. R36's admission Minimum Data Set (MDS), target date 10/30/18, indicated R36's cognition to be moderately impaired with a Brief Interview of Mental Status (BIMS) score of 12. R36's MDS, target date of 10/30/18, also indicated that R36 was always continent of bowel and was not on a bowel toileting program. *It is important to note resident's constipation status, diagnosis, history of large bowel obstruction, and follow-up orders as noted by hospital. R36's Admission Bowel and Bladder Assessment, dated 10/24/18, includes, in part: Bowel continence: incontinent of bowel . Onset date: less than a year . Monitor resident for risk factors for Bowel Incontinence: Constipation and Other . Other: Per group home staff, monitor bowel movements daily . Signs and symptoms of bowel incontinence: Abdominal cramping/bloating/discomfort and Prolonged straining during defecation .Diagnosis/Medical Conditions for urinary and/or bowel incontinence: Diabetes, fecal impaction/constipation, history of urinary tract infection . Resident recognizes appropriate time/place to defecate? No . Resident is able to feel urge sensation for bowel movement? No . Bowel Incontinence Plan: Bowel/Retraining Program . Is a 3 day bowel tracking indicated? Yes . Is there a care plan in place? Yes *It is important to note that R36's previous home gave facility instructions to monitor R36's bowel movements daily. R36's Baseline Care Plan, initiated 10/25/18, does not include a focus, goals, or interventions related to R36's constipation or history of bowel obstruction. R36's Comprehensive Care Plan, initiated 10/25/18, does not include a focus, goals, or interventions related to R36's [DIAGNOSES REDACTED]. R36's Physician Orders, dated (MONTH) (YEAR)/ (MONTH) (YEAR)/ and (MONTH) (YEAR), include, in part: Document resident bowel movements every shift (required by Care Managed Organization staff) .every shift . active/start date: 10/24/18 [MEDICATION NAME] Suppository 10 MG (milligram) Insert 10 mg rectally as needed for daily PRN for constipation . active/start date: 10/23/18 Milk Of Magnesia Concentrate Suspension (Magnesium [MEDICATION NAME]) Give 30 ml by mouth as needed for constipation . active/start date: 10/23/18 R36's Medicine Administration Record, dated (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) indicates no PRN medication was given to R36. R36's Treatment Administration Record (TAR), dated (MONTH) (YEAR)/ (MONTH) (YEAR)/ (MONTH) (YEAR) indicates, between 10/24/18 - 11/5/18, R36 did not have a bowel movement and between 11/6/18 - 11/8/18 R36 was hospitalized . R36's TAR also indicated that R36 did not have a bowel movement (BM) between 11/9/18 - 11/14/18, between 11/22/18 - 11/24/18, and between 11/26/18- 11/28/18. (It is important to note 11/09-11/14 is 6 days with no BM, 11/22-11/24 is 3 days with no BM, 11/26-11/28 is 3 days with no BM.) R36's Certified Nursing Charting BM Report, dated 10/23/18 - 12/15/18, indicates: *10/23/18 -10/25/18 R36 had no bowel movement (3 days no BM) *10/27/18 -11/3/18 R36 had no bowel movement (8 days no BM) 11/4/18 - R36 had one medium incontinent bowel movement 11/5/18 - R36 had no bowel movement 11/6/18 -11/8/18 Resident was hospitalized *11/9/18 -11/12/18 no bowel movement (4 days no BM) R36's Hospital Discharge Summary, dated 11/8/18, includes, in part: .admitted : 11/6/18 . discharge date [DATE] . there is a large amount of stool throughout the colon and rectum. Mild rectal wall thickening and minimal perirectal fat stranding are probably related to chronic constipation/ impaction . Impression: . no bowel obstruction . large amount of stool throughout the colon and rectum, consistent with constipation/fecal impaction . Final Diagnosis: [REDACTED]. 2. Nausea and Vomiting; present on admission: yes . R36's Nurse Notes, include, in part: 10/24/18: Resident admitted . related to septic shock, obstructed Foley catheter, catheter associated Urinary Tract Infection, constipation . 10/25/18: .Resident noted to have refusal behaviors . 10/29/18: . complains of back pain . 10/30/18: . Resident has been refusing to sit up in bed, resident has been requesting to stay laying down in bed and take pills and eat that way. Staff have explained the risks of this and resident refuses to sit up . 10/31/18: . Care plan meeting . Resident has been refusing to get out of bed and expresses . lower back pain. Resident states that back is broken. Manage Care Organization team stated that resident has broken back in the past, but that it is not like (R36) to be sitting in bed all day . goal is for resident to return to prior group home, at group home resident was using walker to get around and would spend most of time in R36's chair . 11/1/18: . Refused cares this evening, refused to change clothes this shift . Remained in bed all shift . 11/2/18: . Resident had a period of a few days where R36 was refusing all intake and refusing to get out of bed for meals . 11/6/18: . Change in condition . symptoms or signs of abdominal pain . recommendations to send to emergency room for evaluation . 11/8/18: Resident return from (hospital) . Foley . inserted at hospital for retention . 11/10/18: . Refused cares this evening, resident refused to change clothes this shift . 11/12/18: .Resident resistive to cares at times, does not like to be transferred, complaining of pain because back is broken. 11/20/18: . Document resident's bowel movements every shift (required by Manage Care Organization staff) no BM this shift . 11/21/18: .Resident states to have almost constant pain in the last 5 days. States pain makes it hard to sleep at night and limits day to day activities in the last 5 days. Rates pain 10/10 being the highest the pain has been in the last 5 days. 12/1/18: .Resident complained of pain in butthole due to feeling constipated. Refused Milk of Magnesia. Resident did have a large bowel movement a few hours after stating this discomfort. Resident seems resistive to assistance . participating in therapies sporadically .Incontinent of bowel and bladder. On 12/4/18 at 11:29 AM, during initial screening, R36 stated, My constipation really hurts me. I have to really work to get rid of waste material. Please look into this to see if there is anything else they can do for me. I am still hurting from what I just went through this morning. On 12/6/18 at 12:14 PM, during an interview, R36 stated, During the day time, all day I am in pain. It affects my bladder too and then I get a bladder infection. I have trouble emptying my bladder. When I am in pain, because I am constipated, it is an 8 or 9 out of 10. Not quite as bad today. I stay in bed more when I am in pain from constipation. When I move around the pain gets worse. If I try to go to the lunch room and use my feet to propel my wheelchair the pain gets worse. They haven't done much for my constipation here. I wish they would though. Every day I am in pain due to my constipation. Some days it is worse. I end up going on my own and it hurts like hell, 10 out of 10 pain when I finally go. I would like to see my doctor about it. (Of note, R36 has changed daily routine due to pain and discomfort with constipation and become more self-isolated due to pain related to constipation.) On 12/6/18 at 1:55 PM, during an interview, RN C (Registered Nurse) indicated R36 doesn't voice pain, but indicates pain by getting grumpier and more persistent about being constipated. When asked if R36 ever complains of being constipated, RN C pulled up R36's TAR on computer and stated, Based on (R36's bowel) pattern, I wouldn't consider it an issue. On 12/6/18 at 2:00 PM, during an interview, CNA D indicated that R36 complains a lot of being constipated, but was not sure if it was a behavior, pain, or because of dementia. CNA D indicated that R36 makes statements such as, I can't poop, and I haven't pooped all day, as frequently as a few times a week. CNA D stated, (R36) is fixated on pooping and dwells on it. When asked if CNA D reports this to anyone, CNA D sometimes tells the nurse on the Unit. On 12/6/18 at 2:24 PM, during an interview, DON B (Director of Nursing) was aware R36 had a [DIAGNOSES REDACTED]. DON B was unaware R36 had a history of [REDACTED]. as ordered and per facility policy. An example DON B gave was a nurse runs report and sees that a resident has not had a bowel movement for three days and then starts the intervention using resident's PRN medication. DON B expects R36's care plan to include focus, goals, and interventions related to constipation. DON B stated, We do not use non-pharmaceutical interventions.

Based on observation, interview and record review, the facility failed to prevent unsafe wandering and/or elopement for 1 of 2 residents reviewed for elopement (R1). The facility did not provide adequate supervision and did not implement an appropriate care plan with interventions to limit injury or prevent serious injury, impairment, harm or death, related to elopement/wandering and falls, based on resident assessment. R1 was identified as being at high risk for wandering, and had a known deficit for safety awareness. The facility did not develop a care plan with appropriate interventions, resulting in R1 not being provided adequate supervision to prevent serious injury from occurring. R1 was missing from the 100 unit of the facility and then found deceased lying in a pool of blood in a stairwell on the lower level on [DATE]. Failure to provide needed supervision to prevent an accident created a finding of Immediate Jeopardy (IJ) that began on [DATE]. NHA A (Nursing Home Administrator) was notified of the Immediate Jeopardy on [DATE] at 2:00 PM. The Immediate Jeopardy was removed on [DATE]; however, the deficient practice continues at a scope/severity level of D (potential for more than minimal harm that is not immediate jeopardy/isolated) as the facility continues to implement its action plan. This is evidenced by: Facility policy entitled Elopement Guideline, dated ,[DATE], states, in part: .Environmental Guidelines, the Living Center will identify such environmental hazards such as entrances, stairwells or exits that pose a foreseeable danger to residents who wander or have an exit seeking behavior. The Living Center will implement interventions to minimize these risks and hazards as appropriate. Documentation should include: admission assessment, which may indicate potential to wander or exit living center. Care plan that addresses potential to wander or exit living center and the measures taken to prevent wandering/elopement. All attempts to elope, efforts to locate, notification and results of efforts. Full observation/visualization after an elopement for any injuries or new symptoms or conditions which may have developed . Missing Resident event: the living center will implement the following plan for conducting internal and external searches to locate missing residents: If a Resident is discovered missing or is suspected of having eloped, the Charge Nurse takes the following steps: . 7. Once a search of all respective areas is conducted, all available employees will continue to participate in searching all areas of the living center and the external premises, as directed by the Search Coordinator .Monitoring compliance, the following elements are in place for the Living Center to demonstrate satisfactory compliance with the guide: . care plan for elopement in place and interventions individualized and implemented, physical observation. Facility policy entitled Fall Prevention and Fall Related Injury Management, dated [DATE], states, in part: .Care and Documentation . 2. Patient/Resident fall incidents are reported to the attending physician and responsible party. Date, time, and details are documented in the medical record . Upon entering the facility, there is a hall with administrative offices at the end. The main dining room is straight ahead and two hall ways branch off. One hall goes to the left. This hall also branches and leads down to the ,[DATE] unit, and another that goes to the right leads to the 100 unit and 200 unit, which branch off of this main hallway. An elevator is located near the main dining room, heading down the hallway to your left, towards the ,[DATE] unit. This elevator leads to the basement where therapy is located. Once you exit the elevator in the basement, there is a hall to the right, which has multiple doors, and therapy is located down this hall. Straight across the hall from therapy is another hallway, which goes to the left that has sensor lighting; at the end of this hall there are multiple doors. One door on the left leads to two other doors and a back stairway that leads up to a small hall, behind the kitchen, that leads to dry storage and an alarmed exit to the back of the building, near the employee parking lot. R1 was reviewed as a closed record. R1 was admitted to the facility on [DATE] following a hospital admission for falls, with [DIAGNOSES REDACTED]. R1 also had chronic kidney disease, a history of alcohol abuse, and a history of repeated falls. R1's Risk for Fall assessment, dated [DATE] at 02:25 AM, notes a Score of 11, indicating that R1 was at risk for falls. R1 had ,[DATE] falls in the past 3 months, vision status is poor, and had balance problems while walking. R1's Risk for Elopement assessment, dated [DATE] at 02:17 AM, notes R1's risk score of 17, (a score of 10 or greater equals elopement risk). This assessment indicates that R1 was fully ambulatory, disoriented with no wandering, at time of assessment, voicing desire to leave, and difficult to redirect. R1's admission MDS (Minimum Data Set) assessment, dated [DATE], notes the following: R1 had unclear speech, sometimes understood when making needs known and sometimes understands when responding to communication. R1 scored a 13 on her BIMS (Brief interview of Mental Status), meaning she is cognitively intact. Section E indicated R1 had no wandering behavior exhibited. Section G indicated R1 transferred with supervision and one-person physical assist, walked in room independently with set up help only, walked in corridor with supervision and set up help only. Locomotion off unit: needed supervision and 1 person physical assist. (Emphasis added.) R1's Comprehensive Care Plan, dated [DATE], notes, in part: (R1) at risk for falls related to history of falls, new environment . Goal: risk of injuries related to falls will be minimized with current care plan .Interventions: gait belt with transfers, keep environment well-lit and free of clutter. Physical functioning deficit related to mobility impairment, self-care impairment, and PSP. On [DATE], care plan identifies R1 has poor response to the environment, inappropriate response to stimuli, limited ability to communicate, and not aware of surroundings. On [DATE], care plan identifies R1 has impaired neurological status related to: traumatic brain injury, PSP. Goal: free of injury. Interventions: assist in adult daily living activities (ADL's) and mobility as needed. (It is important to note that R1's Comprehensive Care Plan was incomplete and did not indicate the amount of assistance R1 needed for: assistive devices, mobility assistance, dressing assistance, locomotion assistance, toileting assistance and transfer assistance; these areas were left blank on the care plan.) On [DATE] at 2:00 PM, Surveyor interviewed DON B. DON B stated that R1's care plan was not complete and should have been. R1's undated Certified Nursing Assistant (CNA) Care Assignment form, received by Surveyor on [DATE], indicated that R1 was independent in mobility and transfers. (It is important to note that according to facility staff, the CNA Care Assignment form is a working tool and not part of R1's medical record.) Surveyor asked DON B on [DATE] at 2:00 PM how it was determined that R1 was independent in ambulation according to the facility's CNA Care Sheet. DON B stated that this was discussed in morning stand up meetings with therapy; that this was a verbal recommendation from therapy. (It is important to note that there was no specific documentation or assessment for this determination.) Review of R1's Progress Notes, includes, in part: [DATE] 11:21 AM: .she (R1) is strong but therapy would like her balance to be better to reduce the risk of falls. She is able to walk around independently . [DATE] at 4:19 PM: .Resident needed extra time to understand questions and answer appropriately .BIMS score 13. [DATE] at 5:17 PM SBAR (Situation, Background, Assessment, and Response): R1's son reported a fall to the nurse; vital signs are documented and weight of 101.8 pounds, but there are no other details of this fall in R1's Progress Notes. This report includes, in part: Incident Description: Writer approached by (name) POA, he stated that he found his mom laying on the floor in-between the bed and the wall heating/air unit. (POA) stated that R1 was crying and stated that her butt hurt. (POA) assisted R1 off the floor before informing the nurse. Immediate action taken: Writer asked (R1) about the fall. (R1) would not answer writer's questions. (R1) walking without difficulty in the hallway . Predisposing Environmental Factors: Furniture and Bed Position are checked. Predisposing Physiological Factors: Gait Imbalance and Impaired Memory are checked. Notes: On [DATE], IDT (Interdisciplinary team) reviewed. Bed was placed against wall.) [DATE] at 9:40 AM SBAR: Change of condition, symptoms or signs, Falls. Witnessed fall - no injury. R1's vital signs are documented but there are no other details of the fall in R1's Progress Notes. (The Risk Management Report for R1's fall on [DATE] was dated [DATE] and notes: (R1) finished eating, pushed back chair, chair tipped, patient fell on to floor, no injuries observed, ambulate independently, gait imbalance, dining room chairs do not slide easily on floor. There was no new intervention noted for this fall on the report.) [DATE] at 1:45 PM, (R1) was witnessed pumping hand sanitizer in the hallway several times and then licking it out of her hand. Poison control was called and per instructions juice was given and to watch (R1) for intoxication . All hand sanitizer was removed from patient hallway dispensers difficult to assess due to poor verbal communication and unsteady gait. SBAR was completed noting vital signs. (The Risk Management Report for this event for R1 was dated [DATE], noting no injuries observed. Predisposing Physiological Factors: Gait imbalance, Antihypertensive, Dementia . On [DATE], IDT reviewed. Hand Sanitizer removed from resident's room. Staff to ensure has soap in room.) [DATE], R1's Speech Therapy Progress Notes include, in part: (R1) requires frequent supervision due to fall risk and attempts to eat hand sanitizer . Precautions: (R1) has a history of falls. Cognitive impairments, Impulsive. Impaired safety awareness. [DATE], R1's Physical Therapy Progress Notes include, in part: (R1) requires supervision for all transfers, bed mobility and gait due to increased posterior lean, impaired coordination and balance deficits. (R1) has history of falls, cognitive impairments, and impaired command following and impaired safety awareness. (Emphasis added.) R1's Progress Notes continue: [DATE] at 3:02 AM SBAR-Behaviors (noted between 8:00 PM on [DATE] and 3:00 AM on [DATE]) 8:00 PM - (R1) noted to filling palm of hand with sanitizer from hall. Writer approached patient and encouraged her not to eat the sanitizer. 7:00 PM - 12:00 AM (R1) attempting to make 15+ phone calls with cell phone . 12:00 AM - (R1) ambulating in hallway licking sanitizer off of her hands. 1:30 AM - (R1) brought linens into corridor and appeared to be making a bed on the floor. 2:15 AM - (R1) returned to hallway with cell phone in hand, she put it on the floor and was stomping her foot on it. She threw it (cell phone) down the hall then picked it up and threw it back the other way down the hall. She returned to room, brought linens to hallway, and lowered herself to floor to lay on linen in fetal position .refusing to get up. 3:00 AM - (R1) got up, went to room and returned with teddy bear and intentionally returned to lying on linen on floor. (It is important to note that most of these behaviors were not noted in R1's record before [DATE] and there was no evidence that the facility implemented any new interventions for R1, such as increased monitoring or supervision.) [DATE] at 4:00 PM, Surveyor interviewed CNA H regarding R1's incident. CNA H indicated she had given R1 a shower around 5 PM on [DATE] and walked R1 to the dining room and that was the last time she saw R1. CNA H indicated she was going wing to wing and had a Halloween party. Then a nurse notified CNA H that she hadn't seen R1 in a while. R1's Progress Notes continue: [DATE] at 11:59 PM Late entry: includes, in part: Writer received call from (name) DON, (name) facility has a missing resident (R1). Facility is in process of completing a facility search. DON is on way to building and resident has been missing for approximately 25 minutes . RN called 911 for report of missing resident . At 7:58 PM (DON) has arrived at the building . at 8:02 PM received call from (DON) . resident was found, pulseless, and non-breathing, writer informed DON that resident was a Full Code, DON 911 called and CPR in progress .Writer arrived at the building at 8:17 PM, Police/EMS and Fire Department were at building. Per Fire Department, they took over CPR did (2) rounds of Advanced Life Saving Measures and called medical control to advise (R1) deceased . Police have now initiated death investigation and Medical Examiner called . Writer informed (R1's) son that (R1) was deceased . Family on way to building. Medical Examiner (ME) arrived at building 9:45 PM. Family, Medical Examiner, facility Managers at building until 12:45 AM, [DATE]. Body removed by (Medical Examiner) ME. Per Medical Examiner (ME) his time of death 2335 (11:35 PM) . On [DATE], at 9:35 AM, Surveyors and DON B went to the area where R1 was found deceased . The first door indicates it's a fire door and to keep closed. The stairway has 14 steps and a small stoop at the top, which would make a 15th step. The door at the top of the stairs is a fire exit. DON B indicated that R1's shoe was on the second step and that there was no blood or anything on the steps. R1 was lying on her left side, with her feet at the stairs, facing the electrical room (straight ahead slightly to the left when entering stair way area). DON B indicated that maybe, only outside door alarms. On [DATE] at 2:30 PM, Surveyor interviewed COTA C (Certified Occupational Therapy Assistant) on the phone about R1. COTA C stated that, on [DATE] at about 8:45 AM, he saw R1 sitting on the mat in the Therapy Department as he came in. He asked if anyone was working with her and then he took her to work with. COTA C stated that in the afternoon, R1 walked into the Therapy Department again, that there was a staff member who followed her and talked to him, and he worked with her, and walked her back to her unit. Surveyor asked COTA C if he reported this to anyone. He said he did not and was not aware if anyone else had reported that R1 had come into the Therapy Department on her own. On [DATE] at 5:07 PM, Surveyor interviewed PTA I (Physical Therapy Assistant) regarding R1. PTA I indicated R1 was limited with her intake of information due to cognitive level. PTA I indicated she was working with R1 on balance, walking safety, and that R1's biggest deficit is safety awareness. PTA I indicated R1 had ataxic movements that R1 was not in control of and had a hard time coordinating movements. PTA I indicated R1 was safe to walk independent on the unit. PTA I indicated they were working on gait training with R1 due to R1 not noticing obstacles and would bump or walk close to them. PTA I indicated that R1 did come down to the Therapy Department twice on her own. The day before she passed, R1decided to come down instead of waiting for staff and sat in a chair and waited. PTA I indicated R1 used the elevator to get down to physical therapy, as she couldn't use the stairs due to needing a code to get into stairway. PTA I indicated she saw R1 on her unit or between her unit (100 wing) and the main dining room and a lot of times at the nurses station. (Please note: Two staff have indicated that R1 had been found downstairs in therapy alone at times. There is no documentation to indicate that staff had assessed this behavior and determined if it was safe or what could be done to prevent it from occurring.) On [DATE] at 2:45 PM, Surveyor interviewed RD D (Rehab Director) about R1. RD D stated that it was noted that R1 came down to therapy in the elevator one time on her own. Surveyor asked if R1 was safe to go on the elevator by herself. RD D stated that R1 did not have good safety awareness and that R1 would not be safe or able to recognize safety hazards off of the unit (the 100 unit). Surveyor discussed with RD D about the fact that nursing staff had reported to Surveyors that R1 was independent in ambulation on the unit, transferred herself, and that R1's CNA Care Sheet indicated that R1 was independent. Surveyor asked if R1 was safe to be independent on the unit based on R1's therapy assessments. RD D stated that R1 would have got up on her own anyway and that it would have been difficult to keep R1 from moving on her own. RD D stated that R1 had general supervision on the unit, with nursing staff overseeing her mobility from a distance. Surveyor asked if Therapy wrote specific recommendations or were involved in writing the care plans for nursing to follow regarding R1's (and other residents) ability to ambulate and transfer. RD D stated that Therapy did not write specific recommendations, but did communicate in daily stand up meetings residents' status for recommendations and then nursing would write the specific Nursing Care Plan. RD D stated that perhaps the recommendations should be written. [DATE] at 10:00 AM, Surveyor interviewed NHA A regarding incident on [DATE]. NHA A indicated the facility had a trick or treating event that evening. NHA A indicated that a staff member used that stair well around 6:45 PM and no one was in the stair well at that time. NHA A indicated that the basement had been searched three times and that the first two times, the basement was searched, they didn't open those doors; thought area was locked. NHA A indicated that CNA G checked doors in the maintenance hall, opened the door, and saw R1's legs. NHA A indicated that LPN F indicated the room was blocked with R1's body and had to push to get into room. NHA A stated yeah indicating staff should have opened that door on the first two checks of the basement. NHA A indicated that at night, the maintenance hall is scary looking as the lights turn on automatically when you go into the area. At 11:15 AM, NHA A came back to Surveyor to clarify that staff didn't open the door because it was marked a fire door and they thought it would alarm to the fire department. [DATE] at 4:00 PM, Surveyor interviewed CNA H regarding R1's incident. CNA H indicated she went by the area, where R1 was found, twice and that CNA H does not go down in that area (back stair well) and it said emergency exit. CNA H indicated she thought an alarm would go off if R1 went in there, as CNA H has never been in or around that area. CNA H indicated she thought an alarm would go off if she opened the door. CNA H also indicated that R1 would walk up and down the hall and hang around by the nurse's station. CNA H indicated she didn't know R1 could even use the elevator. CNA H indicated she did not know if R1 worked with therapy. [DATE] at 1:20 PM, Surveyor interviewed LPN F (Licensed Practical Nurse), regarding R1's incident on [DATE]. LPN F indicated that she was told the basement was already checked. After informed R1 was not found, LPN F went to check the basement again with CNA G. LPN F indicated they were checking behind unlocked doors and happened to find her. LPN F indicated, when she opened the door, she could only see bottom of legs and feet. R1 was lying at the bottom of the stairs, face down with a big pool of blood around R1's head. LPN F indicated, once she was in the door, she checked for a pulse and breathing and at that time DON B arrived and initiated CPR until police arrived. LPN F indicated in the past, she had seen R1 by the elevator a few times, but was not getting on the elevator. LPN F indicated she had recently seen R1 near the elevator, the day before ([DATE]), by herself. LPN F indicated that R1 wandered around and that staff just kept an eye on her. [DATE] at 2:05 PM, Surveyor interviewed CNA G regarding incident on [DATE]. CNA G indicated that she and LPN F went down the maintenance hall, where lights are censored, checking door knobs. The knob turned (on door in the area R1 was found), asked if she could go in, opened the door, and saw R1's legs. CNA G indicated R1's feet were at the stairs and R1 was face down. CNA G indicated LPN F did not move R1, told CNA G to get DON B, and then DON B came down and started CPR. CNA G indicated she did not know if R1 was deemed safe to be on the elevator by herself. CNA G indicated she was not aware R1 went to therapy and that R1 had come down on the 300 wing (North end) a couple times. [DATE] at 11:19 AM, Surveyor interviewed CW K (Case worker) and CW L regarding R1. CW K indicated that R1 would walk and that R1's family would often find her by the neighbors. CW L indicated that to be wandering. CW L also indicated that they were looking at speech therapy to work with R1 due to expressive aphasia and for cognitive testing. CW K indicated that R1 has [DIAGNOSES REDACTED]. CW K indicated R1's Nursing Care Manager related R1's history to facility SW M (Social Worker) after [DATE] care conference. Despite knowledge that R1 used the elevator previously on her own, the facility did not implement a care plan or revise interventions or implement greater supervision or assistive devices that would prevent R1 from wandering down stairs unsupervised. The failure to provide adequate supervision, implement an appropriate care plan with interventions to limit injury or prevent serious injury, impairment, harm or death, related to elopement/wandering and falls, based on Resident assessment as being at high risk for wandering and having a known deficit for safety awareness created a finding of Immediate Jeopardy. The facility removed the immediate jeopardy on [DATE] when it had completed the following: 1) Shut down elevator until key pad has been installed to ensure Residents and/or Visitors do not have access to the lower level 24 hours per day. Elevator Company to have key pad installed on elevator so that elevator will only operate with an employee code or key. 2) Therapy Department will provide therapy services in Resident rooms until elevator key pad has been installed. Therapy will bring needed equipment upstairs to use with Residents. Laundry and housekeeping needs will be brought up to the units via the stairs by employees. 3) Facility has vending machines (snacks/soda) put on the first floor for Residents and visitor use. 4) Key pad has been purchased and is being installed by maintenance on employee break room door. 5) Elopement/ wandering assessment completed. Residents deemed to be at risk for elopement will have appropriate interventions, such as; WanderGuard, updated picture taken and placed in wandering books. Care plans will be updated to reflect assessment results and appropriate interventions. TARs will be updated to reflect placement checks every shift and function checks completed daily. Resident MD (Medical Doctor) and representatives will be updated on assessment findings. 6) Education provided to staff regarding elevator, keypad, vending machines, wandering/elopement WanderGuard placement, monitoring placement/functioning/picture and placing in book. 7) Staff will be alerted to Residents deemed at risk for wandering/elopement by 24 hour report board x 72 hours, longer if needed. 8) Care plans will be updated to reflect risk and appropriate interventions 9) All staff education will be provided wandering, elopement and missing resident policy and procedure and completing Resident head count to ensure all Residents are accounted for. 10) New employees will be given a thorough tour of the facility to ensure knowledge of building and places to search for missing Residents. New employees will be educated on elopement, wandering and missing Resident policy and procedures prior to starting. 11) All staff will be educated on searching entire facility and opening every door, including doors that are alarmed, following diagram of facility, for any Resident identified as missing. 12) Residents assessed as high risk for wandering/elopement will be identified on CNA Care Cards in bold, capital letters to ensure staff see and are cognizant of Resident(s) need for monitoring. 13) When therapy makes accommodations, the therapist will put accommodations in written form and will bring them to the IDT team so changes can be made to the care plan and care cards. 14) Therapy Department staff will receive education on providing accommodations for a Resident, that it needs to be in a written format and brought to the IDT team, so care plan and care cards can be updated. 15) Ensure elevator remains in shut down mode and padlock is in place and secured. After key pad installed, the maintenance dept./designee will ensure keypad/elevator is functioning correctly 5 times per week x 3 months, then 2 per week, ongoing. 16) Weekly mock elopement/missing Resident drills will be conducted starting [DATE] on varying shifts x1 month. If compliance has been met, elopement drills will be conducted on varying shifts monthly, ongoing. Staff will be evaluated on process and provided further education as needed for process improvement.

Based on observation, interview, and record review, the Facility did not ensure that a Resident who enters the Facility without a pressure injury does not develop a pressure injury and a Resident having pressure injuries receives necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing for 2 of 4 Residents (R5 and R1) reviewed for pressure injuries. R5 was admitted to the Facility without a pressure injury (PI) and was identified to be at moderate risk for PI development. R5 developed an avoidable stage III pressure ulcer without new interventions to promote healing or prevent future pressure injuries from developing. R1's Tubi grip (compression stocking) became bunched up causing a pressure injury to her Right ankle. The Facility did not have documentation to support that education was provided to the staff regarding Tubi grips use and monitoring. This is evidenced by: Example 1 The National Pressure Ulcer Advisory Panel (NPUAP): Prevention and treatment of [REDACTED]. As a result of pressure or pressure in combination with shear a number of contributing or confounding factors are associated with pressure ulcers. Pressure ulcer classification should be used to document tissue loss in ulcers resulting from pressure re or pressure rein combination of shear. Preventive skin care: 1. Avoid positioning the individual on an area of [DIAGNOSES REDACTED] whenever possible. [DIAGNOSES REDACTED] indicates that the body has not recovered from the previous loading and requires further respite from repeated loading. Repositioning and early mobilization: General repositioning for all individuals: 2. Consider the condition of the individual and the pressure redistribution support surface in use when deciding if repositioning should be implemented as a preventive strategy. Repositioning to prevent and treat heel pressure ulcers: 1. Ensure that the heels are free of the surface of the bed. Use heel suspensions devices that elevate and offload the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon. Apply heel devices according to the manufacturing instructions. The Facility's Skin Integrity Guideline, undated, includes in part: Purpose: To decrease PI formation by identifying those Residents who are at risk and developing interventions. Pressure redistribution mattresses are in place. If there is a decline in skin integrity, pressure redistribution surfaces will be reviewed for appropriateness. Licensed nurse to document weekly on all wounds using the Wound Evaluation Flow Sheet. R5 was admitted on [DATE] with [DIAGNOSES REDACTED]. R5's initial Minimum Data Set (MDS), dated [DATE], Section C0500: Cognitive score 13 indicating R5 is cognitively intact. Section G0110: Needs extensive assist of 2 with bed mobility and transfers. Section M0150 Pressure Ulcers: R5 is at risk for PI. Section M0210: R5 does not have any unhealed PI's. R5's quarterly MDS, dated [DATE], Section C0500: Cognitive score 11 indicating R5 has Moderate Cognitive Impairment. Section G0110: Needs extensive assist of 2 with bed mobility and transfers. Section M0150 Pressure Ulcers: R5 is at risk for PI. Section M0210: R5 does not have any unhealed PI's. (It is important to know that R5 developed an in-house acquired PI on 5/3/17). A PI Care Area Assessment (CAA) worksheet, dated 2/8/17, includes in part: Triggers: bed mobility self - performance problem is indicated - extensive assistance is required; Extrinsic Risk Factors: needs special mattress or seat cushion to reduce or relieve pressure; [MEDICATION NAME] Factors: immobility, incontinence, altered mental state, and cognitive loss; Analysis of Findings: admitted to Facility after emergency room visit for Left hip strain. Needs assistance with bed mobility, transfers, toileting, locomotion, hygiene, dressing, and bathing. Braden score 14. Proceed to care plan for skin integrity risk. R5's admission Braden score (skin assessment for PI risk) was 13 indicating that R5 was at moderate risk for PI development. R5's comprehensive care plan Pressure Ulcer actual or at risk due to assistance required with bed mobility, dated 2/27/17 with a revision date of 5/4/17, includes in part: Goal: skin integrity will be promoted with current care plan; Interventions: Complete Braden Scale, conduct weekly skin inspection, provide pressure reducing wheelchair cushion, provide pressure reduction/ relieving mattress, treatments as ordered, turning and repositioning schedule, weekly wound assessment. (It is important to know all the interventions are dated 2/27/17 as initiated). R5's admission assessment, dated 2/1/17, indicates that R5 has bunions on her feet and no other skin breakdown. R5's mattress is an Invacare Glissando Gliding Mattress. On 5/31/17 at 3:35 PM, Surveyor interviewed Invacare Rep K via phone. Invacare rep K indicated that the Glissando Gliding Mattress is not pressure reducing or offloading, as it is made of foam. Invacare rep K indicated that the Glissando Gliding Mattress is not rated for any skin deficit. R5 has the Glissando Gliding Mattress made of foam. Review of physician progress notes [REDACTED]. Review of R5's nursing notes late entry for 5/3/17, dated 5/5/17 at 4:26 PM, per Registered Nurse (RN) F, includes in part: Situation, Background, Assessment, and Response (SBAR) while doing ADL cares observed on R5's Right heel a scab with redness around the wound. Observed the Right heel scab that measured 1 centimeter (cm) x 1.3 cm x 0.2 cm. Hard scab with no drainage / odor or [MEDICAL CONDITION] with undefined wound edges. Peri wound is 1 cm around the edges are red. R5's physician's orders [REDACTED]. Check placement of Allevyn foam dressing every shift for scab Right heel. Review of R5's nursing notes dated 5/5/17 at 10:39 PM, per RN F, includes in part: Removed the dressing from R5's Right heel. Dressing had moderate sero-sang drainage with no odor. The wound measured 1cm x 1.3 cm x 0.2 cm. Wound bed with 90% slough and 10 % granulation. Wound edges were macerated with the surrounding tissue 1 cm red. Review of R5's nursing notes dated 5/15/17 at 1:01PM, per Licensed Practical Nurse (LPN) G, includes in part: Right heel scab has fallen off, wound bed is yellow slough in color, no foul odor noted. Review of physician progress notes [REDACTED]. On 5/31/17 at 1:05 PM, Surveyor observed R5's hoyer transfer from the wheelchair to the bed with Certified Nursing Assistant (CNA) H and CNA J. R5 had a blue boot on her Right foot. Surveyor observed a dressing to the back of R5's heel when CNA H removed the boot to lower R5's slacks. Surveyor asked CNA H if R5 had a sore on her heel. CNA H indicated that R5 had a scab on her heel the last time she saw it. On 5/31/17 at 3:00 PM, Surveyor interviewed RN E who is the Facility wound nurse. RN E indicated that she is not wound certified. Surveyor asked RN E if anyone in the Facility is WCC. RN E indicated the Nursing Home Administrator (NHA) A is WCC. Surveyor asked RN E if NHA A does wound rounds. RN E indicated the NHA A sometimes will look at a wound. Surveyor asked RN E when she looked at R5's wound on the back of her heel. RN E indicated that she did not see the wound until 5/20/17. Surveyor asked RN E what stage the wound was. RN E indicated a stage 3, as there was slough in the wound. RN E indicated that the last time she looked at the wound it looked like a little sideways cut. RN E indicated that she would have ordered an air mattress, blue boots, and made sure R5's heels were floated. RN E indicated she has created a new form to document wound on. Surveyor asked RN E what caused the wound on R5's Right posterior heel. RN E did not have an answer to the cause but did indicate R5 has tried to self -transfer in the past. On 5/31/17 at 3:05 PM, Surveyor observed R5 lying in bed on her Left side without her feet offloaded and no boot on her Right foot. Surveyor asked CNA L if R5 was to have a blue boot on her Right foot. CNA L indicated that she did not know where the blue boot was but was to have the blue boot on her Right foot. On 5/31/17 at 3:40 PM, Surveyor observed R5's Right heel with RN F. RN F removed the dressing from the back of R5's Right heel. The foam dressing was 90% coved in brown - red drainage. Surveyor asked RN F what the color of the wound bed was. RN F indicated white. RN F attempted to remove the drainage from the wound bed but it was adherent. Surveyor asked RN F what percent of the wound was covered in white material. RN F indicated one third of the wound was covered. RN F did not measure the wound. Surveyor observed the wound to be semi-circular and the adherent slough was light yellow in color and covered 40% of the wound bed. Surveyor asked RN F what the cause of the wound was. RN F did not have an explanation to the cause of the wound. Surveyor asked for weekly wound measurements and the Facility did not provide any. The Facility failed to ensure that a Resident who entered the Facility without a PI did not develop a PI. Example 2 According to Molnlycke Skin and Wound Product Information for Tubi grips, dated 10/16, includes in part: Precautions: Very thin legs and bony prominences are susceptible to excessive pressure and tissue damage. Do not leave stockings pulled down or slouched around ankles as it may cause a tourniquet effect. Contraindications: Do not use in the presence of an uncontrolled lower limb or skin or wound infection. R1 was admitted to the facility on [DATE], with a readmission date of [DATE], with [DIAGNOSES REDACTED]. R1's recent quarterly Minimum Data Set, dated dated [DATE], Section for Cognitive scored a 6, indicating R1 has severe cognitive impairment. Section G0110 Functional status indicates that R1 required extensive assistance with bed mobility, transfers, and ambulation. Section M0150 indicates R1 is at risk for a pressure injury (PI). Section M0210 indicates R1 does not have a PI. Section M1030 indicates R1 has 5 venous and arterial ulcers. R1's Braden (PI risk), dated 1/27/17, scored an 18 which indicates R1 is at risk for PI development. R1's Active Physician Orders, dated 1/24/17, include in part: Single layer Tubi grips to each leg from base of toes to just below knees. If extra length is needed, ok to fold over by toes. On in morning. Check placement of Tubi grips to ensure correct positioning and no bunching. R1's Active Physician Orders, dated 4/1/17, include in part: Avoid sharp debridement and excessive compression (no wraps or Jobst) (Compression stockings) ), initiated 3/22/17. Blue prevalon boot to Right lower extremity at all times except for transfers, initiated 2/22/17. Cleanse ulcers daily with Vashe or wound cleanser. Heel protector boots when in bed or recliner, initiated 3/9/17. May walk as tolerated, initiated 3/9/17. Nurse to check placement of Tubi grips, should be folded at toes, not at knees, every shift, initiated 2/16/17. Tubi grips single only, on AM off at HS (bedtime) every day and evening shift, initiated 3/22/17. R1's comprehensive care plan Potential for altered skin integrity, dated 3/16/15, includes in part: Tubi grips on in AM, off in PM with a revision date of 12/2/16. R1's comprehensive care plan Potential for altered skin integrity, dated 1/27/17, includes in part: Heel boot dated 5/5/17, Weekly wound assessment dated [DATE], Treatments as ordered dated 1/27/17. Review of R1's Treatment Administration Record (TAR), dated 12/16, includes in part: Tubi grips to bilateral lower extremities on in AM off at HS every day. (To be noted, it is not documented to verify placement of the Tubi grips. Verification of Tubi grip placement is documented starting 1/25/17- 1/30/17, except 1/26/17 is not documented as being verified). Review of Wound MD (Medical Doctor) C Outpatient wound care progress notes, dated 5/23/17, include in part: R1 is a [AGE] year old female well known to me from prior treatment for [REDACTED]. R1 is doing quite well but sustained a traumatic abrasion to the Right lateral ankle at her nursing home when her Tubi grip stocking rolled up her foot and caused friction on the lateral ankle. R1 was also treated for [REDACTED]. R1 also took a course of [MEDICATION NAME]. R1 also has chronic venous stasis and requires compression from Tubi grips due to chronic [MEDICAL CONDITION]. R1 continues to have ulceration at the Right lateral ankle and medical ankle. Using topical Santyl daily, covered with [MEDICATION NAME], ABD, Kerlix (wound treatment and dressings). We had the Tubi grip removed because they seemed to be causing R1 pain in the ankle when trying to walk. R1 is having increased need for assistance ambulating and transferring. R1 is using [MEDICATION NAME] for pain and is noted to be sleeping more. X-rays of Right ankle and knee done last week to eval for any other causes of pain and arthritic changes were noted. No acute injuries. Wound measurement 70% slough. The slough is moist and yellow. Medical Decision Making: R1 has an ulcer into the fat layer of tissue Right lateral ankle. 2 smaller ones into the skin. MD C documented that she would treat these as mixed vascular ulcers. On 5/31/17 at 10:55 AM, Surveyor interviewed MD C regarding R1's wound that developed from the Tubi grip. Surveyor asked MD C if the friction that caused the wound would be considered pressure. MD C indicated that yes, it would be considered a medical device type of PI. Surveyor asked MD C if the [MEDICATION NAME] was to treat the PI caused by the Tubi grip. MD C indicated yes. Surveyor asked MD C what stage the wound was. MD C indicated that she did not stage it but indicated since wound was caused by friction and it is in the fat layer it would be staged as a 3. Surveyor asked MD C if the PI could have been avoidable. MD C indicated the Facility could have prevented this. MD C indicated that the pain R1 is having is causing increased weakness and thus leading to decreased mobility. MD C indicated that lower extremity wounds are the straw that breaks the camel's back which leads to decreased mobility. Wound Center Documentation, dated 1/25/17, includes in part: Right lateral ankle. 2.8 cm x 1.5 cm x 0.1 cm. 50% slough, 50 % granular. Nursing progress notes, dated 1/30/17 at 1:25 PM, includes in part: Transfers and ambulates with gait belt and walker with one assist. R1 ambulates in room, to and from dining room, and to her bathroom. Right outer ankle with [MEDICAL CONDITIONS] for which R1 is on an antibiotic. Wound measurements 2.5 cm x 2.5 cm. Wound bed with 100% slough with red edges. Wound Center Documentation, dated 3/9/17, includes in part: Right lateral ankle. 3.6 cm x 4.4 cm x 0.2 cm. Wound Center Documentation ,dated 5/2/17 includes in part: Right lateral ankle. 3.3 cm x 2.5 cm x 0.2 cm. On 5/31/17 at 11:05 AM, Surveyor interviewed CNA D, via phone, regarding R1 and her Tubi grips. CNA D indicated that sometimes R1's Tubi grips would get rolled around her ankles. CNA D indicated that R1 received a new pair of Tubi grips in January and they were cut long and had to be rolled up making a double layer on her foot and up her leg. Surveyor asked CNA D if R1 wears any type of footwear. CNA D indicated R1 wears gripper socks and pink slippers over the gripper socks. Surveyor asked CNA D if the pink slippers are low or cover R1's ankles. CNA D indicated that the pink slippers go over R1's ankles. On 5/31/17 at 11:10 AM, Surveyor went into R1's room and noted the pink slippers on the floor next to the cabinet that housed the sink. Surveyor measured the height of the slippers at 3.94 inches (10 cm). On 5/31/17 at 12:45 PM, Surveyor interviewed CNA I regarding Tubi grip education she may have received at the Facility. CNA I indicated that she did not have any education on Tubi grips and if she would notice a Resident with bunched up Tubi grips she would pull them back up. On 5/31/17 at 12:50 PM, Surveyor asked Director of Nursing (DON) B if she has any documentation regarding education on Tubi grip monitoring. DON B indicated that she has worked at the Facility for 8 months and has not provided any education. DON B indicated that Tubi grips are part of general CNA training. On 5/31/17 at 12:55 PM, Surveyor interviewed Licensed Practical Nurse (LPN) G regarding education on Tubi grips. LPN G indicated that she did have education from the therapy department on how to measure and apply Tubi grips. Surveyor asked LPN G if she was instructed on how to monitor the Tubi grips. LPN G indicated that she would look at the Tubi grips as she is a nurse and that is general practice to do. Nursing notes, dated 5/7/17 at 8:53 PM, includes in part: R1 is an assist with 1 and a walker but has had increased difficulty walking / transferring lately due to Right lower extremity wounds. Nursing notes, dated 5/20/17 at 2:05 PM, includes in part: R1 complained of pain during dressing change even with narcotic pain medication given 1 hour before treatment. Nursing notes, dated 5/21/17 at 10:42 AM, includes in part: R1 was an assist of 1 for all transfers, has been unable to walk due to open areas. The Facility did not ensure that R1's Tubi grips were monitored to prevent an avoidable PI causing increased pain and decreased mobility.

Based on interview and record review the facility did not ensure the resident environment remained free of accident hazards to prevent accidents for residents residing on 4 of 4 wings in the facility. On 12/9/15 Resident 2 received first and second degree burns when she fell against the baseboard heater in her room. The facility was unaware that the temperature of the metal on the heater was as hot as it was and no interventions had been in place to prevent residents from being burned. Subsequent to this incident, the administrator directed that the baseboard heater be turned off to the rooms on the 300 and 400 hallway. This plan was communicated from Nursing Home Administrator (NHA) A to Licensed Practical Nurse (LPN) D. There was no education provided to the facility staff and staff indicated they would turn up the heaters if requested. During the initial environmental tour of the facility six days later, the baseboard heater in room 416 was on and the temperature of the heater was greater than 125 degrees. Multiple baseboard heaters on the 100 and 200 hallways were also found to be hot and unable to touch due to the hotness of the metal on the baseboard heater. Failure to ensure that residents residing on all 4 wings of the facility, were free from accident hazards created a finding of immediate jeopardy. The immediate jeopardy began on 12/9/15. Nursing Home Administrator (NHA) A was officially notified of the immediate jeopardy on 12/15/15. The facility removed the immediate jeopardy on 12/15/15, however, the deficient practice continues at a scope/severity level F (potential for harm that is not immediate jeopardy/widespread) as the facility continues to implement its removal plan. This is evidenced by: The maximum temperature of 125 degrees that is normally acceptable on the surface of a heating unit in a nursing home or long term care facility 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 Moritz and Henriques. This maximum acceptable temperature is based on a maximum acceptable injury level of a first degree burn, which is reversible, and causes no permanent tissue damage, and a maximum contact time with the heated surface of 60 seconds, to reflect the slower reaction times of the elderly or the infirm. At this temperature, one must recognize that there is some risk. While those who can react should have sufficient time to remove themselves from contact with the heated surface without sustaining permanent damage, it is incumbent upon the facilities to identify those residents who may be unable to recognize the danger or pull away from the heat source and provide extra protective measures for those residents as needed. Liquids or solids at 72 degrees C./162 degrees F. will cause third degree burns almost instantly. The material being contacted is also significant; hot metals burn the worst because they conduct a continued supply of heat to the burn point, while wood, fabric, or other lesser conductors of heat will not burn as badly because the hot surface will be cooled by the initial transfer of heat to the person being burned. (http://list.uvm.edu/cgi-bin/wa?A2=ind0308C&L=SAFETY&P=3519) ASTM C 1055 - 99 Standard Guide for Heated System Surface Conditions That Produce Contact Burn Injuries notes at 6 .4 .2, If the, surface temperature exceeds 70°C (158oF) and the surface is metallic, it may present a hazard regardless of contact duration. It rephrases this by noting, For extremely high-temperature metallic surfaces (>70°C), damage occurs almost instantaneously upon contact. <http://legacy.library.ucsf.edu/documentStore/x/d/b/xdb34a00/Sxdb34a00.pdf> Resident 2's [DIAGNOSES REDACTED]. Resident 2's Annual Minimum Data Set, dated dated [DATE], Section B0600: Speech is clear. Section B0700: Usually able to make self understood, difficulty communicating some words. Section C0500: Cognitive score 00 indicating Resident 2 is severely cognitively impaired. Section G0110: Needs extensive assist of 2 with bed mobility and transfers. Incident report dated 12/9/15 at 9:00 PM, at 9:00 PM indicated Resident 2 was noted yelling in room. Resident 2 noted to be lying on left side on floor next to window with her back resting on the register. Blood Pressure 130/60, Pulse 109. Resident kept stating to get me home. Contributing factors and Observations: Resident 2 will open the curtain while in bed. Intervention taken to prevent reoccurrence: Bed turned toward the wall. Post fall analysis/plan, dated 12/9/15 at 9:00 PM, Fall details: Roll/slid out of bed. Impaired safety awareness/judgment. Physical assessment after fall: Redness to back. Possible cause: Resident 2 will reach out to open curtain when in bed. Intervention taken: bed was turned to wall. Resident 2's Hospital history of present illness, dated 12/9/15. [AGE] year old female for a fall, found against radiator in the nursing home this evening. Patient has second degree burn to left shoulder and upper arm and 1st degree burn to back. Patient is not oriented but reports pain only with Blood pressure cuff. Review of systems: Complaint of: burn to left shoulder and upper arm (second degree) and back (1st degree). Comments: Wound dressed with silvadene, nonadherent dressing. Review of Resident 2's nursing notes from 12/9/15 through 12/15/15 indicates the following in part: *12/9/15 at 9:19 PM, Situation: Fall. Background: Res (Resident 2) will reach out to open up curtain when in bed. Assessment: at 9:00 PM heard Res yelling in room. Res noted to be lying on left side on floor next to window with back resting in the register. Response: Immediate intervention: Res bed was turned towards wall. At 9:15 Pm (Medical Director name) consulted on res fall. new order received, May send to ER (emergency room ). At 9:21 PM EMS (Emergency Medical Services) here. At 9:25 PM Res sent to ER via ambulance. *12/9/15 at 9:57 PM: Writer (Registered Nurse (RN) I) called to resident room to assess situation. Resident was lying on floor next to the bed and against the wall and baseboard heater. No bleeding noted. Resident moved away from wall with assist of three. Resident was then assisted off the floor and into the bed with gait belt and assist of three. *12/9/15 at 11:34 PM, Resident returned from ER at 10:50 PM. Awake and alert, denies any pain when asked states I'm fine. ABD (abdominal) dressing to left back area and kerlix wrap to left arm per report from ER, Silvadene cream applied to areas. *12/10/15 at 3:00 AM: New order for Silvadene to arm and back daily and cover with non stick dressing and wrap with bandage. *12/11/15 at 10:23 AM: Dressing changed this AM. Shoulder is red and wet as should be, healing as expected no sign/symptom (s/s) of infection. *12/11/15 at 2:23 PM: Dressing remains intact and dry at this time. Resident in gown due to rubbing on burn. Dressing on back remains changed this AM. Will change every other day, new order for dressing on back. *12/11/15 at 10:50 PM: Dressing changed to left shoulder, area is yellow in center with green tinged to edge surrounded with reddened area. Area cleansed and treatment done as ordered with Silvadene cream to area covered with vaseline gauze the abd pads, secured with kerlix. *12/12/15 at 10:26 AM: Patient (Pt) lethargic this am *12/12/15 at 12:20 PM: Patient (Pt) sleepy this afternoon. Pt did not eat lunch. *12/14/15 at 6:32 AM: Late entry, Resident injuries assessed on 12/10/15. Left shoulder is bruised. There is also a burn to bicep that is 14 centimeters (cm) x 8 cm, across the left top of shoulder. Closer to the neck there is a burn that measures 2 cm x 2 cm. Center of mid back shows an area of 9 cm x 5 cm, this area is pink and skin is intact. Treatment (TX) silvadene with vaseline gauze wrapped cling twice a day (BID). On 12/15/15 at 3:40 AM Surveyor interviewed LPN D regarding Resident 2's burn related to the baseboard heater. Surveyor asked LPN D to describe what occurred to Resident 2 the night of 12/9/15 and what were the directions you were given after the incident. LPN D stated she was at the nurses' station and heard Resident 2 yelling. She entered Resident 2's room and Resident 2 was lying on the register. LPN D stated Resident 2 fell between the bed and the wall and landed onto the baseboard heater. LPN D moved Resident 2 away from heater and called for the RN. LPN D stated she then called the Medical Doctor and sent Resident 2 to the hospital. (Note: Resident 2 had cold compresses applied to her back as first aid by RN I prior to being sent to the hospital) LPN D then stated she called NHA A and was directed to turn off all the breakers to the baseboard heaters off on the 300 and 400 hallways. LPN D stated she turned off the breakers on the 400 hall and another nurse turned off the 300 hallway breakers as directed. Surveyor 2904 asked LPN D if she was directed to do anything else from NHA A. LPN D stated no, NHA A just told me to turn off the breakers. On 12/15/15 at 3:20 AM Surveyor interviewed NHA A regarding the incident that occurred with Resident 2. NHA A stated he received a call from LPN D. At that time he was informed she had called the Medical Doctor and was going to send Resident 2 to the hospital. NHA A stated he then informed LPN D to shut everything off (baseboard heaters) to the North unit (300 and 400 hallways). Maintenance (staff) came in then on Thursday and began to investigate an alternative to using the baseboard heat and still maintain the heat to comfortable levels. On 12/15/15 at 3:30 PM Surveyor spoke with Director of Nursing (DON) B regarding the hot baseboard heaters and the burn resulting to Resident 2 from the hot baseboard heaters. DON B stated she was immediately aware of the incident and gave direction to move all beds 3 feet away from the heaters. DON B stated she did provide training to the staff right after the incident to help prevent reoccurrence. According to the sign-in sheet for this meeting, staff was informed to keep all bed three feet from registers and to offer blankets if residents complained of being cold. On 12/15/15 at 3:30 PM Surveyor asked DON B if there was a training form for turning off the baseboard heaters and leaving them off. DON B stated, no, she did not do training on the baseboard heaters with the facility staff. No further information was provided to Surveyor 2909 On 12/15/15 at 8:55 AM Surveyor entered room 208. While checking the heating unit the Surveyor touched the heating baseboard unit and was unable to keep a hand on the top of the baseboard due to the high temperature. A sign on baseboard heater stated: Caution high Temperature. Keep drapes, cords and other furnishings away from heater. Not for residential use in the USA. Subsequent to determining that the register in room 208 was hot to touch, surveyors checked the baseboard heaters in other rooms. Surveyor noted the following on 12/15/15 at 9:15 AM on the 100 and 200 hallways of the facility: In rooms 203, 205, 211, 220, 222, 103, 105, 109, 111, and 115, the baseboard heaters were noted to be very hot. Surveyor touched the heating baseboard units in each room and was unable to keep a hand on the top of the baseboard due to the high temperature. In addition, in room 103 the window was open in the room, due to room being very warm. On 12/15/15 at 9:22 AM Surveyor entered Resident 3's room with permission. Resident 3 was sitting in his wheel chair in the middle of his room. Resident 3's reclining chair was placed against the baseboard heater next to the window. Chair cords were noted to be lying directly on the baseboard heating unit. While checking the heating unit the Surveyor touched the heating baseboard unit and was unable to keep a hand on the top of the baseboard due to the high temperature. Temperature of the heating unit was taken and registered 265 degrees. Surveyor asked Resident 3 if he ever sits in the reclining chair in his room. Resident 3 indicated he likes his chair and does ask to be placed in his recliner during the day. On 12/15/15 at 9:35 AM, Surveyor entered Resident 3's room with Nursing Home Administrator (NHA) A. NHA A felt Resident 3's baseboard heater. NHA A stated Resident 3's baseboard heater was hot. Surveyor informed NHA A of the temperature results at 9:22 AM. NHA A stated yes that is too hot to be on in Resident 3's room. NHA A stated he directed last Wednesday (12/9/15) night that all of the baseboard heaters on the 300 and 400 units be shut off. NHA A stated a couple of people in the building are aware of how to turn on and off the baseboard heaters by the breaker switches. NHA A exited Resident 3's room and walked up the Registered Nurse (RN) E and instructed RN E to turn off the breaker for Resident 3's baseboard heater. On 12/45/15 at 9:42 AM Surveyor and NHA A entered the lounge on the 200 unit. Surveyor and NHA A observed a small couch sitting directly in front of the baseboard heater and next to the couch was a wooden end table directly touching the baseboard heater. NHA A moved the furniture away from the baseboard heater. NHA A and Surveyor felt the back of the couch. NHA A acknowleded that the back of the couch was warm. While checking the heating unit the Surveyor touched the heating baseboard unit and was unable to keep a hand on the top of the baseboard due to the high temperature. Surveyor asked NHA A to assess the temperature of the baseboard heater. NHA A stated the baseboard heater is hot. Surveyor asked NHA A how long he thought he could keep his hand on the baseboard heater. NHA A stated it is too hot to keep hand still on heater. NHA A rubbed his hand along the heater and did not keep his hand in 1 area on the heater. Temperature of the baseboard heater was taken and the reading was 228 degrees. NHA A stated that is too hot and then stated I will have the 100 and 200 hallway baseboard heaters turned off immediately. (Note: All 74 residents in the facility have access to the lounge area on the 200 hallway.) On 12/15/15 at 11:35 AM, Surveyor interviewed Maintenance Director (MD) C regarding the baseboard heaters. Surveyor asked MD C when he became aware of the baseboard heaters running too hot. MD C stated he came to the facility per NHA A request on Thursday morning 12/10/15 to evaluate the heating problem on the 300 hallway. MD C stated he became aware of the incident with Resident 2 and was informed by NHA A that all of the baseboard heaters were shut off on the 300 and 400 wings by using the breaker box in the electrical closet. MD C stated there is an electrical closet on each wing that has breakers for all of the baseboard heaters in every room in the facility. MD C stated the facility has an HVAC (Heating ventilating and air conditioning) system that supplies hot and cold forced air that he was trying to fix so the building would run on the HVAC system and not have to use the baseboard heaters in the rooms. MD C stated he has companies coming in to evaluate the HVAC unit to see what needs to be fixed so the air will be warm in the facility. Surveyor asked MD C if he took baseboard heating temperatures while he was in the facility. MD C stated on Thursday he tested the heaters in room 407 and 409. MD C stated in room 407 the temperature was within range at 98 degrees, but in room 409 the heater temperature was 222 degrees. MD C stated you could not touch the unit it was too hot. MD C also stated on Friday (2 days after the incident occurred) he tested the room where Resident 2 resides. MD C stated he had the baseboard heater on for 10 minutes and tested the heat from the heater. MD C stated just after 10 minutes the heater read 186 degrees. MD C stated he turned down the baseboard heater in the room just a 1/4 turn and the heater turned off. MD C stated at that point we knew we were dealing with a malfunctioning heater system; the heater should have turned down and not just turned off right away. Surveyor asked MD C if he told anyone about the high temperatures of 222 degrees and 186 degrees. MD C stated he informed NHA A of the heater temps and the malfunctioning heaters on Thursday and again had another conversation with NHA A on Friday related to Resident 2's heater temperature because she was the one who had the incident. Surveyor asked MD C who all has access currently to the baseboard heaters. MD C stated he was informed last week there is a key to the closet and everyone has access; he also stated he was told by staff how to turn up or down the heat to the baseboard heaters by using a screw driver. This was general knowledge by all staff. Surveyor asked MD C when the last time the baseboard heaters were tested by anyone in the facility. MD C stated last Friday when he tested room 302. Surveyor asked MD C if he tested any heaters on the 100 or 200 hallway. MD C stated he did not test or look at any baseboard heaters on the other side of the building only on the north side, which consists of the 300 and 400 hallways. Surveyor asked MD C if he had been asked to turn off the breakers to the north side of the building. MD C stated he was only instructed to turn off the 300 and 400 hallways. Surveyor asked MD C if the South side of the building (the 100 and 200 hallway) used the same baseboard heating system as the North side of the building. MD C stated yes the baseboard heaters are the same throughout the building. MD C stated the Dining rooms and the lounges have the same baseboard heaters on the North and South side of the building. Surveyor informed MD C of the hot baseboards located on the 100 and 200 hallways during initial tour of the facility. MD C stated he was not surprised of the same issue going on the 100 and 200 hallways. Surveyor asked MD C why the electrical closets were accessible to all staff to turn on and off the breakers. MD C stated that is a good question. The closets and heater should have been locked out and keyed out for resident and staff safety especially after the heaters were found to be hot and possibly malfunctioning. MD C also stated; it just takes one CNA to turn up the units with a screw driver and no one monitoring the heaters temperature to cause another burning potential. On 12/15/15 at 11:44 AM Surveyor spoke with Certified Nursing Assistant (CNA) H regarding the baseboard heaters in the resident rooms. CNA H was found working on the 300 hallway where Resident 2 resides. Surveyor asked CNA H if she had training related to the baseboard heaters and if she was aware the baseboard heaters were not to be in use. CNA H stated she was not trained related to not using the baseboard heaters and was not aware the baseboard heaters were not allowed to be turned on for the residents when they complained they were cold. CNA H stated she does go to the nurse to have the heater turned on when the residents complain they are cold. On 12/15/15 at 11:47 AM Surveyor spoke with Licensed Practical Nurse (LPN) F regarding the baseboard heaters in the residents' room. LPN F is the assigned nurse for the day shift for the 300 hallway, where Resident 2 resides. Surveyor asked LPN F is she had any training related to using the baseboard heaters in the resident rooms. LPN F stated no she was not trained that the baseboard heaters in the resident rooms were not to be turned on. Surveyor asked LPN F if she had a key to the electrical closet where the breakers are located to turn on and off other baseboard heaters. LPN F stated she does not have a key on her, the key may be on the charge nurse key ring or it could be the key hanging by the medication room door. LPN F stated she is aware some of the beds were turned away from the heaters so the foot of the bed was closest to the baseboard heaters. Surveyor asked LPN F what she would do today if a resident requested the heat to be either turned on or turned up due to being cold in their room. LPN F stated she would inform Registered Nurse (RN) E of the request. LPN F stated RN E is the charge nurse and she would take care of it. On 12/15/15 at 11:49 AM Surveyor spoke with CNA G regarding the baseboard heaters in the resident rooms, CNA G was found working on the 300 hallway where Resident 2 resides. Surveyor asked CNA G if she had training related to the baseboard heaters and if she was aware the baseboard heaters were not to be in use. CNA G stated she was not trained related to not using the baseboard heaters and was not aware the baseboard heaters were not allowed to be turned on for the residents. CNA G stated she is aware of how to turn on and turn up the baseboard heaters. CNA G stated she has not touched any heaters today, but is aware there is a screw driver in the cupboard to use to turn up the baseboard heaters in the rooms when a resident states he or she is cold. CNA G stated she is aware CNAs are using the screw driver to adjust the heat for the residents. CNA G also stated the breakers to the heaters are in the closet and the key is obtained from the nurse at the desk. On 12/15/15 at 11:55 AM, Surveyor spoke with RN E regarding the baseboard heaters in the resident rooms. RN E stated she is the RN in charge today on the 400 wing. Surveyor asked RN E is she had any training regarding the use of the baseboard heaters. RN E stated no she has not had any training regarding using the baseboard heaters. Surveyor asked RN E who has the key to open the electrical closet for the breakers to the baseboard heaters to turn them on and off. RN E stated she is the one who turns the breakers on and off in the facility on the 300 and 400 wing when she is on duty. RN E stated the key to the electrical closets is hanging in the nurses' station just outside of the medication room door. The key is on a white stick type device; most staff in the facility knows where to find the key. RN E stated everyone has access to the closet and knows how to turn up the baseboard heaters in the rooms. Surveyor asked RN E if this morning at 7:00 AM if a CNA would have approached you and indicated a resident was cold and wanted their heat on what would you have done. RN E stated I was not aware that the heaters were not to be turned on, I would have gone to the closet and turned on the breaker per the resident request. RN E also stated there is not a note posted in the electrical closet to indicate not to turn on the breakers to restart the baseboard heaters. RN E stated there was no indication in report or anywhere to tell me not to use the baseboard heaters prior to NHA informing her to turn off room 416. On 12/15/15 at 12:02 PM Surveyor spoke with MD C regarding current temperature of baseboard heaters. MD C made a room sweep of the 100 and 200 hallway and stated the base board heaters are still on and working. MD C reported the following temperatures. *Room 222 current baseboard temperature registered 173. 48 degrees higher than the maximum temperature of 125. *Room 103 current baseboard temperature registered at 170 degrees. 45 degrees higher that the maximum temperature of 125. On 12/15/15 at 1:47 PM, Surveyor asked RN E, who was sitting in the nurses' station, to show Surveyor the process of turning on the breakers to the baseboard heaters in the 4 wings of the facility. RN S stated the closet on 400 wing only controls the 400 wings rooms. RN E removed the key from the side of the cupboard near the medication room door. They key was placed on a hook inside the open nurses station available for the entire facility staff to have access. RN E walked down the 400 hallway to a closet named Electrical closet. RN E attempted to open the door. RN E stated the door won't open. MD C walked up to RN E and stated he changed the lock this afternoon. MD C stated NHA A is the only person in the facility now with access to the electrical closet. MD C left to get the key. RN E walked inside the closet and a note was posted on the electrical unit. The note stated Do not turn on baseboard heaters until further notice. RN E stated this note was not here this morning when NHA A asked me to turn off the heater to room 416. On 12/15/15 at 1:47 PM Surveyor and MD C reviewed all the breakers to the 400 hallway. MD C validated all the breakers to the baseboard heaters were off. Surveyor and MD C went to the 300 hallway closet. MD C opened the door to the breakers. MD C validated all of the breakers to the baseboard heaters were off. Surveyor asked MD C what is the maximum temperature per the facility policy the heaters are to reach MD C stated the maximum temperature is 125 degrees. On 12/15/15 at 1:56 PM Surveyor and MD C went to the 100 hall way electrical closet. A note was posted on the electrical panel door; Do not turn on the baseboard heaters until further notice. MD C began turning off the breaker switches. MD C stated, I do not believe this note is posted on the right breaker box. MD C left the room and stated he just shut off the lights in the next room. MD C opened the breaker box across the closet. MD C stated this is the right box. MD C again stated the baseboard heaters are still on for the 100 hall. MD C turned 6 breaker switches to the baseboard heaters in the resident rooms to the off position. MD C moved the note to the baseboard breaker box. On 12/15/15 at 2:02 PM Surveyor and MD C entered the 200 hall way electrical closet. MD C stated the lounge and the rooms on the 200 hallway are still in the on position. MD C turned 3 rooms and lounge baseboard heaters to the off position on the 200 hallway. Failure to ensure that the residents' environment was free of accident hazards created a potential for serious burns to occur. Third-degree burn affects all layers of the skin. The outer layer (epidermis) and the layer underneath it (dermis) are both burned. A third-degree burn may also injure the nerves, blood vessels, and muscles under the skin.A third-degree burn is the worst type of burn. Third-degree burns are always medical emergencies .A third-degree burn must be treated properly. If the burn is not treated, your body can lose important fluids. This type of burn can also cause infection and lasting injury. Very bad third-degree burns may need to be treated at a hospital that has a burn unit. http://www.sw.org/HealthLibrary?page=Third-Degree%20Burn The facility removed the Immediate Jeopardy on 12/15/15 by implementing the following interventions: * All facility electrical closets have had locks changed - ED (Executive Director - NHA A) and Maintenance only are designated key holders. *All baseboards heating units are and will remain off until appropriate repairs or alternatives are made. *HVAC vendor to be onsite for alternatives beginning 12/16/15. *House wide education will be provided related to the prevention and non-use of the facility baseboards and reporting of any concerns to both Executive Director and Director of Nursing Services. Training will be provided at huddles prior to staff working the floors. No staff shall work until the training is completed. *Temperature Maintenance will be conducting and audited for adjustments by facility staff using laser gun for accuracy. Results will be recorded and out of compliance temperatures will be reported to Executive Director, Director of Nursing and Maintenance for adjustment, as needed.

Based on observation, interview and record review the facility did not ensure that a resident who enters the facility without a pressure ulcer does not develop a pressure ulcer and a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for 2 of 3 residents (Residents 1 and 3) reviewed for PU. Resident 1 was admitted to the facility without a pressure ulcer (PU) and was identified to be at risk for PU development. Resident 1 developed multiple stage II pressure ulcers without new care plan interventions to promote healing or prevent future pressure ulcer from developing. Resident 1 is incontinent of bladder and the facility developed a plan of care that directs staff to check and change every 2 - 3 hours for incontinence and to reposition every 2 hours. These interventions were developed to promote healing of the current pressure ulcer and to decrease the risk of developing new pressure ulcers. These interventions were not followed and Resident 1 was observed for an extended period of time without staff assistance. When staff did assist with repositioning/personal cares, Resident 1 was observed to be saturated with urine up the resident's back. Furthermore, during a bladder incontinent episode, the dressing which protected the pressure ulcer became saturated with urine. Resident 3 was identified to be at risk for pressure ulcers. Observation was made where Resident 3's heels were not floated off of the bed. This is evidence by: The National Pressure Ulcer Advisory Panel (NPUAP): Prevention and treatment of [REDACTED]. As a result of pressure or pressure in combination with shear a number of contributing or confounding factors are associated with pressure ulcers. Pressure ulcer classification should be used to document tissue loss in ulcers resulting from pressure re or pressure rein combination of shear. Preventive skin care: 1. Avoid positioning the individual on an area of [DIAGNOSES REDACTED] whenever possible. [DIAGNOSES REDACTED] indicates that the body has not recovered from the previous loading and requires further respite from repeated loading. Repositioning and early mobilization: General repositioning for all individuals: 2. Consider the condition of the individual and the pressure redistribution support surface in use when deciding if repositioning should be implemented as a preventive strategy. Repositioning techniques: 1. Reposition the individual in such a way that the pressure is relieved or redistributed. 2. Avoid positioning the individual on bony prominences with existing non blanchable [DIAGNOSES REDACTED]. Non-blanchable [DIAGNOSES REDACTED] is an early sign of pressure ulcer damage. If an individual is positioned directly onto bony prominences with pre-existing non-blanchable [DIAGNOSES REDACTED], the pressure and/or shearing force sustained will further occlude blood supply to the skin, there by worsening the damage and resulting in more severe pressure ulceration. 3. Avoid subjecting the skin to pressure or shear force. Additional recommendation for individuals with existing pressure ulcers: 1. Do not position an individual directly on a pressure ulcer. Repositioning to prevent and treat heel pressure ulcers: 1. Ensure that the heels are free of the surface of the bed. Use heel suspensions devices that elevate and offload the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon. Apply heel devices according to the manufacturing instructions. Example 1 Resident 1 [DIAGNOSES REDACTED]. Resident 1's Annual Minimum Data Set, dated dated [DATE], Section C0500: Cognitive score 00 indicating Resident 1 is severely cognitively impaired. Section G0110: Needs extensive assist of 2 with bed mobility and transfers. Section H0300 Incontinent: Always incontinent of urine with no episodes of continent. Section M0150 Pressure ulcers: Resident 1 is at risk for pressure ulcers and Section M0300: Resident 1 currently has a stage II pressure ulcer. Resident 1's Care Area Assessment (CAA) dated 9/22/15, triggering condition: Pressure ulcer: Is long term resident on Hospice services. Needs assist with bed mobility, transfer, toileting, locomotion, dressing, hygiene, and bathing. Has short and long term memory problem. [DIAGNOSES REDACTED]. Is Incontinent of bowel and bladder. Braden scale 12. Resident 1's care plan titled Pressure ulcer risk, dated 9/30/14, Actual acquired 4/16/15 Coccyx, right buttock, left buttock (coccyx resolved 5/7/15 and right buttock resolved 5/3/15) Stage II acquired 7/4/15 and resolved 7/28/15. Stage II pressure ulcer to gluteal cleft (Just below the coccyx area groove between the buttock) 8/25/15. Goal: Skin will remain intact thru next review date. Date initiated 9/30/14 revision 8/27/15. (Resident 1 has a current alteration in skin.) Interventions: Reposition every 2 hours date initiated 10/3/14, revised on 3/24/15. Pressure reducing cushion to wheel chair and pressure reducing mattress to the bed date initiated 9/30/14. Use wedge pillow for positioning in bed dated 7/30/15. Resident 1's care plan titled Pressure ulcer actual or risk due to pressure ulcer present, dated 9/30/14, Actual acquired 4/16/15 Coccyx, right buttock, left buttock (coccyx resolved 5/7/15 and right buttock resolved 5/3/15) Stage II acquired 7/4/15 and resolved 7/28/15. Stage II pressure ulcer to gluteal cleft (Just below the coccyx area groove between the buttock) 8/25/15. Goal: Skin will remain intact thru next review date. Date initiated 9/30/14 revision 8/27/15. Note: Resident 1's has a history of recurring pressure ulcers to her coccyx and buttock area. Resident 1's care plan does not show evidence of how long Resident 1 should be sitting in her wheelchair or when Resident 1 should be placed in bed to off load complete pressure from her buttock and coccyx area. Resident 1's Braden scale for predicting pressure ulcers, dated 6/18/15, total score = 14 (A score of 13 - 14 Moderate risk for developing pressure ulcers). Resident 1's Braden scale was completed again on 9/13/15, total score = 12 (A score of 10 - 12 high risk for developing pressure ulcers). (Note: Resident 1's Braden scale declined from Moderate risk to High risk in 3 months. There have been no changes to Resident 1's care plan to off load Resident 1 related to her current pressure ulcer or to prevent further pressure ulcers.) Resident 1's Nutrition assessment in part, dated 9/18/15, Nutrition Data: Skin status, Stage 2 (Note: History of Pressure ulcers is not checked on the assessment). Pertinent laboratory (lab) tests: None is marked for [MEDICATION NAME] value and [MEDICATION NAME]. (All lab test indicating protein for wound healing.) Nutrition Diagnosis: [REDACTED]. Interventions: Encourage fluids throughout the day. Monitor meal consumption. Obtain and update food and beverage preferences. Provide diet as ordered. Sit with Resident 1 when she needs encouragement to keep eating. Gaol: Maintain adequate intake to prevent significant weight changes. Additional information: Current intake at meals is 38%. Intake of house supplements is 100%. Per nursing resident has a Stage II wound to the gluteal cleft. No other open areas. Will continue to monitor and provide fluid and foods as resident desires for comfort. (Note: The assessment does not calculate the added nutrition or protein needed for wound healing. No changes in the nutrition plan of care were made to promote wound healing or wound reoccurrence.) Review of Resident 1's nursing notes related to Pressure ulcer history: *4/26/15 at 6:46 PM- 3 small open areas noted in upper gluteal fold, each 3 centimeters (cm) long. *4/26/15 at 9:17 PM, Registered Nurse (RN) assessment of open areas to buttocks, 3 open slits, one located medial upper gluteal measuring 1.2 cm by 0.2 cm, second on right buttock 1.0 by 0.5 cm and the third to the left buttocks measure 1.0 by 0.5 cm. Mepelix and Mepore applied. *5/8/15 at 6:00 AM, Area is healed to gluteal fold. *7/4/15 at 3:15 PM, Change of condition: Open are noted to gluteal fold. Assessment: Open are measuring 3.0 cm by 0.5 cm small amount of white macerated skin at the left. *7/4/15 at 8:40 PM, Open area to coccyx measure 3.0 cm by 0.5 cm. Mepore and [MEDICATION NAME] applied. *7/8/15 at 11:20 AM, Nursing reports stage II ulcer to gluteal fold. *7/22/15 at 5:45 AM, Weekly wound note: Macerated area measuring approximately 1 cm by 0.2 cm noted in the interglutael cleft. *7/29/15 at 2:01 PM, Gluteal fold healed. Review of Resident 1's Wound evaluation flow sheets from 2/25/15 through 7/29/15 *2/25/15 Stage II right buttock. (Original onset date) *4/26/15 Stage II coccyx, medial upper gluteal fold. (Original onset date) *4/26/15 Stage II Left Buttock (Original onset date) *4/26/15 Stage II Right Buttock (Original onset date) *7/6/15 (date written above first entry indicates 7/4/15 3.0 X 0.5 cm) Stage II coccyx (intergluteal cleft). (Original onset date) Resident 1's Physician order, dated 8/25/15, Apply skin prep, [MEDICATION NAME] and Mepore to coccyx every day shift every 2 days. Review of Resident 1's current Wound evaluation flow sheet pressure ulcer form states the following: *8/25/15 Stage II Gluteal fold re-opened 2 cm by 0.5 cm. Surrounding tissue: Pink and blanches. [MEDICATION NAME]/Mepore every other day. *9/8/15, 1.8 centimeters (cm) long by 0.3 centimeters wide. Pink with maceration. Current treatment: [MEDICATION NAME] border every other day. *9/15/15, 3 cm long by 0.3 cm wide (increased in size) 75 % maceration. Current treatment [MEDICATION NAME]/Mepore, keep fold dry. (Increase in size, Resident 1 physician not consulted, no changes to treatment plan or Resident 1's plan of care.) *9/22/15, 3 cm long by 0.3 cm wide (no change in wound) 60 % maceration. Current treatment: as above. (Note: No changes to Resident 1's treatment plan or Resident 1's plan of care.) *9/29/15, 3 centimeters (cm) long by 0.3 cm wide (no change in wound). 70% macerated and 30% granulation. Wound status/additional comments: Monitor. Note: Resident 1's pressure ulcer continues to be macerated and no change in wound size or appearance. No changes to Resident 1's treatment have occurred to promote pressure ulcer healing. No changes to Resident 1's care plan to promote off loading or to give the staff direction when to place Resident 1 completely off of her pressure ulcer area. Resident 1's Treatment Administration record (TAR), dated 10/1/15 through 10/31/15, Apply skin prep, [MEDICATION NAME] and Mepore to coccyx every day shift for slit to coccyx until healed. Apply A&D to buttock, after urination every time every shift for [MEDICATION NAME]. Note: Medline company recommendations for [MEDICATION NAME] self-adhesive absorbent dressing. May be used for surgical wounds, minor burns, and abrasions. ([MEDICATION NAME] does not contain a pressure ulcer healing medication or properties.) On 10/2/15 at 5:40 AM Surveyor observed Resident 1 up in her wheel chair leaning to the left sleeping in the north lounge. On 10/2/15 at 6:10 AM Surveyor spoke with Certified Nursing Assistant (CNA) N regarding what time Resident 1 was out of bed this AM and when last rounds to check for incontinence was completed. CNA N stated the last round was completed prior to 5:00 AM. The residents are then gotten out of bed and not further rounds for incontinence are completed. Resident 1 has been out of bed since around 5:15 AM. On 10/2/15 at 8:30 AM, Surveyor observed Resident 1 being removed from the North lounge and placed in the dining room for breakfast. On 10/2/15 at 9:49 AM, Surveyor observed Resident 1 being taken to her room. Resident 1was removed from her wheelchair via the EZ stand lift onto the commode. Licensed Practical Nurse (LPN) O removed Resident 1's incontinent brief. Resident 1's incontinent brief was saturated with urine. Resident 1's white bordered dressing ([MEDICATION NAME]) was removed from her Stage II pressure ulcer just below the coccyx area extended into the groove between the buttock (Gluteal cleft per facility definition). Resident 1's pressure ulcer was white in color and macerated within the wound bed and the surrounding skin. Resident 1's pressure ulcer was approximately 3 cm long by .03 cm wide. Resident 1 was then placed on the commode at her bedside. Resident 1 remained sitting her in wheel chair for 4 1/2 hour before she was lifted by the EZ lift mechanical machine and placed on the commode in her room. On 10/2/1 4 at 1:58 PM, Surveyor interviewed Director of Nursing (DON) B regarding Resident 1 pressure ulcer and not being repositioned for over 4 hours. DON B stated Resident 1's pressure ulcer keeps reoccurring after she has healed the old ones. DON B stated she would expect Resident 1 to have been toileted and repositioned every 2 hours. DON B also stated she would expect Resident 1's care plan to be followed. There is no indication throughout the record that the facility made changes in Resident 1's care to prevent the redevelopment of pressure ulcers. Example 2 Resident 3's [DIAGNOSES REDACTED]. Resident 3's Quarterly Minimum Data Set, dated dated [DATE], Section C0500: Cognitive score 7 indicating Resident 3 is cognitively impaired. Section G0110: Needs extensive assist of 2 with bed mobility, transfers and toileting. Section H0300 Incontinent: Always incontinent of urine with no episodes of continent. Section M0150 Pressure ulcers: Resident 3 is at risk for pressure ulcers. Resident 3's care plan titled, Potential for altered skin integrity due to Assistance required in bed mobility. Intervention: Encourage: Floating heels. Resident 3's Braden scale was completed again on 9/25/15, total score = 12 (10 - 12 high risk for developing pressure ulcers). On 10/2/15 at 7:50 AM, Surveyor observed Resident 3 lying in bed. Certified Nursing Assistant (CNA) D remove the covers from Resident 3's lower half of her body to expose her legs and feet. Resident 3's feet were lying directly on the bed. Resident 3 had a pillow placed under her bilateral knees to her mid calves. CNA U removed Resident 3's socks. Resident 3's bilateral heels were pink/red in color and soft/spongy in appearance. CNA U replaced Resident 3's socks. On 10/2/15 at 1:58 PM, Surveyor interviewed Director of Nursing (DON) B regarding Resident at risk for Pressure ulcers and prevention interventions for Resident 3's heels. DON B stated she would expect Resident 3 to have her heels floated when in bed. DON B stated Resident 3's pillow should have been placed to ensure her heels would be floated while lying in the bed.

Based on interview and record review the facility did not ensure each resident or the resident's legal representative was offered the influenza vaccination and received education regarding the benefits and potential side effects of the immunization for 1 of 12 residents (Resident 6) Resident 6's guardian was not offered the opportunity for Resident 6 to be vaccinated against influenza and was not provided with the risks and benefits of the influenza immunization. As a result, Resident 6 did not receive the immunization. Resident 6 subsequently became ill with influenza. This is evidenced by the following: Resident 6 was placed under guardianship in 2010 and is protectively placed in the facility. Resident 6's face sheet, dated 9/25/12 indicates Resident 6 has a guardian. In 2011, Resident 6's guardian (Guardian O) consented for and Resident 6 received the influenza vaccination. The facility's "Immunization Consent or Declination" form is signed by Resident 6 on 10/8/12 and refuse is circled. Resident 6's nursing notes for 10/8/12 indicate Resident 6 was offered and refused the influenza vaccination. There is no indication that the facility obtained Guardian O's consent/declination for the influenza vaccination or informed Guardian O that Resident 6 refused the vaccination. Resident 6's nursing notes indicate on 1/17/13 Resident 6 has a non-productive cough and runny nose. Resident 6 complains of not feeling well. Resident 6's physician ordered an influenza test. Resident 6's laboratory test results show a positive influenza A test on 1/17/13. Resident 6's nursing notes on 1/24/13 indicate: Non-productive, congested cough noted. Continues on droplet precautions for influenza. Resident 6 is listed on the facility's "Acute Respiratory Illness: Data Collection Line Listing" with an onset date of 1/17/13. Symptoms noted are: Temperature-98.2; "NP" Non-Productive Cough, and Congestion. The listing indicates an Influenza Test completed on 1/17/13 was positive (+) for Influenza A. A note states: "1/23 still s/sx (signs/symptoms.)" There is no information noted that states when the symptoms resolved. The column for Outcome-Date is blank. Resident 6 did not have an Infection Control Care Plan for the Influenza (cross reference F441.) On 1/30/13, at 9:45 AM, Surveyor interviewed Registered Nurse (RN) C who is also in charge of the infection control program. RN C stated at the beginning of the flu season consents for the immunizations were obtained by a nurse or RN C. RN C stated the consents were signed by the resident or the power of attorney (POA) or guardian if activated. RN C confirmed he was the one who had Resident 6 sign the consent form and stated he thought Resident 6 was his own person. RN C then looked at Resident 6's face sheet and stated he has a guardian. RN C then stated if he spoke with the guardian about the vaccination he would have made a note in Resident 6's nursing notes. On 1/30/13, at 9:54 AM, Surveyor interviewed Guardian O via phone. Guardian O stated he did not recall being asked about Resident 6 receiving the influenza vaccination or the risks and benefits of the vaccination. Guardian O stated if he would have been asked he would have consented as he always does. On 1/30/13, at 12:04 PM, Surveyor interviewed RN C again. RN C stated he had obtained a list from Social Services to indicate who had an activated POA or guardian. RN C stated Resident 6 must not have been on their list thus RN C had Resident 6 sign the consent. RN C stated Resident 6 would have been on droplet precautions when the first symptoms developed for the duration of the illness or outbreak. RN C stated Resident 6 probably came off isolation last Friday (1/25/13).

Based on record reviews, interviews, and observation, the facility did not ensure that 2 of 7 sampled residents (Residents 5 and 3) were provided the necessary supervision and assistive devices to prevent falls. The facility did not take into account all of Resident 5's available completed assessments when determining appropriate interventions after he fell on [DATE] and [DATE]. Speech therapy assessments had shown that the resident had poor cognitive and memory scores, yet the facility continued to rely on verbal cuing and reminders as the primary means for keeping the resident safe. Resident 5's care plan was not updated after these falls. Resident 5 fell on [DATE] and broke his left hip. Resident 3 experienced multiple falls in the facility. Following the falls the facility did not ensure measures were in place and that an assessment was completed to find the root cause of the problem and appropriate interventions were put into place. As evidenced by: The facility's policy "Falls Management Clinical Guidelines" revised [DATE] indicates the following: The center implements the falls prevention and intervention program including: -The resident and/or resident's representative are provided education regarding fall risk incorporating "Fall Risk Brochure." -The interdisciplinary team evaluates the fall prevention plan of care for residents "at risk" for falls...This evaluation may include a screening by a rehabilitation services representative and pharmacy consultant for medications that could affect balance or gait. -Following a resident's fall: --Appropriate interventions are implemented. --Care plan is updated. -Continue ongoing assessment and documentation by licensed nurses per center practice. --The Interdisciplinary Team reviews the Change of Condition Report-Post Fall/Trauma and makes additional recommendations within 72 hours of the fall. Example 1 Resident 5 was admitted to the facility on [DATE] after a left fourth toe amputation with [DIAGNOSES REDACTED]. Resident 5's Minimum Data Set (MDS) completed [DATE] indicates under Cognitive Patterns a score of 9. His 14 day MDS completed [DATE] indicates a Cognitive Patters score of 8. A score of 8 to 12 indicates moderately impaired cognitive pattern. Resident 5 is his own person and does not have advance directives activated. The facility Clinical Health Status form for Resident 5 completed on [DATE] states his cognitive skills for decision making were independent, consistent, and reasonable. Under Section M, risk for falls, Resident 5 had a score of 14 (10 or higher deems resident at risk for falls). Resident 5 fell from his bed on [DATE]. The facility Change in Condition Report - Post Fall/Trauma completed [DATE] indicates under interventions used prior to fall: safety cues/reinforcement/reminder. It is important to note the Resident 5's care plan with print dates [DATE] and [DATE] does not include this intervention. Surveyor interviewed Director of Nursing (DON) B on [DATE] at 2:55 PM; the DON stated the intervention of safety cues/reinforcement/reminder would be to remind or educate Resident 5 to use the call light to ask for assistance when he needs it. The facility Clinical Health Status form for Resident 5 completed on [DATE] states next to short term memory, occasional confusion and that his cognitive skills for decision making were independent, consistent, and reasonable. Under Section M, risk for falls, Resident 5 had a score of 12 (10 or higher deems resident at risk for falls). The facility speech therapy initial assessment signed [DATE] states Resident 5's current cognitive level as moderate/severe and breaks it down: immediate memory - moderate/severe ,[DATE]% accuracy, short term memory - moderate ,[DATE]% accuracy, and problem solving/reasoning - moderate/severe ,[DATE]% accuracy. The facility Clinical Health Status form for Resident 5 completed on [DATE] states his cognitive skills for decision making were independent, consistent, and reasonable. Under Section M, risk for falls, Resident 5 had a score of 8 (10 or higher deems resident at risk for falls). The facility speech therapy initial assessment signed [DATE] indicates Resident 5 participated in Allen Cognitive Placemat Test to assess cognition. Resident 5 achieved a score consistent with moderate to severe cognitive impairments. Resident 5 fell from his bed on [DATE]. The facility Change in Condition Report - Post Fall/Trauma completed [DATE] indicates under interventions used prior to fall: safety cues/reinforcement/reminder. It is important to note that this intervention was not included on Resident 5's care plan with print date of [DATE]. The facility continued to rely on cuing and reminders even though the speech therapy assessments showed that cuing and reminders would not have been effective approaches given the resident's cognitive and memory limitations. The facility Speech Therapy - Therapist Progress Report signed on [DATE] states Resident 5 under executive function presents with low-level cognitive abilities, unable to accurately complete simple convergent problem solving tasks, had 35% accuracy defining words by function, presents limited ability to name everyday objects presented, unable to name one of his children, demonstrated success responding to yes/no questions, and demonstrated difficulty responding to open-ended questions. Under orientation it states Resident 5 demonstrated limited awareness and orientation to time/place, and unable to independently accurately generate current time/place with exception of current town at times. Under Memory the report states Resident 5 demonstrates a moderate/severe impairment of memory, impacting ability to safely/independently complete activities of daily living. Resident 5 demonstrated difficulty remembering personal details. The clinical impression is Resident 5 presents with lower-level cognitive abilities, demonstrates confusion i.e. during one session patient (Resident 5) was convinced he was just drinking a beer, however, he was not. Patient (Resident 5) demonstrates physical jerkiness at times. The facility documentation on [DATE] indicates a Brief Interview for Mental Status (BIMS) was attempted but Resident 5 fell asleep during the interview and describes him as very difficult to arouse. "Confusion" is also written on the form. The MDS with date [DATE] indicates staff were interviewed and Resident 5 is independent in making decisions regarding tasks of daily life and does not indicate short term or long term memory problems. On [DATE] at 4:00 PM Surveyor interviewed RN Assessment Coordinator (RNAC) C who stated she did not complete the MDS assessment dated [DATE]. RNAC C stated since Resident 5 was unable to complete the BIMS assessment the nursing staff that work with Resident 5 would have been interviewed to gather data to complete the MDS assessment. RNAC C stated therapy staff is not interviewed for the MDS assessment. Resident 5 fell on [DATE]. The facility Change in Condition Report - Post Fall/Trauma completed [DATE] indicates under interventions used prior to fall: safety cues/reinforcement/reminder. Under IDT Review and Recommendations the form states for an intervention education on calling for assistance when needed. It is important to note there was no evidence that Resident 5's care plan was updated with this intervention or that other approaches that would have been more effective with this resident's cognitive and memory limitations were attempted. On [DATE] at 2:55 PM Surveyor interviewed DON B who stated she spoke to the nurse who filled the form out and Resident 5 had fallen from his wheelchair but that was not indicated in the facility documentation. DON B stated that after the fall on [DATE] Resident 5 was responsible for himself. When Surveyor asked DON B if she had reviewed Resident 5's BIMS, MDS, or speech therapy assessments regarding his cognitive status when considering new interventions after his fall on [DATE], DON B stated she did not consider any of those assessments. DON B stated that the Interdisciplinary team met to discuss and determine new interventions after Resident 5's fall on [DATE]. DON B went on to say that if she had reviewed the BIMS, MDS and speech therapy assessments she would have considered a different intervention such as a reevaluation of Resident 5's wheelchair. The facility Change in Condition Report - Post Fall/Trauma completed [DATE] indicates Resident 5 fell from his wheelchair on [DATE] and fractured his hip. Resident 5's Discharge Summary from the hospital dated [DATE] states reason for admission was a left hip fracture. The Surgical Consult Report signed by a physician from Watertown Regional Medical Center documentation date [DATE] regarding Resident 5's history states: Resident 5 is exhibiting mental status changes now which may be related to his pain medication. On [DATE] at 3:50 PM Surveyor attempted to interviewed Resident 5. When Surveyor knocked on the door there was not an immediate response. Resident 5 made a sound that resembled grunting. When asked "how are you?" again Resident 5 also made a grunting sound. When asked to confirm his name Resident 5 closed his eyes and when Surveyor repeated the question Resident 5 did not open his eyes or respond. Example 2 Resident 3's [DIAGNOSES REDACTED]. Resident 3 had expired on [DATE]. Resident 3's plan of care, print date [DATE], identifies the focus area of "At risk for falls related to: History of falls." Interventions include: Bed in low position with amputated side against the wall. Landing mat next to bed at all times. Bolstered mattress. On [DATE], at 5:30 AM, Resident 3 fell . The Post Fall/Trauma report indicates Resident 3 was found sitting on the floor next to his bed. The "Interventions Used Prior to Fall" indicate a night light, bed in low position, and call light. The investigation follow up recommendations for new interventions state bolsters were in place. Resident 3's care plan was not updated with any new interventions to prevent falls. On [DATE], at 5:15 AM, Resident 3 fell . The Post Fall/Trauma report indicates Resident 3 was found kneeling on the floor next to the bed. The "Interventions Used Prior to Fall" does not indicate a bolster mattress. The IDT Recommendation is to turn the head of the bed to the opposite side. On [DATE], at 1:15 AM, Resident 3 fell . The Post Fall/Trauma report indicates Resident 3 slid out of bed with lip mattress, body pillow and bedding all on the floor under him. The CNA and Nurses recommendation was for a bigger bed. The IDT Recommendation was to reposition Resident 3 on farthest side of bed. On [DATE], at 2:30 AM, Resident 3 fell . The Post Fall/Trauma report indicates Resident 3 was found on the floor mat leaning against the bed. The "Interventions Used Prior to Fall" only indicate the use of a night light and call light in reach. The IDT Recommendations were for a regular mattress and bed bolsters. On [DATE], at 11:59 PM, Resident 3 fell . The Post Fall/Trauma report indicates Resident 3 was found laying on his back on the floor mat. "Interventions Used Prior to Fall" only indicates call light in reach. IDT recommendations were for close monitoring for the rest of the shift. There is no indication what to do after the shift. Resident 3's care plan was updated on [DATE] and a wider bed was added. On [DATE], at 5:05 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and Director of Nursing (DON) B about Resident 3's falls. NHA A stated the facility struggled with Resident 3 and the multiple falls he had. NHA A stated Resident 3 did have a scoop mattress then a bed with bolsters, later it was changed to an air mattress with bolsters, they turned the bed around, obtained a bariatric bed then added bolsters to the bariatric bed. NHA A and DON B stated the changes to the bed were made following the above listed falls. The facility could not find documentation when the bed changes were made for Resident 3. There is no evidence that the facility looked at the root cause of the falls to determine if the above changes were appropriate or if something else would have been more appropriate for Resident 3 given the number of falls.

Based on interview and record review the facility did not ensure that each resident received 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 resident out of 6 reviewed (Resident 1) for assessing, evaluating and implementing interventions for a significant change of condition. Resident 1 had a change of condition on [DATE] at 1:45 PM. The symptoms presented as left side of mouth droop, flaccid arms, right eye shut, and weak grasps. The physician was called and the POA (Power of attorney) was called with messages left. The physician called back at 2:25 and ordered a baby aspirin daily and an EKG. The family came to the facility around 3:45 PM and was concerned as to why no physician had seen Resident 1 yet with the symptoms she was presenting. The family took Resident 1 to the hospital through the tunnel to the emergency room where when was diagnosed with [REDACTED]. The facility did not thoroughly assess Resident 1 and did not monitor Resident 1 closely following her symptoms of a stroke/TIA. The facility did not call the MD back when the family was very concerned that no treatment was being done to Resident 1. The facility did not give Resident 1 prompt or urgent treatment for [REDACTED]. Such interventions are required to reduce the possibility of long-term disability following a stroke. The lack of prompt treatment, lack of complete assessment and monitoring created a situation of immediate jeopardy beginning [DATE]. The facility removed the immediate jeopardy on [DATE], but the deficient practice continues at a scope/severity level of D (potential for harm that is not immediate jeoaprdy/isolated) as all of staff are not inserviced. The administrator was informed of the immediate Jeopardy on [DATE]. Findings as follows: The American Heart Association's website for signs of a heart attach, stroke and [MEDICAL CONDITION] includes the following information: Stroke Warning Signs-Numbness or weakness of the face, arm or leg especially on one side of the body. -confusion, trouble, or speaking or understanding. -trouble seeing in one eye or both eyes, -trouble walking, dizziness, loss of balance or coordination, -severe headache with no known cause. IF THESE SIGNS ARE PRESENT CALL [DATE]. Additional information: Check the time so you'll know when the first symptoms appeared. It is very important to take immediate action. If given within 3 hours of the onset a clot busting drug can be given, and may reduce the long term disability for the most common type of stroke. The AMDA (American medical directors association) Protocols for Physician Notification-Assessing and Collecting Data on Nursing Facility Patients includes the following protocol for weakness or paralysis arm or leg-Physical data to collect is: Vital signs, details of impairment, any associated complications, Neurological exam including any impairments of sensations, temperature, position sense and any alterations in consciousness or function, pain assessment and signs of head trauma. (Please note the neurological nursing physical exam is described in the AMDA guidelines as the following: Motor function intact? Sensory function WNL (within normal limits) for age? gait normal for age? Evidence of Paralysis/paresis? Speech normal? Reflexes normal? Grip strength equal? Observe response to the following requests noting asymmetry, loss of movement drooping eyelids facial weakness or lack of coordination. --Show me a smile, Raise your eyebrows, show me your teeth, close your eyes tightly, and stick out your tongue. On [DATE], at 10:30 AM, Surveyor interviewed DON B, who stated, "We use the AMDA guidelines for a standard of practice". Surveyor reviewed the medical record of Resident 1 on [DATE]. Resident 1 was a [AGE] year old woman with [DIAGNOSES REDACTED]. Resident 1 was not her own legal decision maker and she was a DNR, but no other advanced directives were indicated in her medical record referring to hospitalize or not to hospitalize. The resident's history indicates the family was not adverse to having Resident 1 hospitalized as Resident 1 had 3 hospital visits in the last 6 months: on [DATE] for treatment to trauma of her eye; on [DATE] hospital treatment for [REDACTED]. A nursing note on [DATE] at 1:45 PM, states, "Change of condition Situation: CNA stated that resident "seemed different" Background: resident has [DIAGNOSES REDACTED]. Assessment-Resident left side of mouth was drooping, left arm which was usually tight was easy to move for aides and resident right eye was shut. Resident not looking at writer and res grip was weak. Res, VS-96.5, ,[DATE]-,[DATE]. Pox 99% RA. Resident head of bed is up. RN assessed resident. Response: Message left for DR via voice mail regarding droopy mouth res R eye closed and left arm is easy to move. VSS (vital signs stable), no distress noted. No new orders noted. Message left for DPOA, to call back on resident condition. No call back noted." A nursing note on [DATE] at 1:52 PM, states, "Change of condition. Situation: Called to residents room by team leader who states the CNA's called her because res wasn't eating well in the dining room for lunch and "seemed different" in that while usually resident holds L (left) arm very stiff and almost fights the girls with cares, res L arm is very flaccid. Background: resident has [DIAGNOSES REDACTED]. Skin pink warm and dry. No indication of any pain noted. Abdomen soft non tender or distended. LCTA (lungs clear to auscultation) bilaterally slightly diminished. No cough, SOB or congestion noted. No S/SX dehydration noted mucous membranes are moist, skin turger is non-tenting." There is no documentation in this note of a head-to-toe assessment or a complete assessment as directed by the AMDA guidelines. A nursing note on [DATE], at 5:05 PM states, "General note. Res. Sitting in broada chair. No respiratory distress. Res calm eyes are closed. Res per normal behavior. BP ,[DATE]. Skin warm and pink, dry. LCTA. No cough or congestion skin turgor good." There is no documentation in this note of an assessment into the symptoms that Resident 1 presented with (i.e, droopy mouth, weak grasps, and flaccid arms). A nursing note on [DATE] at 5:17 PM states, "General note at 2:25 PM telephone order read back from DR to RN-Do EKG and fax results to my office, add a baby ASA daily. DON notified and unit clerk notified of need to order to be transcribed." A nursing note on [DATE], at 5:27 PM states, "General note-RN assessment: Writer went to assess resident earlier this afternoon and resident laying in bed with her eyes closed. Color is pink and skin is warm to the touch. Left side of the mouth slightly drooping but not really pronounced. Resident name was called and res opened eyes. Skin turgor good and mucous membranes moist. No s/sx of dehydration noted. No respiratory distress noted upon assessment. Abdomen is non tender when palpated. No [MEDICAL CONDITION] noted to bilateral lower extremities and pedal pulses palpable. Team leader consulted with DR and DR returned call around 2:25 PM and orders received toe EKG and ASA (aspirin) daily. Mobilex contacted by ward clerk for a stat order for EKG. Team leader contacted POA but message left to call facility back. Family here to see resident and made decision to transport resident thru tunnel to be evaluated at the ER." This entry was written by DON B. There is not an assessment related to her symptoms of weakness, flaccid arms or any vital signs taken at this time for monitoring of her original symptoms. On [DATE] at 8:31 PM states, "General note-admitted to hospital for left sided stroke." Resident 1's Hospital Admission and Physical dated [DATE] included: The patient was noted to have an acute left sided flaccidity earlier this afternoon. There may also have been some left sided facial drooping at that time. DR was notified and may have requested that ASA (Asprin) be given but was not. Family brought her in for eval. In ER eval consistent with a dense left hemi paresis consistent with a right cerebral [MEDICAL CONDITION], CT scan confirmed a large cerebral infarct in. Given a dose of 300 mg of ASA in ER. admitted to ICU. MD assessment -BP ,[DATE], pulse 104 Unresponsive to verbal or vigorous tactile stimuli with no spontaneous or response of eye opening and no verbal communication. She moves her right leg and right arm but does not follow commands and really has no clear purposeful movement. Appears to have dense flaccid paralysis on the left side of the body. Pupils- the pupils are irregular bilaterally, unreactive on the right, slightly reactive on the left. Heart-Irregularly irregular. Slightly [MEDICAL CONDITION]. [DIAGNOSES REDACTED]. Resident was unable to eat or drink and family was told that the stroke was not reversible. Resident was placed on comfort measures at hospital with in house hospice and expired on [DATE]. A physician progress notes [REDACTED]. This note on [DATE] at 5:40 PM, "called about change in patient condition earlier today-pt noted by staff to have weakness. No report of chest pain or SOB. Pt has past history of [MEDICAL CONDITION] fib currently on [MEDICATION NAME]. EKG was ordered and baby ASA 81 mg was ordered. IMP (impression)-TIA vs [MEDICAL CONDITION] came to evaluate pt but family took pt to ER." On [DATE], at 10:30 AM, Surveyor interviewed DON B regarding Resident 1. Surveyor asked what the standard of practice was to assess for a stroke. DON B stated, "A head to toe assessment, check pupils, hand grasps, vital signs neuro checks. I would expect the nurse to call the MD immediately." Surveyor asked DON B if the RN was going to assess the resident for signs of a stroke, shouldn't the RN do a neuro checks, vital signs, a complete head to toe assessment to rule out or confirm the symptoms? DON B stated, "I reviewed the record and seen the RN assessment and there was no head to toe assessment, probably not a complete assessment. I did see her in the afternoon too and I did see a slight droop. No, I did not do a head to toe assessment." DON B continued on to state, "A no code means you don't do CPR not withhold treatment. If we cannot reach the family we go by what the MD says. We did counsel the nurse for not following through with the MD orders. The family was angry when they came in and nothing was done. Our policy on calling in an emergency is to attempt to reach the MD, if cannot call back in 15 minute and if still no response call the medical director." On [DATE], at 11:15 AM, Surveyor interviewed NM C (Nurse Manager) regarding [DATE]. NM C stated that she was asked to go look at Resident 1 as she was different and not eating, vital signs good. I noted no distress or respiratory trouble, I did not do a head to toe assessment as I felt there was no reason too, her skin was warm and dry. I went out and talked to LPN F about what she saw as I didn't see anything different. The aides took me back in there to show what they reported earlier. Her arm was not as flaccid as before and now has tone, and no facial droop. I told LPN F to call the physician still and report what she saw as it was a change of condition that she was. NM C stated that a stroke is an emergent situation; to assess you need to check her neuro status, strength on each side, pupil checks and vital signs. I didn't do them as I didn't see any signs that LPN F did. On [DATE], at 12:30 PM DON B stated that she misspoke and the information regarding getting a hold of the MD was for a critical INR not change of condition. In the case of resident 1 she was not in respiratory distress so just calling as soon as possible would have been the expectation." Surveyor asked DON B about monitoring Resident 1 and what was the expectation, and DON B responded, "I would expect vital signs and a blood pressure every shift." On [DATE], at 12:45 PM via phone, Surveyor interviewed LPN F regarding [DATE] as she was the nurse who first noted the symptoms. LPN F stated, "The aides told me that something was wrong with resident 1 she didn't eat well for lunch and she was just different. I went down to check her out and noticed that her left side of her mouth was drooping, only one eye was open, and she was able to loosely move her arm where it was tight before and her grasps were weak. There was no sign of distress and her vitals were okay. I requested the charge nurse to look at her and she did, then came and asked me what she normally looked like and then told me to call the MD. I called the MD and the family and was waiting for a call back. I did get a hold of one family member and she said to make sure to call the 1st POA (power of attorney) too, I wasn't going to leave until someone called back and then the MD did so I felt better that we got a hold of someone to alert of her condition. I do know that the CNA came and got the RN a few minutes after we looked at her to let her know what she saw. Stroke signs are emergent and if you cannot get the MD you call him back. The RN stated that she was in no distress." On [DATE], at 1:45 PM Surveyor interviewed via phone FM I who is Power of Attorney. FM I stated that she received the message at 3:00 PM via her voice mail. FM I called the facility and just stated that (Resident 1) was not feeling well and didn't eat lunch and may have had a mini stroke. I asked the nurse if she (Resident 1) was seen a physician yet and the nurse said no and then asked why they were diagnosing over the phone. They told me about the orders for the EKG and ASA but not done yet. The nurse made it sound like no big deal. I called up FM J as she lives there and told her to go and see what was going on. The FM J called me and told me that nothing was done for her yet and she took her to the ER. I have never talked to the MD before about any end of life cares we, if she was sick or hurt we had her treated, she was just at the ER a month before. I was not satisfied at all." On [DATE] at 2:30 PM, Surveyor interviewed RN G as the nurse working the floor on [DATE] on the PM shift. RN G stated that she came to work and received report and was told about Resident 1 and symptoms of a stroke. RN G stated that she took the call from the physician and she stated he just ordered an ASA and EKG. RN G wrote the orders and then went and assessed Resident 1, at about 2:30 PM. RN G stated that she went and saw her and she was in no apparent distress. She did not do vital signs at that time as they had just been done at 1:30 PM. RN G stated that Resident 1 looked like what LPN F had told her in report, with the flaccid arms and droopy mouth. Resident 1 always was very tight and now you could move her arm. RN G stated she then started her medication pass. RN G stated that FM J (Family Member) came to the building at about 3:45 PM and asked what was being done for (Resident 1). RN G stated that she told FM J about the orders that Resident 1's primary physician had given. FM J was upset that the ASA and the EKG were not done yet. RN G stated that the family gave her a sip of liquid and she could not swallow it and coughed. They became more anxious about her condition and again asked what was going to be done and they wanted her seen. RN G stated she got the charge nurse at that time (RN E). RN G stated that she didn't blame the family; the resident had stroke symptoms and that is emergent and needed to be seen by an MD. The family told RN G that they would follow protocol of getting all the paperwork ready if it didn't take longer than 30 minutes and it did so they left through the tunnel to go to ER. RN G stated to Surveyor that she did not chart her assessment when she looked at Resident 1 at 2:30 PM, and she should have. RN G stated that she should have been monitored frequently with those symptoms, but was stable and family was with her. On [DATE], at 2:45 PM, Surveyor interviewed FM J regarding the events of [DATE]. FM J stated, the facility called me first when this happened. The nurse stated that (Resident 1) may have had a stroke or a TIA, but her regular doctor was not in. I told them to get another doctor or send her to the emergency room . I told them they better call FM I as she is first power of attorney. I came in and (Resident 1) had a left side of the mouth droop, hands were flaccid and she was making a growling sound. I gave her water and she choked on it. I went to the nurse and asked her if she had been seen by an MD yet. She told me no but they had received orders for an ASA and EKG but they were not done yet and she didn't know when they would be. I know when someone has these stroke symptoms they need urgent treatment. I wanted to see the charge nurse and then the NHA and he told me I had to follow protocol, with paperwork and call 911 to get an ambulance. I asked if we can take her through the tunnel and I told them if it didn't take too long as she needed treatment. Getting the paperwork took to long so I just took her through the tunnel myself. The ER doctor there told us she had a large stroke and could not reverse it, and that she should have been her hours ago." On [DATE], at 2:50 PM Surveyor interviewed NHA A regarding Resident 1 on [DATE]. NHA A stated, "I was called to talk to the family. The family stated that she needed to go to the hospital now to see an MD. I explained to them the MD was called and what he ordered and that he was now on his way. The family didn't want to wait and I explained our procedure of getting paperwork ready and calling 911. The family didn't want to wait and they took her through the tunnel, they were very angry." On [DATE], at 3:00 PM Surveyor asked RN G about any assessment after she originally went to see Resident 1. RN G stated, "No I didn't do vital signs as they were just done one hour ago and I should have documented the assessment I did, I know I did not." On [DATE], at 3:30 PM Surveyor interviewed PM Charge Nurse E regarding the PM of [DATE] as she was in charge that evening. RN E was asked if stroke symptoms in a resident were an emergent situation and how she would handle the phone call with the MD. RN E stated that stroke symptoms were emergent and you would want to get someone with stroke symptoms seen right away. If the MD doesn't call back within ,[DATE] minutes then call the medical director, then report it to the ED and DON. RN E continued to state that the wing nurse (RN G) asked her to come and look at Resident 1 as the family wants her too. RN E stated that Resident 1 was in no distress but did not do an assessment. The family wanted her seen in the ER and they were angry. RN E stated that NHA A (talked to her in the hallway) told her that she may have had a TIA earlier and the family was angry that she was not treated yet. NHA A told RN E that RN G got her blood pressure and I was to tell the family that the MD was on his way and they ordered ASA and and EKG. RN E stated that the family was very angry and just wanted her treated at the ER and RN E assisted in getting paperwork, the family stated that if it took to long they were just taking her in the tunnel. RN E stated that the family said they had waited long enough and took her through the tunnel. Surveyor asked RN E what would be involved with an assessment for someone that had a possible stroke or TIA. RN E replied, "You would do a full head to toe assessment, including checking pupils, hand grasps, leg strengths, symmetry and vital signs. RN E stated that she did not do a head to toe assessment, nor vitals signs (the vital signs in RN E's nursing note are from RN G told to chart in her note by NHA A). The facility failed to provide Resident 1 care that was consistent with professional standards of nursing practice on [DATE], by failing to assess for symptoms of a stroke, by failing to closely monitor those symptoms, and by failing to call the physician to update him that the family was upset that she hadn ' t been treated when they had arrived at the facility. The RN's failure to thoroughly assess the symptoms that Resident 1 was experiencing and to implement interventions created a situation of immediate jeopardy. The facility removed the immediate jeopardy on [DATE] when: *All staff inservices were initiated on [DATE], regarding timely MD notification with change of condition, inservice on complete assessments, inservicing on updating care plans, and signs and symptoms of a stroke/TIA. *All other resident with change of condition with have immediate assessment and MD notification with all residents on the 24 hour board will be reviewed for change of condition. *Random audits will be completed 3 times a week to ensure compliance in the above areas.

Based on interview and record review the facility failed to provide services that met the professional standards of quality for 1 resident out of 6 reviewed (Resident 1). Resident 1 had a change of condition on [DATE] at 1:45 PM. The symptoms presented as left side of mouth droop, flaccid arms, right eye shut, and weak grasps. The physician was called and the POA was called with messages left. The physician called back at 2:25 and ordered a baby aspirin daily and an EKG. The family came to the facility around 3:45 PM and was concerned as to why no physician had seen Resident 1 yet with the symptoms she was presenting. The family took Resident 1 to the hospital through the tunnel to the emergency room where she was diagnosed with [REDACTED]. The facility did not thoroughly assess Resident 1 and did not monitor Resident 1 closely due to her symptoms of a stroke/TIA, per professional standards of practice. The facility did not call the MD back when the family was very concerned that no treatment was being done to Resident 1. The facility did not give Resident 1 prompt or urgent treatment for [REDACTED]. The failure to follow professional standards of practice created a situation of immediate jeopardy, which began on [DATE]. The facility removed the immediate jeopardy on [DATE], but the def/icient practice continues at a scope/severity level of D (potential for harm that is not immediate jeopardy/isolated) as all staff are not yet inserviced. The administrator was informed of the immediate Jeopardy on [DATE]. Findings as follows: Wisconsin Administrative Code, Board of Nursing, N6, Standards of Practice for Registered Nurses and Licensed Practical Nurses, at N 6.03(1) requires RNs to "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. The Protocols for Physician Notification: Assessing Patients and Collecting Data on Nursing Home Facility Patients, A guide for Nurses on Effective Communication with Physicians, by the American Medical Directors Association copyright 2000 notes that the standard of practice for physician notification relating to a "Complaint, medical, by family or patient (Always demand to speak to physician or have a medical assessment without delay)." The physical data to assess states, "1. Vital signs. 2. Physical assessment in relation to nature of complaint. (Use the companion to decide what to assess. For example, if family member reports that the patient has back pain, see section on back pain)." The American Heart Association's website for signs of a heart attach, stroke and [MEDICAL CONDITION] includes the following information: Stroke Warning Signs-Numbness or weakness of the face, arm or leg especially on one side of the body. -confusion, trouble, or speaking or understanding. -trouble seeing in one eye or both eyes, -trouble walking, dizziness, loss of balance or coordination, -severe headache with no known cause. IF THESE SIGNS ARE PRESENT CALL [DATE]. Additional information: Check the time so you'll know when the first symptoms appeared. It is very important to take immediate action. If given within 3 hours of the onset a clot busting drug can be given, and may reduce the long term disability for the most common type of stroke. The AMDA (American medical directors association) Protocols for Physician Notification-Assessing and Collecting Data on Nursing Facility Patients includes the following protocol for weakness or paralysis arm or leg-Physical data to collect is: Vital signs, details of impairment, any associated complications, Neurological exam including any impairments of sensations, temperature, position sense and any alterations in consciousness or function, pain assessment and signs of head trauma. (Please note the neurological nursing physical exam is described in the AMDA guidelines as the following: Motor function intact? Sensory function WNL (within normal limits) for age? gait normal for age? Evidence of Paralysis/paresis? Speech normal? Reflexes normal? Grip strength equal? Observe response to the following requests noting asymmetry, loss of movement drooping eyelids facial weakness or lack of coordination. --Show me a smile, Raise your eyebrows, show me your teeth, close your eyes tightly ,and stick out your tongue. The Long Term Care Nursing Desk Reference, second edition 2009 indicates that The Cincinnati Pre-Hospital Stroke Scale identifies that early identification of [MEDICAL CONDITIONS] and [MEDICAL CONDITION] (TIA) in the long-term care facility can have a dramatic effect of the mortality and morbidity of the residents. Take stroke monitoring seriously and monitor the time frame carefully. Using these guidelines will help identify who will benefit from drug therapy. Keep the physician apprised of your findings. Careful assessment is essential. Remember the signs of a stroke can be very subtle. Rapidly recognizing signs and symptoms, assessing the resident and arranging for rapid emergency ambulance transport are key. The Cincinnati Pre-hospital stroke scale has 3 parts: arm drift, facial droop, and speech impairment. To do: 1. Have resident close eyes and hold both arms out. Abnormal: one arm does not move or one arm drifts down compared with the other arm. (Other finding such as hand grip may be helpful). 2. Facial Droop: Have the resident show their teeth or smile. Abnormal: one side of the face does not move as well as the other side or does not move at all. 3. Speech impairment: Have the resident say "you cannot teach an old dog new tricks" Abnormal: Resident slurs words, uses inappropriate words or is unable to speak." Nursing Actions: Time is of the essence. The presents of an acute stroke is a load and go event. Immediately contact the physician and send a resident 911 to a hospital for treatment. These standards were not met in the care of Resident 1, as follows: Resident 1 was a [AGE] year old woman with [DIAGNOSES REDACTED]. Resident 1 had 3 hospital visits in the last 6 months: on [DATE] for treatment to trauma of her eye; on [DATE] hospital treatment for [REDACTED]. Resident 1 was not her own legal decision maker and she was a DNR, but no other advanced directives were indicated in her medical record referring to hospitalize or not to hospitalize. A nursing note on [DATE] at 1:45 PM, states, "Change of condition Situation: CNA stated that resident "seemed different" Background: resident has [DIAGNOSES REDACTED]. Assessment-Resident left side of mouth was drooping, left arm which was usually tight was easy to move for aides and resident right eye was shut. Resident not looking at writer and res grip was weak. Res, VS-96.5, ,[DATE]-,[DATE]. Pox 99% RA. Resident head of bed is up. RN assessed resident. Response: Message left for DR via voice mail regarding droopy mouth res R eye closed and left arm is easy to move. VSS (vital signs stable), no distress noted. No new orders noted. Message left for DPOA, to call back on resident condition. No call back noted." A nursing note on [DATE] at 1:52 PM, states, "Change of condition. Situation: Called to residents room by team leader who states the CNA's called her because res wasn't eating well in the dining room for lunch and "seemed different" in that while usually resident holds L (left) arm very stiff and almost fights the girls with cares, res L arm is very flaccid. Background: resident has [DIAGNOSES REDACTED]. Skin pink warm and dry. No indication of any pain noted. Abdomen soft non tender or distended. LCTA (lungs clear to auscultation) bilaterally slightly diminished. No cough, SOB or congestion noted. No S/SX dehydration noted mucous membranes are moist, skin turger is non-tenting." There is no documentation in this note of an assessment relating to the symptoms that were reported by LPN and CNA's. A nursing note on [DATE], at 5:05 PM states, "General note Res. Sitting in broada chair. No respiratory distress. Res calm eyes are closed. Res per normal behavior. BP ,[DATE]. Skin warm and pink, dry. LCTA. No cough or congestion skin turgor good." There is no documentation in this note of an assessment into the symptoms that Resident 1 presented with (i.e, droopy mouth, weak grasps, and flaccid arms). A nursing note on [DATE] at 5:17 PM states, "General note at 2:25 PM telephone order read back from DR to RN-Do EKG and fax results to my office, add a baby ASA daily. DON notified and unit clerk notified of need to order to be transcribed." A nursing note on [DATE], at 5:27 PM states, "General note-RN assessment: Writer went to assess resident earlier this afternoon and resident laying in bed with her eyes closed. Color is pink and skin is warm to the touch. Left side of the mouth slightly drooping but not really pronounced. Resident name was called and res opened eyes. Skin turgor good and mucous membranes moist. No s/sx of dehydration noted. No respiratory distress noted upon assessment. Abdomen is non tender when palpated. No [MEDICAL CONDITION] noted to bilateral lower extremities and pedal pulses palpable. Team leader consulted with DR and DR returned call around 2:25 PM and orders received toe EKG and ASA (aspirin) daily. Mobilex contacted by ward clerk for a stat order for EKG. Team leader contacted POA but message left to call facility back. Family here to see resident and made decision to transport resident thru tunnel to be evaluated at the ER." This entry was written by DON B. There is not an assessment related to her symptoms of weakness, flaccid arms or any vital signs taken at this time for monitoring of her original symptoms. On [DATE] at 8:31 PM states, "General note-admitted to hospital for left sided stroke." Resident 1's Hospital Admission and Physical dated [DATE] included: The patient was noted to have an acute left sided flaccidity earlier this afternoon. There may also have been some left sided facial drooping at that time. DR was notified and may have requested that ASA (Asprin) be given but was not. Family brought her in for eval. In ER eval consistent with a dense left hemi paresis consistent with a right cerebral [MEDICAL CONDITION], CT scan confirmed a large cerebral infarct in. Given a dose of 300 mg of ASA in ER. admitted to ICU. MD assessment -BP ,[DATE], pulse 104 Unresponsive to verbal or vigorous tactile stimuli with no spontaneous or response of eye opening and no verbal communication. She moves her right leg and right arm but does not follow commands and really has no clear purposeful movement. Appears to have dense flaccid paralysis on the left side of the body. Pupils- the pupils are irregular bilaterally, unreactive on the right, slightly reactive on the left. Heart-Irregularly irregular. Slightly [MEDICAL CONDITION]. [DIAGNOSES REDACTED]. Resident was unable to eat or drink and family was told that the stroke was not reversible. Resident was placed on comfort measures at hospital with in house hospice and expired on [DATE]. A physician progress notes [REDACTED]. This note on [DATE] at 5:40 PM, "called about change in patient condition earlier today-pt noted by staff to have weakness. No report of chest pain or SOB. Pt has past history of [MEDICAL CONDITION] fib currently on [MEDICATION NAME]. EKG was ordered and baby ASA 81 mg was ordered. IMP (impression)-TIA vs [MEDICAL CONDITION] came to evaluate pt but family took pt to ER." On [DATE], at 10:30 AM, Surveyor interviewed DON B regarding Resident 1. Surveyor asked what the standard of practice was to assess for a stroke. DON B stated, "A head to toe assessment, check pupils, hand grasps, vital signs neuro checks. I would expect the nurse to call the MD immediately." Surveyor asked DON B if the RN was going to assess the resident for signs of a stroke, shouldn't the RN do a neuro checks, vital signs, a complete head to toe assessment to rule out or confirm the symptoms? DON B stated, "I reviewed the record and seen the RN assessment and there was no head to toe assessment, probably not a complete assessment. I did see her in the afternoon too and I did see a slight droop. No, I did not do a head to toe assessment. We use the AMDA guidelines for a standard of practice". DON B continued on to state, "A no code means you don't do CPR not withhold treatment. If we cannot reach the family we go by what the MD says. We did counsel the nurse for not following through with the MD orders. The family was angry when they came in and nothing was done. Our policy on calling in an emergency is to attempt to reach the MD, if cannot call back in 15 minute and if still no response call the medical director." On [DATE], at 11:15 AM, Surveyor interviewed NM C (Nurse Manager) regarding [DATE]. NM C stated that she was asked to go look at Resident 1 as she was different and not eating, vital signs good. I noted no distress or respiratory trouble, I did not do a head to toe assessment as I felt there was no reason too, her skin was warm and dry. I went out and talked to LPN F about what she saw as I didn't see anything different. The aides took me back in there to show what they reported earlier. Her arm was not as flaccid as before and now has tone, and no facial droop. I told LPN F to call the physician still and report what she saw as it was a change of condition that she was. NM C stated that a stroke is an emergent situation; to assess you need to check her neuro status, strength on each side, pupil checks and vital signs. I didn't do them as I didn't see any signs that LPN F did. On [DATE], at 12:30 PM DON B stated that she misspoke and the information regarding getting a hold of the MD was for a critical INR not change of condition. In the case of resident 1 she was not in respiratory distress so just calling as soon as possible would have been the expectation." Surveyor asked DON B about monitoring Resident 1 and what was the expectation, and DON B responded, "I would expect vital signs and a blood pressure every shift." On [DATE], at 12:45 PM via phone, Surveyor interviewed LPN F regarding [DATE] as she was the nurse who first noted the symptoms. LPN F stated, "The aides told me that something was wrong with resident 1 she didn't eat well for lunch and she was just different. I went down to check her out and noticed that her left side of her mouth was drooping, only one eye was open, and she was able to loosely move her arm where it was tight before and her grasps were weak. There was no sign of distress and her vitals were okay. I requested the charge nurse to look at her and she did, then came and asked me what she normally looked like and then told me to call the MD. I called the MD and the family and was waiting for a call back. I did get a hold of one family member and she said to make sure to call the 1st POA (power of attorney) too, I wasn't going to leave until someone called back and then the MD did so I felt better that we got a hold of someone to alert of her condition. I do know that the CNA came and got the RN a few minutes after we looked at her to let her know what she saw. Stroke signs are emergent and if you cannot get the MD you call him back. The RN stated that she was in no distress." On [DATE], at 1:45 PM Surveyor interviewed via phone FM I who is Power of Attorney. FM I stated that she received the message at 3:00 PM via her voice mail. FM I called the facility and just stated that (Resident 1) was not feeling well and didn't eat lunch and may have had a mini stroke. I asked the nurse if she (Resident 1) was seen a physician yet and the nurse said no and then asked why they were diagnosing over the phone. They told me about the orders for the EKG and ASA but not done yet. The nurse made it sound like no big deal. I called up FM J as she lives there and told her to go and see what was going on. The FM J called me and told me that nothing was done for her yet and she took her to the ER. I have never talked to the MD before about any end of life cares we, if she was sick or hurt we had her treated, she was just at the ER a month before. I was not satisfied at all." On [DATE] at 2:30 PM, Surveyor interviewed RN G as the nurse working the floor on [DATE] on the PM shift. RN G stated that she came to work and received report and was told about Resident 1 and symptoms of a stroke. RN G stated that she took the call from the physician and she stated he just ordered an ASA and EKG. RN G wrote the orders and then went and assessed Resident 1, at about 2:30 PM. RN G stated that she went and saw her and she was in no apparent distress. She did not do vital signs at that time as they had just been done at 1:30 PM. RN G stated that Resident 1 looked like what LPN F had told her in report, with the flaccid arms and droopy mouth. Resident 1 always was very tight and now you could move her arm. RN G stated she then started her medication pass. RN G stated that FM J (Family Member) came to the building at about 3:45 PM and asked what was being done for (Resident 1). RN G stated that she told FM J about the orders that Resident 1's primary physician had given. FM J was upset that the ASA and the EKG were not done yet. RN G stated that the family gave her a sip of liquid and she could not swallow it and coughed. They became more anxious about her condition and again asked what was going to be done and they wanted her seen. RN G stated she got the charge nurse at that time (RN E). RN G stated that she didn't blame the family; the resident had stroke symptoms and that is emergent and needed to be seen by an MD. The family told RN G that they would follow protocol of getting all the paperwork ready if it didn't take longer than 30 minutes and it did so they left through the tunnel to go to ER. RN G stated to Surveyor that she did not chart her assessment when she looked at Resident 1 at 2:30 PM, and she should have. RN G stated that she should have been monitored frequently with those symptoms, but was stable and family was with her. On [DATE], at 2:45 PM, Surveyor interviewed FM J regarding the events of [DATE]. FM J stated, the facility called me first when this happened. The nurse stated that (Resident 1) may have had a stroke or a TIA, but her regular doctor was not in. I told them to get another doctor or send her to the emergency room . I told them they better call FM I as she is first power of attorney. I came in and (Resident 1) had a left side of the mouth droop, hands were flaccid and she was making a growling sound. I gave her water and she choked on it. I went to the nurse and asked her if she had been seen by an MD yet. She told me no but they had received orders for an ASA and EKG but they were not done yet and she didn't know when they would be. I know when someone has these stroke symptoms they need urgent treatment. I wanted to see the charge nurse and then the NHA and he told me I had to follow protocol, with paperwork and call 911 to get an ambulance. I asked if we can take her through the tunnel and I told them if it didn't take too long as she needed treatment. Getting the paperwork took to long so I just took her through the tunnel myself. The ER doctor there told us she had a large stroke and could not reverse it, and that she should have been her hours ago." On [DATE], at 2:50 PM Surveyor interviewed NHA A regarding Resident 1 on [DATE]. NHA A stated, "I was called to talk to the family. The family stated that she needed to go to the hospital now to see an MD. I explained to them the MD was called and what he ordered and that he was now on his way. The family didn't want to wait and I explained our procedure of getting paperwork ready and calling 911. The family didn't want to wait and they took her through the tunnel, they were very angry." On [DATE], at 3:00 PM Surveyor asked RN G about any assessment after she originally went to see Resident 1. RN G stated, "No I didn't do vital signs as they were just done one hour ago and I should have documented the assessment I did, I know I did not." On [DATE], at 3:30 PM Surveyor interviewed PM Charge Nurse E regarding the PM of [DATE] as she was in charge that evening. RN E was asked if stroke symptoms in a resident were an emergent situation and how she would handle the phone call with the MD. RN E stated that stroke symptoms were emergent and you would want to get someone with stroke symptoms seen right away. If the MD doesn't call back within ,[DATE] minutes then call the medical director, then report it to the ED and DON. RN E continued to state that the wing nurse (RN G) asked her to come and look at Resident 1 as the family wants her too. RN E stated that Resident 1 was in no distress but did not do an assessment. The family wanted her seen in the ER and they were angry. RN E stated that NHA A (talked to her in the hallway) told her that she may have had a TIA earlier and the family was angry that she was not treated yet. NHA A told RN E that RN G got her blood pressure and I was to tell the family that the MD was on his way and they ordered ASA and and EKG. RN E stated that the family was very angry and just wanted her treated at the ER and RN E assisted in getting paperwork, the family stated that if it took to long they were just taking her in the tunnel. RN E stated that the family said they had waited long enough and took her through the tunnel. Surveyor asked RN E what would be involved with an assessment for someone that had a possible stroke or TIA. RN E replied, "You would do a full head to toe assessment, including checking pupils, hand grasps, leg strengths, symmetry and vital signs. RN E stated that she did not do a head to toe assessment, nor vitals signs (the vital signs in RN E's nursing note are from RN G told to chart in her note by NHA A). On [DATE], Surveyor received a fax from Resident 1's primary physician, which stated that (Resident 1's) past medical history includes: Severe end state dementia, nonverbal, non ambulatory, with minimal social interaction, history of [MEDICAL CONDITION] Fibrillation, History of Recurrent UTI, Chronic Hypertension, [MEDICAL CONDITIONS] with B12 deficiency, History of [MEDICAL CONDITION] related to sick sinus syndrome, status [REDACTED]. I did not feel that the hospital would treat her any differently then I would at (the facility). The nurses at (the facility) communicated to me (Resident 1's) symptoms. This was based on their assessments; I was actually impressed that they were able to catch the symptoms of a TIA or early stroke as quickly as they did. I returned their call within 30 minutes. My decision was to treat her by adding a baby aspirin daily and to get an EKG and fax me the results. The EKG was ordered to determine the cause not the course of treatment. I informed the unit clerk that I would come by to view the EKG results, see (Resident 1) and to talk with her granddaughter about her treatment. Upon my arrival I found out they (the family) had requested (Resident 1) to be seen by the emergency department and she was transported to the hospital. (This was a statement that Resident 1's primary physician wrote). The facility failed to provide Resident 1 care that was consistent with professional standards of nursing practice on [DATE], by failure to assess for symptoms of a stroke and closely monitor those symptoms, and to call the physician to update him that the family was upset that she hadn't been treated when they arrived at the facility. The RNs failure to thoroughly assess the symptoms that Resident 1 was experiencing and to implement interventions created a situation of immediate jeopardy. The facility removed the immediate jeopardy on [DATE] when: *All staff inservices were initiated on [DATE], regarding timely MD notification with change of condition, inservice on complete assessments, inservicing on updating care plans, and signs and symptoms of a stroke/TIA. *All other resident with change of condition with have immediate assessment and MD notification with all residents on the 24 hour board will be reviewed for change of condition. *Random audits will be completed 3 times a week to ensure compliance in the above areas.

Based on interview and record review the facility did not ensure 1 of 6 residents (Resident 4) received adequate supervision and assistance devices to prevent accidents. Resident 4 suffered 2 falls with in 24 hours with both falls resulting in a closed head injury (with a laceration to the head on both falls), mental status changes and the second falls included laceration to the hand. The facility did not update the care plan following the first fall. The resident was hospitalized after the second fall and required one staple to close the head wound and five sutures to close a hand wound. This is evidenced by; The facility policy titled "Falls Management Clinical Guidelines," dated January 2011, indicates ... A. Following a resident's fall: 1. The licensed nurse assesses the resident for injuries (including neurological checks if indicated) and provides necessary treatment and initiates the change of condition report ... The resident's physician and resident's representative is notified... 2. Appropriate interventions are implemented. 3. The care plan is updated. B. Continue an ongoing assessment and documentation by the licensed nurses per the facility practice... Resident 4 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident 4's medications include; Aspirin 81 Milligrams (mg) every day and Simvastatin 40 mg very PM. Resident 4's Minimum Data Set (MDS), dated [DATE], indicates Resident 4 is limited assist of 1 with bed mobility and all transfers. Resident 4's MDS also indicates Resident 4 has impaired short and long term memory. In addition Resident 4's MDS indicates Resident 4 has no current behaviors of refusing cares, wandering or any verbal or physical behavioral symptoms. Resident 4's care plan date initiated 2/3/11 titled "At risk for falls" related to use of antidepressant medication and a falls risk score of 6. Resident 4's goal is no fall related injuries. Resident 4's care plan interventions indicates footwear to prevent slipping, gait belt with transfers, Keep environment well lit and free from clutter, and observe for side effects of medication. Resident 4's interventions also indicate date initiated 5/17/11 pain assessment, neurological checks, and emergency room evaluation. Resident 4's nursing notes, dated 5/17/11 at 6:35 AM,indicate: Situation: at 2:45 AM Resident 4 was on the floor next to the bed on the window side... Assessment: Resident 4 has a laceration to his left eyelid with bruising around the left eye... Response: First aid to left eye, Neurological checks implemented, and bedspread removed. Resident 4's nursing notes, dated 5/17/11, at 7:23 AM indicate Resident 4 was placed on 1 on 1 to prevent further falls. Resident 4's nursing notes, dated 5/17/11, at 11:13 AM indicate Resident 4's Physician was notified at 7:23 AM, about 50 minutes after vital signs had changed, and an order was received to send to the ER for evaluation. Resident 4's Emergency Department Physician Documentation, dated 5/17/11, indicates Resident 4's [DIAGNOSES REDACTED]. Resident 4's Emergency Department Physician Documentation, dated 5/17/11, also indicates Resident 4's Patient Instructions: Follow up with Physician (Physician Name) and pulmonologist as scheduled, Urine culture is pending ..., and Head injury sheet (Neurological assessment) ... (It is important to note the Neurological assessment sheet indicates an assessment was not completed from return from ER at 12:15 PM until PM documented in the nursing notes at 8:55 PM.) Resident 4's nursing notes, dated 5/17/11, indicate Resident 4 returned from the ER at 12:15 PM. There is no documentation in the nurse ' s notes indicating if the 1:1 intervention initiated at 7:23 AM was to continue. No changes were made to the care plan with respect to preventing falls from bed or preventing injuries if another fall was to occur. Resident 4's nursing notes, dated 5/17/11 at 8:55 PM indicates Resident 4 was in bed all shift, and Resident 4 was noted to have increased drowsiness. Resident 4's nursing notes also indicates Resident 4's medications were held the enter PM shift due to Resident 4's drowsiness. Resident 4's nursing notes also indicates Resident 4 attempted to get self transfer out of bed at 5:00 PM and was assisted to transfer with 2 assist and a gait belt. Resident 4 was placed back in bed due to poor positioning in his wheelchair. Resident 4's nursing notes, dated 5/18/11, at 2:15 PM indicates Situation: Resident 4 was found lying on the floor by the foot of his bed lying on his left side (It is important to note Resident 4 was found on the floor at 1:00 AM). Resident 4's nursing notes Resident 4's vital signs are Blood pressure 158/83, heart rate 106, respiration 24, Oxygenation saturation on room air at 83%, and oxygen applied at 2 liters. (It is important to note Resident 4's physician orders [REDACTED]. Background: Resident 4 has a history of frequent falls recently. Assessment: Resident 4 is weak and shaky. Resident 4 has a 4 centimeter (cm) laceration to his left forehand, and a bump to his posterior head with a 1.5 cm laceration ... Neurological checks initiated. Response: Resident 4's physician was notified of the fall and Resident 4's change in condition. physician's order [REDACTED]. Neurological Assessments at 1 AM, 1:15 AM, 2 AM, 1:30 AM, 1:45 AM, 2:15 AM, and 2:45 AM all indicate that the resident ' s left pupil was non-reactive following this fall. Resident 4's nursing notes dated 5/18/11 at 3:00 AM Resident 4's POAHC was contacted and informed of the incident and agrees to send Resident 4 to the ER. 911 called. Resident 4's Nursing notes, dated 5/18/11 at 3:20 AM Resident 4 was transported to the hospital via 911. Resident 4's Emergency Department Physician Documentation, dated 5/18/11, at 3:23 AM indicate Resident 4's O2 sat was 88% on room air. Resident 4 was placed on 5 liters of oxygen to improve O2 sats to 96%. Emergency Department Physician Documentation also indicates Resident 4's general appearance as lethargic, tachypneic (very rapid respirations) and in moderate distress Resident 4's Emergency Department Physician Documentation, dated 5/18/11 indicates Resident 4's [DIAGNOSES REDACTED]. Resident 4's Emergency Department Physician Documentation, dated 5/18/11 indicates Resident 4's also indicates Resident 4's procedures; Wound #1: Wound length 3 cm, Location: Hand ... Repair skin: nylon 4-0 number of sutures - 5 Wound #2: Wound length 0.5 cm Location: Head ... Repair number of staples - 1 On 5/18/11 at 3:30 PM Surveyor spoke with DON B regarding Resident 4's care plan. DON B indicated Resident 4's care plan should have been reviewed and adjusted after his first return from the hospital by the charge nurse. DON B also indicated resident 4 was on 1:1 prior to going to the hospital due to acute change of condition and when returned from the hospital Resident 4 1:1 should have continued until his condition was stable. In addition DON B indicated Resident 4's care plan was not updated to reflect current change in mental status and increased fall risk.

Based on observation, interview and record review, the facility failed to ensure that each resident receives adequate supervision and assistive devices to prevent accidents for 1 of 11 residents reviewed for falls (Resident 11). Resident 11 sustained a fall at the facility that resulted in a left clavicle fracture. After this fall the facility determined that Resident 11 was in need of one person assist using a gait belt for transfers and is not to wear clog-type shoes. Surveyor observed Resident 11 wearing clog-type shoes while ambulating and receiving no assistance or supervision with transferring and ambulating, even though a caregiver was in Resident 11's bathroom. This is evidenced by the following: The facility's policy and procedure titled "Change in Condition Report-Post Fall Investigation Summary Guidelines For Completion," dated January 2011 states the following: "Purpose: To assess individual condition after a fall occurs to identify the reason and/or risk factors for the fall in order to prepare a plan of care to reduce the potential for future falls ...Procedure: If a resident falls ...2 ...Nurse Notes/Interventions: Summarize the significant assessment findings, actions taken to treat injuries, the resident's response to the treatment, and the interventions that were in place at the time of the fall ...Care Plan Developed/Revised as indicated: Identify if the care plan was updated and new approaches to be implemented. Interventions used prior to fall: Identify ALL interventions implemented prior to fall ...Recommendations and Interventions Post Fall: Identify and new interventions that will be immediately implemented to reduce the potential for falls to reoccur. Attain any physician order [REDACTED]...4. The interdisciplinary Care Plan team will complete a review of the Change in Condition Report-Post Fall Investigation ..." Resident 11 was admitted to the facility 6/14/11 and has the following [DIAGNOSES REDACTED]. "Physician's Statement of Incapacity" dated 6/10/11 indicates that Resident 11 is unable to receive and evaluate information effectively or to communicate decisions to such an extent that he/she lacks the capacity to manage her health care decisions, including decisions about her post-hospital care. Resident 11 has an activated Health Care Power of Attorney. According to "Verification of Investigation" Resident 11 sustained a fall at the facility on 7/8/11 at 3:30 AM. "Resident was noted laying on her left side on food of her bed...Per DNS (Director of Nursing Services) interview with Resident at 06:30 am (upon return from hospital), resident states that she was on her way to the bathroom and somehow tripped and fell . Does not know what she tripped on could've been her shoes. She denied dizziness or lightheadedness at the time of fall ...Up ad lib with walker (therapy changed ambulation status to up ad lib with walker on 6/29/11); .. Recommendations and Interventions Post Incident: 1. Different pair of shoes for ambulation; 2. Pull tab alarm when in w/c (wheelchair); 3. Up with assistance only. (Resident notified of this per DNS); 4. PT (physical therapy) screen for proper transfer and ambulation; 5. Landing strip removed as resident has not had falls out of bed; 6. (Resident 11) educated on asking for assistance and use of call light with return demonstration." "Fall Scene Investigation for CNAs and Nurses" dated 7/8/11 states "Footwear? Shoes, Crocs ..." Emergency Department Notes from UW Health Partners, Watertown Regional Medical Center, dated 7/8/11 state "Diagnosis: [REDACTED]. Resident 11's plan of care was updated to include: 7/8/11 Pull tab alarm when in w/c (wheelchair), sling to lt (left) arm, ice on and off for 15 min (minutes) and prn, ? (up) c (with) assistance only; Resume transfer c 1 assist and gait belt 7/8/11; Resident in restorative for ambulation ...call light within reach, gait belt with transfers ...7/8/11 Different pair of shoes (no clogs) pull tab alarm when in w/c, PT screen for eval of transfer and ambulation, education on asking for assistance c call light c retn (return) demonstration." "PT-Therapist Progress Report and Updated Plan of Care" dated 7/12/11 states the following: "Patient suffered a fall during the night of 7/8/11 during self-transfer to the toilet; fall resulted in L (left) distal clavicle fracture and pt (patient) is no NWB (non weight bearing) with sling on L UE (upper extremity), this has resulted in change of assistive device from FWW to cane, and downgrade from up ad lib to supervision/CGA (caregiver assist) from transfer and ambulation ...Ambulating well with cane and min (minimum) assist/CGA ...Remaining Functional Deficits/Underlying Impairments: Patient still has deficits in safety, balance, endurance which limit the ability to perform transfers and ambulation without physical assist ..." On 7/20/11 at 1:12 PM, Surveyor observed Certified Nursing Assistant (CNA) P assist Resident 11 in Resident 11's bathroom. Surveyor observed Resident 11 walk out of her bathroom independently, while CNA P remained in the bathroom. Surveyor noted that Resident 11 was wearing clog-like (Crocs) footwear, did not have a gait belt on, and did not receive assistance or supervision with the transfer or ambulation. Resident 11 did not use her cane, but carried it with her from the bathroom to a straight chair, approximately ten feet from the bathroom. CNA P then exited the bathroom and offered Resident 11 fresh water. Surveyor asked Resident 11 what shoes she wears when ambulating in her room. Resident 11 stated that she had other shoes, but does not wear them "around here." Resident 11 stated that she wears them only for therapy. On 7/20/11 at 1:25 PM, Surveyor interviewed CNA P. CNA P stated that Resident 11 is up ad lib now and that her transfer status had went back and forth. CNA P stated that Resident 11 does not use any alarms and that today she (CNA P) was told by a night CNA that Resident 11 was up ad lib. Surveyor asked to review CNA P's care plan grid (used by CNA staff). CNA P showed Surveyor Resident 11's care instructions for that day. CNA P stated that she did not assist Resident 11 with the transfer and did not use a walker or a gait belt. Surveyor asked CNA P what shoes Resident 11 was supposed to wear. CNA P stated that Resident 11 likes to wear the green Crocs. CNA P stated that she gets a new CNA ADL sheet (activities of daily living) sheet everyday and the one discussed with Surveyor was from today. CNA P's ADL sheet (undated) states the following interventions for Resident 11: "Mobility and Transfer: A1 (one assist) and gait belt and walker ..." Surveyor spoke with Director of Nursing (DON) B on 7/20/11 at approximately 2:00 PM. DON B stated that Resident 11 is now a one-assist transfer. Surveyor asked DON B to define what she meant by one-assist transfer. DON B stated that the CNA should be with the resident, and use a gait belt for transferring and ambulating Resident 11. DON B stated that Resident 11's husband brought different shoes for Resident 11 to wear when ambulating. DON B stated that according to Resident 11's care plan and the ADL sheet, Resident 11 should have one-assist with transferring and ambulation and should use the gait belt. No further information was provided.