Every finding on record at Wood Aven Health and Rehabilitation

Based on observation, interview and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections staff did not complete hand hygiene per standards of practice during wound care for 2 of 3 residents (R2 and R3). Evidenced by: The facility policy titled Hand Hygiene, revised 3-2026, states in part: 2. Use an alcohol-based hand rub containing at least 62% alcohol. for the following situations. b. Before and after direct contact with residents. d. Before performing any non-surgical invasive procedures. g. Before handling clean or soiled dressings, gauze pads, etc. i. After contact with a resident's intact skin. Example 1R2 was admitted to the facility on [DATE]. R2's Comprehensive Minimum Data Set (MDS) dated [DATE] indicates that R2 was admitted with a pressure ulcer. R2's Brief Interview of Mental Status (BIMS) score is 14/15, indicating R2 is cognitively intact. On 7/22/26 at 9:10 AM, Surveyor observed Registered Nurse (RN) D perform wound care on R2's right ischium. Surveyor observed RN D enter the room to set up supplies, and then RN D put on a gown and gloves without completing hand hygiene. RN D removed the dressing and packing from the ischial wound. RN D took the dermal wound spray/cleaner, sprayed down the wound, and wiped it with an ABD (abdominal pad) wearing the same gloves. RN D started the clean portion of the dressing change by opening a roll of gauze packing, cutting off a piece, dipping it into a bottle of normal saline to moisten it. RN D packed the wound with the moistened gauze. RN D finished the dressing by covering it with a clean 4x4 border gauze. RN D did not remove dirty gloves or perform hand hygiene per standards of practice. On 7/22/26 at 1:36 PM, Surveyor interviewed RN D who stated dressing changes are completed because we want wounds to stay clean. RN D stated hand hygiene is required when entering and exiting a resident's room and between working with a soiled dressing and the clean dressing. RN D stated she had additional gloves with her and normally used them. RN D stated she was not sure why she did not use them. Example 2 R3 admitted to facility on 10/12/23. R3's MDS (Minimum Data Set) indicates R3 has one unstageable pressure injury. R3 has a BIMS score of 10/15 indicating their cognition is moderately impaired. On 7/22/26 at 12:35 PM, Surveyor observed Licensed Practical Nurse (LPN) B provide wound care for R3. LPN B did not perform hand hygiene prior to entering the room or prior to putting on gloves and a gown. Surveyor observed LPN B take off the prevalon boot, cut off the dirty dressing with scissors, and remove the dressing from the wound. With the same gloves, LPN B opened the clean container of chitosan based gelling fiber and cut a piece off. LPN B opened the package of rolled 4x4 gauze and set the clean dressing aside. LPN B then took the bottle of dermal wound cleaner and cleaned the wound. LPN B continued by fan folding the new fiber dressing over the wound bed and placed an ABD dressing over the fiber dressing. LPN B then wrapped the dressings in place with a roll of gauze. LPN B completed the entire wound care procedure with the same gloves. On 7/22/26 at 12:57 PM, Surveyor interviewed LPN B who stated that hand hygiene should be completed any time you go into room and get everything ready, and obviously afterward. LPN B stated if there were several different wounds staff would change gloves in between wounds. Staff should also put new gloves on between different treatments or if going from dirty to clean task. LPN B stated R3 only had one wound on their heel. LPN B stated for that dressing I kept the same gloves on. Surveyor asked if gloves replace the need for hand hygiene. LPN B stated no. Surveyor asked when taking off old dressings and putting on new dressings are both tasks considered clean or dirty tasks. LPN B paused and stated well, taking off old is dirty, putting on new is clean. LPN B stated they should have changed gloves and completed hand hygiene in-between the dirty dressing and the clean dressing. On 7/22/26 at 1:36 PM, Surveyor interviewed Assistant Director of Nursing (ADON) C and asked about hand hygiene during wound cares and peri care. ADON C stated hand hygiene should be performed before entering and exiting a room, before and after providing resident care, if going from a dirty task to a clean task, and when staff change gloves. Surveyor informed ADON C of observations with RN D and LPN B completing wound care from beginning to end without hand hygiene and glove changes. ADON C indicated hand hygiene should be performed when staff were going from dirty dressing to clean dressing and there should have been gloves changes.

Based on interview and record review, the facility did not ensure residents were free from unnecessary medications for 1 of 3 residents (R) reviewed for medication errors (R2). R2 received Metformin (a medication to treat diabetes) for 8 days. R2 does not have a diagnosis of diabetes.Findings: R2 was admitted to the facility on [DATE] with diagnoses which included paranoid schizophrenia and chronic kidney disease. R2 has a Brief Interview for Mental Status (BIMS) score of 7/15 which means severe cognitive impairment. R2 has a legal representative for health care decision making. R2's care plan, last revised 01/26/2025, with a target date of 01/27/2026, states: At risk for impaired cognitive function/dementia or impaired thought process. Interventions include.review medications and record causes of cognitive deficit: new medications. R2's record review indicated the following:- Physician order dated 10/29/2024 to check R2's HgbA1c level (a blood test that measures an average blood sugar level over the past 2-3 months) annually for Zyprexa use (antipsychotic medication used to treat schizophrenia which has a side effect of elevated blood sugar levels). -Nurse Practitioner (NP) H progress note dated 04/28/2026 at 10:45 AM, stated.Assessment and Plan.E11.65 - Type 2 diabetes mellitus [DM].HgbA1c 12.1% on 04/13/2026. Metformin ER 1000mg by mouth daily started. Follow-up HgbA1c ordered. Encounter type: Add on visit.-04/29/2026 at 5:24 PM, nursing note by licensed practical nurse (LPN) G stated R2 received new order from NP H on 04/28/2026: Metformin 1000mg ER (extended release).-R2's Medication Administration Record (MAR) indicated R2 received Metformin daily from 04/30/2026 to 05/07/2026 - a total of 8 doses.-05/06/2026 at 11:08 AM, nursing note by Registered Nurse (RN) F stated RN F spoke with R2's guardian at 11:00 AM and updated him on R2's recent diagnosis of diabetes mellitus (DM) and initiation of Metformin. R2's guardian agreed with new diagnosis and medication.-On 05/07/2026 at 10:22 AM, nursing note by Licensed Practical Nurse (LPN) D informed NP I, R2 received new orders on 04/28/2026 for scheduled Metformin with new diagnosis of type 2 diabetes. LPN D was unable to find any recent HgbA1c results to support this order and diagnosis. R2's guardian was questioning orders for Metformin and new diagnosis of DM. NP I's stated NP H must have dictated wrong. NP I stated R2 did not have a diagnosis of DM and discontinued Metformin orders. LPN D updated R2's guardian and facility management of medication error and misdiagnosis.-05/20/2026 at 1:05 PM, NP H appended the 04/28/2026 progress note for R2 and removed diagnosis of DM and the order for Metformin. -R2's most recent HgbA1c prior to ordered Metformin, was drawn on 09/25/2025 with a value of 5.5, which is within normal range. A follow up HgbA1c was drawn on 05/08/2025 with a value of 5.6, which is within normal range.-05/07/2026 an investigation by facility administration was initiated including chart audits to ensure accurate diagnosis and treatments on all residents, provider education regarding laboratory value interpretation and reinforcement of processes requiring verification of laboratory results prior to initiation of treatment. Facility's medical director was informed and an ongoing investigation by provider's health clinic was in effect. On 05/27/2026 at 9:57 AM, Surveyor interviewed R2's legal guardian. R2's guardian acknowledged the facility's investigation and was satisfied with the follow up care R2 received. R2's guardian voiced concern to Surveyor that the provider did not look at lab [HgbA1c] trending, and facility staff did not question new diagnosis and medication order. On 05/27/2026 at 11:12 AM, Surveyor interviewed R2 regarding the medication error incident that occurred on 04/28/2026. R2 could not recall the incident. R2 could not recall medications currently or previously prescribed and administered. Surveyor asked R2 if he had any concerns regarding his safety at facility and R2 shook head no. Surveyor asked R2 what his overall health was while at facility and R2 stated good. RN F and LPN G were not available for interview on 05/27/2026. On 05/27/2026 between 1:08 PM and 1:15 PM, Surveyors interviewed LPN C, LPN D and Certified Medication Assistant (CMA) E on what type of education the facility provided following the specific medication error incident on R2. LPN C, LPN D and CMA E had no recollection of staff education being provided by the facility specific to that incident. On 05/27/2026 at 12:30 PM, Surveyor interviewed NHA A and DON B about what education was provided to direct staff involved with R2's medication error, as well as facility staff receiving providers' medication orders, lab value monitoring, and recognition of residents with new diagnosis. NHA A and DON B could not provide evidence staff received education and did confirm the facility should have provided immediate education to nursing staff.

Based on interview and record review, the facility did not ensure 4 of 5 residents (R1, R8, R19, and R67) or their representatives received the proper notice of transfer, reason for transfer, and ombudsman notification.-Facility did not have a specific reason for the transfer notice for R1, R8, R19, and R67.-Facility did not notify the ombudsman of R8, R19, and R67's transfers to the hospital.Findings include: Surveyor reviewed policy titled, Criteria for Transfer and Discharge, dated 12/25 last reviewed, .Procedure: 5. If the transfer or discharge is necessary for the resident's welfare and the residents' needs cannot be met in the Facility, the resident's physician shall document in the resident's medical record: a. The specific residents need that cannot be met . Surveyor reviewed policy titled, Transfer and Discharge (including AMA), dated 03/26, .3. The facility's transfer/discharge notice will be provided to the residents and residents representative in a language and way they can understand. The notice will include all the following at the time it is provided: a. The specific reason and basis for transfer or discharge. 10. h. The Social Services Director, or designee, will provide copies of notices for emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents monthly, if the list meets all requirement for content of such notices. Example 1 R8 was admitted on [DATE], transferred to hospital on [DATE], and re-admitted on [DATE] with diagnosis of sepsis and cellulitis. Surveyor reviewed form titled, Notice of Transfer, dated 10/31/25, which states in part, .The transfer or discharge is/was necessary for the resident's welfare, and the residents' needs cannot/could not be met with the facility. Surveyor did not find a specific reason for the transfer. Surveyor reviewed Social Services Manager F's email notifications to Ombudsman, dated 12/16/25, which states in part, Notified of October 2025 hospitalizations including R8's hospitalization on 10/31/25 on 12/16/25. R8 was transferred to hospital on [DATE] and re-admitted on [DATE] with diagnosis of status post below the knee amputee. Surveyor reviewed form titled, Notice of Transfer dated 11/24/25, states in part, .An immediate transfer or discharge is/was required by the residents' urgent medical needs. Surveyor did not find a specific reason for the transfer. On 04/01/26 at 8:29 AM, Surveyor interviewed Social Services Manager F and asked for verification documentation that Ombudsman was notified of hospitalizations. Social Services Manager F reported that they would gather the information. Surveyor asked Social Services Manager F for the process for notifying Ombudsman. Social Services Manager F reported to Surveyor that usually Social Services Manager F will send notifications to Ombudsman around the 10th of each month. Social Services Manager F reported that they like to wait until everything has been cleared up in the medical record so that Social Services Manager F can print the report which is sent to the Ombudsman. On 04/01/26 at 8:45 AM, Surveyor received and reviewed the Ombudsman notification via Social Services Manager F's emails. On 04/01/26 at 9:12 AM, Surveyor interviewed Social Services Manager F and asked why October hospitalizations were not sent to Ombudsman until 12/16/25. Social Services Manager F stated, I cannot recall why it didn't get sent until then. Example 2 R67 was admitted on [DATE], transferred to hospital on [DATE], and re-admitted on [DATE] with diagnosis of Urinary Tract Infection (UTI) and Hyperkalemia. Surveyor reviewed form titled, Notice of Transfer dated 01/13/26, states, .An immediate transfer or discharge is/was required by the residents' urgent medical needs. Surveyor did not find a specific reason for the transfer. Surveyor reviewed Social Services Manager F's email notifications to Ombudsman, dated 03/27/26, which states in part, Notified of January hospitalizations including R67's hospitalization on 01/13/26 on 03/27/26. R67 was transferred to hospital again on 02/27/26 and re-admitted on [DATE] with diagnosis of status post Covid infection. Surveyor reviewed form titled, Notice of Transfer, dated 02/27/26, which states in part, .An immediate transfer or discharge is/was required by the residents' urgent medical needs. Surveyor did not find a specific reason for the transfer. On 04/01/26 at 9:12 AM, Surveyor interviewed Social Services Manager F and asked why January 2026's hospitalizations were not sent to Ombudsman until 03/27/26. Social Services Manager F stated, I cannot recall why it didn't get sent until then. On 04/01/26 at 9:43 AM, Surveyors interviewed Director of Nursing (DON) B about R67's and R8's discharges. DON B stated the expectation is for nursing staff to fill out transfer forms accurately with a specific reason on why residents are being transferred so the resident, representative, and hospital are aware of the medical needs residents will need when transferring to higher level of care. Example 3 R19 was admitted to the facility on [DATE]. On 09/10/25, R19 was transferred to the hospital via ambulance for evaluation of worsening surgical incision wound. R19 was admitted to the hospital for osteomyelitis and discharged back to the facility on [DATE]. The facility's written notice of transfer did not include the specific reason for transfer. The facility did not notify the Ombudsman of the transfer until 03/31/26. On 10/28/25, R19 was transferred to the hospital via ambulance for evaluation after a fall and was admitted to the hospital. There was no written notice of transfer documented. The facility did not notify the Ombudsman of the transfer until 12/16/25. On 12/01/25, R19 was transferred to the hospital via ambulance and was admitted to the hospital. The facility's written notice of transfer did not include the specific reason for transfer. On 04/01/26 at 9:10 AM, Surveyor interviewed Social Services Manager F regarding written notice of transfers and Ombudsman notification. Social Services Manager F stated the transfers/discharges from September 2025 were missed and accidently sent the wrong month. This wasn't recognized until March 2026 and was then sent to the Ombudsman. Surveyor asked Social Services Manager F about the Ombudsman notifications for October 2025 not being completed within 30 days. Social Services Manager F stated she could not recall why this happened. Example 4 R1 was admitted to the facility on [DATE]. On 12/21/25, R1 was transferred via ambulance to the hospital and was admitted for treatment of UTI. The facility's written notice of transfer did not include the specific reason for transfer.

Based on observation, interview, and record review, the facility did not ensure a resident who is continent of bladder on admission receives services and assistance to maintain bladder function as possible for 1 of 5 residents (R54). The facility did not ensure an accurate bowel and bladder assessment completed upon admission to determine an appropriate toileting program or plan in place to manage current urinary status or regain/maintain urinary continence status. The facility policy titled Bowel and Bladder Assessment last revised 03/26 states: It is the policy of this facility to provide the resident who is incontinent of bowel and/or bladder the appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. Under the section titled Purpose states: The purpose of the bowel and bladder evaluation is to develop an individualized, goal-oriented approach to elimination. Under the section titled Procedures states in part: 1. The Bowel and Bladder Evaluation will be completed on residents upon admission, quarterly and as needed for changes in condition to determine the appropriate level of bowel and bladder program. Bowel and Bladder scoring: 1. 0-4 = Good Candidate for Bowel and Bladder re-training . 2. Residents identified to have the potential to benefit from a bowel and bladder program (residents with the score of 0-12 on the Bowel and Bladder Evaluation form) will be started on a d day Bowel and Bladder diary. 3. Based on the results of the voiding diary, the appropriate toileting program will be established. R54 was admitted to facility on 02/25/26 from hospital after a fall causing a displaced fracture of left humerus, pubis and hip socket, and pelvic hematoma of urinary bladder causing slight displacement to the right. R54's Medicare 5-day Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 11/15 (mildly impaired). R54's Medicare 5-day Minimum Data Set (MDS), dated [DATE], indicated prior to the current injury was: *Independent with activities of daily living including toilet use, dressing, and ambulation without an assistive device. *Independent with toilet use. *Independent with activities of daily living and functional cognition with planning regular tasks, such as shopping or remembering to take medication. R54's admission MDS dated [DATE] indicated: *Dependent for: toileting hygiene, lower body dressing, sitting to stand positioning and transfers. *Impairment on one side of both upper and lower extremity. *Requires use of a wheelchair for mobility. *Frequently urinary incontinence. *Does not have a toileting program for schedule toileting, prompted voiding or bladder retraining attempted. R54's daily skilled nursing notes dated 02/25/26 through 04/01/26 indicated, Genitourinary: Resident continent of bladder. Urine clear yellow. Denies urinary complaints. R54's Bowel and Bladder evaluation completed on 02/28/26 indicates continent or good candidate. R54's Certified Nursing Assistant (CNA) task completed every shift 02/25/26 through 04/01/26 indicates incontinent of bladder every day. R54's care plan does not address bladder concerns, goals or interventions. On 03/30/2026 at 11:16 AM, Surveyor interviewed R54 who stated they had no urinary problems and did not wear any products prior to the fall with fractures. R54 stated now I wear a diaper or at times stated will use urinal or puts on call light, but they are busy, and I don't like to bother them. On 03/31/2026 between 6:03 AM and 8:18 AM, Surveyor completed a continuous observation outside R54's room. The door was shut, and no call light use observed. On 03/31/2026 at 8:18 AM, 2 staff entered R54's room and repositioned R54 for breakfast. Resident did not request to use bathroom, and staff did not offer or assist with toileting. On 04/01/2026 at 5:17 AM, Surveyor interviewed CNA C. CNA C stated R54 will at times attempt to use the urinal independently, or ring for assistance to use urinal, but is sometimes still unaware of incontinence. On 04/01/2026 at 7:10 AM, Surveyor interviewed Director of Nursing (DON) B regarding R54's continence status. DON B stated that R54 was incontinent of urine in hospital prior to admission due to bladder being shifted due to hematoma from fall at home with fractures. DON B stated that based on licensed nursing staff documenting R54 was continent of bladder upon admission. DON B stated further assessment, monitoring or toileting plan was not developed. On 04/01/2026 at 8:51 AM, DON B indicated they were unable to locate a care plan on R54's bladder incontinence, goals or interventions to manage, maintain or improve incontinence status.

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 3 of 17 sampled residents (R7, R43, and R31). Staff did not implement enhanced barrier precautions for R7 and R43. Staff did not perform hand hygiene during R31's medication administration.The facility policy, titled Enhanced Barrier Precautions, dated 03/24/2026, states, Initiation of Enhanced Barrier Precautions (EBP), the facility will have the discretion in using EBP for residents who do not have a chronic wound.an order for enhanced barrier precautions will be obtained for residents with any of the following: wounds (chronic wounds such as pressure ulcers.) even if a resident is not known to be infected or colonized with a methicillin drug resistant organism (MDRO).make gowns and gloves available immediately near or outside the resident's room. Example 1 R7 was admitted to the facility on [DATE]. R7 was documented to have a stage II pressure injury, facility acquired, to buttock area on 03/18/2026. According to the facility's policy and procedure, EBP should have been initiated for R7. R7's care plan did not have focus or interventions in place for EBP. A review of R7's medical record found no standing orders for EBP were started. On 03/30/2026 at 12:52 PM, Surveyor observed a certified nursing assistant (CNA) assist R7 into bed with a mechanical stand device. The CNA was not wearing personal protective equipment (PPE). After completion of R7's transfer to bed, CNA left room and Surveyor then noticed a red bag garbage container in room. Surveyor did not observe signage for EBP in place outside of R7's room. There was no PPE cart outside of room; however, a container with blue gowns and gloves was hanging on a wall just inside the door. On 03/31/2026, between 6:30 AM and 4:00 PM, Surveyor did not observe signage for EBP outside of R7's room. Example 2 R43 was admitted to the facility on [DATE]. R43 currently has a port-a-cath device (a central venous access to administer chemotherapy through) in place right anterior chest. R43's care plan did not have focus or interventions in place for EBP. On 03/24/2026, nursing documentation for R43 indicated a boil/pustule without drainage on upper right chest was noted by staff. On 03/26/2026, area over port site right chest was cultured and antibiotics started. Culture results on 03/27/26 indicated methicillin susceptible staphylococcus aureus infection. Despite antibiotic therapy, port was visible through open wound. No orders for EBP were in place On 03/30/2026 at 10:39 AM, Surveyor observed a red bag garbage container inside R43's room. No signage for EBP in place outside of room. Shelving on wall inside door of room was empty of gowns and gloves. On 03/31/2026 at 6:45 AM, Surveyor was informed by staff that R43 was admitted to the hospital on [DATE] at 8:19 PM for an infected port-a-cath site. On 03/31/2026 at 6:50 AM, Surveyor interviewed Wound Care Registered Nurse (RN) Q and asked if wound care management was being done for R7 and R43. RN Q confirmed wound cares were being done for both residents, and both residents had open, draining wounds. RN Q stated EBP were taken during wound cares. Physician orders for wound management to sacrum were initiated on 03/11/2026. No standing orders for EBP are in place. On 03/31/2026 at 1:33 PM, Surveyor interviewed infection prevention RN N when EBP precautions would be initiated for a resident. RN N stated for any open wounds with drainage, or when working with closed system devices, such as a urinary catheter. Surveyor asked if R7 and R43 should have EBP in place and RN N stated yes, they both should because both have open wounds. Surveyor asked RN N to indicate if EBP signage was in place for R7 and R43 and RN N confirmed there was no signage in place outside either room. Surveyor asked RN N if PPE was available in R43's room and RN N confirmed no PPE was available inside R43's room. RN N stated it was housekeeping's task to stock PPE in rooms. Example 3 The facility's policy titled, Hand Hygiene reviewed 3/2026, states in part, . 2. Use alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations. c. Before preparing and after handling medications.l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident. On 3/31/2026 11:59 AM, Surveyor observed RN M set up R31's medication. RN M positioned the medication cart in front of R31's doorway. RN M reviewed the medication record on the laptop touching the laptop in the process. RN M then opened various drawers of the medication cart, opened narcotic book, took a pen out and wrote in the book. RN M touched multi-use stock medication bottles and various medication cards of multiple residents. RN M then locked her cart and entered R31's room. RN M gave R31 medications with a spoon. RN M then picked up R31's water cup and assisted R31 to take a drink. RN M then exited the room and returned to her medication cart. Surveyor did not observe RN M using hand hygiene at any time during this observation. Immediately after this observation, Surveyor asked RN M about hand hygiene during medication pass. RN M replied, Oh yeah and then proceeded to use the hand sanitizer which was on the medication cart. On 4/01/2026 at 9:22 AM, Surveyor interviewed Infection Preventionist (IP) N about hand hygiene. IP N stated hand hygiene should be performed before preparing residents' medications and prior to assisting a resident with taking the medications.

Based on observation, interview and record review, the facility did not ensure that residents are free from significant medication errors for 1 of 17 residents (R55) R55 was not administered medication for bowel regimen based on physician orders. R55 was admitted to the facility on [DATE] with diagnoses of dysphagia, amyotrophic lateral sclerosis (ALS,) pneumonitis due to inhalation of food and vomit, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R55's physician orders dated 03/24/2026 state: Metamucil Oral Powder 48.57 % (Psyllium) Give 1 Tbsp via PEG-Tube one time a day for loose stools mixed in 4-8 ounces free water. R55's record shows last bowel movement was documented on 3/28/26 at 19:45 7:45 PM of incontinent small formed soft/normal stool. On 03/31/2026 at 8:41 AM, Surveyor observed Licensed Practical Nurse (LPN) D set up R55's medications which included order for Metamucil. LPN D measured 1 tablespoon of Metamucil and placed it into a 30cc medication cup and added 5 cc of water without stirring medication.When mixed with water, Metamucil thickens. When only a small amount of water is used, the Metamucil can clump into one solid mass. LPN D then took the plunger out of the 60 cc syringe and connected it to PEG tube and gravity fed 5cc of water alternating each medication followed by 5cc of water. During administration of Metamucil, LPN D stated, I don't feel Metamucil is right choice for resident and gravity feeds and addition 30 cc of water as Metamucil clumps in cup and in tubing.The physician's order was to mix the Metamucil with 4 to 8 ounces, or 120 to 240 ccs of water. LPN D only used 30 ccs or a quarter of the minimum ordered amount. LPN D was unable to administer the full dose of Metamucil and discarded the majority of the clumped medication in the trash. Surveyor reviewed Medication Administration of Metamucil which indicated LPN D had administered R55's medication 4 additional dates of 3/25, 3/28, 3/29 and 3/30/26. On 03/31/2026 at 12:46 PM, Surveyor interviewed LPN D after reviewing R55's physician orders. LPN D stated he was not aware of the order to mix with the 4-8 ounces of water and has not been administering extra water per order since order was entered. On 03/31/2026 at 1:16 PM, nurses notes state: Resident has not had BM for 3 days. ABD soft and non-tender with active bowel sounds in all 4 quadrants, denied any GI discomfort, administered PRN MiraLAX, waiting for results.

Based on observation, interview and record review, the facility did not ensure the resident's environment remains as free of accident hazards as possible for 1 out of 4 residents (R44).Staff transferred R44 with the incorrect mechanical lift resulting in a fall after Occupational Therapy (OT)'s recommendations for transfer were ordered. R44's care plan was not updated with transfer changes in a timely fashion.Findings include: Facility policy titled, Safe Resident Transfer Program, dated reviewed on 03/26, states: .Steps for Program use: #1. All transfers will be indicated in the care plan. 6. Staff always have the option of using higher level of transfer assist, if in their judgement, the residents condition warrants it; for example, a resident normally uses Ez-Stand but suddenly is unable to bear weight, then a full body lift should be used. Facility policy titled, Fall Prevention, dated reviewed on 11/24, states in part: .Procedure: A care plan is formulated based on the fall risk assessment. If a potential for a fall is triggered, a care plan will be formulated pertaining to fall prevention. If a resident sustains a fall, the care plan is updated. R44 was admitted to the facility on [DATE] with diagnoses including, in part, unspecified encephalopathy, urinary tract infection, cellulitis of right upper limb, spontaneous rupture of other tendons in the right upper arm, polymyalgia rheumatica, venous insufficiency peripheral, gastro-esophageal reflux disease, atrial fibrillation, hypertension, and chronic kidney disease. R44's Minimum Data Set (MDS) assessment, dated 01/13/26, identified on admission that R44 had a Brief Interview for Mental Status (BIMS) score of 15/15. This indicated R44 had intact cognition. The MDS assessment also identified R44 has impairment of upper extremity (shoulder, elbow, wrist, and hand) bilaterally requiring partial/moderate assistance with bathing/showering self, and upper body dressing. R44 was dependent on lower body dressing. R44 was substantial/maximal assistance with sit to stand, chair to bed transfer, and toilet transfer.Surveyor reviewed R44's self-care deficit care plan initiated on 11/21/24 and revised on 01/20/26:-Ambulation: I require assistance of one contact guard assist with wheelchair to follow.-Bathing-Max assist.-Bed mobility: I require extensive assist of 1 to assist me with bedmobility.-Dressing: I require max assist of one with upper and lowerbody dressing.-Personal hygiene: I require total assistance with one with toilet.-Transfers: I require extensive assistance x1.Surveyor reviewed R44's fall care plan initiated on 11/21/24 and revised on 01/20/26:-Fall 10/17; maintenance to fix wheelchair brakes, initiated on 10/17/25.-Fall 03/26/26; changed to Hoyer lift, PT/OT eval and treat, initiated on 03/31/26.-Keep personal items in reach as well and call light; proper foot wear when up, initiated on 11/21/24.On 03/19/26 at 8:26 PM, bruising to right lower abdomen, sent on communication to provider: Noted with night cares: Bruise to right abdominal. Staff continue to report resident is having difficulty transferring especially using left leg. Staff reports that when resident gets off the toilet she leans heavily into toilet paper dispenser due to not using left leg. Most probable cause of bruise. Writer has sent a request for therapy to evaluate. Not sure if that has been done yet but will request again. Will monitor bruise until resolved. R44's progress note on 03/20/26 at 9:57 PM, states a note was sent to the provider stating Patient has been having an increased difficulty with transfers; she is not standing well and her positioning on her toilet riser does not seem appropriate. Can we get an order for PT/OT to eval and treat? Thanks. Awaiting response.A progress note on 03/22/2026 at 5:41 AM, states, Nursing: CNA (Certified Nursing Assistant) just reported to this nurse that resident was uncooperative with cares this morning. She has been having more difficulty with transfers and has a PT/OT referral for re-evaluation. For the weekend it is nursing's suggestion from previous shifts to use a Hoyer lift for resident and staff safety.R44's 3/25/2026 progress note at 12:45 PM, states Therapy: Received verbal consent from resident on 3-25-26 @ 11:43am regarding an PT/OT evaluation due to resident having more difficulty with upper body strength and transfers. Reviewed residents' insurance coverage of therapy services.Surveyor reviewed OT evaluation progress note dated 03/26/26, states, .Initial evaluation: Upper and lower body dressing max assist x1, toileting hygiene max assist x1, and transfer using sit to stand with min-mod assist.Surveyor reviewed OT evaluation progress note dated 03/27/26, states .Updated: Patient to stand pivot with 1-2 assist using grab bars or walker, condition varies, and if weakness noted use Hoyer lift.On 03/27/26 at 9:31 PM, Nursing: Resident complained of arms hurting with writer receiving report that staff has been using EZ stand to transfer resident. Received scheduled Tylenol as ordered.On 03/28/26 at 5:23 PM, Nursing: Resident has been having an increased difficulty with transfers with an order for PT/OT that was obtained on 03/20. Resident has a dark purple bruise noted to right inner upper arm into her right axilla area. Writer was notified that staff have been using EZ stand to transfer the resident. Resident states she got it from the machine that they use to haul you around. She complained of 5/10 general pain all over, mostly in her arms. Scheduled Tylenol administered and ice to right axilla area. DON notified. Provider notified.On 03/28/26 at 6:16 PM, Nursing Late Entry: Adding to note above: Dark purple bruise noted to residents' inner breast and a smaller bruise to left breast. Resident on Eliquis 5mg twice a day. Provider ordered Hold Eliquis for one dose, continue to monitor.On 03/28/26 at 6:23 PM, SBAR summary: Situation: The Change in Condition/s reported on this CIC (change in condition) Evaluation are/were: BruisingOutcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were:- Functional Status Evaluation: General weakness Decreased mobilityNursing observations, evaluation, and recommendations are Ice, rest, and scheduled Tylenol to be given. PT/OT to evaluatePrimary Care Provider Feedback: Primary Care Provider responded with the following feedback:A. Recommendations: Hold Eliquis and monitor.On 3/29/26 at 12:27, SBAR Situation: The Change in Condition/s reported on this CIC Evaluation are/were: FallsOutcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were:- Functional Status Evaluation: General weakness FallNursing observations, evaluation, and recommendations are:Primary Care Provider Feedback: Primary Care Provider responded with the following feedback:A. Recommendations: follow facility protocolC. New Intervention Orders: - Hoyer for transfers.-On 3/29/26 at 12:56, Nursing: Staff were in bathroom with the resident and was transferring her to the toilet when her knees gave out and she was helped to floor. She did not hit her head. Denies dizziness or new pain. We have started vital/neuro checks per facility protocol and intervention will be to use Hoyer for transfers until re-assessed by therapy.-On 3/30/26 at 1:18 PM, alert charting: Skin Alteration (monitor bruising to right axilla and right/left breasts) Purple bruising remains to right breast and axilla. States are still sore. Does not appear to be increasing in size. Eliquis had been held yesterday.Surveyor reviewed OT evaluation progress note dated 03/30/26, states in part, .Updated: Hoyer lift.03/31/26 at 8:56 AM, IDT (Interdisciplinary Team) Note Text: IDT met to review fall on 3/29. The resident was lowered to the floor with transfer via EZ stand. The resident had been experiencing weakness, seen by PT and OT. Transfer status changed to Hoyer lift. MD and brother updated. Care plan updated to reflect change in transfer status. On 03/31/26 at 9:01 AM, IDT, Note Text: IDT met to review bruising to right arm and bilateral breasts. Resident had been experiencing increased weakness. Resident reports bruising was caused by machine they use to haul me around. Resident's is seen by PT and OT r/t (related to) increased weakness. MD and DON notified, resident is own person. Eliquis was held times one dose. Resident has now been downgraded to Hoyer lift. Resident placed on alert charting to monitor .On 03/30/26 at 12:58 PM, Surveyor interviewed R44 who indicated that R44 has a bruise under right shoulder/armpit because staff keep picking her up by that machine that hauls you around. Surveyor asked R44 to specify what machine R44 is speaking of. R44 reported to Surveyor that R44 is unsure of the name of the machine but that it's the one with the sling that goes under arms to lift to stand. R44 stated to Surveyor, I told those girls I can't lift my arm due to my left shoulder having very limited range of motion. I tell them it hurts so bad and now look at me. On 03/31/26 at 10:24 AM, Surveyor interviewed Registered Nurse (RN) E and RN H and asked about Physical Therapy (PT) updates. RN E reported that updates are placed in the 3 binders per hall at the nurse's station as well as updating the medical record for all to see right away. RN H reported there is also a daily update pink binder near the time clock that all CNAs and nurses are to view when clocking into each shift. It is located near the time machine.Surveyor reviewed the pink binder near the time clock and observed R44's care plan was not updated with R44's new transfer changes until 03/31/26 even though PT had recommended using a Hoyer beginning on 3/27/26.On 03/31/26 at 10:35 AM, Surveyor interviewed Therapy Program Manager J and asked about R44's transfer status. Therapy Program Manager J reported that R44 is a Hoyer lift now. Therapy Program Manager J reported that PT received the evaluation order on 03/26/26. PT evaluated and implemented R44's new transfer status on 03/26/26, Transfer using non-mechanical sit to stand with min-mod assist. Therapy Program Manager J reported that an updated evaluation was completed by OT I on 03/27/26, patient to stand pivot with 1-2 using grab bars or walker condition varies, if weakness noticed use Hoyer, and then on 03/30/26, Hoyer lift. Surveyor reviewed the pink binder near the time clock and noted that R44's care plan was updated on 03/30/26 and that R44 was changed to Hoyer lift due to weakness on 03/30/26. On 03/31/26 at 12:18 PM, Surveyor interviewed OT I and asked OT I to walk Surveyor through the process for when R44 was evaluated and what was decided with transfer status due to weakness.OT I reported that R44 was having difficulties transferring. PT was notified and OT I evaluated R44 on 03/26/26 and deemed R44 to transfer using sit to stand with mid-mod assist. OT I reported to Surveyor that at the time the staff on the floor must not have understood the order for R44 to use the sit to stand as staff were noted to be using the EZ-Stand lift. OT I reported to Surveyor that then OT I re-evaluated R44 due to further weakness and complaints of pain. R44 was mad that staff were using the EZ-Stand as it hurts R44's shoulders. OT I reported that R44 is not a candidate for EZ-Stand due to R44's history of shoulder concerns. OT I reported to Surveyor that on 03/27/26, OT I changed status to patient to stand pivot with 1-2 using grab bars or walker, condition varies, if weakness noticed use Hoyer. OT I stated to Surveyor, [R44] was having a very hard time even transferring with stand by assist over the last couple weeks, which is why [OT I] educated [R44] heavily that if [R44] does not show [OT] I that [R44] can stand strong, [R44] will need to be Hoyer.OT reported that two days later, R44 had fallen via EZ-Stand by CNAs transferring R44 and that's when OT I changed R44 to full Hoyer. OT I reported that staff must have been confused about transferring R44 with sit to stand versus EZ-Stand, so on 03/30/26 at the IDT review meeting, OT I brought up concern with needing very detailed language explained to staff on mechanical and non-mechanical lifts so that staff understand the correct transfer means.On 03/31/26 12:33 PM, Surveyor asked CNA G what the difference between an EZ-Stand and Sit-to-Stand were. CNA G reported that every facility is different and thought they were both the same here at this facility. CNA G stated there was confusion over the sit-to-stand being the stand alone which is not mechanical but then the EZ-Stand was used on R44 when staff were not supposed to. On 03/31/26 at 12:45 PM, OT I approached Surveyor and stated, I just looked back at notes and confirmed that if [R44] was feeling weak or having difficulties transferring, staff were to use straight Hoyer for [R44]. [R44] was transferred by staff via mechanical EZ-Stand two days later and fell or lowered while in mechanical lift. On 03/31/26 at 1:35 PM, Surveyor interviewed Director of Nursing (DON) B and reviewed R44's progress notes pertaining to R44's fall and in the improper transfer on 03/29/26. DON B reported that R44 should have went straight to Hoyer until further evaluation for safety. DON B indicated staff did not do that. DON B stated there are standing orders allowing staff to downgrade R44's transfer status from stand pivot to Hoyer. DON B reported that aides did not use a Hoyer for R44's transfers. DON B reported that R44 should have went straight to Hoyer until further evaluation for safety. Surveyor asked DON B about R44's fall on 03/29/26. DON B reported to Surveyor that staff were not supposed to be using EZ-Stand at all, and the EZ-stand is not what was ordered for transfers. DON B acknowledged R44's care plan was not updated until 03/31/26. DON B stated the process is usually done by unit managers but should have been done timely.

Based on record review and interview, the facility did not implement policy and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 2 of 8 employees reviewed. -The facility did not ensure their abuse policy was implemented when two employees' Background Information Disclosures (BID) did not include results from the Department of Justice (DOJ) and Integrated Background Information System (IBIS) before Certified Nursing Assistant (CNA) P and Facility Driver O started working for the facility. Findings include:The facility's policy titled, Abuse Prevention reads in part, . Employee Screening . 2. All employees will be properly screened for criminal background.On 04/01/26 at 10:14 AM, Surveyor reviewed 8 random staff's BID.1. On 04/01/26 at 10:32 AM, Surveyor interviewed Regional Human Resource K and asked if facility had CNA P's DOJ and IBIS forms completed when facility ran CNA P's background on 11/01/24. Regional Human Resource reported that when the company took over last year, they had a 3rd party company re-run all employees' backgrounds to start fresh. Regional Human Resource Staff K reported to Surveyor that Regional Human Resource will work on finding the information. On 04/01/26 10:47 AM, Regional Human Resource K entered conference room and reported to Surveyor that upon reviewing CNA P's background information, Regional Human Resource K reviewed that facility only has the DOJ and IBIS from prior background ran on 10/07/21. Regional Human Resource K reported that the 3rd party company must have missed CNA P's DOJ and IBIS as there is not an updated one on file. 2. On 04/01/26 at 11:01 AM, Surveyor interviewed Human Resource (HR) Manager L and asked if HR has the DOJ and IBIS for Facility Driver O as Surveyor could not find the reviews. HR L stated they are not able to provide a DOJ or IBIS for Facility Driver O.

Based on interview and record review, the facility did not ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications for 2 of 2 residents (R10 and R55).The facility's policy and procedure included a method that is no longer recognized as a nationally accepted standard of practice. Staff were unable to provide a reference to a nationally recognized standard of practice used to develop their policy and procedure. Facility staff were observed using auscultation as it may not provide accurate results. R55 and R10's tube placement was checked using auscultation. This is evidenced by: Facility's policy titled, Gastrostomy Tube Care and Management, with a reviewed date of 03/2026, states in part: Policy: It is the policy of this facility to provide proper care and maintenance of gastrostomy tubes. Procedure: 4. Before every feeding, verify the tube position.check the position every shift and as needed using aspiration of gastric contents, air auscultation, X-ray examination, or external graduation marks. 9. Verifying Tube Placement: a. Verify gastrostomy tube placement prior to starting the administration of the tube feeding. i. Use of external graduations mark: Most gastrostomy tubes are graduated for easy verification. Note this graduation measure on the resident record as a reference point. ii. Aspiration of stomach contents: The physician may recommend that you draw back on the syringe to check for residual feeing contents in the stomach. If the amount of residual is less than 100 cc, continue feeding. If the amount of residual is greater than 100 cc, return aspirated gastric contents to the stomach and hold the feeding for one hour. After one hour, check the residual again. If the amount is still large, continue to hold the feeding and notify the physician. Follow physician orders. iii. Air auscultation: This method involves listening to the stomach with a stethoscope while injecting air into the tube with a syringe. You should hear a bubbling or gushing sound as the air enters the stomach. Example 1: R10 was admitted to the facility on [DATE] with a diagnosis of dysphagia oropharyngeal phase. On 01/22/26, R10 had a PEG tube inserted after failed swallow study and aspiration pneumonia. R10's physician orders: 01/27/26 Check gastric residual volume Q 8 hours and PRN. 01/27/26 Check tube placement by auscultation before initiating enteral feeding every shift. According to American Society of Parenteral Nutrition, auscultation is no longer a recommended process for checking tube placement. R10's care plan, dated 01/28/26, with a target date of 05/13/26 states: Requires tube feeding related to dysphagia with a goal to remain free of side effects or complications related to tube feeding. Interventions include: Check for tube placement and gastric contents/residual volume and record. On 03/31/26 at 7:06 AM, Surveyor observed Licensed Practical Nurse (LPN) D administer prepared medications via R10's PEG tube. Prior to administering medications, LPN D gathered a stethoscope, graduate container with tap water, and a large syringe with plunger and brought items to R10's bedside. Surveyor asked LPN D to describe what she was going to do. LPN D stated that he was going to verify placement of R10's PEG tube by auscultating air into the tube and listening for a 'whooshing' sound. Surveyor then observed LPN D place the stethoscope on R10's abdomen. LPN D then pulled back the plunger on the syringe, connected it to the PEG tube, and push in approximately 30 ml of air into R10's PEG tube. LPN D stated that he heard the whoosh and disconnected the plunger from the PEG tube. LPN D stated that they also check the gastric residual volume to ensure placement. Surveyor asked LPN D what the nurse would be looking for in gastric volume. LPN D stated he couldn't remember exactly but that if it is under a certain amount then it's fine, but if it's over a certain amount then the nurse is supposed to call the provider. On 03/31/26 at 10:20 AM, Surveyor interviewed Director of Nursing (DON) B regarding enteral feeding tube assessments. Surveyor asked DON B what the current procedure is for nursing to assess placement of PEG tubes. DON B stated by using auscultation to listen for the 'whoosh' sound and residual volume. Surveyor asked DON B what guidance the facility uses to determine their PEG tube placement assessments. DON B stated the Medical Director. DON B did not provide a nationally recognized standard of practice on which the facility's policy and procedure is based on. Example 2 R55 was admitted to the facility on [DATE] with pertinent diagnoses of dysphagia, amyotrophic lateral sclerosis (ALS,) pneumonitis due to inhalation of food and vomit, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R55's care plan, dated 03/17/26, states: Requires tube feeding related to recent aspiration pneumonia, dysphagia, and progression of ALS. Interventions include in part Monitor/document/report to MD: Tube dysfunction or malfunction, .Self-extubating. R55's physician orders dated 03/17/26 state: Check tube placement by auscultation before initiating enteral feeding. Every shift. Of note: order to check tube placement by auscultation does not follow current practice guidelines. Check for tube placement and gastric contents/residual volume and record. Check gastric residual volume Q 8 hours and PRN. Every shift if there is more than 250ml of GRV, withhold further and recheck in an hour. Notify physician if the GRV is more that 250ml on the second check. If the GRV is greater than 500ml, withhold feeding and notify the physician. On 03/31/26 at 8:41 AM, Surveyor observed LPN D administer prepared medications via R55's PEG tube. Prior to administering medications, LPN D gathered a stethoscope, graduate container with tap water, and a large syringe with plunger and brought items to R55's bedside. Surveyor observed LPN D fill the large syringe with plunger with 30 cc of water and pushed in the 30cc of water into the PEG tube. LPN D then proceeded to place the stethoscope on R55's abdomen. LPN D then pulled back the plunger on the syringe, connected it to the PEG tube, and push in approximately 30 ml of air into R5's PEG tube stating, That sounds good, I heard a swish sound. Surveyor noted LPN D did not check gastric residual during process. On 04/01/2026 at 6:30 AM, Surveyor interviewed LPN D regarding auscultation and checking gastric residual. LPN D described what surveyor observed of listening for swish per policy and stated did not check residual as ordered.

Based on interview and record review, the facility did not notify the provider of changes in condition for 1 of 17 residents (R19) reviewed.This is evidenced by:The facility's Standing Orders, most recently reviewed and approved by the Medical Director on 03/05/26, states, Please follow these standing orders unless otherwise indicated by healthcare provider. Provider Notification: Systolic Blood Pressure less than 90 or greater than 200.R19 was admitted to the facility on [DATE] with diagnoses that include cognitive communication deficit, acquired absence of right leg above knee, chronic kidney disease stage 3.R19's most recent quarterly Minimum Data Set (MDS) assessment, dated 03/18/26, noted a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact.Surveyor reviewed R19's vital signs:*10/24/25, R19's blood pressure (BP) was documented as 83/50. No provider notification of systolic blood pressure (SBP) less than 90 was noted.*10/25/25, R19's BP was documented as 87/56. No provider notification of SBP less than 90 was noted.*11/07/25, R19's BP was documented as 83/54. No provider notification of SBP less than 90 was noted.*11/17/25, R19's BP was documented as 89/61. No provider notification of SBP less than 90 was noted.*02/25/26, R19's BP was documented as 84/53. No provider notification of SBP less than 90 was noted.Surveyor reviewed R19's progress notes:*10/27/25 at 1:48 PM, Speech Therapy (ST) entered a note stating R19 had reported experiencing recent visual hallucinations of seeing animals and spiders in room. No additional documentation was noted of informing nursing staff of this change in mental status. No documentation was noted of nursing staff informing provider of change in mental status.On 04/01/26 at 8:29 AM, Surveyor interviewed Registered Nurse (RN) E regarding provider notification of changes. Surveyor asked RN E when the facility's standing orders are implemented. RN E stated that she honestly had no idea and that typically the provider will enter orders of when to be notified. Surveyor asked RN E if provider notifications would be documented in the resident's chart. RN E stated yes, in a progress note. Surveyor asked RN E what the facility's procedure was when other staff, such as ST, identify a change in mental status. RN E stated that other staff, like ST, would typically tell the nurse and the nurse would handle notifying the provider of the change and write a progress note in the resident's chart.On 04/01/26 at 8:33 AM, Surveyor interviewed Licensed Practical Nurse (LPN) D regarding provider notifications. Surveyor asked LPN D when nursing would notify the provider of abnormal vital signs, such as a low BP. LPN D stated that they typically follow the provider's orders for when to notify of changes, but typically when an abnormal BP is taken, the nurse would review the resident's chart to see if there was a trend of lower/higher BP. Then the nurse would decide if it is something that should be reported to the provider. Surveyor asked LPN D what an abnormally low BP would be for reporting to the provider. LPN D stated 82/52. Surveyor asked LPN D why this exact reading. LPN D stated he didn't know, but that would be a reading he would report to the provider. LPN D stated after notifying the provider, the nurse would enter a progress note in the resident's chart documenting what was reported to the provider.On 04/01/26 at 9:15 AM, Director of Nursing (DON) B stated nursing staff are expected to follow the standing orders. Surveyor asked DON B what the expectations are when ancillary staff, such as ST, identify a change in a resident. DON B stated she honestly did not know if that staff should report directly to the provider or the nurse. DON B stated the nurse would be expected to write a progress note in the resident's chart of what the notification was regarding and any response by the provider. Surveyor informed DON B of R19's BP findings and no evidence of notifying the provider. DON B stated that those BPs should have been reported to the provider.

Based on observation, interview and record review, the facility did not determine if self-administration of medications was clinically appropriate for 1 resident (R7) out of 3 residents reviewed for self-administration of medications in a sample of 17 residents. The facility did not ensure the interdisciplinary team (IDT) assessed and determined R7 was clinically appropriate to self-administer prescription topical creams and inhalers, located in R7's room and at bedside. This could result in an adverse event happening because of R7 incorrectly self-administering medications. Findings include:The facility policy, titled Self-Administration of Medications, last revised 03/2026, states, . a resident's cognitive, communication, visual, and physical ability to carry out this responsibility will be evaluated quarterly and as needed.if the resident is a candidate for self-administration of medications, this will be indicated in the medical record.resident's care plan will be updated to reflect self-administration.R7 was admitted to the facility on [DATE] and has diagnoses that include chronic obstructive pulmonary disease (COPD), muscle weakness, low back pain and reduced mobility.R7's Minimum Data Set (MDS) assessment, dated 02/09/2026, indicated R7 has a Brief Interview for Mental Status (BIMS) score of 13, which means cognitively intact. R7 makes own health care decisions. R7's care plan, last revised 03/27/2026, does not include any information related to self-administration of medications.R7's physician orders included*Fluticasone-Salmeterol (Advair) inhalation aerosol powder breath activated 250-50 MCG/ACT - 1 inhalation orally two times a day related to COPD*Tiotropium Bromide Monohydrate (Spiriva) inhalation aerosol solution 2.5 MCG/ACT - 2 inhalations orally one time a day related to COPD*Voltaren external gel 1%. Apply to affected areas topically four times a day for painThere is no physician order for R7 to self-administer medications or for medications to be stored at bedside/roomThere is no evidence that a self-administer assessment has been done by IDT to determine if R7 is clinically appropriate to self-administer medications or safely store medications in room.On 03/30/2026 at 12:52 PM, Surveyor observed:*4 partially used tubes of generic Voltaren gel on the windowsill in R7's room.*Advair inhaler also sitting on windowsill of R7's room. There was no pharmacy label attached to these medications identifying who the medication was prescribed for, or instructions for use. *Spiriva inhaler sitting on a tray table next to R7's bed. A pharmacy label was observed with R7's name and instructions for use. Both the Spiriva and Advair inhalers had a written date of 3/6 on them. On 03/30/2026 at 12:52 AM, R7 was lying in bed. Surveyor asked R7 about the medications and if he used the medications independently. R7 indicated he used the Spiriva inhaler when he is having breathing difficulty, Maybe 3 times a day. When asked about the Voltaren gel on the windowsill, R7 indicated he was not aware of them. R7 informed Surveyor the Voltaren gel was for an area on the butt but could not remember if staff applied the gels yet that day. R7 stated certified nursing assistants (CNAs) apply the gels during cares because R7 is unable to reach buttock area. When asked about the Advair inhaler, R7 was not aware of Advair inhaler on windowsill. R7 could not provide Surveyor with instructions for use or if it was administered by staff that day. On 03/31/2026 at 7:33 and 10:19 AM, Surveyor observed the Voltaren gel and Advair inhaler on still on the windowsill in R7's room, along with Spiriva inhaler on the tray table. On 04/01/2026 at 6:40 AM, Surveyor observed the tube of Voltaren gel and Advair inhaler on the windowsill, and the Spiriva inhaler was on tray table next to R7. Surveyor asked R7 if he administered any inhalers that day. R7 could not recall if inhalers were administered by staff or himself stating, I don't think I did yet. Surveyor asked R7 if able to reach the medications sitting on windowsill to self-administer and R7 stated he could not. Surveyor asked R7 if he knew when to administer the Spiriva inhaler. R7 stated, I have a body clock. I know when to use it. On 04/01/2026 at 7:07 AM, Surveyor asked License Practical Nurse (LPN) D if R7 was able to self-administer the inhalers sitting in his room. LPN D stated yes. LPN D was unsure if R7 knew when to take them and stated R7 required cueing from staff. LPN D stated CNAs administer the Voltaren gel as needed during cares for R7's shoulder pain. On 04/01/2026 at 11:30 AM, Surveyor asked Director of Nursing (DON) B how residents are determined to be clinically appropriate to self-administer medications. DON B stated upon admission, a self-administration assessment is done on all residents. DON B stated if a resident is clinically appropriate to self-administer medications, it is documented in the resident's medical record. DON B stated no medications are to be left in a resident's room.

Based on interviews, record review, and policy review, the facility failed to administer medications as scheduled for one of two residents (Resident (R) 1) reviewed for pharmacy services out of a total sample of six residents. The failure to acquire and administer routine medications to R1 had the potential for unrelieved pain and adverse consequences.Findings include:Review of R1's undated admission Record located under the Profile tab in the electronic medical record (EMR) revealed R1 was admitted to the facility on [DATE] with diagnoses of radiculopathy (a pinched nerve) and spinal stenosis (narrowing) in the cervical region (relating to the neck).Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/01/25, located under the MDS tab in the EMR revealed R1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R1 was cognitively intact.Record review of R1's undated Order Summary Report located under the Orders tab in the EMR revealed Licensed Practical Nurse (LPN) 1 entered an order on 08/29/25 at 5:46 PM, to administer Lyrica Capsule 25 mg [milligram] [Pregabalin] [a prescription medication used to treat certain types of nerve pain] Give 2 capsules by mouth two times a day for pain related to radiculopathy, cervical region. The medication was scheduled to start on 08/30/25 to be administered at 6:00 AM and 4:00 PM. Record review of R1's August 2025 Medication Administration Report (MAR) located under the Orders tab in the EMR, reflected Lyrica Capsule 25 mg (Pregabalin) was not administered two times a day on 08/30/25 and 08/31/25. Registered Nurse (RN) 1 entered a chart code, 7=Other/See Nurse Notes in the row labeled AM 06 (6:00 AM) and LPN2 entered a chart code, 7=Other/See Nurse Notes in the row labeled PM 16 (4:00 PM) under the column 08/30/25. The nurse notes reflected medication unavailable. Medication Aide (MA) 1 entered a chart code, 7=Other/See Nurse Notes in the row labeled AM 06 (6:00 AM) and MA2 entered a chart code, 7=Other/See Nurse Notes in the row labeled PM 16 (4:00 PM) under the column 08/31/25. MA1's comment reflected pending pharm (pharmacy) and MA2 entered medication unavailable.Record review of R1's October 2025 Medication Administration Report located under the Orders tab in the EMR, reflected A chart code, 7=Other/See Nurse Notes in the rows labeled AM 06 (6:00 AM) and PM 16 (4:00 PM) under the column 10/26/25 for Lyrica Capsule 25 mg (Pregabalin). The nurse's notes entered by MA2, for 6:00 AM time and MA3 for 4:00 PM time, reflected the medication was not available.During an interview on 12/22/25 at 11:51 AM, R1 said that she did not receive her Lyrica after she admitted to the facility and called a Family Member (FM) 1 to inform him of increased pain related to not receiving medication (Lyrica). R1 said that she received Tylenol, an as needed (PRN) medication to manage pain when requested. R1 denied not receiving other medications or other doses once Lyrica was available. FM1 was present during the interview and stated that he inquired why R1 did not receive Lyrica and an unknown staff member said that the facility did not receive an order from the transferring facility on the day R1 was admitted . FM1 said that R1 did not receive the Lyrica for three days. During an interview and record review on 12/22/25 at 3:35 PM, MA3 said that she administered medications as reflected on the administration records. MA3 said that she would notify the charge nurse if a medication was not available on the medication cart to administer at the time the medication was scheduled. MA3 reviewed the MAR and progress note, dated 10/26/25, and stated that she entered the comment not available because the medication was not in the medication cart. MA3 said that she notified the nurse in charge, the nurse acknowledged and said that she would notify the pharmacy. MA3 said that she did not have access to medications that were not over-the-counter medications available in the medication room.During an interview and record review on 12/23/25 at 9:25 AM, RN2 said that nurses could access essential first-dose or emergency medications from an automated system in the medication room. RN2 reviewed a progress note she entered on 08/30/25 at 8:48 AM. RN2 acknowledged the note that reflected RN2's attempt to contact the pharmacy about the inability to retrieve R1's routine medications from the automated system due to R1 not registered in the system. RN2 said that the call went straight to voicemail, she left a message and did not receive a call back from the pharmacy before the end of her shift. RN2 said that she placed two outbound calls to the pharmacy and informed the oncoming nurse (RN1) that R1 did not receive her morning medications and to follow up with the pharmacy. RN2 said that she followed up with the pharmacy on 09/01/25 to inform them that there was one dose of Lyrica in the automated system to retrieve and administer to R1 for the morning dose and would not have a dose available for the evening dose if not received by the pharmacy in time. RN2 said that the physician was contacted and a prescription was called into a local retail pharmacy for pick up. RN2 said that she went to the retail pharmacy and picked up the prescription to ensure R1 had medication to receive that evening (09/01/25) and the next morning if not received from the pharmacy.During an interview on 12/23/25 at 12:00 PM, LPN1 said that she was a Unit Manager and assisted nurses with admissions by entering the new orders into the EMR. LPN1 said that the admitting nurse was still responsible for reviewing the orders and completing a medication reconciliation to ensure all medications were entered correctly. LPN1 said that the admission orders were faxed to the pharmacy for review and delivery. LPN1 said that medications were delivered overnight if sent to the pharmacy after 5:00 PM, including Saturday and Sundays. LPN1 said if a medication was not available or needed clarification, the nurse must contact the pharmacy to ensure the order was received and to deliver as soon as possible or provide access to the automated system to retrieve the medication. LPN1 said that the physician must be notified by phone or secured messaging if a resident did not receive a medication dose.During an interview and record review on 12/23/25 at 12:26 PM, RN1 said that she placed a call to the pharmacy (on 08/30/25) to inquire about R1's missing medications and that she was unable to retrieve the medications from the automated system. Review of the progress notes did not reflect documentation that RN1 contacted the pharmacy or the physician. RN1 said that she forgot to write a progress note, she remembered that it was a holiday weekend that she did not call the pharmacy or physician, that she sent a secure message through the EMR.During an interview and record review on 12/23/25 at 1:46 PM, MA1 reviewed the MAR and the comment she entered. MA1 said that she entered pending pharm in the comment because that was what the charge nurse said when MA1 notified the nurse that R1's Lyrica was not available on the medication cart. MA1 said that she must notify the charge nurse about missing medications.Record review of printed secured messages sent and received on 08/29/25 - 08/31/25, provided by the Director of Nursing (DON), did not reflect any messages related to R1, sent by RN1, or received by the physician or pharmacy on 08/30/25.Record review of a printed Packing Slip, dated 08/30/25, provided by LPN1, reflected R1's medications were delivered and received overnight (after midnight), signed, and dated 08/31/25 by a nurse.During an interview on 12/23/25 at 4:14 PM, the DON stated she expected to be notified if medications were not available for administration. The DON said that she was not aware that R1 did not receive her scheduled Lyrica for two days. The DON said that she would have followed up with the pharmacy and the physician to request an alternative medication equivalent to Lyrica. The DON said that RN1 should have followed through with the pharmacy and notified the physician about R1's missing dose. The DON said that the facility discontinued services with the pharmacy related to similar issues of not receiving medications in a timely manner and as of December 1, 2025, contracted with a new pharmacy. The DON said that the facility did not have a written policy for the process by which a facility requests and obtains medication (acquiring medication).Record review of the facility's policy titled, Medication Monitoring, implemented 11/24, indicated: 6. Licensed nurses, with periodic oversight by nurse managers, shall: c. Report refusals of medications, frequent holding of medications, or signs of adverse consequences of medications to the physician. d. Reorder and crossmatch medications according to facility policy to assure accurate and adequate supply of medications. 9. Each resident's medication regimen is reviewed by a licensed pharmacist at designated intervals and whenever changes in condition that could be related to medications are noted. Irregularities are reported and addressed in accordance with facility policy for medication regimen reviews and addressing irregularities.

Based on interview and policy review, the facility did not ensure allegations of mistreatment were thoroughly investigated for 1 of 1 (R3) resident reviewed. Certified Nursing Assistant (CNA) C made a comment about the way R3 smelled, allegedly stating R3 needed a bath because he smells like he came out of a barn. The facility investigation did not include all nursing staff working R3's rehabilitation unit during the time of the reported incident. This is evidenced by: The facility policy, Resident Rights-Abuse Prevention, which was not dated, included in part: Policy: It is the policy of this facility that each resident has the right to be free from abuse .Residents must not be subjected to abuse by anyone . Procedures: Investigation-All identified events are reported to the Administrator/Designee immediately and will be thoroughly investigated. The investigation shall consist of: 5. An interview with staff members (on all shifts) having contact with the resident during the period of the alleged incident. 7. An interview with staff members (on all shifts) having contact with the accused employee . R3's most recent Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS), completed 3/05/25, indicated a score of 15/15, meaning R3 is alert and oriented and able to answer questions correctly. Surveyor reviewed the Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report submitted to the State of Wisconsin by the facility. Surveyor noted the following: Briefly Describe the Incident: On 1/05/25 [R3] refused a bath and an agency CNA made a comment to the effect of 'you should (have a bath) because you smell like you just came out a barn.' The Resident [R3], a former Social Services Director, took offense and assumed the comment made was with hurtful intent. Resident Specifics: 69 y/o (year old) male who is his own self. Resident Statement: I felt degraded when during my initial contact with [CNA C]. R3 stated he was told, He smelled like I came out of a barn. He never came back to state that was a joke or jest at any point in time. It was degrading. He then stated that I need to soak my fingers and said I am going to soak your hands today. I have sores on both my hands and my orthopedic surgeon said I should not get them wet. He said I am still going to and made derogatory remarks about the ortho surgeon. He did not soak my hands. As he got ready to go leave the room I felt he was overall disrespectful and degrading. At one point he said 'I've never worked someplace where so many people were rude to me.' I said, Did you consider it is your behavior eliciting that treatment. He said nothing and left the room. Ultimately, I felt like I was being bullied. Surveyor noted the facility investigation included interviews conducted with 12 residents who reported no concerns of staff treatment. Surveyor also noted two staff interviews that had been conducted as follows: 1/07/25 at 4:15 via phone: CNA C who stated, The resident [R3] had been refusing care since his return from the hospital. [CNA C] acknowledged he told [R3] his room had odor but respected [R3's] wishes to refuse care. 1/08/25 (no noted time): CNA D who indicated she went with CNA C to give R3 a bed bath. R3 refused a bath stating he had a bath in the hospital. [CNA C] told him he had to take a one in a very blunt manner which made the resident agitated. Facility did not provide any evidence of other staff interviews being conducted. Surveyor reviewed the nursing staff schedules for 1/04/25 and 1/05/25 and noted 9 other nursing staff working R3's rehabilitation unit. On 3/26/25 at 10:12 AM, Surveyor spoke with Nursing Home Administrator (NHA) A about the facility investigation. NHA A indicated he was the individual who conducted and submitted the facility report. NHA A explained he began an investigation immediately upon learning of the report of mistreatment, which was submitted to the State of Wisconsin. NHA A expressed he immediately placed CNA C on suspension, NHA A expressed residents on the rehabilitation wings were interviewed as well as CNA C and D. The facility concluded the incident occurred, and CNA C will not be returning to the facility. NHA A stated he believed he talked with other staff but has no proof of who he spoke with. NHA A further expressed he should have spoken with all staff working the rehabilitation on all shifts per the facility policy to ensure no other staff had seen any other potential mistreatment of residents.

Based on interview and record review, the facility did not ensure that a resident (R) received treatment and care in accordance with professional standards of practice for 1 out of 18 residents sampled. (R321) R321 has a history of daily opiate use and constipation. The facility bowel protocol was not followed or a thorough GI assessment completed, causing actual harm to R321. R321 was hospitalized with severe pain and was admitted with a fecal impaction. Findings include: The facility's bowel protocol, reviewed on 11/18/24, includes, in part: Bowel and Bladder Management . Bowel: Constipation (If no bowel movement in > 48 hours; Perform steps sequentially) -Perform rectal check to determine if impaction is present - Encourage 2,000 ml daily fluid intake unless contraindicated -Consult Dietician for dietary recommendations -Sennoside 8.6 mg take 2 tablets by mouth at evening prn for 3 days -Bisacodyl suppository 10 mg per rectum daily prn for 3 days - Reattempt Sennoside or Bisacodyl if no results after 24 hours and notify provider - Fleets enema per rectum x1 if no results from suppository -Monitor and record results from treatment. Lipincott 2020 Critical Care: Assessing the abdomen Use sight, sound, and touch to assess your patient's abdomen for abnormalities. Assessing your patient's abdomen can provide critical information about his internal organs. Always follow this sequence: inspection, auscultation, percussion, and palpation. https://www.ncbi.nlm.nih.gov/books A digital rectal examination is mandatory as the first diagnostic evaluation to confirm the diagnosis of fecal impaction. R321 was admitted to the facility on [DATE] with the following pertinent diagnoses: chronic pain syndrome, constipation by delayed chronic transit, Raynaud's syndrome with gangrene, unspecified severe protein-calorie malnutrition. The Minimum Data Set (MDS) dated [DATE] indicates R321 had a Brief Interview for Mental Status (BIMS) of 15 out of 15 which indicates R321 is cognitively intact. R321's MDS indicates R321 is dependent on toileting, hygiene, bed, and wheelchair transfers. MDS indicates frequently incontinent of bowel, no toileting program in place, and no bowel patterns. R321's Medication Administration Record (MAR) indicates the following orders: HYDROcodone-Acetaminophen Oral Tablet 7.5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth six times a day for pain Senna Oral Tablet 8.6 MG (Sennosides) Give 1 tablet by mouth every 12 hours as needed for constipation -Ordered on 12/10/2024 at 05:56 PM. No documentation that this was given. Dulcolax Suppository 10 MG (Bisacodyl) Insert 1 suppository rectally every 24 hours as needed for Bowel Care. Order on 12/02/2024 at 03:18 PM. No documentation this was given in December 2024. Fleet Oil Rectal Enema (Mineral Oil) Insert 1 application rectally as needed for constipation *use residents home supply in room* -Ordered on 12/21/2024 at 08:35 PM. On 01/06/25 at 12:02 PM, Surveyor interviewed R321 regarding his general care at the facility. R321 indicated that he was still in bed because he was recently hospitalized . R321 reported he is still weak and tired. R321 had been hospitalized on [DATE] due to a fecal impaction. R321 reported that at approximately 11:30 AM on 12/22/24, he had told Licensed Practical Nurse (LPN) O that he had intense rectal pain and needed something done. R321 indicated LPN O called the charge nurse who gave the direction to LPN O to observe him for the afternoon. R321 then explained to LPN O he had a history of fecal impaction, once resulting in a bowel perforation and he could not wait because the pain was unbearable. R321 reported that LPN O again called the charge nurse, and LPN O then told R321 she was waiting to hear from the nurse. R321 reported he then asked LPN O that he be sent to the hospital. When LPN O did not send him, R321 called 911 himself, shortly after 1:00 PM. R321 reported he went to the ER where it was discovered R321 had a fecal impaction. R321 reported he is unsure if the facility was aware that he had not had a bowel movement (BM) in several days. Medical record was reviewed; no documentation of abdominal pain prior to 12/22/24. On 1/08/25, Surveyor reviewed R321's bowel movement records which indicated that R321's last BM was 12/18/24 at 7:06 PM med BM. No BM recorded for the next 4 days 12/19/24 through 12/22/24. Surveyor reviewed R321's progress notes. -nursing note indicates in part on 12/21/24- GASTROINTESTINAL: Bowel Sounds are Present Bowel Sounds are Hypoactive -Active SX: constipation. No GI appliance(s) used No nutritional deficits observed. 12/21/2024 20:36 Nursing -Note Text: HUCU message sent: Resident brought in his own supply of Fleet enemas that he says he uses if he has not had a BM in several days. May we have order for Fleet enema PRN? HUCU message received: OK to use the enema. Please update if no BM Resident is refusing enema at this time On 12/22/24- GASTROINTESTINAL: Bowel Sounds are Present Bowel Sounds are Active Active SX: constipation. No GI appliance(s) used Active SX: meal intolerance or PO intake less than 25%. Of note, R321 has a history of daily opiate use and constipation. Despite this history the facility failed to complete a thorough GI assessment including palpating the abdomen, rectal check and bowel sounds. There is no evidence the facility staff checked to see when R321 had his last BM. R321 had to call 911 on his own due to severe pain and was admitted with a fecal impaction. On 01/07/25 at 10:17 AM, Surveyor interviewed LPN O. When asked about interventions for residents who are experiencing constipation, LPN O reported she would follow the bowel protocol when a resident is symptomatic of constipation. When asked about R321's constipation, LPN O reported an enema order was obtained the day prior and the enema was given per R321's request on 12/22/24. LPN O stated, [R321] was screaming he wanted to go to the hospital, but I was in with another resident and before I got a chance to go back in by him, [R321] had already called 911 LPN O then notified DON via telephone. On 12/22/24 at 12:19 AM, documentation in the MAR shows Fleet Oil enema was given; no results reported or documented from administering the enema. No documentation found, or provided by facility, that the provider was notified that this was day 4 with no bowel movement or that the enema given on 12/22/24 failed to produce results of a BM for R321. On 1/08/25, Surveyor reviewed R321's hospital discharge summary, which indicates in part, R321 .who presents with abdominal pain and was admitted for fecal impaction. On admission, he had a large fecal mass palpable in the rectal vault. Imaging showed a 7.6 CM stool ball with surrounding inflammation .was evaluated by GI. He is a difficult situation secondary to chronic opiate use, chronic immobility, and medical noncompliance in the past. He was treated with as needed suppositories and enemas here which seemed to work. Patient was treated for a urinary tract infection (UTI) with Keflex. Raynaud's, chronic diastolic heart failure, and atrial fibrillation were managed with patient home regimen. His chronic pain from neuropathy/scleroderma was treated with his home hydrocodone PRN. While here, he requested this whenever it could be given. Opiate use is thought to be a contributing to his constipation issues. R321 was hospitalized and treated for fecal impaction on 12/22/24 through 1/3/25. On 01/08/25, Surveyor requested facility's bowel protocol and documentation of interventions done for R321's constipation prior to his hospitalization from Director of Nursing (DON) B. On 01/08/25 at 11:00 AM, Surveyor interviewed DON B, who provided documentation of a late entry completed on 01/08/25 by LPN O after Surveyor asked questions about R321's constipation. This late entry for 12/22/24 states, Writer performed abdominal assessment including listening to bowel sounds that were present in all four quadrants. Writer also performed rectal exam .informed resident stool was at anus. Writer encouraged resident to drink water and resident stated he would rather drink soda than water. Encouraged resident to use bathroom to defecate rather than laying in the bed and going in the depends. Resident refused to use bathroom. DON B provided documentation that staff education was provided to LPN O about proper and timely documentation. DON B verbalized that the interventions documented on the late entry were not in R321's records prior to Surveyor's request of bowel interventions performed for R321 as indicated by the facility's Bowel Protocol. DON B verbally agreed there was no evidence to indicate that R321's constipation was addressed or that the facility's Bowel Protocol was followed, resulting in R321 experiencing pain and requiring hospitalization for fecal impaction.

Based on observation, record review and interview, the facility did not allow clean dishes sufficient time to air dry or store the clean dishes in a manner to prevent potential contamination. The facility practice has the potential to affect all 76 residents. This is evidenced by: The facility policy tilted Dishwashing and Ware Washing which was not dated was requested and received by Surveyor. The policy in part read: Objective: To ensure cleaning, sanitization and infection control in the dishwashing area to promote food safety, prevent contamination and minimize the risk of spreading infections. Washing (Mechanical or Manual): Dish Drying: ~Dishes, utensils and cookware will be allowed to air dry completely on clean, sanitized racks or drying shelves. Inverting Dishes: Inversion: All plates, bowls, cups and similar items will be inverted (placed upside down) during storage to prevent contamination from airborne particles and dust. On 1/07/25 at 9:55 AM, Surveyor observed Dietary Aide (DA) C doing dishes in the dish room. DA C was observed spraying dirty dishes and loading dishes to a dish rack. DA C removed her apron and gloves and performed hand hygiene. DA C donned a clean apron and gloves and proceeded to the clean dishes to stack the coffee cups and bowls on trays. The coffee cups and bowls were not completely air dried. The bowls were not inverted and placed on the racks to store. Surveyor observed the bowls to have standing water in the bottom of the bowls. Surveyor observed racks of bowls that were stacked below the rack DA C had placed the bowls just removed from the dish rack/dish machine. Surveyor and DA C observed standing water in the bowls that had been stacked and not allowed sufficient time to air dry or inverted when stacked. Surveyor asked DA C to observe the coffee cups that had been removed from the dishwasher and not allowed to air dry before being stacked on trays in an inverted manner. Surveyor and DA C observed the coffee cups to have water that had not air dried in the bottom of the coffee cups. Surveyor asked DA C how long she has been in her position and if dish washing is part of her responsibilities. DA C expressed she has been on staff [AGE] years and doing breakfast dishes is part of her daily responsibilities. Surveyor asked DA C if the observed process of washing dishes, unloading immediately from dish machine and stacking to trays as observed by Surveyor is her normal process. DA C indicated the observed process is the way she does dishes each day for breakfast. Surveyor asked DA C if the observed standing water in the dishes may pose a risk for contamination. DA C responded the water in the dishes could grow mold and other bacteria and pose a risk for contamination. Following the observation Surveyor was joined by Dietary Supervisor (DS) D in the dish room. Surveyor spoke with DS D about the observation and the still remaining water in the bottom of the bowls that were not inverted and the slight water in the coffee cups that were not allowed to air dry. DS D instructed DA C on allowing more time for dishes to air dry and stacking the bowls in a different manner to invert and not allow for standing water. Surveyor asked DS D if the current manner of dish washing poses a risk for contamination of the presumed clean dishes. DS D responded she understood how the process and the water in the clean dishes could pose a risk for contamination. She will be changing the manner the dishes would be stacked and instructing staff to allow more time for the dishes to air dry.

Based on observation, interview and record review, the facility did not effectively monitor psychotropic medications to ensure residents are receiving the lowest possible effective dose. The facility practice had the potential to affect 1 of 5 residents reviewed for unnecessary medications (R19). This is evidenced by: Surveyor requested and reviewed the facility policy titled Psychoactive Medications dated as most recently reviewed on 12/2024. The policy in part read: Policy: It is the policy of this facility to maintain every resident's right to be free from the use of psychoactive medication. ~Psychoactive medications .are to be administered only when required to treat the residents' medical symptoms. ~No psychoactive medications will be utilized without .a diagnosed specific condition and will include the target behavior .with the goal of reducing the duration and/or dose of the medication. ~Monitor and track progress towards the therapeutic goal (s) . ~Perform gradual dose reductions (GDR) as per regulatory guidelines to find the optimal dose or to determine whether continued use of the medication is benefiting the resident. Tapering may be indicated when the resident's clinical condition has improved or stabilized, the underlying causes of the target symptoms have resolved and/or non-pharmacological interventions, including behavioral interventions, have been effective in reducing the symptoms. Surveyor reviewed R19's record and noted the following: R19's most recent quarterly Minimum Data Set (MDS) assessment completed 12/27/24, indicated resident understands, is understood and has severely impaired cognition. R19 has no mood or behavioral symptoms of verbal, physical or other behaviors. R19 has delusions and rejects care. R19's diagnoses include unspecified dementia-unspecified severity with behavioral disturbance, anxiety and dysthymic disorder (persistent depressive disorder). R19 takes antipsychotic, antianxiety and antidepressant medications. Has a gradual dose reduction been attempted: No. R19's annual MDS, dated [DATE], indicated resident understands, is understood and is cognitively intact. R19 has no mood or behavioral symptoms of verbal, physical or other behaviors. R19 has no delusions and does not reject care. R19's diagnoses include unspecified dementia-unspecified severity with behavioral disturbance, anxiety and dysthymic disorder (persistent depressive disorder). R19 takes antipsychotic and antidepressant medications. Has a gradual dose reduction been attempted: No. R19's Orders: 11/01/24: Rexulti Oral Tablet 2 MG (Brexpiprazole) Give 1 tablet by mouth one time a day for Dementia with behavioral disturbances Surveyor reviewed summary of Rexulti medications since the facility's last recertification survey and noted: Rexulti: ~9/08/23-3/24/24 Dose: 1 mg oral QD, Diagnosis: unspecified dementia, unspecified severity with other behavioral disturbance ~3/25/24-4/01/24 Dose: 1.5 mg oral QD, Diagnosis: unspecified dementia, unspecified severity with other behavioral disturbance ~ 4/02/24 to present: Dose: 2 mg oral QD, Diagnosis: unspecified dementia, unspecified severity with other behavioral disturbance R19's care plan which transitioned to facility's new electronic record November 2024 included: Focus: Resident receives antipsychotic, and SSRI (selective serotonin reuptake inhibitors/antidepressant) medication related to dementia with behaviors. Goal: Resident will be prescribed the lowest effective dose of medication. Date Initiated: 11/21/24, Target date: 3/19/25. Interventions: ~Attempt a gradual dose reduction per facility protocol. ~Monitor for targeted behaviors r/t (related to) rexulti use physical aggression, verbal aggression. ~Monitor for target behaviors every shift: tearfulness, low mood. Care plan in facility's previous electronic record from previous recertification survey to 11/2024. The care plan had no visible dates for initiation or target dates. Resident has a history of accusatory/paranoid comments, refusing cares, meals and medications r/t dx of dysthymic disorder and undiagnosed personality disorder per husband. I have a HX (history) of experiencing anger/agitation related to my cognitive functioning deficits/memory issues r/t DX of Dementia, my cognitive deficit, decline in ADL ability As evidenced by: HX of persistent anger with self or others HX of delusional thoughts/verbal expressions HX of unpleasant mood HX of verbalizations of anger over loss HX of verbalization of non-acceptance over change of status day, persons involved, and situations. Document behavior and potential causes. Resident has a history of resisting care (e.g., blood work, taking medications, ADL assistance). Surveyor reviewed R19's record in the facility's previous medical record (Matrix Care) from previous recertification survey and the facility's current medical record (Point Click Care) and found no notes showing R19 had targeted behavioral concerns. Surveyor reviewed Consultant Pharmacist Recommendation to Physician reports and noted the following: ~12/22/24: Federal guidelines state antipsychotic drugs should have an attempt at gradual dose reduction (GDR) twice per year for the first year in 2 different quarters with a least 1 month between attempts, then annually thereafter. This resident has been taking Rexulti 2 mg QD (every day) since 3/04/24 without a GDR. Could we attempt a dose reduction at this time to perhaps Rexulti 1 mg QD to verify this resident is on the lowest possible dose? if not, please indicate response below: Response signed by physician 1/07/25: Reduce the dose of Rexulti to 1 mg po (orally) QD (every day). 3/18/24: Federal guidelines state antipsychotic drugs should have an attempt at gradual dose reduction (GDR) twice per year for the first year in 2 different quarters with a least 1 month between attempts, then annually thereafter. This resident has been taking Rexulti 1 mg since 9/8/23 without a GDR. Could we attempt a dose reduction at this time to perhaps Rexulti 0.5 mg QD to verify this resident is on the lowest possible dose? If not, please indicate response below: Response from physician: Box checked: Use in accordance with relevant current standards of practice for psychiatric disorder (i.e.: schizophrenia, delusional behavior, bipolar, atypical psychosis in absence of dementia, huntingtons, mania) All options require clinical rationale for continuing by physician stated below . Physician/Prescriber Response Contraindicated increase 3/25/24 r/t (related to) increased agitation/restlessness Although the physician noted R19 with increased agitation/restlessness, R19's record showed no targeted behaviors of physical/verbal aggression. Surveyor observed R19 throughout survey in her room eating meals, watching television and interacting with staff. No behavioral or mood concerns were observed. On 1/07/25 at 8:03 AM, Surveyor spoke with Certified Nursing Assistant (CNA) E regarding R19's routine, preferences, and behavioral concerns. CNA E expressed R19's cares had been done already this morning and are done when she wakes up which is sometimes day shift and sometimes night shift. R19 is given the choice if she wants to get up out of bed. Most often R19 prefers to stay in bed and eats her meals in bed in her room. R19 enjoys certain television shows that are turned on her TV. R19 is also offered a busy box in bed for her to manipulate. Sometimes R19 wants it and sometimes not. R19 does not show indicators of pain and is good as far as behaviors when her routine is kept. On 1/08/25 at 10:52 AM, Surveyor spoke with Registered Nurse (RN) F who has worked at the facility several years and is familiar with R19 regarding R19's behavioral concerns. RN F indicated R19 has no recent mood or behavioral concerns. R19 has history years ago of intense behaviors. R19 will occasionally get a little agitated with cares which is very sporadic. R19 is not combative and does not appear in any distress. On 1/08/24 at 11:02 AM, Surveyor spoke with Director of Nursing (DON) B, Regional Administrator Lead (RAL) G and Clinical Resource Registered Nurse (CRRN) H about the facility's process for monitoring effectiveness of psychoactive medications and ensuring residents are on the lowest possible effective dose of medications when treating behavioral disturbance for residents with dementia; specifically, R19. DON B explained nurses chart daily on behaviors. If behaviors occur nurses do a corresponding note. The facility transitioned from one medical record system to another during change of ownership in November 2024. R19 has a history of verbal and physical aggression towards staff. R19 is treated with Rexulti for her behaviors associated with dementia. R19 had a care plan in the previous medical record for her targeted behaviors of aggression that was transitioned to point click care in November 2024. Both record systems were checked and R19 has not demonstrated targeted behaviors. The facility has a behavioral committee that looks at residents on psych medications and review pharmacist recommendations for GDRs. Surveyor asked DON B for clinical rationale for increasing R19's Rexulti (antipsychotic medications) when no targeted behaviors were occurring. DON B expressed there was one occasion R19 attempted to crawl out of bed. The team thought she may have had increased restlessness when she attempted to crawl from bed thus her medication was increased. Surveyor asked DON B if the team considered R19's lack of targeted behaviors when the increases in the Rexulti occurred. DON B expressed there was no clinical rationale based on R19's targeted behaviors to increase her medication. DON B further expressed she would continue to check R19's record and provide surveyor with any information that would support the increase and lack of GDR if anything was found. RAL G expressed the facility is aware the process for monitoring residents on psychoactive medications needs improvement. The facility has not yet implemented a process improvement plan since acquisition of the facility in November 2024.

Based on observation, interview and record review, the facility did not provide measures to prevent and treat Pressure Injuries (PI) while completing wound care for a PI, ensure that pressure relieving air mattress was operational and in continuous working order, and did not document pressure injury assessment including wound staging at least weekly for R12, R31 was not provided off-loading of pressure or repositioned timely. The facility practices had the potential to affect 2 of 3 (R12 and R31) residents reviewed for pressure injuries. This is evidenced by: Example 1 Surveyor reviewed facility policy titled, Prevention and Treatment of Skin Breakdown, noting NPUAP as reference included, in part: Those residents' who experience a break in skin integrity or wounds are provided care and service to heal the skin according to professional standards of care. Professional standards of practice as suggested by Centers for Disease Control and Prevention (CDC) include cleaning and disinfecting patient care equipment, instruments, and devices, clean and disinfect environment appropriately, and practice proper hand hygiene as warranted. On 11/29/23 at 10:07 a.m., Surveyor observed Registered Nurse (RN) E complete wound care for R12 who was admitted to facility on 10/30/23 with a pressure injury on coccyx. RN E used resident's bedside table as surface to place supplies for wound care and dressing change. Surveyor observed that RN E did not sanitize surface or place any kind of barrier on table. Surveyor observed multiple incidents of not practicing proper hand hygiene by completing tasks with dirty gloves on that included: reaching into pocket, documenting in paper binder, touching resident's personal items, and looking for items in clean supply box. After completing wound care, RN E brought dirty scissors used during wound care to nurses station, set on counter, and grabbed sanitizing wipes to clean. Surveyor observed that RN did not wipe counter surface that dirty scissors had been on. On 11/29/23, following the observation, Surveyor asked RN E what infection prevention measures should be used and how they know what Personal Protective Equipment (PPE) and supplies are needed for wound care. RN E replied that it depended on the wound. If there is a possibility of coming into contact with blood or fluids, then a gown and glasses would be used. RN E states to otherwise follow the standard infection prevention methods which would include cleaning surface to be used for wound care supplies, use of a barrier, and cleaning surface after use. RN E stated that she is currently in the process of being certified in wound care and that she is responsible for all the wound care at the facility. RN E states that she can be quite busy at times and forgets things. On 11/28/23 at 10:52 a.m., Surveyor observed R12 lying supine (on back) in bed, in lowest position, with air mattress in use and operating. The bed appeared to be slanting to the right with R12 very close to the edge. Surveyor asked R12 if his bed is always like this and he responded, I guess. It deflates every night. On 11/29/23 at 7:48 a.m., Surveyor observed R12 supine in bed, lowest position, and air mattress appeared to be off. Surveyor asked R12 if the mattress was inflated and in working order. R12 stated that he didn't think so. R12 stated that it turns off every night like this. Director of Nursing (DON) B came into the room to assess the bed and stated that it had been unplugged from the wall. She plugged the unit back in and the bed reinflated. Surveyor asked DON B whose responsibility it was to assess if air mattress was on and working. DON B stated that all nursing staff are responsible. DON B was not aware of the pressure mattress issue until Surveyor asked about it. On 11/29/23, following the observation, Surveyor interviewed DON B regarding standard of practice in ensuring pressure relieving devices are in place and in working order. DON B stated that they currently did not have any practice in place for assessing and documenting pressure relieving devices. DON B and RN E stated that they implemented all interventions noted in care plan and wound care orders, but despite their best efforts, R12 developed new pressure injuries to both heels after being in their care. DON B acknowledges that no measures were in place to assess and document pressure relieving device was in place and working and likely contributed to the development of the new pressure injuries. Surveyor reviewed R12's record and noted: R12 was admitted to facility on 10/30/23 following hospitalization for rehabilitation services. R12 has medical diagnoses that include rhabdomyolysis, congestive heart failure, hypertension, diabetes mellitus type II, a flutter, coronary artery disease, and fracture of right toe(s). The following wound documentation was reviewed: 10/31/2023 buttocks injury measures at 3.8cm x 2.2cm, depth <0.1cm, bloody serous drainage, minimal pain, calazime cream applied as ordered. 11/1/2023 Buttocks pressure injury measures at 5.5cm x 6cm, depth <0.1cm. Pain with pressure injury when sitting for to long in wheelchair. Mild serosanguineous drainage. Wound bed has about 80% yellow slough, 10% slight black eschar, wound cleansed with gentle cleanser, thick layer of calazime applied to wound, no brief on he is open to air (OTA). 11/16/23 (First notation of documentation of R12's bilateral heel pressure injuries) Left heel Deep Tissue Injury (DTI) measures at 1cm x 0.8cm x depth <0.1cm. Skin intact, minimal pain. Heel prepped with skin prep, heel cupped with ABD and wrapped with kerlix. Prevalon boot applied once wound care complete. Right heel DTI measures at 1.5cm x 4.7cm x depth <0.1cm. Skin intact, minimal pain. Heel prepped with skin prep, heel cupped with ABD and wrapped with kerlix. Prevalon boot applied once wound care complete. Order for Prevalon boots to be worn bilaterally at all times when in bed and up in wheelchair. 11/22/23 Buttocks pressure injury measures at 4.5cm x 5cm, depth <0.1cm. Pain with pressure injury when sitting for to long in wheelchair. Mild serosanguineous drainage. Wound cleansed with gentle cleanser, thick layer of calazime applied to wound. Left heel measures at 0.5cm x 1cm, depth <0.1cm. Heel painted with betadine, let dry, covered with heel cover and wrapped with kerlix. No pain, skin intact nothing open. Right heel DTI measures at 0.7cm x 3.3cm x Depth <0.1cm. Skin intact, minimal pain. Heel prepped with betadine, heel cupped and wrapped with kerlix. Prevalon boot applied once wound care complete. 11/29/23 Buttocks pressure injury measures at 3.5cm x 7.5cm, depth <0.1cm. Pain with pressure injury when sitting for to long in wheelchair. Mild serosanguineous drainage. Wound cleansed with gentle cleanser stoma powder applied, then thick layer of calazime applied over stoma powder. Resident repositioned wound care done. Left heel measures at 0.5cm x 0.5cm x <0.1cm. Heel painted with betadine, let dry, covered with heel cover and wrapped with kerlix. No pain, skin intact. nothing open. Prevalon boot applied once wound care complete. Pillow placed under legs to float heels. Right heel DTI measures at 0.8cm x 3.5cm x depth <0.1cm. Skin intact, minimal pain. Heel prepped with betadine, heel cupped and wrapped with kerlix. Prevalon boot applied once wound care complete. Facility documentation did not include staging and was not completed on a weekly basis per facility policy titled, Prevention and Treatment of Skin Breakdown. Surveyor did not find any wound assessment documentation between 11/1/23 - 11/16/23. Surveyor reviewed R12's most recent wound care orders as followed: 11/22/23 Left buttock/coccyx ulcer: Apply a nickel thick layer of calazime cream PRN. Special lnstructions: May use stoma powder to assist with adhering cream to the wound. Use foaming cleanser to remove the soiled cream. Do not scrub off soiled cream. Every shift and As Needed. 11/22/23 Wound Clinic Standing orders: Limit sitting in wheelchair or chair to no longer than 2 hours at a time. Offloading cushion to wheelchair or chair. Avoid laying in a supine position. Remove hoyer sling from underneath patient while sitting in wheelchair every shift. 11/22/23 Bilateral deep tissue pressure injuries of the heels: Apply betadine daily. Let dry. Cover with an ABD heel cups and secure with rolled gauze daily and as needed. Surveyor reviewed R12's most recent care plan dated 11/27/22, which in part states: Skin - I have the following skin protective measures in place: air mattress, heel protectors with offloading when in bed, skin treatment as ordered. I must use a full body sling for safety and comfort to my skin, and unable to remove when sitting in wheelchair. I have aquagel wheelchair (w/c) cushion. Update MD as required. Prevalon boots on at all times ordered on 11/16/23 when in bed and up in w/c. On 11/30/23 at 12:47 p.m., Surveyor interviewed DON B and RN E regarding findings. RN E stated that she thought she had documented appropriately as there is a template that is used in wound documentation. Surveyor requested and received facility policy titled, Prevention and Treatment of Skin Breakdown with a copyrighted date of 2018 and identifying CMS State Operations Manual, Appendix PP and NPUAP as reference source states in part: Resident skin integrity is assessed upon admission and weekly thereafter. A skin risk assessment is completed upon admission and weekly for 4 weeks upon significant change, and quarterly thereafter. Those residents at an increased risk for impaired skin integrity are provided preventative measures to reduce the potential for skin breakdown. Those residents' who experience a break in skin integrity or wounds are provided care and service to heal the skin according to professional standards of care. Weekly the licensed nurse will stage, measure, and examine the wound bed and surrounding skin. 30570 Example 2 R31's diagnosis includes stroke, heart failure, hemiplegia/hemiparesis, morbid obesity and restless leg syndrome. R31's quarterly Minimum Data Set (MDS) dated [DATE] notes R31 has no behaviors and does not reject care. R31 has a bims of 15 indicating he is cognitively intact. R31 requires extensive assist of 2 for bed mobility and is dependent on 2 staff for transfer. R31 has range of motion impairments on one side upper and lower. R31 has a catheter and is incontinent of bowel. R31 is at risk for developing pressure injury with no actual pressure injury. R31's significant change in status MDS dated [DATE] notes the same status as above MDS. R31's most recent Skin Risk Assessment with Braden Scale dated 9/29/23 notes the following: Clinical Risk Factors: chronic end stage disease-heart, liver, renal, decreased ROM (range of motion), diabetes. Hemiplegia, terminal illness Evaluation of Braden: 14 (moderate risk) Interventions: pressure reducing device for chair, applications of ointments Continue care plan. R31's care plan shows the following: start date: 2/24/20. Category: Skin I am at risk for alteration of skin status related to CVA (cardiovascular accident) with left sided weakness, bowel incontinence and foley catheter. Goal: I will not develop any skin alterations target date: 1/09/2024 The comprehensive care plan and Certified Nursing Assistant (CNA) care card give no approaches or direction to staff on frequency of repositioning or when to offload. On 11/28/23 at 9:56 AM, Surveyor observed R31 being propelled to his room in his broda type wheelchair. CNA C reclined R31 slightly in his wheelchair and told him he will be laid down after lunch. R31 remained in his room in his wheelchair until he was taken to the dining room for lunch. Surveyor observed R31 in the dining room being assisted by staff. On 11/28/23 at 1:22 PM, Surveyor noted R31 continued up in his wheelchair in his room. Again, CNA C slightly reclined R31 in his wheelchair, emptied his urinary catheter and exited R31's room. Following the observation Surveyor spoke with R31 about his repositioning schedule. R31 expressed he is gotten up into his chair very early and is not laid down to bed until after lunch. Surveyor asked R31 if he would like to lay down to bed after breakfast. R31 responded on some days he might want to lay down after breakfast, but staff do not ask him. R31 further expressed some days he wants to go to activities, but he gets tired. Surveyor asked R31 if he has other options for repositioning. R31 responded he was not aware of any. On 11/28/23 at 1:58 PM, CNA C and another staff entered R31's room and laid R31down in bed. This is almost 4 hours of observation where R31 was not repositioned to prevent a pressure injury from occurring. Following R31 being laid down, Surveyor spoke with CNA C about R31's routine and repositioning/off-loading pressure. CNA C indicated she routinely cares for R31. R31 gets up in morning by night shift. R31 is up when CNA C starts her shift at 6:00 am. This morning R31 was up to his wheelchair at 3:00 am. R31 is not repositioned out of wheelchair until after lunch, shortly before shift change at approximately 1:00-2:00pm. CNA C expressed this is R31's routine. CNA C expressed R31 does not wish to lay down in bed after breakfast and no other off-loading of pressure or repositioning is offered. R31 is reclined in his wheelchair around 10:00 am and after lunch when catheter is emptied. Surveyor asked CNA C if a slight shift or recline in the wheelchair is pressure relief. CNA C responded CNA C was not sure. CNA C further expressed R31 is at risk for pressure injuries as R31 cannot move self to off load pressure. On 11/29/23 at 7:19 AM, Surveyor noted R31 was up and seated in his wheelchair in his room. On 11/29/23 at 10:12 AM, Surveyor noted R31 up in wheelchair in church activity. On 11/29/23 at 10:15 AM, Surveyor spoke with CNA D about R31. CNA D explained R31 was gotten up by the night shift and was up when she started her shift at 6:00 AM this morning. CNA D explained R31 gets up daily by the night shift and should be laid down after breakfast. R31 was not laid down yet as he went to exercise class then church. No repositioning was offered or done after breakfast. This observation is almost 3 hours without repositioning. CNA D indicated she will try to lay him down after church and before lunch. CNA D expressed R31 should be repositioned every two hours as he is at risk for pressure injury as he cannot physically move himself. On 11/29/23 at 10:42 AM, Surveyor spoke with Director of Nursing (DON) B about observations of R31 and her expectations related to offloading pressure and repositioning. DON B expressed she would expect someone like R31 to be offered to lay down after all meals including breakfast. If the resident does not want to lay down staff should off load pressure by other means. DON B further expressed it is important to off load pressure for dependent residents who cannot reposition themselves. R31 cannot reposition himself, he has left sided weakness and cannot lift himself. Staff should ask him if he wants to get up so early. Allowing him to stay in bed longer would not have him up in his chair for so long. Staff can ask to him to use the bathroom and offer laying down every 2-3 hours. If he does not wish to lay down staff should offload pressure with the hoyer lift. Shifting/reclining him slightly in his wheelchair would not relieve pressure. DON B further expressed R31's care plan does not direct staff to reposition him every 2-3 hours and will be updated to reflect this.

Based on observation, interview and policy review, the facility did not establish and maintain an infection prevention and control program when staff did not offer hand hygiene prior to meal service for 3 of 8 residents (R) R209, R210 and R214, or provide wound care in a manner to prevent infection for (R) 42. Findings include: Facility policy titled, Hand Hygiene by Residents, dated June 2017, stated in part .3. Residents are asked and encouraged to perform hand hygiene before and after meals . On 11/30/23 at 12:13 PM, Surveyor observed trays passed to residents on the 500 hall by Registered Nurse (RN) D. R209, R210 and R214 were not offered any hand hygiene in their rooms when the trays arrived. Surveyor asked RN D, Do the residents get hand hygiene offered to them prior to meals being delivered? RN D replied, They all have hand sanitizer in their rooms for the residents to use. Surveyor replied to RN D, These 3 residents observed were not offered any hand hygiene today when I was observing trays passed. RN D replied, Oh. On 11/30/23 at 1:42 PM, Surveyor interviewed Director of Nursing (DON) B and Quality Management Coordinator (QMC) F. Surveyor asked, How do you offer hand hygiene prior to meal service to the residents? DON B replied, Well we offer them hand sanitizer. QMC F replied, Well actually we have hand sanitizer wipes on the food carts to offer the residents. Surveyor informed them that Surveyor did not observe any hand hygiene offered on the 500 hall to these three residents. QMC F replied, We will definitely work on that. 17661 Example 2 R42 has medical diagnoses that include but are not limited to, heart failure, type 2 diabetes mellitus with diabetic neuropathy, type 2 diabetes mellitus with diabetic polyneuropathy, hypothyroidism and essential (primary) hypertension. According to the most recent Minimum Data Set Assessment (MDSA) dated 11/8/23 which is an admission assessment, R42 has no mood or behavior indicators. There was no Brief Interview of Mental Status (BIMS) score, but the assessment scored R42 as having intact long-term and short-term memory. Also according to this MDSA, R42 required some set up assistance with meals and oral and personal hygiene tasks, partial to moderate assistance with dressing upper body and substantial to maximal assistance for lower body dressing. R42 was dependent on staff for toileting. R42 has no limitations with range of motion abilities. R42 was admitted to the facility under hospice services. Surveyor then reviewed the Comprehensive Care Plan for R42 and noted the following included: 1. I require protein d/t (due to) my multiple open areas. 2. Resident requires an indwelling urinary catheter R/T (related to) neurogenic bladder. 3. I have a self care deficit with the following activities of daily living; bathing, grooming, oral cares, ambulation, transferring, mobility, vision, bowel and bladder. 4. I am at risk for alteration of skin status d/t weakness, immobility, diabetes, poor nutritional status and history of diabetic ulcers to BLE (Bilateral Lower Extremities) and open areas to buttocks. R42 was admitted to the facility 11/3/23 with numerous diabetic and vascular ulcers on her lower extremities, currently in the healing phase. On 11/29/23 at 10:47 AM, Surveyor observed Registered Nurse (RN) E conduct wound care for R42. Upon entering the room, RN E placed a small white binder with wound assessments on the soiled linen hamper. RN E then opened the binder to check the wound care orders and then removed the needed supplies from a box in R42's room and placed these supplies on top of the soiled hamper. R42 granted Surveyor permission to observe the wound care. RN E sanitized her hands and donned a gown and gloves. A surgical mask was already on RN E as facility was practicing precautions for Covid-19 tested in the city water system. RN E then placed the supplies on the over the bed table of R42. RN E did not sanitize the table beforehand, nor was there a protective covering placed on top of the table. RN E proceeded to complete wound care first on R42's left leg. RN E removed the gauze dressing from R42's calf, which contained drainage from the wounds, with her bandage scissors. Once removed, RN E did not sanitize the bandage scissors, instead placed the contaminated scissors on the table with other clean supplies. RN E then poured normal saline over one wound covered with Xeroform and proceeded to remove the old Xeroform from the medial shin (wound 1). RN E did not then remove her gloves and sanitize her hands. Instead RN E proceeded to cleanse the wound with wound cleanser. RN E then poured wound cleanser over the other three wounds on R42's left leg and then removed the Xeroform from these. Note: Wound #2 was located approximately 2 centimeters below Wound 1, on the medial ankle bone. Wound 3 was located on the lateral ankle, and wound 4 was located on the lateral calf area. RN E did not wash or sanitize her hands and don a fresh pair of gloves in between each wound cleansing. RN E then proceeded to measure each wound with paper rulers, one for each wound. Once completed, RN E did not wash or sanitize her hands, and with the same gloves from cleansing each wound, pulled off pieces of tape from the tape roll and proceeded to dress the wounds, cutting off Xeroform pieces to fit each wound from the clean large square of Xeroform in the package and using the contaminated scissors that were not sanitized earlier from cutting off the old dressing. RN E then wrapped the leg with Kerlix gauze. RN E then removed her soiled gloves and dated and initialed the left leg dressing. RN E then sanitized her hands and donned a fresh pair of gloves, then replaced R42's sock. RN E then felt under R42's left knee and noted a wound located in this area was weeping. RN E washed this wound with wound cleanser and again, cut off a piece of Xeroform to fit the area with the dirty scissors. The wound was then wrapped with Kerlix and fresh tape was torn from the roll. RN E then proceeded to R42's right leg wounds. The old dressing was again cut off with the same dirty scissors. The scissors had not yet been sanitized. RN E sanitized her hands and donned a fresh pair of gloves. There were two small wounds located on the shin of this leg. RN E washed each with wound cleanser, one at a time with fresh gauze for each. However, after cleansing each wound, RN E did not remove her soiled gloves, wash or sanitize her hands and don a fresh pair of gloves. Also, RN E again used the dirty scissors to again cut off pieces of Xeroform to fit each wound. RN E then dressed R42's right leg with Kerlix, dated and initialed the dressing, then removed her soiled gloves. RN E did not yet sanitize her hands and proceeded to replace R42's sock, covered R42 with the bed sheet and blanket and cleaned up her supplies, replacing unused supplies into the box of supplies in R42's room. RN E then cleaned up R42's over the bed table of uneaten breakfast items (yogurt and empty milk glass), emptied the garbage and disposed of these in the room hamper. RN E then removed the plastic bag from this hamper and replaced it with a clean bag. RN E then removed her gloves and gown, sanitized hands, and then sanitized the scissors. At 12:02 PM, Surveyor interviewed RN E regarding her practice and the expectation of infection control during a dressing change. RN E stated, I always want to protect the resident from anything I may be carrying by using a gown, gloves and mask with weepy wounds or splash risks. I should perform hand washing or sanitizing when changing gloves and going from dirty to clean. Surveyor explained the observations made as noted above regarding the placement of the binder and clean supplies on the soiled hamper cover, no protective barrier or sanitization of the over the bed table and the missed opportunities for hand hygiene, as well as not sanitizing the scissors after removing soiled dressings and before cutting off clean Xeroform. RN E stated, That makes sense. Thank you for your input. I am always open for learning. I wasn't aware of that.

Based on observation, record review and interview, the facility did not ensure a medication error rate of five percent or less. The error rate was 8.11% (percent) as calculated by 3 errors out of 37 opportunities for error. Registered Nurse C (RN-C) made 3 medication errors when giving R202 medication via a G-Tube (Gastrostomy Tube/feeding tube) by not administering each medication separately. When administering medications via a G-Tube, crushing and combining medications can lead to physical or chemical interactions such as altered therapeutic response, or tube blockage. It is standard practice to flush the G-Tube between each medication. Findings include: On 9/28/21 at 11:31AM, Surveyor observed RN-C give R202 medications via R202's G-Tube. RN-C prepared the medications by crushing three medications, in tablet form, in the same container. Medications administered were Acetaminophen (Tylenol) 1000mg (two 500mg tabs), [MEDICATION(S)] 80mg, and [MEDICATION(S)] 2.5mg. RN-C then added water to the crushed medication to dissolve the medications to be able to administer them through the G-Tube. By combining all three medications into the same solution, RN-C was unable to flush the G-Tube with water in between each medication. Surveyor reviewed R202's physician's orders. There was no order to crush and combine all medications into one solution. Surveyor reviewed the facility's policy titled Medication Administration, and the pharmacy's policy (Alixa Rx) titled Medication Administration-Preparation and General Guidelines: General Guidelines for Administering Medications Via Enteral Tube. The Alixa Rx policy stated under the Procedures in section D: Enteral tubes are flushed with at least 15ml of purified or sterile water before administering medications, between each medication, and after all medications have been administered. On 9/28/21 at 1:17PM, Surveyor interviewed RN-C in regards to medication administration via a G-Tube. RN-C stated she had worked at the facility for about three months, and had always combined R202's medication. RN-C stated it was the way she had been shown when she was orientating and following another nurse at the facility. RN-C stated the orientation process was the only training from the facility that she has received in regards to tube feeding and medication administration via G-Tubes. RN-C stated there were no physician orders that would alert her to either combine or not combine the medications. On 9/28/21 at 2:22PM, Surveyor interviewed Director of Nursing B (DON-B) in regards to medication administration via G-Tube. DON-B stated the expectation would be for the nurses to crush and administer each medication separately. DON-B stated there are usually standing orders that are put into the EHR (electronic health record) system that would alert the nurses to administer each medication separately and flush in between each medication. DON-B stated she did not see these orders in R202's EHR.

Based on observations, record review, and interviews the facility did not accurately reflect 1 of 16 sampled residents (R56) advanced directive decision. R56 had a change in CPR (cardiopulmonary resuscitation) status from full code to DNR (Do Not Resuscitate); however there was discrepancy with the code status. This is evidenced by: R56 was admitted to the facility on [DATE] following a stroke which affected R56's speech, swallowing, and mobility. R56 was also diagnosed with [REDACTED]. R56 received all nutrition, hydration, and medication via a feeding tube due to the stroke affects. R56 was deemed incapacitated on [DATE] (prior to admission) and R56's daughter was named as the HCPOA (Health Care Power of Attorney). Upon admission, R56's HCPOA elected full code status for R56. In the event R56 had signs of death, staff should initiate artificial chest compressions, provide oxygen, and immediately transfer R56 to the hospital. R56 was hospitalized due to chest pain from [DATE] and return to the facility on [DATE]. On [DATE] CSW-C (Certified Social Worker) documented in R56's progress notes of R56's request to discuss the discontinuation of the feeding tube with the HCPO[NAME] CSW-C progress note read the HCPOA would discuss R56's concerns regarding feeding tube on [DATE] and update the Social Worker when a decision was made on tube feeding or code status. Surveyor was unable to locate any further documentation from the Social Worker regarding R56's request to discontinue feeding tube or change code status. Review of the physician progress notes [REDACTED]. Review of the medical record noted R56 had an EMERGENCY CARE DO NOT RESUSCITATE (DNR) document signed by the physician on [DATE] but never signed by the HCPO[NAME] According to DON-B (Director of Nurses), the facility labeled the resident's physical medical record with a blue dot as well as placed a blue dot on the door of any resident who was a full code. In addition, the electronic medical record would reflect full code or DNR. DON-B also stated when a resident elected DNR status, the resident or legal representative signed an advanced directive document, the physician would also sign the advanced directive document and then the document was placed into the resident's medical record. On [DATE] at 9:48 a.m., Surveyor interviewed CSW-C regarding her role with advanced directives. CSW-C stated R56 was a full code until recently when the HCPOA elected to change R56 to a DNR and palliative care. CSW-C stated after R56's code status was changed, the advanced directive document was sent to the physician for signature, and the electronic medical record was updated to reflect the change in code status. CSW-C stated she did not follow through with the required signature from R56's HCPOA and did not document R56's code status change in the medical record. R56's medical record had a blue dot on the spine as well as a CODE STATUS sticker on the front page with conflicting information. The blue dot indicated full code and the CODE STATUS sticker read No code [DATE] On [DATE] at 9:30 a.m. and [DATE] at 7:28 a.m., Surveyor observed a blue dot on the door of R56's. Review of the physician orders [REDACTED]. On [DATE] at 7:47 a.m., Surveyor interviewed DON-B who stated code status was reviewed at all care conferences by the social worker and when changes were made, the social worker would alert the HUC (Health Unit Coordinator) who would update the electronic medical record. On [DATE] at 7:52 a.m., Surveyor interviewed HUC-D regarding changes in code status. HUC-D stated when a resident changes code status from a full code to a DNR, she would remove the blue dot from the resident's door and medical record, change the code sticker to DNR, and update the face sheet to reflect DNR status. HUC-D stated once the face sheet was updated, the electronic medical record would reflect the DNR status. HUC-D stated she had not updated R56's medical record as she was unaware of the change from full code to DNR status. On [DATE] at 4:30 p.m., Surveyor interviewed LPN-F (Licensed Practical Nurse) regarding the facility's DNR procedures. LPN-F stated in the event of a resident's death, she would check the electronic medical record or the physical medical record for the code status. LPN-F stated a full code would be indicated by a blue dot on the resident room door and the resident's physical medical record. LPN-F stated if a resident was DNR, there would be a signed DNR document in the front of the medical record. On [DATE] at 10:15 a.m., Surveyor interviewed LPN-E regarding code status procedures. LPN-E confirmed R56 had a blue dot on her medical record as well as outside of her room door. LPN-E stated the blue dot would indicate full code for R56. LPN-E stated there was conflicting information on R56's code status because the electronic medical record stated DNR but the blue dot indicated full code. LPN-E stated in the event of a discrepancy, she would check the physical medical record for the DNR document and follow that guidance. LPN-E stated the conflicting information would cause a delay in emergency care.

Based on interview and record review the facility did not ensure 1 of 21 sample residents' (R21) physician was consulted with a significant change in condition. On [DATE] at 4:17 p.m. R21 had a fall from the bed. R21 sustained a head injury from the fall including a contusion to the right forehead and bruising around the right eye. An assessment completed post fall indicated R21 was also noted to have congestion with audible wheezing and low oxygen saturation. By [DATE] R21 was noted with a changes in condition including increased lethargy, increased confusion, decreased ability to eat independently, restlessness, non-verbal, unable to follow instructions, and had changes in respiratory status. Symptoms of concern following head trauma include decreased mental abilities, confusion, shallow breathing, drowsiness, and restlessness. These symptoms indicate the probability of increased intracranial pressure. Untreated increased intracranial pressure can lead to a number of negative outcomes including death. There was no consultation with R21's physician regarding the change in condition. On [DATE] at 8:35 a.m., less than 2 days after R21 fell and hit his head, R21 expired. Failure to consult with R21's physician of regarding the significant changes in condition following a fall with a head injury resulted in the findings of immediate jeopardy that began on [DATE] at 12:16 p.m. The NHA (Nursing Home Administrator) was notified of the immediate jeopardy on [DATE] at 11:30 a.m. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement its removal plan. This is evidenced by: R21 had [DIAGNOSES REDACTED]. R21 was under palliative care. R21's advanced directives only included DNR (Do Not Resuscitate). The most current MDS (Minimum Data Set) was dated [DATE] and indicated R21: ~Had a BIMS (Brief Interview for Mental Status) score of 10 indicating a moderate cognitive impairment; ~Required extensive assistance of 1 to 2 staff persons for all aspects of care except eating; ~Ate independently; and ~Did not walk. On [DATE] R21 was seen by a NP (Nurse Practitioner) from the palliative care clinic. The NP progress note indicated R21 was noted to have a cognitive decline including episodic confusion. The progress note indicated, .awakened from nap. Able to converse appropriately after initial confusion . The progress note indicated if R21 began to decline functionally, hospice may be a consideration. Surveyor completed a review of R21's nursing notes and noted the following. ~[DATE], .16:17 (4:17 p.m.) .resident found on the floor next to bed, on R (right) side with head resting on the floor .Resident rolled on his back with bump on his forehead and sm (small) amt (amount) of blood noted on the bump .Did c/o (complain of) some discomfort for (sic) forehead but no other area .LS (lung sounds) were congested with audible wheezing heard .Neuros WNLs (Neurological check within normal limits). R21's fall report dated [DATE] also indicated R21 had a headache. R21's physician was contacted and due to R21's congestion ordered an x-ray and indicated the facility should continue to check R21's neurological status. R21's x-rays were suggestive of [MEDICAL CONDITIONS]. The physician increased R21's diuretics, ordered oxygen, and a nebulizer treatment as needed. There were no further nursing notes describing R21's condition until [DATE] at 12:16 p.m. ~[DATE] 12:16 p.m., .more lethargic than usual, confused .needing additional assistance w/meals (with meals) as he was dropping things .Daughter .expressed interest .about enrolling resident in Hospice .Nursing to f/u (follow up) w/primary (with primary) tomorrow .Will continue to monitor . Lethargy, confusion, and requiring more assistance to eat were all signs of increased intracranial pressure. This was an emergent change in R21's condition. There was no evidence of physician consultation. ~[DATE] 10:46 p.m., .more confused than usual. Loud audible congestion heard when awake in bed. When resting no congestion noted. PRN (as needed) neb tx (nebulizer treatment) given with no change in congestion .Bump on forehead noted .Bruising noted to R (right) eye socket .several attempts at self transfer out of bed . R21 continued to show changes in condition including changes to respiratory status, confusion, and restlessness. R21 was also noted to have right orbital bruising. Orbital bruising is typically associated with a fracture in the base of the skull. There was no physician consultation. ~[DATE] 6:10 a.m., .is lethargic, non-verbal .Several attempts needed to cue resident to follow instructions .Bruising remains to right eye socket area and right side of forehead . R21 continued to show significant changes in condition. There was no physician consultation. ~[DATE] 9:06 a.m., .When assisting .in transferring residents .resident suddenly went limp w/blank (with blank) stare .Placed back into bed .not responding .took a few slow labored breaths .and having no signs of life .time of death 0835 (8:35 a.m.) . Surveyor completed a review of a facility form titled Neurological Flow Sheet. The form was an assessment of neurological status typically completed after head trauma and done at specified intervals. The assessment assists the assessor in identifying changes in neurological status. Surveyor completed a review and questioned the accuracy of R21's Neurological Flow Sheet. The Neurological Flow Sheet identified R21 for all recorded assessments as being .awake, aware, oriented . This was not accurate according to R21's nursing notes. R21's nursing notes described R21 as lethargic and confused, restless, non-verbal and having difficulty following directions. The assessment also included the directive to staff, .Notify MD (Medical Doctor) Immediately of signs and symptoms of Intracranial Pressure!!! . The facility did not recognize and capture the neurological changes in R21's condition as symptoms of increased intracranial pressure. On [DATE] at 9:41 a.m. Surveyor spoke with RN-L (Registered Nurse). RN-L indicated she saw R21 right after his fall. RN-L stated R21 seemed per his norm and was answering questions per his norm. Surveyor asked RN-L what the facility's practice was with changes in neurological status following a fall with a head injury. RN-L indicated the physician should be contacted with any change in neurological status. RN-L also indicated she would request evaluation in emergency room . On [DATE] at 1:25 p.m. Surveyor spoke with RN-O. Surveyor asked RN-O about the facility's practice for monitoring changes in resident condition following falls with head injuries. RN-O indicated there was a standard protocol in which they were to check a residents neurological status at consistent intervals. RN-O indicated any change in a residents neurological status including level of consciousness, changes in behaviors, or changes in vital signs should have immediate physician notification and evaluation in the emergency room . On [DATE] at 10:09 a.m. Surveyor spoke with RN-D. RN-D stated she would send a resident to the emergency room with any changes in residents cognition including lethargy following a fall with head injury. On [DATE] at 11:23 a.m. Surveyor spoke with LPN-Q (Licensed Practical Nurse). LPN-Q indicated she was the nurse who responded to R21's fall. LPN-Q also indicated she was the nurse on duty the following evening. LPN-Q indicated R21 was more lethargic and restless following R21's fall. LPN-Q indicated she noted R21 was also congested however the congestion was noted only when awake and not when R21 sleeping. LPN-Q stated she didn't think R21 ate that evening. Surveyor asked LPN-Q if she notified R21's physician with the changes she noted. LPN-Q indicated she did not. LPN-Q indicated she contacted RN-G on another wing who came down and saw R21 and instructed her to give R21 a nebulizer treatment. Surveyor completed a review of R21's nursing notes for [DATE] evening shift . There was no indication in R21 record of an RN assessment and directive to LPN-Q to administer a nebulizer treatment. On [DATE] at 3:53 p.m. Surveyor spoke with RN-G. RN-G indicated she assessed R21 the day that R21 fell . RN-G indicated right after R21's fall R21 was alert, awake, and winking at me when I asked him questions. RN-G stated she worked the following evening. Surveyor asked RN-G if she assessed R21 on [DATE]. RN-G stated she had not. On [DATE] at 12:12 p.m. Surveyor spoke with RN-R. RN-R indicated she was the nurse who worked on [DATE], the day following R21's fall during the day shift. RN-R indicated she assessed R21 and felt his neurological checks were normal. RN-R stated, however, R21 was not as alert as he usually was, was dropping food and required assistance to eat. RN-R indicated she felt R21 was acting like his normal self, however, was very lethargic but still able to answer questions appropriately. Surveyor asked RN-R about the R21's facial bruising. RN-R indicated she could not tell if R21 had a bruise or not as R21 had a dressing on his head which RN-R indicated she did not remove. RN-R indicated she noted bruising around R21 right eye on [DATE]. RN-R indicated she did have conversation with R21's family regarding hospice, and the family was interested in pursuing that. RN-R stated, however, she did not speak with the family regarding transporting R21 to the emergency room for an evaluation due to R21's declining condition. Surveyor asked RN-R if she notified R21's physician of the neurological changes as noted. RN-R indicated she had not as she didn't consider them substantial and didn't consider them changes in R21's neurological status. RN-R indicated she was also the nurse on duty on [DATE] when R21 expired. RN-R indicated she saw R21 for only 2 about minutes in the morning and indicated she felt R21 was about the same as the day prior yet still very tired. RN-R stated they were trying to get R21 up when R21 passed out and when they got him back into bed he was just gone. On [DATE] at 2:10 p.m. Surveyor spoke with CNA-P (Certified Nursing Assistant). CNA-P indicated she took care of R21 after R21 fell . CNA-P described R21 as being more tired and required more help to eat. [DATE] at 3:43 p.m. Surveyor spoke with CNA-S. CNA-S indicated she worked the evening following R21's fall. CNA-S indicated she didn't think R21 ate that night, wasn't talking like he usually did, was more sleepy, was leaning slightly to the left in his wheel chair which CNA-S indicated was new for R21, and R21's speech was more slurred than normal. [DATE] at 1:13 p.m. Surveyor spoke with NP-T (Nurse Practitioner). NP-T indicated she would expect a call with any resident with changes in neurological status following a fall with a head injury. NP-T indicated symptoms such as R21 was exhibiting were signs of increased intracranial pressure. NP-T stated any resident with neurological changes would require transport to the emergency room in order to determine cause. NP-T stated the only time she would not order a resident to be evaluated in the emergency room was if the resident or POA (Power of Attorney) wishes were for no evaluation. On [DATE] at 10:15 a.m. Surveyor spoke with the DON (Director of Nursing) regarding R21's fall and lack of physician notification. The DON indicated she was unsure of the circumstances and follow up to R21's fall and would need to check. There was no further information received. On [DATE] at 8:28 a.m. Surveyor spoke with the NHA (Nursing Home Administrator) and DON. The DON indicated she felt R21's condition was declining and there had been consideration for R21 to enroll in hospice care. The failure to immediately consult with a physician when R21 showed signs of a significant change in condition created a finding of immediate jeopardy. The jeopardy was removed on [DATE] when the facility began implementing the following: 1. Post incident investigation for R21 to complete root cause analysis; 2. Review of documentation to identify other residents with changes in condition that require physician consultation; 3. Review of all policies and procedures to ensure consistent with current standards of practice; 4. All licensed nurses, prior to the start of their next scheduled shift were educated on changes of condition and physician consultation; and, 5. All CNAs, prior to the start of their next scheduled shift, were educated on reporting changes in condition and the use of the Stop and Watch tool.

Based on observations, staff interviews and record reviews the facility did not provide the necessary supervision and assistive devices to prevent falls for 3 of 5 residents reviewed for falls (R43, R7 and R21). R43 had a fall from her wheelchair on 10/25/18 sustaining a head injury resulting in facial bruising and sutures above her left eyebrow. Staff were to keep R43 within line of vision when R43 was in her wheelchair and they did not do this. In addition, surveyor observed R43 in her wheelchair and was not in vision of staff. On 10/27/18 R21 had a fall from bed and sustained head trauma including a contusion on the right forehead and bruising around the right eye. 2 fall prevention modalities the facility put into place to prevent R21 from falling failed to work. R21 subsequently had an injury fall. R7 has a history of falls. An approach of a clip alarm while in the wheelchair was an was added after a fall on 07/10/18. Staff were observed not consistently implementing this approach by the surveyor. This is evidenced by: Example 1: On 10/29/18 11:31 a.m., Surveyor observed R43 in low bed with a mat on the floor alongside her bed. A sensor pad alarm was also on. Surveyor observed bruising around R43's upper and lower left eye and sutures in brow area of R43's left eye. The most recent MDS (Minimum Data Set Assessment), dated 09/12/18, indicates R43 has a BIMS (Brief Interview of Mental Status) of 4/15, indicating severe cognitive impairment. R43 requires extensive assistance of 2 staff for transfers and when moving from a seated to a standing position. R43's care plan includes a problem dated 1/13/17 of Falls. It indicates R43 is at risk for falling related to weakness, status [REDACTED]. Approaches include, .Approach start date 06/28/18 Keep Resident in staff line of vision when up in wheelchair . A 10/25/18 entry in R43's medical record states, At around 0850 (8:50 a.m.) the resident's wheelchair alarm went off and the nurse was across the hall turned and noted the resident on the floor. Nurse noted blood on the floor and noted the blood was coming from her nose and forehead. The resident was turned on her back and there was an open area on her left side forehead and a open area to the top of her nose. The resident was cleaned up and management arrived to the room and stated that we should send her out. Paperwork was completed by management. On 10/30/18, The ADON (Assistant Director of Nursing) gave Surveyor a copy of R43's fall investigation. On the morning of 10/25/18, .was in bed until 0800 (8:00 a.m.) when she was washing up and assisted into her wheelchair for breakfast. She was then taken into the dining room and ate 1-25% of breakfast She self-propelled herself back to her room where the nurse then gave her her morning medications outside her bedroom door. The nurse then went across the hall to prepare medications for a different resident, still visualizing R43 sitting outside her room in her wheelchair. When the nurse entered the other resident's room to administer his medications, she heard R43's alarm sounding, and when she entered R43's room, R43 was laying on the floor The investigation also states, A fall risk assessment was recently completed for R43 on 09/12/18. Her score was 11, putting her at risk for falls related to her impaired mobility, varied mental status and diminished safety awareness, and use of antidepressants and aspirin therapy. Current safety interventions in place: Low bed, mat on floor facing bathroom, mat propped between bed and wall, pressure alarm in bed and chair, do not leave alone in the bathroom, bilateral padded u-bars to bed, 30 minute checks, lay resident down in bed following meals, wander guard left wrist, keep resident in staff line of vision when up in wheelchair . On 10/30/18 at 12:59 p.m., Surveyor spoke with the ADON. The ADON said R43's mentation varies and R43 has had falls with the last in (MONTH) (YEAR). The ADON said that R43 likes to get into bed after meals. The ADON said that the fall on 10/25/18 was right after breakfast. The ADON said that R43 had gone back to her room, the nurse went across the hall, and R43 was found in her room on the floor. The ADON said R43's alarms were on and sounding. The ADON said R43 can't walk at all and has had multiple [MEDICAL CONDITION]. On 10/31/18 at 9:18 a.m., Surveyor spoke with the DON (Director of Nursing). The DON said R43's care plan indicates she is to be in line of sight when in her wheelchair. The DON said the nurse turned her back on her. The DON said R43 is very quick. When asked which nurse was involved, DON said she believed the nurse was RN-D (Registered Nurse). The DON said the investigation report says the nurse entered another resident's room to give medication and when she was doing this she heard R43's alarm sounding and found her on the floor in her room. On 10/31/18 at 9:27 a.m., Surveyor observed R43 in her wheelchair in hallway by her room. R43 was not in visual sight of staff. Staff was not providing the necessary supervision to R43 to prevent another fall. On 10/31/18 9:48 a.m., Surveyor spoke with RN-D. RN D said on 10/25/18 R43 was outside her door in her wheelchair and she gave her medication. RN D said R43 mentioned that she wanted to go to bed. RN D said that she told R43 she has to wait for the girls to come to help her as she uses a sit to stand. RN D said she moved across the hall by another resident and was outside his room, with my back turned to R43. RN-D stated she heard the alarm sound, she turned, and R43 was on the floor in her room. RN-D indicated she didn't have her eyes on R43. Surveyor reviewed the emergency department report dated 10/25/18 which states, Patient presents with trauma unwitnessed fall from wheelchair onto face. Laceration and bleeding to face XXX[AGE] year old female with a history of [MEDICAL CONDITION] not on anticoagulation therapy presenting to emergency room by EMS (emergency medical services) after unwitnessed fall from presumed standing height with evidence of head and facial trauma including the left supraorbital area and bridge of her nose .[MEDICAL CONDITION] 3 cm (centimeters), sutured with 7 interrupted sutures. Nasal abrasion cleansed and there was no need for laceration repair .1. Closed head injury and 2. facial laceration. Example 2: R21 had [DIAGNOSES REDACTED]. R21's most current MDS (Minimum Data Set) was dated 8/22/18. The MDS indicated R21 ~ Had a BIMS (Brief Interview for Mental Status) score of 10 indicating a moderate cognitive impairment; ~ Required extensive assistance of 1 to 2 staff persons for all aspects of care except eating; ~ Did not walk; ~ Was unable to maintain balance without staff support; and ~ Had no falls. R21's fall care plan was dated 2/24/17. The care plan had the following approaches. ~ 8/29/18, .Alarming mat to bathroom side of bed on top of mattress to floor . Surveyor completed a review of R21's nursing notes and noted the following. ~ On 10/27/18 at 4:17 PM R21 had a fall from the bed. The nursing note indicated, .resident found on the floor next to bed, on R (right) side with head resting on the floor .rolled on his back with bump on his forehead and sm amt of blood noted on the bump .Floor alarming mat was not functioning and clip alarm had been placed but failed to alarm. Alarm was found on the floor still attached to resident . According to the nursing note R21 was to have 2 fall prevention measures in place, an alarming floor mat and clip alarm. The clip alarm was not noted on R21's plan of care. Surveyor was unable to determine when the clip alarm was placed. ~ On 10/28/18, R21 was noted to have right orbital bruising. Surveyor completed a review of the facility's investigation completed after the fall. The fall investigation was dated 10/27/18. The investigation indicated R21 had been looking for his hearing aid, the alarming floor mat was functioning correctly and the tabs alarm was found still attached to R21. There were no new approaches added to R21's plan of care following the fall. On 10/30/18 at 4:45 PM Surveyor spoke with the DON (Director of Nursing). The DON indicated the clip alarm did not sound as the magnet did not release from the control box when R21 exited the bed The DON stated the control box was not secured and subsequently slid off the bed when R21 exited the bed. The DON indicated the facility had ordered Velcro which the facility was going to utilize to secure the control box to headboards. The DON stated R21's alarming mat malfunctioned. The DON stated the alarming mat had been replaced. Example 3: According to the medical record, R7 had a fall on 07/10/18 and was found on the floor in the bathroom. A new intervention was added to the care plan of clip alarm in chair. R7's current care plan includes, Category: Falls. Resident at high risk for falling . date: 08/10/18 .Clip alarm in w/c (wheel chair) . The CNA (Certified Nursing Assistant) resident profile indicates, under falls, 08/10/18: Clip alarm in w/c . On 10/30/18 at 7:27 a.m., Surveyor observed R7 in his room sitting in his wheelchair watching television. There was no clip alarm on the wheelchair or R7. Surveyor observed the clip alarm box was laying on the recliner in R7's room. On 10/31/18 10:14 AM Surveyor spoke with RN-F. RN F said R7's care plan for falls includes a clip alarm when he is in his wheelchair. Surveyor spoke with CNA-E on 11/01/18 at 9:00 a.m. Surveyor asked CNA-E if they have care plans in resident rooms. CNA-E said the care plans are on the computer, but they have a book on the unit with the individual care plans. CNA-E showed Surveyor the book which includes a CNA care plan dated 08/28/18 for R7. It includes the clip alarm in the wheelchair.

Based on interview and record review the facility did not ensure 1 out of 18 sampled residents (R28) received the necessary care and treatment to ensure the highest possible level of functioning and well-being. R28 had [MEDICAL CONDITION]. The facility was to monitor R28's weights and report any weight gain of 3 pounds or greater to R28's cardiologist. This was critical in order to effectively manage R28's fluid balance and prevent fluid overload. Beginning in (MONTH) (YEAR), R28's weight began to increase. By 9/24/18 R28's weight had increased from 220 pounds to 241.5 pounds, an increase of 21.5 pounds. During this period of time the cardiologist was not consulted timely in order to determine treatment. R28 was subsequently hospitalized following an appointment with R28's cardiologist due to significant fluid overload. R28 was hospitalized for [REDACTED]. This is evidenced by: R28 had current [DIAGNOSES REDACTED]. The most current MDS (Minimum Data Set) dated 10/16/18 indicated R28: ~ Had a BIMS (Brief Interview for Mental Status) score of 14, indicating no cognitive deficit. ~ Required extensive assistance of 1 to 2 staff with all aspects of ADL's except eating; and ~ Had trouble breathing when laying flat. R28's care plan for [MEDICAL CONDITION] was dated 8/30/18. The care plan had the following approaches; ~ 9/12/18, .Assess for fluid excess .Monitor and report signs of respiratory distress .Monitor weight. Notify MD (Medical Doctor) and family of significant weight change . Surveyor completed a review of R28's weights, physician progress notes [REDACTED]. All weights are noted in pounds. On 6/7/18, the facility received a physician order [REDACTED].Call if weight gain 3 pounds or more . On 7/8/18, R28's weight was 220#. According to R28's weight record, since admission R28's weight was generally 220#. On 7/9/18, R28 was seen by a NP (Nurse Practitioner) from the cardiology clinic. The NP's progress notes indicated R28's weight was stable. On 7/10/18, R28 was seen by a NP from the palliative care clinic. The NP's progress note indicated R28 was stable. On 7/15/18, R28's weight was 220#. On 7/20/18, R28's weight was 223#. R28's weight had increased by 3 pounds. There was no indication the facility notified the physician. On 7/27/18, R28 was seen by a NP from the palliative care clinic. The NP progress notes indicated R28 had no respiratory distress or cough, and just trace leg [MEDICAL CONDITION]. On 8/5/18, R28's weight was 224#. This was an additional weight gain of 1 pound to equal a 4 pound weight gain. There was no indication the facility contacted the physician. On 8/6/18, R28's weight was 227#, an increased of 7 pounds. There was no indication the facility contacted the physician. On 8/9/18 the facility received a call from the cardiology clinic. The progress note from the cardiology clinic per information obtained from the facility indicated R28's weight was 227.5#. R28 had no shortness of breath and no lower extremity [MEDICAL CONDITION]. The progress note indicated the facility was advised to call the cardiology clinic with any concerns. The progress note also indicated the cardiology clinic would call back in another month to check on R28's status. On 8/15/18 R28's weight was 230.3#, an increase of 10.3#. There was no indication the facility contacted the physician. It was critical for the facility to contact R28's cardiologist to determine treatment in order to manage R28's fluid status and prevent crisis management of R28's fluid status. On 8/27/18 R28's weight was 234.3#, an increase of 14.3 pounds. There was no indication the facility contacted the physician. A nursing note on 8/30/2018 indicated, .resident has had a weight gain. Weight currently at 230.1 lbs (pounds). Report shows that resident has had about an 8 lb weight gain in 1 month and about an 11 lb weight gain since admission on 5/30. C/O (Complaints Of ) SOB (shortness of breath) w (with) exertion and previously at rest when he was on RA (Room Air). Was briefly weaned to RA for a few days, but then put back on oxygen .+2 [MEDICAL CONDITION] to BLE (Bilateral Lower Extremities). Lungs were diminished bilaterally .Offered to lay resident down and elevate BLE, resident refused .stated understanding, but was more comfortable siting (sic) in chair . The nursing note dated 8/30/18 indicated R28 was symptomatic for fluid overload. R28 was short of breath, had lower extremity [MEDICAL CONDITION], required oxygen, and did not want to lay down due to shortness of breath. R28's cardiologist was not consulted. On 9/5/18 the facility spoke with the cardiology clinic. The cardiology clinic progress note indicated the facility called and indicated R28 had an 8 pounds weight gain. This was not accurate information. R28 had an actual weight gain of 14.3#. The cardiology clinic progress note indicated per facility information R28 had no shortness of breath or cough and had [MEDICAL CONDITION] in both lower extremities. The cardiologist clinic increased R28's dose of [MEDICATION NAME], a diuretic. A nursing note dated 9/05/2018 indicated, .resting in bed with HOB (head of bed) elevated, has c/o (complaints of) shortness of breath when lying flat . On 9/14/18, R28 was seen by a NP from the palliative care clinic. The progress note indicated R28 had a weight gain, however had no cough, no shortness of breath, and no [MEDICAL CONDITION]. The NP progress note indicated the NP felt R28's weight gain was due to venous stasis and recommended the facility get a recliner for R28 so R28 could elevate his legs when sitting. A nursing note dated 9/22/18 indicated, . will not go into bed, said .I hate going into that bed. I can't breathe in bed . On 9/23/18 R28's weight was 239.9#, an increase of 19.9#. R28 could no longer lay in bed due to shortness of breath and inability to effectively breathe. R28 also had a weight increase of 19.9#. These were significant findings. There was no indication the facility contacted R28's physician. On 9/24/18 R28's weight was 241.5, an increase of 21.5 pounds. A nursing note 9/24/18 indicated, .refused to sleep in recliner, he is sleeping in his wheel chair at this time . On 9/24/18 the facility contacted the cardiology clinic. The cardiology clinic documentation of the facility's phone call included R28 weight was 239.9#, R28 had increased lower extremity [MEDICAL CONDITION], and was sleeping in recliner as R28 could not lay down to sleep due to shortness of breath. The cardiology clinic ordered an additional dose of [MEDICATION NAME] (a diuretic medication). The information given to the cardiology clinic was not accurate. R28's weight on 9/24/18 was not 239.9#. It was 241.5#. On 9/25/18 R28 was seen by his physician. The progress note indicated R28 was followed by cardiology, R28 had lower extremity [MEDICAL CONDITION], and shortness of breath with exertion. The physician made no changes to R28's medication regimen. A nursing note from 9/25/18 indicated, .refused to get into bed or his recliner for the night . attempted to educate resident on the effects of sitting in wheel chair all night. Resident stated 'I don't care,' resident stated that he did not want to go to bed or recliner .Stated 'he is staying right here in his wheelchair' . On 9/26/18 the cardiology clinic received a phone call from R28's daughter concerned about R28's weight gain. Per the cardiology notes R28's daughter indicated R28's .legs were tight . and R28 had .energy low . On 9/26/2018 a nursing note indicated, .continues to refuse to sit in recliner chair. He says: I am not sitting in that death chair, I am not gonna wake in that thing .I am comfortable right here in my wheel chair .declined to get into bed or sleep in recliner throughout the night . There was no weight recorded on 9/27/18. A nursing note on 9/27/18 indicated, .insists to sleep in his wheel chair .Again, it was explained that elevating his legs and resting in the recliner is best to reduce [MEDICAL CONDITION], however, resident refuses .Resident would not go to bed for us on the night shift. Education provided. Resident stated 'no, I am sitting in my chair' . R28's respiratory status was significantly compromised. The only way R28 could breathe and feel as though was getting enough oxygen was to sit up straight in the wheel chair 24 hours a day. There was no indication the facility contacted R28's physician. A nursing note on 9/28/18 indicated, .refuses to lay down or sit in recliner, insists of staying in W/C (Wheel Chair). Encouraged to elevate BLE (Bilateral Lower Extremities) and refuses . On 9/28/18 R28 was seen in the cardiology clinic. The progress notes indicated, .He normally runs around 217 (217 pounds) here in the clinic. Today, his weight was noted to be 241 .lungs have crackles bilaterally and midway up .Severe [MEDICAL CONDITION], actually up to the mid back .significantly volume overloaded. His weight is up, at least, 25 pounds from his previous time here .We will plan admission to .Hospital. We will start him on IV (Intravenous) [MEDICATION NAME] (a diuretic) drip . Due to R28's significant fluid volume overload, R28 was admitted to the hospital directly from the clinic. R28 was hospitalized from [DATE] to 10/8/18. R28 returned to the facility under hospice services. On 10/31/18 at 3:50 p.m. Surveyor spoke with RN-G about the facility's practice for monitoring weights. RN-G indicated daily weights were generally monitored by the day shift. RN-G stated any weight gain within the ordered parameter would require a call to the cardiac clinic. On 11/01/18 at 9:34 a.m. Surveyor spoke with RN-L. Surveyor asked RN-L about the facility's practice for monitoring weights. RN-L stated daily weights were typically ordered and monitored by the cardiac clinic. RN-L stated when monitoring weights she would would check weights daily and if she saw a weight gain of 3 pounds or more in a day she would call the cardiac clinic. Surveyor asked RN-L about R28's order to notify the cardiac clinic of a weight gain of 3 pounds or more. RN-L indicated the order was unusual and she was not sure in what time frame she would call with a 3 pound increase in weight. RN-L stated the order should have been clarified. RN-L indicated when a resident with heart failure had weight gain with associated systems such as shortness of breath or more [MEDICAL CONDITION] she would contact the physician. On 11/01/18 at 11:52 a.m., Surveyor spoke with the ADON (Assistant Director of Nursing) about the facility's practice for monitoring weights. The ADON indicated the nurses should be monitoring and calling cardiology according to the cardiologist order.

Based on observations, interviews and record reviews, the facility failed to provide appropriate care and services to promote the healing of existing pressure ulcers, prevent development of avoidable pressure ulcers, and prevent development of recurrent pressure ulcers in 7 of 8 sampled residents. This resulted in a finding of immediate jeopardy for Resident #4, findings of actual harm for Residents #2, #1, and #6, and findings of potential for more than minimal harm for Residents #14, #10, and #3. 1. Resident #4 was assessed as being at high risk for the development of pressure ulcers and has a history of pressure ulcers to his heels. Resident #4 developed a stage III pressure ulcer to his right ischial prominence. The wound appeared to have healed. However, induration was present in the area surrounding the pressure ulcer. Induration is the hardening of soft tissue, especially the skin, when there is infection present. There was no further evidence the facility continued to complete a comprehensive assessment of the area to determine if it was resolved or if an alteration in treatment needed to occur. The wound then re-opened and became severely infected. The facility did not consistently make changes to the plan of care when the wound declined, nor did they complete tissue tolerance testing to determine if two-hour repositioning was appropriate for this individual. There is no evidence the facility consulted with outside resources, (pharmacist, dietitian, physical therapy) other than the wound clinic to assist in developing interventions appropriate for Resident #4. In addition, the facility's RNS (Registered Nurse Supervisor) oversees the wound program. The RNS does not complete assessments of the pressure ulcers in the facility. Through review of Resident #4's medical record, it was evident that ten different nurses completed the documentation of the wound which led to inconsistent assessments, measurements, and description of wound characteristics. The RNS indicated her weekly assessment documentation is based on previously entered entries from other nurses. The RNS stated she will only occasionally assess the wounds herself. As a result of the deficient practices, Resident #4 is on bed rest except for one-hour time periods for mealtimes, which prevents him from engaging in activities within or outside of the facility. The wound has tested positive [MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus Aureus), which also increases the risk for systemic infection or death. Three observations were made in which Resident #4 was not repositioned for extended periods of time to completely offload the areas of breakdown or other potential risk areas from pressure. Furthermore, observations were made where care plan interventions of floating his heels were not consistently followed. The immediate jeopardy began on 9/1/15, when the facility no longer comprehensively assessed the healing pressure ulcer which included extensive induration in the areas surrounding the resolving pressure ulcer. The NHA (Nursing Home Administrator), DON (Director of Nursing), and RNS (Registered Nurse Supervisor) were notified of the immediate jeopardy at 2:49 p.m. on 9/29/15. The immediate jeopardy was removed on 9/29/15 but noncompliance remains at the lower scope and severity level of H (actual harm/pattern) as the facility still needs to fully implement plans for other residents. 2. Resident #2 has a history of pressure ulcers. Resident #2 also had multiple re-occurrences of pressure ulcers over the past year. The facility did not complete a comprehensive wound assessment, at least weekly, of the characteristics of Resident #2's pressure ulcers, nor did they change treatment modalities aside from physician ordered dressings and/or ointments when pressure ulcers re-occurred and deteriorated. In addition, staff did not follow Resident #2's plan of care for repositioning and toileting. Resident #2 subsequently developed avoidable pressure ulcers including pressure ulcers that were unstageable. 3. Resident #1 has a history of pressure ulcers. Resident #1 also had recurring stage I and stage II pressure ulcers. The facility did not complete a comprehensive wound assessment at least weekly, change treatment modalities timely, nor follow Resident #1's care plan for positioning. 4. Resident #6 had a significant change in condition which resulted in an overall decline in Resident #6's functional status. While the facility identified the decline in physical functioning, there were no changes made to Resident #6's plan of care to prevent the development of pressure ulcers. Resident #6 subsequently developed a stage III pressure ulcer behind the left ear, stage I pressure ulcers to the ischium and coccyx, and unstageable pressure ulcers to both heels. Additionally, documentation of the pressure ulcers was inconsistent. There was never a comprehensive assessment completed of any of the pressure ulcers. 5. The facility identified Resident #14 had an abrasion to the right buttocks. Observations of the abrasion revealed the abrasion was actually a pressure ulcer. This was not identified by the facility. 6. Resident #10 has a history of a pressure ulcer to her lower right buttocks 9/11/14. This area healed on 9/21/14. Observations were made where care plan interventions of strict side-to-side positioning in bed and the floating of heels were not consistently implemented. Resident #10 was not repositioned and was not toileted/provided incontinent care for over four hours. 7. Resident #3 was assessed as being a high risk for the development of pressure ulcers. Observations were made in which care plan interventions were not consistently implemented. Also, Resident #3 was observed for a 3 hour 14 minute time frame in which no personal cares were provided for the resident. This is evidenced by: Example #1: Resident #4 was admitted to the facility 9/3/14. Current medical [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment dated [DATE], indicated Resident #4 did not have any pressure ulcers but was at risk for the development of them. The most current MDS dated [DATE], indicates Resident #4 requires extensive assistance of staff for bathing, dressing, personal hygiene, and bed mobility. Resident #4 is non-ambulatory and transfers with the use of a mechanical lift. He is incontinent of bowel and has an indwelling Foley catheter which was reinserted on 7/8/15 related to [MEDICAL CONDITION]. In reviewing Resident #4's care plan history, Surveyor # noted the facility created a care plan for the risk for the developing of skin breakdown on 9/11/14. Interventions in this plan of care included to reposition the resident every two hours, use a lifting device to move the resident in bed, avoid shearing, conduct a systematic skin inspection weekly paying special attention to bony prominences, use a therapy recommended cushion for pressure reduction when the resident is in the chair, and use a HeelZup device to relieve pressure on the heels. The 11/22/14 Braden Scale (used to predict pressure ulcer risk) indicated Resident #4 scored 15 (15-18 indicates At Risk). The following risks were identified: 1. Cardiovascular Disease, Cognitive Impairment, Catheter, [MEDICAL CONDITION]. 2. A current unhealed pressure ulcer, one unstageable covered with slough or necrotic tissue present on admission (measurements were not entered into the assessment). 3. Extensive assistance with bed mobility. 4. Wheelchair mobility. 5. Occasionally incontinent of bowel. 6. Moisture associated skin damage. 7. Pale skin was entered under hydration status. 8. Sensory perception was coded as slightly limited. 9. Moisture was coded as occasionally moist. 10. Activity was coded as chairfast. 11. Mobility was coded as very limited. 12. Nutrition was coded as adequate. 13. Friction and shear was coded as potential problem. Interventions to prevent pressure ulcer development included heels up on pillow or HeelZup device, pressure reducing devices for bed and chair, turning/repositioning program, and applications of ointments/medications other than to feet. In the plan of care section the facility marked to continue current plan of care. No referrals necessary was also marked. A Braden Scale completed on 2/20/15, indicated the same information as did the 11/22/14 assessment. The Braden Scale completed on 5/21/15, indicated a score of 15. The following changes were identified on this assessment: 1. Bowel incontinence declined from occasionally to frequently. 2. The peri-area was coded as having redness. 3. The facility coded Resident #4 as having three stage II pressure ulcers not present on admission that began on 5/16/15. Measures taken included the same as the 11/22/14 assessment with the addition of pressure ulcer care being given. The Summary does include that an air mattress was .just put into place . and repositioning every two hours. Even with the new three stage II pressure ulcers, the facility indicated on this assessment that they will continue with the current plan of care and no referrals were needed. ~ A final Braden assessment dated [DATE], was provided to Surveyor # on 9/29/15, in which Resident #4 scored 12 (10-12 indicates high risk for the development of pressure ulcers). The following changes were noted from the previous assessment: 1. Moisture was coded as very moist. 2. Mobility was coded as completely immobile. 3. The facility added interventions of nutrition or hydration interventions to manage skin problems and application of nonsurgical dressings other than to feet. The facility indicated on this assessment that they will continue with the current plan of care and no referrals were needed. On 9/29/15 at 12:15 p.m., Surveyor # sat down with the RNS (Registered Nurse Supervisor) who oversees all the facility wounds, and together, went through the findings below (obtained from the nursing progress notes or NPNs) with the care plan and facility interventions. The RNS stated to the Surveyor that she oversees the wounds in the facility and completes a weekly skin assessment of each wound. However, she also stated that often she completes these assessments based on the documentation of other nurses or the wound clinic dictations, and only occasionally does she physically assess the wounds. She stated when she physically assesses the wounds, she completes documentation in the NPNs, as do all the nurses completing wound care and/or assessments. The RNS's statements are included in the timeline below: ~ On 5/16/15 Resident #4 presented with three small open areas, which the facility assessed as being stage II located to the right gluteal crease: 1) Right upper area was measured as 0.6 x 0.7 cm (centimeters); 2) Left upper area was measured as 1.0 x 0.7 cm; and 3) Lower area was measured as 1.7 x 1.5 cm. The wound bed was documented as being pink with surrounding skin intact. However, there is no documentation of palpation being conducted to determine if the surrounding skin was firm, soft, or mushy to determine if damage was being done underneath the skin surface. According to the Wound Care Education Institute, 2011, a wound assessment should be conducted through inspection (looking), palpation (touching), listening, and smelling, and should include the following: ~ The type of wound; ~ The correct staging or classification; ~ The correct anatomical location; ~ Measurements in centimeters, including depth if able; ~ Wound base tissue (slough, eschar, granulation, [MEDICATION NAME] documented in percentage of tissue noted in the wound bed); ~ Symptoms of infection that are present; ~ Drainage color, amount, and consistency; ~ Odor; ~ Tunneling/undermining, its depth and size; ~ Wound edge appearance (calloused, macerated, detached, curled); ~ Periwound appearance; and ~ Pain presence. The RNS stated a Roho cushion and a [MEDICATION NAME] treatment was added as well as repositioning the resident every two hours. ~ On 5/19/15 the treatment was changed to [MEDICATION NAME], covered with a foam and a [MEDICATION NAME] occlusive dressing. The facility also initiated an air mattress overlay and the resident was to lay down for one hour every morning and afternoon with repositioning in bed from side-to-side. The three areas had now merged into two open areas to the right gluteal crease, measuring 1.8 x 3.0 cm and 2.4 x 2.0 cm. The old dressings removed were saturated with serosanguinous drainage. There is no indication in the documentation which area is the upper or lower, or which is the right or left. According to the documentation, there was a small amount of slough around the edges. The documentation also does not indicate if the slough (non-viable tissue that inhibits wound healing) is present in both open areas or just one. It also does not indicate which sections of the open areas contain the slough. There was no description of the surrounding skin/tissue and no evidence that the surrounding area was palpated. The current standard of practice for wound assessment documentation is for the documentation of a wound to resemble a clock method (the head of the body would resemble 12 o'clock and the feet would be 6 o'clock) in order to accurately identify the areas of the wound that contain the slough, as well as percentage of the wound covered in slough. This allows practitioners to be able to determine if a wound is improving or declining. ~On 5/24/15 the wounds were assessed as being 1.7 x 3.0 cm and 2.3 x 2.0 cm. Again, one does not know which wound is located where, only that both exist on the right gluteal crease. There was a small amount of yellow drainage on the old dressing and granulation appeared to be present. There is no clarification which wound is draining and which wound has the appearance of granulation. ~ On 5/26/15 the wound was measured as one, being 4.8 x 2.6 cm. The care plan was updated to include the approach of laying Resident #4 down following meals and positioned side to side every one to two hours. The RNS stated it was at this point that the two open areas had merged into one. This is a significant change in the wound and the assessment of the wound does not include pertinent information that should be included in a wound assessment. ~ On 6/1/15 the wound was documented as being 4.2 x 2.5 cm to the right buttock. The right buttock is not the right gluteal crease. These are anatomically different areas. The consistency of the assessment is a concern. The RNS stated she was unable to locate where any changes were made to the resident's plan of care. ~ On 6/3/15 the wound was documented as having pink [MEDICATION NAME] tissue approximately 4.1 x 3.5 cm with a small area of brownish-yellow scabbing to the right outer area. The scabbed area was not measured. There is no assessment of the surrounding tissue. The RNS stated she thought this resembled healing of the wound, however, this is not documented as such. The interventions include a Roho cushion and that the resident is layed down in the morning and afternoon and repositioned every one to two hours. This conflicts with the intervention noted above in which the resident was to be layed down after meals and positioned side-to-side. No new interventions were added to the care plan according to the RNS. ~ On 6/9/15 documentation states that a new open area was revealed to the right lower buttocks region that measured 0.3 x 0.4 cm. The wound was described as being . pinkish red with white sloughing to center . with a small amount of serosanguinous drainage present. Again, of concern is the percentage of slough not being recorded. There were no changes to the care plan interventions despite the development of a new pressure ulcer. The physician was updated and ordered Santyl and covering with a foam dressing and [MEDICATION NAME]. The facility also did add Arginate supplements, four ounces twice daily to promote healing. The RNS stated this was a new wound as the previous wound healed. ~ On 6/11/15 the documentation states a small amount of yellow drainage was present on the old dressing and the open area remains with white tissue at the center. The surrounding skin was pink. The documentation does not indicate if the white tissue was slough and does not indicate what percentage of the wound is covered with white tissue. ~ On 6/13/15 documentation stated there was a small amount of tan drainage with an open yellow/white tissue to the site. The surrounding skin was slightly red. ~ On 6/14/15 the wound measured 0.6 x 0.6 open area off-white in color, with a small amount of tan drainage present. The surrounding skin was ruddy red and blanchable. This is an increase in size from the measurement taken on 6/9/15. The RNS stated no new interventions were added to the resident's plan of care. At this point in reviewing the documentation, Surveyor # asked the RNS why there are ten different nurses completing the wound assessments. The RNS stated an RN was placed into the primary wound nurse roll, however, she was unsure of the date this was implemented. ~ On 6/17/15 the documentation stated the area measured 0.8 x 0.9 cm with a yellow slough. The peri-wound was described as being firm and deep purple. This entry was completed by the RNS. The sudden discoloration of the surrounding wound indicates some degradation of tissue underneath the skin surface. A call was placed to the physician who ordered to discontinue the Santyl and instead, start Polymem Silver dressings. No other changes to the resident's plan of care were initiated. The RNS indicated she had assessed the wound on this date, evidenced by her NPN entry, and completed a Skin-Ulcer Documentation Report on 6/25/15. On 6/18/15 the physician ordered a [MEDICATION NAME] level to be done. ~ On 6/19/15 the wound measured 1.0 x 1.0 cm with a white slough center. The surrounding skin was pink. This is an increase in size and no changes were made to the resident's plan of care. ~ On 6/22/15 the wound was measured as being 1.1 x 1.2 cm with a white slough center. The surrounding skin was described as being red and blanchable. This is another increase in size to the wound and no changes were made to the plan of care for caregivers to initiate. ~ On 6/23/15 the wound was measured as being 1.8 x 1.5 cm with a white slough center and surrounding skin as being red. The RNS stated no changes were made to the plan of care. ~ On 6/26/15 Resident #4 developed an elevated body temperature of 100.8 degrees Fahrenheit with additional symptoms of runny nose, lethargy, loose stools and shakes. ~ On 6/27/15 bladder scans indicated a large amount of urine being retained. The wound measured the same as the day before. ~ On 6/29/15 the wound was recorded as being 1.5 x 1.6 cm with white slough in the center and a firm area around the open area measuring 6.5 x 5.5 cm. A fax was sent to the physician to request a treatment change. No changes were made to the plan of care. The resident remained on a Roho cushion with repositioning every two hours. Later that day the facility received orders from the physician for an antibiotic to treat a Urinary Tract Infection [MEDICAL CONDITION] and change the treatment to [MEDICATION NAME] Blue under a bordered [MEDICATION NAME] dressing. The RNS stated the facility also changed the Arginate supplements to Juven twice daily, however no other changes to the plan of care were made. ~ On 7/1/15 the wound measured 1.6 x 2.4 cm with white sloughing 0.1 cm deep. There was a hardened area around the wound that measured 12 x 8 cm in size. The physician ordered a wound clinic referral. The [MEDICATION NAME] Blue treatment was discontinued and Polymem Silver was initiated. A different air mattress was placed, an M85 Micro Air alternating air mattress. However, there were no other changes made for the caregiving staff to follow, such as repositioning every hour, or to not position the resident onto the right side. Later that same date the wound was recorded as being 1.5 x 1.0 cm with the surrounding area being hard, red and blanchable. Note: This appears to be a dramatic improvement in the wound within only a few hours time. The inconsistencies with the measurements and documentation make it difficult to determine improvement or declining of the wound, as different individuals are measuring and documenting on the wounds. ~ On 7/2/15 the wound was recorded as measuring 1.5 x 1.4 cm with white slough. The surrounding area was described as being hard and measuring 12 x 8 cm. The resident complained of pain to the area. The RNS stated the Juven was increased on this date to three times daily, however, this is not documented in the progress notes. The skin ulcer documentation dated 7/2/15, conducted by the RNS, only gives a summary of previous nurse documentation entries. There is no evidence that she physically assessed the wound. ~ On 7/3/15 the wound was documented as measuring 3.5 x 4.0 cm. Again, a dramatic increase in the wound according to the documentation. No changes were made to the care plan. ~ On 7/6/15 Resident #4 was seen by the wound clinic. He continued to be on antibiotics for the UTI. The wound clinic's initial assessment included the following information: .Stage III pressure ulceration overlying the right ischial prominence that measures 2.8 x 1.9 x 0.2 cm. The edges are attached, but irregular. The entire ulcer base is covered with adherent [MEDICATION NAME] (slough). There is significant palpable induration (hardness) extending circumferentially around the ulcer base and up into the right groin . The wound clinic conducted a partial thickness wound debridement to remove the [MEDICATION NAME] tissue and bring the wound to a healthier base to allow for healing to occur. This did not change the size of the wound itself. The wound clinic consulted with the wound clinic surgeon, who recommended to continue the antibiotic therapy and would evaluate following the antibiotics to determine if surgery would be needed. ~ On 7/7/15 the wound clinic was sent the results of the [MEDICATION NAME] lab work from the facility and ordered a nutrition consult. The [MEDICATION NAME] result was 12, indicating severe protein malnutrition. The wound was documented by the facility as a red area measuring 3 x 2.9 cm with two open areas with slough measuring 1.4 x 1.5 cm and 1.0 x 0.3 cm The surrounding area was hardened and measured 7 x 11 cm. This is another increase in size without new interventions for caregiving staff to implement. ~ On 7/8/15 the documentation stated the wound was .right inner buttock firm red area 8 x 8 cm open area 2.5 x 2 cm with two areas of white slough 1.1 cm x 1.2 cm and 1.5 cm x 0.5 cm. The indwelling Foley catheter was placed on this date. The accuracy of the wound assessments again comes into question related to the dramatic change of the wound in one day's time. No other changes were made to the care plan. The RNS stated they had increased the Juven to three times daily on this date, but when questioned on an earlier statement that they increased it on 7/2/15. She was unsure which date it was actually increased as it was not clearly documented. ~The skin ulcer documentation dated 7/9/15, completed by the RNS, only gives a summary of previous nurse documentation entries. There is no evidence that she physically assessed the wound. ~ On 7/10/15 the documentation indicated the wound was in the right inner gluteal crease and was showing slough that measured 2.5 x 1.3 cm The hardened area was measured as being 11 x 6 cm that surrounded the open area. ~ On 7/13/15 the wound was measured as being 1.7 x 1.0 cm with white slough center. Firmness surrounded the wound measuring 3.0 x 3.0 cm at 12 o'clock. Again, a dramatic change in the assessment from the previous one documented. ~ On 7/16/15 the wound measured 1.2 x 0.8 cm. This was the last day of antibiotics for Resident #4. The wound clinic assessed the resident on this date and ordered a high profile Roho cushion and made a referral to the wound clinic's occupational therapist for pressure mapping. According to the RNS, a high profile Roho is one that is four inches thick, whereas the regular Roho cushion is three inches thick. ~The skin ulcer documentation dated 7/16/15, completed by the RNS, only gives a summary of previous nurse documentation entries. There is no evidence that she physically assessed the wound. ~ On 7/20/15 the wound measured 1.5 x 0.8 cm with a 1.0 cm firmness surrounding the open area. The wound was documented as having a pink center. ~ On 7/21/15 Resident #4 was assessed by the wound clinic and pressure mapping was conducted by an occupational therapist (OT) through the wound clinic. They determined that Resident #4 was only allowed to be up in the wheelchair for one-hour periods at mealtimes, and in bed all other times, positioned every two hours, side-to-side. Also, the wound clinic and OT determined that the foot pedals of Resident #4's wheelchair were to be on only with transport, and his feet should rest on the floor at all other times while in the wheelchair in order to alleviate the pressure to the ischial Tuberosity. Also recommended was a higher wheelchair frame with a longer 18 inch seat depth. According to the RNS, the facility implemented these orders on this date. The wound clinic measured the wound as being 0.6 x 0.8 x 0.2 cm with circumferential induration as well as hyperemia (increased redness) noted around the ulcer. The dictation indicates that the induration previously extending into the groin has resolved with the antibiotic therapy. ~Skin ulcer documentation dated 7/22/15, completed by the RNS, only gives a summary of previous nurse documentation entries. There is no evidence that she physically assessed the wound. ~ On 7/23/15 the facility measured the wound as being 1.0 x 0.9 cm with a 0.2 x 0.2 cm area of slough at the center. The firm area surrounding measured 8.0 x 6.5 cm in size. When asked what the above documentation indicates the RNS stated, It's worsening, something is brewing inside . When asked if any further changes to the care plan were implemented the RNS stated, No, I'm not seeing any. ~ On 7/29/15 the facility documented the wound as being 1.0 x 0.5 cm with hardness surrounding the area. ~The skin ulcer documentation dated 7/31/15, completed by the RNS, only gives a summary of previous nurse documentation entries. There is no evidence that she physically assessed the wound. ~ On 8/1/15 the facility documented the wound as being 0.9 x 0.5 cm with a pink center and firmness lateral and medial 3 cm. ~ On 8/2/15 Resident #4 began having loose stools (these loose stools continued through 8/12/15). ~ On 8/3/15 the wound was measured as being 0.9 x 0.5 cm with a pink wound bed. No drainage or slough present. ~ On 8/4/15 Resident #4 was seen by the wound clinic. The dictation indicated the wound had [MEDICATION NAME] (healed over) but there continued to be areas of mild to moderate induration present. The wound clinic ordered to discontinue the current treatments and apply Clear-Aid to the perineum and ischial tuberosities twice daily and as needed, and also to continue with activity restrictions and pressure relief measures. The physician ordered [MEDICATION NAME] and to decrease the medication Tamulosin. ~The skin ulcer documentation dated 8/6/15, completed by the RNS, only gives a summary of previous nurse documentation entries. There is no evidence that she physically assessed the wound. ~ On 8/11/15 the facility documents the wound as being fragile healed. ~ On 8/14/15 the facility documented an 11 pound weight loss for Resident #4 in one month's time. ~The skin ulcer documentation dated 8/13/15, conducted by the RNS, indicates an entry from the RNS indicating she assessed the wound on 8/11/15 as being fragilely healed. ~ On 9/1/15 Resident #4 was assessed by the wound clinic. The dictation indicates the stage III pressure ulcer has significantly improved but there continues to be mild to moderate induration and that the zinc-based barrier cream previously ordered was only noted in the gluteal crease and not over the right ischial tuberosity as ordered. The wound clinic then liberalized the activity level of Resident #4, allowing him to be up in the wheelchair throughout the day and return to bed once mid-morning and once mid-afternoon for at least one hour for full relief of the ischial tuberosity. They also reiterated their previous order to cover the right ischial tuberosity with the Clear-Aid cream. The RNS stated even though the wound clinic liberalized Resident #4's activity levels, the facility continued with having him up in the wheelchair only for meals for a one-hour time period. All other times she stated Resident #4 was to be in bed, positioned side-to-side every two hours. There was no further assessment of the pressure ulcer or the induration identified in the area of the pressure ulcer. The facility provided skin review sheets that are completed on each shower day. Although staff are reviewing for new skin issues, this is not considered a comprehensive assessment of an existing pressure ulcer. On 9/20/15 the nurse documented a small open area on right medial buttock measuring 0.2 x 0.3 cm. .During the process of cleansing a moderate to a large amount of [MEDICAL CONDITION]/yellow purulent exudate (pus) present. There is slight hardness present on interior area of discolored surrounding skin. Temp of skin is warm, tender to touch . The on-call physician was contacted and antibiotics were ordered as well as an order to culture the wound. ~ On 9/21/15 the wound contained a large amount of thick purulent yellow/green drainage that was expressed from the firm area around a small opening of 0.3 x 0.3 cm and the firm area measured 7 cm. The color of the drainage indicates severe infection present. The DON (Director of Nurses) then evaluated the wound and the physician was contacted. A new treatment was ordered which consisted of light packing with alginate. Arginade was discontinued (this was actually discontinued back on 6/30/15) and Juven was ordered, six ounces twice daily (also previously ordered on 6/30 then increased to three times daily on 7/2/15). There was no entry that this had since been discontinued once the area appeared to have been healed on 8/11/15. There were no other changes to the care plan for caregiving staff to implement. The facility did contact the wound clinic to be seen earlier than the scheduled appointment. On 9/21/15 the care plan was updated with the wound clinic recommendations of a different cushion and an improved air mattress back on 7/21/15. The facility also created a new entry for Pressure Ulcer Stage 4 . however, no different or new approaches were added other than what was listed above. On 9/22/15 during the initial tour of the facility, Surveyor # observed Resident #4 lying in bed on his left side at 9:13 a.m. A HeelZup device was set on top of the over-the-bed table near the doorway to the room. Resident #4's heels were in direct contact with the mattress. At 9:22 a.m. Surveyor # was told by RN-O (Registered Nurse) that she had completed the treatment to Resident #4's pressure ulcer earlier and had positioned him onto his left side. Subsequent observations at 10:55 a.m., 11:35 a.m., and 12:20 p.m. found Resident #4 still on his left side with

Based on observations, interviews and record review, the facility did not ensure: resident safety in wheelchair for 1 of 15 (#3) residents reviewed; a thorough investigation of the root cause of the fall for 1 of 15 (#15) residents reviewed for fall safety and implementation of appropriate interventions after falls. 1. Resident #3 received a fracture to right tibia when being pushed in wheelchair by facility staff. Facility staff member did not follow plan of care by applying foot rest extender/black board to wheelchair, to assist in safety for the resident, while being transferred in the wheelchair. 2. The facility did not thoroughly evaluate the root cause analysis of the fall for Resident #15, in order to develop appropriate interventions to prevent future falls, when the residents behaviors changed, causing increased risk, the facility did not implement new interventions prior to another fall occurring. This is evidenced by: 1. On 9/19/13 at 9:40 a.m., Surveyor reviewed CNA Care Plan dated 9/18/13 for Resident #3. Care plan stated, "TO HAVE BLACK SUPPORT ON LEG RESTS WHEN BEING TRANSPORTED, MAY TAKE OFF AT DESTINATION, THEN PUT ON AGAIN FOR TRANSPORT." On 9/19/13, Surveyor reviewed Therapy Care Plan (TCP), dated 2/8/13. TCP stated, "Foot rest extender recommended when in chair...Pt has w/c foot rest extender. " On 9/19/13, Surveyor reviewed physician progress notes [REDACTED].C." Progress note stated, "one of the aids at (Resident #3's) nursing home was pushing (Resident #3) in a wheelchair when (Resident #3's) right leg fell off of the foot pad and as the foot caught the floor and the chair continued forward, it gave her an external rotation stress as it folded underneath the chair. There was immediate pain. The aid stopped immediately and paramedics were called and she was taken to the emergency department where a tibia fracture was identified, splinted and (Resident #3) was sent back to the nursing home with follow up scheduled with me." On 9/19/13, Surveyor requested copy of investigation of tibia fracture to Resident #3 from DON. Event Investigation, dated 8/6/13, provided to this surveyor by DON. Upon review of event report, it was noted that Resident #3 was being transported in wheelchair and Resident #3's right foot slipped off foot pedal and planted on floor and twisted. Resident #3 was sent to emergency room where an x-ray was obtained. The results of the x-ray showed a fracture to the right tibia. On 9/23/13 at 10:40 a.m., Surveyor interviewed Business Service Manager (BSM) H. BSM H stated Resident #3 was treated by both Physical Therapy and Occupational Therapy for transfers. BSM H stated due to risk for bruising, pressure to skin and safety from legs falling off foot pedals, a foot extender/black board for Resident #3 was recommended. BSM H stated foot extender/black board was needed due to Resident #3's feet being externally rotated out when placed on the wheelchair foot pedal which can easily cause foot to fall off the foot pedal thus potentially causing injury to resident. BSM H stated foot extender/black board was recommended by both Physical Therapy and Occupational Therapy to promote safety for Resident #3 while in wheelchair. BSM H stated the foot extender was received and implemented on 2/8/13. On 9/23/13 at 2:20 p.m., Surveyor reviewed CNA Care Plan dated 4/30/13. Upon review of care plan, there was no mention of a foot extender/black board for Resident #3's wheelchair. On 9/23/13 at 2:20 p.m., Surveyor interviewed Registered Nurse Unit manager (RNUM) A. RNUM A stated the foot extender/black board was not written on either the CNA Care Plan or the Comprehensive Nursing Care Plan, however, the TCP, which discussed the implementation and proper use of the foot extender/black board, was attached to the CNA Care Plan and then placed on the inside of Resident #3's closet door for staff to view and follow. RNUM A stated facility has implemented new procedure and no longer has care plans in resident rooms. RNUM A stated CNA's currently carry the care plans for the residents with them and that they are done electronically now. RNUM A stated that TCP for Resident #3 had been implemented on 2/8/13 and nursing staff where educated and trained on intervention at that time. On 9/23/13 at 9:45 a.m., Surveyor interviewed CNARA G (Certified Nursing Assistant/Restorative Aide). CNARA G stated on 8/6/13 she was transporting Resident #3 from Resident #3's room to the Wellness class or exercise. During transport Resident #3 went "ohh." CNARA G stated Resident #3's right foot had slipped off the wheelchair foot pedal and was on the floor. CNARA G stated she placed Resident #3's foot back onto the foot pedal and proceeded to take her to Wellness class. CNARA G stated Resident #3 did bilateral foot and ankle flexion and rotation exercises during class and no pain was noted to Resident #3 during these exercises. CNARA G stated when wellness class was completed, Resident #3's feet were placed on the foot pedals and then transported her to church. CNARA G stated foot extender/black board was to prevent Resident #3's feet from falling off the wheelchair. CNARA G stated Resident #3 has had the board for a long time but did not know when the intervention had first started. CNARA G stated that no other intervention has been given to her or was on the CNA Care Plan addressing further safety measures to help protect Resident #3's feet from falling of the foot pedal to prevent injury. CNARA G stated she had forgotten to apply the foot extender/black board to Resident #3's wheelchair on 8/6/13 when transporting to Wellness Class. CNARA G stated "I just forgot to ask" Resident #3 if she wanted the black support board on the wheelchair. CNARA G stated, "I was really busy." 9/23/13, Surveyor interviewed BSM H. BSM H stated she was unaware of any refusals by Resident #3 to use the foot extender/black board. BSM H stated it is the expectation when a therapy intervention is put into place for a resident, a Therapy Care Plan (TCP) is written and then any/all interventions are to be placed on the resident's care plan and then implemented by the nursing department. BSM H stated expectation would be for nursing department to notify Therapy of any refusals of interventions so an assessment can be completed to ensure the safety of the resident. BSM H stated there was no notification from the nursing department that Resident #3 was refusing the foot extender/black board. On 9/23/13 at 11:30 a.m., Surveyor interviewed BSM H and Physical Therapy Assistant (PTA) I. BSM H stated on 2/8/13, the Therapy Department implemented the foot extender/black board for Resident #3's wheelchair. BSM H stated that education and training was provided to the nursing staff on how to properly install and use the foot extender/black board. On 9/24/13 at 10:30 a.m., Surveyor interviewed RNUM A. RNUM A stated it was expectation that CNARA G attempt to apply foot extender/black board to Resident #3's wheelchair prior to transporting in wheelchair on 8/6/13 according to Resident #3's plan of care. On 9/23/2013, Surveyor requested copies of all documented education on refusals to Resident #3. No documentation provided. No further information provided. 2. Resident #15 has a care plan for falls which was developed on 06/18/13. Resident #15 experienced a fall at 9 a.m. on 07/27/13. According to Resident #15's medical record he was found by a CNA in his room kneeling by bedside after self-transferring from the commode. Resident #15 stated he could not sit any longer on the commode so he stood up and waited for a CNA to come and wipe his bottom. Resident #15 stated he leaned across the bed then kneeled on floor to wait for the CNA. This is where the Resident was when staff found him. Resident #15 did not get injured during this incident. Interventions put into place by the facility included a clip alarm while in bed, not to be left alone on the toilet, offering toileting every 2-3 hours, and having the call light within reach of the resident. An investigation into the fall, dated 07/29/13, states to place a clip alarm on resident in bed only, and for staff to offer toileting every 2-3 hours. The report also states that the CNA stated the resident was only on the commode for a few minutes. The investigation does not include interviews with staff on duty at the time, as to whether or not the Resident's call light was available to him at the time of the incident, whether or not the resident activated the call light if it was available, or how long the CNA was away from the resident. Following the fall a temporary care plan was put into place including a "clip alarm to bed" for resident safety. The temporary care plan was then discontinued on 08/01/13 by LPN D. The interventions that were initiated were not updated on the plan of care. Resident #15 experienced another fall on 08/18/13 at 7:53 p.m. where he was found kneeling by the bed with his upper body lying on the bed. Resident #15 received a skin tear during this incident. The intervention put into place following this fall includes a pressure pad alarm. The investigation into this fall does not include information related to whether or not the resident's clip alarm was sounding at the time of the fall and why, the investigation also did not discover that the interventions put into place after the 07/27/13 fall were not added to the plan of care, nor did it discover that Resident #15's behaviors changed prior to the fall, which may have contributed to the fall. Surveyor interviewed RN P who indicated that she was the nurse on duty at the time of the fall. RN P stated she recalled the incident, and that Resident #15's clip alarm was not sounding at the time of the fall. Resident #15 stated that the alarm did not sound because Resident #15 had removed his gown with the alarm still attached to it. RN P stated that Resident #15's behavior had changed a few days prior to his death, he had increased confusion and restlessness, and he began removing his oxygen and clothing. When asked if there had been any changes in his care because of knowing he could remove the alarm, prior to the second fall. RN P said not that she was aware of. Surveyor reviewed the nursing documentation which reveals that on 08/15/13 at 10 a.m. Resident #15 was requesting to have his clothing off. Documentation over the next few days also reveals Resident #15 began removing his oxygen, which increased his confusion and restlessness. Despite staff being aware of increased confusion, restlessness and desire to remove his clothing, which his alarm was connected to; staff did not make any changes to Resident #15's plan of care until after a second fall occurred.

Based on interviews and record reviews, the facility did not ensure 1 of 3 sampled residents received appropriate assistive devices to prevent accidents. Resident #1 was placed on an alternating air mattress. The facility's practice, but not policy, when placing these mattresses initially is to position a resident's bed in the lowest position with a floor mat on each side of the bed, with the repositioning of the furniture in the room to ensure a clear path should the resident fall. The day shift nurse supervisor directed staff to place the bed in the lowest position and to position mats on both sides of the bed. This same information was also included in the 24-hour report. On 3/9/13, at 9:15 a.m., Resident #1 fell from her bed and sustained 7 broken ribs. Interviews conducted indicate the bed was not in the lowest position, there was no floor mat in place on the side that she fell from, and the furniture was not repositioned to ensure safety. This is evidenced by: On 3/22/13 at 9:10 a..m., Surveyor # requested the facility policy for alternating air mattresses from the NHA (Nursing Home Administrator). At 11:10 a.m., the NHA approached the Surveyor with a policy titled "Alternating Pressure Pad." This document was not dated and gives direction only on the set up of the device, but not its use or staff practices relating to the device. The NHA stated this was the only one the facility had and they did not have a policy specific to the air mattress use. Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #1 requires extensive assistance of staff to meet her most basic daily tasks of bed mobility, transfers, dressing, bathing, personal hygiene, and toilet use. Staff interviews also completed on 3/21/13 through 3/22/13, indicated Resident #1 normally spent the majority of her time in her recliner and occasionally in her bed. Interviews also indicated she did not make attempts to exit the bed without assistance. Staff interviews also suggested that Resident #1 was alert and oriented with occasional forgetfulness or confusion. The Fall Assessment completed by the facility on 2/13/13 indicated minimal risk for falls; however, it was incomplete in the sense that areas of orthostatic blood pressures were not completed, fracture risk was left blank (Osteopenia), environmental risk factors were left blank, and potential interventions were left blank. On 3/6/13, staff noted an open area to Resident #1's coccyx. The facility ordered an alternating air mattress and a Roho cushion. The air mattress was delivered to the facility and put into place late afternoon of 3/8/13. On 3/9/13 at 9:15 a.m., Resident #1 sustained a fall off the right side of her bed. Staff responded to her calls for help, and found her lying on her right side between her bed and the roommate's bed, with her right arm underneath her. The remote control for the bed was under her right leg, and her head was resting on the lower frame of the roommate's (Resident #4) over-the-bed table. Resident #1 was sent by ambulance to the local hospital where they diagnosed her with Pneumonia seconded by Congestive Heart Failure exacerbation. She was also found to have a right displaced shoulder, which was a chronic problem for the resident, and seven fractured right-sided ribs. On 3/12/13, the resident passed-away at the hospital. On 3/21/13 at 2:05 p.m., Surveyor # interviewed CNA-A (Certified Nursing Assistant). CNA-A was the first staff on the scene responding to Resident #1's calls for help. CNA-A stated she was assigned to another floor on 3/9/13, but she heard the resident yelling, "Please help!" She stated when she responded and entered the room, she found Resident #1 on the floor between her bed and the roommate's bed, indicating the resident fell out of the right side of her bed. She stated the resident's bed, "was not low when I found her. The head of the bed was up, like she was sitting up maybe for breakfast. The bed height was at my hip level. She fell out of the right side of the bed toward her roommate and was laying between her bed and the roommate's with her head toward the window and her arm was pinned under her with the (mechanical lift) sling under her and she was facing the wall with her feet toward the door..." CNA-A stated there was no floor mat on the right side of the bed; only one floor mat and it was positioned on the left side of the resident's bed. She then called for help from LPN-B (Licensed Practical Nurse). She stated Resident #1 was frantic because she couldn't breathe. On 3/21/13 at 2:25 p.m., Surveyor # interviewed LPN-B, the second staff on the scene. LPN-B stated CNA-A alerted her to Resident #1's fall. LPN-B stated when she entered the room, she noted the resident was lying on her right side with her head on the base of the roommate's tray table. She directed staff to seek out the Registered Nurse (RN-D). LPN-B stated the Hoyer sling was under the resident and she had a large hematoma on her right arm. LPN-B stated she noted that the resident's bed was not low, but at a regular height and there was no floor mat on the right side of the bed. LPN-B indicated to Surveyor # that it was the facility's practice to implement 2 floor mats, one on each side of the bed and to move furniture in the room so if a fall occurred, a resident wouldn't hit any furniture pieces. LPN-B stated once RN-D arrived a full assessment was completed and the resident was assisted back to bed. LPN-B stated after the resident fell , "...we changed the position of the bed to create less clutter. The night before, she was to be placed in a low bed with floor mats on each side of the bed and the furniture was to be cleared, (Resident #1) was in an old bed with the new air bed apparatus, and the old beds do not go to the floor like a low bed..." LPN-B stated she made all the necessary phone calls (physician, family, and ambulance) then called RN-L, who was the second shift nurse on duty and the one responsible for implementing RN-C's interventions. LPN-B stated she was told by RN-L that the mattress was placed on an old bed, and the old beds don't go to the floor like a low bed and the mats didn't fit on the floor. She stated RN-L told her she didn't know what to do. On 3/22/13 at 12:05 p.m., Surveyor # made contact with RN-L. RN-L stated she implemented the low bed but only one floor mat as she felt the second floor mat would hinder the roommate's mobility and potentially cause her to fall. When asked if any other changes to the room were made, such as the moving of furniture, she stated no other changes were made. On 3/21/13 at 2:45 p.m., Surveyor # interviewed RN-C (Registered Nurse and Nurse Manager/Wound Nurse). RN-C stated she ordered the air mattress with clearance by the Director of Nursing (DON). RN-C stated it was the practice of the facility that when an air mattress is initiated for a resident, they first go through an evaluation phase until it can be determined what reaction a resident will have toward the new surface. She stated part of the evaluation phase is placing the resident in a low bed with floor mats, one on each side of the bed, and furniture is moved to ensure that should a resident fall from the bed they will not fall against furniture. RN-C stated once the mattress is determined safe for the resident, the bed can be placed at a regular level and floor mats could be removed if that was the resident's preference. RN-C stated Resident #1 did not spend much time in her bed but was more comfortable in her reclining chair, but that she was compliant to try to new mattress. RN-C also stated the new mattress arrived in the late afternoon and she instructed the oncoming, or next shift nurse (RN-L) to supply the low bed and two floor mats, one on each side of Resident #1's bed, and to maneuver the furniture so that should a fall occur the resident would have a clear path. RN-C stated she did not double check prior to her leaving work for the day if RN-L implemented the safety measures but that she assumed these measures were carried out. RN-C stated once an air mattress is initiated, this information is placed on the care plan behind the resident's door, on the Medication Administration Record (MAR), in the computer, and on the 24-hour monitoring report so all staff are made aware. The 24-hour report dated 3/8/13, does list "air mattress, bed in low position, 1 mat" which was initiated under the PM (afternoon) time slot. However, there was no mention on the MAR except as an intervention dated 3/9/13 after the fall. The care plan on the resident's door could not be located. On 3/21/13 at 3:48 p.m., Surveyor # interviewed RN-D regarding her recollection of Resident #1's fall. RN-D performed the nursing assessment of Resident #1 after the fall. RN-D could not recall if the bed was in a low position or whether floor mats were on each side of the bed. RN-D did state it was common practice for residents with an air mattress to initially have the beds in a low position with two floor mats, one on each side of the bed. On 3/21/13 at 4:05 p.m., Surveyor # interviewed CNA-E. CNA-E stated when a resident is placed on an air mattress, they should be in a low bed with floor mats on each side of the bed to prevent injury. On 3/21/13 at 4:40 p.m., Surveyor # interviewed CNA-F. CNA-F could not recall new approaches for Resident #1 regarding the air mattress and floor mats, but stated common practice of the facility is when a resident is placed on an air mattress, the bed should be low with floor mats on each side of the bed. On 3/21/13 at 4:50 p.m., Surveyor # interviewed CNA-I. CNA-I stated she worked with Resident #1 often on the night shift. She recalled new approaches given in the night shift report on the night of 3/8/13 into the day shift of 3/9/13; Resident #1 was to have a low bed with mats, one on each side of the bed. CNA-I stated, "...the PM Shift nurse changed it and only placed one floor mat down on the side of the bed by the bathroom (indicating the resident's left side of the bed). CNA-I stated all through her shift the bed was in its lowest position. She stated she last had contact with the resident at around 6:00 a.m. CNA-I stated she heard someone ask another CNA that she had to do audits and would be watching her complete them on Resident #1. She said they went into the room but she could not recall which CNA it was. Note: CNA-G and CNA-HO were assigned to the unit in which Resident #1 resided on this date. They were both unavailable for interview. On 3/22/13 at 9:25 a.m., Surveyor # interviewed CNA-K. CNA-K was on duty at the time of Resident #1's fall. CNA-K stated she was returning from break at the time and noticed "...a bunch of people in (Resident #1's ) room. I entered and she (Resident #1) was on the floor. Her head of the bed was way up, like she was sitting up in bed. It shouldn't have been like this. She was laying on the floor by her roommate and the Hoyer sling was underneath her. She shouldn't have been up at 90 degrees and the sling shouldn't have been left under her in bed. She fell out of the right side of the bed. There was no floor mat on that side and there should have been..." When asked what the normal practice is when an air mattress is initiated, CNA-K stated, "They are supposed to be in a low bed. Her bed was not all the way to the floor and it had a bar on the side. Those beds don't go all the way to the floor, and there was no floor mat on the side of the bed that she fell on ." Note: Surveyor # and RN-C made frequent attempts to determine the actual bed in which the resident fell from, but a determination could not made. On 3/22/13 at 11:30 a.m., Surveyor # interviewed the Director of Nursing (DON). The DON stated all air mattresses are cleared through her first. The DON stated the practice followed when a new air mattress is placed for a resident, that the bed is a low bed and floor mats are placed on the side of the bed in which a resident most commonly uses. She stated Resident #1 was not deemed a fall risk and there are different set ups of the room (low bed, floor mats, etc) based on a case-by-case basis or individualized. On 3/22/13 at 11:40 a.m., an interview with the NHA (Nursing Home Administrator) was completed. The NHA stated there is no facility policy directing staff to use additional safety measures with the application of an air bed, and he was unaware of where staff were acquiring this directive.

Based on observations, interviews, and record reviews, the facility did not provide a safe environment or provide the necessary supervision and assistive device to 1 of 1 residents reviewed for elopement (Resident #1), resulting in a finding of immediate jeopardy. In addition, the facility did not provide necessary supervision and/or assistive devices to prevent falls, resulting in actual harm and/or potential for more than minimal harm that is not immediate jeopardy for 3 of 10 residents reviewed for falls (Residents #8, #14, and #3). Resident #1 was admitted to the facility on [DATE] following hospitalization . On 07/03/12, staff implemented a clip alarm in the bed and chair to alert staff to attempts at unassisted transfers due to Resident #1 being unsteady. Subsequently, however, Resident #1 would routinely remove the clip alarm, thus rendering it an ineffective assistive device. On 07/04/12, after Resident #1 had wandered into a female resident's room, staff brought him to the nurse's station and reattached the clip alarm. Staff then left the area for approximately 5 minutes. Upon return, Resident #1 was gone. The alarm had been removed and did not sound. At this same time, because facility staff had failed to ensure that all exit doors had been locked at 9 p.m. per facility policy, Resident #1 was able to exit undetected through one of the unlocked and unalarmed doors. Resident #1 was found 40 minutes later at 12:05 a.m. on 07/05/12, across the road lying in a 4 foot deep ditch in a wooded area. Resident #1 sustained abrasions to his left elbow. The facility documented that had the doors been alarmed per policy, Resident #1 would not have exited the building without staff knowledge. The immediate jeopardy began on 7/5/12 when the facility did not secure the exit doors or provide adequate supervision to Resident #1. The NHA (Nursing Home Administrator) and DON (Director of Nursing) were notified of the immediate jeopardy on 7/10/12 at 11:25 a.m. The immediate jeopardy was removed on 7/5/12, but noncompliance remained at the lower scope and severity level of G (actual harm that is not immediate jeopardy/isolated), as evidenced below. Resident #8 had a history of [REDACTED]. Both falls resulted in a head injury requiring medical attention. After each fall there was no root cause analysis completed in attempts to determine the cause of the fall in order to implement the most appropriate interventions to prevent further falls. Additionally, after the second fall, there was no evidence that the facility developed immediate interventions to keep Resident #8 from further falls. Resident #14 had a witnessed fall in which Resident #14 was lowered to the floor. Resident #14 sustained multiple injuries from the fall including abrasions and bruising. Resident #14 also had a decline in ambulation requiring a significant change to her care plan. Despite the significant injuries, there was no investigation into the cause of the fall. Resident #3 had a history of [REDACTED]. This is evidenced by: Example #1: The facility is a one story building with eleven doors that lead to the outside; 8 of the doors are locked at all times. Three of the doors (long term care front entrance, rehab unit and employee entrance by the kitchen) have wanderguard alarms and are unlocked from 5 a.m. to 9 pm (meaning that anyone without a wanderguard bracelet could enter/leave through these doors without staff knowledge). The facility is located a block away from North Central Technical College and has a wooded area to the north and west. Review of the facility policy and procedure entitled "Door Alarms" dated 05/13/04 includes the following: "Policy: In an effort to ensure resident safety and security within the facility, Marywood Convalescent Center has keyed door alarms on all exit doors. The Front doors and Employees entrances are also equipped with a Bracelet Activated Door Alarm...Procedure: 1. Keyed Door Alarm System: A. The keyed door alarm system is connected to each building exit. A light panel indicating the door status is located at the nursing station. When the alarm sounds the light to the corresponding door becomes brighter than the rest. The alarm is turned off at the activated door with an alarm key. Wing nurses carry alarm keys. B. All door alarms should be keyed ON during the nighttime hours. To allow the flow of employees and visitors in and out of the building, the keyed door alarms for the front entrances/exit and the employee entrance/exit is turned OFF during certain hours. *Front door alarm is ON approximately 9:00 p.m. to 5:00 a.m. *Employee entrance alarm is ON from approximately 9:00 p.m. to 5:00 a.m..." Resident #1 was admitted to the nursing home for rehabilitation on 07/02/12, following hospitalized from [DATE] to 07/02/12 for recurrent [DIAGNOSES REDACTED] and cardiopulmonary arrest. Upon discharge to the nursing home, Resident #1 was to use a walker with the assist of one. Resident #1's [DIAGNOSES REDACTED]. Resident #1 has an implantable cardioverter-defibrillator (pacemaker/defibrillator). Review of Resident #1's safety measures flow sheet reveals the following interventions: ~07/03/12, Clip alarm to bed and wheelchair. Do not leave alone in bathroom. Reason: self transfers. ~07/03/12 and 07/04/12, Low bed floor mats. Reason: confusion, self transfer. Review of Resident #1's nurse's notes reveal the following entries: "07/03/12, 03:34:46 (3:34 a.m.) Safety Measures: clip alarm to bed and w/c (wheelchair), do not leave alone in BR (bathroom) added to safeties d/t (due to) resident transferring out of bed and into hallway without calling for assistance or using footwear or assistive device (walker). Call light had been on resident's night gown prior to self transfer." "07/04/12, 22:13:48 (10:13 p.m.) Late entry for 07/03/12 pm shift. Incident type: fall pt (patient) was up indep (independently) in hall way and writer heard alarm and saw pt walking, walked with him until his legs got tired and put him on floor...Vitals: temperature 98.6 pule 68 respirations 26 blood pressure 100/60...Safety Device/Devices applied: Increase add low bed and floor mats with clip alarm to bed and chair..." ~"07/05/12, 01:10:56 (1:10 a.m.) Incident type: other. During HS report 2320 (11:20 p.m.) Nurse Aide came and reported that Pt was up walking in hall way, he had removed his clip alarm when she found him, the CNA put him in w/c and reapplied clip alarm. Resident placed in w/c near nurse's station on rehab. Staff made the decision to change his room to one closer to nurse's station and use motion alarm by bed. CNA went to check on him and was not able to find him at 2325 (11:25 p.m.). A search of the building was completed. Search was initiated outside the building-DON (Director of Nursing) informed at 2355 (11:55 p.m.) and immediately following the police. Repeat search of outside the building and resident was located in roadside ditch 2405 (12:05 a.m.). He was alert, some pain as his norm, knew he had recent heart surgery-speech clear, 'I got myself into trouble this time.' Skin tear noted to elbow. Police arrived shortly after resident found-ambulance called and family notified at 2420 (12:20 a.m.)..." "01:25:18 (1:25 a.m.) Incident type: other Resident was found by writer...lying on his back in the ditch with his arms crossed behind his head with head resting on his arms at approximately 2405 (12:05 a.m.). Was awake, alert and responsive. Writer...went down into the ditch by resident. Asked what had happened and he responded, 'I fell on the sidewalk out there.' Writer then asked why he left the facility he responded, 'I don't know.' Pupils assessed and were equally round and reactive to light. Claims he did bump his head but was unable to show or tell writer a specific location. No lacerations were noted to his head, but do note it was dark outside and only lighting was from flashlight..." "07/05/12, 07:31:59 (7:31 a.m.). Incident type: other: Resident had self transferred and was walking in hallway at 2320 (11:20 p.m.) per CNA (Certified Nursing Assistant), he had removed his clip alarm when aide had found him walking around in hallway, he was then put in wheelchair with clip alarm attached and was placed at nurses station. CNA stated that at 2245 (10:45 p.m.) resident was found in another resident room in that room's bed. He was helped back to bed at that time, aide was answering call light, when came back the wheelchair was empty and resident was missing this was at 2325 (11:25 p.m.) as CNA reported to writer and PM nurse. No alarm sounding as resident had taken clip alarm off, immediately a search was done with unable to find resident on Rehab unit, started search on Long term unit with staff on that end, writer called DON at 2355 (11:55 a.m.) with DON stating to call 911 with incident. Writer called 911 with missing resident report. Staff had searched outside with not finding him around building, second search was done with staff finding him in a ditch at 2410 (12:10 a.m.)..." On 07/09/12 at 5:05 p.m., Surveyor # spoke with the Director of Nursing (DON). The DON said Resident #1 left the building in the late evening of 07/04/12 early morning of 07/05/12, through the rehab entrance door. The DON said Resident #1 did not take a walker or wheelchair. The DON said the rehab door should have been locked/alarmed at the time Resident #1 left but staff were locking the door later and later in the evening because of staff coming in and out of the building. The DON said the policy and procedure which has been in place for years was for the rehab entrance, front entrance to long term care unit and the employee entrance to be alarm locked at 9:00 p.m. until 5:00 a.m. The DON said Resident #1 had been having difficulties with waiting for staff assistance to walk, had a clip alarm placed in bed and wheelchair in the days prior to the wandering incident. The DON said on the evening Resident #1 left the building, he had removed his clip alarm, had wandered into a female resident's room, and had laid on top of the covers next to her. The DON said Resident #1 had also removed his clip alarm and had been found walking in the hallway. The DON said the clip alarm to bed and wheelchair had been applied on 07/03/12. This was done because Resident #1 was observed not calling for assistance of staff and was found walking around on his own and had to be lowered to the floor on 07/03/12. The DON said Resident #1 was observed missing on 07/04/12 at 11:25 p.m., and was found in ditch across the street from the nursing home about 40 minutes later on 07/05/12 at 12:05 a.m. The DON said Resident #1 sustained an abrasion to his left elbow. The DON said Resident #1 was sent to the emergency room to be checked out and upon return a wanderguard bracelet was placed on Resident #1. The DON said staff were inserviced on locking/alarming the doors as specified in the policy. On 07/10/12 at 5:00 a.m., Surveyor # spoke with CNA-C (Certified Nursing Assistant). CNA-C said she worked with Resident #1 the first night he was at the facility and he was confused and would get up and walk on his own without waiting for staff assistance. CNA-C said a clip alarm had been applied when he was in bed to alert staff of his attempts to get up on his own. CNA-C said she had been off for a few days and when she came back she was told about Resident #1's wandering incident. CNA-C said the doors (front entrance, rehab entrance) are locked and alarmed at night and the alarm is very loud if activated. CNA-C said the policy is for those doors to be locked and alarmed from 9:00 p.m. to 5:00 a.m. On 07/10/12 at 5:30 a.m., Surveyor # spoke with RN-D (Registered Nurse). RN-D said she had worked the night Resident #1 had been admitted to the nursing home. RN-D said the first night Resident #1 had been at the facility he had trouble sleeping and at 3:00 a.m. they had found him sitting in a chair by the family room at the end of the hall. RN-D said Resident #1 had walked down to that room without his walker and without staff's knowledge. RN-D said they helped Resident #1 back to bed and applied a clip alarm. RN-D said later in the morning Resident again removed his clip alarm and went to the bathroom. RN-D said the doors are locked at night and they check at the beginning of the shift. RN-D said the front door is locked after the pm shift leaves between 10:45 p.m. and 11:00 p.m. On 07/10/12 at 6:00 a.m., Surveyor # spoke with Resident #1 who was up and awake and sitting in a lounge chair in his room. Resident #1 indicated he came to the facility a few days prior after being in the hospital for nearly 2 weeks. Resident #1 said he had fainted at home and had fallen in the bathroom. Resident #1 said while at the hospital, a code blue had been called and he didn't wake up for 2 days. Resident #1 said he has a walker to use, but he has never used a walker before. Resident #1 said a few days prior he had heard staff talking about him and he was afraid that someone was going to kill him. Resident #1 said he ran until he found an open door. He fell on the concrete onto his knees. He crossed the road and fell and rolled into a ditch. He then crawled to a telephone pole. Resident #1 said he hurt his left elbow and pointed to the wrap on his left elbow. Surveyor # asked Resident #1 if he had any alarms. Surveyor # observed Resident #1 stand up from his lounge chair, and point to a sensor pad alarm as it went off. Resident #1 then sat back down. On 07/10/12 at 7:00 a.m., Surveyor # spoke with LPN-E (Licensed Practical Nurse). LPN-E said she was working the night Resident #1 wandered from the building. LPN-E said she had punched in for work around 11:00 p.m. and was on the Rehab unit by 11:10 p.m. LPN-E said around 11:20 p.m., an aide said Resident #1 had been up walking around in the hall without assistance. LPN-E said they assisted Resident #1 into a wheelchair and placed him by the nurse's station with a clip alarm attached. LPN-E said she was in the charting room with the p.m. nurse. LPN-E said it was 5 minutes later when they discovered Resident #1 missing from his wheelchair and the alarm unclipped. LPN-E said they immediately did a room to room search throughout the building and then expanded to the parking lot around the building. LPN-E said staff continued searching outside. The DON was called and the instruction was to call the police. LPN-E said they had searched for a half an hour inside and outside before she called the DON. LPN-E said Resident #1 was found in a ditch area across the road just as the police arrived. LPN-E said the doors are to be locked and alarmed at the beginning of the shift (front entrance, rehab entrance and employee entrance). LPN-E said she didn't get the keys to check the doors before this happened. LPN-E said they had been re-educated on the times in which the doors are to be locked and alarmed. On 07/10/12 at 8:40 a.m., Surveyor # spoke with the NHA (Nursing Home Administrator). The NHA said the facility policy is to have the door locked/alarmed at 9:00 p.m. The NHA said the thought was that Resident #1 went through the Rehab Entrance door when he left the building and this door should have been locked/alarmed at that time. The NHA said Resident #1 had been showing signs of confusion but not exit seeking prior to the wandering incident. The Administrator said Resident #1 had wandered into another resident's room earlier in the evening. On 07/11/12 at 11:40 a.m., Surveyor # spoke with Resident #1's daughter. Resident #1's daughter said Resident #1 went to the facility after being hospitalized for [REDACTED].#1 had told her he had fallen to his knees when he got out of the building and then went across the road falling into a ditch. Resident #1's daughter said a CNA had stated Resident #1 had taken off his clip alarm and he had been confused, talking about bad dreams and someone chasing him. Resident #1's daughter said she didn't understand how Resident #1 got out of the building and that he is lucky to be alive. On 07/10/12 at 4:50 a.m., Surveyor # arrived at the facility. Surveyor # observed staff walking into the front entrance of the nursing home (long term care entrance). Surveyor # walked into the front entrance of the building at 4:55 a.m. The door was not locked and no alarm sounded. On 07/11/12 at 10:00 a.m., Surveyor # spoke with the DON. The DON said she has checked a couple of times to make sure the doors are locked and alarmed but has not written anything down regarding these checks. Review of the facility investigation of the wandering incident of 07/04/12, signed by the DON, indicates the following: "Incident Reviewed-conclusion if policy and procedure of locking and alarming doors from 9 pm to 5 am had been completed incident would not have occurred. All nursing staff inserviced due to wide spread non-compliance..." The failure to provide a safe environment and to provide appropriate supervision created a finding if immediate jeopardy. The immediate jeopardy began on 07/05/12 was removed on 07/05/12 when the facility: 1. Completed a full-house assessment of wandering/elopement to ensure appropriate approaches were in place to prevent residents from leaving without assistance. 2. The facility updated their policy and procedure for monitoring residents displaying a change in mental status in order to prevent unsafe exit from the facility. 3. The facility updated their policy and procedure for alarming/locking doors. A lock door audit tool was developed and implemented for daily review. Random audits of the doors will be conducted. 4. Designated nursing staff will review 24 hour report daily to identify changes in mental status with random audits conducted to ensure updated policies and procedures were implemented. 5. All staff were inserviced on the updated policies and procedures prior to beginning their next scheduled shift. Example #2: Resident #8 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. The MDS dated [DATE], indicated Resident #8: ~Had moderately impaired cognition; ~Required extensive assistance of 1 staff person for bathing, dressing, toileting, transfers, bed mobility; ~Did not walk; ~Could not maintain balance without staff support; and, ~Was occasionally incontinent of urine. Surveyor # completed a review of Resident #8's fall care plan dated 3/16/09 and noted the following approaches: ~Encourage and remind Resident #10 to wear appropriate shoes; and, ~Directs the Certified Nursing Assistants (CNAs) to follow the CNA care plan. Surveyor # completed a review of Resident #8's CNA care plan noted as "recopied" on 1/25/12 and noted the following fall approaches: ~Up in the wheelchair for meals; ~Assist with toileting before and after meals and activities; and, ~A U-bar to the right side of Resident #8's bed. None of the care planned approaches were dated. Surveyor # completed a review of a form titled "Marywood Center Falls Assessment upon Admission/Quarterly/Incident" dated 1/27/12. The form was utilized for both the documentation of falls as well as a fall assessment. The form did not include a systematic scoring system which indicated fall risk. Resident #8's nurse's notes included an entry dated 9/23/11 which states, "...observed on floor. Was found at 1750 (5:50 p.m.) laying on right side next to bed...Head was up by head of bed and night stand. Noted to have a large pool of blood under head..." Resident #8 was subsequently transported to the emergency room . Hospital records dated 9/23/11 indicated, "...Patient states that she was trying to pick something up on the floor, lost her balance, fell forward and struck her head...presents with a complex laceration to the face, above the right eye. She also injured her right shoulder, but denies any loss of function...reveals a complex 4-cm (4.0 centimeter) gaping laceration with bleeding from the right supraorbital area, with exposed muscle and bone...The patient's presentation is consistent with a significant fall, closed head injury, and complex facial wound with multiple contusions..." Resident #8 returned to the facility. Surveyor # requested the investigation into the fall of 9/23/11. Surveyor # received a form dated 9/23/11 titled "Marywood Incident Report." The report indicated Resident #8 was found on the floor next to the bed lying on her right side. The report also indicated Resident #8 had been seated on the bed for supper. Resident #8 reported she had leaned over to pick up something on the floor and lost her balance. The interventions put into place were: Resident #8 was to sit in a wheelchair for meals; and, 15-minute checks were to be done during meals. Resident #8 indicated she fell from the side of the bed as a result of leaning over to pick up something on the floor, which resulted in significant head injuries. There was no evidence that the facility had addressed this. A nurse's note dated 6/3/12 states, "...observed on floor @ (at) 1740 (5:40 p.m.) on 6/2/12 at supper time resident's room...laceration on rt (right) upper forehead along hairline 2 cm long & (and) 1 cm wide and deep with hair embedded in wound. Wound bleeding profusely...Transferred by ambulance to...E.R. (emergency room ). Possible Cause: slide from chair..." Surveyor # completed a review of the hospital records dated 6/2/12. The records indicated, "...was reaching...when she fell off of her bed and hit her head on some tile...has kind of a S-shaped laceration over the right frontal area...The wound was explored...It was multilayered and was down to the skull...The wound was then closed with 6-0 plain gut (absorable sutures)..." Resident #8 returned to the facility. Surveyor # requested the investigation into the fall of 6/2/12. Surveyor # received a form dated 6/2/12 titled "Marywood Center Falls Assessment upon Admission/Quarterly/Incident Form." The form indicated Resident #8 was found on the floor lying on her back and right side with her legs under the bed and her head by the night stand. The form also indicated Resident #8 was reaching for something on the floor. Interventions as listed on the report indicated staff were to continue to educate Resident #8 regarding her risk for falls when seated at the edge of her bed and to encourage Resident #8 to sit in the wheelchair for meals. Surveyor # reviewed a nursing note dated 6/8/12 which indicated, "IDT Review" (Interdisciplinary Team Review). The nursing note reiterated the interventions of reminding Resident #8 to sit in the wheelchair for meals. The nursing note also indicated, "...alert but not aware of he (sic) physical limitation esp (especially) with reaching forward, has poor trunk control and falls forward...no other suggestions re: (regarding) safety except to continue to remind resident..." The fall dated 6/2/12 mirrored the fall of 9/23/11. Despite this knowledge and the fact that Resident #8 was known to have poor trunk control, there were no new interventions put into place to prevent Resident #8 from further falls. On 7/12/12 at 11:50 a.m., Surveyor # spoke with the Director of Nursing (DON) about their falls program. The DON indicated with every fall, the facility is to investigate the fall and place new interventions to prevent further falls. The DON indicated the nurse on each wing is responsible to begin the investigation and place new interventions. The DON indicated falls are then reviewed with the IDT. Surveyor # asked the DON about the falls and interventions for Resident #8. The DON indicated she felt there was nothing more they could do to prevent Resident #8 from further falls. Example #3: Surveyor # completed a review of Resident #14's clinical record and noted the following. Resident #14 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. The MDS dated [DATE], indicated Resident #14: ~Had both long and short term memory problems with moderately impaired cognitive skills; ~Required extensive assistance of 1 staff person for bathing, dressing, toileting, and walking; ~Was frequently incontinent of urine; and, ~Could not maintain balance without staff support. Surveyor # completed a review of Resident #14's care plan dated 6/16/08. Under the problem titled "Self Care Deficit...High risk for falls," it directed staff to: ~Review the use of alarms on a weekly basis or if Resident #14 sustained a fall; ~Ensure Resident #14 was wearing rubber soled shoes; ~Ensure Resident #14's bed was at the appropriate height with the wheels locked; ~Ensure personal items are within reach; ~Assist with toileting; ~Respond to alarm immediately as is impulsive; and, ~Follow the Certified Nursing Assistant (CNA) care plan. Surveyor # completed a review of Resident #14's CNA care plan noted as "recopied" on 5/1/12. The CNA care plan directed staff to refer to the Therapy Care Plan (TCP). Surveyor # completed a review of the TCP. An entry dated 6/28/12 indicated, "...No ambulation at this time..." in both Resident #14's room and hall. Surveyor # completed a review of Resident #14's nursing notes and noted the following: ~5/21/12, "...Requires one aide assist to walk in room...Requires one aide assist to walk in corridor..." ~6/16/12, "...fall observed on floor...night shift...walking with walker and CNA to bathroom...Injury: bruising x (times) 3 to RFA (right forearm) 1 x 1 cm (1.0 centimeters by 1.0 centimeters), 1 x .5 cm (1.0 cm x 0.5 cm), 1.5 x .5 cm (1.5 cm x 0.5 cm)...purple...Possible Cause: legs have way..." ~6/18/12, "...F/U (Follow Up) Incident...scratch to left knee..." ~6/19/12, "...F/U Incident...Abrasions to bilateral knee...skin around abrasions slightly redden (sic)..." ~6/21/12, "...Bruising remains to right distal lateral forearm/wrist...abrasions remain to bilateral knees with small amount of bluish purple bruising surrounding injury to left knee..." ~6/23/12, "...noted to have change in gait, more unsteady..." ~6/28/12, "...Therapy Screen Request: Please re-evaluate...has been declining any (sic) is unable to ambulate..." On 7/12/12, Surveyor # requested the investigation into Resident #14's fall on 6/16/12. Surveyor # received a form dated 6/16/12 titled "Marywood Center Falls Assessment upon Admission/Quarterly/Incident Form." The form indicated Resident #14 was found sitting on the floor leaning against a CNA. The form also indicated a CNA was walking Resident #14 to the bathroom when Resident #14's legs gave out. According to the form, the interventions implemented were a therapy screen and staff are to use a wheelchair when taking Resident #14 to the bathroom at night. Resident #14 had injuries associated with a decline in function. While the facility put new interventions into place, there was no investigation conducted regarding the circumstances regarding Resident #14's fall. On 7/12/12 at 11:50 a.m., Surveyor # spoke with the Director of Nursing (DON) regarding Resident #14's fall. Surveyor # asked the DON what investigation was conducted regarding the circumstances of Resident #14's fall. The DON indicated that since the fall was witnessed, an investigation was not done. Surveyor # asked the DON how she knew whether or not Resident #14's care plan was being followed. The DON indicated she assumed it had been as there was no documentation indicating that staff had not followed Resident #14's care plan. Example #4: Resident #3 was admitted to the nursing home on 08/01/06 with the following, but not all inclusive, Diagnoses: [REDACTED]. The MDS assessment dated [DATE] indicated the following for Resident #3: ~Moderate difficulty hearing; ~Highly impaired vision; ~Rarely/never able to make self understood or understand others; ~Severely impaired daily decision making skills; ~Short and long term memory deficits; ~Mood indicators present nearly every day (little energy, poor appetite, and trouble concentrating); ~Required extensive staff assistance with bed mobility, transfers, ambulation, dressing, eating, hygiene, bathing, and toilet use; and, ~Had an indwelling catheter for bladder function. The significant change in status MDS assessment dated [DATE], indicated Resident #3 had the following changes: ~Mood indicators present nearly every day (little interest and sleeping too much); ~Required total staff assist for dressing and hygiene; ~No longer had an indwelling catheter; and, ~Was frequently incontinent of bladder and had no toileting program. During the initial facility tour which began on 07/09/12 at 10:30 a.m. and conducted by Surveyor # , LPN-M stated Resident #3 required 1 staff person to assist with ADLs. LPN-M also stated Resident #3 had a history of [REDACTED]. On 07/12/12 at 1:15 p.m., Surveyor # interviewed CNA-F regarding Resident #3's care needs. CNA-F stated she was familiar with Resident #3's care needs. CNA-F stated Resident #3 required 1 staff to assist with dressing and hygiene and 2-3 staff to assist with ambulation. CNA-F stated fall prevention approaches for Resident #3 was a low bed with a lipped mattress, the bed against the wall, and a clip alarm. Review of the care plan dated 05/21/12 and titled "ADL" had a goal of "No Falls/Injuries." The approaches noted "See ADL Care Plan...For Most Current Approaches To Safety..." Review of the ADL (Activities of Daily Living) care plan noted Resident #3 should have a clip alarm when in bed, the bed against the wall with a mat to the outside, a lipped mattress, and the bed in the lowest position. Review of the nurse's notes indicated Resident #3 had five falls in the past year. The falls were as follows: ~08/07/11, out of bed and onto the mat. A motion alarm was immediately added. On 08/08/11 the motion alarm was discontinued and a lipped mattress was added. ~09/06/11, partially out of bed and onto the mat. Resident #3 was found with her head, chest, and arms on the mat while her hips and legs were still in the bed. Resident #3 had her head under the baseboard heater. Resident #3 was noted to have several red and swollen areas on her face, back, and leg. There was no root cause of the fall identified and no care plan changes were implemented. ~01/02/12, out of bed and onto the mat. A clip alarm was placed and has continued. ~05/28/12, out of bed and onto the mat. There was no root cause of the fall identified and no care plan changes were implemented. ~06/29/12, Resident #3 was found with her head and shoulders off of the bed and the alarm was sounding. The bed was placed against the wall with a mat to the outside. Continued use of the low bed with a lipped mattress and a clip alarm when in bed. On 07/11/12 at 10:20 a.m., Surveyor # interviewed RN-N regarding Resident #3's fall history. RN-N confirmed no changes to the care plan following the 09/06/11 fall and also the 05/28/12 fall. RN-N stated Resident #3 was monitored for pain following the 09/06/11 fall, but no concerns identified or changes to the care plan resulted from the pain monitoring. RN-N stated Resident #3 had a toileting diary completed following the 05/28/12 fall, but no

Based on observation, interview, and record review, the facility did not ensure that 11 of 12 sampled residents reviewed for incontinence received the necessary care and treatment to maintain and/or to restore bladder function. Residents #14, #8, #3, #6, #12, #7, #9, #10, #13, #4, and #16 were all incontinent of bladder. Residents #14, #8, #3, #6, #12 and #4 also had a decline in bladder function. While the facility completed a bladder assessment and documented voiding patterns for all residents, the bladder assessments were either completed prior to the completion of the Toileting Diary, or were inaccurate. The voiding pattern collection tool used by the facility directed staff to prompt the resident every 2 hours. Accepted standards of practice indicate hourly checks are required. This makes it impossible for the practitioner to determine an individualized toileting schedule to restore and/or improve bladder function. This is evidenced by: According to the American Medical Directors Association (AMDA) Clinical Practice Guideline for Urinary Incontinence, "...urinary incontinence may be associated with negative outcomes, including falls and numerous psychological effects..." The Clinical Practice Guidelines indicate that, "...Urinary incontinence...can often be managed and modified, and in some cases reversed, even in frail older adults and individuals with dementia..." The Clinical Practice Guidelines indicated, "...Urinary incontinence is identified by direct observation...Document any signs and symptoms of urinary incontinence in the patient's medical record. Documentation should include details such as the related circumstances...the frequency of incontinence episodes, the time of day or night...A bladder record or voiding diary may help to characterize the patient's incontinence..." According to WOCN (Wound Ostomy and Continence Nurses Society), reversible causes of incontinence include: [MEDICAL CONDITION], infection, medications, bladder irritants, vaginitis, pharmaceuticals, polyuria, retention, constipation, environmental barriers, and physical limitations. Assessment of these factors is needed to determine a plan of care that could include bladder retraining, prompted voiding, and individualized scheduled toileting. This individualized schedule should be used rather than the facility's incontinence management toileting schedule currently being used for all cognitively impaired and incontinent residents who are unable to communicate with staff that they have to go to the bathroom. The outcome of incontinence services can be determined by recognition of the problem, nursing assessment, and referral for diagnostic evaluation and treatment. All residents with incontinence should be evaluated for causative factors, as treatment is dependent on these factors. However, before successful treatments can be initiated, the problem needs to be identified. The identifying of the type of incontinence is essential in a multidisciplinary collaboration for both the assessment of the individual and the treatment of [REDACTED]. The goal should be to restore as much normal bladder function as possible for each resident by decreasing or eliminating the incontinent episodes. This promotes dignity, reduces risk factors for skin breakdown, and reduces the incidents of urinary tract infections. Example #1: Resident #14 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Resident #14's Minimum (MDS) data set [DATE], indicated Resident #14: ~ Had both long and short term memory problems with moderately impaired cognitive skills; ~ Required extensive assistance of 1 staff person for bathing, dressing, toileting, and walking; and ~ Was frequently incontinent of bladder. Surveyor # also completed a review of Resident #14's MDS dated [DATE]. Resident #14's care needs were the same as that as noted in the MDS dated [DATE]. The MDS however indicated that Resident #14 at that time was occasionally incontinent of urine. Resident #14 went from being mostly continent of urine to frequently incontinent of urine. This was a significant decline in Resident #14's bladder function. Surveyor # completed a review of Resident #14's care plan 6/16/08. Under the problem titled, "Self Care Deficit..." it directed staff to assist Resident #14 with toileting and to follow Resident #14's toileting schedule. Surveyor # completed a review of Resident #14's Certified Nursing Assistant (CNA) care plan noted as "recopied" on 5/1/12. The care plan directed staff to offer to assist Resident #14 to the bathroom before and after meals and activities, at bed time, and twice during the night. Surveyor # completed a review of a form title "Bladder Assessment." The form was incomplete and not dated. It indicated Resident #14 had functional incontinence. Surveyor # completed a review of a corresponding Toileting Diary dated 4/16/12 through 4/18/12. The tool directed staff to check and/or assist Resident #14 to the bathroom every 2 hours on the even hour. The facility practice of prompting the resident every 2 hours on the even hour would make it impossible to determine an appropriate individualized toileting schedule to improve Resident #14's bladder function. On 7/12/12 at 11:50 a.m., Surveyor # spoke with the Director of Nursing (DON). The DON indicated upon admission, the bladder assessment was done before the completion of the Toileting Diary. (The Bladder Assessment asks the writer to analyze information gathered from the Toileting Diary. The Bladder Assessment would be inaccurate if completed before the voiding patterns are collected.) Surveyor # also asked the DON about the scheduled times as noted on the Toileting Diary to assist residents every 2 hours. The DON indicated the Toileting Diary probably should be done sooner than every 2 hours. Example #2: Resident #8 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Resident #8's Minimum (MDS) data set [DATE], indicated Resident #8: ~ Cognition was moderately impaired; ~ Required extensive assistance of 1 staff person for bathing, dressing, toileting, transfers, bed mobility; and, ~ Was occasionally incontinent of bladder. Surveyor # completed a review of Resident #8's MDS dated [DATE]. This MDS indicated Resident #8 was always continent of urine. Resident #8 went from having total bladder continence to occasionally incontinent of bladder. This was a decline in bladder function. Surveyor # completed a review of Resident #8's care plan dated. There was no problem identifying bladder incontinence. Under the problem dated 5/1/08 titled "Self Care deficit..." it directed staff to assist Resident #8 to the bathroom according to the Certified Nursing Assistant (CNA) care plan. Surveyor # completed a review of Resident #8's CNA care plan noted as "Recopied" on 1/25/12. The care plan directed staff to assist Resident #8 to the bathroom before and after meals and activities as well as at night during rounds. Surveyor # requested the most current bladder assessment and Toileting Diary for Resident #8. Surveyor # received a bladder assessment dated [DATE] and a Toileting Diary dated 2/6/12 through 2/18/12. There was no bladder assessment or Toileting Diary completed when Resident #8 exhibited a decline in bladder function. On 7/12/12 at 9:15 a.m., Surveyor # spoke with CNA-G about when Resident #8 was assisted to the bathroom. CNA-G indicated Resident #8 will put on the call light when she needs to use the bathroom. CNA-G also indicated Resident #8 was incontinent about 50% of the time. On 7/12/12 at 11:50 a.m., Surveyor # spoke with the Director of Nursing (DON). The DON indicated that on admission, the bladder assessment was done before the completion of the Toileting Diary. The DON indicated that the quarterly bladder assessment were either done before or after the bladder assessment. Surveyor # also asked the DON about the scheduled times as noted on the Toileting Diary to assist residents every 2 hours. The DON indicated that the Toileting Diary probably should be done sooner than every 2 hours. Example #3: Resident #3 was admitted to the nursing home on 08/01/06 with the following, but not all inclusive, Diagnoses: [REDACTED]. The facility completed a quarterly MDS (Minimum Data Set) assessment for Resident #3 on 03/22/12 and noted the following data: ~Moderate difficulty hearing; ~Highly impaired vision; ~Rarely/never able to make self understood or understand others; ~Severely impaired daily decision making skills; ~Short and long term memory deficits; ~Mood indicators present nearly every day (little energy, poor appetite, and trouble concentrating); ~Required extensive staff assistance with bed mobility, transfers, ambulation, dressing, eating, hygiene, bathing, and toilet use; and, ~Had an indwelling catheter for bladder function. The facility completed a significant change in status MDS for Resident #3 on 05/07/12 with the following changes noted: ~Mood indicators present nearly every day (little interest and sleeping too much); ~Required total staff assist for dressing and hygiene; ~No longer had an indwelling catheter; and, ~Was frequently incontinent of bladder and had no toileting program. The urinary incontinence CAA (Care Area Assessment) summary completed on 05/10/12 for Resident #3 noted, "...resident had a Foley catheter and was incontinent of urine prior, retention is being monitored but doesn't to appear to be the problem any more...total urinary incontinence due to severe dementia..." Review of the ADL (Activities of Daily Living) care plan noted Resident #3 should be toileted every 2-3 hours, before bed, and during every night shift round. The facility completed a bladder assessment for Resident #3 dated 10/12/11 and noted use of Foley catheter for a [DIAGNOSES REDACTED]. The facility completed a 3-day toileting diary beginning on 12/23/11 and ending on 12/25/11 for Resident #3. The diary recorded bladder control every 2 hours for a 24-hour period. The toileting diary indicated continence and use of Foley catheter. The facility completed a bladder assessment dated [DATE] and noted use of Foley catheter for bladder function. The facility completed 2 three day toileting diaries. The first diary began on 03/16/12 and ended on 03/18/12. The diary indicated Resident #3 was continent and used a Foley catheter. The second diary began on 03/21/12 and ended on 03/23/12. The diary indicated Resident #3 was continent and used a Foley catheter. The facility completed a bladder assessment dated [DATE] for Resident #3 and noted continued use of Foley catheter with no potential for improvement. Review of the nurse's notes indicated Resident #3 had the indwelling Foley catheter removed on 04/06/12 and was both continent and incontinent of urine. The facility completed 3 3-day toileting diaries following the removal of Resident #3's Foley catheter; however never used that data collected to formulate any toilet plan and did not complete a bladder assessment identifying possible reversible causes of incontinence. The first toileting diary began on 04/17/12 and ended on 04/19/12. The diary was incomplete for 2 out of the 3 days; however Resident #3 did have periods of continence during waking hours for up to 8 hours. The second toileting diary began on 05/08/12 and ended on 05/10/12. The diary indicated Resident #3 again had long periods of bladder control (12-20 hours). The third toileting diary began on 05/31/12 and ended on 06/02/12. The diary indicated Resident #3 again had long periods of bladder control (6-18 hours). During the initial facility tour which began on 07/09/12 at 10:30 a.m. and conducted by Surveyor # , LPN-M (Licensed Practical Nurse) stated Resident #3 was incontinent of bladder and bowel and required 1 staff person to assist with ADLs. On 07/12/12 at 1:15 p.m., Surveyor # interviewed CNA-F (Certified Nursing Assistant) regarding Resident #3's toileting habits. CNA-F stated she was familiar with Resident #3's care needs. CNA- F stated Resident #3 was "absolutely incontinent of bladder" since the removal of the Foley catheter. CNA-F stated Resident #3 was toileted every 2 hours and required 1 staff to assist with dressing and hygiene and 2-3 staff to assist with ambulation. Example #4: Resident #6 was admitted to the facility on [DATE] and readmitted following brief hospital stays on 04/14/12 and 04/28/12. Resident #6 had the following, but not all inclusive, Diagnoses: [REDACTED]. The facility completed an admission MDS assessment for Resident #6 on 02/17/12, and noted the following data: ~Sometimes able to make self understood; ~Able to understand others; ~No cognitive impairments; ~No mood indicators; ~Required extensive assist with bed mobility, transfers, dressing, hygiene, bathing, and toilet use; ~Was always continent of bladder; and, ~Was on a trial toileting program and with completely dry response to program. The urinary incontinence CAA completed with the above comprehensive assessment noted Resident #6 was at risk for incontinence due to her immobility and need for staff assistance with toilet use. The facility inappropriately completed another admission MDS assessment for Resident #6 on 04/23/12 with the following changes: ~Mood indicator (trouble concentrating) present half or more of the days; and, ~Frequently incontinent of bladder, but still on a toilet program. This is a decline in bladder control. The urinary incontinence CAA completed with this comprehensive assessment noted Resident #6 to have mixed incontinence related to her loose stools and need for staff assistance with toilet use. The CAA also stated, "Resident has limited mobility and requires a transfer assistance at all times, she is confined due to wound vac and pivot transfer, and has loose stools that are causing her incontinence of both bowel and bladder..." Review of the ADL care plan noted Resident #6 had a discontinued toilet program of pivot transfer with assist of 2 staff onto the commode. There was no other updated toilet program. Review of the care plan titled "Alteration in Skin Intetrity" dated 04/13/12, noted Resident #6 should be toileted every 2-3 hours and as needed. The facility completed a 3-day toileting diary beginning on 02/09/12 and ending on 02/11/12 for Resident #6. The diary recorded bladder control every 2 hours for a 24 hour period. The diary indicated Resident #6 was always continent of bladder. The facility completed a bladder assessment and noted Resident #6 had no current or prior problems with bladder control. The assessment also noted Resident #6 had occasional bladder incontinence which started about a month ago when she leaked urine on the way to the bathroom. The assessment noted unknown bladder dysfunction with potential for improvement. The facility conducted another 3-day toileting diary beginning on 03/10/12 and ending on 03/12/12 for Resident #6. The diary was incomplete for day 2 and noted 2 episodes of incontinence on day 3. The facility completed a bladder assessment on 03/09/12, and noted Resident #6 to have urge and stress incontinence with potential of improvement. The bladder assessment was completed prior to the toileting diary, thus no patterns of voiding could be reviewed as part of the assessment. The facility conducted another 3-day toileting diary beginning on 04/15/12 and ending on 04/17/12 for Resident #6. The first day of the diary noted 9 out of 12 notations of bladder incontinence. The second day of the diary noted 5 out of 7 notations of bladder incontinence. On the third day of the diary, there were 10 out of 12 notations of bladder incontinence; all of the incontinence episodes were during the waking hours. The facility completed another bladder assessment on 04/14/12 but did not include any data from the diary. The bladder assessment was completed prior to the toileting diary, thus no patterns of voiding could be reviewed as part of the assessment. In addition, the bladder assessment was incomplete and did not identify the type of incontinence, the potential for improvement, or whether to proceed to care plan. The facility conducted a fourth 3-day toileting diary beginning on 04/29/12 and ending on presumably 05/01/12. The third day of the diary had no date. The diary noted Resident #6 to be continent of bladder except for 8:00 a.m. daily and 8:00 p.m. on 2 out of the 3 days. The facility completed a fourth bladder assessment on 04/28/12, but again did not include any data from the diary as it was conducted prior to the toileting diary. The bladder assessment noted Resident #6 to have mixed incontinence with potential for improvement and proceeding to care plan. During the initial facility tour which began on 07/09/12 at 10:30 a.m. and conducted by Surveyor # , RN-N (Registered Nurse) stated Resident #6 was continent of bladder and bowel and requires 1 staff person to assist with ADLs. RN-N stated Resident #6 was interviewable. On 07/12/12 at 12:50 p.m., Surveyor # interviewed CNA-Q regarding care provided to Resident #6. CNA-Q stated she had cared for Resident #6 since her admission and had worked for the nursing home for approximately 7 years. CNA-Q stated Resident #6 used the call light to request help with toilet use. CNA-Q stated she assisted Resident #6 to the toilet approximately 5-6 times per day shift. CNA-Q stated Resident #6 was incontinent approximately 2 times per day shift. CNA-Q stated she learns the habits of her residents and then can prompt them to toilet prior to that time to aide them in bladder control. On 07/11/12 at 8:30 a.m., Surveyor # interviewed Resident #6. During the interview, the Surveyor asked Resident #6 about call light response time and Resident #6 stated staff was busy, but would get to her when they could. The Surveyor asked if Resident #6 every soiled herself while she waited for staff to help her to the toilet and she stated, "Oh yes, all of the time." Resident #6 stated she urinates frequently in the early part of the day because of the "water pill" she takes and urinates less as the day goes on. Example #5: Resident #12 was admitted to the nursing home on 01/31/06 and readmitted on [DATE] with the following, but not all inclusive, Diagnoses: [REDACTED]. The facility completed an annual MDS assessment for Resident #12 on 0930/11 with the following data noted: ~Minimal difficulty with hearing and vision; ~Able to make self understood and understand others; ~Impaired cognitive function; ~Mood indicator present nearly every day (trouble falling or staying asleep, or sleeping too much); ~Required extensive staff assist with bed mobility, transfers, dressing, hygiene, bathing, and toilet use; and, ~Was frequently incontinent of bladder; however was on a toileting program. The urinary incontinence CAA completed on 10/04/11 noted Resident #12 had functional incontinence following the stroke and [MEDICAL CONDITION]. The CAA also noted Resident #12 had a "significant HX (history) of UTI (Urinary Tract Infection)." The facility completed a significant change in status MDS assessment for Resident #12 on 04/05/12 with the following changes noted: ~Slight decline in cognitive function; ~Mood indicator present nearly every day (feeling tired or having little energy); ~Required total staff assist with transfers and toilet use; and, ~Was always incontinent of bladder, but still on a toileting program. The facility completed a quarterly MDS assessment for Resident #12 on 07/02/12 with the following changes noted: ~Further cognitive function decline; ~Mood indicator present nearly every day (poor appetite); and, ~Was always incontinent of bladder and no longer on a toileting program. Review of the ADL care plan noted Resident #12 preferred to be checked and changed for urine incontinence. The facility completed a 3-day toileting diary for Resident #12 beginning on 09/23/11 and ending on 09/25/11. The diary recorded bladder control every 2 hours for a 24-hour period. Resident #12 had 6 notations of bladder control during the 3-day diary. Resident #12 had 15 refusals to toilet during the 3-day diary. The facility completed a bladder assessment for Resident #12 on 09/28/11 noting a progressive decline in control. The bladder assessment identified functional incontinence with no potential for improvement. The facility completed another 3-day toileting diary for Resident #12 beginning on 12/09/11 and ending on 12/11/11. The diary again noted few continence episodes per day and multiple refusals to toilet. The facility completed a bladder assessment for Resident #12 on 12/16/11 and noted mixed and functional incontinence with no potential for improvement. The facility completed another 3-day toileting diary for Resident #12 beginning on 03/02/12 and ending on 03/04/12. The diary was incomplete for all 3 days. The facility completed another 3-day toileting diary for Resident #12 beginning on 03/28/12 and ending on 03/30/12. The facility completed a bladder assessment for Resident #12 on 03/14/12 and noted urge, stress, mixed, and functional incontinence with no potential for improvement and history of refusals to toilet. During the initial facility tour which began on 07/09/12 at 10:30 a.m. and conducted by Surveyor # , LPN-M (Licensed Practical Nurse) stated Resident #12 was incontinent of bladder and bowel and was not on any toileting program. LPN-M also stated Resident #12 used a Hoyer mechanical lift for all transfers. LPN-M stated Resident #12 was interviewable. On 07/11/12 at 6:10 p.m., Surveyor # interviewed CNA-O regarding Resident #12's care. CNA-O stated she was familiar with Resident #12. CNA-O stated Resident #12 was incontinent of bladder and was no longer placed on the toilet because of the use of the Hoyer mechanical lift for all transfers. CNA-O stated Resident #12 will call for help after she has urinated in her brief and staff will assist her with incontinence care. On 07/12/12 at 1:15 p.m., Surveyor # interviewed CNA-F regarding Resident #12's toileting habits. CNA-F stated Resident #12 was not toileted and did not use the bedpan or the commode. CNA-F stated Resident #12 would let staff know when she was wet and staff would provide incontinence care. CNA-F stated Resident #12 preferred to stay in bed and tolerates the Hoyer mechanical lift for all transfers because she has to. On 07/10/12 at 10:10 a.m., Surveyor # observed CNA-R and CNA-S assist Resident #12 with hygiene and dressing. Resident #12 had been incontinent of urine. CNA-R provided Resident #12 with proper frontal and rear incontinence care; however she did not apply barrier cream to prevent pressure ulcers or IAD (Incontinence Associated [MEDICAL CONDITION]). Example #6: Resident #7 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Resident #7's Minimum Data Set ((MDS) dated [DATE], indicated Resident #7: ~ Cognition was moderately impaired; ~ Required extensive assistance of 1 staff person for transfers, walking, bathing, dressing, and toileting; and, ~ Was frequently incontinent of urine. Resident #7's care plan was dated 3/13/12. It did not contain a specific problem for incontinence. Under the problem titled "Alteration in Health Maintenance," it indicated Resident #7 had urge incontinence. Under the problem titled "Self Care Deficit," it directed staff to monitor for changes in continence and to refer to the Certified Nursing Assistant (CNA) care plan. Surveyor # completed a review of Resident #7's CNA care plan. An approach dated 3/12/12, directed staff to assist Resident #7 to the bathroom before and after meals, and before going to bed at night, as well as to offer toileting during every round time during the night. Surveyor # completed a review of a bladder assessment dated [DATE]. It indicated Resident #7 had both urge and functional incontinence. It also indicated Resident #7 had no potential for improvement. Surveyor # completed a review of Resident #7's Toileting Diary dated 5/18/12 through 5/20/12. The Toileting Diary for 5/19/12 and 5/20/12 were incomplete. The diary also directed staff to check and/or toilet Resident #7 every 2 hours on the even hour. The facility practice of completing the Toileting Diary every 2 hours on the even hour would make it impossible to determine an appropriate individualized toileting schedule to improve Resident #7's bladder function. Resident #7 had not been afforded the opportunity to improve bladder function. To determine Resident #7 had no potential for improvement would have been inaccurate. On 7/12/12 at 9:15 a.m., Surveyor # spoke with CNA-G. CNA-G indicated she assisted Resident #7 with toileting when Resident #7 would put on her light. CNA-G indicated Resident #7 was incontinent quite a lot. CNA-G indicated when she answered Resident #7's call light, Resident #7 was many times already incontinent. On 7/12/12 at 11:50 a.m., Surveyor # spoke with the Director of Nursing (DON). The DON indicated upon admission the bladder assessment was done before the completion of the Toileting Diary. The DON indicated the quarterly bladder assessment were either done before or after the bladder assessment. Surveyor # also asked the DON about the scheduled times as noted on the Toileting Diary to assist residents every 2 hours. The DON indicated the Toileting Diary probably should be done sooner than every 2 hours. Example #7: Surveyor # completed a review of Resident #9's clinical record and noted the following. Resident #9 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Resident #9's Minimum Data Set ((MDS) dated [DATE], indicated Resident #9: ~ Had a severe cognitive impairment; ~ Required extensive assistance of 1 to 2 staff persons for transfers, bathing, dressing, and toileting; ~ Did not walk; and, ~ Had frequent bladder incontinence. Surveyor # completed a review of Resident #9's care plan dated 6/12/12. Under the problem titled "Alteration in Bowel & (and) Bladder Incontinence" and "Self Care Deficit," it directed staff to record the number of incontinent episodes and to assist Resident #9 with toileting as needed. Surveyor # completed a review of Resident #9's Certified Nursing Assistant (CNA) care noted as "Recopied" on 4/23/12. The CNA care plan directs staff to assist Resident #9 with toileting every 2 to 3 hours. Surveyor # completed a review of form titled "Bladder Assessment" dated 6/1/12. The form indicated Resident #9 had mixed incontinence. The Toileting Diary associated with the bladder assessment was dated 6/2/12 through 6/4/12. The diary directed staff to check and/or assist Resident #9 with toileting every 2 hours on the even hour. The facility practice of completing a bladder assessment prior to the completion of the Toileting Diary as well as completing a Toileting Diary every 2 hours on the even hour would make it impossible for the practitioner to determine an individualized toileting schedule. On 7/11/12 at 10:00 a.m., Surveyor # observed CNA-F and CNA-G assist Resident #9 into bed. There was no toileting offered. On 7/11/12 at 4:46 p.m., Surveyor # observed CNA-I and CNA-DJ adjust Resident #9 in the wheelchair. There was no toileting offered. On 7/11/12 at 6:35 p.m., Surveyor # observed CNA-K and CNA-DJ assist Resident #9 with cares. There was no toileting offered. On 7/12/12 at 9:15 a.m., Surveyor # spoke with CNA-G about Resident #9's toileting schedule. CNA-G indicated that because Resident #9 was a Hoyer lift, they could not get her into the bathroom. CNA-G indicated they would just change Resident #9 in bed. Surveyor # asked about a commode. CNA-G indicated they had not thought of that. On 7/12/12 at 11:50 a.m., Surveyor # spoke with the Director of Nursing (DON). The DON indicated upon admission the bladder assessment was done before the completion of the Toileting Diary. The DON indicated the quarterly bladder assessment was either done before or after the bladder assessment. Surveyor # also asked the DON about the scheduled times as noted on the Toileting Diary to assist residents every 2 hours. The DON indicated the Toileting Diary probably should be done sooner than every 2 hours. Example #8: Surveyor # completed a review of Resident #10's clinical record and noted the following. Resident #10 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Resident #10's Minimum Date Set ((MDS) dated [DATE], indicated Resident #10: ~ Had both short and long-term memory problems; ~ Required extensive assistance of 1 staff person for bathing, dressing, grooming, toileting; ~ Did not walk; and, ~ Was frequently incontinent of bladder. Surveyor # completed a review of Resident #10's care plan. Under the problem dated 2/17/09 titled "Self Care Deficit..." it directed staff to assist Resident #10 to the bathroom according to the schedule and to follow the Certified Nursing Assistant (CNA) care plan. Surveyor # completed a review of Resident #10's CNA care plan noted as "Recopied" on 4/18/12. It directed staff to assist Resident #10 to the bathroom every 2 to 3 hours, and to check and change during the night. Surveyor # completed a review of a form titled "Bladder Assessment." The assessment was undated. The assessment indicated Resident #10 had functional incontinence and had no potential for improvement. Surveyor # completed a review of a form titled "Toileting Diary" dated 5/11/12 through 5/13/12. The form directed staff to check and/or assist Resident #10 with toileting every 2 hours on the even hour. The diary was not complete. The diary also indicated long periods of time when Resident #10 had not been incontinent. The facility practice of completing the Toileting Diary every 2 hours on the even hour would make it impossible to determine an appropriate individualized toileting schedule to improve Resident #10's bladder function. Additionally, determining Resident #10 had no potential for improvement was inaccurate based on the facility practice of completing the Toileting Diary, as well as information the facility was able to capture from Resident #10's existing Toileting Diary. On 7/12/12 at 9:15 a.m., Surveyor # spoke with CNA-G about Resident #10. CNA-G indicated Resident #10 was incontinent about 75% of the time. On 7/12/12 at 11:50 a.m., Surveyor # spoke with the Director of Nursing (DON). The DON indicated upon admission the bladder assessment was done before the completion of the Toileting Diary. The DON indicated the quarterly bladder assessment was either done before or after the bladder assessment. Surveyor # also asked the DON about the scheduled times as noted on the Toileting Diary to assist residents every 2 hours. The DON indicated the Toileting Diary probably should be done sooner than every 2 hours. Example #9: Resi

Based on interview and record review, the facility did not ensure that 2 of 16 sampled residents' physician was consulted timely with a significant change in condition. On 5/24/12, Resident #9 began to complain of right knee pain. The physician was updated on 5/25/12. From 5/25/12 until 5/29/12, Resident #9 continued to have significant pain in her right leg and knee. Despite the increased pain and suffering, the physician was not consulted until 5/29/12. This was 4 days after the original physician contact. On 5/29/12, the physician ordered an x-ray. The x-ray report indicated that Resident #9 had a right femur fracture. Resident #3 sustained an injury of unknown origin to her left hand on 02/25/12 (Saturday) at 7:20 p.m. The injury was described as red, swollen, and painful knuckles of the left hand. The physician was consulted via facsimile on Sunday 02/26/12 at 9:00 p.m. There was no evidence of physician acknowledgement of the injury until 03/02/12. This is evidenced by the following; Example #1: Resident #9 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] indicated Resident #9: ~Had a severe cognitive impairment; ~Required extensive assistance of 1 to 2 staff persons for transfers, bathing, dressing, toileting; and, ~Did not walk. Resident #9's MDS dated [DATE], indicated Resident #9 was able to ambulate with extensive assistance of 2 staff persons. Surveyor # completed a review of Resident #9's nursing notes and noted the following entries: ~5/24/12, "...c/o (complains of) pain to right knee with movement, right knee appears slightly swollen...ice applied to right knee with little improvement...Dr. (doctor)....updated...rated pain to right knee a 10/10 (10 out of 10) with rest, ice applied...prn (as needed) Tylenol and [MEDICATION NAME] given..." ~5/26/12, "...complained of pain to right knee...noted with whimpering when writer approached her and with facial grimacing, slight swelling to knee...has had an increase in pain. Unable to verbalize quality, severity or location of pain...Facial grimacing present with making whimpering noises and labored breathing..." ~5/27/12, "...Taut skin with [MEDICAL CONDITION] to right knee, crying of pain to right knee/leg..." ~5/28/12, "...Right knee remains swollen and tender to touch..." On 5/29/12, Resident #9's physician was contacted and ordered an x-ray. The x-ray report dated 5/30/12, indicated Resident #9 had an acute [MEDICAL CONDITION] femur. Resident #9 was subsequently transported to the hospital. Hospital records dated 5/30/12, described Resident #9's right knee as, "...[DIAGNOSES REDACTED]tous, swollen, hot, and painful..." On 7/17/12 at 12:00 p.m., Surveyor # asked RN-U when a physician should be notified if there is a change in condition related to pain. RN-U stated a full assessment would be completed and pain medication would be given. After about an hour, if the pain is unrelieved, then call the physician. When asked if waiting 4 to 5 days would be acceptable, RN-U stated you shouldn't wait that long. On 7/17/12 at 12:10 p.m., Surveyor asked LPN-V when she would notify the physician. LPN-V indicated if pain medication is not effective, she would notify the physician within an hour. Example #2: Resident #3 was admitted to the nursing home on 08/01/06 and readmitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE], indicated Resident #3: ~Had moderate difficulty hearing; ~Had highly impaired vision; ~Was rarely/never able to make self understood or understand others; ~Had severely impaired daily decision making skills; ~Had short and long term memory deficits; ~Mood indicators present nearly every day (little energy, poor appetite, and trouble concentrating); ~Required extensive staff assistance with bed mobility, transfers, ambulation, dressing, eating, hygiene, bathing, and toilet use; and, ~Had an indwelling catheter for bladder function. The facility completed a significant change in status MDS on 5/7/12, which indicated Resident #3 had the following changes noted: ~Mood indicators present nearly every day (little interest and sleeping too much); ~Required total staff assist for dressing and hygiene; ~No longer had an indwelling catheter; and, ~Was frequently incontinent of bladder and had no toileting program. During the initial facility tour which began on 07/09/12 at 10:30 a.m. and conducted by Surveyor # , LPN-M (Licensed Practical Nurse) stated Resident #3 had a decline due to failure to thrive and was now under Hospice care. LPN-M stated Resident #3 was incontinent of bladder and bowel and required 1 staff person to assist with ADLs. On 07/12/12 at 1:15 p.m., Surveyor # interviewed CNA-F (Certified Nursing Assistant) regarding Resident #3's care needs. CNA-F stated she was familiar with Resident #3's care needs. CNA-F stated Resident #3 was toileted every 2 hours and required 1 staff to assist with dressing and hygiene, and 2-3 staff to assist with ambulation. During the 4 days of survey, Surveyor # observed Resident #3 numerous times up in a high back wheelchair that had a contour back with bilateral side trunk supports and a head support. In addition, the wheelchair had a contoured foot and calf support in place. Resident #3 often had her eyes closed while up in the wheelchair and had little interaction with the environment around her or the staff who were assisting her during meals. On 07/09/12, Surveyor # completed a comprehensive record review and noted an injury of unknown origin on 02/25/12 (Saturday) involving Resident #3's left hand. On 07/09/12, Surveyor # requested the investigation into the injury of Resident #3's left hand from the DON (Director of Nurses). The DON stated there was no investigation. The DON referred Surveyor # to RN-N (Registered Nurse) for discussion. On 07/11/12 at 10:20 a.m., Surveyor # interviewed RN-N regarding Resident #3's injury of unknown origin that occurred on 02/25/12. RN-N stated no investigation was completed. RN-N stated the nurse who first was notified of the injury probably suspected an acute arthritic problem such as gout. The Surveyor asked if the documentation supported the arthritic suspicion and RN-N stated it did not. RN-N stated Resident #3 was referred to the primary physician who examined Resident #3 on 03/02/12 (6 days later). The Surveyor asked if any lab data or X-rays were obtained to support the arthritic suspicion and RN-N stated no lab data or X-rays were obtained. Review of the nurse's notes dated 02/26/12 at 12:13 a.m. read, "@1920 (7:20 p.m.) CNA came to have me check resident's left hand, as she was resistive to having hand pulled through sweat shirt to have shirt taken off; noted proximal knuckles of left hand being warm, red and slightly swollen and tender to touch. Crying when hand examined; Finger stiff on left hand...We will monitor for 2 days and update MD." The nurse's notes did not reflect the physician being updated until the next day, 02/27/12 (Sunday), at 9:00 p.m. via facsimile. There was no evidence of physician acknowledgement of the injury until 03/02/12. The nurse's notes did not reflect an update to the DON or NHA either.

Based on observation, interview, and record review, the facility did not ensure that 1 of 16 sampled residents received the appropriate care and treatment to promote comfort during transfers and positioning. Resident #9 sustained an unexplained fracture to her right femur which was not surgically repaired. Observations of transfers and positioning revealed staff not supporting the fractured leg during transfers and positioning and that Resident #9 had insufficient pain control. This caused Resident #9 significant distress. This is evidenced by: Surveyor # completed a review of Resident #9's clinical record and noted the following; Resident #9 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #9: ~Had a severe cognitive impairment; ~Required extensive assistance of 1 to 2 staff persons for transfers, bathing, dressing, toileting; and, ~Did not walk. On 7/10/12 at 11:30 a.m., during the initial tour, LPN-T (Licensed Practical Nurse) indicated Resident #9 had a leg immobilizer to the right leg. There was no direction to staff regarding the care of the immobilizer for Resident #9's fractured right leg on either care plan. Resident #9's care plan dated 6/12/12, contained a problem related to the fractured right femur. The care plan directs staff to assist Resident #9 with transfers and positioning by splinting and supporting the fractured leg. The care plan also directs staff that if Resident #9 is not tolerating transfers and turning, to not move Resident #9 and seek direction from nursing. Surveyor # reviewed Resident #9's Certified Nursing Assistant (CNA) care plan. The only direction to the CNAs regarding transfers and positioning was to place a pillow between Resident #9's legs when turning her. On 7/11/12 at 10:00 a.m., Surveyor # observed CNA-F and CNA-G assist Resident #9 into bed via a Hoyer lift. CNA-F and CNA-G placed a sling behind Resident #9's back. Both CNA-F and CNA-G then brought the straps of the slings under and around both of Resident #9's upper thighs. As Resident #9's right leg was lifted, Resident #9 cried out, "Ouch! Ouch!" CNA-G then obtained the Hoyer lift controls and raised Resident #9 out of the wheelchair as CNA-F attempted to maneuver Resident #9 around to place her in bed. Surveyor # noted Resident #9's feet were on the wrong side of the bar of the Hoyer lift to allow staff to place her in bed. CNA-F attempted to move Resident #9's feet to the opposite side of the bar, however Resident #9 began to cry out with pain. CNA-F then attempted to place the Hoyer lift in a different direction. This also was not successful and CNA-F placed the Hoyer lift back in the original position. CNA-F then asked CNA-G to pull Resident #9 backwards in the sling at which point CNA-F brought Resident #9's feet to the opposite side of the bar of the Hoyer lift which allowed Resident #9 to be lowered into bed. During this time, Surveyor # noted that Resident #9 cried out several times, "Ouch!" or was grimacing. Both CNA-F and CNA-G turned Resident #9 from side to side to remove the sling and then completed incontinence cares. Resident #9's leg was not supported and neither staff sought assistance from a licensed nurse when Resident #9 displayed verbal and nonverbal indicators of pain. During no time during the transfer into bed or when turning from side to side did either CNA-F or CNA-G support Resident #9's fractured leg. On 7/11/12 at 6:35 p.m., Surveyor # observed CNA-DJ and CNA-K assist Resident #9 into bed via a Hoyer lift. During this process, Surveyor # noted Resident #9 began crying. Neither CNA-DJ nor CNA-K supported Resident #9's fractured leg during the transfer. Both CNA-DJ and CNA-K then assisted Resident #9 into bed and removed the Hoyer sling as well as Resident #9's pants by turning Resident #9 from side to side. During the process neither CNA-DJ or CNA-K supported Resident #9's fractured leg. There was also no pillow placed between Resident #9's legs while positioning from side to side. Surveyor # noted that Resident #9 continued to cry during most of the transfer, turning, and positioning. Again, the leg was not supported and nursing staff were not informed. On 7/12/12 at 11:50 a.m., Surveyor # spoke with the Director of Nursing (DON) and relayed the observation of Resident #9's transfers and positioning. The DON stated the fashion in which Resident #9 was transferred and positioned was "not OK." The DON indicated staff should have supported Resident #9's leg as well as utilize pillows during turning and repositioning.

Based on observation, interview, and record review, the facility did not ensure that 4 of 10 sampled and supplemental sampled residents reviewed for weight loss maintained acceptable parameters of nutritional status. Resident #6 had a severe 14 pound or 11.5% weight loss in 3 months. Speech Therapy determined Resident #6 required assistance with meals and outlined specific feeding guidelines. ~Observations found that staff were not assisting as directed by Speech Therapy which impacted Resident #6's food intake. ~The Certified Dietary Manager (CDM) used inaccurate nutritional information during Resident #6's nutritional assessment and did not follow accepted standards of practice in calculating percentage of weight loss. ~The CDM indicated that high calorie/fortified foods were discontinued due to Resident #6's poor intake and "monetary" reasons. Resident #21 required total assistance with eating. Over the past 6 months, Resident #21 has had a 23 pound or 13.88% severe weight loss. This severe weight loss was not identified and addressed by the facility staff. Observations of meal time revealed that Resident #21 did not receive the assistance as required to eat. Resident #20 required total assistance with eating. Since 5/5/11, Resident #20 has had a 12 pound or 7.89% weight loss in less than 3 months. The severe weight loss was not identified or addressed by the facility staff. Observations of meal time revealed that Resident #20 did not receive the assistance to eat as required. Resident #22 required assistance with eating. Since admission on 7/7/11 until 7/21/11, a total of 14 days, Resident #22 has lost 5.5 pounds. Observations of meal time revealed that Resident #22 did not receive that assistance to eat as required. This is evidenced by: Example #1: Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with the following, but not all inclusive, Diagnoses: [REDACTED]. The annual MDS (Minimum Data Set) assessment dated [DATE] indicated that Resident #6: *Was able to make self understood and understand others; *Had mood indicators present (problems sleeping, having little energy, and poor appetite); *Required supervision for eating; *Had no disease or condition that may result in life expectancy of less than 6 months; *Weighed 122#; *Had no weight loss; *Was on a mechanically altered diet. The quarterly MDS assessment, dated 05/03/11 indicated that Resident #6: *Was able to make self understood and usually able to understand others; *Had no indicators of depression; *Required only set up for eating; *Had no disease or condition that may result in life expectancy of less than 6 months; *Weighed 118#; *Had no weight loss; *Was on a mechanically altered diet. Review of Resident #6's care plan titled "Alteration in nutrition has Potential for weight loss" dated 12/20/07, had an undated entry that read "fractured teeth/missing teeth." The goal was last updated on 02/14/11 and read: "Will ingest and retain 50% of meal, understand need to consume this amount. Will maintain weight, no further weight loss and have no s/s (signs or symptoms) of dehydration. Will not have complications R/T (related to) dental status." The approaches noted were, "Set up tray and assist as needed." Resident #6 was referred to ST (Speech Therapy) with an initial assessment completed on 06/08/11. The ST identified swallowing problems and noted "excellent" rehabilitation potential due to no medical [DIAGNOSES REDACTED]. ST notes on 06/15/11, indicates that Resident #6 was trialed on a puree with honey thick liquids and had no signs of aspiration. On 06/22/11, Resident #6 was discharged from ST with recommendations of a pureed diet with honey thick liquids, needs maximum assist (assist with 75% of task) with eating, and requires direct supervision. Additional information per ST recommendations were: Needs assistance being fed. Encourage a second swallow every 3 to 4 bites of food. Must be seated upright during dining and at least 15 minutes following meals. If Resident #6 is not drinking liquids from the cup, present liquids on a spoon. These recommendations were found on the CNA (Certified Nursing Assistant) care plan, but not on the comprehensive care plan in the medical record. Review of the Nutritional Assessment completed on 02/15/11, notes that Resident #6's weight was 122#. The assessment form does not identify Resident #6's usual body weight; however review of the past quarterly nutrition notes on 05/17/10, 08/16/10, and 11/10/10 indicated that Resident #6 had consistently weighed 121 to 122#. The quarterly note dated 04/29/11, noted Resident #6 weighed 115#, consumed 25-75% of all meals, and was on a mechanical soft diet over the past year. On 06/15/11, she was changed to puree and honey thick liquids. Surveyor # requested all weights taken on Resident #6 for the past 4 months and was provided with: *04/04/11 weight was 117#; *04/29/11 weight was 115#; *05/02/11 weight was 118#; *05/26/11 weight was 115#; *06/02/11 weight was 110#; *07/04/11 weight was 107#; *07/18/11 weight was 103#. The RD (Registered Dietician) noted on 07/07/11 that Resident #6 had a weight loss and open area on her buttock. The RD noted a 7# (2.7%) weight loss in 1 month and a 10# (8.5%) weight loss in 3 months. The RD noted that Resident #6 received fortified cereal at breakfast, and Magic Cup twice daily to provide increased calories and protein. The RD noted that Resident #6 was provided with assistance at meals because of recent decline. The RD recommended no changes to the care plan. On 07/22/11 another Nutritional Assessment was completed on Resident #6 by the CDM (Certified Dietary Manager) and co-signed by the RD. The weight was documented as 107#. The usual body weight was 128-156#. The loss/gain was marked as stable at 122#. The nutrition at risk score was at a high risk based on recent weight change, poor intakes, medical diagnoses, medications, laboratory data, skin problems, and needing supervision with eating. The comments noted were, "Resident has recent change in condition. Nutritionally with (sic) continue with [MEDICATION NAME] (sic) approaches at this time." The CDM did not use the most current weight of 103# (documented on 07/18/11) and incorrectly documented that Resident #6's weight was stable in this assessment. The RD noted on 07/22/11 that Resident #6 had a significant change in status secondary to progressive dementia. Current weight was 103# which represented a significant weight loss. The RD documented, "Supplements and hical (high calorie) foods DC'd (discontinued) on 07/11 r/t (related to) refusal. Intakes of meals and fluids are poor at 0-25% which is inadequate to meet needs..." There were no changes made to Resident #6's care to increase intake or calories in order to avoid continued weight loss. On 07/27/11 beginning at 7:50 a.m. through 9:07 a.m., Surveyor # observed Resident #6 in the dining room. Review of her dining room tray card for Resident #6 was, "Resident needs assistance being fed. Encourage a second swallow every 3-4 bites of food. If resident is not drinking liquids from the cup, present liquids on a spoon." Resident #6 was on a puree diet with honey thick liquids. Surveyor # observed that Resident #6 had difficulty swallowing and was taking only very small bites. Resident #6 had consumed only a few bites of her hot cereal and toast, sips of her milk, and approximately 30 ml (milliliters) of her supplement drink. Resident #6 was not provided any assistance with eating. On 07/27/11 at 11:35 a.m., Resident #6 was seated at the dining room table. Resident #6 was served her lunch at 12:03 p.m. and was not assisted according to her care plan throughout the lunch meal. Resident #6 ate 100% of her spaghetti, 25% of her garlic toast, 25% of her broccoli, sips of her coffee, and sips of her juice, and approximately 50mls of her milk. On 07/27/11 at 5:33 p.m., Resident #6 was served her supper meal and again received no assistance with her meal. Resident #6 ate 50% of her potato soup and drank 120ml of juice. Resident #6 did not eat her sandwich, supplement, coffee, or milk. On 07/29/11 at 10:15 a.m., Surveyor # interviewed the CDM regarding Resident #6. The CDM stated Resident #6 had fortified breakfast cereal as well as Magic Cup twice daily, but the high calorie foods were discontinued due to poor acceptance and "monetary" decisions. Surveyor # discussed the inaccuracy of the Nutritional assessment dated [DATE] and the CDM stated that the information was entered by himself and reviewed by the RD. The Surveyor asked the CDM who was responsible for the reevaluation of interventions implemented and the CDM stated that he relies on nursing to update him on any nutrition concerns. On 07/29/11 at 10:45 a.m., Surveyor # interviewed CNA-U (Certified Nursing Assistant) who identified herself as a person who cares for Resident #6 four days/week for the past year. CNA-U stated that Resident #6 only required set up and supervision for her meals. Surveyor # and CNA-U reviewed the CNA care plan. CNA-U stated that she was unaware of the changes made by ST on 06/22/11. On 07/29/11 at 2:20 p.m., Surveyor # interviewed the RD regarding Resident #6's weight loss. The RD stated that she comes to the facility weekly and is provided a worksheet of concerns completed by the CDM. The RD stated she relies on the CDM to keep her up to date on any changes in resident status or interventions that were unsuccessful. The RD stated her recommendations are noted on the care plan by the CDM and follow up of those interventions was also the responsibility of the CDM. Surveyor # informed the RD of the observations of Resident #6 was not receiving the assistance in the dining room per ST recommendations. The RD stated she had assumed that Resident #6 was receiving assistance in the dining room as per ST recommendations. The RD stated she would reconsider the return of the fortified foods and supplements for Resident #6. Example #2: Resident #21 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. The most current MDS assessment dated [DATE] indicated Resident #21: ~Required extensive to total assistance of 1-2 staff persons for bathing, dressing, grooming, and toileting; ~Required extensive assistance of 1 staff person for eating; and ~Weighed 165 pounds. Resident #21's previous MDS dated [DATE], indicated Resident #21's weight was 182 pounds. Surveyor # completed a review of Resident #21's care plan dated 3/20/06. The problem titled, "...Alteration in Nutrition..." directed CNAs to follow the FRP (Functional Restorative Program). Surveyor # completed a review of the FRP dated 5/24/11 for Resident #21. This indicated Resident #21 was to be fed by staff. A dietary note dated 11/30/10, states Resident #21's "...Current weight: 182 pounds...Weight history reviewed, 180 pounds 10/6/10 and 180 pounds- 9/1/10. Weight stable..." Surveyor # completed a review of Resident #21's weights and noted the following: ~11/30/10 - 182# ~2/18/11 - 178# ~3/2/11 - 163# ~4/4/11 - 165# ~5/2/11 - 163# ~6/7/11 - 156.5# ~7/18/11 - 155# In the 6 month period between November 2010 and May 2011, Resident #21 had a 19 pound or 10.4% severe weight loss. In the 3 month period between May 2011 and July 2011, Resident #21 had an 8 pound or 4.9% weight loss. Overall, in the 9 month period since November 2010, Resident #21 has had a 27 pound or 14.8% weight loss. On 07/27/11 at 8:11 a.m., Surveyor # observed a table of 5 residents, with 2 residents eating independently and 3 residents waiting to be served. Resident #21 was among the 3 waiting to be served. On 07/27/11 at 5:05 p.m., Surveyor # observed Resident #21 seated at a table with Resident #5 and Resident #20. There was 1 CNA to assist. Resident #21 was lethargic and not swallowing the food when fed by CNA-Q. At 5:55 p.m., RN-P entered the dining room and sat down next to Resident #21 and attempted to feed him. Resident #21 continued to be lethargic and not swallowing the food in his mouth. On 7/28/11 from 5:20 p.m. until 6:15 p.m., Surveyor # observed the following: ~At 5:20 p.m., Surveyor # noted the cart containing the supper trays was in the dining room. Surveyor # counted 28 residents including Resident #21 were in the dining room along with 1 staff person, AA-Z (Activity Assistant). AA-Z indicated she was not able to pass trays until staff from the nursing department entered the dining room. ~At 5:43 p.m., Resident #21 was noted to have had received his supper tray. Surveyor # noted Resident #21 had not yet eaten any food. ~At 5:48 p.m., RN-F began to assist Resident #21 to eat. ~At 5:56 p.m. RN-F left Resident #21 and began to assist Resident #22 to eat. No other staff assisted Resident #21. ~At 6:08 p.m., RN-F again began to assist Resident #21 to eat. ~At 6:12 p.m., RN-F was no longer noted to be assisting Resident #21 to eat. Many residents were noted to have left the dining room. CNA-W was moving from table to table documenting the amount of food each resident ate. ~At 6:15 p.m. no other staff were noted since 6:12 p.m. to assist Resident #21 to eat. Surveyor # noted that Resident #21 had only eaten bites of food. Example #3: Resident #20 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. and [MEDICATION NAME] Degeneration. Resident #20's current MDS (Minimum Data Set) dated 6/9/11 indicated Resident #20: ~Required extensive assistance of 1-2 staff persons for bathing, dressing, grooming, and toileting; ~Required limited assistance of 1 staff person for eating; and, ~Weighed 150 pounds. Resident #20's care plan dated 12/4/08 under the problem titled "...Alteration in Nutrition...Advanced end stage [MEDICATION NAME] Degeneration needs assist with feeding...loss of vision..." directed staff to assist Resident #20 with eating. Surveyor # completed a review of Resident #20's weights and noted the following: ~2/24/11 - 152# ~3/10/11 - 152# ~3/31/11 - 150# ~4/28/11 - 150# ~5/5/11 - 150# ~5/26/11 - 148.5# ~6/2/11 - 148# ~6/16/11 - 143# ~7/28/11 - 140# Since 5/5/11, Resident #20 has lost 10 pounds. This is a severe weight loss of 7.89% over the past 3 months. On 07/27/11 at 5:05 p.m., Surveyor # observed 12 residents needing assistance with eating and only 3 CNA staff. Resident #20 was seated at a table with Residents #5 and #21. There was 1 CNA to assist. Resident #20 received no physical assist, only verbal cues. At 5:55 p.m., RN-P entered the dining room and sat down next to Resident #21 and attempted to feed him. RN-P also provided verbal cues to Resident #20 who wanted to leave the dining room and return to her room. On 7/28/11 from 5:20 p.m. until 6:15 p.m., Surveyor # observed the following: ~At 5:20 p.m., Surveyor # noted the cart containing the supper trays was in the dining room. Surveyor # counted 28 residents including Resident #20 in the dining room along with 1 staff person, AA-Z (Activity Assistant). AA-Z indicated she was not able to pass trays until staff from the nursing department entered the dining room. ~At 5:43 p.m., Resident #20 was noted to have her meal tray. Surveyor # noted Resident #20 had not yet eaten any food. ~From 5:43 p.m. until 6:06 p.m. Resident #20 had not eaten any food from her tray and no staff had assisted Resident #20 to eat. ~At 6:06 p.m., CNA-X entered the dining room. RN-F directed CNA-X to assist Resident #20 indicating to CNA-X that she had not yet had the time to assist Resident #20. ~At 6:11 p.m., CNA-X was no longer in the dining room. There was no other staff assisting Resident #20 to eat. Resident #20 had only eaten bites of food. ~At 6:12 p.m., many residents had left the dining room. CNA-W was moving from table to table documenting what residents had eaten. ~At 6:14 p.m., RN-F asked Resident #20 if she had had enough to eat. RN-F did not however assist nor cue Resident #20 to eat. Resident #20 had only eaten bites of food. Example #4: Surveyor # completed a review of Resident #22's clinical record and noted the following. Resident #22 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Resident #22's admission MDS (Minimum Data Set) was dated 7/18/11 and indicated Resident #22: ~Required extensive assistance of 1 staff person for bathing, dressing, grooming, and toileting; ~ Required extensive assistance with eating; and, ~Weighed 131 pounds. Resident #22's care plan dated 7/29/11 under the heading titled, "...Alteration in Nutrition"...directed staff to follow Resident #22's ADL (Activities of Daily Living) care plan. Surveyor # reviewed Resident #22's ADL care plan. The ADL care plan was not dated. Under the heading "Dietary" it indicated that Resident #22 required set-up assistance to eat. Surveyor # completed a review of Resident #22's weights and noted the following. All weights are noted in pounds. ~7/7/11 - 131.5# ~7/21/11 - 126# This is a 5.5 pound or 4% weight loss in 14 days. (A weight loss of greater than 5% in 1 month is considered severe.) Included with the ADL care plan there was a document titled, "Therapy Care Plan." Under the heading "Speech Therapy" dated 7/26/11, it indicated that Resident #22 required direct supervision to eat as well as set up to moderate assistance with eating. On 7/28/11 from 5:20 p.m. until 6:15 p.m., Surveyor # observed the following: ~At 5:20 p.m., Surveyor # noted the cart containing the supper trays was in the dining room. Surveyor # counted 28 residents in the dining room along with 1 staff person, AA-Z. AA-Z indicated she was not able to pass trays until staff from the nursing department entered the dining room. ~At 5:30 p.m. RN-F entered the dining room. ~At 5:34 p.m., RN-F began to assist Resident #22 to eat. ~At 5:36 p.m. Resident #24 had not received her meal tray and attempted to grab another resident's tray. RN-F left Resident #22 and assisted Resident #24. ~At 5:38 p.m. RN-F again began to assist Resident #22 to eat. ~At 5:45 p.m., RN-F left Resident #22 and began to direct the staff in the dining room. ~At 5:47 p.m., Resident #22 was attempting to hold a fork in her right hand. The prongs of the fork were turned around and facing to the right. Resident #22 was unable to manipulate the fork to the appropriate direction to allow Resident #22 to eat. ~At 5:55 p.m., Resident #22 was unsuccessfully attempting to pick up food with her fingers. ~At 5:56 p.m., RN-F again began to assist Resident #22 to eat. ~At 6:01 p.m., RN-F left Resident #22 and began to assist other residents. ~At 6:12 p.m., many residents were noted to have left the dining room and CNA-W was documenting the amount of food each resident ate. ~From 6:01 p.m. until 6:15 p.m., no staff had assisted Resident #22 to eat. Surveyor # noted that Resident #22 had only eaten bites of food. On 7/29/11 at 8:45 a.m., Surveyor # spoke with an anonymous staff person. Staff indicated that it was typical for staff to be late in getting to the dining room due to the difficult work load on the wings. Staff stated that many times there were only 2 staff in the dining room to pass trays, and on some days only 1 staff person. Staff stated there was never a nurse in the dining room and indicated what the surveyors have seen in terms of a nurse in the dining room "is not how it usually happens." Staff stated a lot of residents were eating cold food, and because of time limitations, the food was not getting reheated. Surveyor # asked staff how many residents required assistance to eat. Staff indicated 9 residents require total assistance to eat and 8 residents require supervision and cueing assistance to eat. On 7/29/11 at 11:10 a.m., Surveyor # spoke with the CDM. The CDM indicated he tracked weights monthly. The CDM stated he looks back over a 6-month period to determine if residents had a weight loss. Surveyor # asked the CDM how he calculated weight loss. The CDM indicated he uses a weight conversion table and based weight loss on previous weights. Surveyor # asked the CDM if he used usual body weight (UBW) to calculate percentage of weight loss. The CDM stated he did not. The CDM also stated he was not aware of the standard formula for calculating weight loss. Surveyor # asked the CDM what his involvement was in dining room service. The CDM stated he was not typically involved in passing trays. The CDM also stated he did not monitor the type of assistance residents needed nor if residents were receiving the assistance as required. The CDM stated that was a function of the nursing department. The CDM stated they had been meeting monthly as a team and discussing weight, however it had been "some time since they met as a team."

Based on interview and record review, the facility did not ensure that 1 of 6 residents who received [MEDICATION NAME] received the necessary care and treatment to attain the highest practicable physical, mental, and psychosocial well-being. Resident #1 was admitted to the facility on [DATE] after surgical repair of Resident #1's left hip. Resident #1 admission physician orders [REDACTED]. admission orders [REDACTED]. The test was not completed as ordered. On 5/9/11, Resident #1 had a change in her vital signs including blood pressure lower than usual and a pulse rate higher than usual. On 5/10/11, shortly after midnight, Resident #1 began to bleed from her surgical incision. The surgical incision had been previously documented as almost healed. A nurse in the facility assessed the incision and placed a thick gauze dressing over the incision. There was no evidence of a complete assessment done at that time including vital signs. The physician was not called. On 5/10/11, at 5:54 p.m., Resident #1 began to bleed from her rectum. A nurse at the facility contacted a Physician who gave orders to hold Resident #1's [MEDICATION NAME] and Aspirin, and to obtain blood work in the morning. There is no evidence that the physician who was called was informed of the bleeding at the incision site earlier that same day. There was no evidence that a complete assessment was done at that time. There were no vital signs obtained. On 5/10/11 at approximately 7:30 p.m., Resident #1 became unresponsive while being toileted. Resident #1's blood pressure at that time was 60/30 and pulse was 118. Resident #1 was subsequently transported to the hospital and diagnosed with [REDACTED]. The facility failed to: ~Ensure that physician orders [REDACTED]. ~Recognize the missed PT/INR; ~Recognize a change in condition; ~Notify a physician when Resident #1 began to bleed from the incision that was healed to the point that staples were removed; and, ~Complete a comprehensive assessment of Resident #1's condition according to current standards of practice This resulted in a finding of immediate jeopardy, which began on 5/10/11. The facility was notified of the finding on 6/14/11 at 12:32 p.m. by Surveyors # and # . The immediate jeopardy was removed on 6/16/11, however the scope/severity continues at an E (potential for more than minimal harm/pattern) as 13 other residents (Residents #2, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, and #18) remain in the facility and receive [MEDICATION NAME]. The facility still needs to fully implement their plan. This is evidenced by: According to the "Drug Information Handbook for Nursing", [MEDICATION NAME] is an anticoagulant. Nursing Considerations state, "Black Box Warning. [MEDICATION NAME] ([MEDICATION NAME]) can cause major or fatal bleeding, which is more likely to occur during the starting period and with a higher dose. Regularly monitor INR (International Normalization Rate) in all patients..." Patient Teaching states, "Black Box Warning. Tell patient and family to watch for signs of bleeding or abnormal bruising and to call prescriber at once if they occur..." A black box warning appears on the label of a prescription medication to alert consumers about any important safety concerns, such as serious side effects or life threatening risks. According to the "Drug Information Handbook for Nursing", Aspirin is a [MEDICATION NAME]. The "Drug Information Handbook for Nursing" indicated, ..."Increased Effect/Toxicity...Aspirin with oral anticoagulants ([MEDICATION NAME])...may increase the risk of bleeding...Adverse Reactions...bleeding is associated with aspirin. Hemorrhage may occur at virtually any site..." DQA (Division of Quality Assurance) memo 08-002 [MEDICATION NAME] ([MEDICATION NAME]) Monitoring indicates as a standard of practice: ~"...When a [MEDICATION NAME] regimen is started, a baseline INR is typically obtained. This initially should be performed within two to three days..." Resident #1 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) dated 5/12/10 indicated that Resident #1: ~Had moderately impaired cognition; ~Had no behavioral symptoms; ~Had mood indicators of feeling tired, and poor appetite; ~Required extensive assistance of 1-2 staff persons for all activities of daily living; and ~Weighed 127 pounds. Resident #1's undated care plan did not include that Resident #1 was on [MEDICATION NAME], nor did it direct staff to monitor for signs and symptoms of adverse reactions to [MEDICATION NAME]. Resident #1's hospital records from 4/29/11 until 5/2/11 indicated that Resident #1 had sustained a left [MEDICAL CONDITION] after falling at an assisted living facility. The left [MEDICAL CONDITION] was surgically repaired on 4/29/11. The hospital records indicated that Resident #1 was started on [MEDICATION NAME] as [MEDICATION NAME] for [MEDICAL CONDITION] (blood clots). According to the hospital records, Resident #1's hemoglobin was 10.1 g/dl (grams per deciliter) and INR was 1.4 when discharged to the facility. Resident #1's admission orders [REDACTED]. The admission orders [REDACTED]. Resident #1's MAR (Medication Administration Record) noted that Resident #1 received [MEDICATION NAME] 4mg (milligrams) every day from 5/2/11 through 5/9/11 and Aspirin 325mg every day from 5/3/11 through 5/10/11. Surveyor # completed a review of Resident #1's nursing notes and noted the following: ~5/2/11, "...admitted ...is alert and oriented X (times) 3...Vital signs..95.8 (temperature) 72 (pulse) 16 (respirations) 118/78 (blood pressure)..." ~5/3/11, "...alert and oriented...no bleeding with [MEDICATION NAME] to left hip well approximated (healing), staples intact, incision proximal has serous moderate amount on dressing...vitals 96.4, 72, 18, 130/68..." ~5/4/11, "...giving negative response to any activity ie refuse supper...Requesting just to be left alone to sleep...left hip incisions well approximated, proximal incisions has small amount of serous drainage on dressing...vitals: 96.3, 70, 16, 116/72..." The nurse's notes on 5/4/11 did not indicate that Resident #1's PT/INR had been drawn. Surveyor # reviewed all of Resident #1's chart and found no evidence that the lab work had been completed as ordered by the physician. ~5/5/11, "...No drainage showing on x3 dressing to L (left) hip and thigh...Vitals: 96.7 72 16 120/74..." ~5/6/11, "...Respiratory Rate: 20...Temperature: 96.2...Pulse: 72...Blood Pressure: 118/64...No s/sx (signs and symptoms) of depression...Dressings, x3 to L (left) hip and thigh, intact. Small amt (amount) of light yellow drainage shadowing proximal dressing..." ~5/7/11, "...Dressing change to left hip incision, proximal incision had small amount of yellow drng. (drainage) All incisions staples intact, edges well approximated...VS: (vital signs) 96.1-64-16-138/60..." ~5/8/11, "...Vitals: 96.3-88-16-130/68...No s/sx of depression...staple is intact dressing intact no drainage...Left hip incisions dressings clean dry intact..." ~5/9/11, "...flat affect during shift...alert and oriented times three...no nausea,vomiting or loose stools...left hip incisions well approximated, no drainage...no bleeding with [MEDICATION NAME] dry and intact to left hip. No drainage noted...Resident out to see Dr. (doctor)...Progress note states healing well-wounds stable...Vitals: 96.4 86 18 100/68..." On 5/9/11, Resident #1 began to display signs of a change in condition including blood pressure lower than what it had typically been running, pulse higher than what it had typically been running, and also a change in Resident #1's demeanor. This would have been the first indicator of a medical problem warranting further assessment. According to www.medicinenet.com, when there is a drop in blood pressure and an increase in pulse, it is indicative of intravascular volume loss including blood loss. There were no further vital signs done. There was no further comprehensive assessment of Resident #1's condition. According to the physician's note from 5/9/11, Resident #1's incisions were healing without evidence of infection. The incisions had healed to the point that the surgical staples were removed on that date. Nursing notes continue: ~5/10/11, documented at 1:33 a.m., "...Resident up in w/c (wheel chair) just prior to supper trays arriving - noted to be calling out to return to bed 'I just want to die Please don't make me eat, I'm ready to die'..." The above incident occurred during the supper meal on 5/9/11. Resident #1 had a significant change in her behavior combined with a low blood pressure and higher than normal pulse rate as noted previously. This was the second indicator of a medical problem warranting further assessment. There was no evidence that vital signs were completed and no evidence that a comprehensive assessment was completed. ~5/10/11, documented at 3:39 a.m., "...2400 (midnight) Incision to L hip assessed. All were OTA (open to air). Dry blood noted to proximal and middle incision, distal incisions near knee, healed...0030 (12:30 a.m.) CNA (Certified Nursing Assistant) summoned Writer, noted blood from incision. Writer assessed. Petri dish size blood spot noted on chux. Blood beading up on proximal and distal incision...cleansed with normal saline, [MEDICATION NAME] dressing applied, covered the ABD (Abdominal) dressing..." Resident #1 has now had changes in her vital signs, changes in her behavior, and new bleeding from surgical wounds which had been previously documented as clean, dry and well approximated. This is the third indicator of a medical problem warranting further assessment. This is also indication that Resident #1's blood may be becoming too thin from the anticoagulants. There was no comprehensive assessment completed including vital signs. Nursing notes continue: ~5/10/11, "...05:51AM...No drainage showing on dressing to L hip..." ~5/10/11, "...10:00AM...Right hip dressing to proximal incision is dry and intact, no drainage, incision well approximated...middle and distal incision well approximated..." On 5/10/11, the facility sent a fax to Resident #1's physician noting the change in Resident #1's behavior, requesting a medication for depression. The physician declined and indicated to continue to monitor Resident #1. The fax from the facility did not include information regarding the changes in Resident #1's vital signs nor the bleeding as noted during the night. Nursing notes continue: ~5/10/11, "...05:35PM...loose stool..." ~5/10/11, "...05:54PM...Call Placed To...physician on call pt (patient) continue with loose stool and bleeding order obtained to hold [MEDICATION NAME] tonight and asa (Aspirin) in am also labs in am..." ~5/10/11, documented at 9:37 p.m., "...Out Of The Building: to ER (emergency room ) pt went unresponsive on toilet for a few mint (minutes) and bp (blood pressure) was 60/30 p (pulse) 118...very weak and pale sweating continue bleeding too order obtained...pt send..to hospital..." According to the nursing notes, on 5/10/11 at 7:35 p.m. the facility sent Resident #1 to the emergency room and subsequently admitted . Surveyor # reviewed Resident #1's hospital records from the 5/10/11 admission. Upon admission to the hospital, Resident #1's hemoglobin was 7.7 (normal range being 12.0-15.6g/dl), PT was greater than 200 (normal range being 9.5 to 11.8 seconds) and INR was greater than 29 (normal range being 2.00 to 3.50). Resident #1 received Vitamin K 10 mg to counteract the [MEDICATION NAME], 4 units of fresh frozen plasma, and 4 units of blood while hospitalized for [REDACTED]. On 6/13/11 at 4:15 p.m., Surveyor # spoke with RN-A (Registered Nurse). RN-A indicated that the facility utilized a ward clerk who processed all orders. RN-A indicated that when the ward clerk was not there, the nurses processed their own orders. RN-A stated that once an order was gotten for lab work, the order was placed on a lab calendar as well as a lab slip. RN-A indicated that when the ward clerk processed orders a nurse was required to double check the order to ensure it was appropriately transcribed. On 6/13/11 at 6:05 p.m., Surveyor # spoke with RN-B regarding Resident #1. RN-B indicated that the order for Resident #1's PT/INR, which was to be drawn on 5/4/11, was missed. RN-B stated that the order had not been appropriately transcribed. RN-B indicated that the order had not placed on the lab calendar and a lab slip was not made out. On 6/14/11 at 10:20 a,.m., Surveyor # spoke with RN-C. RN-C indicated she was the unit manager on the unit in which Resident #1 had resided. RN-C also indicated that she was the nurse who noted and documented the events of Resident #1's incisional bleeding. On 6/14/11 at 12:00 p.m., Surveyor # again spoke with RN-C regarding Resident #1. RN-C indicated that when she had noted Resident #1's incisional bleeding she had not considered it worrisome. RN-C stated that Resident #1's incisions were well approximated and that staff had just turned her. RN-C indicated that she thought that the bleeding may have been from a fluid pocket. RN-C indicated that she had checked Resident #1 later and there was no further bleeding. RN-C again stated that she did not consider the bleeding "worrisome" at the time but in "hind sight it was." On 6/14/11 at 5:15 p.m., Surveyor # spoke with RN-D. RN-D indicated that she was the nurse caring for Resident #1 during the day shift on 5/10/10. RN-D indicated that there was nothing during her shift that "alarmed me." RN-D indicated that she was aware that Resident #1 had had bleeding from her incisions during the night. RN-D indicated that she had checked Resident #1's dressing and there was no bleeding noted. On 6/16/11 at 11:30 a.m., Surveyor # spoke with MD (Medical Doctor)-E. MD-E indicated that he was the physician on call and had given orders to the facility for Resident #1 the evening of 5/10/11. MD-E indicated that he was not aware of the changes to Resident #1's vital signs and demeanor. MD-E also indicated that he was not aware that Resident #1 had been bleeding from the incisions earlier that day. MD-E stated that as he recalled, he had been told only that Resident #1 was on [MEDICATION NAME] and had had some diarrhea with some blood. MD-E stated that had he been told the scope of the problem he would have given orders for Resident #1 to be sent to the emergency room at that time. Surveyor # attempted to speak with RN-F. RN-F did not return Surveyor # 's phone call. The facility's failure to properly monitor and assess Resident #1 created a situation of immediate jeopardy. The facility removed the immediate jeopardy on 6/16/11 when: 1. Prior to survey, the facility had identified the error in not obtaining timely lab work. RN-A indicated on 6/13/11 at 4:15 p.m. that the facility had been utilizing only 1 lab calendar for the entire facility. RN-A stated that last month the facility implemented a second lab calendar which was placed on the rehab unit. A facility memo dated 5/19/11 indicated, "...5/19/11, There will be 2 lab calandars (sic), one for rehab, and one for long term..." 2. Reviewed all 13 residents on anticoagulation to ensure that lab work was done timely; 3. Implemented a new system for direct care staff to quickly identify residents who are receiving anticoagulation therapy; 4. Held mandatory inservices for all direct care staff addressing the new identification system, recognizing and reporting signs and symptoms of bleeding; and, 5. Inserviced all licensed nurses on reporting changes of condition following guidelines set forth by the American Medical Directors Association. On 6/14/11 at 8:10 a.m., RN-B stated that the facility previously had only counseled the staff involved because the facility had considered this to be an individual performance issue.